Chapter 37 Management of Patients w/ Musculoskeletal Trauma Flashcards
Simple (Closed) Fracture
Damage to the surrounding tissues but, no skin breakage
Open (Compound) Fracture
Broken bone penetrates through the skin
Type I Compound/ Complex Fracture
Clean wound < 1 cm long w/ simple fracture pattern
Type II Compound/ Complex Fracture
Larger wound w/ minimal soft tissue damage
- No flaps or avulsions
Type III Compound/ Complex Fracture
MOST SEVERE!!!!
Highly contaminated & has extensive soft tissue damage
- Involves vascular injury or possibly traumatic amputation
Compression Fracture
Occurs when the bone is pressed together (compressed) on itself
Impacted Fracture
Fracture in which one bone fragment is pushed into another
Oblique Fracture
Fracture at an angle to the bone
Spiral Fracture
A fracture in which the bone has been twisted apart
Stress Fracture
A small crack in the bone that often develops from chronic, excessive impact
Intra-Articular Fracture
Fracture that extends into joint surface of a bone
Fracture Causes
Caused by direct blows, crushing forces, sudden twisting
motions, and extreme muscle contractions
Clinical Manifestations of Fractures
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
Emergency Management of Fractures
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
Medical Management of Fractures
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
Closed Reduction
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
Open Reduction
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
Immobilization
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
Nursing Management of Fractures: Maintaining & Restoring Function
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
Nursing Management of Closed Fractures
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
Nursing Management of Open Fractures
Risk for osteomyelitis, tetanus, and gas gangrene
Objective is to prevent infection
Minimize edema
Frequent pain & neurovascular assessments
Maintain proper alignment
Monitor for complications
Factors that Inhibit Fracture Healing
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
Avascular Necrosis
A disease caused by the temporary or permanent loss of blood supply to bones (bone lacking blood can collapse and die)
Fat Embolism Syndrome (FES)
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
Disseminated intravascular coagulation (DIC)
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
Compartment Syndrome
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
Compartment Syndrome Monitoring
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
Nursing Interventions for Compartment Syndrome
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
Acute Compartment Syndrome
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
Nursing Interventions for Acute Compartment Syndrome
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
Univalved Cast
Split cast on only 1 side
Bivalved Cast
2 splits in the cast
Delayed Union
Prolongation of expected healing time for a fracture
Nonunion
Failure of the bone ends to grow together
Complex Regional Pain Syndrome (CRPS)
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
Heterotopic Ossification
Misplaced formation of bone
Cast
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
Short Arm Cast
Extends from below the elbow into the palmar crease, secured around the base of the thumb
Long Arm Cast
Extends from the axillary fold to the proximal palmar crease
Elbow is usually immobilized at a right angle
Short Leg Cast
Extends from below the knee to the base of the toes
Foot is flexed at a right angle in a neutral position
Long Leg Cast
Extends from the junction of the upper & middle 1/3 of the thigh to the base of the toes
Knee may be slightly flexed
Walking Boot/Cast
Protects & supports the foot, ankle, or lower leg by controlling the alignment & reducing movement
Support the user’s weight while walking
Body Cast
Encircles the trunk
Splint
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
Nursing Management of Casts, Splints, or Braces
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
Brace
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
Nursing Assessments for Fractures
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
Nursing Interventions for Fractures
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)
Monitor for Pressure Ulcers
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
Monitor for Disuse Syndrome
Deterioration of body systems resulting from prescribed or unavoidable MS inactivity
Isometric exercises can prevent this; should be performed hourly while awake
Traction
The application of pulling force to a part of the body
Traction Indications & Purposes
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.
Principles of Effective Traction
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
Skin Traction
Pulling mechanisms are attached to skin with adhesive material or elastic bandage (Buck’s extension traction)
Skeletal Traction
The most effective means of traction, applying to a bone with wire pins or tongs
Buck’s Extension Traction
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
Nursing Intervention for Buck’s Traction
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
Nursing Interventions for Traction: Monitor & Manage Possible Complications from Immobilization
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
Nursing Interventions for Traction Complications: Skin Breakdown
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
Nursing Interventions for Traction: Nerve Damage Complications
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
Nursing Interventions for Skeletal Traction
Preventing skin breakdown
Monitor neurovascular status
Provide pin site care
Promoting exercise
The nurse NEVER removes the weights from skeletal traction UNLESS…
…a LIFE-THREATENING event occurs
Removing the weights defeats their purpose & may result in patient injury
Nursing Interventions for Both Types of Traction
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)
Trapeze
Overhead assistive device to promote patient mobility in bed
Amputation
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
Nursing Care Before Amputation Surgery
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
Nursing Implications for Patients w/ Amputations
Prevent further loss of circulation to extremity
Promote comfort
Promote optimal level of mobility
Promote independent self-care
Resolve grief & enhance body-image
Post-Op Stump Wound Care
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
Phantom Limb Pain
Pain perceived in an amputated section
Stump Care after Wound has Healed
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
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
A) Assess for hip pain
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
C) Assess the pedal pulses
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”
C) “I will apply an ice pack to the cast over the fracture site off and on for about 24 hrs”
