Ch 54: Care of Pt with Musculoskeletal Trauma (Hannah)

Created by ashleyholland00 

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Musculoskeletal Traumas

affect mobility, sensation; primary goal for nursing is prevention

Fracture

break or disruption in continuity of bone; types: extent of break (complete/incomplete), extent of associated soft tissue damage (open/closed/Grades 1,2,3), pathologic (spontaneous), fatigue or stress, compression

Common Types of Fractures

closed, nondisplaced; open/compound; comminuted (fragmented), displaced; oblique; spiral; impacted; greenstick

Grades of Fractures

1: least severe; 2: open with skin/muscle contusion; 3: muscle/skin/nerve tissue/blood

Stress Fracture

overuse injury; occurs when muscles become fatigued and cannot absorb shock; eventually muscle transposes stress to bone and cause tiny crack in the bone; women are more susceptible; 50% occur in lower leg; Treatment: rest 6-8wks if you don't it will eventually cause more damage and become a regular fracture

Bone Healing

Staged 1-5

Stage 1 of Bone Healing

hematoma formation within 24-72h after injury; hematoma at fracture site

Stage 2 of Bone Healing

occurs in 3d-2wks when granulation tissue begins to invade hematoma, stimulating formation of fibrocartilage

Stage 3 of Bone Healing

usually occurs within 2-6wks as a result of vascular & cellular proliferation; fracture site is surrounded by new vascular tissue known as a callus that begins the non-boney union

Stage 4 of Bone Healing

usually takes 3-6mos; results in gradual reabsorption of the callus with transformation into bone

Stage 5 of Bone Healing

may start as early as 6wks after fracture & continue up to 1yr; consists of bone consolidation & remodeling

Callus

loose, fibrous, vascular tissue that forms at the site of a fracture as the first phase of healing & is normally replaced by hard bone as healing continues

Acute Compartment Syndrome

serious condition in which increased pressure within one or more compartments causes massive compromise of circulation to the area; often occurs in compartments in lower leg and forearm; prevention of pressure build-up of blood or fluid accumulation; patho sometimes referred to as ischemia-edema cycle; 6 P's

6 P's of ACS

pain, pressure, paralysis, paresthesia, pallor, pulselessness

ACS Emergency

uncommon but creates an emergency situation; within 4-6h after onset of compartment syndrome, neurovascular & muscle damage are irreversible; limb can become useless in 24-48h

Emergency Care of ACS

monitor compartment pressures; fasciotomy may be performed to relieve pressure; pack & dress wound following fasciotomy

ACS Prevention

Goal is early recognition of S/S; can begin in 6-8h after injury or take up to 2d to appear; if suspected, implement interventions to relieve pressure: loosen dressing/bandage; if cast know policy on who can remove it; notify provider immediately

Possible Outcomes with ACS

infection; motor weakness; Volkmann's Contractures (involve structure muscles of the forearm); Myoglobinuric renal failure (aka rhabdomyolysis); Crush syndrome

Rhabdomyolysis/Myoglobinuric Renal Failure

body breaking down muscles & excretion through kidneys, resulting in kidney failure; hyperkalemia so give kayexelate by mouth or enema

Fasciotomy

opening in the fascia made by making an incision through the skin and subQ tissues into the fascia of the affected compartment; relieves pressure & restores circulation

Crush Syndrome

occurs from external crush injury that compresses 1+ compartments in the leg, arm or pelvis; potentially life-threatening, systemic complication that results from hemorrhage & edema after severe fracture injury assess pulses distal to injury

Causes of Crush Syndrome

twisting-type injuries; natural disasters; work-related injuries (ex: trapped under heavy equipment); drug or alcohol OD (ex: one limb may be compressed by body weight for a prolonged period of time after you pass out); older adults who fall & are unable to get up for a prolonged period of time

Current Crush Syndrome Tx

flood with IV fluids before removing crushing object in order to save person's limb or life & prevent bleeding out

If lower leg crush injury & pt complains of numbness & tingling, what does the nurse do first?

assess pedal pulse

Other Complications due to Fractures

shock due to blood loss; fat embolism syndrome; venous thromboembolism; infection; chronic complications: ischemic necrosis, delayed union

Fat Embolism Syndrome

serious complication resulting from fracture; fat globules are released from yellow bone marrow into blood stream; S/S: confusion, tachypnea, restless; intervention: administer O2 via nasal cannula

Musculoskeletal Assessment

assess & document, use standard precautions; assess all major body systems for life-threatening injuries & address those first

Fracture Care

inspect the site: look for change in alignment, shortening/lengthening of bone, change in bone shape, ROM, pain on ROM, crepitus, outward bruising or bleeding-ecchymosis may be present; control bleeding; VS; place in supine position; keep pt warm; immobilize fracture by splinting; place sterile gauze over compound fracture; check neurovascular status after splinting

Subcutaneous Emphysema

bubbles under the skin because of air trapping; uncommon but usually seen later in assessment

Swelling at fracture site

neurovascular assessment including: skin color, skin temp, movement active & passive, sensation(ask about paresthesia); palpate pulses distal from injury; capillary refill; degree of soft tissue damage; amount of bleeding; muscle spasm (usually the cause of pain)

Special Musculoskeletal Assessment Consideration

for fractures of shoulder & upper arm, assess pt in sitting or standing position & support affected arm to promote comfort; for distal areas of the arm, assess pt in supine position; for fractures of lower extremities & pelvis, assess in supine position

Risks for Peripheral Neurovascular Dysfunction

Interventions include: emergency care (assess respiratory distress, bleeding, head injury), nonsurgical management (closed reduction & immobilization with a bandage/splint/cast/traction)

Cast

rigid device that immobilizes affected body part while allowing other body parts to move; materials: plaster, fiberglass, polyester-cotton; types for various parts of body: leg, arm, brace, body

Plaster-of-Paris cast

requires application of well-fitted stockinette under tha material; 24-72h to dry; warm initially; handle with palms of hands rather than fingers to avoid leaving imprint of fingers on cast which will cause extra pressure on cast; heavy; rough edges; do not cover unless dry; have the ability to bear more weight for a longer period of time so they're often used on lower extremity

Fiberglass cast

dries in 10-15min; often used on upper extremities; can bear weight within 30 min

Polyester cast

bears weight in 20 min

Spica cast

encases a portion of the trunk & 1-2 extremities; potential complications r/t severe impairment in mobility: skin breakdown, respiratory dysfunction, constipation, joint contractures

Body cast

encircles the trunk of the body; potential complications r/t severe impairment in mobility: skin breakdown, respiratory dysfunction, constipation, joint contractures

Cast syndrome

AKA superior mesenteric artery syndrome; uncommon but serious complication; most often seen in orthopedic pts with hip spica or body casts; partial or complete upper intestinal obstruction results in: abdominal distention, epigastric pain, N/V; vomiting appears after meals & pt typically has normal BS; placing a window in the abdominal portion or bivalving the cast may be sufficient to prevent or relieve pressure on the duodenum

Cast care

frequently monitor neurovascular status to ensure that cast isn't too tight--do this qh for first 24h after application if pt is hospitalized; allow wet casts to air dry; inspect q8h for drainage, cracking, crumbling, alignment & fit; report any sudden increase in drainage or change in integrity of cast

Cast complications

infection: distinct, unpleasant odor, may have drainage
circulation impairment: teach pt to notify & see physician if cast feels tight & fingers are puffy
peripheral nerve damage
complications of immobility

Traction

Application of a pulling force to the body to provide reduction, alignment, and rest at that site; types: skin, skeletal, plaster, brace, circumferential

Running Suspension

pulling force is in one direction & the patient's body acts as countertraction; uses bucks extension

Balanced Suspension

provides the countertraction so that the pulling force of the traction is not altered when the bed or patient is moved

Skeletal Traction

check pin sites; used to realign the bone; clean around pin q shift; may put antibiotic ointment around pins-depends on MD order

Circumferential Traction

usually used for pelvic/lumber problems; put belt on you and pulleys go down the end of the bed

Crutchfield Tongs

stabilize head & neck while still in bed; move to halo so they can get up & walk

Traction Care

maintain correct balance between traction pull & countertraction force; weights are not removed without order, should be freely hanging at all times--do not rest weights on floor; care for pins monitor for infection (swollen, red, crusty, dried drainage) should be cultured; assess neurovascular status; inspect ropes/knots/pulleys q12h

Operative Procedures

open reduction with internal fixation (ORIF); external fixation (monitor pin sites); postoperative care: similar to any other surgery; certain complications specific to fractures & musculoskeletal surgery include fat embolism & venous thromboembolism

Procedures for Non-Union

electrical bone stimulation; bone grafting; bone banking; low-intensity pulsed ultrasound (Exogen therapy); non-union is usually over 6mos

Acute Pain Interventions for Non-Union

reduction & immobilization of fracture; assessment of pain; drug therapy (opioid & non-opioid); complementary & alternative therapies: ice, heat, elevation of body part, massage, baths, back rub, therapeutic touch, distraction, imagery, music therapy, relaxation technique do not use Demerol because it causes seizures, esp in older adults

Risk for Infection following Non-Union procedures

assess for pneumonia & UTI; admin broad-spectrum ATB prophylactically; interventions: apply strict aseptic technique for dressing changes & wound irrigations; assess for local inflammation; report purulent drainage immediately to provider

Impaired Physical Mobility Interventions

use of crutches, canes or walkers to promote mobility; put cane on which side?; with crutches put pressure on hands not arm pits-do not want to damage brachial nerve

Imbalanced Nutrition: Less than Body Requirements Interventions

diet high in protein, calories, & calcium, supplement Vit B &C; low fat milk, vitamin C supplements, roast pork; frequent, small feedings & supplements of high-protein liquids; intake of foods high in iron (can get anemia due to lost blood from fractures)

Upper Extremity Fractures

Clavicle (splint or bandage for immobilization); Scapula (immobilize until healed); humerus (closed reduction with arm cast or splint); olecranon (closed reduction with cast or splint); radius & ulna (closed reduction with cast); wrist & hand (closed reduction with cast)

Why can we use softer bandages for clavicle & scapula?

Not as much pressure on those bones, not weight-bearing, so they can be healed this way

Fractures of the Hip

Complain of groin pain or pain behind knee of affected side; may not be able to stand; intracapsular or extrascapular

Hip Fracture Tx of Choice

surgical repair, when possible, to allow the older patient to get out of bed; Open reduction with internal fixation with Intramedullary rod, pins, a prosthesis, or a fixed sliding plate; prosthetic device; many times now they do a hip replacement if patient can handle it

Lower extremity fractures

fractures include those of the: femur, patella, tibia & fibula, ankle & foot

Pelvic Fractures

associated internal damage the chief concern in fracture management of pelvic fractures; damage to blood vessels>loss of blood volume & hypovolemic shock monitor BP frequently; non-weight-bearing fracture of the pelvis; weight-bearing fracture of the pelvis; first interventions include inserting foley to ensure no blood in bladder/urine

Compression fractures of the spine

most are associated rather than acute spinal injury; multiple hairline fractures result when bone mass diminishes; nonsurgical management: bed rest, anlagesics, PT; minimally invasive surgeries: vertebroplasty & kyphoplasty in which bone cement is injected

Surgical Amputation

most are elective & r/t complications of peripheral vascular disease & arteriosclerosis or DM; considered only after other interventions have no restored circulation

Traumatic Amputation

most often result from accidents & are the primary cause of upper extremity amputation; injuries that cause severe crushing of tissuesor significant blood vessel damage usually results in amputation to preserve the function of the residual limb

Levels of amputation

common: above-knee, below-knee, syme, mid-foot amputation, toe amputation

Complications of amputations

hemorrhage, infection, phantom limb pain, neuroma, flexion contracture

Phantom limb pain

frequent complication of amputation; pt complains of pain at the site of removed body part, most often shortly after surgery; pain is intense burning feeling, crushing, cramping, itching or stabbing; some pts feel that the removed body part is in a distorted position

Management of Phantom Limb Pain

must be distinguished from residual limb pain because they're managed differently; recognize that pain is real & interferes with amputee's ADLs; opioids are effective for residual limb pain; IV calcitonin (Calcimar) for week after amputation is effective for phantom pain

Exercise after Amputation

ROM to prevent flexion contractures, particularly of hip & knee priority intervention; trapeze & overhead frame, firm mattress; prone position q3-4h to prevent hip flexion contractures; elevation of lower-leg residual limb controversial

Prostheses

devices to help shape & shrink residual limb & help patient adapt; wrapping of elastic bandages; individual fitting of the prosthesis; requires special care

McMurray Test

performed to assess for torn meniscus; examiner flexes & rotates the knee & then presses on the medial aspect while slowly extending the leg; test result is positive if clicking is palpated or heard; a negative finding does not rule out a tear

Meniscectomy

if treatment for a locked knee r/t torn meniscus i unsuccessful, this is performed; open meniscectomy requires a surgical incision & removal of all or part of the meniscus-rarely performed; closed meniscectomy removes only the affected portion & is done arthroscopically

Post-op care for Menisectomy

bulky pressure dressing is applied & affected leg is wrapped in elastic bandages; leg exercises immediately; knee immobilizer; elevation of leg on 1-2pillows; ice

Knee injuries: Ligaments

When the anterior cruciate ligament is torn, a snap is felt, the knee gives way, swelling occurs, and stiffness and pain follow; tx can be surgical or nonsurgical; complete healing of knee ligaments after surgery can take 6-9mos

Tendon ruptures

rupture of the achilles tendon is common in adults who participate in strenuous sports; for severe damage, surgical repair is followed by leg immobilized in cast for 6-8wks; tendon transplant may be needed

Dislocations & Subluxations

pain, immobility, alteration in contour of joint, deviation in length of the extremity, rotation of the extremity; closed manipulation of the joint performed to force it back into its original position; joint immobilized until healing occurs

Strains

excessive stretching of a muscle or tendon when it's weak or unstable; classified according to severity: 1st, 2nd, & 3rd degree; management: cold and heat applications, exercise and activity limitations, anti-inflammatory drugs, muscle relaxants, and possible surgery

Sprains

excessive stretching of a ligament treatment: 1st degree: rest, ice for 24-48h, compression bandage, elevation (RICE); 2nd degree: immobilization, partial weight bearing as tear heals; 3rd degree: immobilization 4-6wks, possible surgery

Sprain vs. Strain

sprain=ligament; strain=tendon

Rotator Cuff Injuries

shoulder pain; cannot initiate or maintain abduction of the arm or shoulder; tx: NSAIDs, physical therapy, sling support, ice or heat applications during healing, surgical repair for complete tear

Meniscus tear

more common in medial meniscus because it is less mobile than lateral; tearing is usually a result of twisting the leg when the knee is flexed & foot is placed firmly on the ground; treatment with meniscectomy is a last resort

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