Musculoskeletal Notes PDF

Musculoskeletal System Overview The musculoskeletal system consists of voluntary muscles and connective tissues that: 1. Protect body organs 2. Provide support and stability 3. Store minerals (e.g., calcium, phosphate) 4. Enable coordinated movement Bone Struc...

Musculoskeletal System Overview The musculoskeletal system consists of voluntary muscles and connective tissues that: 1. Protect body organs 2. Provide support and stability 3. Store minerals (e.g., calcium, phosphate) 4. Enable coordinated movement Bone Structure and Function Functions of Bones: 1. Support: Provides structural framework for the body. 2. Protection: Protects internal organs (e.g., skull protects the brain). 3. Movement: Assists with voluntary movement. 4. Blood Cell Production: Bone marrow produces red blood cells, white blood cells, and platelets. 5. Mineral Storage: Bones store important minerals like calcium and phosphate. Types of Bone Cells: 1. Osteoblasts: Cells responsible for forming new bones. 2. Osteocytes: Mature bone cells that maintain the bone matrix. 3. Osteoclasts: Cells involved in the breakdown of bone tissue during bone remodeling. Bone Remodeling: Continuous process where old bone is resorbed by osteoclasts and new bone is deposited by osteoblasts. ○ Critical for maintaining healthy and strong bones over time. Bone Types and Anatomy Types of Bones: 1. Long Bones: Found in arms and legs (e.g., femur, humerus). 2. Short Bones: Found in the wrist and ankle (e.g., carpals, tarsals). 3. Flat Bones: Found in the skull and ribs (e.g., cranial bones, sternum). 4. Irregular Bones: Bones with complex shapes (e.g., vertebrae). 5. Sesamoid Bones: Embedded in tendons (e.g., patella). Joints: 1. Ball-and-socket joints: Allow for rotational movement (e.g., shoulder). 2. Hinge joints: Permit movement in one plane (e.g., elbow, knee). 3. Pivot joints: Allow for rotational movement (e.g., neck). 4. Saddle joints: Allow for a wide range of motion (e.g., thumb joint). Types of Cartilage Hyaline Cartilage: Provides support and reduces friction between bones in joints. Found in places like the nose, trachea, and at the ends of long bones.  Elastic Cartilage: Provides flexibility (e.g., in the ear). Fibrocartilage: Found in intervertebral discs and absorbs shock. Muscle Types and Function Three Types of Muscle: 1. Cardiac Muscle: Found only in the heart; contracts involuntarily to pump blood. 2. Smooth Muscle: Found in the walls of hollow organs like intestines and blood vessels; also contracts involuntarily. 3. Skeletal Muscle: Voluntary muscles attached to bones that enable movement. Muscle Contractions: Isometric Contractions: Muscle length does not change during contraction (e.g., holding a plank). Isotonic Contractions: Muscle changes length during contraction (e.g., lifting weights). Muscle Atrophy and Hypertrophy: Atrophy: Decrease in muscle size, often due to disuse or immobility. Hypertrophy: Increase in muscle size due to resistance training or other physical demands. Muscle Fiber Types: Slow-twitch fibers: Fatigue-resistant, designed for endurance activities (e.g., marathon running). Fast-twitch fibers: Fatigue quickly but generate powerful, quick contractions (e.g., sprinting). Neuromuscular Function Skeletal Muscle Contraction: Requires a nerve impulse to trigger contraction. Energy for muscle contraction comes from ATP (Adenosine Triphosphate), produced via cellular respiration. Nursing Assessment of the Musculoskeletal System Neurovascular Assessment of Injured Extremities: Essential to assess for any neurovascular compromise after injury or surgery. 6 P’s to assess include: 1. Pain: Does the patient have pain in the affected limb? 2. Pulses: Are pulses present and palpable in the affected area? 3. Pallor: Is there any change in skin color indicating poor circulation? 4. Paresthesia: Does the patient experience tingling or numbness in the affected extremity? 5. Paralysis: Is there any loss of motor function in the limb?  6. Pressure: Is there increased pressure, indicating swelling or compartment syndrome? Fractures and Amputations Fracture Management (Nursing responsibilities include): ○ Immobilizing the affected area. ○ Monitoring for complications like compartment syndrome and fat embolism. ○ Administering medications for pain management. ○ Encouraging early mobilization and physical therapy when appropriate. Amputations: ○ Nursing care for amputations involves: ○ Ensuring proper wound care and infection prevention. ○ Managing phantom limb pain. ○ Assisting with rehabilitation and prosthetic fitting. ○ Providing emotional support to the patient coping with the loss of a limb. Common Complications of Fractures Compartment Syndrome: A medical emergency where increased pressure in a muscle compartment impairs blood flow, leading to tissue damage. Signs include pain out of proportion to the injury, pallor, and pulselessness. Fat Embolism: Occurs when fat globules from bone marrow enter the bloodstream, usually after long bone fractures. Symptoms include respiratory distress, mental confusion, and petechial rash. Bone Diseases 1.Osteomyelitis: Infection of the bone, often caused by bacteria. Clinical manifestations include fever, localized pain, and swelling. Management includes IV antibiotics and sometimes surgical debridement. 2. Osteomalacia: Softening of the bones due to vitamin D deficiency. Patients experience bone pain and muscle weakness. Treatment involves vitamin D supplementation and dietary changes. Postoperative Management after Spine Surgery Nursing management includes: Monitoring for neurological deficits post-surgery. Ensuring proper positioning to avoid stressing the spine. Encouraging early mobilization and physical therapy. Assessing for signs of infection at the surgical site. Low Back Pain Acute Low Back Pain:  Usually resolves within a few weeks. Management includes rest, NSAIDs, and physical therapy. Chronic Low Back Pain: Lasts longer than 3 months. Requires a more multidisciplinary approach for management, including physical therapy, medications, and sometimes surgical interventions. Ligaments and Tendons Tendon: Attaches muscles to bones. Tendons are strong, flexible tissues that help muscles exert force on bones, allowing movement. Ligament: Attaches bones to bones via fibrous connective tissue. Ligaments provide stability to joints. They have a poor blood supply, which leads to slow repair after injury. ○ Example: A torn ligament can take a long time to heal due to poor blood flow. Effects of Aging on the Musculoskeletal System Functional Problems: Slower mobility as people age (e.g., getting out of bed, walking). Bone Density Decrease: Aging leads to decreased bone density, increasing the risk of osteopenia and osteoporosis. Muscle Mass and Strength: There is a decrease in muscle mass, muscle strength, and flexibility with age. Osteoarthritis: Increased risk of osteoarthritis leads to aching pain in the joints. Falls: Decreased proprioception (awareness of body position in space) increases the risk of falls in the elderly. Fracture risk: When elderly individuals fall, their weakened bones are more prone to fractures. Mobility Issues: Falls can lead to serious mobility issues, contributing to the decline in physical independence among the elderly. Musculoskeletal System Assessment 1. Subjective Data: Gather health history: How long has the patient had the disease? Medications taken, surgical history, and medical conditions (e.g., diabetes, heart disease, kidney problems).  Functional patterns: Any difficulty walking, getting out of bed, or performing daily activities due to conditions like arthritis or rheumatoid arthritis. 2. Objective Data: Physical Assessment: General Observation: Assess patient’s mobility and how quickly they move. Inspection: Look for open wounds, masses, or deformities. Palpation: Feel for any masses, nodules, or tender areas. Motion Assessment: Assess smoothness of movement, and check for jerky movements or slow, limited motion. Muscle Strength: Evaluate muscle strength using a grading scale. Posture and Gait: Observe how the patient walks (e.g., stability, balance) and check for any spinal abnormalities like scoliosis. Diagnostic Studies for the Musculoskeletal System 1. X-ray: Most common initial diagnostic test, used to evaluate bone fractures or joint conditions. 2. MRI (Magnetic Resonance Imaging): Used when x-rays do not provide enough detail; helpful for viewing soft tissue injuries, ligaments, or tendons. 3. Bone Scan: Detects bone abnormalities such as cancer or lesions that may not show up on standard x-rays. 4. CT Scan (Computed Tomography): Provides detailed images of bones, joints, and surrounding tissues. 5. Electromyogram (EMG): Evaluates the health of muscles and the nerve cells that control them. Used to detect muscle defects. 6. Dual-Energy X-ray Absorptiometry (DEXA): Measures bone density and is used to diagnose osteoporosis. 7. Serology Studies: Blood tests to check for conditions that affect musculoskeletal health, such as HIV, STDs, or syphilis. 8. Myelogram: Involves injecting a contrast dye into the spine to detect spinal cord or nerve issues. 9. Somatosensory Testing: Measures nerve conduction to assess potential nerve damage. 10. Thermography: Uses temperature readings to evaluate muscle function. 11. Quantitative Ultrasound: Similar to a traditional ultrasound but used to assess the characteristics of bones or fluids. 12. Interventional Radiology: Techniques used in diagnostic studies, such as injecting contrast dyes or performing biopsies to detect and assess issues in organs and tissues. Musculoskeletal Trauma and Orthopedic Surgery Health Promotion: Education is key in preventing musculoskeletal injuries:  Accidents: Younger populations are more prone to accidents, while the elderly face higher risks of falls. Public education should focus on promoting safe environments at home, work, and during sports or driving. Safety Tips: Wear seatbelts and follow traffic rules (e.g., speed limits, avoid distractions while driving). Avoid driving under the influence of alcohol or drugs. Warm up before exercising and use protective gear (e.g., knee pads, helmets) to prevent sports injuries. Use proper safety equipment at work, particularly for individuals lifting heavy objects (e.g., use back braces to prevent back strain). Fall Prevention in the Elderly Falls cause a high percentage of mobility-related injuries in the elderly, often resulting in fractures or reduced independence. Health Promotion strategies include educating the elderly and their caregivers on: Creating a safe home environment (e.g., removing trip hazards, installing handrails). Encouraging regular exercise to maintain muscle strength and balance. Regular bone density checks to assess for conditions like osteoporosis that increase fracture risk. Preventive Care for Musculoskeletal Injuries in the Elderly Falls: A major cause of musculoskeletal injuries in the elderly, especially in the home setting. Risk Factors: ○ Gait instability ○ Vision impairment ○ Age-related muscle weakness ○ Preventive Measures: ○ Age-appropriate exercise to maintain muscle strength and balance. ○ Ensure adequate calcium and vitamin D intake for bone health. ○ Assess the living environment for safety risks, such as trip hazards. Traumatic Injuries Types of Injuries: Sprains: Ligament injuries caused by excessive stretching or tearing. Dislocation: Occurs when a bone is forced out of its normal position in a joint. Subluxation: A partial dislocation where the bone is partially out of the socket. Sports-Related Injuries  1. Impingement Syndrome: Involves nerve compression, often causing tingling or numbness in the affected area. Considered an emergency when nerve compression becomes severe. Treatment focuses on relieving pressure in the impingement area. 2. Rotator Cuff Injuries: A common injury involving the muscles and tendons around the shoulder joint. Causes shoulder pain, weakness, and limited range of motion. Often diagnosed with MRI for confirmation. 3. Shin Splints: Pain in the lower leg caused by inflammation of the muscles and tendons, often due to repetitive activities like running. 4. Tendonitis: Inflammation of a tendon, such as in tennis elbow. 5. Ligament Injuries: Examples include anterior cruciate ligament (ACL) injuries common in athletes. Management of Sprains and Strains RICE Protocol for Soft Tissue Injuries: 1. Rest: Limit movement and stop activities that cause pain. 2. Ice: Apply ice for 20–30 minutes at a time for 24 to 48 hours to reduce swelling. 3. Compression: Use an elastic bandage, applying from distal to proximal (from far to near the injury). 4. Elevation: Elevate the injured limb above the heart to reduce swelling. 5. Analgesia: Use ibuprofen (400–800 mg) or acetaminophen for pain management, always taken with food to protect the stomach. Soft Tissue Injuries and Hip Dislocations 1. Dislocation: When the humerus (arm bone) is completely out of the shoulder socket. 2. Subluxation: A partial dislocation where the bone is partially out of the socket. Repetitive Strain Injury (RSI) Repetitive Strain Injury (RSI): Also known as cumulative trauma disorder or overuse syndrome, RSI is caused by prolonged force or repetitive movements. Common Affected Areas: Wrist (e.g., from typing, sewing, or using tools). Occupations at Risk: Hairdressers, dancers, butchers, athletes, and cable operators. Symptoms: Pain, tingling, numbness, and difficulty performing repetitive tasks. Prevention: Incorporate proper ergonomics, rest breaks, and posture correction during repetitive activities. Carpal Tunnel Syndrome (CTS):  Caused by compression of the median nerve within the wrist, resulting in pain and numbness. Hurts a lot when it’s cold and treated with acupuncture and a hot compress. ○ Risk Factors: Associated with activities requiring continuous wrist movement. Often seen in patients with diabetes, rheumatoid arthritis, peripheral vascular disease, or hormonal changes. Higher incidence in women. Symptoms: Pain, numbness, and weakness in the hand. Difficulty holding objects, frequent dropping of items. Positive Tinel’s Sign and Phalen’s Test. In late stages, atrophy may occur, leading to dysfunction of the hand. Rotator Cuff Injuries Rotator Cuff: ○ Comprises four muscles that stabilize the shoulder and assist with range of motion. ○ Causes of Injury: Aging Repetitive stress (e.g., repetitive arm motions). Traumatic injury. Symptoms: Shoulder pain, weakness, and limited range of motion. Positive Drop Arm Test: Inability to raise the arm or keep it raised. The arm is abducted 90 degrees straight out. The patient is asked to slowly lower down to the side. If the arm falls SUDDENLY, they can’t do it slowly, rotator cuff injury is suspected Diagnosis: Best confirmed through MRI for diagnostic accuracy. An X ray alone is not beneficial, the MRI confirms the tear. Treatment (Conservative Management): Rest, ice, heat, and NSAIDs for pain and inflammation. Corticosteroid injections to reduce inflammation. Physical therapy to improve strength and mobility. ○ Surgical Treatment: If pain persists or function declines, arthroscopic surgery may be performed to repair the torn rotator cuff. After surgery, the shoulder may be immobilized for six weeks, followed by passive exercises and physical therapy. Conservative and Surgical Treatment of Rotator Cuff Injuries 1. Conservative Treatments: Rest, ice, heat, and NSAIDs for pain and inflammation.  Physical therapy to improve mobility and strength. Corticosteroid injections to reduce inflammation in severe cases. A shoulder mobilizer or sling can be used immediately after shoulder to limit mobility, but not for too long bc frozen shoulder (arthrofibrosis) can occur. 2. Surgical Treatment: If conservative treatments fail, arthroscopy or acromioplasty may be performed. Post-surgery, the shoulder is immobilized for six weeks, followed by passive exercises and then active physical therapy to regain strength and range of motion. Meniscus Injury Meniscus: A type of fibrocartilage located in the knee, acromioclavicular, sternoclavicular, and temporomandibular joints. Function: Acts as a cushion between bones to reduce friction during movement. Injury Mechanism: Often associated with rotational stress in sports or work activities that involve knee flexion and foot planting. ○ Can occur due to a blow to the knee or shearing forces, causing tears in the meniscus. ○ Older adults and individuals who frequently squat or engage in knee-straining activities are also prone to meniscus injuries. Diagnosis: Arthroscopic views of the meniscus can reveal normal tissue (smooth and soft) or torn areas. The arthroscopy allows for repair or removal of damaged tissue. Anterior Cruciate Ligament (ACL) Injury ACL: A critical ligament in the knee, responsible for stability during movement. ○ Accounts for >50% of all sports injuries involving the knee. Mechanism of Injury: Common in athletes when landing from a jump or abruptly stopping with the knee in a twisting motion. ○ “Pop” sound may be heard, followed by acute pain and swelling. ○ Injuries can range from partial tears to complete tears, sometimes involving avulsion fractures (when a piece of bone is torn off by the ligament). Diagnosis: Landmark tests and MRI are used to confirm ACL injuries. Common findings include partial tears or complete ligament tears. Bursitis Bursa: A small fluid-filled sac that reduces friction between bones and tissues during movement. Bursitis: Inflammation of the bursa due to repeated trauma, friction, gout, rheumatoid arthritis, or infection. ○ Commonly affects the hands, elbows, shoulders, knees, and hips.  Symptoms: Warmth, pain, swelling, and limited range of motion. The affected area may be sensitive to touch. Treatment: Rest, immobilization, ice, and NSAIDs to reduce inflammation. Surgery (bursectomy) is rare but may be necessary if conservative treatments fail. Fractures Types of Fractures: Open fracture: The bone breaks through the skin. Closed fracture: The bone breaks but does not penetrate the skin. Pathologic fracture: A fracture caused by an underlying disease process (e.g., cancer or osteoporosis), often discovered through x-rays when a patient presents with bone pain. Fracture Classifications (based on the fracture line’s direction): Linear: A fracture running parallel to the bone’s long axis. Oblique: An angled fracture across the bone. Transverse: A straight-across break. Spiral: A twisted fracture that winds around the bone. Comminuted: Multiple fracture pieces. Fracture Manifestations: Edema and swelling around the fracture site. Pain and tenderness. Muscle spasms around the injured area. Deformity, such as one limb appearing shorter than the other. Contusions (bruising) or loss of function. Crepitation: A grating or crackling sensation felt when pressing the area around the fracture, indicating a break. Fracture Healing Process 1. Hematoma formation: Blood clots at the fracture site. 2. Granulation tissue: The tissue becomes granulated as the body begins to heal. 3. Callus formation: A soft callus forms around the fracture. 4. Ossification: The soft callus hardens as it turns into bone. 5. Consolidation: The bone continues to strengthen. 6. Remodeling: The bone reshapes itself into its original form. Factors Influencing Fracture Healing 1. Displacement and type of fracture: Fractures in certain areas or involving significant displacement may take longer to heal. 2. Blood supply: Adequate blood flow is essential for timely healing. 3. Immobilization: Lack of movement helps the fracture heal more quickly, but inadequate immobilization can slow the process. 4. Internal fixation devices: Hardware like screws or plates can aid in the healing process but may also introduce risks like infection. 5. Nutrition: Proper nutrition, including protein intake, is vital for tissue repair. 6. Age: Older adults often experience slower healing due to reduced regenerative capacity. 7. Smoking: Nicotine constricts blood vessels, reducing blood flow to the fracture site, and delaying healing. Fracture Treatment Goals Pain management: Control pain with medications, immobilization, and physical therapy as needed. Restoration of function: Aim to restore the patient’s ability to move and use the affected area. Prevention of complications: Avoid infection, promote proper alignment, and monitor for issues like compartment syndrome. Goals of Effective Fracture Treatment 1. Anatomic Realignment (also called Reduction): The broken bone fragments must be aligned properly to promote healing. This allows for proper healing and the eventual restoration of normal or near-normal function in the affected area. 2. Immobilization: The fractured area must be immobilized to maintain alignment and prevent further injury. This is achieved through casting, splinting, traction, or fixation devices. 3. Restoration of Function: The goal is to return the affected area to normal or near-normal function as quickly and effectively as possible, allowing the patient to resume activities. Diagnostic Assessment of Fractures Health and Medical History (HMP): A full health assessment is required. Imaging Studies: X-rays: Used to visualize the fracture. CT scans and MRIs: Provide detailed images, especially for complex or hidden fractures. Additional Tests: If the patient has comorbidities (e.g., diabetes), tests like blood sugar and kidney function assessments may be needed. Fracture Reduction Methods  1. Manual Traction (Closed Reduction): Involves manually realigning the bone without surgery. 2. Skeletal Traction: Involves applying a steady pulling force to maintain alignment. 3. Open Reduction: Surgical procedure to align the bone, often involving the use of internal fixation devices (e.g., screws, rods). Fracture Immobilization 1. Casting or Splinting: Immobilizes the fracture site to allow healing while enabling the patient to carry out some activities of daily living (ADLs). 2. External Fixation: Pins and screws are placed into the bone through the skin and connected to external rods to stabilize the bone. Visible hardware outside the body. 3. Internal Fixation: Surgical fixation using devices like plates, screws, or rods placed inside the body to stabilize the bone. Open Fractures Surgical Debridement: Removal of foreign material and dead tissue to prevent infection. Irrigation: Cleaning the wound site. Tetanus and Diphtheria: If the patient’s tetanus status is unclear or the last shot was more than 10 years ago, a tetanus shot is administered. Prophylactic Antibiotics: Prevent infection, especially in cases of open fractures. Types of Traction 1. Skin Traction: Used for short-term treatment (4–72 hours). Includes tape, boots, or splints applied to the skin to reduce muscle spasm and align the bones. Weight is generally 5–10 lbs. Skin assessment is critical to prevent breakdown. 2. Skeletal Traction: Used for long-term alignment. Pins or wires are inserted directly into the bone, and weights are applied to maintain alignment (weights range from 5–45 lbs). Risks include infection, delayed union, or non-union of the bone. Fracture Immobilization Methods: Casts Casts are used to maintain alignment after closed reduction and allow the patient to perform ADLs while immobilizing the fractured area. Common materials include plaster of Paris and fiberglass. The cast should encompass joints above and below the fracture for stability. Sling: Used to support and elevate the arm after an upper extremity fracture. Contraindicated in proximal humerus fractures. Fracture Fixation Types  1. External Fixation: Metal pins and wires are inserted into the bone and attached to external rods. 2. Internal Fixation: Devices such as pins, rods, screws, and plates are surgically inserted to stabilize the bone internally. The hardware is not visible externally. Nursing Management of Fractures 1. Assessment: Obtain a brief history of the trauma, the mechanism of injury, and the patient’s position at the time of injury. Perform a thorough neurovascular assessment both before and after treatment, focusing on areas distal to the injury. Compare findings bilaterally to detect asymmetry (e.g., one limb shorter than the other, indicating dislocation or fracture). 2. Pre-operative Care: Immobilize the affected area and educate the patient on the use of assistive devices. Discuss the expected limitations in mobility and ensure that their needs will be met. Administer pain medication as needed. 3. Post-operative Care: Monitor vital signs closely for any signs of bleeding or infection. Use an incentive spirometer and encourage deep breathing exercises to prevent pneumonia. Continue frequent neurovascular assessments to ensure proper blood flow and nerve function. If the cast is too tight or swelling compresses nerves, it may require immediate attention. Administer adequate pain relief and monitor for signs of bleeding or drainage. Use aseptic techniques when cleaning surgical sites. 4. Potential Complications: Pneumonia or other complications due to immobilization. Pressure injuries: Ensure proper fit and comfort with casts, especially as swelling increases after the initial injury. Infections: Maintain vigilant wound care, especially in open fractures or surgical sites. 5. Blood Salvage and Autotransfusion: Some patients opt for autotransfusion, where their own blood is collected and used during surgery to reduce the need for donor blood. Important Considerations for Casts Check for tightness of the cast, especially if swelling occurs, as this can obstruct circulation and cause nerve damage.  Encourage movement of non-immobilized joints to maintain mobility and reduce the risk of stiffness. Monitor for pain and administer appropriate pain relief based on the patient’s needs. 1. Nutrition for Healing in Patients with Body or Hip Spica Casts: Increased Protein Intake: For optimal healing of soft tissues and bones, the patient needs to consume 1 gram of protein per kilogram of body weight. Protein is essential for rebuilding damaged tissues and supporting the immune system during recovery. Vitamins: ○ Vitamin B: Supports energy production and aids in wound healing. ○ Vitamin C: Helps in collagen formation, which is crucial for the repair of skin, cartilage, and bones. ○ Vitamin D: Enhances calcium absorption, essential for bone health. Minerals: Calcium, Phosphorus, and Magnesium: These minerals are vital for bone repair and strengthening. Fluid Intake: The patient should consume 2,000-3,000 milliliters of fluids per day to stay hydrated and support normal bodily functions, such as preventing constipation. Fiber: Encourage a diet high in fiber to help prevent constipation, a common issue with immobility. Meal Planning: Patients in a body or hip spica cast should have six small meals per day instead of large ones. ○ Large meals can lead to discomfort, especially because the cast can restrict abdominal expansion. 2. Complications and Emergencies Related to Fractures: Medical Emergencies: Immediate attention is required for open fractures with severe blood loss or fractures that damage vital organs. Such cases can result in significant internal bleeding, and prompt intervention is needed to prevent death due to damage to vascular structures or underlying organs. Common Complications: ○ Fat embolism: A serious complication where fat globules enter the bloodstream and block small vessels, particularly in the lungs or brain. Often occurs with long bone, rib, or pelvic fractures. ○ Infection: The risk is higher with open fractures and poor wound care. ○ Delayed healing or non-union: This can occur due to poor blood supply, infection, or improper immobilization. Complications of Immobility:  ○ Blood clots (Venous thromboembolism): Especially common with hip and leg fractures, immobility can lead to deep vein thrombosis (DVT). ○ Bedsores: Pressure ulcers develop from prolonged immobility. ○ Compartment syndrome: A medical emergency that occurs when swelling increases pressure within a confined space (usually a limb), compromising circulation. 3. Compartment Syndrome: Pathophysiology: Swelling or bleeding within a muscle compartment increases pressure, restricting blood flow and causing ischemia to nerves and muscles. Signs and Symptoms: Pain: Severe pain that is out of proportion to the injury and unrelieved by pain medication. 6 Ps of Compartment Syndrome: 1. Pain: Severe, unrelieved by opioids. 2. Pressure: A tight or tense feeling in the affected limb. 3. Paresthesia: Numbness or tingling sensation. 4. Pallor: Pale appearance of the skin. 5. Paralysis: Loss of function or movement. 6. Pulselessness: Absence of pulse, a very late and serious sign. Interventions: ○ Do not elevate the limb above heart level as it can reduce circulation further. ○ Do not apply ice as it constricts blood vessels and worsens circulation. ○ The treatment of choice is fasciotomy (surgical decompression), which involves cutting into the fascia to relieve pressure. 4. Rhabdomyolysis: Definition: A serious condition where damaged muscle tissue breaks down, releasing myoglobin into the bloodstream. Complications: ○ Myoglobin can block the renal tubules, leading to acute kidney injury (AKI). ○ Signs include dark reddish-brown urine, indicating muscle breakdown. ○ Intervention: Monitor urine output closely, and assess for signs of AKI. Fluids are essential to flush out myoglobin from the kidneys and prevent further damage. 5. Venous Thromboembolism (VTE):  Risk Factors: Increased risk in patients with hip fractures, total hip replacements, and total knee replacements due to prolonged immobility. Prevention: ○ Use of prophylactic anticoagulation for 10-14 days postoperatively. ○ Application of intermittent pneumatic compression devices and encouraging exercise to promote blood flow. 6. Fat Embolism Syndrome: Definition: ○ Occurs when fat globules from the bone marrow are released into the bloodstream, usually after long bone fractures (e.g., femur, pelvis). ○ Symptoms: Respiratory distress, altered mental status, petechiae (small red or purple spots on the skin). Risk Factors: ○ Fracture of long bones, liposuction, or bone marrow transplant. ○ Treatment: ○ Focus on early immobilization of the fracture to reduce the release of fat into circulation. 7. Fracture Types and Their Complications: Distal Radius Fractures: Often occur when individuals try to break a fall by extending their arm and hand. Pelvic Fractures: High risk of complications due to the proximity of major blood vessels and organs. Patients with pelvic fractures are more susceptible to severe bleeding and fat embolism. 1. Fractures in Older Adults: Fragility Factors: Most fractures in adults over 50 are due to osteopenia and osteoporosis, making bones more susceptible to injury. Common Fractures: ○ Distal Radius Fracture: Known as a silver fork deformity due to the shape of the displaced distal fragments. Symptoms include pain, swelling, and deformity. Complication: Can cause vascular insufficiency if not managed properly. ○ Humeral Shaft Fracture: Common complications include radial nerve injury and brachial artery damage, which can lead to muscle spasms or further injury. Treatment may involve observation or surgery if it’s an open fracture. Clavicular Fracture:  ○ Can limit shoulder range of motion. Surgery is required for open fractures or severe displacement. 2. Pelvic Fractures: Range of Severity: Can range from minor to life-threatening, depending on the mechanism of injury and the extent of vascular damage. High Mortality Rate: Especially in the elderly, where 95% of hip fractures are due to falls, more common in women with osteoporosis. 75% of all hip fractures occur in women over 65 due to their decreased bone density. Management: ○ Pre-op Instructions: Focus on patient education regarding post-op care. Post-op Care: ○ Monitor vital signs (especially intake and output) and respiratory status. ○ Encourage deep breathing, coughing, and use of the incentive spirometer to prevent lung complications. ○ Pain management and dressing care to monitor for bleeding. ○ Conduct frequent neurovascular assessments to ensure proper circulation and sensation (e.g., pink skin, no edema, intact sensation). 3. Hip Fractures: Hemiarthroplasty or Total Hip Replacement: Often performed after severe hip fractures, especially in the elderly. ○ Care includes preventing dislocations, ensuring neurovascular integrity, and managing pain effectively. 4. Femoral Fractures: High-Risk Factors: ○ Result from severe direct force, leading to significant blood loss (1 to 1.5 liters). ○ Common in young adults and presents with pain, deformity, and swelling with visible hematomas. Types of Fractures: ○ Transverse, Spiral, Comminuted, Oblique, and Open fractures are common manifestations. 5. Amputations: Statistics: ○ Two million Americans live with limb loss, with 185,000 amputations per year. ○ The leading cause of amputations is peripheral vascular disease, particularly in diabetic patients. ○ Trauma is the primary cause of amputations in younger individuals. Common Causes:  ○ Peripheral vascular disease, diabetes, thermal injury, tumors, osteomyelitis, and congenital limb disorders. ○ Types of Amputations: Shoulder disarticulation, elbow amputation, above-knee and below-knee amputations, hip disarticulation, and transmetatarsal amputations. Phantom Limb Pain: Patients often experience phantom limb pain post-amputation, which feels like pain from the removed limb. ○ Phantom pain is real to the patient and should be treated accordingly. 6. Surgical and Post-Operative Care: Common Joint Surgeries: Hemiarthroplasty, osteotomy, debridement, and arthroplasty. Complications include infections (common pathogens: strep and staph), loose prosthesis, and the need for prophylactic antibiotics. Pre-op and Post-op Care: ○ Neurovascular assessments are critical, especially for assessing circulation and preventing complications such as compartment syndrome. ○ Administer anticoagulants and antibiotics prophylactically to prevent infection and blood clots. ○ Consider epidural, intrathecal, or nerve block for pain management, alongside options like PCA (patient-controlled analgesia). ○ Early mobility is encouraged to prevent complications such as DVT (deep vein thrombosis) and promote recovery. 7. Amputation Surgical Goals: The primary goals: 1. Preserve life by preventing infection or complications. 2. Regain as much function as possible in the amputated area (e.g., fitting for a prosthetic limb). 3. Provide thorough patient and caregiver education to prepare for life post-amputation. 8. Complications of Amputation and Joint Surgery: Infections: ○ Common with joint surgeries, usually caused by gram-positive bacteria. Venous Thromboembolism (VTE): ○ Common after joint surgeries or amputations due to immobility. Preventing anticoagulants, compression devices, and encouraging early ambulation. Loosening of Prosthesis: ○ Can cause pain and functional limitations, often requiring revision surgery. Pain Management: ○ Ensure effective post-op pain management to improve recovery and encourage early ambulation. 1. Promotion of Early Healing and Prevention of Infection: Early Mobility: Encourage getting the patient out of bed early post-surgery to promote circulation and prevent complications such as deep vein thrombosis (DVT) and pneumonia. Use of Incentive Spirometer: Important for preventing respiratory complications by encouraging deep breathing and improving lung function. Anticoagulation Therapy: When patients are on anticoagulants, monitor laboratory values (such as INR, PT/PTT) to ensure appropriate levels and prevent bleeding complications. 2. Neurovascular Assessment for Orthopedic Injuries: Neurovascular Assessment: Check for signs of neurovascular compromise in orthopedic injuries or surgeries, such as impingement, compression syndromes, or circulation issues. Regular assessments help prevent complications like compartment syndrome, where blood flow is restricted due to swelling. 3. Osteomyelitis: Definition: A severe infection of the bone marrow and surrounding soft tissues, most commonly caused by Staphylococcus aureus. Routes of Entry: ○ Indirect Entry (20%): The infection travels through the bloodstream to the bone (hematogenous spread). ○ Direct Entry (80%): Direct contamination of bone from an external source, such as an open wound, surgery, or trauma. Pathophysiology: The infection increases pressure within the bone, leading to ischemia (restricted blood flow) and necrosis of the bone. ○ This causes sequestration, where dead bone separates from healthy bone, and can lead to abscess formation. Types: Acute Osteomyelitis: Rapid onset with systemic symptoms like fever, chills, nausea, and malaise, as well as localized pain and swelling. Chronic Osteomyelitis: More localized symptoms with less systemic involvement. Often results in granulation tissue and scarring that makes it hard for antibiotics to penetrate. Treatment: Antibiotic Therapy: Usually starts with IV antibiotics for 4-6 weeks, sometimes extending to 3-6 months. May switch to oral antibiotics afterward.  Central Catheters (e.g., PICC lines) are often used for long-term IV antibiotic administration. Surgical Debridement: Removal of infected bone and tissue is often necessary in chronic cases. Patient Education: Instruct patients to watch for signs of osteomyelitis, such as bone pain, fever, swelling, and limited limb movement, and seek medical attention if these occur. ○ Treatment is long-term, requiring adherence to antibiotics, possibly for several months. 4. Muscular Dystrophy (MD): Definition: A group of genetic diseases causing progressive wasting of skeletal muscles, without involvement of the nervous system. Most Common Type: Duchenne Muscular Dystrophy (DMD), primarily affecting boys, leading to muscle weakness and progressive disability. Symptoms: ○ Gradual loss of muscle strength, with increasing deformities and mobility issues. ○ Life Expectancy: Has increased due to advancements in cardiac and respiratory care. ○ Diagnosis: Includes genetic testing, serum creatinine kinase levels, EMG, and muscle biopsies. ○ Treatment: No cure, but corticosteroids can slow progression by up to 2 years. ○ Management includes maintaining mobility and independence through physical therapy and assistive devices. ○ Monitor for cardiac complications (e.g., cardiomyopathy, heart failure) and provide respiratory support as needed (e.g., CPAP, ventilation). 5. Intervertebral Disc Disease: Role of Intervertebral Discs: Discs separate vertebrae and act as shock absorbers, providing flexibility and cushioning. Degenerative Disc Disease (DDD): A common condition where discs lose fluid, reducing their elasticity and flexibility. This leads to deterioration and potential herniation. Aging Process: Disc degeneration is a normal part of aging but can cause significant pain if the disc thins and the nucleus pulposus (the soft center) pushes out, leading to a herniated disc.  Herniated Disc: When the disc material pushes out of its normal boundary, it can press on nearby nerves, leading to pain, numbness, or weakness in the affected area (e.g., the legs or arms, depending on the location of the herniation). 6. Chronic Osteomyelitis Management: Surgical Removal: Chronic osteomyelitis often requires the removal of poorly perfused tissue, such as dead bone. Antibiotics: Extended use of antibiotics is necessary, with treatments such as fluoroquinolones (e.g., levofloxacin) given for 6-8 weeks. Health Promotion: Patients at risk include those with diabetes, prosthetic devices, or vascular insufficiency. These patients should monitor for signs of infection and seek prompt treatment. 7. Amputation: Causes: Amputations are often necessary due to peripheral vascular disease, diabetes, trauma, infections, or congenital defects. Trauma is the leading cause of limb loss in young individuals, while diabetes and vascular disease are the main causes in older adults. Types of Amputations: Upper Extremity: Includes shoulder disarticulation, elbow amputation, and below-elbow amputation.  Lower Extremity: Includes hip disarticulation, above-knee, and below-knee amputations, as well as transmetatarsal amputations. Post-Amputation Care: Address phantom limb pain, which is real and experienced by many patients after an amputation. Focus on rehabilitation, including the use of prosthetics and maintaining mobility and independence. Early mobility and ambulation are important for reducing the risk of complications such as infections and DVT. 1. Age-Related Degeneration, Stress, and Trauma: Causes of Intervertebral Disc Issues: ○ Age-related degeneration, repeated stress, and trauma can contribute to spinal stenosis. ○ These factors can lead to herniated discs and pinched nerves that emerge through the intervertebral foramen. Symptoms: Radiculopathy: Characterized by radiating pain, numbness, tingling, decreased strength, and reduced range of motion. Osteoarthritis: Can lead to the formation of bone spurs, resulting from damaged cartilage. 2. Lumbar Disc Disease: Symptoms and Complications: Compression of multiple nerve roots can cause cauda equina syndrome, a medical emergency. Symptoms include severe low back pain, progressive weakness, bowel or bladder incontinence or retention, and saddle anesthesia (loss of sensation in the groin area). ○ These symptoms may develop slowly or suddenly and vary in intensity, requiring immediate surgical decompression to prevent permanent paralysis. 3. Diagnostic Studies for Spinal Issues: X-rays: Can reveal structural defects in the spine. Myelogram, MRI, or CT scans: Help localize damaged sites and assess the condition of the spine. Electromyography (EMG): Measures the severity of nerve irritation and helps differentiate spinal issues from other conditions. 4. Conservative Treatment for Spinal Problems: Non-Surgical Approaches: ○ Limiting extreme spinal movement. ○ Use of local heat or ice, ultrasound, massage, and traction. ○ Transcutaneous electrical nerve stimulation (TENS) for pain management.  ○ Back strengthening exercises, performed twice daily, are encouraged for life. ○ Patients should avoid extreme flexion and torsion of the spine. Recovery Time: Most patients heal within six months of conservative treatment, but surgical intervention may be needed if there is worsening radiculopathy, loss of bowel or bladder control, or persistent pain and neurological deficits. 5. Surgical Indications for Spinal Issues: Surgery may be indicated when conservative treatments fail, or there is a progression of symptoms. Artificial Disc Replacement: A procedure where the damaged disc is replaced with an artificial one. Post-Operative Care: After spine surgery, maintain proper alignment during movement. The patient is moved using a log roll technique to keep the spine in alignment. For lumbar fusion patients, use pillows under the thigh or between the legs to support proper posture and alignment. 6. Post-Operative Management: Pain Management: ○ Opiates are often used for 24-48 hours post-op. ○ PCA (Patient-controlled analgesia) is provided, allowing the patient to control pain medication. ○ Muscle relaxants may be used but can cause dizziness and sleepiness. Patients should be advised not to drive when taking these medications after discharge. Spinal Fluid Leak: ○ Post-op, monitor for cerebrospinal fluid (CSF) leaks, which can cause severe headaches. ○ Report any signs of leakage immediately. Spinal Fusion: ○ Healing time for spinal fusion may be longer. Use of rigid orthosis (e.g., TLSO braces) is preferred for support and stability. Monitoring: Regularly check for spinal cord impingement, respiratory distress, and changes in neurological function in the upper extremities. Neurovascular assessment: Pay close attention to the donor site (fibula or posterior iliac crest), which is often more painful than the fusion site. 7. Metabolic Bone Diseases: Osteomalacia: Caused by vitamin D deficiency, leading to soft bones. Common causes include limited sun exposure, gastrointestinal malabsorption (e.g., after gastrectomy, gastric bypass, or chronic diarrhea), pregnancy, obesity, and chronic liver or kidney disease.  Symptoms: Bone pain, especially at night, affecting the lower back, pelvis, hips, legs, and ribs. Patients may develop muscle weakness, waddling gait, and fractures. Diagnostic Studies: ○ Labs show low calcium, low phosphate, and low vitamin D levels. ○ Elevated alkaline phosphatase indicates bone disease. ○ Treatment: Vitamin D supplements: Vitamin D3 (cholecalciferol) or Vitamin D2 (ergocalciferol). ○ Calcium and phosphorus supplements. ○ Dietary sources: Eggs, meat, oily fish, fortified milk. ○ Encourage sunlight exposure and weight-bearing exercises to improve bone strength. 8. Paget’s Disease (Osteitis Deformans): Definition: A chronic skeletal disorder characterized by excessive bone resorption followed by abnormal bone formation, leading to larger, weaker, and disorganized bones. ○ Commonly affects the pelvis, long bones, spine, ribs, sternum, and skull. Epidemiology: ○ Affects about 5% of adults in the U.S., typically men twice as often as women. It is uncommon in individuals under age 40. ○ Etiology is unclear, but a genetic or viral factor is suspected. About 4% of patients have a relative with Paget’s disease. Complications: Pathologic fractures are common. ○ There is a risk of osteosarcoma, fibrosarcoma, and osteoclastoma (bone cancers). ○ Diagnostic Studies: ○ Elevated alkaline phosphatase levels suggest bone activity. ○ X-rays can show bone changes, while bone scans confirm the diagnosis. ○ Treatment: Calcitonin and bisphosphonates are used to slow bone resorption and relieve symptoms.