CHAPTER 9 Musculoskeletal Disorders

Section One Arthritic Disorders

Arthritic disorders are among the most common disorders causing pain and disability in individuals over the age of 15 yr in the United States. Arthritis is simply defined as inflammation of a joint. Arthritis is an often predominant manifestation of more than 100 diffuse joint and connective tissue diseases, including osteoarthritis (OA), fibromyalgia, gouty arthritis, rheumatoid arthritis (RA), Reiter’s syndrome, ankylosing spondylitis, systemic lupus erythematosus, and psoriatic arthritis. OA and RA, which are often seen in hospitalized patients, are discussed in this section (TABLE 9-1).

TABLE 9-1 DIFFERENTIAL DIAGNOSIS OF OSTEOARTHRITIS AND RHEUMATOID ARTHRITIS

FEATURE	OSTEOARTHRITIS	RHEUMATOID ARTHRITIS
Age at onset	4th-5th decade	2nd-5th decade
Gender ratio	3 : 1 female	2 : 1 female
Disease course	Variable, progressive	Remissions and exacerbations
Symptoms	Localized	Systemic
Commonly affected joints	Weight-bearing joints (knees, hips), spine, MCP, DIP, PIP	Small joints (PIP, DIP, MTP)
Joint involvement	Asymmetric	Symmetric
Joint effusions	Uncommon	Common
Synovial fluid	Usually normal	Decreased viscosity; WBCs 3000-25,000/mm³
Nodules	Heberden’s and Bouchard’s nodes	Rheumatoid nodules over bony prominences, extensor surfaces, juxtaarticular regions
Pain	Follows activity, improves with rest	Pain at rest, nocturnal pain
Duration of stiffness	Minutes; after prolonged rest (articular gelling)	Hours; most severe after rest
Weakness	Usually localized, mild to moderate	Often pronounced
Fatigue	Not typical	Often severe, especially in the afternoon
X-ray examination	Osteophytes, subchondral cysts, sclerosis; asymmetric narrowing of joint space	Osteoporosis related to steroid use; erosions, narrowed joint space; subluxation in advancing disease
Rheumatoid factor assay results	Negative	Positive in approximately 80% of patients

DIP, Distal interphalangeal; MCP, metacarpophalangeal; MTP, metatarsophalangeal; PIP, proximal interphalangeal; WBCs, white blood cells.

Osteoarthritis

Overview/Pathophysiology

Osteoarthritis (OA) is the most prevalent articular disease in adults 65 yr of age and older. OA has been known by many names, including degenerative joint disease (DJD), degenerative arthritis, and hypertrophic arthritis. It is no longer regarded as a wear-and-tear condition that occurs as a normal result of aging. In fact, joint changes that result from arthritis can be distinguished readily from age-related changes in articular cartilage of an asymptomatic older adult. In OA, chondrocytes within the joint fail to synthesize good-quality matrix in terms of both resistance and elasticity; resulting defective the bony cartilage is more prone to deterioration. OA is recognized as a process in which all joint structures produce new tissue in response to joint injury or cartilage destruction. This chronic, progressive disease is characterized by gradual loss of articular cartilage combined with thickening of the subchondral bone and formation of bony outgrowths (osteophytes) at the joint margins. Affected individuals experience increasing pain, deformity, and loss of function. Prevalence of OA varies among different populations, but it is a universal human problem that actually may begin by 20-30 yr of age. A majority of people are affected by 40 yr of age, but few experience symptoms until after 50 to 60 yr of age. Before 50 yr of age, men are affected more often than women. After 50 yr of age, however, incidence of OA is twice as great in women as in men.

OA may be classified as either idiopathic or secondary. Idiopathic OA occurs in individuals with no history of joint injury or disease or of systemic illness that could contribute to the development of arthritis. Secondary OA occurs from wear and tear, joint injury, or disease.

OA is characterized by site specificity, with certain synovial joints showing higher disease prevalence. These include the weight-bearing joints (hips, knees); cervical and lumbar spine; distal interphalangeal (DIP), proximal interphalangeal (PIP), and metacarpophalangeal (MCP) joints in the hands; and metatarsophalangeal (MTP) joints in the feet (bunion deformity, or hallux valgus). The hips are most often affected in men and the hands in women, especially after menopause.

Assessment

Signs and symptoms/physical findings

Diagnostic Tests

OA almost always can be diagnosed by history and physical examination.

Laboratory tests

Rule out other arthropathic conditions (e.g., rheumatoid arthritis [RA], septic arthritis) and establish baselines before starting therapy.

CBC

Renal and liver function tests

For older adults starting aspirin or NSAID therapy, with further testing done every 6 mo to monitor for occasional side effects such as electrolyte imbalance, hepatitis, or renal insufficiency.

Rheumatoid factor (RF) assay and erythrocyte sedimentation rate (ESR)

Neither test excludes a diagnosis of OA in the older patient. About 20% of healthy older adults are in fact RF-seropositive, and ESR tends to rise with age. ESR evaluation is useful to rule out chronic conditions such as polymyalgia rheumatica.

Synovial fluid analysis

Reliable method for differentiating OA from other arthritic disorders.

X-ray examination

Radiographic findings do not always correlate with severity of patient’s clinical symptoms. With disease progression, x-ray examination reveals joint space narrowing, osteophytes at joint margins, subchondral cysts, and altered shape of bone ends that suggests bone remodeling.

MRI

Much more sensitive than x-ray examination in marking progression of joint destruction.

Collaborative Management

Exercise

Identified by American College of Rheumatology as a critical part of OA management to improve strength, endurance, and flexibility and ability to walk or perform daily tasks. Inactivity may increase arthritis problems. Low-impact exercise, walking, swimming, and water aerobics are often well tolerated by people with arthritis. In addition, quadriceps-strengthening exercises improve joint stability for people with knee OA.

Joint protection

Principles include need for a balance of rest and activity. An affected joint should be rested and weight bearing restricted during periods of acute inflammation. Splints or braces should be used to maintain the joint in a functional position if necessary. Joint immobilization should not exceed 1 wk to prevent additional stiffness from prolonged rest. Modification of occupational and recreational activity also may be needed to protect the joint from stress, and use of assistive devices may be beneficial.

Weight reduction

Obesity is clearly associated with increased incidence of OA. Nutritional counseling will benefit obese patients who need to lose weight in order to control arthritis symptoms and slow disease progression.

Heat and cold applications

Thermal therapy may lessen pain and stiffness. Ice can be helpful during episodes of acute inflammation, whereas heat therapy may be beneficial for stiffness. Heat therapy is delivered via numerous modalities, including hot packs, ultrasound, whirlpool, paraffin wax, and massage.

Topical analgesics

For pain relief. Capsaicin cream in particular has shown significant reduction of knee pain when used along with regular arthritis medications. Necessity for several applications daily often leads to poor adherence to treatment. Topical analgesics should not be used in combination with heat treatments because of risk of burns.

Corticosteroids

Systemic therapy is not indicated in OA because of its side effects, but intraarticular injections of glucocorticoids are often used to treat inflamed joints. Injections should be separated by 3-4 mo because of risk of damage to intraarticular structures by residual corticosteroid crystals.

Viscosupplementation

Hyaluronic acid has been administered via intraarticular injections for treatment of knee OA because of its potential to supplement joint lubrication by synovial fluid. Clinical studies have shown mixed results.

Pharmacotherapy

Medications are aimed at pain management only because no drug can reverse the effects of OA.

Acetaminophen

NSAIDs

Ibuprofen, naproxen, diclofenac, and meloxicam are indicated if pain persists or worsens. NSAIDs may increase patient’s risk for gastric ulceration or renal impairment because of inhibition of cyclooxygenase-1 (COX-1), which reduces prostaglandin levels in the stomach and kidneys. Traditional NSAIDs can be taken with a proton pump inhibitor to minimize GI effects.

Celecoxib

For severe or continued pain. Celecoxib (Celebrex) with cyclooxygenase-2 (COX-2) selectivity has shown less GI toxicity.

Salicylates (e.g., aspirin)

These drugs are still preferred by many patients and doctors for pain management. An opioid analgesic can be safely added to acetaminophen or NSAID therapy if pain is unremitting.

Complementary and alternative treatment

Many therapies have become popular with patients seeking relief of arthritis symptoms. Although some modalities such as wearing copper or magnetic bracelets are harmless and possibly worthless, other treatments such as bee venom injections may lead to severe toxicities. A few therapies such as acupuncture have shown modest beneficial effects in arthritis pain management. Movement therapies (e.g., tai chi, yoga) provide a low-impact form of exercise. Some herbal supplements (e.g., ginger) have been shown to reduce the pain and inflammation of arthritis, but the person with arthritis should be encouraged to discuss use of herbal products with the health care provider.

Surgical interventions

Initial treatment may be through procedures that preserve natural tissues, including debridement, cartilage transplantation, osteotomy, and arthrodesis (fusion). Joint arthroplasty traditionally has been reserved for older patients, but if disease progression indicates, the procedure may be performed on a younger adult with the expectation that revision will be needed in the future.

Nursing Diagnoses and Interventions

Acute pain

Desired outcomes

Within 1-2 hr of intervention, patient’s subjective perception of pain decreases as documented by a pain intensity scale. Patient demonstrates ability to perform activities of daily living (ADL) with minimal discomfort.

Nursing Interventions

♦ Assist patient in use of a pain intensity rating scale with 0 (no pain) to 10 (worst pain imaginable). This is to evaluate pain and analgesic relief.

♦ Administer simple analgesics, NSAIDs, and opioid analgesics as prescribed and reassess their effectiveness in approximately 1 hr using pain intensity rating scale. Document preintervention and postintervention pain scores. Determines medication effectiveness.

♦ Teach patient about use of epidural or patient-controlled analgesia (PCA) as needed.

♦ Advise patient to coordinate time of peak effectiveness of analgesic or NSAID with periods of exercise or other use of arthritic joints. This is to minimize pain.

♦ Teach patient to use nonpharmacologic methods of pain management, including guided imagery, relaxation, massage, distraction, biofeedback, heat or cold therapy, and music therapy. This helps to minimize pain.

♦ Supplement other pain management strategies with traditional nursing interventions such as back rubs, repositioning, and encouraging patient to discuss impact of chronic disease.

♦ Encourage patient to use principles of joint protection, which include a balance of rest and activity. This facilitates movement while minimizing pain.

Deficient knowledge

Desired outcome

Within 1-2 hr of instruction, patient verbalizes understanding of potential interactions between NSAIDs and herbal products that potentiate bleeding.

Impaired physical mobility

Desired outcomes

Within 1 wk of instruction, patient demonstrates adequate upper body strength for use of an assistive device. Patient demonstrates appropriate use of assistive device on flat and uneven surfaces.

Nursing Interventions

♦ Ensure patient has necessary strength of upper extremities for using prescribed assistive device before beginning gait training. Facilitates successful adaptation to device.

♦ Teach armchair push-ups. Helps patient attain and maintain triceps muscle strength necessary for use of assistive device.

♦ Ensure that assistive device is appropriately sized to patient (i.e., height of walker, crutches, or cane allows patient to have approximately 15 degrees of elbow flexion when ambulating). Crutch tops should rest 1-1.5 inches (width of two fingers) below axillae. Prevents upper extremity paresthesia caused by pressure on brachial plexus.

♦ Describe and demonstrate use of prescribed assistive device, and supervise return demonstration. Ensures patient’s ability to ambulate safely with the device.

♦ Begin ambulation in small increments on a flat surface and progress to all surfaces patient is expected to encounter; ensure that patient can safely get into and out of a motor vehicle. This helps prevent falls.

Ineffective sexuality patterns

Desired outcome

Within 1 wk of intervention, patient describes increased physical and psychologic comfort during sexual intimacy.

Patient-Family Teaching and Discharge Planning

Include verbal and written information about the following:

♦ Medications and supplements, including names, dosage, purpose, schedule, precautions, and potential side effects. Also discuss drug/drug, herb/drug, and food/drug interactions.

♦ Importance of laboratory follow-up (e.g., blood or urine testing) for needed monitoring while patient is taking selected medications.

♦ Importance of joint protection, with balance of rest and activity.

♦ Use, care, and replacement of orthotics and assistive devices.

♦ If surgery was performed, any precautions related to procedure, wound care, and signs of infection (i.e., persistent redness or pain, swelling or localized warmth, fever, purulent drainage) or other complications of surgery.

♦ Importance of follow-up care, date of next appointment, and a telephone number to call if questions arise.

♦ Referral to community resources, including local arthritis support activities and the Arthritis Foundation (website): www.arthritis.org

♦ Additional information on arthritis may be available through the following:

National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS): www.nih.gov/niams/health%20info

Rheumatoid Arthritis

Overview/Pathophysiology

Rheumatoid arthritis (RA) is a chronic systemic disease associated with severe morbidity and functional decline caused by inflammation of connective tissue, primarily in the synovial joints. The mortality rate for people with RA is double that of the general population, particularly if the disease is not well controlled. Individuals with RA are at increased risk for heart attack and stroke. Although no single known cause for RA exists, theory suggests that RA occurs in a susceptible host who initially experiences an immune response to an antigen. Because complex genetic factors appear to be involved, the antigen is probably not the same in all patients. Autoimmunity has been suggested as a cause because of the association of RA with the occurrence of rheumatoid factor (RF), the antibody against an abnormal immunoglobulin G (IgG).

The immune response appears to center on synovial tissue, where disease changes are first seen. Synovitis develops when immune complexes are deposited onto the synovial membrane or superficial articular cartilage. As hypertrophied synovium invades surrounding tissues, highly vascularized fibrous exudate (pannus) forms to cover the entire articular cartilage. Pannus also scars and shortens adjacent tendons and ligaments to create the laxity, subluxation, and contractures characteristic of RA.

Assessment

Signs and symptoms/physical findings

Fatigue; anorexia; weight loss; generalized stiffness that becomes localized as time progresses; morning joint stiffness lasting 1-4 hr; joint pain and swelling, especially in hands and wrists, although knees, ankles, and MTP joints also may be affected; increasing difficulty with mobility and performance of activities of daily living (ADL); spindle-shaped fingers with swan-neck and boutonniere deformities from flexion contractures that occur with disease progression; ulnar deviation with a “zigzag” wrist deformity; metatarsal head subluxation and hallux valgus (bunion) in the feet that leads to walking disability and pain; symmetric (bilateral) joints that are swollen, red, warm, and tender with decreased ROM; subcutaneous nodules over bony prominences, extensor surfaces, or juxtaarticular areas; hoarseness if nodules have invaded the vocal cords; and guarded movement and gait abnormalities resulting from joint changes.

History and risk factors

Women are affected two to three times more often than men. Genetic studies have confirmed a familial tendency. Unlike in osteoarthritis (OA), no environmental factors have been identified as disease precipitators.

Diagnostic Tests

Diagnosis of RA is based primarily on physical findings and patient history. Radiographic studies are not usually needed to make a diagnosis. Laboratory results are helpful in confirming diagnosis and monitoring disease progression.

RF

Positive in about 85% of patients. Higher titers appear to be correlated with severe and unremitting disease. However, the RF titer has little prognostic value, and serial titers have no usefulness in following disease process.

Antinuclear antibodies

Elevated titers seen in 5%-20% of patients.

Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP)

Elevation is a general indicator of active inflammation.

Synovial fluid analysis

Fluid is opaque with cloudy yellow appearance, with elevated WBC count and polymorphonuclear leukocytes in the presence of RA. Glucose level will be lower than serum glucose.

X-ray examination of affected joints

Radiographs may be inconclusive in early disease, but baseline films, especially of the hands, aid in monitoring disease progression. Presence of erosions also helps determine prognosis. In advanced disease, loss of articular cartilage leads to narrowed joint space. Subluxation and joint malalignment can be identified on x-ray film and reflect changes noted on physical examination. Osteopenia or osteoporosis may be evident in the patient with RA who has been treated with corticosteroids.

Arthroscopy

Reveals pale, hypertrophic synovium with destruction of cartilage and formation of fibrous scar tissue.

Collaborative Management

Pharmacotherapy

Pharmacotherapy remains the cornerstone of an interdisciplinary approach to care.

Disease-modifying antirheumatic drugs (DMARDs)

These drugs have been shown to control active synovitis and prevent joint erosions and damage. The early use of DMARDs is critical because these drugs do not heal erosions or reverse other effects of established RA. Methotrexate is most commonly prescribed by rheumatologists in the United States. Gold has been a standard therapy since the 1940s. Other DMARDs include leflunomide, sulfasalazine, penicillamine, cyclosporine, and cyclophosphamide.

Tumor necrosis factor inhibitors

These agents interfere with cell surface antigens of modulating cytokines to manage RA symptoms in patients with moderate to severe disease who have not responded to DMARDs. Adalimumab, etanercept, and infliximab block a cytokine known as tumor necrosis factor-α (TNF-α), whereas anakinra blocks interleukin-1 (IL-1). TNF inhibitors are frequently given with a DMARD. Adalimumab, etanercept, and anakinra are given by subcutaneous injection, a route that may be problematic for self-administration by patients with RA who have muscle weakness and deformities of advanced disease. Infliximab is administered by IV infusion over 2 hr in a physician’s office, clinic, or hospital.

NSAIDs (ibuprofen, naproxen, diclofenac, meloxicam, celecoxib)

These drugs provide largely equal analgesic and antiinflammatory effects in the treatment of RA. They do not affect disease progression, and their use in alleviating RA symptoms may in fact delay initiation of DMARD therapy or referral to a rheumatologist. Patients who have had myocardial infarction (MI), transient ischemic attack (TIA), or stroke and who require antiplatelet therapy can safely use the cyclooxygenase-2 (COX-2) inhibitor celecoxib (Celebrex) because it has no effect on bleeding time or platelet aggregation.

Corticosteroids

Injection of corticosteroids directly into affected joints can temporarily relieve the pain and inflammation of RA exacerbations. Long-term use of oral corticosteroids, however, has been associated with development of avascular necrosis (AVN) or osteoporosis. Low-dose prednisone (less than 10 mg) may be useful in selected patients to minimize disease activity until the prescribed DMARD becomes therapeutic, but it should not be a mainstay of treatment.

Antimalarials (hydroxychloroquine, chloroquine)

Mechanism of action is unknown, but it is thought to alter innate immunity. These drugs are used most commonly for patients with mild or nonerosive disease and are given in combination with methotrexate and sulfasalazine.

Joint protection

Inflammation appears to resolve more quickly in a splinted joint.

Therapeutic exercise

ROM, stretching, strengthening, and conditioning exercises preserve function, increase muscle strength, and improve overall endurance. Low-resistance endurance exercises such as bicycling, swimming, golf, and dancing are also appropriate for overall fitness. Performance of progressive muscle contraction and relaxation, however, tends to exacerbate the pain of RA.

Heat and cold therapy

Thermotherapy is an important adjunct to exercise. Heat treatments can be delivered superficially (hot packs, paraffin baths) or deeply (ultrasound). Cold applications may provide greater relief during acute episodes of pain exacerbation.

Assistive devices

Sock donners, long-handled reachers and brushes, raised toilet seats, and other devices may help minimize stress on joints. Clothing can be adapted to encourage independence in dressing (e.g., zipper pulls, Velcro closures).

Nutritional therapy

Research has shown several positive connections between food or nutritional supplements (e.g., omega-3 fatty acids) and some types of arthritis, including RA. However, there are also many claims that special diets, foods, or supplements can cause harm in arthritis. Some specific diets that are known to have harmful side effects include those that rely on large doses of alfalfa, copper salts, or zinc or the so-called immune power diet or the low-calorie/low-fat/low-protein diet. Patients who are taking methotrexate may experience folic acid deficiency that requires supplementation.

Alternative therapies

See discussion in “Osteoarthritis,” p. 567.

Surgical interventions

Arthroscopy may be performed to diagnose joint disease or to treat RA by allowing removal of loose bodies or abrasion of cartilage. Synovectomy prevents pannus formation through removal of inflamed synovium; it may be appropriate when one or two joints are affected more severely than others. Carpal tunnel release, tarsal tunnel release, ganglionectomy, tendon repair, and removal of Baker’s cysts may correct concurrent connective tissue defects associated with RA. Osteotomy corrects bony malalignment resulting from medial or lateral joint erosion, whereas arthrodesis allows for a stable, painless joint through fusion of surfaces in severely affected joints with extremely weak periarticular tissues and muscle atrophy. Implant arthroplasty is performed to replace eroded joints with Silastic implants that correct deformity and allow greater ROM. Total joint arthroplasty improves joint function by replacing eroded surfaces with prostheses.

Nursing Diagnoses and Interventions

Fatigue

Desired outcome

Within 24 hr of instruction and interventions, patient verbalizes a reduction in fatigue.

Nursing Interventions

♦ Investigate patient’s sleep pattern and suggest strategies (e.g., warm bath at bedtime). Helps facilitate rest.

♦ Assist patient to evaluate food preparation methods that may contribute to fatigue and suggest changes (e.g., set table for next day’s breakfast before going to bed at night, use convenience foods whenever possible). These activities help minimize fatigue.

♦ Assess patient’s ability to manage pain and encourage use of interventions. Maximizes quality of rest periods.

♦ Encourage patient to pace activities and allow adequate rest periods during the day. Reduces fatigue.

♦ Assess patient’s stress or psychoemotional distress. Suggest coping strategies or refer patient to appropriate clinical specialist in psychiatric nursing. Helps minimize stress.

♦ Discuss rationale for a stepped approach to exercise that increases endurance and strength without fatiguing patient. Encourage patient to set realistic exercise goals and share them with associated health care providers.

♦ Instruct patient in use of assistive devices to minimize fatigue.

♦ Assist patient to evaluate time that fatigue occurs, its relationship with necessary activities, and activities that relieve or aggravate symptoms.

Disturbed body image

Desired outcome

Within 1 mo of intervention, patient verbalizes positive adjustment to body image changes.

Nursing Interventions

♦ Provide anticipatory counseling about possible joint deformities/body image changes following initial diagnosis, including ways for patient to prepare for reaction of others.

♦ Routinely assess patient for negative body image, as indicated by refusal to discuss or participate in care, withdrawal from social contacts, and avoidance of intimate relationships. This facilitates identification of negative body image so that corrective actions can be implemented.

♦ Assess patient for negative feelings about body image linked specifically to use of assistive devices/mobility aids.

♦ Ask patient to complete the Baird Body Image Assessment Tool or other self-assessment survey. Helps determine subjective response to physical changes.

♦ Use survey results (Baird Body Image Assessment) along with patient statements to help patient consider meaning and impact of any physical changes.

♦ Demonstrate positive regard for patient and acceptance of any physical changes associated with chronic illness. Helps patient accept physical changes.

Dressing/grooming self-care deficit

Desired outcome

Within 1 wk of instruction, patient verbalizes/exhibits increased independence in dressing/grooming.

Patient-Family Teaching and Discharge Planning

Provide verbal and written information about the following:

♦ Treatment regimen, including physical therapy (PT) and exercises, systemic rest/principles of joint protection, and thermotherapy.

♦ Medications and supplements, including names, dosage, schedule, precautions, and potential side effects. Also discuss drug/drug, herb/drug, and food/drug interactions.

♦ Potential complications of disease and therapy, as well as need to recognize and seek medical attention promptly if they occur.

♦ Potential concurrent pathologic conditions, such as pericarditis and ocular lesions, and need to report them promptly to health care provider.

♦ Use, care, and replacement of splints, orthotics, and assistive devices.

♦ Use of adjunctive aids as appropriate, including long-handled reacher, long-handled shoehorn, elastic shoelaces, Velcro fasteners, crutches, walker, and cane.

♦ Referral to visiting/public health or home health nurse as necessary for ongoing care after discharge.

♦ Importance of laboratory follow-up (e.g., blood or urine testing) when taking selected medications and the importance of keeping follow-up appointments. Include date of next appointment and telephone number to call if questions arise.

♦ Referral to community resources, including local arthritis support activities:

Arthritis Foundation: www.arthritis.org

American Academy of Pediatrics: www.aap.org

National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS): www.nih.gov/niams/health%20info

Section Two Muscular and Connective Tissue Disorders

Ligamentous Injuries

Overview/Pathophysiology

Injury occurs when the ligament is stressed in a direction other than the one in which it accepts the stress, or when stress exceeds inherent structural strength. Ligament tears usually result from direct trauma or transmission of force to a joint (e.g., injury to shoulder ligaments resulting from twisting the distal arm). Tears can be longitudinal, transverse, tangential, complete, or partial and can involve avulsion fractures at the ligament origin or insertion. Severity of ankle sprains is described as grade 1 (first degree, least severe) to grade 3 (third degree, most severe). Grading is based on edema/hemorrhage, pain, ROM, decreased ligament strength, and joint stability.

Collaborative Management

Uncomplicated injuries

The acronym RICE (rest, ice, elevation, compression) describes standard treatment for ligamentous injuries. Rest involves splinting, casting, or bracing and/or avoiding active use of the affected joint. Plaster or fiberglass previously prepared splints and air or gel splints may be used. Use of ice (cryotherapy) is well established as a means of controlling inflammation from trauma. Compression via elastic wraps prevents swelling and supports joints. Elevation decreases further edema formation while aiding resolution of existing edema. In addition, nonsteroidal antiinflammatory drugs (NSAIDs) may be used for analgesic and antiinflammatory effects.

Surgical repair

For injuries resulting in grossly unstable joints, surgery allows removal of a nonviable ligament or suture repair of the stretched ligament with the use of strong, absorbable suture material. Following avulsion injury (ligament torn from bone) without fracture, the ligament may be reattached to its insertion site by using bone staples or passing a suture through holes drilled into the affected bony area. Additional procedures may involve use of prosthetic devices to stent, temporarily replace, or augment ligament repairs.

ROM and muscle-strengthening exercises

Treatment may begin after an appropriate period of joint immobilization (several days to 3 wk).

Nursing Diagnoses and Interventions

Deficient knowledge

Desired outcome

Within 30 min of instruction, patient verbalizes understanding of suggested treatments and returns demonstration of prescribed exercises.

Nursing Interventions

♦ Assess patient’s facility with language; engage an interpreter or provide language-appropriate written materials if necessary.

♦ Teach pathophysiology of injury and concomitant inflammatory response. Provide instructions concerning need for a graded muscle-strengthening and joint ROM exercise regimen. This enables return of normal joint function.

♦ Teach use of RICE interventions for 3-5 days, depending on severity of injury. Encourage use of ice for first 48-72 hr to prevent excessive edema; advise patient to cover ice with at least two layers of terry cloth. Protects skin from injury.

♦ Avoid ice application for patients with suspected compartment syndrome or those with peripheral vascular disease, decreased local sensation, coagulation disorders, or a similar pathologic condition. Minimizes the potential for thermal injury.

♦ Explain each prescribed exercise in detail, including rationale. An effective method is to teach an appropriate exercise, demonstrate it, and then have patient return the demonstration. This helps ensure patient’s understanding of exercise.

♦ Provide written instructions that describe the exercises, and list frequency and number of repetitions for each one. Include a phone number in case patient has questions after hospital discharge.

Risk for peripheral neurovascular dysfunction

Desired outcomes

Patient has adequate peripheral neurovascular function in the involved limb, as evidenced by normal muscle tone, brisk (less than 2 sec) capillary refill (or capillary refill consistent with the contralateral extremity), minimal edema or tautness, and absence of paresthesia. Patient verbalizes understanding of the importance of reporting symptoms indicative of impaired neurovascular function.

Anterior Cruciate Ligament Tears

Overview/Pathophysiology

The anterior cruciate ligament (ACL) prevents excessive forward motion and internal rotation of the tibia. Injury to this ligament can result in strain, microtears, partial tears, complete tears, or avulsion of tibial or femoral attachments. Untreated ACL tears result in gross instability, which eventually can cause osteoarthritis (OA).

Diagnostic Tests

Radiographic studies

Physical examination findings may strongly suggest ACL injury. If appropriate, radiographic studies may be performed to confirm or rule out ligamentous damage. Anteroposterior (AP), lateral, and patellar views of the knee and intercondylar notch views with and without stress on the joint may be obtained to determine the presence of abnormal joint contours.

Lachman’s test

Results are positive if the ACL is torn. Patient’s knee is partially flexed at 15-20 degrees, and the foot is planted flat on the examining table. The examiner then pulls the patient’s tibia forward while holding the femur stable. Excessive forward movement of the tibia is evidenced by a convex curve of the patellar tendon, which is indicative of an ACL tear.

Drawer test

Performed with the patient’s knee flexed at 60-90 degrees and the foot planted flat on the table. The tibia is pulled forward as the femur is stabilized. Excessive forward movement (6 mm or more) indicates a tear. The test is then repeated with the foot externally rotated 15 degrees to assess concurrent injury of medial joint structures (meniscus or periarticular ligaments). Finally, the test is repeated with the foot internally rotated 30 degrees to assess concurrent lateral joint injury.

Pivot shift maneuver (jerk test)

Provides evidence of anterolateral instability of the knee. The tibia is internally rotated with one hand while the other hand is used to apply valgus stress on the knee. The knee is then flexed 20-30 degrees. The result is positive when the tibia subluxates anteriorly as evidenced by a palpable “clunk” on the lateral aspect of the knee.

MRI

Enables identification of ACL tears and other soft tissues not visible on x-ray film.

Arthroscopy

Enables direct visualization of the ACL injury to determine extent of damage and to assess need for surgery.

Collaborative Management

The type of therapy is determined by type of injury, length of time since original injury, concurrent joint pathology, and patient’s age and functional goals.

RICE

Rest, ice, compression and elevation. See “Ligamentous injuries,” p. 577.

Bracing

Provides primary support for an incompletely torn ACL or supplements other ligaments and menisci associated with the affected joint. Functional braces provide support and immobilization following reconstruction and allow controlled ROM in rehabilitation. Several types of commercial braces are available to provide AP, lateral, and rotational stability to the joint.

Physical therapy (PT)

Concurrent PT strengthens periarticular structures and muscles.

Surgery

ACL surgery should be considered for all persons who wish to return to sports or activities that require lateral pivoting of the knee or for those who experience recurrent instability.

Primary ACL repair

Involves direct suturing of the torn ligament during arthrotomy or arthroscopy. Suture is heavy and nonabsorbable and is used in repairing incomplete tears that are less than 6 wk old.

ACL reconstruction

Involves use of either anatomic graft (autograft or allograft) or synthetic graft replacements. Autografts are commonly taken from the patellar tendon, although the semitendinosus tendon or hamstring tendon also may be used. Allograft (cadaver) patellar tendon also has been used for repair but is not generally the first choice. Use of a continuous passive movement (CPM) machine often immediately follows ACL reconstruction, and extensive PT follows to help with ROM and strengthening. A protective brace is often recommended for athletic activities after rehabilitation. Most reconstructive procedures are performed by arthroscopy, which permits dramatically less joint trauma, early hospital discharge or even outpatient surgery, and excellent long-term results.

Nursing Diagnoses and Interventions

Acute pain

Desired outcomes

Within 1-2 hr of intervention, patient’s subjective perception of pain decreases as documented by pain intensity rating scale. Patient demonstrates ability to perform activities of daily living (ADL) with minimal complaints of discomfort.

Nursing Interventions

♦ Assist patient in use of pain intensity rating scale based on 0 (no pain) to 10 (worst pain imaginable). This allows for accurate evaluation of pain and analgesic relief.

♦ Administer simple analgesics, nonsteroidal antiinflammatory drugs (NSAIDs), and opioid analgesics as prescribed, and reassess their effectiveness in approximately 1 hr using pain intensity rating scale. Helps determine pain control effectiveness.

♦ If intraarticular anesthetic or opioid was administered intraoperatively, advise patient that lack of pain in the immediate postoperative period does not mean that it is allowable to move the joint excessively.

♦ Instruct hospitalized surgical patient in use of patient-controlled analgesia (PCA) or epidural analgesia if prescribed. This helps to minimize pain.

♦ Monitor effectiveness of patient’s pain management (PCA or epidural) while observing for excessive sedation, respiratory depression, and decreased level of consciousness.

♦ Closely observe for hemorrhage at the surgical site. NSAIDs increase the potential for excessive bleeding.

♦ Avoid administration of NSAIDs during epidural analgesia. This reduces the risk of bleeding into the epidural space, bleeding that may create pressure on spinal nerves.

♦ Advise patient to coordinate time of peak effectiveness of analgesics with periods of exercise or ambulation. Minimizes pain and facilitates ambulation/exercise.

♦ Supplement other pain management strategies with traditional nursing interventions such as back rubs and repositioning. These help minimize pain.

Deficient knowledge

Desired outcome

Within 30 min of instruction, patient verbalizes understanding of CPM machine use and returns a demonstration of prescribed exercises.

Patient-Family Teaching and Discharge Planning

Include verbal and written information about the following:

♦ Use of any external support devices (elastic wraps, knee immobilizer, orthosis), including care of the device, care of skin beneath the device, and monitoring for areas of skin irritation or neurovascular deficit.

♦ Prescribed exercise regimen, including how exercise is performed, number of repetitions, frequency of exercise, and rationale for exercise performance.

♦ Use of CPM for rehabilitation and joint ROM, including need to use CPM machine for appropriate amount of time each day.

♦ Ambulation with assistive device, including patient’s demonstration of independence on level and uneven ground.

♦ Medications and supplements, including names, rationale, dosage, schedule, precautions, and side effects. Also discuss drug/drug, herb/drug, and food/drug interactions.

♦ Indications of wound infection that require medical attention, including erythema, edema, joint effusion, purulent discharge, local warmth, pain, and fever.

♦ Importance of follow-up care, date of next appointment, and a telephone number to call if questions arise.

Dislocation/Subluxation

Overview/Pathophysiology

A dislocation occurs when contact between opposing joint surfaces is completely interrupted. A subluxation is an incomplete dislocation in which joint surfaces are partially in contact. Some subluxations are associated with pronounced connective tissue disease, such as the ulnar deviation of phalanges and metacarpals seen with severe rheumatoid arthritis (RA). Complications include recurrent dislocation, joint contracture, neurovascular injury, and eventual traumatic arthritis.

Collaborative Management

Interventions vary with the degree of subluxation or dislocation and the joint involved. Shoulder dislocation is the most common dislocation treated in emergency departments, whereas traumatically dislocated knee is much less common. Prompt diagnosis is critical, and assessment must include any associated neurovascular injury. Many patients are discharged from the hospital with instructions to use temporary immobilization of the affected part, thermotherapy, elevation, and analgesics/nonsteroidal antiinflammatory drugs (NSAIDs).

Immediate reduction

Preferred to decrease likelihood of inflammation and muscle spasm. If immediate reduction is not possible, patient may require NSAIDs and muscle relaxants before a later attempt may be made at joint reduction. A splint, harness, or padding may be needed for up to 8 wk after acute dislocation until pain is adequately decreased and muscular function provides sufficient support.

Manual reduction

Many joints can be manually reduced by using local or general anesthesia. Occasionally open reduction and internal fixation (ORIF) with screws, pins, or wires may be needed to maintain reduction.

Exercise regimen

After satisfactory joint stability has been achieved, patient may begin an exercise regimen to improve muscle strength and joint ROM. Strengthening muscles surrounding the joint will help prevent future dislocation. For persons involved in strenuous sports or heavy work, the affected joint may be protected by elastic bandage or tape wraps, pads, or support stockings. Long-term problems may be prevented by allowing adequate time for an injured joint to rest and heal before resumption of full activity.

Nursing Diagnoses and Interventions

SEE “Osteoarthritis,” p. 571, for Pain related to arthritic joint changes and associated therapy, “Rheumatoid Arthritis,” p. 576, for Dressing/grooming self-care deficit related to pain and limitations in joint range of motion, and “Ligamentous Injuries,” p. 578, for Deficient knowledge related to therapies and exercise for involved extremity.