Musculoskeletal System Part 1

This nursing lecture briefly discusses the anatomy of the musculoskeletal system.
  1. Musculoskeletal System
    • Functions
    • Movement and maintains posture
    • Support
    • Protection
    • Hematopoiesis
    • Mineral homeostasis
  2. Contusions, Strains, and Sprains
    • Contusion- soft tissue injury produced by blunt force.
    • Strain - “muscle pull” from overuse, overstretching, or excessive stress.
    • Sprain- injury to the ligaments surrounding a joint, caused by a wrenching or twisting motion.
    • Treatment : “RICE”
    • Rest, Ice, Compression, Elevation
  3. Musculoskeletal Injuries
    • Fracture
    • Break in the continuity of bone
    • Resulting from trauma or various disease processes.
  4. Types
    • Complete - fracture extends
    • through entire bone,
    • producing 2 or more
    • fragments.
    • 1. Simple or Closed- fractured bone; does not protrude through skin
    • 2. Compound or Open- fractured
    • bone extends through skin and mucous membranes
    • 3. Comminuted fracture- multiple bone fragments
  5. A. Complete Fracture
    • 4. Oblique fracture- fracture line at 45-degree angle to long axis of bone
    • 5. Spiral fracture- fracture line
    • encircling the bone
    • 6. Transverse fracture- fracture line perpendicular to long axis
    • of bone
  6. B. Incomplete Fracture
    • Incomplete- when only part
    • of the bone is broken.
    • 1. Greenstick fracture- fracture
    • of one side of bone; other side
    • merely bends; usually seen
    • only in children
    • 2. Bowing fracture- bending of
    • bone.
    • 3. Stress fracture- microfracture.
    Stress Fracture Bowing Fracture Greenstick Fracture
  7. Fracture
    • Clinical Manifestation
    • Pain and tenderness
    • Soft tissue edema
    • Abnormal motion
    • Crepitus
    • Obvious deformity
    • Discoloration or ecchymosis
    • Diagnostic Studies
    • X-ray
    • Objectives of Treatment
    • Optimal realignment
    • Rigid immobilization
    • Restoration of function
  8. Fracture Management
    • Treatment Modalities for Fractures
    • Closed or Open Reduction
    • Casting
    • Traction
    • Internal or External Fixation Devices
    Internal Fixation External Fixation
  9. Fracture Management
    • Reduction (“setting” the bone)
      • Refers to restoration of the fracture fragments into anatomic rotation and alignment
  10. Fracture Management
    • Closed Reduction (Manipulation)
    • Bone ends are realigned w/o surgical exposure of the fracture site
    • Anesthesia may or may not be used
    • Followed by casting to maintain proper alignment
  11. Fracture Management
    • Open Reduction
    • Operative procedure utilized to achieve bone alignment
    • Pins, wire, nails or rods may be used to secure bone fragments in position
    • Prosthetic implants may also be used
  12. Fracture Management
    • Immobilization
      • Maybe accomplished by internal or external fixation
  13. Fracture Management
    • Internal Fixation Devices
    • Implanted surgical devices to align and stabilize the fracture site until healing can occur
    • Used when closed reduction does not provide stable immobilization
  14. Internal Fixation Devices The advantage of internal fixation is that it often allows early mobility and faster healing.
  15. Fracture Management
    • External Fixation Devices
    • Two or more rigid bars are placed horizontally above and below the fracture site in the long bones of the extremities
  16. Complication of Fractures
    • Early complications
    • Shock
    • Fat embolism
    • Assessment
    • (S) dyspnea
    • (O) tachypnea, tachycardia, hypoxia, crackles, wheezes, chest pain, cerebral disturbances
    • N/I
      • High Fowler’s position
      • O2 stat
      • Respiratory support measures, CPR in event of respiratory failure
      • Corticosteroids: reduce inflammatory lung reaction
      • Morphine
  17. Complication of Fractures
    • Compartment syndrome
    • Assessment:
    • (S) deep, throbbing, unrelenting pain not controlled by narcotics
    • (O) paresthesia (early), swelling, motor weakness
    • N/I:
      • Elevate injured extremity
      • Avoid tight bandages, splints or casts
      • Prepare patient for fasciotomy
  18. Complication of Fracture
  19. Complication of Fractures
    • Infection
    • Assessment:
    • (S) pain
    • (O) ↑ temperature and pulse, edema, sudden local induration, thin, watery, foul-smelling exudate, crepitation (maybe indicative of gas gangrene; with cast-warm area, foul smell
    • N/I:
      • Monitor V/S, drainage
      • Prophylactic tetanus toxoid
      • Prophylactic anti-infectives as ordered if wound is contaminated at time of injury
      • Instruct patient not to touch open wound, pin sites or put anything inside cast
  20. Complication of Fractures
    • Delayed complications
    • Delayed union/Non-union
    • Assessment:
    • (S) pain
    • (O) callus formation, on X-ray- poor alignment
    • N/I:
    • Maintain immobilization and alignment
    • Maintain adequate nutrition
    • Avoid trauma to affected extremity
    • Increase calcium in diet
  21. Complication of Fractures
    • Avascular Necrosis/Circulatory impairment
    • Assessment:
    • (S) tenderness, pain, especially on passive motion
    • (O) limited movement
    • Treatment:
    • Revitalize the bone with bone grafts
    • Prosthetic replacement
    • Arthrodesis
  22. Fracture Care
    • Maintain in optimal alignment
    • Check all bony prominences for evidence of pressure q4h and prn, depending on amount of pressure
    • Monitor: circulation, sensation and motion of affected part
    • Assess circulation in the injured limb: warmth and color, capillary refill, peripheral pulses
  23. Fracture Care
    • Assessing nerve supply to the limb
      • Upper extremities/lower extremities
        • Sensory: pinprick over fingertips/heel, dorsum of hand/foot
        • Motor: dorsiflexion and plantar flexion of wrist/foot
    • Maintain mobility in unaffected limb and unaffected joints of affected limb by active and passive ROM exercises
    • Prevent foot drop by using ankle-top sneakers
  24. Traction
    • mechanism by which a steady pull is placed on a part or parts of the body
    • 2 Types:
    • Skin traction
    • Application of wide band of moleskin, adhesive, or commercially available devices directly to the skin and attaching weights to them.
  25. A. Skin Traction
    • 1. Buck’s extension
    • Exerts straight pull on the affected extremity; to immobilize the leg in patient with a fractured hip
    • Has a horizontal weight
    • Turn towards unaffected side
    • Check for pressure sore at the heel of the foot*
    Balance suspension Buck’s extension
  26. A. Skin Traction
    • 2. Russel traction
    • Knee is suspended in a sling attached to a rope and pulley on a Balkan frame, creating upward pull from the knee
    • Weights are attached to the foot of the bed
    • Used to treat fracture of the femur
    • Allows patient to move about in bed more freely and permits bending of the knee joint
    • Assess back of the knee for pressure sores
  27. A. Skin Traction
    • 3. Bryant’s traction
    • Both legs raised 90 angle to bed
    • Used for children under 3 years and 30 lbs to treat fractures of the femur and hip dislocation
    • Buttocks must be slightly off mattress
    • Knees slightly flexed
    The knees should be slightly flexed, and the legs should be extended at a right angle to the body. The body provides a traction mechanism.
  28. A. Skin Traction
    • 3. Pelvic traction
      • Pelvic girdle with extension straps attached to ropes and weights
      • used for low back to reduce muscle spasm and maintain alignment
  29. B. Skeletal Traction
    • Traction applied directly to the bones using pins, wires, or tongs (Crutchfield) that are surgically inserted, used for fractures femur, tibia, humerus, cervical spine
  30. 1.Balanced suspension traction
    • Produced by a counterforce other than the patient’s weight
    • Extremity floats or balances in the traction apparatus
    • Patient may change position without disturbing the line of traction
    • Used for displaced or overriding fx of femur
    • Relieves muscle spasms
    • Realigns fx fragments
    • Promotes callus formation
    Initial weights: 30 to 40 lbs Suspension weights: 7 to 8 lbs Countertraction: 7 to 8 lbs
  31. Pearson attachment Thomas splint
  32. Care of the Clients in Traction
    • 5 General Principles in Traction Care:
    • 1. Line of pull should be in line with the deformity
    • 2. Adequate countertraction present
    • 3. Apply traction continuously
    • 4. Allow the weights to hang freely
    • 5. Avoid friction
  33. Care of the Clients in Traction
    • Turn the client as indicated
    • Pin site care for skeletal traction:
      • Cleanse and apply antibiotic ointment
    • Do neurovascular checks
    • Prevent complication of immobility
  34. Nursing Intervention
    • Promote healing and prevent complications
    • diet: high protein, iron, vitamins (tissue repair), moderate carbohydrates (prevent weight gain)
    • increase fluid intake
    • assess for complications of immobility (pneumonia, constipation, decubitus ulcers, osteoporosis)
    • assess casted extremity for presence of foul odor, drainage, paleness or blueness, change in temperature, pulselessness, tingling, numbness
    Fracture bedpan
  35. Nursing Intervention
    • Prevent injury or trauma
    • avoidance of high-risk activities (sky diving, high impact sports, rollerblading)
    • avoidance of safety hazards (throw rugs, untreated vision problems)
    • regular exercise
    • provide care related to ambulation with crutches
    • provide safety measures related to possible complications following fracture
    Fracture bedpan
    • The distance between the axilla and the arm piece on the crutches should be at least 3 fingerwidths below the axilla
    • The elbows should be slightly flexed, 30 degrees
    • When ambulating with the client, stand on the affected side.
    • Crutch stance: tripod (triangle) position (6-10 inches in front and to the side).
    • Instruct the client never to rest the axilla on the axillary bars.
    • Instruct the client to look up and outward when ambulating.
    • Instruct the client to stop ambulation if numbness or tingling in the hands or arms occurs.
  38. Crutch gaits
    • Four-point gait
    • Sequence:
    • Advance left crutch 4-6 inches
    • Advance right foot
    • Advance right crutch
    • Advance left foot
    • Advantages : most stable crutch gait
    • Requirements : Partial weight bearing on both legs
  39. Crutch gaits
    • Three-point gait
    • Sequence:
    • Advance both crutches forward with the affected leg and shift weight to crutches.
    • Advance unaffected leg and shift weight onto it.
    • Advantages: allows the affected leg to be partially or completely free of weight bearing
    • Requirements: full weight bearing on one leg, balance and upper-body strength.
  40. Crutch gaits
    • Two-point gait
    • Sequence:
    • Advance left crutch and right foot
    • Advance right crutch and left foot
    • Advantages: Faster version of the four-point, normal walking pattern.
    • Requirements: Partial weight bearing on both legs
    • Swing-through gait
    • Sequence:
    • Move both crutches forward.
    • Move both legs farther ahead than crutches.
  41. Amputation of a Lower Extremity
    • Removal of a body part, usually an extremity
    • 10% of patients experience uncomfortable sensations  phantom limb pain.
    • Risk Factors
    • Atherosclerosis obliterans
    • Uncontrolled DM
    • Malignancy
    • Extensive and intractable infection
    • Severe trauma

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