Adult Medical-Surgical Nursing

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Adult Medical-Surgical Nursing

• Musculoskeletal Module Introduction

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The Bones of the Skeleton Classification

• 206 bones make up the skeleton
• Axial skeleton (skull and vertebral column)
• Appendicular skeleton (limbs)
• Bone classification
• Long bones (eg. femur)
• Short bones (metacarpals, metatarsals)
• Flat bones (scapula, ileum, facial)
• Irregular bones (vertebrae)

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Joints, Ligaments, Tendons

• Classification of joints
• Immoveable (skull, sacro-iliac)
• Limited motion (symphysis pubis, vertebral)
• Synovial/ freely moveable (synovial membrane
  lining the joint, secreting lubricating synovial
  fluid for movement)
• Ligaments articulate bone with bone
• Tendons attach bone to adjacent muscles

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Bone Tissue

• Cancellous (spongy) more open plan
• Cortical (compact) more close together
• Lacunae (bone matrix units) arranged in
  irregular network, trabeculae
• Periosteum dense fibrous covering of the bones
  (attaches ligaments, tendons)
• Yellow bone marrow long bone diaphysis
• Red marrow flat bones, vertebrae, ribs, sternum,
  ileum, epiphyseshaematopoiesis

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Long Bones

• The shaft of long bones (diaphysis) is cortical
  tissue for weight-bearing
• The ends of long bones (epiphyses) are cancellous
  tissue
• The ends of long bones are covered at joints with
  cartilage
• The epiphyseal plate area of growth in
  childhood, puberty. This is calcified in
  adulthood

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Types of Bone Cells (Osteocytes)

• Bone is a dynamic tissue constantly reforming and
  resorbing
• Osteoblasts (bone formation)
• Osteoclasts (bone destruction, resorption,
  remolding)

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Ossification (Bone Formation) Osteoblasts

• Osteoblasts secrete collagen and glycoproteins to
  form a bone matrix
• Deposit minerals in the matrix (calcium,
  magnesium, phosphorus, chloride)
• Two ways
• Intramembranous (face and skull) from fibrous
  tissue
• Endochondrial (long bones) from cartilage

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Bone Maintenance Osteoblasts and Osteoclasts

• Bone formation by osteoblasts and resorption by
  osteoclasts is influenced by
• Local stress usage/ weight-bearing aids bone
  formation
• (Immobility leads to increased calcium resorption
  from bone and osteoporosis)
• Vitamin D (intestinal absorption of calcium)
• Parathormone
• Calcitonin
• Blood supply (inadequate ? necrosis)

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Stages of Bone Healing following Fracture

• Initial trauma ? haemorrhage and haematoma
• Inflammation/ revascularisation
• Callus formation and ossification
• Remodelling

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Bone Healing Stage 1

• Haemorrhage and haematoma from initial trauma ?
• Interrupted blood supply causing devitalisation
  of fractured ends

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Bone Healing Stage 2

• Inflammatory process and neovascularisation
• Macrophages promote physiological debridement
  (inflammation, swelling, pain, loss of function
  for several days)
• Fibrin strands form within fracture haematoma as
  network for revascularisation, fibroblasts,
  osteoblasts

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Bone Healing Stage 3

• Callus formation
• Collagen and fibrous connective tissue (formed by
  fibroblasts and osteoblasts) grow towards each
  other from fractured ends (3-4 weeks)
• Ossification of callus (3-4 months in long bone)
• Encouraged by immobility, disturbed by excessive
  movement

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Bone Healing Stage 4

• Remodelling to former structure (months-years)

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Factors Influencing Healing

• Type of fracture and contact of segments
• Blood supply
• General health, age, nutritional status of the
  patient (calcium, vitamin D supplement)
• Immobilisation until callus formation with
  ossification on Xray (serial monitoring)
• Surgery firm approximation/ fixation ? quicker
  healing by direct growth of bone from the
  endosteum (space within bone)