NLE Musculoskeletal Nursing — Musculoskeletal Assessment and DiagnosticsCheat Sheet

Section Title

Functional Anatomy of the Musculoskeletal System

Important Facts

• Bone is living vascular tissue that constantly remodels — it stores 99% of total body calcium and phosphorus.
• Parathyroid hormone increases serum calcium by stimulating osteoclasts and renal calcium reabsorption.
• Calcitonin lowers serum calcium by inhibiting osteoclast activity and promoting renal excretion.
• Vitamin D (calcitriol) increases intestinal calcium absorption and bone mineralization.
• Cartilage is avascular; it is nourished by diffusion from synovial fluid — movement increases nutrition.
• The synovial joint capsule is lined with synovium that produces synovial fluid for lubrication and joint nutrition.
• Ligament and tendon injuries are slower to heal than bone because they have less blood supply.

Key Definitions

Diagrams To Know

• Cross-section of a long bone (epiphysis, metaphysis, diaphysis, medullary canal, periosteum)
• Synovial joint anatomy (articular cartilage, synovial membrane, joint capsule, ligaments)
• Components of bone matrix (organic collagen, inorganic minerals)

Common Values

Section Title

Health History Assessment — PQRST Framework

Important Facts

• Stiffness worse in the morning suggests rheumatoid arthritis; stiffness after activity suggests osteoarthritis.
• Ask about swelling, deformity, weakness, and loss of function in activities of daily living (ADLs).
• Document the mechanism of injury (falls, trauma, overuse) and chronology.
• Ask about occupational and recreational demands that may stress joints.
• Assess calcium and vitamin D intake; deficiency increases fracture risk.
• Review medications: corticosteroids weaken bone; anticoagulants increase bleeding risk.
• Screen for family history of arthritis, osteoporosis, or gout.
• Ask about previous orthopedic injuries and treatments; residual weakness or stiffness may be present.

Key Definitions

Common Values

Section Title

Physical Assessment — Inspection, Palpation, ROM, Muscle Strength, Gait

Important Facts

• ALWAYS compare affected limb with unaffected limb for symmetry.
• Inspect for swelling (edema, effusion), deformity (angular, rotational), muscle atrophy, erythema, and abnormal posture.
• Palpate systematically: bones, joints, soft tissue; assess for tenderness, warmth, crepitus, and masses.
• Assess active ROM FIRST; never force a joint through pain or resistance.
• Document ROM in degrees if possible; note end-feel (normal springy, boggy, hard, empty).
• Normal end-feel is firm (ligament or muscle tension) or soft (tissue approximation); abnormal = pain, spasm, or mechanical block.
• Muscle strength grading: 0 = no contraction; 1 = flicker; 2 = gravity eliminated; 3 = against gravity; 4 = against gravity plus resistance; 5 = full strength.
• Gait assessment includes stance phase (foot on ground) and swing phase (foot forward); observe symmetry, stride length, arm swing, and assistive device use.
• Antalgic gait is protective; patient favors the unaffected limb.
• Wide-based ataxic gait occurs with cerebellar or proprioceptive dysfunction.
• Shuffling gait is typical of Parkinson disease.
• Always guard the patient during gait assessment for fall prevention; assess fall risk.

Key Definitions

Diagrams To Know

• ROM of major joints (shoulder, elbow, wrist, hip, knee, ankle)
• Muscle strength grading scale (0–5)
• Stance and swing phases of normal gait
• Abnormal gait patterns

Common Values

Section Title

Neurovascular Assessment — The 5–6 Ps (CRITICAL)

Important Facts

• PAIN is the EARLIEST and most SENSITIVE indicator of compartment syndrome — do not dismiss it as normal post-injury pain.
• Pain OUT OF PROPORTION to the injury is the red flag; pain on passive stretch of fingers or toes is highly specific.
• PALLOR includes pale, dusky, or cyanotic skin; compare color with opposite limb.
• PULSELESSNESS is a LATE sign; absence of distal pulse indicates severe vascular compromise — report immediately.
• PARESTHESIA (numbness, tingling, "pins and needles") indicates nerve ischemia.
• PARALYSIS (inability to move digits) is a LATE sign indicating severe nerve damage.
• POIKILOTHERMIA (coldness): compare skin temperature; cool skin indicates reduced perfusion.
• Perform neurovascular checks on patients with fractures, casts, splints, traction, or recent orthopedic surgery.
• Initial frequency: every 15–30 minutes; then every 2–4 hours if stable.
• ALWAYS report ANY deterioration immediately — this is a patient safety imperative per RA 9173 scope of practice.
• Document findings on a flow sheet; note comparison with opposite limb.
• Loss of pulse + pain is a surgical emergency; notify physician/surgeon at once.
• Compartment syndrome can develop even days after injury — maintain vigilance.

Key Definitions

Diagrams To Know

• Sequence of findings in compartment syndrome (pain → paresthesia → paralysis → pulselessness)
• Correct technique for capillary refill assessment
• Anatomical location of distal pulses (radial, ulnar, dorsalis pedis, posterior tibial)

Common Values

Section Title

Diagnostic Imaging and Investigations

Important Facts

• X-RAY: First-line for suspected fracture; shows bone detail but not soft tissue; no special prep; confirm patient not pregnant; remove metal.
• CT: Provides cross-sectional detail of complex fractures, spine, and pelvis; faster than MRI; assess for contrast allergy and renal function if contrast used.
• MRI: BEST for soft tissue (ACL, meniscus, cartilage, disc herniation, osteomyelitis, tumors); NO metal implants allowed; screen for pacemakers, cochlear implants; warn patient about enclosed space and noise.
• BONE SCAN: Inject tracer (Tc-99m) IV; expect 2–3 hour delay before scanning; ENCOURAGE FLUIDS to help distribute and excrete tracer; assure patient dose of radiation is minimal.
• DEXA: No special prep; measures T-score; T<−2.5 = osteoporosis, −2.5 to −1 = osteopenia, >−1 = normal.
• ARTHROSCOPY PRE-OP: Verify informed consent; keep NPO; check vital signs.
• ARTHROSCOPY POST-OP: Neurovascular checks distal to site; compression dressing and ice; elevate extremity; assess for increasing pain, fever, swelling; limit strenuous activity; may have small bandage over portal sites.
• ARTHROCENTESIS: Usually outpatient; fluid sent to lab (culture, glucose, cell count, crystal analysis); patient may have knee effusion post-procedure — apply ice and elevate.
• Lab tests for bone and joint disease: serum calcium, phosphorus, alkaline phosphatase (elevated with bone healing/disease), uric acid (gout), ESR and CRP (inflammation/infection), rheumatoid factor and anti-CCP (RA).

Key Definitions

Diagrams To Know

• Decision tree for choosing imaging modality (X-ray vs. CT vs. MRI vs. bone scan)
• Contraindications to MRI (metal implants, pacemakers)
• Timeline of bone scan procedure (injection → 2–3 hour delay → imaging)

Common Values

Section Title

Principles of Casts — Nursing Management

Important Facts

• NEVER support a wet plaster cast on fingertips — use palms of both hands to avoid denting and creating pressure points.
• Allow plaster cast to AIR DRY; do NOT cover it while wet; open weave allows evaporation.
• Fiberglass casts dry much faster (30 minutes) and can be exposed to water after drying.
• ELEVATE the extremity above heart level for the FIRST 24–48 hours to reduce swelling.
• Apply ICE as ordered for the first 24–48 hours; remove ice periodically (15–20 min on, 15–20 min off) to prevent skin damage.
• Perform FREQUENT neurovascular checks distal to the cast (every 15–30 min initially, then every 2–4 hours).
• Teach patient NEVER to insert objects into the cast to scratch — this breaks skin and invites infection.
• Keep the cast CLEAN and DRY; waterproof the cast before bathing if directed.
• Assess for HOT SPOT, FOUL ODOR, or DRAINAGE — signs of infection or pressure ulcer; circle and date any drainage to track spread.
• Teach patient to report INCREASING PAIN, NUMBNESS, COLDNESS, or SWELLING that does not relieve with elevation — these are signs of compartment syndrome or cast too tight.
• Skin at the cast edges may itch; loosen cast padding or advocate for cast modification, but never try to insert objects.
• Teach proper use of crutches or other assistive devices for ambulation while in cast.
• Schedule follow-up X-rays as ordered to verify healing and alignment.
• When cast is removed, expect atrophied muscle and stiff joint; gradual ROM and strengthening exercises are required.

Key Definitions

Diagrams To Know

• Proper hand placement for supporting a wet plaster cast
• Correct positioning: extremity elevated above heart level
• Neurovascular check locations distal to cast (pulses, color, temperature, sensation, motor)

Common Values

Section Title

Principles of Traction — Nursing Management

Important Facts

• FUNDAMENTAL PRINCIPLE: Weights must HANG FREELY and NEVER rest on the floor or bed — this breaks the traction pull.
• NEVER add or remove weights without a physician/surgeon order.
• Keep ROPES on the pulleys and KNOTS secure; inspect daily for fraying or slipping.
• Maintain PROPER ALIGNMENT with countertraction — usually the patient's body weight provides this.
• Use a DRAWSHEET under the patient (from shoulders to above knees) to support alignment and prevent sliding.
• PIN-SITE CARE for skeletal traction: Use ASEPTIC technique; clean with sterile normal saline or ordered solution; assess for redness, warmth, drainage, exudate, or loosening.
• Perform frequent NEUROVASCULAR CHECKS distal to traction (every 15–30 min initially, then every 2–4 hours).
• Assess SKIN regularly, especially under the adhesive strips in skin traction or around pin sites — high risk of pressure injury.
• Prevent COMPLICATIONS OF IMMOBILITY: turn patient (if allowed by traction setup), perform range-of-motion exercises to uninvolved joints, use sequential compression devices to prevent deep vein thrombosis, provide adequate nutrition and hydration, manage constipation with fluids and stool softeners, assess for signs of pneumonia.
• Encourage BREATHING EXERCISES and coughing to prevent atelectasis and pneumonia.
• Maintain PROPER BED HEIGHT and ensure traction weights are suspended from an overhead frame (a Balkan frame or traction frame).
• Monitor for FOOT DROP in lower-extremity traction — use footboard or devices to keep foot in neutral position.
• Teach the patient to avoid hip and knee flexion beyond the angle set by the physician in lower-extremity traction.
• In skeletal traction, monitor pin sites daily for signs of osteomyelitis (bone infection).

Key Definitions

Diagrams To Know

• Setup of skin traction (Buck's traction): boot, rope, pulley, weights hanging freely
• Setup of skeletal traction: pin through bone, rope, pulley, weights
• Proper body alignment in traction (countertraction, neutral hip/knee angles)
• Pin-site care technique (aseptic, circular motion from center outward)

Common Values

Section Title

Assistive Devices and Gait Training

Important Facts

• CRUTCHES: Proper fit = two to three finger-widths (about 5 cm) space between axilla and axillary pad.
• Weight-bearing on HANDS/GRIP, NOT on the AXILLA (armpit) — leaning on axilla causes crutch palsy.
• Hand placement: Hands hold the grip below the axillary pad; elbows should be slightly bent (25–30°).
• THREE-POINT GAIT: Used when one leg cannot bear weight (e.g., fracture, major surgery); crutches and bad leg advance together, then strong leg swings through; slowest gait pattern.
• FOUR-POINT GAIT: Used when both legs can bear some weight; right crutch → left leg → left crutch → right leg; safest and most stable; used early in recovery.
• TWO-POINT GAIT: Used when both legs can bear weight; right crutch and left leg together → left crutch and right leg together; more natural, faster than four-point.
• STAIRS with crutches: 'Up with the good, down with the bad' — the STRONG leg leads going UP the stairs; the crutches and WEAK leg lead going DOWN.
• When going up stairs: strong leg step, then crutches and weak leg step to same level ("up with the good").
• When going down stairs: crutches and weak leg step down first, then strong leg step to same level ("down with the bad").
• WALKER: Provides the most stability; patient lifts walker and advances it, then steps into it; slowest gait.
• CANE: Held on the STRONG (unaffected) side; patient advances weak leg with cane; reduces weight on weak leg by up to 25%.
• Always GUARD the patient during initial gait training for fall prevention.
• Teach patient to look ahead while walking, not down at feet.
• Ensure that crutches, walker, or cane have rubber tips and are in good condition.
• Practice with assistive devices on a flat surface before attempting stairs or uneven terrain.

Key Definitions

Diagrams To Know

• Crutch fitting and proper axillary clearance
• Three-point, four-point, and two-point gait sequences (step-by-step)
• Stair climbing with crutches: 'up with good, down with bad'
• Proper cane placement on strong side

Section Title

Common Musculoskeletal Nursing Diagnoses and Interventions (NANDA-I Framework)

Important Facts

• Priority nursing diagnoses in musculoskeletal trauma align with Maslow's hierarchy: Safety (compartment syndrome, neurovascular compromise) > Pain > Mobility > Self-care.
• COMPARTMENT SYNDROME is the highest priority — it is a surgical emergency with time-sensitive intervention window (4–6 hours).
• Pain management is essential for mobilization and healing; multimodal analgesia (NSAIDs, opioids, non-pharmacologic) is standard.
• Immobility complications include deep vein thrombosis, pressure injury, contracture, and pneumonia; prevention is key.
• Teach patient REALISTIC expectations: healing takes weeks to months; ROM and strength return gradually.
• Discharge planning must address fall risk, home safety, medication adherence, and follow-up appointments.
• For cast patients: report any sign of compartment syndrome immediately; do not delay.
• For traction patients: monitor for signs of pin-site infection, pressure injury, DVT, and pneumonia daily.
• Encourage participation in physical therapy and occupational therapy for functional recovery.

Key Definitions

Diagrams To Know

• Maslow's hierarchy applied to musculoskeletal nursing priorities
• Nursing process for acute pain management in fracture care
• Monitoring algorithm for compartment syndrome detection

Rows

Columns

• Modality
• Best For
• Pros
• Cons
• Special Precautions

Table Title

Imaging Modalities — Quick Comparison

Rows

Columns

• Type
• Force Application
• Weight Range
• Duration
• Infection Risk
• Nursing Focus

Table Title

Traction Types — Key Differences

Rows

Columns

• Material
• Weight
• Drying Time
• Water Resistance
• Cost
• Radiopacity
• Best Use

Table Title

Cast Types — Material Comparison

Rows

Columns

• Gait Pattern
• Number of Points
• Indication
• Weight-Bearing Requirement
• Stability
• Speed

Table Title

Gait Patterns — Indication and Use