Assessment of Musculoskeletal Function

Functions:
• Protection of vital organs
• Framework to support body structures, mobility
• Movement; produce heat and maintain body temperature
• Facilitate return of blood to the heart
• Reservoir for immature blood cells
• Reservoir for vital minerals

Structure
• 206 bones in the body
- Long bones
- Short bones
- Flat bones
- Irregular bones
• Joints
• Muscles

Bone Cells

Osteoblast
• Function in bone formation

Osteocytes
• Mature bone cells that function in bone maintenance
Structure of a Long Bone; Composition of Compact Bone • Located in the lacunae

Osteoclasts
• Multinuclear cells function in destroying, resorbing, and remodeling
bone
• Located in Howship lacunae
Bone Formation and Maintenance

Osteogenesis: process of bone formation

• Ossification: the process of formation of the bone matrix and
deposition of minerals
Bone is in constant state of turnover
Regulating factors
• Stress and weight bearing
• Vitamin D
• Parathyroid hormone and calcitonin
• Blood supply
Role of calcium

Bone Formation
• Osteogenesis (bone formation)
- begins long before birth.
• Ossification
- process by which the bone matrix is formed and hard
mineral crystals composed of calcium and phosphorus
- give bone its strength

Bone Maintenance
• During childhood, bones form by a process called modeling.
• By early adulthood (early 20s), remodeling is the primary process that
occurs.
• Maintains bone structure and function through resorption and
osteogenesis
• complete skeletal turnover occurs every 10 years

Bone Healing
Stage I: Hematoma formation
• 1 to 2 days after fracture

Stage II: Fibrocartilaginous callus formation

• Fibroblasts and osteoblasts migrate to fracture site

Stage III: Bony callus formation

• Ossification begins during 3rd or 4th week

Stage IV: Remodeling

• Osteoclasts remove necrotic bone
 Other Structures of the Joint
• Joint capsule
• Ligaments
• Tendons
• Bursa sac

Hinge Joint of the Knee

Joints: Junction of Two or More Bones

• Synarthrosis: immovable joints
• Amphiarthrosis: allow limited movement
• Diarthrosis: freely movable
- Ball and socket
- Hinge
- Saddle
- Pivot
- Gliding
Muscles
• Attached to bones and other structures by tendons
• Encased in a fibrous tissue—fascia
• Contraction
• Causes movement
• Uses energy in the form of ATP

• Sarcomere: the contractile unit of skeletal muscle that contains actin

and myosin
• Muscle cell fibers react to electrical stimulation
• Anaerobic pathways using glucose metabolized from stored glycogen
provide energy for more strenuous muscle activity

Muscle Maintenance
• Muscle tone
- Flaccid (w/o tone) Assessment of the Musculoskeletal System-History
- Spastic (>normal) • Include data related to function ability
- Atonic (denervated) • Family history
• Muscle actions • General health maintenance; occupation
- Exercise, disuse, and repair • Learning needs; socioeconomic factors
- Hypertrophy • Medications (include over-the-counter)
- Atrophy
Assessment of the Musculoskeletal System
• Physical Assessment
• Pain, tenderness, altered sensation
• Posture and gait
• Bone integrity
• Joint function
• Muscle strength and size
• Skin
• Neurovascular status
Diagnostic Tests
• Radiographs
• Computed tomography
• MRI
• Arthrography
• Bone densitometry
• Bone scan
• Arthroscopy
• Arthrocentesis
• Electromyography
• Biopsy
• Laboratory studies
Clinical Indications of Diagnostic Tests
• Study changes in the structure of the bone
• Assess for tumors, soft tissue injury, fractures
• Visualize torn muscles, ligaments, cartilage, herniated disks
• Identify cause of unexplained joint pain and joint disease progression
• Evaluation of bone mineral density

MRI
• May hear knocking sound
• Assess for contraindications
• Assess for allergies for contrast testing
• Be aware for claustrophobia

Arthrography
• acute or chronic tears of the joint capsule or ligaments
• contrast agent or air is injected into the joint cavity while a series of
x-rays is obtained.
• After an arthrogram, a compression elastic bandage is applied
• joint is rested for 12 hours.
• clicking or crackling in the joint for 1-2 days post-procedure is
normal, until the contrast agent or air is absorbed.

Management
• Most back pain is self-limited and resolves within 4 weeks with
analgesic agents, rest, and relaxation.
• Focuses on relief of pain and discomfort, activity modification, and
patient education.
• Nonprescription analgesic -acetaminophen (Tylenol) and
• Bone Scan nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, ibuprofen)
• detect metastatic and primary bone tumors, osteomyelitis, fractures, • Application of superficial heat and spinal manipulation (eg,
and aseptic necrosis. chiropractic therapy)
• radioisotope is injected IV. • Exercise regimens, spinal manipulation, physical therapy,
• Scan is performed 2 to 3 hours after the injection acupuncture, massage & yoga are all effective nonpharmacologic
interventions for treating chronic low back pain but not acute low
back pain
• Ask patient with low back pain to describe the discomfort (eg,
location, severity, duration, characteristics, radiation, associated
weakness in the legs)

• Arthrocentesis
• Joint aspiration to obtain synovial fluid
• Used in diagnosis of septic arthritis and and reveals hemarthrosis
(bleeding into the joint cavity)

• Electromyography (EMG)
• Provides information about the electrical potential of the muscles and
nerves
• Evaluate muscle weakness, pain, and disability
• Needle electrodes are inserted into muscles, and responses are
recorded on an oscilloscope.
Nsg Interventions for Pts w Low Back Pain
• Pain management
• Biopsy
• Exercise
• Determine the structure and composition of bone marrow, bone,
• Body mechanics
muscle, or synovium
• Work modifications
• Analgesic agents is provided.
• Stress reduction
• Monitor the site for edema, bleeding, pain, and infection.
• Health promotion; activities to promote a healthy back
• Ice is applied to control bleeding and edema.
• Dietary plan and encouragement of weight reduction

Common Upper Extremity Problems (Structures in the upper

Management of Patients With Musculoskeletal Disorders
extremities are frequently the sites of painful syndromes.)
Low Back Pain
• Bursitis and tendonitis
• Caused by lumbosacral strain, unstable ligaments and weak muscles
• Loose bodies (joint mice)
• Osteoarthritis of the spine, spinal stenosis, intervertebral disk
• Impingement syndrome
problems, and unequal leg length.
• Carpal tunnel syndrome
• Obesity, stress, and depression may contribute to low back pain.
• Ganglion
usually is aggravated by activity
• Dupuytren contracture
Manifestations
• Acute back pain (<3 mos)
BURSITIS AND TENDINITIS
• Chronic back pain (>3 mos without improvement) and fatigue.
• Inflammatory conditions that commonly occur in the shoulder.
• Pain radiating down the leg (radiculopathy or sciatica)
• Bursae are fluid-filled sacs that prevent friction between joint
structures during joint activity. CARPAL TUNNEL SYNDROME
• Painful with repetitive stretching. • Entrapment neuropathy that occurs when the median nerve at the
• Proliferation of synovial membrane and pannus formation wrist is compressed by a thickened flexor tendon sheath, skeletal
• Intermittent ice and heat to the joint, and NSAIDs to control the encroachment, edema, or a soft tissue mass.
inflammation and pain. • Most commonly occurs in women between 30 and 60 years of age.
• Caused by repetitive hand and wrist movements, but it may also be
LOOSE BODIES associated with arthritis, diabetes, tumors, or trauma
• May occur in a joint as a result of articular cartilage wear and bone • Hands are repeatedly exposed to cold, vibrations, or extreme direct
erosion. pressure
• Interfere with joint movement, locking the joint, resulting in painful • Pain, numbness, paresthesia, and weakness along the median nerve
movement. (thumb, index, and middle fingers).
• Removed by arthroscopic surgery. • Tinel’s sign help identify carpal tunnel syndrome
- Elicited by percussing lightly over the median nerve, if the
patient reports tingling, numbness or pain, the test is positive.
• Night pain is common.

IMPINGEMENT SYNDROME
• General term that describes all lesions that involve the rotator cuff of
the shoulder
• Usually occurs from repetitive overhead movement of the arm

• Research findings suggest that intraarticular injections of

corticosteroids are very effective at relieving symptoms.
• Application of wrist splints to prevent hyperextension and prolonged
• Traditional open nerve release or endoscopic laser surgery are the two
most common surgery
• Local anesthesia and involve making small incisions into the affected
wrist, cutting the carpal ligament so that the carpal tunnel is widened.
• Smaller incisions are made with the endoscopic laser procedure and
there is less scar formation and a shorter recovery time than with the
open method.
• Patient wears a hand splint and limits hand use during healing.
• Full recovery of motor and sensory function may take several weeks
or months.

Stage I
- Edema and hemorrhage of the rotator cuff tendons or
subacromial bursa
- May experiences pain, shoulder tenderness, limited
movement, muscle spasm, and eventual atrophy.
Stage II & stage III
- Progress to a partial or complete rotator cuff tear
GANGLION
• Collection of gelatinous material near the tendon sheaths and joints,
appears as a round, firm, cystic swelling, usually on the dorsum of
the wrist.
• Most frequently occurs in women younger than 50 years.
• Locally tender and may cause an aching pain.
• Treatment may include aspiration, corticosteroid injection, or
surgical excision.
• After treatment, a compression dressing and immobilization splint
are used.
DUPUYTREN’S DISEASE • Flatfoot: pes planus
• Results in a slowly progressive contracture of the palmar fascia
(Dupuytren’s contracture) Common Foot Deformities
• Causes flexion of the fourth and fifth fingers, and middle finger.
• Caused by an inherited autosomal dominant trait and occurs most
frequently in men who are older than 50 years

• Associated with arthritis, DM,gout, smoking, and alcoholism

• Starts as a nodule of the palmar fascia that may not change or may
progress to the skin in the distal palm and produces a contracture of
the fingers.
• Experience dull aching discomfort, morning numbness, cramping,
and stiffness in the affected fingers.
• This condition starts in one hand, but eventually both hands are
affected.
• Fingerstretching exercises or intranodular injections of
corticosteroids may prevent contractures
• Palmar and digital fasciectomies are performed to improve function. PLANTAR FASCIITIS
• Finger exercises are begun on postoperative day 1 or 2. • Inflammation of the foot- supporting fascia, presents as an acute
onset of heel pain experienced with the first steps in the morning
• The pain is localized to the anterior medial aspect of the heel and
diminishes with gentle stretching of the foot and Achilles tendon.

Nursing Care of the Patient Undergoing Surgery of the Hand or Wrist

• Surgery is usually an outpatient procedure
• Pt education is a major nursing need for a patient undergoing
outpatient surgery
• Neurovascular assessment is vital; every hour for the first 24 hours,
assess motor function only as prescribed; instruct patient in signs and
symptoms to assess and report
• Pain control measures: medication, elevation, intermittent ice or cold
• Prevention of infection: keep dressing clean and dry, wound care,
signs and symptoms of infection Mgt
• Assistance with ADLs and measures to promote independence • Exercise, wearing shoes with support and cushioning to relieve pain,
Common Foot Problems orthotic devices (heel cups, arch supports, night splints), and
- Caused by poorly fitting shoes, which distort normal corticosteroid injections
anatomy while inducing deformity and pain • May progress to fascial tears at the heel and eventual development of
• Plantar fasciitis heel spurs.
• Corn
• Callus CORN
• Ingrown toenail • Area of hyperkeratosis (overgrowth of a horny layer of epidermis)
• Hammer toe produced by internal pressure (underlying bone is prominent
• Hallux valgus • Congenital or acquired abnormality, commonly arthritis) or external
• Clawfoot: pes cavus pressure (ill-fitting shoes)
• Morton neuroma • Fifth toe is most frequently involved, but any toe may be involved.
 • Acute bursitis symptoms include a reddened area, edema, and
tenderness.
• Heredity, ill-fitting shoes, and aging

• Treated by a podiatrist by soaking and scraping off the horny layer

• Soft corns are located between the toes and are kept soft by moisture
• Treatment - drying the affected spaces and separating the affected
toes with lamb’s wool or gauze
• A wider shoe may be helpful

CALLUS
• Discretely thickened area of the skin that has been exposed to PES CAVUS
persistent pressure or friction. • Clawfoot
• Faulty foot precede the formation of a callus. • Refers to a foot with an abnormally high arch and a fixed equinus
• Felt padding with an adhesive backing is also used to prevent and deformity of the forefoot
relieve pressure. • Shortening of the foot and increased pressure produce calluses
• Orthotic devices can be made to remove the pressure from bony
protuberances

INGROWN TOENAIL (onychocryptosis)

• Free edge of a nail plate penetrates the surrounding skin
• Improper self-treatment, external pressure (shoes or stockings),
internal pressure (deformed toes, growth under the nail), trauma, or
infection.
• Active treatment consists of washing the foot 2x a day
• Local antibiotic ointment
• Decrease pressure of the nail plate on the surrounding soft tissue.
• Warm, wet soaks help drain an infection

HAMMER TOE
• Flexion deformity of the interphalangeal joint, which may involve • Orthotic devices alleviate pain and can protect the foot
several toes • In severe cases, arthrodesis (fusion) is performed to reshape and
• Usually an acquired deformity stabilize the foot.
• Tight socks or shoes may push an overlying toe back into the line of
the other toes. MORTON’S NEUROMA
• Corns develop on top of the toes, and tender calluses develop under • Aka plantar digital neuroma or neurofibroma
the metatarsal area. • Swelling of the third (lateral) branch of the median plantar nerve.
• Microscopically, digital artery changes cause an ischemia of
the nerve.

• Local injections of a corticosteroid and a local anesthetic agent may

• Wearing open-toed sandals or shoes that conform to the shape of the provide relief
foot • If these fail, surgical excision of the neuroma is necessary. Pain relief
• Manipulative exercises, and joints pads. and loss of sensation areimmediate and permanent.
• Surgery (osteotomy) may correct a deformity
• There is little evidence to support treatment of hammer toe when the FLATFOOT
patient does not report pain or other symptoms • Aka pes planus
• Common disorder in which the longitudinal arch of the foot is
HALLUX VALGUS diminished.
• Commonly called a bunion • Congenital abnormalities or associated with bone or ligament injury,
• Deformity in which the great toe deviates laterally muscle and posture imbalances, excessive weight, muscle fatigue,
• Marked prominence of the medial aspect of the first poorly fitting shoes, or arthritis.
metatarsophalangeal joint. • S/s include a burning sensation, fatigue, clumsy gait, edema, and
• Osseous enlargement (exostosis) of the medial side of the first pain.
metatarsal head • Exercises
• foot orthoses
 • Most prevalent bone disease in the world.
• Costly disorder not only in terms of money but also in terms of
human suffering, pain, disability and death.
• Progressive kyphosis (“dowager’s hump”)

Typical Loss of Height Associated With Osteoporosis and Aging

Risk Lowering Strategies

• Increased dietary calcium and vitamin D intake
• Smoking cessation
• Alcohol/caffeine moderation
• Regular weight bearing exercise
• Outdoor activity

Nursing Interventions
Metabolic Bone Disorders • Promoting understanding of osteoporosis
Osteoporosis • Relieving Pain
• Reduced bone mass, deterioration of bone matrix, and diminished • Improving bowel Elimination
bone architectural strength. • Preventing Injury
• Normal homeostatic bone turnover is altered
• Osteoclasts (resorption) is greater than osteoblasts (bone formation) Prevention
• Balanced diet high in calcium and vitamin D throughout life
• Bones become progressively porous, brittle, and fragile - fracture • Use of calcium supplements to ensure adequate calcium intake: take
easily. in divided doses with vitamin C
First clinical manifestation • Regular weight-bearing exercises: 20 to 30 minutes a day
• compression fractures of thoracic and lumbar spine, hip fractures, • Increases balance
and Colles’ fractures of the wrist. • Reduces incidence of falls and fractures
• Weight training stimulates bone mineral density (BMD)

Pharmacologic Therapy
• Calcium and vitamin D
• Bisphosphonates
• Calcitonin
• Estrogen agonists/antagonists
• Parathyroid hormone
• Receptor activator of nuclear factor kappa-B ligand inhibitors

Nsg Diagnoses of Pts w Osteoporosis

• Deficient knowledge about the osteoporotic process and treatment
regimen
• Acute pain related to fracture and muscle spasm
• Risk for constipation related to immobility or development of ileus
(intestinal obstruction)
• Risk for injury: additional fractures related to osteoporosis
Nsg Interventions of Pts w Osteoporosis
• Promoting understanding of osteoporosis and the treatment regimen;
education
• Relieving pain
• Short periods of rest
• Supportive mattress
• Intermittent local heat and back rubs
• Improving bowel elimination
• High fiber diet, increase fluids, stool softners
• Preventing injury
• Physical activity to strengthen muscles, improve balance, and prevent
disuse atrophy
Osteomalacia
• A metabolic bone disease characterized by inadequate bone
mineralization
• Softening and weakening of the long bones causes pain, tenderness,
and deformities caused by the bowing of bones and pathologic
fractures
• Deficiency of activated vitamin D causes lack of bone mineralization
and low extracellular calcium and phosphate
• Causes include gastrointestinal disorders, severe renal insufficiency,
hyperparathyroidism, and dietary deficiency
Treatment
• Physical, psychological, and pharmaceutical measures to reduce
discomfort and pain
• Correct underlying cause
• Kidney disease: supplement calcitriol
• Malabsorption: Increased doses of vitamin D and calcium are usually
recommended
• Exposure to sunlight may be recommended; ultraviolet radiation
transforms a cholesterol substance (7-dehydrocholesterol) present in
the skin into vitamin D
Gerontologic Consideration
• Nutritious diet
• Adequate intake of calcium and Vitamin D
• Spend more time in the sun
• Prevention, identification and management of osteomalacia in the
elderly
Paget Disease
• Disorder of localized bone turnover: skull, femur, tibia, pelvic bones,
and vertebrae
• Incidence: 2% to 3% of the population older than age 50 years
• More common in men, and risk increases with aging; familial
predisposition has been noted
• Pathophysiology: excessive bone resorption by osteoclasts is followed
by
increased osteoblastic activity; bone structure disorganized, weak, and
highly vascular
• Cause is unknown
• Manifestations include skeletal deformities, mild to moderate aching
pain, and tenderness and warmth over bones
• Symptoms may be insidious and may be attributed to old age or
arthritis; most patients do not have symptoms
• Pharmacologic management
• Antineoplastic therapy
• NSAIDs
• Calcitonin
• Bisphosphonates (etidronate—Didronel)
• Plicamycin (Mithracin): a cytotoxic antibiotic may be used for severe
disease resistant to other therapy
• Proliferation of osteoclasts which produces bone resorption
• Most patients never experience symptoms but have skeletal deformity
• Skull may thicken, and cranium but not the face is enlarged. This
gives the face a small, triangular appearance.
Musculoskeletal Infections
Osteomyelitis
• Infection of the bone
• Bone becomes infected in one of three ways:
• 1. extension of soft tissue infection
• 2. direct bone contamination
• 3. Hematogenous spread from other sites of infection
High risks are: • Osteoclastomas: benign for long periods but may invade local tissue
• Poorly nourished and cause destruction
• Elderly
• Obese
• Those with impaired immune system

Post-op surgical wound infection occurs within 30 days after surgery

Classified as: Incisional or Deep. Deep sepsis maybe classified as

Follows
Stage 1 - Acute Fulminating – occurs during the 1st 3 months after
orthopedic surgery
Stage 2 – Delayed Onset – between 4 and 24 months after surgery
Stage 3 – late Onset – 2 or more years after surgery

Nursing Interventions
• Relieving pain
• Improving physical mobility
• Controlling infection process
• Promoting home and community-based care

Septic (Infectious) Arthritis

• Joints can become infected thru spread of infection from other parts
of the body or directly thru trauma or instrumentation
• With warm, painful, swollen joint, with decreased ROM, systemic
chills, fever, and leukocytosis
Bone Tumors-Malignant (Primary)
Primary tumors
• High risk: older adults >80, and those with comorbid conditions such
• Osteosarcoma-most common and most often fatal
as
• Chondrosarcoma, Ewing sarcoma, fibrosarcoma
diabetes, RA, skin infections
Soft tissue sarcomas
• Most commonly single knee and hip joints
• Liposarcoma, fibrosarcoma of soft tissue, rhabdomyosarcoma
• Prompt recognition and treatment are key
Prognosis depends on the type and whether the tumor has
• Treatment includes aspiration of joint to remove fluid, exudate and
metastasized
debris; immobilization of joint; pain relief; and antibiotics

Bone Tumor-Metastatic (Secondary)

• More common than primary bone tumors
• Common primary sites that metastasize: kidney, prostate, lung,
breast, ovary, thyroid
• Metastatic tumors are most frequently found in the skull, spine,
pelvis, femur, and humerus and often involve more than one bone
(polyostotic)
• Treatment is palliative
• Goal: relieve pain and promote quality of life

Care of Pts w Bone Tumor—Assessment

• Onset and course of symptoms
• Knowledge of disease and treatment
Diagnostic Studies
• Pain
• Aspiration
• Patient coping
• Culture of Sinovial fluid
• Family support and coping
• Physical examination of area, including neurovascular status and
ROM
• Mobility and ADL abilities

Tumor—Postoperative
• Postoperative assessment as for a patient who has had orthopedic
surgery
• Monitor VS, LOC, neurovascular status, pain
• Signs and symptoms of complications
• Monitor laboratory results: WBC and serum calcium level
• Signs and symptoms of hypercalcemia

Bone Tumors-Benign
Collaborative Problems and Potential Complications
• More common, generally are slowgrowing, and present few symptoms
• Delayed wound healing
• Most common isosteochondroma
• Nutritional deficiency
• Bone cysts: expanding lesions withinthe bone
• Infection
• Osteoid osteoma: Painful tumor in children and young adults
• Hypercalcemia
Care of Pts w Bone Tumor—Planning
• Major goals include:
• Knowledge of disease process and treatment regimen
• Control of pain
• Absence of pathologic fractures
• Effective coping patterns
• Improved self-esteem
• Absence of complications

Care of Pts w Bone Tumor— Interventions

• Care is similar to that of patients who have undergone orthopedic
surgery
• Patient and family education regarding diagnosis, disease process, Types of Casts
and treatment Short-arm cast:
• Prevention of pathologic fractures • Extends from below the elbow to the palmar crease, secured around
• Support affected extremities at all times and handle gently the
• External supports or fixation devices may be required base of the thumb. If the thumb is included, it is known as a thumb
• Restrict weight bearing and activity as prescribed spica or
• Use of assistive devices gauntlet cast.
Long-arm cast
Care of Pts w Bone Tumor—Interventions • Extends from the axillary fold to the proximal palmar crease. The
• Promoting proper nutrition elbow usually is immobilized at a right angle.
• Administer antiemetics as prescribed
• Relaxation techniques
• Oral care
• Nutritional supplements
• Provide adequate hydration
• Use strict aseptic technique

Short-leg cast
• Extends from below the knee to the base of the toes.
• The foot is flexed at a right angle in a neutralposition.
Musculoskeletal Care Modalities Long-leg cast
• Extends from the junction of the upper and middle third of the thigh
to the base of the toes.
• Knee may be slightly
flexed.

Walking cast
• A short- or long-leg cast reinforced for strength.
Shoulder spica cast
• A body jacket that encloses the trunk, shoulder, and elbow.

Cast
• A rigid, external immobilizing device
• Uses
- Immobilize a reduced fracture
- Correct a deformity Body cast
- Apply uniform pressure to soft tissues • Encircles the trunk.
- Support and stabilize weakened joints Hip spica cast
• Materials: • Encloses the trunk and a lower extremity.
- nonplaster (fiberglass) • A double hip spica cast includes both legs.
- plaster of Paris
 • Requires 24 to 72 hours to dry completely, depending on its thickness
• Should be exposed to circulating air to dry and should not be covered
with clothing or bed linens
• Wet plaster cast appears dull and gray, sounds dull on percussion,
feels damp, and smells musty.
• A dry plaster cast is white and shiny, resonant to percussion, odorless,
and firm.

Splints
• Contoured splints of plaster or pliable thermoplastic materials may be
used for:
• Conditions that do not require rigid immobilization
• For those in which swelling may be anticipated
• And for those who require special skin care

Fiberglass Casts
• Composed of water-activated polyurethane materials that have the
versatility of plaster
• Lighter
• Stronger
• more durable than plaster
• Water resistant (thorough drying is needed)

Braces (i.e.,orthoses)
• Custom fitted to various parts ofthe body and are used to:
• Provide support
• Control movement
• And prevent additionalinjury
• Indicated for longer use than splints

• Consist of an open-weave, nonabsorbent fabric impregnated with cool

water– activated hardeners that bond and reach full rigid strength in
minutes.
• Heat is given off (an exothermic reaction) while the cast is applied.

• Should not be placed on a plastic surface.

• Prepare patient for the sensation of increasing warmth
• handle with the palms and not allowed to rest on hard surfaces or
sharp edges.

Plaster Casts
• Less costly and achieve a better mold than fiberglass casts
• Not as durable and take longer to dry.
• Rolls of plaster of Paris-impregnated bandages are wet in cool water
and applied smoothly to the body.
• Does not have its full strength until it is dry
• Assessing for neurovascular changes using “6 Ps”
• Pain
• Pallor
• Pulselessness
• Paresthesia
• Paralysis
• Poikilothermia
• (takes on ambient temperature)

Monitoring and treating pain
• Describe exact site, character, and intensity of pain
• Treat with elevation, ice packs, and analgesics
Pressure ulcer
• Caused by inappropriately applied cast
• Lower extremities most susceptible
• Patient reports painful “hotspot” and tightness
• Dx: May cut window in the cast for inspection and access
• Treatment: dressing applied over exposed skin

Collaborative Problems and Potential Complications

• Compartment syndrome:
• Serious complication
• Occurs from increased pressure in a confined space
• Compromises blood flow
• Ischemia and irreversible damage can occur within hours
• 6 Ps; pain - early indicator
• Treatment: Notify physician, cast may be removed, and emergency
fasciotomy may be necessary

Disuse Syndrome
• muscle atrophy and loss of strength
• Treatment: Isometric exercises, muscle setting exercises

Patient Education
• Impact of injury to physiologic functioning
• Activity, exercise, rest
• Medications
• Techniques for cast drying
• Controlling of swelling and pain
• Care of minor skin irritation
• Pad rough edges with tape or moleskin
• Blow with hair dryer to relieve itching
• Do not stick foreign objects into the cast
• Signs and symptoms to report:
• Persistent pain or swelling,
• Changes in sensation, movement, skin color or temperature
• Signs of infection or pressure areas
• Required follow-up care
• Cast removal and after care

External Fixation Devices

• Used to manage open fractures with soft tissue damage
• Provide support for complicated or comminuted fractures
• Pt requires reassurance because of appearance of device
• Discomfort is usually minimal, and early mobility may be anticipated
with these devices
• Elevate to reduce edema Principles of Effective Traction
• Monitor for s/s of complications • Whenever traction is applied, a counterforce must be applied.
• Pin care Frequently, the patient’s body weight and positioning in bed supply the
• Patient education counterforce
• Traction must be continuous to reduce and immobilize fractures
• Skeletal traction is never interrupted
• Weights are not removed unless intermittent traction is prescribed
• Any factor that reduces pull must be eliminated
• Ropes must be unobstructed, and weights must hang freely
• Knots or the footplate must not touch the foot of the bed

Types of Traction
• Skin traction
- Buck extension traction
- Cervical head halter
- Pelvic traction

• After application, extremity is elevated

• If there are sharp points on the fixator or pins, they are covered with
caps to prevent device- induced injuries
• Monitor neurovascular status of the extremity every 2 to 4 hours
• Assess each pin site for redness, drainage, tenderness, pain, and
loosening of the pin.
• Some serous drainage from the pin sites is to be expected.
• Clean each pin site separately 1-2 times a day with cotton- tipped
applicators soaked in chlorhexidine solution

Traction
• The application of pulling force to a part of the body
• Purposes
• Reduce muscle spasms
• Reduce, align, and immobilize fractures
• Reduce deformity
• Increase space between opposing forces
• Used as a short-term intervention until other modalities are possible
• All traction needs to be applied in two directions. The lines of pull are
“vectors of force.” The result of the pulling force is between the two
lines of the vectors of force
 Needs of Pts w/ Hip Needs of Pts w/ Hip Replacement Surgery
• Preventing Dislocation of Hip Prosthesis
• Correct positioning using splint, wedge, pillows
• Keep hip in abduction when turning, adduction when transferring
• Limited flexing of the hip; <90 degrees
Nsg Interventions in Skin Traction • Mobility and ambulation
• Patients usually begin ambulation within 1 day after surgery using
• Proper application and maintenance of traction walker or crutches
• Monitor for complications of skin breakdown, nerve damage, and • Weight bearing as prescribed by the physician
circulatory impairment • Drain use postoperatively
• Inspect skin at least 3x a day • Assess for bleeding and fluid accumulationReplacement Surgery
• Palpate traction tapes to assess for tenderness • Preventing Dislocation of Hip Prosthesis
• Assess sensation and movement • Correct positioning using splint, wedge, pillows
• Assess 6 Ps • Keep hip in abduction when turning, adduction when
• Assess for indicators of DVT transferring
• Assess for indicators of infection • Limited flexing of the hip; <90 degrees
• Evaluate traction apparatus and patient position • Mobility and ambulation
• Maintain alignment of body • Patients usually begin ambulation within 1 day after surgery using
• Report pain promptly walker or crutches
• Regular shifting of position • Weight bearing as prescribed by the physician
• Special mattresses or other pressure reduction devices • Drain use postoperatively
• Perform active foot exercises and leg exercises every hour • Assess for bleeding and fluid accumulation
• Elastic hose, pneumatic compression hose, or anticoagulant therapy • Prevention of infection
may be prescribed • Remove drain within 24 to 48 hours
• Pin care • Strict hygiene practices
• Exercises to maintain muscle tone and strength • At risk for up to 24 months
• Trapeze to help with movement• Assess pressure points in skin every • Prophylactic antibiotic may be given
8 hours • Prevention of DVT
• Assessing anxiety • Appropriate prophylaxis,
• Assisting with self-care • Instituting preventive measures, and
• Monitor and manage complications • Monitoring the patient closely for clinical signs of the development of
• Pressure ulcer DVT and PE
• Atelectasis and pneumonia • Patient education and rehabilitation
• Constipation
• Anorexia Needs of Pts With Knee Replacement Surgery
• Urinary stasis • Postoperatively
• Infection • Compression bandage on knee
• DVT • Assess neurovascular status every 2 to 4 hours
• Monitor for complications; VTE, infection, bleeding
Joint Replacements
• Used to treat severe joint pain and disability and for repair and mgt of • Wound suction drain
joint fractures or joint necrosis • Removed in 24 to 48 hours
• Frequently replaced joints include the hip, knee, and fingers • Antibiotics prophylactically
• Joints including the shoulder, elbow, wrist, and ankle may also be • Autotransfusion of extensive bleeding
replaced
• Continuous passive motion (CPM)
• Promote range of motion,
circulation, and healing
• Prevent scar tissue in knee
• Placed in device immediately
after surgery
• Physical therapy
• Strength and ROM
• Assistive devices
• Ambulate first post op day

• Acute rehab
• 1 to 2 weeks
• Total recovery 6 weeks

Strain
Pulled muscle injury to the musculotendinous unit,
• Overuse, overstretching, or excessive stress
• Pain, edema, muscle spasm, ecchymosis, and loss of function

Sprain
Injury to ligaments & supporting muscle fiber around a joint
• caused by wrenching or twisting motion.
• Joint is tender, and movement is painful, edema; disability and pain
increases during the first 2 to 3 hrs

Dislocation
Articular surfaces of the joint are not in contact
• A traumatic dislocation is an emergency with pain change in contour,
axis, and length of the limb and loss of mobility

RICE - IA
• Rest
• Ice
• Compression
• Elevation
• Immobilize
• Anti-inflammatory medications

Rotator Cuff Tears

• Results from injury or chronic joint stresses
• Pain (can’t sleep on the involved side), limited ROM, muscle
weakness

Management of Patients With Musculoskeletal Trauma
Contusions
Soft tissue injury produced by blunt Force
• Pain, swelling, and discoloration: ecchymosis
• Management –debridement (removal of devitalized tissues)
• Immobilize for several days to 4 weeks after surgery
• Full recovery is expected 6 to 12 months
 • Injury occurs when the foot is firmly planted, knee is hyperextended,
and the person twists the torso and femur
• Patient reports hearing of a “Pop” (feeling of tearing sensation)
• Mgt - RICE

Meniscal Injuries
• Menisci - 2 crescent-shaped cartilages in the knee
• Each moves slightly backward and forward to accommodate the
condylesof the femur when the leg is flexed or extended

Epicondylitis (Tennis Elbow)

• Chronic, painful condition that is caused by excessive repetitive
extension, flexion, pronation, and supination activities of the forearm

Rupture of Achilles tendons

• Occurs during activities with sudden contraction of the cuff muscle
with the foot fixed firmly to the floor or ground
Mgt
• Sharp pain, can’t plantar flex the foot
• Ice application, NSAIDS / pain medication
• Immediate surgical repair of complete achilles tendon ruptures is
• Immobilization (Cast or Splint)
usually recommended to obtain satisfactory results
Lateral and Medial Collateral Ligament Injury
• Injury of the ligaments (knee) occurs when the foot is firmly planted
and the knee is struck
• Inability to walk without assistance
• Mgt – RICE
• Assisting ambulatory devices
• Activity limitation

Anterior and Posterior Cruciate Ligament Injury

• Injury of the ligaments crossed in the center of the knee Fractures
• Closed or simple
• No break in the skin Medical Mgt
• Open or compound/complex • Fracture reduction: restoration of the fracture fragments to anatomic
• Wound extends to the bone alignment and positioning
• Grade I: 1 cm long clean wound • Closed
• Grade II: larger wound without extensive damage - Uses manipulation and manual traction
• Grade III: highly contaminated, extensive soft tissue injury, may have - Traction may be used (skin or skeletal)
amputation • Open
- Internal fixation devices hold bone fragment in position
(metallic pins, wires, screws, plates)
• Immobilization
- External (cast, splints) or internal fixations

Factors that Affect Fracture Healing

• Inadequate fracture immobilization
• Inadequate blood supply
• Multiple trauma
• Extensive bone loss
• Infection
• Poor adherence to prescribed restrictions
• Malignancy
• Certain medications (e.g., corticosteroids)
• Older age
• Some disease processes (e.g., rheumatoid arthritis)

Early complications of Fractures

• Shock
• Fat embolism
• Compartment syndrome
• VTE (venous thromboemboli, PE

Compartment Syndrome

Manifestations of Fracture
• Acute pain
• Loss of function
• Deformity
• Shortening of the extremity Delayed complications
• Crepitus • Delayed union, malunion, and nonunion
• Local swelling and discoloration • Avascular necrosis of bone
• Diagnosis by symptoms and radiography • Complex regional pain syndrome (CRPS)
• Patient usually reports an injury to the area • Heterotrophic ossification

Emergency Management Rehab Related to Specific Fractures

• Immobilize the body part
• Splinting: joints distal and proximal to the suspected fracture site
must be supported and immobilized
• Assess neurovascular status before and after splinting
• Open fracture: cover with sterile dressing to prevent contamination
• Do not attempt to reduce the fracture
• Clavicle
- Use of clavicular strap or sling
- Exercises for elbow, wrist, fingers asap
- Do not elevate arm above shoulder for approximately 6
weeks
- Humeral neck and shaft fractures
 - Slings and bracing
- Activity limitations until adequate period of immobilization

Femoral shaft fractures

• Lower leg, foot, and hip exercises to preserve muscle function and
• Elbow fractures improve circulation
• Monitor regularly for neurovascular compromise and signs of • Early ambulation stimulates healing
compartment syndrome • Physical therapy, ambulation, and weight bearing are prescribed
• Potential for Volkmann contracture • Active and passive knee exercises are begun as soon as possible to
• Active exercises and ROM are encouraged to prevent limitation of prevent restriction of knee movement
joint movement after immobilization and healing (4 to 6 weeks for
nondisplaced, casted) or after internal fixation (about 1 week)
• Radial, ulnar, wrist, and hand fractures
• Early functional rehabilitation exercises
• Active motion exercises of fingers and shoulder

• Pelvic fractures
• Management depends on type and extent of fracture and associated
injuries
• Stable fractures are treated with a few days of bed rest and symptom
mgt
• Early mobilization reduces problems related to immobility

Care of the Pt W Hip Fracture -Assessment

• Health history and presence of concomitant problems
• Pain
• VS, respiratory status, LOC, and signs and symptoms of shock
• Affected extremity including frequent neurovascular assessment
• Bowel and bladder elimination; bowel sounds, I&O
• Skin condition
• Anxiety and coping

Hip fracture Collaborative Problems and Potential Complications

• Surgery is usually done to reduce and fixate the fracture • Hemorrhage
• Care is similar to that of a patient undergoing other orthopedic • Peripheral neurovascular dysfunction
surgery or hip replacement surgery • DVT
• Pulmonary complications
• Pressure ulcers

Care of the Pt W Hip Fracture - Planning

• Major goals include:
• Relief of pain
• Achievement of a pain-free, functional, and stable hip
• Healed wound
• Maintenance of normal urinary elimination pattern
• Use of effective coping mechanisms
• Absence of complications

Relief of Pain
• Administer analgesics as prescribed
• Use of Buck traction as prescribed
• Handle extremity gently
• Support extremity with pillows and when moving • Psychological support
• Positioning for comfort • Prostheses fitting and use
• Frequent position changes • Physical therapy
• Alternative pain relief methods • Vocational or occupational training and counseling
• Use a multidisciplinary team approach
Prompting Physical Mobility • Patient teaching
• Maintain neutral position of hip
• Use trochanter rolls Care of the Pt W an Amputation—Assessment
• Maintain abduction of hip • Neurovascular status and function of affected extremity or residual
• Isometric, quad-setting, and gluteal-setting exercises limb and of unaffected extremity
• Use of trapeze • Signs and symptoms of infection
• Use of ambulatory aids • Nutritional status
• Consultation with physical therapy • Concurrent health problems
• Psychological status and coping
Care of the Pt W Hip Fracture - Interventions
• Use aseptic technique with dressing changes Care of the Pt W an Amputation—Diagnoses
• Avoid or minimize use of indwelling catheters • Acute pain
• Supporting coping • Impaired skin integrity
• Provide and reinforce information • Disturbed body image
• Encourage patient to express concerns • Grieving
• Support coping mechanisms • Self-care deficit
• Encourage patient to participate in decision making and planning • Impaired physical mobility
• Consult social services or other supportive services
• Orient patient to and stabilize the environment Collaborative Problems and Potential Complications
• Provide for patient safety • Postoperative hemorrhage
• Encourage participation in self- care • Infection
• Encourage coughing and deep breathing exercises • Skin breakdown
• Ensure adequate hydration • Phantom limb pain
• Apply TED hose or SCDs as prescribed • Joint contracture
• Encourage ankle exercises
• Patient and family teaching Care of the Pt W an Amputation—Planning
• Major goals include:
Common Sports-Related Injuries • Relief of pain
• Fracture; clavicle, wrist, ankle, metatarsal stress • Absence of altered sensory perceptions
• Dislocations; shoulder, elbow • Wound healing
• Sprains; wrist, ankle • Acceptance of altered body image
• Knee; sprain, strain and meniscal tears • Resolution of grieving processes
• Use of proper equipment; running shoes for runners, wrist guards for • Restoration of physical mobility
skaters, and so on • Absence of complications
• Effective training and conditioning specific for the person and the
sport Care of the Pt W an Amputation— Interventions
• Stretching • Relief of pain
• Hydration • Administer analgesic or other medications as prescribed
• Proper nutrition • Changing position
• Putting a light sand bag on residual limb
Rehab of Pts w Amputation • Alternative methods of pain relief: distraction, TENS unit
• Amputation may be congenital or traumatic or caused by conditions • Promoting wound healing
such as progressive peripheral vascular disease, infection, or • Handle limb gently
malignant tumor • Residual limb shaping
• Amputation is used to relieve symptoms, improve function, and
improve quality of life Resolving Grief & Enhancing Body Image
• The health care team needs to communicate a positive attitude to • Encourage communication and expression of feelings
facilitate acceptance and participation in rehabilitation • Create an accepting, supportive atmosphere
• Provide support and listen
• Encourage pt to look at, feel, and care for the residual limb
• Help patient set realistic goals
• Help patient resume self-care and independence
• Referral to counselors and support groups

Achieving Physical Mobility

• Proper positioning of limb; avoid abduction, external rotation and
flexion
• Turn frequently; prone positioning if possible
• Use of assistive devices
• ROM exercises
• Muscle strengthening exercises
• “Preprosthetic care”; proper bandaging, massage, and “toughening”
Rehabilitation Needs of the residual
limb

Educating About Self-Care

• Encourage active participation in care
• Continue support in rehabilitation facility or at home
• Focus on safety and mobility