ADULT HEALTH musculoskeletal system
Terms in this set (76)
overview of musculoskeletal
- ligaments connect bones to bones, provide stability
- tendons connect muscle to bone
- when someone has a musculoskeletal injury the blood supplied to that area of the body is decreased and that is why it takes a long time to heal, anywhere between 6 and 8 weeks, sprains are less, depends on the extent of the injury
- soft tissue injuries- any soft tissue surrounding the bones
is an injury to the ligaments around a joint common around the ankles and knees from some kind of twisting motion
is excess stretching of the muscle mostly seen in large muscle groups of the body
- RICE- rest, ice (in the acute injury phase for 24 - 48 hours), compression (from distal to proximal, to move the swelling towards the heart), elevation
Normal Physical Assessment of the Musculoskeletal System
Normal spinal curvature
No muscle atrophy or asymmetry
No joint swelling, deformity or crepitation
No tenderness on palpation of spine
Full range of motion of all joints without pair or laxity (double jointed)
Muscle strength 5 out of 5
Effects of Aging on the Musculoskeletal System
- Decreased number of muscle cells and replacement of cells by fibrous connective tissue results in decreased muscle strength and bulk, abdominal protrusion, flabby muscles and increased rigidity in neck, shoulders, hips and knees
- Loss of elasticity in ligaments and cartilage result in decreased fine motor dexterity and decreased agility
- Reduced ability to store and release glycogen results in slowed reaction times and reflexes
- Increased cartilage erosion results in joint stiffness, decreased mobility, limited ROM and crepitation with movement
- Loss of water from disks between vertebrae results in loss of height and disk compression
- Decrease in bone density results in loss of height, back pain, deformity such as dowager's hump ( kyphosis)
Common Assessment Abnormalities of the Musculoskeletal System
- pain in posterior leg with movement but can progress to pain at rest - results from cumulative stress on tendon
- stiffness and fixation of a joint - results from chronic joint inflammation
- shortened stride with little weight bearing on the affected side - may be related to trauma or inflammatory processes
- Staggering, uncoordinated gait generally associated with neurological disorders
- flabby appearance of muscles leading to decreased function and tone - results from muscle denervation, contracture, prolong disuse
- resistance of movement of muscles or joint as a result of shortening of muscles or ligaments
- audible cracking or grating sound with movement associated with fracture, dislocations, joint dysfunction and osteoarthritis
- bone displacement from its normal joint resulting from trauma or disorders of the surrounding soft tissue
- quick, shuffling gait with flexed neck, trunk, knees and rigid body; associated with Parkinson's disease and neurogenic disorders
- small fluid filled bump or mass over a tendon, sheath or joint resulting from inflammation
- tennis elbow
dull ache along outer aspect of elbow
- general muscle tenderness and pain
- numbness, tingling
- ( Flat foot) results from heredity, muscle paralysis, and muscular diseases
- Burning, sharp pain on sold of foot worse in the morning - chronic degenerative/reparative cycle in inflammation
- asymmetric elevation of shoulders, scapulae and iliac crest resulting from congenital anamoly, fracture, dislocation or osteomalacia
Short Leg Gait
- limp resulting from leg length discrepancy of 1 inch or more
- Dowager's Hump - forward bending of thoracic spine with exaggerated thoracic curvature - poor posture, TB, inflammatory disorders
- Asymmetric scapulae and shoulders with exaggerated lumbar curvature
- partial dislocation of joint resulting from trauma, arthritis
- (wryneck) neck twisted to one side
- ( ulnar drift) fingers drift to ulnar side of forearm often seen with arthritis
imaging studies are the number one to do for these type of injuries
(any type of x ray procedures check for chance of pregnancy)
Magnetic resonance imaging (MRI)
(cant have anything metal on them, claustrophobic may need to be sedated)
look at the whole skeletal system, most used for ppl who have had cancer to see if it is anywhere else in the body, fractures, and diseases of the bone, a radioactive material injected 2-3 hr before the scan, ppl are mostly sedated, need to check renal function to be able to flush out dyes and check allergies of shellfish
(x ray of the disks in the back, for ppl who have back pain)
Computed tomography (CT) scan
(check for soft tissue injuries, bony abnormalities and any kind of trauma, can be done with or without contrast)
Myelogram with or without CT
(sensitive test for nerve impingement.)
Bone mineral density (BMD) measurements
Dual energy x-ray absorptiometry (DXA)
sees how dense the bones are, usually done on either the hip or the spine, no contrast is used
Quantitative ultrasound (QUS)
Duplex venous doppler
-ultra sound of the veins, diagnosis DVT
visualize the internal structures of a joint, CANNOT be done if pt has an infection in the joint or is unable to bend the joint at least 40 degrees, for a pt who has had injuries to the joints to ascertain the extent of damage, can also repair the damage with an arthroscope
diagnostic tests cont
evoked potential (SSEP)
lab work that can be r/t musculoskeletal problems
(increased in a healing fracture of someone who has bone cancer
- decreased serum levels are found in osteomalacia, renal disease, and some bone tumors may have increased levels
Rheumatoid factor (RF)
- blood test that assesses for the antibody in the serum, not specific for just rheumatoid arthritis, generalized tests for inflammatory diseases
Erythrocyte sedimentation rate (ESR)
- generalized inflammation
Antinuclear antibody (ANA)
- blood test that looks for antibodies in the body that destroy cells, 95% of ppl with lupus have a positive ANA
Complement, total hemolytic (CH50)
- increased in gout
C-reactive protein (CRP)
Human leukocyte antigen (HLA)-B27
Creatine kinase (CK)
- fluid between the synovial joints can be aspirated and tested
done to determine the cause and presence of muscle weakness, needles are placed in the muscle and attached to an electrode, client must not be taking anticoagulants or muscle relaxants, bruising may be present at insertion sites apply ice to reduce hematoma formation and notify Dr. for any swelling or tenderness at the site
Disruption or break in continuity of structure of bone
- Majority of fractures from traumatic injuries
- Pathologic in origin - some fractures secondary to disease process; Cancer or osteoporosis
-primary bone cancer is very rare, called sarcoma
break is completely through bone
bone is still in one piece, more of a crack. An incomplete fracture is often the result of bending or crushing forces applied to a bone.
is a fracture in which the line of the fracture extends across the bone shaft at a right angle to the longitudinal axis.
is a fracture in which the line of the fracture extends in a spiral direction along the shaft of the bone.
is an incomplete fracture with one side splintered and the other side bent. often seen with abuse
is a fracture with more than two fragments. The smaller fragments appear to be floating.
is a fracture in which the line of the fracture extends in an oblique direction.
is a spontaneous fracture at the site of a bone disease.
is a fracture that occurs in normal or abnormal bone that is subject to repeated stress, such as from jogging or running.
the two ends of the broken bone are separated from one another and out of their normal positions.
Displaced fractures are usually comminuted (more than two fragments) or oblique
the periosteum is intact across the fracture, and the bone is still in alignment.
Nondisplaced fractures are usually transverse, spiral, or greenstick.
Clinical Manifestations of a fracture
If a fracture is suspected, the extremity is immobilized in the position in which it is found. Unnecessary movement increases soft tissue damage and may convert a closed fracture to an open fracture or create further injury to adjacent neurovascular structures.
-Localized pain and/or decreased movement at the are of the fracture of distal to the site
-Inability to bear weight or use
-Guard against movement
-May or may not have deformity
-Edema and Swelling
-Pain and Tenderness
-Loss of Function
Fracture Healing stages
-generally takes around 6 weeks for a bone to heal
-kids heals a lot faster than adults, sometime children will get fractures in the growth plate and cause the bone to keep growing, more severe bc the child can have limb length discrepancy
Bone goes through a complex multistage healing process (termed union) that occurs in the following stages:
1) Fracture hematoma.
When a fracture occurs, bleeding creates a hematoma, which surrounds the ends of the fragments. The hematoma is extravasated blood that changes from a liquid to a semisolid clot. This occurs in the initial 72 hours after injury.
2) Granulation tissue.
active phagocytosis absorbs the products of local necrosis. The hematoma converts to granulation tissue. Granulation tissue (consisting of new blood vessels, fibroblasts, and osteoblasts) produces the basis for new bone substance called osteoid during days 3 to 14 postinjury.
3) Callus formation.
As minerals (calcium, phosphorus, and magnesium) and new bone matrix are deposited in the osteoid, an unorganized network of bone is formed that is woven about the fracture parts. Callus is primarily composed of cartilage, osteoblasts, calcium, and phosphorus. It usually appears by the end of the second week after injury. Evidence of callus formation can be verified by x-ray.
Ossification of the callus occurs from 3 weeks to 6 months after the fracture and continues until the fracture has healed. Callus ossification is sufficient to prevent movement at the fracture site when the bones are gently stressed. However, the fracture is still evident on x-ray. During this stage of clinical union, the patient may be allowed limited mobility or the cast may be removed.
As callus continues to develop, the distance between bone fragments diminishes and eventually closes. During this stage ossification continues. It can be equated with radiologic union. Radiologic union occurs when there is x-ray evidence of complete bony union. This phase can occur up to a year following injury.
Excess bone tissue is reabsorbed in the final stage of bone healing, and union is completed. Gradual return of the injured bone to its preinjury structural strength and shape occurs. Bone remodels in response to physical loading stress or Wolf's law. Initially, stress is provided through exercise. Weight bearing is gradually introduced. New bone is deposited in sites subjected to stress and resorbed at areas where there is little stress.
Factors influencing healing
-Many factors influence the time required for complete fracture healing including displacement and site of the fracture, blood supply to the area, immobilization, and internal fixation devices (e.g., screws, pins).
-The ossification process may be arrested by inadequate reduction and immobilization, excessive movement of the fracture fragments, infection, poor nutrition, and systemic disease.
-Healing time for fractures increases with age. For example, an uncomplicated midshaft fracture of the femur heals in 3 weeks in a newborn and in 20 weeks in an adult.
-Smoking also increases fracture healing time. Fracture healing may not occur in the expected time (delayed union) or may not occur at all (nonunion).
-Displacement and site of fracture
-Blood supply to area
-Internal fixation devices
-Infection or poor nutrition
Complications of Fracture Healing
Fracture healing progresses more slowly than expected. Healing eventually occurs.
Fracture fails to heal despite treatment. No x-ray evidence of callus formation.
Fracture heals in expected time but in unsatisfactory position, possibly resulting in deformity or dysfunction.
Fracture heals in abnormal position in relation to midline of structure (type of malunion).
Type of nonunion occurring at fracture site in which a false joint is formed with abnormal movement at site.
New fracture occurs at original fracture site.
Deposition of calcium in muscle tissue at site of significant blunt muscle trauma or repeated muscle injury. bone deposits grow inside the muscle
Overall goals of fracture treatment
done by reducing the fracture, reduction
to maintain realignment so that it can have time to heal
of normal or near-normal function of the injured part
Fracture Reduction: Closed reduction
-a nonsurgical, manual realignment of bone fragments to their previous anatomic position.
Traction and countertraction
are manually applied to the bone fragments to restore position, length, and alignment.
Closed reduction is usually performed while the patient is -
under local or general anesthesia.
-After reduction, traction, casting, external fixation, splints, or orthoses (braces) immobilize the injured part to maintain alignment until healing occurs.
Fracture Reduction: Open reduction internal fixation(ORIF)
*the correction of bone alignment through a surgical incision.
It usually includes internal fixation of the fracture with the use of wires, screws, pins, plates, intramedullary rods, or nails.*
-The main disadvantages of this form of fracture management are the
possibility of infection
complications associated with anesthesia
, and the
effect of preexisting medical conditions
-If open reduction with internal fixation (ORIF) is used for intraarticular fractures, early initiation of ROM of the joint is indicated.
-Machines that provide continuous passive motion (CPM) to various joints (e.g., knee, shoulder) are used to prevent extraarticular and intraarticular adhesions.
-The use of CPM results in faster reconstruction of the subchondral (beneath cartilage) bone plate, more rapid healing of the articular cartilage, and decreased incidence of post-traumatic arthritis.
facilitates early ambulation
that decreases the risk of complications related to prolonged immobility.
nursing actions - prevent dislocation of the hip, monitor skin integrity, ensure heels are off the bed at all times, inspect bony prominences, neurovascular assessment, observe cast or dressing for drainage, observe for signs of a fat or pulmonary embolism, provide TED hose and SEC devices, monitor pain level, signs of infection, increase physical mobility as appropriate, support nutrition
- Pulling force to attain realignment - countertraction pulls in opposite direction
- Two most common types of traction
- Skin traction
- Skeletal traction
- Prevent or ↓ pain and muscle spasm associated with low back pain or cervical sprain (e.g., whiplash),
- Immobilize joint or part of body.
- Reduce fracture or dislocation.
- prevent soft tissue injury
-correct or prevent further deformities
- Treat a pathologic joint condition.
generally used when ppl who have a hip fracture need surgery but have to wait for surgery for whatever reason, to decrease pain and keep the fracture immobilized and decrease pain
--prescriptions for traction should include the type of traction, amount of weight, and whether it can be removed for nursing care
Traction: Skin traction
-primary purpose is to decrease muscle spasm and immobilize the extremity prior to surgery.
- The traction weights are usually limited to 5 to 10 lbs (2.3 to 4.5 kg).
- Tape, boots, or splints applied directly to skin to maintain alignment, assist in reduction, and help diminish muscle spasms in the injured extremity.
- Short-term (48-72 hours) non invasive. until skeletal traction or surgery is possible.
- Pelvic or cervical skin traction may require heavier weights applied intermittently.
assessment of the skin is a priority
as pressure points and skin breakdown may develop quickly. Assess key pressure points every 2 to 4 hours. make sure boot is not on too tight
A Buck's traction boot is a type of skin traction that is used to immobilize a fracture, prevent hip flexion contractures, and reduce muscle spasms.
-assess neurovascular status q1h for the first 24 and q4h following
-maintain proper body alignment
-Maintain appropriate countertraction
-Avoid interrupting traction by maintaining limb and lines in straight position and keeping weights hanging freely.
-Assess the patient's ability to evert the affected foot
notify the provider if the pt complains of severe pain from muscle spasms unrelieved by meds and/or repositioning
- use heat and massage as prescribed for muscle spasms
Traction: Skeletal traction
-generally in place for longer periods than skin traction, is used to align injured bones and joints or to treat joint contractures and congenital hip dysplasia.
-It provides a
long-term pull that keeps the injured bones and joints aligned.
-To apply, the physician inserts a pin or wire into the bone, either partially or completely, to align and immobilize the injured body part.
have some kind of pin care you have to do, generally cleaned with peroxide
-Weight for skeletal traction ranges from 5 to 45 lbs (2.3 to 20.4 kg).
-The use of too much weight can result in delayed union or nonunion.
disadvantages of skeletal traction are infection in the area of the bone where the skeletal pin is inserted and the consequences of prolonged immobility.
-For extremity traction to be effective, forces must be pulling in the opposite direction (countertraction).
-Fracture alignment depends on the correct positioning and alignment of the patient while the traction forces remain constant.
-Countertraction is commonly supplied by the patient's body weight or by weights pulling in the opposite direction and may be augmented by elevating the end of the bed.
-It is imperative to maintain traction continuously and keep the weights off the floor and moving freely through the pulleys.
-Keep weights off the floor.
*When traction is used to treat fractures, the forces are usually exerted on the distal fragment to obtain alignment with the proximal fragment.
One of the more common types of skeletal traction is balanced suspension traction*
Nursing Care: Assessment
when looking at Neurovascular integrity:
- Assess for the 5 P's:
pain, pallor, pulses, paresthesias, and paralysis. if you note pulselessness, increased pain or sudden onset of numbness notify the Dr.
- Follow your facility's protocol for frequency, usually at least every 2 to 4 hours.
- Compare your findings to the patient's unaffected extremity -- his norm.
- Neurovascular integrity in the extremity distal to the fracture is demonstrated by warm pink skin, a palpable pulse, brisk capillary refill on blanching, normal skin sensation, and joint range of motion.
One or more of the following can indicate neurovascular compromise: cool, pale, pulseless extremity, sensations of numbness, tingling or severe pain, and muscle paralysis
- Unrecognized and untreated neurovascular injury can lead to permanent sensory and motor deficits or amputation.
- Report any changes to physician immediately
Nursing Care: Traction, alignment, and positioning
-Assess the traction setup, the patient's positioning, and general body alignment according to your facility's protocol, which is usually at least every 4 hours and when the patient is moved.
- Is the patient supine with the foot of the bed elevated?
-Is the hip flexion between the bed and thigh at a maximum of 20 degrees (except for short periods to eat and perform activities of daily living)?
- Is the affected extremity positioned in the sling abducted (away from the body) without hip rotation?
-Are his toes pointing toward the ceiling?
-Are the correct weights being used and do they hang free?
-Are the knots free from the pulleys?
-Maintaining correct traction, alignment, and positioning promotes fracture alignment, reduces muscle spasms around the fracture, and prevents hip flexion contractures and pressure sores.
Nursing Care: Pin insertion sites
- Provide pin care according to hospital policy. Cleanse with peroxide and apply antibiotic ointment
- Assess sites according to your facility's protocol, which is usually at least once a shift.
- Is there any purulent drainage, redness, pain, or swelling? Report immediately
-monitor for loosening of the pins and tenting of the skin at the pin sites (skin is rising up); could be signs of infection
- The insertion sites poses risk for developing osteomyelitis, infection in the bone
-crusting at the pic site should be left alone, body's natural defense
Fracture Immobilization Cast
- Temporary, commonly used after a closed reduction
- Allows patient to perform many normal activities of daily living while providing sufficient immobilization to ensure stability.
- Made of various materials
- Typically incorporates joints above and below fracture, allows stabilization and give healing time to occur
-Immobilization above and below a joint restricts tendon and ligament movement, therefore assisting with joint stabilization while the fracture heals.
- Affected part covered with stockinette that is cut longer than the extremity.
-Padding is then placed over the stockinette with the bony prominences given extra padding.
- Plaster of paris material immersed in warm water, wrapped and molded around the affected part.
- Set in 15 minutes, after it is dry check neurovascular status to make sure they can move things, have feeling and not a lot a swelling, not too tight. Assess circulation and nerve function cast can be too tight
-it is not strong enough for weight bearing until about 24 to 72 hours after application. (The decision about weight bearing is determined by the physician.)
A fresh plaster cast should never be covered because air cannot circulate, heat builds up in the cast that may cause a burn, and drying is delayed.
-Avoid direct pressure on the cast during the drying period.
-Handle the cast gently with an open palm to avoid denting the cast.
-Once the cast is thoroughly dry, the edges may need to be petaled to avoid skin irritation from rough edges and to prevent plaster of paris debris from falling into the cast and causing irritation or pressure necrosis.
-Several strips (petals) of tape are placed by the health care provider over the rough areas to ensure a smooth cast edge.
-elevate above the heart for the first 24-48 hr prevent edema, drainage should be noted and monitored for changes
-Casts made of
are being used more than plaster because they
are lightweight, stronger, relatively waterproof, and provide for early weight bearing.
-The synthetic casting materials (thermolabile plastic, thermoplastic resins, polyurethane, and fiberglass) are activated by submersion in cool or tepid water. Then they are molded to fit the torso or extremity.
Upper Extremity Immobilization: Types of casts
Immobilization of an acute fracture or soft tissue injury of the upper extremity is often accomplished by use of
the sugar-tong splint* used for acute wrist injuries or injuries that may result in significant swelling. Plaster splints are applied over a well-padded forearm, beginning at the phalangeal joints of the hand, extending up the dorsal aspect of the forearm around the distal humerus, and then extending down the volar aspect of the forearm to the distal palmar crease. The splinting material is wrapped with either elastic bandage or bias stockinette.
(2) the posterior splint
accommodates post injury swelling in the fractured extremity.
(3) the short arm cast
used for the treatment of stable wrist or metacarpal fractures. An aluminum finger splint can be incorporated into the short arm cast for concurrent treatment of phalangeal injuries. A circular cast extending from the distal palmar crease to the proximal forearm. This cast provides wrist immobilization and permits unrestricted elbow motion.
(4) the long arm cast
commonly used for stable forearm or elbow fractures and unstable wrist fractures. It is similar to the short arm cast but extends to the proximal humerus, restricting motion at the wrist and elbow.
Upper Extremity Immobilization: Sling
-removable and allow for monitoring of the skin swelling or integrity
-can be used support and elevate arm or fracture prior to casting till swelling is decreased
-Direct your care in supporting the extremity and reducing the effects of edema by maintaining elevation of the extremity with a sling.
When a hanging arm cast is used for a proximal humerus fracture, elevation or a supportive sling is contraindicated because hanging provides traction and maintains fracture alignment.
-When a sling is used, ensure that the axillary area is well padded to prevent skin excoriation and maceration associated with direct skin-to-skin contact.
-Placement of the sling should not put undue pressure on the neck.
-Encourage movement of the fingers (unless contraindicated) to enhance the pumping action of vascular and soft tissue structures to decrease edema.
-Encourage the patient to actively move nonimmobilized joints of the upper extremity to prevent stiffness and contractures.
Vertebral Immobilization: Body jacket brace
-used for immobilization and support for stable spine injuries of the thoracic or lumbar spine.
-The brace goes around the chest and abdomen and extends from above the nipple line to the pubis.
-After application of the brace,
assess the patient for the development of superior mesenteric artery syndrome
occurs if the brace is applied too tightly, which results in compression of the superior mesenteric artery against the duodenum.
-The patient generally
complains of abdominal pain, abdominal pressure, nausea, and vomiting.
-Assess the abdomen for
decreased bowel sounds
(a window in the brace may be left over the umbilicus).
Treatment includes gastric decompression with a nasogastric (NG) tube and suction.
-Assessment also includes
monitoring respiratory status, bowel and bladder function, and areas of pressure over the bony prominences, especially the iliac crest.
- The brace may need to be adjusted or removed if any complications occur.
Lower Extremity Immobilization
-usual indications for applying a
long leg cast
unstable ankle fracture, soft tissue injuries, a fractured tibia, and knee injuries.
The cast usually
extends from the base of the toes to the groin and gluteal crease.
Short leg cast
can be used for a variety of conditions but is primarily used for stable ankle and foot injuries.
used for knee injuries or fractures, extends from the groin to the malleoli of the ankle.
Robert Jones dressing
composed of bulky padding materials (absorption dressing and cotton sheet wadding), splints, and an elastic wrap or bias-cut stockinette.
Prefabricated knee and ankle splints and immobilizers
are used in many settings.
-This type of immobilization is easy to apply and remove, which permits close observation of the affected joint for signs of swelling and skin breakdown.
-Depending on the injury, removal of the splint or immobilizer facilitates ROM of the affected joint and a faster return to function.
Lower Extremity Immobilization: Hip spica cast
now mainly used for femur fractures in children.
-The purpose is to immobilize the affected extremity and the trunk securely.
-Extends from above the nipple line to the base of the foot (single spica) and may include the opposite extremity up to an area above the knee (spica and a half) or both extremities (double spica).
-After the application of a lower extremity cast or dressing, the extremity should be elevated on pillows above the heart level for the first 24 hours.
-After the initial phase, a casted extremity should not be placed in a dependent position because of the possibility of excessive edema.
-Following cast application, *observe for signs of compartment syndrome and increased pressure, especially in the heel, anterior tibia, head of fibula, and malleoli. This increased pressure is manifested by pain or burning in these areas.
pts are on bed rest for a long time, all the risk for immobility come along, pt has to use a fracture bed pan
Assess patient for same problems as body jacket cast.
-Nurse should instruct patient in positioning activities required to get on and off bedpan.
Skin care: Cast care
- Toes/ fingers should be pink
- Skin warm , cap refill < 2 sec
- Raise the casted extremity above heart
and rest on pillows to prevent swelling - avoid plastic pillows (could get hot and remold the cast, does not help with air flow)
- Expose drying cast to air to dry
-Mark areas of drainage as baseline
- Keep cast dry
- Don't stick anything into the cast
- Trim rough edges
- Relieve itching with cool hairdryer and benadryl
- Exercise the extremity
- Apply an ice bag to the cast (only if dry)
- Call MD if problems
-Pad rough cast edges to prevent skin irritation
-Apply plastic around cast in groin area
Cast Care Assessment
long term process, great risk for infection, used when trying to salvage an extremity that otherwise might be amputated
-An external fixator is a metallic device composed of
metal pins that are inserted into the bone and attached to external rods to stabilize the fracture while it heals.
-It can be used to a
pply traction or to compress fracture fragments
immobilize reduced fragments
when the use of a cast or other traction is not appropriate.
-The external device
holds fracture fragments in place similar to a surgically implanted internal device.
Patient teaching and nursing actions
-Assess for pin loosening and infection. and notify the Dr.
-Pin site care every 8 to 12 hours, monitor for drainage, color, odor, redness
-elevate extremity, monitor neurovascular status and skin integrity
-observe for signs of a fat or pulmonary embolism
-provide TED hose and SEC devices
-if activity is reduced teach the pt to perform deep breathing and leg exercises and other techniques to prevent immobilization complications
-often used in an attempt to salvage extremities that otherwise might require amputation.
-Because the use of an external device is a long-term process, ongoing assessment for pin loosening and infection is critical.
-Infection signaled by exudate, erythema, tenderness, and pain may require removal of the device.
-Instruct the patient and caregiver about meticulous pin care.
-Although each physician has a protocol for pin care cleaning, half-strength hydrogen peroxide with normal saline is often used.
Electric Bone Growth Stimulation
used to facilitate the healing process for certain types of fractures, especially when there is nonunion or delayed healing.
The mechanism of action of electrical bone stimulation may include:
(1) increasing the calcium uptake of bone
(2) activating intracellular calcium stores
(3) increasing the production of bone growth factors (e.g., bone morphogenic protein).
-Non-invasive, semi-invasive, and invasive methods of electrical bone growth stimulation are used.
Non-invasive bone growth stimulators
use direct current or pulsed electromagnetic fields (PEMFs) to generate a weak electrical current.
-Electrodes are placed over the patient's skin or cast and are used 10 to 12 hours each day, usually while the patient is sleeping.
Semi-invasive or percutaneous bone growth stimulators
use an external power supply and electrodes that are inserted through the skin and into the bone.
Invasive bone growth stimulators
require surgical implantation of a current generator in an intramuscular or subcutaneous space. An electrode is implanted in the bone fragments.
Emergency Management of Fractured Extremity
- check the mechanism of injury, can help you determine the type of problems that are going to come with it
-Treat life threatening injuries first; ABCs
-assess neurovascular status and vital signs
- Control external bleeding with pressure and elevation of the limb
- Splint joints above and below fracture site to stabilize, maintaining proper alignment of the joint
- Check neurovascular status before and after splinting and continue at least every hour
KEY, color, temp, cap refil, pulses and swelling, sensation, motor function, and pain level
- Elevate limb and apply ice
-assess for bleeding and apply pressure if needed, cover wounds with sterile dressing
- Do not attempt to straighten leg or dislocated joints
- Do not manipulate protruding bone ends
- Prepare for x-ray
- Administer diphtheria and tetanus prophylaxis if skin integrity compromised
- Assess and mark peripheral pulses
Nutritional Therapy with Fractures
-Protein 1g/kg daily
-Vitamins especially B, C, D
-Calcium, phosphorous and magnesium to promote soft tissue and bone healing
-Low serum protein and vitamin C level interfere with healing
-3 meals plus fluid intake of 2000-3000 ml/day to promote optimal bladder and bowel function
- 6 small meals per day may work better for immobilized patient
-Fluid and high fiber diet to prevent constipation
Patients with fractures experience varying degrees of pain associated with muscle spasms.
Central and peripheral muscle relaxants
, such as carisoprodol (Soma), cyclobenzaprine (Flexeril), or methocarbamol (Robaxin), may be prescribed for relief of pain associated with muscle spasms.
the threat of tetanus can be reduced with
tetanus and diphtheria toxoid or tetanus immunoglobulin
for the patient who has not been previously immunized.
-Bone-penetrating antibiotics, such as a cephalosporin (e.g., cefazolin [Kefzol, Ancef]), are used prophylactically before surgery.
Complications of Fractures
-The majority heal without complications.
-If death occurs after a fracture, it is usually the result of damage to underlying organs and vascular structures or from complications of the fracture or immobility.
-Complications of fractures may be either direct or indirect.
include problems with bone infection, bone union, and avascular necrosis.
are associated with blood vessel and nerve damage resulting in conditions such as compartment syndrome, venous thromboembolism, fat embolism, rhabdomyolysis (breakdown of skeletal muscle), and hypovolemic shock.
-Although most musculoskeletal injuries are not life-threatening,
open fractures or fractures accompanied by severe blood loss and fractures that damage vital organs (e.g., lung, heart) are medical emergencies requiring immediate attention.
-High incidence in
open fractures and soft tissue injuries
Devitalized and contaminated tissue is an ideal medium for many common pathogens
, including gas-forming (anaerobic) bacilli such as Clostridrium tetani.
Best to prevent
as treatment of infection is costly in terms of extended nursing and medical care, time for treatment, and loss of patient income.
- Osteomyelitis can become chronic.
- Open fractures require aggressive surgical debridement. The wound is initially cleansed by pulsating saline lavage in the operating room.
extent of the soft tissue damage determines whether the wound will be closed at the time of surgery
, if repeat debridement will be required, whether closed suction drainage may be necessary, and whether skin grafting will be needed.
-Depending on the location and extent of the fracture, reduction may be maintained by external fixation or traction.
During surgery the open wound may be irrigated with antibiotic solution
. Antibiotic-impregnated beads may also be placed in the surgical site.
phase the patient may have
antibiotics administered IV for 3 to 7 days.
-Antibiotics, in conjunction with aggressive surgical management, have greatly reduced the occurrence of infection.
a condition in which there is swelling and an increase in pressure within a limited space (a compartment) that presses on and compromises blood vessels, nerves, and/or tendons that run through that compartment.
may result when someone is trapped under a heavy object or a person's limb is trapped beneath the body
because of an obtunded state such as drug or alcohol overdose
may occur initially from the physiologic response of the body to the injury,
may be delayed for several days after the original insult or injury.
-Decreases viability and function of tissue within the space
-Causes capillary perfusion to be reduced below a level necessary for tissue viability.
-Tissue damage can occur within 30 minutes, can lose limb without treatment
- greater than 4 hours irreversible damage
-Usually involve the leg but can also occur in the arm, shoulder, and buttock.
-Fractures of the distal humerus and proximal tibia are the most common fractures
-injury can also occur following knee or leg surgery.
-38 compartments in upper and lower extremities
Two basic causes of compartment syndrome
↓ Compartment size
e*, resulting from restrictive dressings, splints, casts, excessive traction, or premature closure of fascia
↑ Compartment contents
s*, related to bleeding, inflammation, edema, or IV infiltration.
-Arterial flow compromised → ischemia → cell death → loss of function
Edema can create sufficient pressure to obstruct circulation and cause venous occlusion
, which further increases edema. -Eventually
arterial flow is compromised, resulting in ischemia
to the extremity.
-As ischemia continues,
muscle and nerve cells are destroyed over time
, and fibrotic tissue replaces the healthy tissue.
Ischemia can occur within 4 to 8 hours after the onset
Compromises neurovascular function of tissues within that space
Contracture, disability, and loss of function can occur.
Delays in diagnosis and treatment cause irreversible muscle and nerve ischemia, resulting in a functionally useless or severely impaired extremity.
Most commonly associated with trauma, fractures (especially the long bones), extensive soft tissue damage, and crush injury.
Early recognition and treatment essential
May occur initially or may be delayed several days
Ischemia can occur within 4 to 8 hours after onset.
, recognize the problem and notify the provider immediately
- if left untreated can lead to gangrene and tissue ischemia
- neuromuscular damage occurs within 4 to 6 hours
Compartment Syndrome: Manifestations: Six Ps
- unrelieved with elevation or by pain meds, intense pain when passively moved, unrelated to and distal to the site of injury
- palpated muscles are hardened and swollen from edema
- or numbness, burning, and tingling are early signs
- tissue is pale and nail beds are cyanotic
- motor weakness, or inability to move the extremity indicate nerve damage and are late signs
- is a late sign
-assess urine output, myoglobinuria released from damaged urine cells and high amount of this can decrease filtration in the renal tubules and cause decreased urine output
Compartment Syndrome: Collaborative Care
Prompt, accurate diagnosis is critical.
Perform and document regular neurovascular assessments on all patients with fractures
especially those with an injury of the distal humerus or proximal tibia or soft tissue injuries in these areas.
-Early recognition and effective treatment of compartment syndrome are essential to avoid permanent damage to muscles and nerves.
assess the location, quality, and intensity of the pain.
-Evaluate the patient's level of pain on a scale of 0 to 10.
Pain unrelieved by drugs and out of proportion to the level of injury is one of the first indications
Pulselessness and paralysis (in particular) are later signs.
Notify the health care provider immediately of a patient's changing condition.
-Because of the possibility of muscle damage,
assess urine output.
-Myoglobin released from damaged muscle cells precipitates and causes obstruction in renal tubules.
-This condition results in acute tubular necrosis and acute kidney injury.
Common signs are dark reddish brown urine and clinical manifestations associated with acute kidney injury.
-Elevation of the extremity may lower venous pressure and slow arterial perfusion.
the extremity should not be elevated above heart level.
the application of cold compresses may result in vasoconstriction and exacerbate symptoms, DO NOT DO
- It may also be necessary to
remove or loosen the bandage and split (bivalving) the cast in half.
reduction in traction weight may decrease external circumferential pressures.
-Surgical decompression (e.g., fasciotomy) of the involved compartment may be necessary.
-The fasciotomy site is left open for several days to ensure adequate soft tissue decompression.
Infection resulting from delayed wound closure is a potential problem following a fasciotomy.
-In severe caseS, an amputation may be required.
Nursing Management- Compartment Syndrome
-Relieve pressure, by loosing the ace wrap or dressing
- Inspect dress/cast frequently
- Elevate cast
- Petal edges of cast
- Loosen dressing
- Monitor intracompartment pressure
- > 30 mm HG, will probably take them to the OR and do a Fasciotomy (will open up the skin in the compartment to relieve the pressure)
DO NOT elevate the extremity above the heart, will slow arterial perfusion and make complications worse, DO NOT apply ice, will cause vasoconstriction will keep the blood from perfusion in the area
- call a Dr asap, relieve the pressure in any way that you can loosen the dressing, if there is a cast petal the edges as much as you can do not take cast off, document that you called the Dr and do within your scope
report pain unrelieved by pain meds or pain that continues to increase in intensity, be instructed to report numbness, tingling, or a change in color of the extremity
-The veins of the lower extremities and pelvis are highly susceptible to thrombus formation after a fracture, especially a hip fracture.
-may also occur after total hip or total knee replacement surgery.
-In patients with limited mobility, venous stasis is aggravated by inactivity of the muscles that normally assist in the pumping action of venous blood returning to the extremities.
-Because of the high risk of venous thromboembolism in the orthopedic surgical patient,
prophylactic anticoagulant drugs such as warfarin (Coumadin), low-molecular-weight heparin such as enoxaparin (Lovenox), fondaparinux (Arixtra), or rivaroxaban (Xarelto) may be ordered.
-In addition to
wearing compression gradient stockings (antiembolism hose) and using sequential compression devices
instruct the patient to move (dorsiflex/plantar flex) the fingers or toes of the affected extremity against resistance
and to perform
ROM exercises on the unaffected lower extremities.
Fat Embolism (FES)
Presence of systemic fat globules from fracture that are distributed into tissues and organs after a traumatic skeletal injury, fat is stored in the bone marrow, can obstruct blood flow when a break in a long bone occurs
- Contributory factor in many deaths associated with fracture, or multiple traumas
- Most common with fracture of long bones, ribs, tibia, and pelvis
-has also been known to occur following total joint replacement, spinal fusion, liposuction, crush injuries, and bone marrow transplantation.
that fat emboli may originate from the fat that is released from the marrow of injured bone. The fat then enters the systemic circulation where it embolizes to other organs such as the brain. Microvascular lodging of droplets produces local ischemia and inflammation.
hormonal changes caused by trauma and/or sepsis stimulate the systemic release of free fatty acids such as chylomicrons, which form the fat emboli.
Fat Embolism (FES): Clinical Manifestations
- Early recognition of FES is crucial to prevent a potentially lethal course.
-Most patients usually manifest symptoms within 24 to 48 hours after the injury. Severe forms have occurred within hours of injury.
- after a long bone fracture need to assess them for the first 12 to 72 hours for signs and symptoms; headache, mental status changes, feeling of impending doom, increased pulse and fever, trouble breathing, using accessory muscles
- Fat globules transported to lungs cause a hemorrhagic interstitial pneumonitis.
The fat emboli in the lungs cause a hemorrhagic interstitial pneumonitis that produces signs and symptoms of acute respiratory distress syndrome (ARDS), such as chest pain, tachypnea, cyanosis, dyspnea, apprehension, tachycardia, and decreased partial pressure of arterial oxygen (PaO2)
-Bc of poor oxygen exchange.
changes in mental status (a result of hypoxemia) are important to recognize. Memory loss, restlessness, confusion, elevated temperature, and headache should prompt further investigation
so that central nervous system involvement is not mistaken for alcohol withdrawal or acute head injury.
- neck, chest wall, axilla, buccal membrane, conjunctiva may appear due to intravascular thromboses caused by decreased oxygenation.
- Clinical course of fat embolus may be
rapid and acute emergency situation
- Patient frequently expresses a
feeling of impending disaster.
- In a
short time skin color changes from pallor to cyanosis the patient may become comatose.
No specific lab test but things to aid in diagnosis:
- Fat cells in blood, urine, or sputum
- ↓PaO2 < 60 mm Hg
- ST segment changes
- ↓ platelet count and hematocrit levels
- Prolonged prothrombin time
- Chest x-ray may reveal areas of pulmonary infiltrate or multiple areas of consolidation → white out
Fat Embolism (FES)
-Treatment is directed at prevention
Careful immobilization of a long bone fracture is probably the most important factor in prevention.
- Management is essentially symptom-related and supportive.
- Encourage Cough and deep breathing
- Reposition the patient as little as possible before fracture immobilization or stabilization because of the danger of dislodging more fat droplets into the general circulation.
- Use of corticosteroids to prevent or treat fat embolism is controversial.
Treatment includes fluid resuscitation to prevent hypovolemic shock, correction of acidosis, and replacement of blood loss.
- Oxygen/intubate/mechanical ventilation
high O2 concentrations will be most likely a prophylactic order, cough and deep breath (do not turn might worsen the fracture), adequate hydration IV fluids , pain and antianxiety meds as needed
*Oxygen is administered to treat hypoxia.
Intubation or intermittent positive pressure ventilation may be considered if a satisfactory PaO2 cannot be obtained with supplemental oxygen alone. Some patients may develop pulmonary edema, ARDS, or both, leading to an increased mortality rate. Most persons survive FES with few sequelae.*
Hip Fractures Types
considered if it is the proximal 1/3 of the femur that is fractured. more common in older women due to osteoporosis, 30% of ppl with these die within 1 year bc of complications of immobility
-Between greater and lesser trochanter
Hip Fractures Assessment
-External rotation of the hip
-Shortening of the affected limb extremity
-Pain and tenderness at fracture site
-Discoloration or bruising of surrounding tissue
-Inability to move injured leg while lying supine
Management of Hip Fractures
-Surgical Repair preferred method of managing hip fractures - permits early mobilization of patient and decreases risk for complications
-Initially fracture is temporarily immobilized with Buck's traction for 24-48 hours before surgery
Hip Fracture Management
- Intracapsular (femoral neck) fractures repaired with endoprosthesis to replace femoral head
- Extracapsular fractures are repaired using fixed/sliding nail plates
pre operative check; how did you fall, what caused it? if it was casued by an underlying cause (stroke, MI) worry about the underlying cause as well
Postoperative Management of Hip Repair Surgery
-Routine post-operative assessments
-Routine post-operative care
-Assess extremity for five "P'S
-Position patient with head slightly elevated with affected leg in neutral position.
-Utilize pillows or abductor pillow between legs when turning to either side
-Utilize sandbags/pillows to prevent adduction or internal rotations of the hip (legs need to stay close to the body in alignment)
-Avoid turning on the operative side until surgeon orders
-Avoid extreme hip flexion >90 degrees
-Weight bearing determined by surgeon based on prosthesis.
-Cemented prosthesis such as total hip replacements allow weight bearing first day while non cemented structures provide for limited weight bearing until healing
Physical Therapy Consult
- Ambulation usually begins on the first or second post operative day
- For discharge, the patient must demonstrate use of crutches or walker as well as ability to transfer into and from a chair and bed and the ability to ascend and descend stairs
- Arrange for elevated toilet seats and straight raised chairs with arms, prevent knees being bent at a 90 degree angle
- Physical therapy consults is key to get them up and moving
- Before discharge the pt needs to demonstrate that they now how to walk with crutches and walker
Total Hip Arthroplasty
surgical removal of a diseased joint and replacing it with a prosthesis
-replacement of the acetabular cup, the femoral head, and the femoral stem
-Avoid extreme internal rotation, adduction and 90 degree flexion for 4-6 weeks
-Utilize abduction pillow
-Tub baths and driving car not allowed for 4-6 weeks
-Exercise to restore muscle tone in the quadricep muscles will improve ROM (quadricep and gluteal setting)
monitor for s/s of PE; dyspnea tachycardia and chest pain, not allowed to cross legs, no knee flexion above 90 degrees, use an abdution pillow
Total Knee Arthroplasty
Knee joint - Largest and most complex joint in the body, typically easier to perform than a total hip
-removal and replacement of the distal femoral component, the tibia plate, and the patellar button
-surgical option when conservative options have failed
- Synovial joint consisting of fibrous joint capsule, synovial membrane, joint cavity and synovial fluid
Seven ligaments are associated with the knee
Anterior/posterior cruciate ligaments
Tibia and fibula collateral ligaments
--- the replacement of the surfaces of the knee joint; the distal portion of the femur, the tibial plateau and the patella are replaced with metal and plastic components
This is attached using acrylic cement; may or may not use cement
total knee Arthroplasty management
-post op look for s/s or DVT, ppl lose a lot of blood (use auto-transfusions),
-check for bleeding at the site post op, s/s or hypovolemia/shock (hypotension, tachycardia)
-HgB might be less than 9 when they come back from surgery H&H might be a certain number and you think they are fine even though they lost a lot of blood then over 24 to 48 hours the H&H will continue to drop bc the IV fluids will dilute the blood
-will often come out into the recovery room in a CPM (continuous massive motion) machine (keeps the legs moving)
-need to have 90 degrees of flexion before going home(might go home with home health nurse or nursing home to make sure they get that flexion, if don't get 90 degrees within a certain period of time the Dr will have to reopen the knee and allow it).
-want to avoid flexion contractures keep the leg extended following surgery
-will be in a lot of pain, may be on PCA pumps after surgery, physical therapy will help with movement, as a nurse provide pain management before physical therapy
-risk for DVT, PE; will be on lovenox or warfarin
is the usual cause of chronic knee pain and functional disability
- erosion of the cartilage that cushions the knee bones leads to pain stiffness and swelling; locking of the knee
- systemic inflammatory disease that causes swelling and pain in multiple joints causing knee deformity and loss of function
-if someone has arthritic problems in the body they will try conservative measures before surgery; loose weight, modify activity, hot and cold therapy, physical therapy, analgesics, steroid injections in the joint (a series of three between 3 and 6 months apart - can prolong having surgery
Management of knee pain and disability
usually managed conservatively initially to control pain and maintain or increase mobility
Heat and cold therapy
Intra-articular steroid injections
Alternative therapies: acupuncture, glucosamine, chondroitin
total knee Arthroplasty Post operatively
always at increased risk for infection. could have a repeated infection that wont go away, may have to have it removed
the patient will be hospitalized for 3-5 days
Post operative Interventions:
- Monitor VS and Neuro status
- Monitor circulation, cap refill, sensation and mobility of affected limb- patient should be able to dorsiflex, plantar flex and wiggle toes on both feet
- Monitor and control pain - (often PCA or epidural used for 2-3 days)
- Assess dressing and surgical drain - drainage greater than 250cc in 8 hours should be reported
- Assist the patient to turn and reposition every 2 hours
total knee Arthroplasty Interventions
Monitor urine output
Assess abdomen for bowel sounds
- A continuous passive motion machine may be ordered to help restore range of motion, decrease swelling and improve venous circulation
- Once healing is satisfactory and knee flexion of 90 degrees is obtained, the patient is discharged
total knee Arthroplasty Complications
- Peroneal nerve injury: foot drop and decreased sensation between great and second toe
- DVT/PE (at risk for up to 6 weeks)
- TEDS and SCD's to both extremities, Lovenox, Coumadin
- Encourage ambulation and teach exercises such as ankle pumps
- monitor for and prevent Infection
Infection of the bone, begins as inflammation within the bone secondary to penetration by infectious organisms following trauma or surgery
-leads to necrosis of bone/marrow tissue
-Weakens the bone
-Risk for fractures
-Open fracture with open wound
-Transmitted by the blood
-Travels to the bone
Initial infection or infection of less then 1 month in duration
Common in children bc there outside with open lesions
General Assessment Findings:
- Night sweats
- Elevated temperature, older adults might not have fever
- Rapid pulse
Acute Osteomyelitis: Local assessment
Localized bone pain:
- Warmth, redness and edema at the site
-may have leukocytosis and elevated ESR
- Diffuse swelling over the bone
- Bone pain that is constant pulsating, localized, and worse with movement
- Unrelieved by rest
- Worse with activity
Holds part in semi-flexion
Surrounding muscle tense with resistance to passive movements
Acute Osteomyelitis Management
-Halt infection and Prevent spread
- Possible debridement of necrotic tissue
- Antibiotic wash during surgery and IV
- Pain management
-bone scan with radioactive material to diagnose and MRI may also facilitate
Acute Osteomyelitis Complications
Tenosynovitis any joint in the body
Gradual progression; many common manifestations will disappear
Infection for more than 4 weeks or failure to respond to antibiotics
try to prevent as much extensive damage as you can
- Pus accumulation=ischemia bone=tissue forms scar tissue=avascular scar impenetrable to antibiotics
Worse at night
Red, swollen, warm, tender
-Surgical removal of involved tissue
- Continuous closed suction wound drainage
- Combination antibiotic therapy
- Window casts
- Supports weakened bone
- Assessment of the wound
- Myocutaneous flaps
- Bone grafting
Decreased rate of bone growth
Non-union of fractures
Osteomyelitis Nursing Management
-Non-steroidal anti-inflammatory drugs; monitor GI bleeding
-Schedule activities around medication; 20-30 min before activities
-Elevate and support
Avoid exercise; can make the disease process spread by Increased circulation may spread disease
-Maintain proper alignment/positioning
Removal of an extremity or part of an extremity
-Severe thermal or crushing injuries
-Auto-amputation traumatic event
Types of amputations
-Closed allowed to do weight bearing
-Flaps of muscle or tissue
-Disarticulation - through the joint
-Through the joint
-Soft tissue and bone are severed at the same level
*goal of surgery preserve the extremity length and function as much as possible, remove all infected and ischemic tissue or it will grow and spread
r/t the nerve pathways that have been cut
Aching, knife-like, jabbing, throbbing, tearing, shooting, burning pain in amputated part
*Relief: Exercise residual limb, Diversional activities
-treated differently than incisional operative pain
-post op day one would be incisional pain
-post op 6 weeks more likely to be phantom pain
treat phantom pain with beta blockers and antiepileptic meds helps with the sharp burning stabbing pain, antidepressants and antispasmodics can also help relieve phantom pain
Post- Op Nursing Care
-Assess for hemorrhage and infection
-Assess types of dressings
-Risk for skin breakdown
-Application of prosthesis immediately
-Elastic wrap dressing
-Pain Control incisional pain immediately after surgery
-Elevate limb for the 1st 24 hours to help with edema but avoid longer than that they might develop a contracture
-Prevent external rotation and abduction contractures
-Avoid dangling stump over bed
-Teach follow-up care
Metabolic bone disorder
-rate of bone reabsorption exceeds the rate of bone formation
-Thinning, less dense or porous bone mass
- post menopausal women, over 60, low levels of calcitonin, male with low testosterone
- DXA scans are diagnostic
- if someone has risk for pathologic fractures; avoid lifting objects or straining
-Localized low-back or mid-thoracic pain, pain on palpation of affected area, reduced height, hx of fractures
- dietary intake of of high amounts of calcium and vit D esp before age 35
-Vit D foods; most fish, egg yolks, fortified milk, and cereal
-Calcium foods; milk products, green vegetables, fortified orange juice, cereals, white beans, and figs
-supplements if foods can not be tolerated, take with food
-limit carbonated beverages
-sun exposure to skin for 5 to 30 min
-engage in weight bearing activities; walking and lifting weights
Osteoporosis Diagnostic test
Avoid lifting objects
Calcium & Vit D, 1000mg, 1500 mg post menopause, 400 IU Vit D
Decreases rate of bone loss