GLOSSARY

• Atonic- without tone; denervated muscle that atrophies

• Atrophy- decrease in the size of a muscle
• Bursa- cartilaginous/fibrous tissue at fracture site
• Cancellous bone- latticelike bone structure; trabecular
bone
• Cartilage- tough, elastic, avascular tissue at ends of bone
• Clonus- rhythmic contractions of muscle
• Contracture- abnormal shortening of muscle, joint, or
both; fibrosis
• Cortical bone- compact bone
• Crepitus- grating or crackling sound or sensation; may occur with
movement of ends of a broken bone or irregular joint surface
• Diaphysis- shaft of long bone
• Effusion- excess fluid in joint
• Endosteum- a thin, vascular membrane covering the marrow cavity
of long bones and the space in cancellous bone
• Epiphysis- end of long bone
• Fascia (epimysium)- fibrous tissue that covers, supports, and
separates muscles
• Fasciculation- involuntary twith of muscle fibers
• Flaccid- limp; without muscle tone
• Hypertrophy- enlargement; increase in the size of a muscle
• Isometric contraction- muscle tension is increased without changing
its length; there is no associated joint motion
• Isotonic contraction- muscle is shortened without a change in its
tension; a joint is moved as a result
• Joint- area where bone ends meet; provides for motion and flexibility
• Joint capsule- fibrous tissue that encloses bone ends and other
surfaces
• Kyphosis- increase in the convec curvature of the thoracic spine
• Lamellae- mature compact bone structures that form concentric
rings of bone matrix; lamellar bone
• Ligament- ropelike bundles of collagen fibrils connecting bones
• Lordosis- increase in concave curvature of the lumbar spine
• Ossification- process in which minerals (calcium) are deposited in bone
matrix
• Osteoblast- bone-forming cell
• Osteoclast- bone resorption cell
• Osteocyte- mature bone cell
• Osteogenesis- bone formation
• Osteon- microscopic functional bone unit
• Osteopenic- refers to a reduction in bone mass to below normal levels
• Paresthesia- abnormal sensation (e.g., burning, tingling, numbness)
• Periosteum- fibrous connective tissue covering bone
• Remodeling- process that ensure bone maintenance through
simultaneous bone resorption and formation
• Resorption- removal/destruction of tissue, such as bone
• Scoliosis- lateral curving of the spine
• Spastic- having greater-than-normal muscle tone
• Synovium- membrane in joint that secretes lubricating
fluid
• Tendon- cord of fibrous tissue connecting muscle to bone
• Tone (tonus)- normal tension (resistance to stretch) in
resting muscle
• Trabeculae- latticelike bone structure; cancellous bone
Musculoskeletal system is composed of:
• Bones
• Joints
• Muscles
• Tendons
• Ligaments
• Bursae of the body
- The major functions of this system is to support and protect the body and foster
movement of the extremeties.
- Musculoskeletal disorders and injuries are the leading cause of of disability in the
United States.
- Arthritis is the chieft cause of musculoskeletal-related disability in the United
States, with an estimated 52.5 million adults diagnosed with this
disorder.Incidence of arthritis is expected to increase to 67 million by 2030.
Anatomic and Physiologic
Overview
• Musculoskeletal system provides protection for vital organs
:including the brain, heart, and lungs;serves as a framework to support
body structures; and makes mobility possible.
📍Produce heat that helps maintain body temperature.
📍reservoir for immature blood cells and essential minerals,
: Including the calcium, phosphorus, magnesium, and fluoride.
📍98% of total body calcium is present in bone
 Structure and Function of the Skeletal System
• 📍206 bones in the human body
:divided into four categories classified by
their shape:
📍long, short, flat, and irregular.
:The shaft, known as the diaphysis, is
primarily cortical bone.
:The ends of the long bones, called
epiphyses, are primarily cancellous bone.
📍The short bones are the irregularly shaped bones located in the ankle
and hand.
📍Irregular bones have unique shapes related to their function.
Generally, irregular bone structure is similar to that of flat bones.
📍Bone is composed of cells, protein matrix, and mineral deposits.
📍The cells are of three basic types-
1. osteoblasts- function in bone formation by secreting bone matrix.
2. osteocytes- are mature bone cells involved in bone maintenance;
they are located in lacunae.
3. osteoclasts- located in shallow Howship’s lacunae (small pits in
bones), are multinuclear cells involved in dissolving and resorbing bone.
• 📍The micro- scopic functioning unit of mature cortical bone is the
osteon, or Haversian system.
📍Around the capillary are. Circles of mineralized bone matrix called
lamellae.
📍 Within the lamellae are lacunae that contain osteocytes.
Nourished through tiny structures called canaliculi (canals)
📍Lacunae in cancellous bone are layered in an irregular lattice network
known as trabeculae.
• periosteum contains nerves, blood vessels, and lymphatics.
• The endosteum is a thin, vascular membrane that covers the marrow
cavity of long bones and the spaces in cancellous bone.
BONE FORMATION
OSTEOGENESIS

 development and formation of bone

 This process begins between the sixth and seventh

weeks of embryonic development and continues
until about age twenty-five; although this varies
slightly based on the individual.
OSSIFICATION

the process by which the bone

matrix is formed and hard mineral
crystals composed of calcium and
phosphorus (e.g., hydroxyapatite)
are bound to the collagen fibers.
These mineral components give
bone its characteristic strength,
Bone is a dynamic tissue in a constant state of turnover. Throughout the lifespan,
a process known as bone remod- eling occurs, in which old bone is removed and
new bone is added to the skeleton (formation).

During childhood and the teenage years,

new bone is added faster than old bone is
removed; therefore, bones become larger,
heavier, and denser. This continues until
peak bone mass is reached, typically by age
20 years

Remodeling maintains bone structure and

func- tion through simultaneous resorption
and osteogenesis, and as a result, complete
skeletal turnover occurs every 10 years
 The balance between bone resorption and formation
is influenced bythe ff. factors:

① physical activity
② dietary intake of certain nutrients,
especially calcium;
③ several hormones, including
calcitriol (i.e., activated vitamin D),
parathyroid hormone (PTH),
calcitonin, thyroid hormone,
cortisol, growth hormone, and the
sex hormones estrogen and
testosterone (Florence, Allen
Physical activity, particularly weight-bearing activity, acts to stimulate
bone formation and remodeling. Bones subjected to continued weight
bearing tend to be thick and strong.
people who are unable to engage in regu lar weight-bearing activities, such as those on prolonged
bed rest or those with some physical disabilities, have increased bone resorption from calcium
loss, and their bones become osteopenic (reduced in terms of mass) and weak. These weak- ened
bones may fracture easily.
Good dietary habits are integral to bone health.
1000 to 1200 mg of calcium daily intake of essen- tial to maintaining adult
bone mass.

Good sources of calcium include:

① low-fat milk, yogurt, and cheese.
② Foods with added calcium such as orange juice, cereals, and bread are also beneficial.
③ Vitamin D also plays a major role in calcium absorption and bone health. Young
adults need a daily vitamin D intake of 600 IU, whereas adults 50 years and older require a
daily intake of 800 to 1000 IU to ensure good bone health

Dietary sources of vitamin D include:

④ vitamin D-fortified milk and cereals,
⑤ egg yolks
⑥ saltwater fish
⑦ liver
Several hormones are vital in ensuring that calcium is properly absorbed and
available for bone mineralization and matrix formation.
① Calcitriol functions to increase the amount of calcium in the blood by
promoting absorption of calcium from the gastrointestinal tract.

② PTH and calcitonin are the major hormonal regulators of calcium

homeostasis.

③ Both thyroid hormone and cortisol have multiple systemic effects with
specific effects on bones.

④ Growth hormone has direct and indirect effects on skel-etal growth and remodeling.

⑤ The sex hormones testosterone and estrogen have impor cant effects on bone
remodeling. Estrogen stimulates osteo- blasts and inhibits osteoclasts; therefore,
bone formation isenhanced and resorption is inhibited. Testosterone has both direct
and indirect effects on bone growth and formation.
During the process of bone remodelingosteoblasts produce a
receptor for activated nuclear factor-kappa B ligand (RANKL) that
binds to the receptor for activated nuclear factor-kappa B (RANK)
present on the cell membranes of osteoclast precursors, causing
them to differentiate and mature into osteoclasts, which causes
bone resorption.

osteo- blasts may produce osteoprotegerin (OPG), which blocks the

effects of RANKL, thereby turning off the process of bone
resorption. T cells that may become activated as a result of the
inflammatory process may also produce RANKL, overrid ing the
effects of OPG and causing continued bone resorption during times
of stress and injury, which can lead to loss of bone matrix
andfracture.
BONE HEALING
 WHEN BONE IS FRACTURED

① the bone begins a healing process to reestab- lish continuity and strength.

B
② The bone fragments are not patched together with scar tissue; instead, the bone regener- ates itself.

Fracture healing occurs in the bone marrow, where endothelial cells rapidly differentiate into osteoblasts;
in the bone cortex, where new osteons are formed; in the periosteum, where a hard callus (fibrous tissue)
is formed through intra- membranous ossification peripheral to the fracture, and where cartilage is
formed through endochondral ossification adjacent to the fracture site; and in adjacent soft tissue, where
a bridg ing callus forms that provides stability to the fractured bones.
③
The repair of a simple fracture occurs in essentially four
stages:

① Stage 1: Hematoma formation occurs during the first 1 to 2 days of the fracture. Bleeding
into the injured tissue and local vasoconstriction occur, and a hematoma forms at the site
of the fracture.
② Stage II: Fibrocartilaginosa callus formation occurs with the formation of granulation
tissue. Fibroblasts and osteoblasts migrate into the fractured site and begin the
reconstruction of bone.

③ Stage III: Bony callus formation (ossification) usually begins during the third or fourth week
of fracture healing and con- tinues until a firm bony union is formed.

④ Stage IV: Remodeling occurs as necrotic bone is removed by the osteoclasts. Compact bone
replaces spongy bone around the periphery of the fracture. Although the final structure of
the remodeled bone resembles the original unbroken bone, a thick- ened area on the
4 STAGES OF BONE REPAIR
Serial x-rays are used to monitor the progress of bone heal ing.

Factors influence the rate of fracture healing:

① the type of bone fractured,
② the adequacy of blood supply,
③ the condition of the fracture fragments
④ the immobility of the fracture site,
⑤ general health of the person

Adequate immobilization is essential until there is

x-ray evidence of bone forma- tion with ossification.
Serial x-rays
When fractures are treated with internal or external
fixation techniques

• the bony fragments can be placed in direct contact.

• Primary bone healing occurs through cortical bone
(Haversian) remodeling.
• Little or no cartilaginous callus develops. Immature bone
develops from the endosteum.
• There is an intensive regeneration of new osteons, which
develop in the fracture line by a process similar to normal
bone maintenance.
Fracture strength is obtained when the new
osteons have become established.
STRUCTURE AND
FUNCTION OF THE
ARTICULAR SYSTEM
 THREE BASIC KINDS OF JOINTS

Synarthrosis joints Referred to as “fibrous joints.” (e.g., the skull sutures)

Are immovable because of
fibrous tissue banding.

Amphiarthrosis joints Referred to as “cartilaginous (e.g., the vertebral joints and the
joints.” symphysis pubis)
Allow limited motion.

Diarthrosis joints Referred to as “synovial joints.” Examples:

Freely movable tissue. Ball-and-socket
Hinge joints
Saddle joints
Pivot joints
Gliding joints
 • Ball-and-socket joint

SEVERAL TYPES • Hinge joint

OF DIARTHROSIS • Saddle joints
JOINTS
• Pivot joints
• Gliding joints
BALL-AND-
SOCKET
JOINT
PERMIT FULL FREEDOM OF MOVEMENT.
HINGE JOINTS

• Permit bending in only one

direction, either flexion or
extension
SADDLE JOINTS

• ALLOW MOVEMENT IN
TWO PLANES AT RIGTH
ANGLES TO EACH OTHER.
THE JOINT AT THE BASE OF
THE THUMB IS A SADDLE,
BIAXIAL JOINT.
PIVOT JOINT

• ALLOW ONE BONE TO

MOVE AROUND A CENTRAL
AXIS WITHOUT
DISPLACEMENT. AN
EXAMPLE OF A PIVOT JOINT
IS THE ARTICULATION
BETWEEN THE RADIUS AND
THE ULNA. THEY PERMIT
ROTATION FOR SUCH
ACTIVITIES AS TURNING A
DOORKNOB.
GLIDING JOINTS

• ALLOW FOR LIMITED MOVEMENT IN ALL DIRECTIONS AND ARE REPRESENTED

BY THE JOINTS OF THE CARPAL BONES IN THE WRIST.
 STRUCTURE AND
FUNCTION OF THE
SKELETAL MUSCLE SYSTEM
SKELETAL MUSCLE CONTRACTION

 Depolarisation and calcium ion release

 Actin and myosin cross-bridge formation
 Sliding mechanism of actin and myosin filaments
 Sarcomere shortening (muscle contraction)
Video: https://www.youtube.com/watch?v=bjyM13pe9NA
MUSCLE TONE
MUSCLE ACTIONS

• occurs when the force

produced by a muscle
exactly balances the
resistance imposed
upon it and no
movement results.
 Flexion: decreasing the angle Extension: increasing the angle
between two bones (bending). between two bones (straightening a
bend).

Abduction: moving away from the Adduction: moving toward the

MUSCLE ACTION body’s midline. body’s midline.

Pronation: rotating the forearm so Supination: rotating the forearm so

• Muscles Act on Synovial the palm is facing backward or down. the palm is facing forward or up.

Joints to Move the Body

Elevation: moving a body part up. Depression: moving a body part
down

Protraction: moving a bone forward Retraction: moving a bone

without changing the angle. backward without changing the
angle.

Inversion: turning the sole of the Eversion: turning the sole of the
foot inward. foot outward.

Dorsiflexion: bringing your Plantar flexion: depressing

foot upward toward your your foot
shin.
 EXERCISE, DISUSE, AND REPAIR
EXERCISE
BENEFITS:
• Increased muscle mass
• Stronger bones:
• Joint flexibility:
• Weight control
• Balance
EXERCISE, DISUSE, AND REPAIR
EXERCISE, DISUSE, AND REPAIR
•Three main
phases process
of muscle
regeneration
1. destruction
phase
2.a regeneration
phase
3. remodeling
phase
GERONTOLOGIC
CONSIDERATION
Reporter: Hugo Rielgie
• Multiple changes in the musculoskeletal system
occur with aging.
• There is a loss of height due to osteoporosis
(abnormal excessive bone loss), kyphosis
(forward curvature of the thoracic spine),
thinned intervertebral discs, compressed
vertebral bodies, and flexion of the knees and
hips.
• Numerous metabolic changes, including
menopausal withdrawal of estrogen and
decreased activity, contribute to osteoporosis
(NOF, 2016a). Women lose more bone mass
than men.
• Women lose more bone mass than men. In
addition, bones change in shape and have
reduced strength. Fractures are common.
• This may lead individuals to depend on others for
completion of their activities of daily living (ADLs);
in turn, they may grieve over the loss of
independence.

• Collagen structures are less able to absorb energy.

Increased inactivity, diminished neuron
stimulation, and nutritional deficiencies contribute
to the loss of muscle strength.
Assessment

Health History

The nursing assessment of the patient with

musculoskeletal dysfunction includes a health history
and physical examination that evaluate the effects of
the musculoskeletal disorder on the patient.
Common Symptoms

During the interview and physical assessment, the

patient withand
a musculoskeletal disorder
altered sensations (Webermay
& report
Kelley,
pain, tenderness,
2014).
Pain

Most patients with diseases and traumatic conditions or

disorders of the muscles, bones, and joints experience
pain. pain is typically described as a dull, deep ache that
is"boring" in nature. This pain is not typically related
tomovementand may interfere with sleep.
Muscular pain is
described as soreness or
aching and is referred to
as"musclecramps."Fractur
e pain is sharp and
piercing and is relieved by
immobilization. Sharp
pain may also result from
bone infection with
muscle spasm or pressure
on a sensory nerve. Joint
pain is felt around or in
the joint and typically
worsens with movement
Rest relieves most musculoskeletal pain. Pain that
increases with activity may indicate joint sprain,
muscle strain, or compartment syndrome,where a
steadily increasing pain points to the progression of an
infectious process (osteomyelitis), a malignant tumor,
or neurovascular complications. Radiating pain occurs
in conditions in which pressure is exerted on a nerve
root.
The patient's pain and discomfort must be managed
successfully. Not only is pain exhausting, but also, if
prolonged, it can force the patient to become
increasingly withdrawn and dependent on others as
the musculoskeletal disorder continues.
Altered Sensations

Sensory disturbances are

frequently associated
with musculoskeletal
problems. The patient
may describe
paresthesias, which are
sensations of burning,
tingling, or numbness.
These sensations may be
caused by pressure on
nerves or by circulatory
impairment.
Musculoskeletal Structural changes Functional History and
system changes physical findings

BONES Gradual, Bones fragile and Loss of height

progressive mass prone to fracture - Postural Changes
after 30 years of vertebrae, hip, Kyphosis
age wrist Loss of flexibility
Vertebral collapse Flexion of hips and
knees
Back pain
Osteoporosis
MUSCLES Increase in Loss of strength Loss of strength
collagen and and flexibility Diminished agility
resultant fibrosis Weakness Decrease
Muscles fibrosis Fatigue Endurance
Muscles diminish Scumbling Prolonged
in size (atrophy); Falls response time
wasting ( Diminished
Tendons less reaction time)
elastic Diminished Tone
Broad base of
support
History of falls
JOINTS Cartilage- Stiffness, reduced Diminished range of
progressive flexibility, and pain motion
deterioration interfere with Stiffness
Thinning of activities of daily Loss of height
intervertebral discs living

LIGAMENTS Lax ligaments (less- Postural joint Joint pain on

than-normal abnormality motion; resolves
strength; weakness) Weakness with rest
Crepitus
Joint
swelling/enlargeme
nt
Osteoarthritis(dege
nerative joint
disease)
Body movements produced
by muscle contraction
THAT'S ALL THANK
YOU !!!
PAST HEALTH,
SOCIAL, AND FAMILY
HISTORY
Antipuesto, Jiecel L.
Occupation (e.g., does the patient’s work require physical
activity or heavy lifting?),
Exercise patterns, alcohol consumption, tobacco use, and
dietary intake (e.g., calcium and vitamin D).
Concurrent health conditions (e.g., diabetes,
heart disease, chronic obstructive pulmonary disease, infection,
and preexisting disability)
Related problems (e.g., familial or genetic
abnormalities [see Chart 39-1]) need to be considered when
developing and implementing the plan of care.
Genetics In Nursing Practice
MUSCULOSKELETAL DISORDERS
 Achrondroplasia
 Nail-Patella syndrome
 Osteogenesisimperfecta
 Polydactyl
 Van der Woude syndrome
Achondroplasia
is a bone disorder that results in dwarfism. Children who are
born with achondroplasia typically have short arms and legs, a
large head, and an average-sized trunk. They are shorter than
most other people because of their bone abnormalities.
• Common tests & procedures
• Ultrasound: Detects achondroplasia characteristics such as
hydrocephalus.

• Genetic test: Amniotic fluid (for prenatal diagnosis), or blood

samples, detect the defective FGFR3 gene.

• X-ray: Measures the length of an infant's bones.

Complications
Most of the people can lead a normal life; in some cases, the
complications can include:

Frequent ear infections-could lead to hearing loss

Bowing of the legs
Sleep apnoea/difficulty breathing during sleep
Hydrocephalus/excess fluid around the brain
Crowded teeth
Spinal stenosis-due to pressure on the spinal cord may lead to numbness
and pain in the legs
Hunching of the back with back pain
Delay in development of motor skills such as walking and crawling
Pregnant women with achondroplasia may develop respiratory problems
Nail-Patella syndrome
a genetic disorder that results in small, poorly developed nails
and kneecaps, but can also affect many other areas of the body,
such as the elbows, chest, and hips
Osteogenesisimperfecta
Is a rare genetic disorder that makes bones fragile and prone to
breaking, sometimes even before birth.

The severity of symptoms can vary widely depending on the sub-type

and include:

Multiple broken bones

Bone deformities
Loose joints
Small stature
Undersized chest, barrel-shaped rib cage
Weak teeth
Bowed legs and arms
Blue sclera
Curved spine
Common tests & procedures
X-ray: Enables visualization of broken bones and facilitates
detection of bone defects.

Laboratory examination: To observe the structure of collagen.

Skin punch biopsy: Determines the structure and quality of

collagen.

Genetic test: Detects the defective gene.

Polydactyl
also known as
hyperdactyly, is an
anomaly in humans
and animals resulting
in supernumerary
fingers and/or toes
Van der Woude Syndrome
• a condition that
affects the
development of the
face. Many people
with this disorder are
born with a cleft lip, a
cleft palate (an
opening in the upper
lip or roof of the
mouth), or both.
Autosomal Recessive

 Tay Sachs

Forms of Muscular Dystrophy:

 Becker muscular dystrophy

 Congenital muscular dystrophy
 Distal muscular dystrophy
 Duchene muscular dystrophy (X-linked)
 Emery-Dreyfuss muscular dystrophy (X-linked)
 Facibscapulohumcl muscular dystrophy (autosomal dominant)
Limb-girdle mascular dystrophy (autosomal dommant and
autosomal recessive forms)
Tay-Sachs disease
a rare disorder passed
from parents to child. It's
caused by the absence of
an enzyme that helps break
down fatty substances.
These fatty substances,
called gangliosides, build
up to toxic levels in the
child's brain and affect the
function of the nerve cells.
As the disease progresses,
the child loses muscle
control
Other genetic disorders that impact the musedloskeletal system:

Amyotrophic lateral sclerosis (neurologic disorder)

 Ehlers-Danlos syndrome (connective tissue disorder)
Marfan syndrome (connective tissue disorder)
Spina bifida (neurologic disorder) Shickler syndrome (connective
tissue disorder
Sticker syndrome (connective tissue disorder)
Nursing Assessment
Family History Assessment Related to Genetic
Musculoskeletal Disorders
• Assess or other similarly affected family members in the past
three generations
• Assess for the presence of other related genetic conditions
(eg.
hematologics cardiac, integumentary conditions).
• Determine the age at onset (eg, fractures present at birth
such as osteogenesis imperfecta, hip dislocation present at
birth in DDH, or carly-onset osteoporqais).
Patient Assessment Specific to Genetic Musculoskeletal
Disorders

• Assess stature for general screening purposes (unusually

short stature may be related to achondroplasia; unusually
tall stature may be related to Marian syndrome).

• Assess for disease-specific skeletal findings (e.g.,

pectusexcavatum, scoliosis, long fingers [Marfan
syndrome], osteoarthritis of the hip or waddling gait)
Assessment findings that could indicate a genetic
musculoskeletal disorder include:

• Bone pain
• Emarged hands or feet
• Excessive height, short stature, or decrease in height
• Flat feet or highly arched feet
• Frequency of bone-related injuries or unexplained fractures
• Hypermobility of joints Large or small head circumference
• Protruding jaw or forehead
• nexplained changes in muscle tone (hypotonia)