MUSCULOSKELETAL DISORDERS Diagnostic Evaluation: X-ray

Process of Management
Grading of Muscle Strength 1. Reduction - the restoration of the fracture
fragments into anatomic position and alignment
5/5: Normal: patient moves the joint through full ROM
by closed reduction with external fixation or by
and against gravity with full resistance.
open reduction with internal fixation.
4/5: Good: patient completes ROM against gravity with 2. Immobilization - maintenance of reduction until
moderate resistance; slight weakness. bone healing occurs by the use of cast
(fiberglass/POP), traction (skin/skeletal), brace
3/5: Fair: patient completes ROM against gravity only; & splint.
average weakness 3. Rehabilitation
2/5: Poor: patient completes ROM with gravity
eliminated; poor ROM Nursing Management
1. Immobilize the fractured extremity with a splint
1/5: Trace: patient’s attempt at muscle contraction is in the position of deformity before moving the
palpable but without joint movement; severe weakness. client & support above and below the fracture
site when repositioning the client.
0/5: Zero: no evidence of muscle contraction; paralysis.
2. Cover any breaks in the skin with clean or sterile
dressings.
Range-of-motion exercises (ROM)
3. Elevate the affected extremity above heart level
1. Passive ROM - an exercise carried out by the & application of cold packs within 24 hours.
therapist or nurse without assistance from the 4. Relieve pain & discomfort (non-pharmacological
patient. & pharmacological pain management)
2. Active-Assistive - an exercise carried out by the 5. Promote physical mobility (AROM exercises of
patient with the assistance of the therapist or
unaffected parts of the body & isometric
nurse.
3. Active ROM - an exercise accomplished by the exercise to affected parts).
patient without assistance.
Compartment Syndrome - a condition involving an
4. Active-Resistive - an active exercise carried out
by the patient working against resistance by increased pressure within an anatomic compartment in
either manual or mechanical means. the arm or leg leading to constriction of nerves & blood
vessels
FRACTURE - is a break in the continuity of bone
Etiology: decrease in compartment size & increase in
Etiology: result from crushing force/direct blow, sudden compartment content.
twisting movement, & extreme forceful muscle
contraction Pathophysiology:
Fracture
Pathophysiology: ↓
The stress placed on a bone exceeds the bone’s ability to Edema of muscle tissue in the compartment & tight cast
absorb it. ↓
↓ Increased P⁰ within the closed compartment
Disruption (break) in the continuity of bone & in severe ↓
cases blood vessels, nerve, muscle, & skin may be Vessel compression (deceased tissue perfusion)
damaged ↓
↓ Nerve & Muscle ischemia → necrosis
Bleeding & hematoma formation ↓
↓ Permanent nerve & muscle damage
Bone tissue surrounding the fracture site dies ↓
↓ Permanent loss of function or amputation
Inflammatory response
Clinical Manifestations: “6 Ps” Pallor, Pulselessness,
Types of Fracture Poikilothermia, Pain, Paresthesia, & Paralysis
1. Complete - involves the entire cross-section on
the bone, usually displaced Collaborative Management
2. Incomplete - involves only a portion of the 1. Early detection and elevation of extremity at the
cross-section of the bone heart level and application of cold packs.
3. Closed or simple - skin not lacerated 2. Notify physician immediately for prompt
4. Open or compound - skin lacerated with or treatment to relieve pressure
without protrusion of bone 3. Remove tight cast/dressing
5. Pathological: a fracture in an area of diseased 4. Surgical Management: Fasciotomy
bone
6. Stressed: due to prolonged, repeated use of the Fat Embolism- fat globule diffuse from the marrow into
bone the venous circulation at the time of fracture occluding
small blood vessels especially in pulmonary capillaries
Clinical Manifestations
Clinical manifestations
1. Pain (sharp) at the site of injury aggravated by
1. Respiratory distress- tachypnea, tachycardia,
movement
crackles, wheezes, dyspnea, acute pulmonary
2. Swelling & tenderness
edema, and sputum production.
3. Abnormal movement & crepitus
2. Mental disturbances- irritability, restlessness,
4. Deformity
confusion, disorientation, stupor, & coma.
5. Loss of function
6. Ecchymosis
Nursing Management
7. Paresthesia
1. Evaluate changes in mental status & ABG values
 2. Position: high or semi fowler’s position Surgical Management
3. Encourage coughing & deep breathing exercise. 1. Osteotomy
4. Administration of oxygen as prescribed 2. Arthroplasty - surgical repair and replacement of
the diseased or damaged joint with prostheses

CLUB FOOT (Talipes Equinovarus) - congenital RHEUMATOID ARTHRITIS - a chronic progressive

deformity in which the affected foot and leg have a club-
like appearance.
Etiology: (Unknown) mixed genetic & environmental.
Incidence: males are affected more
Clinical Manifestations
1. Foot is twisted downward and inward
2. Child bears weight on the lateral border of the
foot → formation of callus over the lateral side
of the foot
Diagnostic Evaluation: based on clinical manifestations
and X-ray
Collaborative Management
1. Early recognition and prompt treatment
2. Manipulation of the foot into normal position,
with or without serial casting.
Surgical Management
1. Tenotomy - lengthening of the Achilles tendon
2. Osteotomy – surgical cutting of bone
3. Tendon Transfer - anterior tibial tendon transfer
on the lateral aspect of the foot.
Nursing Management
1. Corrective passive stretching exercises into the
normal position of the foot.
2. Serial casting to maintain the correction gained
by manipulation.
3. Observe toes for signs of circulatory impairment
and skin irritation during cast/splint application.
4. Denis Browne splint: worn day and night for
about 23 hours except for periods of exercise
and bathing for about 3 months and then only at
night for 2-4 years to assist in maintaining the
corrected position of the foot accomplished by
manipulation and serial casting.
OSTEOARTHRITIS – slowly progressive degenerative
disease affecting the articular cartilage of weight-bearing
joints
Risk Factors: Aging (5th to 6th decade), obesity, trauma,
repetitive use, and genetic predisposition
systemic autoimmune disease that primarily affects the
synovial membrane of the small peripheral joint of hands,
wrist & feet. Symmetrical and bilateral affectation
Etiology: Unknown
Incidence: Women are more affected.
Pathophysiology:
Deterioration Synovitis → (↑) synovial fluid→
joint swelling→ pain
Pannus formation
↓
Attraction of phagocytes
↓
Release of the lysosomal destructive enzyme
↓
Cartilage & bone destruction & erosion
↓
Ankylosis
Clinical Manifestations
1. Joint pain even when not in use
2. Signs & symptoms of inflammation
3. Morning joint stiffness
4. Limitation of motion
5. Hand and feet deformity
a. Ulnar deviation of the fingers
b. Swan neck deformity: hyperextension
of the PIP joints with flexion of the DIP
joints
c. Boutonniere’s deformity: flexion of the
PIP joints with hyperextension of the
DIP joints
6. Subcutaneous (Rheumatoid) nodules
7. Systemic manifestations: fatigue, anorexia,
malaise, weight loss, fever, anemia, lymph node
enlargement & muscle atrophy in later stage
Diagnostic Evaluation
1. Elevated ESR & (+) Rheumatoid factor
2. X-ray: bony erosion & narrowed joint space

Pathophysiology:
Medical Management: Pharmacotherapy
Deterioration of articular cartilage of joint
↓ 1. Aspirin
Osteophytes formation at joint margin & subchondral 2. NSAID’s: anti-inflammatory and analgesic
areas a. celecoxib (Celebrex)
↓ b. naproxen (Naprosyn), salicylates
Friction due to bone to bone contact of the joint (Dolobid), ibuprofen (Advil),
↓ indomethacin (Indocin), diclofenac
Joint damage & pain (Voltaren) , ketorolac (Toradol)
3. Gold Compounds (chrysotherapy) like gold
Clinical Manifestations
1. Joint pain aggravated by use sodium thiomalate (Myochrysine); auranofin
(Ridaura)
2. Morning joint stiffness
3. Limitation of motion 4. Corticosteroids like prednisone, prednisolone,
4. Crepitus hydrocortisone
5. Nodes (Heberden’s & Bouchard’s) 5. Methotrexate (Rheumatrex)

Diagnostic Evaluation: enlarged joint & narrowing of the Surgical Management

1. Synovectomy: removal of the synovial
joint space on X-ray
membrane
Collaborative Management 2. Arthroplasty
1. Weight reduction
2. Hot compress Nursing Management
3. Analgesic 1. Bed rest & immobilize the affected joints using
4. Trunk assistive devices splint during the acute period
5. Joint rest 2. Cold and heat application to relieve pain and to
decrease swelling.
3. ROM exercise within pain limits
GOUT- a disorder of purine metabolism that results in HERNIATED NUCLEUS PULPOSUS- protrusion of the
hyperuricemia nucleus pulposus of the IV disc into the annulus fibrosus
Incidence: male & primarily affects the big toe
Predisposing Factors: aging, heavy lifting & trauma
Pathophysiology:
Hyperuricemia Pathophysiology:
↓ Rupture of the annulus fibrosus
Formation of urate (uric acid) crystals ↓
↓ Protrusion of nucleus pulposus
Precipitation of uric acid crystals to joints, connective ↓
tissues & may occur in the kidneys Compression of the spinal nerve roots
↓
Tophi formation Clinical Manifestations (Lumbar Disc)
↓ 1. Lower back pain radiating the affected leg
Joint irritation 2. Weakness on affected leg & foot
3. Numbness on affected leg, foot & toes
Clinical Manifestations 4. Muscle spasm
1. Signs and symptoms of inflammation 5. (+) straight leg raise test (Lasegue’s sign)
2. Tophi (metatarsophalangeal joint)
3. Oliguria, low back pain, and HPN Diagnostic Evaluation: MRI
4. Joint damage
Medical Management
Nursing Management 1. Analgesic & Anti-inflammatory agents
1. Increase the fluid intake of at least 2-3 L/day 2. Muscle relaxant (methocarbamol,
2. Dietary modifications cyclobenzaprine)
a. Avoid purine-rich food
b. Avoid alcohol and caffeine Surgical Management
3. Bed rest for 24 hours after the attack 1. Chemonucleolysis – injection of chymopapain
4. Ice compress to affected joint into the herniated lumbar disc
5. Elevation of the affected extremity 2. Laminectomy – excision of a part of the
posterior arch of the vertebra
Medical Management 3. Discectomy – excision of an IV disc
1. Allopurinol (Zyloprim)- inhibit uric acid
production Nursing Management
2. Probenecid (Benemia, Benemid)- ↑ excretion of 1. Bed rest on a firm mattress
uric acid & ↓ serum urate level 2. Heat application
3. Colchicine- ↓ deposition of uric acid crystal & ↓ 3. Teach patient proper body mechanics
inflammation
CARPAL TUNNEL SYNDROME - compression of the
OSTEOPOROSIS- loss of bone matrix and diminished median nerve as it passes through the carpal tunnel from
bone architectural strength leading to bone weakness the wrist to the hand
making it susceptible to fracture
Risk factors: Etiology
1. Aging 1. Thickening of the flexor tendon sheet
2. Diet
2. Skeletal encroachment
3. Lifestyle 3. Edema or soft tissue mass in the wrist

Pathophysiology:
Pathophysiology:
The rate of bone loss is greater than the rate of bone
Compression or entrapment of the median nerve
formation
↓
↓
Median nerve injury or damage
Reduce total bone mass due to loss of bone matrix
↓
↓
Sensory & motor disturbances in the parts of the hand
Bone demineralization
innervated by the nerve
↓
↓
Bones become progressively porous, brittle, and fragile
Pain & loss of function
↓
Pathologic fracture
Clinical Manifestations
1. Pain, numbness & weakness of the thumb, index
Clinical Manifestations
& middle fingers
1. Decrease in height
2. (+) Tinel’s sign & (+) Phalen’s sign
2. Kyphosis →pulmonary insufficiency
3. Back pain
Medical Management:
4. Pathologic fracture
1. Analgesic & anti-inflammatory drugs
2. Vitamin B6
Medical Management
1. Calcium and Vitamin D supplement
Surgical Management: Transverse Carpal Ligament
2. Bisphosphonates
release

Nursing Management
Nursing Management
1. Diet: high in calcium, Vitamin D & protein
1. Rest & application of wrist splint
2. Exercise (at least 30 mins, 5 X a week)
2. Avoid repetitive flexion of the wrist
3. Avoid the use of tobacco, alcohol, caffeine &
3. Cold compress
carbonated beverages
DUCHENNE’S MUSCULAR DYSTROPHY- progressive a. Meticulous skincare to areas in contact
muscle weakness and wasting of the skeletal muscles with the brace
b. Use of smooth fitting undershirt under
Etiology: sex-linked genetic pattern of inheritance the brace
3. Post-op care
Pathophysiology: a. Turn patient using logroll technique
Degeneration and loss of muscle fibers due to absence of every 2 hours
protein dystrophin b. Do not lift the patient under the axilla
↓
Phagocytosis of muscle fibers
↓ ARTHROPLASTY - replacement or reconstruction of a
Replacement of muscle tissue by connective tissue (scar diseased or damaged joint
tissue & fat cells)
↓ Common Type: total hip replacement - replacement of a
Progressive muscle weakness severely damaged hip joint with metal or synthetic ball
and socket.
Clinical Manifestations
1. Progressive weakness: pelvic girdle → LE → UE Nursing Management for Total Hip Replacement
2. Gower’s sign 1. Position the client supine and on the unoperated
3. Scoliosis side.
4. Complications of immobility 2. Avoid hip adduction. Maintain the operative leg
5. Respiratory failure in abducted position with abductor splint,
sandbags, or two pillows between legs for 8
Diagnostic Evaluation: elevated CK-MM serum enzyme weeks.
3. Avoid hip flexion beyond 90 degrees
Collaborative Management 4. Prevent external rotation of the hip with a
1. Keep the child as active & independent as trochanter roll or pillow splint.
possible 5. Keep the head of the bed flat, elevated only for
2. Assist patient in the performance of ADL a short period of time during the first 24 hours
post-surgery especially during meals (20-30⁰).
6. Decrease the risk of deep vein thrombosis (DVT)
SCOLIOSIS- lateral curvature of the spine development by administering anticoagulants,
application of anti-embolic stockings, encourage
Etiology: idiopathic, congenital & neuromuscular early ambulation (2-4 days post-op) &
progressive weight bearing as prescribed by the
Pathophysiology: physician
Lateral flexion of the spine causes shortening of the spine 7. Teach proper use of a walker or crutches.
& simultaneously, the spine rotates on its longitudinal 8. Instruct the client to pivot on the affected leg
axis toward the convex side → Rib hump when turning.
↓ 9. Avoid sitting on a low chair & encourage the
Vertebrae become permanently wedge-shaped causing client to obtain a raised toilet set for use after
permanent deformity discharge.
↓
10. Avoid crossing the legs
Thoracic cavity narrows
11. Avoid bending down to put on shoes, socks, or
↓
pants until 8 weeks after the surgery.
Decrease Vital Lung Capacity (with angle > 60%)
↓
AMPUTATION - total or partial surgical removal of an
Shortness of breath
extremity.
Purposes:
Clinical Manifestations
1. To preserve function on a remaining part in
1. Uneven shoulder, waistline, hemline, or pant
cases of severe traumatic injuries
legs are longer on the other side
2. To prevent death caused by cancer, thermal
2. Curved spine/poor posture
injury, progressive tissue necrosis leading to
3. Rib hump
gangrene formation.
4. Shortness of breath
5. Chest and back pain Patient Postoperative Care
1. Monitor the patient’s vital signs, intake & output,
Classification: mild, moderate & severe
surgical wound, and stump dressing for signs of
excessive bleeding. A tourniquet is kept at the
Diagnostic Evaluation
client’s bedside after surgery.
1. Forward bending test: (+) Rib hump
2. Control edema by elevating the residual limb
2. X-ray: reveal the curvature of the spine
with a pillow for the first 24 hours
3. Maintain pressure dressing and reinforce
Conservative Treatment
dressing as required using an aseptic technique
1. Exercise
secured with an elastic bandage to prevent
2. Braces
bleeding, maintain adequate tissue perfusion,
3. Traction
and shapes the residual limb for prosthesis
4. Cast
fitting.
4. Supporting effective coping by accepting patient
Surgical Management: spinal fusion & HRI
responses to the loss of body parts (depression,
Nursing Management withdrawal, denial, & frustration) and encourage
1. Appropriate exercises the expression of fears and concerns. Assist
2. Caring for the patient using a brace patient to adapt to changes in self-care
activities.
 5. Controlling pain. Use of physical modalities &
TENS for phantom pain.
6. Promoting physical activity
a. Encourage frequent repositioning in bed
and help the patient with turning and
positioning as needed.
b. Prevent deformities like hip flexion
contracture (avoid placing residual limb
on a pillow after 24 hours; encourage
prone position twice a day (20 minutes)
and abduction deformity (use
trochanteric roll and avoid pillows
between legs for lower extremity
amputation.
c. Encourage active ROM and muscle
strengthening exercises to prevent
contractures, minimized muscle
atrophy, increase muscle strength in
preparation for use of assistive devices,
and prepare residual limb for a
prosthesis.
d. Promote reestablishment of balance by
transfer the patient to a chair within 48
hours of surgery & guard lower limb
amputee during balance exercises (i.e.,
arising from a chair, stand on toes
holding unto chair; bend knee holding
onto the chair; balance on one leg
without support; hop on one foot while
holding onto a chair).
e. Encourage and supervise ambulation
using assistive devices and self-care
activities.
Patient Education
1. Teach the patient and family how to wrap the
residual limb with an elastic bandage.
a. Use diagonal figure of 8 bandaging
technique.
b. Wrap distal to proximal to maintain a
pressure gradient
2. Teach patient residual limb-conditioning
a. Push the residual limb against a soft
pillow then gradually against harder
surfaces.
3. Continuing care of residual limb and prosthesis.
a. Instruct patient to wash, rinse, and dry
limb thoroughly at least twice a day to
prevent skin irritation and infection.
b. Avoid soaking the residual limb
c. Inspect residual limb and skin under
prosthesis harness daily for pressure,
irritation, and actual skin breakdown.
d. Wear residual limb sock/cotton
underwear.
e. Instruct the patient not to use torn
socks and avoid wrinkles in residual
limb sock.
ASSISTIVE DEVICES FOR WALKING
Crutches
Preparation for Crutch Walking
1. Strengthen the muscles needed for ambulation
thru quadriceps & gluteal setting exercise.
2. Strengthen the muscles of the upper extremities
and shoulder girdle: push-ups, sit-ups, use of
weights, and a rubber ball.
Proper Adjustment of Crutches:
The patient is standing erect, with feet slightly apart. The
elbow is flexed 30⁰ with the hand resting on the grip.
There should be a 2-finger-width insertion between the
axillary fold and the axillary piece.
Patent Teaching:
1. Instruct the patient to wear comfortable, firm,
low-heeled walking shoes
2. Instruct the patient to support their weight
primarily on the hands, not on the axillae.
3. Instruct the patient to use crutches in pairs to
prevent muscle imbalances.
Crutch Gaits:
1. 4-point gait: a slow but stable gait. The patient
advances the crutch on one side then advances
the opposite foot, repeat on the opposite side.
Right crutch → Left foot → Left crutch → Right foot
2. 2-point gait: a progression from the 4-point gait
and allows faster ambulation. Advance the
crutch on one side and simultaneously advance
and bear weight on the opposite foot, repeat on
the opposite side.
Right crutch & Left foot → Left crutch & Right foot
3. 3-point gait: used when one leg is involved.
Advanced both crutches and the involved lower
leg are moved forward simultaneously then the
stronger lower extremity is moved forward while
putting most of the bodyweight on the crutches.
Both crutches & affected leg → Unaffected leg
4. Swing - to gait: advance both crutches together
and then follow by lifting both lower extremities
to the level of crutches.
5. Swing- through gait: advance both crutches
together and then follow by lifting both lower
extremities past the level of crutches.
Crutch Maneuvering Techniques
1. To go upstairs. Advance the stronger leg first up
to the next step. Then advance the crutches and
the weaker extremity.
2. To go down the stairs. Advance crutches to the
lower step. The weaker leg is advanced first and
then the stronger one. The stronger extremity
shares the work of raising and lowering the
bodyweight with the patient’s arms.
Cane
Measuring cane
1. Have the patient flex his elbow at a 30⁰ angle
and hold the cane 6 inches (15 cm) lateral to
the base of the little toe.
2. Adjust the cane so that the handle is
approximately level with the greater trochanter.
Techniques for walking with a cane
1. Hold the cane on the hand opposite to the
affected extremity (the cane should be used on
the good side).
2. Advance the cane at the same time the affected
leg is moved forward.
3. Keep the cane fairly close to the body to prevent
leaning.
4. To go up and down the stairs, step up on the
unaffected extremity then place cane and
affected extremity on the step. Reverse this
procedure for descending steps.
Walker: provides more support than crutches or a cane
for the patient who has poor balance and cannot use
crutches.
Measuring walker: The height of the walker should be at
the level of the greater trochanter (hip).
Techniques for walking with a walker: “Lift and Walk”
technique