ORTHOPEDICS

ANATOMY PHYSIOLOGY DIAGNOSTIC TESTS

Orthopedics
 Objectives:
After 5 hours of interactive discussion, the
learners will be able to:
1. recall anatomy and physiology of the
musculoskeletal system;
2. know the importance of assessment of
patients w/ musculoskeletal disorder;
3. compare & contrast the different
diagnostic procedures of clients w/
musculoskeletal disorders.
4. Understand the different nursing
responsibilities of the different diagnostic
procedures
 STRUCTURE &
FUNCTION OF THE
MUSCULOSKELETAL
SYSTEM
 Structure
1. Bones. The body
contains 206 different
bones
A. Types:
- Cortical bone
(compact bone) is
dense & looks smooth
& homogenous. Exists
in areas where support
is needed.
 Structure
- Cancellous bone
/trabecular bone
/Spongy is composed of
small, needlelike pieces
of bone & lots of open
space. Found where
hematopoiesis &
bone formation occur
 Bone classification according to
shape
:
- Long bones- are
found in the upper &
lower extremities
(femur). Are designed
for weight bearing &
movement. Composed
of cortical bone
 A long bone has several components.

 Diaphysis/ shaft
makes up most of the
bones length & is
composed of
cortical/compact)
bone.
 A long bone has several components.
 Periosteum
- are primarily
cancellous /trabecular
bone.
- covering of the bone w/c
is a dense, fibrous
membrane. Nourishes the
bone & facilitates its
growth. Contains nerves,
blood vessels & lymphatics.
Provides for attachment of
tendons & ligaments.
 A long bone has several components.
 Epiphyses are the ends of
the long bones that consist of
thin layers of compact bone
enclosing an area filled with
spongy bone.
 Epiphyseal plate/growth
plate nurtures & facilitates
longitudinal growth
It is the remnant of the
epiphyseal part that closes
when the growing bone has
reach its full length.
 A long bone has several components.

 Endosteum is a thin,
vascular membrane
that covers the
marrow cavity of
long bones & the
spaces in cancellous
bone
 Structure & function of the
Skeletal system:
- Short bones- are
irregularly shaped bones
located in the ankle &
hand (metacarpals).
Consist of cancellous
bone covered by layer of
cortical bone.
 Structure & function of the
Skeletal system:
- Flat bones- are located
where extensive
protection of underlying
structures is needed
(sternum & skull). Important
sites of hematopoiesis &
are made up of
cancellous bone layered
between compact bone.
 Structure & function of the
Skeletal system:
- Irregular bones-
have unique shapes
related to their
function (vertebrae & bones
of the jaw). Similar to that
of flat bones.
Bone marrow is vascular tissue located in the
medullary( shaft) cavity of long bones & flat bones.
 Yellow marrow is
primarily a storage
area for adipose
tissue, &
red marrow
( located in the sternum, ilium,
vertebrae & ribs)

produces red &

white blood cells.
 Skeleton is divided into two parts.
 The axial skeleton forms
the longitudinal axis of
the body in the skull, the
vertebral column, & the
bony thorax.
 The appendicular
skeleton is composed of
126 bones of the limbs &
the pectoral & pelvic
girdles, w/c attach to the
limbs of the axial
skeleton
 Bone is composed of cells, protein matrix, &
mineral deposits. 3 Basic CELL types:

1. Osteoblasts function in
bone formation by
secreting bone matrix
( consist of collagen & ground
substances- glycoproteins &
) that provides
proteoglycans

a framework in w/c
inorganic mineral
(composed of Ca & Ph) salts are
deposited
 3 basic cell types:
2. Osteocytes are mature
bone cells involved in
bone maintenance;
locates in lacunae (bone
matrix units).
 3 basic cell types:
3. Osteoclasts located
in shallow Howship’s
lacunae (small pits in
bones), are multinuclear
cells involved in
dissolving & resorbing
bone
- bone resorption &
remodeling
 Bone Functions:
1. Bone functions
 to support and to give shape to the body
 to protect the different structures of the
body
 to provide attachment for muscles,
tendons, and ligaments
 aids in the formation of blood cells
 regulates calcium and phosphate
concentrations
STRUCTURE & FUNCTION OF
THE ARTICULAR SYSTEM/
JOINTS
 Joint/ Articulation
CHARACTERISTICS OF
JOINTS:
- consist of bone ends which
are covered with cartilage &
enclosed in a capsule; cavity
is filled with synovial fluid
- traversed by ligaments
which hold the bones and the
joint in correct alignment
- traversed by muscles which
provide the force to move the
bones; muscles assist in
maintaining posture
 Joint/ Articulation
FUNCTIONS OF
JOINTS:
- hold the skeleton
together
- give the skeleton
mobility
 Articulations ( joints)- junction of 2 or more bones.
3 BASIC KINDS of JOINTS:

a. Synarthrosis
(fibrous) are
immovable
because of
fibrous tissue
banding( e.g.
skull sutures).
Articulations ( joints)- junction of 2 or more bones.
3 BASIC KINDS of JOINTS:

b. amphiarthrosis
(cartilaginous)
allow limited
motion (e.g.
vertebral joints;
symphysis pubis)
Articulations ( joints)- junction of 2 or more bones.
3 BASIC KINDS of JOINTS:

c. Diarthrosis
(synovial) are
freely movable
joints (e.g.
mandible,
vertebrae, ear
ossicles)
 Types of Diarthrosis/ synovial
joints:
1. Ball & socket
joints permit full
freedom of
movement (e.g.
hip; shoulder)
 Types of Diarthrosis/ synovial
joints:
2. Hinge joints
permit bending
in only one
direction, either
flexion or
extension(e.g.
elbows, knees)
 Types of Diarthrosis/ synovial
joints:
3. Saddle joints
allow movement
in 2 planes at
right angles to
each other( e.g.
base of the
thumb)
 Types of Diarthrosis/ synovial
joints:
4. Pivot joints allow one
bone to move around
a central axis w/o
displacement.
(articulation bet the
radius & the ulna).
They permit rotation
for such activities as
turning a doorknob.
 Types of Diarthrosis/ synovial
joints:
5. Gliding joints
allow for limited
movement in all
directions & are
represented by
the joints of the
carpal bones in
the wrist.
STRUCTURE & FUNCTION OF
THE SKELETAL MUSCLE
SYSTEM:
 Skeletal ( striated) muscles are attached by
tendons to bones, connective tissue, other
muscles, soft tissue, or skin.
a. The endomysium is the
delicate connective tissue
sheath that encloses each
muscle fiber.
b. The perimysium is a
coarse fibrous membrane
that wraps around muscle
fibers.
c. The fasciculi parallel
groups of muscle cells
d. The epimysium/ fascia – a
fibrous tissue w/c encases
fasciculi
Characteristics of Muscle Tissue

1. Excitability - ability to respond to stimuli

2. Contractility - ability to shorten forcefully
3. Extensibility - ability to stretch
4. Elasticity - ability to return to original shape and
length
 TYPES OF MUSCLE CONTRACTION:

1. concentric - muscle is actively shortening

ex. contraction of the biceps when lifting
a weight
2. eccentric - muscles are actively
lengthening
ex. lengthening of the biceps when
bringing down an object which has been
lifted
 TYPES OF MUSCLE CONTRACTION:
3. isometric - muscle is actively held at a fixed
length
ex. carrying an object in front of you - the
weight of the object would be pulling downward,
but your hands and arms would be opposing
the motion with equal force going upwards;
since your arms are neither raising nor
lowering, your biceps will be isometrically
contracting
4. passive stretch - muscle is being lengthened
while in a passive state
(i.e. not being stimulated to contract)
ex. the pull one feels in their hamstrings
while touching their toes
Isometric vs Isotonic contraction
isometric contraction
- length of the muscle remains constant but
the force generated by the muscle is
increased
ex. pushing against an immovable wall

* isotonic contraction
- shortening of the muscle with no increase in
tension within the muscle
ex. flexion of the forearm
 Skeletal muscle functions:
a. Facilitation of voluntary body movement
through contraction.
b. Maintenance of body posture.
c. Production of body heat
4. Ligaments are
ropelike bundles of
collagen fibrils. Binds the
articulating bones
together. Are pliable
enough to allow
movement of the joints;
but they can tear w/
excess stress.
- bind bone to bone
- provide joint stability &
allow restricted joint
movement
Ligaments
5. Tendons are
cords of fibrous
tissue that
connect/ bind
muscle to bone.
6. Cartilage is a
nonvascular, supporting
connective tissue composed
of various cells & fibers.
a. Hyaline cartilage is a
pearly, glass-like cartilage
that covers articular bone
surfaces (larynx & trachea,
joints)
b. Fibrocartilage consists of
a white, tough, fibrous
tissue found in the
intervertebral disc.
c. elastic cartilage is an
elastic, fibrous cartilage
found in the external ear.
 Cartilage functions:
a. Absorption of weight, shock, stress,
& strain.
b. Protection of bones, joints, & joint
tissue.
Nursing process overview

The Musculoskeletal system

 A. Assessment
1. Health history
a. Elicit a description of the client’s present illness &
chief complaints, including onset, course, duration,
location, & precipitating & alleviating factors. Cardinal
signs & symptoms indicating altered musculoskeletal
function include:
- moderate to severe pain
- inability to move body part
- localized edema
- altered sensation to affected area
- contour deformity & asymmetry
- contusions.
 A. Assessment
b. Explore the client’s health history for risk factors
associated with musculoskeletal disorders, such as:
- medical conditions or medications that would
cause dizziness, falls, or injuries.
- environmental or physical conditions or unsafe
behavior that would cause injuries
- decreased dietary intake of essential nutrients for
bone formation
- history of infrequent exercise & sedentary
lifestyle
- family history of musculoskeletal problems.
2. Physical examination
a. Inspection
- Note upright body alignment, including posture.
- Assess bone discrepancies, including contour,
length, alignment & symmetry.
- Assess the clients ability to move each joint
through its range of motion, noting smoothness,
pain, crepitus, and clicks.
- Note the client’s gait, including coordination,
rhythm, stride and balance.
- Assess the joint alignment, including symmetry,
size, shape, contour, stability, tenderness,
& edema.
- Note muscle discrepancies, including
 Physical Examination
b. Palpation
- palpate muscle mass, including
shape, size, symmetry, and firmness.
- Palpate muscle strength, including
symmetry, resistance, and contractility.
 B. Nursing diagnoses
1. Acute or chronic pain
2. Ineffective peripheral tissue perfusion
3. Impaired physical mobility
4. Risk for infection
5. Risk for injury
6. Bathing or hygiene, dressing or grooming,
feeding, or toileting self-care deficit
7. Deficient knowledge
8. Anxiety
 C. Planning & outcome
identification
 Goals of the client diagnosed with a
musculoskeletal disorder include:
a. Pain relief,
b. Maintenance of adequate tissue perfusion
c. Improved physical mobility
d. Prevention of infection & injury, achievement of
maximum level of self-care
e. Understanding the treatment regimen
f. Decreased anxiety
 D. Implementation
1. Perform a neurovascular assessment. Remember the 6 P’s:
pain, pulse, pallor, paresthesia, paralysis, polar)
a. Assess pain, w/c signals the beginning of muscle ischemia.
- Assess pain on a scale of 1 to 10
- Rule out complications that require medical intervention
- Take action: Medicate; use nonpharmacologic
interventions, such as relaxation, massage & guided
imagery; or call the health care provider.
- Institute appropriate safety measures.
- Evaluate the effectiveness of the medication or
nursing interventions.
 D. Implementation
b. Assess pulses; pulselessness indicates disruption
of arterial blood flow.
- Assess various locations, including radial,
brachial, pedal, posterior tibial, popliteal &
femoral pulses.
- Document pulse strength using a scale of 0 to
4+; 0, no pulse; 1+ weak; 2+ normal; 3+ strong; 4+
bounding
- Use a doppler device to verify pulselessness.

c. Assess for pallor, w/c indicates disruption of arterial

blood flow. Check capillary refill time, w/c should be
less than 3 seconds
 D. Implementation
d. Assess for paresthesia; nerve function may be
disrupted by nerve compression.
- Determine whether the client experiences
numbness, tingling sensation
- Ascertain whether the client feels pinching
or touching of an extremity.
- Determine whether the client can feel dull
or sharp touch sensation.
 D. Implementation
e. Assess for paralysis; increasing edema causes
nerve compression
- Determine whether the client can move & lift the
affected extremity.
- Ascertain whether the client can push the
affected extremity against pressure
f. assess for polar/ coldness w/c indicates disrupted
arterial blood flow.
- Determine whether the client’s extremity feels
cool or has a bluish color.
- Note whether the client complaints of a cold
extremity.
2. Provide pain relief.
a. Elevate the injured extremity above the level of the
client’s heart for the 1st 24 hours or as directed
b. Apply cold packs as directed for the first 24 hours.
3. Promote mobility. Assist the client with active &
passive ROM exercises for unaffected body parts to
help maintain function.
4. Prevent infection. Monitor the client’s vital signs,
assess for S/S of infection, & monitor the wbc count.
5. Protect the client from injury. Instruct the client in &
request a return demonstration of safe transferring,
ambulating & sitting techniques to prevent further
injury from immobilization or assistive device.
6. Promote the client’s participation in self-care activities
w/in limitation of the injury & treatment regimen.
7. Provide client & family teaching.
a. Provide explanations for the cause, treatment, &
expected course for the client w/ a musculoskeletal
disorder.
b. Provide additional teaching ,
8. Minimize anxiety. Assist the client w/ identifying &
addressing feelings of anxiety to include therapeutic
conversation, distraction therapy, or medication if
needed
COMMON DIAGNOSTIC TESTS
UTILIZED IN

ORTHOPEDICS
AND THEIR CORRESPONDING

NURSING
INTERVENTIONS
 Roentgenography
> e.g. radiography,
radiographs,
photographic images
> Detects
musculoskeletal
structure, integrity,
texture or density
problems. To
evaluate disease
progression &
treatment efficacy.
 Roentgenography
 X-rays pass thru the
body, diff. tissues absorb
different amounts of X-
rays; e.g., bones are
dense & absorb X-rays
well but soft tissues (skin,
fat, muscles & organs) allow
more X-rays to pass thru
them - the result is that
bones appear white on
the X-ray
Roentgenography
 Nursing interventions:Radiography
> handle injured area carefully
> administer analgesics as prescribed before the
procedure
> remove any radiopaque material e.g. metal,
jewelry
> shield the client’s testes, ovaries, or pregnant
abdomen, if x-ray must be performed
> instruct the client to be still during a radiograph
> inform the client that exposure to radiation is
minimal & not dangerous
> if staying with the client during a radiograph, the
health care provider must wear a lead apron
 Arthrocentesis
- process of inserting a
needle into a joint
cavity & aspirating
fluid e.g. synovial
fluid, blood, pus
- medication may also
be instilled into the
joint after aspiration
 Arthrocentesis
 Nursing Interventions:
> obtain informed consent
> apply compression
bandage postprocedure
as prescribed
> instruct the patient to rest
the joint for 8 to 24 hrs.
postprocedure
> instruct the client to notify
the physician if fever or
joint swelling occur
postprocedure
 Arthrogram
 an x-ray of the joint
wherein a contrast
media /radiopaque
substance is used to
visualize acute or
chronic tears of the joint
capsule or supporting
ligaments of the knee,
shoulder, ankles, hips, or
waist
 Arthrogram
> a preliminary film of the
joint is taken & the joint
cleaned with special
solution; infiltration with
local anesthetic is done
before placing a needle
into the joint area after
which, a contrast media
will then be injected
> X-rays pictures will then
be taken of the joint
 Nursing interventions -
Arthrogram
> some require total fasting from
food & fluids for 8hrs; some
require fasting for 8hrs.but
allows pt. to drink clear liquids
2 to 3 hrs. pre procedure
> assess the client for allergies
to iodine or seafood
preprocedure
> obtain an informed consent
> inform the client to remain still
during the procedure unless
he is asked to reposition
 Nursing interventions -
Arthrogram
> minimize use of the joint for 12
hrs. post procedure
 instruct client that joint may be
edematous & tender for 1 to 2
days postprocedure & treated
with ice packs & analgesics as
prescribed
> instruct client to notify the
physician if edema & tenderness
last longer than 2 days
> if air was used for injection,
crepitus may be felt in the joint
for up to 2 days
 Arthroscopy
- in arthroscopic exam, an
ortho surgeon makes a
small incision in the client's
skin & inserts pencil-sized
instruments containing a
small lens & lighting system
to magnify & illuminate the
structures inside the joint;
light is transmitted through
fiberoptic to the end of the
arthroscope that is inserted
into the joint
 Arthroscopy
 by attaching the
arthroscope to a
miniature television
camera, the surgeon
is able to see the
interior of the joint
through this very
small incision.
 Nursing interventions-
Arthroscopy
> fast for 8 to 12 hours
preprocedure
> obtain informed
consent
> administer pain
medication as
prescribed post
procedure
> apply an elastic wrap
for 2 to 4 days as
prescribed post
procedure
 Nursing interventions-
Arthroscopy
> non-weight bearing is
permitted once
sensation returns;
activity must be limited
during the next 1 to 4
days as prescribed
postprocedure
> instruct the client to
elevate the extremity as
often as possible for 2
days following procedure
& to place ice on the site
to minimize swelling
 Nursing interventions-
Arthroscopy
> crutch ambulation for
5 to 7 days post
procedure
> instruct client to notify
the physician if fever
or increased joint pain
occurs, or if edema
continues for more
than 3 days post
procedure
 DEXA (Dual Energy X-Ray
Absorptionmetry)
- Considered the golden
standard for measuring
bone mineral density
- uses low level of radiation
but detects low levels of
bone loss much better
than a simple X-ray
- some machines use
ultrasound waves rather
than x-rays
 DEXA (Dual Energy X-Ray
2 types: Absorptionmetry)
1. p(peripheral)-DEXA
- measures bones on the body’s
periphery e.g. heel, wrist, or finger
2. central DEXA
- measures bone density in
the center of the body e.g.
Spine & hip
- this can provide an accurate
diagnosis & method of tracking
your progress from year to year
 Nursing interventions - DEXA

> remove any metal

object which may
interfere with the x-
ray images
 Nursing interventions - DEXA
> a client who has received
a contrast material for
another study must wait
for 10 to 14 days before
the DEXA exam may be
performed

> instruct the client to

inform physician if she is
pregnant
 BONE SCAN
- uses tiny amounts of
radioactive materials
called tracers
(radionuclides)
- these tracers accumulate
in certain organs &
tissues such as bones
- tracers emit gamma
waves of radiation,
which are detected by a
special camera
 BONE SCAN
 a bone scan is the
opposite of a standard
X-ray examination

• a bone scan detects

skeletal Trauma &
disease by determining
the degree to which the
matrix of the bone “takes
up” a bone seeking
radioactive isotope.
 Nursing interventions – Bone
Scan
> hold fluids 4 hrs.
postprocedure
> obtain an informed
consent
> remove all jewelry & metal
objects
> following injection of the
radioisotope, the client
must drink 32oz. of water
(if not contraindicated) to
promote renal filtering of
excess isotope
 Nursing interventions – Bone
Scan
> 1 to 3 hrs. following
the injection, ask
client to void & then
perform the scanning
procedure
> inform client of the
need to lie supine &
remain motionless
when told to do so &
that procedure is not
painful
 Nursing interventions – Bone
Scan
> no special
precautions are
required post
procedure because
there is only a
minimal amount of
radioactivity
> monitor the injection
site for redness and
swelling
> encourage oral fluid
intake following the
procedure
 Bone / Muscle Biopsy
 may be done through
aspiration, punch,
needle or incision
biopsy; studies bone,
synovium or muscle
tissue.
 Nursing interventions: Bone/
muscle biopsy
> obtain informed
consent
> monitor for bleeding,
swelling, hematoma,
or severe pain
> elevate the site for 24
hrs. post procedure to
reduce edema
 Nursing interventions: Bone/
muscle biopsy
> apply ice packs as
prescribed post
procedure to prevent
hematoma
> monitor for signs of
infection post procedure
> inform the client that mild
to moderate discomfort
is normal post procedure
 EMG-NCV
(Electromyography - Nerve
-
Conduction
electromyography -
Velocity)
measures muscle
electrical impulses for
diagnosis of muscle or
nerve disease
- to perform EMG, a
needle electrode is
inserted through the skin
into the muscle tissue &
electrical activity is
observed while inserting
the electrode
 EMG-NCV
(Electromyography - Nerve
Conduction
- the electrical
Velocity)
activity is studied
during insertion of
the electrode
& when the
muscle is both at
rest & while
contracting
Myelogram
- a procedure in which
contrast material (dye or air)
that can be seen on an x-
ray, is injected into the
subarachnoid space of the
spine to detect herniation,
tumor, & congenital or
degenerative conditions of
the spinal canal.

- this is used to detect

abnormalities in the spinal
column, spinal cord, &
surrounding structures
 Nursing interventions -
Myelogram
Preprocedure:
> obtain informed
consent
> provide hydration for
at least 12hrs. before
the test
> assess clients for
allergies to iodine or
seafood (shellfish)
 Nursing interventions - Myelogram
Post procedure
> obtain vs & perform neurological
assessment regularly
> encourage fluids & monitor intake
and output
> the position is based on contrast
material used:
a. water-based dye - elevate
the head 15 to 30 degrees
for 8 hrs as prescribed
b. air - keep the head lower
than the trunk for up to 4hrs as
prescribed