Nursing Care of the Patient with Musculoskeletal System Problems
General Principles
•	Rest is the essential therapy
–	Promotes the healing process

•	Elevation of affected body part above the level of the heart
–	Decreases Edema

•	Immobilization and alignment

Complications of rest/immobility
•	Pneumonia
–	Temp 101 >
•	Thrombophlebitis
•	Demineralization of bone
•	Muscle atrophy

•	Urinary stasis
•	Renal calculi
•	Constipation
•	Pressure ulcers
General Principles of Nursing Care
•	Body parts must be in alignment

•	Prevent foot drop

•	Logrolling
–	Body is moved as “one” unit using two or more individuals, aligning with pillows, blankets, etc.
General Principles
•	Circulatory/Neurovascular Checks “The 5 P’s”
–	Pulselessness
–	Pallor
–	Pain 
–	Parasthesia
–	Paralysis

Review
•	Quickly review stages of bone healing
–	Hematoma
–	Inflammation and neovascularization
–	Reparative phase
–	Ossification
–	Remodeling
•	Found on page 1766 of text
Managing the Patient in a Cast	
•	Plaster Cast
–	24-72 hrs to dry completely 
•	Nonplaster fiberglass cast
–	lighter 
–	relatively waterproof
–	support earlier mobilization
–	used when multiple casts not needed & severe edema not present

Bivalve casts
•	Cast cut in half to allow for inspection of underlying skin, relieve pressure, change dressings
–	Resecured with elastic compression bandage to maintain immobilization
Nursing Diagnoses
•	Knowledge deficit
•	Pain
•	Impaired physical mobility
•	Self-care deficit
•	Risk for impaired skin integrity
•	Risk for peripheral neurovascular dysfunction (5 Ps)
Potential Complications
•	Compartment syndrome
–	associated with extensive soft tissue damage or crush injury.
–	Forearm & lower leg most common sites
–	Occurs when there is increased pressure within a limited space
–	Compromises circulation and tissue function
Compartment syndrome
–	watch for decreased circulation,  pain, motor loss, numbness, tingling, sensory loss, paleness
•	Interventions
–	Notify MD
–	elevate extremity to heart level
–	Bivalve the cast
•	Surgical intervention: fasciotomy

Complications
•	Pressure ulcer/necrosis
–	heels, ankles, dorsum of foot, patella, head of fibula
–	pain
–	heat palpable through cast
–	tissue breakdown with drainage
–	odor to cast
•	 Interventions: bivalve, cut a window

Complications
•	Disuse syndrome
–	isometric exercises hourly in the cast
–	quadriceps- & gluteal- setting (see Chart 61-2)
–	make a fist
–	exercise fingers and toes

Nursing care review

•	Check neurovascular
•	Check integrity of cast (note any rough edges)
•	Check for drainage and odor
•	Teach exercises
•	Instruct patient on what to report
•	Rest & elevation
Management of Fractures with Soft Tissue Damage
•	External Fixator - provides stable support for comminuted (crushed or splintered) fracture
–	metal pins inserted into the bone and attached to external rods
–	fracture is reduced, aligned, and immobilized by pins inserted in the bone fragments
Nursing Care
•	Ensure sharp points are covered
•	Elevate extremity
•	Neurovascular checks q 2hr (5 Ps)
•	Assess pin site for:
–	redness, drainage, tenderness, pain, loosening of pin
•	Pin care tid
•	Isometric exercises
•	Weight-bearing as ordered
•	Teach self care
Remember
•	DO NOT adjust the clamps on the external fixator.
Managing the Patient In Traction
•	Traction applies a pulling force to establish realignment
•	Traction Types:
–	Skin traction
•	Buck’s, Russell’s, Dunlop’s, Pelvic belt & pelvic sling, Head halter
–	Skeletal traction applied to bone
•	Fx of femur, tibia, humerus & cervical spine
•	traction applies with metal pin or wire
•	Thomas splint in femur fractures

Nursing Care
•	Skin Traction
–	check weights & pulleys
–	skin breakdown
•	special mattress if must be supine
–	circulation checks
•	pulses, color, temp, capillary refill, DVT
–	neuro check to extremities
•	peroneal nerve - dorsiflexion
•	tibial nerve - plantar flexion
•	ulnar nerve - little finger movement & sensation
–	 traction exercises	
Skeletal traction
•	Skeletal Traction
–	check weights and pulleys
–	check position - pull patient up in bed
–	DO NOT remove weights unless an emergency!
–	maintain body alignment
–	skin breakdown
–	neurovascular checks (5Ps)
–	isometric exercises & trapeze
–	pin care
•	prevent osteomyelitis

Nursing Diagnoses
•	Knowledge deficit
•	Anxiety
•	Pain
•	Self-care deficit
•	Impaired physical mobility
•	*Risk for all problems associated with bedrest: pressure ulcers, pneumonia, constipation, urinary stasis, DVT

Common problems of the upper extremity
•	Painful shoulder syndromes
–	Bursitis 
–	Tendinitis
–	Loose bodies
–	Impingement syndrome
–	Rotator cuff tears
•	Conservative interventions: rest, contrast heat and cold; NSAIDS
•	Arthroscopic surgery
•	Joint injections, physical therapy
Upper extremities
•	Carpal tunnel syndrome – entrapment neuropathy of the median nerve at the wrist due to repetitive hand activities, arthritis, pregnancy
–	S & S – tingling, weakness (thumb, 1st and 2nd fingers), numbness, night pain
–	Tx: rest splints, avoidance of repetitive flexion of wrist, NSAIDs, cortisone injections, surgical release
Upper extremities
•	Ganglion – collection of gelatinous material near the tendon sheaths and joints
–	Round, firm, cystic swelling on dorsum of wrist
•	Tx: aspiration, cortisone injection, surgical excision
•	Tennis elbow – epicondylitis
–	Tx: RICE
Upper extremities
•	Dupuytren’s contracture – inherited autosomal dominant trait in which the there is a flexion of the 4th and 5th fingers and frequently the middle finger
–	Due to slowly progressive contracture of the palmar fascia with nodule development and thickening of palmar skin
•	Tx: palmar and digital fasciectomy; exercises
Foot problems and deformities
•	Corns – hyperkeratoses of small, circumscribed skin with central core
•	Calluses – diffuse hyperkeratoses over weight-prone areas
•	Ingrown toenail – spicule that forms from nail tissue that penetrates soft tissue around nail
•	Flatfoot – pes planus
Foot problems
•	Hammer toe – deformity of proximal and distal interphalangeal joint
•	Hallus valgus – lateral deviation of the great toe
•	Pes cavus – “high arch” (clawfoot), prominent metatarsal heads, can be related to diabetes
•	Morton’s Neuroma – swelling of 3rd branch of median plantar nerve
Nursing care
•	Conservative 
–	proper footwear with high toe box
–	Inserts
•	Surgical
–	Goals of care include adequate tissue perfusion, relief of pain, improved mobility, absence of infection
•	Check 5 P’s, dressings, elevation, ice

Metabolic Bone Disorders
•	Osteoporosis
–	Reduction in total bone mass and a change in bone structure which increases susceptibility to fracture.
–	Incidence of fractures increased along with disability
•	Http://odp.od.nih.gov.consensus/cons/111/111
•	(March 27-29, 2000, Vol. 17, No. 1)

Websites
•	http://www.osteo.org

Kyphosis
•	Gradual collapse of the vertebrae
•	Loss of height
•	Postural change results in relaxation of abdominal muscles
•	Pulmonary insufficiency
Osteoporosis - Risk Factors
•	Small framed nonobese white women
•	Inadequate supply of Ca and Vit. D
•	Smoking
•	No weight bearing or muscle activity
•	Cushing's syndrome
Risk factors
•	Medications affecting calcium
–	Corticosteroids, INH, heparin, furosemide, anticonvulsants, thyroid supplements affect body’s use and metabolism of calcium
–	The degree of osteoporosis is related to the duration of medication therapy

Osteoporosis - Risk Factors
continued
•	Alcohol Abuse
•	Liver failure
•	Renal Failure
•	Hyperthyroidism
•	Hyperparathyroidism

Diagnosis
•	Routine X-rays 
–	25-40% demineralization
•	Serum Calcium & Phosphate
•	Ultrasonic heel-density studies 
–	dx osteoporosis & predict fractures
•	Dual energy x-ray absorptiometry (DEXA)
–	for spine & hip bone mass

Diagnosis
•	Bone mineral density tests (BMD) of spine, wrist, and/or hip (most common fracture sites)
–	Detect low bone density before a fracture occurs
–	Confirm a diagnosis of osteoporosis if Fx present
–	Predict changes of fracturing in the future
–	Determine rate of bone loss
Medical Management
•	Diet,  Ca (citrate) & vit. D
•	Ca Supplement throughout life
•	ERT???????
•	Weight-bearing exercise
•	Medications
–	Calcitonin - nasal spray, SQ or IM
–	Fosamax (Alendronate) 
–	Evista (Raloxifene) – SERM
–	Actonel (Risedronate) 

Nursing Interventions
•	Teaching
–	prevention 
•	diet, activity, Ca supplements, ERT
–	treatment regimen
•	Meds
•	Drink adequate fluids
•	Understand GI side effects of meds
•	Pain Management
–	rest, good mattress, heat, back rubs, avoid twisting, assistive devices
Nursing Interventions
continued
•	Prevent Constipation
–	high fiber diet
–	fluids
–	stool softeners
–	** monitor intake & bowel sounds 
•	Ileus may develop if Vertebral collapse involves T10 to L2
•	Prevent Injury
–	activity, muscle strengthening, walking, correct body mechanics

Website
•	www.hiprotector.com

Osteomyelitis
•	Infection of the bone
–	extension of soft tissue infection
–	bone surgery
–	GSW
–	Blood borne spread from other sites of infection
•	S. aureus - 70%
•	Proteus sp.
•	Pseudomonas sp.
•	E. Coli

Clinical Manifestations
•	Chills, fever, rapid pulse, general malaise
•	Pain
–	constant pulsing pain
•	Swelling present
•	Area is warm
•	Tender to the touch

Diagnosis
•	X-rays
•	MRI
•	Bone Scan
•	Wound Culture
•	Blood Cultures
–	elevated sed. rate & leukocytes
•	with chronic osteomyelitis may be normal
Medical Management
•	Immobilize limb
•	Antibiotics **after culture**
•	Surgery
–	bone exposed & irrigated
–	infection drained
–	all dead and infected bone removed
–	wound drain device

Nursing Interventions
•	Pain Relief
•	Encourage self-care
•	Monitor circulation
•	Monitor infections process
–	temp, labs, drainage device, dressings
•	Diet
–	high protein
–	high Vit. C?????

Contusions, strains, sprains
•	Contusion – soft tissue injury due to blunt force resulting in ecchymosis, hematoma, pain, swelling, discoloration
•	Strain – muscle pull from overuse
•	Sprain – injury to ligament due to twisting 
–	Intervention: RICE (after 24 to 48 hours, may apply heat), immobilization, exercise
Fractures
•	Types
–	Complete (may be displaced)
–	Incomplete
–	Comminuted (fragments)
–	Closed (no break in skin)
–	Open (compound/complex)
•	Grade I clean wound < 1cm
•	Grade II larger wound w/o extensive soft tissue damage
•	Grade III highly contaminated w/ extensive soft tissue damage
Clinical Manifestations
(not all present with every Fx)
•	Muscle Spasm 
•	Pain
•	Loss of Function
•	Deformity
•	Shortening
•	Crepitus
•	Swelling & Discoloration
Early Complications
•	Shock
•	Fat embolism
•	Compartment syndrome – pressure increases within a muscle compartment
•	Thromboembolism
•	Pulmonary embolism
•	DIC
•	Infection
•	DVT

Clinical Manifestations of 
Fat Embolus - Lungs
•	May occur up to 1 week following Fx
•	**Sudden onset of symptoms**
–	hypoxia
–	tachypnea, wheezes, crackles
–	large amount of thick white sputum
–	precordial chest pain
–	Tachycardia
–	pale
–	mental status changes
Goal:  support respiratory system! Life threatening!
Late Complications of fractures
•	Delayed union – slow to heal
•	Nonunion – ends of bone fail to unite
•	Avascular necrosis – pain and limited movement
•	Reaction to internal fixation devices
•	Reflex sympathetic dystrophy (RSD) – severe burning pain, skin changes (see page 1839)

Emergency Management of a Closed Fracture
•	Immobilize the body part
–	Support body part if need to remove person from a vehicle
–	Apply padded splints over clothes – bandage to chest or place in sling
–	Bandage one leg to the other
–	Asses vascular status

Emergency Management
Open Fracture
•	Cover with clean (sterile) dressing
•	DO NOT TRY TO REDUCE THE FX
•	Splint for transport
•	Move extremity as little as possible
•	*Call EMS if cannot transport in car
Management of Fracture
•	Reduction (setting the bone)
–	Closed - manipulation & manual traction
•	cast
•	traction
–	Open - surgery often with internal fixation devices
–	Immobilization after reduction
–	Maintain & restore function
•	Refer to earlier lecture notes

Nursing Management
Closed Fracture
•	Watch for S & S of complications
Patient Teaching
–	Swelling & pain control
–	REPORT UNCONTROLLABLE PAIN
–	S & S of complications
–	Exercises
–	Nutrition
–	Medications
–	Crutch walking/transfer techniques

Nursing Management
Open Fracture
•	Prevent infection
•	Tetanus prophylaxis
•	IV antibiotics
•	Aseptic dressing changes
•	Nutrition
•	Patient Teaching
–	Complications, wound care, neurovascular checks, watch temp.

Review
•	Fractures of specific sites
–	Clavicle
–	Humeral neck
–	Elbow
–	Radial
–	Ulnar
–	Wrist
–	Pelvic
Gerontologic Considerations
•	Hip fracture contributor to death >75
–	Pneumonia
–	Sepsis
–	Presence of comorbidity
•	Cardiovascular
•	Peripheral Vascular
•	Pulmonary 
•	Renal
•	Endocrine / diabetes

Gerontologic Considerations
Continued
–	Altered mental status
•	Sleep deprivation
•	Pain / Medications
•	Malnutrition / Dehydration
•	Infection
•	Blood loss
–	Frail elderly

Hip Fractures
•	Two major types
–	Intracapsular
•	Fx at neck of femur
–	Extracapsular
•	Fx of the trochanteric region

** Fractures of the neck of the femur may compromise the blood supply to the head and neck of the femur. 
–		Non-union & avascular necrosis common

Care for older patient with hip fracture
•	Get patient in best condition for surgery
–	Traction while waiting
•	Open reduction & internal fixation (ORIF) – pins, nails, plates, screws
•	Total hip replacement (femoral head with a prosthesis - hemiarthroplasty

Nursing Care
•	Traction care - Pre-op
–	 Immobilize & muscle spasm prevention
•	Post-op
–	VS - hemorrhage
–	Neurovascular checks and edema 
–	Prevent complications
•	DVT (most common)
•	Pulmonary (deep breathing, spirometry)
•	Skin breakdown (no tape!!!!)
•	Incontinence
•	Infection
•	Altered mental status (pain)
Discomfort
•	Do not rely on self report at an indicator of pain and discomfort in the elderly confused patient
–	Reposition
–	Deep breathing
–	Pain medication frequently
–	Elimination
•	Website: Quick reference guide to hip fracture www.sign.ac.uk

Amputation
•	Causes
–	PVD  - most common
•	Diabetes often root cause of PVD
–	Gas gangrene
–	Trauma
–	Burns
–	Frostbite
–	Congenital deformities
–	Chronic osteomyelitis
–	Malignant tumor

Level of Amputation
•	A limb is amputated at the most distal point that will heal successfully.
–	Circulation
–	Functional usefulness
Staged Amputation
•	Used in gangrenous & infected limbs
–	Antibiotic
–	Guillotine amputation
–	Wound debrided and allowed to drain 
–	Further amputation with skin closure

Complications
•	Hemorrhage
•	Infection
•	Skin breakdown
•	Phantom limb pain
–	due to severing of nerves
Medical Management
•	Objective
–	Healing of the residual limb
•	non-painful
•	healthy skin on residual limb
–	Control of edema
•	Closed rigid cast
–	enables early  minimum weight-bearing
–	Elevate foot of bed, do not place residual limb on pillows to avoid flexion contracture of hip
•	Soft Dressing – w/ or w/o compression
–	enables viewing may also have a wound drainage device

Goals of nursing care
•	Relief of pain
•	Absence of altered sensory perceptions
•	Wound healing
•	Acceptance of altered body image
•	Resolution of grieving process
•	Independence in self-care
•	Restoration of physical mobility
•	Absence of complications
Nursing Management
•	Monitor carefully for:
–	Bleeding
•	hemorrhage or may develop slowly
–	Infection 
•	Note any change in drainage, temp, wbc
–	Skin breakdown
•	Watch for pressure or irritation from dressing

•	Relieve Pain 
–	change position
–	analgesics
–	light sand bag to prevent muscle spasms
•	Phantom pain may persist for months to years

•	Relieve Phantom Pain
–	Early rehab for wound desensitization
•	Kneading massage
–	TENS
–	Distraction
–	Beta blockers

•	Promote wound healing
–	Aseptic technique for dressing changes

**If the cast or ace wrap comes off, apply an elastic compression bandage to prevent edema formation

•	Enhance body image
–	Encourage to look at, feel, and care for residual limb (stump)
–	Assist to become independent in functioning
–	Establish a trusting relationship
•	Allow to express feelings
•	Offer information on local and national amputation support groups
•	Refer to local mental health specialists

•	Promote independence and self-care
–	Teach for activities of daily living (ADLs)
–	Encourage PT exercises
–	Encourage use of adaptive equipment
–	Encourage use of temporary prosthesis

•	Increase physical mobility
–	Encourage upper body muscle strengthening exercises
–	Encourage exercises of affected limb
•	prevents edema 
•	increases circulation
–	Prevent contractures of residual limb
•	Sitting in chair for short periods only
•	Move from side to side and lay prone
•	Assist with ambulation
–	Rehabilitation

Patient and family teaching
•	Teach patient and family
–	Correct method of bandaging
–	Skin inspection
–	Skin Care
–	Massage
•	circulation & decrease tenderness
–	Limb toughening in preparation for prosthesis
•	Push into pillow then firmer surface

Patient and family teaching

–	Residual limb will change shape
–	Prosthetic adjustments will be made
–	When not wearing prosthesis – will need to use a  compression bandage or shrinking sock to limit edema
–	Emphasize need to continue therapies
–	Continued need for good nutrition
–	Community agencies

Teaching
•	Instruct patient/family:
	*** to call the MD immediately if:
•	Uncontrolled pain
•	Signs of infection
•	Residual limb skin breakdown