COMMON MUSCULOSKELETAL

PROBLEMS
PAIN
• 5th Vital Sign
• Most clients with disease and traumatic conditions (fx, sprain, dislocation) of muscles, bones, joints
experience pain
• Highly subjective, individualized
• Defined:
o Subjective state which a variety of unpleasant sensations with wide range of depressing factors
may be experienced by the sufferer
o Strongest human hear after the fear of death
Tendon – Connects muscle to
• Pan can arise from emotional, psychological, culture influences, spiritual
bone
• Accepted as described by sufferer Ligaments – Connects bone to
bone
• Specific types of pain: Must have intact nerves to be
able to send impulses to move
o Bone Pain the bone
 Dull, deep ache, boring in nature
o Muscular Pain
 Soreness or aching, muscle cramps
o Fracture Pain
 Sharp, piercing
 Immobilization decreases pain – Will not have pain once immobile
o Bone Infection
 Steadily increase of pain – Difficult to manage – Dugs do not help
 Reports of increased pain after discharged
 DC Instructions: If you get home and use the pain meds the DR gave and
you still experience pain then you would need to call the DR because may
be infection.
o Joint Sprain / Strain
 Pain that increases with activity
 As long as they are off the extremity it is OK
o Nerve Root Pressure
 Radiating Pain

ASSESSMENT
• Body alignment
• Check pressure from appliances or hardware
• Location of pain – Localized indicate where Describe pain severe or tense (use scale)
• Anything onsets discomfort Describe movement if any
• Other locations of pain Identify if consistent or relief maintained by anything

MANAGING PAIN
• Relaxation techniques
o Behavioral therapy Diaphragmatic breathing
o Diversion Biofeedback
o Guided imagery Gentle message
• Rest
o Systemic Local
 • Medication
o Opioid: Morphine most effective
• Heat and Ice
• Positive nurse/client relationship

IMMOBILITY
• Causes physiological problems affecting majority of body systems
• Complications Related To Immobility:
o Respiratory (Pneumonia)
 TCDB, turn q2o, IS – Leading cause of death
 Nurses ultimate responsibility to see if app PT treatments are being done.
o Cardiovascular (Venous Pooling)
 Venous Stasis due to no muscle contractions
 DVT treat with Lovenox <100 platelets call MD
• May use Fragmen
 TED, Plexi Pulses, SCD – Teach importance of use.
 Monitor SE:
• Blood in urine
• Bleeding anywhere outside the norm
 Orthostatic HTN
 At risk for Emboli
o Musculoskeletal (Hypercalcium)
 Will become stiff with decrease inflexability
• Aging
• Prevent contractures
• Prevent muscle atrophy
• Prevent Osteoporosis
 Perform ROM if able
o Integumentary
 Breakdown risk
 Turn Q2hours
o Genitourinary
 Not able to empty bladder
 May have a foley and be at risk for infection
o Gastrointestinal
 Constipation
 Decrease in GI motility
 Nausea
o Metabolic
 Calcium will be increased if immobilized due to breakdown of calcium in
the bones. It is spilling into the blood serum.
 Osteoporosis
NEUROVASCULAR COMPROMISE
• Altered sensations or sensory disturbances frequent associations with musculoskeletal
problems
• Often experience paresthesia, numbness
• Loss of function can result from impaired nerves, circulatory structures

ASSESSMENT
• Wash Hands and Identify patient
• Abnormal sensations or numbness
• Experiencing Pain
o Begin and is it getting worse
• Color of part distal to affected area equal and is rapid capillary refill
o Compare with other hand (Remember: Injury may not be as pink as healthy
hand)
• Able to move part
o If forearm broken have them move hands and fingers (Flexion and extension)
o Motor compartment
• Blanching / Capillary refill
• Temperature
• Edema
o Edema present (Symptoms decrease by elevating affected area)
 Can lead to impairment of tissue perfusion
 Swelling occurs confined space – cast, muscle fascia, tissue sheath of
extremity leads to swelling until out of room leading to compartment
syndrome
• If swelling occurs the MD should be notified and get the cast
removed or whatever type bandage loosened or removed.
 Assess for Volkmans Contracture
• Presence of pulse and character
o Pulse distal to injury
o If you are unable to palpate pulse do rest of assessment and document “unable
to assess”
• Constrictive device or clothing
o Causes nerve vascular compression

THINGS THAT LEAD TO NEUROVASCULAR COMPROMISE

• Soft tissue swelling or broken leg
• Major concern; if not minimized or controlled can lead to impairment of tissue perfusion
o Sluggish Capillary refill
o Cool Skin
o Discoloration
• Swelling causes altered or diminished sensory and motor function
• Swelling in a confined space, may lead to compartment syndrome
o There may be a compromise but through a good assessment and elevating
extremities when we have to. Can remove an ace bandage. (nurse can do it)
o Swelling of a part of a confined space: Cast, Dressing, or muscle Fascia (thin
covering around the muscle – not elastic and will not move much)
Bi-valving cast: remove top cast relieve pressure cut two pieces
COMPARTMENT SYNDROME
• Can lead to loss of extremity
• Occurs with increase tissue pressure within closed anatomical space that
compromises circulation, tissue function (Calf, forearm) Peroneal Nerve
• Usually seen in leg muscles or forearm -Begins at groin and
continues to foot and great
• Can be caused by a blood clot toe.
-If Peroneal Nerve impaired
SIGNS AND SYMPTOMS OF COMPARTMENT SYNDROME the client will not be able to
Dorsal flex their Great Toe.
• Unrelieved pain
o May elevate and medicate for pain but they still have pain
o Throbbing unrelenting pain possible due to build up of metabolic waste
o Perfusion impaired leads to acidosis, metabolic waste build up.
o With increasing build up there is increase pain
• Excessive swelling with harder consistency
• Poor capillary refill
• Inability to move fingers or toes
• Positive Tinel’s sign
o Tingling sensation distal limbs brought on by tapping over injured nerve of
extremity such as in Carpal Tunnel Syndrome
• Elevated tissue pressure
• Still feel pulses
o Major arteries not occluded, muscles more affected

TREATMENT
• Bi-valve
o If a cast is involved MD would cut alongside of cast and remove top. May leave
bottom for support, the underlying pad may be to tight
• Fasciotomy
o Surgical excision fibrous membrane, covers and separates muscles, wound is
left open, covered with moist saline dsg.
o Volkman’s Contracture: Paralysis forearm due to compartment syndrome
• Minimize / Prevent edema
o Elevate extremities
o Ice packs
o Fasciotomy: Surgical excision of fibrous membrane covering separates muscle;
left open and pressure relieved immediately.
FAT EMBOLISM SYNDROME – FES
• Potentially serious and life threatening complication of long bone trauma (femur), blunt
trauma, intramedullary manipulations (rods) placement.

TWO THEORIES ABOUT FES

• Fat globules may move into blood because marrow pressure is greater than capillary
pressure

• Catecholomines elevated by stress reaction which mobilizes fatty acids and promotes
development of fat globules into blood stream.

• Either theory will combine with platelets that will from emboli that will block small
vessels that can supply blood to brain, lung, kidneys, and other major organs.

TRIAD FAT EMBOLISM SYNDROME

• Cardiopulmonary Changes

o Related to hypoxia caused by emboli blocking system, tachypnea, tachycardia

o Keep clients on constant O2 sats
o Can lead to life threatening problems:
 Pulmonary pressure increase
 Vessels block off
 Alveoli no longer got vital perfusion of blood
o Develop RDS – Respiratory Distress Syndrome

• Cerebral Dysfunction

o May have personality changes, agitated related to hypoxia will lead to delirium,
confusion, coma
o Petechial rash

• Respiratory Response

o Patients PO2 < 60mmHg

o Tachypnea Chest X- Ray will show “Snow Form Effect”
o Dyspnea
o Crackles and wheezes
 Due to pulmonary edema
o Precordial chest pain
o Cough
o Large amounts of thick white sputum
o Tachycardia
MEASURES TO REDUCE INCIDENCE OF FAT EMBOLI

• Immediate immobilization of fracture

• Respiratory monitoring
• Minimal fracture manipulation
• Adequate support of fractured bones during turning and positioning

MANAGEMENT / TREATMENT OF FES

• ABG’s
• Prevent shock
• Give O2 – To Increase the levels of O2 concentration
• Corticosteroids – Mask infection
o Tx inflammatory lung Tx Heparin (Lipolytic action) Prevents other clots forming
• Vasopressors
• Input and Output
• Analgesic
o Monitor respirations
 MUSCULOSKELETAL TRAUMATIC
INJURIES
CONTUSIONS
• Ecchymosis or Bruising
• Soft tissue injuries due to blunt force
• Small vessels rupture with bleeding into tissue
• Cause hematoma
• Pain, swelling, discoloration
• Control with intermitted application of cold. 15 min X many times

STRAINS
• Over use of muscles, stretching, stress
• Complaints of soreness, sudden pain
• Tendons are affected (connects muscle to bone)

SPRAINS
• Associated with stretched, tear or completely ruptured ligaments
o Involves a Ligament – Bone to bone – more serious because it surrounds a joint
• Rotate out leg – Soccer
• Avulsion fracture: pulls away part of bone

JOINT DISLOCATIONS
• Subluxation means out of joint
• When the articular surface of the bones forming the joint are no longer an anatomical contact
• Congenital, trauma, diseased joint
o Need plenty of rest Neuro checks Control pain
o Compression bandage Elevate

MANAGEMENT
• Neurovascular Checks
• R – Rest
o Prevents additional injury and promotes healing
• I – Ice
o Produces vasoconstriciton which decreases bleeding, edema and discomfort. Moist or
dry cold intermittently for 20-30 minutes during first 24-48 hours of injury.
• C- Compression
o Controls bleeding and reduces edema, provides physical support
• E – Elevation
o Controls swelling
• After acute inflammatory stage, heat may be applied intermittently for (15-30min.)
o Relieves muscle spasms
o Promotes vasodilatation, absorption, and repair

PREVENTION OF INJURIES
• Proper way to lift – Good body mechanics
• Bend at knees – Not back
• Carry loads close to body and not away
• Should not twist when reaching for something
• Don’t bend down or reach up high unnecessarily
• Watch where you walk
• Stretch
FRACTURES
• Disruption in continuity (breaking) of bone as a result of trauma or venous disease
• Process that weakens bone structure
• Defined according to extent o and location
• Weight greater can support
• Immobilization helps with pain the most

CAUSES
o Direct blow
o Crushing force
o Extreme muscle contracture
o Sudden twisting motion

PATHOPHYSIOLOGY
o Force applied to bone results in vasculature and neurological destruction.
o Blood vessels and nerves are torn and tendons are ruptured. WILL BLEED
o Bones broken with disruption of normal movement of bone
o Soft tissue swelling
o Hemorrhage of bone into muscles and joints
o May have dislocations, strains, sprains and injury to body organs are protected

TYPES OF FRACTURES
• When defining fractures look at the type and extent (Degree and Integrity)

Degree
• Complete
o Break across entire cross section of bone
 Often displaced: not in normal alignment anymore and must be complete
fracture for this to happen
• Incomplete
o Break through only part of cross section
 Example: Green stick in children

Integrity
• Closed / Simple
o Break in bone with no break in skin
• Open / Compound
o Air exposure; skin or mucus membrane wound extend to fractured bones
 Deep enough for bone to gat air – Exposed to environment
 Increased R/F Infection - Osteomyletis
• Antibiotics 4-6 weeks to prevent infection

GRADES OF FRACTURES
• I - Clean wound <1cm long
o Least extensive damage
• II - Larger wound with no extensive soft tissue damage
 • III - Most severe with extensive soft tissue damage
SPECIFIC TYPES OF FRACTURES
• Greenstick
o One side bone broken, other side just bent

• Transverse
o Break straight across bone – Complete fracture

• Oblique
o At an angle across the bone

• Spiral
o Bone has been twisted – Associated with abuse

• Comminuted
o Bone splatters or shatters 3 or more fragments
o Spinal cord injuries
o External Fixation
 Type devices commonly used to treat an extremity

• Depressed
o Depression of skull inward
o Facial

• Compression
o Usually back or neck
o Compression into spinal cord
o C5-C7
o Lower Lumbar region

• Pathological
o Disease process that weakens bone to where minor movements of any kind can
fracture bone
o Tumors, osteoporosis – already exist pathological

• Avulsion
o Ligaments torn at attachments that rip bone with it
o Usually a sports injury - Sprain

• Epiphyseal
o Seen in children
o Goes into growth plate
o May affect childs growth

• Impacted Hip Fx
o Head/Neck ball with femur into head/neck area
CLINICAL MANIFESTATIONS
• Pain
o Increase in severity unless fracture immobilized
o Muscle spasms: can cause pain – hurts worse than fracture – total disruption of bone so
muscle not aligned so spasms occur
• Loss of Function
o Cannot use like before
• False Motion
o Bone not rigid and straight so moves unnaturally
o Does not typically occur
• Deformity
o Compare opposite extremity
o Extremity rotates out
• Shortening
o Seen in long bone(Femur) or hip fracture
o The muscle wraping around the femur can cause the bone not to align thus causing
shortening.
o Cause misalignment
• Crepitation
o Rubbing bone fragments
o Physical exam done by MD
• Local Swelling and Dislocation
o Bruising
o Bleeding and Edema
o Common with fractures

TREATMENT
o Emergency – Immobilize body part unless airway is compromised
o With moving support extremity above and below fracture site
o Palpate distal pulses
o Open Fracture – Find something to clean and cover

GOALS OF TREATMENT Important!!!

• Reduction
o Getting things back to normal position – Realign bones
 Closed Reduction - No surgery, manipulation by MD – Manual traction
 Traction - a means of reduction by helping realign an extremity
 ORIF – Open reduction and Internal fixation is a surgical procedure
 Open or closed manipulation
• Immobilization
o Keep fragments aligned so healing can occur / Maintain reduction by keeping in place
 External: Any kind of support or bandage
 Internal: Inside screws, plates, rods, etc.
• Rehabilitation
o Promote and regain normal function and strengthen
Very Important
 Maintain reduction and immobilization
 Elevate extremities to decrease swelling
 Frequent neurovascular checks
 Control Pt anxiety and pain to help pt with participation
 Assist with ADL’s to increase independence
 Promote circulation
 • Ankel pump
 Try to medicate prior to PT
 Isometric exercises – Tensing mucles without moving extremity

TYPES OF TRACTION
• Buck’s Traction – Temporarily for Hip fracture
• Cast, Splints – Placed on lower calf and may be wrapped in ace bandage
o Do not touch weights; if complaint give extra pillow
o Purulent drainage noted at pin holes – start on antibiotics
o Surgery may be performed with open reduction / internal fixation (ORIF)
 Once surgery has been done they will not be in Bucks Traction
o Maintenance with Internal Devices
 Nails, screws, rods, plates, wires

NEUROVASCULAR CHECKS
• Circulation (Capillary refill)
Reassure and help with anxiety
• Assess for pain Teach isometric exercises and gradually resume
• Color activities
• Edema Flat bones and ends of long bones heal fast
• Sensation Sternum, pelvis, scapula
Hips take longer to heal
• Movement
• Pulses

FRACTURE HEALING STAGES

• Stage 1 - Inflammation and Swelling or Hematoma Formation
o Each end of bone
o Last 2-3 days
o Put on ice, give NSAIDS for inflammation
o Bleeding – leads to hematoma formation (weak fibrous network) – macrophages
arrive for healing

• Stage 2 - Cellular Proliferation

o Hematoma organizes within 5 days – Begin to create network
o Have osteoblast and fibroblast cells
o Purpose is to produce collagen for collagen matrix (Callus)

• Stage 3 - Callus Formation

o Hematoma and cellular proliferation grow together for callus (hardening bone)
o Takes 3-4 weeks but begins around the 6th day
o United by cartilage and fibrous tissues
o Degree stability with fragments locked together and cant easily move
o Callus gradually reabsorbed

• Stage 4 - Remodeling
 o Previous anatomical condition
o Further hardening may take years to complete
o Monitor with X-Ray

FACTORS AFFECTING FRACTURE HEALING

• Location of the bone involved
• Age
• Factors Enhancing Fracture Healing
o Immobilization of fracture fragments
o Sufficient blood supply
o Proper nutrition
o Exercise – Weight bearing for long bones
o Hormones
 Growth hormone, thyroid, calcitonin, vitamin D, Anabolic steroids
o Electric potential across fracture

• Factors Inhibiting Fracture Healing

o Extensive local trauma
o Bone loss
o Inadequate immobilization
o Inadequate nutrition and exercise
o Space/tissue between bone fragments
o Infection
o Local malignancy
o Metabolic bone disease
 Paget’s Disease
o Irradiated bone
 Radiation Necrosis
o Avascular necrosis
o Intra-Articular fracture
o Age
 Elderly heal more slowly
 Increased osteoclast cells (breaking down bone cells)
o Corticosteroids
 Inhibit repair rate by increasing Ca in the blood
 Anti-inflammatory agent, lengthens the 1st stage of healing
o Poor diet
COMPLICATIONS OF FRACTURES
• Shock
o With severe injuries or femur fracture
 Neurogenic
 Hypovolemic
• Due to loss of blood volume
• Nursing Action: Replace BV, Relieve Pain, Adequate
splinting/mobilization
• Fat Embolism Syndrome
o Occurs within 24-72 hours and can also occur up to 1 week after injury
 Seen more severe injuries
 Mostly men 20-30 y/o
 FIRST Symptom: Change in Mental status (mild agitation – Confusion – Delirium
– Coma)
 Tachycardia, SOB, Dyspnea, tachypnea, petechia on shoulder and conjunctiva
 First give increased concentration of O2
 Steroids
• Compartment Syndrome
o Swelling peaks at 24-48 hours after fracture
o Signs and Symptoms
 Deep Throbbing pain that doesn’t respond to morphine
 Muscle is hard
 Diminished capillary refill
 Cyanotic nail beds
 Paralysis
 Parasthsia
 Edema – Can’t get a pulse

• Other Complications
o Thromboembolism
o Infection
o DIC – Disseminated Intravascular Coagulation

• Delayed Complications
o Delayed Union
 Healing not at rate expected possible due to Steroids, diabetic, age

o Non Union
 Bone didn’t unite the way is should
o Avascular Necrosis
 Complete blood loss to bone or neck of femur
o Reaction to Internal Fixation Devices
 Left in permanently – a rare occurrence
 Treatment is by removal of hardware
o Osteomyelitis
 Infection of bone occur with our without surgery

• Emergency: Maintain airway, assess distal pulses

FRACTURES
• Clavicle most common in children
• Stress Fracture
o Overuse injury R/T sports
o Most common is fibula