nursing management: musculoskeletal problems

1. Nursing Management: Musculoskeletal Problems George Ann Daniels, MS, RN

2. Soft tissue treatment: RICE- Rest Ice Compression ElevationSoft tissue treatment: RICE- Rest Ice Compression Elevation

3. Meniscal tear Knee is caught between femoral condles and plateau of tibia- tear the meniscus Rotator Cuff injuries Tear in the rotator cuff muscles of the shoulders Bursitis Inflammation of the bursa in the joint Tennis elbow, housemaid�s knees

4. Carpal Tunnel Syndrome Compression of the medial nerve under the carpal ligament in the wrist Causes: trauma/edema, tumors, ganglion, excessive use wrists Key board operators, paper boys, carpenters, needle work, sewing, driving Key board operators, paper boys, carpenters, needle work, sewing, driving

5. Assessment of Carpal Tunnel Weakness, pain, tingling, numbness night and day Paresthesia thumb, forefingers, and middle finger Phalen�s sign EMG Especially the thumb Wrist in flex position for 60 sections=numbness and tingling symptoms Phalen�s signTap wrist pain shoot up arm Especially the thumb Wrist in flex position for 60 sections=numbness and tingling symptoms Phalen�s signTap wrist pain shoot up arm

6. Surgical Repair

7. Management Wrist splints Special keyboard pads Avoid aggravating action Occupational change

8. Fractures Crack or break in the continuity of a bone Assessment Pain, point tenderness, muscle spasms, numbness, Tingling, paralysis Change in shape Loss of function Edema Ecchymosis Crepitus Severe muscle rigidity

9. Types of fractures Avulsion- Fracture from strong pulling effect of tendons/ligaments at the bone attachment Communited- Bone is splintered-fragments Displace- bone fragments override other bone Impacted- communited fragments are driven into each other Interarticular- fracture through the articular surface Longitudinal-Fracture along the length of the bone Oblique- fracture runs oblique Pathologic- spontaneous fracture from bone disease Spiral- fracture spirals along the shaft of the bone Stress- repeated stress on the bone Transverse Fracture straight across Bends � bent but not broken Buckle or tores- compression of the porous bone appears as a raised or bulging projection at fracture site Greenstick- Incomplete fracture , one side fragmented the other side bent Complete-Total break Avulsion- Fracture from strong pulling effect of tendons/ligaments at the bone attachment Communited- Bone is splintered-fragments Displace- bone fragments override other bone Impacted- communited fragments are driven into each other Interarticular- fracture through the articular surface Longitudinal-Fracture along the length of the bone Oblique- fracture runs oblique Pathologic- spontaneous fracture from bone disease Spiral- fracture spirals along the shaft of the bone Stress- repeated stress on the bone Transverse Fracture straight across Bends � bent but not broken Buckle or tores- compression of the porous bone appears as a raised or bulging projection at fracture site Greenstick- Incomplete fracture , one side fragmented the other side bent Complete-Total break

10. Hematoma Formation-blood collects around the broken bone ends, forming a clot. within 24 hours a mesh like network forms a framwork for growing new bone tissue Ostoclasts and ostoblasts invade clot. Osteoclasts startsmooth the jagged edged of the bone Osteoblasts bridge the gap between bone ends Callus formation in 6-10 days post injury. The bone bridge has a callus form around it to splint movement during healing Bone hardens in 3-10 weeks, new blood vessels bring CA to harden the new bone called ossification bone ends knit together It may take up to 1 year before bone is strongHematoma Formation-blood collects around the broken bone ends, forming a clot. within 24 hours a mesh like network forms a framwork for growing new bone tissue Ostoclasts and ostoblasts invade clot. Osteoclasts startsmooth the jagged edged of the bone Osteoblasts bridge the gap between bone ends Callus formation in 6-10 days post injury. The bone bridge has a callus form around it to splint movement during healing Bone hardens in 3-10 weeks, new blood vessels bring CA to harden the new bone called ossification bone ends knit together It may take up to 1 year before bone is strong

11. Healing times Neonatal period 2-4 weeks Early childhood 4 weeks Later childhood 6-8 weeks Adolescence 8-12 weeks

12. Fracture Treatment Splint Immediately Traction Realignment Skin or skeletal Closed Reduction Open Reduction ORIF- Open reduction internal fixation External Fixation Page1776

13. Types of Casts

14. Cast Material Fiberglass Light weight, water proof Dries within one hour Stronger Plaster Paris Dries 24-48 hours Turn Q2H with palms Do not turn with adbuctor bar Do not cover cast with plastic coated pillow Inspect for crumbling and cracking

15. Cast Care Table 59-9 Cast Removal Cast cutter

16. Complication of Cast Therapy Impaired circulation Pressure areas Skin lesions Drainage Nerve damage Tissue necrosis Nerve damage- change in sensation, increasing pain, or motor weakness Circulation- change in pulse, skin color, sensation, pain, cap refill or function Drainage may take several days to appear, circle, and record. Check under cast, inquire about wetness feeling Necrosis-warmth in area, must offensice odor Nerve damage- change in sensation, increasing pain, or motor weakness Circulation- change in pulse, skin color, sensation, pain, cap refill or function Drainage may take several days to appear, circle, and record. Check under cast, inquire about wetness feeling Necrosis-warmth in area, must offensice odor

17. Compartment Syndrome Pressure within a limited anatomic space Forearm and lower leg Depresses circulation Decreases viability and function of tissue within the space Tissue damage can occur within 30 minutes > 4 hours irreversible damage

18. Assessment Assessment 5 P�s Pain- severe or increased unrelieved Pallor Paresthesia Numbness, tingling, decrease in sensation Paralysis Decrease or loss of movement and strength Pulselessness Loss of distal pulse Compartment pressure monitor

19. Nursing Management Relieve pressure Prevention Inspect dress/cast frequently Elevate dressing /cast Ice pack Petal edges of cast Loosen dressing Monitor intracompartment pressure > 30 mm HG Fasciotomy Complications of Compartment syndrome: Infection. Amputation, contractures, loss of function and renal failure ( due to release of myoglobin in the blood. Myoglobin molecule too large for effective filtration and excretion by kidney- blocks. Complications of Compartment syndrome: Infection. Amputation, contractures, loss of function and renal failure ( due to release of myoglobin in the blood. Myoglobin molecule too large for effective filtration and excretion by kidney- blocks.

20. Fat Embolism Fat globules are released from the marrow of long bone fractures or multiple trauma into the blood stream Cause platelets to clump Forms fat emboli Obstruction of pulmonary/vascular beds Effected organs Lungs Vessels Brain Heart Kidneys Tissue/organs Circulatory insufficiency, tissue infarcts and sudden death

21. Assessment Assessment 12-72 hours post injury HA, drowsiness, irritability, memory loss, confusion, rapid pulse, apprehension, and fever Pulmonary Tachypnea, dyspnea, use of accessory muscles, wheezing, inspiratiory stridor Skin manifestations Petechiae-neck, upper chest, shoulder, axillary and buccal membranes

22. Diagnosis Symptoms and history ABG�s Decrease Pa02 < 60 mm Hg PaC02 > 50 mm Hg Acidosis Elevated lipase and ESR Nursing Management Improve oxygenation and prevent deterioration 02 high concentrations Adequate hydration Titrated to prevent pulmonary congestion Dextran Steroids Decrease lung inflammation/cerebral edema Heparin Prevent future formation of emboli

23. Hip Fractures Types Intracapsular Subcapital-(A) Transcervical-(B) Basilnar neck Extracapsular Intertronchanteric (C) Between greater and lesser trochanter Subtrochanteric Below trochanter

24. Assessment External rotation Shortening of the affected extremity Pain and tenderness at fracture site Discoloration of surrounding tissue Inability to move injured leg while lying supine

25. Surgical Interventions

26. Avascular Necrosis Necrosis of bone/intra-articular structures Lack of circulation Misalignment, Fracture thrombus, constriction from device Ischemic bone becomes necrotic collapse

27. Post-Op Interventions VS I & O Respiratory TCDB, IS Infection Assessment Thrombus/emboli Precautions Pain control Assess incision Assess circulation Abductor pillow or splint ( Hip) Controls rotation Mobility Use opposite leg to pivot

28. Home Teaching Hip FractureTable 59-11

29. Osteomyelitis Infection of the bone Necrosis of bone/marrow tissue Weakens the bone Risk for fractures Staph Direct contamination Open fracture with open wound Surgery Transmitted by the blood Travels to the bone

30. Acute Osteomyelitis Initial infection or infection of less then 1 month in duration Common in children Assessment General Night sweats Chills nausea Irritable Restlessness Elevated temperature Rapid pulse Dehydration Local assessment Tenderness Warmth Diffuse swelling over the bone Bone pain Unrelieved by rest Worse with activity Holds part in semi-flexion Surrounding muscle tense with resistance to passive movements Muscle spasms

31. Management Halt infection Prevent spread Possible debridement of necrotic tissue Antibiotics Big guns Pain management nutrition Complications Septicemia Meningitis Tenosynovitis Thrombophlebitis

32. Chronic Osteomyelitis Gradual progression Infection for more than 4 weeks or failure to respond to antibiotics Pus accumulation=ischemia bone=tissue forms scar tissue=avascular scar impenetrable to antibiotics Pain Worse at night Red, swollen, warm, tender Deformed bone Dusky skin Atrophied muscles

33. Medical Management Surgical removal of involved tissue Continueous closed suction wound drainage Combination antibiotic therapy Window casts Supports weakened bone Assessment of the wound Splint Comfort/support Myocutaneous flaps Bone grafting Complications Muscle contractures Septic arthritis Osteoarthritis Decreased rate of bone growth Non-union of fractures

34. Nursing Management Pain management Analgesics Non-steroidal anti-inflammatory drugs Schedule activities around medication Elevate and support Teach Avoid exercise Increased circulation may spread disease Avoid heat Maintain proper alignment/positioning Cast care

35. Amputation Removal of an extremity or part of an extremity Reasons Circulatory disorders PVD DM ASHD Traumatic injury Malignant tumors Uncontrolled infection Gangrene Severe thermal or crushing injuries Congenital deformities Auto-amputation Spontaneous separation

36. Types of Amputation Closed Flaps of muscle or tissue Disarticulation Through the joint Open Guillotine amputation Soft tissue and bone are severed at the same level Infection present Closed creates an anterior flap that is pulled over and covers the bone stumpClosed creates an anterior flap that is pulled over and covers the bone stump

37. Phantom Limb Sensation Patient feels the amputated part is still present Pain, tingling, numbness, itching, and temperature changes Several months to years

38. Phantom Pain Aching, knifelike, jabbing, throbbing, tearing, burning pain in amputated part Relief Exercise residual limb Divisional activities

39. Post- Op Nursing Care Assess for hemorrhage and infection Assess types of dressings Application of prosthesis immediately Cast/rigid dressing Elastic wrap dressing Pain Control Elevate limb for the 1st 24 hours Prevent external rotation and abduction contractures ROM Prevent edema Avoid dangling stump over bed Teach follow-up care Table 59-15 Assess drainage on the bottom and back of dressing Types of dressings: soft bandage, rigid dressings ( casts), air splint,- reduces edema and shapes the stump Elevate- intervals due to contractures Prevention of hip contractures- place on abdomen for 30 minutes 3-4 time a day External rotation prevention- Correct alignment in bed, rolled towels or sand bags when in chair prevent external rotation otherwise avoid sitting in chair Avoid pillows under stump for extended periods while prone in bed Elastic wrap prevents edema, helps shrink and shape limb, Cover all skin when wrapping, Remove and reapply wrap q4-8 H, make sure wrap is smooth and not constricting Assess drainage on the bottom and back of dressing Types of dressings: soft bandage, rigid dressings ( casts), air splint,- reduces edema and shapes the stump Elevate- intervals due to contractures Prevention of hip contractures- place on abdomen for 30 minutes 3-4 time a day External rotation prevention- Correct alignment in bed, rolled towels or sand bags when in chair prevent external rotation otherwise avoid sitting in chair Avoid pillows under stump for extended periods while prone in bed Elastic wrap prevents edema, helps shrink and shape limb, Cover all skin when wrapping, Remove and reapply wrap q4-8 H, make sure wrap is smooth and not constricting

40. Malignant BoneTumors Rapid growth with metastasizes Blood and lymph Destroys surrounding tissue Primary tumors Arise from Musculoskeletal tissue Osteosarcomas, Ewings sarcomas, chondrosarcomas, fibrosarcomas, and malilgnant fibrous histicytomas Secondary metastatic tumors Cancer spreads to the bone from another malignancy

41. Osteoporosis Metabolic bone disorder Thinning, less dense or porous bone mass Localized low-back or mid-thoracic pain from vertebral Collapse Dowager�s hump Pathogenic fractures

42. Diagnostic test X-ray Bone density Management Avoid lifting objects Straining House safety Back brace Calcium & Vit D 1000mg 1500 mg post menopause 400 IU Vit D Exercise Medication Decreases rate of bone loss Fosamax

43. Osteosarcoma Most common Rapid growth and metastases Highest in adolescent males Elderly with Paget�s disease

44. Assessment Debilitating pain unrelieved by analgesics Awaken from sleep Enlargment of affected area Restriction of movement Children Limb Curtails physical activity Unable to hold heavy objects Diagnosis Xray Soft tissue looks like a sunburst Biopsy Treatment Surgical excision Wide section from 7-10 cm beyond involved area Amputation Radiation and chemotherapy

45. Ewing�s Sarcoma Rare, highly malignant Originates in the marrow Early metatasizes Long bones, flat bones, and ribs Pulmonary involvement Age < 30 years Diagnosis X-ray

46. Assessment Pain, malaise, lethargy, and weight loss Treatment Systemic chemotherapy Two or more drugs Radiation after chemotherapy

47. Developmental Dysplasia of the Hip (DDH) Hip abnormality 10 per 1000 births Usually left hip Caucasian girls Cultural considerations Tightly wrapped blankets Carrying infants on the hips Straddle position

48. Acetabular dysplasia, subluxation, dislocation 1st slide normal hip Dysplasia delay in the development of the acetabvular osseous hypoplasia- that results in an oblique and shallow acetbalum Subluxation-incomplete dislocation of the hip femoral head remains in the acetbalum, stretch capsule will cause the femur to displace, producing a flattened socket Dislocation- femoral head is not in contact with the acetabulum 1st slide normal hip Dysplasia delay in the development of the acetabvular osseous hypoplasia- that results in an oblique and shallow acetbalum Subluxation-incomplete dislocation of the hip femoral head remains in the acetbalum, stretch capsule will cause the femur to displace, producing a flattened socket Dislocation- femoral head is not in contact with the acetabulum

49. Assessment data of DDH Infant Shortening of limb on affected side Restricted abduction of hip on affected side Unequal gluteal folds Positive Ortolani-Barlow test

50. Older infant/child Affected leg shorter Telescoping or piston mobility of joint Trendelenburg sign Prominent greater trochanter Lordosis Waddling gate

51. Therapeutic management NB-6months Pavlik harness Continuous for 3-6 months Skin traction Adduction contracture Hip spica cast 3-6 months then to a brace

52. 6-18 months After standing or walking Gradual traction Cast immobilization Abduction splint Older child Open reduction surgery

53. Nursing management Compliance with corrective devices by parents Not removed for bathing Sponge bath No powder/lotions Prevent skin irritation Cast care Diaper area

54. Congenital Clubfoot Talipes Equinovarus Feet are pointed inward and down Serial casting Immediately post birth Change cast via growth and manipulation of foot

55. Legg-Calve-Perthes LCP Self �limiting disorder Aseptic necrosis of the femoral head Age 3-12 yrs Most common 4-8 years Cause unknown Delayed skeletal maturation

56. Stages of LCP Stage I Avascular stage Aseptic necrosis of the femoral capitol epiphysis with degenerative changes producing flattening of the femoral head Stage II Fragmentation/ revascularization stage Old bone absorption and revascularization Stage III Reparative stage New bone formation Stage IV Regeneration stage Gradual reformation of the femoral head

57. Assessment Insidious onset Intermitten limping on affected side Pain Soreness, aching, Pain in hip, anterior thigh Stiffness in the morning, end of day, or after rest Limited ROM, weakness, muscle wasting Shortening of limb External hip rotation Nursing Management Reduce inflammation and restore motion Rest, avoid weight bearing on lower extremities, traction, abduction braces, leg casts, leather harness slings Objective is to keep head of femur in contact with acetabulum, serves as a mold for the femoral head Possible surgery

58. Scoliosis Lateral curvature lf the spine Seen during growth spurts of adolescents

59. Assessment One shoulder higher than the other Scapula prominences Rib prominences Chest asymmetry Uneven waist line Hems hang unevenly Screened during school at 5th grade scoliometer

60. Treatment Curve < 15-20 degrees Monitor every 3-6 months Postural exercises Curve > 24 degrees Treatment by orthopedic surgeon Curve < 40 degrees Boston Brace Milwaukee Brace Electrical stimulation Mild to moderate curvatures Causes muscle to contract at regular and frequent intervals Helps straighten spine Surgical treatment rods, and screws with fusion

61. Post Operative Care Log roll when changing position Vital signs Wound assessment Circulation assessment Assess for paralytic ileus May have N/G until bowel function returns Monitor foley Strict I & O Pain management

62. Milwaukee Brace Brace is worn 23 hours/day Brace off for show, bathe, and swim Wear T-shirt under brace Exercise Keep brace on Pelvic tilt and lateral strengthening Muscle aches in the beginning Stay active Don�t hid away from friends