Musculo-skeletal Disorders

Ms. Ruchi Saini

Strains, Sprains & Dislocations

Sprains & Strains

Most common musculo skeletal injuries

Sprain

Injury to the tendeno ligamentous structure surrounding a joint Usually caused by twisting motion Excessive stretching of muscle and its facial sheath Often involves tendons

Strain

Clinical Manifestations Sprains & Strains

Pain

Edema
Decrease in function Contusion

Management Usually self limiting Severe sprains may require suturing of the muscle & Surrounding fascia

Compress Ice Elevation of the extremity

Activity limitation

Nursing manageme nt

Analgesia

Dislocation
Severe injury of the ligamentous structure that surround a joint Results in complete displacement and separation of the articular surface of the joint

Dislocation

It is a partial or incomplete Subluxation displacement of joint surface

Dislocation

Clinical Manifestations
Deformity Pain

Tenderness
Loss of function of injured part Swelling in the soft tissue

Management Orthopedic emergency Realignment of the joint Immobilization post realignment

Relief of pain
Protectio n of injured part

Health Education

Nursing Managemen t

ROM Exercises

Rehabilitatio n

Fractures

Fractures
A fracture is a break in the continuity of the bone caused by trauma, twisting as a result of muscle spasm or indirect loss of leverage, or bone decalcification & disease that results in osteopenia. Assessment findings Pain or tenderness over the involved area. Loss of function. Obvious deformity.

Crepitation
Erythema,edema,ecchymosis Muscle spasm & impaired circulation

Fractures: Causes

Causes

Traumatic

Pathologi c

Hyper-para thyroidism

Cancer

Osteoporos is

Others

Classification of fractures according to type

Fracture Type Avulsion Description Fracture resulting from the strong pulling effect of the tendons and ligaments at the bone attachment Fracture with more than two fragments.

Comminuted

Displaced / Involves a displaced fracture fragment that is overriding fracture overriding the other bony fragment Green stick fracture Incomplete fracture with one side splintered and the other side bent. Impacted fracture Comminuted fracture in which more than two fragments are driven into each other Intra articular Fracture extending to the articular surface of fracture the bone Longitudinal An incomplete fracture in which fracture line fracture runs along the longitudinal axis of the bone

Classification of fractures according to type

Fracture Type Oblique fracture Spiral fracture Stress fracture Description Fracture in which the line of fracture extends in an oblique line Line of fracture extends in a spiral fashion along the shaft of the bone A fracture that occurs in a normal or abnormal bone that is subjected to repeated stress Line of fracture extends across the bone shaft at right angle to the longitudinal axis of the bone Spontaneous fracture at the site of a bone disease

Transverse fracture

Pathological fracture

Edema and swellin g Crepetitio n

Pain & tenderne ss

Loss of functio n

Manifestatio n

Muscle spasm

Ecchymosis /contusion

Deformity

Pain & Swelling

Phases of Fracture Healing

Fracture hematoma Granulation tissue Callus formation

Ossification
Consolidation

Remodeling

Healing in the bone

Healing in the bone cont..

Callus tissue formation

Fracture Healing

Age
Initial displacem ent

Infections

Factors affecting fracture healing

Implants

Blood supply to the area Immobili ze

Complications of fracture healing

Problem Delayed union Non union Mal union Angulations Description Healing progresses more slowly than expected ; healing eventually occur Fracture fails to heal properly despite treatment resulting in fibrous union or pseudo arthrosis Fracture heals in expected time but in unsatisfactory position, possibly resulting in deformity or dysfunction Fracture heals in abnormal position in relation to midline of structure

Pseudo arthrosis Type of non union occurring at the fracture site in which false joint is formed on shaft of long bone. It is a fracture site that has failed to fuse. Each bone end is covered with fibrous scar tissue Refracture Myositis ossificans New fracture occur at original fracture site Deposition of calcium in muscle tissue at the site of significant blunt muscle trauma or repeated muscle injury

Diagnosis
History and physical examination
X-ray CT- scan and MRI

Emergency Management
Etiology BLUNT Motor vehicle collision , Pedestrian event Falls, direct blows, Forced extension / flexion Assessment finding Deformity Edema/ Ecchymosis Muscle spasm Tenderness/ pain Loss of function numbness, tingling, loss of peripheral pulses Grating Open wound, exposure of bone Interventions INITIAL 1. Treat life threatening injuries first 2. Ensure ABC 3. Control bleeding, Splint joints 4. Check neurovascular status before and after splinting 5. Elevate limb if possible 6. Do not attempt to straighten/ manipulate protruding bone/dislocated limb 7. Apply icepack, Get X ray, Administer TT

PENETRTING Gunshot blast OTHERS Pathologic conditions Violent muscle contractions

ONGOING ASSESSMENT 1. Monitor vitals, LOC, SpO2,neurovascular status, pain 2. Assess for compartment syndrome, embolism

Splinting

Collaborative therapy
Fracture reductio n
Manipulation Closed reduction Traction devices Open reduction /internal fixation

Fracture immobili zation

Casting/ splinting Traction Internal fixation External fixation

Open fractures

Surgical debridement and irrigation TT/DT immunization Prophylactic anti biotic therapy Immobilization

Fracture reduction
Closed reduction
Non- surgical manual realignment of bone

fragments to their previous anatomic position

Under LA /GA
After reduction, traction, casting, external

fixation, splints or orthosis to immobilize

the part to maintain alignment

Fracture reduction cont..

Open reduction : Correction of bone alignment

through a surgical incision. Usually involves internal fixation of the fracture by using wires, screws, pins, plates, intramedullary rods or plates Disadvantages: Infection, Complications of anesthesia, Effects of pre-morbid diseases. ORIF Facilitates early ambulation Promotes fracture healing

Traction
Application of a pulling force to any of the

extremity Counter traction pulls in the opposite direction Purposes : prevent or reduce muscle spasm Immobilization Reduce a fracture/ dislocation

Traction cont..
Skin traction
Short term (48-72 hrs)

Skeletal traction
Long term

2.3-4.5 kg

2-20 kg

Tapes, boots , splints Skin excoriation

Pins, wires

Infections, prolonged immobility

Skin traction

Skin traction

Skeletal traction

Casts
Temporary circumferential immobilization device Common treatment following closed reduction Material of cast : PoP, synthetic acrylic, latex free

polymer
Incorporates joint above and below fracture Types :

Short arm cast, Long arm cast, Body jacket cast,

Single hip spica, Double hip spica, Long leg cast, Short leg cast

External fixation
An external fixator is a metallic device composed of metal pins that are inserted into the bone and attached to external rods to stabilize the fracture while it heals. Uses : To apply traction To compress fracture fragments Immobilization Salvage of limb Indications: Extensive soft tissue damage Correction of bony defects Non/ Mal union Limb lengthening

External fixation -Tools

Internal Fixation
Devices (biologically inert metal )
Pins, Plates, intra-medullary rods, metal and bio-

absorbable screws
Devices surgically inserted

Others
Drug therapy Pain management Involuntary reflexes(edema/ nerve injury ) Central/ peripheral muscle relaxants TT/DT Prophylactic antibiotics Nutritional Management Protein : 1 gm /kg BW Vitamins :Especially B,C,D Calcium , Phosphorous, magnesium Fluid intake : 2- 3 liter/ day Small meals for body casts

Nursing Management
Nursing management

NURSING ASSESSMENT SUBJECTIVE DATA Important health information Past health history: traumatic injury , long term repetitive forces, bone/ systemic disease, prolonged immobility, osteoporosis Medications :use of corticosteroids, estrogen replacement therapy Surgery or other treatment :first aid treatment of fracture, previous musculoskeletal surgeries Cognitive perceptual :sudden and severe pain in the affected area, numbness, tingling, loss of sensation ,loss of sensation distal to the injury chronic pain which increases with activity

NURSING ASSESSMENT

OBJECTIVE DATA General :apprehension , guarding of injured site Integumentary : skin lacerations , pallor and cool skin or bluish and warm skin distal to injury , Ecchymosis, hematoma, edema at the site of the injury Cardiovascular :reduced or absent pulses distal to the injury , decreased temperature, delayed capillary refill Neurovascular : parasthesias, absent or decreased sensation , hyper sensation Musculoskeletal :restricted or lost function of the affected part ; local bony defects, abnormal angulations , shortening, rotation or Crepetition of affected part muscle weakness

NURSING DIAGNOSIS
Impaired physical mobility related to loss of integrity of bone structures, movement of bone fragments, soft tissue injury, and prescribed movement restrictions.

Ineffective therapeutic regimen r/t lack of knowledge regarding muscle atrophy, exercise programme, care of cast and external immobilizers
Risk for peripheral neuro vascular dysfunction related to vascular insufficiency and nerve compression Acute pain related to edema , movement of bone fragments, and muscle fragments

Nursing implementation
Health promotion Safety precautions for public

Reduce falls(elderly )

Acute interventions
Preoperative management Pre-op preparation

Skin preparation
Post operative management
Vitals monitoring Neurovascular assessment

w/f bleeding

Pain and discomfort Mx

Post op management

Aseptic technique

Nursing interventions
Other measures: Prevention of complication R/T immobility

Constipation
Renal calculi CV complications

DVT prophylaxis

Nursing intervention -Care of traction

Inspection of exposed skin
Pin site care Proper alignment

Promote patient activity

ROM exercises Deep breathing

cast
DO NOT
Get plaster cast wet Remove any padding, Insert any object inside the cast Bear weight on new cast for 48 hrs Cover cast for prolonged periods DOS Elevate extremity for 48 hrs Dry cast thoroughly blow dry Move joints above and below the cast regularly REPORT THE FOLLOWING Increasing pain Swelling with pain and discoloration Pain, burning and tingling under cast Sour and foul odor under cast

Nursing intervention-Rhabilitation

Complications
Compartment syndrome Infection DVT Fat embolism

Compartment Syndrome
Elevated intra-compartmental pressure within a confined myo-fascial compartment.

Reduced Capillary perfusion below a level necessary for tissue viability

Compromised the neuro-vascular function of tissues within that space

Compartment Syndrome.
Causes: Restrictive Dressings, Splints, casts, excessive traction, Premature closure of fascia Bleeding Edema Chemical response to snake bite IV infiltration Risk Factors: Trauma Fractures Extensive soft tissue damage Crush injury Reperfusion syndrome Severe burns Knee or Leg surgery

Compartment Syndrome.
Clinical Manifestations 6 Ps 1. Paresthesia: Numbness & Tingling 2. Pain: Distal to injury, not relieved by opioids analgesics & pain on passive stretch of muscle travelling through the compartment 3. Pressure: Increases in the compartment 4. Pallor, coolness, loss of normal color of extremity 5. Paralysis or loss of function 6. Pulselessness or diminished/absent peripheral pulses Myoglobinuria: Dark reddish-brown urine, C/M associated with Acute Renal Failure

Compartment syndrome Management: Fasciotomy

Infection & Osteomyelitis

Infection & osteomyelitis can be caused by the interruption of the integrity of the skin; the infection invades bone tissue.

Clinical Manifestations
Fever & Pain Erythema in the area surrounding the fracture Tacchycardia Elevated white blood cell count

Interventions
Notify the physician. Prepare to initiate aggressive IV antibiotic therapy.

Deep Vein Thrombosis

Formation of thrombus in the veins of lower extremities and pelvis.

Precipitating Factors: Inappropriately applied casts or traction Local pressure on a vein Immobility
Clinical Manifestations: Pain and Swelling in the involved extremity Management: Wearing compression stockings Isometric exercises of the fingers, toes and affected exercises ROM Exercises

Fat Embolism
Fat embolism is characterized by the presence of systemic fat globules from fractures that are distributed into the tissues and organs after a traumatic skeletal injury. Occurs within 12-72 hours of injury Risk Factors: Fracture of long bones ribs, tibia, pelvis Total joint replacement surgeries Spinal fusion

Liposuction
Crush injuries Bone marrow transplantation

Fat Embolism.
Clinical Manifestations Signs & Symptoms of ARDS: Chest Pain, Tachypnea, Cyanosis, Dyspnea, Apprehension, Tachycardia, Decreased PaO2 to less than 60 mmHg Memory loss Restlessness & Confusion Petechial Rash over upper chest & neck Elevated temperature and Headache

Investigations:
Fat cells in blood, urine & sputum; ST-segment changes on ECG; Decreased platelet count & hematocrit levels, Prolonged prothrombin time; Pulmonary infiltrates on Chest X-Ray

Fat Embolism.
Management Prevention: Careful immobilization of the long bone fracture Supportive: Fluid resuscitation

Correction of acidosis
Replacement of blood loss Oxygen administration through mask or mechanical ventilation Coughing and Deep breathing

Amputation

Amputation
Surgical removal of all part of a limb Two types of amputation: 1. Closed(flap)-myoplastic: Residual limb is covered by a flap of skin. Flap of skin is sutured posteriorly, common technique in vascular diseases 2. Open(guillotine): Used with infection & who are prone to surgical risks. Wounds heals by granulation or secondary closure in a week.

Amputation
Clinical Indications Circulatory impairment resulting from peripheral vascular disorder Traumatic and Thermal Injuries Malignant tumors Uncontrolled & Widespread infection of the extremity Congenital disorders

Clinical Manifestations Pain Loss of sensation Pallorness Local or systemic manifestations of sepsis

Amputation
Diagnostic History and Physical Examination

Physical Appearance of soft tissues

Skin temperature Sensory Function

Presence of peripheral pulses

Arteriography Venography Plethsymography Transcutaneous ultrasonic Doppler recordings

Amputation: Collaborative Therapy

Medical Appropriate management of underlying disease Stabilization of trauma victim Surgical Selective type of amputation Residual limb management Immediate prosthetic fitting Delayed prosthetic fitting

Rehabilitation Coordination of prosthesis-fitting and gait training Coordination of muscle-strengthening and physicaltherapy regimens

Joint Surgeries

What is Joint Replacement ?

Joint replacement is a surgical

procedure in which the joint is replaced after

the degeneration of the joint.

Joints frequently replaced include the hip, knee, shoulder, elbow, wrist, and ankle and finger joints.

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Types of joint implants

Cemented

Non-cemented

implants

implants

We will study

Total Hip replacement (THR)

Total Knee replacement (TKR)

TOTAL HIP REPLACEMENT (THR)

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HIP JOINT- Anatomical Overview

The hip joint consists of
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Pelvis Socket Femur Head (Ball) Neck Articular Cartilage

Total Hip Replacement

The total hip arthroplasty or replacement is performed to restore joint motion by replacing arthritic bone with metal components.

The modular prosthetic hip replacement system used today has three components the femoral stem, the femoral head, and the acetabulum. Each component has multiple sizes which allow for a custom fit.

Total Hip Replacement (Contd..)

The components are made of cobalt chrome

stainless steel and ultra high molecular weight polyethylene. Cementless and cemented prosthesis systems are available.
First performed in 1960. Since then, improvements in joint replacement

surgical techniques and technology have greatly increased the effectiveness of this surgery.

Indications
Osteoarthritis

Indications.
Rheumatoid arthritis Traumatic arthritis

Indications.
Fracture Other s Failure of previous reconstructive surgeries (Failed prosthesis, osteotomy, femoral head replacement) Problems resulting from congenital hip diseases.

Contra-indications

Recent or active joints sepsis Inability to co-operate with immediate post-

operative requirements rehabilitation Poor clients general health

or

long-term

Hip Prosthesis

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Surgical Technique
1. Removing the

femoral head

2. Reaming acetabulum

the

Operation (contd..)
3. Inserting Acetabular Component the 4. Preparing Femoral Canal the

Operation (contd..)
5. Inserting Stem Femoral 6. Attaching Femoral Head the

Operation (contd..)
7. The Completed Replacement Hip

TOTAL KNEE REPLACEMENT (TKR)

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KNEE JOINT Anatomical Overview

Knee joint consists of : Femur Patella Ligament Tibia
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Fibula

Total Knee Replacement

Total knee arthroplasty or replacement , allows resurfacing of the arthritic joint with the use of metal and polyethylene metal prosthetic components. The surgeon attempts to recreate the motions of flexion, extension, rotation, abduction, and adduction that may have been lost with progressive arthritis.
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Indications
Osteoarthritis Cartilage defects Ligament tears

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Contra-indications
Clients 65 years of age and older Clients with weight 200 pounds and more Conditions such as diabetes mellitus and peripheral vascular disorders.

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Knee Joint And Prosthesis

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Surgical Technique
1. 2.

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Surgical Technique.
3. 4.

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Surgical Technique.
5. 7.

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Surgical Technique.
8. 9.

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Total Knee Replacement: After Surgery

The incision is closed The patient is sent to recovery

Physical therapy begins

day 1

post-op
Discharge
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from

the

hospital in

NURSING MANAGEMENT

ASSESSMENT
Pain localized region in hip Gait pattern Exaggerated gait pattern (limp) Increase in pain when weight-bearing Reduction in the degree of ROM As the degeneration of the joint worsen, individual may be awakened at night with pain
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Muscle atrophy
Active Range Of Motion

Passive ROM
X-ray clear degeneration of the bone

MRI determines underlying complications (e.g.avascular necrosis)

Bone spurs may occur

Pre-operative phase Post-operative phase Rehabilitative phase

Pain: Hip/Knee

Knowledge deficit

Pre-operative phase

Pain : hip/knee
0 1 2 3 4 5 6 7 8 9 10 no terrible Desired outcomes pain pain Verbalization of reduction of pain. Relaxed facial expression and body positioning. Increased participation in activities. Stable vital signs.

Knowledge deficit
Desired outcomes Verbalize an understanding of usual preoperative and postoperative care and routines.
Demonstrate the ability to

perform techniques designed to prevent postoperative complications.

Pain

Potential complication s

Impaired skin integrity

Potential for trauma

Potential for infection

Pain : hip/knee
0 1 2 3 4 5 6 7 8 9 10 no terrible Desired outcomes pain pain Verbalization of reduction of pain. Relaxed facial expression and body positioning. Increased participation in activities. Stable vital signs.

Impaired skin integrity

Surgical incision
Impaired wound healing Irritation and breakdown

Desired outcomes Experience normal healing of the surgical wound Maintain skin integrity as evidenced by absence of redness and irritation and no skin breakdown

Potential for infection

Introduction of the organisms into the wound

during and after the surgery. Tissue necrosis Hematoma formation Desired outcomes Absence of chills and fever. Absence of redness, warmth and swelling around incisions or open wound Usual drainage from the wound. WBC count returning to the normal. Negative cultures of the wound drainage.

Potential for trauma

Weakness,

fatigue and orthostatic hypotension Weakness and pain in the weight bearing extremity Improper transfer or ambulation techniques.

Desired outcomes
The client will not experience falls.

Potential complications
Shock Neuro-vascular damage Dislocation of prosthesis Fat embolism Thrombo-embolism Contractures

Shock
Asses

for following:

and

report

the

Excessive wound drainage

Persistent vomiting
Difficulty

maintaining oral or intravenous intake Significant decline in RBC, Hct, Hb levels, PT and aPTT more than 2 times the control Signs and symptoms of the

Neuro-vascular damage
Assess for and report signs and symptoms Diminished or absent pedal pulses. Capillary refill time in toes greater than 3

seconds. Pallor, blanching, cyanosis or coolness of the extremity. Inability to flex or extend the toes. Numbness or tingling in the foot or toes. Pain in foot during passive motion of the toes or foot. Significant internal or external (10) rotation of the extremity.

Dislocation of prosthesis
Assess and report signs and symptoms Sudden, severe hip/knee pain followed by

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continued pain and muscle spasms during hip movement Palpable bulge over femur head Abnormal rotation of operative leg Inability to move or bear weight on operative leg, Shortening of operative leg Decline in neurovascular status in operative leg.

Fat embolism
Assess for the signs and symptoms : Restlessness Apprehension Confusion Sudden onset of chest pain, tachypnea, pallor with subsequent elevated temperature Pulse, petechiae on buccal conjunctival sac , face, neck (petechiae are late sign) 114 Low PaO2 level.

dyspnea, cyanosis, mucosa, or chest

Thrombo-embolism
Assess for symptoms
Tenderness

signs

and

or

pain

in

extremity Increase in the circumference of calf and thigh Usual warmth or redness of the extremity 115 Positive homans sign.

Contractures

Assess for and report

Limitations in range of motion (cannot be assessed for first 2-3 days because of position and movement restrictions)
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HEALTH TEACHING

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DOS
Keep operative leg in proper alignment and avoid rotating hip and knee. Turn only as directed by the physician (many physicians allow turning to un operative side only and instruct client to keep pillows between legs while on side).

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DOS
Elevate operative extremity TKR.

after

Sit in chairs with arms and utilize arms to raise self from chair.
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DOS
Support weight on unoperative leg when raising self from a sitting position.
Reinforce physician instructions about amount of weight bearing on operative extremity
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DOS
Reinforce instructions about correct transfer and ambulation techniques and proper use of walker, quad cane or crutches. Reinforce importance of continuing prescribed exercises for at least a year.
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Exercise ( Earlier stages)

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Exercise ( Later stages)

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DONTS
Do not turn the operated leg inward

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DONTS
Do not sit with cross legs. Do not sit for more than 1 hour at a time. Do not reach to the end of the bed to pull covers up. Do not put on shoes or 126 socks without using an

DONTS
Do not sit on low chairs, stools or toilet seats, place a cushion on low chairs, purchase a raised toilet seat for home use and use high toilets for handicapped when in public facilities.
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Preparation of Home
Make modifications to your home prior to surgery that will decrease your risk for falls or injury

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 Move electrical and telephone cords away from walkways Use chairs with arm rests Avoid low chairs/sofas surface

Remove throw rugs or use skid resistant backing 129

 Install stable handrails on both sides of the stairs.

Stairs and hallways should be brightly lit.

Floor should be skidfree.

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 Install grab bars in the bathtub Install skid resistant strips or a rubber mat both in and in front of the bathtub
Recommend raised toilet seat
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 Have a lamp and phone within reach of the bed

Keep a clear path from the bedroom to the bathroom

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Always sit while getting dressed

 Store frequently used items at waist level and less frequently used items in higher cabinets

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