Vascular and Musculoskeletal Disorders

• The following are facts about vascular disorders, peripheral circulation, musculoskeletal assessment, management of musculoskeletal disorders, and musculoskeletal trauma.

Hormones Affecting Peripheral Vascular Regulation

• Norepinephrine and epinephrine from the hypothalamus cause vasoconstriction.
• Angiotensin I is converted to Angiotensin II by ACE, resulting in potent vasoconstriction. It is especially important in heart failure and hypovolemia.
• Nitric oxide, prostacyclin, histamine, bradykinin, and prostaglandin cause vasodilation.
• Inflammatory cytokines cause vasoconstriction.

Pathophysiology of Vascular System

• Heart failure with reduced ejection fraction (HFrEF) causes blood accumulation in the lungs and reduced cardiac output, leading to inadequate tissue blood flow.
• Heart failure with preserved ejection fraction (HFpEF) causes venous congestion and reduced forward flow.
• Arterial occlusion can be caused by plaque, thromboembolus, trauma, infections, vasospastic disorders, or congenital malformation, which can lead to tissue damage.
• Venous insufficiency, caused by thromboembolism, incompetent venous valves, or reduced muscle pumping, can increase venous pressure, capillary pressure, and edema.
• Lymphatic vessel blockage can lead to edema.
• Circulatory insufficiency of extremities causes ischemia, leading to pain, skin changes, diminished pulses, and possible edema.

Assessment of Vascular System

• Intermittent claudication is pain or fatigue caused by inadequate arterial blood flow to tissues during increased demand, resolved by rest.
• A 50% arterial lumen obstruction or 75% cross-sectional area obstruction is required for intermittent claudication to occur.
• Rest pain is typically worse at night and requires the extremity to be lowered to a dependent position to improve perfusion.
• Cool and pale skin indicates inadequate blood flow.
• Pallor indicates significantly reduced blood flow.
• Rubor is a reddish-blue discoloration observed within 20-120 seconds of putting the extremity in a dependent position.
• Cyanosis is a bluish tint due to reduced oxygenated hemoglobin.
• Reduced nutrient supply can cause hair loss, brittle nails, dry skin, atrophy, and ulcerations.
• Edema is due to a chronically dependent position.
• Gangrene indicates prolonged, severe ischemia.
• Absent pulses suggest stenosis or occlusion and must be palpated bilaterally.

Diagnostic Evaluation of Vascular System

• Doppler ultrasound flow studies are used when pulses cannot be reliably palpated.
• The Ankle-Brachial Index (ABI) is the ratio of systolic BP in the ankle and arm.
• An ABI >1.4 is abnormal, indicating noncompressible arteries.
• An ABI of 1.0–1.4 is normal.
• An ABI of 0.91–0.99 is borderline.
• An ABI of 0.5–0.9 indicates moderate to mild insufficiency in patients with claudication.
• An ABI of 0.90 diastolic with new or worsening tissue damage indicates the need to reduce BP by 25% in one hour, to 160/100 in 2-6 hours, and to normal in 24-48 hours.
• Urgency is defined as >180 systolic and/or >120 diastolic in stable patients without tissue or organ damage, requiring close monitoring.
• VS every 5 minutes if BP changes rapidly and VS every 15-20 minutes in a more stable patient.

Musculoskeletal Assessment: Bone Health and Strength

• Good nutrition and weight-bearing exercise are important for bone health and strength.
• Adults need 1000-1200 mg of calcium per day and 600 IU of vitamin D.
• Calcitriol increases calcium in the blood by promoting absorption from the GI tract.
• PTH increases in response to low calcium to initiate calcium mobilization, bone demineralization, and bone cyst formation.
• Calcitonin, secreted by the thyroid in response to elevated calcium levels, inhibits bone resorption and increases calcium deposit in bone.
• Increased thyroid hormone levels can lead to increased bone resorption and decreased bone formation.
• High cortisol levels increase the risk for osteopenia and fractures.
• Growth hormone stimulates the liver and bones to produce growth factor to accelerate bone modeling in young people.
• Estrogen stimulates osteoblasts and osteoclasts, while testosterone causes skeletal growth and converts to estrogen in adipose tissue.

Stages of Bone Healing

• Hematoma formation (1–2 days) involves bleeding, bruising, and initial granulation tissue formation.
• The inflammatory stage involves the formation of granulation tissue, with fibroblasts and osteoblasts migrating to the fractured site.
• The reparative stage (3–4 weeks) involves the formation of a firm union as bone replaces the callous.
• The remodeling stage involves the removal of necrotic bone by osteoclasts and the replacement of spongy bone with compact bone.

Musculoskeletal Assessment

• Bone pain is a dull, deep ache, while muscle pain is a sore, ache, or cramp, and fracture pain is sharp and piercing.
• Rest usually relieves most pain.
• Increased pain with movement indicates a sprain, strain, or compartment syndrome.
• Steadily increasing pain indicates infection.
• Radiating pain indicates nerve damage.
• Assess for body alignment, symmetry, and signs/symptoms of inflammation, pressure, and tension.
• Paresthesia (burning, tingling, numbness) indicates nerve damage or circulatory impairment.
• History includes occupation, exercise, alcohol, tobacco, diet, concurrent health conditions, and family history.
• The Fracture Risk Assessment Tool (FRAX) considers age, gender, BMI, previous fracture, smoking, corticosteroids, rheumatoid arthritis, alcohol, and secondary causes.

Diagnostics and Labs

• Diagnostics include X-ray, CT, MRI, arthrography, bone densitometry, bone scan, arthroscopy, arthrocentesis, electromyography, and biopsy.
• Assess for allergies or conditions that contraindicate bone scans.
• For invasive procedures, assess for anticoagulant use.
• Serum calcium and serum phosphorus (inverse to calcium) are lab assessments.
• Acid phosphatase is elevated in Paget's disease and metastatic cancer.
• Alkaline phosphatase (ALP) is elevated during fracture healing and osteoblast activity.
• Calcitonin, PTH, Vitamin D, and thyroid levels are assessed for bone metabolism.
• CK and aspartate aminotransferase are elevated with muscle damage.
• Osteocalcin indicates the rate of bone turnover.
• Urine calcium indicates bone destruction.

Low Back Pain

• Intervertebral disc degeneration may be the cause.
• Manifestations include pain, fatigue, radiculopathy, sciatica, and affected gait, spinal mobility, reflexes, leg length, motor strength, and sensory perception.
• Treatment includes rest and pain medication.
• Nursing interventions include pain assessment, promoting physical mobility, and teaching good body mechanics.

Upper Extremity Disorders

• Bursitis: Treat with pain meds, rest, ice/heat
• Tendonitis: Treat with rest, pain meds
• Loose bodies: Removed with arthroscopy
• Impingement Syndrome: Treat with NSAIDs or corticosteroid injections, therapeutic exercise
• Carpal Tunnel: Treat with NSAIDs, corticosteroids, splinting, or open nerve release surgery
• Ganglion: Treat with aspiration, corticosteroid, or surgery
• Dupuytren Disease: Treat with exercises, corticosteroids, or fasciotomy

Nursing for Hand/Wrist Surgery Patients

• Perform hourly neurovascular checks for 24 hours.
• Monitor the surgical site and external fixators for infection.
• Apply ice to control swelling.
• Provide pain management.
• Encourage active flexion of fingers, unless contraindicated.
• Assist with ADLs for a few days.

Common Foot Problems

• Callus: Treat with ointment, padded shoes, well-fitting shoes/socks, or orthotics
• Corn: Treat with soaking and scraping, applying shield/pad, or surgical modification
• Hammer toe: Treat with open-toed sandals, shoes that conform to shape, manipulative exercises, or osteotomy
• Onychocryptosis: Treat by washing, warm/wet soak to drain infection, or surgical removal
• Pes Cavus: Treat with manipulative exercises or orthotics; severe cases may require arthrodesis
• Hallux Valgus: Treat with shoes that fit shape, corticosteroids, or surgical removal of exostosis and toe realignment
• Morton Neuroma: Treat with rest, massage, insoles, pads, corticosteroids, or surgical excision
• Pes Planus: Treat with exercises to strengthen and improve posture or orthotics
• Plantar Fasciitis: Manage with stretching exercises, supportive shoes, cushioning, orthotics, or corticosteroids

Nursing for Foot Surgery Patients

• Perform neurovascular checks every hour for 24 hours and monitor for VTE.
• Provide pain management.
• Elevate foot to control swelling and edema.
• Teach limits for weight-bearing.
• Teach correct use of assistive devices.

Osteoarthritis

• Breakdown of articular cartilage and formation of bone spurs decrease joint space and movement.
• Risk factors include older age, female gender, and obesity.
• Manifestations include pain, stiffness, impairment, enlargement, and crepitus.
• Management includes decreasing pain and improving joint mobility through exercise, weight loss, insoles, braces, orthotics, and NSAIDs.
• Nursing interventions include pain management, optimal functioning, weight loss promotion, and activity promotion.

Arthroplasty

• Prevent blood loss, VTE, and infection.
• Manage pain.
• After hip replacements, prevent dislocation by avoiding hip flexion >90 degrees and using abduction splints or pillows between legs.
• Instruct patients to keep replacement extended and pivot on the unaffected leg.
• High seats and semi-reclining chairs should be used.
• Avoid internal/external rotation, hyperextension, acute flexion, crossing legs, and bending at the waist.
• Promote ambulation.
• Monitor wound drainage.
• After knee replacements, perform neurovascular checks every 2-4 hours.
• Apply ice/cold packs to reduce swelling and bleeding.
• Instruct patient to flex foot every hour.
• Monitor wound drainage.
• Ambulate on the first post-op day.
• PT aims for 125 degrees of flexion.

Osteoporosis

• Osteoporosis is the most prevalent bone disease in the world.
• Prevention includes increasing calcium and Vitamin D intake and performing weight-bearing exercise.
• Risk factors include post-menopausal status, caffeine, tobacco, soda, alcohol, sedentary lifestyle, and being of Asian or Caucasian descent.

Osteomalacia

• Inadequate mineralization of bone may occur.
• Causes include failed calcium absorption, excessive calcium loss, GI disorders, metabolic acidosis, and hyperparathyroidism.
• It may be seen on x-rays.

Paget Disease

• Localized rapid bone turnover occurs, usually in the skull, femur, tibia, pelvis, and vertebrae.
• Increased osteoblast activity results in a mosaic pattern of bone.
• It is insidious and often only presents with skeletal deformity.
• Elevated serum ALP concentration and urinary hydroxyproline reflect increased osteoblast activity.
• Management includes NSAIDs, weight reduction, gait correctives, and bisphosphonates.

Osteomyelitis

• Infection of the bone may occur.
• S.aureus and MRSA can lead to inflammation, increased vascularity, edema, thrombosis, ischemia, necrosis, bone abscess, and new bone growth.
• Manifestations include sudden onset, signs/symptoms of sepsis, pain, swelling, and tenderness.
• It can be seen on x-ray, bone scan, or MRI.
• Management includes antibiotics and surgery to remove necrotic material.

Contusions, Sprains, Strains

• A contusion is a soft tissue injury caused by blunt force.
• A strain is an injury to a muscle from overuse, overstretching, or stress.
• First-degree strain: no loss of RoM, palpation-induced tenderness, mild muscle spasm
• Second-degree strain: acute pain during event, tenderness, increased pain with passive RoM, edema, muscle spasm, ecchymosis
• Third-degree strain: immediate pain described as tearing, snapping, or burning with muscle spasm, ecchymosis, edema, and loss of function
• A sprain is an injury to ligaments and tendons caused by twisting or hyperextension.
• Grade I sprain: stretching or slight tearing of ligament(s), localized hematoma, mild pain, edema, tenderness
• Grade II sprain: pain with motion, edema, tenderness, instability, ecchymosis, partial loss of joint function
• Grade III sprain: severe pain, edema, tenderness, ecchymosis, abnormal joint motion
• Management includes RICE (ice 24-72 hrs), immobilization if severe, NSAIDs, and monitoring neurovascular status of extremity

Joint Dislocations

• Dislocation occurs when articular surfaces are no longer aligned.
• Subluxation is a partial or incomplete dislocation.
• Avascular necrosis may develop if a dislocation is not reduced quickly.
• Priorities include avoiding neurovascular complications and reducing the joint.
• Immobilize the joint, administer pain meds, muscle relaxants, or anesthesia, and perform neurovascular assessment every 15 minutes.

Rotator Cuff

• Diagnosis includes pain with movement, tenderness, inability to sleep on affected side, and decreased RoM and strength, confirmed with x-ray, MRI, or CT.
• Treatment includes PT, NSAIDs, rest, corticosteroids, or surgery.
• Post-op, immobilize for 4-6 weeks, and begin PT.

Lateral & Medial Epicondylitis

• Diagnosis includes pain and tenderness.
• Treatment includes rest, ice, NSAIDs, PT, electrophysical modalities, and possible arm immobilization.

LCL and MCL Injuries

• Treatment includes RICE, pain meds, hinged brace, and crutches.
• Severe injuries may require non-weight-bearing exercises for 8-12 weeks or surgical repair.

ACL Injuries

• Treatment includes RICE, NSAIDs, and stabilizing the joint.
• Arthroscopic surgery is scheduled after near-normal RoM is achieved.

Meniscus Injuries

• Initial treatment includes RICE, NSAIDs, pain meds, and modification of activities.
• Diagnosis is confirmed with x-ray, MRI, or arthroscopy.
• Surgical repair depends on age and type of injury.

Achilles Tendon Injuries

• Diagnosis includes inability to plantar flex and dorsiflex, with extent determined by MRI or ultrasound.
• Non-operative treatment includes immobilization for 2-8 weeks.
• Operative treatment is usually reserved for young, healthy individuals.