14.1 Complex Musculoskeletal

Question 1

Crush Injuries

Answer 1

• Caused by pressure from a heavy object onto a body part or squeezing of a body part between 2 objects
• “Smiling Death” because they are cheerful before being removed but die shortly after pressure is released
• They die because lack of blood flow causes anaerobic metabolism and as muscle cells die they absorb sodium, water, calcium and release potassium, myoglobin phosphate and other toxins. Once blood flow is returned all these substances circulate throughout the body and cause shock, renal failure, cardiac arrest.
• To lower chances of this happening, treatment must begin before removal of weight

Question 2

Crush Syndrome

Answer 2

• Due to crush injury, crush syndrome is the systemic manifestations of muscle cell damage.
• Associated with bleeding, bruising, broken bones, open wounds, poor circulation, breakdown of muscle

Question 3

Rhabdomylosis

Answer 3

• Characterized by muscle necrosis and noted through elevated CK (Creatine Kinase Levels), myoglobin and potassium
• Hallmark is elevated CK
• Manifestations include muscle pain, weakness, and dark red/brown urine

Question 4

Compartment Syndrome

Answer 4

- Caused by increased pressure in a confined space (usually muscle compartment). Pressure greater than 30 mmHg causes compromised tissue circulation which leads to necrosis
MANIFESTATIONS 6Ps
P - Pain out of proportion
P - Poikilothermia
P - Pallor
P - Pulselessness
P - Paresthesia
P - Paralysis 

TREATMENT

• KEEP EXTREMITY BELOW HEART TO MAXIMIZE BLOOD FLOW
• DO NOT APPLY COLD TO THE SITE
• Fasciotomy - Incision to decrease pressure in the compartment

Question 5

Traumatic Asphyxia

Answer 5

• Due to increase in thoracic pressure, and pressure in superior vena cava, inspiration can lead to capillary rupture of the head and neck
  MANIFESTATIONS
• Cervicofacial cyanosis, edema, subconjunctival hemorrhage, petechial eruptions of the face neck and torso.
• Typically seen after short duration of crushing forces.

Question 6

Hypovolemic Shock

Answer 6

• Loss of blood or loss of extracellular fluid

- Hemorrhagic shock is hypovolemic shock from blood loss

Question 7

Erythema/Blistering

Answer 7

• Prolonged hypo-perfused state can lead to ischemia which results in swelling, erythema, blistering of skin

Question 8

Spinal Cord Injury

Answer 8

• Can damage spinal cord and nerves

Question 9

Fractures

Answer 9

• Usually in the extremities

Question 10

Acute Kidney Injury

Question 11

Fat Embolism Syndrome

Answer 11

• Fat globules released from long bone fractures are deposited throughout body including lung and brain.
• LIFE THREATENING EMERGENCY
• CLASSIC SIGN IS PINPOINT (PETECHIAL) RASH ON CHEST AND AXILLA, hypoxemia and neurologic decline
  TREATMENT
• ABC’s administer oxygen (may need BiPAP if severe)
• IV fluids to prevent hypovolemic shock

Question 12

Osteomyelitis

Answer 12

• Infection of the bone (most commonly caused by staph). Can reach bone via blood stream or spread from nearby tissue
• Osteomyelitis can also develop from a skin lesion causing vascular insufficiency most commonly seen in diabetes foot ulcers

RISK FACTORS
- Immunocompromised, DM, PVD, Cancer, Prosthetic Hardware in place, after traumatic injuries

MANIFESTATIONS

• Persistent/Recurring Fevers
• Increased pain at operative/trauma site
• Poor wound healing and separation
• Vascular insufficiency causes local cellulitis, inflammation and necrosis

DIAGNOSIS
- CBC, ESR, C-Reactive Protein, Blood Cultures, Wound Cultures, MRI/CT, Biopsy, Bone Scan

TREATMENT
- Immobilization of affected bone and antibiotics. Given via PICC line.

Question 13

Amputation

Answer 13

• Removal/Loss of a limb due to trauma, medical illness, surgery.
• Surgery is usually to control pain by removing diseased limbs such as malignant or gangrene.

Question 14

Traumatic Amputation

Answer 14

• Accidental cutting off/removal of some or all of the body part
• COMPLETE - Total Detachment of limb
• PARTIAL - Some tissue remains at the site
• Most commonly caused by traffic accidents
• Construction accidents, lawnmowers, fireworks, military

Question 15

Surgical Amputation

Answer 15

• Most commonly caused by DM, PVD, Atherosclerosis, Tumors, Cancers, Infection.
• Need for amputation is based off WBC (Infection), arteriograms, doppler flow studies, venography, pain and effects on ADL’s.

INTERVENTIONS
- Prepare for surgery, utilize community resources, work with orthic about prosthetics teach about phantom pain.

Question 16

Diffuse Connective Tissue Disease

Answer 16

• Characterized by diffuse inflammation, and degeneration in connective tissue.
• Unknown cause but is immunologically based
• Assess health history with attentino to onset and evolution of symptoms.

Question 17

Systemic Lupus Erythematosus (SLE)

Answer 17

• Autoimmune disorder (genetic defect or environmental trigger). Environmental causes can include sun exposure, oral contraceptives, pregnancy, anti-seizure medications.
• Host cells attack their own cells.
• Most commonly affects 10-50 years old
• Direct T-cell mediated cytotoxicity has been implicated
• Multiple organs can be effected but most common are joints, kidney, CNS, skin, Blood, Serosal surfaces.
  MANIFESTATIONS
• Joint pain, butterfly rash in sun exposed areas, hypercoagulability, increased infection risk (especially pneumonia)
  DIAGNOSIS
• Requires 4/11 typical characteristics of disease be present.
• Positive anti-nuclear antibody (ANA) test, Elevated Anti-DNA, Anti-Smith, and ESR
  TREATMENT
• I&O, daily weight, 24 hour urine protein, creatine clearance, assessment of bleeding, neuro assessment
• Prevention of complications
• Avoid stress
  MEDICATIONS
• NSAIDs, Corticosteroids (prednisolone), immunosuppressants,
  EDUCATION
• Differentiating between exacerbation and remission and how to prevent exacerbations (avoid fatigue, overexposure to sun, emotional stress, infection, drugs, surgery, pregnancy)
• Exacerbations are common post-partum

Question 18

Sjogren’s Syndrome

Answer 18

• Autoimmune disease where b-cell mediated antibodies attack exocrine glands which cause gland dysfunction/destruction. (Genetic)

MANIFESTATIONS

• Dry Eyes and Mouth
• Palpable purpura, optic neuritis, neuropathy, vertigo, Raynaud’s Phenomenon, cough, dyspnea, abdominal pain.

DIAGNOSIS
- 6 Factors (Dry Eyes, Tear Production, Dry Mouth, Salivary Gland Evaluation to see cause of dry mouth, Autoantibodies test)

MANAGEMENT

• No cure, so we treat symptoms.
• Artificial tears for dry eyes, topical cyclosporine, punctum plugs,

NURSING DIAGNOSIS
- Altered skin integrity, self-care deficit, deficient knowledge of self-management techniques

NURSING INTERVENTIONS
- Education about meds and diet

Question 19

Scleroderma

Answer 19

• Overproduction of collagen which leads to platelet aggregation and fibrosis
• Collagen disrupts normal organ function (lungs, kidneys, heart, GI tract)
• Caused by exposure to coal, plastic, silica dust

MANIFESTATIONS
C - Calcinosis (painful deposits of calcium on the skin)
R - Raynaud’s Phenomenon (First Complaint fingers change color with temperature)
E - Esophageal Dysfunction (Difficulty swallowing due to scarring)
S - Sclerodactyly (Fingers in semi-flexed position from tightening of skin)
T - Telangiectasia (Red spots on hands, forearms, palms, face, and lips)

OTHER SYMPTOMS

• GERD from fibrosis, diarrhea/constipation, cough from pleural thickening, pulmonary fibrosis,
• CAN LEAD TO RENAL DISEASE WHICH IS THE MAJOR CAUSE OF DEATH

TREATMENT

• Physical/Occupational Therapy
• Nifedipine (Procardia) to treat Raynaud’s disease
• Corticosteroids for inflammation
• NSAID’s For Pain
• Cimetidine/Omeprazole for GERD
• Tetracycline for Diarrhea
• Captopril for HTN
• Methotrexate for Immunosuppression

NURISNG INTERVENTIONS
- Education about temperature extremes with raynaud’s, moist heat to aid skin flexibility, 4-6 small meals a day, don’t smoke.

Question 20

METABOLIC BONE DISEASES

Answer 20

• Disorders of bone strength and structure

- Most common is osteoporosis

Question 21

Paget’s Disease

Answer 21

• Irregular bone breakdown and formation
• New bone is produced more rapidly than old bone can breakdown
• BONES ARE LARGER AND WEAKER THAN NORMAL

MANIFESTATIONS
- Bone pain, fatigue, edema, deformity, waddling, loss of height, increased skull size, hearing loss, visual defects, headache, dementia

COMPLICATIONS
- Pathologic fractures, hypercalcemia, renal calculi, spinal cord injury, bone sarcoma

MEDICAL MANAGEMENT
- Pain relief (NSAID’s), prevention of bone loss, Firm Mattress, Calcitonin, Biphosphates (Fosamax)

NURSING MANAGEMENT
- Palliative treatment, exercise, diet, importance of maintaining healthy weight.

Question 22

Bone Cancer

Answer 22

• Most commonly affects the pelvis or long bones of extremities
• Benign tumors are slow and symmetrical in growth
• Pathological tumors can displace tendons and muscles and weaken bone. They can cause bone destruction, surface bone changes, and enlarged bone contours.

MANIFESTATIONS
- Bone pain worse at night or after exercise. Limited ROM

Question 23

Primary/Secondary Bone Cancer

Answer 23

Primary - Come from connective/supportive tissue cells of bones. Caused by acquired mutations
Secondary - Cancer comes from breast, prostate, kidney, or lung cancer.

Question 24

Osteosarcoma

Answer 24

• Most Common Bone Cancer

MANIFESTATIONS

• Pain, Swelling
• Sunburst appearance on x-ray

Question 25

Ewing Sarcoma

Answer 25

• “Onion Skin” Appearance on x-ray

Question 26

Chondrosarcoma

Answer 26

• Starts in cartilage

- Lobular appearance on X-ray

Question 27

Manifestations of Bone Cancer

Answer 27

• Most common is pain, ROM limitations, and joint effusion