Chapte 54: Care of Patients with musculoskeletal Trauma

Question 1

Classification of Fractures

Answer 1

Complete-Incomplete
Open-compound Closed-simple
Open Grade 1 skin, 2 muscle, 3 also nerves and bv
Pathological-spontaneous is minimal trauma
Fatigue-stress from excess strain
Compression-load to the long axis of cancellous bone such as vertebrae

Question 2

Stages bone healing

Answer 2

1. 24 to 72 hrs a hematoma forms
2. 3 days to 2 weeks granulation tissue replaces hematoma, prompting formation of fibrocartilage
3. callus formation begins the nonbony union
4. Callas is resorbed and transformed into bone. 3wks to 6 months (osteoblastic)
5. Consolidation and remodeling of the bone from 4-6 wks up to year

Question 3

Complications of FXs

Answer 3

Acute compartment syndrome
Crush syndrome
Hypovolemic shock
Fat embolism syndrome
Venous thromboembolism
Infection
Chronic:  ischemic necrosis and delayed union

Question 4

Acute compartment syndrome

Answer 4

Increased pressure in 1 or more compartments reduces circulation to the area. Most common in lower leg and forearm. Ischemia-edema cycle. Sensory deficits usually appear first, tissue pales, pulses weaken, tense, pain with passive motion. If untreated progresses to cyanosis, tingling, numbness, paresis, and severe pain. Monitor the 6 Ps. After 4-6 hrs, the damage is irreversible.

Pressure can be from external or internal

Treatment: fasciotomy. Usually has open wound that heals with secondary closure in 4 to 5 days. Debridement and grafting may be necessary

Complications: infection, motor weakness, contracture, myoglobinuric renal failure. MRF is from muscle breakdown, myoglobin is released, it clogs the renal tubules. Potassium is also released from damaged muscle cells which cant be secreted because of kidney failure>hyperkalemia>cardiac dysrhythmias and cardiac arrest.

***Must recognize early. Begins 6-8 hrs after injury up to 2 days.

Question 5

6 Ps

Answer 5

Pain
Pressure
Paralysis
Paresthesia
Pallor
Pulseless

Question 6

Crush Syndrome

Answer 6

From and external crush injury that compresses one or more compartments. Can cause myoglobinuric renal failure

Causes: twisting type injuries, natural disasters, work related, overdose where limbs compressed with own body weight, fall and cant get up

Symptoms: acute compartment syndrome, hypovolemia form decreased circulating blood, hyperkalemia, rhabdomyolysis, acute tubular necrosis from hypovolemia and rhabdomyolysis, dark brown urine, weakness and pain

Treatment: IV fluids, diuretics, low dose dopamine to increase renal perfussion. Aim for urine output of 100-200 mL per hour. Kayexalate or dialysis if K is bad or kidney failure.

Question 7

Rhabdomyolysis

Answer 7

Myoglobulin release, from the break down of skeletal muscle, into the bloodstream

Question 8

Fat embolism Syndrome

Answer 8

Fat globules are released from yellow bone marrow into the bloodstream within 12 to 48 hours after an injury or illness. They clog small vessels (usually of the lungs) and impair organ perfussion.

Causes: long bone fx, fx repair, total joint, pancreatitis, ostomyelitis, blunt trauma, sickle cell anemia.

Risk higher in men 20-40, and old 70-80, fx hip and pelvis

Manifestations: altered mental status from low arterial O2 level, decreased LOC, drowsiness, sleepiness. Respirtory distress, tachycardia, tachypnea, fever, hemoptysis (bloody sputum). Petechiae is a late manifestation, chest pain, dyspnea, crackles

Labs: ^ESR, decreased serum calcium, decreased RBC and platelets, ^serum lipase level

Can cause respiratory failure or death from pulmonary edema, may be misdiagnosed as pulmonary embolism. Treatment is like that of an embolism

Decrease risk by early immobilization

Question 9

osteomyelitis

Answer 9

inflammation of bone tissue caused by pathogenic microorganisms, produces and increased vascularity and edema often involving the surrounding soft tissues.

Question 10

Ischemic necrosis

Answer 10

AKA avascular necrosis, osteonecrosis, aseptic necrosis.

blood supply to bone disrupted > death of bone tissue. Usually hip or displaces fx or surgical repair. Long term Corticosteroid therapy also increases risk

Question 11

Delayed union

Answer 11

Not healed within 6 months.

Muscle contractions may pull on the bone. ^risk if have osteoporosis, and some genetic factors

Question 12

Assessment for neurovascular status in pts with musculoskeletal injury

Answer 12

Skin color distal to injury > no change
Skin temp > warm
Movement or area or distal area > no discomfort
Area distal passive motion > no discomfort
Paresthesia
Palpate with paper clip (web of fingers and toes), compare to opposite side
Pulses distal
Capillary refill
Pain

Assess every hour for 1st 24 hours, the every 4. Elevate and apply ice for 24 to 48 hours.

Question 13

Fx Nursing Diagnoses

Answer 13

RF Peripheral Neurovascular Dysfunction
Acute pain
RF infection
Impaired Mobility
Imbalance Nutrition rt additional metabolic needs for healing

Additional:
activity intolerance, constipation from drugs and immobility, ineffective coping, compromised family coping, self care deficit, disturbed body image, sexual dysfunction, sleep deprivation, fear, impaired skin integrity,

Question 14

Cast syndrome

Answer 14

superior mesenteric artery syndrome

Most often in pts with hip spica or body cast. Partial or complete bowel obstruction: distention, epigastric pain, N&V after meals. Normal bowel sounds. From compression of the duodenum between the superior mesenteric artery and aorta. Remove portion of cast of bivalve it.

Question 15

Types of traction

Answer 15

Skin: velcro boot, belt, or halter and is used to decrease painful muscle spams. 5-10 lbs pulling

Skeletal Traction: pins, wires, tongs, screws are surgically placed, allowing longer traction and increased wt. 15-30lbs. Used for bone realignment. Pin care needed

Plaster: combines skeletal and plaster cast
Brace:device for correction of alignment deformities
Circumferential: a belt around the body such as pelvic traction for low back pain

Always recheck weights to make sure they match the order, watch for skin breakdown.

Question 16

Ilizarov external fixator

Answer 16

Promotes rotation, angulation, lengthening, or widening of the bone to correct bony defect and allows for healing of any soft tissue. If used for filling bone gaps, the nurse must teach the patient how to manually turn the 4-sides nuts. Pain control is a priority outcome

Question 17

Nonunion fx treatment

Answer 17

An electronic bone stimulation system uses magnetic coils on the skin or over the cast to deliver a pulsed magnetic field. There are no risks, but the patient with a pacemaker cannot use it on their arm. These can also be implanted directly to the fracture site. They would require six months of treatment.

Bonr grafting may be done using chips of bone from the iliac crest or other site or allograft from a cadaver. Bone banking is becoming common for people with total joint replacements that donate their bones.

Low intensity pulsed ultrasound: treatment for 20 minutes a day and has no adverse effects

Question 18

Crutches

Answer 18

2-3 finger widths between axilla and the top of the cruch. The elbow flexed no more than 30° when palm is on handle. Three-point gait allows little weight bearing on the effected leg.

Cane is placed on the UNaffected side and no more than 30 degrees in elbow

Question 19

Nutrition for fractures

Answer 19

High protein, high calorie diet. Supplements and vitamin B & C required. Increase calcium intake.

Question 20

Instructions after removal of cast

Answer 20

Remove scaly dead skin by soaking. Do not scrub.
Move extremity carefully. Expect pain, weakness, decreased range of motion. Support the extremity with pillows until strength and movement return. Exercise slowly or as physical therapist instructs. Where support stockings to decrease edema.

Question 21

Upper extremity fractures

Answer 21

Clavicle: usually from fall on outstretched hand, on the shoulder, direct blow. Most are self healing. May be immobilized. Rarely they may perform an ORIF

Scapular: Uncommon, by direct impact. Internal trauma such as pneumothorax, pulmonary contusion, fractured ribs accompanied these fractures. Mobilizer for 2 to 4 weeks.

humerus: proximal treated with sling or ORIF. shaft: closed reduction and hanging arm cast, possible rod or screws. Nonunion and radial nerve palsy complications. Bone grafting and prolonged splinting. Distal: fx of condyles injures the brachial or median nerve. ORIF

Colles is a wrist fx from falling on outstretched hand

Question 22

Fractures of the hip

Answer 22

Hip fracture is the most common injury and older adults. It has a high mortality rate as the result of multiple complications related to surgery and prolonged immobility. Osteoporosis is the biggest risk factor for hip fractures. The treatment of choice is surgical repair so the patient can be ambulatory. Bucks traction, bed rest, and pain management is used when patients are unable to have surgery.

Care of the ORIF. Ambulate the next day. Prevent abduction and rotation to avoid dislocation.

Balance is cognitive ability are the best predictors of a full recovery

Question 23

Lower extremity fractures

Answer 23

Fractures of the femur may take up to six months or longer to heal.

Patellar fractures are from direct impact and usually require close reduction or internal fixation and a knee immobilizer.

Tib-fib fracture takes 8 to 10 weeks to heal. Delayed union is not unusual.

Ankle:
Bimalleolar (potts)fx medial malleolus of tib and lateral mall of fib

Question 24

Pelvic fx

Answer 24

They are the second most common cause of death from trauma. Usually from a motor vehicle crash for fall from the building. Major concern is venous oozing or arterial bleeding. Lots of blood volume leads to hypovolemic shock. Assess for internal trauma by checking for blood in stool and urine and abdomen for rigidity.

non-weight bearing part of pelvis: bedrest and stool softenrs. 2 months to heal

weight bearing fx: fixation required, wt bearing activities depends on stability

Question 25

Kyphoplasty

Answer 25

For compression factors of the vertebrae. Inserts a small balloon into the fracture site in inflates it to contain the cemented and restore height to the vertebrae. Preoperative care includes platelet count, DC anticoagulant drugs, assessed neural status, pain level, ability to lie prone for 1 hours, IV and vitals

Post op care includes placing the patient in a flat supplying position for 1 to 2 hours, frequent vital signs and neurological assessments. Icepack to the puncture site. Control pain level. Monitor for bleeding, shortness of breath and assist with ambulation.

Discharge teaching includes avoiding driving while on meds, monitor puncture site for infection, keep dressing dry and remove next day, begin usual activities next day increasing in small amounts, do not soak in bath for 1 week.

Question 26

Levels of amputation

Answer 26

Loss of any or all of the small toes presents minor disability. One of the great toe is significant because it affects balance and gait. Midfoot amputations also called the Lisfranc and the Chopart are common for peripheral vascular disease. Syme is a little further up the foot, but leaves the ankle.
BKA
AKA:hip disarticulation is removal of hip
hemipelvectomy removal of leg and half the pelvis.

Blacks and hispanics at greater risk for amputation because of diabetes and arteriosclerosis, and access to health care

Question 27

Complications of amputation

Answer 27

Hemorrhage, infection, phantom limb pain, neuroma, and flexion contractures. Phantom limb pain is more common in patients who had chronic pain before surgery and rare in those who have a traumatic amputation. Neuroma is a sensitive tumor consisting of damaged nerve cells. It’s diagnosed by sonography and can be treated surgically or not surgically. Nonsurgical includes nerve blocks, steroid injections, and hypnosis.

Question 28

Emergency care of traumatic amputation

Answer 28

Call 911. Assess ABC. Direct pressure with layers of gauze or cloth. Elevate extremity above heart. If finger is severed, put it in a water tight bag and then put it in a bag in icewater one part ice to three-part water. Never directly on ice or in contact with water.

Question 29

Pain management of amputation.

Answer 29

Phantom limb pain must be distinguished from residual limb pain. Opioids are not as effective for phantom limb pain. IV infusions of calcitonin during the week after amputation can reduce phantom limb pain. Beta blocking agents such as propranolol are used for constant, dull, burning pain. Anti-epileptics such as tegretol and neurotin may be used for sharp burning pains. antispasmodics such as baclofen is for cramps or spasms.

Question 30

Mobility after amputation

Answer 30

Teach exercises prior to amputation if possible. Range of motion exercises help prevent flexion contractures. A firm mattress is essential for leg amputation. Position the patient into a prone position every 3 to 4 hours for 20 or 30 minutes if tolerated. It helps prevent hip flexion contractures. Also teach how to push the residual limb down with this pillow. After sutures are removed, resistance exercises may begin. Elevations may be contraindicated because it may lead to a contracture.

Question 31

Preparation for prostheses

Answer 31

Several devices help shape and shrink the residual limb in preparation. A rigid removable dressing is preferred to decrease edema, protect the shape of the land, and allow easy access. That Jobst air splint is used and is inflated to 20 mm for 22 out of 24 hours. Wrapping with elastic bandages can also help. Bandages need rewrapped every 4 to 6 hours. Figure 8 wrapping prevents restriction of blood flow.

Question 32

Complex regional pain syndrome (CRPS)

AKA reflex sympathetic dystrophy (RSD)

Answer 32

Disorder that includes debilitating pain, atrophy, autonomic dysfunction(excessive sweating, vascular changes), and motor impairment(most notably muscle paresis), probably caused by an abnormally hyperactive sympathetic nervous system. This syndrome most often results from traumatic injury and commonly occurs in the feet and hands

Most common symptom includes continues pain that gets worse and doesn’t match up to the injury.
Stage 1: about 1-3 months, local, severe, burning pain, edema and spasm
Stage 2: over next 3 months. Gets worse with muscle atrophy, decreased hair growth, and spotty osteoporosis.
Stage 3: marked atrophy, severe pain, limited mobility, contractures, diffuse osteoporosis.

Priority is pain relief. Possible sympathetic nerve block. Physical therapy,

Question 33

Carpal tunnel syndrome

Answer 33

Compression of the median nerve in the wrist. Usually affects the sensory function of the first three fingers of the hand. It is a complication of metabolic and connective tissue disease such as rheumatoid arthritis, diabetes mellitus. the most common repetitive stress injury. Women are more likely than men to get it.

Phalens maneuver Requires you to place the wrist in flexion and within 60 seconds it produces the numbness and tingling. Tinel’s sign can produce the numbness and tingling by tapping on the nerve.

Nonsurgical: immobilization, antiinflamatories, steroid injection

Surgical: open or endoscopic release, synovectomy if RA,

Take it easy for 4-6 wks after surgery

Question 34

Strain

Answer 34

Excessive stretching of a muscle or tendon.
1st degree-mild: causes inflamation but little bleeding. Swelling, ecchymosis, and tenderness.
Second-degree/moderate: tearing of the muscle or tendon fibers without complete disruption.
Third-degree/severe: ruptured muscle or tendon with separation. Severe pain and disability

Question 35

Sprain

Answer 35

Stretching of a ligament. From twisting motions.
First-degree/mild: tearing of a few fibers. Function not impaired. Treatment includes rest, ice, compression, elevation.
Second-degree/moderate: more fibers are born but the joint is stable. Immobilization, brace or wrap, partial weight bearing.
Third-degree/severe: causes marked instability of the joint. Immobilization for 4 to 6 weeks or surgery

Question 36

Pulmonary embolism

Answer 36

Solid liquid or air that enters venous circulation and lodges in the pulmonary vessels. It obstructs the pulmonary bloodflow leading to reduced oxygenation of the whole body, pulmonary hypoxia, and death. Symptoms include dyspnea with a sudden onset, chest pain, apprehension and restlessness, feeling of impending doom, cough, hemoptysis, tachypnea, crackles, pleural friction rub, tachycardia, S3 or S4 heart sound, diaphoresis, low-grade fever, Petechiae over chest, decreased O2 sats.

Treatment involves increasing gas exchange, improving lung perfusion, reducing further clot risk, and preventing complications. Priority is implementing oxygen therapy, administering anticoagulants and fibrinolytics, and monitor the response.