Chapter 37 Management of Patients w/ Musculoskeletal Trauma

Question 1

Simple (Closed) Fracture

Answer 1

Damage to the surrounding tissues but, no skin breakage

Question 2

Open (Compound) Fracture

Answer 2

Broken bone penetrates through the skin

Question 3

Type I Compound/ Complex Fracture

Answer 3

Clean wound < 1 cm long w/ simple fracture pattern

Question 4

Type II Compound/ Complex Fracture

Answer 4

Larger wound w/ minimal soft tissue damage
- No flaps or avulsions

Question 5

Type III Compound/ Complex Fracture

Answer 5

MOST SEVERE!!!!

Highly contaminated & has extensive soft tissue damage
- Involves vascular injury or possibly traumatic amputation

Question 6

Compression Fracture

Answer 6

Occurs when the bone is pressed together (compressed) on itself

Question 7

Impacted Fracture

Answer 7

Fracture in which one bone fragment is pushed into another

Question 8

Oblique Fracture

Answer 8

Fracture at an angle to the bone

Question 9

Spiral Fracture

Answer 9

A fracture in which the bone has been twisted apart

Question 10

Stress Fracture

Answer 10

A small crack in the bone that often develops from chronic, excessive impact

Question 11

Intra-Articular Fracture

Answer 11

Fracture that extends into joint surface of a bone

Question 12

Fracture Causes

Answer 12

Caused by direct blows, crushing forces, sudden twisting
motions, and extreme muscle contractions

Question 13

Clinical Manifestations of Fractures

Answer 13

Acute pain

Loss of function

Deformity

Shortening

Crepitus

Localized edema and ecchymosis

Diagnosis by symptoms and radiography

Patient usually reports an injury to the area

Question 14

Emergency Management of Fractures

Answer 14

Immobilization via splinting or bandaging

Neurovascular assessment to determine adequacy of peripheral tissue perfusion and nerve function

Open fractures: cover with sterile dressing to prevent contamination of deep tissues

-No attempt to reduce fracture

-Splints applied for immobilization

In ED, remove clothing from uninjured side, then injured side; maybe cut away

-Move injured extremity as little as possible to prevent further damage

Question 15

Medical Management of Fractures

Answer 15

Fracture reduction: restoration of the fracture fragments to anatomic alignment and positioning

Closed: Uses manipulation and manual traction

-Traction may be used (skin or skeletal)

Open:Internal fixation devices hold bone fragment in position (metallic pins, wires, screws, plates)

Immobilization

-External (cast, splints) or internal fixation

Question 16

Closed Reduction

Answer 16

Brings the bone fragments into anatomic alignment via manipulation or manual traction

Extremity is held in the aligned position while, cast, splint, or other device is applied
- Immobilizing device maintains the reduction & stabilizes the extremity for bone healing

X-rays are obtained after reduction to verify that the bone fragments are properly aligned

Traction may be used

Question 17

Open Reduction

Answer 17

Bone fragments are anatomically aligned via surgical approach

Internal fixation devices may be used to hold the bone fragments in position until solid bone healing occurs
- Metallic Pins
- Wires
- Screws
- Plates
- Nails
- Rods

These devices may be used to attach to side of bone or inserted through bony fragments or directly into medullary cavity of the bone

Internal fixation devices ensure firm approximation & fixation of bony fragments

Question 18

Immobilization

Answer 18

After fracture has been reduced, the bone fragments must be immobilized & maintained in proper position & alignment until union occurs
- May be accomplished via external or internal fixation
- External fixation: bandages, casts, splints, continuous traction & external fixators

Question 19

Nursing Management of Fractures: Maintaining & Restoring Function

Answer 19

Reduction and immobilization

Elevating injured extremity and applying ice as
prescribed

Neurovascular assessment
- Notify provider IMMEDIATELY if signs of neurovascular compromise develop

Reassurance, position changes, and pain relief
strategies, including use of analgesics

Isometric and muscle setting exercises

Participation in ADLs

Gradual resumption of activities

Question 20

Nursing Management of Closed Fractures

Answer 20

Patient education:

-Reducing edema and pain

-Proper exercises and use assistive devices

-Home environment modification, if necessary

-Safety and self-care

-Medication information

-Monitoring for potential complications and need for follow up care and supervision

Question 21

Nursing Management of Open Fractures

Answer 21

Risk for osteomyelitis, tetanus, and gas gangrene

Objective is to prevent infection

Minimize edema

Frequent pain & neurovascular assessments

Maintain proper alignment

Monitor for complications

Question 22

Factors that Inhibit Fracture Healing

Answer 22

Age > 40 years

Avascular necrosis: No blood flow to bones-> bone tissue dies

Bone loss

Cigarette smoking

Comorbidities (e.g., diabetes,
rheumatoid arthritis)

Corticosteroids, NSAIDs

Extensive local trauma

Inadequate immobilization

Infection

Local malignancy

Malalignment of the fracture fragments

Space or tissue between bone fragments

Weight bearing prior to approval

Question 23

Avascular Necrosis

Answer 23

A disease caused by the temporary or permanent loss of blood supply to bones (bone lacking blood can collapse and die)

Question 24

Fat Embolism Syndrome (FES)

Answer 24

Classic Triad: hypoxemia, neurological compromise, petechial rash 2 days

Fat globules released into bloodstream, travel to lungs and brain, cause ischemia and inflammation

–Also be deposited on kidney and retina

Critical period: 24-72 hrs. after injury

Question 25

Disseminated intravascular coagulation (DIC)

Answer 25

Abnormal blood clotting in small vessels throughout the body that cuts off the supply of oxygen to distal tissues, resulting in damage to body organs

Question 26

Compartment Syndrome

Answer 26

Involves the compression of nerves and blood vessels due to swelling w/in the enclosed space created by the fascia that separates groups of muscles

Question 27

Compartment Syndrome Monitoring

Answer 27

Associated with a tight or rigid cast/splint that constricts a swollen limb Most serious complication of casting and splinting Pain is relentless and not controlled by common modalities Ischemia and potential irreversible damage to soft tissue can occur w/in a few hours if action is not taken Pulselessness, paresthesia, and complete paralysis are late stages

Question 28

Nursing Interventions for Compartment Syndrome

Answer 28

Loosen ace wraps, compression dressings, splints and uni- or bivalving casts Maintain limb alignment; emergency surgical fasciotomy may be necessary Frequent neurovascular checks; promptly report changes to provider Negative-pressure wound therapy Monitor output, maintain prescribed pressure, and occlusive dressing

Question 29

Acute Compartment Syndrome

Answer 29

Most serious complication of casting & splinting Occurs when increased pressure w/in confined space (cast, splint) compromises blood flow & tissue perfusion - Tight/ rigid cast that constricts a swollen limb is associated w/ this complication Ischemia & potentially irreversible soft tissue damage w/in space can occur w/in couple of hours if action is not taken

Question 30

Nursing Interventions for Acute Compartment Syndrome

Answer 30

If complication is due to a cast/splint being too tight, loosen or remove the splint; Univalve/ bivalve the cast to release constriction & allow for inspection of the skin - Cast saw is used (uses vibration to cut the cast) Extremity must be elevated no higher than heart level to maintain arterial perfusion If pressure & circulation are not relieved, an emergent surgical fasciotomy may be necessary Monitor & record frequent NV checks Report changes to provider

Question 31

Univalved Cast

Answer 31

Split cast on only 1 side

Question 32

Bivalved Cast

Answer 32

2 splits in the cast

Question 33

Delayed Union

Answer 33

Prolongation of expected healing time for a fracture

Question 34

Nonunion

Answer 34

Failure of the bone ends to grow together

Question 35

Complex Regional Pain Syndrome (CRPS)

Answer 35

Disorder of the SNS typically triggered by a surgery or trauma, resulting in pseudomotor and vasomotor changes and disproportionate pain beyond the region of the surgery or injury

Question 36

Heterotopic Ossification

Answer 36

Misplaced formation of bone

Question 37

Cast

Answer 37

Used to immobilize a reduced fracture, correct or prevent a deformity, apply uniform pressure to underlying soft tissue, or support and stabilize weakened joints Fit the shape of the injured limb correctly to provide the best support Permits mobilization of patient while restricting movement of affected body part

Question 38

Short Arm Cast

Answer 38

Extends from below the elbow into the palmar crease, secured around the base of the thumb

Question 39

Long Arm Cast

Answer 39

Extends from the axillary fold to the proximal palmar crease Elbow is usually immobilized at a right angle

Question 40

Short Leg Cast

Answer 40

Extends from below the knee to the base of the toes Foot is flexed at a right angle in a neutral position

Question 41

Long Leg Cast

Answer 41

Extends from the junction of the upper & middle 1/3 of the thigh to the base of the toes Knee may be slightly flexed

Question 42

Walking Boot/Cast

Answer 42

Protects & supports the foot, ankle, or lower leg by controlling the alignment & reducing movement Support the user's weight while walking

Question 43

Body Cast

Answer 43

Encircles the trunk

Question 44

Splint

Answer 44

Preferred method of fracture immobilization in the acute care setting and initial treatment of fractures Faster and easier to apply; easily removed, facilitating inspection of the injury site Often used for simple and stable fractures, sprains, tendon injuries, and other soft tissue injuries. Can be indicated to provide initial stability for fractures that are unstable while awaiting definitive care

Question 45

Nursing Management of Casts, Splints, or Braces

Answer 45

Before cast, splints, or braces are applied, nurse completes an assessment: - General health - Presenting s/s - Emotional status - Understanding need for the device - Condition of the body part to be immobilized Skin lacerations & abrasions secondary to trauma must be taken care of before device is applied - Thoroughly cleanse & treat the skin as prescribed NV checks every hour for 1st 24 hrs - Every 1-4 hrs after for signs of nv compromise Watch for 5 P's of NV Compromise!! NEVER IGNORE c/o pain!!! If pain is unrelieved by analgesics, report IMMEDIATELY to provider!!! - To avoid avascular necrosis, neuromuscular damage, or possible paralysis

Question 46

Brace

Answer 46

Custom-fitted, tend to be indicated for longer-term use than splints Adjusted for fit, positioning, and motion so that movement is enhanced, any deformities corrected, and discomfort minimized

Question 47

Nursing Assessments for Fractures

Answer 47

General Health Assessment  Signs and symptoms  Emotional status  Understand need for device  Condition of body part to be immobilized Educational Needs  Condition, purpose, and expectations of treatment regimen  Application of cast, splint, or brace Physical assessment  Skin assessment  Degree and location of swelling, bruising and skin abrasions  Neurovascular status  Main concern following application of immobilization device  Prevention of neurovascular dysfunction or compromise of the affect extremity  Performed every hour at least for first 24hrs, then every 1-4hrs thereafter

Question 48

Nursing Interventions for Fractures

Answer 48

Explain what to expect during cast removal Instruct patient to avoid rubbing and scratching the skin Patient education on resuming activities and how to control swelling Upper extremities:  Suggest devices designed to aid one-handed activities  Remove arm from sling and elevate frequently  Prevent complications with surveillance and proper care  Acute compartment syndrome or Volkmann ischemic contracture Lower extremities:  Cold therapy or ice packs as prescribed for 1-2 days  Elevate immobilized leg when seated  Toe and ankle exercise for isometric contraction of muscles beneath cast  In collaboration with PT, instruct patient how to transfer and ambulate safely with assistive devices (e.g., crutches, walker)

Question 49

Monitor for Pressure Ulcers

Answer 49

Patient reports very pain"hot spot" or tightness Drainage stain on cast/splint w/unpleasant odor Univalve, bivalve or window by provider to assess development

Question 50

Monitor for Disuse Syndrome

Answer 50

Deterioration of body systems resulting from prescribed or unavoidable MS inactivity Isometric exercises can prevent this; should be performed hourly while awake

Question 51

Traction

Answer 51

The application of pulling force to a part of the body

Question 52

Traction Indications & Purposes

Answer 52

Purposes:  Reduce muscle spasms  Reduce, align, and immobilize fractures  Reduce deformity  Increase space between opposing forces Used as a short-term intervention until other modalities are possible All traction needs to be applied in two directions. The lines of pull are “vectors of force.” The result of the pulling force is between the two lines of the vectors of force.

Question 53

Principles of Effective Traction

Answer 53

Must be continuous to be effective in reducing and immobilizing fractures Skeletal traction is NEVER interrupted Weights not removed unless intermittent traction is prescribed Must eliminate any factor that might reduce the effective pull or alter the resultant line of pull Patient must be in good body alignment in the center of the bed when applied Ropes must be unobstructed Weights must hang freely and not rest on the bed or floor Knots in the rope or the footplate must not touch the pulley or the foot of the bed

Question 54

Skin Traction

Answer 54

Pulling mechanisms are attached to skin with adhesive material or elastic bandage (Buck's extension traction)

Question 55

Skeletal Traction

Answer 55

The most effective means of traction, applying to a bone with wire pins or tongs

Question 56

Buck's Extension Traction

Answer 56

Skin traction to the lower leg Pull is exerted in one plane when partial or temporary immobilization is desired Used as a temporary measure to overcome muscle spasms & promote immobilization of hip fractures in adult patients waiting for more definitive treatment (surgery) Extremity is elevated & supported under patient's heel & knee while foam boot is placed under the leg (patient's heel is in heel of boot) - Weights should hang freely

Question 57

Nursing Intervention for Buck's Traction

Answer 57

Avoid wrinkling and slipping of the traction bandage Maintain countertraction and proper position Monitor for complications -Skin breakdown -Nerve damage -Circulatory impairment Circulatory assessment 15-30mins after traction is applied, then q1-2hrs

Question 58

Nursing Interventions for Traction: Monitor & Manage Possible Complications from Immobilization

Answer 58

Atelectasis & Pneumonia - Lung assessments every 4-8 hrs - Coughing & deep breathing exercises - Use of incentive spirometry Constipation & Anorexia - High fiber diet & fluids stimulate gastric motility - Minimize/avoid loss of appetite by including food preferences w/in the prescribed therapeutic diet - Stool softeners, laxatives, suppositories, or enemas may be needed if constipation develops Urinary Stasis & Infection - Monitor I/O, characteristics of urine, adequate hydration & void every 3-4 hrs - Notify provider s/s of infection Venous Thromboembolism (VTE) - Promote ankle exercises w/limits of traction therapy every 1-2 hrs when awake - Encourage fluid intake

Question 59

Nursing Interventions for Traction Complications: Skin Breakdown

Answer 59

During initial assessment, watch for sensitive fragile skin - Common in older adults Inspect the skin area in contact w/ tape, foam, or shearing forces at least every 8 hrs for signs of inflammation or irritation Remove foam boots to inspect the skin, ankle, & the Achilles tendon at least 2X a day - 2nd person is req to support the extremity during inspection & skin care Palpate the area of traction tapes daily to detect underlying tenderness Frequent repositioning to alleviate pressure & discomfort - Patient in supine position is at elevated risk for pressure injury Use an advanced static mattress or overlays to prevent development of pressure injury

Question 60

Nursing Interventions for Traction: Nerve Damage Complications

Answer 60

Skin traction can place pressure on peripheral nerves - Avoid pressure on peroneal nerve at the point where it passes around the neck of the fibula, below the knee where traction is applied Pressure at this point can cause foot drop Regularly question the patient about sensation & ask them to move their toes & feet IMMEDIATELY investigate c/o BURNING sensation under traction bandage or boots Weakness of dorsiflexion or foot movement or inversion of the foot -> pressure on the common peroneal nerve PROMPTLY REPORT altered sensation or impaired motor function

Question 61

Nursing Interventions for Skeletal Traction

Answer 61

Preventing skin breakdown Monitor neurovascular status Provide pin site care Promoting exercise

Question 62

The nurse NEVER removes the weights from skeletal traction UNLESS...

Answer 62

...a LIFE-THREATENING event occurs Removing the weights defeats their purpose & may result in patient injury

Question 63

Nursing Interventions for Both Types of Traction

Answer 63

Pain management Prevent pressure injuries Assess for anxiety Assist with self-care Monitor and manage potential complications associated w/immobility: -Atelectasis and Pneumonia -Constipation and Anorexia -Urinary stasis and infection -Venous Thromboembolism (VTE)

Question 64

Trapeze

Answer 64

Overhead assistive device to promote patient mobility in bed

Question 65

Amputation

Answer 65

May be congenital or traumatic or caused by conditions such as progressive peripheral vascular disease, infection, malignant tumor, trauma Performed to control pain or disease process, improve function, and improve quality of life Objective is to conserve as much limb length as needed to preserve function and possibly to achieve a good prosthetic fit Health care team needs to communicate a positive attitude to facilitate patient acceptance and participation in rehabilitation

Question 66

Nursing Care Before Amputation Surgery

Answer 66

Assess: - Function and condition of residual limb in traumatic amputations - Circulatory status and function on the unaffected limb - Signs and symptoms of an infection - Psychological status (distorted body image and low self-esteem) - Neurovascular and functional status of the limb Identify and Treat: - Any concurrent health problems - Medications that may influence management or delay wound healing Evaluate: - Nutritional status and develop post-op nutritional plan

Question 67

Nursing Implications for Patients w/ Amputations

Answer 67

Prevent further loss of circulation to extremity Promote comfort Promote optimal level of mobility Promote independent self-care Resolve grief & enhance body-image

Question 68

Post-Op Stump Wound Care

Answer 68

Measure limb every 8-12hrs Elevate limb for first 24hrs Prevent contracture of the joint above amputation Discuss phantom limb pain Relieve pain Promote and evaluate healing Inspect post-op dressing Discourage semi-fowler’s position in client with above the knee amputation to prevent contractures of the hip Monitor for bleeding Monitor for infection NV check every 8-12hrs

Question 69

Phantom Limb Pain

Answer 69

Pain perceived in an amputated section

Question 70

Stump Care after Wound has Healed

Answer 70

Assess for skin breakdown Wash, rinse & dry stump daily Do not apply anything to stump unless prescribed Alcohol-> Dries Lotion-> Skin too soft Encourage client to wear prosthesis when getting up and all day to prevent stump swelling

Question 71

Which action should the nurse take to evaluate the effectiveness of Buck's traction for a patient who has a fracture of the RT femur? A) Assess for hip pain B) Check for contractures C) Palpate peripheral pulse D) Monitor for hip dislocation

Answer 71

A) Assess for hip pain

Question 72

A pedestrian who was hit by a car is admitted to the ED w/ possible RT lower leg fractures. Which initial action should the nurse take? A) Elevate the RT leg B) Splint the lower leg C) Assess the pedal pulses D) Verify tetanus immunization

Answer 72

C) Assess the pedal pulses

Question 73

Which patient statement indicates understanding of the nurse's teaching about a new short-arm synthetic cast? A) "I can remove the cast in 4 weeks using industrial scissors" B) "I should avoid moving my fingers until the cast is removed" C) "I will apply an ice pack to the cast over the fracture site off and on for about 24 hrs" D) "I can use a cotton-tipped applicator to rub lotion on any dry areas under the cast"

Answer 73

C) "I will apply an ice pack to the cast over the fracture site off and on for about 24 hrs"