(NCM 116) CARE OF CLIENTS WITH PROBLEM IN LOCOMOTION (MUSCULOSKELETAL

SYSTEM)

• The ability to move, and maintain a desirable position is a basic human need. The bony
skeleton provides support and movable parts; the musculature facilitates movement.

• Movements serve two general purposes. First, it is necessary to perform normal

activities of daily living. Second, it is in itself a source of pleasure.

Objectives:
On completion of these concepts, the learner will be able to:
1. Describe the basic structure and function of the musculoskeletal system.
2. Discuss the significance of the health history to the assessment of musculoskeletal health.
3. Describe the significance of physical assessment to the diagnosis of musculoskeletal
dysfunction.
4. Specify the diagnostic test used for assessment of musculoskeletal functions.

OVERVIEW OF ANATOMY AND PHYSIOLOGY

The BONE
• Bones have 3 mechanical functions:
1. Support of body tissues as provided by the skeletal framework
2. Protection of body organs
3. Movement, affected by contraction of muscles pulling on bones that provide leverage
for motion.
• Other function of the bones:
1. Storage of calcium
2. Their morrow produces red blood cells (hematopoieses).
• Bones are composed of both living and non-living intracellular material. The living cells
are the osteoblast, osteoclast and osteocytes. The non-living intracellular material
(bone matrix) consists of mucopolysaccharides and collagen.
• There are 4 types of bones according to shape:
1. long (femur, humerus)
2. short ( carpals, tarsals)
3. flat (skull)
4. irregular (vertebrae)
• Each bone is composed of spongy (cancellous) and dense (compact) bone.
• The bone is made up of Haversian units. The haversian unit is composed of the
following structure:
1. Lamellae. These are concentric layers of calcified matrix.
2. Haversian canal. It is located at the center of concentric rings. It contains capillaries.
3. Lacunae. These are small spaces between the rings of the lamellae. These are
occupied by bone cells (osteocytes).
4. Canaliculi. These are very small canals that connect the lacunae with haversian
canal. These are through which the bones receives its nutrients.
• A long bone is composed of epiphysis (end of bone) and diaphysis (shaft).
• The periosteum is a white fibrous membrane that covers the bone, except on its
articular surfaces. The articular surfaces of the bone are covered by hyaline cartilage.

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 • The periosteum provides attachment for muscle fibers.
• The endosteum lines the marrow- filled medullary cavity and the Haversian canals.
• Blood is supplied to the bone through 3 routes:
1. The arteriols in the Harversian canal.
2. Vessels in the periosteum that penetrate the bone through Volkmann’s canals.
3. Vessels in the marrow and the ends of the bone.
• Bone healing is through callus formation. New growth of bone is callus. The 5 stages of
callus formation is as follows:
1. Hematoma formation. Bone is highly vascular so, bleeding occurs at both ends of
the fractured bone. Increased capillary permeability permits further extravasation of
blood into injured area. Blood collects in the periosteal sheath or adjacent tissues and
fastens the broken ends together.
2. Fibrin meshwork formation. Fibroblast invade the hematoma, causing it to become
organized into fibrin meshwork. WBC’s wall off the area, localizing the inflammation.
3. Invasion by osteoblasts. As osteoblasts invade the fibrous union to make it firm,
blood vessels develop from capillary buds, thereby establishing a source of supply for
nutrients to build collagen. Collagen strands become longer and become to incorporate
calcium deposits.
4. Callus formation. Osteoblast continue to lay the network for bone build-up as
osteoclasts destroy dead bone and help synthesize new bone. Collagen strengthens
and becomes further impregnated with calcium.
5.Remodelling. Excess callus is reabsorbed and trabecular bone is laid down along
lines of stress.

THE MUSCLE
• Muscles are divided into the following major groups:
1. Skeletal ( Striated, Voluntary)
2. Visceral ( Smooth, Involuntary)
3. Cardiac
The different types of muscle contractions:
1. Tonic. A continual partial contraction that is vital in maintenance of posture.
2. Isotonic. A contraction in which tension and length of the muscle change.
3. Isometric. Tension within the muscle increases but the muscle does not shorten.
4. Twitch. A jerky reaction to a single stimulus.
5. Tetanic. A more sustained contraction, produced by a series of stimuli in rapid
succession.
6. fibrillation. Asynchronous contraction of individual fibers.
7. Convulsive. Abnormal uncoordinated tetanic contraction occurring in varying groups
of muscles.
• Efficient and adequate muscle contraction is dependent on several factors: adequate
blood supply to and from the muscle fibers, effective enervation.
• The cerebellum is primarily responsible for control of muscle movement.
• Somatic motor neurons are the nerve cells that transmit impulses to skeletal muscles.
• A motor unit is the neuron and the muscle cell it activates.
• Acetylcholine, a chemical contained in small vesicles in the axon terminal promotes
actual muscle contraction. Muscle contraction occurs when acetylcholine contacts the
sarcolemma at the motor end- plate, or neuromuscular junction.
• Other structure of the musculoskeletal system are as follows:
1. Cartilage. These are fibers embedded in a firm gel. These reduce friction in the joint.

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 2. Ligaments. These are bands of dense fibrous tissue that are flexible and tough.
These attach bone to bone.
3. Tendons. These are bonds of fibrous tissues that attach muscle to bone.
4. Fascia. This is a sheet of loose connective tissue that may be found directly under
skin ( superficial fascia) or a sheet of dense, fibrous connective tissue making up
sheath of muscles, nerves and blood vessels (deep fascia).
5. Bursae. These are small sacs of connective tissue located wherever pressure is
exerted over moving parts. These are located between skin and bone, between tendons
and bone, or between muscles. Bursae are lined with synovial membrane and contained
synovial fluid. They serve as cushion between moving parts.

The JOINTS
• The joints provide flexibility within skeletal framework.
• The major classification of joints are:
1. Synarthroses (fibrous joints). Allow no movement ( ex. Sutures of the skull)
2. Amphiarthroses ( cartilaginous joints). Allow little movement ( ex. Intervertebral
joints).
3. Diarthroses ( synovial joints). Allow free movement (ex. Hip, knee, shoulder, elbow).
• The synovial membrane produces synovial fluid that lubricates the joints.
• The diarthrdial joints permit one or more of the following movements: flexion, extension,
adduction, abduction, rotation, circumduction, supination, pronation, inversion, eversion,
protraction or retraction.
• Small pieces of dense cartilage are interpaced between the articulating surfaces called
menisci (ex. Medial meniscus and lateral meniscus of the knee joint).

PHYSIOLOGIC CHANGES OF THE MUSCULOSKELETAL SYSTEM WITH AGING

➢ Connective tissues lose some of their elasticity and resilience, especially the articular
cartilage of the joints and the intervertebral disc of the spine.
➢ Muscles lose bulk, tone and strength as amount of physical activity decreases.
➢ Bone reabsorption takes place more rapidly than bone growth; especially in
postmenopausal women, calcium is lost from the bone.
➢ The shoulders may become stooped and narrower.
➢ The knees and hips maybe slightly flexed when standing or walking, often because of
pain associated with joint degeneration.
➢ Posture becomes stooped as the body attempts to compensate for changes in the
center of gravity.
➢ Heights decreases by 6 to 10 cm. Because the vertebrae lose bone density.
➢ Gait may become unsteady because of loss of muscle strength and coordination and the
individual is more subject to falls.

ASSESSMENT OF THE CLIENTS WITH MUSCULOSKELETAL DISORDERS

History
➢ Biographic data: age sex
➢ Chief complaints:
✓ Pain
✓ Joint stiffness
✓ Swelling
✓ Deformity and Immobility
✓ Sensory changes

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 ➢ Medical History
✓ Childhood and infectious Diseases (TB, poliomyelitis, haemophilia)
✓ Major illnesses, Hospitalizations (DM, arthritis, trauma)
✓ Medications (corticosteroids, anticonvulsants)
✓ Family history (gout, scoliosis, arthritis)
➢ Psychosocial History and Lifestyle
✓ Daily activities: Occupation ( heavy lifting, lot of driving, strenuous activities);
habits (recreational activities, exercise pattern, nutritional history).
➢ Review of systems
✓ Muscle pain, spasm, tenderness
✓ Joint pains, swelling, redness
✓ Weakness, limited movement, clumsiness
✓ Crepitus, backache, changes in joints and bones.
➢ Physical Examination
✓ Inspection and palpation of
▪ Muscle masses for symmetry, involuntary movements, tenderness, tone ,
strength and size: weakness due to polyneuropathy, electrolyte
embalance. Ex. Grasp strength by handshake; measure the girth of
extremity for increase in size due to edema, swelling, bleeding into the
muscle
▪ Joints for symmetry, crepitus, tenderness or pain, ROM
▪ Bone deformity
▪ Note for:
o Kyphosis- increased roundness of the thoracic curve
o Scoliosis- obvious lateral curvature of the spine
o Lordosis- abnormal increase in the lumbar curve
o Genu varum- “bowed legs”
o Genu valgum- “knock-knees”
Posture: Normal—normal curvature of the spine is convex through the thoracic portion and
concave through the cervical and lumbar portion.
▪ Observe the gait for smoothness and rhythm
o Note for unsteadiness or irregular movement, limping motion.
o Spastic hemiparesis gait (stroke)
o Steppage gait ( lower motor neuron disease)
o Shaffling gait (Parkinsons’ disease)
▪ Observe for bone integrity: assess for deformities and alignment

LABORATORY/DIAGNOSTIC TESTS
✓ Bood test
• ESR (elevated in SLE and arthritis)
• Rheumatoid factor (+ in rheumatoid arthritis)
• Antinuclear antibodies (ANA) (+ in rheumatoid arthritis)
• Anti-DNA (+ in SLE)
• C-reactive protein (+ in rheumatoid arthritis)
• Uric acid(elevated in gout)
• Minerals
▪ Calcium ( decreased levels in osteomalacia, osteoporosis;
increased levels in bone tumors, healing fractures, Paget’s
disease)

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 ▪ Alkaline phosphatase (elevated in bone cancer, osteoporosis,
osteomalacia, Paget’s disease)
▪ Phosphoros (increasesd levels in healing fractures)
• Muscle enzymes
▪ Adolase (elevated in muscle dystrophy, dermatomyosis)
▪ AST
▪ CK-MM (creatine Phosphokinase)- elevated in traumatic injuries
▪ LDH (Lactic Dehydrogenese)- elevated in muscle necrosis,
extensive cancer.
✓ X-rays. Done primarily to detect bone fractures
✓ Bone scan
▪ Measures radioactivity in bones 2 hours after iv injection of a radioisotope;
detect bone tumors, osteomyelitis
▪ Nursing care: patient must void before procedure, to prevent irritation of
the bladder by radioisotope; patient must remain still during scan.
✓ Arthroscopy
▪ Insertion of fiberoptic scope into a joint to visualize it, perform biopsies or
remove loose bodies.
▪ Performed in OR under sterile technique. Ensure that the correct joint is
examined-right or left joint.
▪ Nursing care: Apply pressure dressing over the area for 24 hours; Patient
must limit activity for several days to prevent bleeding.
✓ Arthrocentesis: removal of synovial fluid, blood or pus from a joint.
✓ Myelography. Lumbar future is done to withdraw a small amount of CSF, which is
replaced with a radiopaque dye; used to detect tumors or herniated intravertebral
disc.
▪ Nursing care pretest: consent form must be signed, check for iodine
allergy, keep on NPO after liquid breakfast.
▪ Nursing care posttest: if dye has been completely removed, keep patient
flat for 12 hours (oil dye), put patient in seizure precaution and do not
administer any phenothiazine drugs (water-based dye amipaque)
✓ Electromyography (EMG). Measures and records activity of contracting muscles
in response to electrical stimulations; helps differentiate muscle disease from
motor neuron dysfunction.

Second week: 5 hours (2 sessions).

PATHOPHYSIOLOGIC MECHANISMS OF ALTERATION IN PERCEPTION AND
COORDINATION: LOCOMOTION.
A. Infections/ Inflammatory and degenerative Disorders
➢ OSTEOMYELITIS
✓ Acute or chronic infection of the bone and surrounding soft tissues, most
commonly caused by Staphylococcus Aureus.
✓ Infection may reach bone through open wound, blood stream or by direct
extension from infected adjacent structures.
✓ Clinical Manifestations
• Malaise, fever
• Pain and tenderness of bone, redness and swelling over bone

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 • Difficulty with weight bearing
• Drainage from wound site may be present; necrosis of bone tissue
(sequestrum).
• Diagnostic test
▪ CBC –WBC may be elevated (active infection)
▪ ESR – may be elevated (indicates inflammatory process)
✓ Collaborative Management:
• Analgesics as prescribed
• Antibiotics as prescribed
• Dressing changes – use of sterile technique.
• Maintain proper body alignment and change position frequently to prevent deformities.
• Immobilization of affected parts
• Surgery if needed
▪ Incision and Drainage of bone abcess
▪ Sequestrectomy – removal of dead, infected bone and cartilage
▪ Bone grafting is recommended after repeated infections.

➢ SEPTIC ARTHRITIS
✓ Also known as Pyogenic arthritis, septic joint disease, bacterial arthritis, and suppurative
arthritis.
✓ A closed-space infection caused by invasion of the synovial membrane by pus-forming
bacteria or other pathogens.
✓ Neisseria gonorrhoeae is the most common causative pathogens in adults under 30
years of age.
✓ Joints most commonly affected in adult clients are knee, hip, shoulder, wrist and ankle.
✓ Clinical manifestations:
• Pain, swelling, warmth and tenderness in a single joint
• Low grade fever, malaise
• High grade fever and chills I client with positive blood cultures
✓ Predisposing factors:
• Recent surgery or injury, diagnostic procedures
• IV drug abuse
• Systemic disease

✓ Collaborative management:
• Synovial fluid culture
• Antibiotic therpy
• Decompression of the infected joint
• Synovectomy, joint aspiration and irrigation
• Scrupulous attention to the client’s joint position, exercise, and rehabilitations

➢ SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)

✓ It is a chronic, multisystem, collagen disorder.
✓ The cause are unknown, Autoimmune, Drugs, viral infections, genetics.
✓ Higher incidence in females (15 to 40 years old)

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✓ Precipitated by the following medications: Pronestyl, Phenergan, Apresoline, Dilantin,
INH, and Quinidine.
✓ Diagnostic test that support diagnosis of SLE: CBC (Pancytopenia), elevated ESR, (+)
ANA, (+) anti-DNA, (+) LE factor.
✓ Clinical Manifestations:
• Weakness, malaise, fatigue
• Fever, anorexia joints pain
• Oral/naso pharangeal ulcerations
• Alopecia
• Photosesitivity
• Butterfly rash over the nose and cheeks (most characteristics manifestations)
• Peri-neuropathy, seizures
• Psychosis
• Renal, CNS, Cardiopulmonary involvement
✓ Collaborative Management:
• Rest. To relieve muscle and joint pains.
• ROM exercises. To prevent contractions.
• Prevent infection. The client is immunocompromized.
• Avoid exposure to sunlight. To prevent exacerbation of manifestations: use
sunblock—lotion with SPF, long sleeved clothing, hats, sunglasses.
• Pharmacotherapy(These medications have anti-inflammatory effects): ASA, NSAIDs,
Steroids, Anti-malarial, cytotoxic agents (Cyclophosphamide/methotrexate)
• Plasmapheresis. This is separation of antibodies from the plasma. It inhibits
autoimmune response.

➢ RHEUMATOID ARTHRITIS
✓ Chronic systemic disease characterized by inflammatory changes in joints and related
structures, specifically the synovial membrane.
✓ Occurs in women more than men (3:1); peak incidence between 20 and 40 years of age.
✓ Cause is unknown
• May be autoimmune process or genetic in nature.
• Predisposing factors include fatigue, cold, emotional stress, infections.
• Joint distribution is symmetrical (both sides of the body is affected)- most
commonly affects smaller peripheral joints of hands; commonly involves wrist,
elbows, shoulders, knees, hips, ankles and jaws.
• If unarrested, affected joints progress through four stages of deterioration
synovitis, pannus formation, fibrous ankylosis and bony ankylosis.

✓ Clinical Manifestations:
• Fatigue, anorexia, malaise, weight loss, slight temperature elevation.
• Painful, warm, swollen joints with limited motion, stiffness in the morning and after
periods of inactivity
• Crippling deformity in long standing disease.
• Muscle weakness secondary to inactivity.
• Some patients have other manifestations: subcutaneous nodules, eye, vascular,
lung or cardiac problems.
• Sjogren’s syndrome characterized by excessive dryness of the eyes, mouth and
vagina.

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 • Felty’s syndrome characterized by leucopenia (causes low resistance to infection),
Splenomegaly (causes haemolytic anemia because trapped RBC’s in the spleen
undergo hemolysis.

✓ Collaborative Management
• Bed rest during acute pain
• Passive ROM exercises of joints to prevent contractures
• Splint painful joints
• Heat and cold applications (cold application during acute pain; 20 minutes at a time,
then followed by heat applications).
• Warm bath in the morning to relieve morning stiffness.
• Protect the client from infection.
• Provide well-balanced diet.
• Physical therapy as prescribed.
• Surgery: OSTEOTOMY (surgical removal of a wedge from the joint);
SYNOVECTOMY (removal of synovia); ARTHROPLASTY (replacement of joints
with prostheses).
• Pharmacotherapy:
▪ Aspirin – mainstay of treatment, has both analgesic anf anti-inflammatory
effects.
▪ Nonsteroidal anti-inflammatory drugs (NSAID’s):
o Indocin (Indomethacin)
o Butazolidin (Phenylbutazone)
o Motrin (Ibuprofen)
o Nalfon (Fenoprofen)
o Naprosyn ( Naproxen)
o Clinoril ( Sulidac)
▪ Gold compounds (chrysotherapy)
o Injectable forms: myochrysine (gold sodium thiomalate), Solganal
(aurothioglucose); given IM once a week; takes 3-6 months to become
effective.
o Oral form: Ridaura (auranofin); smaller dases are effective; diarrhea is a
common side effect of the drug.
o Corticosteroids (intra- articular injection) if pain become intolerable.

➢ OSTEOARTHRITIS (HYPERTROPHIC ARTHRITIS)

✓ Chronic, nonsystemic disorder of joints characterized by degeneration of joint
cartilage.
✓ Women and men affected equally, incidence increases with age. Also related to age and
joint trauma.
✓ Weight-bearing joints- spine, knees, hips, and ends of fingers are most commonly
affected.
✓ Clinical manifestations:
• Pain aggravated by use and relieved by rest.
• Stiffness of joints.
• Heberden’s nodes- bony overgrowth at terminal interphalangeal joints.
• Bouchard’s nodes- bony overgrowth at the proximal interphalangeal joints.
• Decreased ROM, crepitus
✓ Collaborative Management
• Assess joints for pain and ROM

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 • Relieve strain and prevent further trauma to joints:
o Use cane or walker when indicated.
o Maintain good posture and body mechanics, avoid excessive weight-
bearing and continuous standing.
o Physical therapy to maintain joint mobility and muscle strength.
o Promote comfort/relief pain (analgesics and NSAID’s)
o Joint replacement as needed.

➢ GOUT
✓ It is a disorder of purine metabolism.
✓ It is characterizedby high levels of uric acid in the blood and in the urine.
✓ There is precipitation of urates crystals (tophi) in the joints. This causes inflammation
and pain.
✓ Occurs most often in male; it is familial.
✓ Clinical Manifestations:
• Joint pain, redness, heat, swelling; great/big toe and ankle are most commonly
affected
• Headache, malaise, anorexia.
• Tachycardia, fever, tophi in the great toe, outer ear, hands and feet.
✓ Collaborative management:
• Drug therapy
o Acute attack—colchicine, NSAID
o Prevention- uricosuric agents. Agents that increase excretion of uric acid
in the urine: Probenecid, allopurinol(inhibits uric acid formation).
• Nursing intervention in antigout medications:
o Antigout medications should be used cautiously in clients with
gastrointestinal, renal, cardiac or hepatic diseases.
o Maintain a fluid intake of at least 2000 to 3000 ml. a day to avoid kidney
stones.
o Avoid purine-rich food (caffeine, alcohol, organ meats, sardines, salmon,
scallops and gravy).
o Instruct client to take medications with food to prevent GI irritation.
o Instruct client to avoid large doses of vitamin c while taking Allopurinol to
prevent kidney stone.
o Advise client to have yearly eye examination. Visual changes can occur
from prolonged used of allopurinol.
o Do not take ASA with antigout medications to prevent gout attacks.
o Allopurinol may increase the effect of Coumadin and oral hypoglycemic
agents.
o Observe for the following side-effects of antigout medications:
• Headache
• Nausea ,vomiting, diarrhea
• Bone marrow depression
• Flushed skin and skin rash
• Uric acid kidney stone
• Sore gums
• Mettalic taste
o Low purine diet
1. Organ meat
2. Shellfish

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 3. Legumes
4. Sardines
5. Salted anchovies
6. Mushrooms
7. Herring
8. Sweetbreads
9. Consommé
10. Beer/wine

➢ PAGET’S DISEASE (OSTEITIS DEFORMANS)

✓ Increase rate of bone tissue breakdown (resorption) by osteoclasts followed by
excessive abnormal bone formation by the osteoblasts.
✓ The diseased bone is weak and prone to fracture.
✓ Usually affects femur, tibia, lower spine, pelvis and cranium.
✓ Clinical manifestations:
• Bone pain
• Bone deformity
• Pathologic fractures
• Nerve compression
✓ Collaborative management:
• Analgesic/anti-inflammatory agents
• Calcitonin/Etidronate- to retard bone absorption
• Cytotoxic antibiotic (mithracin)- to decrease serum calcium, hydroxyproline,
serum alkaline phosphatase.

➢ LEGG-CALVE-PERTHE’S DISEASE (LCPD)

✓ Coxa plana or osteochondritis deformans juvenilis.
✓ It is characterized by aseptic necrosis of the head of the femur. It may lead to
fracture.
✓ The cause is unknown, however it is associated with decreased circulation to the head
of the femur.
✓ The disease is self-limiting. It runs a course of 8 months to 3 years.
✓ Children who are 3 to 12 age are most commonly affected.
✓ Clinical manifestations:
• Pain and impaired ambulations
• Joint dysfunction, limited ROM
• X-ray reveals changes in the bone.
✓ Collaborative management:
• Relief of pain in the joints (ASA, anti-inflammatory agents)
• Limitations of activities, bed rest to relieve synovitis, muscle spasm, and pain in
the joint.
• Encourage activities to maintain range of motion (swimming, bicycle riding)
• Provide mobility equipment
• Use of brace
• Cast application
• Surgery (osteomy)
• Prevent trauma to the hips (avoid contact sports, high impact running).

➢ FIBROMYALGIA

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✓ Chronic syndrome of musculoskeletal tissues characterized by widespread pain.
✓ Clinical manifestations:
• Diffuse pain and tender points on the skin which is symmetrical.
• Sleep disturbance
• Headache
• Restless leg syndrome
• Excess response to cold
• Periods of depression
• Memory loss
• Sleep apnea (characterized by excessive snoring during sleep).
✓ Massage back, neck, or shoulders as desired.
✓ Use heat via ultrasound for tender points
✓ Group therapy to assist with problem solving
✓ Passive stretching exercise by physical therapist.
✓ Active exercise, aerobic conditioning guided by physical therapist
✓ Aqua therapy program
✓ Pharmacotherapy:
1. NSAID’s
2. narcotic- analgesic for short term treatment of headache.
3. Antidepressant agents
4. Anti- parkinsonism agents for treatment of restless leg.

➢ OSTEOPOROSIS
✓ Systemic skeletal disease characterized by low bone mass, leading to enhanced bone
fragility and a consequent increase in fracture risk.
✓ Risk factors:
• Age-50years old and above
• Low body weight (less than 70 kg.)
• Family history
• Low physical activity
• White race
• Medications (especially glucocorticosteroids)
• Female (due to lower peak bone mass)
• Tobacco use
• Previous fracture
• Estrogen deficiency (postmenopausal period)
• Low calcium intake
• Increases with age.
✓ Clinical manifestations:
• Decreasing height (10 to 15 cm) due to collapsing vertebrae
• Back pain (T5 to L5).
• Dowager’s hump (curved upper back)
• Fracture with minimal trauma.
✓ Collaborative management:

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 • Diet and supplementation: calcium, vitamin D, phytoestrogen (beans, cabbage, rice,
berries, sesame seeds and grains).
• Exercise. At least 30 minutes, 5 days a week, then work up to 60 minutes. This
increases bone mass and total body calcium.
• Avoid use of tobacco products and alcohol.
• Pharmacotherapy:
o Evista (Raloxifene)
o Calcitonin (calcitonin)
o Forteo (Teriparatide)
o Medications are best taken with full glass of water after rising in the morning.
The client should remain upright for 30 minutes after taking the medication to
prevent GI side effects especially esophageal irritation.

➢ MUSCULAR DYSTROPHY
✓ A muscular disease characterized by progressive muscle weakness and deformity.
✓ The child will be confined to wheelchair by age 8 to 10 years (Duchenne type)
✓ Death occurs by age 20 years in 75% of clients.
✓ Clinical manifestations:
• Pelvic girdle weakness (the child waddles and falls)
• Gower’s sign(uses hand to push up and falls)
• Scoliosis(weakness of the shoulder girdle)
• Contractures and hypertrophy of muscles.
• Diagnostic test:
1. Muscle biopsy shows degeneration of muscle fibers and replacement of
fibers with fat.
2. EMG shows decrease in amplitude and duration of potentials
3. Serum enzymes are elevated, especially CK-MM.
✓ Collaborative Management:
• Maintain function as at optimal level; keep the child as active and independent
as possible.
• Plan diet to avoid obesity
• Support child and parents: provide information on availability of community
agencies and support groups.
B. Traumatic injuries
➢ Trauma
• Strain. Damage to tendon due to twisting motion.
• Sprain. Damage to ligaments due to twisting motion.
• Subluxation. Partial disarticulation of joint.
• Fracture. Any impairment in the bone integrity.
✓ Collaborative treatment for strain and sprain:
✓ R-est/immobilized affected point
I- ce application (first 72 hours)
C- ompression (elastic bandage)
E- levate affected point.
✓ ASA, NSAID’s as prescribed.
✓ Types of fractures:
• Complete. The entire circumference of the bone is impaired.
• Incomplete. Only partial circumference of the bone is impaired.
• Transverse. The line of break is across the bone.
• Oblique. The line of break goes diagonal along the bone.

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 • Spiral. The line of break goes around the bone.
• Greenstick. One side of the bone is impaired, the other is bent. It affects
cartilaginous bones; common in children.
• Comminuted. Bone ends are splintered into two more small pieces.
• Impacted. One bone end enters the intramedullary space of another bone end.
• Closed or simple. No break in skin integrity.
• Open or compound. With break in skin, with or without protrusion of bone.
• Stress. This is due to prolonged, repeated use of the bone.
• Pathologic. This is due to other systemic diseases like osteoporosis, cancer,
renal failure.
✓ Clinical Manifestations:
• Pain aggravated by motion, tenderness
• Loss of motion
• Edema(after 24 hours)
• Crepitus (grating sounds as bone ends rub together)
• Ecchymosis (after 24 hours)
• Shortening of the limbs due to spasm of muscle
• Obvious deformity
• X-ray confirms fracture
✓ Collaborative Management:
• Traction
• Reduction: (CREF) Closed reduction with internal fixation. Done through manual
fixation followed by application of cast; (ORIF) Open reduction with internal
fixation. Done through surgery which involves applications of pins, wires, screws,
and plates to the affected bones.
• Cast application
• Monitor for disorientation and confusion in the elderly.
• Do neurovascular checks.
• Prevent complications of immobility
• Encourage use of trapeze to facilitate movement
• Analgesics as prescribed
✓ Care of client with open reduction:
• Check dressing for bleeding and infection
• Empty hemovac. Serosanguinous drainage is normal.
• Assess LOC. Bleeding causes altered LOC.
• Turn every 2 hours
• Turn to unoperative side only to prevent pressure to operative site.
• Place 2 pillows in between legs while turning and when lying on side.
• Implement measures to prevent thrombus formation.
▪ Elastic hose
▪ Dorsiflexion of foot
▪ Anticoagulants such as aspirin as prescribed
▪ Encourage quadriceps setting and gluteal setting exercise
• Observe for adequate bowel and bladder function
• Assist client on getting in and out of bed on first and second post-op days
• Avoid weight bearing on affected leg until allowed.

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✓ Complications of fractures:
• Hypovolemic shock due to massive bleeding.
• Fat embolism. This usually follows fracture of the long bones. It may lead to
acute respiratory distress syndrome (ARDS).
• Compartment syndrome. This results from fractures of arms or legs where
closed compartments are present: it will result to function disability or
contractures like Volkmann’s contracture (irreversible wrist drop).
• Peroneal nerve palsy. It follows fracture of the leg. This results to foot drop.
• Avascular necrosis. Decreased bone tissue perfusion leads to bone tissue
death. Neck of femur is commonly affected.
• Delayed union or malunion or non-union. May result from infection, poor
circulation, ineffective immobilization, inadequate reduction or poor health
condition.

➢ HERNIATED NUCLEUS PULPOSUS ( HNP)

✓ It is rupture of intervertebral disc.
✓ It involves protrusion of nucleus pulposus (central part of intervertebral disc) into spine
causing compression of spinal nerve roots.
✓ Occurs more often in men.
✓ The 4th and 5th intervertebral disc in the lumbar region are most commonly affected.
✓ Predisposing factors: heavy lifting or pulling and trauma; degeneration of the
intervertebral disk; congenital predisposition.
✓ Clinical Manifestation:
• Lumbosacral disk
▪ Back pains radiating across the buttock and down the leg
▪ Weakness of leg and foot on the affected side
▪ Numbness and tingling in toes and foot.
▪ Positive straight leg raise test; pain on leg below the knee when leg
raised from a supine position (Lasegue’s sign).
▪ Depressed or absent Achilles reflex
▪ Muscle spasm in lumbar region.
• Cervical disk
▪ Shoulder pain radiating down the arm to hand, weakness of affected
upper extremity, paraesthesia’s and sensory disturbances.
• Diagnostic test for HNP:
▪ Myelogram
▪ CT Scan or MRI; MRI has greater sensitivity.
✓ Collaborative Management:
• Conservative management
▪ Bed rest on a firm mattress with bed board.
▪ Pelvic traction
▪ Drug therapy: anti-inflammatory, muscle relaxants
▪ Local application of heat and diathermy
▪ Use of corsetfor lumbosacral disk; cervical collar for cervical disk.
▪ Epidural injections of corticosteroids if pain becomes intolerable.
▪ Prevent complications of immobility.
• Surgery
▪ Chemonucleolysis – introduction of chymopapain (chymodiactin) into
disc to reduce size and pressure on affected nerve root.

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 ▪ Laminectomy- surgical excision of a part of posterior arch of vertebra
and removal of protruded disc to relieve compression of spinal nerve
▪ Spinal fusion- fusion of spinous processes with bone graft from iliac
crest to provide stabilization of spine.

➢ CARPAL TUNNEL SYNDROME (CTS)

✓ It occurs when the median nerve of the wrist is compressed by thickened flexor sheath,
skeletal encroachment, edema or soft tissue mass. It commonly due to repetitive hand
activities.
✓ Clinical manifestations:
• Pain from the wrist to the shoulder
• Numbness, paresthesia
• Thumb, index, and middle fingers are affected.
• (+) Tinel’s sign ( tingling sensation on percussion of inner wrist)
• (+) Phalen’s sign(tingling sensation on holding the wrist in flexion for few
minutes).
• Weak grip of hands.
✓ Collaborative management:
• Rest and splint the affected wrist.
• Avoid repetitive flexion of the wrist.
• NSAIDs as prescribed
• Carpal canal cortisone injections
• Surgical release of transverse carpal ligaments

➢ AMPUTATION OF A LIMB
✓ It is a surgical procedure done for peripheral vascular diseases if medical management
is ineffective. It may also be done in trauma.
✓ Types of amputation:
• Guillotine
• Closed/flap
✓ Nursing intervention- preoperative:
• Establish open and honest communication.
• Offer support and encouragement and accept patient’s response of anger/grief.
• Discuss treatment during the postop periods.
✓ Nursing intervention- postoperative
• Observe stump dressing for signs of hemmorhage and mark outside of dressing
so, rate of bleeding can be assessed (have tourniquet at bedside)
• Prevent edema.
• Prevent hip/knee contracture.
• Pain medication as ordered (for phantom limb pain)
• Provide stump care.
• Don’t’s on stump care:
▪ Hang stump over the bed
▪ Sit in wheelchair or edge of bed with stump flexed
▪ Place pillow under hip or knee
▪ Rest above knee stump on crutch handle.
▪ Place pillow between thigh.
▪ Abduct above knee stump.

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 ➢ BONE AND CARTILAGE TUMORS
• Benign cartilage-forming tumor
▪ Enchondroma. Lesion in mature cartilage but lacking histologic characteristic of
chondrosarcoma: found in hands, feet, humerus, ribs, femur; age range 20-40 years
of age.
▪ Osteochondroma. Most common bone tumor; cartilage-capped bony projection on
external bone surface; metaphyses of long bone, especially proximal tibia and distal
femur; age range birth-30 years of age.
• Benign bone-forming tumor
▪ Osteoid osteoma. Small osteoblastic lesion (less than 1 cm) with demarcated
outline and reative long bone formation; femur and tibia; age range 10-20 years
of age.
▪ Osteoblastoma. Similar to osteoid osteoma but larger , more than 2 cm; spine,
long bones, hands.
▪ Giant cell tumor (Osteoclastoma). Aggressive benign bone tumor with richly
vascularized tissue consisting of plump spindle shaped cells and numerous giant
cells; distal femur, distal radius, proximal humerus; age range 20-40 years of
age.
• Malignant bone-forming tumor
▪ Osteosarcoma. Most common primary malignant bone tumor; formation of bone
or osteoid by tumor cell; metaphyses, especially of distal femur, proximal tibia
and humerus; intermedullary region involved;age range 10-30 years of age.
▪ Ewing’s sarcoma. Composed of densely packed small cells with round nuclei;
often confused with osteomyelitis because it presents with fever, anemia,
leucocytosis, increased ESR; diaphyseal regions of long and flat bones; age
range 5-15 years of age.
▪ Fibrosarcoma. Formation of spindle-shaped tumor cell of interlacing bundlesof
collagen fibers, absence of other type of histologic differentiation; femur, tibia;
age range 5-80 years of age.
• Malignant cartilage forming tumor
▪ Chondrosarcoma. Formation of cartilage by tumor cells; higher cellularity and
greater pleomorphism than in chondromas; femur,pelvis, ribs, scapula; age range
30-60 years of age.

COMMON MUSCULAR INTERVENTIONS

1. ROM (range of motion) exercises
➢ Active ROM. Is done by the patient. It increases and maintains muscle tone and
joint mobility.
➢ Passive ROM. Is done for the patient. It maintains joint mobility.
➢ Active-Assistive ROM. Patient moves body parts as far as possible and the
health worker completes the exercise; or the stronger arm and leg perform
exercises to the weaker arm and leg.
➢ Active-Resistive ROM. Is contraction of muscle against an opposing force or
weight. It increases muscle power.

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2. Isotonic exercises. It involves change in both muscle length and tension.
3. Isometric Exercises. Active exercise that involve alternate contraction and relaxation of
muscle. There is no joint movement, the length of muscle does not change. It maintains muscle
strength and size.
▪ Hamstring or quadriceps setting. It is alternate tension and relaxation of thigh
muscle.
▪ Gluteal setting. Is alternate tension and relaxation of gluteus muscle. The client
presses the buttocks together, then release. It prevents thrombophlebitis.
▪ Kegel’s exercise. Is alternate tension and relaxation of pubococcygeal muscle.
It helps regain control of voiding among incontinent clients.
4. Assistive Devices for Walking
➢ Cane. The client must hold cane on the unaffected hand. The cane and the affected leg
are advanced together, to shift the weight unto the cane.
➢ Walker. Instruct the client to use “lift and walk” technique ( lift the walker forward, then
make few steps toward the walker); the height of the walker should be hip level; When
going up the stairs, use the walker at the back, when going down, use the walker in
front. The walker will protect the client from fall.
➢ Crutches
▪ Differrent crutch-walking gaits:
1. Four point gait. Advanced the right crutch, followed by the left foot, then the
left crutch, followed by the right foot. Weight bearing is allowed.
2. Two-point gait. Advanced the right crutch and left foot together, then the left
crutch and the right foot together. Weight-bearing is allowed.
3. Three-point gait. Advanced both crutches and affected leg together, followed
by the unaffected leg. Little or no weight-bearing is allowed, e.g. after total hip
replacement or total knee replacement.
4. Swing- to gait. Advanced both crutches, swing the body so that the feet will
be to the level of the crutches.
5. Swing-through gait. Advance both crutches, swing the body so that the feet
will be past the level of the crutches.
❖ Going up and down the stairs using crutches. “up with good and down
with the bad”.
❖ When going down the stairs, advanced the” bad leg” and the crunches
first, followed by the “good leg”. The bad leg should always be with the
crunches to provide support.

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Fourth week: 3 hours ( 1 session)
CARE OF THE CLIENT WITH CAST
➢ Carry the newly casted body parts with palm of the hand to prevent indentation and
pressure.
➢ Elevate the body parts with pillow support to prevent edema.
➢ Expose the cast to dry. It should not be covered with blanket or towel while it is drying
because the retained heat can burn the client. Dry cast appears white, shiny, hard and
resonant.
➢ Keep the cast dry and clean. Plaster of Paris cast dries within 48 hours or longer.
Fiberglass cast may dry in 10 to 15 minutes. The client is allowed weight bearing after
30 minutes.
➢ Observes “hot spots” and musty odor, or drainage from the cast. These are signs of
infection.
➢ Maintain skin integrity- by “petalling” (applying adhesive tapes at the edges of the cast
to smoothen the area).
➢ Do neurovascular checks. The following findings distal to application indicates that the
cast is too tight.
✓ Skin color- pallor, cyanosis
✓ Skin temperature- cold skin
✓ Sensation- numbness, tingling
✓ Mobility-inability to move the body parts
✓ Pulse-absence of pulse

➢ Windowing. Is done to facilitate observation under the cast. It is also done to assess
pulse or to prevent “cast syndrome” which occur if the client has body cast: manifested
by bloated feeling, prolonged nausea, repeated vomiting, abdominal distention, vague
abdominal pain, shortness of breath. Procedure involves removing of a part of a cast.
➢ Bivalving-is done for wound care or x-rays. It is also done when the cast is too tight or
when healing process has occurred. The procedure involves splitting of the cast.

CARE OF THE CLIENT WITH TRACTION

Traction. The act of pulling associated with counter pull.
Purposes:
➢ Reduced/ immobilized fracture
➢ Relieved muscle spasm
➢ Relieve pain
➢ Prevent/ correct deformities
Types of Tractions:
1. Skin Traction
➢ Buck’s Traction. Exerts straight pull affected extremity; temporary intervention
to immobilize the leg in patient with a fractured hip. Shock blocks at the foot of
the bed produce counter-traction and prevent the patient from sliding down in
bed. Has a horizontal weight. It can immobilize one bone only. Turn clients
towards unaffected side. Check for pressure sore at the heel of the foot and
signs and symptoms of thrombophlebitis.

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 ➢ Russell Traction. Knee is suspended in a sling attached to a rope and pulley on
a Balkan frame, creating upward pull from the knee (vertical traction); weights
are attached to the bed creating horizontal traction ; it has vertical and horizontal
weights; used to treat fracture of the femur, it can mobilize more than one bone.
Allow patient to move about in bed more freely and permits bending of the knee
joints. Hip should be flexed at 20-30 degrees. Foot bed usually elevated by
shock blocks to provide counter traction. Assess back of the knee for pressure
sores; check the leg for signs and symptoms of thrombophlebitis.
➢ Bryant Traction. Both legs are raised at 90 degrees angle to bed.Used for
children under 2 years or below 30 pounds to treat fractures of the femur and hip
dislocation- because the weight of the child is not adequate to provide counter
traction. Buttocks must be slightly off the mattress to enhance efficacy of the
weight as counter traction. Knees slightly flexed to prevent hyperextension
deformity of the knees—which will make the child unable to bend knees when
walking.
➢ Cervical Traction.A cervical head halter attached to weights that hang over
head of bed. Used for soft tissue damage of degenerative disc disease of
cervical spine to reduce muscle spasm and maintain alignment. Usually
intermittent traction, elevate head of the bed to provide counter traction.
➢ Pelvic traction.A pelvic girdle is secured around iliac crest with extension straps
attached to ropes and weights; used for low back to reduce muscle spasm and
maintain alignment. Usually intermittently applied; patient is placed in semi-
fowler’s position with knee gatched at 20-30 degrees angle, (William position).
Encourage client to overhead trapeze.
2. Skeletal Traction. Traction applied directly to the bones using pins, wires, or tongs (e.g.
Crutchfield) that are surgically inserted. Used for fractured femur, tibia, humerus, cervical
spine.
➢ Balanced suspension Traction. Produced by a counterforce other than the patient’s
weight; Extremity floats or balances in the traction apparatus; patient may change
position without disturbing the line of traction.
➢ Thomas splint with Pearson attachment. Used with skeletal traction in fractures of the
femur; hip should be flexed at 20 degrees. Use footplate to prevent foot drop. Check
pressure sore at the inguinal area.
Principles in the care of client with traction:
✓ The line of pull should be in line with the deformity
✓ There should be an adequate counter traction. The weight of the body serves as
counterattraction.
✓ Apply traction continuously.
✓ Allow the weights to hang freely. Weights should not touch the floor.
✓ Turn the client as indicated.
✓ Avoid friction. There should be no knots along the rope.
✓ Pin site care for skeletal traction:
• Cleanse and apply antibiotics ointment as prescribed
• Observe site for signs and symptoms of infection.
✓ DO neurovascular check
✓ Prevent complications of immobility.

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 ➢ Nursing diagnosis
• Pain related to tissue and bone trauma, swelling, skeletal traction, or cast
pressure.
❖ Expected outcome: client will report relief of pain after analgesics and
comfort measures.
• Risk for peripheral neurovascular dysfunction related to venous stasis, arterial
insufficiency, and swelling.
❖ Client will maintain intact circulation, sensation and mobility.
• Impaired mobility related to pain, swelling, surgical procedure, or immobilization
from traction, cast, or splint.
❖ Client will regain or maintain maximum mobility and optimal functional
position; client will have increased strength and function in the affected
limb.
• Self-care deficit: feeding, hygiene, dressing, toileting related to immobility
secondary to traction or cast.
❖ Client will maintain maximum self-care.
• Impaired tissue integrity related to punctured wound, compoundfractures; pins
wires, screws, or other surgical intervention; or physical immobility.
❖ Client will demonstrate adequate wound healing without infection. Skin
will remain intact.
• Risk for constipation related to immobility and change in toileting methods.
❖ Client will experience normal bowel elimination.

Prepared by:
Reca Rose Egano-Tuban, RN,MAN, MIB

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