Dysfunction of the Musculoskeletal System

Dysfunction of the Musculoskeletal System Accounts for 75% of body weight Composed of 206 bones & other structures Muscles Joints Ligaments Tendons Fascia Bursae Cartilage Synovial lining Functions Provides shape & framework Allows for movement Provides support & protection for vital organs (brain, heart, lungs) Hematopoesis Chemical Buffer Main storage for inorganic minerals Types of bones: long, short, flat, irregular Bone is a dynamic living tissue that remodels itself constantly, when mobility occurs Classification of Bone types & cells Cancellous bone- spongy Compact bone – dense Osteocytes-mature bone cells Osteoblasts- forming cells that secrete collagen network Osteoclast- absorption cells for remodeling Three regulatory factors that determine the balance between Osteoblasts and Osteoclasts. Local stress acts to stimulate bone dynamics Vitamin D- Promotes absorption Ca+(GI tract),  it is associated with insufficient calcification (rickets, osteomalacia). PTH- regulates level of Ca+ ion in blood by biofeed back Δ. Low levels of Ca+ & Mg++ stimulate PTH, which can lead to demineralization of bone.  levels of Ca+ in the blood will lead to  in PTH  Estrogen inhibits the action of PTH  Calcitonin  Ca+ levels by inhibiting osteoclastic activity. (c cells of thyroid gland) Didronel(Rx) inhibits osteoclast activity & Vertebral bone mass,  rate of fracture to spine Blood Supply to bones- 8% total C.O.  3 routes to bones (200 to 400 mL/min)  Vessels in the marrow & ends of bones Vessels penetrate the periosteum Volkman’s Vessels in the Haversian canals Joints  Junction of 2 or more bones that articulate- 3 types joint movement:  Diarthrosis (free moveable)  Synarthrosis (immoveable) Amphiarthrosis (partially moveable)  Joint capsule, lining of Synovial membrane, supporting structures Cartilage avascular materials composed of fibers embedded in a gel. 3 types: Fibrous greatest # of fibers Hyaline moderate # of fibers Elastic fewest # of fibers  Hyaline cartilage cover the end of articulating bones Fibrous cartilage connect ribs to sternum, discs (interveterbral & meniscus) Elastic cartilage- ear,nose & larynx more flexible Ligaments- dense, fibrous, flexible,tough connective tissue that provide joint stability ( bone to bone) Tendons- bands of dense fibrous connective tissue that attach the end of muscles to bone. Tendon sheath- tubular structure of CT that encloses certain tendons- wrist, hand, ankle. Lined with Synovial membrane  Bursa- sacs of CT located wherever pressure is exerted over moving parts. Lined with Synovial membrane to product gliding mechanism. Olecranon –skin to bone Achilles – tendon to bone Subdeltoid- muscle to muscle Fascia- is CT that surrounds & divides muscles, blood vessels, & nerves into compartments. Muscles-Skeletal voluntary striated, cause movement, generate heat, maintain posture Contract on the all or none law with a minimum threshold stimulus  Neuromuscular junction is where acetylecholine (neurotransmitter) secreted for contraction.  Muscles extremely vascular & require O2 to function properly. With adequate O2 will contact more forcefully. Hypoxia cause pain & fatigue. Flexor(stronger) & extensor muscles  Contracts: Tonic-Continuous partially contraction Isometric- force generated in muscle, but length remain constant Isotonic- Shortening of muscle with no  in tension.  Subjective Data- present condition & dysfunction, the major reason a client seeks care is for PAIN and how this is effecting their lives. Onset,location,duration,timing, quality,associated symptoms, exacerbates or alleviates,past family, medical, psysocial history, lifestyle, occupation, deformities.  Pain- key findings Bone- dull, deep ache that is boring in nature Muscle- aching, soreness, tightness (cramp/spasm) Facture- sharp piercing, relieved by immobilization (Osteomyelitis) referred pain Assessment  Radiating- pressure exerted on nerve root Steadily  pain- indicates infection, vascular complications or malignant tumor.  Most musculoskeletal pain is relieved by rest. Objective data: Local swelling- edema measure circumference of area (effusion) General edema of body (RA)  Change in color-erythema, eccchymosis, pallor,cyanosis, associated with rash Temperature- cool, warm, hot, moist dry  Tenderness- palpated area  Turgor- texture elasticity fullness Integrity- any breaks, ulcerations, or loss of continuity of skin & tissue. Stiffness of joints- when does it occur, on rising or after exercising. Symmetry of body and weight Deformities: described in terms of appearance & limitations. Can be thought of as a change in size, shape, stability, position,alignment, loss of strength & ROM of a body part. Swan- neck, ulna deviation, Scoliosis, Kyphosis, Lardosis, Hammer toe, fixed joints. Contractive deformities: disuse, prolonged immobility, nonfunctional positioning, atrophy Sensory deficit-peripheral nerve entrapment- numbness, sensation loss, tingling, burning Coordination, dexterity, strength(tone), ROM-(gait, agility,grade Denny Brown Scale- capacity to perform work)  flaccid, spastic, paralysis DB- 0-5 (0) 0% no palpable or observable movement. Trace (1) 10% No joint movement, but palpable or observable muscle movement Poor (2) 25% Active ROM with gravity eliminated  Fair (3) 50% Active ROM Good (4) 75% against moderate resistance Normal (5) 100% against maximal resistance ROM of each joint to evaluate function & stability (crepitus) Physical Assessment steps: Inspection- symmetry muscle wasting,masses, nodes, swelling, deformities, color changes Measure and document Palpation-lightly, bimanual pressure, feel for temperature, texture, edema, etc Neurovascular Assessment / CMS  Radiological Procedures- X-rays plane films evaluate the following on bones:  density, texture, erosion, change in bone relationships, widening or narrowing, irregularity Joints reveals: Fluid, spurs, narrowing, irregularity Diagnostic Testing  CT scan- ID soft tissue injuries & specific facture of the acetabulum Bone scan- with an isotope (Tc99m) IV injection, radioactive deposit in the bone called uptake,  lack circulation or  increase in circulation in uptakes. Excreted in urine & feces. MRI’s more accurate than CT for spine and knee problems & soft tissue injuries. NO MENTAL, except titanium & stainless steel EMG- electromyogram measure contract of a muscle as a result of electrical stimulation. (off Rx relaxants) Bone or muscle biopsy- bone has either open or closed method, diagnosis cancer. muscle biopsy are done to diagnosis atrophy or inflammation Arthroscopy & arthrogram –endoscope procedure which allows for direct visualization of the joint. Sterile procedure in OR as an outpatient either local/regional block or general anesthetic. Joint expanded with R/L that baths the joint will scope is in. Trimming and remodeling the joint, removal of tumors or floaters. Post-op the client will have an immobilizator or ace wrap, ice applied, elevation, rest of 24 hour and limited activities for at least 3days depending on the OR. During OR while the scope is still in dye is injected and films are made with the joint through ROM Arthrocentesis-or joint aspiration is carried out to obtained Synovial fluid for examination: Local anesthetic Needle inserted to withdraw fluid also medication, such as Xylocaine & a steroid may be injected. DSG & ace applied rest joint for 24 hours Synovial Fluid tested for cells, glucose, fibrin, etc. Normal SF- clear, pale straw colored, small amount like oil.  Serological testing- AST/SGOT , CPKMM,AKP, C-reactive Proteins, Ca, PO, CBC, Urine 24 hour (BenceJones Proteins /uric acid) RAF (Latex fixation), ANA, ESR, LE Prep /factor, uric acid (serum) page 1089 Trauma  Head injury most common cause of death, if you have a head injury you have a neck injury. Most common cause of death between ages 1 & 40, 3rd most common 35 to 55.  3.6 million admit to hospital for injuries costing $100-140 billion annually  Contusions-soft tissue, blunt force, hemorrhage due to small vessels being ruptured, ecchymosis, hematoma Assessment- pain, edema, discoloration, limited ROM Treatment-RICE rest, ice 20 to 30 minutes on and then 20 to 30 off for first 24 to 48 hours. Uniform compression (ace, bulky dressing, splint), elevate above heart. After acute period then apply moist heat, mild analgesic . NV √ Sprain- injury to a ligament around a joint by a twisting motion, Treat with  Strains –is an injury to the muscular-tendon unit by excessive force or stretching. Treat with RICE or possible surgery will be needed. NV√ Dislocations or subluxations-condition in which the articular surfaces forming a joint are no longer in anatomical contact. 3 types: Congenital Pathological Traumatic Assessment: Pain, changes in contour of joint, change in length of extremity (shorter), Loss of ROM, change in axis of dislocated bones.  Treatment-immobilization or splint in position found. Don’t reduce. Physician will reduce the dislocation- either with a conscious sedation, regional block, general anesthetic, the joint is manually manipulated back into cavity, then immobilized. REST, apply ice, maintain immobilizer, and flex and extend the finger to reduce edema. NV √ FRACTURES- IS A BREAK IN THE CONTINUITY OF BONE & DEFINED ACCORDING TO TYPE AND EXTEND.  FRACTURE TERMONOLOGY Displaced vs. non displaced Open vs. closed Intrarticular vs. extrarticular Incomplete vs. complete  Valgus vs. varus Epiphyseal Dislocated Union vs. nonunion Damaged: blood vessels, nerves, Signs & symptoms of fracture  Pain- immediate, severe, until fracture is immobilized (joint distal & proximal to injury)  loss of function, ROM (false motion)  Deformity  Edema/swelling  Discoloration  Crepitus  Shorten limb & rotation  Diagnostic test- Xrays  Assessmentinspection/palpation  Immediate care: splint in position found, extension, or functional position, apply ice as directed, rest. Elevated above heart, Neurovascular checks, cover open wounds. Healing of a fracture  Hematoma forms to bridge the two ends of the bones 72 hr  Cell proliferationdeveloping CT & cartilage  Callus formationOsteoblasts 2-6 wks  Ossification of callus & union 3 wks –6 month  Consolidation & remodeling into mature bone 1 yr  Bone healing complete Health young adult healing takes 6 wks older clients 3-6 months. Types of treatments Reduction –restore to fragments to original anatomical position. Closed reduction with immobilization Open reduction with internal (ORIF) or external fixation Reduction-manual with immobilization or traction skin or skeletal. Casting/ splinting functions:  to hold reduction by immobilization Apply uniform compression to soft tissue Permit early mobilization Cast application & care  types of casting materials- plaster vs. fiberglass Cast vs. splint Types of castArm- short, long, hanging, spica (thumb, shoulder)  Leg-short, long, cylinder, walking, Hinge Body- hip spica, jacket (Risser or Halo)  Plaster cast –cost less, are heavier, if cast need to changed frequently this is the material.  Handle with palms of hand, not to leave indentation.  Cast will take 48 hrs to dry-color changes from gray to white.  Heat is produced from the evaporation of H2O  Turn body cast q 2 hr  Keep open to the air Don’t allow cast to lean on hard surface or sharp edge while damp. Support cast with pillow to elevate above Apply ice to the cast next to the area of trauma  Check neurovascular status of distal extremity frequently q hourly/24 hrs Blue tinge suggests  in venous return , pale/white, cold suggest arterial obstruction.  Move distal extremity ROM, sensation When cast is acting as a constrictor then the cast my need to be split or Bi-valve. remove part of cast to make splint) Splitting a leg cast would mean to cut it anteriorly & arm cast posteriorly, spread cast apart and cut cotton wrapping/stocking net. If neurovascular check are better then you need to tape or apply an ace bandage to the cast for stability. Bi-valve a leg or arm cast is to cut in medially and laterally spread the cast, cut cotton wrap/ stocking net.If neurovascular check are better then you need to tape or apply an ace bandage to the cast for stability. May remove top part of cast & use bottom as splint with ace applied. If an indentation has been made into the cast, then a pressure area may develop under the cast. That is why we pad bony prominence before casting If there is a wound, pressure area, or the client complains of burning, pressure at specific area under cast or there is drainage on cast & odor may developed a necrosis. A window may be cut in the cast to directly visualize the skin. Make sure you place new padding and the cast window in place with tape, so edema will not swell out the window.  Cast syndromewith body cast/hip spica, pressure is applied to the abdomen from the cast & can cause partially or complete upper intestinal obstruction- N/V/ gastric distention. Cut a abdominal window in the cast or bi-valve for relief. Complications  Pad plastic around perineal areas for a hip spica cast, use fracture pan.  Marking drainage on cast.  Systemic Complication  Hemorrhage,DVT, Pneumonia, Fat embolism, etc.  Local complications Avascular necrosis, compartment syndrome, osteomyelitis, nonunion ,contractures   pressure within one or more compartments causing massive compromise.  Occurs in the lower leg or dorsal or volar of forearm  Caused from external or internal sources.  Early diagnosis mostly easily remembered by the 6P’s 1. Pain-specially, progressive pain, not relieved by immobilization or RX Compartment syndrome-ACS 2. Pain on passive motion-severe this is muscle ischemia 3. Paralysis-inability to voluntarily move distal extremity. 4. Paraesthesianumbness & tingling 5. Pulselessness- least important, pulse may remain intact 6. Pallor to dusky skin color Normal compartmental pressure 0-8 mm Hg Initial trauma> edema > flow of O2 > ischemia> histamine> capillary dilatation> permeability of capillaries> allows transudation of plasma into the muscle> edema> intramuscular pressure> compression of the small veins & arteries> reflex spasm> occlusion of larger arteries entering the compartment>if the ischemia (necrotic tissue & infection)/edema is allowed to continue longer than 6-12 hours> irreversible damage to muscle & nerve begins to occur>Motor weakness or Volkmann's contractures, if steps not taken to break cycle in 24 hours permanent damage has occurred. C/O myoglobinuric renal failure;  in K+ Treatment Measuring interstitial pressure in the compartment, 2530 mm Hg ACS Lower the extremity to heart level Notify the physician Split or bi-valve cast, leave part as splint. Get client ready for OR & a fasciectomy or fasciotomy If not done the extremity will develop a permanent deformity & dysfunction & be useless. Secondary closure & or graft made need to occur. Fat Embolism Relatively rare & often fatal complication of fracture of one or more major bones (femur, pelvis) Usually occur in the first 48 hours post trauma, seem more in males Signs and symptoms: Early changes in VS, since shock may be concurrent. serum lipase & fatty acid levels Cyanosis, dyspnea, tachypnea, fever, confusion or agitated, disorientation, petechial rash. Free fat in sputum/urine. Drop in H & H,  PaO2 below 60 mm Hg Fluffy infiltrates on CXR ECG- Prominent S wave in lead I & Q wave in lead 2 Petechiae do not blanch with pressure. Primarily supportive- O2 therapy Anticoagulant therapy- heparin Steroid therapy LOCAL COMPLICATIONS  Infection- compound fx Avascular necrosis Nonunion Pressure ulcers Interventions Vertebral fractures MVA, falls diving, athletic injury Stable fx is one that fragment are not likely to move or cause spinal cord damage All spinal injuries should be considered unstable initially & splinted Pain, tenderness in affected region, deformity, bowel & bladder function, sensation, movement, respirations Interventions: Alignment until union Traction, OR fusion, brace,  May log roll  pain medications, muscle relaxants Fractures of Femur Hip fx- most frequent cause of traumatic death after age 75, because they experience more falls due to:  cerebral perfusion, confusion, osteoporosis, muscle weakness, etc. incident higher in women ? WHY Two types of fracture Intracapular- neck or head of femur Extracapular-between the base of the neck and the lesser trochanter Intracapular fx have more difficulty healing due to the blood supplies are more easily damage. This can lead to nonunion or Avascular necrosis occurs when it loses its blood supply and cells die-pain at rest, restricted motion, gait disturbances. Signs & symptoms: Affected leg is shortened & externally rotated Pain in hip, if impacted pain may be in groin, referred pain. Splint with pillows or trochanter rolls or a Haire splint. Apply ice intermittently,  FOB, x-rays May be placed in Bucks or Russell’s traction prior to going to OR, since that will be ASAP Lab test- CBC, T & C Match, u/a, ESR, SMAC 24  ECG,CXR,  Pain relieve pre & post op- PCS pump  Pre op start on an anticoagulant therapy: heparin ( low dose SQ), ASA, Coumadin PO   FOB 25-30o to promote venous return  Teach deep breathing and coughing, isometric exercises of the quad. & gluteus,  upper arm strength  ORIF-general anesthesia or spinal block  Replace head of the femur prosthesis  Post op local complication is to prevent dislocation of the prosthesis and infection  Remember to have direct visualization of the joint, it had to be dislocated to the removed the femoral head.  Client can turn to the unaffected side with place of pillows between legs. Post operative care Pillow between legs to remind client not to abduct legs, turn q 2hrs TED’s, maintain foot alignment (might have slight internal or external rotation), use trochanter rolls, Pain relief PCA, DP, cough, Triflow Heel cord stretching, isometric, ROM to all unaffected joint, N-V √  Ambulation- NWB until physician orders with hip pinning, but client may sit in W/C pivot to chair or place in the chair by a lift Prosthesis may be ambulated with physician order with or with weight bearing. Diet needs to increase in fiber, Vit. C , protein, Ca+, H2O Check all boney prominences- heels, coccyx, elbows, etc for pressure or friction.  TOTAL JOINT REPLACEMENTArthroplasty KNEES- MOST COMMON HIPS- MOST COMMON  SHOULDERS FINGER & TOES ELBOWS WRISTS ANKLES  PATHOPHYSIOLOGY FOR TOTAL JOINT REPLACEMENT:  LAST RESORT FOR PAIN MX FOR OA, RA  CONGENTIAL ANOMALIES TRAUMA AVASCULAR NECROSIS CONTRAINDICATIONS  INFECTION ANYWHERE IN THE BODY ADVANCED OSTEOPORSIS SEVERE INFLAMMATION PRE OPERATIVE CARE:  COMPLETE EXPLANATION & ATTENDING PREADMISSON PROGRAMM, IF AVAILABLE.  LAB WORK, ECG, CXR, TYPE & CROSS MATCH, DONATION OF 2 UNITS AUTOLOGOUS BLOOD.  ABILITY TO DO ADL’S, USE ASSISTIVE DEVICES, & PHYSICAL THERAPY ADMITTED MORNING OF SURGERY.  OPERATIVE- USE OF THE FOLLOWING: Laminar airflow suites Body exhaust systems (spacesuits) In & Out of room kept to a minimum. Early morning procedure IV antibiotics- Ancef 1 hour prior to OR  General or epidural anesthesia  Blood loss during OR 300mL or more  Hip 8 to 10” incision; knee 8” incision  The replacement may be cemented or noncemented or porous coated( press fitted). (cemented joints last about 10 yrs- the polymethyl methacrylate is impregnated with antibiotic beads  Use of 1 or 2 wound drains- hemovac less 50 mL/ hr or autotransfusion system. Less than 200 mL/hr.  Revision Arthroplasty- occurs when the hard ware become loosen and replacement is needed. All cement must be removed & use porous coated hardware with a bone graft. 6- 12 weeks for bone to grow into pores.  Postoperative care- Prevention of complications:  Turn client toward either side with pillows or affected leg in abduction. √ - with doctor.  Neurovascular √  Dislocation/Subluxations- keep legs abducted, position correctly, hip flexion 90o or less, assess for pain in groin; rotation or shortening of leg. Keep in bed & call doctor.  Infection- temperature, drainage, erythema,  ESR  DVT- TEDs; foot exercises,  FOB, encourage fluids, observe for s/s of thrombosis & change in mental status.  Hypotension- check drainage, observe for bleeding.  Pain Management- epidural analgesia, PCA pump, IM, PO ( perocet then to toradol)  Activity- Up day after surgery PT is started. Pivot to chair-flexion less than 90o , cemented (PWBFWB) noncemented PWB for 6 weeks. Assistive devices-walker-cane, no limp after 1 month drive. PT- leg exercises. Several types. Anticoagulants- ASA, warfarin, heparin (LMW) 4 to 6 weeks D/C 3 days  TKR- Similar preoperative care, more cemented implants used, drains, pressure dressing. Postoperative care- maintain position, FOB, if ordered CPM machine, ice packs, pain control, preventive measures, PT exercises, do not hyperflex or kneel for prolonged periods  Osteomyelitis-infection of the bone 2 typesAcute infection last less than 4 weeks Chronic infections last longer than 4 weeks Pathogen Invasion Superimposed Bone Abscess infection Tissue Inflammation Increased Vascularity Edema Formation Bone necrosis (sequestrum formation) Blood vessel thromboses Decreased Blood Flow to Bones  Acute hematogenous- starts in another part of the body and then moves and invades bone tissue that is rich in vascular supply & a marrow cavity. Common in children and older adults  Occur by direct inoculation (puncture wound) skin microbes, also will invade the soft tissue Chronic can occur as a result of any of the acute types Compromised vascular supply has greatest risk Gram - & + account for 50%of chronic bone infections Signs and symptoms:  Acute-  temperature, swelling, erythema, tenderness, bone pain, pain with movement Chronic- ulceration of skin, sinus tract, localized pain drainage  Lab results: WBCs, ESR as it progresses, + blood cultures X-ray- bone scans or MRIs  Bone biopsy; c & s of drainage or tissue. Treatment: IV Drug therapy-antibiotics my given as long as 3 months. PO drug therapy-Irrigation with antibiotics, impregnation of wound with antibiotic beads Contact precautions Hyperbaric O2  Surgical MX- I & D, Sequestrectomy- removal of necrotic bone Bone graft, bone segment transfers, Muscle Flaps, amputation