ch 62 musculoskeletal trauma & orthopedic surgey Flashcards
is a traumatic event resulting in fracture, dislocation, subluxation, and/or soft tissue injury
most common cause of musculoskeletal injury
urge them to wear nonskid, hard-soled footwear and assess their living environment for safety risks (e.g., remove throw rugs, ensure adequate lighting, maintain clear paths to the bathroom for nighttime use)
reduce risk for falls, for elderly by
sprains, strains, dislocations, and subluxations. They usually result from trauma.
Soft tissue injuries include
sprains and strains, growth plate injuries, and repetitive motion injuries
younger patients sport injuries include
abnormal stretching or twisting forces during vigorous activities. These injuries tend to occur around joints and in the spinal musculature.
Sprains and strains often result from
is an injury to the ligaments surrounding a joint.
sprain
a wrenching or twisting motion. Most occur in the ankle, wrist, and knee joints.
Sprains are usually caused by
. A first-degree (mild) sprain involves tears in only a few fibers, with mild tenderness and minimal swelling. A second-degree (moderate) sprain results in partial disruption of the involved tissue with more swelling and tenderness. A third-degree (severe) sprain is a complete tear of the ligament with moderate to severe swelling.
A sprain is classified according to the degree of ligament damage
s tears in only a few fibers, with mild tenderness and minimal swelling
A first-degree (mild) sprain involve
in partial disruption of the involved tissue with more swelling and tenderness.
second-degree (moderate) sprain results
is a complete tear of the ligament with moderate to severe swelling.
A third-degree (severe) sprain
is an excessive stretching of a muscle and its fascial sheath, often involving the tendon
strain
the lower back, calf, and hamstrings.
Most strains occur in the large muscle groups, including
first degree (mild or slightly pulled muscle), second degree (moderate or moderately torn muscle), and third degree (severely torn or ruptured muscle). A defect in the muscle may be apparent or palpated through the skin if the muscle is torn.
Strains are classified as
pain, edema, decreased function, and bruising. Continued use of the joint, tendon, or ligament makes pain worse.
Manifestations of sprains and strains are similar. They include
usually self-limiting. Full function generally returns within 3 to 6 weeks.
Mild sprains and strains are
in which the ligament pulls loose a fragment of bone. The joint structure may become unstable, causing subluxation or dislocation
-hemarthrosis (bleeding into a joint space or cavity) or disruption of the synovial lining may occur.
severe sprain can cause an avulsion fracture,
(1) stopping the activity and limiting movement to the injured part, (2) applying ice packs to the injured area, (3) compressing the involved area, (4) elevating the extremity, and (5) providing analgesia as needed
f an injury occurs, immediate care focuses on
decrease local inflammation and pain for most musculoskeletal injuries.
RICE (Rest, Ice, Compression, Elevation) may
cold therapy
(cryotherapy)
vasoconstriction in the soft tissue and reduces the transmission and perception of nerve pain impulses. These changes also reduce muscle spasms, inflammation, and edema. Cold is most useful when applied immediately after an injury has occurred and used for 24 to 28 hours. Apply ice no more than 20 to 30 minutes at a time. Do not apply ice directly to the skin.
Cold causes
edema and pain. We often use an elastic compression bandage.
Compression helps decrease
It can be wrapped around the injured part. To prevent edema and encourage fluid return, wrap the bandage starting distally (at the point farthest from the trunk of the body) and progress proximally (toward the trunk of the body).
elastic compression bandage
numbness or tingling below the area of compression or pain or more swelling occurs beyond the edge of the bandage. Leave the bandage in place for 30 minutes, then remove it for 15 minutes.
bandage is too tight if there is
circulation and helps resolve bruising and swelling.
Muscle contraction improves
is the complete displacement or separation of the articular surfaces of the joint.
Dislocation
is a partial or incomplete displacement of the joint surface.
Subluxation
around hip and shoulder sockets and the meniscus at the knee, play an important role in joint stability
Fibrocartilage structures, such as the labrum
forces on the joint that disrupt the surrounding soft tissue support structures.
Dislocations typically result from
the thumb, elbow, and shoulder.
The joints most often dislocated in the upper extremity include
anteriorly.
shoulder most often dislocates
are rare. They typically only happen after electrocution or seizure
Posterior shoulder dislocations
deformity.
most obvious sign of a dislocation is
local pain, tenderness, loss of function of the injured part, and swelling of soft tissues near the joint.
Other manifestations of dislocated joint include
open joint injuries, intraarticular fractures (within the joint), avascular necrosis (bone cell death from blood supply), and damage to adjacent nerves and blood vessels.
Major complications of a dislocated joint are
hemarthrosis or fat cells.
joint may be aspirated to assess for
a probable intraarticular fracture.
Fat cells in the aspirate indicate
an orthopedic emergency because it may be associated with significant vascular injury. The longer the joint is dislocated, the greater the risk for avascular necrosis.
dislocation requires prompt attention. It is often considered
avascular necrosis.
femoral head of the hip joint is especially susceptible to
to vascular injury and resulting ischemia
Compartment syndrome may occur after dislocation due
realign the dislocated part of the joint to its original anatomic position
first goal of management of a dislocation is to
(no incision)
Closed reduction
(joint visualized through surgical incision
open reduction
a brace, splint, or sling or by taping to allow torn ligaments and surrounding tissue to heal.
After reduction, the extremity is immobilized by
repeated dislocations because of damage or laxity to the previously mentioned structures
patient who has dislocated a joint may be at greater risk for
and cumulative trauma disorder are terms used to describe injuries resulting from prolonged force or repetitive movements and awkward postures
Repetitive strain injury (RSI)
repetitive trauma disorder, nontraumatic musculoskeletal injury, overuse syndrome (sports medicine), regional musculoskeletal disorder, and work-related musculoskeletal disorder.
RSI is also called
tendons, ligaments, and muscles, causing tiny tears that become inflamed.
Repeated movements strain the
musicians, dancers, butchers, grocery clerks, vibratory tool workers, and those who frequently use a computer mouse and keyboard.
-Competitive athletes and poorly trained athletes
Persons at risk for RSI include
poor posture and positioning, poor workspace ergonomics, badly designed workplace equipment (e.g., computer keyboard), and repetitive lifting of heavy objects without sufficient muscle rest. Inflammation, swelling, and pain in the muscles, tendons, and nerves of the neck, spine, shoulder, forearm, and hand may result.
swimming, overhead throwing (e.g., baseball), weight lifting, gymnastics, tennis, skiing, and kicking sports (e.g., soccer) require repetitive motion. Overtraining compounds the effects of RSI.
Other factors related to RSI include
pain, weakness, numbness, or impaired motor function.
Symptoms of RSI include
(the science that promotes efficiency and safety in the interaction of humans and their work environment).
ergonomics
compression of the median nerve, which enters the hand at the wrist through the narrow carpal tunnel
Carpal tunnel syndrome (CTS) is caused by
in the upper extremity.
CTS is the most common compression neuropathy
hobbies or work that require continuous wrist movement (e.g., musicians, carpenters, computer operators).
Carpal tunnel syndrome (CTS) associated with
by pressure from trauma or edema (due to inflammation of a tendon [tenosynovitis]), cancer, rheumatoid arthritis (RA), or soft tissue masses, such as ganglia. Hormones may be involved because CTS often occurs during the premenstrual period, pregnancy, and menopause
CTS is often caused
because of swelling that changes blood flow to the nerve and narrows the carpal tunnel
Persons with diabetes, peripheral vascular disease (PVD), and RA have a higher incidence of CTS
impaired sensation, pain, numbness, or weakness in the distribution of the median nerve
Numbness and tingling may awaken the patient at night. Shaking the hands often relieves these symptoms. Clumsiness in performing fine hand movements is common
-patient may have a positive Tinel’s sign and Phalen’s sign.
Manifestations of CTS are
can be elicited by tapping over the median nerve as it passes through the carpal tunnel in the wrist. A positive response is a sensation of tingling in the distribution of the median nerve over the hand.
Tinel’s sign (positive = CTS)
can be elicited by allowing the wrists to fall freely into maximum flexion and maintain the position for longer than 60 seconds. A positive response is a sensation of tingling in the distribution of the median nerve over the hand. In late stages, atrophy of the muscles around the base of the thumb results in recurrent pain and eventual dysfunction of the hand.
Phalen’s sign (positive = CTS)
6 months or if there is significant impairment to conduction on electromyography (EMG).
Carpal tunnel release is generally done if symptoms last more than
open release and endoscopic surgery
types of carpal tunnel release surgery include
an incision is made in the wrist and then the carpal ligament is cut to enlarge the carpal tunnel.
open release surgery,
1 or more small puncture incisions in the wrist and palm. A camera is attached to a tube, and the carpal ligament is cut. The endoscopic approach may allow a faster recovery and cause less discomfort than traditional open release surgery.
Endoscopic carpal tunnel release is performed through
the supraspinatus, infraspinatus, teres minor, and subscapularis muscles.
rotator cuff is made up of 4 muscles in the shoulder:
a gradual, degenerative process due to aging, repetitive stress (especially overhead arm motions), or injury to the shoulder.
tear in the rotator cuff may occur as
in swimming, weight lifting, and swinging a racquet (tennis, racquetball), often cause injury.
In sports, repetitive overhead motions, such as (rotator cuff )
adduction forces applied to the cuff while the arm is held in abduction. Other causes include (1) falling onto an outstretched arm and hand, (2) a blow to the upper arm, (3) heavy lifting, or (4) repetitive work motions.
rotator cuff can tear because of sudden
shoulder weakness, pain, and decreased ROM. The patient usually has severe pain when the arm is abducted between 60 and 120 degrees (the painful arc). A positive drop arm test is a sign of rotator cuff injury.
Manifestations rotator cuff include
In this test, the arm is abducted 90 degrees, and the patient is asked to slowly lower the arm to the side. If the arm falls suddenly, rotator cuff injury is suspected.
drop arm test (rotator cuff)
An x-ray alone is not helpful in the diagnosis. A tear can usually be confirmed by MRI.
diagnosis of rotator cuff
patient with a partial tear or cuff inflammation may be treated conservatively with rest, ice and heat, NSAIDs, corticosteroid injections into the subacromial space, ultrasound, and PT.
Tx for rotator cuff
(acromioplasty) to relieve compression of the rotator cuff during movement.
-shoulder immobilizer with an abduction pillow is typically used for 6 weeks after surgery to limit shoulder movement
If the tear is extensive, part of the acromion may be surgically removed
shoulder should not be immobilized for too long because “frozen” shoulder
arthrofibrosis ( “frozen” shoulder )
crescent-shaped pieces of fibrocartilage in the knee.
menisci are
the acromioclavicular (AC), sternoclavicular, and temporomandibular joints
Menisci are also found in other joints, including
ligament sprains common among athletes in sports such as basketball, football, soccer, and hockey.
-activities produce rotational stress when the knee is in varying degrees of flexion and the foot is planted or fixed
Meniscus injuries are associated with
shearing of the meniscus between the femoral condyles and tibial plateau, causing a torn meniscus
blow to the knee can cause
Older adults and people who have jobs that require squatting or kneeling are at
risk for degenerative tears
edema because most cartilage is avascular.
Meniscus injuries alone do not usually cause significant
localized tenderness, pain, and effusion . Pain occurs with flexion, internal rotation, and then extension of the knee (McMurray’s test). The patient may feel that the knee is unstable and often reports that the knee “clicks,” “pops,” “locks,” or “gives way.” Quadriceps atrophy is usually present if the injury has been present for some time.
acutely torn meniscus may present with (sign/symp)
repeated meniscus injury and chronic inflammation.
Traumatic arthritis may occur from
MRI can confirm the diagnosis before arthroscopy.
diagnose Meniscus injuries
patient’s age, occupation, sport activities, degree of knee pain, and dysfunction may affect the decision whether to have surgery.
surgery Meniscus injuries based on
ice application, immobilization, and use of crutches with weight bearing as tolerated. Using a knee brace or immobilizer during the first few days after the injury protects the knee and offers some pain relief.
Initial care involves for Meniscus injuries
, PT can help the patient regain knee flexion and muscle strength to aid in returning to full function. Teach athletes to do warm-up exercises to reduce the risk for sports-related injuries.
After acute pain has decreased of Meniscus injuries
progressive exercise therapy may improve neuromuscular function and muscle strength.8
In older adults with degenerative meniscus tears,
Surgical repair or excision of part of the meniscus
(meniscectomy)
Meniscal surgery is done by arthroscopy. Pain relief may include NSAIDs or other analgesics. Rehabilitation starts soon after surgery, including quadriceps and hamstring strengthening exercises and ROM. When the patient’s strength is back to its preinjury level, normal activities may be resumed.
Tx after surgery
anterior cruciate ligament (ACL)
most commonly injured knee ligament is the
noncontact injuries that occur when the athlete pivots, lands from a jump, or stops abruptly when running.
ACL injuries are usually
coming down on the knee, twisting, and hearing a pop, followed by acute knee pain and swelling
Patients often report ACL injuries as
a partial tear, a complete tear, or an avulsion (tearing away) from the bones that form the knee
Injury to the ACL can result in
A positive Lachman’s
test suggests an ACL tear
This test is done by flexing the knee 15 to 30 degrees and pulling the tibia forward while the femur is stabilized. The test is considered positive for an ACL tear if forward motion of the tibia occurs with the feeling of a soft or indistinct endpoint.
Lachman’s test process
MRI is often used to diagnose an ACL tear and coexisting conditions, including a fracture, meniscus tearing, and collateral ligament injuries.
diagnose an ACL tear by
rest, ice, NSAIDs, elevation, and ambulation as tolerated with crutches. If present, a tight, painful effusion may be aspirated. A knee immobilizer or hinged knee brace may provide support. PT often helps the patient maintain knee joint motion and muscle tone.
Conservative treatment for an intact ACL injury includes
physically active patients who have sustained severe injury to the ACL and meniscus.
Reconstructive surgery is usually recommended for
removed and replaced with graft tissue.
- prior level of physical functioning may take 6 to 8 months.
In reconstruction, the torn ACL tissue is
are closed sacs that are lined with synovial membrane and contain a small amount of synovial fluid
Bursae are
found at sites of friction, such as between tendons and bones and near the joints
Bursae found
(inflammation of the bursa) results from repeated or excessive trauma or friction, gout, RA, or infection.
Bursitis
warmth, pain, swelling, and limited ROM in the affected part.
Symptoms of bursitis include
the hands, elbows, shoulders, knees, and greater trochanters of the hip.
Common sites of bursitis are
Improper body mechanics, repetitive kneeling (carpet layers, coal miners, and gardeners), jogging in worn-out shoes, and prolonged sitting with crossed legs are
common precipitating activities.leading to Bursitis
Rest is often the only treatment needed.
only treatment needed for Bursitis
immobilized in a compression dressing or splint. Ice and NSAIDs can reduce pain and inflammation.9 Aspiration of the bursal fluid and intraarticular corticosteroid injection may be needed.
affected part may be (Tx or Bursitis/ implementation)
If the bursal wall has become thickened and continues to interfere with normal joint function,
surgical excision (bursectomy) may be done if
oral antibiotics, but usually need surgical incision and drainage
Septic bursae may be treated with
is a disruption or break in the continuity of bone
fracture
a disease process, such as cancer or osteoporosis (pathologic fracture).
Although traumatic injuries cause most fractures, some fractures are due to
open or closed based on communication with the external environment
Fractures are described as
the skin is broken and bone exposed, causing soft tissue injury.
open fracture
, the skin is intact over the site.
closed fracture
complete or incomplete
fractures also described as
he break goes completely through the bone.
fracture is complete if t
occurs partly across a bone shaft, but the bone is still intact.
-result of bending or crushing forces applied to a bone.
incomplete fracture
the direction of the fracture line.
Fractures are identified according to
linear, oblique, transverse, longitudinal, and spiral fractures
Types fractures based on direction of fracture line include
displaced or nondisplaced
fractures can be classified as
, the 2 ends of the broken bone are separated from each other and out of their normal positions.
displaced fracture
comminuted (more than 2 fragments) or oblique
Displaced fractures are often (ex of types)
the bone fragments stay in alignment
nondisplaced fracture,
transverse, spiral, or greenstick
Nondisplaced fractures are usually (ex of types)
occurs in normal or abnormal bone that is subject to repeated stress, such as from jogging or running.
Stress fracture:
a spontaneous fracture at the site of a diseased bone
Pathologic fracture:
immediate localized pain, decreased function, and inability to bear weight or use the affected part. The patient guards and protects the extremity against movement. Obvious bone deformity may be present.
Manifestations fracture include
- Fracture hematoma
- Granulation tissue
- Callus formation
4.Ossification
5.Consolidation - Remodeling
Bone goes through a complex multistage healing process (union) that occurs in 6 stages:
When a fracture occurs, bleeding creates a hematoma that surrounds the ends of the bone fragments. The hematoma is composed of extravasated blood that changes from a liquid to a semisolid clot in the first 72 hours after injury
Fracture hematoma: (1st step in healing fracture)
During this stage, active phagocytosis absorbs the products of local necrosis. The hematoma converts to granulation tissue. Granulation tissue (consisting of new blood vessels, fibroblasts, and osteoblasts) forms the basis for new bone substance (osteoid) during days 3 to 14 after injury.
Granulation tissue:(2nd step in healing fracture)
As minerals (calcium, phosphorus, and magnesium) and new bone matrix are deposited in the osteoid, an unorganized network of bone is formed and 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. An x-ray can show evidence of callus formation.
Callus formation ( 3rd step in healing fracture)
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.
Ossification ( 4th step in healing fracture)
As callus continues to develop, the distance between bone fragments decreases and eventually closes. Ossification continues and can be equated with radiologic union, which occurs when an x-ray shows complete bony union. This phase can occur up to 1 year after injury.
Consolidation (5th step in healing fracture)
Excess bone tissue is resorbed in the last stage of bone healing, and union is complete. Gradual return of the injured bone to its preinjury structural strength and shape occurs. Bone remodels in response to physical loading stress (Wolff’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 of little stress.
Remodeling (6th step in healing fracture)
granulation tissue.
hematoma converts to
new blood vessels, fibroblasts, and osteoblasts
Granulation tissue consists of
forms the basis for new bone substance
osteoid
is primarily composed of cartilage, osteoblasts, calcium, and phosphorus
Callus
air usually fills the small airways in lungs is replaced with something else. it can be either; fluid, pus, blood or water, a solid such as stomach contents or cells
lung consolidation
new bone is built up as osteoclasts destroy dead bone
Callus formation
Fracture heals in abnormal position in relation to midline of structure (type of malunion).
Angulation (complication of fracture healing)
Fracture healing progresses more slowly than expected. Healing eventually occurs.
Delayed union (complication of fracture healing)
Fracture heals in expected time but in unsatisfactory position. May cause deformity or dysfunction.
Malunion (complication of fracture healing)
Deposition of calcium in muscle tissue at site of significant blunt muscle trauma or repeated muscle injury.
Myositis ossificans (complication of fracture healing)
Fracture does not heal despite treatment. No x-ray evidence of callus formation.
Nonunion (complication of fracture healing)
Type of nonunion occurring at fracture site in which a false joint is formed with abnormal movement at site.
Pseudoarthrosis (complication of fracture healing)
New fracture occurs at original fracture site.
Refracture
displacement and site of the fracture, blood supply, other local tissue injury, immobilization, and use of internal fixation devices (e.g., screws, pins)
Many factors influence the time needed for complete fracture healing. They include
inadequate immobilization, excessive movement of fracture fragments, infection, poor nutrition, and systemic disease (e.g., diabetes)
Ossification may be slowed or even stopped by
Fracture healing may not occur in the expected time (delayed union) or may not occur at all (nonunion).
Smoking increases fracture healing time. by
(1) anatomic realignment of bone fragments through reduction, (2) immobilization to maintain realignment, and (3) restoration of normal or near-normal function of the injured part.
overall goals of fracture treatment are
- Manual traction
- Closed reduction
- Skeletal traction
- Open reduction
Management
Fracture Reduction (Realignment)
- Casting or splinting
- Skeletal traction
- External fixation
- Internal fixation
Fracture Immobilization
- Surgical debridement and irrigation
- Tetanus and diphtheria immunization
- Prophylactic antibiotic therapy
Open Fractures
is the nonsurgical, manual realignment of bone fragments to their anatomic position.
-Traction and countertraction are manually applied to the bone fragments to restore position, length, and alignment.
Closed reduction
the patient is under local or general anesthesia
Closed reduction is usually done while
Traction, casting, splints, or orthoses (braces) may be
used after reduction to maintain alignment and immobilize the injured part until healing occurs. (closed reduction)
is the correction of bone alignment through a surgical incision.
Open reduction
internal fixation of the fracture with wires, screws, pins, plates, intramedullary rods, or nails
Open reduction usually includes
type and location of the fracture, patient age, and concurrent disease
influence the decision to use open reduction
are infection, complications associated with anesthesia, and effects of preexisting medical conditions (e.g., diabetes)
-facilitates early ambulation, thus decreasing the risk for complications related to prolonged immobility
main risks of open reduction
is the application of a pulling force to an injured or diseased body part or extremity.
Traction
(1) prevent or reduce pain and muscle spasm (e.g., whiplash, unrepaired hip fracture), (2) immobilize a joint or part of the body, (3) reduce a fracture or dislocation, and (4) treat a pathologic joint condition (e.g., tumor, infection).
Traction is used to
(1) provide immobilization to prevent soft tissue damage, (2) promote active and passive exercise, (3) expand a joint space during arthroscopic procedures, and (4) expand a joint space before major joint reconstruction.
Traction is also used to
apply a pulling force on a fractured extremity to attain realignment while countertraction pulls in the opposite direction
Traction devices (work by)
pulls in the opposite direction. in a traction
countertraction
skin traction and skeletal traction
The most common types of traction are
short-term treatment (48 to 72 hours) until skeletal traction or surgery is possible.
Skin traction is generally used for
to help decrease muscle spasms in the injured extremity
Tape, boots, or splints are applied directly to the skin, mainly
is a type of skin traction sometimes used for the patient with a hip, knee, or femur fracture
Buck’s traction
heavier weights applied intermittently
Pelvic or cervical skin traction may require
fractures of the femur, hip, and lower leg.
Balanced suspension skeletal traction. Most often used for
align injured bones and joints or to treat joint contractures and congenital hip dysplasia
Skeletal traction is used to
a long-term pull that keeps the injured bones and joints aligned
Skeletal traction provides
a pin or wire into the bone, and weights are attached to align and immobilize the injured body part
To apply skeletal traction, the HCP inserts
infection at the pin insertion site and the effects of prolonged immobility.
major complications of skeletal traction are
balanced suspension traction
common type of skeletal traction is
the correct positioning and alignment of the patient while the traction forces stay constant.
Fracture alignment skeletal traction depends on
is supplied by the patient’s body weight or by weights pulling in the opposite direction.
-Elevating the end of the bed can help
Countertraction
Keep the weights off the floor and moving freely through the pulleys.
Skeletal Traction must be maintained continuously.
casts, braces, splints, immobilizers, and external and internal fixation devices.
Fracture immobilization is achieved with
is a temporary immobilization device often applied after closed reduction
cast
to perform many normal ADLs while providing enough immobilization to ensure stability.
cast allows the patient
c the joints above and below a fracture. This restricts tendon and ligament movement, thus assisting with joint stabilization while the fracture heals
ast generally immobilizes
natural (plaster of Paris) and fiberglass.
2 most common cast materials are
they are lighter, relatively waterproof, and longer wearing than plaster of Paris.They also allow early weight bearing.
use fiberglass casts most often because
contact casting in the treatment of diabetic foot ulcers
Plaster of Paris is now used primarily for
cover the affected part with stockinette that is cut longer than the extremity. Then place cotton padding over the stockinette, with extra padding for bony prominences.
To apply a cast on an extremity, first
immerse it in warm water and then wrap and mold it around the affected part. The number of layers of plaster bandage and the technique of application determine the strength of the cast. The plaster sets within 15 minutes, so the patient may move around without difficulty. However, it is not strong enough for weight bearing until about 36 to 72 hours after application.
If using plaster of Paris (applying cast)
submersion in cool or tepid water. Then they are molded to fit the torso or extremity.
Casts made of fiberglass or other synthetic materials (thermolabile plastic, thermoplastic resins, polyurethane) are activated by
Leave a fresh plaster cast uncovered to allow air circulation. Covering the cast allows heat to build up in the cast. This may cause a burn and delay drying. 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 rough edges may be petaled to minimize skin irritation. Petaling also prevents plaster of Paris debris from falling into the cast and causing irritation or pressure necrosis. Place several strips (petals) of tape over the rough areas to ensure a smooth cast edge.
If using plaster of Paris (applying cast)
(1) sugar-tong splint, (2) posterior splint, (3) short arm cast, or (4) long arm cast
acute fracture or soft tissue injury of the upper extremity can be immobilized by using a
is applied for acute wrist injuries or injuries that may result in significant swelling.
sugar-tong splint
Splints are placed 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 down the volar aspect of the forearm to the distal palmar crease.
-splinting material is wrapped with either elastic bandage or bias stockinette.
how sugar-tong splint placed
early swelling in the fractured extremity.
sugar-tong posterior splint accommodates
for the treatment of stable wrist or metacarpal fractures
-aluminum finger splint can be built into the short arm cast for treatment of phalangeal injuries.
-circular cast extending from the distal palmar crease to the proximal forearm
-cast immobilizes the wrist and allows unrestricted elbow motion.
short arm cast is often used
for stable forearm or elbow fractures and unstable wrist fractures.
- similar to the short arm cast but extends to the proximal humerus, restricting motion at the wrist and elbow.
-Support the extremity and reduce edema by elevating the extremity with a sling.
long arm cast is often used
elevation or use of a supportive sling. The hanging provides traction and maintains fracture alignment.
hanging arm cast is used for a proximal humerus fracture, avoid
ensure the axillary area is well padded to prevent skin breakdown from direct skin-to-skin contact. Apply the sling carefully to avoid putting undue pressure on the neck.
sling is used,
immobilization and support for stable spine injuries of the thoracic or lumbar spine.
body jacket brace is used for
the chest and abdomen, extending from above the nipple line to the pubis
brace goes around
After application of the brace, assess the patient for the development of
superior mesenteric artery syndrome (cast syndrome)
condition occurs if the brace is too tight, compressing the superior mesenteric artery against the duodenum
superior mesenteric artery syndrome (cast syndrome)
patient generally has abdominal pain, abdominal pressure, nausea, and vomiting. Assess the abdomen for decreased bowel sounds (there may be a window in the brace over the umbilicus).
superior mesenteric artery syndrome (cast syndrome) sign/symp
gastric decompression with a nasogastric (NG) tube and suction. Assess respiratory status, bowel and bladder function, and areas of pressure over the bony prominences, especially the iliac crest. The brace may have to be adjusted or removed if any complications occur.
Treatment of cast syndrome includes
a long leg cast, short leg cast, cylinder cast, or prefabricated splint or immobilizer.
Injuries to the lower extremity can be immobilized with
an 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.
usual indications for a long leg cast are (lower extremity)
stable ankle and foot injuries
short leg cast is used for (lower extremity)
knee injuries or fractures. It extends from the groin to the malleoli of the ankle.
cylinder cast is used for
temporarily to limit mobility of a joint. It is composed of soft padding materials (absorption dressing and cotton sheet wadding), splints, and an elastic wrap or bias-cut stockinette
Robert Jones dressing may be used
elevate the extremity above the heart on pillows for the first 24 hours. After that, a casted extremity should not be placed in a dependent position as this may increase edema. After cast application, observe for signs of compartment syndrome (discussed on p. 1460) and increased pressure, especially in the heel, anterior tibia, head of the fibula, and malleoli. Increased pressure presents as pain or a burning feeling in these areas.
After application of a lower extremity cast or dressing,
type of immobilization is easy to apply and remove, which allows close observation of the affected joint for swelling and skin breakdown
-Depending on the injury, removal of the splint or immobilizer promotes ROM of the affected joint and faster return to function.
Prefabricated knee and ankle splints and immobilizers are
for femur fractures in children to immobilize the affected extremity and trunk
hip spica cast is mainly used
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).
hip spica cast covers
is composed of metal pins and wires that are inserted into the bone and attached to external rods to stabilize the fracture while it heals
external fixator
used to apply traction or to compress fracture fragments and immobilize reduced fragments when the use of a cast or traction is not appropriate.
external fixator used to
external device holds fracture fragments in place similar to a surgically implanted internal device.
external fixator similar to
complex fractures with extensive soft tissue damage, correction of congenital bony defects, nonunion or malunion, and limb lengthening.
-used to try to salvage extremities that otherwise may require amputation.
External fixation is used mainly for
surgically inserted to realign and maintain position of bony fragments
Internal fixation devices (pins, plates, intramedullary rods, metal and bioabsorbable screws) are
stainless steel, vitallium, or titanium. Proper alignment and bone healing are evaluated regularly by x-rays.
nternal fixation metal devices are biologically inert and made from
healing, especially with fracture nonunion or delayed union
Electrical bone growth stimulation can promote
(1) increasing calcium uptake and the production of bone growth factors, (2) increasing collagen synthesis, and (3) promoting the growth of new blood vessels
mechanism of action of Electrical bone growth stimulation may include
noninvasive, semi-invasive, and invasive
methods of electrical bone growth stimulation.
use direct current or pulsed electromagnetic fields (PEMFs) to generate a weak electrical current.
-Electrodes are typically in a band applied over the patient’s skin or cast and worn 10 to 12 hours each day, usually while the patient is sleeping.
Noninvasive stimulators of electrical bone growth stimulation.
an external power supply and electrodes that are inserted through the skin and into the bone.
Semi-invasive or percutaneous bone growth stimulators use
a current generator in an IM or subcutaneous space. An electrode is implanted in the bone fragments.
Invasive stimulators of electrical bone growth require surgical implantation of
carisoprodol (Soma), cyclobenzaprine, or methocarbamol (Robaxin), may be given to manage pain associated with muscle spasms.
Central and peripheral muscle relaxants, such as (drug therapy)
the patient with an open fracture who has not been previously immunized or whose immunization is expired
Give tetanus and diphtheria toxoid or tetanus immunoglobulin to
prophylactically before surgery
Bone-penetrating antibiotics, such as a cephalosporin (e.g., cefazolin), are used
adequate protein (e.g., 1 g/kg of body weight), vitamins (especially B, C, and D), calcium, phosphorus, and magnesium.
patient’s dietary requirements must include
tissue healing. Immobility and bone healing increase calcium needs.
Low serum protein and vitamin C deficiencies interfere with
6 small meals. This helps avoid overeating that can cause abdominal pressure and cramping.
If immobilized in bed with skeletal traction or in a body jacket brace, the patient should eat
thorough neurovascular assessment of the affected extremity, should be done
distal to the fracture site, is a primary concern.
Poor positioning, physiologic responses to the traumatic injury, and application of a cast or constrictive dressing can
cause nerve or vascular damage, usually distal to the injury
(excessive pain, pain with passive stretch of the affected extremity muscles, pallor, paresthesia, with late signs of paralysis and pulselessness).
compartment syndrome sign/symp
dyspnea, chest pain, temperature elevation).
FES (fat embolism) sign/symp
(color, temperature, capillary refill, peripheral pulses, edema) and
-peripheral neurologic assessment (sensation, motor function, pain).
neurovascular assessment consists of peripheral vascular assessment
Pallor or a cool-to-cold extremity below the injury could
-delay in returning to its original color (greater than 3 seconds)
indicate arterial insufficiency.
warm, cyanotic extremity could
indicate poor venous return.
decreased or absent pulse distal to the injury can
indicate vascular dysfunction and insufficiency.
(1) abduct the fingers (ulnar nerve), (2) oppose the thumb and small finger (median nerve), and (3) flex and extend the wrist (or the fingers, if in a cast) (radial nerve).
Assess motor function by asking the patient to
(peroneal nerve)
perform dorsiflexion
(tibial nerve).
plantar flexion
(fresh fruits and vegetables)
roughage
bone demineralization due to reduced mobility
Renal stones can develop from
a rise in urine pH and stone formation from calcium precipitation
Hypercalcemia from demineralization causes
prolonged bed rest, resulting in orthostatic hypotension and decreased lung capacity
Rapid deconditioning of the cardiopulmonary system can occur from
of the affected extremity is a classic assessment finding for a patient with unrepaired hip fracture.
External rotation
(1) non–weight bearing (no weight on the involved extremity), (2) touch-down/toe-touch weight bearing (contact with floor for balance but no weight borne), (3) partial–weight-bearing ambulation (25% to 50% of patient’s weight borne), (4) weight bearing as tolerated (based on patient’s pain and tolerance), and (5) full–weight-bearing ambulation (no limitations).
Ambulation occurs in different degrees of weight-bearing:
cane(can relieve up to 40% of the weight normally borne by a lower limb) to a walker or crutches (may allow for complete non–weight-bearing ambulation).
Devices for ambulation range from a cane-crutches
(can relieve up to 40% of the weight normally borne by a lower limb)
cane
(may allow for complete non–weight-bearing ambulation).
walker or crutches
advanced at the same time or immediately after advance of the device. The uninvolved limb is advanced last.
The involved limb is usually (which foot goes first w/ walker or cane)
opposite the involved extremity. (strong side)
Canes are held in the hand
the neurovascular bundle that passes across the axilla.
A patient with inadequate upper limb strength or poorly fitted crutches bears weight at the axilla rather than at the hands. This can damage
the transition from dependence to independence in performing simple ADLs.
Short-term rehabilitative goals address
preventing problems associated with musculoskeletal injury
Long-term rehabilitative goals are aimed at
direct or indirect
Complications of fractures may be
problems with bone infection, bone union, and avascular necrosis.
Direct complications include
compartment syndrome, VTE, fat embolism syndrome (FES), breakdown of skeletal muscle (rhabdomyolysis), and hypovolemic shock.
Indirect complications include
a high rate of infection
Open fractures and soft tissue injuries have
severe external forces.
open fracture usually results from
anaerobic bacilli, such as Clostridium tetani.
Dying or contaminated tissue is an ideal medium for many common pathogens, including
saline lavage in the operating room. Gross contaminants are irrigated and mechanically removed.
-Contused, contaminated, and devitalized tissue (muscle, subcutaneous fat, skin, and bone fragments) is surgically excised (debridement)
-During surgery, the open wound may be irrigated with antibiotic solution.
-Antibiotic-impregnated beads also may be placed in the surgical site. Patients usually receive IV antibiotics for at least 3 days
Open fractures require aggressive surgical debridement. The wound is initially cleaned by
is a condition in which swelling causes increased pressure within a limited space (muscle compartment). Because the fascia surrounding the muscle has limited ability to stretch, continued swelling can cause pressure that compromises the function of blood vessels and nerves in the compartment
Compartment syndrome
the leg but can occur in any muscle group.
Compartment syndrome often involves
(1) decreased compartment size resulting from restrictive dressings, splints, casts, excessive traction, or premature closure of fascia; and (2) increased compartment contents due to bleeding, inflammation, edema, or IV infiltration.
Two basic causes of compartment syndrome are
pressure to obstruct circulation and cause venous occlusion, which further increases edema
Edema can create enough
Fractures of the distal humerus and proximal tibia are the
most common fractures associated with compartment syndrome.
knee or leg surgery.
Compartment injury can also occur after
when someone is trapped under a heavy object or a person’s limb is trapped beneath the body because of response to drugs or alcohol.
Prolonged pressure on a muscle compartment may result
Ischemia can occur within 4 to 8 hours after the onset of compartment syndrome.
One or more of the “6 Ps” are specific to compartment syndrome: (1) pain out of proportion to the injury that is not managed by opioid analgesics, and pain on passive stretch of muscle in the compartment; (2) increasing pressure in the compartment; (3) paresthesia (numbness and tingling); (4) pallor, coolness, and loss of normal color of the extremity; (5) paralysis or loss of function; and (6) pulselessness (decreased or absent peripheral pulses).
sign/symp of compartment syndrome
Pain unrelieved by drugs and out of proportion to the level of injury is one of the
-Paresthesia is also an early sign.
first signs of compartment syndrome.
Pulselessness and paralysis are
later signs of compartment syndrome
do not elevate the extremity above the heart. Similarly, do not apply cold compresses. They may cause vasoconstriction and worsen compartment syndrome.
NOT DO with compartment syndrome
fasciotomy (surgical decompression) site is left open for several days to allow adequate soft tissue decompression. Infection resulting from delayed wound closure is a potential problem after fasciotomy. In severe cases of compartment syndrome, amputation is done.
surgical decompression on compartment syndrome
clot (thrombus) formation after a fracture, especially a hip fracture.
Veins of the lower extremities and pelvis are at great risk for
total hip or total knee replacement surgery.
VTE may also occur after
at least 10 to 14 days
prophylactic anticoagulant drugs should be given for (VTE SURGERY)
(1) warfarin (Coumadin), (2) low-molecular-weight heparin (LMWH) (e.g., enoxaparin [Lovenox], fondaparinux), (3) aspirin, or (4) a factor Xa inhibitor (e.g., rivaroxaban [Xarelto], apixaban)
most common agents used include (anticoagulant drugs for VTE)
dorsiflex and plantar flex the ankle of an affected lower extremity against resistance and perform ROM exercises on the unaffected leg.
Besides wearing compression gradient stockings (antiembolism hose) or using intermittent pneumatic compression devices, the patient should
(e.g., nosebleeds) or internal bleeding (e.g., tea-colored urine).
Monitor for signs of external bleeding (anticoagulant therapy)
is characterized by fat globules entering the circulatory system from fractures.
Fat embolism syndrome (FES)
collect in areas with abundant blood vessels, especially the lungs and brain.2
Fat embolism syndrome (FES) collect
long bones, ribs, tibia, and pelvis.
fractures most often associated with FES are those of the
total joint replacement, spinal fusion, liposuction, crush injuries, and bone marrow transplantation.
FES can also occur after
, fat emboli originate from fat released from the marrow of injured bone. The fat enters systemic circulation, where it travels to other organs. As fat droplets become stuck in small blood vessels, local ischemia and inflammation occur
According to the mechanical theory
hormonal changes caused by trauma or sepsis stimulate systemic release of free fatty acids (e.g., chylomicrons) that form the fat emboli.
biochemical theory suggests
acute respiratory distress syndrome (ARDS).
Fat emboli in the lungs cause hemorrhagic interstitial pneumonitis with signs and symptoms of
chest pain, tachypnea, cyanosis, dyspnea, apprehension, tachycardia, and hypoxemia.
-Changes in mental status due to hypoxemia are common
-Petechiae on the neck, anterior chest wall, axilla, buccal membrane, and conjunctiva of the eye
Fat emboli in the lungs cause hemorrhagic interstitial pneumonitis with signs and symptoms of include
include fat cells in blood, urine, or sputum; a decrease of PaO2 to less than 60 mm Hg; ST segment and T-wave changes on ECG; decreased platelet count and hematocrit; and high erythrocyte sedimentation rate (ESR)
-hest x-ray may show bilateral pulmonary infiltrates.
diagnosis of Fat emboli
is a syndrome caused by the breakdown of damaged skeletal muscle cells
Rhabdomyolysis
myoglobin into the bloodstream. Myoglobin precipitates and causes obstruction in renal tubules. This results in acute tubular necrosis and acute kidney injury (AKI).
Rhabdomyolysis breakdown causes the release of
are dark reddish-brown urine and symptoms of AKI
Common signs Rhabdomyolysis
is a fracture of the distal radius styloid process of the ulna may be involved as well.
Colles’ fracture
the patient falls on an outstretched arm and hand.
-one of the most common types of fractures in adults.
Colles’ fracture injury usually occurs when
over 50 years old whose bones are osteoporotic (fragility fracture)
-younger person with a Colles’ fracture caused by a low-energy force should be referred for an osteoporosis evaluation
Colles’ fracture most often occurs in patients
pain in the immediate area of injury, pronounced swelling, and dorsal displacement of the distal fragment (silver-fork deformity). This displacement appears as an obvious deformity of the wrist. The major complication is vascular insufficiency from edema. CTS can be a later complication.
Symptoms Colles’ fracture include
closed reduction of the fracture and application of a splint or cast. If displaced, the fracture is typically managed with open reduction and internal or external fixation.
Colles’ fracture is usually managed with
Encourage active movement of the thumb and fingers to reduce edema and increase venous return. Teach the patient to perform active movements of the shoulder to prevent stiffness or contracture.
Encourage pt with Colles’ fracture
among young and middle-aged adults.
Fractures involving the shaft of the humerus are common
obvious displacement of the humeral shaft, shortened extremity, abnormal mobility, and pain.
The most common symptoms shaft of the humerus are
radial nerve injury and injury to the brachial artery due to laceration, transection, or muscle spasm.
Complications associated shaft of the humerus include
a hanging arm cast, shoulder immobilizer, sling and swathe (a type of immobilizer that prevents shoulder movement), or humeral cuff brace
Nonoperative treatment may include
is typically used to stabilize mid-shaft humerus fractures.
-good option for nonoperative fracture management
humeral cuff brace
minor to life threatening, depending on the mechanism of injury and associated vascular damage.
Pelvic fractures range from relatively
s intraabdominal injury, including laceration and hemorrhage of the urethra, bladder, or colon. They can cause acute pelvic compartment syndrome. Paralytic ileus may occur after pelvic fracture
Pelvic fractures may cause serious
sepsis, FES, or VTE.
Patients may survive the pelvic injury, only to die from
local swelling, tenderness, deformity, unusual pelvic movement, and bruising. Assess the neurovascular condition of the lower extremities and determine associated injuries.
Abdominal assessment may show (pelvic fract)
x-ray and CT scan.
Pelvic fractures are diagnosed by
external fixation alone or combined with ORIF (e.g., screws), often done emergently.
-Turn the patient only when ordered by the HCP
Complex or displaced fractures (e.g., open book fracture) need
to a fracture of the proximal (upper) third of the femur, which extends 5 cm below the lesser trochanter
Hip fracture refers
Fractures within the hip joint capsule are
intracapsular fractures.
(1) capital (fracture of the head of the femur), (2) subcapital (fracture just below the head of the femur), and (3) transcervical (fracture of the femoral neck).
Intracapsular fractures are further identified by their specific locations:
These fractures, which are often associated with osteoporosis and minor trauma, are called
fragility fractures.(Intracapsular fractures)
outside the joint capsule.
Extracapsular fractures occur
(1) intertrochanteric (in a region between the greater and lesser trochanter) or (2) subtrochanteric (below the lesser trochanter). Most are caused by severe direct trauma or a fall.
Extracapsular fractures occur either
external rotation, muscle spasm, shortening of the affected extremity, and severe pain and tenderness around the fracture site. Displaced femoral neck fractures may disrupt blood supply to the femoral head, resulting in avascular necrosis of the femoral head.
Manifestations Extracapsular fractures include
Initially the affected extremity may be immobilized with Buck’s traction
used for 24 to 48 hours to relieve painful muscle spasms.
hip fracture Tx
(1) closed reduction with percutaneous pinning (CRPP) (minimally invasive surgery to stabilize the femoral neck and head with screws), (2) repair with internal fixation devices (e.g., hip compression screw, intramedullary devices), (3) replacement of the femoral head with a prosthesis (partial hip replacement or hemiarthroplasty, often used for fracture of the femoral neck) (Fig. 62.19), and (4) total hip replacement (involves both the femur and acetabulum)
Surgical hip fracture options include
(1) color, (2) temperature, (3) capillary refill, (4) distal pulses, (5) edema, (6) sensation, (7) motor function, and (8) pain.
Assess the patient’s extremity for
elevating the leg when the patient is in bed or in a chair. Pain in the affected extremity can be reduced by maintaining limb alignment with pillows between the patient’s knees when turning the patient to the nonoperative side.
Decrease edema by
(incision posterior to the midline of the greater trochanter down the femoral shaft), measures to prevent dislocation must be used
If hemiarthroplasty or total joint replacement was done by a posterior approach
(1) putting on shoes and socks, (2) crossing the legs or feet while seated, (3) assuming the side-lying position incorrectly, (4) standing up or sitting down while the hip is flexed more than 90 degrees relative to the chair, and (5) sitting on low seats, especially low toilet seats. Teach the patient to avoid these activities until the soft tissue capsule around the hip has healed enough to stabilize the prosthesis (usually at least 6 weeks).
positions to be avoided with hemiarthroplasty or total joint replacement posterior approach
(incision is made in the front of the hip with patient lying on the back), the hip muscles are left intact.
hemiarthroplasty or total joint replacement was done by an anterior approach
motion and weight bearing are few. They typically include instructions to avoid hyperextension.
Precautions related to hemiarthroplasty or total joint replacement was done by an anterior approach
Limited weight bearing is typically the
-until x-ray examination shows adequate healing, usually 6 to 12 weeks.
-Taking a tub bath and driving a car are not allowed for 4 to 6 weeks
only restriction for the patient who had ORIF of the hip fracture.
nonunion, avascular necrosis, dislocation, and osteoarthritis (OA).
Complications associated with femoral neck fracture include
affected leg may be shorter if the patient had an intertrochanteric fracture. A cane or shoe lift may be needed for safe ambulation.
intertrochanteric fracture. complications
Sudden severe pain, a lump in the buttock, limb shortening, and external rotation
indicate prosthesis dislocation.
requires closed reduction with moderate to deep sedation or open reduction under general anesthesia to realign the femoral head in the acetabulum. If any of these signs occur (regardless of the setting), keep the patient NPO in anticipation of surgical intervention.
Tx prosthesis dislocation.
include quadriceps setting (e.g., pressing the kneecap down), gluteal muscle setting (e.g., tightening the buttocks), leg raises in supine and prone positions, and abduction exercises from the supine and standing positions (e.g., swinging the leg out but never crossing midline).
-Swimming and stationary cycling
Exercises to restore strength and tone in the quadriceps and muscles around the hip are essential
jogging and tennis, because they may loosen the implant
avoid high-impact exercises and sports, such as
(1) increased risk for falling due to an altered center of gravity and inability to correct a postural imbalance, (2) decreased fat and muscle to act as local tissue shock absorbers, and (3) reduced skeletal strength.
Factors that increase the risk for a hip fracture in older adults include
(1) gait and balance problems, (2) altered vision and hearing, (3) slowed reflexes, (4) orthostatic hypotension, and (5) medication use
Other factors that increase the older adult’s risk for falling include
y (1) eliminating tripping hazards (e.g., throw rugs, uneven surfaces), (2) adding grab bars inside and outside the tub or shower, and beside the toilet, (3) adding railings on both sides of the stairs, and (4) installing better lighting.23
Homes can be made safer b
Older adults may have low bone density (osteopenia) or osteoporosis, which
increases their risk for fragility fractures. (older adult)
may be prescribed to decrease bone loss or increase bone density. This reduces the chance of fracture
bisphosphonate drug (e.g., alendronate [Fosamax])
the fracture (e.g., from a motor vehicle crash or gunshot wound) often also damages the adjacent soft tissue. These injuries may be more serious than the bone injury.
femoral shaft fracture occurs from a severe direct force. The force exerted to cause t
increased soft tissue damage.
-Considerable blood loss (1 to 1.5 L) can occur
Displacement of fracture fragments often causes
transverse, spiral, comminuted, oblique, and open
most common types of femoral shaft fracture include
pain, notable deformity and angulation, shortening of the extremity, and inability to move the hip or knee. Complications include FES; nerve and vascular injury; and problems associated with bone union, open fracture, and soft tissue damage.
femoral shaft fracture is marked by
patient stabilization and fracture immobilization. Traction may be used as a temporary measure before surgery or in the patient unable to have surgery. Placement of an intramedullary rod is the most common surgical treatment for femoral shaft fracture.
Initial management of femoral shaft fracture involves
the marrow canal of the femur. The rod passes across the fracture to keep fragments in position. Plates and screws also may be used.
—***Internal fixation is preferred because it reduces the hospital stay and complications associated with prolonged bed rest.
metal rod is placed into
an open fracture.
External fixation may be used for (femur fracture)
gluteal and quadriceps isometric exercises will promote and maintain strength in the affected extremity. Encourage the patient to perform ROM and strengthening exercises for all uninvolved extremities to prepare for ambulation.
After surgery, of femoral shaft fracture
As a result, soft tissue damage, devascularization, and open fracture are common.
-common site for stress fracture.
causes tibial fracture (strong area)
compartment syndrome, FES, delayed union or nonunion, and possible infection with an open fracture.
Complications of tibial fractures include
is closed reduction followed by immobilization in a long leg cast
Recommended management for closed tibial fractures
ORIF with intramedullary rods, plate fixation, or external fixation is
-emphasis of care is maintaining quadriceps strength.
Tx needed for complex fractures and those with extensive soft tissue damage of tibial fracture
unlikely to move or cause spinal cord damage. This type of injury is often confined to the vertebral body (anterior part of the spinal column) in the lumbar region
-Sometimes it involves the cervical and thoracic regions.
In a stable fracture, the fracture fragments are
displacement by intact spinal ligaments.
Vertebral bodies are usually protected from
motor vehicle crashes, falls, diving, or sports injuries.
Stable fractures of the vertebral column are usually caused by
Instability and injury to the spinal cord may result (unstable fracture). These injuries generally require surgery.
unstable fracture
fracture displacement, which can cause damage to the spinal cord
The most serious complication of vertebral fractures is
patient usually has pain and tenderness in the affected region of the spine.
signs/symp of stable spine fracture
(flexion angulation of thoracic vertebrae) known as a dowager’s hump
kyphotic deformity
(extreme inward curve of lumbar spine) and cervical spine involvement are possible.
Lordosis
spinal cord impingement and paraplegia. Bowel and bladder dysfunction may occur if there is interruption of the autonomic nervous system nerves or injury to the spinal cord.
Sudden loss of function below the fracture indicates
is to keep the spine in good alignment until union is achieved. Many nursing interventions are aimed at assessing for spinal cord trauma
-Regularly evaluate vital signs and bowel and bladder function. Monitor the motor and sensory function of peripheral nerves distal to the injured region
verall goal in managing stable vertebral fractures
pain medication followed by early mobilization and bracing. The patient’s mattress should be firm to support the spinal column, relax muscles, decrease edema, and prevent potential compression on nerve roots
Treatment stable vertebral fractures includes
turning by moving the shoulders and pelvis together. The patient will need nursing help to learn the technique of logrolling
Teach the patient to keep the spine straight when
Several days after the initial injury, the HCP may apply a specially constructed orthotic device (e.g., thoracolumbar sacral orthosis [TLSO]), a jacket cast, or a removable corset if there is no evidence of neurologic deficit. The device gives extra support during healing and is used for a short period of time.
constructed orthotic device (e.g., thoracolumbar sacral orthosis [TLSO]),
patients with stable vertebral compression fractures due to osteoporosis
Lightweight bracing (e.g., Jewett or Bähler-Vogt brace) may be used for
vertebroplasty or balloon kyphoplasty.
Patients with osteoporosis also may be treated with 2 outpatient procedures:
radioimaging to guide the injection of bone cement into a fractured vertebral body. When hardened, the cement stabilizes the vertebra and prevents further compression
- However, later compression fractures of adjacent vertebrae are a risk.
Vertebroplasty uses
first inserting a balloon into the vertebral body and then inflating it. This creates a cavity that is filled with bone cement under low pressure to restore the height of the vertebral body.
Balloon kyphoplasty involves
Kyphoplasty is now the
-due to the decreased incidence of bone cement leakage into nearby structures (e.g., colon, lung) compared to vertebroplasty.
- However, later compression fractures of adjacent vertebrae are a risk.
surgical treatment of choice for compression fractures
wear a hard cervical collar. Some cervical fractures are immobilized by use of a halo vest
If the fracture is in the cervical spine, the patient may
consists of a plastic jacket or cast fitted about the chest and attached to a halo held in place by skeletal pins inserted into the cranium. These devices immobilize the spine in the fracture area while allowing the patient to ambulate.
halo vest (cervical fracture)
(1) showing safe ambulation, (2) learning care of the cast or orthotic device, and (3) stating ways to address safety and security concerns related to the injury and treatment
patient with a stable vertebral fracture is discharged after
trauma, such as a motor vehicle crash, an assault, or a fall.
Any bone of the face can be fractured from
patent airway and provide adequate ventilation
After facial injury it is critically important to establish and maintain a
occur together.
Facial fractures and cervical spine injuries often
the extent of the injury.
X-rays help determine
between bone and soft tissue injury.
CT scanning helps distinguish
and place a protective shield over the eye.
If an eye-globe rupture is suspected, stop
vitreous humor forced out of the eye. Brown tissue (iris or ciliary body) may be seen on the surface of the globe or penetrating through a laceration, with an off-center or teardrop-shaped pupil.
Signs of eye-globe rupture include
trauma to the face or jaw.
Mandibular fracture may result from
no bone displacement, or may involve loss of tissue and bone.
mandibular fracture may be simple, with
to ensure the patient’s survival. Long-term treatment is sometimes needed to restore satisfactory appearance and function.
The mandibular fracture may need immediate treatment
to correct an underlying alignment problem (malocclusion) that cannot be adjusted by orthodontics alone.
-mandible is resected during surgery and manipulated forward or backward to correct the occlusion problem
Mandibular fractures may be done therapeutically
immobilization, usually by wiring the jaws (intermaxillary fixation).
Surgery for a mandibular fracture includes
, the lower jaw is wired to the upper jaw. Wires are placed around the teeth, and then cross-wires or rubber bands are used to hold the lower jaw tight against the upper jaw
In a simple fracture with no loss of teeth
(e.g., metal arch bars in the mouth or insertion of a pin in the bone). Bone grafting may be needed
If teeth are missing or bone is displaced, other forms of fixation may be needed
are airway obstruction and aspiration of vomitus
Two potential problems in the immediate postoperative period (intermaxillary fixation)
the side with the head slightly elevated.
-Tape a wire cutter or scissors (for rubber bands) to the head of the bed. Send it with the patient to all appointments and examinations away from the bedside
After surgery place the patient on (mandibular fraction)
Liquid protein supplements may improve the patient’s nutrition. The low-bulk, high-carbohydrate diet and intake of air through the straw contribute to constipation and gas. Ambulation, prune juice, and bulk-forming laxatives may help relieve these problems.
diet for mandibular surgery post op
is the removal of a body extremity by trauma or surgery.
amputation
peripheral neuropathy that progresses to deep ulcers and gangrene
PVD w/ diabetes have
trauma (e.g., motor vehicle crashes, farm-related injury). Battle injuries
Amputation in young people is usually due to
thermal injuries, tumors, osteomyelitis, and congenital limb disorders.
Other common reasons for amputation include
a weight-bearing residual limb (or stump).
closed amputation creates
the bony part of the residual limb. The skin flap is sutured posteriorly so that the suture line will not be in a weight-bearing area
An anterior skin flap with dissected soft tissue padding covers
is an amputation done through a joint.
Disarticulation
is a form of disarticulation at the ankle.
syme’s amputation
the surface of the residual limb is left uncovered with skin. This type of surgery is generally done to control actual or potential infection.
-wound is usually closed later by a second surgical procedure or closed by skin traction surrounding the residual limb.
After an open amputation (guillotine amputation),
(measures blood flow in the arms or legs)
Plethysmography
amputated limb may feel like it is still present after surgery. This phenomenon, termed
phantom limb sensation
may be the best choice for older adults, patients with infection, or patients who have had amputations above the knee or below the elbow
delayed prosthetic fitting
partial weight bearing after sutures are removed. If there are no problems, the patient can bear full weight on a permanent prosthesis about 3 months after amputation.
temporary prosthesis may be used for
because they still perceive pain in the missing part of the limb. As recovery and ambulation progress, phantom limb sensation and pain usually subside. However, the pain may become chronic.
Patients are often extremely worried about phantom limb sensation bc
patient may have shooting, burning, or crushing pain as well as feelings of coldness, heaviness, and cramping,
s/symp phantom limb sensation
We do not know why looking in the mirror at the remaining limb would improve symptoms. The mirror is thought to give visual information to the brain, replacing sensory feedback expected from the missing limb. Mirror therapy may also improve patient function after a stroke.
Mirror therapy reduces symptoms in some patients (for phantom limb sensation)
is hip flexion
most common and debilitating contracture
have patients avoid sitting in a chair for more than 1 hour with hips flexed or having pillows under the surgical extremity. Unless contraindicated, patients should lie on their abdomen for 30 minutes 3 or 4 times each day and position the hip in extension while prone.
To prevent flexion contractures,
the residual limb is shaped and molded for eventual prosthesis fitting
Proper bandaging ensures
support soft tissues, reduce edema, hasten healing, and minimize pain. Compression also promotes residual limb shrinkage and maturation.
HCP usually orders a compression bandage to be applied right after surgery to
mold of the residual limb and measures landmarks for creation of the prosthesis. The molded limb socket allows the residual limb to fit snugly into the prosthesis. The residual limb is covered with a stocking to ensure good fit and prevent skin breakdown
prosthetist makes a
from trauma
Because most upper extremity amputations result
the below-the-elbow amputee.
Both immediate and delayed prosthetic fittings are possible for
the above-the-elbow amputee. The usual functional prosthesis is the arm and hook.
Prosthetic fitting is delayed for
to relieve chronic pain, improve joint motion, correct deformity and misalignment, and remove diseased cartilage.
goals of surgery are
contraction with permanent limitation of motion may occur
If the joint problem is not corrected,
remove inflamed tissue that is causing unacceptable pain or limiting ROM in RA
Synovectomy (removal of synovial membrane) is done to
the elbow, wrist, and fingers. Synovectomy in the knee is done less often because knee joint replacement is usually done.
Common sites for Synovectomy surgery include
removing a wedge or slice of bone to restore alignment (joint and vertebral) and to shift weight bearing, thus relieving pain
osteotomy involves
kyphotic deformity in patients with ankylosing spondylitis
-Halo vests and body jacket braces are worn until fusion occurs (3 to 4 months).
Cervical osteotomy may be used to correct a
some pain relief and improve motion in select patients with hip osteoarthritis (OA)
femoral osteotomy may provide
also provides pain relief in some patients with knee instability or OA
Tibial osteotomy
is the removal of debris, such as pieces of bone or cartilage (loose bodies) or osteophytes, from a joint using a fiberoptic arthroscope
-on the knee or shoulder
-compression dressing is applied after surgery. Weight bearing is permitted after knee arthroscopy.
-restricting activity for 24 to 48 hours
Debridement
is the reconstruction or replacement of a joint to relieve pain, improve or maintain ROM, and correct deformity
Arthroplasty
s most often done on patients with OA, RA, avascular necrosis, congenital deformities or dislocations, and other systemic problems.
Arthroplasty i
surgical reshaping of the bones of the joints, replacement of part of a joint (hemiarthroplasty), and total joint replacement.
Types of arthroplasty include
elbows, shoulders, fingers, wrists, ankles, and feet.
Arthroplasty is also available for
significant relief of pain and improved function for patients with joint deterioration from OA, RA, and other conditions.
-treat hip fractures
Total hip arthroplasty (THA), or a total hip replacement, provides
the ball-and-socket joint formed by the upper shaft of the femur and pelvis
THA, the prosthesis (implant) replaces
polymethyl methacrylate, which bonds to the bone.
Both the ball-and-socket components can be cemented in place with
longer stability by enabling ingrowth of new bone tissue into the porous surface coating of the prosthesis. Cementless devices are recommended for younger, more active patients and patients with good bone quality so that bone ingrowth into the components can be readily achieved.
may also be inserted without cement (cementless). Cementless THA may provide
It preserves and reshapes the femoral head (ball) rather than replacing it as in THA.
alternative to hip replacement is hip resurfacing arthroplasty.
Unrelieved pain and instability due to severe deterioration of the knee joint are the main reasons for
total knee arthroplasty (TKA), or a total knee replacement
, a knee immobilizer or posterior plastic shell to maintain extension may be used during ambulation and at rest for about 4 weeks
If the patient is unable to perform a straight-leg raise (TKA)
is used to restore function in the fingers of the patient with RA. Ulnar deviation often causes severe functional limitations of the hand.
A silicone rubber arthroplastic device
restore function related to grasp, pinch, stability, and strength rather than to correct cosmetic deformity.
goal of hand surgery is primarily to
, the patient is taught hand exercises, including flexion, extension, abduction, and adduction of the fingers.
Before surgery (hand surgery)
severe pain because of RA, OA, avascular necrosis, or trauma.
Shoulder replacements are done in patients with
may be done for pain and dysfunction caused by massive, irreparable, rotator cuff tears.
A specialized type of shoulder replacement, called a reverse total shoulder arthroplasty,
the elbow is usually done first because a severely painful elbow interferes with the shoulder rehabilitation program.
If joint replacement is needed for both elbow and shoulder,
indicated for RA, OA, trauma, and avascular necrosis.
Total ankle arthroplasty (TAA) is
several fixed-bearing devices and a mobile-bearing cementless prosthesis. This device more closely imitates natural ankle function. (Ankle fusion is often done over arthroplasty because the result is more durable)
Available devices Total ankle arthroplasty include
to change heel height. TAA achieves a more normal gait pattern.
-After surgery, the patient may not bear weight for 6 weeks.
fusion leaves the patient with a stiff foot and the inability
is the surgical fusion of a joint
-This procedure is done only if articular surfaces are too severely damaged or infected to allow joint replacement or if reconstructive surgery fails.
Arthrodesis
the articular hyaline cartilage and adding bone grafts across the joint surface.
fusion is usually done by removing (Arthrodesis)
wrist, ankle, cervical spine, lumbar spine, and metatarsophalangeal (MTP) joint of the great toe.
Common areas fused are
are gram-positive aerobic streptococci and staphylococci.
-Infection may lead to pain and loosening of the prosthesis, generally requiring further surgery
most common causative organisms (after joint surgery)
Give ordered anticoagulant medication, analgesia, and parenteral antibiotics. Pain management strategies may include epidural or intrathecal analgesia, femoral nerve block, patient-controlled IV analgesia, and oral opioids or NSAIDs
drug treatment joint surgery
day of surgery and the INR and prothrombin times are measured daily.
If the patient is taking warfarin, therapy starts on the
the morning after surgery
Therapy with LMWH (e.g., enoxaparin), apixaban, or rivaroxaban usually starts