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Med Surge Chapter 54

Terms in this set (46)

Med Surge Chapter 54
Exam 5
Care of Patients with Musculoskeletal Trauma
Classification of Fractures
A fracture is a break or disruption in the continuity of a bone.
Types of fractures:
Complete - accross the entire width of the bone
Incomplete - does not divide the bone into two portion
Fractures
is described by the extent of associated soft-tissue damage as:
Open(compound) -skin surface is disrupted, external wound
--Grades I - least severe skin damage is minimal
--Grade II - open fracture is accompanied by skin and muscle contusions
--Grade III - damage to skin, muscle, nerve tissue and blood vessels
Closed (simple) - does not extend through the skin
Fractures
Pathologic (spontaneous) - occurs after minimal trauma to a bone that has been weakened by disease
Fatigue or stress - results from excessive strain and stress on the bone
Compression - produced by a loading force applied to the long axis of cancellous bone
Stages of Bone Healing
Stage 1: Hematoma formation within 24 to 72 hr after injury at the sit of the fracture
Stage 2: occurs in 3 days to 2 weeks when granulation tissue begins to invade hematoma, stimulating formation of firbrocartilage providing the foundation for bone healing
Stage 3: Usually occurs within 2-6 weeks as a result of vascular & cellular proliferation fracture site is surrounded by new vascular tissue known as a callus that begins the nonboney union.
Stages of Bone Healing
Stage 4: the callus is gradually reasorbed and transformed into bone, takes 3-6 months.
Stage 5: Consolidation and remodeling of bone continue to meet mechanical demands, may start as early as 4 to 6 weeks after fracture and can continue up to 1 year.
Acute Compartment Syndrome (ACS)
Serious condition in which increased pressure within one or more compartments causes massive compromise of circulation to the area
Prevention of pressure buildup of blood or fluid accumulation
Pathophysiologic changes sometimes referred to as ischemia-edema cycle
Acute Compartment Syndrome (ACS)
Six Ps - including pain, pressure, paralysis, paresthesia, pallor, and pulselessness
ACS is not common, but it creates an emergency situation when it does occur. Within 4 to 6 hours after the onset of compartment syndrome, neurovascular and muscle damage are irreversible. The limb can become useless in 24 to 48 hours.
Emergency Care
Monitor compartment pressures.
Fasciotomy may be performed to relieve pressure.
Pack and dress the wound after fasciotomy.
Goal is early recognition of s/s.
Can begin in 6-8 hours after an injury or take up to 2 days to appear.
If suspected, implement interventions to relieve pressure: loosen dressing/bandage. If cast, know policy of who can cut it off.
notify provider immediately
Possible Results of Acute Compartment Syndrome
Infection
Motor weakness
Volkmann's contractures
Myoglobinuric renal failure, known as rhabdomyolysis
Crush syndrome
Crush Syndrome
Occurs from an external crush injury that compresses one or more compartments in the leg, arm, or pelvis. It is a potentially life-threatening, systemic complication that results from hemorrhage and edema after a severe fracture injury. (Assess pulses distal to injury)
Crush Syndrome
Specific causes of CS include:
Twisting-type injuries
Natural disasters, such as earthquakes
Work-related injuries, such as being trapped under heavy equipment such as a car
Drug or alcohol overdose, when one or more limbs may be compressed by body weight for a prolonged time
Older adults who fall are unable to get up and lie for a prolonged time
Other Complications of Fractures
Shock
Fat embolism syndrome—
serious complication resulting from a fracture; fat globules are released from yellow bone marrow into bloodstream
*S/S: confusion, tachypnea, restless
Intervention: Administer O2 via NC.*
Venous thromboembolism
Infection
Chronic complications—
ischemic necrosis (avascular necrosis [AVN] or osteonecrosis)
Delayed Union - not healed within 6 months
Musculoskeletal Assessment
Assess all major body systems first for life-threatening complications of respiratory, CV, and neurologic systems (priority) -esp head, chest, and abdomen; quick head to toe; Address life-threatening issues before fx.
FX Care:
1. inspect the Fracture site:
a. When inspecting the site of a possible fracture, look for a change in bone alignment.
b. shortening of length of bone & change in bone shape
c. ROM
d. Pain on ROM. If pain, stop movement immediately!
e. crepitus (grating sound caused by bone fragments)
f. Outward Bruising or bleeding. Ecchymosis (bruising) over fx may be present from bleeding into underlying soft tissue)
Musculoskeletal Assessment
2. control bleeding
3. VS
4. place pt in supine position
5. keep pt warm
6. immobilize area of fracture by splinting (object/device that extends to the joints above & below the fx.). esp> if grating or grinding sound heard
7.place sterile gauze loosely over open area of a compound fx
8. check neurovascular status after splinting.
Musculoskeletal Assessment (Cont'd)
Subcutaneous emphysema with bubbles under the skin
Swelling at the fracture site neurovascular assessment including :
skin color (no change),
skin temperature (warm-normal),
movement active and passive (can move without discomfort; sensation: ask paresthesia present; pulses -palpate pulses distal to injury (normal-strong equal); capillary refill (least reliable)
Degree of soft tissue damage and amount of bleeding
Muscle spasm- pain is usually due to muscle spasm or edema.
Special Assessment Considerations
For fractures of the shoulder and upper arm, assess patient in sitting or standing position.
Support the affected arm to promote comfort.
For distal areas of the arm, assess patient in a supine position.
For fracture of lower extremities and pelvis, patient is in supine position.
Risk for Peripheral Neurovascular Dysfunction
Interventions include:
Emergency care—
assess for respiratory distress, bleeding, and head injury
Nonsurgical management—
closed reduction and immobilization with a bandage, splint, cast, or traction
Casts
Rigid device that immobilizes the affected body part while allowing other body parts to move
Cast materials—plaster, fiberglass, polyester-cotton
Types of casts for various parts of the body—arm, leg, brace, body
Casts (Cont'd)
Cast care and patient education
Cast complications—
infection,
circulation impairment,
Teach patient to notify & see physician if the cast feel tight and 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

Running or Balanced Suspension
Running-the pulling force is in one direction and the patient's body acts as countertraction
Balanced Suspension- provides the countertraction so that the pulling force of the traction is not altered when the bed or patient is moved.
Traction - Types of traction
Skin traction - involves the use of Velcro boot, belt, or halter which is usually secured around the affected leg
Skeletal traction - pins, wires, tongs, or screws are surgically inserted directly into bone
Plaster traction - combines skeletal traction adn a plaster cast
Brace traction - exerts a pull for correction of alignment deformities
Circumferential traction - uses a belt around the body, such as pelvic traction for low back problems
Traction (Cont'd)
Traction care:
Maintain correct balance between traction pull and countertraction force
Weight are not removed without order
Should be freely hanging at all times (do not rest on floor)
Care of Weights
Skin inspection
Pin care
*Monitor for infection (swollen, red, crusty w/dried drainage
Culture the drainage*
Assessment of neurovascular status
Operative Procedures
Open reduction with internal fixation (ORIF)
External fixation - pins inserted thru skin with external frame
Monitor for infection at pin sites
Postoperative care—similar to that for any surgery; certain complications specific to fractures and musculoskeletal surgery include fat embolism and venous thromboembolism
Procedures for Nonunion
Electrical bone stimulation - uses magnetic coils applied on the skin or over a cast to deliver a pulsed magnetic field
Bone grafting - relacement of diseasede bone or increase bone tissue for join replacement
Bone banking - living donors
Low-intensity pulsed ultrasound (Exogen therapy)
Acute Pain
Interventions include:
Reduction and immobilization of fracture
Assessment of pain
Drug therapy—opioid and non-opioid drugs
Complementary and alternative therapies—ice, heat, elevation of body part, massage, baths, back rub, therapeutic touch, distraction, imagery, music therapy, relaxation techniques
Risk for Infection
Assess for pneumonia and urinary tract infection.
Administer broad-spectrum antibiotics prophylactically.
Interventions include:
Apply strict aseptic technique for dressing changes and wound irrigations.
Assess for local inflammation.
Report purulent drainage immediately to health care provider.
Impaired Physical Mobility
Interventions include:
Use of crutches to promote mobility
Use of walkers and canes to promote mobility
Imbalanced Nutrition: Less Than Body Requirements
Interventions include:
Diet high in protein, calories, and calcium; supplemental vitamins B and C
LOW FAT MILK, VIT C SUPPLEMENTS, ROAST PORK
Frequent, small feedings and supplements of high-protein liquids
Intake of foods high in iron
Upper Extremity Fractures
Fractures include those of the:
Clavicle - SPLINT OR BANDAGE FOR IMMOBILIZATION
Scapula - Immobilization until healed
Humerus - Closed reduction with arm cast or splint
Olecranon - Closed reduction with cast or splint
Radius and ulna - Closed reduction with cast
Wrist and hand - Closed reduction with cast
Fractures of the Hip
C/O groin pain or pain behind knee of affected side. May not be able to stand.
Intracapsular(within the joint capsule) or extracapsular(outside the joint capule)
Treatment 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
Lower Extremity Fractures
Fractures include those of the:
Femur
ORIF
Patella
Tibia and fibula
Ankle and foot
Fractures of the Pelvis
Associated internal damage the chief concern in fracture management of pelvic fractures
Damge to blood vessels > loss of blood volume and hypovolemic shock
Monitor Blood Pressure frequently
Non-weight-bearing fracture of the pelvis
Weight-bearing fracture of the pelvis
Compression Fractures of the Spine
Most are associated with osteoporosis rather than acute spinal injury.
Multiple hairline fractures result when bone mass diminishes.
Nonsurgical management includes bedrest, analgesics, and physical therapy.
Minimally invasive surgeries are vertebroplasty and kyphoplasty, in which bone cement is injected.
Amputations
Surgical amputation
Traumatic amputation
Levels of amputation
Complications of amputations—hemorrhage, infection, phantom limb pain, neuroma, flexion contracture
Phantom Limb Pain
Phantom limb pain is a frequent complication of amputation.
Patient complains of pain at the site of the removed body part, most often shortly after surgery.
Pain is intense burning feeling, crushing sensation, or cramping.
Some patients feel that the removed body part is in a distorted position
Management of Pain
Phantom limb pain must be distinguished from residual limb pain because they are managed differently.
Recognize that this pain is real and interferes with the amputee's ADLs.
Opioids are effective for residual limb pain.
IV calcitonin (Calcimar) for week after amputation effective for PLP.
Exercise After Amputation
ROM to prevent flexion contractures, particularly of the hip and knee
Priority intervention after amputation
Trapeze and overhead frame
Firm mattress
Prone position every 3 to 4 hours
To prevent hip flexion contractures
Elevation of lower-leg residual limb controversial
Prostheses
Devices to help shape and shrink the residual limb and help patient adapt
Wrapping of elastic bandages
Individual fitting of the prosthesis; special care
Knee Injuries, Meniscus
McMurray test
Meniscectomy
Postoperative care
Leg exercises begun immediately
Knee immobilizer
Elevation of the leg on one or two pillows; 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.
Treatment can be nonsurgical or surgical.
Complete healing of knee ligaments after surgery can take 6 to 9 months.
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 a cast for 6 to 8 weeks.
Tendon transplant may be needed.
Dislocations and 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 is weak or unstable
Classified according to severity—first-, second-, and third-degree strain
Management—cold and heat applications, exercise and activity limitations, anti-inflammatory drugs, muscle relaxants, and possible surgery
Sprains
Excessive stretching of a ligament
Treatment of sprains:
First-degree—rest, ice for 24 to 48 hr, compression bandage, and elevation (RICE)
Second-degree—immobilization, partial weight bearing as tear heals
Third-degree—immobilization for 4 to 6 weeks, possible surgery
Rotator Cuff Injuries
Shoulder pain; cannot initiate or maintain abduction of the arm at the shoulder
Conservative treatment—NSAIDs, physical therapy, sling support, ice or heat applications during healing
Surgical repair for a complete tear
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