Jessica A.

Soh BSN-3B
The Vertebral Column

The Bone 1. Scoliosis- lateral curvature that causes the spine

to “lean” one side more than the other
Functions of the bone: 2. Kyphosis- exaggeration of the thoracic curve
1. Support of body tissues as provided by the skeletal - “humpback” appearance
framework 3. Lordosis (swayback)
2. Protection of body organs -exaggeration of the lumbar curve
3. Movement, affected by contraction of muscles pulling -causes a “sway back”
on bones that provide leverage for motion
2. Gait
Other functions:
1. Storage of calcium  Have the patient walk away from the examiner
2. Their marrow produces red blood cells for a short distance
(haematopoiesis)  Observe for smoothness and rhythm
 Abnormal: unsteadiness or irregular
Four types of bones: movements, limping
1. Long bones  Abnormal: caused by neurologic conditions
2. Short bones - Spastic hemiparesis gait
3. Flat bones - Step-page gait
4. Irregular bones - Shuffling gait

Haversian Unit: 3. Bone Integrity

1. Lamellae- concentric cylindric layers of ciliated  Abnormal: abnormal bony growth, shortened
matrix extremities, amputations, body parts not in
2. Haversian canal- located at the center of anatomical alignment
concentric rings. It contains capillaries.  Fracture: abnormal angulation of long bones,
3. Lacuanae- small spaces between the rings of the motion at points other than joints, and crepitus
lamellae. These are composed of bone cells (grating sound) at the point of abnormal motion
(osteocytes).
4. Canaliculi- small canals that connect the lacunae 4. Joint Function
with haversian canal. These are through which
 Note ROM, deformity, stability, and nodular
bone receives the nutrients. formation
 Measured by a goniometer
ASSESSMENT
 Abn: skeletal deformity, joint pathology,
Health History
contracture
-common symptoms
 If joint is painful, further testing is done
1. PAIN
 Effusion: check for balloon sign and
 Bone pain
ballottement of the knee
 Muscular pain
 Joint deformity may be caused by contracture,
 Fracture pain
dislocation, subluxation, disruptions of
 Pain that increases with activity
structures around the joint
 Steadily increasing pain
 Palpate the joint when passively moved
 Radiating pain - Abnormal: snap/crack
**managed by rest - Abnormal: crepitus (grating/crackling
2. ALTERED SENSATIONS sound)
 (paresthesias) burning, tingling senasations or  Examine for nodule formation of tissues
numbness
surrounding the joints
 Caused by pressure on nerves or by circulatory - Rheumatoid (RA)- autoimmune d/o
impairment causing systemic inflammatory dse
- Gouty (Gouty Arthritis)- deposits of uric
PAST HEALTH, SOCIAL, AND FAMILY HISTORY acid and urate crystals in the joint that
 Occupation causes an acute inflammatory response
 Exercise patterns - Osteoarthritis (OA)- degenerate or
 Dietary intake “wear and tear”
 Health conditions ( DM, heart dses, COPD,
infection, pre-existing disability) 5. Muscular Strength and Size
 Familial or genetic abnormalities  Weakness: polyneuropathy, electrolyte
disturbance (K and Ca), myasthenia gravis,
PHYSICAL ASSESSMENT poliomyelitis, muscular dystrophy
1. POSTURE- normal: convex then concave  Muscle grading: for strength
 Kyphosis  Girth: for size
 Lordosis - Increase and decrease in size
 Scoliosis - measure unaffected first, measure at
Cervical and lumbar- convex the maximum circumference
Thoracic and sacral- concave - measure at the same location, 1cm
variation is already significant
Jessica A. Soh BSN-3B
6. Skin 5. Myelography
 inspect for edema, temp, and color  Involves the injection of contrast medium or
 warm or cool dye, into the subarachnoid space of the spine
 Vertebral column intervertebral disks, spinal
7. Neurovascular Status nerve roots, and blood vessels can be visualized
 CMS  Hydration for at least 12hrs before the test
 Assessing peripheral nerve functions: 2 Post procedures:
components:  v/s including neurologic assessment
- Peroneal nerve  if a water-based dye is used, elevate HOB 15 to
- Tibial nerve 30 degrees for 8 hrs
- Radial nerve  if an oil-based dye is used, keep client flat 6 to 8
- Ulnar nerve hours as prescribed
- Median nerve  If air is used, keep the head lower than the
trunk
DIAGNOSTIC PROCEDURE  Force fluids
Imaging procedures
1. Radiography (x-ray) 6. Bone Scan
 Skeleton is readily visible on standard x-  Uses IV injection of radionuclide to detect the
ray films (white) uptake of radioactive substances by the bone
 Observations on bone density, measured 2 hrs after injection
alignment, swelling, and intactness  Detects metastatic bone lesions, fractures, and
Responsibilities: certain types of inflammatory disorders
 Contraindicated for pregnant clients  Radionuclide is taken up in areas of increased
 Remove any radiopaque objects, such as metabolism
jewelry
 Client must lie still during an x-ray 7. Electromyography
 Provides information about the electrical
2. Computed tomography potential of the muscles and nerves leading to
 With or without contrast medium them evaluates muscle weakness, pain, and
 Shows in detail a specific plane of disability
involved bone  Needle electrodes are electrical stimuli are
 Identify location and extent of fracture muscles , and responses for electrical stimuli are
in areas that difficult to evaluate recorded on an oscilloscope
Responsibilities:  Warm compress is applied to relieve procedure
 Pt must remain still discomfort
 NPO status may vary but some may allow liquid
until 2hrs before the test 8. Bone Densitometry
 Used to estimate bone mineral density
3. Magnetic Resonance Imaging (BMD)
 Non-invasive that uses magnetic field,  Performed thru the use of x-rays or UTZ
radiowaves, and computers to  DUAL-ENERGY X-RAY ABSORPTIOMETRY
demonstrate abnormalities (DEXA): determines bone density at the
 Usually 30-90 minutes wrist, hip or spine to estimate the extent of
 Need to be still-> 5-20 min osteoporosis
 Rhythmic clicking sound  Useful for osteoporosis screening in clients
Responsibilities: older than 65 yrs old
 CI: with metal implants, pacemakers, and
pregnancy BLOOD STUDIES
 Obese clients may not fit (>400lbs)
 For claustrophobic: distraction/ open MRI Serum Calcium and Phosphorus
 Inverse relationship
4. Arthrography  Serum Ca= 8.6-10 mg/dL (2.15-2.50mmol/L)
 X-ray study of a joint after contrast  Serum phosphorus= 2.7-4.5 mg/dL (0.87-
medium has been injected 1.45mmol/L)
Responsibilities:
 NPO for 8hrs prior to the procedure Alkaline Phosphorus
 Asses the client for allergies  An enzyme normally present in blood
 Remain still as possible  Increases with bone or liver damage
 Minimize the use of the joint 12 hrs after the  Elevated in early fracture healing, metastatic
procedure bone tumors
 (+) edema and tenderness for 1 to 2 days  25-100 units/L
-treat with cold compress and analgesics as
prescribed Creatine Kinase (CK-MM)
 If air was used for contrast medium, crepitus  Increased as a result of muscular damage
may be felt up to: days  Begins to rise 2 to 4 hours after muscle injury
 Men= 38-174 units/L
 Women= 26-140 units/L
Jessica A. Soh BSN-3B
OTHER TESTS:
Bone or muscle biopsy
 May be performed to identify the structure and
composition of bone marrow, bone, muscle or
synovium to help diagnose specific dses
 Nurse monitors the biopsy site for edema,
bleeding, pain
 Ice and analgesics
Arthrocentesis
 Joint aspiration; is carried out to obtain synovial
fluid for purposes of examination or to relieve
pain due to effusion
 Normally, synovial fluid is clear, straw-colored,
and scanty in volume
 Physician inserts a needle into the joint and
aspirates fluid using aseptic technique
 Anti-inflammatory medications are given
 Sterile dressing is applied
Arthroscopy
 Internal inspection of a joint using an
instrument called an arthroscope
 Large bone needle is inserted into the joint
 Post-arthroscopy care:
- Entire leg is elevated without flexing the
knee
- Cold pack is placed over the bulky
dressing
- Monitor for unusual pain, bleeding,
drainage, or swelling
MUSCULO-SKELETAL TRAUMA
CONTUSIONS
 Soft tissue injury-> blunt force
 Small blood vessels rupture into soft tissues
(ecchymosis or bruising)
 A hematoma develops when the bleeding is
sufficient to cause an appreciable collection of
blood
 s/s: pain, swelling, discoloration
 ttt: intermittent cold compress (15-20 min, 4-
8x/day)
 most contusions resolve in 1 to 2 weeks
STRAIN
 excessive stretching of a muscle or tendon
 sometimes referred to as muscle pulls
 causes: falls, lifting heavy items, exercise
Classifications:
 first degree/mild
 mild inflammation but little bleeding
 second degree/moderate
 tearing of muscle or tendon without complete
disruption
 third degree/sever
 ruptured muscle or tendon with separation of
muscle from muscle tendon from muscle or
tendon from bone
Interventions:
 cold (first 24-48hrs) heat applications (after
48hrs)
 activity limitations then exercise
 elevate
 anti-inflammatory drugs and muscle relaxants
 surgical repair for the third degree strains
SPRAIN
 excessive stretching of a ligament
 twisting motion from a fall or sports activity
typically precipitate the injury
 classified accdng for severity:
- first degree: stretched ligaments, very
few tearing
- second degree: more fibers are torn
- third degree marked instability of the
joint
 ttt of first degree sprains:
- rest the affected extremity
- ice pack for the first 24 to 48 hours
- compression bandage for a few days to
reduce swelling and provide joint
support
- elevate the affected extremity
 ttt for second degree sprains:
- require immobilizations with elastic
bandage, splint, or cast
- partial weight bearing while tear heals
 ttt for third degree sprains:
- immobilization for 4 to 6 weeks is
necessary;
- surgery may be recommended for
chronic instability
JOINT DISLOCATION
 articular surfaces of the bones forming the joint
are no longer in anatomic contact
 the bones are literally “out of joint”
 subluxation
- partial dislocation of the circulating
surfaces
- sharp severe pain, visible displacement
and stiffness
- if vertebral cord: + balance issues,
headache
 Dislocation may be:
- Congenital
- Spontaneous or pathologic
 Caused by disease of the articular or
periarticular structure
- Traumatic
 Resulting from injury in which in the
joint is disrupted by force
Manifestations:
 Pain
 Change in the contour of te joint
 Change in the length of the extremity
 Loss of normal ability
 Change in the axis of the dislocated
bones
Diagnosis: radiographic studies
Management:
 Immobilize the affected joint
 Disclocation is promptly reduced to preserve
joint fxn
Jessica A. Soh BSN-3B
 Analgesia, muscle relaxant, and possibly
anesthesia are used to facilitate closed
reduction
- Immobilize joint by using bandages,
splints, cast or traction
- Monitor neurovascular status
- Exercise- gentle, progressive, active,
and passive movement
Nursing management:
 Directed towards providing comfort, evaluating,
the pt’s neurovascular status and protecting the
joint during healing
ROTATOR CUFF INJURY
 Fxn: to stabilize the head of the humerus in the
glenoid cabity during shoulder abduction
 Caused by trauma (throwing a ball or heavy
lifting)
 Client has shoulder pain and cannot initiate or
maintain abduction of the arm at the shoulder
 DROP ARM TEST
Management:
 NSAIDs
 Physical therapy
 Sling support
 Ice/heat applications while the tear heals
EPICONDYLITIS
 Chronic: painful condition, caused by excessive,
repetitive extension, flexion, pronation, and
supination activities of the forearm
 Activities contributing to epicondylitis- tennis,
racket sports, pitching, gymnastics, and
repetitive use of a screwdriver
 Pain radiates down the extensor (dorsal)
surface of the forearm
 Weakened grasp
Management:
 Ice packs
 NSAIDs
 Immobilization
 Rehabilitation exercises
 Use of tennis elbow counterforce strap to limit
extension of the elbow
MENISCAL INJURIES
 Twisting of the knee or repetitive squatting
 Impact-tearing or detachment of the cartilage
from its attachment to the head of the tibia
 Loose cartilages in the knee may slip between
the femur and the tibia, preventing full
extension of the leg
Manifestations:
 Hear or feel a click in the knee-walking, and
extension of leg
 If the cartilage is attached to the front and back
of the knee but torn loose laterally (bucket-
handle tear), it may slide between the bones-
causing the knee to “lock”
 Pain
 Inflammation, chronic, synovitis, and effusion
Management:
 Immobilization of the knee
 Use of crutches
 Anti-inflammatory agents
 Meniscectomy- thru arthroscope
FRACTURES
 Break or disruption in the continuity of a bone
 Occur when the one is subjected to stress
greater than it absorb
TYPES of fractures:
 Complete fracture- break across the entire cross
section of the bone
 Incomplete fracture- break in only part of the
cross section of the bone
 Comminuted fracture- produce several bone
fragments
 Closed fracture- no break in the skin
 Open/compound fracture- skin or mucous
membrane extends to the fractures bone
SPECIFIC TYPES OF FRACTURE:
 Avulsion- fragment of bone is pulled away by a
tendon and its attachment
 Colle’s fracture- break in the radius at the
epiphysis within 1 in of the joint of the wrist
 Compression- bone has been compressed
 Depressed- fragments are driven inward
 Epiphyseal- through the epiphysis
 Galeazzi fracture- break in the distal radius with
dislocation of radioulanar joint
 Greenstick- one side of the bone is broken ad
the other is bent
 Impacted- bone fragment is driven into another
bone fragment
 Oblique- occurring at an angle across the bone
 Spiral- twists around the shaft of the bone
 Transverse- straight across the bone shaft
 Pathologic- area of diseased bone
5 STAGES OF BONE HEALING
1. Hematoma formation- bone is highly vascular,
bleeding occurs at both ends of the fractured
bone. Increased capillary permeability permits
further extravasation of blood into the injured
area, blood collects in the periosteal sheath or
adjacent tissues and fastens the broken ends
together.
2. Fibrin Meshwork Formation- fibroblasts invade
the hematoma, causing it to become organized
into fibrin meshwork. WBC’s wall off the area,
localizing the formation
3. Invasion by osteoblasts- as osteoblasts invade
the fibrous union to make it firm, blood vessels
develop from capillary buds, thereby
establishing a source of supply for nutrient’s to
build collagen. Collagen strands become longer
and begin to incorporate calcium deposits.
4. Callus formation- osteoblasts to lay the
network for bone build up as osteoblasts
destroy dead bone and help synthesize new
bone. Collagen strengthens and becomes
further impregnated with calcium.
Jessica A. Soh BSN-3B
5. Remodelling- excess callus is reabsorbed and  Warn pt that heat is produced during the drying
trabecular bone is laid down along the lines of stage of the cast
stress  Relieve itchinesss; use of a fan o a hair dryer set
on cool air
Manifestations:  Check for tightness of cast application
 Pain  Encourage mobility ad active participation in
 Swelling self-care
 Deformity  Report to the physician any break in cast or foul
odor from cast
Initial care:  Tell pt not to scratch skin underneath cast, skin
 Immobilize may break and infection can set in; don’t put
 Splint the affected extremity as it is anything underneath cast
 Continuously monitor for neurovascular status
Principles of ttt: of the affected extremity (check for Circulation,
 Reduction Motion, and Sensation)
- “setting the bone” - Absent or diminished pulse
- Refers to restoration of the fractured - Cyanosis or blanching
fragments to its anatomic alignment ad - Coldness
rotation - Swelling
Closed reduction- manipulation - Pain
and manual traction - Inability to move fingers or toes
Open reduction- surgical
approach Cast removal:
 Immobilization  Removed usually after 4-8 weeks
- Held in correct position and alignment  Uses an electric cast cutter with a rapidly
until union occurs vibrating, circular disk
- May be accomplished by external or  Do not cut skin
internal fixation  Skin looks macerated after
An ILIZAROV circular fixator  If casted in flexion, elbow may feel stiff and
used to stabilize and lengthen even sore as child extends arm for the 1st time
the tibia  Encourage use of extremity again
 Regaining of normal function and strength  Wash skin gently
through immobilization  Apply baby powder, or baby oil
 Have pt gradually adjust to movement without
Management: support of cast
 Cast  Inform pt that swelling is common
- A rigid external immobilizing device that
is molded to the contours of the body Traction
- Functions:  The application of a pulling force to a part of the
To immbolize a reduced body
fracture NOTE: traction must be applied in the correct
To correct a deformity direction and magnitude; countertraction must be
To apply uniform pressure to used to achieve effective traction
underlying soft tissue
To support and stabilize Purposes:
weakened joints
 To minimize muscle spasms
Allow mobilization of
 To reduce, align, and immobilize fractures
unaffected part
 To reduce deformity
 To increase space between opposing surfaces
After application:
Assess for the 6P’s that may indicate neurovascular
Types of Traction:
compromise:
 Pain
A. Skin Traction- used to control muscle spasms
 Pallor
and to immobilize an area before surgery
 Pulselessness
- Cannot reduce a fracture
 Paresthesia Buck’s traction- for hip fracture
 Paralysis Russell’s traction- for hip and knee
 Poikilothermia fracture
Bryant’s traction - for hip fracture in
Nursing Care for Cast: children
 Do not use heat lamps on plaster cast Cervical traction- for soft tissues
 Use palms of hands, not finger tips, to support damage or degenerative disc dse of the
cast when moving or lifting patients cervical spine
 Elevate cast on pillows -to relieve spasm and pain at the neck,
 Leave cast expose to air until dry shoulders, and arms
 -to maintain alignment
Jessica A. Soh BSN-3B
Pelvic traction- for low back pain and I- infection prevention
to maintain alignment O- output and intake monitoring
B. Skeletal Traction N- nutrition (appropriate diet)
 Traction applied directly to the bone S- skin must be checked frequently
 Capable of reducing fracture
 Used to treat fractures of the femur, tibia, and Complications of Fracture
cervical spine Early:
 Kirschner wire, Steinmann’s pin, Crutchfield Local
tongs,Thomas splint or Pearson attachment  Vascular injury
 Damage to surrounding tissue, nerves or skin
Buck’s Traction  Hemarthrosis
 Used to reduce femoral fracture in children  Compartment syndrome or Volkmann’s
 Remove periodically to assess skin status ischemia
 Skin should be clean and dry  Wound infxn
 Position: flat or trendelenburg Systemic
 fat embolism
Russell’s Traction  shock
 Used to immobilize the hip/knees and to reduce  thromboembolism ( pulmonary or venous)
fracture  exacerbation of underlying dses such as DM or
 Heels should be off the bed CAD
 pneumonia
Bryant’s Traction
 Used to reduce femoral fracture in children Late:
 Buttocks are slightly elevated and clear off the Local
bed  delayed union, non-union or mal union
 Position: Flat  joint stiffness
 contractures
Cervical/ Crutchfield Tong  myositis ossificans
 Used to immobilize the cervical spine  avascular necrosis
 X-rays are taken to verify placement  algodystrophy (or Sudeck’s atrophy)
 osteomyelitis
Halo Vest Traction  grown disturbance or deformity
 Used to immobilize the cervical spine Systemic
 Avoid putting powder inside the vest  gangrene, tetanus, septicaemia
 Turn the patient as a unit  fear of mobilizing
 osteoarthritis
C. Balanced Suspension Traction
 Produced by a counter-force other than Compartment Syndrome
the client’s weight  vascular insufficiency and nerve compression
 Allows greater freedom for pt to move due to unrelieved swelling
body in bed  increased pressure on an enclosed space
causing decrease blood flow to area potentially
Provide Traction Care: threatening damage to and necrosis to
a. Ensure effectiveness of therapy surrounding area and nerves
- Weight should hang freely
- Maintain proper alignment Manifestations:
- Keep ropes and pulleys freely movable - new and persistent deep pan felt on area
b. Prevent complications of immobility - numbness, pins and needles sensation,
- Encourage coughing and deep- electricity-like characteristic of pain
breathing exercises - swelling, tightness, and bruising
- Increase fluid intake
- Provide high fiber, low calcium, high Management:
protein diet - elevate the area not higher than the level of the
- Assess for thrombophlebitis heart
c. Monitor neurovascular status of immobilized - bivalving
extremity - fasciotomy
d. Monitor and prevent infection at the pin site
e. Involves pt in pt care and help ac=void PRESSURE ULCERS
depression and boredom - due to inappropriately applied brace on soft
tissues that may cause tissue anoxia
TRACTION - common areas: heel, malleoli, dorsum of the
T- trapeze bar overhead is used to raise and lower the foot, head of fibula, anterior surface of patella
upper body - main pressure sites: medial epicondyle of the
R- requires free-hanging weights humerus and ulnar styloid
A- analgesic is given to relieve pain - to inspect: bivalving or cut an opening (window)
C- check the pt’s circulation (pulse) then applied with elastic compression or tape
T- temperature monitoring
Jessica A. Soh BSN-3B
Manifestations:
- pain and tightness in the area, warmth, staining
of cast if with drainage associated with foul
smell

DISUSE SYNDROME
- Muscle atrophy and loss of strength secondary
to immobilization
- Prevention:
Isometric exercise (tensing of muscles)
without moving the part- done hourly
during waking hours
Other exercises: muscle-setting
exercise (quadriceps-setting and
gluteal-setting)