musculoskeletal system disorders

01/24/2025
 Musculoskeletal terms
• Skeletal and Muscular systems - works together to allow

movement
• Ligaments - attach bone to bone

• Tendons- attach Muscle to bone via

• Skeletal muscles - produce movement by bending the skeleton at

movable joints. Muscles work in antagonistic pairs.

• Skeleton - provides structure of body and

•01/24/2025
Muscles - allow skeleton mobility – pull by contraction of muscle.
 Musculoskeletal system

• The musculoskeletal system includes the bones, joints, muscles,

tendons, ligaments, and bursae of the body.
• The functions of these components are highly integrated

• Diseases and injuries that involve the musculoskeletal system are

commonly implicated in disability and death
• Musculoskeletal diseases and injuries can significantly affect overall
productivity, independence, and quality of life in people of all ages.

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 Function of musculoskeletal system

• The musculoskeletal system provides protection for vital organs,

• framework to support body structures; and makes mobility possible.

• Muscles and tendons hold the bones together and joints allow the
body to move.
• They also move to produce heat that helps maintain body temperature.

• Movement facilitates the return of deoxygenated blood to the right

side of the heart

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 Musculoskeletal Disorders

 Caring for patients with soft tissue injuries

AND
 Caring for patients with joint & connective tissue disorders

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 Learning Objectives

At the end of this session you will be able to:-

• Define sprain, strain & dislocation

• Identify the sign & symptoms of soft tissue injuries

• Describe the general management of soft tissue injuries

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 I/ Soft tissue injuries
 Sprain

 Strain

 Dislocation

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 Sprain
is an injury to the ligaments and tendons that surround a joint .

Caused by a wrenching or twisting motion

There are three grades of sprain
A/ First degree sprain:-
Caused by tearing a few ligament fibers
B/ Second degree sprain:- partial tearing of the ligament. It results in increased
edema, tenderness,pain with motion, joint instability, and partial loss of normal
joint function
C/ Third degree sprain:- Occurs when a ligament is completely torn
It is manifested by severe pain, tenderness, Increased edema, and abnormal joint
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motion
 S & Sx of Sprain
• Pain

• Tenderness

• Swelling

• Discoloration

DX
• Complete Hx taking

• P/E

• X-ray
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 General management of sprain
Mnemonic “ A RICE”
A= Anti pain
R = Rest
- Prevent additional injury and promote healing
I = Immobilize
- Applying an elastic compressive bandage to control bleeding, reduce
edema and provide support for injured tissue.
– Monitoring the neuromuscular status
– Surgical repair or cast application
– Splinting may be used to prevent injury
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 General management of sprain---
C = Cold
• Apply intermittently for 20-30 minutes during the first 24-48 hours after
injury produces vasoconstriction, which decrease bleeding, edema and
discomfort.
– After 24-48 hours after injury heat may be applied intermittently (for 15-30
minutes, 4 times a day) to relieve muscle spasm and to promote
vasodilatation, absorption and repair
E = Elevate the part above the level of the heart
Elevation control swelling
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 STRAIN

• Strains are microscopic, incomplete muscle tears with some bleeding in to

the tissue.
• Is a "pulled muscle or tendon" due to overuse, overstretching or excessive

stress.
• There are three grades of strain

A/ First degree strain:- Caused by tearing a few muscle fibers

B/ Second degree strain:-Caused by tearing more muscle fibers

C/ Third degree strain:- severe muscle or tendon stretching with rupturing and

tearing of the involved tissue

The most severe type

Significant pain , muscle spasm, eccymosis, edema & loss of function.

 Its management is similar to sprain
-S&SX
-DX Similar to sprain
-Mgt

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 JOINT DISLOCATION
 Is a displacement of a bone end from the joint
 A subluxation is a partial dislocation of the articulating surfaces

Dislocation may be:-

 Traumatic due to injury in which the joint is disrupted by force Congenital
(present at birth, due to some mal development) hip
 Spontaneous or pathologic due to disease at articular or periarticular structures

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 THE S/SX OF TRAUMATIC DISLOCATION
• Pain upon movement

• Change in contour of joints (swelling)

• Change in the length of extremity

• Loss of normal mobility

• Change in the axis of the dislocated bones

( Obvious deformity)
• Tenderness to touch

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 Management of dislocation

Goal of treatment
 Relieve pain

 Reduce dislocation

 Prevent further dislocations

General management

- Apply splint & immobilize the part

- Elevate the part

- Anti- pain

- Prevent complications

- Refer for surgical repair

• Assess neurovascular status before and after reduction, including strength of the pulse, capillary

refill time, sensation, movement, pain, and color of the skin

 Learning Objectives

At the end of this lesson you will be able to:-

• Define osteoarthritis, RA & osteomyelitis

• Compare & contrast osteoarthritis & RA

 Describe the general management of joint and connective tissue disorders (

osteoarthritis, RA ,osteomyelitis, osteoporosis Rhabdomyolysis, systemic
lupus erythematus & gout)

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 II/ Joint& Connective Tissue D/Os
 Osteoartritis

 Rheumatoid Arhtritis

 Osteomyelitis

 Osteoporosis

 Gout

 Fracture

 Traction

 Amputation
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 Arthritis
• Inflammation of joints and the
breakdown of cartilage, which
normally protects the joint,
allowing for smooth movement
• 1 in 3 adult Americans suffer from
some form of arthritis
• Affects about twice as many
women as men

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 Cont’d...
– Chronic forms arthritis include

• Osteoarthritis,

• Rheumatoid arthritis, and

• Gouty arthritis.

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 Clinical Forms of Arthritis
1. Osteoarthritis
• Osteoarthritis is also known as degenerative joint disease which is the
most common and frequent disabling joint disease.
– Most common chronic arthritis

– Probably related to normal aging processes

– Most common type of arthritis; “wear and tear” arthritis;

– affects the articular cartilages, causing them to soften, fray, crack, and
erode
– It is non inflammatory- Only cartilage is affected, not synovial
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membrane.
 Cont’d...
– Deterioration of cartilage produces bone spurs- Restricts
movement
– Pain upon awakening—disappears with movement

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 Cont’d...
Causes and types
• Osteoarthritis can be primary or secondary
– OA is results from a series of
• Cellular, biochemical, and biomechanical factors affecting
cartilage, subchondrial bone and soft tissues of diarthrodial
joint.
1. Primary /Idiopathic/ OA:-
– The cause is Unknown but
– Genetic factors and allergy is the most common predisposing
factors
– It is not inflammatory joint disease
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 Cont’d...
2. Secondary OA
• Caused by any conditions that damages cartilage subjects the joints to chronic
stress, causes joint instability such as:
– Previous joint infection
– Inflammation
– Trauma , surgery
– Certain occupation or activities
– Endocrine disorder (acromegally or hyperparathyroidism
– Skeletal deformity
– Hemophilia
Other Predisposing factors to OA:
– Age
– Weight
– genetic indisposition
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 Cont’d...
Clinical Manifestations
– Pain – worse with weight breaking and improve with rest
– Swelling and joint enlargement due to inflammatory exudates,
blood, fragments of osteophaytes entering synovial cavity
– Decreased range of motion
– Muscular atrophy due to disuse, joint instability
– Criptus, Joint stiffness
Dx-
– Hx taking
– Physical examination
– X-ray
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 Cont’d...
Management (Medical and Nursing care)
The objective of management includes:
– Relief pain
– Restoration of joint functions
– Prevention of disability and complication
Pharmacological Rx:
– Acetaminophen
– NSAID
– Analgesics
– Intra articular steroid injection

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 Cont’d...
Non-pharmacological mgt
– Weight reduction
– Heat application to improve correlation and relief pain relaxing
the muscles before exercise
– Application of cold after exercise to decrease pain and swelling
– Exercise and prevent injuries
– Surgical management like
– Arthrodesis or joint fusion
– Joint replacement

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 Clinical Forms of Arthritis cont’d…
2. Rheumatoid arthritis
• Rheumatoid arthritis – is a chronic ,systemic disease
characterised by recurrent inflammation of the diarthrodial joint
and surrounding soft tissue .
• RA is characterized by periods of remission & exacerbation.
– Remission-period when disease symptoms are reduced or
absent.
– Exacerbation –a period when disease symptoms occur or
increased.
• An autoimmune disease (the immune system attacks its own
tissues)
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 RA cont’d...
 Symptoms begin with bilateral inflammation of certain joints
 Often leads to deformities
 Cartilage attacked
 Inflammation, swelling & pain
 Final step is fusion in joint

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 RA cont’d...
– Occurs in around 3% of women and 1% of men
– Caused by a cell-mediated (T-cell) autoimmune response
– Rheumatoid factor positive in 80%
– Often starts with symmetrical disease affecting small joints of
the hands and feet

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 RA cont’d...
Etiology
• Unknown
• Predisposing includes
– Autoimmune reaction (a condition in w/c the body produces an
immune response against its own tissue)
– Genetic predisposition
– Infection – viral & bacterial
– Other factors such as metabolic ,nutritional & environmental
factors.

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 RA cont’d...
The key pathophysiologic features include
– Stage -1: Unknown etiologic factor initiates joint inflammation with
swelling of the synovial lining membrane & production of excess
synovial fluid.
– Stage-2: Pannus formation (Proliferation of synovial membrane)
– Stage-3: Pannus destroys the cartilage & erodes the bones (Erosion
of articular cartilage and Erosion of subchondral bone ) w/c results in
loss of articular surfaces & loss of joint motion ,malignant &
deformity
– Stage-4 :As fibrous tissue calcifies bony ankylosis may result.
(Ankylosis –immobility of a joint)
– Pannus: is a condition in which a layer of vascular fibrous tissue covers an
organ.
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 RA cont’d...
Clinical Features
• Early symptoms include:
• Fatigue
• Weight loss
• Fever
• Malaise
• Morning stiffness of joints
• Pain at rest and with movement
• Edematous, Erythemataus “baggy” joint

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 RA cont’d...
• Late symptoms include
• Color changes of digitalis (bluish, rubor, pallor)
• Muscle weakness, atrophy
• Joint deformity
• Decreased joint mobility , Contractures
• Subluxation or complete dislocation
• Increasing pain
• Formation of rheumatoid nodules are aggregate of
inflammatory cues

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 RA cont’d...
• Extra- articular manifestations of RA:
– Skin – subcutaneous nodules
– Eyes – scleritis, iritis
– Lungs – interstitial lung disease, pleural effusion
– Heart – myocarditis
– Kidneys – nephritis
– Amyloid – lungs, kidneys, heart, bowel
– Compression and vascular neuritis

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 RA cont’d...
• Problems in the hand and wrist caused by RA:
– Radial deviation of the wrist
– Extensor tendon ruptures
– Ulnar deviation metacarpophalangeal joints
– deformity of the thumb
– deformity of the fingers
– Swan neck deformities
– Carpal tunnel syndrome

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 RA cont’d...
• Virtually all joints can be involved, but most commonly involved
joints are:
• Hand joints, wrists , Ankles, Elbow and knees
• Most often it evolves bilaterally or symmetrical pattern

Dx
– Clinical Features
– Lab finding ESR increased, RBCs decreased
– X-ray study
– Biopsy
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 RA cont’d...
Diagnostic Criteria:
– Morning stiffness > 1 hours and at least 6 weeks duration
– Soft tissue swelling of 3 or more joints for at least 6 weeks
– Swelling of wrist, metacarpophalangeal or proximal interphalangeal
joints at least 6wks
– Symmetric soft tissue swelling
– Rheumatoid nodules
– Positive serum rheumatoid factors
– Radiographic changes (bone erosion or decalcification) in hand or
wrist joint
– N.B four of these criteria are necessary to diagnosis RA.
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 RA cont’d...
Management
Pharmacological Rx:
– NSAIDS like aspirin – inhibiting prostaglandin synthesis,
analgesics, antipyretic
– Corticosteroids like prednisone (oral), hydrocortisone (intra
articular)
– Disease – modifying antirheumatic drugs (DMARD) like-
chloquine phosphate 150-300mg po, or methotrexate 7.5 mg
p.o weekly or
– Azathioprine 50-coonry/day P.O
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 RA cont’d...
Nondrug mgt /nursing management
• Health education about balance of rest and exercise
• Monitor drug side effects
• Give the prescribed drugs
• Encourage physiotherapy and occupational therapy
• Teach the pt about application of heat and cold
Surgical mgt like:
• Arthroplasty, synovectomy, tendon transplants.

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 Cont’d...

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 Clinical Forms of Arthritis cont’d…
3. Gouty arthritis/Gout
– Gout is a clinical syndrome resulting from the deposition of urate
crystals in the synovial fluid, joints or articular cartilage
– Inflammation of joints is caused by a deposition of uric acid
crystals from the blood
– Results from prolong hyperuricemia (elevated serum uric acid)
caused by problems in the synthesis of purines or by poor renal
excretion of uric acid

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 Cont’d...
N.B
• It Primary affects adult men.
• Postmenopausal women
• Uric crystals build up in joints—pain
- waste products of DNA & RNA metabolism
- builds up in blood
- deposited in cartilage causing inflammation and swelling
• Bones fuse
• Middle-aged men with abnormal gene
• Can usually be controlled with diet

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 Cont’d...
Causes
• It can be primary or secondary gout
– In general; it is caused by excess levels of uric acid (a waste
normally excreted in urine) in the body; the excess acid
precipitates as a solid crystal of urate in the synovial membranes
– The primary gouty arthritis is caused by sever dieting or
starvation, excessive intake of food that is high in purines
(shellfish, organ meat)

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 Cont’d...
Secondary gout is caused by:
• Over production of uric acid caused by:
• Polycythemia Vera
• Cancer
• Cytotoxic drugs
• Hemolytic anemia
• Leukemia
• Multiple myeloma
• Decreased excretion uric acid by:
• Chronic renal insufficiency
• Lactic acids)
• Keto acidosis
• Certain drugs that results in under excretion of uric acid like diuretics like thiazides,
frusomide.
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 Cont’d...
Predisposing factors/Risk factors:
• Family history
• Male gender
• Obesity
• Excessive alcohol in take
• Hyperlipidemia
• Hypertension
• diuretic uses

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 Cont’d...
Clinical Manifestation
It has four stages these are:
1. Asymptomatic hyperuricemia
2. Acute gouty arthritis – recurrent affects per articular inflammation
– Abrupt onset often occurs at night, symptoms awakening the pt include:
– Sever pain, swelling, erythematic of the involved joint, tenderness and warmth.
– Early attack may subside by itself without treatments with in 3-10 days
3. Intercritical gout stage – is the symptom free period after the attack until the
next attack, which may stay for months or years
4. Chronic tophaceous gout stage
– Development of tophi (crystalline deposits accumulating in the articular tissue,
soft tissue and cartilage)
– Development of gouty nephropathy (renal impairment)
– First noted on average of 10 years after the onset of gout
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 Cont’d...
Dx
–
History and physical examination
–
Arthrocenthesis- Finding of Urate in the synovial fluid
–
Serum uric acid level elevated
–
Urinary uric acid level
Management
Pharmacologic Rx:
– NSAID
– Indometaine 50mg P.O or 100 mg rectally
– Colchicines 0.5-1mg P.O
– Prednisolone -30-40 my/day P.O
For chronic gout
– Allopurinol 100 mg P.O
– Probenecid 500 mg P.O BID
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 Cont’d...
Nursing management
– Monitor drug side effects and administer as prescribed
– Avoid the predisposing factors
– Advise the patient to avoid alcohol intake
– Rest and immobilization until the acute attack subside
– local cold application to reduce the a pain
– Avoid heat application since of increase the inflammation
– Encourage life style modification like high fluid intake,
avoidance of purines rich food.

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 Septic arthritis
• Septic arthritis is inflammation of the joint that resulted
of invasion of the synovial membrane by
microorganisms.
Causes
– Neisseria gonorrheal
– Meningococcal
– Streptococci
– Staphylococcus aureus
– Salmonella
– Haemophilus influenza
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 Cont’d...
N.B
– S . aureus causes at least 50% of all joint infections, and 80% of
cases of septic arthritis in pts with RA and diabetes.
– The knee is the joint that is most commonly infected (50% of
cases ), followed by the hip & the shoulder ,respectively.
Knee Hip Shoulder
Method of entry for the bacteria in to the joints include:
– Hematogenous spread/blood the most common
– Direct inoculation
– Extension from an adjacent infection

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 Cont’d...
Risk factors include :
– Advanced age
– Immunodeficiency
– Chronic diseases e.g., diabetes,rheumatoid arthritis
– Preexisting joint disease or joint replacement
– Intravenous drug abuse like pt taking corticosteroid or
immunosuppressive drugs
– Local joint surgery or trauma
– Intraarticular injection

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 Cont’d...
Pathophysiology
• Bacterial invasion of synovial space and results in
inflammation of the synovial tissue…… accumulation pus
in the synovial membrane and synovial fluid….. Abscess
accumulation in the synovium and subchondral bone….
destroying of the cartilage and ankylosis of joints.

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 Cont’d...
Clinical manifestations;
– Pain, swelling and tenderness of the joint
– Pus in the synovial membrane
– Abscess in the synovium and subchondral bone
– Ankylosis of joints,
– Loss of the normal joint motion, Erythema
Dx
– Joint aspiration/synovial fluid analysis
– WBC count
– X-ray
– Culture
– CT scan & MRI may reveal damage to the joint lining

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 Cont’d...
General management
– Antibiotics e.g. cloxacillin
– Anti-pain to control pain
– Immobilization of the affected joint
– Aspiration & drainage when indicated (arthrocentesis)
– After the infection has responded to antibiotic
therapy ,NSAIDs may be prescribed to limit joint
damage
– When infection subside and motion is tolerated initiate
active ROM
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 Group Work
Scenario 1
Kemila is a 36-year-old woman presenting to her primary care
physician with a 2-month history of pain and inflammation in
her hands and feet. On questioning, she indicates that she
experiences pain and stiffness for at least an hour in the
morning. Kemila is an artist and avid runner, and she wonders
if her activities are causing this pain.
1/ What information is suggestive of RA?
2/ What risk factors does she have for RA?
3/ What additional information is necessary to differentiate
between osteoarthritis and RA?
4/ What additional information do you need before creating
a 01/24/2025
treatment plan for this patient?
 OSTEOPOROSIS

Defn:- It is a systemic disease in which bone density and bone mass

decrease because of a disturbance in the balance between bone resorption
and bone deposition
• Common after 30 yrs, but progresses rapidly in postmenopausal women;
70% of women older than age 45 have osteoporosis.

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 Continued…
Causes:-
• Genetics(Caucasian or Asian, Female andFamily history)

• Age(Postmenopause ,Advanced age)

• Nutrition(Low calcium intake, Low vitamin D intake and High phosphate

intake
• Physical exercise (Sedentary ,Lack of weight-bearing exercise)

• Lifestyle choices ( Caffeine ,Alcohol)

• Medications(corticosteroids)

 Patients with osteoporosis are susceptible to fractures (particularly of the

01/24/2025
femur, radius, and ulna) and compression or crush injuries of the vertebrae
 Continued…
Signs and symptoms

◆ Pain may affect the lower back or thoracic spinal area

◆ A loss of height may occur

◆ Kyphosis, may be present

◆ A minor twist or turn can cause a sudden fracture

◆ Numbness or tingling in arms or legs may occur

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 Diagnosis
 Patient history, P/E, and CT scans

 Serum Ca++ < 8.5mg/dl

Medical management
 A diet rich in calcium and vitamin D throughout life

 Regular weight-bearing exercise promotes bone formation

◆ Elemental Calcium intake is increased to 1,000-5000 mg daily

◆ Estrogen and progesterone are prescribed to restore hormonal balance

◆ Calcitonin 4 units/kg BID

◆ 01/24/2025
Bisphosphonates (Ex. Alendronate 10-70 mg /d)
 Continued...
Oral vitamin D
o Calcitriol (0.5 µg/day) If kidney not functioning or

o Calcifediol (1000 IU/day) or

o Vit D3 100-200 u/d

◆ Back or neck supports are used to prevent stress fractures

◆ Active exercises are encouraged to help retain calcium in the bones

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 Vitamin D Synthesis

7-Dehydrocholesterol(Skin)

UV light

Diet / Cholecalciferol(VitD3)

25,hydroxylase(Liver)

Calcidiol (25(OH),cholecalciferol)

1∝-hydroxylase (Kidney)

Calcitriol(1,25(OH)2,cholecalciferol)

01/24/2025
 Continued…
Nursing interventions

◆ Monitor the amount and type of pain to determine its extent

◆ Give an analgesic

◆ Teach the patient how to use an ambulatory aid to maintain mobility, and
apply a neck or back support, if ordered

◆ Teach the patient about dietary sources of calcium (dairy products ,cereals
(oats, beans) ,juices, green leafy vegetables, etc

◆ Don’t give Alendronate with Al2(OH)3 PO ,it binds phosphate and promote
excretion through GI
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 Continued…
Nursing interventions---

◆ Discuss how to ensure a safe home environment to decrease the risk of falls,
for example, by removing loose rugs and avoiding long uncovered electrical
cords

◆ Encourage the patient to participate in active, weight-bearing exercises, such

as walking and swimming, to maintain calcium in bones and preserve muscle
strength

◆ Encourage the patient to modify lifestyle choices by avoiding smoking,

alcohol, caffeine, and carbonated beverages, and increasing protein intake.
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 Osteomyelitis

• Defn:- Osteomyelitis is an infection of the bone that results in inflammation,

necrosis, and formation of new bone.

Causes

- Bacterial contamination (from open wound)

(Staphylococcus aureus (90%), Streptococcus pyogenes, Pseudomonas

aeruginosa, Escherichia coli, Neisseria gonorrhoeae, Haemophilus influenzae,
and Salmonella typhi)

- Hematogenic osteomyelitis
• 01/24/2025
Osteomyelitis with vascular insufficiency(DM, peripheral vascular disease)
 Continued…
Common sites

Metaphyseal area in long bones (femur, tibia, humerus, and vertebrae )

Risk factors
• Poorly nourished, elderly, or obese

• Impaired immune systems those with chronic illnesses

• Those receiving long-term corticosteroid therapy

01/24/2025
 Continued...
 Signs and symptoms
• Pain and pressure; heat, edema, and tenderness

• Associated systemic signs and symptoms include chills, fever, malaise,

nausea, and tachycardia
• The affected limb may be sore with use

• An open, draining area may appear

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  Diagnosis

• Patient history, bone scan, MRI, physical examination, X-rays of the

involved bone, culture of the drainage, WBC count and ESR
Treatment

• An antibiotic is administered I.V. in large doses after blood cultures are

taken for 3month-6months
• Aspirin

• TAT 3000 IU

• After antibiotic therapy is completed, the bone is surgically scraped to clear

away the dead bone and residue of infection
01/24/2025
 Continued…
Treatment---
• Bone grafts may be used to aid bone healing and prevent fracture

• Tubes or catheters may be inserted to flush the site with an antibiotic to

clear any residual organisms
• An external fixates may be placed above and below the osteomyelitic site
to decrease the possibility of bone fracture
• Surgery to drain infection may be necessary

• Immobilization of the infected bone may be necessary using a cast,

traction, or bed rest
01/24/2025
 Continued…
Nursing interventions
• Monitor the type and amount of pain to determine the disease’s status

• Administer an antibiotic, an analgesic, or tetanus toxoid or antitoxin as

prescribed
• Administer I.V. fluids to maintain hydration

• Perform neurovascular checks, and monitor vital signs

• Use strict aseptic technique when required; the patient is more susceptible to
additional infection or nosocomial infection

01/24/2025
 Continued…
• Help the patient achieve a comfortable position to relieve pressure on the
affected tissues
• Encourage the patient to perform ROM exercises for all unaffected tissues
and joints to maintain strength
• Teach the patient how to use an ambulatory aid (or arm sling)
• Discuss concerns about types of treatment
• Provide and encourage diversionary activities to help the patient maintain a
positive outlook

01/24/2025
 Fracture

• A fracture is a complete or incomplete disruption in the continuity of

bone structure
• is defined according to its type and extent

Causes
o Trauma: a major cause for fracture e.g. Fall, motor accident

o Disease process : a Fracture resulting from a disease is called pathological

fracture

E.g. Cancer, malnutrition, osteoporosis

• The commonest fracture is hip fracture that resulted from osteoporosis
01/24/2025
especially in the middle aged women
 Types of fracture
• Open fracture: is a fracture that breaks the continuity of the skin

N.B. Open fracture is prone to infection

• Closed fracture: Does not disrupt the skin integrity

• Avulsion: Piece of bone is torn away, while still attached to a ligament or

tendon
• Comminuted: Bone splintered or shattered into numerous fragment, often
occur in crushing injury

01/24/2025
 Continued…
• Impacted: Fracture with one end wedged into the opposite end or into the
fractured fragment
• Greenstick: Bone is bent and fractures on the outer area of the bend & often
seen in children

= Break in only one cortex of the bone

• Intrarticular: Fracture involves bones in to a joint

01/24/2025
 Continued…
• Spiral: Fracture curves around the shaft of the bone

• Longitudinal: Fracture occurs along the length of the bone

• Stress: Results in the bone being fractured across cortex this is an

incomplete fractures
• Transverse: Bone fractured horizontally

• Depressed: Bone pushed inward, often seen with skull and facial fracture

01/24/2025
 Continued…
Sign & symptoms
• Tenderness

• Pain

• Pts with hip fracture complain of pain the groin area and of the knee – i.e
referred pain
• Shortening of affected limb- common in displaced fractures result of muscle
contraction
• Limb rotation or deformity

• Decreased Range of motion (ROM)

01/24/2025
• Ecchymosis (bruising)
 Continued….
Diagnostic test
• X-ray, CT – scan to detect fracture of complex area such as hip fracture

• MRI: to determine damage to surrounding soft tissue

• Hematocrit and hemoglobin: For patient experiencing moderate to severe

bleeding
• Serum calcium level: may be inquired by physician b/c calcium is
important in bone healing

01/24/2025
 Continued…
Fracture Management

Primary survey
• ABCDEF

Secondary survey(HX,PE and work up)

Definite mgt
• Reduction

• Immobilization

• Rehabilitation

01/24/2025
 Continued…

Purposes of immobilization
- Prevent further injury

- Promote healing/circulation.
- Reduce pain

- Correct a deformity

01/24/2025
 Complications of fracture
A/ Hemorrhage:- bone is highly vascular

B/ Infection- common in open fracture

C/ Thromboembolitic complications

D/ Acute compartment syndrome (ACS)

Early symptoms of acute compartment syndrome

• Increasing pain- Not relieved even by narcotics

• Pain exacerbated by active movement rather than passive

• Decreased sensation follows before ischemia becomes severe

• The Six “P” s appear with severe acute compartment syndrome.

1.Pain ( severe, non stopping) 2. Parasthesia

3. Paralysis 4. Pallor 5. Pulselessness

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6. Poikilothermia
 Continued…
Treatment of acute compartment syndrome (ACS)
• By removing source of pressure Ex. cast

• Fascioctomy incision in to the fascia that enclose the compartment

• Renal failure is a potentially fatal complication of ACS

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 Continued…
E/ Fat embolism Syndrome (FES)

= A condition in which small fat globules are released from yellow bone
marrow into the blood stream
• Globules travel to the lung fields causing respiratory complications

• Long bones especially the femoral shaft

• When pts have multiple fractures

• Elderly pts with fractured hip are at high risk for Fat embolism
Syndrome.
• FES can occur after 72 hrs late from the time of initial injury
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Sign and symptoms
• Altered mental status

• Low arterial oxygen level and then pt experience: - Tachycardia

- Tachypnea

- Fever

- High blood pressure

- Severe respiratory distress (shortens of breath)

• Patechiae (measles like rush) in the upper body

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 Continued…
Action that must be taken if Fat embolism Syndrome is suspected
• Promote oxygen

• Maintain bed rest and keep movement of extremity to a minimum

• Prepare pt for a chest x-ray examination or lung scan

• Administer intravenous fluids as ordered

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 Traction

Traction is the application of a pulling force to a part of the body.

Purposes of traction

- To minimize muscle spasms

- To reduce fractures

- To align fractures

- To immobilize fractures

- To reduce deformity

- To increase space between opposing surfaces.

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 Continued…
Two types of traction exist
 A).Skin traction

 B).Skeletal traction

A/ Skin traction: used to relieve muscle spasms that are painful.

• Less use in aligning or healing process

• A wt of 2.2 to 4.5 kg is usually applied

Ex. Buck’s extension(hip), Cervical head halter, Cotrel’s (scoliosis), Dunlop’s

(humur), Russell’s (hip), Pelvic sling, Pelvic belt or girdle

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 Continued…
B).Skeletal traction (balanced suspension) involves the use of pins, screws,
wires or tongs.
• The materials are surgically inserted

• To align the bones while it heals

• A weight of 9-18 kg serve as a pulling force depending on the orthopedist's

order

Ex. Balanced suspension to femur, Cervical traction via skull tongs, & Halo-
pelvic traction (scoliosis)

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 Continued…
Care of patient in Traction
Frequent monitoring of:-
• Neurovascular status for impaired blood flow
• Checking the equipment to ensure proper functioning
• Skin condition for pressure or irritation from equipment
• Traction should be applied at all times
• Inspect every 8-12 hrs the tightness
• Patients legs should not rest at the end of the bed
• For patients with skeletal traction, observe pin site for redness and drainage
• A clear and odorless drainage is expected
• As patient are immobile for extended period
 Pressure ulcers on heels - Constipation - Muscle dystrophy
• Social isolation
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 continued…

• Maintain body alignment and realign if the client seems uncomfortable or

reports pain.
• Avoid lifting or removing weights

• Assure that weights hang freely

• If the weights are accidentally displaced, replace the weights. If the problem
is not corrected, notify to the orthopedists.
• Assure that pulley ropes are free of knots

• Notify the orthopedists if the client experiences severe pain from muscle
spasms unrelieved with medications and/or repositioning.
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• Routinely monitor skin integrity and document.
 Traction---
Open Reduction With Internal Fixation (ORIF)
• Open reduction: the correction and alignment of the fracture after surgical
dissection and exposure of the fracture
• Internal fixation: the stabilization of the reduced fracture by the use of metal
screws, plates, nails, and pins
• Can be used after traction
• Indicated for clients that can’t be managed with a cast traction
• Involves direct visualization to re-align the bones and use of internal fixation
• ( IF) devices to keep the bone ends together i.e. metal plate screws
• Commonly indicated for fractured hip, If device are not removed in lip
fracture after healing
• Hardware removed after healing in ankle and long bone application

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 Traction---
External fixation
• External fixators are used to manage open fractures with soft tissue damage.
Complicated fractures of the humerus, forearm, femur, tibia, and pelvis are
managed with external skeletal fixators.
• The fracture is reduced, aligned, and immobilized by a series of pins inserted
in the bone.
• Indicated in sever bone damage as in crushed or splintered fracture

• After bone reduction pins are inserted and pins are placed in place by an
external metal frame
• 01/24/2025
Ideal for open fracture that require wound care at the same time bone
 Traction---
External fixation---
• There is a risk for pin site infection then check sign/symptoms of infection

• After the external fixation is applied, the extremity is elevated to reduce

swelling. If there are sharp points on the fixate or pins, they are covered to
prevent device-induced injuries.
• The nurse monitors the neurovascular status of the extremity every 2 to 4
hours and assesses each pin site for redness, drainage, tenderness, pain, and
loosening of the pin

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 AMPUTATION

• Amputation is the absence or removal of all or part of a limb

• Amputation is used to relieve symptoms, improve function, and save
or improve the patient’s quality of life.
Causes
- Progressive peripheral vascular disease (DM)– most common
- Fulminating gas gangrene
- Malignant tumors
- Trauma (crushing injuries, burns, frostbite, electrical burns)
- Congenital deformities
- Chronic osteomyelitis

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 Amputation---
Complications of amputation
• Edema, skin breakdown caused by the prosthesis

• Bleeding

• Infection

• Ischemic necrosis

• Flexion contracture/ joint contracture

• Chronic pain- phantom limb pain, psychogenic, neuromas, etc.

• Phantom limb pain is caused by the severing of peripheral nerves

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 Amputation---
Medical management
• The objective of treatment is to achieve healing of the amputation wound,
the result being a non tender residual limb (stump) with healthy skin for
prosthesis use.
• Healing is enhanced by gentle handling of the residual limb, control of
residual limb edema through rigid or soft compression dressings, and use
of aseptic technique in wound care to avoid infection.

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 Amputation---
Nursing Interventions

A/ Relieving pain

B/ Minimizing altered sensory perceptions

C/ Promoting wound healing

D/ Enhancing body image

E/ Helping the patient to resolve grieving

F/ Promoting independent self-care

G/ Helping the patient to achieve physical mobility

H/ Monitoring and managing potential complications

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I/ Teaching the patient to manage self-care
 NURSING DIAGNOSIS
• Knowledge deficit

• Chronic pain

• Impaired physical mobility

• Self care deficit

• Risk for disuse syndrome

• Risk for injury

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