ORTHOPAEDIC NURSING - located on bone surfaces

ANATOMY & PHYSIOLOGY of the - resorption pits

MUSCULOSKELETAL SYSTEM
B. Types of osseous tissue
FUNCTIONS:
1. Support a) Spongy/Cancellous
2. Protection
3. Body movement - forms the interior
4. Hemopoiesis
5. Fat storage - it will serve as reservoir - can withstand forces in many directions
(calcium, phosphorus…)
6. Mineral storage - has trabeculley?
SKELETON 300-350 bones in baby
b) Compact/Cortical
206 bones in adults
- Outer shell of a bone
- when old some of the bones are fused
- can withstand forces predominantly in one
• Axial - 80 bones direction

22 bones in skull OSTEON - Final unit of a compact bone

6 on the ossicles C. Bone classification

1 hoid bone According to shape:

25 Thoracic cage 1. long bones - often bears weight

26 vertebra column 2. short bones - small & bear little or no weight

- Cranium 3. flat bones - protect vital organs & often

contain blood forming cells
- Vertebrae
4. irregular bones - has unique shape
- Ribs
D. long bones have several components:
• Appendicular 126
• diaphysis - makes up most of the
• 4 bones pectural
bone’s length
• Scapula -
• periosteum - covers & protects the
• 6 bones in arm and forearm diaphysis

- Limbs • epiphyses - ends of the long bone

- Shoulder • epiphyseal line - remnant of the

epiphysial plate that closes when the
- Hips growing bone has reached its full length

A. Types of bone cells: • endosteum - covers the marrow cavity

of the long bones & the spaces in
a) Osteoblasts
spongy bones
- bone formation
E. Bone marrow
- When old, osteoblasts will lessen?
1. Red bone marrow - produces RBC, WBC &
b) Osteocytes platelets

- bone maintenance - @ birth red marrow only

c) Osteoclasts - primarily located in the ribs, vertebrae,

sternum, and bones of the pelvis
- bone resorption
- can be collected at iliac crest and the sternum
2. Yellow bone marrow - storage area for SKELETAL MUSCLES
adipose tissue
- the only muscle type subject to conscious
- located at internal cavity of long bones control

- in severe blood lost the body will convert the - muscles are attached by tendons to bones
yellow marrow back into red marrow to
Functions:
increase blood cell production

ARTICULATIONS - junctions or spaces between a) Provide the force to move bones

2 or more bones
- an area where 2 bones are attached for the
purpose of motion of body parts
Ligaments - Strong, elastic bands of tissue that
connect bone to bone
-hold the bone & joint in the correct position
- BBL(bone to bone) - Ligaments
- MBT (muscles to bone) - tendon
- MM (muscle to muscle)- Fascia
Joint capsules -tough, fibrous sheath
surrounding the articulating bone
SYNOVIUM - lined with synovial membrane
which secretes synovial fluid into the joint
capsule
b) Assist in maintaining posture
c) Assist in heat production
Types of muscle contraction:
1) isometric – “same length” length of the
muscle remains constant but the force
generated by the muscle is increased ; “static”
2) isotonic – “same tension” characterized by
shortening of the muscle with no increase in
tension within the muscle; “dynamic”
(photo)
YT video link: (Title: Isotonic & isometric
Contractions)
https://www.youtube.com/watch?
v=PHTUIwCnCe8
MINERALS & HORMONES AFFECTING
MUSCULOSKELETAL SYSTEM

BURSA - is a sac filled with synovial fluid that 1. Calcium

cushions the movement of tendons, ligaments,
and bones at a point of friction.

Types of joints 2. Phosphorus

a) synarthroses - fixed joints

b) ampiarthroses - slightly movable 3. PTH

c) diarthroses - freely movable

c.1. ball & socket - permit full freedom 4. Calcitonin

of movement
5. Vitamin D
c.2. hinge - permit movement in one
plane only
6. Growth hormone
C.3. Saddle - allows movement in 2
planes at right angles to each other.

c.4. pivot - allow for rotation, 7. Sex hormones

supination & pronation
MUSCULOSKEKETAL ASSESSMENT
c.5. gliding/plane joint - allows limited
movement in all direction Subjective Data

C.6. ellipsoid - allows movements in all PAIN

angular motions
Bone pain
---- 6 types of Synovial Joints picture
Muscular pain -allows direct visualization of a joint; treatment
of tears, defects and disease may also be
Sharp pain preformed
Pain that increases with activity

Altered Sensations/Sensory Changes 7. BONE SCAN

Paresthesia -imaging study with the use of a contrast
Objective Data radioactive material

Posture

Kyphosis 8. Electromyography

Lordosis -measures muscle electrical impulses for

diagnosing muscle or nerve disease
Scoliosis

Bone Integrity
9. BONE MARROW ASPIRATION
Joint Function
-usually involves aspiration of the marrow to
Neurovascular Status diagnose diseases like leukemia, aplastic
anemia
DIAGNOSTIC EXAMINATIONS

1. Radiography
10. ANA (Anti Nuclear Antibody)
-detects musculoskeletal structure, integrity,
texture or density problems 11. ESR (Erythrocyte Sedimentation Rate)

12. RF (Rheumatoid Factor)

2. CT Scans 13. SUA (Serum Uric Acid)

-show soft tissue, bone & spinal cord in 3 MUSCULOSKELETAL DISORDERS

dimensional, cross-sectional images
INJURIES

Strain - “muscle pull” from overuse,

3. MRI overstretching, or excessive stress

-allows study of soft tissue in multiple planes of

the body

Sprain - injury to the ligaments surrounding a

4. Arthrography joint, caused by wrenching or twisting motion

-injection of radiopaque substance or air into Management for strain & sprain:
the joint cavity to identify acute or chronic tears
of the joint capsule or supporting ligaments R

5. Arthrocentesis C

-involves aspirating of synovial fluid, blood or E

pus via a needle inserted into a joint cavity for H
examination or to relieve pain
I

S
6. Arthroscopy
Joint dislocations 3. Obvious deformity

dislocation 4. Crepitation

5. Erythema, edema, ecchymosis

6. Muscle spasm and impaired sensation

subluxation
Initial care of a fracture of an extremity

1. immobilize
Management:
2. splint the extremity; cover the wound with a
• immobilization
sterile dressing
• reduction
Medical management
• meds
1. REDUCTION
• passive ROM
-restores the bone to proper alignment
Fractures
a. Closed reduction
-break in the continuity of the bone
-is performed by manual manipulation
a. according to type
b. Open reduction
complete
-correction and alignment of the fracture after
incomplete surgical dissection and exposure of fracture

b. according to extent 2. FIXATION

• simple/closed a. Internal fixation

• compound/open -follows open reduction

c. according to lines of fracture -involves the application of screws, plates, pins,

or nails
greenstick
b. External fixation
spiral
-an external frame is used with multiple pins
comminuted applied through the bone

transverse 3. Traction

oblique -is the exertion of a pulling force applied in two

directions to reduce and immobilize a fracture

a. Skeletal traction
d. other specific types:
-is applied mechanically to the bone with pins,
avulsion
wires, or tongs
compression

epiphyseal
b. Skin traction
pathologic
-traction is applied by the use of elastics
Signs & Symptoms: bandages or adhesive

1. Pain or tenderness over the involved area a. Buck’s traction

2. Loss of function
 b. Russell’s traction

2. Cellular proliferation

c. Balanced Suspension Traction -3 days to 2 weeks

-is used with skin & skeletal traction 3. Callus formation

-2-6 weeks

Interventions: 4. Ossification

1. Maintain proper body alignment -3 weeks to 6 months

2. Ensure that the weights hang freely and do
not touch the floor 5. Remodelling
3. Do not remove or lift the weights without a
physician's order -6 months to 1 year
4. Ensure that pulleys are not obstructed and
that ropes in the pulleys move freely COMPLICATIONS of Fractures
5. Check the ropes for fraying
A. Fat embolism -is the release of fat globules
6. Avoid moving or jarring the bed
7. Inspect traction sites for signs of irritation or from the bone marrow into the venous
infection; do circulatory checks circulation after fracture

4. CASTS Signs & Symptoms:

- are made of plaster or fiberglass to provide -Restlessness

-Respiratory distress
immobilization of bone and joints after a
-Hypotension, Tachycardia, Tachypnea
fracture or injury
-Petechial rash over the upper chest and neck
Interventions:
Management:
1. Instruct to expect sensation of heat while the
cast is drying.
1. Prevention: careful handling, appropriate
2. Keep the cast and extremity elevated.
splinting, & avoidance of unnecessary
3. Handle with palms of the hands and not with
manipulation of injured areas
the fingertip.
2. Bedrest
4. Turn the extremity unless contraindicated.
3. Oxygen
5. Expose the cast to air and avoid use of fans,
4. Intubation
heat lamps, hair drier to unnaturally dry the
5. Fluid volume replacement
cast.
6. Corticosteroids
6. Petal edges when cast is totally dried.
7. Instruct the patient not to place sticks or any
B. COMPARTMENT SYNDROME - is increased
objects inside the cast
pressure within one or more compartments,
8. Use additional padding around bony
prominences causing massive compromise of circulation to
9. Monitor for the presence of a foul odor or an area
hot spots (infection) ; wet spots (need for drying
/ drainage) Signs & Symptoms:
10. Teach the client to keep the cast clean and
dry  Pain
11. Instruct the client in isometric exercises to  Paresthesia
prevent muscle atrophy  Pallor
12. Neurovascular checks; 6 P’s  Pulselessness
13. Prepare for window or bivalving if  Paralysis
circulatory impairment occurs
Management:

PHYSIOLOGY of BONE HEALING 1. Relief of the source of pressure: constrictive

bandage to be removed or cast to be bivalved
1. Hematoma formation 2. Elevation of affected extremity to heart level
3. Avoid cold application
-occurs 1-3 days after fracture 4. Analgesics
5. Fasciotomy

METABOLIC DISORDERS OF THE BONE

C. AVASCULAR NECROSIS-is an interruption in
the blood supply to the bony tissue, which A. OSTEOPOROSIS
results in the death of the bone
-is an age-related metabolic disease
Signs & Symptoms:

 Pain
Risk factors:
 Decreased sensation
1. Aging
Management:
2. Gender
1. Removal of necrotic tissue 3. Family history
4. Immobility; Sedentary lifestyle
2. Bone grafts 5. Medications (corticosteroids, heparin)
6. Diet
3. Prosthetic replacements
7. Prolonged Use of caffeine, cigarettes, alcohol
AMPUTATION - is the surgical removal of a part 8. Other diseases (osteomalacia,
of the body hyperthyroidism)

Signs & symptoms:

 Possibly asymptomatic
Pre operative interventions:
 Back Pain
1. Health teachings especially on acceptance of
situation  “Dowager’shump”
2. Strengthen extremities not affected, trunk  Pathologic fracture
and abdominal muscles
 Constipation, abdominal distention, and
Postoperative interventions : respiratory impairment

1. Monitor for infection and hemorrhage. Management:

2. Keep a tourniquet at the bedside.
a. Institute safety measures.
3. If prescribed, during the first 24 hours,
b. Provide range of motion exercises.
elevate the foot of the bed.
c. Provide a diet high in protein, calcium,
4. Do not elevate the stump itself.
vitamins C and D, and iron.
5. After 24 and 48 hours postoperatively,
d. Encourage adequate fluid intake & high fiber
position the client prone if prescribed.
diet
6. In the prone position, place a pillow under
e. Instruct the client to avoid alcohol and coffee.
the abdomen and stump and keep the legs
close together.
Medications:
7. Wash the stump with mild soap and water
and apply lanolin to the skin if prescribed. a. Exogenous calcium
8. Massage the skin toward the suture line.
9. Teach how to ambulate using crutches. b. Vit. D supplements
10. Encourage the client to look at the stump. c. Biphosphonates
11. Assist the client to identify coping
mechanisms to deal with the loss. d. Selective Estrogen Receptor Modulators

e. Calcitonin
Complications:
f. Hormone Replacement Therapy:
1. Hemorrhage
B. OSTEOMALACIA
2. Infection
-bone becomes abnormally soft because of a
3. Phantom limb sensation
disturbed calcium & phosphorus balance
4. Phantom limb pain secondary to Vit D deficiency
Etiology:  localized bone pain
 tenderness, heat & edema
*defiency in activated Vit D (calcitriol)  restricted movement
 purulent drainage from a skin abscess
 fever & chills
 Elevated ESR & WBC

Signs & symptoms:

Management:
 bone pain
♠ Prevention - main goal
 muscle weakness
 Spinal deformity ♠ Antibiotic therapy
 unsteady gait
♠ Infection control
Management:
♠ Surgery
1.daily Vit D supplement

2. adequate intake of calcium, phosphorus &

protein

• DISORDERS OF THE JOINTS

C. PAGET’S DISEASE (osteitis deformans) A. OSTEOARTHRITIS

-unknown cause - is a slowly progressive, degenerative joint

disease characterized by variable changes in
weight-bearing joints.

- Etiology: obesity, aging, trauma, genetic

Signs & symptoms: predisposition, and congenital abnormalities

 deep, aching bone pain Signs & symptoms:

 skeletal deformity ∞ Asymmetrical inflammation of joints
 pathologic fracture
 vertigo, hearing loss with tinnitus, & ∞ Joint pain
blindness
∞ Crepitus
Management:
∞ Heberden's nodes or Bouchard’s nodes
 Exercise
 Heat application Management:
 Diet rich in Calcium
• Immobilization
 Medications:
a. NSAID ex. Ibuprofen • Heat applications
b. Calcitonin
c. Biphosphanates: • Adequate rest
- etidronate disodium
(Didronel) • Encourage weight loss
- Alendronate sodium
(Fosamax) • Exercises should be active rather than
d. Mithramycin (Mithracin) – potent passive
antineoplastic
• Medications:
INFECTIOUS DISORDER OF THE BONE
- analgesics (Acetaminophen), NSAIDS
OSTEOMYELITIS (Celecoxib), corticosteroids

-infection of the bone • Totall Joint Arthroplasty / TJR

Signs & symptoms:

Nursing Management: - Minocycline

1. Proper alignment 3. Corticosteroids

2. Prevent flexion 4.Methotrexate

3. Avoid wt bearing C. GOUTY ARTHRITIS

4. Monitoring wound drainage -a genetic defects in purine metabolism that

5. Preventing DVT causes increased serum uric acid.

6. Preventing infection

7. Total Knee Replacement

8. CPM (continuous passive motion) SIGNS & SYMPTOMS

9. Ice 1. Excruciating pain & inflammation usually

small joints (PODAGRA)
10. Neurovascular check
2. Tophi
11. Monitor for drainage
3. Presence of renal stones
12. Neutral position
4. Elevation of Serum uric acid
B. RHEUMATOID ARTHRITIS
Managements:
-is a chronic systemic inflammatory disease
(immune complex disorder) a. Provide a low-purine diet; increase alkaline
ash foods; avoid alcohol and starvation diets
-leads to destruction of connective tissue and
b. Encourage a high fluid intake of 2000 ml.
synovial membrane within the joints
c. Rest & elevate the affected extremity.
Signs & symptoms:
d. heat or cold application
1. Morning stiffness
e. Medications:
2. Symmetric joint swelling
- NSAIDs
3. Subcutaneous nodules - Colchicine
4. Joint deformity
- Probenecid
5. Elevated ESR
- Allopurinol
6. (+) RF
DISORDERS OF THE VERTEBRA
MANAGEMENT: A. SCOLIOSIS

1.) Rest -lateral deviation of the spine from the midline

2.) Splinting
3.) Heat or cold application
4.) Positioning
5.) Exercise Signs & symptoms:
6.) Diet: High CHON, iron, vitamins
 Asymmetry of hip or shoulder
MEDICATIONS:  restricted respiration

1. Salicylates (acetylsalicyic acid [aspirin]) MANAGEMENT:

2. Nonsteroidal antiinflammatory drugs  Exercise

(NSAIDs)  Weight reduction
 Brace
2. Disease-Modifying Anti-Rheumatic Drugs
 Spinal fusion
(DMARDs)

- Hydroxychloroquine B. KYPHOSIS – increased forward curvature at

- Sulfalazine the thoracic spine
C. LORDOSIS – exaggerated curvature at the
lumbar spine
ASSISTIVE DEVICES
CANES
-Indicated to patient with minimal weakness of
lower extremities, with good balance and
coordination
-Place 4-6 inches to the side of the foot; hand
grips level with the greater trochanter
-Elbow should be flexed at 15 – 30 angle
-Cane is held on the hand
Opposite the Affected Leg
-Gait: device & affected leg,then unaffected leg
Ω Place feet next to crutches
E. Swing through
ю Advance both crutches
ю Lift both feet
ю Swing forward
ю Place feet in front of crutches
.
Assisting the client with crutches To Sit
 Place the unaffected leg against the
front of the chair
 Move the crutches to the affected side,
& grasp the arm of the chair with the
hand on the unaffected side
 Flex the knee of the unaffected leg to
lower self into the chair while placing
the affected leg straight out in front

Assisting the client with crutches in going up

WALKERS and down stairs
Up the stairs
-Provides more support and stability than canes  the unaffected leg up first.
or crutches  then affected leg and the crutches up
-Put all four points of the walker flat on the
floor before putting weight on the hand pieces Down the stairs
-Instruct to move the walker forward & walk  crutches and the affected leg down
into it first.
 then unaffected leg down
CRUTCHES

 2 inches below the axillary folds

 6 inches diagonally from small toe
 Elbow is at approximately 30 degree
flexion
 Place the weight on the hand piece not
the axilla

Crutch gaits
A. Four point gait
 Advance left crutch
 Advance right foot
 Advance right crutch
 Advance left foot

B. Two point gait

∞ Advance left crutch and right foot.

∞ Advance right crutch and left foot.

C. Three point gait

♠ Advance both crutches & affected leg

♠ Advance unaffected leg

D. Swing to

Ω Advance both crutches

Ω Lift both feet
Ω Swing forward