Care of Patients with Musculoskeletal Trauma Flashcards
break or disruption in continuity of a bone that often affects mobility and sensory perception
Fracture
Break is across the entire width of the bone; bone is divided into two distinct sections
Classified by extent of the break: Complete
Break is only through part of the bone
Classified by extent of the break: Incomplete
skin surface over the broken bone is disrupted and causes an external wound
Classified by the extent of associated soft-tissue damage: Open or compound
does not extend through the skin and therefore has no visible wound
Classified by the extent of associated soft-tissue damage: Closed or simple
Occurs after minimal trauma to a bone that has been weakened by disease
Not sig amount trauma causes break
Classified by the cause of fractures: Pathologic (spontaneous)
Results from excessive strain and stress on the bone
Classified by the cause of fractures: Fatigue (stress)
Produced by a loading force applied to the long axis of cancellous bone
Commonly occur in the vertebrae of older patients with osteoporosis
Compresses vertebrae with all the pressure
Classified by the cause of fractures: Compression
24 to 72 hours after the injury
Hematoma forms at the site of the fracture because bone is extremely vascular
Stop bleeding
Stage 1 - 5 Stages of bone healing
3 days to 2 weeks after injury
Granulation tissue begins to invade the hematoma
Beginning Formation of fibrocartilage - bone; Foundation for bone healing
Stage 2 - 5 Stages of bone healing
3-6 weeks
Fracture site is surrounded by new vascular tissue known as a callus
Callus formation is the beginning of a non-bony union occurs
Result of vascular and cellular proliferation
Stage 3 - 5 Stages of bone healing
3-8 weeks
Callus is gradually resorbed/disappears and transformed into bone
Stage 4 - 5 Stages of bone healing
From 4-6 weeks up to 1 year
Bone remodeling
Length of time depends on the severity of the injury and the age and health of the patient and interventions needed
In young, healthy adult bone, healing takes about 4 to 6 weeks
Healing time is lengthened in older adults: 3 months or longer
Stage 5 - 5 Stages of bone healing
Increased pressure within one or more compartments reduces circulation to the area - pressure cannot be released
Pressure can be from an external or internal
Complication:
Early signs of acute compartment syndrome
Late signs
Release pressure
Acute compartment syndrome - Complications of fractures
tight, bulky dressings and casts - muscle around damaged
External - Acute compartment syndrome
blood or fluid accumulation - kills tissue
Internal - Acute compartment syndrome
Infection
Persistent motor weakness
Contracture
Myoglobinuric renal - muscles break down releases myoglobin and causes a build up
Amputation in extreme cases
Complication: - Acute compartment syndrome
pressure, paresthesia (abnorm sensations), pallor, paralysis
Better outcomes
Early signs of acute compartment syndrome - Acute compartment syndrome
pain, cyanosis, decreased pulses, pulselessness (rare), necrosis
Late signs - Acute compartment syndrome
Systemic complication: Results from severe or prolonged pressure, hemorrhage and edema after a severe fracture or crush injury
Causes severe damage to kidneys
Myoglobin is released into circulation, where it can occlude the distal renal tubules and result in kidney failure
Rhabdomyolysis: Release myoglobulin in the bloodstream
Identify and prevent renal failure
Priority of care is to prevent Acute Tubular Necrosis
Crush syndrome - Complications of fractures
From blood loss of trauma
Hypovolemic shock - Complications of fractures
DVT and PE
Venous thromboembolism - Complications of fractures
Fat globules are released from the yellow bone marrow into the bloodstream within 12 to 48 hours after an injury or illness
Early signs
Petechiae is a classic manifestation, but is usually the last sign to develop - want catch early signs
Can result in respiratory failure or death, often from pulmonary edema
Fat embolism syndrome - Complications of fractures
Globules clog small blood vessels that supply vital organs and impair organ perfusion
Fat globules are released from the yellow bone marrow into the bloodstream within 12 to 48 hours after an injury or illness - Fat embolism syndrome
Altered mental status (earliest sign)
Increased respirations, pulse, and temperature
Chest pain
Dyspnea
Crackles
Low arterial oxygen level
Early signs - Fat embolism syndrome
Superficial skin wound infections
Deep wound abscesses
Bone infection (osteomyelitis) - SEVERE
Clostridial infections can lead to gas gangrene or tetanus and may result in a loss of an extremity - keep open fracture as clean as possible to prevent infection
Infection - Complications of fractures
Cutting off/From loss of blood supply to the bone
Chronic complications: Ischemic necrosis - Complications of fractures
Fracture that has not healed within 6 months of injury
Chronic complications: Delayed union - Complications of fractures
History
Clinical manifestations
Lab
Imaging
Assessment
Mechanism of injury - clues what eval; fracture tells injury
Medical history
Drug history
History
Hx of DM, osteoporosis, CKD, diabetes
Medical history
including substance abuse
Drug history
Depends on the specific traumatic event
Moderate to severe pain - common
Edema
Ecchymosis (bruising)
Check for neurovascular compromise - changes in all
Clinical manifestations
could be rapid and result in neurovascular compromise
IR - neurovascular checks imp
Edema
Bleeding into the underlying soft tissues
Ecchymosis (bruising)
Skin color and temperature – distal to the injury
Movement
Sensation – any numbness or tingling (paresthesia)
Pulses - distal to the fracture site
Capillary refill (least reliable)
Pain
Imp to look at
Check for neurovascular compromise - changes in all
No special laboratory tests are available for assessment of fractures
Hemoglobin and hematocrit
Erythrocyte sedimentation rate (ESR) may be elevated
Increased WBC
Elevated serum calcium and phosphorus
Lab
Low because of bleeding caused by the injury
Lot bleeding
Hemoglobin and hematocrit
Indicates inflammatory response - lot inflammation
Erythrocyte sedimentation rate (ESR) may be elevated
Indicates bone infection
Increased WBC
During healing, bone releases these elements into the blood
Elevated serum calcium and phosphorus
X-rays - BIG and gold oe
CT
MRI
Imaging
Useful for fractures of complex structures, e.g., joints, spine, pelvis; not get something on x-ray
CT
Useful in determining the amount of soft tissue injury
MRI
Acute pain related to one or more fractures, soft-tissue damage, muscle spasm, and edema
Risk for neurovascular compromise related to tissue edema and/or bleeding
Risk for infection related to a wound caused by an open fracture
Impaired physical mobility related to need for bone healing and/or pain
Priority N diagnoses and collaborative probs
Assess ABC’s and perform a quick head-to-toe assessment
Remove clothing from the fracture site - swelling/edema least amount of pressure further cause issues
Remove jewelry on the affected extremity
Apply direct pressure on the area if there is bleeding
Keep the patient warm and in a supine position
Check the neurovascular status of the area distal to the fracture- imp
Immobilize the extremity
Cover any open areas with a dressing
Emergency care of the patient with an extremity fracture
temperature, color, sensation, movement, and capillary refill
compare the affected and unaffected limbs; see if any changes
Check the neurovascular status of the area distal to the fracture- imp
preferably sterile - infection prevention imp
Cover any open areas with a dressing
Closed reduction and immobilization with a bandage, splint, cast, or traction
Cast care
Prevent neurovascular dysfunction or compromise - with cast care
Elevate extremity higher than the heart - immbolize
Ice for the first 24 to 48 hours - decrease IR
Drug therapy
Improve physical mobility and prevent complications of impaired mobility
Prevent infection
Nonsurgical management
For small, closed incomplete bone fractures in the hand or foot, reduction is not required
Realign bones and immobilize
Not for open or small fractures
Closed reduction and immobilization with a bandage, splint, cast, or traction
Four primary groups of casts
Arms, legs, braces, and body or spica casts.
Cast care
Primary nursing concern
Assess the neurovascular status every hour for the first 24 hours and then every 1-4 hours; esp if have a cast
Prevent neurovascular dysfunction or compromise - with cast care
Opioid and non-opioid analgesics, anti-inflammatory drugs, muscle relaxants (muscles tense with fracture) - pain control imp
Meperidine (Demerol) should never be used for older adults because it has toxic metabolites that can cause seizures and other complications; many AE
Drug therapy
Collab with PT/OT
Improve physical mobility and prevent complications of impaired mobility
Proper wound care - sterile technique
IV antibiotics
Wound vacuum-assisted closure system - VAC; sig abscess use this
Prevent infection
If needed to realign the bone for the healing process
Open reduction with internal fixation (ORIF) most common method of reducing and immobilizing a fracture
Surgical management
If closed but sig
Open reduction
Internal fixation
External fixation
Open reduction with internal fixation (ORIF) most common method of reducing and immobilizing a fracture
Allows the surgeon to directly view the fracture site
Open reduction
Uses metal pins, screws, rods, plates, or prostheses to immobilize the fracture during healing
After the bone achieves union, the metal hardware may be removed, depending on the location and type of fracture
Internal fixation
Pins or wires are inserted through the skin and affected bone and then connected to a rigid external frame
Stablize them
increased risk for pin site infection
Have for long-period time so make sure keep clean
External fixation
related to complications of peripheral vascular disease, arteriosclerosis, DM
Least amount required goal
Amputations: Types: Elective
often result of accidents
Amputations: Types: Traumatic
Toe
Mid-foot
Syme: most of the foot is removed, but the ankle remains
Below-knee
Above-knee
Amputations: Levels of amputation for lower extremities
Hemorrhage - traumatic
Infection - traumatic
Phantom limb pain
Neuroma
Flexion contractures
Comps of amputations
More common in patients who had chronic limb pain before surgery and less common in those who have traumatic amputations
Sensation is felt in the amputated part immediately after surgery and usually diminishes over time
If sensation persists and is unpleasant or painful, it is referred to as phantom limb pain
Painful and addressed as if is present
Phantom limb pain
Sensitive tumor consisting of damaged nerve cells
more common in upper extremity amputations
Neuroma
Hip or knee flexion contractures are seen in patients with amputations of the lower extremity
Careful to ensure moving joints
Flexion contractures
Emergency care for traumatic amputations
Assess tissue perfusion
Manage pain
Prevent infection
Promote mobility and preparation for prosthesis - as mobile as possible; collab with team
Promote body image and lifestyle adaptation
Interventions
Stop the bleeding, stabilize the patient, ABCs
Wrap the amputated part (finger, hand, toe) in a clean or sterile cloth - try save it
Place it in a water tight sealed plastic bag
Place the bag in ice water – but never directly on ice - tissue damage
Clean, cold
Avoid contact between the body part and the water to prevent tissue damage
Emergency care for traumatic amputations
After surgical closure, the skin flap at the end of the remaining limb should be pink in a light-skinned person and not discolored in a dark-skinned patient
Tissue should be warm, but not hot
Assess tissue perfusion
Pain medications per HCP
IV infusions of calcitonin (Miacalcin, Calcimar) during the week after amputation can reduce phantom limb pain
Massage
Heat
TENS unit - PT
Ultrasound therapy per PT
Manage pain
Health teaching should focus on:
Airbags and seatbelts
Osteoporosis screening and self-management - risk for compression fractures; focus on educating young women
Fall prevention
Home safety assessment and modification, if needed
Dangers of drinking and driving
Drug safety (prescribed, OTC, illicit)
Older adults and driving
Helmet use when riding bicycles, motorcycles, all-terrain vehicles (ATVs), and skateboards
Health promotion and maintenance
