Common Musculoskeletal

Problems
ACUTE LOW BACK PAIN
Causes:
1. Acute lumbosacral strain.
2. Unstable lumbosacral.
3. Ligaments and weak muscles.
4. Osteoarthritis of the spine.
5. Spinal stenosis.
6. Intervertebral disk problems.
7. Unequal leg length.
8. Kidney disorders.
9. Pelvic problems retroperitoneal tumors.
10. Abdominal aneurysms.
11. Psychosomatic problems.
12. Disk degeneration is a common cause of back pain.
The spinal column can be considered as
an elastic rod constructed of rigid
units (vertebrae) and flexible units
(intervertebral disks) held together by
complex facet joints, multiple
ligaments, and paravertebral muscles.
The intervertebral disks change in
character as a person ages.
>A young person’s disks are mainly
fibrocartilage with a gelatinous
matrix.
>As a person ages, the disks become
dense, irregular fibrocartilage.
Clinical Manifestations
1. Either acute back pain or chronic back
pain (lasting more than 3 months
without improvement) and fatigue.
2. Pain radiating down the leg, which
is known as radiculopathy or sciatica and
which suggests nerve root involvement.
3. The patient’s gait, spinal mobility,
reflexes, leg length, leg motor strength,
and sensory perception may be altered.
The initial evaluation of acute low back pain
includes:
1. History and physical examination. >general
observation of the patient.
>back examination.
>neurologic testing (reflexes, sensory
impairment, straight-leg raising, muscle
strength, and muscle
atrophy).
2. If the initial examination does not suggest a
serious condition, no additional testing is
performed during the first 4 weeks of
symptoms.
Diagnostic Procedures:
1. X-ray of the spine—may demonstrate a
fracture, dislocation, infection,
osteoarthritis, or scoliosis.
2. Bone scan and blood studies—may
disclose infections, tumors, and bone
marrow abnormalities.
3. Computed tomography (CT scan)—
useful in identifying underlying problems,
such as obscure soft tissue lesions
adjacent to the vertebral column and
problems of vertebral disks.
4. Magnetic resonance imaging (MRI)—
permits visualization of the nature and
location of spinal pathology.
5. Electromyogram (EMG) and nerve
conduction studies—used to evaluate
spinal nerve root disorders
(radiculopathies).
Medical Management:
1. Most back pain is self-limited and resolves
within 4 weeks with
analgesics, rest, stress reduction, and
relaxation.
2. Management focuses on relief of pain and
discomfort, activity
modification, and patient education.
3. Nonprescription analgesics (acetaminophen,
ibuprofen) are
usually effective in achieving pain relief.
4. Heat or cold therapy frequently provides
temporary relief of symptoms.
Health Teaching:
1. Twisting, bending, lifting, and reaching, all of
which stress the back, are avoided.
2. The patient is taught to change position
frequently.
3. Sitting should be limited to 20 to 50 minutes
based on level of comfort.
4. Bed rest is recommended for 1 to 2 days, with a
maximum of 4 days only if pain is severe.
5. A gradual return to activities and low-stress
aerobic exercise is recommended.
6. Conditioning exercises for the trunk muscles
are begun after about 2 weeks.
Nursing Interventions:
1. RELIEVING PAIN
>Encourages the patient to reduce stress on the
back muscles and to change position frequently.
>Diaphragmatic breathing and relaxation help
reduce muscle tension contributing to low back
pain.
>Diverting the patient’s attention
from the pain to another activity (eg, reading,
conversation, watching television) may be helpful
in some instances.
> Guided imagery, in which the relaxed patient
learns to focus on a pleasant event, may be used
along with other pain-relief strategies.
2. IMPROVING PHYSICAL MOBILITY
>The nurse assesses how the patient moves and
stands.
> Position changes should be made slowly and
carried out with assistance as required.
> The patient may find that sitting in a chair with arm
rests to support some of the body weight and a soft
support at the small of the back provides comfort.
>The patient rests in bed on a firm, nonsagging
mattress (a bed board may be used).
> A prone position is avoided because it accentuates
Lordosis.
> Activities should not cause excessive lumbar strain,
twisting, or discomfort; for example, activities such
as horseback riding and weight-lifting are avoided.
3. USING PROPER BODY MECHANICS
>Good body mechanics and posture are essential
to avoid recurrence of back pain.
>The patient must be taught how to stand, sit,
lie, and lift properly.
> The patient who wears high heels is
encouraged
to change to low heels.
>The patient who is required to stand for long
periods should shift weight frequently and
should rest one foot on a low stool, which
decreases lumbar Lordosis.
> Locking the knees when standing is avoided,
as is bending forward for long periods.
4. IMPROVING SELF-ESTEEM
> Role-related responsibilities may have
been modified with the onset of low back
pain.
> As recovery from acute low back pain and
immobility progresses, the patient may
resume former role related responsibilities.
> Psychotherapy or counseling may be
needed to assist the person in resuming a
full, productive life.
5. MODIFYING NUTRITION FOR WEIGHT
REDUCTION
> Obesity contributes to back strain by
stressing the relatively weak back muscles.
> Weight reduction is based on a sound
nutritional plan that includes a change in
eating habits to maintain desirable weight.
> Frequently, back problems resolve as
normal weight is achieved.
Common Problems of the Upper
Extremity:
1. BURSITIS AND TENDINITIS - are
inflammatory conditions that
commonly occur in the shoulder.
Bursae are fluid-filled sacs that prevent
friction between joint structures
during joint activity.
Manifestations:
1. Pain
2. Inflammation
The inflammation causes proliferation
of synovial membrane and pannus
formation, which restricts joint
movement.
Conservative Treatment:
1. Rest of the extremity.
2. Intermittent ice and heat to the joint.
3. Nonsteroidal anti-inflammatory
drugs (NSAIDs) to control the
inflammation and pain.
4. Arthroscopic synovectomy may be
considered if shoulder pain and
weakness persist.
2. LOOSE BODIES
> Loose bodies may occur in a joint as
a result of articular cartilage wear and
bone erosion.
>These fragments interfere with joint
movement, locking the joint, and
cause painful movement.
> Loose bodies are removed by
arthroscopic surgery.
3. IMPINGEMENT SYNDROME
> Overuse (microtrauma) may produce
an impingement syndrome in the
shoulder.
Manifestations:
a. Pain
b. Shoulder tenderness
c. Limited movement
d. Muscle spasm
e. Atrophy
Conservative Treatment:
1. Rest
2. NSAIDs
3. Joint injections
4. Physical therapy
5. Arthroscopic débridement is used for
persistent pain.
4. CARPAL TUNNEL SYNDROME
- is an entrapment neuropathy that
occurs when the median nerve at the
wrist is compressed by a thickened
flexor tendon sheath, skeletal
encroachment, edema, or a soft tissue
mass.
Causes:
- Repetitive hand activities but may be
associated with arthritis, hypothyroidism, or
pregnancy.
Manifestations:
1. Pain
2. Numbness
3. Paresthesia
4. Possibly weakness along the median nerve
(thumb and first two fingers).
5. Tinel’s sign may be used to help identify
carpal tunnel syndrome.
Management:
1. Rest splints to prevent hyperextension and
prolonged flexion of the wrist.
2. Avoidance of repetitive flexion of the
wrist (eg, use of ergonomic changes at work to
reduce wrist strain).
3. NSAIDs, and carpal canal cortisone injections
may relieve the symptoms.
4. The patient wears a hand splint after surgery
and limits hand use during healing.
5. The patient may need assistance with personal
care and ADLs.
6. Full recovery of motor and sensor function after
nerve release surgery may take several weeks or
months.
5. GANGLION
- a collection of gelatinous material
near the tendon sheaths and joints,
appears as a round, firm, cystic swelling,
usually on the dorsum of the wrist.
- It most frequently occurs in women
younger than 50 years of age.
Manifestations:
1. Aching pain.
2. Weakness of the finger occurs.
Treatment:
1. Aspiration
2. Corticosteroid injection
3. Surgical excision
4. After treatment, a compression
dressing and immobilization splint are
used.
6. DUPUYTREN’S CONTRACTURE
- a flexion deformity caused by an
inherited trait, is a slowly progressive
contracture of the palmar fascia,
which severely impairs the function of
the fourth, fifth, and sometimes, the
middle fingers.
Causes:
1. Inherited autosomal dominant trait and
occurs most frequently in men who are
older than 50 years of age and who are of
Scandinavian or Celtic origin.
2. It is also associated with arthritis, diabetes,
gout, and alcoholism.
3. It starts as a nodule of the palmar fascia.
4. The nodule may not change, or it may
progress so that the fibrous thickening
extends to involve the skin in the distal
palm and produces a contracture of the
fingers.
Manifestations:
1. Experience dull aching discomfort.
2. Morning numbness
3. Cramping
4. Stiffness in the affected fingers.
Nursing Interventions:
1. PROMOTING NEUROVASCULAR
FUNCTION
> Neurovascular assessment of the
exposed fingers every hour for the
first 24 hours is essential for
monitoring function of the nerves and
perfusion of the hand.
> The nurse compares the affected
hand with the unaffected hand and the
postoperative status with the
documented preoperative status.
2. RELIEVING PAIN
> The nurse elevates the hand to
heart level with pillows.
> Intermittent ice packs to the
surgical area during the first 24 to 48
hours may be prescribed to control
swelling.
> Generally, the pain and discomfort
can be controlled by oral analgesics.
3. IMPROVING SELF-CARE
>During the first few days after surgery, the
patient needs assistance
with ADLs because one hand is bandaged
and independent self-care is impaired.
>The patient may need to arrange for
assistance with feeding, bathing and
hygiene, dressing, grooming, and
toileting.
> Within a few days, the patient develops
skills in one handed ADLs and is usually
able to function with minimal assistance
and use of assistive devices.
4. PREVENTING INFECTION
> As with all surgery, there is a risk
for infection.
> The nurse teaches the patient to
monitor temperature and signs and
symptoms that
suggest an infection.
> It also is important to instruct the
patient to keep the dressing clean and
dry and to report any drainage, foul
odor, or increased pain and swelling.
Common Foot Problems:
Causes:
1. Poorly fitting shoes.
2. Fashion, vanity, and eye appeal,
rather than function and physiology
of the foot, are the determining
factors in the design of footwear.
3. Ill-fitting shoes distort normal
anatomy while inducing deformity
and pain.
1. PLANTAR FASCIITIS
- an inflammation of the foot-
supporting fascia, presents as an
acute onset of heel pain experienced
with the first steps in the morning.
Characteristics of Pain
- The pain is localized to the
anterior medial aspect of the heel and
diminishes with gentle stretching of
the foot and Achilles tendon.
Management:
1. Stretching exercises.
2. Wearing shoes with support and
cushioning to relieve pain.
3. Orthotic devices (eg, heel cups, arch
supports).
4. NSAIDs.
2. CORN
- is an area of hyperkeratosis
(overgrowth of a horny layer
of epidermis) produced by internal
pressure (the underlying bone is
prominent because of congenital or
acquired abnormality, commonly
arthritis) or external pressure (ill-
fitting shoes).
- The fifth toe is most frequently
involved, but any toe may be involved.
Management:
1. Soaking and scraping off the horny
layer by a podiatrist, by application of
a protective shield or pad.
2. Surgical modification of the
underlying offending osseous
structure.
3. Drying the affected spaces and
separating the affected toes with
lamb’s wool or gauze.
4. A wider shoe may be helpful.
3. CALLUS
- is a discretely thickened area of
the skin that has been exposed to
persistent pressure or friction.
- Faulty foot mechanics usually
precede the formation of a callus.
Management:
1. Treatment consists of eliminating the
underlying causes and having the callus
treated by a podiatrist if it is painful.
2. A keratolytic ointment may be applied
and a thin plastic cup worn over the heel if
the callus is on this area.
3. Felt padding with adhesive backing is also
used to prevent and relieve pressure.
4. Orthotic devices can be made to remove
the pressure from bony protuberances, or
the protuberance may be excised.
4. INGROWN TOENAIL
- (onychocryptosis) is a condition in
which the free edge of a nail plate
penetrates the surrounding skin, either
laterally or anteriorly.
Causes:
1. Improper selftreatment.
2. External pressure (tight shoes or
stockings)
3. Internal pressure (deformed toes, growth
under the nail).
4. Trauma
5. Infection
Treatment:
1. Washing the foot twice a day.
2. Application of a local antibiotic
ointment.
3. Relieving the pain by decreasing the
pressure of the nail plate on the
surrounding soft tissue.
4. Warm, wet soaks help to drain an
infection.
5. HAMMER TOE
- is a flexion deformity of the inter
phalangeal joint, which may involve
several toes .
- The condition is usually an
acquired deformity.
- The toes usually are pulled
upward, forcing the metatarsal joints
(ball of the foot) downward.
Treatment:
1. Wearing open-toed sandals or shoes
that conform to the shape of the foot,
carrying out manipulative exercises,
and protecting the protruding joints
with pads.
2. Surgical correction (osteotomy) is
necessary for an established
deformity.
6. HALLUX VALGUS
- (commonly called a bunion) is a
deformity in which the great toe
deviates laterally.
- Associated with this is a marked
prominence of the medial aspect of
the first metatarsal–phalangeal joint.
Factors:
1. Heredity
2. Ill-fitting shoes
3. Gradual lengthening and widening of
the foot associated with aging.
Management:
1. Corticosteroid injections control acute
inflammation.
2. Surgical removal of the bunion
(exostosis) and osteotomies to realign
the toe may be required to improve
function and appearance.
Post operative management:
1. The foot is elevated to the level of
the heart to decrease edema and
pain.
2. The neurovascular status of the toes
is assessed.
3. Toe flexion and extension exercises
are initiated to facilitate walking.
4. Shoes that fit the shape and size of
the foot are recommended.
7. PES CAVUS
- (claw foot) refers to a foot with an
abnormally high arch and a fixed equinus
deformity of the forefoot.
Management:
1. Exercises are prescribed to manipulate the
forefoot into dorsiflexion and relax the
toes.
2. Bracing to protect the foot may be
used.
3. In severe cases, arthrodesis (fusion) is
performed to reshape and stabilize the foot.
8. MORTON’S NEUROMA
- (plantar digital neuroma,neurofibroma)
is a swelling of the third (lateral) branch of
the median plantar nerve.
- The third digital nerve, which is located
in the third intermetatarsal (web) space, is
most commonly involved.
Manifestations:
1. Throbbing
2. Burning pain
Treatment:
1. Inserting innersoles and metatarsal
pads designed to spread the
metatarsal heads and balance the
foot posture.
2. Local injections of hydrocortisone
and a local anesthetic may provide
relief.
3. If these fail, surgical excision of the
neuroma is necessary.
9. FLATFOOT
- (pes planus) is a common disorder
in which the longitudinal
arch of the foot is diminished.
- It may be caused by congenital
abnormalities or associated with bone
or ligament injury, muscle and posture
imbalances, excessive weight, muscle
fatigue, poorly fitting shoes, or
arthritis.
Manifestations:
1. Burning sensation.
2. Fatigue
3. Clumsy gait
4. Edema
5. Pain.
Management:
1. Exercises to strengthen the muscles
and to improve posture and walking
habits are helpful.
2. A number of foot orthoses are
available to give the foot additional
support.
3. Orthopedic surgeons and podiatrists
treat severe flatfoot problems.
THANK YOU….