MUSCULOSKELETAL SYSTEM

MODULE I NURSING 105: ADULT NURSING Myrna Williamson, MSN, RN, OCN

In the very young

The skeleton is composed of mostly cartilage and is therefore, pliable with a decreased incidence of bone fractures and breakage in childhood

Mature Bone
Rigid connective tissue consisting of cells;
Collagen Calcium Phosphate

SKELETON

From Herlihy, B. & Maebius, N. (2000). The human body in health and illness. Philadelphia: W.B. Saunders.

SKELETON
AXIAL PORTION Cranium Vertebrae Ribs APPENDICULAR PORTION Limbs Shoulders Hips

ANATOMY & PHYSIOLOGY REVIEW

Structure & Function
Skeletal System
Bone Formation, Maintenance, Healing

Articular System
Joints synarthrosis, amphiarthrosis, & diarthrosis

Skeletal Muscle System

Contraction Tone Actions Exercise, Disuse, & Repair

Bone Cells

Osteogenic Cells
Osteoblasts Osteocytes Osteoclasts

Bone Formation & Maintenance

Ossification Resorption & Formation
Local stress Vit. D Parathyroid hormone Calcitonin Blood supply

TYPES OF BONES

From Herlihy, B. & Maebius, N. (2000). The human body in health and illness. Philadelphia: W.B. Saunders.

SPONGY BONE
Located in the ends of long bones and the center of flat and irregular bones Can withstand forces applied in many directions

DENSE (COMPACT) BONE

Covers spongy bone Cylinder around a central marrow cavity Can withstand force predominantly in one direction

SPONGY BONE AND COMPACT BONE

From Herlihy, B. & Maebius, N. (2000). The human body in health and illness. Philadelphia: W.B. Saunders.

FUNCTIONS OF BONE
Framework Support Movement Shape Maintain Position Attachment of Muscles Protects Organs Storage Hematopoiesis Remodeling Reformation Movable Joints

CHARACTERISTICS OF JOINTS
Allow the movement between bones Formed where two bones join Surfaces are covered with cartilage Enclosed in a capsule

Classification of Joints
A-C; Synarthrotic (immovable) & amphiarthrotic (slightly movable) joints. D-E: Diarthrodial (freely movable) joints

Types of Diarthrodial Joints

Hinge Ball & Socket Pivot Condyloid Saddle Gliding

SYNOVIAL JOINT

From Applegate E: The Anatomy and Physiology Learning System, ed. 2, Philadelphia, 2000, W.B. Saunders.

SYNOVIAL JOINT OF THE KNEE

From Herlihy, B. & Maebius, N. (2000). The human body in health and illness. Philadelphia: W.B. Saunders.

ANTERIOR VIEW OF MAJOR MUSCLES

From Herlihy, B. & Maebius, N. (2000). The human body in health and illness. Philadelphia: W.B. Saunders.

POSTERIOR VIEW OF MAJOR MUSCLES

From Herlihy, B. & Maebius, N. (2000). The human body in health and illness. Philadelphia: W.B. Saunders.

SKELETAL MUSCLE

From Herlihy, B. & Maebius, N. (2000). The human body in health and illness.

Neuromuscular Junction

CHARACTERISTICS OF MUSCLES
Made up of bundles of muscle fibers Provide the force to move bones Assist in maintaining posture Assist with heat production

4 Steps of Muscle Contraction

Excitation Coupling Contraction Relaxation

Body Movements
Flexion Extension Abduction Adduction Rotation Circumduction Supination Pronation Inversion Eversion Protraction Retraction

Age Related Changes of Musculoskeletal System

Bones Muscles Joints Ligaments

Nursing Assessment
Health History
Initial Interview Assessment Data
Pain Altered Sensations

Nursing Assessment
Physical Assessment
Posture Gait Bone Integrity Joint Function Muscle Strength & Size Skin Neurovascular Status

RISK FACTORS
Autoimmune disorders Calcium deficiency Degenerative conditions Falls Hyperuricemia Infection

RISK FACTORS (Continued)

Medications Metabolic disorders Neoplastic disorders Obesity Postmenopausal states Trauma and injury

Diagnostic Evaluation
Imaging Procedures
X-ray Computed Tomography (CT) Magnetic Resonance Imaging (MRI) Arthrography Bone Densitometry

Diagnostic Evaluation
Nuclear Studies
Bone Scan

Laboratory Studies
(CBC) Urinalysis (Calcium) Blood Chemistry Serum Calcium Serum Phosphate Uric Acid Serum Creatinine LDH, SGOT, CPK

Endoscopic Studies
Arthroscopy

Other Studies
Arthrocentesis Electromyography Biopsy

X-RAYS
DESCRIPTION IMPLEMENTATION

ARTHROCENTESIS
DESCRIPTION IMPLEMENTATION

ARTHROGRAM
DESCRIPTION IMPLEMENTATION

Arthrogram of the Knee

ARTHROSCOPY
DESCRIPTION IMPLEMENTATION

BONE SCAN
DESCRIPTION IMPLEMENTATION

BONE OR MUSCLE BIOPSY

DESCRIPTION IMPLEMENTATION

Muscle Biopsy Showing Polymyositis

ELECTROMYOGRAPHY (EMG)

From Mourad LA (1991) Orthopedic disorders. St. Louis: Mosby.

MYELOGRAM

From Herlihy B, Maebius NK: The human body in health and illness, Philadelphia, 2000, W.B. Saunders.

MUSCULOSKELETAL INJURIES
Skeletal Trauma Injuries to Support Structures

Fractures
Described according to location and type

Types of Fractures
Complete or Incomplete Open (formerly referred to as compound) Closed (formerly referred to as simple)

Complete Fractures
Linear Oblique Transverse Spiral

Complete Fractures
Comminuted Impacted Pathologic Avulsion

Complete Fractures
Compression Displaced Extracapsular Intracapsular

Incomplete Fractures
Greenstick Torus Bowing fracture Transchondral fracture Stress Fractures

TYPES OF FRACTURES

From Ignativicius, D. & Workman, M. (2002). Medical-surgical nursing, ed 4, Philadelphia: W.B. Saunders.

Types of Fractures

Pathophysiology of a Fracture
Tissue Disrupted Bleeding Occurs Hematoma Forms Bone Tissue

Healing of a Fracture
Inflammatory response Vascular tissue Bone-forming cells Callus formation Osteoblasts Remodeling

Speed of Healing
Hematoma formation within hours Procallus within days Callus formation within weeks Replacement and remodeling up to 4 years

Fractures Clinical Manifestations

Impaired function Deformity (unnatural alignment) Swelling Muscle spasm Tenderness Pain Impaired sensation

FRACTURE OF AN EXTREMITY
ASSESSMENT INITIAL CARE

INTERVENTIONS FOR A FRACTURE

Reduction Fixation Traction Casts

Fractures - Treatment
Reduction
Closed manipulation Traction (skin or skeletal) Open reduction and internal fixation (ORIF), (insertion of prosthesis, screw, plate, nail or wire).

CLOSED REDUCTION

From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6, Philadelphia: W.B. Saunders.

INTERNAL FIXATION

From Browner BB et al (1992) Skeletal trauma. Philadelphia: W.B. Saunders.

Types of Internal Fixation for a Hip Fracture

EXTERNAL FIXATION

From Ignatavicius, D., Workman, M. (2002). Medical-surgical nursing, ed 3, Philadelphia: W.B. Saunders. Courtesy of Smith and Nephew, Inc., Orthopedics Division, Memphis, TN.

TYPES OF HIP FRACTURES

Intracapsular Extracapsular

HIP REPLACEMENTS

From Mosbys Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby. Courtesy of Zimmer, Inc., Warsaw, IN.

TOTAL HIP REPLACEMENT

From Beare PG, Myers JL (1998): Adult Health Nursing, ed. 3 St. Louis: Mosby.

HIP FRACTURE
POSTOPERATIVE CARE CLIENT EDUCATION

TOTAL KNEE REPLACEMENT

DESCRIPTION POSTOPERATIVE CARE

KNEE PROSTHESIS

From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6, Philadelphia: W.B. Saunders.

CONTINUOUS PASSIVE MOTION

CASTS

Cast Care
Educate Apply Ice Instruct Prevent Attend

TRACTION
DESCRIPTION IMPLEMENTATION

SKELETAL TRACTION
DESCRIPTION IMPLEMENTATION

SKIN TRACTION
DESCRIPTION
Traction applied by the use of elastic bandages or adhesive

Side Arm

CERVICAL SKIN TRACTION

From James, S. Ashwill, R., & Droske, S. (2002). Nursing care of children, ed 2, Philadelphia: W.B. Saunders.

HEAD HALTER TRACTION

From Black JM, Matassarin-Jacobs E (1993) Luckman and Sorensens medical-surgical nursing: a psychophysiologic approach, 4th ed., Philadelphia: W.B. Saunders.

BUCKS SKIN TRACTION

From Black JM, Matassarin-Jacobs E (1993) Luckman and Sorensens medical-surgical nursing: a psychophysiologic approach, 4th ed., Philadelphia: W.B. Saunders.

PELVIC SKIN TRACTION

From Black JM, Matassarin-Jacobs E (1993) Luckman and Sorensens medical-surgical nursing: a psychophysiologic approach, 4th ed., Philadelphia: W.B. Saunders.

BALANCED SUSPENSION

From Black JM, Matassarin-Jacobs E (1993) Luckman and Sorensens medical-surgical nursing: a psychophysiologic approach, 4th ed., Philadelphia: W.B. Saunders.

DUNLOPS SKIN TRACTION

From Mosbys Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby.

COMPLICATIONS OF FRACTURES
Fat embolism Compartment syndrome Infection and osteomyelitis Avascular necrosis Pulmonary emboli Venous thrombosis Delayed union & nonunion

FAT EMBOLISM
DESCRIPTION ASSESSMENT IMPLEMENTATION

COMPARTMENT SYNDROME

INFECTION AND OSTEOMYELITIS

DESCRIPTION ASSESSMENT IMPLEMENTATION

AVASCULAR NECROSIS
DESCRIPTION ASSESSMENT IMPLEMENTATION

PULMONARY EMBOLISM
DESCRIPTION
Caused by immobility precipitated by a fracture

Venous Thrombosis
Description Assessment Implementation

Delayed Union & Nonunion

Description Assessment Implementation

Other Skeletal Trauma

Dislocation Subluxation Injuries to Support Structures Tendon tear Ligament tear Strain Sprain Avulsion Tendonitis Bursitis

Soft Tissue Injury of Hip

CARPAL TUNNEL SYNDROME

Associated with occupations that require continuous wrist movement.

Sports-Related Injuries
Rotator Cuff Tears Epicondylitis (Tennis Elbow) Lateral & Medial Collateral Ligament Injury Anterior & Posterior Cruciate Ligament Injury Meniscal Injuries Rupture of Achilles Tendon

CRUTCH WALKING

CRUTCH GAITS

From Mosbys Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby.

SINGLE- AND QUAD-FOOT CANES

From Beare PG, Myers JL (1998): Adult Health Nursing, ed. 3 St. Louis: Mosby.

WALKERS

HERNIATION: INTERVERTEBRAL DISC

CERVICAL DISC

CERVICAL COLLAR

LUMBAR DISC
DESCRIPTION IMPLEMENTATION

LOW BACK CARE

From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6, Philadelphia: W.B. Saunders.

TYPES OF DISC SURGERY

CHEMOLYSIS DISCECTOMY DISCECTOMY WITH FUSION LAMINOTOMY LAMINECTOMY

DISC SURGERY
PREOPERATIVE POSTOPERATIVE: CERVICAL DISC POSTOPERATIVE: LUMBAR DISC

AMPUTATION OF A LOWER EXTREMITY

DESCRIPTION
The surgical removal of a lower limb or part of the limb

AMPUTATION FLAPS

From Beare PG, Myers JL (1998): Adult Health Nursing, ed. 3 St. Louis: Mosby.

AMPUTATION OF A LOWER EXTREMITY

POSTOPERATIVE
Monitor vital signs Monitor for infection and hemorrhage Mark bleeding and drainage on the dressing if it occurs Keep a tourniquet at the bedside Monitor for pulmonary emboli

STUMP WRAPPING

From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6, Philadelphia: W.B. Saunders.

BELOW-THE-KNEE AMPUTATION
POSTOPERATIVE
Prevent edema Do not allow the stump to hang over the edge of the bed Do not allow the client to sit for long periods of time to prevent contractures

ABOVE-THE-KNEE AMPUTATION
POSTOPERATIVE
Prevent internal or external rotation of the limb Place a sandbag or rolled towel along the outside of the thigh to prevent rotation

DISORDERS OF BONE
Metabolic Bones Diseases Infectious Bone Disease Bone Tumors

Infectious Bone Disease: Osteomyelitis

Difficult to treat Physical disability Bacteria
Exogenous Endogenous

OSTEOMYELITIS
DESCRIPTION ASSESSMENT IMPLEMENTATION

Bone Tumors
Incidence Signs & Symptoms Diagnosis

DISORDERS OF JOINTS
Noninflammatory joint disease Inflammatory joint disease

INFLAMMATORY JOINT DISEASE

Rheumatoid arthritis Ankylosing Spondylitis Gouty arthritis

RHEUMATOID ARTHRITIS (RA)

DESCRIPTION ASSESSMENT

RHEUMATOID ARTHRITIS

BOUTONNIERE DEFORMITY

MUSCLE ATROPHY
SWAN NECK DEFORMITY
From Lemmi FO, Lemmi CAE: Physical assessment findings CD-ROM, Philadelphia, 2000, W.B. Saunders.

RHEUMATOID NODULE

From Lemmi FO, Lemmi CAE: Physical assessment findings CD-ROM, Philadelphia, 2000, W.B. Saunders.

RHEUMATOID ARTHRITIS (RA)

NONSTEROIDAL ANTIINFLAMMATORY DRUGS (NSAIDs) CORTICOSTEROIDS ANTINEOPLASTIC MEDICATIONS GOLD SALTS

RHEUMATOID ARTHRITIS (RA)

PHYSICAL MOBILITY SELF-CARE

RHEUMATOID ARTHRITIS (RA)

FATIGUE BODY IMAGE DISTURBANCE

RHEUMATOID ARTHRITIS (RA) SURGICAL INTERVENTIONS

SYNOVECTOMY ARTHRODESIS JOINT REPLACEMENT (ARTHROPLASTY)

Ankylosing Spondylitis
Chronic Inflammatory Disease Systemic autoimmune disease Differs from RA Signs & Symptoms Treatment

GOUTY JOINT
Description Phases Assessment Implementation

GOUT

From Clinical Slide Collection of the Rheumatic Diseases, 1991,1995,1997. Used with permission of the American College of Rheumatology.

Noninflammatory Joint Disease

Degenerative joint disease (osteoarthritis) is the most common

OSTEOARTHRITIS
DESCRIPTION
Also known as degenerative joint disease (DJD)

JOINT CHANGES IN OSTEOARTHRITIS

OSTEOARTHRITIS

HEBERDENS NODES

SEVERE OSTEOARTHRITIS
From Kamal A, Brockelhurst J: Color atlas of geriatric medicine, ed. 2, St. Louis, 1991, Mosby.

BOUCHARDS NODES

OSTEOARTHRITIS
PHYSICAL MOBILITY

OSTEOARTHRITIS SURGICAL INTERVENTIONS

OSTEOTOMY TOTAL JOINT REPLACEMENT (TJR)

RHEUMATOID ARTHRITIS AND OSTEOARTHRITIS CLIENT EDUCATION

Assist Instruct Review

Metabolic Bone Diseases

Osteoporosis Osteomalacia Pagets Disease

OSTEOPOROSIS

DOWAGERS HUMP

OSTEOPOROTIC CHANGES

From Black, J., Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6, Philadelphia: W.B. Saunders.

SEVERE OSTEOPOROSIS

From Lemmi FO, Lemmi CAE: Physical assessment findings CD-ROM, Philadelphia, 2000, W.B. Saunders.

MILWAUKEE BRACE

From Mosbys Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby.

OSTEOMALACIA
Metabolic disease Bone volume unchanged Osteomalacia adults Rickets - children

Pagets Disease
Osteitis Deformans Increased metabolic activity Usually no TX Affects men and women equally

Nursing Diagnoses
Knowledge Deficit Impaired Physical Mobility Self-care Deficit Risk for Infection Impaired Skin Integrity Imbalanced Nutrition Acute/Chronic Pain

THE END OF MUSCULOSKELETAL