VIH 3 LO 4 - Variations in Health of the Musculoskeletal System PDF

LO 4 - Variations in Health of the Musculoskeletal System LS01 - Examine the Diagnosis and Management of Musculoskeletal Trauma The Musculoskeletal System Definition: relating to or denoting the musculature and skeleton together. It’s an intricate network of bones, muscles, tendons, liga...

LO 4 - Variations in Health of the Musculoskeletal System LS01 - Examine the Diagnosis and Management of Musculoskeletal Trauma The Musculoskeletal System Definition: relating to or denoting the musculature and skeleton together. It’s an intricate network of bones, muscles, tendons, ligaments, and other connective tissue. Provides shape and armor to the body. The Skeletal System 206 bones: ○ Long bones (ie: femur) ○ Short bones (ie: metacarpals) ○ Flat bones (ie: sternum) ○ Irregular bones (ie: vertebrae) Bones are comprised of cells, protein matrix, and mineral deposits ○ Osteoblasts – for bone formation ○ Osteocytes – mature bone cells, that support maintenance ○ Osteoclasts – active in bone resorption How are bones formed? Osteogenesis: begins before birth ○ Bone matrix is formed during ossification and hard mineral crystals composed of calcium and phosphorus are bound to the collagen fibers Minerals give strength Collagen gives resilience Bone Resorption and Formation Modeling – happens in childhood, bones grow and form. ​ Remodeling – happens in the early 20’s, is a primary process, maintains bone structure, and function through simultaneous reabsorption and formation. ​ Skeletal replacement – every year 20% of the adult skeleton is replaced through this process ​ ○ Every 10 years, the adult skeleton is completely replaced Must maintain a balance of resorption and formation: physical activity, dietary intake, and various hormones Activity: if we are bedridden/ unable to put pressure on our bones, resorption occurs faster and bones weaken Diet: The body requires calcium to build bone mass; and vitamin D to ensure the absorption of minerals (also helps to protect against fractures) Calcitonin and PTH: major hormonal regulators of calcium homeostasis. ○ Calcitonin: secreted by the thyroid gland in response to elevated blood calcium levels. It inhibits resorption and increases calcium deposits in bone  ○ PTH: regulates the concentration of calcium in the blood. If Ca+ is low in the blood, it demineralizes bone to mobilize calcium. How Bones Heal Three Phases: ○ Phase One: Reactive Phase Immediately after injury The body responds to a fracture by bleeding into the injured tissue causing hematoma formation at the fracture site ​ Inflammation occurs, release of cytokines initiates proliferation of fibroblasts and angiogenesis (growth of new blood vessels) ​ Granulation tissue begins to form within the clot in days 3-14 Phase Two: Reparative Phase ○ Granulation tissue is initially replaced with procallus (a callus precursor) ○ Fibroblasts invade and produce a denser type of callus mostly fibrocartilage ○ 3-4 weeks post-injury, denser body calluses replaced the fibrocartilaginous callus. ○ Lamellar bone then forms as the body callus calcifies months post-injury Phase Three: Remodeling Phase ○ Creates new bone in its formal structural arrangement ​(5 stages) Osteoclasts resorb excess bone Osteoblasts deposit new bone tissue (bone modeling) ○ May take months to years ​  ○ Depends on the extent of bone modification needed, the function of the bone and the stress to the bone. How Bones Heal X-rays are used to monitor the progress of bone healing The rate of healing depends on the type of bone fracture, the adequacy of blood supply, the surface contact of the fragments, age, and the general health of the patient, and if immobility or the fracture site was adhered to ○ You can use an external fiberglass cast to immobilize ○ Or can insert hardware (pins, rods, screws, plates) for an ORIF How to Assess Neurovascular Status Circulation, Motion, and Sensations (CMS) Required frequently in patients with musculoskeletal disorders (especially fractures), because of the risk of tissue and nerve damage Compartment syndrome (caused by pressure within a muscle compartment that increases to an extent where microcirculation decreases, leading to nerve and muscle anoxia, and necrosis) Diagnostic Tests and Labs X-ray: ○ Important for musculoskeletal injuries. ○ Determines bone density, texture, erosion, and changes in bone relationship. ○ Multiple views (anterior-posterior, lateral, oblique) are needed for full assessment of the structure being examined ○ Serial x-rays can determine the status of the healing process ○ Must be ordered on Xray req what positioning they want Computed Tomography (CT) ○ With or without contrast ○ Shows in detail a specific plane of involved bone ○ Can show if there are tumors of soft tissue or injuries to ligaments and tendons ○ Used to identify location and extent of fractures in areas that are difficult to evaluate  Magnetic Resonance Imagining (MRI) ○ Uses magnetic fields, radio waves, and computers to demonstrate alterations of soft tissues (muscle, tendon, cartilage, nerve, and fat). ○ Contrast may be used to enhance anatomic structures Arthrography ○ Imagining to view joints (shoulder, knee, hip, ankle) ○ Contrast is injected into the joint cavity to visualize irregular surfaces ○ ROM exercises are done while imaging takes place Bone Densitometry ○ X-rays or ultrasound to measure bone strength ○ Can measure the extent of osteoporosis and monitor a patient’s response to treatment Bone Scan ○ Detects metastatic and primary bone tumors, osteomyelitis, and some fractures, and aseptic necrosis ○ Inject a bone-seeking isotope 2-3 hrs before the scan ○ Distribution of the isotope is measured in the scan ○ The degree of uptake shows the metabolism of the bone Increased uptake = primary skeletal disease (osteosarcoma), metastatic bone disease, inflammatory skeletal disease (osteomyelitis), and fractures that do not heal as expected Arthroscopy ○ Direct visualization of joints to diagnose disorders ○ Treatment of tears, defects, and disease processes may be performed ○ Done in the OR with local anesthetic or general anesthesia ○ Saline is injected and enlarges the joint space, allowing the arthroscope to visualize the structures. Arthrocentesis ○ Joint aspiration ○ Collects synovial fluid to relieve pain due to effusion ○ Can diagnose septic arthritis and other inflammatory issues ○ Anti-inflammatory medications can be injected into the joint Electromyography (EMG) ○ Info about the electrical potential of the muscles and the nerves innervating them ○ Evaluates muscle weakness, pain, and disability ○ Differentiates muscle and nerve disorders ○ Needles are inserted into the muscle, and responses to electrical stimuli are recorded Biopsy ○ To aid in diagnosis ○ Determines the structure and composition of bone marrow, bone, muscle, or synovium. Laboratory tests:  Coagulation studies: completed before surgery to evaluate bleeding tendencies because the bone is a vascular tissue Serum calcium: is altered in patients with osteomalacia, parathyroid dysfunction, Paget’s disease, metastatic bone tumors, prolonged immobilization Serum Phosphorous: inversely related to calcium and are diminished in osteomalacia Calcitonin, PTH, and vitamin D levels: can tell us about the bone metabolism Types of Musculoskeletal Injury 1. Contusions Soft tissue injury caused by blunt force to the skin 2. Strains Overuse or overstretching or muscles of tendons 3. Sprains Overstretching or tearing of ligaments ➔ Nursing Interventions: ➔ resting and elevating the affected part, applying cold, and on occasion, using compression bandages. ➔ PRICE – Protection, Rest, Ice, Compression, Elevation Musculoskeletal Trauma Joint Dislocations ○ Articular surfaces of the bones forming the joint are no longer in anatomic contact ○ Traumatic dislocations are orthopedic emergencies because the joint structures, blood supply, and nerves are distorted and severely stressed Necrosis and nerve palsy can occur if not treated. ○ Symptoms: pain, change in the contour of the joint, change in length of extremity, loss of ROM Sports-Related Injuries ○ Can be acute (sprains, strains, dislocations, fractures); or be gradual from repetitive use (tendinitis, stress fractures) Fractures A complete or incomplete disruption in the continuity of bone structure Defined by its type and extent Occur when the bone is subjected to stress greater than it can absorb ○ Direct blows ○ Crushing forces ○ Sudden twisting motions ○ Extreme muscle contractions  When broken, it can cause adjacent structures to be affected ○ Soft tissue edema ○ Hemorrhage into muscles and joints ○ Joint dislocations ○ Ruptured tendons ○ Severed nerves ○ Damaged blood vessels ○ Body organ damage Classification Location (proximal, midshaft, distal) Type Degree of break Appearance, position and alignment of fragments Stable or unstable Break in Skin: closed or open Avulsion - fracture of the bone resulting from the strong pulling effect of tendons or ligaments of the bone attachment. Spiral - A fracture that twists around the shaft of the bone Depressed - A fracture in which fragments driven inward (seen frequently in fractures of skull and facial bones) Impacted - A fracture in which a bone fragment is driven into another bone ligament Pathologic - A fracture that occurs through an area of diseased bone (e.g., osteoporosis, bone cyst, Paget’s disease, bony metastasis, tumor); can occur without trauma or fall Simple - A fracture that remains contained, with no disruption of the skin integrity Stress - A fracture that results from repeated loading of bone and muscle. Signs and Symptoms of Fractures Immediate localized pain  Edema and swelling Decreased function Inability to weight bear or use affected part Guarding May not be accompanied bone deformity Crepitation (Crackling or rattling sound) Ecchymosis (Discoloration of the skin because of bleeding under the skin) LSO2 - The Nursing Process and Potential Complications for Patients with Fractures Goal of Treatment Anatomic realignment of bone fragments (reduction) Immobilization to maintain alignment Restoration of normal function Emergency Management Immobilization of limb (support above and below the fracture) Splints help reduce soft tissue damage, pain, and bleeding from fragments moving Open fracture: cover the wound with a sterile dressing. Do not attempt to reduce the fracture. Move fractured extremity as little as possible when beginning care Medical Management Reduction: (“setting” the bone) refers to the restoration of the fracture fragments to anatomic alignment and position. The surgeon completes it as soon as possible, as immobilization restricts ROM at the site of injury. ○ Closed Reduction Non-surgical manual realignment Immobilized by traction, casting, external fixation, splints or braces applied ○ Open Reduction Correction of bone alignment through a surgical incision Often uses wires, screws, pins, plates, rods, nails to internally fixate the fracture (ORIF) ORIF facilitates early ambulation which decreases the risk of complications related to prolonged immobility and promotes healing Immobilization: after it has been reduced, the bone fragments must be immobilized until union occurs. ○ External immobilization: bandages, casts, splints, continuous traction, and external fixators ○ Internal Immobilization: metal implants Traction  Devices apply a pulling force on the fractured extremity to attain realignment while counter traction pulls in the opposite direction. Seen more in children.​ Skin traction (short-term) ○ 48-72hr until skeletal traction or surgery. ie. Tape, boots, splints applied directly to skin. 5-10lb wts. Skeletal traction (longer periods) ○ align bones and joints or to treat joint contractures and congenital hip dysplasia. ie. Pin or wire inserted into the bone to align or immobilize the injured body part. Wt is 5-45lb. Care of a patient Casts ○ Temporary circumferential immobilization devices ○ Common treatment following a closed reduction ○ Non-Plaster (synthetic casts): lighter, stronger, water resistant, durable. For non-displaced fractures with minimal swelling or for long term wear ○ Plaster: moistened rolls are applied over cotton. A crystallization process makes it rigid when dry. Ensure no skin contact Care: ○ Frequent neurovascular assessments ○ Elevation of extremity about level of heart ○ Signs of cast complications ○ Exercise joints both above and below the cast Splints and Braces ○ An alternative or supplement to a cast ○ More practical and is preferred Splints often used for simple and stable fractures, sprains, tendon injuries, and other soft tissue injuries ○ Faster and easier to apply than a cast ○ Noncircumferential to allow or natural swelling and inflammation ○ Easily removable to inspect site ○ Can be used while awaiting definitive care Braces are used to provide support, control movement, and prevent additional injury ○ Custom fitted and made for long-term use ○ Adjusts for fit, positioning, and motion so that movement is enhanced, any deformities are corrected, and discomfort is minimized Fracture Healing and Complications Weeks to months are required for most fractures to heal Many factors can influence this time frame (negative or positive) Fractures must be properly aligned to attain the best healing possible Essential for fractured bone to have blood supply to the area  If fracture healing is disrupted, bone union may be delayed or stopped ○ Inadequate immobilization ○ Inadequate blood supply ○ Extensive space between bone fragments ○ Interposition of soft tissue between bone ends ○ Infection ○ Metabolic problems Early Complications: ○ Shock ○ Fat embolism ○ Compartment syndrome ○ DVT ○ PE ○ Disseminated intravascular coagulopathy (DIC) ○ Infection Later Complications: ○ Delayed union ○ Nonunion ○ Necrosis of bone ○ Reaction to internal fixation devices ○ Complex regional pain syndrome (CRPS) ○ Heterotrophic ossification Early Complications Shock: ○ Hypovolemic and traumatic shock resulting from hemorrhage (both visible and nonvisible blood loss) ​ ○ Also due to loss of extracellular fluid into damaged tissues may occur ○ Bones are very vascular, and large quantities of blood may be lost as a result of trauma, especially in femur and pelvis fractures Treatment Restore blood volume and circulation ​ Relieve pain ​ Provide adequate splinting ​ Protect patient from further injury and other complications Fat Embolism Syndrome: ○ Fat emboli enter circulation following orthopedic trauma, especially long bone fractures ○ Fat globules diffuse from the marrow into the vascular compartment and may occlude the small blood vessels that supply the lungs, brain, kidneys, and other organs ○ Onset is rapid (within 12-72 hours)  ○ Presents with hypoxia, tachypnea, dyspnea, tachycardia, substernal chest pain, crackles (potentially leading to respiratory failure- Acute Respiratory Distress Syndrome), neurologic compromise (agitation, seizures, focal deficits, encephalopathy), and petechial rash Treatment: Immobilize fracture Support the symptoms (cardiorespiratory - vasopressors, mechanical ventilation, fluid resuscitation) Acute Compartment Syndrome: ○ Condition in which pressure within a confined myofascial compartment is elevated ○ Can be caused by an increase in compartment volume, a decrease in compartment size, or both ○ Compromising the neurovascular function of tissues within the space ○ Can cause cell death if treatment isn’t initiated timely ○ CMS is a vital assessment (see next slide) Treatment: Elevation of the extremity to the level of the heart Release restrictive devices Fasciotomy is indicated if previous interventions do not work within one hour Pain and wound management once complete Venous Thromboembolism (DVT and PE) Veins of the lower extremities and pelvis are highly susceptible to thrombus formation after fracture, especially hip fracture Precipitating Factors: ○ Venous stasis caused by incorrectly applied casts or traction ○ Local pressure on a vein ○ Immobility  Interventions for Prevention ○ AE stockings/Sequential compression devices ○ Leg/Hand exercises ○ Anti-coagulation Early Complications ❖ Infection Open and soft tissue injuries have increased incidence Osteomyelitis can become chronic Open fractures require aggressive surgical debridement Post-op IV antibiotics for 3-7 days Late Complications ❖ Delayed Union Occurs when healing does not occur at a normal rate for the location and type of fracture ​ May be associated with distraction (pulling apart) of bone fragments, infection, poor nutrition, or comorbidity​ Eventually the fracture heals ❖ Nonunion Results from failure of the ends of a fractured bone to reunite ​ Patient complains of persistent pain and abnormal movement at the fracture site ​ Contributing factors include infection, interposition of tissue between the bone ends, inadequate mobilization or manipulation that disrupts callus formation, excessive space between bone fragments, limited bone contact and impaired blood supply ❖ Avascular Necrosis of Bone Occurs when bone loses blood supply May occur after a fracture disruption of the blood supply Seen with dislocations, bone transplantation, prolonged high doses of corticosteroids, chronic renal disease, sickle cell anemia and other diseases Symptoms: starts with pain on movement, then progresses to pain at rest ○ Treatment: ○ NSAIDS ○ Exercises ○ Limiting weight bearing of the affected region ○ Total joint replacement when located in hip and knees LS03 - Nursing Process for Specific Types of Fractures Specific Cast Management 1. Arm Cast Control swelling Use a sling when the patient ambulates (support not just on the back of neck) Monitor hand for complications (cyanosis, swelling, inability to move fingers) OT for one-handed devices to help the patient Frequent rest as the modified activities and weight of the cast can cause fatigue 2. Leg Cast Assist/ teach how to transfer and ambulate with assistive devices (keeping in mind weight bearing orders) Control swelling (elevate while laying/ seated) Assess neurovascular status 3. Body/Spica Cast *rarely used, emphasis is on ORIF Educate on proper hygienic interventions (cast and skin) Ensuring proper positioning Preventing complications Managing an External Fixator Used to manage open fractures with soft tissue damage Support for crushed or splintered fractures while permitting active treatment of damaged soft tissues Uses a series of pins inserted into bones that are attached to an external frame Interventions: ○ Elevate ○ Cover sharp points of fixator ○ Neurovascular assessment q2-4 hrs including pin assessment ○ Pin care as prescribed ○ Encourage isometric and active exercise within the limits of tissue damage LS04 - Nursing Process related to amputations Amputations Amputation – the surgical removal of a limb. Reason for amputation depends on underlying disease or trauma: ○ Circulatory impairment ○ Traumatic and thermal injuries ○ Malignant tumors  ○ Congenital disorders Most lower limb amputations are from PVD and most upper limb amputations are from traumas. Done to relieve symptoms, improve function, and save or improve the patient’s quality of life Levels of Amputation is performed at the most distal point that will heal successfully Determined by adequacy of circulation and functional usefulness Doppler, blood pressure, and transcutaneous PaO2 are all diagnostic aids for the determination of the level The goal of surgery is to conserve as much extremity as possible and preservation of knee and elbow joints is preferred Complications Hemorrhage Infection Skin breakdown Phantom limb pain Joint contracture Medical Management The objective of treatment is to achieve healing of the amputation wound, the result being a nontender residual limb (stump) with healthy skin for prosthetic attachment Healing is enhanced by gentle handling of the residual limb, control of residual limb edema through ridged or soft compression dressings, and use of aseptic technique in wound care to avoid infection Dressings: ○ Compression bandage often applied immediately after surgery to support soft tissue, reduce edema, hasten healing , minimize pain and promote residual limb shrinkage and maturation. ○ Proper stump bandaging fosters shaping & moulding for eventual prosthesis fitting. After the incision is healed, the nurse teaches the patient to care for the residual limb. Nursing Diagnosis Disturbed body image r/t amputation and impaired mobility Impaired skin integrity r/t immobility and improperly fitting prosthesis Chronic pain r/t amputation  Impaired physical mobility r/t amputation Risk for infection r/t amputation Risk for sensory perception r/t amputation Nursing Interventions Manage pain Minimize altered sensory perceptions Promote wound healing Enhance body image Help resolve grieving Promote independent self care Achieve physical mobility Monitoring and managing potential complications Promoting home, community-based and transitional care Nursing Care ❖ Preop Reinforce already taught information to patient and family Know level of amputation, type of dressing, and type of prosthesis planned Educate about post-op exercises – included upper extremity exercises Post-op nursing care and expectations discussed Teach about phantom limb sensation and pain Postop ○ Very individualized based on general state of health, reason for amputation and age ○ Prevention and detection of complications ○ Signs and symptoms of hemorrhage VS Dressings assessment ○ Sterile technique to reduce chance of infection