Management of Clients with Musculoskeletal Disorders

1. Review functions of the musculoskeletal system to include: support, locomotion,

protection, mineral storage, hematopoiesis, and heat production.
2. What does the musculoskeletal system consist of?
a. Bones, joints, muscles, and ligaments
3. Discuss common musculoskeletal problems to include: pain, altered mobility,
neurovascular compromise, and infection.
a. Pain – all who have fx, sprain, and dislocation have pain
b. Altered mobility – loss or decrease in mobility due to pain or inability to move
extremity
c. Neurovascular compromise - Altered sensations or sensory disturbances
frequently associated with musculoskeletal problems.
d. Infection – Occurs mostly with compound fractures where the skin has been
damage along with the bone
4. When a client is immobilized, what are potential complications related to the major body
systems (hazards of immobility)?
a. Weakened muscles, joint contractor, and deformity pg165
5. Define neurovascular compromise.
a. Altered sensations or sensory disturbances frequently associated with
musculoskeletal problems.
6. What causes neurovascular compromise?
a. Failure to treat traumatic dislocations promptly
7. Define compartment syndrome. Pg2084
a. A complication that develops when tissue perfusion in the muscles is less than that
required for tissue viability.
8. Define musculoskeletal traumatic injuries to include: contusion, strain, and sprain. Pg
2076
a. Contusion – soft tissue injury produced by blunt force. Many small blood vessels
rupture bleed into soft tissue resulting in development of hematoma.
b. Strain – a muscle pull caused by overuse overstretching or excess stress. They
are microscopic incomplete muscle tears with some bleeding into the tissues.
c. Sprain – an injury to the ligaments surrounding a joint that is caused by a
wrenching or twisting motion.
9. Discuss RICE (rest, ice, compress, and elevate) as a management technique for
musculoskeletal injuries.
a. Rest prevents additional injury and promotes healing. Ice produces
vasoconstriction, which decreases bleeding, edema, and discomfort. Compression
bandage controls bleeding, reduces edema, and provides support, and elevation
controls swelling pg2076
10. Define subluxation. Pg2076
a. Partial separation or dislocation of joint surfaces.
11. Define avascular necrosis.
a. Tissue death due to anoxia and diminished blood supply
12. Define fracture.
a. A break in the continuity of a bone pg2076
13. Discuss types of fractures to include: complete, incomplete, simple (closed), and
compound (open). Pg 2079
 a. Complete – involves a break across the entire cross section of the bone and is
frequently displaced
b. Incomplete – the break occurs through only part of the cross section of bone.
c. Simple (closed) – a fracture that remains contained does not break the skin
d. Compound (open) – a fracture in which damage also involves the skin or mucous
membranes
14. The specific types of fractures include: greenstick, transverse, oblique, spiral,
comminuted, depressed, compression, pathological, avulsion, and epiphyseal. Pg2081
a. Greenstick – a fracture in which one side of the bone is broken and the other side
is bent
b. Transverse – fracture straight across the bone
c. Oblique – fracture occurring at an angle across the bone less stable than a
transverse
d. Spiral – a fracture that twists around the shaft of the bone
e. Comminuted – a fracture in which bone has splintered into several fragments
f. Depressed – fracture in which fragments are driven inward, seen in skull and facial
bone
g. Compression – a fracture in which bone has been compressed, seen in vertebral
fractures
h. Pathological – a fracture that occurs through an area of diseased bone, can occur
without trauma or a fall
i. Avulsion – a fracture in which a fragment of bone has been pulled away by a
ligament or tendon and its attachment.
j. Epiphyseal – a fracture through the epiphysis
15. The clinical manifestations of a fracture include: pain, loss of function, false motion,
deformity/shortening, crepitation, and swelling/discoloration.
16. Discuss emergency management in relation to a fracture.
a. Important to immobilize the body part before the patient is moved. If injured patient
must be removed before splints are applied the extremity is supported above and
below the fracture site to prevent rotation and angular motion. With an open
fracture the wound is covered with a clean sterile dressing to prevent
contamination of deeper tissues. The fractured extremity is moved as little as
possible to avoid injury.
17. The goals of fracture treatment include: reduction, immobilization, and rehabilitation.
18. Reduction includes: closed reduction, traction, and open reduction and internal fixation
(ORIF).
19. Immobilization may involve: external devices, internal devices, physiological splinting,
and traction
20. Discuss nursing interventions to assist the client during rehabilitation.
a. Elevate extremities to decrease swelling
b. Frequent neurovascular checks
c. Control patient anxiety
d. Assist with ADL’s to increase independence
e. Promote circulation
f. Medicate prior to PT
g. Isometric exercises
h. Maintain reduction and immobilization
21. What are some inhibiting and enhancing factors of fracture healing? Pg2083
a. Enhancing:
i. Immobilization of fracture fragments
 ii. Maximum bone fragment contact
iii. Sufficient blood supply
iv. Proper nutrition
v. Exercise: weight baring for long bones
vi. Hormones: growth hormone, thyroid, calcitonin, Vit. D, anabolic steroids
vii. Electric potential across fracture
b. Inhibiting
i. Extensive local trauma
ii. Bone loss
iii. Inadequate immobilization
iv. Space or tissue between bone fragments
v. Infection
vi. Local malignancy
vii. Metabolic bone disease
viii. Irradiated bone
ix. Avascular necrosis
x. Intra-articular fracture
xi. Age
xii. Corticosteroids
22. List the stages of fracture healing: inflammation, cellular proliferation, callous formation,
ossification, and remodeling.

23. Discuss the complications of fractures: hypovolemic shock, fat embolism syndrome,
compartment syndrome, thromboembolism, infection, and delayed complications.
a. Hypovolemic shock – Results from hemorrhage and loss of extracellular fluid into
damage tissues and may occur in fractures of the extremities, thorax, pelvis, or
spine.
b. Fat embolism Syndrome (FES) – Fat emboli may develop following fracture of long
bone or pelvis, multiple fractures, or crush injuries, most frequently seen in young
adults and elderly adults who experience fractures of the proximal femur, at the
time of the fracture fat globules may move in the blood because marrow pressure
Is greater than capillary pressure, the fat globules occlude small BV that supply
the lungs, brain, kidney, and other organs. Onset is rapid usually within 24-72
hours, but may occur up to a week after the injury.
c. Compartment syndrome – is a complication that develops when tissue perfusion in
the muscles is less than that required for viability, the patient will complain of a
deep throbbing unrelenting pain, which is not controlled by opiods. The forearm
and leg muscle compartments are involved most frequently. Permanent function
can be lost if the anoxic situation continues for longer than six hours.
d. Thromboembolism – patients with fractures of the lower extremities and pelvis are
at high risk for thromboembolism.
e. Infection – all open fractures are considered contaminated and surgical internal
fixation of fractures carries the risk for infection. Monitor for and teach patient to
monitor for s/s of infection including: tenderness, pain, redness, swelling, local
warmth, elevated temp, and purulent drainage. Must be treated promptly
f. Delayed complications –
i. Delayed union – occurs when healing does not occur at a normal rate for
the location and type of fracture.
 ii. Delayed non-union – results from failure of the ends of the fractured bones
to unite
iii. Delayed Avascular Necrosis of bone – Avascular necrosis occurs when the
bone losses its blood supply and dies. It may occur after a fracture with
disruption of the blood supply especially of the femoral neck. Also seen with
dislocations, bone transplantation, prolonged high dosage corticosteroid
therapy, chronic renal disease, and sickle cell anemia. Treatment generally
consists of attempts to revitalize the bone with bone grafts, prosthetic
replacement, or arthrodesis
iv. Delayed reaction to internal fixation devices – pain, and decreased function
are prime indicators that a problem has developed, may include mechanical
failure, material failure, corrosion of the device, allergic response to the
metallic alloy, and osteoporotic remodeling adjacent to the fixation device.
v. Delayed complex regional pain syndrome – it is a painful sympathetic
nervous system problem that occurs infrequently. When it does occur it is
most often in an upper extremity after trauma and seen most often in
women. This syndrome is frequently chronic with extension of symptoms to
adjacent areas of the body. Disuse muscle atrophy and bone deossification
occur with persistence of CRPS.
vi. Delayed heterotrophic ossification – this is the abnormal formation of bone,
near bones or in muscle, in response to soft tissue trauma after blunt
trauma, fracture, or total joint replacement.
24. What are the clinical manifestations of FES and how is it managed
a. Presenting features include
i. Hypoxia
ii. Tachypnea
iii. Tachycardia
iv. Pyrexia
b. Management
i. Immediate immobilization of fracture
ii. Minimal fracture manipulation
iii. Adequate support for fractured bones during turning and positioning
iv. Maintenance of fluid electrolyte balance
25. Define intracapsular and extracapsular hip fractures
a. Intracapsular – Fracture of neck of femur
b. Extracapsular – Fracture of trochanteric region
26. What are the clinical manifestations of a hip fracture?
a. Femoral Neck fracture
i. Pain with movement
ii. Leg shortened, adducted, externally rotated
iii. Ecchymosis
iv. C/O slight pain in groin or medial side of knee
v. Unable to move leg without significant increase in pain
b. Impacted Femoral neck fracture
i. Moderate discomfort
ii. May allow weight bearing
iii. May not demonstrate obvious shortening or rotational changes
c. Extracapsular Femoral Fractures
i. Extremity significantly shortened
ii. Externally rotated greater degree than intracapsular fracture
 iii. Exhibits muscle spasm- resists positioning of extremity in neutral position
iv. Large hematoma or area of ecchymosis
27. Discuss Buck’s traction and surgical treatments in medically managing a hip fracture
(open reduction and internal fixation (ORIF), hemiarthroplasty, and total hip arthroplasty
(THA).
a. Buck’s Traction – skin traction to the lower leg where the pull is exerted in one
plane when partial or temporary immobilization is desired, used to proved
immobility of fractures to the proximal femur before surgical fixation.
b. ORIF – Excision of damaged and diseased tissue, repair of damaged structures,
removal of loose bodies, arthroplasty (replacement of all of the joint surfaces),
arthrodesis (immobilizing fusion of a joint).
c. Hemiarthroplasty – is the replacement of the head of the femur with prosthesis and
is usually reserved for fractures that cannot be satisfactorily reduced or securely
nailed, or to avoid complications of non-union and avascular necrosis of the head
of the femur.
d. THA – The replacement of a severely damaged hip with an artificial joint.
28. Discuss the major post-operative complications associated with a hip fracture to include:
DVT, infection, dislocation, hemorrhage, neurovascular deficit, and pneumonia.
a. DVT – incidence of DVT is 45%-70%. The peak occurrence is 5-7 days after
surgery. About 20% of patients with DVT development pulmonary emboli. Nurse
must institute preventative measures and monitor patient closely for the
development of DVT and pulmonary emboli. The patient is encouraged to
consume adequate amounts of fluid, to perform ankle and foot exercises hourly
while awake, to use elastic stockings, and sequential compression devices, and to
transfer out of bed and ambulate with assistance beginning on the first post-op
day. Lo-dose heparin is usually prescribed as prophylaxis.
b. Infection – is serious complication of THA and may necessitate removal of the
implant. All efforts are undertaken to minimize the occurrence of infection.
Prophylactic antibiotics are prescribed, acute infections may occur within three
months after surgery, and are associated with progressive superficial infections or
hematoma, delayed surgical infections may appears 4-24 months after surgery.
c. Dislocation – Maintenance of the femoral head component in the acetabular cup is
essential. The nurse teaches the patient to position the leg in abduction; the use of
an abduction splint keeps the hip in abduction, when turning patient in bed the
operative hip must be kept in abduction. Patients hip is never flexed more than 90
degrees; the nurse does not elevate the head of the bed more than 60 degrees.
d. Hemorrhage – if excessive blood loss is anticipated of THA, and autotransfusion
drainage system may be used to decrease the need for homologous blood
transfusion.
e. Neurovascular deficit – neurovascular checks must be made 3 times per day
f. Pneumonia – nurse monitors breath sounds and encourages death breathing and
coughing exercises, if signs of resp problems develop, nurse reports immediately
to physicians
29. Be familiar with the purposes of using braces, splints, and soft immobilizers.
a. Braces – are used to provide support, control movement, and prevent additional
injury, for long term use
b. Splints – may be used for conditions that do not require rigid immobilization, for
those in which swelling may be anticipated, and for those that require special skin
care.
 c. Soft immobilizers – used to support an injured body part, the extremity is wrapped
with elastic bandage then secured in a padded, contoured, canvas, immobilizer.
30. Discuss the purpose of casting and cast care.
a. A cast is a rigid external immobilizing device that is molded to the contours of the
body, the purpose of the cast is to immobilize a body part in a specific position and
to apply uniform pressure on incased soft tissue.
b. Cast care
i. Describe techniques to promote cast drying
ii. Describe approaches to control swelling and pain
iii. Report pain uncontrolled by elevation and by analgesics
iv. Demonstrate ability to transfer
v. Use mobility aids safely
vi. Avoid excessive use of injured extremity
vii. Manage minor irritations from cast
viii. Demonstrate exercises to promote circulation and minimize disuse
syndrome
ix. Report complications to physician promptly
x. Describe care of extremity following cast removal
31. What are external fixators? What must the nurse include in “pin care?”
a. External fixators are used to manage open fractures with soft tissue damage.
b. Pin care
i. Cleaning each pin site separately 3x a day with cotton tipped applicators
soaked in sterile saline solution
ii. Crusts should not form at the pin site
iii. If signs of infection are present or if the pins or clamps seem loose nurse
notifies physician
32. What is the purpose of the continuous passive motion (CPM) machine?
a. To increase range of motion, circulation, and healing. Of the knee joint
33. What is a re-infusion device (Stryker drain)?
a. Autotransfusion drainage system may be used to decrease the need for
homologous blood transfusions
34. Know the crutch walking gaits to include: 4-point, 2-point, 3-point, swing-through, and
swing-to. Also, how does one go up and down the stairs on crutches? Pg 171
a. 4-point – partial weight baring, both feet, maximal support provided requires
constant shift of weight.
b. 2-point – Partial weight baring, both feet, less support, faster than 4-point
c. 3-point – non-weight baring, requires good balance, requires arm strength, a faster
gait, can use with walker.
d. Swing-through – weight baring, requires arm strength, requires coordination and
balance, most advanced gait
e. Swing-to – weight baring, both feet, provides stability, requires arm strength, can
use with walker.
f. Stairs
i. Up – advance the stronger leg first up to the next step, next advance the
crutches and weaker extremity (note strong leg goes up first and down last)
ii. Down – walk forward as far as possible on the step, next advance crutches
to lower step, the weaker leg is advanced first then the stronger one, this
allows the stronger extremity to share the work of raising and lowering the
body weight with the arms.
35. List the purposes of traction to include:
 a. Minimizing muscle spasms
b. Reducing, aligning, and immobilizing fractures
c. Increasing space between opposing surfaces within a joint
d. Preventing soft tissue damage
36. What are the principles of traction?
a. Whenever traction is applied counter traction must be used to achieve affective
traction. Usually patients body weight and bed position adjustments supply the
needed counter traction.
b. Traction must be continous to be affective
c. Skeletal traction is NEVER interrupted
d. Weights are not removed unless intermittent traction is prescribed.
e. Any factor that might reduce the affective pull or alter its resultant line of pull must
be eliminated
i. Patient must be in good body alignment in center of bed
ii. Ropes must be unobstructed
iii. Weights must hang free and not rest on the bed or floor
iv. Knots in the rope or the foot plate must not touch the pulley or the foot of
the bed

37. Define the two methods of traction: skin and skeletal

a. Skin – Is used to control muscle spasm and to immobilize an area before surgery,
accomplished by using a weight to pull on traction tape or on a foam boot attached
to the skin.
b. Skeletal – Is applied directly to the bone, it is applied by use of a metal pin or wire
that is inserted through the bone distal to the fracture, avoiding nerves, blood
vessels, muscles, tendons, and joints. Tongs applied to the head are fixed in the
skull to apply traction that immobilizes cervical fractures.
38. What is Buck’s traction used for?
a. It is used to provide immobility after fractures of the proximal femur before surgical
fixation
39. What is the purpose of skin and skeletal cervical traction?
a. Skin cervical – is used to occasionally treat neck pain. AKA cervical head halter
b. Skeletal Cervical – immobilize cervical fractures
40. When is pelvic traction used?
a. Is sometimes used to treat back pain. AKA pelvic belt
41. What are examples of suspension tractions?
a. Thomas Splint w/ Pearson attachment
b. Russell’s
c. Dunlop’s
d. Halo Vest
42. What is balanced suspension traction with Thomas splint and Pearson attachment
specifically used for?
a. Used for skeletal traction with fractures of the femur
43. What nursing care is essential in caring for a client in skin or skeletal traction?
a. This includes:
i. Maintaining effective traction,
ii. Proper body positioning,
iii. Skin care,
iv. Neurovascular assessment,
v. Pin-site care,
vi. Exercises, and
vii. Measures to prevent nerve pressure.