Musculoskeletal Disorders
Strains and Sprains Injuries
A strain is excessive stretching of a muscle or tendon.
A sprain is excessive stretching of a ligament, sometimes resulting in a tear; it is usually caused
by a twisting motion.
These injuries are characterized by pain and swelling.
Nursing Considerations
Management of a strain consists of cold and heat application, exercise with activity limitations,
anti-inflammatory medications, and muscle relaxants.
Surgical repair may be required for a severe strain (ruptured muscle or tendon).
Management of a sprain involves rest, ice, and a compression bandage to reduce swelling and
provide joint support.
Casting may be required for a moderate sprain to allow the tear to heal.
Surgery may be necessary for severe ligament damage resulting from a sprain.
Rotator Cuff Injury
The tendons that connect the muscles and bones of the shoulder, better known as the rotator
cuff, sometimes sustain tears, usually as a result of trauma.
Such injuries are characterized by shoulder pain and inability to maintain abduction of the arm
at shoulder (drop-arm test).
Nursing Considerations
Management consists of nonsteroidal anti-inflammatory medications, physical therapy, sling
support, and ice/heat application.
Surgery may be required if medical management is unsuccessful or if the tear is complete.
Fracture
A fracture is a break in the continuity of a bone resulting from trauma, twisting as a result of
muscle spasm or indirect loss of leverage, or bone decalcification and disease that result in
osteopenia (soft bones).
Assessment findings include:
Pain or tenderness over the affected area
Decrease or loss of muscle strength or function
Obvious deformity
Erythema, edema, ecchymosis
Muscle spasm or neurovascular impairment
Pediatric Considerations
Fractures in children are usually a result of increased mobility and inadequate or immature
motor and cognitive skills.
Fractures in infancy are generally rare and warrant further investigation to rule out child abuse.
Nursing Considerations
Initial Care
Immobilize the affected extremity.
If the injury is a compound fracture, splint the extremity and cover the wound with a sterile
dressing.
Once a physician has examined the injury, reduction (closed or open), fixation (internal or
external), casting, traction or some combination thereof will likely be prescribed.
Fracture Treatment
Traction
Pulling force, applied in two directions, is used to reduce and immobilize a fracture.
Traction ensures proper bone alignment and reduces the incidence of muscle spasms.
Types include skin traction and skeletal traction.
Skin Traction
Traction is applied with the use of elastic bandages or adhesives in various configurations.
There are three main types of skin traction: Cervical, Buck, and Pelvic.
Skeletal Traction
Tension is mechanically applied to the bone with the use of pins, wires, or tongs to ensure good
approximation and healing of fracture edges.
Cervical tongs and halo devices are also forms of skeletal traction.
Cervical (Head Halter) Skin Traction
This type of traction is used to relieve muscle spasms and compression in the upper extremities
and neck.
A head halter and a chin pad are used to attach the traction.
Use powder to protect the ears from friction rub.
Position the client with the head of the bed elevated 30 to 40 degrees and attach the weights to
a pulley system over the head of the bed.
Buck Traction
This type of traction is used to alleviate muscle spasms; a straight pull on the limb with the use
of weights immobilizes the lower extremity and relieves the spasms.
A boot appliance is applied to attach to the traction.
Elevate the foot of the bed to provide traction.
Pelvic Skin Traction
This type of traction is used to relieve low back, hip, or leg pain and to reduce the incidence of
muscle spasm.
Apply the device (belt) snugly over the pelvis and iliac crest and attach the belt to the ropes
holding the weights.
Use prescribed measures to prevent the client from slipping down in bed.
Nursing Considerations for Tractions
Maintain proper body alignment.
Ensure that traction weights hang freely and do not touch the floor.
Do not remove or lift the weights without a physician's prescription.
Ensure that pulleys are not obstructed and that the ropes in the pulleys move freely.
Tie knots in the ropes to prevent slipping.
Check the ropes for fraying.
Skin Traction
Applied by using elastic bandages, belts, foam boot, or sling, depending on the type of traction.
Avoid applying lotion under the application device to prevent slipping of the device.
Monitor skin for breakdown from the application device.
Skeletal Traction
Monitor color, motion, and sensation in the affected extremity.
Monitor insertion sites for infection (redness, swelling, and drainage)
Provide care for the insertion site as prescribed.
Casts
Plaster or fiberglass is used to provide immobilization of a bone or joint after a fracture or other injury.
Nursing Considerations
Keep the cast and extremity elevated.
Allow 24 to 48 hours for a wet cast to dry; synthetic casts dry in 20 minutes.
Handle a wet cast with the palms until dry.
Monitor the extremity for circulatory impairment (e.g., pain, swelling, discoloration, tingling,
numbness, coolness, diminished pulse).
Notify the physician immediately if circulatory compromise occurs and prepare for bivalving
(cutting of the cast) if circulatory impairment occurs.
Nursing Considerations
“Petal” the cast; maintain smooth edges to prevent crumbling.
Monitor the client's temperature and be alert for the presence of a foul odor, which may
indicate infection.
Monitor the cast for wet spots, which may indicate a need for drying or the presence of
drainage under the cast.
If an open draining area exists on an affected extremity, a window will be cut into the cast by
the physician to permit treatment and monitoring.
Instruct the client not to stick objects inside the cast.
Teach the client to keep the cast clean and dry.
Instruct the client in isometric exercises to prevent muscle atrophy.
Fat Embolism
A fat embolism originates in bone marrow after a fracture.
Clients with long-bone fractures (hip, femur) are at greatest risk.
Embolism usually occurs within 48 hours of injury.
Assessment findings include:
Findings indicative of pulmonary embolism
Restlessness
Mental status changes
Tachycardia, tachypnea, hypotension
Hypoxemia, dyspnea
Petechial rash over the upper chest and neck
Nursing Considerations
Notify the physician immediately if an embolism is suspected.
Treat symptoms as prescribed (e.g., administration of oxygen) to prevent respiratory failure and
death.
Compartment Syndrome
Compartment syndrome is increased pressure within one or more compartments that causes
massive compromise of circulation to an area, leading to decreased perfusion and tissue anoxia.
Within 4 to 6 hours of onset, neuromuscular damage is irreversible.
Assessment findings include:
Unrelieved or increased pain and swelling
Pale, dusky, or edematous tissue distal to the involved area
Pain with passive movement
Loss of sensation (paresthesia)
Pulselessness (a late sign)
Nursing Considerations
Elevate the affected site and apply ice as prescribed to prevent swelling.
Monitor for signs of compartment syndrome and inform the client to notify the nurse
immediately if pain or paresthesia develops.
Notify the physician immediately if compartment syndrome is suspected.
Infection and Osteomyelitis
These complications are caused by the introduction of organisms into bones, leading to localized
bone infection.
Assessment findings include:
Tachycardia and fever (usually above 101° F)
Erythema and pain in the area surrounding the infection
Leukocytosis (WBCs) and increased erythrocyte sedimentation rate
Nursing Considerations
Notify the physician.
Prepare to initiate aggressive IV antibiotic therapy, usually Vancomycin.
Hyperbaric oxygen therapy may be prescribed.
Surgery and bone grafting may be necessary.
Hip Fracture
Hip fractures may be intracapsular (in which the femoral head is broken within the joint
capsule) and extracapsular (fracture is outside the joint capsule).
Signs and symptoms include severe pain at the fracture site, inability to move the affected leg
voluntarily, and shortening and external rotation of the leg.
Treatment varies, depending on the location and type of fracture.
Skin traction (Buck) or balanced suspension traction may be applied before surgery to
immobilize the extremity and help prevent pain and spasms.
Treatment may consist of total hip replacement or internal fixation (ORIF) with replacement of
the femoral head with a prosthesis.
Nursing Considerations
Maintain the leg and hip in proper alignment and prevent internal or external rotation; avoid
extreme hip flexion.
Turn the client onto the unaffected side; only turn the client onto the affected side as prescribed
by physician.
Elevate the head of the bed 30 to 45 degrees for meals only.
Avoid weight bearing on the affected leg as prescribed; instruct the client in the use of a walker
to avoid weight bearing and always refer to the physician's prescriptions.
Keep the affected leg extended, supported, and elevated when getting the client out of bed.
Avoid hip flexion greater than 90 degrees and avoid low chairs when the client is out of bed.
Monitor the wound for signs of infection or hemorrhage.
Nursing Considerations
Conduct a neurovascular assessment of the affected extremity, checking color, pulses, capillary
refill, movement, and sensation.
Maintain the compression of the Hemovac or Jackson-Pratt drain to facilitate wound drainage.
Monitor and record the drainage amount, which should decrease consistently by about 80 mL
every 8 hours until 48 hours after surgery.
Use antiembolism stockings or sequential compression stockings; encourage the client to flex
and extend the feet to reduce the risk of deep vein thrombosis.
Instruct the client to avoid crossing the legs and activities that require bending over.
Physical therapy will be instituted after surgery, with progressive ambulation as prescribed by
the physician.
Total Knee Replacement
A device is implanted as a substitute for the femoral condyles and tibial joint surfaces.
Nursing Considerations
Monitor surgical incision for drainage and infection.
Begin continuous passive motion 24 to 48 hours postoperatively as prescribed to exercise the
knee and provide moderate flexion and extension.
Administer analgesics before continuous passive motion to decrease pain.
Prepare the client for out of bed activities as prescribed; have the client avoid leg dangling.
Avoid weight bearing and instruct the client in the use of the prescribed assistive device, such
as a walker.
Leg Amputation
An entire leg or part of the leg is removed surgically.
Amputation may be necessary if the blood supply to the part is affected and unable to provide
the part with sufficient oxygen and nutrients; this leads to the death of tissues.
Examples of conditions that can result in death of tissues include frostbite or peripheral arterial
disease.
Nursing Considerations
Monitor the wound for signs of infection and hemorrhage; mark bleeding and drainage on the
dressing and keep a surgical tourniquet at the bedside if prescribed.
Watch for and take measures to prevent contracture.
Evaluate the client for phantom limb sensation and pain; explain the phenomenon to the client
and provide medication as prescribed.
Check the physician's prescriptions regarding positioning.
If prescribed, during the first 24 hours, elevate the foot of the bed to reduce edema, then keep
the bed flat to prevent hip flexion contractures; do not elevate the residual limb itself using a
pillow, because elevation can cause flexion contracture of the hip joint.
Between 24 and 48 hours after surgery, position the client prone, if prescribed, to stretch the
muscles and prevent flexion contracture of the hip; while the client is prone, place a pillow
under the abdomen and residual limb and keep the legs close together to prevent abduction.
Maintain surgical application of a dressing, elastic compression wrap, or elastic stump shrinker
as prescribed to reduce swelling, minimize pain, and mold the residual limb in preparation for a
prosthesis.
Massage the skin toward the suture line to mobilize scar and prevent its adherence to
underlying bone.
Prepare the limb for a prosthesis and instruct the client in progressive resistive techniques by
gently pushing the residual limb against pillows and progressing to firmer surfaces.
Discuss the procedure used to fit the residual limb for a prosthesis.
Instruct the client in crutch walking.
Teach the client to maintain range of motion.
Rheumatoid Arthritis
This chronic systemic inflammatory disease may be related to a combination of environmental
and genetic factors.
Rheumatoid arthritis results in destruction of connective tissue and synovial membrane within
the joints, leading to permanent deformity.
Vasculitis can impede blood flow, leading to organ or organ system malfunction and failure
caused by tissue ischemia.
Pediatric Considerations
In children, the disease is known as juvenile idiopathic arthritis (JIA); it is more common in girls
than in boys.
There is no definitive test with which to diagnosis JIA.
Surgical intervention may be implemented when the child has problems with joint contracture
and unequal growth of extremities.
Iridocyclitis (inflammation of the iris and ciliary body) may occur.
Assessment Findings
Inflammation, tenderness, and stiffness of joints
Moderate to severe pain and morning stiffness lasting longer than 30 minutes
Joint deformities, including rheumatoid nodules, Boutonniere deformity, and swan-neck
deformity
Muscle atrophy and decreased range of motion
Spongy, soft feeling in joints
Low-grade temperature, fatigue, weakness
Anorexia, weight loss, anemia
Increased sedimentation rate and positive results on testing for rheumatoid factor
Radiographic findings indicating joint deterioration
Inflammation on synovial tissue biopsy
Nursing Considerations
Pain
A combination of pharmacological therapies includes nonsteroidal anti-inflammatory drugs
(NSAIDs), disease-modifying antirheumatic drugs (DMARDs), and glucocorticoids may be
prescribed.
Physical Mobility
Perform range-of-motion exercises to maintain joint motion and strengthen muscles.
Balance rest and activity.
The client should wear splints during acute inflammation to help prevent deformity.
Apply heat or cold therapy as prescribed to joints.
Encourage a consistent exercise program.
Use joint-protecting devices.
Teach the client to avoid bearing weight on inflamed joints.
Instruct the client to sit in a chair with a high, straight back.
Instruct the client to use only a small pillow when lying down.
Osteoarthritis (Degenerative Joint Disease)
This type of arthritis is marked by progressive deterioration of the articular cartilage.
It affects the weight-bearing joints and other joints that sustain the greatest stress (e.g., hips,
knees, lower vertebral column, hands).
Risk factors include trauma, aging, obesity, genetic changes, and smoking.
Assessment findings:
Early in the disease process, joint pain diminishes after rest and intensifies after activity.
As the disease progresses, pain occurs with slight motion or even at rest.
Symptoms are aggravated by temperature and humidity changes.
Skeletal muscle atrophy is seen. Joint enlargement, crepitus, and limited range of
motion may be noted.
Heberden nodes (formed on the joints closest to the fingertips) or Bouchard nodes
(formed on the middle joints of the fingers) may be present.
The client may have difficulty getting up after prolonged sitting.
Spinal compression is manifested as radiating pain, stiffness, and muscle spasms in one
or both extremities.
Osteoporosis
This metabolic disease is characterized by bone demineralization with loss of calcium and
phosphorus salts leading to the development of fragile bones and an increased risk for fractures.
The client may be asymptomatic until the bones become fragile.
Assessment findings include:
Back pain after lifting, bending, or stooping
Back pain that worsens with palpation
Pelvic or hip pain, especially while bearing weight
Problems with balance
Decline in height resulting from vertebral compression
Kyphosis of the dorsal spine, leading to “dowager’s hump” (backward curvature of the
cervical spine)
Radiographic findings indicating degeneration of the lower thorax and lumbar vertebrae
Nursing Considerations
Take steps to prevent injury in the client's environment.
Move the client gently during turning and repositioning.
Instruct the client in the use of good body mechanics.
Instruct the client in exercises to strengthen abdominal and back muscles to improve posture
and provide support for the spine.
Instruct the client to avoid bending over or twisting the body.
Instruct the client to eat a diet high in protein, calcium, vitamins C and D, and iron.
Instruct the client to avoid alcohol and coffee.
Instruct the client to maintain adequate fluid intake to help prevent the development of renal
calculi.
Administer medications (e.g., calcium and vitamin D supplementation and bisphosphonates) as
prescribed to promote bone strength and decrease pain.
Gout
In this systemic disease, urate crystals are deposited in joints and other body tissues in four
phases: asymptomatic, acute, intermittent, and chronic.
Asymptomatic: Client has no symptoms but serum uric acid level is elevated.
Acute: Client has excruciating pain and inflammation of one or more small joints,
especially the great toe.
Intermittent: Client has intermittent periods without symptoms between acute attacks.
Chronic: Results from repeated episodes of acute gout and the deposition of urate
crystals under the skin and within major organs, such as the kidneys, leading to organ
dysfunction.
Assessment findings include:
Swelling and inflammation of joints resulting in excruciating pain
Tophi (hard, fairly large, irregularly shaped deposits in the skin).
Pruritus as a result of the presence of urate crystals in the skin
An increased level of uric acid
Nursing Considerations
Provide a low-purine diet; instruct the client to avoid organ meats, wines, and aged cheeses.
Encourage a high fluid intake—2000 mL/day—to help prevent calculus formation.
Encourage a weight-reduction diet, if one is needed.
Instruct the client to avoid alcohol and starvation diets, which may precipitate gout attacks.
Provide bed rest, with the affected extremity elevated and the joint in mild flexion during acute
attacks.
Provide heat or cold for local treatments of affected joint and medications (analgesics and
uricosurics) as prescribed.
How to Use Crutches
Make Sure the Crutches Fit
1. Stand straight.
2. Place the top of the crutches under your arms.
3. Put the ends 12 to 20 cm (5 to 8 inches) to the side of your feet.
The crutches are the correct length if there is a 2 to 3 finger space between the top of the crutch
pad and your armpit.
The hand grip should be at wrist level when your arm is hanging by your side. Your elbows are
slightly bent as you push down on the handgrips.
Remember:
Support your weight with the hand grips, not the crutch pads under your armpits.
Your weight bearing order is:
Non Weight No body weight on your injured leg. Keep your injured
Bearing leg off the floor at all times.
Able to touch your toe down to floor, for balance only.
Feather Weight Don’t put any weight on the injured leg. Imagine
Bearing having an egg under your foot that you don’t want to
crush.
Partial Weight Able to put up to half of your weight through your
Bearing injured leg.
Weight Bearing Can take most or all of your weight through your
as Tolerated injured leg, as pain or strength allows.
Full Weight
Able to take full weight through your injured leg.
Bearing
Walking
1. Put the crutches ahead and to the sides of your feet for the best balance.
2. Move both crutches forward at the same time.
3. Move the injured leg forward between the crutches.
4. Gently squeeze each crutch into your ribs. Put weight through your hands and keep your elbows
straight.
5. Move your uninjured (good) leg ahead of the crutches, or to between the crutches for better
balance.
Repeat these steps to keep walking—crutches, injured leg, good leg.
Note: Don’t lean on the crutch top
Sitting
1. Step backwards until the back of your good leg touches the front of the chair. Keep your injured leg
forward
2. Keeping your weight on the good leg, take the crutches from under your arms. Transfer 1 crutch and
hold both crutches by the hand grips in 1 hand.
3. Lean forward and bend your good knee. Hold the armrest of the chair (or chair seat) with the other
hand.
4. Sit down slowly. Keep your crutches next to the chair.
Standing
1. Make sure the chair is steady before you try to stand.
2. Move forward to the edge of the chair so your good foot is flat on the floor. Slide your injured leg
forward and follow the weight bearing order.
3. Hold the crutches by the handgrips in one hand. Hold the armrest of the chair (or chair seat) with
the other hand.
4. Stand up, taking weight through your good leg. Transfer the crutches under your arms after you get
your balance.
Steps and Stairs
Use the handrail if there is one. Put both crutches under the arm away from the railing (or hold as in the
diagram below) and use both crutches as one.
Hold the railing with your free hand and stand close to the rail.
On stairs without a railing: follow the instructions for going up and down stairs, except leave one crutch
under each arm (as for walking).
Going Up Stairs
1. Stand close to the bottom step.
2. Put your good leg up first.
3. Lean forward taking your weight on your good leg.
4. Lift your injured leg and crutches up.
5. Climb one stair at a time. If someone is helping you, have them stand behind and to the side of you.
Going Down Stairs
1. Stand close to the edge of the top step.
2. Move your hand down the railing.
3. Lower your crutches, then your injured leg, to the next step.
4. Step down with your good leg.
5. Step down one step at a time. If someone is helping you, have them stand in front and to the side of
you.
Using One Crutch
Use the crutch in the hand opposite to the injured leg. This gives you better support and helps you walk
with more normal movements.
Using a 4-Point Gait-Style
Only use this method if your therapist has shown you. You’ll be shown either partial weight bearing or
weight-bearing as tolerated.
Follow these steps to walk:
1. Move your right crutch forward
2. Move your left foot forward so it’s even with the right crutch.
3. Move your left crutch forward.
4. Move your right leg forward so it’s even with the left crutch.
Repeat these steps to keep walking.
Note: If you start with your left crutch, reverse the above order.
Follow the same instructions for crutch walking to:
sit down
stand up
go up and down stairs
Safety Tips
Make sure that your crutches have rubber tips, padded shoulder pieces and hand grips. These should be
checked regularly, kept in good condition, and replaced as needed.
It’s important to use your crutches correctly. If you feel any numbness or tingling below your armpits or
in your upper arms, you’re probably not using the crutches as you were shown.
Never stand on your injured leg unless your doctor says you can. Always follow your doctor’s order
about the weight-bearing status of the injured leg.
Always wear good supportive shoes or bare feet rather than slippers.
Use a waist pouch or a backpack as a purse.
Watch for wet surfaces. Use small steps if you must walk on a wet or slippery surface.
Be careful when walking on uneven ground. Ask for help if you need it.
Remove loose mats and rugs, electric cords, and cables—these could cause you to trip or slip.
