Management of Patients with

Musculoskeletal Disorders
• Anatomy & Physiology Overview
• Assessment of Musculoskeletal Function
• Musculoskeletal Care Modalities
 Musculoskeletal System

There are 206 bones & approximately 640 muscles in the body
 Anatomy & Physiology Overview

Ø The Musculoskeletal system consists of :

1-Bones 2- Joints 3- Muscles 4-Tendons & Ligaments.
§ Functions of the Musculoskeletal System:
• Protection of vital organs
• Support body structures
• Mobility and movement
• Producing heat that helps maintain body temperature
• Facilitate return of blood to the heart
• Production of blood cells (hematopoiesis)
• Reservoir for immature blood cells
• Reservoir for vital minerals: Calcium 98%,
Phosphorus, Magnesium & Fluoride
 Bone Formation and Maintenance
q Bone Maintenance:
§ Bone Remodeling: old bone is removed (resorption)
& new bone is added (formation).
§ Bone is in constant state of turnover (every 10 Y)
q Factors that affect Bone Maintenance:
• Stress and weight bearing activity (stimulate bone
formation). Weight bearing activity:which forces you to
work against gravity. E.g. weight training, walking,
hiking, jogging, climbing stairs, tennis, and dancing.
• Vitamin D (increase absorption of Ca from GI)
• Parathyroid hormone (Increase Ca level in blood by
increase resorption) and Calcitonin (Inhibits bone
resorption).
• Blood supply & Diet.
 Bone Healing

§ Factors Affecting Bone Healing:

• The type of bone fractured.

• Adequacy of blood supply.

• The condition of fracture fragments.

• The immobility of fracture site.

• The age.

• General health of the person.

 Anatomy of the Joint

§ Joint Capsule: surround the articulating bones

§ Synovium: membrane that line the capsule, it

secretes the lubricating synovial fluid.
§ Ligaments: fibrous tissue bind the articulating
bones together.
§ Maintain stability while permitting mobility.
§ Tendon: fibrous tissue bind bone to muscle.
§ A bursa: is a sac filled with synovial fluid that
cushions the movement of tendons, ligaments &
bones over bones or other joint structures.
 Joint of the Knee

§Functions of the Joints:

Holds the bones together
Allow the body to move
 Assessment of the Musculoskeletal System

§ Include data related to function ability; ADLs,

and ability to perform various activities; note any
problems related to mobility.
§ Health History: family history, general health
maintenance, nutrition, occupation, learning
needs, socioeconomic factors, and medications.
§ Assessment of pain, tenderness & altered
sensations.
§ Physical Assessment: posture, gait, bone
integrity, joint function, muscle strength and
size, skin, and neurovascular status: CMS
(Circulation, Motion, Sensation).
Normal Spine and Three Abnormalities
 Assess Neurovascular Dysfunction

§ Circulation
• Color: pale, cyanotic
• Temperature: Cool
• Capillary refill: More than 3 seconds
§ Motion
• Weakness
• Paralysis
§ Sensation
• Paresthesia
• Pain on passive stretch
• Absence of feeling
 Diagnostic Evaluation

§ Bone X-rays § Arthrocentesis (Joint

aspiration)
§ CT scan & MRI
§ Electromyography
§ Arthrography: To
(EMG)
identify tears of the § Biopsy (bone marrow,
joint capsule. bone, muscle or
synovial)
§ Bone densitometry § Laboratory studies
§ Bone scan: (bone (CBC, & ESR, Ca, P &
tumors, osteomylitis) Vitamin D levels)
§ Arthroscopy
Musculoskeletal Care Modalities
 Casts

§ A cast is a rigid external immobilizing device.

§ Uses:
• Immobilize a reduced fracture
• Correct or prevent a deformity

• Apply uniform pressure to soft tissues

• Support & stabilize weakened joints

o Casts permit mobilization of the patient while
restricting movement of the affected body part.
§ Materials: Nonplaster (Fiberglass), or Plaster.
 Casts

§ The joints proximal & distal to the area are

included in the cast.
§ Casts three main groups: arm casts, leg
casts, & body or spica casts.
• Short arm cast & Long arm cast
• Short leg cast & long leg cast
• Walking cast
• Body cast: encircles the trunk
• Shoulder spica cast: a body jacket encloses
the trunk, shoulder, & elbow.
• Hip spica cast: enclosed the trunk & lower
extremity.
Short and Long Cast
Long-Arm and Short-Leg Cast and Common
Pressure Areas
 Type of Cast
§ Fiberglass (Nonplaster) Cast:
• Water resistant
• Lighter in weight, stronger
• Full rigidity within 30 minutes
• Used for simple fractures of upper & lower
extremities & for long-term wear.
§ Plaster:

• Less costly & achieve better mold

• Heavy & not water resistant

• Can take up to 24 to 72 hours to dry

 Plaster Casts

§ A freshly applied plaster casts should be

exposed to circulating air to dry.

§ Supported on a firm and smooth surface.

§ If elevation is requested to reduce swelling, a
cloth covered pillow is preferred.
§ Handle wet casts with palm of hand.
§ A wet plaster cast feels damp, gray, sounds dull
on percussion.
§ Cast is dry when it feels hard, firm, white & shiny
appearance & resonant to percussion.
Plaster Casts

Cast sow
 Splints and Braces

§ A splint: is a device designed specifically to

support and immobilize a body part in a desired
position.
§ Splints are often used for simple & stable
fractures, sprains, tendon injuries & other soft
tissue injuries.
§ Contoured splints of plaster or pliable
thermoplastic materials may be used for
conditions:
§ That do not require rigid immobilization.
§ For those in which swelling may be anticipated.
§ For those who require special skin care.
 Splints and Braces

§ A brace: is an externally applied device to

support the body or a body part, control
movement, and prevent injury.
§ Braces (i.e., orthoses) are used to provide
support, control movement, and prevent
additional injury. They are custom fitted to
various parts of the body.
Education Needs of the Patient With a Cast

q Before Cast Application

§ Explanation of condition necessitating the cast
§ Purpose and goals of the cast
§ Expectations during the casting process (e.g.,
heat from hardening plaster)
§ Cast Care: keep dry; do not cover with plastic

§ Positioning: elevation of extremity, use of slings

§ Hygiene

§ Activity and mobility

Education Needs of the Patient With a Cast

§ Exercises

§ Do not scratch or stick anything under cast

§ Cushion rough edges

§ Signs and symptoms to report: persistent
pain or swelling, changes in sensation,
movement, skin color or temperature, signs
of infection or pressure areas.
§ Required follow-up care

§ Cast removal
Nursing Process: The Care of the Patient With
a Brace, Splint, or Cast—Assessment

§ Before Application
• General health assessment
• Emotional status
• Presenting signs and symptoms and condition of
the area
• Knowledge
• Monitoring of neurovascular status and for
potential complications
• The “Five Ps” indicative of symptoms of
neurovascular compromise are: Pain, Pallor,
Pulselessness, Parethesia, & Paralysis.
Nursing Process: The Care of the Patient With
a Brace, Splint, or Cast—Diagnoses

§ Deficient knowledge

§ Acute pain

§ Impaired physical mobility

§ Self-care deficit

§ Impaired skin integrity

§ Risk for peripheral neurovascular dysfunction

 Collaborative Problems and Potential
Complications

§ Compartment Syndrome: occurs when

increased pressure within a confined space (cast)
compromises blood flow & low tissue perfusion
occurs.
§ Pressure ulcer

§ Disuse Syndrome: which is the deterioration of

body system as a result of prescribed or
unavoidable musculoskeletal inactivity.

§ Delayed union or nonunion of fracture(s)

 Cross-Section of Normal Muscle Compartments
and Cross-Section With Compartment Syndrome

B. Lower leg with compartment syndrome. Swelling of

muscles causes compression of nerves & blood vessels.
Nursing Process: The Care of the Patient With
a Brace, Splint, or Cast—Planning

n Major goals include knowledge of the treatment

regimen, relief of pain, improved physical
mobility, achievement of maximum level of self-
care, healing of any trauma-associated
lacerations and abrasions, maintenance of
adequate neurovascular function, and absence of
complications.
Nursing Process: The Care of the Patient With
a Brace, Splint, or Cast—Interventions

§ Relieving Pain
• Elevation to reduce edema
• Intermittent application of ice or cold
• Positioning changes
• Administration of Analgesics
Ø Note: Unrelieved pain may indicate compartment
syndrome; discomfort caused by pressure may
require change of cast.
§ Muscle-setting exercises
§ Patient Education: how to use assistive devices
safely (crutches, walker).
 Nursing Process: Interventions

§ Healing skin wounds and maintaining skin

integrity
• Treat wounds to skin before the brace, splint,
or cast is applied
• Observe for signs and symptoms of pressure
or infection
Ø Note: Patient may require Tetanus booster
§ Maintaining adequate Neurovascular status
• Assess circulation, sensation, and movement
• Five “Ps”
• Immediately notify physician of signs of
compromise
• Elevate extremity no higher than the heart
• Encourage movement of fingers or toes Q hour
 External Fixation Devices

§ Used to manage complex open fractures with soft

tissue damage.
§ Provide support for complicated or comminuted
(crushed) fractures.
§ External fixation involves the surgical insertion of
pins through the skin & soft tissues into & through
the bone.
§ Advantages: immediate fracture stabilization,
minimization of blood loss, increased patient
comfort, improved wound care, early mobilization.
§ Disadvantage: increased risk for pin site
infections.
External Fixation Device
External Fixation Device
Nursing Management- External Fixator
• Patient reassurance that the discomfort with the
device is minimal & early mobility is anticipated.
• After applied external fixator elevate to reduce
swelling.
• Sharp points on fixator or pins covered with caps
• Monitor for signs and symptoms of complications,
including infection, & compartment syndrome
• Monitor neurovascular status of extremity every 2
to 4 hours: Assess color, sensation, cap refill,
movement, pain, and pulses.
• Pin site care: dressing & assess signs of
inflammation every 8 to 12 hr (redness, swelling,
pain around pin sites, warmth, & purulent
drainage)
• Patient education: pin site care, monitor
neurovascular status, report loose pins or clamps.
 Traction

§ The application of pulling force to a part of the body

§ Purposes:

• Reduce muscle spasms & pain

• Reduce, align, and immobilize fractures

• Correcting or preventing deformities

• Increase space between opposing forces

§ Used as a short-term intervention until other
modalities are possible.
§ The effects of traction evaluated with X-ray
 Traction

n All traction needs to be applied in two directions.

The lines of pull are “vectors of force.” The
result of the pulling force is between the two
lines of the vectors of force.
Traction
 Principles of Effective Traction

• Whenever traction is applied, a counterforce must be

applied. Frequently, the patient’s body weight and
positioning in bed supply the counterforce.
• Traction must be continuous to reduce and
immobilize fractures.
• Skeletal traction is never interrupted.
• Weights are not removed unless intermittent traction
is prescribed.
• Any factor that reduces pull must be eliminated.
• Patients must be in the center of the bed.
• Ropes must be unobstructed, and weights must hang
freely.
• Knots or footplate must not touch the foot of the bed
 Types of Traction

§ Skin Traction: for short term use to stabilize a

fractured leg & control muscle spasm.

• Weight applied no more than 2 to 3.5 kg.

§ Buck’s extension traction
§ Cervical head halter
§ Pelvic traction: 4.5 to 9 kg
§ Skeletal Traction: for continuous traction to
immobilize, position & align a fracture of the
femur, tibia & cervical spine.
Buck’s Extension Traction
Balanced Skeletal Traction with Thomas
Leg Splint
 Skeletal Traction

§ Pull directly
applied to bone by
pin.
§ Pin care
§ Increased risk of
infection.
§ Never interrupted
 Pin Care in Skeletal Traction

§ Provide pin care as ordered.

Cleanse area around pin with
normal saline or half-strength
hydrogen peroxide.

§ Swab cultures of any

suspicious discharge.

§ Have parent / caretaker

demonstrate pin care before
discharge.
Preventive Nursing Care Needs of the Patient
in Traction

• Ensuring Effective Traction

• Proper application and maintenance of traction

• Avoid wrinkling & slipping of the traction bandage.
• Checks that the ropes are in the wheel grooves of
the pulleys, weights hang freely.
• Evaluate patients position (slipping down in bed
results in ineffective traction).
• Proper positioning to keep the leg in a neutral
position
• Patient should not turn from side to side.
 Nursing Interventions - Traction

§ Monitor & Manage Potential Complications:

Ø Skin breakdown, Nerve pressure, & Circulatory
impairment.
q Skin Breakdown:
• Inspect skin at least every 8 hours
• Palpate traction tapes to assess for tenderness
• Provide frequent repositioning
• Use special mattress (air-filled or high density
foam) or other pressure reduction devices
• Frequent back care and skin care
• Trapeze overhead to help with movement for
patients in skeletal traction.
• Encourage movement without using elbows or heel
 Nursing Interventions - Traction

q Nerve Pressure:
n Assess sensation & ask patient to move the toes &
dorsiflexion & planter flexion of the foot.
n Promptly report any alteration in sensation or
impaired motor function.
q Circulatory Impairment
n Assess circulation of the foot within 15 to 30 minutes
& then every 1 to 2 hours.
n Circulatory assessment consists of: peripheral pulses,
color, capillary refill & temperature of fingers or toes
n Assess for indicators of DVT
n Perform active foot exercises and leg exercises every
hour
n Elastic stocking & Anticoagulant therapy to prevent
thrombus formation.
Nursing Process: The Care of the Patient in
Traction—Assessment

§ Assessment of neurovascular status and for

complications
§ Assessment for mobility-related complications
of pneumonia, atelectasis, constipation,
nutritional problems, urinary stasis, or UTI
§ Pain and discomfort
§ Emotional and behavioral responses
§ Coping
§ Thought processes
§ Knowledge
Nursing Process: The Care of the Patient in
Traction—Diagnoses

§ Deficient knowledge

§ Anxiety

§ Acute pain

§ Self-care deficit

§ Impaired physical mobility

Collaborative Problems and Potential
Complications

§ Pressure ulcer

§ Atelectasis

§ Pneumonia

§ Constipation

§ Anorexia

§ Urinary stasis and infection

§ DVT
Nursing Process: The Care of the Patient in
Traction—Planning

§ Major goals include understanding of the

treatment regimen, reduced anxiety,
maximum comfort, maximum level of self-
care within the therapeutic limits of the
traction, and absence of complications.
Nursing Process: The Care of the Patient in
Traction—Interventions

§ Interventions to prevent skin breakdown, nerve

pressure, and circulatory impairment
§ Measures to reduce anxiety
§ Providing and reinforcing information
§ Encourage patient participation in decision
making and in care
§ Frequent visits (family and of caregivers and
nurses) to reduce isolation
§ Diversional activities
§ Use of assistive devices
Nursing Process: The Care of the Patient in
Traction—Interventions

§ Consultation with referral for physical therapy

§ Prevention of atelectasis and pneumonia
§ Auscultate lungs every 4 to 8 hours
§ Coughing and deep breathing exercises
§ High-fiber diet & fluid to prevent constipation
§ Encourage fluids & to void every 3 to 4 hrs.
§ Identify and include food preferences; encourage
proper diet
§ Assess for indicators of infection
§ Pin care
§ Exercises to maintain muscle tone and strength
 Joint Replacement

q Joint surgery is one of the most frequently

performed orthopedic surgeries.

Ø Indications for joint replacement:

• Severe joint pain and disability
• Repair and management of joint fractures or
joint necrosis
• Osteoarthritis & Rheumatoid arthritis
• Trauma
• Congenital deformity
• Disruption of blood supply & avascular necrosis
 Joint Replacements

§ Frequently replaced joints

include hip, knee, & fingers.
§ Joints including the
shoulder, elbow, wrist, &
ankle are replaced less
frequently.
§ Joint arthroplasty refers to
the surgical removal of an
unhealthy joint &
replacement of joint surfaces
with metal (titanium) or
synthetic materials.
 Total Hip Arthroplasty (THA)

q THA; (total hip replacement) is the replacement

of a severely damaged hip with an artificial joint.
q Indications Include: femoral neck fracture,
osteoarthritis, rheumatoid arthritis, failed
prosthesis, & congenital hip disease.
§ Nursing Interventions:
• Monitor for potential complications
associated with THA: dislocation of hip
prosthesis, excessive wound drainage, DVT,
infection, neurovascular dysfunction & heel
pressure.
 Hip Replacement: Postoperative Care

§ Preventing dislocation of the Hip prosthesis:

q Correct Positioning is maintained all time:
• Put patient in a supine position, head slightly
elevated, affected leg in neutral position.
• Positioning of the leg in abduction to prevent
dislocation of the prostheses- Abduction pillow
• Do not flex hip more than 90 degrees.
• Avoid internal rotation; do not cross the legs
• Do not elevate the head of the bed more than 600
• Keep the affected hip in extension.
• Do not position on affected side.
Use of an Abduction Pillow to Prevent Hip
Dislocation After Total Hip Replacement
Hip Replacement: Postoperative Care
Hip Replacement: Postoperative Care

q Signs & Symptoms of Prosthesis

dislocation:

• Increased pain at surgical site

• Swelling & immobilization

• Acute groin pain in the affected hip

• Shortening of the affected extremity

• Abnormal external or internal rotation

• Inability to move the leg

 Hip Replacement: Postoperative Care

§ Promoting Ambulation
• Ambulation within 1 or 2 days after surgery with
crutches or walker (whether surgery is total hip
or total knee replacement).
§ Routine post-op care
o Prevent Infection
o Monitor Wound Drainage: Assess for bleeding
and fluid accumulation.
o Prevent DVT: ankle and foot exercises hourly &
elastic stocking, ambulation, and low-dose
heparin.
 v Total Knee Arthroplasty (TKA)

§ TKA is considered for sever pain & functional

disabilities related to destruction of joint surfaces
by osteoarthritis, rheumatoid arthritis

or posttraumatic arthritis.

§ Metal or ceramic prosthesis.

§ If ligaments are weakened, a fully constrained

(hinged) or semiconstrained prosthesis may be
used to provide joint stability.
 TKA Postoperative Care

§ Knee is dressed with compression bandage.

§ Apply ice or cold packs to reduce edema &
bleeding.
§ Assess the neurovascular status every 2 to 4 hrs.
§ Encourage active flexion exercises every hour.
§ Prevent complications: DVT, infection, bleeding,
limited range of motion.
§ Assess wound suction drain: the color, type, &
amount of drainage are documented.
§ Use of continuous passive motion (CPM) device
to promote ROM, circulation & healing.
 CPM Device

§ The patient leg is placed in this device immediately

after surgery.
 TKA Postoperative Care

§ Patient post TKA should mobilize & ambulate by

the first postoperative day.

§ Educate patient how to use assistive devices.

§ Education to limit positions of flexion of the

knee to avoid flexion contractures.
§ Protect the knee with a knee immobilizer
(splint, cast) & elevated when the patient sits in
a chair.
§ Relieving pain.