Musculoskeletal

System Assessment &

Disorders

Skeletal System
Bone

types
Bone structure
Bone function
Bone growth and metabolism
affected by calcium and
phosphorous, calcitonin, vitamin
D, parathyroid, growth hormone,
glucocorticoids, estrogens and
androgens, thyroxine, and insulin.

Bones
Human

skeleton has 206 bones

Provide structure and support for
soft tissue
Protect vital organs

Figure 41-1 Bones of the human skeleton.

Figure 41-2 Classification of bones by shape.

Bones
Compact

bone

Smooth and dense

Forms shaft of long bones and
outside layer of other bones
Spongy

bone

Contains spaces
Spongy sections contain bone
marrow

Bone Marrow
Red

bone marrow

Found in flat bones of sternum, ribs,

and ileum
Produces blood cells and hemoglobin
Yellow

bone marrow

Found in shaft of long bones

Contains fat and connective tissue

Joints (Articulations)
Area

where two or more bones

meet
Holds skeleton together while
allowing body to move

Joints
Synarthrosis

Immovable (e.g., skull)

Amphiarthrosis

Slightly movable (e.g., vertebral

joints)
Diarthrosis

or synovial

Freely movable (e.g., shoulders,

hips)

Synovial Joints
Found

at all limb articulations

Surface covered with cartilage
Joint cavity covered with tough
fibrous capsule
Cavity lined with synovial
membrane and filled with
synovial fluid

Ligaments
Bands

of connective tissue that

connect bone to bone
Either limit or enhance
movement
Provide joint stability
Enhance joint strength

Tendons
Fibrous

connective tissue bands

that connect bone to muscles
Enable bones to move when
muscles contract

Muscles
Skeletal

(voluntary)

Allows voluntary movement

Smooth

(involuntary)

Muscle movement controlled by

internal mechanism
e.g., muscles in bladder wall and GI
system
Cardiac

(involuntary)

Found in heart

Skeletal Muscle
600

skeletal muscles
Made up of thick bundles of
parallel fibers
Each muscle fiber made up of
smaller structure myofibrils
Myofibrils are strands of
repeating units called sarcomeres

Skeletal Muscle
Skeletal

muscle contracts with

the release of acetylcholine
The more fibers that contract,
the stronger the muscle
contraction

Changes in Older Adult

Musculoskeletal

changes can be

due to:
Aging process
Decreased activity
Lifestyle factors

Changes in Older Adult

Loss

of bone mass in older

women
Joint and disk cartilage
dehydrates causing loss of
flexibility contributes to
degenerative joint disease
(osteoarthritis); joints stiffen, lose
range of motion

Changes in Older Adult

Cause

stooped posture, changing

center of gravity
Elderly at greater risk for falls
Endocrine changes cause skeletal
muscle atrophy
Muscle tone decreases

Assessment
Health

history
Chief complaint
Onset of problem
Effect on ADLs
Precipitating events, e.g., trauma

Assessment
Examine

complaints of pain for

location, duration, radiation
character (sharp dull),
aggravating, or alleviating factors
Inquire about fever, fatigue,
weight changes, rash, or swelling

Physical Examination
Posture
Gait
Ability

to walk with or without

assistive devices
Ability to feed, toilet, and dress
self
Muscle mass and symmetry

Physical Examination
Inspect

and palpate bone, joints

for visible deformities, tenderness
or pain, swelling, warmth, and
ROM
Assess and compare
corresponding joints
Palpate joints knees and shoulder
for crepitus

Physical Examination
Never

attempt to move a joint

past normal ROM or past point
where patient experiences pain
Bulge sign and ballottement sign
used to assess for fluid in the
knee joint
Thomas test performed when hip
flexion contracture suspected

Figure 41-4 Checking for the bulge sign.

Figure 41-5 Checking for ballottement.

Diagnostic Tests
Blood

tests
Arthrocentesis
X-rays
Bone density scan
CT scan
MRI
Ultrasound
Bone scan

Diagnostic Evaluation
Procedures CT, Bone Scan, MRI
Nuclear Studies - radioisotope bone density,
Imaging

Endoscopic

Studies

arthrocentesis,

arthroscopy
Other

Studies

biopsy, synovial fluid,

Arthrogram, venogram,
Electromyography
Myelography*
Laboratory

Studies

Musculoskeletal
Assessment Diagnostic Test
Laboratory

Laboratory

Urine Tests

Blood Tests

24 hour creatinecreatinine ratio

Urine Uric acid 24
hr specimen
Urine
deoxypyridinoline

Serum muscle
enzymes
Rheumatoid Factor
LE Prep/Antinuclear
Antibodies(ANA)
Erythrocyte
Sedimentation Rate
Calcium,
Phosphorous,
Alkaline
phosphatase

Muscoluloskeletal
Assessment Diagnostic
Blood

Tests

CBC Hgb, Hct

Acid phosphatase
Metabolic/Endocri
ne
Enzymes
Increase creatine
kinase, serum
increase glutaminoxaloacetic due to
muscle damage,
aldolase, SGOT

Musculoskeletal Radiographic
Standard

radiography,
tomography and
xeroradiography, myelography,
arthrography and CT
Other diagnostic tests: bone and
muscle biopsy

Arthroscopy
Fiberoptic

tube is inserted into a

joint for direct visualization.
Client must be able to flex the
knee; exercises are prescribed for
ROM.
Evaluate the neurovascular status
of the affected limb frequently.
Analgesics are prescribed.
Monitor for complications.

Bone Scan
Nuclear

medicine procedure in
which amount of radioactive
isotope taken up by bones is
evaluated
Abnormal bone scans show hot
spots due to malignancies or
infection
Cold spot uptakes show areas of
bone that are ischemic

Arthroscopy
Flexible

fiberoptic endoscope
used to view joint structures and
tissues
Used to identify:

Torn tendon and ligaments

Injured meniscus
Inflammatory joint changes
Damaged cartilage

Interventions for Clients

with Musculoskeletal
Trauma

Musculoskeletal Trauma
Tissue

is subjected to more force

than it can absorb
Severity depends on:
Amount of force
Location of impact

Musculoskeletal Trauma
Mild

to severe
Soft tissue
Fractures
Affect function of muscle, tendons,
and ligaments
Complete

amputation

Preventing Trauma
Teach

importance of using safety

equipment

Seat belts
Bicycle helmets
Football pads
Proper footwear
Protective eyewear
Hard hats

Soft Tissue Trauma

Contusion

Bleeding into soft tissue

Significant bleeding can cause a
hematoma
Swelling and discoloration (bruise)

Soft Tissue Trauma - Sprain

Ligament

injury (Excessive
stretching of a ligament)
Twisting motion
Overstretching or tear
Grade Imild bleeding and inflammation
Grade IIsevere stretching and some
tearing and inflammation and hematoma
Grade IIIcomplete tearing of ligament
Grade IVbony attachment of ligament
broken away

Sprains
Treatment

of sprains:

first-degree: rest, ice for 24 to

48 hr, compression bandage, and
elevation
second-degree: immobilization,
partial weight bearing as tear
heals
third-degree: immobilization for
4 to 6 weeks, possible surgery

Soft Tissue Trauma - Strain

Microscopic

tear in the muscle

May cause bleeding
Pulled muscle
Inappropriate lifting or sudden
acceleration-deceleration

Soft Tissue Trauma

To

decrease swelling and pain,

and encourage rest
Ice for first 48 hours
Splint to support extremities and
limit movement
Compression dressing
Elevation to increase venous return
and decrease swelling
NSAIDs

Soft Tissue Trauma

Diagnosis

X-ray to rule out fracture

MRI

Fractures
Break

in the continuity of bone

Direct blow
Crushing force (compression)
Sudden twisting motions (torsion)
Severe muscle contraction
Disease (pathologic fracture)

Fractures
Classification of Fractures
Closed

or simple
Open or compound
Complete or incomplete
Stable or unstable
Direction of the fracture line
Oblique
Spiral
Lengthwise plane (greenstick)

Stages of Bone Healing

Hematoma

formation within 48
to 72 hr after injury
Hematoma to granulation tissue
Callus formation
Osteoblastic proliferation
Bone remodeling
Bone healing completed within
about 6 weeks; up to 6 months in
the older person

Fractures Emergency Care

Immobilize

before moving client

Joint above and below
Check pulse, color, movement,
sensation before splinting
Sterile dressing for open wounds

Fractures Emergency Care

Fracture

reduction

Closedexternal manipulation
Opensurgery

Acute Compartment Syndrome

Serious

condition in which
increased pressure within one
or more compartments causes
massive compromise of
circulation to the area
Prevention of pressure buildup
of blood or fluid accumulation
Pathophysiologic changes
sometimes referred to as
ischemia-edema cycle

Emergency Care - Acute

Compartment Syndrome
Within

4 to 6 hr after the
onset of acute compartment
syndrome, neuromuscular
damage is irreversible; the
limb can become useless
within 24 to 48 hr.
Monitor compartment
pressures.
(Continued)

Emergency Care (Continued)

Fasciotomy

may be
performed to relieve
pressure.
Pack and dress the wound
after fasciotomy.

Possible Results of Acute Compartment

Syndrome
Infection
Motor

weakness
Volkmanns contractures:

(a

deformity of the hand, fingers, and wrist

caused by a lack of blood flow (ischemia) to the
muscles of the forearm)

Other Complications of Fractures

Shock
Fat

embolism syndrome: serious

complication resulting from a
fracture; fat globules are
released from yellow bone
marrow into bloodstream
Venous thromboembolism
(Continued)

Other Complications of Fractures

(Continued)

Infection
Ischemic

necrosis
Fracture blisters, delayed
union, nonunion, and
malunion

Musculoskeletal
Complications (continued)
Muscle

Atrophy, loss of muscle

strength range of motion, pressure
ulcers, and other problems associated
with immobility
Embolism/Pneumonia/ARDS
TREATMENT hydration, albumin,
corticosteroids
Constipation/Anorexia
UTI
DVT

Musculoskeletal Assessment - Fracture

Change

in bone alignment
Alteration in length of
extremity
Change in shape of bone
Pain upon movement
Decreased ROM
Crepitation
Ecchymotic skin
(Continued)

Musculoskeletal Assessment Fracture

(Continued)
Subcutaneous

emphysema
with bubbles under the skin
Swelling at the fracture site

Special Assessment Considerations

For

fractures of the shoulder and

upper arm, assess client in sitting or
standing position.
Support the affected arm to
promote comfort.
For distal areas of the arm, assess
client in a supine position.
For fracture of lower extremities
and pelvis, client is in supine
position.

CAST
CAST

Casts
Rigid

device that immobilizes the

affected body part while allowing
other body parts to move
Cast materials: plaster,
fiberglass, polyester-cotton
Types of casts for various parts of
the body: arm, leg, brace, body

(Continued)

Casts (Continued)
Cast

care and client education

Cast complications: infection,
circulation impairment, peripheral
nerve damage, complications of
immobility

Managing Care of the Patient in a Cast

Casting

Materials
Relieving Pain
Improving Mobility
Promoting Healing
Neurovascular Function
Potential Complications

Cast, Splint, Braces, and Traction

Management Considerations
Arm

Casts
Leg Casts
Body or Spica Casts
Splints and Braces
External Fixator
Traction

POLYESTER/FIBERGLAS
S

UPPER EXTREMITY CAST

LOWER EXTREMITY CAST

Musculoskeletal
Nursing Care - Casts
Neurovascular
Check
color/capillary
refill
Temperature
Pulse
Movement
Sensation

Traction

Nursing

Care
Pin Site care
Skin and
neurovascular
check

Cast Care

(continued)

Elevate

Extremity
Exercises to unaffected side; isometric
exercises to affected extremity
Keep

heel off mattress

Handle with palms of hands if cast wet
Turn every two hours till dry
Notify MD at once of wound drainage
Do not place items under cast.

Traction
Application

of a pulling force
to the body to provide
reduction, alignment, and
rest at that site
Types of traction: skin,
skeletal, plaster, brace,
circumferential
(Continued)

Traction (Continued)
Traction

care:

Maintain correct balance

between traction pull and
counter traction force
Care of weights
Skin inspection
Pin care
Assessment of neurovascular
status

Musculoskeletal Fractures
Treatment
Primary

Goal reduce fracture-

Realign and immobilize

Medications

Analgesics, antibiotics, tetanus toxoid

Closed

Reduction Manual and Cast;

External Fixation Device
Traction; Splints; Braces
Surgery
Open reduction with internal fixation
Reconstructive surgery
Endoprosthetic replacement

Figure 42-5 In external fixation, pins placed through the bone above and below the fracture are attached to external
fixation rods that hold the pins and bone in place.

Nursing
Management

Positioning

Strengthening
Potential

Exercises

Complications

Musculoskeletal
Nursing Care
Promote

comfort
Assess infection
Promote mobility
Teach safety
Vital Signs
Flotation, sheep
skin
Nutrition
Vital Signs
Monitor
elimination

Elevate

extremity to
decrease
swelling/ ice
pack
Teach skin care,
cast care, diet,
complications

Operative Procedures
Open

reduction with internal

fixation
External fixation
Postoperative care: similar to
that for any surgery; certain
complications specific to
fractures and musculoskeletal
surgery include fat embolism
and venous thromboembolism

Managing the Patient Undergoing

Orthopedic Surgery

Joint

Replacement
Total Hip Replacement
Total Knee Replacement

Risk for Infection

Interventions

include:

Apply strict aseptic technique

for dressing changes and wound
irrigations.
Assess for local inflammation
Report purulent drainage
immediately to health care
provider.
(Continued)

Risk for Infection (Continued)

Assess for pneumonia and
urinary tract infection.
Administer broad-spectrum
antibiotics prophylactically.

Imbalanced Nutrition: Less Than Body

Requirements
Interventions

include:

Diet high in protein, calories,

and calcium, supplemental
vitamins B and C
Frequent small feedings and
supplements of high-protein
liquids
Intake of foods high in iron

Upper Extremity Fractures

Fractures

include those of

the:

Clavicle
Scapula
Humerus
Olecranon
Radius and ulna
Wrist and hand

Lower Extremity Fractures

Fractures

include those of

the:

Femur
Patella
Tibia and fibula
Ankle and foot

Fractures of the Hip

Intracapsular

or extracapsular
Treatment of choice: surgical
repair, when possible, to allow the
older client to get out of bed
Open reduction with internal
fixation
Intramedullary rod, pins, a
prosthesis, or a fixed sliding plate
Prosthetic device

Fractures of the Pelvis

Associated

internal damage
the chief concern in fracture
management of pelvic
fractures
Nonweight-bearing fracture
of the pelvis
Weight-bearing fracture of
the pelvis

Compression Fractures of the Spine

Most

are associated with

osteoporosis rather than
acute spinal injury.
Multiple hairline fractures
result when bone mass
diminishes.
(Continued)

Compression Fractures of the Spine

(Continued)

Nonsurgical

management
includes bedrest, analgesics,
and physical therapy.
Minimally invasive surgeries
are vertebroplasty and
kyphoplasty, in which bone
cement is injected.
(Continued)

Amputations
Surgical

amputation
Traumatic amputation
Levels of amputation
Complications of amputations:
hemorrhage, infection,
phantom limb pain, problems
associated with immobility,
neuroma (a growth or tumour of nerve
tissue), flexion contracture

Amputation

Nursing Management

relieving pain
minimizing altered sensory
perception
promoting wound healing
enhancing body image
self-care

Phantom Limb Pain

Phantom

limb pain is a frequent

complication of amputation.
Client complains of pain at the
site of the removed body part,
most often shortly after surgery.
Pain is intense burning feeling,
crushing sensation or cramping.
Some clients feel that the
removed body part is in a
distorted position.

Management of Phantom Pain

Phantom

limb pain must be

distinguished from stump pain
because they are managed
differently.
Recognize that this pain is real
and interferes with the
amputees activities of daily
living.

(Continued)

Management of Phantom Pain

(Continued)

Some

studies have shown that

opioids are not as effective for
phantom limb pain as they are
for residual limb pain.
Other drugs include
intravenous infusion
calcitonin, beta blockers,
anticonvulsants, and
antispasmodics.

Exercise After Amputation

ROM

to prevent flexion
contractures, particularly of
the hip and knee
Trapeze and overhead frame
Firm mattress
Prone position every 3 to 4
hours
Elevation of lower-leg
residual limb controversial

Prostheses
Devices

to help shape and

shrink the residual limb and
help client readapt
Wrapping of elastic bandages
Individual fitting of the
prosthesis; special care

Crush Syndrome
Can

occur when leg or arm injury

includes multiple compartments
Characterized by acute
compartment syndrome,
hypovolemia, hyperkalemia,
rhabdomyolysis, and acute tubular
necrosis
Treatment: adequate intravenous
fluids, low-dose dopamine, sodium
bicarbonate, kayexalate, and
hemodialysis

Metabolic Bone Disorders

Osteoporosis
Osteomalcia
Pagets

Disease

Osteoporosis
A

disease in which loss of bone exceeds

rate of bone formation; usually increase
in older women, white race, nulliparity.
Clinical Manifestations bone pain,
decrease movement.
Treatment Calcium, Vit. D, estrogen
replacement, Calcitonin, fluoride,
estrogen with progestin, SERM (Selective
Estrogen Receptor Modulator) with antiestrogens, exercise.
Pathologic fracture-safety.

Classification of
Osteoporosis
Generalized

osteoporosis occurs
most commonly in postmenopausal
women and men in their 60s and
70s.
Secondary osteoporosis results
from an associated medical
condition such as
hyperparathyroidism, long-term
drug therapy, long-term immobility.
Regional osteoporosis occurs when
a limb is immobilized.

Health Promotion/Illness
Prevention - Osteoporosis
Ensure

adequate calcium

intake.
Avoid sedentary life style (a
type of lifestyle with a lack of
physical exercise) .
Continue program of weightbearing exercises.

Osteoporosis - Assessment
Physical

assessment
Psychosocial assessment
Laboratory assessment
Radiographic assessment

O
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Drug Therapy
Osteoporosis
Hormone

replacement therapy
Parathyroid hormone
Calcium and vitamin D
Bisphosphonates
Selective estrogen receptor
modulators
Calcitonin
Other agents used with
varying results

Diet Therapy - Osteoporosis

Protein
Magnesium
Vitamin

K
Trace minerals
Calcium and vitamin D
Avoid alcohol and caffeine

Fall Prevention Osteoporosis

Hazard-free

environment
High-risk assessment through
programs such as Falling Star
protocol
Hip protectors that prevent
hip fracture in case of a fall

Others - Osteoporosis
Exercise
Pain

management
Orthotic devices

Osteomalacia
Softening

of the bone tissue

characterized by inadequate
mineralization of osteoid
Vitamin D deficiency, lack of
sunlight exposure
Similar, but not the same as
osteoporosis
Major treatment: vitamin D from
exposure to sun and certain
foods

Pagets Disease of the Bone

Metabolic

disorder of bone
remodeling, or turnover; increased
resorption (the process by which osteoclasts
break down bone and release the minerals, resulting
in a transfer of calcium from bone fluid to the blood )

of loss results in bone deposits that

are weak, enlarged, and disorganized
Nonsurgical management: calcitonin,
selected bisphosphonates,
mithramycin
Surgical management: tibial
osteotomy or partial or total joint
replacement

Pagets Disease
An

imbalance of increase
osteoblast and osteoclast cells;
thickening and hypertrophy.
Bone pain most common symptom;
bony enlargement and deformities
usually bilateral, kyphosis, long
bone.
Analgesics, meds bisphosphonates
and calcitonin, NSAID, assistance
devices, and hot/cold treatment.

Osteomyelitis
A

condition caused by the

invasion by one or more
pathogenic microorganisms
that stimulates the
inflammatory response in bone
tissue
Exogenous, endogenous,
hematogenous, contiguous

Osteomyelitis
Infection

of bone; causative agent Staph/Strept

Typical signs and symptoms : Acute osteomyelitis
include:
Fever that may be abrupt
Irritability or lethargy in young children
Pain in the area of the infection
Swelling, warmth and redness over the area of
the infection
Chronic osteomyelitis include:
Warmth, swelling and redness over the area of
the infection
Pain or tenderness in the affected area
Chronic fatigue
Drainage from an open wound near the area of
the infection
Fever, sometimes
Treatment IV antibiotic; long term for 4-6
months

Surgical Management
Osteomyelitis
Sequestrectomy (Surgical removal
of a sequestrum), a detached piece of
necrotic bone that often migrates to a
wound, abscess, etc.

Bone

grafts
Bone segment transfers
Muscle flaps
Amputation

Bone Tumors
Benign

Bone Tumors
Malignant Bone Tumors
Metastatic Bone Disease

Bone Tumors
Benign

bone tumors
(noncancerous):

Chrondrogenic tumors:
osteochondroma, chondroma
Osteogenic tumors: osteoid
osteoma, osteoblastoma, giant
cell tumor
Fibrogenic tumors

Interventions
Nondrug

pain relief measures

Drug therapy: analgesics,
NSAIDs
Surgical therapy: curettage
(simple excision of the tumor
tissue), joint replacement, or
arthrodesis

Malignant Bone Tumors

Primary

tumors, those
tumors that originate in the
bone

Osteosarcoma
Ewings sarcoma
Chondrosarcoma
Fibrosarcoma
Metastatic bone disease

Osteosarcoma
Cancer

of the bone metastasis to

the lung is common. Most in long
bones.
Clinical manifestations dull pain,
swelling, intermittent but increases
per time; night pain common.
Treatment radiation,
chemotherapy, hormonal therapy,
surgical excision with prosthetics,
assistance devices, palliative
measures.

Treatment Cancer of Bone

Interventions

include:

Treatment aimed at reducing the

size or removing the tumor
Drug therapy; chemotherapy
Radiation therapy
Surgical management
Promotion of physical mobility
with ROM exercises

Cancer of Bone
Anticipatory Grieving
Interventions

include:

Active listening
Encouraging client and family to
verbalize feelings
Making appropriate referrals
Helping client and others to
cope with the loss and grieving
Promoting the physician-client
relationship

Cancer of Bone
Disturbed Body Image
Interventions

include:

Recognize and accept the

clients view of body image
alteration.
Establish and maintain a
trusting nurse-client
relationship.
Emphasize the clients strengths
and remaining capabilities.
Establish realistic mutual goals.

Potential for Fractures

Bone Cancer
Interventions

Nonsurgical management: radiation

therapy and strengthening
exercises.
Surgical management: replace as
much of the defective bone as
possible, avoid a second procedure,
and return client to a functioning
state with a minimum of
hospitalization and immobilization.

Carpal Tunnel Syndrome

Common

condition; the median

nerve in the wrist becomes
compressed, causing pain and
numbness
Common repetitive strain injury
via occupational or sports
motions
Nonsurgical management: drug
therapy and immobilization
Possible surgical management

Scoliosis
Abnormal

spinal curvature of
various degrees or severity
involving shortening of
muscles and ligaments.
Milwaukee brace (a back brace
used in the treatment of spinal
curvatures)

devices.

, internal fixative

Scoliosis
Changes

in muscles and ligaments

on the concave side of the spinal
column
Congenital, neuromuscular, or
idiopathic in type
Assessment: complete history, pain
assessment, observation of posture
Interventions: exercise, weight
reduction, bracing, casting, surgery