MUSCULOSKELETAL

SYSTEM
Review of Anatomy and
Physiology
 The musculo-skeletal system consists
of the muscles, tendons, bones and
cartilage together with the joints
 The primary function of which is to
produce skeletal movements
Muscles
Three types of muscles exist in the
body
 1. Skeletal Muscles
 Voluntary and striated
 2. Cardiac muscles
 Involuntary and striated
 3. Smooth/Visceral muscles
 Involuntary and NON-striated
 Visceral, plain muscles
Muscle Types:
2. Skeletal Muscle
ü accounts for at least 40% of body mass
ü aids in the formation of the smooth
contour of the body
Parts:
1.1 Epimysium
Ø Tough connective tissue covering of the
entire muscle.
Ø It binds many fascicles together.
Ø Tendon/Apponeurosis : blending of the
epimysia
1.2 Perimysium
Ø Fibrous membrane covering several
sheathed muscle fibers
Ø Fascicles – are bundles of muscle fibers
covered by perimysium.
 Skeletal Muscle
Characteristics:
Ø Voluntary

control (but can

also be
activated by
reflexes)
Ø (+) Striations

Ø Multinucleated

Ø Shape:

Cylindrical
Ø Speed of

contraction:
Variable
2. Smooth Muscle
ü Found mainly in the walls of hollow
visceral organs such as the
stomach, urinary bladder and
respiratory passages.
ü propels substances along a definite
tract, or pathway, within the body.
Smooth Muscle Characteristics:
Ø Involuntary control

Ø (-) Striations; no distinct sarcomeres

Ø Uninucleated

Ø Spindle-shaped

Ø Speed of Contraction: slow and

sustained; does not develop an

oxygen debt
Smooth muscle
3. Cardiac Muscle
ü Found only in the heart (cardiac).
ü Heart – serves as a pump, propelling
blood into the blood vessels and to all
tissues of the body.
ü Cardiac fibers are cushioned by small
amounts of soft connective tissue and
arranged in spiral or figure 8-shaped
bundles.
Cardiac Muscle Characteristics:
Ø Involuntary control

Ø (+) Striations

Ø Multinucleated

Ø Branched

Ø Speed of contraction: Variable

Muscle Functions:
2) Production of
movements/locomotion
3) Maintenance of posture
4) Joint stabilization
5) Generating heat
6) Energy production
Similarities of all Muscle Types:
c) All muscle cells are elongated (this
explains the term muscle fibers)
d) Muscle contractions depends on
the types of myofilaments (thin
and thick myofilaments)
e) Terminology (prefixed: myo, mys,
& sarco)
 Microscopic Anatomy of
Skeletal Muscle
1. Sarcolemma
ü Plasma membrane of skeletal
muscle cells.
3. Myofibrils
ü Long ribbon like organelles,
pushing the nuclei aside
ü Alternating dark (A) and light (I)
bands along the length of the
myofibrils, give the muscle cell
(as a whole) a striated
appearance.
Microscopic Anatomy of
Skeletal Muscle
3. Sarcomere
ü Functional unit of a muscle.
ü These are chains of contractile
units of myofibrils.

4. Sarcoplasmic Reticulum
ü Surrounds individual myofibrils
ü Specialized smooth
endoplasmic reticulum.
ü Major function: storage and
release of calcium during
muscular contraction.
 SARCOMERE- functional unit of the muscle; extends from one Z-
line to another Z-line

- mainly composed of actin & myosin myofilaments

Z-disk or Z-line = anchors the actin myofilaments

M-line= holds the myosin filaments in place
 Muscle Physiology
Stimulation and Contraction of a
Single Skeletal Muscle Cell
{ Functional Properties of Muscle
Fibers:
1. Irritability – ability to react and
respond to stimulus
2. Contractility – ability to shorten
when stimulated by adequate
stimulus
{ The Nerve Stimulus and Action
Potential
1. Motor Unit - single motor neuron
and all of the corresponding
muscle fibers it innervates.
SKELETAL MUSCLE:

 LMN control
 Energy is consumed during muscle
contraction – LACTIC ACID (↓O2)
 MUSCLE FATIGUE:
 ↑ work of muscle with inadequate O2 supply
 Depletion of glycogen & energy stores
 Accumulation of lactic acid
 Structure and function of the
skeletal system
 Skeletal system consist of Axial and
Appendicular skeleton.
 Axial Skeleton- which is composed of
bones of the skull, thorax and
vertebral column which forms the axis
of the body.
 Appedicular Skeleton- consist of
bones of the upper and lower
extrimities, including the hip and the
shoulder.
Two types of connective tissue found in the
skeletal system
2. Cartilage – a semi-rigid and slightly
flexible structures that plays an
essential role in prenatal and childhood
development of the skeleton and as a
surface for the articulating ends of the
skeletal joint.
3. Bones – which provide the firm
structure of the skeleton and serve as
reservoir for calcium and phosphate
Three types of cartilage

 Elastic Cartilage- Contain some elastin in

each intracellualr substance. ( ears)
 Hyaline Cartilage- Pearly white, found in
the articulating ends of the bones.
- form the fetal skeleton .
 Fibro cartilage- has a characteristic that
are intermediate between dense
connective tissue and hyaline cartilage.
It is found in the intervertebral disks, in
areas where tendons are connective to
bone and in the symphysis pubis.
- 65-80% are water.
 Bone- is a connective tissue in which
the intracellular matrix has been
impregnated with inorganic calcium
salts so that it has a great tensile and
compressible strength but is light
enough to be move by coordinated
muscle contractions.

BONES

Variously classified according to shape,

location and size
Functions

 1. Locomotion
 2. Protection
 3. Support and lever
 4. Blood production
 5. Mineral deposition
Bone is made up of four major


components:
 mineral (mainly calcium and phosphorus)
 matrix (collagen fibers)
 osteoclasts (bone-removing cells)
 osteoblasts (bone-producing cells).
Osteocytes ( mature bone cells for bone


maintenance fxns)

 SKELETAL SYSTEM:
BONE STRUCTURE
 PERIOSTEUM:
 Dense fibrous membrane covering the bone
 Periosteal vessels supply bone tissue
 EPIPHYSIS:
 Widened area at the end of the long bone
 EPIPHYSEAL PLATE (growth zone)
 Cartilage area in children w/c provides for
longitudinal growth of the bone
 ARTICULAR CARTILAGE:
 Provides smooth surface over the ends of the
bone to facilitate joint movement
 Type of bone cell

 Osteogenic cells- Undifferentiated

cells that differentiate into
osteoblasts. They are found in the
periosteum, endosteum, and
epiphyseal growth plate of growing
bones.
 Osteoblasts- Bone building cells that
synthesize and secrete the organic
matrix of bone. It also participate in
the calcification of the organic matrix.
 Osteocytes- Mature bone cells that
function in the maintenance of bone
matrix. Osteocytes also play an active
role in releasing calcium in the blood .
 Ostroclasts- Bone cells responsible for
the resorption of bone matrix and the
release of calcium and phosphate
from bone.
 SKELETAL SYSTEM:
BONE STRUCTURE
 RED BONE MARROW:
 Hemopoietic tissue located in the central
bone cavities.
 Adults: ribs, sternum, vertebrae, portions
of hips & pelvic bones
 Long Bones filled with fatty, yellow
marrow
 FUNCTIONS:
 Formation of RBC, WBC & platelets
 Destruction of old RBC (phagocytosis)
BONE FORMATION
(Osteogenesis)
 OSSIFICATION
 Process by which matrix (collagen fiber &
ground substance) is formed & hardening
minerals are deposited on collagen fibers
(give tensile strength)
 ENDOCHONDRAL
 Osteoid (cartilage-like tissue) is formed,
reabsorbed, & replaced by bone
 INTRAMEMBRANOUS
 Bone develops within membrane (e.g. face,
skull)
BONE MAINTENANCE &
HEALING:
 REGULATORY FACTORS DETERMINING
BOTH FORMATION & RESORPTION:
 1. Weight-bearing (local stress)
 2. Vitamin D (Calcitrol) promotes
absorption of calcium from GIT
 3. Parathyroid Hormone regulates
calcium
 4. Calcitonin & Amino biphosphate (e.g.
Alendronate [Fosamax]) increases
production of bone cells
BONE MAINTENANCE &
HEALING:
 1. Weight-bearing (local stress)
 Stimulate bone formation & remodelling
 Prolonged bed rest: bone losses calcium
(resorption) & becomes osteopenia & weak
2. Biologically Active Vitamin D
(Calcitrol)
 ↑ amount of Ca in blood by promoting absorption
of Ca from GIT
 Facilitates mineralization of osteoid tse
 Deficiency cause bone demineralization,
deformity & fracture
BONE MAINTENANCE &
HEALING:
 3. Parathyroid Hormone
(parathormone)
 regulates calcium in blood in part by
promoting mov’t of Ca from the bone
 ↓ Ca in blood ► ↑ PTH prompt demineralization
of the bone
 4. Calcitonin & Amino biphosphate (e.g.
Alendronate [Fosamax]) increases
production of bone cells
 Calcitonin- inhibits release of calcium from
the bone into the extracellular fluid and
reduces the renal tubular reabsorptionof
 Parathyroid hormone
Parathyroid gland

Bone – release Kidney

of Ca and reabsorption of
phosphate Calcium

Calcium Urinary
concentration in excretion of
the extracellular Phosphate
fluid

Intestine Activation of
Reabsorption of Vit.D
Ca via activated
BONE MAINTENANCE &
HEALING:
 Estrogen & Androgen
 Stimulate osteoblastic activity & inhibit PTH
 Menopause/Andropause –
 ↓Ca ► bone loss ► osteoporosis
 Androgen-testosterone
 Promote anabolism
 ↑bone mass
 ESTROGEN-It appears that oestrogen
deficiency allows greater expression of these
cytokines, all of which are associated with
increased stimulation of bone resorption
which then leads to increased bone loss and
a reduction in BMD.
 Androgens Androgens, like oestrogens,
can directly affect and modulate bone
cell function. Androgen receptors are
found on osteoblast cell lines and they
can cause osteoblast proliferation.
Hypogonadal men, in common with post-
menopausal women, have decreased
calcium absorption and low vitamin D
levels. The replacement of androgens
with testosterone can correct these
abnormalities, suggesting again that sex
hormones are required for the
maintenance of bone health.
 BONE HEALING:
 STAGE 1. HEMATOMA FORMATION &
INFLAMMATION
 When bone is damaged or injured, hematoma precedes new
tissue formation in the production of new bone substance
 STAGE 2. CELLULAR PROLIFERATION:
 Granular tissue formation where BV & cartilage overlie the
fracture
 Callus forms as minerals are deposited to organize new
network for the new bone
 STAGE 3. PRECALLUS FORMATION: (2-6 wks)
 Callus forms the initial clinical union of the bone & provides
enough stability to prevent movement when bones are gently
stressed
 STAGE 4. CALLUS FORMATION:
 Consolidation & Remodelling (complete healing- 3-6months)
 Continued bone healing provides for gradual return of the
injured bone to its pre-injury shape & structural strength
Bone healing
FACTORS AFFECTING TIME
REQUIRED FOR HEALING:
 1. age
 2. displacement
 3. site of fracture
 4. nutritional level
 5. blood supply to the area of injury
JOINTS

 Permits bone to
change position &
facilitate body mov’t
 Diarthrodial (synovial)
joint is the most
common type of joint
in the body
joints
joints
joints
Joints
joint
joints
CARTILAGE (hyaline)

A dense connective tissue that consists



of fibers embedded in a strong gel-like

substance that cover the end of the
bone
CARTILAGE

 ARTICULAR CARTILAGE
 Rigid, connective, avascular tissue that
covers each bone ends
 Damaged cartilage heals slowly (lacks
direct blood suply)
BURSAE

Sac containing fluid that are located



around the joints to prevent friction

 A fibrous capsule of connective tissue
joins the 2 bones together

 1. SYNOVIUM (synovial membrane)

 Lines the capsule
 2. SYNOVIAL FLUID
 Secreted by the synovium & decreases
friction by lubricating the joints
TENDONS (aponeurosis)

Bands of fibrous connective tissue that



tie bones to muscles

LIGAMENTS

Strong, dense and flexible bands of



fibrous tissue connecting bones to

another bone
ASSESMENT OF THE MUSCULO-
SKELETAL SYSTEM
 The nurse usually
evaluates this small part
of the over-all assessment
and concentrates on the
patient’s posture, body
symmetry, gait and
muscle and joint function
ASSESMENT OF THE MUSCULO-
SKELETAL SYSTEM
 1. HISTORY
 Injury, surgery, disability, inflammatory /
metabolic conditions
 Familial predisposition
 Level of normal activity (occupation,
exercise, recreation)
 2. Physical Examination
 Inspection for gross deformities,
asymmetry, swelling, edema
 Nutritional status: weight, body frame
 ASSESSMENT OF THE
MUSCULO-SKELETAL SYSTEM
 Gait (Antalgic); Genu Valgum (Knock-
Knee), Genu Varum (Bow-Legged)
 Posture (Kyphosis/Lordosis/Scoliosis)
 Muscular palpation
 Joint palpation (Crepitus-grating
sound)
 Range of motion
 Muscle strength
Assessment Findings

 6 P’s of NEUROVASCULAR
DAMAGE
 Swelling
 Loss of function
 Deformity
 Crepitus
P
ai
n
a
ulseless
llo
ness
aresth
esia
araly
sis
oikilothe
ASSESMENT OF THE MUSCULO-
SKELETAL SYSTEM
LABORATORY PROCEDURES
 1. BONE MARROW ASPIRATION
 Usually involves aspiration of the
marrow to diagnose diseases like
leukemia, aplastic anemia
 Usual site is the sternum and iliac crest
 Pre-test: Consent
 Intratest: Needle puncture may be
painful
 Post-test: maintain pressure dressing
and watch out for bleeding
ASSESMENT OF THE MUSCULO-
SKELETAL SYSTEM
LABORATORY PROCEDURES
 2. Arthroscopy
 A direct visualization of the joint
cavity
 Pre-test: consent, explanation of
procedure, NPO
 Intra-test: Sedative, Anesthesia,
incision will be made
 Post-test:
 maintain dressing,
 ambulation as soon as awake,
 mild soreness of joint for 2 days,
 joint rest for a few days & ice
application to relieve discomfort
 ASSESMENT OF THE MUSCULO-
SKELETAL SYSTEM
2. ARTHROSCOPY -
C.I for pt who cannot flex @ 40° and with

infected knee
Uses large pneumatic tourniquet to

minimize bleeding
Apply dressing, neurovascular check,

observe for complications

swelling,hyperthermia,
thrombophlebitis,infxn
KNEE ARTHROSCOPY
ARTHROSCOPY
KNEE ARTHROSCOPY
SHOULDER ARTHROSCOPY
ASSESMENT OF THE MUSCULO-
SKELETAL SYSTEM
LABORATORY PROCEDURES
3. BONE SCAN
 Imaging study with the use of a contrast
radioactive material
 Pre-test: Painless procedure, IV
radioisotope is used, no special
preparation, pregnancy is contraindicated
 Intra-test: IV injection, Waiting period of 2
hours before X-ray, Fluids allowed, Supine
position for scanning
 Post-test: Increase fluid intake to flush out
radioactive material
ASSESMENT OF THE MUSCULO-
SKELETAL SYSTEM
 BONE SCAN
 – Radioisotope injected IV
(technetium, Gallium, Thalium)
Adm. Isotope 1-2 days before scanning

No radioactive threats

Procedure lasts 30-60 min

No special care after procedure

Excreted in Urine & feces

Encourage fluid
ASSESMENT OF THE MUSCULO-
SKELETAL SYSTEM
LABORATORY PROCEDURES
4. DEXA- Dual-energy XRAY
Absorptiometry
 Assesses bone density to diagnose
osteoporosis
 Uses LOW dose radiation to measure
bone density
 Painless procedure, non-invasive, no special
preparation
 Advise to remove jewelry
ASSESMENT OF THE MUSCULO-
SKELETAL SYSTEM
 5. Xray Films: Roentgenograms –
plain xray film is common APL
(Antero-posterior lateral views.
 6. ARTHROGRAPHY: injection of dye
or air in the joint for x-ray study
 7. MYELOGRAPHY: examines spinal
cord after introduction of contrast
medium
Myelography
ARTHROGRAPHY

Arthrography is the
radiographic examination
of a joint, after the
injection of a dye-like
contrast material and/or
air, to outline the soft
tissue and joint structures
ASSESMENT OF THE MUSCULO-
SKELETAL SYSTEM
 8. BONE/MUSCLE BIOPSY: Iliac crest
usual puncture site; not commonly
done today
 Local anesthesia, check PT & PTT
 Coagulant given 2-3 days before &
after procedure
 Pressure dressing after
ASSESMENT OF THE MUSCULO-
SKELETAL SYSTEM
 9. CT SCAN: assess bone & soft
tse tumors
 10. MRI: to assess soft tissue and
joints with myelography
 GANDOLINIUM DTPA
 (DiethyleneTriamine PentaAcetic Acid)
BLOOD STUDIES:
1. ESR (Erythrocyte Sedimentation
Rate):
 non-specific test for inflammation F: 0-20
mm/hr M: 0-10 mm/hr
2. URIC ACID:Elevated in gout
 Normal 2.2-7 mg/dl (F) ;4.2-8 mg/100 ml
(M)
3. ANA (Anti-nuclear Anti-body):
 Measures the presence of antibodies that
destroy the nucleus of the body tissue cells
in auto-immune disorder;
 (+) in about 94% of clients w/ SLE
 Sjoren’s syndrome
 RA
BLOOD STUDIES:

 RHEUMATOID FACTOR (Latex

Fixation):
 Determine presence of auto antibodies (RF)
found in clients with connective tissue dse
 (+) RF is suggestive of RA
 The higher the antibody titer the greater the
degree of inflammation
MINERAL METABOLISM:

 1. CALCIUM : ↓ in osteomalacia,
hypoparathyroidism; ↑bone tumors, acute
osteoporosis,bone fracture(healing phase)
 Normal: 4.5 – 5.8 mEq/L or 9-10.5 mg/dL
 2. PHOSPHORUS:↓ in osteomalacia, ↑
healing fractures, CRF, bone tumor
Normal: 3 - 4.5 mEq/L
MUSCLE ENZYME TESTS:

 1. CREATININE PHOPHOKINASE
(CK3 or CK-MM)
 F: 30-135 U/L; M:55-170 U/L – highest
concentration in traumatic injuries,
progressive muscular dystrophy
 2. ALKALINE PHOSPHATASE (ALP-2)
– Increased in Cancer, Paget’s Dse &
Osteomalacia. Normal: 20-90 IU/L
 COMMON
MUSCULOSKELET
AL PROBLEMS
The Nursing Management
Nursing Management of common musculo-
skeletal problems
1. PAIN
 These can be related to joint
inflammation, traction, surgical
intervention
 1. Assess patient’s perception of pain
 2. Instruct patient alternative pain
management like meditation, heat
and cold application, guided imagery
Nursing Management

PAIN
 3. Administer analgesics as prescribed
 Usually NSAIDS
 Meperidine (demerol)can be given
for severe pain
 4. Assess the effectiveness of pain
measures
Nursing Management

2. IMPAIRED PHYSICAL MOBILITY

 1. Instruct patient to perform range of
motion exercises, either passive or
active
 2. Provide support in ambulation with
assistive devices
 3. Turn and change position every 2
hours
 4. Encourage mobility for a short period
and provide positive reinforcements for
small accomplishments
Nursing Management
3. SELF-CARE DEFICITS
 1. Assess functional levels of the patient
 2. Provide support for feeding problems
 Place patient in Fowler’s position
 Provide assistive device and supervise
mealtime
 Offer finger foods that can be handled by
patient
 Keep suction equipment ready
Nursing Management

SELF-CARE DEFICITS
 3. Assist patient with difficulty bathing
and hygiene
 Assist with bath only when patient has
difficulty
 Provide ample time for patient to finish
activity
FRACTURES
Fracture

 A break in the continuity of the bone

and is defined according to its type
and extent
Fracture

 Severe mechanical Stress to bone

bone fracture
 Direct Blows
 Crushing forces
 Sudden twisting motion
 Extreme muscle contraction
fractures
Fracture
TYPES OF FRACTURE
 1. Closed fracture (SIMPLE)
 The fracture that does not cause a break in the
skin
 2. Open fracture (COMPOUND or COMPLEX)
 The fracture that involves a break in the skin
3. Complete Fracture-involves entire cross section
of the bones
4. Incomplete Fracture – involves only a portion of
the cross section of the bone
Fracture

TYPES OF FRACTURE
 5. Comminuted fracture
 A fracture that involves production of several
bone fragments
 6. Greenstick Fracture
 One side is broken the other side is beat
 7. Depressed
fragment is driven inward (skull,facial
bones)
TYPES OF FRACTURE

 8. Transversed
 Break straight across the bone
 9. Spiral
 Forms oblique angle to the bone
shaft
 Fracture: ASSESSMENT
 CLINICAL MANIFESTATIONS:
2. Pain: immediate, sever
3. Loss of function
4. Deformity; abnormal positioning of extremity
5. Shortening
6. Crepitation: palpable or audible
7. Edema
 7. Paresthesia- burning or
tingling sensation
 8. Numbness
 9. Motor weakness
 10. Pulselessness, impaired
capillary refill time and
cyanotic skin
Fracture

ASSESSMENT FINDINGS
1. Pain
 Continuous and increases in
severity
 Muscles spasm accompanies the
fracture is a reaction of the body to
immobilize the fractured bone
Fracture

ASSESSMENT FINDINGS
2. Loss of function
 Abnormal movement and
pain can result to this
manifestation
Fracture

ASSESSMENT FINDINGS
3. Deformity
 Displacement, angulations or
rotation of the fragments
Fracture

ASSESSMENT FINDINGS
4. Crepitus
 A grating sensation produced
when the bone fragments rub
each other
Fracture

 DIAGNOSTIC TEST

 X-ray
Fracture

EMERGENCY MANAGEMENT OF FRACTURE

 1. Immobilize any suspected fracture
 Support the extremity above and below when
moving the affected part from a vehicle
 Suggested temporary splints- hard board, stick,
rolled sheets
 Apply sling if forearm fracture is suspected or the
suspected fractured arm maybe bandaged to the
chest
Fracture

EMERGENCY MANAGEMENT:
OPEN FRACTURE
 1. Open fracture is managed by covering a
clean/sterile gauze to prevent
contamination
 2. DO NOT attempt to reduce the facture
Fracture

General Nursing MANAGEMENT

For CLOSED FRACTURE
 1. Assist in reduction and immobilization
 2. Administer pain medication and muscle
relaxants
 3. Teach patient to care for the cast
 4. Teach patient about potential complication
of fracture and to report infection, poor
alignment and continuous pain.
General Nursing MANAGEMENT
For OPEN FRACTURE
 1. Prevent wound and bone infection
 Administer prescribed antibiotics
 Administer tetanus prophylaxis
 Assist in serial wound debridement
 2. Elevate the extremity to prevent edema
formation
 3. Administer care of traction and cast
FRACTURE COMPLICATIONS

Early
1. Shock (Hypovolemic Shock)
2. Fat embolism - 1st 48 hrs
3. Infection
4. Impaired Circulation (cast/edema)
5. Compartment syndrome
6. Venous Stasis & thrombus formation
 FRACTURE COMPLICATIONS

Late
 1. Delayed union / Nonunion
 2. Angulation (bone heals at a distorted angle)
 3. Delayed reaction to fixation devices
 4. Complex regional syndrome
FRACTURE COMPLICATIONS:
Fat Embolism
 Occurs usually in fractures of the long bones
 Fat globules may move into the blood stream
because the marrow pressure is greater than
capillary pressure
 Fat globules occlude the small blood vessels
of the lungs, brain kidneys and other organs
 FRACTURE COMPLICATIONS:
Fat Embolism
 Onset is rapid, within 24-72 hours

ASSESSMENT FINDINGS
A. 1. Sudden dyspnea and respiratory
distress & hypoxia
 2. tachycardia
 3. Chest pain
 4. Crackles, wheezes and cough
 5. Petechial rashes over the chest, axilla and
hard palate
Fat embolism

 classic triad: hypoxemia; neurologic

abnormalities; and a petechial rash.
 H- Hypoxemia
 N- N eurologic
 a-bnormalities
 P- Petechial rash
Fat embolism

 Assessment finding
 B. Neurological finding
 1. Cerebral emboli- frequently present
after early stages. 86 % after the
respiratory distress.
 - The more common presentation is
with an acute confusional statebut
focal neurological signs, including
hemiplegia, aphasia,apraxia, visual
field disturbances, and anisocoria,
have beendescribed.
Fat embolism

 The characteristic petechial rash may be

the last componentof the triad to
develop. It occurs in up to 60% of cases
andis due to embolization of small
dermal capillaries leading
toextravasation of erythrocytes. This
produces a petechial rashin the
conjunctiva, oral mucous membrane,
and skin folds ofthe upper body,
especially the neck and axilla.[6] It does
notappear to be associated with any
abnormalities in platelet function.The
rash appears within the first 36 h and is
Nursing Management
Many studies shows that early
immobilization and fixation decrease
the incidence of pulmonary
complication.
- Adequate fluid resuscitation,
transfusion and TPN could decrease
the incidence of FES ( Fat embolism
syndrome )
5. Support the respiratory function
 Respiratory failure is the most common
cause of death
 Administer O2 in high concentration
 Prepare for possible intubation and
ventilator support
2. Administer drugs

 Corticosteroids
 Dopamine
 Morphine
3. Institute preventive measures
 Immediate immobilization of fracture
 Minimal fracture manipulation
 Adequate support for fractured bone during turning
and positioning
 Maintain adequate hydration and electrolyte
balance
 Early complication:
 Compartment syndrome
 A complication that develops when
tissue perfusion in the muscles is less
than required for tissue viability
COMPARTMENT SYNDROME

 Muscles, nerves, vessels are

restricted to confined space
(myofascial compartment) within an
extremity
 ETIOLOGY:
 Decreased Compartment size from cast,
splints, tight bandage, tight surgical
closure
 Increase in compartment contents d/t
edema or hemorrhage
 Early complication:
 Compartment syndrome

ASSESSMENT FINDINGS
 1. Pain- Deep, throbbing and
UNRELIEVED pain by opioids
 d/t reduction in the size of the muscle
compartment by tight cast
 d/t increased mass in the compartment by
edema, swelling or hemorrhage
 Muscle ischemia (compression)
 Arterial compression may not occur;
pulses may be (+) – (early)
 Blisters
 Can result in permanent damage in a
short time (6-8 hrs)
 PARESTHESIA- first sign
 PULSELESSNESS - late sign
Medical and Nursing
management:

1. Assess frequently the

neurovascular status of the
casted extremity
2. Elevate the extremity
above the level of the heart
3. Assist in cast removal and
 Surgical Treatment
 If surgery is required to relieve the
pressure, the physician will make an
incision and cut open the skin and
fascia covering the affected
compartment. This reduces the
pressure in the compartment. The
skin incision is surgically repaired
when swelling recedes. Sometimes a
skin graft may be needed.
4 R’S IN MGMT OF FRACTURE

1. RECOGNITION of presence of
fracture
2. REDUCTION:
 Closed Reduction (manipulation)
 Open Reduction (ORIF – surgery)
 Traction
4 R’S IN MGMT OF FRACTURE
3. RETENTION
 Cast
 Traction
 Braces / splints
 Bandage
4. REHABILITATION – restoration to
normal fxn
 Walker
 Crutches
 Cane
CANES
 C
ANE Should be used
on the side
opposite the
affected leg
 Cane + Affected
leg move
together
Canes

 Handle should be always level of

clients greater trochanter .
 Clients elbow should be flex at a 15-
30 degrees angle
 Instruct the client to hold the cane 4-6
inches on the side of the client.
WALKERS

 LIFT the walker &

place it approx. 2 ft.
in front
 Gain balance before
moving walker
forward again
 Balance provides
stability & equal wt.
bearing
PROSTHESIS
 UP WITH THE GOOD
DOWN WITH THE BAD
 Indication:
Weakness in both legs or poor coordination

 Sequence:
1-Left crutch,
2-right foot,
3-right crutch,
4-left foot. Then repeat.
 Advantages:
Provides excellent stabilty as there are always three points in
contact with the ground
 Disadvantages:
Slow walking speed
Indication:
Inability to bear weight on one leg. (fractures, pain,
amputations)

 Pattern Sequence:
1-move both crutches and
2- the weaker lower limb forward. Then bear all
your weight down through the crutches
3- move the stronger or unaffected lower limb
forward. Repeat.
 Advantages:
Eliminates all weight bearing on the affected leg.
 Disadvantages:
 Indication:
Weakness in both legs or poor coordination.

 Pattern Sequence:
1-Left crutch and right foot together,
then the 2-right crutch and left foot
together. Repeat.
 Advantages:
Faster than the four point date.
 Disadvantages:
Can be difficult to learn the pattern.
 Indications:
Patients with weakness of both lower extremities.

 Pattern Sequence:
Advance both crutches forward then, while
bearing all weight down through both
crutches, swing both legs forward at the
same time to (not past) the crutches.
 Advantage:
Easy to learn.
 Disadvantage:
Requires good upper extremity strength.
 Indications:
Inability to fully bear weight on both legs. (fractures,
pain, amputations)

 Pattern Sequence:
Advance both crutches forward then, while
bearing all weight down through both crutches,
swing both legs forward at the same time past
the crutches.
 Advantage:
Fastest gait pattern of all six.
 Disadvantage:
Energy consuming and requires good upper extremity
TRAUMATIC CONDITIONS:

 1. CONTUSION – soft tissue injury

produce by blunt force, blow, kick or fall

 S/Sx:
 a. hemorrhage (ecchymosis) ruptured
BV
 b. pain & swelling
 CONTUSION

 Mgmt:

 1. elevate affected part

 2. cold compress to diminish edema
(1st 24H)
 3. apply pressure bandage to
reduce swelling
 4. apply heat to affected area after
6 hrs to promote absorption.
Strains

 Excessive stretching of a muscle or

tendon

Nursing management:
1. Immobilize affected part
2. Apply cold packs initially, then heat
packs
3. Limit joint activity
4. Administer NSAIDs and muscle
relaxants
Sprains

 Excessive stretching of the LIGAMENTS

Nursing management
1. Immobilize extremity and advise rest
2. Apply cold packs initially then heat packs
3. Compression bandage may be applied to
relieve edema
4. Assist in cast application
5. Administer NSAIDS
Re
st
I c
e
C ion
ompress

E levati
on
Musculoskeletal Modalities

 Traction
 Cast
Nursing Management

Traction
 A method of fracture immobilization
by applying equipments to align bone
fragments
 Used for immobilization, bone
alignment and relief of muscle spasm
Traction

 Skin traction – applied at the

surface of skin & soft tissue &
indirectly to the bone using adhesive
elastic bandage & spreader. max. 7lbs
(e.g. Bryant, Russel Traction)

 Skeletal traction – applied directly

to the bone using wire, pins, tongs.
max. 40 lbs. (e.g. Halo pelvic,
Crutchfield tong traction)
Traction

Skin
tracti
on

Non-adhesive traction
Bryants traction Cervical traction
 Balance suspension traction
Position clients: low fowlers position
Maintain 20 degree angle at the thigh
to bed
Protect the skin from break down
Provide pin care if pin is used with the
skeletal traction
INDICATIONS/PURPOSES:

 For immobilization
 Prevent & correct deformity
 Maintain good alignment
 Give support to reduce pain & muscle
spasm
 To reduce fracture
 Indications for Traction
 reduction, immobilisation & alignment
of fractures
 relieve muscle spasm & pain
 prevent further soft tissue damage
 to promote rest
ne
RUSSEL’S TRACTION
Russell’s traction

Commonly used to stabilized the

fracture femur before the surgery.
-Similar to bucks traction but provide
double pull with the use of knee sling
-traction pull’s the knee and the foot.
BALANCED SUSPENSION
BUCK’S EXTENSION TRACTION

-Is used to alleviate muscle spasm and

immobilized a lower limb by maintaining a
straight pull on the limb with the use of
weights.
-boot appliance is applied to attach to the
traction.
90-90 TRACTION
 Dunlop’s traction

Description: Horizontal traction used to align

fractures of the humerus.
Vertical traction: used to maintain forearm for
proper alignment
Halo vest
Cervical traction
traction
Nursing Management

Traction: General principles

1. ALWAYS ensure that the weights
hang freely and do not touch the
floor
2. NEVER remove the weights
3. Maintain proper body alignment (dorsal
recumbent)
4. Ensure that the pulleys and ropes are
properly functioning and fastened by
tying square knot
Nursing Management

Traction: General principles

5. Observe and prevent foot drop
 Provide foot plate
6. Observe for DVT, skin irritation and
breakdown
7. Provide pin care for clients in skeletal
traction
EXTERNAL FIXATOR DEVICE
External frame with a lot of pins.
Provide more freedom compare to traction.
 Internal fixator

Provide immediate bone

strength but risk for infection.
Traction: General principles
8.For every traction, there is
always a counter traction – use
shock blocks; use half ring
Thomas splint
9. The line of pull must be in line
with deformity
10. Friction should be eliminated
Nursing Management

CAST
 Immobilizing tool made of plaster of
Paris or fiberglass
 Provides immobilization of the
fracture
PURPOSES:

 IMMOBILIZATION
 PREVENTION/CORRECTION OF
DEFORMITY
 SUPPORT
 OBTAINING A HOLD OF A LIMB TO
SERVE AS MODEL FOR MAKING
ARTIFICIAL LIMB
Nursing Management

CAST: types
1. TRUNK
Minerva Cast, Rizzers Jacket-
Scoliosis,
2. UPPER EXTREMITY
3. LOWER EXTREMITY
4. Spica
 CASTS
CASTS

MINERVA CAST SCOLIOSIS BRACE

 BODY
BODYBRACES
BRACES

SCOLIOSIS BRACE
 Casting
Materials
Plaster of Paris
 Drying takes 1-
3 days
 If dry, it is
SHINY, WHITE,
hard and
resonant.
Fiberglass
 Lightweight and
dries in 20-30
minutes
 Water resistant
CHARACTERISTICS OF GOOD
CAST:
 White, shiny
 Odorless
 Light in wt
 Not too tight
 Not too loose
 Resonant on
percussion
Nursing Management

CAST: General Nursing Care

 1. Allow the cast to dry (usually
24-72 hours)
 2. Handle a wet cast with the
PALMS not the fingertips
 3. Keep the casted extremity
ELEVATED using a pillow
 4. Turn the extremity for equal
drying. Use low cool drier.
CAST: General Nursing Care
 5. Petal (cutting the
edges) the edges of the
cast to prevent crumbling
of the edges
 6. Examine the skin for
pressure areas and
Regularly check the pulses
and skin
CAST: General Nursing Care
 7. Instruct the patient not
to place sticks or small
objects inside the cast
 8. Monitor for the following:
pain, swelling,
discoloration, coolness,
tingling or lack of sensation
and diminished pulses
CAST: General Nursing Care
9. Observe for signs of plaster sore:
itchiness/burning sensation, sever pain,
rise of temp, disturbed sleep,
restlessness, offensive odor,
discharges(windowing-exposing a tight
area to relieve edema/pain, petalling)
10. Observe for signs of cast
syndrome: prolonged N/V, repeated
vomiting, abd.distention, vague
abd.pain, (-)bowel sound
PLASTER CAST SAW
Specific Fractures:

 COLLE’S FRACTURE
 Distal radius
 PELVIC FRACTURE:
 Freq in elderly
 Can cause intra abd injury and urinary
tract injury
 Turn pt only on specific orders
 HIP FRACTURE
 Common in elderly women
 Clinical manifestation:
External rotation & adduction of affected
extremity
Shortening of the length of the affected
extremiety
Severe pain & tenderness
 Treatment:
Initially- Buck’s traction
Surgery
AFTER SURGERY
 Neurovascular check
 Position: PREVENT FLEXION
ADDUCTION & INTERNAL ROTATION
 Do not adduct past neutral position
 Maintain in abducted position with A-
frame pillow or pillows between legs
 Avoid flexion of hip of more than 90
degrees
 Prevent internal or external rotation by
using sandbags, pillows, trochanter rolls
After surgery

 Extreme external rotation

accompanied by severe Pain ---
displaced hip prosthesis
Amputation

 Etiology and pathophysiology

 1. Refers to the removal of a body
part as a result of trauma or
 surgical intervention
 2. Necessitated by:
 a. Malignant tumor
 b. Trauma
 c. Acute arterial insufficiency
Amputation
 Therapeutic interventions
 1. Below-the-knee amputation (BKA)
common in peripheral
 vascular disease; facilitates successful
adaptation to prosthesis
 because of retained knee function
 2. Above-the-knee amputation (AKA)
necessitated by trauma or
 extensive disease
 3. Upper extremity amputation usually
necessitated by severe
 trauma, malignant tumors, or congenital
malformation
Amputation

 Assessment
 1. Neurovascular status of involved
extremity
 2. History to determine
 a. Causative factors
 b. Health problems that can compromise
recovery
 3. Client's understanding of the extent of
the surgery
 4. Client's coping skills
 5. Client's support system
Amputation

 Assessment
 1. Neurovascular status of involved
extremity
 2. History to determine
 a. Causative factors
 b. Health problems that can compromise
recovery
 3. Client's understanding of the extent of
the surgery
 4. Client's coping skills
 5. Client's support system
Amputation
 Planning/Implementation
 1. Provide care preoperatively
 a. Initiation of exercises to strengthen muscles
of extremities in
 preparation for crutch walking
 b. Coughing and deep-breathing exercises
 c. Emotional support for anticipated alteration
in body image
 2. Monitor vital signs and stump dressing for
signs of hemorrhage
 3. Elevate stump for 12 to 24 hours to decrease
edema; remove
 pillow after this time to promote functional
alignment and prevent
Amputation
 4. Provide stump care
 a. Maintain elastic bandage to shrink and shape
stump in
 preparation for prosthesis
 b. When wound is healed, wash stump daily,
avoiding the use of oils, which may cause
maceration
 c. Apply pressure to end of stump with
progressively firmer surfaces to toughen stump
 d. Encourage client to move the stump
 e. Place the client with a lower extremity
amputation in a prone position twice daily to
stretch the flexor muscles and prevent hip
Rheumatoid Arthritis

 Etiology and pathophysiology

 1. Chronic disease characterized by
inflammatory changes in the
 body's connective tissue, particularly
areas that have a cavity
 and easily moving surfaces
 2. Cause unknown, although theories
include autoimmunity,
 heredity, and psychophysiologic factors
 3. Exacerbations are linked to physical
and emotional stress
Rheumatoid arthritis

 Clinical findings
 1. Subjective
 a. Fatigue
 b. Malaise
 c. Joint pain
 d. Stiffness after periods of inactivity,
particularly in the morning
 e. Paresthesia
 f. Anorexia
Rheumatoid arthritis

 Objective
 a. Anemia
 b. Weight loss
 c. Joint inflammation and deformity
 d. Subcutaneous nodules
 e. Elevated sedimentation rate
 f. Low-grade fever
 g. Presence of rheumatoid factors in serum
identified by latex fixation test
 h. Positive C-reactive protein and antinuclear
antibody (ANA) tests
Rheumatoid arthritis

 Therapeutic interventions
 1. Corticosteroids, antiinflammatories,
analgesics,
 immunosuppressive drugs; aspirin is drug
of choice followed by the addition of
nonsteroidal antiinflammatory drugs and
then gold or penicillamine, an oral chelating
agent; corticosteroids are reserved for
acute inflammation, if possible
 2. Physiotherapy to minimize deformities
 3. Surgical intervention to remove severely
damaged joints (e.g.,
 hip replacement)
Rheumatoid arthritis

 4. Application of heat or cold; paraffin

dips of affected extremity for
 relief of joint pain by providing
uniform heat
 5. Plasmapheresis may be used when
the disease is advanced
Rheumatoid arthritis

 Assessment
 1. History of onset and progression of
symptoms, noting degree to
 which pain interferes with normal
activities
 2. Family history of rheumatoid
arthritis
 3. General physical health
 4. Coping skills
Rheumatoid arthritis

 Planning/Implementation
 1. Administer analgesics and other
medications as ordered
 2. Teach the client to take medications as
ordered and observe foraspirin toxicity
(tinnitus, bleeding) and other adverse
effects of medications
 3. Apply heat and cold as ordered; heat
paraffin to 125o to 129o F (52o to 54o C)
 4. Promote rest and position to ease joint
pains
 5. Provide for range-of-motion exercises up
to the point of pain,
 recognizing that some discomfort is always
Rheumatoid arthritis

 6. Emphasize the need to remain active,

but incorporate rest
 periods to avoid fatigue
 7. Encourage the client to verbalize
feelings
 8. Help set realistic goals, focusing on
strengths
 9. Encourage use of supportive devices
to help client conserve
 energy and maintain independence
 10. Provide care for the client following
Rheumatoid arthritis

 11. Encourage diet rich in nutrient-dense

foods such as fruits, vegetables, whole
grains, and legumes to improve and
maintain nutritional status and compensate
for nutrient interactions of corticosteroid
and other treatment medications
 D. Evaluation/Outcomes
 1. Experiences a reduction in pain
 2. Completes activities of daily living using
supportive devices as needed
 3. Accepts life-style consistent with abilities
 4. Maintains or improves range of motion of
involved joints
Osteoarthritis
(Degenerative Joint
Disease)
 Etiology and pathophysiology
 1. Etiology relates to wear and tear of
joints; predisposing factors
 include obesity, aging, and joint
trauma
 2. A degeneration and atrophy of the
cartilages and calcification of
 the ligaments
 3. Primarily affects weight-bearing
joints, spine, and hands
Osteoarthritis
(Degenerative Joint
 Clinical findings
 1. Subjective
 a. Pain after exercise
 b. Stiffness of joints
 2. Objective
 a. Heberden's and Bouchard's nodes
symmetrically occurring
 on fingers (bony hypertrophy)
 b. Decreased range of motion
 c. Crepitus when joint is moved
Osteoarthritis
(Degenerative Joint
 Therapeutic interventions
 1. Weight reduction in instances of
obesity
 2. Local heat to affected joints
 3. Medications to reduce symptoms,
such as analgesics, antiinflammatory
agents, and steroids
 4. Exercise of affected extremities
Osteoarthritis
(Degenerative Joint
 5. Surgical intervention
 a. Synovectomy: removal of the enlarged
synovial membrane
 before bone and cartilage destruction
occurs
 b. Arthrodesis: fusion of a joint performed
when the joint
 surfaces are severely damaged; this leaves
the client with no
 range of motion of the affected joint
 c. Reconstructive surgery: replacement of a
badly damaged
 joint with a prosthetic device
 Assessment
 1. History for risk factors such as
obesity, trauma, athletic
 involvement, and occupation
 2. Joints, noting evidence of
deformities, inflammation, and muscle
 atrophy
 3. Extent of range of motion of
involved joints
 Planning/Implementation
 1. Assist client in activities that require using
affected joints; allow for rest periods
 2. Maintain functional alignment of joints
 3. Attempt to relieve the client's discomfort and
edema by the use of medications or the
application of heat as ordered
 4. Allow client ample time to verbalize feelings
regarding limited motion and changes in life-style
 5. Support client through weight loss program if
indicated
 6. Encourage client to follow physical therapist's
instruction regarding regular exercise program
and use of supportive
 7. Provide care for the client requiring joint
replacement (see Nursing Care of Clients
with Fractures of the Hips)
 8. Refer client and family to the Arthritis
Foundation
 D. Evaluation/Outcomes
 1. Reports a reduction in pain
 2. Completes activities of daily living using
supportive devices as needed
 3. Develops life-style consistent with
limitations
 4. Follows daily program of prescribed
exercise