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Define Musculoskeletal

Musculoskeletal

Case study Part 1: Presentation

Patient admission A 22-year-old female was admitted to the emergency

department after being involved in a motorcycle

accident. On presentation she was unable to weight

bear and there was slight knee effusion without

ecchymosis or deformity. On physical examination,

she was keeping her knee in slight flexion and knee

range of motion was painful and grossly restricted.

Further detailed physical examination could not be

performed due to intentional guarding, pain and

muscle spasm. X-rays and computed tomography

(CT) scans were performed.

Note: At this time you only have access to the X-rays.

Patient presentation (Task 1) The elbow dislocation and the hand fractures are

obvious to observe, however you are not sure about

the knee. You ask the attending physician to help

clarify it for you.

The elbow dislocation and the hand fractures are

obvious to observe, however you are not sure about

the knee. You ask the attending physician to help

clarify it for you.

(Click here for the interactive version of the marked-

up x-rays that the physician made for you. Once you

have done that return to this page)

You return to the physician a couple of minutes later,

after having studied the X-ray over a cup of coffee.

You are ready you say, and you feel confident identify

the landmarks. Give you a big smile the physician

wipes the pen marks off and asks you a question.

(This has been recorded and saved below for as long as the internet

survives).

Physician: So you are feeling confident are you. Let’s test you out then.

Can you point to the lateral

condyle, the medial condyle, and the intercondyle

eminance?

(Click here for an interactive version of the X-ray so

you can point out the correct features for the

physician. Once you have done that return to this

page)

Patient presentation (Task 2)

The physician seeing that you have correctly identify

the appropriate landmarks on the normal knee bones

holds up the two X-rays and gets you to compare

them (below).https://rmit.instructure.com/courses/12025/pages/marked-up-x-rayhttps://rmit.instructure.com/courses/12025/pages/marked-up-x-rayhttps://rmit.instructure.com/courses/12025/pages/marked-up-x-rayhttps://rmit.instructure.com/courses/12025/pages/locate-medial-condyle-lateral-condyle-intercondyle-eminancehttps://rmit.instructure.com/courses/12025/pages/locate-medial-condyle-lateral-condyle-intercondyle-eminancehttps://rmit.instructure.com/courses/12025/pages/locate-medial-condyle-lateral-condyle-intercondyle-eminancehttps://rmit.instructure.com/courses/12025/pages/locate-medial-condyle-lateral-condyle-intercondyle-eminance

Fig. 1. Knee radiographs of the patient before and

after the accident. Left image is an X-ray from a

previous admission (courtesy of Mr Andrew Murphy,

Radiopaedia.org), where no issues were observed.

Right image is an X-ray of the knee at the time of

admission following the accident (courtesy of Gerry

Gardney, Radiopaedia.org)

As part of your “training” with the physician you are

asked to answer the following three questions.

Which bone of the knee do you think was fractured

in the motorcycle accident?

How would you describe the location of the fracture

(Hint: Use directional terms)

Do you think there might be other structures within

the knee joint that could have been affected by the

accident and if so, why?

Part 2: Family arrives Questions from the family The immediate family of the patient have arrived and

the consulting surgeon has explained the injury to

them, however he was brief and used a lot of medical

terminology. (It has been recorded below for clarity)

Surgeon: Your daughter has suffered a lateral

tibial plateau fracture. This will require surgery

and most likely some screws. She has also

sustained an elbow joint dislocation, and

multiple fractures to her phalanges.

The patient and the family all node and say “right, ok,

cool”. And before the surgeon can explain what it all

means he is called away to consult on a critical patient

who just arrived by helicopter. As he leaves the

patients keeps repeating the word cool. (e.g “Cool cool

cool cool cool cooooool.”)

Once the surgeon has left the patients mother turns to

you and states:

Mother: I have no idea what that doctor said. I

don’t know what a lateral blah blah blah is. Can

you please explain what has happened to my

daughter’s leg?

Practical Assessment Task – Part 1 Write a script for how you would explain the injury to the patient and

the mother.

Remember to use terms that they would understand, but also make sure

you explain

the medical terms the doctor used.

Rehabilitation

Following surgery the patient has

been transferred to the ward where

she will continue to receive treatment

relating to her motorcycle accident.

Due to the significant damage that

was sustained by her left knee she

has been informed that it will take

time to recover the majority of her

range of movement, and that it may

not fully return.

She is also told that while her knee is

recovering, she will not be able to

move her leg or foot much, and that

when she starts physiotherapy she

may experience tightness and a

severe limit to her range of motion.

Time passes

The patient is to be released from

hospital today and will be going

home to continue her rehabilitation.

You help her pack her things ready to

leave, then are called away by the

nurse unit manager.

You are brought into a meeting and

notice one very important person

whom you have only met on a

handful of occasions (usually staff

end of year celebrations), the chief

nursing officer. They indicate for you

to take a seat and then introduce you

to two other people behind the table.

The chief medical officer and the

executive director operations.

They inform you that they would like

you to become part of a new team of

health staff that will assist with

intensive home-care for

physiotherapy patients. More is

discussed during the meeting, but as

you leave they make sure to impress

the importance of what you need to

do next.

Chief nursing officer:

Remember, before you start

with the first patient next week

you need to make sure you

understand their situation. This

will require you to familiarise

yourself with the case. The chief

physiotherapist has asked that

you present to him a short

summary of the muscles you

believe would be affected and

the reasoning for your decisions

before the end of this week .

You nod, and thank them for

choosing you.

Chief nursing office: Also

remember that this is a new

appointment and the first time

this type of team has been put

together and we want it to

work. You have been identified

by your nursing unit manager

as the prime candidate for this

position, don’t let them down.

Have a good weekend.

Practical Assessment Task – Part 2 Based on the case you will need to create a document that

outlines the muscles you believe would be affected directly

by the damage to the knee and also provide your reasoning

as to why they are affected. (You may use diagrams or

drawings to help you explain your reasoning).

Hint: Looking at the muscles that attach to the

affected area would be a good place to start.

Part 4 – Rehabilitation

The patient has been undertaking physical therapy for a

period of time, however her progression has plateaued. The

physical therapist reports to the health team that the patient

is able to walk, but requires a cane in order to walk any

significant distance. In fact, one of the tests used to assess

the patient’s walking ability was the 6-minute walk test. The

results from the test showed the patient was only able to

walk 45m.

Further tests are discussed at the meeting and the therapist

concludes her report:

Physical Therapist: The patient experiences

dorsiflexion weakness in her left foot, a result of atrophy

of the tibialis anterior muscles that occurred during the

post-operative period. I suggest that we trial the use of

functional electrical stimulation to strengthen the muscle.

This should aid in helping the patient move past the

progression plateau.

The team agrees that this is a good direction for the patient’s

rehabilitation. At the meeting it is also determined that at

her next visit the PT will discuss the option with the patient.

It is also decided that you will have training relating to

transcutaneous electrical nerve stimulation, and the

functional electrical stimulation protocol.

You spend a day with other nurses learning about the basics

of the TENS units, and experimenting with different

settings. You particularly find it fascinating that you were

able to induce a tetanic contraction in your lab partner’s

hand by increasing the frequency of stimulation

continuously higher.

Part 5 – Questions from the patient

The patient has been undergoing the

FES trial for a couple of weeks now

and is able to now apply the

electrodes herself, and also program

the unit to deliver the appropriate

treatment protocol. While you are

visiting she asks you a couple of

questions.

Patient: Ummm… I feel silly

asking this but I just want to

double check that I understand

what this machine is doing and

how it is supposed to be helping

me.

You look at the patient and smile.

You: Don’t feel silly. Please ask

any questions you have.

Patient: Well if I understand

correctly the electrodes

stimulate electrical sensors in

my muscle, where I place the

electrodes… the tibia muscle…

or something. But, the

electricity is detected by sensors

in my muscle and then my

muscle sends a signal to my

brain that tells my brain to send

a signal back down to my

muscle telling it to contract. Is

that right?

But before you can answer the

patient continues.

Patient: Then because my

muscle contracts it means that it

learns how to contract again,

you know, because it didn’t

know how to contract before. So

it learns and once it has learnt

how to contract again, then I

will be able to walk properly

because at the moment every

time I try to walk my foot just

droops.

She takes a deep breath and

continues quickly on.

Patient: So what I’m saying is

the machine electrocutes my leg,

which causes my brain to tell

my muscle how to contract and

then it will get better walking

and I’ll be able to walk.

It is your turn to speak.

Your task is to write a script explaining to the patient what is

actually happening between the machine and her muscles.

You should also make sure to kindly explain where she is

incorrect about how the machine works. You should also

explain which muscle is affected, and why it is important in

walking. (Hint: remember what the PT said in her report

about the patient. It would also be good to explain what

dorsiflexion weakness is and why it is a problem for

walking).

Criteria Exemplary Mastering Developing Emerging Not attempted

Knowledge

(Scientific)

The patient’s situation

has been clearly,

appropriately, and

systematically

described. The

differences between

normal and abnormal

skeletal structures

have been

methodically

comprehensively

contrasted.

A comprehensive

description of the

patient’s condition is

evident, with

differences between

normal and abnormal

skeletal structures

being sufficiently

discussed. Has

demonstrated sound

understanding of the

underlying scientific

knowledge relating to

the case.

An appropriate

description of the

patient’s condition has

been provided, but is

limited in information.

The differences

between normal and

abnormal skeletal

structures have been

adequately described.

The patient’s situation

has been awkwardly

and/or poorly

explained. Discussion

on the differences

between normal and

abnormal skeletal

structures in this case

study is vague and

limited.

Not attempted or no

clear demonstration of

the criteria

Knowledge

(Terminology)

All anatomical and

medical terminology

has been

comprehensively,

accurately, and

appropriately

explained in part 1,

and applied in part 2 &

3.

Accurate, appropriate,

and clear explanations

have been provided for

the majority of terms

in part 1, and has been

applied accurately and

appropriately in the

majority of parts 2 and

3

There is a clear

attempt to provide

suitable explanations

of the specialised

terminology used in

part 1 and

explanations are

mainly limited in

describing or defining

the terms. There is a

clear attempt to apply

terminology correctly

in parts 2 & 3.

There is an attempt to

explain some terms,

however very few

terms have been

explained to a

satisfactory standard.

Explanations are

confusing and/or

ineffective in

describing the terms.

There is little

appropriate use of

terminology in parts 2

& 3.

Not attempted or no

clear demonstration of

the criteria

Communication

The assessment

demonstrates a clear,

effective, and

comprehensive

approach to presenting

the information. There

is a logical and

professional approach

that demonstrates a

skilful approach in

patient interaction,

scientific

communication, and

The assessment shows

clear examples of a

professional approach

to the situation, and

clearly demonstrates

an appropriate plan for

delivering the

information.

Information is

presented in a

systematic, logical

order.

Information is

presented in a clear,

consistent manner.

There is an obvious

logical approach to the

order in which

information is

presented. Some

information is not

effectively presented.

The assessment lacks

effective, clear, and

appropriate

communication

throughout. There is

no clear indication of a

logical approach to

delivering the

information.

Not attempted or no

clear demonstration of

the criteria

A marking rubric has been provided to assist you in creating your assessment.

written

communication.


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