BRIEF OVERVIEW OF MUSCULOSKELETAL
SYSTEM
I.Anatomy & physiology
a. axial
* cranium, vertebras and ribs
b. appendicular
* limbs, shoulders and hips
Structures
Bones – the body contains 206 different bones
a. Types of bone tissue
1. compact bone –dense, look smooth
and homogenous
2.spongy bone – small needle- like pieces of >Provide the force to move bones.
bone and lots of open spaces
characteristics:
- supports and protects structures of the body.
- provide attachments for muscles, tendons
and ligaments.
- contains tissue in the central cavities, which
aids in the formation of blood cells.
- assist in regulating calcium and phosphate
concentrations.
*Collagen – is the chief organic constituent of the bone. CALCIUM is required to contract muscle fibers to
*2/3 of adult bone is inorganic calcium salts (CaPO4)
(CaCO3).
*CaPO4 is the primary ingredient for proper bone
density
*Vit. D is essential for the absorption of these minerals.
BONE CELLS
- OSTEOBLAST – found at periosteum; for bone
building and bone repairing cells
- OSTEOCYTES – found at haversian system a
compact bone behind periosteum.
- OSTEOCLASTS – found at the center of the bone or
in the medullary cavity; concerned with the absorption
and removal of bone.
BONE GROWTH
- The length of the bone growth results from the
ossification of the epiphyseal cartilage at the ends of
bones, and the bone growth stops between the ages of 18
and 25 years.
-The width of bone growth results from the activity of Reactive
osteoblasts and occurs throughout life but does not slow
down with aging.
- As aging occurs, bone resorption accelerates,
decreasing bone mass and predisposing the client to
injury. Usually starts at the age of 35.
joints-Allow movement between bones.
Are formed when two bones join
Surfaces are covered with cartilage. (gristle; a tough
connective tissue, char. By firmness and avascular).
Are enclosed in a capsule.Contains cavity filled with
synovial fluid.Ligaments hold the bone and joint
incorrect position.Articulation is the meeting of point of
two or more bones.
SYNOVIAL FLUID
>Found in a joint capsule, formed by the synovial
membrane which lies in the joint capsule. It lubricates
the cartilage and provides cushion against shocks.
Muscle-* there are 600 individual muscles and
comprises 45% of the total body weight.
CHARACTERISTICS:
>are made up of bundles of muscle fibers.
>Assist in maintaining posture.
>Assist with heat production.
THE PROCESS OF CONTRACTION AND
RELAXATION
*require large amounts of ATP, CALCIUM which
functions as catalyst.
ACETYLCHOLINE----rel. by motor end plate—
INITIATES ACTION POTENTIAL----destroyed
by ACETYLCHOLINESTERASE.
stimulate ACTIN-MYOSIN SLIDING ACTION
Following contraction, ATP transports Ca out to allow
actin and myosin to separate and allow muscle to
relax.
Process of bone healing
>is a proliferative physiological process, in which the
body facilitates repair of bone fractures.
Phases of fracture healing
There are three major phases of fracture healing, two of
which can be further sub-divided to make a total
of five phases;1. Reactive Phase
i. Fracture and inflammatory phase
ii. Granulation tissue formation
2. Reparative Phase
iii. Callus formation
iv. Lamellar bone deposition
3. Remodeling Phase
v. Remodeling to original bone
contour
After fracture, the first change seen by light and
electron microscopy is the presence of blood cells within
the tissues. Soon after fracture, the blood vessels
constrict,. Within a few hours after fracture, the
extravascular blood cells, known as a "hematoma", form Needles are inserted into the muscle, and recordings of
a blood clot then it degenerates and die. Within this same
area, the fibroblasts survive and replicate. They form a
loose aggregate of cells, interspersed with small blood
vessels, known as granulation tissue.
Reparative
Days after fracture, the cells of the periosteum
replicate and transform. The periosteal cells proximal to EMG refers to the electromyography part of the test.
the fracture gap as well as the fibroblast develop into
chondroblasts and form hyaline cartilage later form
woven bone and they unite with their counterparts from nerve
other pieces of the fracture. This process forms the
fracture callus.
The next phase is the replacement of the hyaline
cartilage and woven bone with lamellar bone. The
replacement process is known as endochondral
ossification with respect to the hyaline cartilage and
"bony substitution" with respect to the woven bone. The
lamellar bone begins forming soon after the collagen
matrix of either tissue becomes mineralized. This new
lamellar bone is in the form of trabecular bone, restoring
much, if not all, of the bone's original strength.
Remodeling
The remodeling process substitutes the trabecular bone
with compact bone. The trabecular bone is first
reabsorbed by osteoclasts, creating a shallow
resorption pit known as a "Howship's lacuna".
Then osteoblasts deposit compact bone within the
resorption pit. Eventually, the fracture callus is
remodelled into a new shape which closely
duplicates the bone's original shape and strength.
DIAGnostic eXAM
1. Angiogram
2. Arthrography
-Injection of radiopaque substance or air into
joint cavity to outline soft tissue structures and contour Injection of a dye or air into the subarachnoid space
of joint
3. Bone Scan
-Parenteral injection of bone seeking
radiopharmaceutical, concentration of isotope
uptake revealed in fracture,osteosarcoma,
osteomyelitis.radioisotope is injected i.v and will
collect in areas that indicate abnormal bone
metabolism and some fractures, if they exist.-
Isotope is excreted in the urine and feces within
48hours and is not harmful to others
4. Bone Densitometry
>The DXA OR Bone Densitometry Scanner is used to
detect osteoporosis
5.CT Scan
6. DEXA
Dual energy X-ray absorptiometry (DEXA). DEXA
uses two different X-ray beams. The amounts of
each X-ray beam that is blocked by bone and soft
tissue are compared to estimate the bone density. 11. XRAYS
DEXA is the most accurate method for measuring 13. Synovial Fluid Analysis
BMD. It is fast and uses very low doses of
radiation. DEXA measures BMD on bones of the 1.Arthrometry
spine and hip. Under good conditions, DEXA can
measure as little as 2% of bone loss per year
7.ELECTROMYOGRAPHY
Measures and records activity of contracting muscles in
response to electrical stim8ulation;helps
differentiate muscle diseasefrom motor neuron
dysfunction
muscular electrical activity are traced on recording
paper through n oscilloscope.
Interventions:
>Obtain an informed consent
>Instruct that needle insertion is uncomfortable.
>Avoid taking stimulants 24hrs before the procedure.
>Slight bruising may occur after insertion
This is a needle exam of the muscles. Selected muscles
of the arms, legs and small muscles along the spinal
regions of the neck and back are examined. If there is
damage or muscle disorders, specific findings may
be observed with the needle exam. The needle is inserted
just under the skin into the underlying muscle. Specific
waveforms are observed on a computer screen. The
waveforms indicate the presence or absence of nerve
injury and its effect on nerve function.
8.Indium (WBC) Scan
An indium scan is a procedure that is used to detect
abscesses, infections and other inflammatory
processes in the body. During an indium scan,
your leukocytes (white blood cells) are “labeled”
with a radioactive substance called indium. A
nuclear medicine camera then will track the
migration of the labeled leukocytes through your
body to the site of possible infection.What to
expectA nuclear medicine technologist first will
withdraw about 50 ml. of blood. White blood cells
will be collected from that sample, exposed to
indium (the “labeling” process), and re-injected
through an intravenous (IV) line back into your
body. Your scan will be scheduled 18 to 24 hours
after the white blood cells have been labeled with
indium.
10. myelogram
followed by radiography to detect abnormalities of
the spinal cord and vertebras
Interventions:
PRE PROCEDURE:
>obtain an informed consent
>Provide hydration for at least 12hrs before the test
>Assess client for allergies to iodine or seafood
>Premedicate for sedation as required.
POST PROCEDURE:
>Obtain vs and nvs
>Water based = elevate the bed
>Oil based = flat on bed
SPECIAL tEST:
Measures the range and movement of the joint
2. ARTHROSCOPY
Insertion of fiberoptic scope into a joint to visualize it,
perform biopsies or remove loose bodies.Done in

OR under sterile technique
Nursing resp:
>Endoscopy procedure that allows direct visualization
of joint structures through a large bore needle,
maybe combined with arthrography
>Is the surgical insertion of arthroscope to visualize
joint surface.
>Position: Flex the knee at least 40 degrees.
Post-procedure:
-Analgesics -Neurovascular
assessment
-Short-term activity restriction
-Ice for 24 hours
5.BONE OR MUSCLE BIOPSY = may be done during
surgery or through aspiration or punch
or needle biopsy.
Interventions:
* obtained an informed consent
* monitor for bleeding, hematoma or severe pain
* elevate the site for 24hrs. After the procedure to
prevent edema.
* apply ice packs as prescribed to prevent the
development of hematoma.
* minor discomforts are normal
6. Joint Aspiration
Synovial fluid analysis is a series of tests performed on
synovial (joint) fluid to help diagnose and treat
joint-related abnormalities. To obtain a synovial
fluid sample, a needle is inserted into the knee
between the joint space. When the needle is in
place the synovial fluid is then withdrawn. The
sample is sent to the lab for analysis.
8. Nerve conduction Studies- a useful diagnostic tool
that measures the rate at which an electrical impulse
moves along a nerve. It is used to diagnose disorders of
the peripheral nerves and muscle.
> commonly used to evaluate the function,
especially the ability of electrical conduction, of the
motor and sensory nerves of the human body. Used
mainly for evaluation of paresthesias (numbness,
tingling, burning) and/or weakness of the arms and legs. 4.Long thigh
The type of study is determined by the problem. Some of
the common disorders which can be diagnosed by nerve
conduction studies are:Peripheral neuropathy, Carpal
tunnel syndrome
Ulnar neuropathy,Guillain-Barré
syndrome,Facioscapulohumeral muscular
dystrophy
9.
Electroencephalogram
(EEGs): This test evaluates brain wave or
electrical function. Patients are referred
for evaluation of seizures, epilepsy,
tumors, attention deficit disorders,
headaches, dizziness, fainting or a brain
injury. Small metal discs (electrodes) are
taped to the scalp. Patients are evaluated
in a quiet, relaxed state. Brain wave
activity is measured and monitored.
10.
Evoked Potentials (EP): This
test evaluates how long it takes for a
stimulus to reach the brain from a point of
stimulation at a distance from the brain.
Stimulation points may be on an arm or
leg. Visual and auditory impulses are also
used. Very specialized tests evaluate
Multiple Sclerosis and other conditions
that affect either brain or spinal cord
function.
11. ARTHROCENTESIS-
Involves aspirating the synovial fluid,
blood, or pus via needle inserted into a
joint cavity.Medication may be instilled
into the joint if necessary to alleviate
inflammation
Interventions:
>Obtained an informed consent.
>Apply a compress bandage post procedure as
prescribed.
>Instruct to rest the joint 24hrs postop
>Instruct to notify the physician if fever and swelling
of the joint occurs.
CAST -Solid dressings applied to a limb or other body
part
Types of Casts
1.Short arm casts - extend from below the elbow to the
proximal palmer crease
2.Long arm casts - extend from the axillary fold to the
proximal palmer crease
3.Short leg casts - extend from below the knee to the
base of the toes
leg casts – extend from the upper third of the
to the base of the toes
5. Spica casts – extend from the
midtrunk to cover one or both
extremity. It includes the trunk of the
body and one or more limbs .A hip
spica includes the trunk of the body
and one or more legs. A hip spica
which covers only one leg to the ankle
or foot may be referred to as a single
hip spica, while one which covers both
legs is called a double hip spica.
6. Body casts – encase the trunk
of the body.body casts
The Minerva cast includes the trunk of the
body (sometimes extending down only so
far as the rib cage) as well as the patient's
head, with openings provided for the
patient's face, ears, and usually the top of
the head and hair.
 The Risser cast was similar, extending from the
patient's hips to the neck and sometimes
including part of the head
7.Splints – bivaled casts that provide immobilization
and allow for edema
Cylinder cast
In some cases, a cast may include the upper and lower
arm and the elbow, but leaves the wrist and hand
free, or the upper and lower leg and the knee,
leaving the foot and ankle free. Such a cast may
be called a cylinder cast, or may simply be called
a long arm or long leg cast.
Double hip, minerva, short arm, long arm, long leg, short
leg casts
Kinds of Casts
1.Plaster Casts – molds very smoothly to the body
contours, traditional casts are made of
plaster. The cast initially emits heat and take
about 15 minutes to cool and 24-72 hours to
dry. The plaster cast must be handled
carefully until dry
2.Non Plaster Casts – commonly used today, the cast any part of the body in the correct position to allow
are lighter weight, stronger, water resistant a certain amount of movement
and durable. Non plaster cast are porous and SPLINT
durable
Nursing Management of the patient with CAST
>Evaluate the client’s pain noting severity,nature,
exact location, source and alleviating n
exacerbating factors
>Neurovascular status
>Inspect and document any skin lesions, discolorations
or no removable foreign material
>Evaluate the client’s ability to learn essential
procedures such as applying slings correctly,crutch
walking or using a walker
Intervention
1.Prepare the client for cast application
a. explain the procedure and what to expect
b.Obtain informed consent if surger is required
c.Clean the skin of the affected part thoroughly
2. Assist with physician during application of cast as 3.Arthroscopy with joint involvement
needed
3.After cast application, provide cast care
>Support an exposed cast with the palms of
your hand to prevent indentions
>Ensure that the stockinet is pulled over rough
edges of the cast
>Elevate the casted extremity above the level
of the heart
> Provide covering and warmth to uncasted
areas
>.Expose the fresh plaster to circulating air,
uncovered until dry(24-72 hrs) expose the
synthetic cast until it is completely set
(20 min)
> Instruct the client to avoid wetting the cast,
tell him to dry a synthetic cast with a hair dryer on
cool setting if it gets worse
4. Initiate pain relief measure if indicated
a. encourage position changes
b. Elevate the affected part
c.Provide analgesic as appropriate
d.Promote non pharmacologic pain relief measures
such as guided imagery,relaxation and distraction
5. Observe and report for signs of cast syndrome with
clients who are immobilized in large cast susch as
body hip or hip spica(abdominal pain and
distention,N&V,elevated BP,tachycardia and
tachypnea)
6. Provide nursing care for compartment syndrome as
indicated
7. Notify the physician if “hot spots” occur along the
spots
8. Provide health teachings to family and client on
proper cast removal
BRACES and SPLINTS
Brace – an orthopedic device used to support and hold
function and healing.it can also be adjusted to allow for
– an orthopedic device for immobilization,
restraint or support of any part of the body, may be rigid
or flexible may be made of acrylic, polyethylene
foam, plaster of paris, or aluminum
ADJUSTABLE KNEE HINGED, ANKLE NAD
WRIST BRACES
FRACTURE
Break in bone’s continuity
Etiology:
Direct force;Indirect force;Twisting forces
(torsion);Diseases of bones (pathological
fractures);Osteoporosis;Tumors
Pathophysiology:
- fracture occurs when stress placed on a bone
exceeds the bone's ability to absorb it.
Laboratory and diagnostic study findings
1. x-ray and other imaging studies to determine integrity
of bone
2. CBC and electrolytes with blood loss & extensive
muscle damage
4.Angiography with blood vessel injury
5.Nerve conduction with nerve injury
Types of fracture
1. complete – bone is broken all the way through
2. incomplete – bone is damage but is still in one piece
3.) Closed (Simple) -Fracture bone does not disrupt soft
tissue and does not protrude through the skin.
4.) Open (Compound)-Fracture bone disrupts soft tissue
and protrudes through the skin.
Grade I – minimal soft tissue injury
Grade II – laceration greater than 1 cm. Without
 extensive soft tissue flaps
Grade III – extensive soft tissue injury,
including skin, muscle, neurovascular
structure
5. Pathological -through an area of diseased
bone( osteoporosis, bone cyst,bone tumor, bone
metastasis)
Fracture Patterns:
1.Comminuted -produce several breaks of the bone,
producing splinters and fragments
2.Spiral (torsion)- involve a fracture twisting around
the shaft of the bone
3.Oblique – occur at an angle across the bone
4.Transverse – occur straight across the bone
5.Greenstick – break one side of a bone and bend the
other
6. Compression – bone collapses on itself (vertebral
Fx)
7.Avulsion – fragment bone pulled off by ligament or
tendon attachment Types of Traction
8. Impacted – fragment of bone wedged into other
bone fragment
Clinical Manifestation: Physical findings
1. pain
2. swelling
3.tenderness
4. false motion or crepitus ( grating sensation)
5.loss of function
6. ecchymosis
7. visible deformity
8. paresthesia
Reducing Fractures
1.) Closed Reduction->Also called
MANIPULATION.Bone ends realigned without 2. fat embolism
surgical exposure of the fracture site.Done under 3. compartment syndrome – involve increased pressure
anesthesia .Cast or splint applied
2.) Open Reductionwith internal Fixation
>involves surgical intervention to achieve
reduction, alignment and
stabilization.Bone fragments directly
visualize.Fracture may be treated with
internal fixation devices (metal pins,
screws, wires, plates, nails and rods).May
involve the removal of damaged bone and mgt:
replacement with a prosthesis, may be
placed in traction or a cast following the
procedure
3. External Fixation
- an external frame is used with multiple pins
applied through the bone,Provides more
freedom of movement
4. Traction-Placing of tension on a limb, bone or muscle
group using various weight and pulley system.Pulling
force applied to maintain reduction and alignment.Used
for fractures of long bones
PURPOSES:
> reduce / immobilize fractures > relieve muscle
spasm, > relieve pain, correct deformities
Principles of Effective Traction
T =temp of both extremities
R= rope should be free from knot ; freely
hanging
A= alignment
C= check circulation 5P’s
(pulse,pallor,pain,paresthesia, paralysis)
T= type and quality of fracture
I= increase fluid ; give VALIUM to muscle
spasm
O= overhead trapeze must be @ the level of the
chest
N= no weights must be reaching on the floor
1.Straight or running traction – pull is exerted in one
plane..2 techniques
a. Skin Traction – force applied t the skin using
foam, rubber, tapes etc
b. Skeletal Traction – force applied to the bony
skeleton directly using wires, pins or tongs
placed into or through the bone
c. Balanced Suspension traction
- involves exertion of a pull while the limb is
supported by hammock or splint held by
balanced weights which allow for some
mobility without disruption of the line of
pull
( e.g pelvic string, Thomas leg splint)
Complications of Fractures
1. hypovolemic shock – massive bleeding
and constriction of nerves and vessels within a
compartment, resulting in impaired circulation,
nerve injury & loss of muscle function
etiology:
1. constrictive dressing or cast
2. fracture or crushig injuries
1. fasciotomy (to allow blood flow)
2. removal of any constrictive dressing
Complications of Fractures
4. Peroneal Nerve Palsy – results to footdrop
5. Avascular Necrosis – decreased bone tissue perfusion
leads to bone tissue death.
6. Bone union Problems – result from infection, poor
 circulation, ineffective immobilization,
inadequate reduction or poor health condition.
a. Delayed Union – takes longer to heal than
average type of fracture
b. Nonunion – fractured bone fails to unite
c. Malunion – union occurs but is faulty
(misaligned)
Assistive Devices
Purposes:
1. Improve and maintain stability on lower limb stability
2. Provide security while developing confidence in
ambulating
3. Reieve pressure on weight bearing joints
4.Assist in increasing speed of ambulation with less
fatigue
5. Provide for better mobility and independence
AMBULATORY AIDS
1. CRUTCHES
To assist patient with ambulation who have an injury,
cast, surgery on lower extremity or who have
disorder of mobility.
Gaits:
Four-point gait: partial weight- bearing
Two-point gait: partial weight- bearing
Three-point gait: Non weight- bearing
Swing to: weight- bearing
Swing through: used for rapid ambulation
Measurement:
2 inches below the axillary folds.6 inches laterally from AMPUTATION-Removal of the body part, usually by
small toe..Elbow is at approximately 30
degree flexion.
Patient Education:Place the weight on the hand piece
not the axilla.
2. CANES
Indicated to patient with minimal weakness of lower
extremities, with good balance and coordination. Check for drainage
Single
Tripod
quad
3.Walkers -Provides a much broader base of support to
patient with limited ability to walk.
Patient teaching:
Safety: hand should be placed on arms of chair when
sitting down.
OTHER SURGICAL PROCEDURES
ARTHRODESIS = also known as artificial ankylosis or
syndesis, is the artificial induction of joint
ossification between two bones via surgery. This is
done to relieve intractable pain in a joint which
cannot be managed by pain medication, splints, or
other normally-indicated treatments.
ARTHROPLASTY = (literally "formation of joint") is
an operative procedure of orthopaedic surgery
performed, in which the arthritic or dysfunctional
joint surface is replaced with something better or
by remodeling or realigning the joint by osteotomy
or some other procedure.
OSTEOTOMY = is a surgical operation whereby a bone
is cut to shorten, lengthen, or change its alignment.
It is sometimes performed to correct a hallux
valgus, or to straighten a bone that has healed
crookedly following a fracture.
AMPUTATION-Is the surgical removal of a lower limb
or part of the limb
Postoperative interventions:
Monitor vital signs, infection and hemorrhage
Mark bleeding and drainage on the dressing if it
occurs\
Keep a tourniquet at bedside*
Monitor for pulmonary emboli*
Evaluate for phantom limb pain sensation
Position: during the first 24hrs elevate the foot of the bed
to reduce edema; then keep it flat after o prevent flexion
contractures.*
Do not elevate the stump itself because
elevation can cause flexion contractures of
the hip.*
After 24-48hrs postop, position the client prone
if prescribed to prevent flexion
contractures of hip*
Remove and rewrap the stump; wash with mild soap and
water, massage the skin toward the suture line
surgery, although it may occur with trauma.
Complication:Phantom Limb pain,Phantom Limb
Sensation
Post-operative care
Vital signs
Observe for infection
Hemorrhage management:
Proper Stump Positioning:
Elevate stump for 24-48 hours.
Do not place pillow under AKA or BKA after
48 hours.
ROM
Assistive Devices