MUSCULOSKELETAL SYSTEM

A. Functions
1. Movement
2. Maintains posture
3. Support
4. Protection
5. Hematopoiesis
6. Mineral homeostasis

B. Contusions, Strains, and Sprains
1. Contusion
a. soft tissue injury produced by blunt
force.
2. Strain
a. muscle pull from overuse,
overstretching, or excessive stress.
3. Sprain
a. injury to the ligaments surrounding
a joint, caused by a wrenching or
twisting motion.
b. Treatment: RICE Rest, Ice,
Compression, Elevation

C. Fracture
Break in the continuity of bone
Resulting from trauma or various disease
processes

Types
1. Complete
fracture extends through entire
bone, producing 2 or more
fragments.
Simple or Closed
fractured bone; does not protrude
through skin
Types
1. Compound or Open- fractured
bone extends through skin and
mucous membranes
2. Comminuted fracture- multiple
bone fragments
3. Oblique fracture- fracture line at
45-degree angle to long axis of
bone
4. Spiral fracture- fracture line
encircling the bone
5. Transverse fracture- fracture line
perpendicular to long axis of bone
2. Incomplete Fracture
when only part of the bone is
broken.
Greenstick fracture- fractureof one
side of bone; other side merely
bends; usually seen only in
children
Bowing fracture- bending of bone
Stress fracture- micro-fracture

Clinical Manifestations
o Pain and tenderness, soft tissue edema,
abnormal motion, crepitus, obvious
deformity, discoloration or ecchymosis

Diagnostic Studies
o X-ray
Objectives of Treatment
1. Optimal realignment
2. Rigid immobilization
3. Restoration of function

Treatment Modalities for Fracture
1. Closed or Open Reductio
2. Casting
3. Traction
4. Internal or External Fixation Devices
5. Reduction (setting the bone)
Refers to restoration of the
fracture fragments into anatomic
rotation and alignment
Closed Reduction (Manipulation)
Bone ends are realigned w/o
surgical exposure of the fracture
site
Anesthesia may or may not be
used
Followed by casting to maintain
proper alignment
Open Reduction
Operative procedure utilized to
achieve bone alignment
Pins, wire, nails or rods may be
used to secure bone fragments in
position
Prosthetic implants may also be
used
Immobilization
Maybe accomplished by internal or
external fixation
Internal Fixation Devices
Implanted surgical devices to align
and stabilize the fracture site until
healing can occur
Used when closed reduction does
not provide stable immobilization
External Fixation Devices
Two or more rigid bars are placed
horizontally above and below the
fracture site in the long bones of
the extremities

Early Complication of Fractures
1. Shock, fat embolism
o Assessment
(S) dyspnea
(O) tachypnea, tachycardia,
hypoxia, crackles, wheezes,
chest pain, cerebral
disturbances
o N/I
High Fowlers position
O2 stat
Respiratory support measures,
CPR in event of respiratory
failure
Corticosteroids: reduce
inflammatory lung reaction
Morphine
2. Compartment syndrome
o Assessment
(S) deep, throbbing,
unrelenting pain not
controlled by narcotics
(O) paresthesia (early),
swelling, motor weakness
o N/I:
Elevate injured extremity
Avoid tight bandages, splints
or casts
Prepare patient for fasciotomy
3. Infection
o Assessment:
(S) pain
(O) temperature and pulse,
edema, sudden local
induration, thin, watery, foul-
smelling exudate, crepitation
(maybe indicative of gas
gangrene; with cast-warm
area, foul smell
o N/I:
Monitor V/S, drainage
Prophylactic tetanus toxoid
Prophylactic anti-infectives as
ordered if wound is
contaminated at time of injury
Instruct patient not to touch
open wound, pin sites or put
anything inside cast

Delayed complications
1. Delayed union/Non-union
o Assessment:
(S) pain
(O) callus formation, on X-ray-
poor alignment
o N/I:
Maintain immobilization and
alignment
Maintain adequate nutrition
Avoid trauma to affected
extremity
Increase calcium in diet
2. Avascular Necrosis/Circulatory
Impairment
o Assessment:
(S) tenderness, pain, especially
on passive motion
(O) limited movement
o Treatment:
Revitalize the bone with bone
grafts
Prosthetic replacement
Arthrodesis

Fracture Care
Maintain in optimal alignment
Check all bony prominences for evidence
of pressure q4h and prn, depending on
amount of pressure
Monitor: circulation, sensation and
motion of affected part
Assess circulation in the injured limb:
warmth and color, capillary refill,
peripheral pulses
Assess nerve supply to the limb
Sensory: pinprick over
fingertips/heel, dorsum of hand/foot
Motor: dorsiflexion and plantar
flexion of wrist/foot
Maintain mobility in unaffected limb and
unaffected joints of affected limb by
active and passive ROM exercises
Prevent foot drop by using ankle-top
sneakers

Cast
Function:
For immobilization
Maintains bone alignment
Prevents muscle spasm
Materials
Gypsum (CaSO4 crystals)
Stockinette: prevents irritation
Lead pencil: to mark area
Basin of water
Warm: slows setting process
Cold: hastens setting process
NURSING CARE:
Priority: Neurovascular Check
C-irculation
M-otion
S-ensation: WOF S/Sx Impaired
Circulation (Mgt:bivalving)
B-lueness/ Coldness
L-ack of distal peripheral pulse
E-dema not corrected by elevation
P-ain on casted extremity
T-ingling sensation (refer asap!)
Use open palm to prevent indentation
Support cast with soft pillow
May use blower: low, cool setting to
dry
Mark area with bleeding with a pen
Dont put anything inside the cast

Traction: mechanism by which a steady pull is
placed on a part or parts of the body
Types:
Skin traction: Application of wide band
of moleskin, adhesive, or commercially
available devices directly to the skin
and attaching weights to them.
Bucks extension:
Exerts straight pull on the
affected extremity; to immobilize
the leg in patient with a fractured
hip; Has a horizontal weight
Turn towards unaffected side;
Check for pressure sore at the heel
of the foot
Russel traction: Knee is suspended
in a sling attached to a rope and
pulley on a Balkan frame, creating
upward pull from the knee;
Weights are attached to the foot of
the bed
Used to treat fracture of
the femur; Allows patient to move
about in bed more freely and
permits bending of the knee joint
Assess back of the knee
for pressure sores
Bryants traction: Both legs raised
90 angle to bed
Used for children under 3
years and 30 lbs to treat fractures
of the femur and hip dislocation
Buttocks must be slightly
off mattress
Knees slightly flexed
Pelvic traction: Pelvic girdle with
extension straps attached to ropes
and weights
Used for low back to
reduce muscle spasm and maintain
alignment

Skeletal Traction: Traction applied
directly to the bones using pins, wires,
or tongs (Crutchfield) that are surgically
inserted, used for fractures femur,
tibia, humerus, cervical spine
Balanced suspension traction:
Produced by a counterforce
other than the patients weight
Extremity floats or balances in
the traction apparatus; Patient
may change position without
disturbing the line of traction
Used for displaced or
overriding fx of femur; Relieves
muscle spasms; Realigns fx
fragments; Promotes callus
formation

Care of the Clients in Traction
5 General Principles in Traction Care:
o Line of pull should be in line
with the deformity
o Adequate countertraction
present
o Apply traction continuously
o Allow the weights to hang
freely
o Avoid friction
Turn the client as indicated; Pin
site care for skeletal traction;
Cleanse and apply antibiotic
ointment; Do neurovascular
checks; Prevent complication of
immobility
Nursing Intervention
Promote healing and prevent
complications
diet: high protein, iron,
vitamins (tissue repair),
moderate carbohydrates
(prevent weight gain)
increase fluid intake
assess for complications of
immobility (pneumonia,
constipation, decubitus ulcers,
osteoporosis)
assess casted extremity for
presence of foul odor,
drainage, paleness or
blueness, change in
temperature, pulselessness,
tingling, numbness
Prevent injury or trauma
avoidance of high-risk
activities (sky diving, high
impact sports, rollerblading)
avoidance of safety hazards
(throw rugs, untreated vision
problems)
regular exercise
provide care related to
ambulation with crutches
provide safety measures
related to possible
complications following
fracture

Crutch Walking
The distance between the axilla and the
arm piece on the crutches should be at
least 3 fingerwidths below the axilla
The elbows should be slightly flexed, 30
degrees
When ambulating with the client, stand
on the affected side.
Crutch stance: tripod (triangle) position
(6-10 inches in front and to the side).
Instruct the client never to rest the
axilla on the axillary bars.
Instruct the client to look up and
outward when ambulating.
Instruct the client to stop ambulation if
numbness or tingling in the hands or
arms occurs.

Crutch gaits
Four-point gait
Sequence:
Advance left crutch 4-6 inches
Advance right foot
Advance right crutch
Advance left foot
Advantages: most stable crutch
gait
Requirements: Partial weight
bearing on both legs
Three-point gait
Sequence:
Advance both crutches
forward with the affected leg
and shift weight to crutches.
Advance unaffected leg and
shift weight onto it.
Advantages: allows the affected leg
to be partially or completely free
of weight bearing
Requirements: full weight bearing
on one leg, balance and upper-
body strength.
Two-point gait
Sequence:
Advance left crutch and right
foot
Advance right crutch and left
foot
Advantages: Faster version of
the four-point, normal walking
pattern.
Requirements: Partial weight
bearing on both legs
Swing-through gait
Sequence:
Move both crutches forward.
Move both legs farther ahead than
crutches.

Amputation of a Lower Extremity
Removal of a body part, usually an
extremity
10% of patients experience
uncomfortable sensations phantom
limb pain.
Risk Factors
Atherosclerosis obliterans
Uncontrolled DM
Malignancy
Extensive and intractable infection
Severe trauma