99. CCA Study Notes: Musculoskeletal Disorders and Supportive Care

The Big Picture

Musculoskeletal disorders affect bones, joints, muscles, and a person’s ability to move. They can result from injury, aging, or disease.

Some conditions cause pain, stiffness, swelling, or decreased movement. Others involve broken bones, damaged joints, or the loss of part of a limb.

CCA support depends on the client’s condition and care plan. Important themes include safe movement, skin care, comfort, fall prevention, observing changes, and reporting concerns.

Look for Nova Scotia CCA Notes throughout this page for current provincial guidance.

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Course Notes: Key Ideas You Need to Know

Fractures

A fracture is a break in a bone. The tissues around the broken bone, including muscles, blood vessels, nerves, and tendons, are usually injured too.

Fractures often result from falls and other accidents. They can also occur when diseases such as cancer, alcoholism, or osteoporosis weaken the bones.

Open and closed fractures

There are two main types:

• Closed fracture, or simple fracture: The bone is broken, but the skin remains intact.
• Open fracture, or compound fracture: The broken bone comes through the skin.

Signs and symptoms of a fracture include:

• A limb that looks bent or out of position
• Pain
• Swelling
• Limited movement or loss of function
• Bruising or skin colour changes at the fracture site
• Internal or external bleeding

Reduction and immobilization

The broken bone ends need to return to their normal position. This process is called reduction.

• Closed reduction: The bone is moved back into position without opening the skin.
• Open reduction: Surgery exposes the bone so it can be brought back into alignment.

Nails, rods, pins, screws, plates, or wires may hold the bone in place.

After reduction, the fracture is immobilized. This prevents movement of the bone ends while healing takes place. A cast or traction may provide immobilization.

The location and seriousness of the fracture determine the type of immobilization used. The goal is for the affected part of the limb to regain as much function as possible after healing.

Casts and Cast Care

A cast keeps a fracture still for an extended period so the bone can heal in the correct position.

Casts may use plaster, fibreglass, plastic, or removable plastic material.

Before a plaster or fibreglass cast is applied, a stockinette ⓘ protects the skin. Padding goes over the stockinette before the casting material is applied.

Drying times

Number to remember:

• Fibreglass casts usually dry in 20 to 30 minutes.
• Plaster casts take 24 to 48 hours to dry.

A dry plaster cast is white, shiny, and odourless. A wet plaster cast is grey, cool, and has a musty smell.

All casts produce heat while drying.

CCA action: Do not cover a cast while it dries. Keeping it uncovered helps it remain cool and allows it to dry.

Elevating a casted limb

The care plan may direct you to elevate the casted arm or leg.

Elevation reduces swelling and pain in the injured area.

Important cast-care rules

• Keep a plaster cast dry. Water can cause it to lose its shape.
• If a cast is near the perineal area, a nurse may apply waterproof material around the area after the cast has dried.
• Do not allow the client to put objects inside the cast to scratch.
• Scratching objects can damage the skin, wrinkle the stockinette, or become lost inside the cast.
• Elevate a casted arm or leg on pillows as directed.
• Use enough help and proper body mechanics when turning or repositioning a client with a heavy plaster cast.
• Position the client according to the supervisor’s directions and the care plan.

Sometimes a window is cut into a cast after open reduction so the incision and healing process can be observed. Allowing oxygen to reach the incision may also assist healing.

Blood loss under the cast may leave a faint outline. Mark and date the outline so changes in its size can be noticed. If the outline grows, it may indicate further blood loss.

Changes that need immediate reporting

Report immediately if the client has:

• Increasing pain
• Numbness or tingling
• Swelling with a tight cast
• Pale skin or cyanosis, which is blue skin colour
• Inability to move the fingers or toes
• Cool or unusually hot skin
• Chills or fever
• Nausea or vomiting
• Odour
• Drainage on or under the cast

Pain can indicate a pressure ulcer, poor circulation, or nerve damage.

Swelling, tightness, numbness, pale skin, or cyanosis can indicate reduced blood flow.

Numbness or inability to move the fingers or toes can indicate pressure on a nerve.

Cool skin can indicate poor circulation. Hot skin can indicate inflammation.

Chills, fever, nausea, vomiting, odour, or drainage may indicate infection under the cast.

Removable Plastic Casts

Some removable plastic casts are inflatable. Inflation compresses the injured area.

These casts can be removed for physiotherapy or hygiene. They can reduce ankle stiffness and muscle atrophy and decrease healing time.

Traction

Traction is now rarely used to treat fractures and bone dislocations. Two types are still used:

• Skin traction
• Skeletal traction

Skin traction

Skin traction is a temporary measure used before surgical repair. It helps prevent fractured bone pieces from becoming displaced.

Weights hang at the end of the bed and are counterbalanced by the client’s body weight.

The traction may attach to the limb below the fracture with wide strips of medical adhesive tape. A securely fitted foam boot may also be used.

A slight Trendelenburg position keeps the client from sliding toward the foot of the bed.

Skin traction can damage the skin.

Number to remember: Traction weights are usually limited to no more than 10% of the client’s body weight, with a maximum of 5 kg.

Heavier weights can irritate or pull apart superficial skin layers. They also increase the risk of friction injury around the coccyx.

Skeletal traction

Skeletal traction is most commonly used for femur fractures.

A surgical pin passes through a bone farther from the fracture. Weights attach to the pin, and an apparatus provides the traction.

Hip Fractures

Hip fractures occur commonly in older adults, especially older women.

Two signs are:

• Shortening of the leg
• Outward rotation of the leg

Hip fractures are a serious concern in older adults because healing is slower.

Older clients with hip fractures are at risk for life-threatening postoperative complications such as:

• Pneumonia
• Urinary tract infections
• Thrombi in the leg veins

They are also at risk for:

• Pressure ulcers
• Constipation
• Confusion

A fractured hip may be fixed with a pin, nail, plate, screw, or artificial hip joint.

Clients usually need care before and after surgery, followed by rehabilitation. Some clients need subacute or long-term care when home care is not possible. Most return home after successful rehabilitation when complications do not develop.

Supporting a Client After Hip-Fracture Surgery

Care depends on the fracture, surgery, supervisor’s directions, and care plan.

• When the client must stay in bed, follow the appropriate bed-care guidelines.
• Transfer, turn, and reposition the client as directed. The client is usually not positioned on the operated side.
• Keep the operated leg abducted, meaning away from the body’s midline, at all times while the client is supine, being turned, or in a side-lying position. Use pillows or abductor splints as directed.
• Prevent external rotation, or outward turning, of the hip. Use the positioning aids directed for the client.
• Provide range-of-motion exercises as directed. Do not exercise the affected leg.
• Use a straight-backed chair with armrests and a high, firm seat. Avoid low, soft chairs.
• Position the chair on the client’s unaffected side during transfers when directed by the care plan.
• Do not let the client stand on the affected leg unless the physician allows it.
• Support and elevate the affected leg as directed when the client sits in a chair.
• Apply elastic stockings only as directed.
• Remind the client not to cross their legs while sitting or lying in bed.

Protecting an Artificial Hip

An artificial hip joint can move out of place with:

• Adduction
• Internal rotation ⓘ
• Bending the leg at the hip more than 90 degrees

For 6 to 8 weeks after surgery, movements and positions to avoid include:

• Lying on the affected side
• Sitting in low seats
• Crossing the legs while sitting
• Bending from the waist
• Putting on shoes, socks, or stockings

An occupational therapist teaches safe ways to complete self-care activities and use dressing devices.

The client needs a raised toilet seat for elimination and a shower chair for bathing.

In bed, the client needs a pillow or abductor splint between the legs.

A physiotherapist helps the client learn strengthening exercises. A walker is usually needed for walking.

Osteomyelitis

Osteomyelitis is inflammation or infection of the bone marrow. Staphylococcus bacteria often cause it.

It can occur as a complication of a fracture or orthopedic surgery. It often affects the femur and tibia.

When osteomyelitis is not recognized early, it can become difficult to cure. It can lead to persistent pain, loss of function, constant drainage, and death.

Osteomyelitis occurs more often in males, possibly because males experience more trauma injuries.

What the CCA should report

When caring for a client with a recent fracture, report symptoms that may indicate osteomyelitis:

• Acute localized pain
• Redness
• Drainage
• Fever
• Malaise, or tiredness

Treatment may include surgery to drain the area followed by antibiotics.

Amputation

An amputation is the removal of all or part of an extremity.

A traumatic amputation happens during an accident.

A surgical amputation may occur when:

• An extremity has severe damage from an accident or disease
• Removing the extremity is needed to treat or prevent a disease such as cancer
• Gangrene develops

The most common cause of amputation is complications from diabetes.

Gangrene

Gangrene involves tissue death.

Causes include:

• Infection
• Frostbite
• Burns
• Injuries
• Circulatory disorders

These problems interfere with blood flow and deprive tissue of oxygen and nutrients. Poisonous substances and waste products then accumulate.

Affected tissue dies and becomes black, cold, and shrivelled.

Untreated gangrene can spread through the body and cause death.

Parts of a Limb That May Be Amputated

An upper-extremity amputation may involve:

• Fingers
• Hand
• Forearm
• Entire arm

A lower-extremity amputation may involve:

• Toes
• Foot
• Lower leg below or above the knee
• Entire leg

Phantom Limb Pain

After an amputation, a client may experience phantom limb pain.

The client feels as though the missing limb is still present and painful. Burning or tingling may also seem to come from the missing limb.

The main theory described for this pain involves irritation of nerve endings in the stump, the part of the limb that remains.

This reaction may last for a short time after surgery or continue for many years.

Supporting a Client After Amputation

An amputation affects much more than the missing part of the limb. It can affect the client’s body image, daily activities, and work.

Clients need supportive care as they adjust to these changes.

Prostheses

Most clients with amputations receive prostheses, also called prosthetic devices.

A prosthesis is an artificial replacement for a missing body part. Prostheses can replace parts such as a hand, arm, leg, eye, or breast.

Preparing the stump

Before fitting an arm or leg prosthesis, the stump needs conditioning.

Conditioning shrinks and shapes the stump into a cone shape. An elastic stocking or bandage is used.

The elastic stocking needs washing. Moisture can damage the stocking and increase the possibility of skin or healed-incision breakdown.

The client also exercises to strengthen other limbs.

Physiotherapists and occupational therapists help clients learn how to use prostheses.

Current prostheses allow limited movement and can be cumbersome ⓘ.

Prostheses and Skin Care

Skin under an arm or leg prosthesis receives little exposure to air. It can become hot and moist.

This can lead to:

• Irritation
• Blisters
• Skin infections

Follow the care plan. The skin at the prosthesis site needs daily care.

Damp skin inside the prosthesis can become irritated. The skin usually needs cleaning at the end of the day so it stays thoroughly dry.

Wash the skin with warm water and soap. Some clients use medicated soap when their needs call for it.

Rinse thoroughly with warm water to remove soap residue. Gently towel-dry the skin.

The care plan may direct the use of lotion or cream over the stump to keep the skin soft and help prevent damage.

What to report

Notify the supervisor at once when the client complains of pain at the prosthesis site.

Also report:

• Redness
• Swelling
• Drainage

Caring for the prosthesis

Most prostheses are washed daily with warm, soapy water, rinsed well, and towel-dried.

Prostheses are valuable.

Role limit: Do not handle a prosthesis unless the care plan instructs you to do so.

Store the prosthesis in its box or container when it is not in use.

Osteoporosis

Osteoporosis is a bone disorder that makes bones porous and brittle. Brittle bones break more easily.

The spine, hips, and wrists are affected most often.

Osteoporosis occurs commonly in older people and postmenopausal women.

After menopause, the ovaries stop producing estrogen, resulting in bone changes. A lack of dietary calcium is also a major cause.

Risk factors include:

• Smoking
• High alcohol intake
• Lack of exercise
• Prolonged bed rest
• Immobility

Bones need to bear weight regularly to form properly. Without weight-bearing activity, calcium is not absorbed and bones become porous and brittle.

Signs and effects include:

• Back pain
• Gradual loss of height
• Stooped posture
• Increased risk of fractures

Bones can become so brittle that activities such as turning in bed or getting up from a chair can cause a fracture.

Safety: Keep this fracture risk in mind when moving a client with osteoporosis.

Preventing and Managing Osteoporosis

Osteoporosis has no cure, so prevention is important.

The diet needs enough calcium and vitamins.

Some women receive estrogen after menopause, although it is used less often than in the past.

Other prescribed medications include:

• Bisphosphonates
• Selective estrogen receptor modulators, or SERMs
• Calcium
• Vitamin D

Weight-bearing activities may help prevent osteoporosis. Examples include:

• Strength training
• Walking
• Jogging
• Dancing
• Stair climbing

Some clients use a back brace, corset, or walking aid.

When providing supportive care:

• Protect the client from falls and accidents.
• Transfer the client gently.
• Turn the client gently.
• Reposition the client gently.

Arthritis

Arthritis means inflammation of a joint. It is the most common joint disease.

Inflammation includes:

• Swelling
• Redness
• Heat
• Pain

Affected joints can become painful and harder to move.

Arthritis affects people of all ages.

Clients with severe arthritis may need arthroplasty, which is surgical replacement of a joint. The goal is to relieve pain and restore joint movement.

Joints that can be replaced include the ankle, knee, hip, shoulder, wrist, finger, and toe joints.

The two most common types of arthritis are osteoarthritis and rheumatoid arthritis.

Osteoarthritis

Osteoarthritis (OA) is the most common form of arthritis.

OA causes cartilage in joints to wear away. This leads to pain and changes in the shape of the joints.

Obesity and a sedentary lifestyle ⓘ are the main contributors.

OA affects 13.6% of adults in Canada. It tends to occur after age 40 and becomes more common with age. Approximately 80% of Canadians are affected by age 75.

Joints affected by OA

OA commonly affects weight-bearing joints:

• Hips
• Knees
• Ankles
• Spine

It can also affect the fingers and thumbs.

Cartilage normally cushions the ends of bones. As the cartilage breaks down, the bones eventually rub together.

The joints can become:

• Painful
• Swollen
• Stiff

Pain is often less severe in the morning and becomes worse during the day.

Pain occurs with weight-bearing and joint movement. Severe pain can disturb rest and sleep.

Joints become stiff after the client has remained still for a period.

Cold weather and dampness can increase symptoms.

Bones may thicken and develop growths called spurs. Heberden’s nodes are spurs that commonly occur in the fingers.

Treatment and support for OA

OA has no cure.

Treatment focuses on relieving pain and stiffness.

Physicians may prescribe Tylenol or arthritis medications. Heat or cold applications may also be prescribed.

Treatment for clients with obesity often includes weight loss using a low-fat, low-calorie diet.

Advanced OA may require a cane or walker.

Fall-prevention measures are important.

Assist with activities of daily living, or ADLs, as needed.

An elevated toilet seat can help clients who have limited range of motion, or ROM, in their hips and knees.

Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a persistent and progressive ⓘ disease.

It is predicted to affect one in six Canadians aged 16 or older.

RA usually develops between ages 25 and 50, but it can affect people from toddlerhood through older adulthood. It occurs more often in women than men.

RA affects connective tissue throughout the body.

The immune system does not recognize the connective tissue as normal and attacks it.

RA can damage connective tissue in the:

• Heart
• Lungs
• Eyes
• Kidneys
• Skin

It mainly affects the joints.

Affected joints become painful, swollen, and stiff.

RA usually occurs on both sides of the body, although this does not always happen.

Pain and stiffness are usually worst when the client wakes in the morning. They gradually decrease during the day.

RA usually begins in smaller joints of the fingers, hands, and feet. It then moves to larger joints, including the wrists, elbows, shoulders, ankles, knees, and hips.

Normal tissue can eventually become replaced by scar tissue. Joint deformities can develop.

Other organs can also become affected over time.

Fatigue and fever are common.

Treatment and support for RA

Treatment aims to:

• Maintain joint movement
• Control pain
• Prevent deformities

Rest needs to be balanced with exercise.

Number to remember: Clients need 8 to 10 hours of sleep each night, along with morning and afternoon rest periods.

Bed rest is needed when several joints are involved and fever is present.

Range-of-motion exercises are helpful.

Some clients need walking aids or splints.

Fall-prevention measures are important.

Physicians or nurse practitioners may prescribe medications and heat or cold applications for pain and inflammation.

Some clients need joint-replacement surgery.

Juvenile Rheumatoid Arthritis

Rheumatoid arthritis in children is called juvenile rheumatoid arthritis, or JRA.

JRA can affect growth and development. Eye inflammation can also occur as a complication.

Gout

Gout, also called metabolic arthritis, results from uric acid accumulating in the cartilage of a joint, especially in the tendons.

It usually affects the big toe first, although other joints can also be affected.

Signs and symptoms include:

• Sudden, severe pain
• Swelling
• Redness
• Warmth
• Joint stiffness
• Possible low-grade fever

The pain can become so severe that even a blanket resting over the affected area hurts.

Treatment includes pain medication and anti-inflammatory drugs. Ice packs may help relieve pain.

Follow the client’s care plan.

Fibromyalgia

Fibromyalgia is associated with aching, stiffness, and fatigue in muscles, ligaments, and tendons.

Commonly affected areas include:

• Neck
• Shoulders
• Upper and lower back
• Hips
• Legs
• Knees
• Feet

Pain and stiffness often occur with fatigue and sleep disturbances.

Persistent fatigue can make simple tasks difficult.

Clients with fibromyalgia often undergo many tests to rule out other disorders because no specific test currently identifies the condition. This process can frustrate clients.

CCA action: Use empathy and encourage the client to accept the treatments identified in the care plan.

Fibromyalgia has no cure.

Helpful treatments include:

• Heat and cold applications
• Massage
• Regular stretching
• Range-of-motion exercises
• Occupational therapy when required
• Prescribed medications for pain, muscle relaxation, and sleep

Supporting Clients With Musculoskeletal Disorders

Decreased activity and mobility can leave clients feeling angry or frustrated.

Communicate with respect

Listen to the client and use empathy. This shows respect.

Protect the skin

Keep the client clean and dry at all times to help prevent skin irritation.

Soiled or moist skin can trap odour and bacteria that cause irritation.

Support comfort

Use pain-reducing comfort measures.

Keep the client in good body alignment at all times.

Make sure the client is sitting or lying on a clean, dry, wrinkle-free surface at all times.

Report and document pain so the client can receive comfort measures and medication according to the care plan.

Reduce boredom

Provide distraction and activities for clients who spend long periods in one place.

Being confined can contribute to frustration and irritability. Diversional activities can reduce this problem.

Protect confidentiality

Always follow confidentiality rules.

Never discuss the client or details about the client with anyone who is not involved in the client’s care.

Fractures in Children

Falls and accidents involving motor vehicles, bicycles, skateboards, scooters, and in-line skates commonly cause fractures in children.

Fractures in infants and certain fracture patterns, including spiral fractures ⓘ, may be signs of child abuse.

Common Mix-Ups

Wrong Idea	Better Idea
A closed fracture breaks the skin.	A closed fracture leaves the skin intact.
An open fracture keeps the skin intact.	An open fracture comes through the skin.
Closed reduction requires surgery to expose the bone.	Closed reduction moves the bone without opening the skin.
Open reduction happens without surgery.	Open reduction uses surgery to expose and align the bone.
OA pain is usually worst after waking.	OA pain is often milder in the morning and worsens during the day.
RA pain usually gets worse throughout the day.	RA pain and stiffness are usually worst in the morning and decrease during the day.