Nursing Management: Musculoskeletal Problems

George Ann Daniels, MS, RN

Musculoskeletal Injuries• Contusion

– Damage to soft tissue , sub-q structures, and muscle

• Strains– Tear to the

musculotendinous unit• Sprains

– Trauma to joint, ligament may be completely torn or stretched

• Dislocation– Displacement of the normal

position

• 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

Carpal Tunnel Syndrome

• Compression of the medial nerve under the carpal ligament in the wrist

• Causes: trauma/edema, tumors, ganglion, excessive use wrists

Assessment of Carpal Tunnel

• Weakness, pain, tingling, numbness night and day– Paresthesia thumb, forefingers, and middle

finger• Phalen’s sign• EMG

Surgical Repair

Management

• Wrist splints• Special keyboard pads• Avoid aggravating action

– Occupational change

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

Types of fractures

Healing times

• Neonatal period– 2-4 weeks

• Early childhood– 4 weeks

• Later childhood– 6-8 weeks

• Adolescence– 8-12 weeks

Fracture Treatment

• Splint Immediately• Traction

– Realignment– Skin or skeletal

• Closed Reduction• Open Reduction

– ORIF- Open reduction internal fixation

• External Fixation– Page1776

Types of Casts

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

Cast Care

• Table 59-9• Cast Removal

– Cast cutter

Complication of Cast Therapy

• Impaired circulation• Pressure areas• Skin lesions

– Drainage• Nerve damage• Tissue necrosis

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

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

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

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

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

• 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

Hip Fractures

• Types– Intracapsular

• Subcapital-(A)• Transcervical-(B)• Basilnar neck

– Extracapsular• Intertronchanteric (C)

– Between greater and lesser trochanter

• Subtrochanteric– Below trochanter

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

Surgical Interventions

Avascular Necrosis

• Necrosis of bone/intra-articular structures– Lack of circulation

• Misalignment, Fracture thrombus, constriction from device

• Ischemic bone becomes necrotic– collapse

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

Home Teaching Hip FractureTable 59-11

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

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

• Management– Halt infection– Prevent spread– Possible debridement of necrotic tissue– Antibiotics

• Big guns

– Pain management– nutrition

• Complications– Septicemia– Meningitis– Tenosynovitis– Thrombophlebitis

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

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

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

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

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

Phantom Limb Sensation

• Patient feels the amputated part is still present– Pain, tingling, numbness, itching, and

temperature changes– Several months to years

Phantom Pain

• Aching, knifelike, jabbing, throbbing, tearing, burning pain in amputated part

• Relief– Exercise residual limb– Divisional activities

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

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

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

• 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

Osteosarcoma

• Most common• Rapid growth and

metastases• Highest in adolescent

males– Elderly with Paget’s

disease

• 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

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

• Assessment– Pain, malaise, lethargy, and weight loss

• Treatment– Systemic chemotherapy

• Two or more drugs

– Radiation after chemotherapy

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

Acetabular dysplasia, subluxation, dislocation

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

• Older infant/child– Affected leg shorter– Telescoping or piston

mobility of joint– Trendelenburg sign– Prominent greater

trochanter– Lordosis– Waddling gate

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

• 6-18 months– After standing or walking– Gradual traction

• Cast immobilization– Abduction splint

• Older child– Open reduction surgery

Nursing management

• Compliance with corrective devices by parents– Not removed for bathing

• Sponge bath• No powder/lotions

• Prevent skin irritation• Cast care

– Diaper area

Congenital Clubfoot

• Talipes Equinovarus– Feet are pointed

inward and down

• Serial casting– Immediately post birth– Change cast via

growth and manipulation of foot

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

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

• 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

Scoliosis

• Lateral curvature lf the spine

• Seen during growth spurts of adolescents

• 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

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

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

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