4.

Volkmann's Canal
- channels that assist with blood
BONES
and nerve supply from
Functions: periosteum to osteon

1. Protection of vital organs Bone is for…

2. Framework to support body structure
• Bone Formation
3. Mobility
- Osteogenesis
4. Reservoir For immature blood cells
- Ossification (bone matrix is formed)
Classification of bones (shape) • Bone Maintenance
- Bone remodeling (old is removed,
1. Long bones
new is added)
a. Diaphysis- cortical bone/ compact
- Bone resorption (removal)
bone
• Bone Healing
b. Epiphyses- cancellous bone /
- Tobacco can restrict blood flow of
trabecular bone, Spongy
oxygen rich blood to the bones
2. Short bones- ankle and hands
- Affects calcium absorption and slows
3. Flat bones- extensive protection is
down production of RBC
needed
4. Irregular bones- vertebrae and jaw Four Stages of Bone Healing
Three Basic Types of Cells in the Bones 1. Hematoma Formation
2. Inflammatory phase
1. Osteoblasts - bone formation to provide
3. Reparative phase
framework
4. Remodeling
2. Osteocytes - mature bone cells for bone
Maintenance
3. Osteoclasts - multinuclear cells in Ligaments - bone to bone
dissolving /resorbing
Tendons - muscle to bone
Haversian System / Osteon
Cartilage - reduce fiction
- basic structural unit of
compact bone. Fascia - loose connective tissue
- microscopic functioning unit of Bursae- small sacs of CT when there is pressure
mature cortical bone
-
Gross Anatomy of Bone
MUSCLES
1. Periosteum
- covers the bone - contractability = movement
- nourish and facilitate growth Types of Contraction:
2. Endosteum
- covers marrow cavity 1. Isometric contraction - length of
3. Bone marrow the muscles remains constant but
• Red Bone Marrow - RBC, WBC, the force is increased.
platelets. Hematopoiesis 2. Isotonic contraction - shortening
of the muscle without an increase
• Yellow Bore Marrow- Fat
in tension

Michaela Katrice J. Macabangun, RN

Types of Muscle Tissues: Gait:
1. Skeletal -striated, voluntary 1. Smoothness and Rhythm
2. Visceral -smooth, involuntary - Limping motion is caused by painful
3. Cardiac weight bearing
Bone integrity:
ARTICULAR SYSTEM (JOINTS) 1. Deformity and Alignment
- abnormal angulation
- Provides Flexibility
- crepitus
Major Classification:
Watch for:
1- Synoarthroses (Fibrous)
1. Flexion/Extension
- allow no movement
2. Warm/cool skin
2. Amphiarthroses (Cartilaginous)
3. Color
- allow little movement
4. Capillary refill
3. Diarthroses (synovial)
5. Edema
- allow free movement
6. Constrictive device/ clothing
Joint Function:
PHYSICAL ASSESSMENT
1. ROM (use goniometer)
Posture: 2. Contracture- shortening of surrounding
joint structure
1. Kyphosis- increase curvature of the 3. Effusion- excessive fluid
thoracic spine 4. Joint deformity- may cause weakness
2. Lordosis- increase curvature of the
lumbar spine Watch for: Balloon Sign
3. Scoliosis- lateral curvature of the spine
Muscle strength and size:
Pain:
1. Atrophy and Hypertrophy
1. Bone pain- dull, deep ache; not related 2. Clonus- rhythmic contraction
to movement 3. Fasciculation- involuntary twitching,
2. Muscle pain- soreness/aching or muscle Determine bone density, texture,
cramps erosion
3. Fracture- sharp, piercing, relieved by
Grading for Muscle Strength
immobilization
1. (Sharp- bone infection, sensory nerve 5 Full resistance
pressure) 4 Moderate resistance
4. Joint pain- worsens with movement 3 w/out any resistance
Watch for: 2 w/ ROM if properly positioned
o pain with activity 1 Muscle contraction w/ palpation
o Steadily increasing pain 0 No muscle contraction
o Pain upon waking up in the
morning that eases by midday
o Pain that worsens throughout the
day

Michaela Katrice J. Macabangun, RN

Neurovascular Status:
1. Compartment Syndrome-
pressure within a muscle
compartment with permanent
damage
a. Pain
b. Pallor
c. Paralysis
d. Paresthesia
e. Pulselessness
❖ X-ray
- Determine bone density, texture,
erosion, and change in bone
relationships.
❖ Computed tomography (CT)
- More detailed cross-sectional image
of the body and is used to identify
the location and extent of fractures
❖ Magnetic resonance imaging (MRI)
- Noninvasive imaging to visualize and
assess torn muscles, ligaments,
cartilage, etc. It is noisy and will be
done in 30 to 90 minutes.
❖ Arthrography
- To identify the cause of any
unexplained joint pain and
progression of joint disease.
❖ Bone densitometry
- Detect fracture risk in pts. With
osteoporosis
Nursing Management:
1. MRI- knocking sound
2. Arthrogram- compression elastic
bandage, rest for 12hrs, avoid
strenuous activity, normal to hear
crackling or clicking in the joint for 24
to 48 hrs.
❖ Bone scan
- Detect metastatic and primary bone
tumors
Nursing Management:
1. There is moment of discomfort from
the isotope, but the radionuclide
poses no radioactive hazard
2. Increase fluid intake
3. Empty the bladder before scanning
❖ Arthroscopy
- direct visualization of the joint
Nursing Management:
1. Ice may be applied to control edema
and comfort
2. Elevate and extend joint
3. Avoid strenuous activity
❖ Arthrocentesis
- Joint aspiration to obtain synovial
fluid to relieve pain due to effusion
Nursing Management:
1. Hair removed from the site
2. Antispasmodic agents for discomfort
3. Ice (24-48hrs) post procedure
❖ Electromyography (EMG)
- Electrical potential of the muscles
and nerves.
- Evaluate muscle weakness, pain,
and disability
Nursing Management:
1. Ask about intake of anticoagulant
meds because it is contraindicated
2. Assess active skin infection
Michaela Katrice J. Macabangun, RN
❖ Biopsy ❖ Braces
- Determine structure and composition - Provide support and control
of bone marrow, bone, muscle, movement
synovium - Custom fit (long term)
- Does not compromise circulation
Nursing Management:
- Initial treatment to stabilize fracture
1. Monitor for edema, bleeding, pain,
Nursing Management:
hematoma formation, and infection.
2. Ice 1. Palm = wet plaster
2. Use wadding sheet/stockinet to
cover
❖ Physical Therapy 3. Watch for 5Ps, pressure ulcers, and
1. ROM Exercises (Active/Passive) disuse syndrome (isometric
2. Isotonic exercises- change in muscle exercises)
length and tension
3. Isometric exercises- ❖ Traction
contraction/relaxation of muscle (ex. - Uses pulling force to promote and
Hamstring, Gluteal setting, Kegel’s maintain alignment of an injured part
exercise)
Types of Traction:
❖ Assistive Devices 1. Straight/Running- straight line of the
1. Cane body in bed
2. Walker (up- back, down-front) 2. Balanced suspension- supports
3. Crutches affected extremity off the bed
3. Skin- for short term
❖ Casts
Nursing Management for ST:
- Molded to the contours of the body
to immobilize a reduced fracture a. Prevent wrinkling and slipping
b. Maintain proper position
Types of Casts:
(neutral)
1. Short arm- below the elbow c. Do not turn side to side
2. Long arm- axillary fold
Complications for ST:
3. Short leg- below knee
4. Long leg- middle 3rd of the thigh a. Skin breakdown
5. Walking- SLC/LLC reinforced for a. Nerve damage (foot drop
strength sensation)
6. Body- encircles the trunk b. Circulatory impairment (DVT)
7. Shoulder spica- body jacket that
encloses trunk 4. Skeletal- continuous traction to
8. Hip spica- encloses trunk and lower immobilize, position, and align
extremities fracture of tibia, femur, and cervical
9. Double hip spica- covers both legs spine. It drills metal wire.

❖ Splints Nursing Management:

- Simple and stable fracture and 1. Maintain neutral position
sprains 2. Muscle pain; weighs may be
too heavy
Michaela Katrice J. Macabangun, RN
 ❖ IMMOBILIZED UPPER EXTREMITIES
Nursing Management: LOW BACK PAIN
1. Rest Causes:
2. Elevate arm (above heart level) to
reduce swelling. Use pillow 1. Acute lumbosacral strain
3. Use sling when ambulating (to 2. Unstable lumbosacral ligaments & weak
prevent pressure) muscles
3. Intervertebral disc problems (L4-L5, L5-
❖ IMMOBILIZED LOWER EXTREMITIES S1)
4. Unequal leg length
Nursing Management:
S/Sx:
1. Legs supported at heart level (avoid
swelling). Use pillow 1. Acute back pain (<3m), Chronic back
2. Cold therapy (1-2 days) pain (>3m), and fatigue
3. Recumbent position to promote 2. Radiculopathy- pain radiating from
venous return diseased spinal nerve root
3. Sciatica- pain radiating from an inflamed
❖ ORTHOPEDIC SURGERY sciatic nerve)
1. ORIF: correction & alignment of 4. Paravertebral spasm- greatly increased
fracture muscle tone of the back postural
2. External Fixation: skin over the muscles.
fracture Medical Mngt:
3. Arthroplasty- repair of joint problem
through a scope/ open joint surgery 1. NSAIDS & short-term relaxant
4. Amputation 2. Opoid analgesics
LEVELS OF AMPUTATION 3. Antidepressants
a. Above/ Below elbow 4. Arcoxia (Etoricoxib)
b. AKA/BKA (knee) 5. Rest
c. Knee disarticulation- young & 6. Avoid strain (twisting, lifting,
active for prosthesis overreaching)
d. Syme- for extensive foot 7. Heat/cold application
trauma 8. Chiropractic (manipulation of spinal)
5. Bone graft- placement of bone tissue 9. Acupuncture
6. Fasciotomy- incision and diversion of 10. Massage
muscle fascia 11. Change position
12. Sitting for only 20-50mins
Complications:
Nursing Mngt:
1. Hemorrhage
2. Infection 1. Weaning to analgesics
3. Skin breakdown 2. Don’t remain in bed rest if severe pain
4. Phantom limb pain- CBT/Massage (deconditioning)
3. Firm and nonsagging bed
4. Avoid prone position (Lordosis)
5. Change position
6. Low stress aerobic exercises

Michaela Katrice J. Macabangun, RN

 OSTEOMYELITIS Medical Mngt:
- Infection of bone, bone marrow, and
1. NSAIDS & Analgesics
soft tissues.
2. Casts and Splints
- Direct/indirect invasion of pathogens
3. PT
in the bone
4. Surgery
- Staphylococcus Aerus and
Hemolytic Streptococcus Nursing Mngt:
S/Sx: 1. Elevate affected joint
2. Heat/Cold compression
1. Redness
3. ROM & strengthening exercises
2. Swelling
3. Warmth
4. Foul smelling drain
CARPAL TUNNEL SYNDROME
5. Intense pain/ tenderness
- Entrapment neuropathy that occurs
6. Guarding behavior
when the median nerve in the wrist is
Medical Mngt: compressed.
1. Proper care S/Sx:
2. Aseptic technique
1. Unable to do ROM in the hands
3. Debridement (Sequestrectomy)
2. Dry and shiny skin
4. IV antibiotic/ analgesics
3. (+) Tinel Sign
5. No weight bearing
6. Increase CHO, protein, Vit C Medical Mngt:
7. Aspiration/Drainage
8. Catheter (for antibiotic and irrigation) 1. NSAIDS
2. PT
Nursing Mngt: 3. Carpal Tunnel Release
4. Neurolysis (freeing of nerve fibers)
1. Immobilization
2. Heat application Nursing Mngt:
3. Proper wound care
1. Splint/ Immobilization
2. Warm compress
3. Gentle ROM daily
TENDINITIS & BURSITIS
Tendinitis- painful inflammation or tearing of
tendons, tendons-muscle, and tendon sheaths. PLANTAR FASCITIS
Affects the SHOULDER. - Inflammation of foot that support fascia
Bursitis- inflammation of 1 or more bursae (pad - Heel pain
like sac that contains synovial fluid. SF reduces Medical Mngt:
friction between tendons, ligaments and bones)
1. Stretching exercise
S/Sx: 2. Wearing shoes
1. Inflammation 3. Orthotic devices
2. Restricted degree of joint mobility 4. Corticosteroids

Michaela Katrice J. Macabangun, RN

 HALLUX VALGUS
- Bunich
CONTUSION
- Deformity of great toe deviated laterally
- Soft tissue injury produced by blunt
Medical Mngt: force (ecchymosis/bruising)
1. Shoes that conform or shape the foot S/Sx:
2. Corticosteroids
1. Pain
3. Surgical removal of exostosis and
2. Swelling
realignment of toes
3. Discoloration

STRAIN
CLUB FOOT
- Musculotendinous stress injury usually
- Foot is inward
caused by overuse, overstretching, or
Medical Mngt: excessive stress
1. Ponsetti method Degrees of Strain:
2. Manipulation and Casting’
Degree Definition S/Sx
3. Achilles tenotomy
First - Mild - Gradual onset
4. Bracing
degree stretching of of palpation
5. French method- stretched/manipulated muscle or - Induced
foot, taped, plastic splint) tendon tenderness
Nursing Mngt: - No loss of - Mild muscle
ROM spasm
1. Educate Second - Moderate - Pain with
2. Listen degree stretching passive ROM
3. Encourage - Partial tearing - Loss of
of the muscle strength
or tendon - Edema
- Ecchymosis
- Tenderness
Third - Severe - Severe pain
Degree muscle or - Ecchymosis
tendon - Edema
stretching - Loss of function
- Rupturing or
tearing of the
tissue

Diagnostic Test
1. MRI
2. Ultrasound
3. X-Ray (to rule out bone injury)

Michaela Katrice J. Macabangun, RN

 SPRAIN 2. Complete- bones are “out of joint”
- Injury to the ligaments caused by
S/Sx:
twisting or hyperextension
1. Acute pain
Degrees of Sprain
2. Change in awkward positioning of the
Degree Definition S/Sx joint
First - Mild - Mild pain 3. Decreased ROM
degree - Localized - Edema
hematoma - Local Medical Mngt:
formation tenderness 1. Immobilization
2. Reduction f the joint dislocation
Second - Moderate - Increase 3. Analgesics, muscle relaxant, anesthesia
degree - Partial tearing edema
4. Splints, cast, traction
of ligaments - Tenderness
- Pain with Nursing Mngt:
motion
- Joint instability 1. Neurovascular monitoring
- Partial loss of 2. PROM
normal joint 3. Watch for increasing pain, numbness,
function tingling, increased edema
Third - Severe - Severe pain
Degree - Completely - Increased FRACTURE
torn or ruptured edema - Complete/incomplete disruption in the
ligaments - Abnormal joint continuity of bone structure
- Avulsion of function
the bone Causes:
1. Bone is subjected to stress > that it can
NURSING MNGT FOR CONTUSION, STRAIN, absorb
& SPRAIN 2. Direct blows
3. Crushing forces
1. Protection- splinting/sling
4. Sudden twisting motions
2. Rest
5. Extreme muscle contractions
3. Ice- 24 to 72hrs; <20mins
4. Compression- bandage Classification:
5. Elevate- at or just above the heart
1. Location (proximal, midshaft, distal)
6. NSAIDS
2. Degree of break
7. Neurovascular Assessment q15m
3. Comminuted (fine grained)
8. Watch for Compartment syndrome (5Ps)
4. Break in the skin (open/close)
Open fracture grading:
JOINT DISLOCATION
TYPE I: clean wound <1cm long
- Articular surfaces of the distal and
proximal bones that form the joint are no TYPE II: larger wound w/out damage
longer in anatomic alignment. AVN.
TYPE III (A, B, C): highly contaminated
Types: w/ damage and traumatic amputation
1. Subluxation- partial dislocation and
does not cause as much deformity
Michaela Katrice J. Macabangun, RN
S/Sx: • Hypoxia
• Chest pain
1. Pain
2. Loss of function • Compartment syndrome
3. Deformity • Fasciotomy
4. Shortening Delayed complications:
5. Crepitus
6. Localized edema 1. Avascular Necrosis (AVN)
2. Complex Regional Pain Syndrome
Emergency Mngt: a. Dysfunctional peripheral and
1. Immediate immobilization CNS responses that mount an
2. Adequate splinting excessive response to
3. Neurovascular status precipitating event
4. Cover wound wt sterile dressing if open b. Sever burning pain, local edema,
fracture hyperesthesia, stiffness,
5. Rush to ED discoloration, vasomotor skin
changes, and tropic changes
Medical Mngt:
Nursing Mngt:
1. Fracture reduction- to prevent loss of
elasticity 1. Immobilization
a. CLOSED: bringing the bone 2. NSAIDS, Topical anesthesia,
fragments into anatomic Corticosteroids, Opiods
alignment through manipulation 3. Gabapentin/Elavil- treat neuropathic
and manual traction pain
b. OPEN: surgical approach,
internal fixation devices is used
Maintaining and restoring function:
ROTATOR CUFF INJURY
1. Immobilization
- Rip in tendon that connects one of the
2. Control edema- elevation/cold therapy
rotator muscles to the humeral head
3. Neurovascular status- circulation,
- Shoulder pain w/ arm abduction or
motion, sensation
rotation
4. Control restlessness, anxiety, pain
- 1 of the 4 tendons in the arm is violently
5. Gradual resumption of activities
stretched/torn
Nursing Mngt:
S/Sx:
1. Wound irrigation
1. Pain that worsen with activity
2. Debridement
2. Tenderness to palpation
3. Iv antibiotic
3. Difficulty in sleeping on affected side
Early complications: 4. Decreased ROM

1. Shock Nursing Mngt:

2. Fat embolism (Triad symptoms)
1. Rest
• Hypoxemia 2. PT (3-6M)
• Neurologic compromise 3. Direct injection of corticosteroid into
• Petechial rash (2 to 3 days) the shoulder joint
• Fever
Michaela Katrice J. Macabangun, RN
 RUPTURE OF TENDON OF ACHILLES 5. Yoga
- Traumatic rupture of achilles tendon 6. Acetaminophen, NSAIDS, COX-2,
occurs with the “pushing off” action of Topical analgesics, and
the gait Viscosupplementation
- Posterior ankle pain with audible “pop”
Surgical Management:
Nursing Mngt:
1. Osteotomy
1. Casting (2-8w) 2. Arthroplassty
2. Non weight bearing activities 3. Nursing Mngt:
3. PT 4. Pharmacologic
5. Non-pharmacologic
6. Education
7. Exercise and weight reduction

OSTEOARTHRITIS
- Degenerative joint disease (DJD) RHEUMATOID ARTHRITIS
- Nonsystematic, noninflammatory, - Autoimmune disease that causes joint
progressive disorder of movable joints pain
- Associated with aging and accumulated - Affects the lining of the joint (swelling)
trauma that can result in bone erosion and joint
- Characterized by ulceration of articular deformity
cartilage that leaves the underlying bone
exposed
- Slow and progressive, w/out
GOUTY ARTHRITIS
exacerbations and remissions
- Inflammatory arthritis
Types: - Tophi (crystalline deposits accumulating
in articular tissue)
• Primary DJD - Gouty nephropathy (renal impairment)
▪ Idiopathic, self-originated, - Uric acid urinary calculi
unknown
▪ Wear and tear 4 STAGES
• Secondary DJD 1. Asymptomatic hyperuricemia
▪ Trauma 2. Acute gouty arthritis
▪ Knee 3. Intercritical gout
S/Sx: 4. Chronic tophaceous gout

1. Pain Definitive Diagnosis:

2. Stiffness (Morning, 30mins) 1. Polarized light microscopy of
3. Functional impairment (enlarged) the synovial fluid of the
4. Mild inflammation involved joint
5. Crepitus
Medical Mngt:
Medical Mngt:
2. Colchine
1. Exercise 3. NSAIDS
2. Weight reduction 4. Corticosteroids
3. PT 5. Xanthine oxidase inhibitors
4. Massage
Michaela Katrice J. Macabangun, RN
 6. Dietary changes
7. Weight loss & avoid alcohol
Nursing Mngt:
1. Weight loss
2. Avoid alcohol
3. Avoid certain meds
4. Maintain weight

OSTEOPOROSIS
- Body loses too much bone, makes little
bone or both
Causes:
1. Inadequate calcium intake
2. Postmenopausal
3. Smoking
4. Advanced aged
5. Heavy caffeine
6. Vitamin D deficiency
7. Excess alcohol intake
8. Long term Heparin/
Costecosteroid
9. Use of laxatives or Antacids
Diagnostic:
1. Dual-Energy Xray Absorptiometry
(DEXA) Scan
Medical Mngt:
2. Increase calcium and Vitamin D
intake
3. Regular weight bearing exercises
(20-30m)
4. Exercise daily
5. Supplements (Calcium and Vit. D&C)
Nursing Mngt:
1. Relieve pain
2. Improve bowel elimination
3. Prevent injury

Michaela Katrice J. Macabangun, RN