Ch.

40 Management of Clients with Musculoskeletal Disorders

Osteoarthritis
Etiology and risk factors
o Idiopathic or secondary
o Bone on bone action
o AKA degenerative bone disease
o Usually affects more males until age 55, then affects menopausal women
o Gradual onset
o Affects neck, hands, wrists, lower back, and hips
Pathophysiology
o Process of cartilage matrix degradation accompanied by the bodys ineffectual
attempts at repair
Clinical Manifestations
o Worsening pain and stiffness
Risk factors
o Idiopathic
Increasing age
Genetics
o Secondary
Trauma
Mechanical stress
Inflammation of joint structures
Joint instability
Neurologic and endocrine disorders
Selected medications
Obesity
Hormones
Inactivity
Athletes
Overweight
RA and Lupus
Ligament and tendon issues with repetitive repair
Medical management
o Goals
Pain relief
Functional independence: ADLs
Maintenance of quality of life
o Approach
Exercise
Topical treatments and heat: Capsaicine cream is OTC
Acetaminophen: Tylenol, Mobec
NSAIDS, COX-2 inhibitors
Dietary supplements

Nursing Management of the Osteoarthritic Client

Goal is promotion of a healthy, positive adaptation
o Decrease purines, caffeinated beverages, and carbs
o Moderate exercise: want active, but dont want to wear down bones

Client education
Collaborate with occupational therapist
Reinforce and encourage client to notify physician of changes in condition
Surgical management
o Osteotomy: incision into bone to realign joint, can delay total joint replacement
o Arthrodesis: debride bone
o Joint arthroplasty: total joint replacement
Nursing diagnosis
o Pain: always primary
o Impaired physical mobility
o Risk for peripheral neurovascular dysfunction
o Risk for infection
o Ineffective tissue perfusion

Metabolic Bone Disorders

Osteoporosis
Pagets disease
Osteomalacia
Gout and gouty arthritis

Osteoporosis
Etiology and risk factors
o Genetic and environmental
o Problems with hard and
collagen bone
o Modifiable and
Nonmodifiable risk factors
o Depends on how much bone
mass is achieved between age
25-35 and how much loss
later
Modifiable risk factors
o Low estrogen
o Low testosterone
o Dietary: low lifetime calcium;
Vit D deficiency
o Medication use:
corticosteroids, some
anticonvulsants
o Lifestyle: inactivity, cigarette
smoking, excess alcohol
Nonmodifiable risk factors
o Older age
o Family history
o History of fracture in first degree relative
o Being female especially Caucasian or Asian
o Being thin or having a small frame
Pathophysiology
o Exact patho not clear

Reabsorption of the bone is greater than new bone formation so there is bone
loss, which is accelerated by risk factor such as Vit D deficiency or
postmenopausal women with low estrogen.
Clinical manifestations
o Diagnosed after fracture (most common)
o Loss of height
o Spine curvature
Medical management
o Prevent loss of bone mass
o Prevention of bone resorption
Medications
o Hormone replacement therapy
Evista: without cancer risks, mimics effects of estrogen
Decrease bone loss
Side effects are risk of cancer
o Calcitonin
Prevent bone loss
Increase osteoblast
o Calcium supplements
Vit D supplements
o Fluoride
Increase the solubility (strength)
o Biphosphonates
Fosamax, Actonel, Didronel, Boniva
Inhibit bone resorption
Preserves bone mass
Nursing diagnoses
o Imbalanced nutrition: Less than body requirements
Encourage calcium intake
o Impaired physical mobility
(dairy, tofu, broccoli, spinach)
o Pain related to fracture
and weight bearing exercise
Pagets Disease (Osteitis Deformans)
o

Etiology
o Idiopathic
Pathophysiology
o Progressive skeletal disorder that results form excessive
metabolism activity in the bone

o Hypermetabolic
o Bones are large and softer
o Bone is replaced with disorganized bone
Clinical manifestations
o Painful deformities
o Progresses slowly
o Demineralization of bone showing on x-ray (bone looks punched out)
o Familial tendency, usually males
o Common complaint is pain in long bones
o Pain most often at night
Outcome management

o Control pain
biophosphonates (Fosamax, Actonel), calcitonin, NSAIDs for
inflammation and pain

Osteomalacia (Adult Rickets)

Etiology
o Inadequate Vit D
o Most common cause is hypophosphatemia or hypocalcemia
Pathophysiology
o Deficiency of phosphates, calcium, and Vit D
o Inadequate delayed mineralization of bone matrix
o Soft bones
Clinical manifestations
o Fatigue
o Malaise
o Bone pain
o Some deformities in weight bearing bones
Outcome management
o Daily Vit D
Gout and Gouty Arthritis
Classifications
o Primary gout
Elevated serum or blood level, uric acid level, from inborn error in a
purine metabolism or decreased excretion of uric acid
Have trouble breaking down purines
o Secondary gout
Hyperuricemia from another disorder (ex. Tumor lysis syndrome)
Can come from treatment
More common in men 40-50 years old
Not normally seen in women before menopause
Clinical manifestations
o Develops in stages
o Can happen in any joint but most commonly in great toe
o Severe pain
o Build up of purines causing uric acid crystals in joints
o Stage 1
Client has asymptomatic hyperuricemia, excreting uric acid but no
symptoms
o Stage 2
Acute vs chronic
Affects a single joint= acute
Chronic occurs when hyperuricemia that is not treated overtime leads to
kidney disease or damage: crystals deposit in tubules or ureters
Outcome management
o Management of the acute attack
o Long-term management of hyperuricemia

o Decrease ingestion of red meats and fish

Gout
Diagnostic tests
o Serum uric acid levels (usually >7.5 mg/dL)
o WBC elevation: due to inflammation
o ESR (sed rate) elevation: to test inflammation, specifically eosinophils can be
increased which can increase sed rate due to uric acid crystals depositing in joints

o 24-hr urine to assess for uric acid

o Aspiration of joint fluid: definitive way to diagnose
Medications
o NSAIDs
o Colchicine
o Corticosteroids
o Analgesics
o Prophylactic (for chronic)
Colchicine
Uricosuric drugs (Probenecid, Anturane)
Xanthine oxidase inhibitors (Allopurinol)
Spinal Column Deformities
Scoliosis
o Curvature of spine
Kyphosis
o Humpback
Lordosis
o Excessive inward curvature of lumbar spine

Scoliosis
Etiology
o Congenital or neuromuscular
Clinical manifestations
o Abnormal spinal curvature
Outcome management
o Observation, braces, exercise
o Spinal fusion
Bone Infections: Septic Arthritis
Etiology and pathophysiology
o Joint space becomes infected by a pathogen and then moves to blood
o Most common pathogen: staphylococcus aureus
Risk factors:
o Persistent bacteremia
o Previous joint damage
o Surgery to joints
Clinical manifestations
o Joint pain
o Swelling
o Tenderness
Outcome management

o Medical management
o Nursing management
Bone Tumors: Malignant
Causes
o Unknown: past trauma?
Diagnosis: needs to be prompt
o Serum AP level: will be increased (alkaline phosphate)
o Bone marrow biopsy
o Radiology (MRI, CT, X-ray)
Disorders of the Foot
Hallux valgus (bunion)
o Enlargement of joint or lump of bone at base or side of big toe
o Forms when toe moves out of place
Mortons neuroma (plantar neuroma)
o Tumor like mass from tight fitting shoes
o Common problem associated is pain or swelling or nerve
o Usually at the ball of the foot on the third of fourth toe
Hammer toe
o Toe contracture at middle joint
o Usually second toe
Muscular Dystrophy
Etiology and risk factors
o Genetic
o Death usually occurs at late teens or early adult
Clinical manifestations
o Progressive weakness
o Skeletal muscle wasting
Diagnosis
o Elevated Creatinine kinase
o Muscle biopsy
Treatment
o Symptomatic and supportive
Sjogrens Syndrome
Autoimmune
Causes inflammation and dysfunction of endocrine glands
More common in women
Artificial tears fix
Manifestations
o Dry eyes
o Dry mouth
o Parotid gland enlargement
o Arthritis (systemic effect)
o Dysphagia (systemic effect)
Fibromyalgia
Common rheumatic syndrome

 Older women 9x more than men

Musculoskeletal pain (dominant symptom), stiffness, and tenderness
Resembles chronic fatigue syndrome
Diagnosis given after three months of pain
Scleroderma (hard skin)
Rare, connective tissue disorder
Causes
o Unknown- genetic, immune, environmental
Starts with dry patches getting thicker and harder then spreads
Persons antibodies directed against own tissues
Affects ADLs
CREST syndrome: abnormal calcium salt deposits seen around joints and tissues
Medications are chosen based on symptoms
Rheumatoid Arthritis
Chronic systemic autoimmune disease
Cause
o Unknown- genetic, hormonal (sex hormones), reproductive, infectious factors
(Epstein Barr)

Insidious onset (may be precipitated by stressor)

Manifestations
o Inflammation
o Fatigue
o Anorexia
o Weight loss
o Nonspecific aching and stiffness
Persistent inflammation leads to joint deformity
Synovial membrane is damaged
Wrist involvement
Visible swelling in the knees knock-knee
Rest and exercise
Walking and swimming
Heat and cold
Surgery
Medications
o ASA and NSAIDs
o Low-dose corticosteroids
o Disease-modifying drugs
o Immunosuppressive therapy
Nursing diagnoses
o Chronic pain
o Fatigue
o Ineffective role performance
o Disturbed body image

Ankylosing Spondylitis
Chronic inflammatory arthritis primarily affecting the axial skeleton
Sacroiliac joints of the spine
Can lead to fusion of the spinal process
More common in males
Cause: unknown (genetic predisposition)
o 90% of patients were born with HLA B27 gene
Onset is gradual
o Pain worse at night with morning stiffness that may radiate down the legs
Treatment
o Physical therapy and exercise
o NSAIDs (Indocin)
o Topical or intra-articular corticosteroids
o Surgery
Reactive Arthritis
Acute, nonpurulent inflammatory arthritis that complicates a bacterial infection of the GU
or GI tracts

Often affects young men with HLA-B27 antigen

Often found in HIV
Usually asymmetric, affecting large weight-bearing joints
Treated with NSAIDs
Antibiotic to treat bacterial infection
Systemic Lupus Erythematosus

Chronic inflammatory immune complex connective-tissue disease

Type III hypersensitivity reaction
Affects almost all body systems
Cause: unknown (genetic, hormonal, and environmental factors)
Manifestations mimic RA
90% have joint symptoms: painful swollen joints
Muscle pain
Red butterfly rash across cheeks
Hair loss
Edema
Photosensitivity
Can be difficult to diagnose
May have increased SED
Medications
o NSAIDs, ASA
o Plaquenil
o Corticosteroids
o Immunosuppressive agents

Polymyositis
Systemic connective tissue disorder characterized by inflammation of connective tissue
and muscle fibers

Autoimmune relation
Skeletal muscle weakness and atrophy
Rash, arthralgias, fatigue
Insidious or abrupt onset
Be supportive and comforting
Lyme Disease
Inflammatory disease caused by Borrelia burgdorferi
Transmitted by ticks
Usually occurs in summer months: hunting season
Manifestations are skin changes, musculoskeletal and CNS changes
Over time develop flu-like symptoms
Slightly red lesion at site of tick bite: bulls-eye shaped lesion
Fatigue, malaise, fever, chills, myalgias, HA, and stiff neck

Ch. 39 Musculoskeletal Trauma and Disorders

Contusion, Strain, or Sprain

Contusion
o Least serious
o Bleeding into soft tissue
Strain
o Stretching injury to a muscle or a muscle-tendon unit
Sprain
o Injury to a ligament surrounding a joint

Ice for 24-48 hrs

and then use heat
Elevate above the
heart

Fractures
A disruption or break in the continuity of the structure of bone
Traumatic injuries account for the majority of fractures
Described and classified according to:
o Type
o Communication or noncommunication with external environment
o Anatomic location

Type

Classification
by Fracture
Communicati
on

Classification
by Fracture
Location

Immediate localized pain

Decreased function
Inability to bear weight or use affected part
o Guarding
o May not be accompanied by obvious bone deformity
Fracture healing
o Reparative process of self-healing (union) occurs in the following stages:
1. Fracture hematoma: clotting factors form fibrin meshwork
2. Granulation tissue: gradually replaces hematoma
3. Callus formation: osteoblasts make collagen that unite bone fragments
4. Ossification: spongy woven bone takes in calcium and starts to harden
5. Consolidation: mature bone starting to form
6. Remodeling: have bone resemble structure before it was injured

Collaborative care
Overall goals of treatment:
o Anatomic realignment of bone fragments (reduction) #1
o Immobilization to maintain alignment
o Restoration of normal function
Fracture reduction
o Closed reduction
Nonsurgical, manual realignment
o Open reduction
Correction of bone alignment through a surgical incision
Fracture immobilization
o Casts
Temporary circumferential immobilization device
Common treatment following closed reduction

External fixation

Metallic device composed of pins that are inserted into the bone and
attached to external rods
For hip, use abduction pillow and isometric exercises. Dont cross legs
o Internal fixation
Pins, plates, intramedullary rods, and screws
Surgically inserted at the time of realignment
Fracture reduction
o Traction
Application of a pulling force to an injured part of the body while
counter traction pulls in the opposite direction
Magic number is 6 lbs or less
Types of traction:
Skin traction (short-term)
Bucks traction: pre-surgery
Skeletal traction (longer periods)
Manual traction
Balanced suspension: pulling at two different places
Purpose of traction:
Prevent or reduce muscle spasm
Immobilization
Reduction
Treat a pathologic condition
Drug therapy
o Muscle relaxant: Soma, Flexeril, Norflex
o Narcotics: IV for severe injuries
o PCA and epidural: serious injuries following surgery; watch O 2 sat
o NSAIDs
o Tetanus-diphtheria toxoid or immunoglobulin
o Bone-penetrating antibiotic
Cephalosporin

Nursing Management
Nursing assessment
o Brief history of the accident: driver, passenger, seatbelt?
o Mechanism of injury
o Special emphasis focused on the region distal to the site of injury: check for
circulation
o Neurovascular assessment: #1 is pain
Color
Temperature
Capillary refill
Peripheral pulses
Edema
Sensation
Motor function pain
Nursing diagnoses
o Risk for peripheral neurovascular dysfunction

o
o
o
o
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Acute pain
Risk for infection
Risk for impaired skin integrity
Impaired physical mobility
Ineffective therapeutic regimen management
Planning
o Overall goals:
Physiologic healing with no associated complications
Pain relief
Achieve maximal rehabilitation potential
Nursing implementations
o Health promotion
Safety precautions
Use of seat belts
Stretching before exercising
Participate in moderate exercise
o Acute intervention
Preoperative management
Inform of immobilization device
and expected activity limitations
Skin preparation
Normal pre-op checklist
Postoperative management
Monitor vital signs
Frequent neurovascular
assessments
Limitations of movement
Other measures
Activity
Maintenance of high fluid intake
Diet high in bulk
Never medicate before getting a culture
Traction
Ensure proper functioning of tractioning equipment
Pin site care
o Ambulatory and home care
Cast care
Frequent neurovascular assessment
Teach patient signs of complications
Elevation of extremity above level of the heart
Exercise joints above and below the cast
Psychosocial problems
Assist patient to adjust to any problems caused by injury

Ambulation
Usually started in mobility training when able to sit in bed and
dangle feet over the side
Assistive devices
Cane
Walker
Crutches

Evaluation
o Expected outcomes:
Normal neurovascular examination
Tolerable or no pain
No evidence of infection
No evidence of skin breakdown
Ambulation devices used correctly
Minimal loss of muscle bulk of affected extremity

Complications of Fractures
Infection
o Collaborative care
Open fractures and soft tissue injuries have increased incidence
Osteomyelitis can become chronic
Open fractures require aggressive surgical debridement
Post-op IV antibiotics for 3-7 days
Compartment syndrome
o Condition in which elevated intracompartmental pressure within a confined
myofascial compartment compromises the neurovascular function of tissues
within that space
o Manifestations (6 Ps)
Paresthesia
Pain
Pressure
Pallor
Paralysis
Pulselessness
Venous thrombosis
o Veins of the lower extremities and pelvis are highly susceptible to thrombus
formation after fracture, especially hip fracture
o Precipitating factors:
Venous stasis caused by incorrectly applied cast or traction
Local pressure on a vein
Immobility
o Lovanox, Coumadin, Heparin
Fat embolism syndrome (FES)
o Characterized by the presence of fat globules in tissues and organs after a
traumatic skeletal injury
o Tissues most often affected: lung, brain, heart, kidney

o Fractures that most cause FES:

Long bones
Ribs
Tibia
Pelvis
o Manifestations:
Interstitial pneumonitis
Chest pain
Tachypnea
Cyanosis
Decreased PaO2
Dyspnea
Apprehension
Tachycardia
Rapid and acute course
Feeling of impending doom
Patient may become comatose in a short time
o Collaborative care
Treatment directed at prevention
Careful immobilization of a long bone fracture (most important)
Symptom management
Fluid resuscitation
Oxygen
Reposition as little as possible
Corticosteroids for inflammation in tissues and bone
Amputation
Partial or total removal of a body part
Acute
Chronic
Goals of amputation
o Alleviate symptoms
o Maintain healthy tissue
o Increase functional outcome
Types
o Open (guillotine)
o Closed (flap) no infection
Post-amputation
Site healing
Stump molding
Dressings
Prosthesis selection
Complications
Infection
Delayed healing

 Pain
Contractures
Prosthesis
Level of amputation
Selection of prosthesis
Timing
Nursing diagnoses
Pain
Disturbed body image
Risk for dysfunctional grieving
Risk for infection
Risk for impaired skin integrity
Impaired physical mobility
Ineffective coping
Disturbed personal identity
Hopelessness
Osteomyelitis
The most common infecting microorganisms are:
o Staphylococcus aureus (most common)
o Escherichia coli
o Pseudomonas
o Salmonella
o Fungi, mycobacteria
o Klebsiella
o Proteus
Direct contamination
Complication of surgery
Adjacent soft-tissue infections
Hematogenous Osteomyelitis
Caused by pathogens carried in the blood from other sites of infection
Primarily affects older adults
Acute Osteomyelitis
An infection of less than one month in duration
Manifestations are both systemic and local
Chronic Osteomyelitis
A bone infection that persists for longer than one month
OR an infection that has failed to respond to the initial course of antibiotic therapy
Either a continuous, persistent problem or a process of exacerbations and remission
Over time, granulation tissue turns to scar tissue providing an ideal site for further
microorganism growth

Systemic signs may be diminished, with local signs of infection more common
Constant bone pain and swelling, tenderness, and warmth at the site
Diagnostic studies
Bone or soft tissue biopsy

 Blood and/or wound cultures

Elevated WBC and ESR
Radionuclide bone scans (gallium and indium)
MRI
CT
Collaborative Care
Vigorous and prolonged IV antibiotic therapy is the treatment of choice of acute
osteomyelitis, as long as bone ischemia has not yet occurred

Home care with a central venous catheter or PICC

4-6 weeks or as long as 3-6 months
Surgical treatment
o Needle aspiration or percutaneous biopsy
o Removal of the poorly vascularized tissue and dead bone
o Antibiotic-impregnated polymethymetharcrylate bead chains may be implanted
at this time to aid in combating the infection

o After debridement the wound may be closed, and a suction irrigation system is
inserted

o Intermittent or constant irrigation of the affected bone with antibiotics may also
be initiated

Hyperbaric oxygen therapy of 100% oxygen may be administered in chronic

osteomyelitis
Orthopedic devices may need to be removed
Myocutaneous flaps or skin and bone grafting may be necessary if destruction is
extensive
Amputation of the extremity may be necessary to preserve life and improve the quality
of life
Long-term and mostly rare complications of osteomyelitis include septicemia, septic
arthritis, pathologic fractures, squamous cell carcinoma, and amyloidosis

Antibiotics
Penicillins
Nafcillin (Nafcil)
Cephalexin (Keflex)
Cefoxitin (Mefoxin)
Gentamycin (Garamycin)
Tobramycin (Nebcin)
Cefazolin (Ancef)
Ciprofloxacin (Cipro)
Vancomycin
Fluoroquinolones
Nursing diagnoses
Acute pain
Impaired physical mobility
Infection
Altered peripheral tissue perfusion
Anxiety

Planning
Overall goals:
o Satisfactory pain and fever control
o No complications
o Cooperation with treatment plan
o Maintenance of a positive outlook on the outcome of the disease
Nursing implementation
Health promotion
o Control existing infections to prevent osteomyelitis
o Instruct patients on local and systemic manifestations of osteomyelitis
o Inform families of their role in monitoring the patients health
o Symptoms of bone pain, fever, swelling, and restricted limb movement should be
reported immediately to the health care provider

Acute intervention
o Bed rest in the early stages for an acute infection
o Good body alignment and frequent position changes
o Avoid activities such as exercise or heat application
o Uninvolved joints and muscles should continue to be exercised
Ambulatory and home care
o Instruct on proper care and management of the venous access device
o Instruct on antibiotic administration
o If there is an open wound, dressing changes are often necessary
o Family needs to understand the infection is not contagious