Chapter 69 Management of Patients With Musculoskeletal Trauma

1. Chapter 69 Management of Patients With Musculoskeletal Trauma

2. Injuries of the Musculoskeletal System • Contusion: soft tissue injury produced by blunt force with bleeding into soft tissue • Pain, swelling, and discoloration: ecchymosis • Strain: Pulled muscle-injury to the musculotendinous unit (Excessive stretching of a ligament) • Pain, edema, muscle spasm, ecchymosis, and loss of function are on a continuum graded 1st , 2nd, and 3rd degree

3. Injuries of the Musculoskeletal System • Sprain: injury to ligaments and supporting muscle fiber around a joint • It is caused by a wrenching or twisting motion. • Joint is tender and movement is painful, edema, disability and pain increases during the first 2–3 hours • Dislocation: articular surfaces of the joint are not in contact • A traumatic dislocation is an emergency with pain change in contour, axis, and length of the limb and loss of mobility

4. RICE • Rest • Ice • Compression • Elevation

5. Common Sports-Related Injuries • Contusions, strains, sprains and dislocations • Tendonitis: inflammation of a tendon by overuse • Meniscal injuries of the knee occur with excessive rotational stress • Traumatic fractures • Stress fractures

6. Knee Ligaments, Tendons, and Menisci

7. Prevention of Sports-Related Injuries • Use of proper equipment; running shoes for runners, wrist guards for skaters, etc. • Effective training and conditioning specific for the person and the sport • Stretching prior to engaging in a sport or exercise has been recommended but may not prevent injury • Changes in activity and stresses should occur gradually • Time to “cool down” • Tune in to the body; be aware of limits and capabilities • Modify activities to minimize injury and promote healing

8. Occupational-Related Injuries • Common injuries include strains, sprains, contusions, fractures, back injuries, tendonitis, and amputations. • Prevention measures may include personnel training, proper use of equipment, availability of safety and other types of equipment (patient lifting equipment, back belts), correct use of body mechanics, and institutional policies.

9. Fractures • Break in the continuity of bone • Causes: • Direct blow • Crushing force (compression) • Sudden twisting motions (torsion) • Severe muscle contraction • Disease (pathologic fracture)

10. Types of Fractures • Complete • Incomplete • Closed or simple • Open or compound/complex • Grade I • Grade II • Grade III

11. Types of Fractures

12. Types of Fractures

13. Types of Fractures

14. Manifestations of Fracture • Pain • Loss of function • Deformity • Shortening of the extremity • Crepitus • Local swelling and discoloration • Diagnosis by symptoms and x-ray • Patient usually reports an injury to the area

15. Emergency Management • Immobilize the body part • Splinting: joints distal and proximal to the suspected fracture site must be supported and immobilized • Assess neurovascular status before and after splinting • Open fracture: cover with sterile dressing to prevent contamination • Do not attempt to reduce the fracture

16. Medical Management • Reduction • Closed: external manipulation • Open: surgery • Immobilization: internal or external fixation • Open fractures require treatment to prevent infection • Tetanus prophylaxis, antibiotics, and cleaning and debridement of wound • Closure of the primary wound may be delayed to permit edema, wound drainage, further assessment, and debridement if needed

17. Techniques of Internal Fixation

18. Factors That Enhance Fracture Healing • Immobilization of fracture fragments • Maximum bone fragment contact • Sufficient blood supply • Proper nutrition • Exercise: weight bearing for long bones • Hormones: growth hormone, thyroid, calcitonin, vitamin D, anabolic steroids

19. Factors That Inhibit Fracture Healing • Extensive local trauma • Bone loss • Inadequate immobilization • Space or tissue between bone fragments • Infection • Local malignancy • Metabolic bone disease (as Paget's disease) • Avascular necrosis • Intra-articular fracture (synovial fluid contains fibrolysins, which lyse the initial clot and retard clot formation) • Age (elderly persons heal more slowly) • Corticosteroids (inhibit the repair rate)

20. Question Is the following statement True or False? Testing for crepitus can produce further tissue damage and should be avoided.

21. Answer True Testing for crepitus can produce further tissue damage and should be avoided.

22. Techniques of Internal Fixation

23. Complications of FracturesAcute Compartment Syndrome • Serious condition in which increased pressure within one or more compartments causes massive compromise of circulation to the area • Pathophysiologicchanges sometimes referred to as ischemia-edema cycle • A hallmark sign is pain that occurs or intensifies with passive ROM • Pain continues to increase despite the administration of opioids and seems out of proportion to the injury

24. Emergency Care (Continued) • Elevate extremity to the level of heart • Remove cast • Fasciotomy may be performed to relieve pressure. • Pack and dress the wound after fasciotomy.

25. Other Complications of Fractures • Shock • Fat embolism syndrome: serious complication resulting from a fracture; fat globules are released from yellow bone marrow into bloodstream • Venous thromboembolism • Infection • Ischemic necrosis • delayed union, nonunion, and malunion

26. Possible Results of Acute Compartment Syndrome • Infection • Motor weakness • Volkmann’s contractures: (a deformity of the hand, fingers, and wrist caused by a lack of blood flow (ischemia)to the muscles of the forearm)

27. Musculoskeletal Complications(continued) • Muscle Atrophy, loss of muscle strength range of motion, pressure ulcers, and other problems associated with immobility • Embolism/Pneumonia/ARDS • TREATMENT – hydration, albumin, corticosteroids • Constipation/Anorexia • UTI • DVT

28. Question Is the following statement True or False? Avascular necrosis is prolongation of expected healing time for a fracture.

29. Answer False Avascular necrosis is death of tissue secondary to poor perfusion and hypoxemia. Delayed union is prolongation of expected healing time for a fracture.

30. Rehabilitation Related to Specific Fractures • Clavicle • Use of claviclar strap (“figure 8”) or sling • Exercises • Limitation of activities • Do not elevate arm above shoulder for approximately 6 weeks • Humeral neck and shaft fractures • Slings and bracing • Activity limitations and pendulum exercises

31. Fracture of Clavicle and Immobilization Device

32. Prescribed Shoulder Exercises (Clavicle Fractures)

33. Immobilizers for Proximal Humeral Fractures

34. Functional Humeral Brace

35. Rehabilitation Related to Specific Fractures • Elbow fractures • Monitor regularly for neurovascular compromise and signs of compartment syndrome • Potential for Volkmann's contracture • Active exercises and ROM are encouraged to prevent limitation of joint movement after immobilization and healing (4–6 weeks for nondisplaced, casted) or after internal fixation (about 1 week)

36. Volkmann's Contracture • Observe the distal part of the extremity for swelling, skin color, nail bed capillary refill, and temperature. Compare affected and unaffected hands. • Assess radial pulse. • Assess for paresthesia in the hand, which may indicate nerve injury or impending ischemia. • Evaluate the patient's ability to move the fingers. • Explore the intensity and character of the pain. • Report indications of diminished nerve function or diminished circulatory perfusion promptly before irreparable damage occurs; fasciotomy may become necessary.

37. Fractures of the Pelvis • Result from falls or accidents • Associated internal damage is the chief concern in fracture management of pelvic fractures • Management depends upon type and extent of fracture and associated injuries. • Stable fractures are treated with a few days bed rest and symptom management. • Early mobilization reduces problems related to immobility.

38. Pelvic Bones

39. Stable Pelvic Fractures • Most fractures of pelvis heal rapidly because the pelvic bones has a rich blood supply

40. Unstable Pelvic Fractures

41. Hip fracture • Most common among elderly (due to falls and osteoporosis) • Fracture can intracapsular or extracapsular • Surgery is usually done to reduce and fixate the fracture. • Care is similar to that of a patient undergoing other orthopedic surgery or hip replacement surgery.

42. Regions of the Proximal Femur

46. Examples of Internal Fixation for Hip Fractures

47. Rehabilitation Related to Specific Fractures • Femoral shaft fractures • Lower leg, foot, and hip exercises to preserve muscle function and improve circulation. • Early ambulation stimulates healing. • Physical therapy, ambulation and weight bearing are prescribed. • Active and passive knee exercises are begun as soon as possible to prevent restriction of knee movement.

48. Femoral Fractures

49. Nursing Process: The Care of the Patient with Fracture of the Hip—Assessment • Health history and presence of concomitant problems • Pain • VS, respiratory status, LOC, and signs and symptoms of shock • Affected extremity including frequent neurovascular assessment • Bowel and bladder elimination; bowel sounds, I&O • Skin condition • Anxiety and coping

50. Nursing Process: The Care of the Patient with Fracture of the Hip—Diagnoses • Acute pain • Impaired physical mobility • Impaired skin integrity • Risk for impaired urinary elimination • Risk for ineffective coping • Risk for disturbed thought processes