MUSCULOSKELETAL DISORDERS

Learning Contents Time Framed Learning activities Learning assessment

Assessment of musculoskeletal function

History  Subjective assessment:
I. 
    

Pain Characteristic of pain(onset, location, intensity, duration) Patterns and types Differentiate pain of musculoskeletal origin from systemic origin Aggravating factors Relieving factors Associated signs and symptoms

11. Altered Sensation

Sensory disturbances may be associated with musculoskeletal problems Parasthesias(burning, tingling sensation or numbness)  PHYSICAL ASSESSMENT I. POSTURE Assessment is performed from the posterior and lateral views taking note of any asymmetry or abnormalities of the spine and its surrounding structures

Common Deformities:
1. Kyphosis an increased forward curvature of the spine 2. Lordosis excessive posterior curvature of the lumbar spine 3. Scoliosis lateral deviation of the spine

11. GAIT:
Assessed by having the patient walk away from the examiner for a short distance, or as soon as the patient walks into the examining room Note for smoothness and rhythm of gait. Inequality in step and stride lengths, limping or abnormal pelvic dipping may indicate muscular imbalances or pathology in the adjoining structures

111. Bone Integrity

Compare the left and right sides of the body, take note any deformities and anatomical misalignment 1V. JOINTS
Evaluate ROM, deformities, stability and nodular formation  Active ROM the joint can be moved by the patient through active contraction of the surrounding muscle  Passive ROM only the examiner can move the joint without participation from the patient

MUSCLES
Note of the ability to change position, strenght and coordination, presence of atrophy or hyperthrophy Check carefully the origin of muscle weakness because patient s fear, unwillingness, or malingering might give false-positive results(muscle strength) Note for muscle tone (sensation of resistance felt as one manipulates a joint through its ROM) Measure the muscle girth at the bulkiest portion of the extremity(location and position must be the same on both extremities)

Diagnostic Evaluation
A. Radiography
1. Computed Tomography(CT scan) - Shows in detail a specific plane of involved bone and can reveal tumors of the soft tissue or injuries to the ligaments or tendons - Identifies the location and extent of fracture in areas difficult to evaluate 11. X-Rays - Imaging technique use to determine bone density, texture, erosion and changes in bone relationship

B. Magnetic Resonance Imaging

- noninvasive, special imaging technique, which uses magnetic fields, radio waves, and computers to determine abnormalities of soft tissue, such as muscle. tendons, cartilage, nerve and fat

C. RADIONUCLIDE IMAGING 1. Arthrographyidentifies acute or chronic tears of the joint capsule or supporting ligaments of the knee, shoulder, ankle, hip or wrist A radiopaque substance or air is injected into a joint cavity to outline soft tissue structure and the contour of the joint Joint is put through its ROM to distribute the contrast agent while series of X-rays are obtained If a tear is present, the contrast agent leaks out of the joint and is evident on the radiographs

D. Bone Scan
- Performed to determine certain fractures, osteomyelitis,
metastatic and primary bone tumors and aseptic necrosis

E. Special Tests/Invasive Tests of Structure 1. Arthroscopy

To visualize joints to confirms and rule out joint disorders To obtain synovial fluid for diagnostic purposes and to relieve pain due to effusion

2. Arthrocentesis
-

3. Electromyography
- To determine abnormalities and differentiates nerve and muscle functions

4. Bone Biopsy - To help diagnose diseases by determining the structure and composition of the bones

Laboratory Studies
1. 2. 3. 4. CBC Coagulation studies Blood chemistry Thyroid Studies

Degenerative Bone Disorder:

Osteoarthritis(OA) Wear and Tear r/t aging - Progressive loss of the joint cartilage

- most common and frequently disabling

- Known as degenerative joints disease or osteoarthrosis Classification: 1. Primary (Idiopathic) with no prior disease 2. Secondary result from previous injury/inflammatory disease

Etiology/Risk Factors
Increased Age: by 40 = 90 % develop the disease - Prevalence of OA 70% in age=55 to 74 Obesity Previous joint damage Genetic susceptibility and hormonal factors Mechanical injury Anatomic deformity Congenital and developmental disorder Cartilage degradation Bone stiffening Reactive inflammation of synovial

Pathophysiology of OA
Genetic & hormonal factors

Mechanical injury
Chondrocytes response

Previous joints damage

others
Release of cytokines

Stimulation, production and release of proteolytic enzyme,metalloproteases, collagenase

Damage predisposes to more injury

OA
S&S: Pain & Stiffness in AM due to inflamed synovium; irritation of nerve ending, muscle spasm, stretching of joint capsule/ligament Redness & Swelling Painless bony nodules Knee effusions Tender and enlarged joints Crepitus DX: History and Physical X-rays narrowing of the joint space

TX: Medications
Analgesics: acetaminophen
NSAIDS Steroids-RARE

Treatments
ROM exercises Rest the joint Assistive devices = walker, cane, crutches

Surgical TX:
Joint Arthroplasty (Reconstruction or Replacement

Hip Replacement

Total Knee Replacement

Total Joint Replacement

Candidate selection Several devices available Significant relief of pain Good return to ADL OOB in 1 -2 days with PT help Best results with PT program for restrengthening muscles Post op CPM
Continuous Passive Motion see next slide

Continuous Passive Motion

Post Op Care Joint Hip Replacement

Monitor incision for bleeding Cough, turn, deep breath OOB as ordered Neurovascular checks hourly 12-24 hours (color, temp, pulses, capillary refill, movement, sensation) Pain management Prevent new hip displacement

Nursing Care Plan

Pain assessment Position changing with Trapeze Sequential compression Incentive spirometer Abduction pillow for hip replacement Monitor temperature and other VS Surgical site assessment Quadriceps and foot exercises

Discharge Health Teaching

Hazards assessment Chronic disease ROM Prevent Overuse/Overstess Pain Management

Metabolic Bone Disorder Osteoporosis (Bone Atrophy)

- Rate of bone resorption is greater than bone formation resulting in a decreased total bone mass - Reduction of bone density and a change of bone structure - Loss of bone mass - Bones becomes porous, brittle and fragile - Increase risk of fractures

Cause of Osteoporosis

Low Calcium

When can you expect a client to have Osetoporosis? Age Sex Race Family History

Who is at Risk for Osteoporosis

Menopause Small frame, non-obese with sedentary lifestyle Inadequate dietary calcium and Vitamin D intake Bidridden status(r/t effects of immobility) Use of antacids and laxatives Calcium deficiencies Skeletal Loss High intake of Sodas Vitamin D Deficiency Smokers and intake of ceffeine Excess ETOH Decrease Estrogen Sedentary Lifestyle

Risk factors and its Effects:

Genetics:Caucasian/asian;
Female; family hx;small frame
Age: post menopause;advanced age; low testosterone in man;decreased calcitonin

Predispose to bone mass

Hormones (estrogen, calcitonin and testosterone) Inhibit bone mass

Reduces nutrients needed for bone remodeling

Nutrition: low calcium intake; Low Vit.D intake; High Phosphate intake(carbonated beverages); Inadequate calories

Physical exercise: sedentary; lack of weight bearing exercise; low weight and body mass index

Bone needs stress for bone maintenance

Lifestyle choices: caffeine; alcohol ;smoking

Reduces osteogenesis in bone remodelling

Medicaton:corticosteroids; antiseizure medicatio; heparin; thyroid hormoe Co-morbidity: anorexia;hyperthyroidism, malabsorption syndrome, renal failure

affects calcium absorption and metabolism

Cardinal Signs and Symptoms Loss of height Curvature of Spine Dowager s Hump Lordosis Low Back Pain Other S&S: Difficulty of bendingover Pulmonary insufficiency and easy fatigability Protrusion of the abdomen

Medical /Surgical MGT:

Medication of Osteoporosis Biphosphonates Fosamax Actonel Didronel Calcitonin Sodium Flouride Raloxifene (Evista)

Medical /Surgical MGT: Brace for vertebral fracture Calcium Supplements; dietary modification and HRT Regular weight-bearing exercise Repair of fractures

Nursing Interventions:
Promote regular weight bearing execise Promote modification of lifestyle Emphasize the needs to have sufficient intake of calcium. Vit D and exposure to sunshine Instruct client to increase fluid intake to reduce the risk of renal calculi If HRT is prescribed, educate about the importance of compliance and periodic screening for breast and endometrial cancer Apply intermittent local heat and back rubs Instruct to move trunks as a unit and to avoid twisting and strenuous lifting

B. Osteomalacia(Adult Rickets)
Is a metabolic bone disease Characterized by an excess of unmineralized bone matrix The bone becomes abnormally soft due to a disturbed calcium and phosphorusbalance secondary to Vitamin D deficiency May result from failure of the intestines to absorb calcium(malabsorption syndrome), or excessive loss of calcium from the body

Risks factors:
Hypoparathyroidism Renal tubular disorder(hypophosphatemic rickets) Hepatobiliary disease Diseases of small intestine Prolonged anti-convulsant therapy Excessive intake of chelating agents

Signs and Symptoms:

Bone pain and tenderness Referred pain to the pelvis, back or hips and muscle cramps Severe progressive muscular weakness Bowing and bending deformities of the long bones X-rays reveals generalized demineralization of bone Hypocalcemia and hypophosphatemia, low urine calcium and creatinine excretion Bone biopsy reveals increase amount of osteoid

Medical/Surgical MGT:
Vit D replacement and supplemental calcium High-calcium and high-phosphorus diet Repair of fracture and corrective osteotomies NURSING INTERVENTION: Monitor calcium and phosphorus levels Encourage high calcium and highphosphorus diet

C. Paget s Disease deformans

Osteitis

- Is a disorder of localized rapid bone turnover, affecting the skull, femur, tibia, pelvic bones and vertebrae Incidence: - Greater in men than woman - Increasing in aging Etiology: UNKNOWN Predisposing factors: Family hx Aging

Pathophysiology
Inc. old age; rapid bone turnover

Primary proliferation of osteoclastproduces bone resorption

Compensatory increase in osteoblastic activity that replace the bone

A classic mossaic(disorganized) pattern of bone develop

Highly vacularized and structurally weak Fx occur

Signs and Symptoms:

Skeletal deformity; bowing of femur and tibia = wading gait Enlargement of the skull Spine is bent forward and rigid The chin rest on the chest The thorax is compressed and immobile on respiration The trunk is flexed on the legs to maintain balance Deformity of the pelvic bone Cortical development of the long bones Cranium enlarge Face small, triangular appearance Impaired hearing due to cranial nerve compression and dysfunction Pain, tenderness and warmth over the bones X-ray result= sclerotic changes

Dx. and Assessment findings

Elevated serum alkaline phosphatase Urinary Hydroxyproline excretion reflect inc. osteoblastic activity X-rays bone overgrowth Bone Biopsy

Medical Mgt
Pharmacologic therapy:
- NSAIDs - Calcitonin: retard bone resorption by decreasing the number and availability of osteoclast. Facilitate remodeling; relieve bone pain - Biphosphonates (Didronel) and Fosamax = produce rapid reduction in bone turnover and relief pain - Caicium 1500mg - Vitamin D(400 to 600 IU) - Plicamycin(Mithracin) cytotoxic antibiotic

D. Arthritis:
Inflammation of a joint usually accompanied by pain swelling and changes in structure Etiology
Degenerative Joint Disease
Osteoarthritis, Rheumatoid

Metabolic disturbances
Gout

Infection
Gonococcus, TB, Pneumonia

Gout and Gouty Arthritis

Metabolic disorder Inflammation 2 deposits of uric acid crystals in joint Body produces too much uric acid
Or

Body excretes too little uric acid

What is Uric Acid

Uric acid is a waste product formed from the breakdown of purines High levels of purines are found in organ meats (liver, brains, kidney), anchovies, herring, mackerel.
Alcohol and some drugs may affect purine excretion.

Stage 1: Asymptomatic Hyperuricemia

Uric acid levels elevated to 9-10 range (normals ~ 3 6) No symptoms Client may not progress to symptomatic disease

Stage 2 Acute Gouty Arthritis

Sudden onset, acute pain, redness, swelling Usually hits the big toe, may affect another joint Fever, chills Elevated WBC, sed rate Attack lasts hours to weeks 60% have recurrent attack in 1 yr

Stage 3 Chronic Tophaceous Gout Hyperuricemia untreated Tophi (urate crystals deposits) develop in cartilage, synovial membranes, tendons, soft tissues Pain, ulceration, nerve damage Uric acid crystals >kidney stones

Gout and Gouty Arthritis

Assessment: - Articular and periarticular inflammation - Presence of tophi - Hyperurecemia - Acute attack usually happens during the night - Severe pain, swelling, redness and warmth - Joint enlargement

Nursing Diagnoses
Acute Pain Impaired Physical Mobility

Nursing Intervention

Medical MGT:
Pain Indocin NSAIDS, Narcotics
Steroids (po/intra-articular)

Interrupt urate crystal formation Colchicine: Does NOT alter uric acid
levels

Inhibit tubular reabsorption of uric acid

Probenecid (Benemid)

Reduce the production of uric acid

Allopurinol (Zyloprim)

Treatment of Gout Attack Continued

Dietary Management
Drink 3-4 quarts of fluids daily Avoid alcohol Sometimes no diet is prescribed

Low purine diet

Meats, seafood, yeast, beans, peas, lentils, oatmeal, spinach, asparagus, cauliflower, mushrooms

Nursing Intervention
Instruct to avoid purine-rich foods Limit alcohol intake Encourage client to maintain normal body weight Avoid stress and trauma

Musculoskeletal infection
OSTEOMYELITIS infection of the bone Acute or Chronic Usually Caused By
Staphylococcus Aureus Fungus Parasite Virus

Ways that Bones become Infected

Extension of soft tissue infection(e.g. infected pressure/vascular ulcer, incisional infection) Direct bone contamination from bone surgery, open fx., traumatic injury(gunshot wound) Hematogenous(bloodborne) spread from other sites of infection(infected tonsils, boils) trauma

RISK FACTORS
Trauma Diabetes Hemodialysis Splenectomy Advanced age q Immune function Poor circulation

CAUSES
Direct Contamination Surgical Infection Adjacent Soft Tissue Infection Hematogenous
Originating in the blood

STAGES OF OSTEOMYELITIS

Pathophysiology-Osteomyelitis
Bone infection 70- 80% caused by staphylococcus Aureus, other: Pseudomonas. Escherichia coli, Proteus

Inflammation inc. vascularity, edema-thrombosis

Ischemia with bone necrosis to =Periosteum soft tissue - joints

Abscess formation abscess cavity contains dead bone tissue(the sequestrum) Does not liquiffy and drain

The cavity can not collapse and heal = involucrum(new bone growth formed and surround the sequestrum

Sequestrum remain infected chonically thus produced recurring abscessess thru out life = osteomyelitis occur

MANIFESTATIONS
Pain Swelling, redness, warmth Purulent exudate Systemic
Fever

Chills Nausea Malaise

DIAGNOSTIC STUDIES
MRI CT Bone Scan Ultrasound Labs: Sed Rate WBC s Cultures

TREATMENT
Medications
Antibiotics Pain Management

Surgical debridement Amputation

Common Nursing Diagnoses for Clients with Osteomyelitis?

Risk for Infection Hyperthermia Impaired physical mobility Acute pain Anxiety Body Image Self Esteem

Prevent Osteomyelitis?
Risk Factors? Trauma DM PVD SHOES, SOCKS

Arthirtis
Septic Arthritis
-results from the activity of pus-forming
bacteria in a synovial joint - Most common sites of infection: hip and Knee -Most common infecting agent:Staphyloccocus aureus ASSESSMENT: Fever and chills Painful, warm and wollen joint MRI and CT scan show damage to joint lining Culture of synovial fluid show presence of pathogens

Nursing intervention
Immobilized affected joints Progressive ROM exercise after the infection subsides Monitor nutritional intake and fluid status of the patient MEDICAL Mgt: Broad spectrum antibiotic Analgesic(codeine) NSAIDs

Rheumatoid Arthritis
Chronic, Systemic Autoimmune Disease
Inflammation of the connective tissue, Inflammation of the joint

Sites affected

Manifestations of RA
Joint symptoms
Pain, swelling, stiffness ( in morning) Deformity and muscle atrophy Limited ROM

Other Symptoms
Fatigue Anorexia Low-grade fever Inflammatory changes of heart and lungs

Diagnosis of RA
History and physical exam Labs
Rheumatoid factors (RF) ESR (Erythrocyte Sedimentation Rate) Synovial fluid exam

X-rays
Narrowing joint space

Treatment of RA
NO CURE Goals of Treatment
Relieve pain Reduce inflammation Stop or slow joint damage and deformity Improve well-being and ability to function

Treatment of RA
Medications NSAIDS Steroids (po or intra-articular) Disease-modifying drugs
Modify immune system
Gold, antimalarial,

Modify the autoimmune and inflammatory response

Enbrel- Tumor necrosis factor blocker Kineret- Interleukin 1 receptor antagonist

Surgery Joint replacement Tendon reconstruction

MUSCULAR DYSTROPHY
- A genetic disorder characterized by gradual degeneration of muscle fibers and is usually accompanied by deformity and disability Treatment: supportive and symptomatic The aim of tx is to increase comfort and functional ability Respiratory exercise is encouraged

Care of Patient with Musculoskeletal Trauma

1. Contusion, strain, sprain a. contusion: bruising of soft tissue caused by a blunt force; results in rupture of blood vessels and bleeding into the soft tissue b. Strain: incomplete muscle tears with some bleeding into the tissues secondary to over-stretching, overuse or unaccustomed repeated trauma of minor degree; less severe than a sprain S&S: Muscle soreness or sudden pain and tenderness upon isometric and active muscle contractions

Sprain
- Severe stress, stretch, ot tear of ligaments surrounding a joint NURSING INTERVENTION: - PRICE method: a. Protect b. Rest c. Ice d. Compression e. Elevation - avoid skin and tissue damage due to excessive cold - Apply elastic bandage - Heat application is done after 24 hr to 48 hr after injury

Joint Dislocation
Dislocation
- Articular surfaces within a joint are being displaced, leading to soft tissue damage, inflammation, pain and muscle spasm

Subluxation
- An incomplete or partial dislocation involving sec. trauma to surrounding soft tissue

Assessment:
Pain Change in length of extremity Loss of normal mobility Change in the axis of the dislocated bones

Nursing Intervention:
Joint immobilization Reduction method to preserve joint function Progressive ROM and strengthening exercise Provide comfort Evaluate neurovascular status Protect the joint during the healing process

Fracture
- Any break in the continuity of a bone Types of Fracture: 1. Open or compound - Communication between the bone and the outside is present 2. Closed or simple - Does not produce a break in the skin 3. Complete - Involves a break across the entire crosssection of the bone 4. Incomplete - Break occurs only on a part of the bone s cross-section(greenstick fx)

5. Comminuted
- Bone is broken into fragments 6. Pathologic - Occurs in bones weakened by pre-existing disease 7. Stress fx - Repetitive unaccustomed loading and inadequate muscular support results in bone fatigue 8. Oblique - Line of breakage runs in a slanted direction across the shaft of the bones 9. Transverse fx - Caused by simple angulatory forces 10. Spiral - Results from torsional injury

Assessment