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

Musculoskeletal Traumas
affect mobility, sensation; primary goal for nursing is prevention
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
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
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)
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
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
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
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
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
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