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Musculoskeletal Disorders

Oct 18, 20247 min read1224 words

As discussed by Dr. Leila Ferrer

Common Musculoskeletal Injuries

  1. Sprains and Strains: Ligaments are supporting tissue that connect bones to other bones. A sprain occurs when ligaments are stretched or torn. Tendons are supporting tissue that connects bones to muscles. A strain occurs when muscles or tendons are stretched or torn.
    • Management: RICE for mild to moderate sprains/strains
      1. Rest
      2. Ice (Intermittently)
      3. Compression Bandage
      4. Elevation
      5. In severe sprains/strains, surgery may be required.
  2. Dislocations: joints are the areas of articulation where two or more bones connect. In any occurrence of malposition (non-approximation) of the joints, they are dislocated. This may be complete or partial (AKA subluxation).
  3. Arthritis: joints contain tissue that may become inflamed; this is termed as arthritis.
  4. Fractures: a discontinuity of the bone produced pathologically or by trauma.
  5. Osteomyelitis: an inflammation of the bone
  6. Osteoporosis: “porous bone”; a decreased density rating of the bone, commonly caused by a lack of calcium in the bone.

Neurovascular Status Impairment

One of the most important aspects of care for patients with musculoskeletal injuries. These are regularly assessed in patients, especially in those with casts and traction. (mn. 6 Ps)

  1. Pain: often the initial complaint
  2. Paresthesia: a tingling sensation of the extremities
  3. Pulselessness: a lack of peripheral pulses
  4. Pallor: pale discoloration of the skin
  5. Poikilathermia: a cool feeling of the skin
  6. Paralysis: often the last complaint

Arthritis

An inflammation of the joints, causing pain.

  1. Management: antiinflammatory medications
    • First line: NSAIDs (MIND; mefenamic acid, ibuprofen, naproxen, diplofenac). This may result in ulceration (GI irritants) and nephrotoxicity in long-term use. Second line is steroids

COX-2 Inhibitor NSAIDs

These are a recent form of NSAIDs that do not produce gastric irritation. Among its forms, Etoricoxib (Arcoxia) is common manifestation

  1. Types:
    1. Osteoarthritis: common in obese and old patients, where the major weight-bearing joints (cervical spine, lumbar spine, knees) degenerate through wear-and-tear.
      • Management: (1) rest, (2) weight loss in obese patients via low carb/low fat diet, (3) pain management (NSAIDs, steroids [-sones], paracetamol, liniments)
      • Signs and Symptoms:
        • Characteristic Pain Pattern: morning pain less than 30 minutes. It is localized, asymmetrical, and non-systematic.
        • Manifestations: Heberden’s (distal metacarpal joint) and Bouchard’s (proximal metacarpal joint) nodes
      • Diagnostic Examination: x-ray (visualization of osteophytes/spur formation), bone density measurement
    2. Rheumatoid Arthritis: a chronic, autoimmune disorder that goes into remission and exacerbations. RA is common in women.
      • Management: pain management (NSAIDs, steroids [-sones], paracetamol, liniments), and the standard treatment of methotrexate. Nursing interventions include:
        • Splints can immobilize the affected extremities.
        • Cold Packs can help with acute exacerbations of pain.
        • Heat Application can help reduce inflammation.
        • Provide regular activities to reduce pain levels. Rest increases the stiffness and pain of RA.
      • Signs and Symptoms: fever, weight loss (painful eating)
        • Characteristic Pain Pattern: stiffness that occurs for more than 30 minutes that appears systemically (all joints), symmetrically, and bilaterally
        • Manifestations: Subcutaneous nodules, Raynaud’s phenomenon
          • In late rheumatoid arthritis, deformities of the hand occurs. From proximal to distal, these are the Boutonniere deformity of the thumb, ulnar deviation of metacarpophalangeal joints, and swan-neck deformity of fingers.
      • Diagnostic Examination: elevated ESR, positive Rheumatoid factors (immunologic markers)
    3. Gouty Arthritis: the result of a metabolic disorder in purine metabolism, increasing levels of uric acid, resulting in the crystallization of gout (tophi) in the synovial spaces, causing pain and inflammation.
      • Management: colchicine is the first line used for acute gout attacks that reduces pain and inflammation. Next, NSAIDs then steroids can be used.
        • Allopurinol is used to lower uric acid by blocking the enzyme for metabolizing purine to uric acid (xanthene oxidase). Colchicine does not does this. In recent development, Febuxostat may be a preference in lowering uric acid.
        • Diet should avoid purine. Avoid alcohol, anchovies, shellfish, oysters, clams, and organ meats. Increase fluid intake to prevent nephrolithiasis.
      • Signs and Symptoms: pain. A kidney stone may also form from uric acid crystals.
        • Characteristic Pain Pattern: monoarticular; only one joint is affected, compared to OA and RA, which are polyarticular.
        • Manifestations: erythematous first metatarsophalangeal joint; podagra; a great toe.
      • Diagnostic Evaluation: serum uric acid

Pyrazinamide

Pyrazinamide, a TB medication, can increase uric acid. This is avoided in patients with gout.

Fractures

A discontinuity in a bone.

  1. Signs and Symptoms:
    • Crepitus: a grating sound between the discontinued bones
    • Loss of function
    • Obvious deformity such as misalignment and shortening of the joint.
    • Pain
  2. Diagnosis: x-ray reveals fractured fragments
  3. Management:
    • In an emergency, immobilize (external, splint, traction, cast; internal, tongs, wires, pins) any suspected fracture.
  4. Complications:
    1. Shock: hypovolemia from hemorrhage.
    2. Fat Embolism Syndrome: the transmission of fat as emboli in circulation from leakage of fat from yellow bone marrow into blood vessels, commonly from femoral or pelvic fractures as large bones of the body. The immediate problem with FES is a pulmonary embolism manifested by dyspnea, which can result in respiratory failure. Hypotension, tachycardia, and tachypnea all appear as sequelae. The emboli also produces petechial rashes on the chest.
    3. Infection as manifested by fever, foul-smelling discharge, erythema
    4. Compartment Syndrome: a syndrome characterized by unrelenting pain (even with opioids) as an extremity experiences pressure such as in internal bleeding (limited by fascia; relieved via fasciotomy) or an external covering (a cast) is set too tight. The core problem of compartment syndrome is of Neurovascular Status Impairment.
    5. Deep Vein Thrombosis as exemplified in Homan’s sign (pain upon dorsiflexion of the foot)

Traction

The use of a traction weight and countertraction to immobilize and reduce fractures to assist in healing. There are various types:

  1. Skin Traction: traction applied over the skin, indirectly to the bone. This utilizes elastic bandages or adhesives.
    1. Buck’s Traction: lower extremity traction. This is not used with weights more than eight pounds.
    2. Russel’s Traction: stabilizes fractured femur
    3. Cervical Traction: for neck affliction
    4. Pelvic Traction: for back pain
  2. Skeletal Traction: traction applied directly into the bone via pin, wire, or tongs. This invasive placement may result in infection. As such, the nurse assesses for infection and cleans pin sites.

Traction Management

Never remove weights unless prescribed by the doctors. The weights should hang freely, be free of friction, and free of knots.

Nursing management includes management of the traction system, neurovascular status (6 Ps), infection, and complications of immobilization.

Complication of ImmobilizationManagement
PneumoniaTeach the patient breathing exercises (deep breathing, coughing)
ConstipationIncrease fluids and fiber (high residue)
Urinary Tract InfectionIncrease fluids
Pressure UlcersAssess skin integrity regularly
ContracturesUtilize positioning and ROM exercises
Deep Vein ThrombosisChecked with Homan’s sign

Casting

These are hard bindings of affected extremities to immobilize and promote healing. This may use two types of materials:

  1. Plaster of Paris, a slow-drying cast material. White.
  2. Fiberglass, a fast-drying cast material, but is more expensive. This comes in more colors, too.

Osteoporosis

“Porous bones” manifested by decreased bone mass density (BMD). This may occur in patients whose osteoclastic activity (bone resorption) is greater than osteoblastic activity (bone deposition).

  1. Risk Factors:
    • Being underweight
    • Smoking
    • Alcoholism
    • Sedentary lifestyles
    • Age
    • Diet (caffeine, alcohol, low calcium): should include ~1,200 mg of Calcium per day.
    • Post-menopausal (decreased estrogen)
    • Immobility

Surgically-Induced Osteoporosis

The removal of ovaries (oophorectomy) or testes (orchidectomy) are considered as essentially causative of osteoporosis. The resulting osteoporosis is considered “surgically-induced”.

  1. Diagnostic Examination: DEXA Scan to measure bone mass density and x-ray studies for pathologic fractures
  2. Management: Calcitonin, Bisphosphonates, Alendronic acid; all prevent bone resorption (breakdown). The patients are kept upright right after consumption, and are given on an empty stomach.
    • Diet: dairy products, dark green leafy vegetables.
    • Lifestyle: exercise, as exercise increases bone density. In immobilized patients, isometric exercises may be used.

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