MUSCULOSKELETAL SYSTEM

Review of Anatomy and Physiology

The musculo-skeletal system consists

of the muscles, tendons, bones and cartilage together with the joints The primary function of which is to produce skeletal movements

Muscles
Three types of muscles e ist in the body !" #keletal Muscles
$oluntary and striated

%" &ardiac muscles

'nvoluntary and striated

(" #mooth)$isceral muscles

'nvoluntary and *+*-striated $isceral, plain muscles

Muscle Types: 2. Skeletal Muscle accounts for at least ,-. of body mass aids in the formation of the smooth contour of the body Parts/ !"! 0pimysium Tough connective tissue covering of the entire muscle" 't binds many fascicles together" Tendon)Apponeurosis / blending of the epimysia !"% Perimysium 1ibrous membrane covering several sheathed muscle fibers 1ascicles 2 are bundles of muscle fibers covered by perimysium"

#keletal Muscle &haracteristics/ $oluntary control 3but can also be activated by refle es4 354 #triations Multinucleated #hape/ &ylindrical #peed of contraction/ $ariable

Smooth Muscle 1ound mainly in the walls of hollow visceral organs such as the stomach, urinary bladder and respiratory passages" propels substances along a definite tract, or pathway, within the body" #mooth Muscle &haracteristics/ 'nvoluntary control 3-4 #triations6 no distinct sarcomeres 7ninucleated #pindle-shaped #peed of &ontraction/ slow and sustained6 does not develop an o ygen debt
2.

#mooth muscle

3. Card ac Muscle

1ound only in the heart 3cardiac4" 8eart 2 serves as a pump, propelling blood into the blood vessels and to all tissues of the body" &ardiac fibers are cushioned by small amounts of soft connective tissue and arranged in spiral or figure 9-shaped bundles" &ardiac Muscle &haracteristics/ 'nvoluntary control 354 #triations Multinucleated :ranched #peed of contraction/ $ariable

Muscle !u"ct o"s: %4 Production of movements)locomotion (4 Maintenance of posture ,4 ;oint stabili<ation =4 >enerating heat ?4 0nergy production

S m lar t es o# all Muscle Types: c4 All muscle cells are elongated 3this e plains the term muscle fibers4 d4 Muscle contractions depends on the types of myofilaments 3thin and thick myofilaments4 e4 Terminology 3prefi ed/ myo, mys, @ sarco4

M croscop c A"atomy o# Skeletal Muscle

!" #arcolemma Plasma membrane of skeletal muscle cells" (" Myofibrils Aong ribbon like organelles, pushing the nuclei aside Alternating dark 3A4 and light 3'4 bands along the length of the myofibrils, give the muscle cell 3as a whole4 a striated appearance"

M croscop c A"atomy o# Skeletal Muscle

(" #arcomere 1unctional unit of a muscle" These are chains of contractile units of myofibrils" ," #arcoplasmic Reticulum #urrounds individual myofibrils #peciali<ed smooth endoplasmic reticulum" Major function/ storage and release of calcium during muscular contraction"

SA$COME$E% #u"ct o"al u" t o# the muscle& e'te"ds #rom o"e (%

l "e to a"other (%l "e % ma "ly composed o# act " ) myos " myo# lame"ts

(%d sk or (%l "e * a"chors the act " myo# lame"ts M%l "e* holds the myos " # lame"ts " place

Muscle Physiology
St mulat o" a"d Co"tract o" o# a S "+le Skeletal Muscle Cell { !u"ct o"al ,ropert es o# Muscle ! -ers: !" 'rritability 2 ability to react and respond to stimulus %" &ontractility 2 ability to shorten when stimulated by adeBuate stimulus { The .er/e St mulus a"d Act o" ,ote"t al !" Motor 7nit - single motor neuron and all of the corresponding muscle fibers it innervates"

#C0A0TAA M7#&A0/
AM* control 0nergy is consumed during muscle

contraction 2 AA&T'& A&'D 3O2) MUSCLE FATIGUE:

work of muscle wit i!"#e$u"te O2 su%%l& 'e%letio! of (l&co(e! ) e!er(& stores Accumul"tio! of l"ctic "ci#

#tructure and function of the skeletal system

#keletal system consist of A ial and

Appendicular skeleton" A ial #keleton- which is composed of bones of the skull, thora and vertebral column which forms the a is of the body" Appedicular #keleton- consist of bones of the upper and lower e trimities, including the hip and the shoulder"

Two types of connective tissue found in the skeletal system %" &artilage 2 a semi-rigid and slightly fle ible structures that plays an essential role in prenatal and childhood development of the skeleton and as a surface for the articulating ends of the skeletal joint" (" :ones 2 which provide the firm structure of the skeleton and serve as reservoir for calcium and phosphate

Three types of cartilage

0lastic &artilage- &ontain some elastin in

each intracellualr substance" 3 ears4 8yaline &artilage- Pearly white, found in the articulating ends of the bones" - form the fetal skeleton " 1ibro cartilage- has a characteristic that are intermediate between dense connective tissue and hyaline cartilage" 't is found in the intervertebral disks, in areas where tendons are connective to bone and in the symphysis pubis" - ?=-9-. are water"

 :one- is a connective tissue in which

the intracellular matri has been impregnated with inorganic calcium salts so that it has a great tensile and compressible strength but is light enough to be move by coordinated muscle contractions"

:+*0#
$ariously classified according to shape, location and si<e 1unctions !" Aocomotion %" Protection (" #upport and lever ," :lood production =" Mineral deposition

:one is made up of four major components/

mineral 3mainly calcium and phosphorus4 matri 3collagen fibers4 osteoclasts 3bone-removing cells4 osteoblasts 3bone-producing cells4"

+steocytes 3 mature bone cells for bone maintenance f ns4

 ,E$0OSTEUM: E,0,1YS0S:

#C0A0TAA #E#T0M/ :+*0 #TR7&T7R0

Dense fibrous membrane covering the bone Periosteal vessels supply bone tissue Fidened area at the end of the long bone

E,0,1YSEAL ,LATE 2+ro3th 4o"e5

&artilage area in children w)c provides for

longitudinal growth of the bone

A$T0CULA$ CA$T0LA6E:
Provides smooth surface over the ends of the

bone to facilitate joint movement

Type of bone cell

+steogenic cells- 7ndifferentiated

cells that differentiate into osteoblasts" They are found in the periosteum, endosteum, and epiphyseal growth plate of growing bones" +steoblasts- :one building cells that synthesi<e and secrete the organic matri of bone" 't also participate in the calcification of the organic matri "

 +steocytes- Mature bone cells that

function in the maintenance of bone matri " +steocytes also play an active role in releasing calcium in the blood " +stroclasts- :one cells responsible for the resorption of bone matri and the release of calcium and phosphate from bone"

#C0A0TAA #E#T0M/ :+*0 #TR7&T7R0

R0D :+*0 MARR+F/
8emopoietic tissue located in the central

bone cavities" Adults/ ribs, sternum, vertebrae, portions of hips @ pelvic bones Aong :ones filled with fatty, yellow marrow 17*&T'+*#/
1ormation of R:&, F:& @ platelets Destruction of old R:& 3phagocytosis4

:+*0 1+RMAT'+* 3+steogenesis4

+##'1'&AT'+*
Process by which matri

3collagen fiber @ ground substance4 is formed @ hardening minerals are deposited on collagen fibers 3give tensile strength4

0*D+&8+*DRAA
+steoid 3cartilage-like tissue4 is formed,

reabsorbed, @ replaced by bone

'*TRAM0M:RA*+7#
:one develops within membrane 3e"g" face,

skull4

:+*0 MA'*T0*A*&0 @ 80AA'*>/

R0>7AAT+RE 1A&T+R# D0T0RM'*'*>

:+T8 1+RMAT'+* @ R0#+RPT'+*/

!" 7e +ht%-ear "+ 2local stress5 %" 8 tam " 9 2Calc trol5 promotes

absorption of calcium from >'T (" ,arathyro d 1ormo"e regulates calcium ," Calc to" " ) Am "o - phosphate 3e"g" Alendronate G1osama H4 increases production of bone cells

:+*0 MA'*T0*A*&0 @ 80AA'*>/

!" 7e +ht%-ear "+ 2local stress5

#timulate bone formation @ remodelling Prolonged bed rest/ bone losses calcium

3resorption4 @ becomes osteopenia @ weak %" : olo+ cally Act /e 8 tam " 9 2Calc trol5 "mou!t of C" i! *loo# *& %romoti!( "*sor%tio! of C" from GIT F"cilit"tes mi!er"li+"tio! of osteoi# tse 'eficie!c& c"use *o!e #emi!er"li+"tio!, #eformit& ) fr"cture

:+*0 MA'*T0*A*&0 @ 80AA'*>/

(" ,arathyro d 1ormo"e

2parathormo"e5
regulates calcium in blood in part by

promoting movIt of &a from the bone C" i! *loo# - .T/ %rom%t #emi!er"li+"tio! of t e *o!e ," Calc to" " ) Am "o - phosphate 3e"g" Alendronate G1osama H4 increases production of bone cells &alcitonin- inhibits release of calcium from the bone into the e tracellular fluid and reduces the renal tubular reabsorptionof

Parathyroid hormone
Parathyroid gland
:one 2 release of &a and phosphate &alcium concentration in the e tracellular fluid 'ntestine Reabsorption of &a via activated Cidney reabsorption of &alcium 7rinary e cretion of Phosphate Activation of $it"D

:+*0 MA'*T0*A*&0 @ 80AA'*>/

Estro+e" ) A"dro+e"
#timulate osteoblastic activity @ inhibit PT8 Menopause)Andropause 2 C" - *o!e loss - osteo%orosis

A"dro+e"%testostero"e
.romote "!"*olism *o!e m"ss 0#TR+>0*-'t appears that oestrogen

deficiency allows greater e pression of these cytokines, all of which are associated with increased stimulation of bone resorption which then leads to increased bone loss and a reduction in :MD"

 Androgens Androgens, like oestrogens,

can directly affect and modulate bone cell function" Androgen receptors are found on osteoblast cell lines and they can cause osteoblast proliferation" 8ypogonadal men, in common with postmenopausal women, have decreased calcium absorption and low vitamin D levels" The replacement of androgens with testosterone can correct these abnormalities, suggesting again that se hormones are reBuired for the maintenance of bone health"

:+*0 80AA'*>/
STA6E ;. 1EMATOMA !O$MAT0O. )

0.!LAMMAT0O.

Fhen bone is damaged or injured, hematoma precedes new

tissue formation in the production of new bone substance

STA6E 2. CELLULA$ ,$OL0!E$AT0O.:

>ranular tissue formation where :$ @ cartilage overlie the

fracture &allus forms as minerals are deposited to organi<e new network for the new bone

STA6E 3. ,$ECALLUS !O$MAT0O.: 22%< 3ks5

&allus forms the initial clinical union of the bone @ provides

enough stability to prevent movement when bones are gently stressed

STA6E =. CALLUS !O$MAT0O.:

&onsolidation @ Remodelling 3complete healing- (-?months4 &ontinued bone healing provides for gradual return of the

injured bone to its pre-injury shape @ structural strength

:one healing

1A&T+R# A110&T'*> T'M0 R0J7'R0D 1+R 80AA'*>/

!" %" (" ," ="

age displacement site of fracture nutritional level blood supply to the area of injury

;+'*T#
Permits bone to

change position @ facilitate body movIt Diarthrodial 3synovial4 joint is the most common type of joint in the body

joints

joints

joints

;oints

joint

joints

&ART'AA>0 3hyaline4
A dense connective tissue that consists of fibers embedded in a strong gel-like substance that cover the end of the bone

&ART'AA>0
A$T0CULA$ CA$T0LA6E
Rigid, connective, avascular tissue that

covers each bone ends Damaged cartilage heals slowly 3lacks direct blood suply4

:7R#A0
#ac containing fluid that are located around the joints to prevent friction

 A fibrous capsule of connective tissue

joins the % bones together

!" SY.O80UM 2sy"o/ al mem-ra"e5 Aines the capsule %" SY.O80AL !LU09 #ecreted by the synovium @ decreases friction by lubricating the joints

T0*D+*# 3aponeurosis4
:ands of fibrous connective tissue that tie -o"es to muscles

A'>AM0*T#
#trong, dense and fle ible bands of fibrous tissue connecting -o"es to a"other -o"e

A##0#M0*T +1 T80 M7#&7A+#C0A0TAA #E#T0M

The "urse usually

e/aluates th s small part o# the o/er%all assessme"t a"d co"ce"trates o" the pat e"t>s posture? -ody symmetry? +a t a"d muscle a"d @o "t #u"ct o"

 ;. 10STO$Y

A##0#M0*T +1 T80 M7#&7A+#C0A0TAA #E#T0M

0"@ury? sur+ery? d sa- l ty? "#lammatory A

meta-ol c co"d t o"s !am l al pred spos t o" Le/el o# "ormal act / ty 2occupat o"? e'erc se? recreat o"5

2. ,hys cal E'am "at o"

0"spect o" #or +ross de#orm t es?

asymmetry? s3ell "+? edema .utr t o"al status: 3e +ht? -ody #rame

 6a t 3Antalgic46 >enu $algum 3Cnock

A##0##M0*T +1 T80 M7#&7A+-#C0A0TAA #E#T0M

Cnee4, >enu $arum 3:ow-Aegged4 ,osture 3Cyphosis)Aordosis)#coliosis4 Muscular palpat o" Bo "t palpat o" 2Crep tus%+rat "+ sou"d5 $a"+e o# mot o" Muscle stre"+th

Assessment 1indings
< ,>s o# .EU$O8ASCULA$

9AMA6E S3ell "+ Loss o# #u"ct o" 9e#orm ty Crep tus

a " a ulseless llo "ess aresth es a araly s s o k lothe

A##0#M0*T +1 T80 M7#&7A+#C0A0TAA #E#T0M

LA:O$ATO$Y ,$OCE9U$ES ;. :O.E MA$$O7 AS,0$AT0O.
Usually "/ol/es asp rat o" o# the

marro3 to d a+"ose d seases l ke leukem a? aplast c a"em a Usual site is the sternum and iliac crest Pre-test: Co"se"t Intratest: .eedle pu"cture may -e pa "#ul Post-test: ma "ta " pressure dress "+ a"d 3atch out #or -leed "+

A##0#M0*T +1 T80 M7#&7A+#C0A0TAA #E#T0M

AA:+RAT+RE PR+&0D7R0# %" Arthroscopy
A d rect / sual 4at o" o# the @o "t

ca/ ty Pre-test: co"se"t? e'pla"at o" o# procedure? .,O Intra-test: Sedat /e? A"esthes a? "c s o" 3 ll -e made Post-test:
ma "ta " dress "+? am-ulat o" as soo" as a3ake? m ld sore"ess o# @o "t #or 2 days? @o "t rest #or a #e3 days ) ce appl cat o" to rel e/e d scom#ort

A##0#M0*T +1 T80 M7#&7A+#C0A0TAA #E#T0M

%" A$T1$OSCO,Y % &"' for pt who cannot fle K ,-L and with infected knee 7ses large pneumatic tourniBuet to minimi<e bleeding Apply dressing, neurovascular check, observe for complications swelling,hyperthermia, thrombophlebitis,inf n

C*00 ART8R+#&+PE

ART8R+#&+PE

C*00 ART8R+#&+PE

#8+7AD0R ART8R+#&+PE

A##0#M0*T +1 T80 M7#&7A+#C0A0TAA #E#T0M

LA:O$ATO$Y ,$OCE9U$ES 3. :O.E SCA. 0ma+ "+ study 3 th the use o# a co"trast rad oact /e mater al Pre-test: ,a "less procedure? 08 rad o sotope s used? "o spec al preparat o"? pregnancy is contraindicated Intra-test: 08 "@ect o"? 7a t "+ per od o# 2 hours -e#ore C%ray? !lu ds allo3ed? Sup "e pos t o" #or sca"" "+ Post-test: 0"crease #lu d "take to #lush out rad oact /e mater al

A##0#M0*T +1 T80 M7#&7A+#C0A0TAA #E#T0M

:O.E SCA. 2 Radioisotope injected '$ 3technetium, >allium, Thalium4 Adm" 'sotope !-% days before scanning *o radioactive threats Procedure lasts (--?- min *o special care after procedure 0 creted in 7rine @ feces 0ncourage fluid

AA:+RAT+RE PR+&0D7R0# ," 9ECA% 9ual%e"er+y C$AY A-sorpt ometry Assesses bone density to diagnose osteoporosis 7ses LOW dose radiation to measure bone density Painless procedure, non-invasive, no special preparation Advise to remove jewelry

A##0#M0*T +1 T80 M7#&7A+#C0A0TAA #E#T0M

A##0#M0*T +1 T80 M7#&7A+#C0A0TAA #E#T0M

=" Cray ! lms: $oe"t+e"o+rams 2

plain ray film is common APA 3Antero-posterior lateral views" ?" A$T1$O6$A,1Y/ injection of dye or air in the joint for -ray study M" MYELO6$A,1Y: e amines spinal cord after introduction of contrast medium

Myelography

ART8R+>RAP8E

Arthrography is the radiographic e amination of a joint, after the injection of a dye-like contrast material and)or air, to outline the soft tissue and joint structures

A##0#M0*T +1 T80 M7#&7A+#C0A0TAA #E#T0M

9" :O.EAMUSCLE :0O,SY: 'liac crest

usual puncture site6 not commonly done today Aocal anesthesia, check PT @ PTT &oagulant given %-( days before @ after procedure Pressure dressing after

 N" CT SCA.: assess bone @ soft

A##0#M0*T +1 T80 M7#&7A+#C0A0TAA #E#T0M

tse tumors !-" M$0: to assess soft tissue and joints with myelography
>A*D+A'*'7M DTPA 3DiethyleneTriamine PentaAcetic Acid4

;. ES$ 2Erythrocyte Sed me"tat o" $ate5:

:A++D #T7D'0#/

non-specific test for inflammation 1/ --%mm)hr M/ --!- mm)hr

%" U$0C AC09:0levated in gout

*ormal %"%-M mg)dl 314 6,"%-9 mg)!-- ml

3M4

(" A.A 2A"t %"uclear A"t %-ody5:

Measures the presence of antibodies that

destroy the nucleus of the body tissue cells in auto-immune disorder6 354 in about N,. of clients w) #A0 #jorenIs syndrome RA

:A++D #T7D'0#/
$1EUMATO09 !ACTO$ 2Late'

! 'at o"5:
Determine presence of auto antibodies 3R14

found in clients with connective tissue dse 354 R1 is suggestive of RA The higher the antibody titer the greater the degree of inflammation

M'*0RAA M0TA:+A'#M/
!" CALC0UM / i! osteom"l"ci",

&%o%"r"t &roi#ism0 *o!e tumors, "cute osteo%orosis,*o!e fr"cture1 e"li!( % "se)

Normal: 4.5 5.8 mEq/L or 9-10.5 mg/dL

22 PHOSPHORUS: i! osteom"l"ci",

e"li!( fr"ctures, C3F, *o!e tumor Normal: 3 - 4.5 mEq/L

M7#&A0 0*OEM0 T0#T#/

!" C$EAT0.0.E ,1O,1OK0.ASE

2CK3 or CK%MM5
1/ (--!(= 7)A6

M/==-!M- 7)A 2 highest concentration in traumatic injuries, progressive muscular dystrophy

%" ALKAL0.E ,1OS,1ATASE 3AAP-%4

2 'ncreased in &ancer, PagetIs Dse @ +steomalacia" *ormal/ %--N- '7)A

COMMO. MUSCULOSKELET AL ,$O:LEMS

The *ursing Management

*ursing Management of common musculoskeletal problems ;. ,A0. These can be related to joint inflammation, traction, surgical intervention !" Assess patientIs perception of pain %" 'nstruct patient alternative pain management like meditation, heat and cold application, guided imagery

*ursing Management
PA'* (" Administer analgesics as prescribed 7sually *#A'D# Meperidine 3demerol4can be given

for severe pain

," Assess the effectiveness of pain

measures

*ursing Management
2. 0M,A0$E9 ,1YS0CAL MO:0L0TY !" 'nstruct patient to perform range of motion e ercises, either passive or active %" Provide support in ambulation with assistive devices (" Turn and change position every % hours ," 0ncourage mobility for a short period and provide positive reinforcements for small accomplishments

*ursing Management
3. SEL!%CA$E 9E!0C0TS !" Assess functional levels of the patient %" Provide support for feeding problems
Place patient in 1owlerIs position Provide assistive device and supervise

mealtime +ffer finger foods that can be handled by patient Ceep suction eBuipment ready

*ursing Management
#0A1-&AR0 D01'&'T# (" Assist patient with difficulty bathing and hygiene
Assist with bath only when patient has

difficulty Provide ample time for patient to finish activity

!$ACTU$ES

1racture
A break in the continuity of the bone

and is defined according to its type and e tent

1racture
Severe mechanical Stress to bone

bone fracture

'irect 4lows Crus i!( forces Su##e! twisti!( motio! E5treme muscle co!tr"ctio!

fractures

1racture
T6.ES OF F3ACTU3E 72 Clo !d "ra#$%r! &S'(PLE)
T e fr"cture t "t #oes !ot c"use " *re"k i! t e

ski!

2. O*!+ "ra#$%r! &CO(POUN, or CO(PLE-) T e fr"cture t "t i!8ol8es " *re"k i! t e ski! 92 Com*l!$! .ra#$%r!:i!8ol8es e!tire cross sectio! of t e *o!es ;2 '+#om*l!$! .ra#$%r! < i!8ol8es o!l& " %ortio! of t e cross sectio! of t e *o!e

1racture
T6.ES OF F3ACTU3E =2 Comm/+%$!d "ra#$%r!
A fr"cture t "t i!8ol8es %ro#uctio! of se8er"l

*o!e fr"(me!ts

>2 0r!!+ $/#1 .ra#$%r!

O!e si#e is *roke! t e ot er si#e is *e"t

?2 ,!*r! !d fr"(me!t is #ri8e! i!w"r# 1skull,f"ci"l

*o!es)

T6.ES OF F3ACTU3E
@2 2ra+ 3!r !d
4re"k str"i( t "cross t e *o!e

A2 S*/ral
Forms o*li$ue "!(le to t e *o!e

s "ft

1racture/ A##0##M0*T
CL'N'C4L (4N'.ES242'ONS:

22 92 ;2 =2 >2 ?2

."i!: imme#i"te, se8er Loss of fu!ctio! 'eformit&0 "*!orm"l %ositio!i!( of e5tremit& S orte!i!( Cre%it"tio!: %"l%"*le or "u#i*le E#em"

 M" Paresthesia- burning or

tingling sensation 9" *umbness N" Motor weakness 1 ! Pulselessness" impaired capillary re#ill time and cyanotic s$in

1racture
ASSESSMEBT FIB'IBGS 72 ."i! Co!ti!uous "!# i!cre"ses i! se8erit& Muscles s%"sm "ccom%"!ies t e fr"cture is " re"ctio! of t e *o#& to immo*ili+e t e fr"cture# *o!e

1racture

ASSESSMEBT FIB'IBGS 22 Lo o" "%+#$/o+ A*!orm"l mo8eme!t "!# %"i! c"! result to t is m"!ifest"tio!

1racture ASSESSMEBT FIB'IBGS 92 ,!"orm/$5 'is%l"ceme!t, "!(ul"tio!s or rot"tio! of t e fr"(me!ts

1racture ASSESSMEBT FIB'IBGS ;2 Cr!*/$% A (r"ti!( se!s"tio! %ro#uce# w e! t e *o!e fr"(me!ts ru* e"c ot er

1racture
'IAGBOSTIC TEST C:r"&

1racture
EME3GEBC6 MABAGEMEBT OF F3ACTU3E 72 Immobilize any suspected fracture
S%**or$ t e e5tremit& "*o8e "!# *elow w e!

mo8i!( t e "ffecte# %"rt from " 8e icle Su((este# $!m*orar5 *l/+$ : "r# *o"r#, stick, rolle# s eets 4**l5 l/+g if fore"rm fr"cture is sus%ecte# or t e sus%ecte# fr"cture# "rm m"&*e *"!#"(e# to t e c est

1racture
EME3GEBC6 MABAGEMEBT: OPEN .R4C2URE 72 O%e! fr"cture is m"!"(e# *& co8eri!( " cle"!Dsterile ("u+e to %re8e!t co!t"mi!"tio! 22 'O BOT "ttem%t to re#uce t e f"cture

1racture
Ge!er"l Bursi!( MABAGEMEBT .or CLOSE, .R4C2URE 72 Assist i! re#uctio! "!# immo*ili+"tio! 22 A#mi!ister %"i! me#ic"tio! "!# muscle rel"5"!ts 92 Te"c %"tie!t to c"re for t e c"st ;2 Te"c %"tie!t "*out %ote!ti"l com%lic"tio! of fr"cture "!# to re%ort i!fectio!, %oor "li(!me!t "!# co!ti!uous %"i!2

Ge!er"l Bursi!( MABAGEMEBT

.or OPEN .R4C2URE 72 .re8e!t wou!# "!# *o!e i!fectio! A#mi!ister %rescri*e# "!ti*iotics A#mi!ister tet"!us %ro% &l"5is Assist i! seri"l wou!# #e*ri#eme!t 22 Ele8"te t e e5tremit& to %re8e!t e#em"

form"tio! 92 A#mi!ister c"re of tr"ctio! "!# c"st

F3ACTU3E COM.LICATIOBS Earl5 72 S ock 1/&%o8olemic S ock) 22 F"t em*olism : 7st ;@ rs 92 I!fectio! ;2 Im%"ire# Circul"tio! 1c"stDe#em") =2 Com%"rtme!t s&!#rome >2 Ee!ous St"sis ) t rom*us form"tio!

 F3ACTU3E COM.LICATIOBS

La$! 72 'el"&e# u!io! D Bo!u!io! 22 A!(ul"tio! 1*o!e e"ls "t " #istorte# "!(le) 92 'el"&e# re"ctio! to fi5"tio! #e8ices ;2 Com%le5 re(io!"l s&!#rome

F3ACTU3E COM.LICATIOBS: .a$ Em6ol/ m Occurs usu"ll& i! fr"ctures of t e lo!( *o!es F"t (lo*ules m"& mo8e i!to t e *loo# stre"m *ec"use t e m"rrow %ressure is (re"ter t "! c"%ill"r& %ressure F"t (lo*ules occlu#e t e sm"ll *loo# 8essels of t e lu!(s, *r"i! ki#!e&s "!# ot er or("!s

 F3ACTU3E COM.LICATIOBS:

.a$ Em6ol/ m O!set is r"%i#, wit i! 2;:?2 ours 4SSESS(EN2 .'N,'N0S A. 1. Sudden dyspnea and respiratory distress & hypoxia 22 t"c &c"r#i" 92 C est %"i! ;2 Cr"ckles, w ee+es "!# cou( =2 .etec i"l r"s es o8er t e c est, "5ill" "!# "r# %"l"te

1at embolism
classic triad/ hypo emia6 neurologic

abnormalities6 and a petechial rash" 8- 8ypo emia *- * eurologic a-bnormalities P- Petechial rash

1at embolism
Assessment finding :" *eurological finding !" &erebral emboli- freBuently present

after early stages" 9? . after the respiratory distress" - The more common presentation is with an acute confusional statebut focal neurological signs, including hemiplegia, aphasia,apra ia, visual field disturbances, and anisocoria, have beendescribed"

1at embolism
The characteristic petechial rash may be

the last componentof the triad to develop" 't occurs in up to ?-. of cases andis due to emboli<ation of small dermal capillaries leading toe travasation of erythrocytes" This produces a petechial rashin the conjunctiva, oral mucous membrane, and skin folds ofthe upper body, especially the neck and a illa"G?H 't does notappear to be associated with any abnormalities in platelet function"The rash appears within the first (? h and is

Bursi!( M"!"(eme!t Many studies shows that early immobilization and fixation decrease the incidence of pulmonary complication. - Adequate fluid resuscitation transfusion and !"# could decrease the incidence of $%S & $at embolism syndrome ' 5. S%**or$ $7! r! */ra$or5 "%+#$/o+
3es%ir"tor& f"ilure is t e most commo!

c"use of #e"t A#mi!ister O2 i! i( co!ce!tr"tio! .re%"re for %ossi*le i!tu*"tio! "!# 8e!til"tor su%%ort

22 4dm/+/ $!r dr%g

Corticosteroi#s 'o%"mi!e Mor% i!e

92 '+ $/$%$! *r!3!+$/3! m!a %r!

Imme#i"te immo*ili+"tio! of fr"cture Mi!im"l fr"cture m"!i%ul"tio!

A#e$u"te su%%ort for fr"cture# *o!e #uri!( tur!i!(

"!# %ositio!i!( M"i!t"i! "#e$u"te &#r"tio! "!# electrol&te *"l"!ce

 0arly complication/
Compartme"t sy"drome

A complication that develops when

tissue perfusion in the muscles is less than reBuired for tissue viability

&+MPARTM0*T #E*DR+M0
Muscles, nerves, vessels are

restricted to confined space 3myofascial compartment4 within an e tremity 0T'+A+>E/

Decreased &ompartment si<e from cast,

splints, tight bandage, tight surgical closure 'ncrease in compartment contents d)t edema or hemorrhage

 0arly complication/
Compartme"t sy"drome

ASSESSME.T !0.90.6S !" Pain- Deep, throbbing and U%&'LI'(') pain by opioids
d)t reduction in the si<e of the muscle

compartment by tight cast d)t increased mass in the compartment by edema, swelling or hemorrhage

 Muscle ischemia 3compression4 Arterial compression may not occur6

pulses may be 354 2 3early4 :listers &an result in permanent damage in a short time 3?-9 hrs4 PAR0#T80#'A- first sign P7A#0A0##*0## - late sign

Medical and *ursing management/ !" Assess freBuently the neurovascular status of the casted e tremity %" 'levate the e*tremity above the level o# the heart (" Assist in cast removal and

 Sur+ cal Treatme"t 'f surgery is reBuired to relieve the

pressure, the physician will make an incision and cut open the skin and fascia covering the affected compartment" This reduces the pressure in the compartment" The skin incision is surgically repaired when swelling recedes" #ometimes a skin graft may be needed"

, RI# '* M>MT +1 1RA&T7R0

!" R0&+>*'T'+* of presence of fracture %" R0D7&T'+*/
&losed Reduction 3manipulation4 +pen Reduction 3+R'1 2 surgery4 Traction

, RI# '* M>MT +1 1RA&T7R0

(" R0T0*T'+*

&ast Traction :races ) splints :andage

," R08A:'A'TAT'+* 2 restoration to normal f n

Falker &rutches &ane

&A*0#

C A.E #hould be used

on the side opposite the affected leg &ane 5 Affected leg move together

&anes
8andle should be always level of

clients greater trochanter " &lients elbow should be fle at a !=(- degrees angle 'nstruct the client to hold the cane ,-? inches on the side of the client"

FAAC0R#
A'1T the walker @

place it appro " % ft" in front >ain balance before moving walker forward again :alance provides stability @ eBual wt" bearing

PR+#T80#'#

U, 70T1 T1E 6OO9 9O7. 70T1 T1E :A9

0"d cat o": Feakness in both legs or poor coordination

SeDue"ce: 1-Le#t crutch" +-right #oot" ,-right crutch" --le#t #oot! .hen repeat! Ad/a"ta+es: Provides e cellent stabilty as there are always three points in contact with the ground 9 sad/a"ta+es: #low walking speed

0"d cat o": 'nability to bear weight on one leg" 3fractures, pain, amputations4

,atter" SeDue"ce:

1-move both crutches and +- the /ea$er lo/er limb #or/ard! .hen bear all your /eight do/n through the crutches ,- move the stronger or una##ected lo/er limb #or/ard! &epeat! Ad/a"ta+es: 0liminates all weight bearing on the affected leg" 9 sad/a"ta+es:

 0"d cat o":

Feakness in both legs or poor coordination"

,atter" SeDue"ce:

1-Le#t crutch and right #oot together" then the +-right crutch and le#t #oot together! &epeat! Ad/a"ta+es: 1aster than the four point date" 9 sad/a"ta+es: &an be difficult to learn the pattern"

 0"d cat o"s:

Patients with weakness of both lower e tremities"

,atter" SeDue"ce:

Advance both crutches #or/ard then" /hile bearing all /eight do/n through both crutches" s/ing both legs #or/ard at the same time to 0not past1 the crutches! Ad/a"ta+e: 0asy to learn" 9 sad/a"ta+e: ReBuires good upper e tremity strength"

 0"d cat o"s:

'nability to fully bear weight on both legs" 3fractures, pain, amputations4

,atter" SeDue"ce:

Advance both crutches #or/ard then" /hile bearing all /eight do/n through both crutches" s/ing both legs #or/ard at the same time past the crutches! Ad/a"ta+e: 1astest gait pattern of all si " 9 sad/a"ta+e/ 0nergy consuming and reBuires good upper e tremity

TRA7MAT'& &+*D'T'+*#/
!. CO.TUS0O. 2 soft tissue injury

produce by blunt force, blow, kick or fall

#)# / a" hemorrhage 3ecchymosis4 ruptured

:$ b" pain @ swelling

CO.TUS0O.
M+mt: ;. ele/ate a##ected part 2. cold compress to d m " sh edema

2;st 2=15 3. apply pressure -a"da+e to reduce s3ell "+ =. apply heat to a##ected area a#ter < hrs to promote a-sorpt o".

Stra "s

E'cess /e stretch "+ o# a muscle or

te"do"

*ursing management/ ;. 0mmo- l 4e a##ected part 2. Apply cold packs " t ally? the" heat packs 3. L m t @o "t act / ty =. Adm " ster .SA09s a"d muscle rela'a"ts

#prains
0 cessive stretching of the A'>AM0*T#

.urs "+ ma"a+eme"t !" 'mmobili<e e tremity and advise rest %" Apply cold packs initially then heat packs (" &ompression bandage may be applied to relieve edema ," Assist in cast application =" Administer *#A'D#

$e st 0 c e ompress C o" E le/at

o"

Musculoskeletal Modalities

Tract o" Cast

*ursing Management
Tract o" A method of fracture immobili<ation by applying eBuipments to align bone fragments 7sed for immobili<ation, bone alignment and relief of muscle spasm

Traction
Sk " tract o" 2 applied at the

surface of skin @ soft tissue @ indirectly to the bone using adhesive elastic bandage @ spreader" ma " Mlbs 3e"g" :ryant, Russel Traction4
Skeletal tract o" 2 applied directly

to the bone using wire, pins, tongs" ma " ,- lbs" 3e"g" 8alo pelvic, &rutchfield tong traction4

Traction

#kin tracti on
*on-adhesive traction

:ryants traction

&ervical traction

:alance suspension traction

Position clients/ low fowlers position Maintain %- degree angle at the thigh to bed Protect the skin from break down Provide pin care if pin is used with the skeletal traction

'*D'&AT'+*#)P7RP+#0#/
1or immobili<ation Prevent @ correct deformity Maintain good alignment >ive support to reduce pain @ muscle spasm To reduce fracture

 0"d cat o"s #or Tract o" reduction, immobilisation @ alignment

of fractures relieve muscle spasm @ pain prevent further soft tissue damage to promote rest

ne

R7##0AI# TRA&T'+*

RussellIs traction &ommonly used to stabili<ed the fracture femur before the surgery" -#imilar to bucks traction but provide double pull with the use of knee sling -traction pullIs the knee and the foot"

:AAA*&0D #7#P0*#'+*

:7&CI# 0PT0*#'+* TRA&T'+*

-'s used to alleviate muscle spasm and immobili<ed a lower limb by maintaining a straight pull on the limb with the use of weights" -boot appliance is applied to attach to the traction"

N--N- TRA&T'+*

DunlopIs traction

Description/ 8ori<ontal traction used to align fractures of the humerus" $ertical traction/ used to maintain forearm for proper alignment

8alo vest traction

&ervical traction

*ursing Management
Traction/ >eneral principles !" ALWA2S ensure that the /eights hang #reely and do not touch the #loor %" %'('& remove the /eights (" Maintain proper body alignment 3dorsal recumbent4 ," 0nsure that the pulleys and ropes are properly functioning and fastened by tying s3uare $not

*ursing Management
Traction/ >eneral principles =" +bserve and prevent foot drop
Provide foot plate

?" +bserve for D$T, skin irritation and breakdown M" Provide pin care for clients in skeletal traction

0PT0R*AA 1'PAT+R D0$'&0

0 ternal frame with a lot of pins" Provide more freedom compare to traction"

'nternal fi ator

Provide immediate bone strength but risk for infection"

1or every traction, there is always a counter traction 2 use shock blocks6 use half ring Thomas splint N" The line of pull must be in line with deformity !-" 1riction should be eliminated
9"

Traction/ >eneral principles

*ursing Management
&A#T 'mmobili<ing tool made of plaster of Paris or fiberglass Provides immobili<ation of the fracture

P7RP+#0#/
'MM+:'A'OAT'+* PR0$0*T'+*)&+RR0&T'+* +1

D01+RM'TE #7PP+RT +:TA'*'*> A 8+AD +1 A A'M: T+ #0R$0 A# M+D0A 1+R MAC'*> ART'1'&'AA A'M:

*ursing Management
&A#T/ types !" T$U.K Minerva &ast, Ri<<ers ;acket#coliosis, %" U,,E$ ECT$EM0TY (" LO7E$ ECT$EM0TY ," Sp ca

&A#T# &A#T#
M0.E$8A CAST SCOL0OS0S :$ACE

:+DE :+DE :RA&0# :RA&0#

SCOL0OS0S :$ACE

&asting Materials
Plaster of Paris
9ry "+ takes ;% 3 days 0# dry? t s S10.Y? 710TE? hard a"d reso"a"t.

1iberglass
L +ht3e +ht a"d dr es " 2E%3E m "utes 7ater res sta"t

&8ARA&T0R'#T'&# +1 >++D &A#T/

Fhite, shiny +dorless Aight in wt *ot too tight *ot too loose Resonant on percussion

*ursing Management
CAST: 6e"eral .urs "+ Care ;. Allo3 the cast to dry 2usually 2=%F2 hours5 +! 4andle a /et cast /ith the PAL5S "ot the # "+ert ps 3. Keep the casted e'trem ty ELE8ATE9 us "+ a p llo3 =. Tur" the e'trem ty #or eDual dry "+. Use lo3 cool dr er.

CAST: 6e"eral .urs "+ Care G. ,etal 2cutt "+ the ed+es5 the ed+es o# the cast to pre/e"t crum-l "+ o# the ed+es <. E'am "e the sk " #or pressure areas a"d $e+ularly check the pulses a"d sk "

CAST: 6e"eral .urs "+ Care F. 0"struct the pat e"t "ot to place st cks or small o-@ects "s de the cast H. Mo" tor #or the #ollo3 "+: pain" s/elling" discoloration" coolness" tingling or lac$ o# sensation and diminished pulses

CAST: 6e"eral .urs "+ Care

N" Observe #or signs o# plaster sore: itchiness)burning sensation, sever pain, rise of temp, disturbed sleep, restlessness, offensive odor, discharges3windowing-e posing a tight area to relieve edema)pain, petalling4 !-" Observe #or signs o# cast syndrome: prolonged *)$, repeated vomiting, abd"distention, vague abd"pain, 3-4bowel sound

PAA#T0R &A#T #AF

#pecific 1ractures/
&+AA0I# 1RA&T7R0
Distal radius

P0A$'& 1RA&T7R0/
1reB in elderly &an cause intra abd injury and urinary

tract injury Turn pt only on specific orders

 10, !$ACTU$E
&ommon in elderly women Cl " cal ma" #estat o":

0 ternal rotation @ adduction of affected e tremity #hortening of the length of the affected e tremiety #evere pain @ tenderness
Treatme"t: 'nitially- :uckIs traction #urgery

A1T0R #7R>0RE
*eurovascular check Position/ PR0$0*T 1A0P'+*

ADD7&T'+* @ '*T0R*AA R+TAT'+*

Do not adduct past neutral position Maintain in abducted position with A-

frame pillow or pillows between legs Avoid fle ion of hip of more than Ndegrees Prevent internal or e ternal rotation by using sandbags, pillows, trochanter rolls

After surgery
0 treme e ternal rotation

accompanied by severe Pain --displaced hip prosthesis

Amputation
Et olo+y a"d pathophys olo+y !" Refers to the removal of a body

part as a result of trauma or surgical intervention %" *ecessitated by/ a" Malignant tumor b" Trauma c" Acute arterial insufficiency

Amputation

Therapeut c "ter/e"t o"s !" :elow-the-knee amputation 3:CA4

common in peripheral vascular disease6 facilitates successful adaptation to prosthesis because of retained knee function %" Above-the-knee amputation 3ACA4 necessitated by trauma or e tensive disease (" 7pper e tremity amputation usually necessitated by severe trauma, malignant tumors, or congenital malformation

Amputation
Assessme"t !" *eurovascular status of involved

e tremity %" 8istory to determine a" &ausative factors b" 8ealth problems that can compromise recovery (" &lientQs understanding of the e tent of the surgery ," &lientQs coping skills =" &lientQs support system

Amputation
Assessme"t !" *eurovascular status of involved

e tremity %" 8istory to determine a" &ausative factors b" 8ealth problems that can compromise recovery (" &lientQs understanding of the e tent of the surgery ," &lientQs coping skills =" &lientQs support system

Amputation
,la"" "+A0mpleme"tat o" !" Provide care preoperatively a" 'nitiation of e ercises to strengthen muscles

of e tremities in preparation for crutch walking b" &oughing and deep-breathing e ercises c" 0motional support for anticipated alteration in body image %" Monitor vital signs and stump dressing for signs of hemorrhage (" 0levate stump for !% to %, hours to decrease edema6 remove pillow after this time to promote functional alignment and prevent

Amputation
," Provide stump care a" Maintain elastic bandage to shrink and shape

stump in preparation for prosthesis b" Fhen wound is healed, wash stump daily, avoiding the use of oils, which may cause maceration c" Apply pressure to end of stump with progressively firmer surfaces to toughen stump d" 0ncourage client to move the stump e" Place the client with a lower e tremity amputation in a prone position twice daily to stretch the fle or muscles and prevent hip

$heumato d Arthr t s
0tiology and pathophysiology !" &hronic disease characteri<ed by

inflammatory changes in the bodyQs connective tissue, particularly areas that have a cavity and easily moving surfaces %" &ause unknown, although theories include autoimmunity, heredity, and psychophysiologic factors (" 0 acerbations are linked to physical and emotional stress

Rheumatoid arthritis
&linical findings !" #ubjective a" 1atigue b" Malaise c" ;oint pain d" #tiffness after periods of inactivity, particularly in the morning e" Paresthesia f" Anore ia

Rheumatoid arthritis
+bjective a" Anemia b" Feight loss c" ;oint inflammation and deformity d" #ubcutaneous nodules e" 0levated sedimentation rate f" Aow-grade fever g" Presence of rheumatoid factors in serum

identified by late fi ation test h" Positive &-reactive protein and antinuclear antibody 3A*A4 tests

Rheumatoid arthritis
Therapeutic interventions !" &orticosteroids, antiinflammatories,

analgesics, immunosuppressive drugs6 aspirin is drug of choice followed by the addition of nonsteroidal antiinflammatory drugs and then gold or penicillamine, an oral chelating agent6 corticosteroids are reserved for acute inflammation, if possible %" Physiotherapy to minimi<e deformities (" #urgical intervention to remove severely damaged joints 3e"g", hip replacement4

Rheumatoid arthritis
," Application of heat or cold6 paraffin

dips of affected e tremity for relief of joint pain by providing uniform heat =" Plasmapheresis may be used when the disease is advanced

Rheumatoid arthritis
Assessme"t !" 8istory of onset and progression of

symptoms, noting degree to which pain interferes with normal activities %" 1amily history of rheumatoid arthritis (" >eneral physical health ," &oping skills

Rheumatoid arthritis
,la"" "+A0mpleme"tat o" !" Administer analgesics and other

medications as ordered %" Teach the client to take medications as ordered and observe foraspirin to icity 3tinnitus, bleeding4 and other adverse effects of medications (" Apply heat and cold as ordered6 heat paraffin to !%=o to !%No 1 3=%o to =,o &4 ," Promote rest and position to ease joint pains =" Provide for range-of-motion e ercises up to the point of pain, recogni<ing that some discomfort is always

Rheumatoid arthritis
?" 0mphasi<e the need to remain active,

but incorporate rest periods to avoid fatigue M" 0ncourage the client to verbali<e feelings 9" 8elp set realistic goals, focusing on strengths N" 0ncourage use of supportive devices to help client conserve energy and maintain independence !-" Provide care for the client following

Rheumatoid arthritis
!!" 0ncourage diet rich in nutrient-dense

foods such as fruits, vegetables, whole grains, and legumes to improve and maintain nutritional status and compensate for nutrient interactions of corticosteroid and other treatment medications 9. E/aluat o"AOutcomes !" 0 periences a reduction in pain %" &ompletes activities of daily living using supportive devices as needed (" Accepts life-style consistent with abilities ," Maintains or improves range of motion of involved joints

Osteoarthr t s 29e+e"erat /e Bo "t 9 sease5 0tiology and pathophysiology

!" 0tiology relates to wear and tear of

joints6 predisposing factors include obesity, aging, and joint trauma %" A degeneration and atrophy of the cartilages and calcification of the ligaments (" Primarily affects weight-bearing joints, spine, and hands

Osteoarthr t s 29e+e"erat /e Bo "t

&linical findings !" #ubjective a" Pain after e ercise b" #tiffness of joints %" +bjective a" 8eberdenQs and :ouchardQs nodes symmetrically occurring on fingers 3bony hypertrophy4 b" Decreased range of motion c" &repitus when joint is moved

Osteoarthr t s 29e+e"erat /e Bo "t

Therapeutic interventions !" Feight reduction in instances of

obesity %" Aocal heat to affected joints (" Medications to reduce symptoms, such as analgesics, antiinflammatory agents, and steroids ," 0 ercise of affected e tremities

Osteoarthr t s 29e+e"erat /e Bo "t

=" #urgical intervention a" #ynovectomy/ removal of the enlarged

synovial membrane before bone and cartilage destruction occurs b" Arthrodesis/ fusion of a joint performed when the joint surfaces are severely damaged6 this leaves the client with no range of motion of the affected joint c" Reconstructive surgery/ replacement of a badly damaged joint with a prosthetic device

 Assessme"t !" 8istory for risk factors such as

obesity, trauma, athletic involvement, and occupation %" ;oints, noting evidence of deformities, inflammation, and muscle atrophy (" 0 tent of range of motion of involved joints

 ,la"" "+A0mpleme"tat o" !" Assist client in activities that reBuire using

affected joints6 allow for rest periods %" Maintain functional alignment of joints (" Attempt to relieve the clientQs discomfort and edema by the use of medications or the application of heat as ordered ," Allow client ample time to verbali<e feelings regarding limited motion and changes in life-style =" #upport client through weight loss program if indicated ?" 0ncourage client to follow physical therapistQs instruction regarding regular e ercise program and use of supportive

 M" Provide care for the client reBuiring joint

replacement 3see *ursing &are of &lients with 1ractures of the 8ips4 9" Refer client and family to the Arthritis 1oundation 9. E/aluat o"AOutcomes !" Reports a reduction in pain %" &ompletes activities of daily living using supportive devices as needed (" Develops life-style consistent with limitations ," 1ollows daily program of prescribed e ercise