Medical-Surgical Nursing Musculoskeletal System Reviewer

Common Health Problems of the Neonate and Infant CONGENITAL HIP DYSPLASIA

improper formation and function of the hip socket evident as subluxation or dislocation of the head of the femur

the acetabulum of the pelvis is flattened or shallow

this prevents the head of the femur from remaining in the acetabulum and rotating adequately

in subluxated hip, the femur rides up because of the flat acetabulum

in dislocated hip, the femur rides so far up that it actually leaves the acetabulum

found more on girls possibly because the hips are more flaring

possibly because the maternal hormone relaxin causes the pelvic ligaments to be more relaxed

Assessment

1. the affected leg appears slightly shorter because the femur head rides so high in the socket 2. one knee is higher 3. asymmetry of skin folds and prominence of the trochanter

Therapeutic Management

1. position the hip into a flexed, abducted (externally rotated) position to press the femur head against the acetabulum and cause it to deepen its contour by the pressure

2. splints, halters, or casts may be used 3. traction is used first to bring the femur head into good position with the acetabulum 4. surgery and a pin is inserted to stabilize the hip 5. Multiple Diapers or Splints

a. to hold the legs in a frog-leg, or abducted, externally rotated position

6. Frejka Splint a. is made of plastic and buckles onto the child like a huge diaper b. keep the splint in place except when bathing or changing the diaper

7. Pavlik Harness a. adjustable chest halter that abducts the legs b. method of choice for long term therapy it reduces the time interval for 2-3 weeks and simplifies care c. assess the skin under the straps daily for irritation or redness

8. Spica Cast

a. used for fully dislocated or severe subluxation b. placed first in a Bryant’s traction for a week to better position the hip c. assess for circulatory constriction for the first 24 hours then daily d. maintained for 6-9 months

CLUB FOOT / TALIPES DEFORMITIES

- talipes comes from the Latin word talus (ankle) and pes (foot) - ankle-foot disorders

Four Types of True Talipes Deformity

1. plantarflexion – an equines or “horsefoot” position with the foot lower than the heel 2. dorsiflexion – the heel is lower than the foot or the anterior foot is flexed toward the anterior leg 3. varus deviation – the foot turns in 4. valgus deviation – the foot turns out

Therapeutic Management

1. correction is achieved best if it is begun in the newborn 2. a cast is applied which extends above the knee to ensure firm correction 3. change diapers frequently to prevent a wet diaper from touching the cast and causing it to become soaked with urine or meconium 4. casts are changed almost every 1 or 2 weeks 5. casts are removed after 6 weeks 6. Denis Browne splints (shoes attached to a metal bar to maintain position) for a few months

TORTICOLLIS (Wry Neck)

- derived from tortus (twisted) and collum (neck) - occurs as a congenital anomaly when the sternocleidomastoid muscle is injured and bleeds during birth - occurs in newborns with wide shoulders when pressure is exerted on the head to deliver the shoulder - a thick mass over the muscle can be palpated

Therapeutic Management

- encourage the infant to look in the direction of the affected side - if condition exists at 1 year of age, surgical correction followed by neck immobilizer is necessary

- if extreme injury to the muscle occurred, torticollis can lead to continued elevation of the shoulder and a potential to lead to scoliosis later in life

Common Health Problems of the Child Disorders of Bone Development FLAT FEET - relaxation of the longitudinal arch of the foot - experience pain at the end of the day due to poor arch development - walk on tiptoe for 5-10 minutes daily - sports shoe is adequate to correct this

BOWLEGS / GENU VARUM

- lateral bowing of the tibia - if present, the malleoli (rounded prominence on either side of the

ankles) are touching and the medial surface of the knees is over 2 inches apart - corrects itself by about 2 years and the latest by school age - if it persists, refer to an orthopedist for further evaluation

BLOUNT’S DISEASE / TIBIA VARA

- retardation of growth of the epiphyseal line on the medial side of the proximal tibia (inside of the knee) resulting in bowed legs

- bracing or osteotomy may be necessary to correct this deformity to prevent it from becoming more severe

KNOCK KNEES / GENU VALGUM - the medial surfaces of the knees touch and the medial surfaces of the ankle malleoli are separated by more than 3 inches - correct itself as the child grows - if becoming more pronounced, needs a referral to orthopedist for further evaluation LEGG-CALVE-PERTHES DISEASE / COXA PLANA - avascular necrosis of the proximal femoral epiphysis from an unknown cause - occurs more often in boys between 4 and 8 years of age - the child notices pain on the hip joint accompanied by spasm and limited motion Children with Legg-Calve-Perthes disease pass through 4 Stages:

a. Synovitis stage – period of painful inflammation b. Necrotic stage – bone in the femur head becomes smaller and shows increased density on x-

ray – lasts 6-12 months c. Fragmentation stage – resorption of dead bone occurs over 1-2-year period d. Reconstruction stage – marks final healing with deposition of new bone occurring

Treatment

1. focuses on pain reduction with non-steroidal anti-inflammatory drugs (NSAID) 2. keep the head of the femur within the acetabulum to act as a mold to preserve the shape of the femoral head and maintain ROM

3. rest to reduce inflammation 4. casts, leather harness slings, abduction braces are used

Common Health Problem of the Adolescents SCOLIOSIS

- lateral curvature of the spine - may be functional – a curve caused by a secondary problem - or structural – idiopathic, permanent curvature of the spine accompanied by

damage to the vertebrae Assessment

1. if the child bends forward, the curve becomes noticeable 2. bra straps are adjusted to unequal lengths 3. a scoliometer, a type of protractor, can be used to detect the extent of the

spinal curve 4. X-rays and photographs help to estimate the extent of the deformity and serves

as baseline Therapeutic Management

1. if the curve is less than 20 degrees, no therapy is required except for close observation until the child reaches about 18 years 2. if the curve is greater than 20 degrees, treatment may be a conservative, non-surgical approach using a body brace or traction,

surgery, or combination of both 3. curves greater than 40 degrees require surgery with spinal fusion

Braces used:

1. Milwaukee brace – thoracolumbar support a. worn 23 hours

2. Charleston Bending Brace a. worn at night to confine the spine to an overcorrected position

3. Halo Traction - use of opposing forces to straighten and reduce severe spinal curves - use a metal ring (halo) held in place with about 4 stainless steel pins inserted into the skull bones - countertraction is applied by pins inserted into the distal femurs or iliac crests

Nursing Diagnosis

- Situational Low Self-Esteem related to obviousness of the brace used for scoliosis correction

Common Health Problems of the Young Adult OSTEOGENIC SARCOMA

- a malignant tumor of long bone involving rapidly growing bone tissue - more common in boys - common sites are the distal femur, proximal tibia, proximal humerus - metastasis occurs early because of the high vascularity present in bones - metastasis to the lungs is the most common site, brain and other bone tissue

Assessment

1. rapid bone growth 2. pain and swelling at the tumor site 3. inflammation at the site and feel warm 4. pathologic fracture as the tumor invades and weakens bone tissue

Diagnosis

1. biopsy at the site 2. elevated alkaline phosphatase – bone cells produce this and rapidly growing bone cells raise the serum level 3. CBC, urinalysis 4. chest X-ray, Chest CT scan, bone scan

Therapeutic Management

1. if the tumor is in the leg and the tumor is small at the time of diagnosis and if the child has reached the adult height, the bone involved is surgically removed and replaced with an internally placed bone or prosthesis

2. if the tumor is extensive at the time of diagnosis, the leg may be amputated at the joint above the tumor 3. If the tumor has spread to the lung, metastases is removed by thoracotomy 4. chemotherapy to shrink the tumor 5. treatment drugs include methotrexate, cisplatin, doxorubicin, and ifosfamide

Common Health Problems of the Adult RHEUMATOID ARTHRITIS - chronic, systemic autoimmune disorder characterized by chronic, symmetrical and erosive inflammation of the synovial tissue of joint Clinical Manifestations 1. begins gradually over a period of several weeks to months accompanied by systemic

manifestations such as anorexia, weight loss, fatigue, muscle wasting and stiffness 2. joint pain and swelling are associated with morning stiffness 3. frequently affected joints are the fingers, hands, wrists, knees and feet Medical Management 1. reduce pain and inflammation

a. NSAID b. whole body rest to reduce inflammation

2. maintain function a. therapeutic exercises b. ROM to improve joint motion c. strengthening exercise to preserve or improve the muscle’s ability to perform work d. endurance e. heat and cold therapy

Diagnosis 1. Chronic Pain 2. Fatigue / Sleep Deprivation 3. Impaired Physical Mobility 4. Chronic Low Self-Esteem, Disturbed Body Image

GOUT AND GOUTY ARTHRITIS

- metabolic bone disorder in which purine metabolism is altered and the by-product, uric acid, accumulates

- primary gout is caused by an inherited defect of purine metabolism leading to increased or decreased renal excretion the initial attack of gout occurs in the third or fourth decade of life

- secondary gout is an acquired condition that occurs following hemotopoietic or renal disorders

Diagnosis 1. persistent hyperurecemia (>7mg/dl) in addition to clinical manifestations 2. presence of uric acid in an aspirated sample of synovial fluid

Therapeutic Management

1. use of colchicines and NSAID to reduce pain and inflammation 2. colchicine reduces the migration of leukocytes to the synovial fluids 3. NSAID – indomethacin or naproxen 4. adenocorticotropic hormone (ACTH) or steroids in resistant cases 5. ice over the inflamed joints to reduce pain 6. medications to lower uric acid 7. allupurinol- blocks the formation of uric acid 8. probenecid – promotes reabsorption of uric acid deposits and excretion of uric acid

OSTEOMALACIA

disease in which the bone becomes abnormally soft because of a disturbed calcium and phosphorus balance secondary to vitamin D deficiency

Signs and Symptoms

1. easy fatigability 2. malaise 3. bone pain accompanied by bony tenderness 4. muscular weakness 5. decreased serum calcium and phosphorus 6. moderately elevated alkaline phosphatase 7. X-rays indicate generalized demineralization with trabecular bone loss

Therapeutic Management

1. daily vitamin D 2. adequate intake of calcium and phosphorus and protein

OSTEOPOROSIS

systemic skeletal disorder characterized by compromised bone strength predisposing to an increased risk of fracture Etiology and Risk Factors

1. marked acceleration in bone loss during perimenopausal period because of the loss of estrogen

2. women start to lose bone about 1.5 to 2 years before their LMP 3. rapid bone loss 1.5 years after their LMP 4. rapid bone loss occurs also in women whose ovaries have stopped functioning

Signs and Symptoms

1. severe back pain that worsens with movement and relieved by rest 2. the lower ribs rest on the iliac crests and downward pressure on viscera causes abdominal

distention and bloating Diagnostic Examinations

1. CBC, 2. urine calcium, 3. alkaline phosphatase, 4. parathyroid hormone, 5. serum and urine electrophoresis (study of substance in biological mixture), 6. thyroid function tests

Medical Management 1. Calcium and Vitamin D intake 2. prevent loss of bone mass

a. adequate intake of calcium and vitamin D 3. regular weight-bearing exercise 4. avoidance of tobacco and alcohol 5. manage pain –

a. strict bed rest 5-7 days

b. lie supine or side-lying position c. non-opioid analgesics

6. flexible corsets with Velcro worn in upright position to relieve back pain and fatigue 7. physical therapy 8. hot and cold compress 9. prevent further fractures 10. promote healing

OSTEOARTHRITIS / DEGENERATIVE JOINT DISEASE A degenerative joint disease, osteoarthritis is one of the oldest and most common forms of arthritis. Signs and Symptoms

a. diagnosis is confirmed by X-ray changes that include the presence of osteophytes and of a narrowed joint space caused by erosion of articular cartilage

b. worsening pain and stiffness that increase with activity and relieved by rest c. crepitus, mild tenderness in the area of joint wear d. ROM deficit e. joint enlargement

Medical Management 1. pain management with improvement or maintenance of mobility 2. functional independence 3. maintenance of quality life Surgical Management 1. Arthrodesis (joint fusion) – the articular joint surfaces, which hold the bone ends

together, are removed so that the bone edges unite like a fracture 2. Osteotomy – is a surgical fracture, a cut across a bone with resection of a bone

fragment 3. Total Hip Arthroplasty (Replacement) – performed to restore joint motion by replacing arthritic bone with metal components CARPAL TUNNEL SYNDROME entrapment neuropathy; median nerve at the wrist is Compressed by

- thickened flexor tendon sheath - skeletal encroachment - edema - soft tissue mass

1. repetitive hand activities 2. also assoc w/ pregnancy, arthritis, hypothyroid 3. characterized by pain & numbness, paresthesias, 4. weakness along median nerve (thumb & 1st 2 fingers) 5. (+) Tinel’s sign 6. (+) Night pain

Treatment

1. rest splints 2. avoidance of repetitive flexion 3. NSAIDs 4. Cortisone injections 5. Laser release

Common Health Problems Across the Life-Span FRACTURES

- any disruption in the normal continuity of a bone - when fracture occurs, surrounding soft tissue is often damaged as well - X-ray confirms the bone injury

Clinical Manifestations

1. Deformity - swelling from local hemorrhage may cause deformity at the fracture site

2. Swelling

- edema may appear quickly as a result of accumulation of serous fluid at the fracture site and extravasation of blood into surrounding tissues

3. Bruising (ecchymosis) - results from subcutaneous bleeding at the fracture site

4. Muscle spasm - serves as a natural splint to decrease further motion of fracture fragments.

5. Pain - continuous, increasing in severity until the fracture is immobilized - results from muscle spasm, overriding of fracture fragments, or damage to adjacent structures

6. Tenderness - caused by underlying injuries

7. Loss of function - results from pain caused by the fracture or from loss of the lever-arm function in an affected extremity

8. Paralysis may be caused by nerve damage 9. Abnormal mobility and crepitus

- caused by motion in the middle of the bone or by fracture fragments rubbing together to create a grating sensation or sound

10. Neurovascular changes - results from damage to peripheral nerves or to the vascular structures

11. Complain of numbness and tingling or have no palpable pulse distal to the fracture 12. Shock

- bony fragments may lacerate blood vessels and can lead to shock Types of Fractures

Reducing Fractures Closed Reduction

- manual traction to move the fracture fragments and restore bone alignment

- done as soon as possible to decrease the client’s risk for loss of function, to prevent or delay joint degeneration, and to minimize the possible deforming effects of the injury

Open Reduction and Internal fixation

- the surgeon makes an incision and realigns the fracture fragments under direct visualization

- treatment of choice for compound fractures that are comminuted or accompanied by severe neurovascular injury

- screws, plates, pins and wires or nails may be used to maintain alignment of the fracture fragments

Traction

- the application of a pulling force to an injured body part or extremity while a counter traction pulls in the opposite direction - pulling force can be achieved through the use of hands (manual traction) or theapplication of weights

Complications After Fracture NERVE INJURY

- bone fragments and tissue edema can cause nerve damage - be alert for pallor and coolness of the affected extremity, changes in the ability to move the digits or the extremity, paresthesia or

complaints of increasing pain COMPARTMENT SYNDROME

- condition of compromised circulation related to progressively increased pressure in a confined space - caused by anything that decreases the compartment size including external compression forces like tight cast or internal forces such

as bleeding or edema - treatment is relief of the source of pressure - constrictive bandage is removed or the cast is bivalved

FAT EMBOLISM SYNDROME - fat globules is released from the bone marrow into the venous circulation after fractures of the long bones

- deposit of embolic fat in the pulmonary circulation can lead to the rapid onset of disorder similar to ARDS - as the lung becomes more rigid, the workload of the right heart increases

DVT AND PULMONARY EMBOLISM - DVT results from the formation of blood clots (thrombus) in a deep vein in the lower extremity - if the thrombus travels into the pulmonary circulation, it is termed as pulmonary embolism - treatment includes oral anticoagulant or subcutaneous heparin

INFECTION - staphylococcus aureus and staphylococcus epidermidis - can result to osteomyelitis, a severe bone infection

CAST SYNDROME - occurs only with body spica cast - the duodenum is compressed causing a decreased blood supply that can lead to hemorrhage and necrosis of the bowel

Common Types of Casts

1. short leg weight-bearing cast 2. long leg cylinder cast 3. short arm cast 4. hanging cast with weight to provide traction on the fracture site 5. non-weight-bearing long leg cast 6. long leg cast for unstable fracture of tibia 7. hip spica cast

Care of a Client in a Cast

1. assist during cast application 2. fingertips should not be pressed into the cast 3. the cast should not rest on a hard or sharp surface 4. clean the skin of excess casting material

Drying a Cast

1. synthetic casts dry to touch in a few minutes but take about 30 minutes to set completely and allow weight-bearing 2. plaster casts set quickly but take hours to days to dry completely 3. client should be instructed to expect sensation of heat 4. cast should not be covered with blanket or towel while drying because the retained heat can burn the client 5. - client should be turned regularly to expose the new cast to air 6. - use of a blower is not advised because it can burn the client’s skin and crack the cast 7. - rest casted area on pillows

Windowing or Bivalving a Cast

1. bivalving is cutting the cast along sides and then splinting it to decrease pressure on underlying tissue 2. for wound care and x-rays 3. windows may also be cut to visualize wounds under the cast or remove drains 4. allows pulse assessment and to prevent cast syndrome

AMPUTATION

- used to treat injuries, cancers, overwhelming limb gangrene, limb-threatening arterial disease - removal of a body extremity by trauma or surgery. As a surgical measure, it is used to control pain or a disease process in the

affected limb, such as malignancy or gangrene.

Phantom Limb Sensation

1. feelings that the amputated part is still present 2. caused by intact peripheral nerves proximal to the amputation site that carries messages between the brain and the now amputated

part 3. sensation of warmth, cold, itching, or pain

4. sensation gradually decreases over the next 2 years Phantom Pain

1. form of central pain 2. pain is usually burning, cramping, squeezing or shooting in nature 3. caused by physiologic and psychological components 4. occurs most often to clients who had pain in the limb before the amputation