Red bone marrow Found in flat bones of sternum, ribs, and ileum Produces blood cells and hemoglobin Yellow bone marrow Found in shaft of long bones Contains fat and connective tissue

2. Skeletal System
 Bone types
 Bone structure
 Bone function
 Bone growth and metabolism affected by calcium and
phosphorous, calcitonin, vitamin D, parathyroid,
growth hormone, glucocorticoids, estrogens and
androgens, thyroxine, and insulin.

3. Bones
 Human skeleton has 206 bones
 Provide structure and support for soft tissue
 Protect vital organs

4. Bones of the human skeleton.

5. Classification of bones by shape.

6. Bones
 Compact bone
 Smooth and dense
 Forms shaft of long bones and outside layer of other
bones
 Spongy bone
 Contains spaces
 Spongy sections contain bone marrow

7. Bone Marrow
 Red bone marrow
 Found in flat bones of sternum, ribs, and ileum
 Produces blood cells and hemoglobin
 Yellow bone marrow
 Found in shaft of long bones
 Contains fat and connective tissue

8. Joints (Articulations)
 Area where two or more bones meet
 Holds skeleton together while allowing body to move

9. Joints
 Synarthrosis
 Immovable (e.g., skull)
 Amphiarthrosis
 Slightly movable (e.g., vertebral joints)
 Diarthrosis or synovial
 Freely movable (e.g., shoulders, hips)

10. Synovial Joints
 Found at all limb articulations
 Surface covered with cartilage
 Joint cavity covered with tough fibrous capsule
 Cavity lined with synovial membrane and filled with
synovial fluid

11. Ligaments
 Bands of connective tissue that connect bone to bone
 Either limit or enhance movement
 Provide joint stability
 Enhance joint strength

12. Tendons
 Fibrous connective tissue bands that connect bone to
muscles
 Enable bones to move when muscles contract

13. Muscles
 Skeletal (voluntary)
 Allows voluntary movement
 Smooth (involuntary)
 Muscle movement controlled by internal mechanism
 e.g., muscles in bladder wall and GI system
 Cardiac (involuntary)
 Found in heart

14. Skeletal Muscle
 600 skeletal muscles
 Made up of thick bundles of parallel fibers
 Each muscle fiber made up of smaller structure
myofibrils
 Myofibrils are strands of repeating units called
sarcomeres

15. Skeletal Muscle
 Skeletal muscle contracts with the release of
acetylcholine
 The more fibers that contract, the stronger the muscle
contraction

16. Changes in Older Adult
 Musculoskeletal changes can be due to:
 Aging process
 Decreased activity
 Lifestyle factors

17. Changes in Older Adult
 Loss of bone mass in older women
 Joint and disk cartilage dehydrates causing loss of
flexibility contributes to degenerative joint disease
(osteoarthritis); joints stiffen, lose range of motion

18. Changes in Older Adult
 Cause stooped posture, changing center of gravity
 Elderly at greater risk for falls
 Endocrine changes cause skeletal muscle atrophy
 Muscle tone decreases

19. Assessment
 Health history
 Chief complaint
 Onset of problem
 Effect on ADLs (Activity of Daily Living)
 Precipitating events, e.g., trauma

20. Assessment
 Examine complaints of pain for location, duration,
radiation character (sharp/ dull), aggravating, or
alleviating factors
 Inquire about fever, fatigue, weight changes, rash, or
swelling

21. Physical Examination
 Posture
 Gait
 Ability to walk with or without assistive devices
 Ability to feed, toilet, and dress self
 Muscle mass and symmetry

25. Physical Examination
 Inspect and palpate bone, joints for visible deformities,
tenderness or pain, swelling, warmth, and ROM
 Assess and compare corresponding joints
 Palpate joints knees and shoulder for crepitus

26. Physical Examination
 Never attempt to move a joint past normal ROM or
past point where patient experiences pain
 Bulge sign and ballottement sign used to assess for
fluid in the knee joint
 Thomas test performed when hip flexion contracture
suspected

27. Figure 41-4 Checking for the bulge sign.

28. Checking for ballottement.

29. Diagnostic Tests
 Blood tests
 Arthrocentesis
 X-rays
 Bone density scan
 CT scan
 MRI
 Ultrasound
 Bone scan

30. Diagnostic Evaluation
 Imaging Procedures – CT, Bone Scan, MRI
 Nuclear Studies - radioisotope bone density,
 Endoscopic Studies –arthrocentesis, arthroscopy
 Other Studies –biopsy, synovial fluid, Arthrogram,
venogram,
 Electromyography
 Myelography*
 Laboratory Studies

31. Musculoskeletal
Assessment – Diagnostic Test
 Laboratory
 Urine Tests24 hour
creatine-creatinine ratio
 Urine Uric acid –24 hr
specimen
 Urine deoxypyridinoline
 Laboratory
 Blood Tests
 Serum muscle enzymes
 Rheumatoid Factor
 LE Prep/Antinuclear
Antibodies(ANA)
 Erythrocyte
Sedimentation Rate
 Calcium, Phosphorous,
Alkaline phosphatase

32. Muscoluloskeletal
Assessment – Diagnostic
 Blood Tests
 CBC – Hgb, Hct
 Acid phosphatase
 Metabolic/Endocrine
 Enzymes
Increase creatine
kinase, serum
increase glutamin-
oxaloacetic due to
muscle damage,
aldolase, SGOT

33. Musculoskeletal - Radiographic
 Standard radiography, tomography and
xeroradiography, myelography, arthrography and CT
 Other diagnostic tests: bone and muscle biopsy

34. Arthroscopy
 Fiberoptic tube is inserted into a joint for direct
visualization.
 Client must be able to flex the knee; exercises are
prescribed for ROM.
 Evaluate the neurovascular status of the affected limb
frequently.
 Analgesics are prescribed.
 Monitor for complications.

36. Bone Scan
 Nuclear medicine procedure in which amount of
radioactive isotope taken up by bones is evaluated
 Abnormal bone scans show hot spots due to
malignancies or infection
 Cold spot uptakes show areas of bone that are
ischemic

37. Arthroscopy
 Flexible fiberoptic endoscope used to view joint
structures and tissues
 Used to identify:
 Torn tendon and ligaments
 Injured meniscus
 Inflammatory joint changes
 Damaged cartilage

39. Musculoskeletal Trauma
 Tissue is subjected to more force than it can absorb
 Severity depends on:
 Amount of force
 Location of impact
Trauma is a very difficult or unpleasant experience that
causes someone to have mental or emotional problems
usually for a long time.
medical: a serious injury to a person's body.

40. Musculoskeletal Trauma
 Mild to severe
 Soft tissue
 Fractures
 Affect function of muscle, tendons, and ligaments
 Complete amputation

41. Preventing Trauma
 Teach importance of using safety equipment
 Seat belts
 Bicycle helmets
 Football pads
 Proper footwear
 Protective eyewear
 Hard hats

42. Soft Tissue Trauma
 Contusion
 Bleeding into soft tissue
 Significant bleeding can cause a hematoma
 Swelling and discoloration (bruise)
Contusion: a region of injured tissue or skin in which
blood capillaries have been ruptured; a bruise.

43. Soft Tissue Trauma -
Sprain Ligament injury (Excessive stretching of a ligament)
 Twisting motion
 Overstretching or tear
◦ Grade I—mild bleeding and inflammation
◦ Grade II—severe stretching and some tearing and
inflammation and hematoma
◦ Grade III—complete tearing of ligament
◦ Grade IV—bony attachment of ligament broken away
◦ (hematoma is a solid swelling of clotted blood within the
tissues.)

44. Sprains
 Treatment of sprains:
 first-degree: rest, ice for 24 to 48 hr,
compression bandage, and elevation
 second-degree: immobilization, partial weight
bearing as tear heals
 third-degree: immobilization for 4 to 6 weeks,
possible surgery
A sprain, also known as a torn ligament, is damage to
one or more ligaments in a joint, often caused by trauma
or the joint being taken beyond its functional range of
motion. ... Sprains can occur in any joint but are most
common in the ankle and wrist.

45. Soft Tissue Trauma - Strain
 Microscopic tear in the muscle
 May cause bleeding
 “Pulled muscle”
 Inappropriate lifting or sudden acceleration-
deceleration
A muscle strain, or pulled muscle, occurs when
your muscle is overstretched or torn. This usually
occurs as a result of fatigue, overuse, or improper use of
a muscle. ... These strains can cause pain and may limit
movement within the affected muscle group.

46. Soft Tissue Trauma
 To decrease swelling and pain, and encourage rest
 Ice for first 48 hours
 Splint to support extremities and limit movement
 Compression dressing
 Elevation to increase venous return and decrease swelling
 NSAIDs
Compression implies the deliberate application of pressure in
order to produce a desired clinical effect. It is usually achieved
by the use of elasticated stockings or an
appropriate bandage, and is most commonly used to control
oedema and reduce swelling in the treatment of venous
disorders of the leg.

47. Soft Tissue Trauma
 Diagnosis
 X-ray to rule out fracture
 MRI

49. Fractures
 Break in the continuity of bone
 Direct blow
 Crushing force (compression)
 Sudden twisting motions (torsion)
 Severe muscle contraction
 Disease (pathologic fracture)

50. Fractures
Classification of Fractures
 Closed or simple
 Open or compound
 Complete or incomplete
 Stable or unstable
 Direction of the fracture line
 Oblique
 Spiral
 Lengthwise plane (greenstick)

51. Stages of Bone Healing
 Hematoma formation within 48 to 72 hr after
injury
 Hematoma to granulation tissue
 Callus formation
 Osteoblastic proliferation
 Bone remodeling
 Bone healing completed within about 6 weeks; up
to 6 months in the older person

52. Fractures – Emergency Care
 Immobilize before moving client
 Joint above and below
 Check pulse, color, movement, sensation before
splinting
 Sterile dressing for open wounds

53. Fractures – Emergency Care
 Fracture reduction
 Closed—external manipulation
 Open—surgery

55. Acute Compartment Syndrome
 Serious condition in which increased pressure
within one or more compartments causes
massive compromise of circulation to the area
 Prevention of pressure buildup of blood or fluid
accumulation
 Pathophysiologic changes sometimes referred to
as ischemia-edema cycle

56. Emergency Care - Acute Compartment
Syndrome
 Within 4 to 6 hr after the onset of acute
compartment syndrome, neuromuscular damage
is irreversible; the limb can become useless
within 24 to 48 hr.
 Monitor compartment pressures.
(Continued)

57. Emergency Care (Continued)
 Fasciotomy may be performed to relieve pressure.
 Pack and dress the wound after fasciotomy.

58. Possible Results of Acute Compartment
Syndrome
 Infection
 Motor weakness
 Volkmann’s contractures: (a deformity of the hand,
fingers, and wrist caused by a lack of blood flow (ischemia) to
the muscles of the forearm)

59. Other Complications of Fractures
 Shock
 Fat embolism syndrome: serious complication
resulting from a fracture; fat globules are
released from yellow bone marrow into
bloodstream
 Venous thromboembolism
(Continued)

60. Other Complications of Fractures
(Continued)
 Infection
 Ischemic necrosis
 Fracture blisters, delayed union, nonunion, and
malunion

61. Musculoskeletal
Complications (continued)
 Muscle Atrophy, loss of muscle strength range
of motion, pressure ulcers, and other problems
associated with immobility
 Embolism/Pneumonia/ARDS (Acute respiratory
distress syndrome (ARDS) is a life-threatening lung
condition that prevents enough oxygen from
getting to the lungs and into the blood.
 TREATMENT – hydration, albumin, corticosteroids
 Constipation/Anorexia
 UTI
 DVT (Deep vein thrombosis (DVT) occurs when a
blood clot (thrombus) forms in one or more of the deep
veins in your body, usually in your legs.

62. Musculoskeletal Assessment - Fracture
 Change in bone alignment
 Alteration in length of extremity
 Change in shape of bone
 Pain upon movement
 Decreased ROM
 Crepitation
 Ecchymotic skin
(Continued)Ecchymosis is the medical term for the
common bruise. Most bruises form when blood
vessels near the surface of the skin are
damaged, usually by impact from an injury.
The force of the impact causes your blood
vessels to burst open and leak blood.

63. Musculoskeletal Assessment – Fracture
(Continued)
 Subcutaneous emphysema with bubbles under
the skin
 Swelling at the fracture site

64. Special Assessment Considerations
 For fractures of the shoulder and upper arm,
assess client in sitting or standing position.
 Support the affected arm to promote comfort.
 For distal areas of the arm, assess client in a
supine position.
 For fracture of lower extremities and pelvis, client
is in supine position.

65. Metabolic Bone Disorders
Osteoporosis
Osteomalcia
Paget’s Disease

66. Osteoporosis
 A disease in which loss of bone exceeds rate of
bone formation; usually increase in older women,
white race, nulliparity.
 Clinical Manifestations – bone pain, decrease
movement.
 Treatment – Calcium, Vit. D, estrogen
replacement, Calcitonin, fluoride, estrogen with
progestin, SERM (Selective Estrogen Receptor Modulator)
with anti-estrogens, exercise.
 Pathologic fracture-safety.

67. Classification of Osteoporosis
 Generalized osteoporosis occurs most commonly
in postmenopausal women and men in their 60s
and 70s.
 Secondary osteoporosis results from an
associated medical condition such as
hyperparathyroidism, long-term drug therapy,
long-term immobility.
 Regional osteoporosis occurs when a limb is
immobilized.

68. Health Promotion/Illness Prevention -
Osteoporosis
 Ensure adequate calcium intake.
 Avoid sedentary life style (a type of lifestyle with a
lack of physical exercise) .
 Continue program of weight-bearing exercises.

69. Osteoporosis - Assessment
 Physical assessment
 Psychosocial assessment
 Laboratory assessment
 Radiographic assessment

70. Five ethnic classes—Caucasians, Negroes, Mongols, Malaysians
& Americans.

71. Os
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72. O
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73. Osteoporosis
 Hormone replacement therapy
 Parathyroid hormone
 Calcium and vitamin D
 Bisphosphonates
 Selective estrogen receptor modulators
 Calcitonin
 Other agents used with varying results

74. Diet Therapy - Osteoporosis
 Protein
 Magnesium
 Vitamin K
 Trace minerals
 Calcium and vitamin D
 Avoid alcohol and caffeine

75. Fall Prevention - Osteoporosis
 Hazard-free environment
 High-risk assessment through programs such as
Falling Star protocol
 Hip protectors that prevent hip fracture in case of
a fall

76. Others - Osteoporosis
 Exercise
 Pain management
 Orthotic devices

77. Osteomalacia
 Softening of the bone tissue characterized by
inadequate mineralization of osteoid
 Vitamin D deficiency, lack of sunlight exposure
 Similar, but not the same as osteoporosis
 Major treatment: vitamin D from exposure to sun
and certain foods

78. Paget’s Disease of the Bone
 Metabolic disorder of bone remodeling, or
turnover; increased resorption (the process by
which osteoclasts break down bone and release the
minerals, resulting in a transfer of calcium from bone fluid
to the blood) of loss results in bone deposits
that are weak, enlarged, and disorganized
 Nonsurgical management: calcitonin,
selected bisphosphonates, mithramycin
 Surgical management: tibial osteotomy or
partial or total joint replacement

79. Paget’s Disease
 An imbalance of increase osteoblast and
osteoclast cells; thickening and hypertrophy.
 Bone pain most common symptom; bony
enlargement and deformities usually bilateral,
kyphosis, long bone.
 Analgesics, meds bisphosphonates and
calcitonin, NSAID, assistance devices, and
hot/cold treatment.

80. Osteomyelitis
 A condition caused by the invasion by one or
more pathogenic microorganisms that
stimulates the inflammatory response in bone
tissue
 Exogenous, endogenous, hematogenous,
contiguous

81. Osteomyelitis
 Infection of bone; causative agent – Staph/Strept
 Typical signs and symptoms : Acute osteomyelitis include:
 Fever that may be abrupt
 Irritability or lethargy in young children
 Pain in the area of the infection
 Swelling, warmth and redness over the area of the
infection
 Chronic osteomyelitis include:
 Warmth, swelling and redness over the area of the
infection
 Pain or tenderness in the affected area
 Chronic fatigue
 Drainage from an open wound near the area of the
infection
 Fever, sometimes
 Treatment – IV antibiotic; long term for 4-6 months

82. Surgical Management
Osteomyelitis
 Sequestrectomy (Surgical removal of a sequestrum), a
detached piece of necrotic bone that often migrates to a
wound, abscess, etc.
 Bone grafts
 Bone segment transfers
 Muscle flaps
 Amputation

83. Bone Tumors
Benign Bone Tumors
Malignant Bone Tumors
Metastatic Bone Disease
A tumor is an abnormal growth of cells that serves no purpose. A benign tumor
is not a malignant tumor, which is cancer. It does not invade nearby tissue
or spread to other parts of the body the way cancer can. In most cases, the
outlook with benign tumors is very good. But benign tumors can be serious if
they press on vital structures such as blood vessels or nerves. Therefore,
sometimes they require treatment and other times they do not.
Multiple myeloma is the most common primary malignant bone tumor but
is often considered a marrow cell tumor within the bone rather than a bone
tumor because it is of hematopoietic derivation . It occurs mostly in older adults.
Multiple myeloma is a cancer of plasma cells that produce monoclonal
immunoglobulin and invade and destroy adjacent bone tissue. Common
manifestations include bone pain, renal insufficiency, hypercalcemia, anemia,
and recurrent infections.

84. Osteosarcoma is the 2nd most common primary bone tumor and is highly
malignant. It is most common among people aged 10 to 25, although it can
occur at any age. Osteosarcoma produces malignant osteoid (immature bone)
from tumor bone cells. Osteosarcoma usually develops around the knee (distal
femur more often than proximal tibia) or in other long bones, particularly the
metaphyseal-diaphyseal area, and may metastasize, usually to lung or other
bone. Pain and swelling are the usual symptoms.
Bone metastasis occurs when cancer cells spread from their original site to a
bone. Nearly all types of cancer can spread (metastasize) to the bones. But
some types of cancer are particularly likely to spread to bone, including breast
cancer and prostate cancer. Bone metastasis can occur in any bone but more
commonly occurs in the spine, pelvis and thigh. Bone metastasis may be the
first sign that you have cancer, or bone metastasis may occur years after
cancer treatment. Bone metastasis can cause pain and broken bones. With
rare exceptions, cancer that has spread to the bones can't be cured.
Treatments can help reduce pain and other symptoms of bone metastases.

85. Bone Tumors
 Benign bone tumors (noncancerous):
 Chrondrogenic tumors: osteochondroma,
chondroma
 Osteogenic tumors: osteoid osteoma,
osteoblastoma, giant cell tumor
 Fibrogenic tumors

86. Interventions Non-drug pain relief measures
 Drug therapy: analgesics, NSAIDs
 Surgical therapy: curettage (simple excision
of the tumor tissue), joint replacement, or
arthrodesis*
*Arthrodesis is the fusion of vertebrae over a joint space that occurs
through a natural process or as a result of surgical procedure. In
surgery, arthrodesis, or fusion between two vertebrae, can be
achieved by placing bone graft and/or bone graft substitute to bridge
the vertebrae so that new bone grows into the spaces. (Mid-foot, Flat
foot deformity , joints, hip, knee, feet etc.)

87. Malignant Bone Tumors
 Primary tumors, those tumors that originate in the
bone
 Osteosarcoma
 Ewing’s sarcoma (bones/ soft tissues)
 Chondrosarcoma (cancer composed of cells derived from
transformed cells that produce cartilage)
 Fibrosarcoma Fibrosarcoma (fibroblastic sarcoma) is a
malignant connective (soft) tissue tumor which originates
from fibroblasts. The tumor may present different degrees of
differentiation : low grade (differentiated), intermediate
malignancy and high malignancy (anaplastic).
 Metastatic bone disease

88. Osteosarcoma
 Cancer of the bone – metastasis to the lung is
common. Most in long bones.
 Clinical manifestations – dull pain, swelling,
intermittent but increases per time; night
pain common.
 Treatment – radiation, chemotherapy,
hormonal therapy, surgical excision with
prosthetics, assistance devices, palliative
measures.

89. Treatment Cancer of Bone
 Interventions include:
 Treatment aimed at reducing the size or
removing the tumor
 Drug therapy; chemotherapy
 Radiation therapy
 Surgical management
 Promotion of physical mobility with ROM
exercises

90. Cancer of Bone
Anticipatory Grieving
 Interventions include:
 Active listening
 Encouraging client and family to verbalize feelings
 Making appropriate referrals
 Helping client and others to cope with the loss and
grieving
 Promoting the physician-client relationship

91. Cancer of Bone
Disturbed Body Image
 Interventions include:
 Recognize and accept the client’s view of body
image alteration.
 Establish and maintain a trusting nurse-client
relationship.
 Emphasize the client’s strengths and remaining
capabilities.
 Establish realistic mutual goals.

92. Potential for Fractures
Bone Cancer
 Interventions
 Nonsurgical management: radiation therapy and
strengthening exercises.
 Surgical management: replace as much of the
defective bone as possible, avoid a second
procedure, and return client to a functioning state
with a minimum of hospitalization and
immobilization.

93. Carpal Tunnel Syndrome
 Common condition; the median nerve in the wrist
becomes compressed, causing pain and
numbness
 Common repetitive strain injury via occupational
or sports motions
 Nonsurgical management: drug therapy and
immobilization
 Possible surgical management

94. Scoliosis
 Abnormal spinal curvature of various degrees
or severity involving shortening of muscles
and ligaments.
 Milwaukee brace (a back brace used in the
treatment of spinal curvatures) , internal fixative
devices.

95. Scoliosis
 Changes in muscles and ligaments on the
concave side of the spinal column
 Congenital, neuromuscular, or idiopathic in
type
 Assessment: complete history, pain
assessment, observation of posture
 Interventions: exercise, weight reduction,
bracing, casting, surgery

97. Treatment for lumbar lordosis is dependent on the severity
of the spine abnormality as well as the occurrence of
additional symptoms. Treatment is aimed at halting the
progression of abnormal curvature and preventing the
onset of further deformity.

98. Some of the treatment options for lumbar lordosis are as
under:
•Physical therapy is beneficial for many patients. Physical therapy along with
some types of postural exercises may be needed to correct the abnormalities
associated with the spine curvature. Physical therapy also helps in
strengthening the main muscles.
•If lumbar lordosis arises due to poor or improper posture, then simple
exercises are all that are needed.
•Patients who suffer from pain may be given anti-inflammatory drugs for
alleviation of pain and reduction of swelling and inflammation.
•Obese people are recommended to lose weight
•Yoga and meditation can help enhance the strength, awareness about the
body, the range of motion,and flexibility.
•Teens and young children may need to wear braces to correct the spine
curvature anomaly.
•Severe instances of lumbar lordosis may need different types of surgical
procedures such as artificial disc replacement, spinal instrumentation, or
kyphoplasty to rectify the condition.

99. A majority of patients do not suffer from any major
health complications even if lumbar lordosis is left
untreated.
However, as the spine plays a vital role in much of human
flexibility and movements, it is essential to manage the
health of the spine.
Untreated cases can also increase the susceptibility
to developing additional problems of the spine, legs, hip
girdle, and internal glands.