Musculoskeletal System Review PDF

Musculoskeletal System Review of Relevant Components and Disorders PHAR8000 Course Objectives In this class, the following objectives will be covered 2.0 – Musculoskeletal System Disorders Musculo-skeletal system The skeleton Bones Joints Soft Tissues Skeletal muscles Tendons Li...

Musculoskeletal System Review of Relevant Components and Disorders PHAR8000 Course Objectives In this class, the following objectives will be covered 2.0 – Musculoskeletal System Disorders Musculo-skeletal system The skeleton Bones Joints Soft Tissues Skeletal muscles Tendons Ligaments (Zettel, 2023) Elements of Bone Tissue Bone cell types include: ◦Osteoblasts-the primary bone-producing cells; once this job is complete, they become osteocytes, trapped in the bone matrix ◦Osteoclasts- resorb (remove) bone during growth and / or repair ◦Osteocytes- old osteoblasts that are trapped in matrix and maintain bone homeostasis (balancing new bone growth with destruction of old) (Zettel, 2023) Compact and Spongy Bone Matrix Made of extracellular elements of bone tissue such as Collagen fibres Structural proteins Carbohydrate protein complexes Ground substances Minerals The basic unit in bone is the Haversian system. Components of Long Bones Epiphyseal disc- also called the ‘growth plate’, a band of hyaline cartilage near both ends Periosteum- covers the outside of the diaphysis for protection; also contains blood vessels Articular cartilage- outer surface of epiphysis; decreases friction in joints (Zettel, 2023) Long bone Diaphysis Metaphysis Epiphysis -Epiphyseal plate Medullary (marrow) cavity Endosteum Periosteum (Zettel, 2023) Synovial Cavity and Fluid Cavity: an enclosed, fluid-filled space between articulating surfaces of two bones o enables two surfaces to glide against one another with little friction o Fluid: filtered plasma fnourishes articular cartilage o covers ends of bones o contains hyaluronic acid which offer biomechanical properties (maintains fluid viscosity and integrity of the joint) o contains leukocytes rom blood vessels that lubricates joint surfaces o and phagocytes to manage debris (Zettel, 2023) Cartilage and Bursae Articular cartilage covers the ends of each bone oreduces friction in the joint and distributes weight-bearing forces ocomposed of chondrocytes and intercellular matrix Bursae are small sacs lined with synovial membrane and filled with synovial fluid olocated between bony prominences and soft tissues (tendons, muscles and ligaments) omay be natural (from birth) or ‘adventitious’ as a result of chronic friction and degeneration of fibrous tissue between adjacent structures) (Zettel, 2023) oseparates, lubricates and cushions adjacent structures Tendons and Ligaments Tendons Ligaments Strong bands of connective tissue Strong bands of tissue that attach that attach muscle to bone bone to bone (Zettel, 2023) MSK System (Tyerman et al., 2023, p. Diagnostic Studies of the MSK System Radiography (X-ray, CT, MRI, arthrography, discography) Bone mineral density studies (DEXA and ultrasound) Bone scan using radioisotopes Arthroscopy Lab studies (calcium, phosphate, rheumatoid factor, ANA, C- reactive protein, uric acid, HLA, enzymes) Invasive procedures (arthrocentesis, EMG, somatosensory evoked potentials) (Zettel, 2023) Musculoskeletal Injuries Tendon and Ligament Review Muscle is attached to bone by a tendon Ligaments attach two bones together Tendons and ligaments have limited perfusion and heal slowly (Zettel, 2023) Types of Injuries to MSK System Sprain Strain Dislocation Subluxation Fractures (Zettel, 2023) Sprains and Strains Tear in ligament is a sprain Tear in tendon is a strain Damaged by trauma to a joint If completely separated from the bone (avulsion) Manifestations of inflammation appear (Tyerman et al., 2023 Clinical Manifestations Pain Edema Decrease in function Bruising Pain (Tyerman et al., 2023 Healing of Sprains / Strains Begins with inflammation Granulation tissue develops at the site Formation of collagen fibres link bone to tendon/ligament Fibrous tissue formation completes the healing Mild sprains and strains are usually self- limiting, with full function returning within 3 to 6 weeks. If severe, surgery may be required (Tyerman et al., 2023 Nursing Management Health Promotion Warm up before exercise Stretching Balance exercises and strengthening exercises to prevent falls Min 150 minutes of exercise a week Acute RICE (rest, ice, compression, elevation) Home Care Patient should use ice and elevate for 24-48-hrs after injury Use mild analgetic Elastic bandage to provide extra support (Tyerman et al., 2023 Proper strengthening and condition to prevent re-injury Dislocation A severe injury of the ligaments that results in the complete displacement of the bone from its normal position Causes tissue damage Deformity is obvious Manifestations include pain, decreased movement, swelling Should be realigned ASAP to avoid avascular necrosis of the bone (Tyerman et al., 2023 Subluxation A partial or incomplete displacement of the joint surface Less severe than dislocation but treated the same way Realignment (open or closed), followed by immobilization of the joint through braces or splints and physiotherapy (Tyerman et al., 2023 Clinical Manifestations & Nursing Interventions CLINICAL MANIFESTATIONS NURSING INTERVENTIONS Deformity Needs prompt attention to avoid avascular necrosis (AVN) and Local pain/tenderness compartment syndrome Loss of function to injured area The dislocated joint needs to be Swelling of the soft tissue aligned (closed reduction) – by a physician under anesthetic or sedation Nursing management is directed at pain relief and support and protection of the injured joint (Tyerman et al., 2023 Repetitive Strain Injury Affects muscles, tendons and nerves Repetition decreases perfusion to the area and damages soft tissue Causes pain, weakness and numbness e.g. tendinitis, carpal tunnel syndrome Treated with cold or heat, NSAIDs and physiotherapy and / or surgery (Zettel, 2023) Common Diagnostic Tests X-ray, CT, MRI demonstrate images Arthrogram uses radiopaque dye or air to view joints Arthroscopy allows internal viewing of a joint using a scope (Zettel, 2023) Fractures A break in the continuity of bone Other structures often affected Hemorrhage, edema, dislocations, ruptured tendons, severed nerves, damaged blood vessels and organ injury (Zettel, 2023)  Classifications Traumatic- majority Pathological (e.g. osteoporosis, metastasis) Further classified according to stability, completeness, communicating or non-communicating with environment, number and location (Zettel, 2023) Traumatic Fracture BOXER’S FRACTURE Pathological Fractures Osteoporosis- Carcinoma- related related (Zettel, 2023) Fractures- Stable vs. Unstable Stable - some periosteum is Unstable - grossly intact across the fracture but displaced and in poor fragments are stationary fixation (Zettel, 2023) Types of Fractures Complete - entire cross-section of bone involved; two pieces Incomplete - a portion of the cross-section of bone is involved. Open - break in the skin and soft tissue leads to the fracture; also called a ‘compound’ fracture Closed- fracture doesn’t communicate with the environment. (Zettel, 2023) Complete (Scaphoid Wrist) Fracture Incomplete (Greenstick) Fracture Closed Simple and Multiple (Comminuted) Fractures Simple fracture - a single break in the bone (Zettel, 2023) Compound Comminuted Fracture Multiple or comminuted fracture multiple fractures and fragments (Zettel, 2023)  Patterns of Fracture Tranverse Fracture occurs straight Fracture twists across the Greenstick: across the bone shaft of the bone Fracture occurs at an One side of the bone is broken, and the other angle across the bone. side is bent (Zettel, 2023)  Patterns of Fracture Displaced Fracture Depressed Fracture Fracture fragments are in driven. Commonly Interarticular Fracture seen with skull and facial Fracture extends to the fractures articular surface of the bone (Zettel, 2023)  Patterns of Fracture Stress Facture Occurs in normal or Pott’s Fracture Colles’ Fracture abnormal bone that is Fracture of the lower fibula Also referred to as a ‘dinner subject to repeated due to excessive stress on fork’ fracture. Break in the stress (often in runners) the ankle; sometimes occurs distal radius at the wrist, when stepping off the curb usually caused by trying to break a fall (Zettel, 2023) Clinical Manifestations Pain at site of injury (maybe from spasm) Swelling (disruption of soft tissues) Tenderness Crepitus (bones grate together) Deformity Ecchymosis (bleeding into soft tissue) Paresthesia (compression on nerves) (Zettel, 2023) Assessment Inspection Palpation X-ray (will demonstrate fracture that is not obvious) Lab values (note Hgb) History of accident Observe the region distal to the extremity (Zettel, 2023) Neurovascular Assessment Neurovascular assessment (nerve or vessel damage can occur) Consider the five ‘P’s’: 1. Pain 2. Pulses 3. Pallor 4. Paresthesia 5. Paralysis (Zettel, 2023) Stages of Bone Healing A. Hematoma formation B. Granulation tissue formation C. Procallus D. Bony callus E. Remodelling (Zettel, 2023, p. 967) Time to Heal Varies with age, displacement of fracture, site and perfusion May have delayed union or nonunion of fragments Healing is delayed if the area is not immobilized, there is excess movement, infection and poor nutrition Electric current sometimes used to stimulate cell activity to speed healing in delayed union (Zettel, 2023, p. 967) Musculoskeletal Disorders: Osteoarthritis and Rheumatoid Arthritis Types of musculoskeletal disorders DEGENERATIVE AUTOIMMUNE ‘Wear and tear’ Immune system fails to Slow progression of distinguish between ‘self’ and destructive changes ‘non-self’ antigens and develops autoantibodies e.g. osteoarthritis, TMJ e.g. Systemic Lupus disorder Erythematosus, Rheumatic Fever, Myaesthenia Gravis, Scleroderma (Zettel, 2023, p. 967)  Osteoarthritis ◦ ◦ (Zettel, 2023) Pathophysiology Wear and tear causes erosion of cartilage, with loss of elasticity Cartilage is rough; less space between joints Release of enzymes from cells accelerates degeneration Bone growth increases at joint margins (bony spurs) Bone and cartilage pieces break off into synovial cavity Secondary inflammation and reduction in movement Local effects (Zettel, 2023) Clinical Manifestations Restricted to the joints; unilateral or bilateral Aching pain with weight-bearing and movement Later, pain at rest Affected by weather Limitation in movement with atrophy of muscles Stiffness with immobility Enlargement of joints with the development of osteophytes Crepitus Bow-legged appearance when knees involved (Zettel, 2023) Heberden’s Nodules and Bouchard’s Nodes Bouchard’s Node Bouchard’s Node Heberde n’s Nodule Hip Joint Osteoarthritis OA of the Knee Pharmacologic Management of Pain and Inflammation Goals: Manage pain and inflammation Prevent disability Maintain joint function (Tyerman et al., 2023 Complete the Standard Learning Outcome for the following medications Glucosamine Chondroitin forms Capsaicin cream Sodium Hyaluronate  Rheumatoid Arthritis o o o o o (Tyerman et al., 2023 Pathogene sis of Rheumatoi d Arthritis Autoimmunity Antigen causes the formation of abnormal IgG Autoantibodies (rheumatoid factors) combine with IgG to form complexes that deposit in joints Inflammation leads to swelling, redness and pain (synovitis) RF is found in most people with RA Moves through stages, from early to terminal (Zettel, 2023)  Stages of Rheumatoid Arthritis Development 1. Early- swelling of the synovial joint with the production of excess synovial fluid 2. Moderate-inflammatory granulation tissue (pannus) forms at the juncture of synovium and cartilage, releasing damaging enzymes and invading the joint capsule and bone; cartilage is eroded no joint deformity yet; some soft tissue lesions 3. Severe- tough fibrous tissue occludes joint space with loss of range of motion; bones out of alignment cartilage and bone destruction evident on x-ray, along with osteoporosis, deformity, muscle atrophy, and tissue lesions 4. Terminal- fibrous tissue calcifies with joint immobilization (Zettel, 2023) Synovial Changes in Rheumatoid Arthritis Clinical Manifestations Usually insidious (although up to 15% of cases have acute onset) Systemic manifestation of inflammation (fever, fatigue, weakness anorexia, weight loss) Aching and tenderness of joints Redness and swelling Symmetrical pattern Joint stiffness after immobility Impairment of joint movement Worsening of systemic signs during exacerbations (Zettel, 2023) Swan Neck Deformity RA of the hand.  Management of Rheumatoid Arthritis Early aggressive therapy Control inflammation and pain o balance of rest and activity o physical and occupational therapy (splints and assistive devices) o heat and cold application o balanced nutrition o surgery o pharmacotherapy (Tyerman et al., 2023 Complete the Standard Learning Outcomes for the following medications Capsaicin topical cream Disease-Modifying Antirheumatic Drugs (DMARDs) Tramadol Hyaluronate Glucocorticoids (prednisone) Osteoporosis Osteoporosis Loss of bone mass and density Deterioration of bone matrix and mineralization Bones become susceptible to fracture “a systemic skeletal disease characterized by low bone density and microarchitectural deterioration of bone tissue with a consequent increase in bone (Tyerman et al., 2023 fragility.” Facts about osteoporosis Common among the elderly, but is NOT a normal process of aging Bone density is maintained by plasma calcium and phosphorus concentrations (a function of the endocrine system) and peaks at age 30 Disease may be generalized, involving a major portion of the axial skeleton or regional, involving one aspect of the appendicular skeleton Common among post-menopausal women Costly to the health care system (Tyerman et al., 2023 Risk Factors Age- osteoblasts are less effective Post menopause- estrogen deficiency Decreased mobility- mechanical stress on bone is required for osteoblastic activity Genetics- vitamin D receptor gene is linked to bone density Calcium and vitamin D deficit Smoking Eating disorders Small frame Excessive caffeine intake (Tyerman et al., 2023  Why are women more susceptible? Less intake of calcium Smaller frame = less bone mass Resorption of bone occurs earlier and faster than bone deposition Pregnancy and lactation depletes calcium stores Women still live longer than men (Tyerman et al., 2023 Pathophysiology of osteoporosis Peak bone mass is achieved by age 30 Bone mass is affected by genetics, diet, activity and hormones Bone loss begins around the 4th decade At menopause, the rate of loss increases oestrogen is thought to limit the lifespan of osteoclasts Pathophysiology Recall that: Osteoblasts deposit bone Osteoclasts resorb bone Balance is essential to prevent loss When resorption exceeds deposition, bone loss occurs Common in the cancellous bone of the spine, hips and wrists Insidious onset Glucocorticoids and osteoporosis Improve osteoclast survival Inhibit osteoblast formation and function Increase osteocyte apoptosis Results in decreased thickness of bone and thinner and more widely spaced trabeculae in the marrow (Tyerman et al., 2023 Clinical manifestations Asymptomatic in early stage; may not be evident till a fracture occurs Back pain Change in posture (wedging and vertebral fractures cause a decrease in height and a ‘humped back’ appearance) Kyphosis and scoliosis Spontaneous or minimal trauma fractures (Tyerman et al., 2023 Spine Curvatures in Osteoporosis Diagnostics X-ray isn’t valuable until disease progresses Bone mineral density test (BMD) Dual energy x-ray absorptiometry (DEXA) helps with diagnosis and serial monitoring Information from DEXA is enhanced by trabecular bone scoring, which evaluates variations in lumbar spine images from DEXA scans (Tyerman et al., 2023 Standard Learning Outcomes Complete the Standard Learning Outcomes for the following medications Selective estrogen receptor modifiers (ie Raloxifene) Calcitonin Calcium Vitamin D Fluoride Supplements Denosumab Human parathyroid hormone Biophosphates ◦ alendronate (Fosamax) ◦ etidronate (Didronel) ◦ risedronate (Actonel) Non-Pharmacological management of osteoporosis Weight-bearing exercise Surgery- to reduce kyphosis and realign vertebral column (Tyerman et al., 2023 Nursing Considerations NURSING BIPHOSPHONATES CONSIDERATIONS establish baseline bone density data address any calcium or vit D deficiency periodic BMD testing baseline bone density data monitor for signs of thrombus formation contraindicated in renal disease supplement with calcium and vit D take on empty stomach, with water, and sit up for 30 min for absorption exercise eat calcium-rich foods (except for those on etidronate) weight-bearing exercise (Tyerman et al., 2023 References Tyerman, J., Cobbett, S.L. & Harding, M.M. (2023). Lewis’s Medical-Surgical Nursing in Canada: Assessment and Management of Clinical Problems (5th Ed.). Toronto, Canada: Elsevier. VanMeter, K.C., & Hubert. R.J. (2014). Gould’s Pathophysiology for the Health Professions, (5th ed). St. Louis, United States of America: Elsevier. Toufic El-Hussein, M., Power-Kean, K., Zettel, S. Understanding Pathophysiology (2nd Cnd). Elsevier Canada. 2023