The Skeletal System and Joints

Skeletal System

• The adult human skeleton is composed of 206 bones
• Bones offer support and protection
• Bones provide attachment to muscles, tendons, and ligaments
• Bones aid in the production of blood cells in central cavities
• Bones regulate calcium and phosphate levels in the body
• Bone growth ceases around ages 18-25
• Bone resorption accelerates with aging which decreases bone mass and increases injury risks

Joints (Articulations)

• Synovial membranes contain synovial fluid
• Synovial fluid cushions and lubricates to reduce friction between bones

Basic Joint Types: SAD

• Synarthrosis (fibrous/fixed joints) allows no movement and is solidified by thick fibrous tissue. Example: skull sutures
• Amphiarthrosis (cartilaginous joints) allows slightly limited movement. Example: vertebral and symphysis pubis
• Diarthrosis (synovial joints) allows free movement
• Some synovial joints contain fibrocartilage discs, like the medial meniscus, for shock absorption

Types of Synovial Joints

• Ball and socket joints facilitates full movement, as seen in hips and shoulders
• Hinge joints facilitates flexion and extension in one direction, as seen in knees and elbows
• Saddle joints allows movement in two planes at right angles, exemplified by the thumb
• Pivot joints allows rotation around a central axis as seen in the ulna and radius
• Gliding joints allows limited movement and are found in carpal bones of the wrist

Additional Joint Structures

• Ligaments connect bone to bone, stabilizing joints
• Tendons connect muscle to bone
• Bursae are synovial fluid-filled sacs that cushion movement, which may become inflamed and cause discomfort

Joint Capsule and Synovial Fluid

• Synovial fluid located in the joint capsule gets secreted by the synovial membrane
• Joint capsules are tough fibrous sheaths surrounding articulating bones and contain a synovium/synovial membrane

Joint Dislocation

• Joint dislocation can result in avascular necrosis and nerve palsy
• Severe ligament damage can occur due to complete displacement or separation
• Requires immediate medical attention due to potential blood vessel and nerve compression

Potential Complications of Joint Dislocation

• Nerve palsy results from bleeding necrosis which can lead to avascular necrosis
• This deprives bones of essential nutrients and blood supply
• Dysplasia occurs when bones do not fit properly, leading to instability
• Subluxation is a partial dislocation where the bone is not fully in the socket

Dislocation Severity and Hip Dislocation

• Dislocation is the complete detachment of a bone from its socket
• Hip displacement commonly affects the elderly
• Untreated hip dislocation may lead to avascular necrosis due to tissue death from anoxia

Causes of Dislocation

• Dislocation may be caused by congenital anomalies, pathological conditions, or trauma

Clinical Manifestations of Dislocation

• Joint deformity is the most obvious sign with changes in contour and location
• Other signs are tenderness, loss of function, swelling, and localized pain

Diagnostic Tests and Treatment for Dislocation

• X-rays are used to confirm diagnosis
• Immobilization uses splints or bandages to prevent further injury
• Closed reduction realigns the joint under anesthesia
• ROM exercises are performed 2-5 days after injury to prevent muscle atrophy

Major Complications From Dislocation

• Avascular necrosis involves bone cell death from decreased blood supply
• Delayed reduction can cause AVN caused by ischemia, resulting in bone cell necrosis or death

Goals of Dislocation Treatment

• The main objective is to realign the dislocated joint to its original anatomical position

Contusions

• Contusions are soft tissue injuries caused by blunt force such as a kick, fall, or blow

Common Symptoms of Contusions

• Symptoms include pain, dislocation, and swelling ("PADIS")

Treatment for Contusions

• Manage with intermittent cold application to numb/constrict and prevent further injury or bleeding
• Contusions typically resolve in 1-2 weeks with medicine

Sprains and Strains

• Sprains and strains are common injuries associated with twisting or stretching forces
• Sprains involve injuries to ligaments
• Strains involve injuries to muscle or tendons

Sprain Classifications

• Mild (Class 1) involves stretching of ligaments without a tear, manifesting as mild edema, mild pain, and local tenderness
• Moderate (Class 2) involves a partial tear of ligament fibers, resulting in tenderness, increased edema, pain with motion, and joint instability
• Severe (Class 3) involves complete ligament disruption, causing severe pain/tenderness, increased edema, and joint abnormality

Strain Classifications

• Mild (First Degree) involves a slightly pulled muscle
• Moderate (Second Degree) involves a moderately torn muscle
• Severe (Third Degree) involves a severely ruptured or torn muscle

Clinical Manifestations of Sprains and Strains

• Both result in edema from tiny hemorrhages in disrupted tissues and hematoma from blood accumulation

Key Considerations for Sprains and Strains

• Mild sprains and strains are self-limiting
• Full function typically returns in 3-6 weeks
• Severe sprains can lead to avulsion fractures
• Severe strains often require surgical repair

Nursing Management of Sprains and Strains

• Apply cold compresses for 20-30 minutes, then warm compresses for 10-15 minutes
• Compress the injured extremity with a bandage for 30 minutes, then remove for 15 minutes to prevent avascular necrosis
• Elevate the extremity and provide analgesics

Remember "RICE"

• Rest, ice, compression to check for arterial insufficiency and prevent constriction, and elevation
• Monitor vascular status every 15 minutes for the first 1-2 hours, then every 30 minutes if stable

Ottawa Rules

• They serve as a guideline for assessing and managing ankle or foot injuries

Imaging Requirements

• Ankle x-rays are required with pain in the malleolar zone plus bone tenderness in either malleolus
• The inability to bear weight necessitates immediate assessment and imaging
• Foot x-rays are required with pain in the midfoot zone plus bone tenderness at the base of the 5th metatarsal or navicular bone
• Inability to bear weight also necessitates immediate assessment and imaging

Fractures

• A fracture is a break in the continuity of bone
• Fractures occur when stress exceeds bone's capacity to absorb it
• A daily intake of 1-2 grams of Calcium and 8 oz equivalents of milk is recommended

Major Causes of Fractures

• Fractures commonly results from trauma or force
• Bone diseases like osteoporosis, or an imbalance in estrogen levels can weaken the bones

General Fracture Classifications

• Complete fractures involve a break through the entirety of the bone
• Incomplete fractures involve a break through only a portion of the bone
• Greenstick fractures impair one side of the bone while bending the other and are more common in children
• Comminuted fractures result in multiple bone fragments
• Closed (simple) fractures do not cause a break in the skin
• Open (complex/compound) fractures cause a break in the skin

Criteria for Open Fractures

• Grade 1: Clean wound < 1 cm long
• Grade 2: Larger wound without extensive soft tissue damage
• Grade 3: Highly contaminated with extensive soft tissue damage

Specific Fracture Classifications

• Avulsion fractures occur when a bone fragment is pulled away by a tendon
• Comminuted fractures causes the bone to splinter into many pieces
• Impacted fractures involves bone fragments being driven into each other
• Oblique fractures occur at an angle across the bone
• Compression fractures involves bone being compressed seen in vertebral fractures
• Depression fractures drives bone fragments inward
• Transverse fractures involves a straight break across the bone
• Spiral fractures involves twisting around the bone
• Overriding fractures involves fragments overlapping, shortening the bone
• Segmental fractures involves two adjacent central areas
• Linear fractures run parallel to the bone’s axis
• Pott's fractures involves a fracture-dislocation of the ankle
• Colle’s fracture involves distal radius with upward displacement
• Smith’s fracture involves palmar angulation of the distal bone

Clinical Manifestations, Diagnosis, and Emergency Goals for Fractures

• Clinical manifestations include: deformity, crepitus, pain, shortening
• Diagnostic tests: X-rays and hematology to rule out internal bleeding
• Emergency Goal: immobilize the patient to prevent further injury

Care for Patients Awaiting Treatment for Fractures

• Splint to prevent movement during transport
• Bandage lower extremities with unaffected leg for support
• Use arm sling in upper extremities
• Assess neuromuscular status before and after splinting
• Use sterile dressing to cover open fracture

Medical Management of Fractures

• Reduction involves restoring fracture fragments to their anatomical positions
• Physician reduces fracture immediately to prevent tissue infiltration
• The timing and necessity of certain procedures requires consent, anesthesia, and analgesics

Two Types of Reduction

• Closed reduction involves manipulating and pulling bone ends together
• Lower extremities are placed in desired position while physician applies splints while after alignment, an x-ray is used to verify the bone is correctly aligned.
• Open reduction uses internal fixation devices to hold bone fragments together
• Approximation and interval fixation ensures firm placement of bony fragments

Immobilization and External Fixators

• After reduction, bone fragments need immobilization until union
• Accomplished by internal or external fixation
• External fixators include bandages and metal implants

Patient Care in Open Fractures

• Involves tetanus prophylaxis, antibiotics, cleaning with PNSS, debridement of dead tissue
• Primary wound closure is delayed 3-5 days to decrease swelling

Patient Care in Closed Fractures

• Isometric exercises strengthens the muscles

Early Complications of Fractures

• Shock involves loss of extracellular fluid into damaged tissue in thorax, pelvis, or spine
• Fat embolism involves rapid onset of symptoms where fat globules move into blood

Additional Information on Early Complications of Fractures

• Check patient vital signs for internal bleeding
• Treat with blood transfusions and adequate splinting
• Marrow or catecholamines causes fat globule
• Fat globule travels due to pressure which occludes small blood vessels in the kidneys, lungs and brain
• Can be prevented and managed with immediate immobilization, minimal fracture manipulation, and adequate support

Compartment Syndrome as an Early Complication of Fractures

• Compartment Syndrome involves pressure that reduces perfusion below the level needed for tissue viability
• Symptoms include deep, throbbing pain
• Wick catheter measure compartmental zone pressure

Severe Compartment Syndrome (6 P’s)

• Includes Pallor, pain, paresthesia, pulselessness, paralysis and poikilothermia

Pain Can Be Caused By

• Pain may result from reduction in size of muscle compartment from tight fascia or dressing
• Pain may result from muscle compartment edema

Compartment Syndrome Management

• Fasciotomy: reduces pressure with excision of fibrous membranes that covers and separate muscle fascia
• Closing site/re-suturing takes place following the improvement of edema
• Amputation: remains a last resort in treating infection due to necrosis, specifically gangrene

Delayed Complications of Fractures

• Delayed Union: healing does not occur at normal rate

Bone Healing

• Process is divided in sequence: hematoma and fibrocartilaginous formation
• Bony Callus Formation
• Bone remodeling takes 6-8 weeks

Delayed Union

• Common in poor nutrition, distraction, commodity, or an untreated infection

Non Union

• Neither capable of bringing 2 bones together, not false joint
• Requires management via internal fixation, bone grafting, electrical bone stimulation, and osteoconduction

Avascular Necrosis

• Results from loss of blood supply

Osteoarthritis

• This chronic systemic disorder of the joints causes degeneration of articular cartilage affecting weight-bearing joints such as hips, knees, and spine
• Primary OA is genetic while secondary OA may come from obesity, joint trauma, or congenital abnormalities

Increased Calcitonin and Parathyroid

• Increased calcitonin suppresses calcium production in bone
• Parathyroid stimulates calcium release

Pathophysiology of Osteoarthritis

• Cartilage softens with age and causes narrowing of spaces
• This leads to flaking, which limits movement

Characteristics

Osteophytes and Assessment Findings

• Space narrows with bone spur growth
• Joint pain is lessened with rest and joint stiffness is lessened with movement

Causes

• Inflammation
• Stretching of joint
• Nerve irritation

Common Occurrences

• Occurs during sleep, where there isn't a lot of circulation
• Lasts for about 30 minutes

Complications: Bony Nodules

• Heberden’s are distal
• Bouchard’s are proximal

Joint Impairment

• Asymmetrical, no fever, atrophy from lack of movement

Increase Pain

• Cold leads to stiffness and pain, because blood doesn't reach the extremities

Dx Tests

• Tests include X-ray, for spurs, and Arthroscopy

Hematology

• Increase ESR

Arthritis

• Pain is aided with cold and warm therapy, stiffness is only warm therapy
• There lies aspirin aid

Prevention

• Include weight loss, ergonomic help, injury prevention, and more

Rheumatoid Arthritis

• Autoimmune attacks
• Involves systems and connective tissues
• Non systemic, only joints
• Pannus, not good Classify

Criteria

• Joint involved, bad serology, lasts 6+ weeks
• Exclude 6+ involved with more

Causes

• Something genetic triggers autoantibodies

Theories

• IGG attacks the joints in rheumatoid

Pathophysiology Synovitis

• Attacks lymphocytes in joints

2nd Stage

• Pannus in cartilage

3rd Stage

• Fibrous invasion

4th Stage

• Calcifying and fused

Manifestation

• Swelling is symmetrical, bones get stiff with warm baths

Extra Feature

• Includes paler skin, rheumatoid, inflammation of dryness (auto attacks gland)

Felty's Syndrome

• Lower wbcs enlargement
• Rare positive
• Low platelets

Deformity

• Includes swan neck, unlar, deviation, and so on,

Remember

• Lie flat and prevent joint contraction