Exam 4: Chapter 42: Management of Patients with Musculoskeletal Trauma Flashcards
What is a contusion?
A soft tissue injury produced by blunt force, such as a blow, kick, or fall, causing small blood vessels to rupture and bleed into soft tissues
What develops at the site where a contusion occured?
A hematoma, leaving a characteristic “Black and Blue” appearance
Local symptoms of Contusion include
Pain, Swelling, and Discoloration; Ecchymosis
Contusions are managed with what acronym?
PRICE
Protection, Rest, Ice, Compression, and Elevation
Most contusions resolve in
1-2 weeks
What is a strain?
Injury to a muscle or tendon from overuse, overstretching, or excessive stress
Strains can be categorized as
acute or chronic
What is a first-degree stain?
Mild stretching of a muscle or tendon with no loss of range of motion
Signs of symptoms of first-degree strain?
GRadual onset of palpation-induced tenderness and mild muscle spasm
What is a second-degree strain?
Involves moderate stretching and/or partial tearing of the muscle or tendom
signs and symptoms of second-degree strain?
Acute pain during the precipitating event, followed by tenderness at the site with increased pain with ROM, edema, significant muscle spasm, and ecchymosis
What is a third-degree strain?
Severe muscle or tendon stretching with rupturing and tearing of the involved tissue
Signs and symptoms of third-degree strain?
Immediate pain described as tearing, snapping, or burning, muscle spasm, ecchymosis, edema, and loss of function
What test should be performed to test for third-degree strain?
X rays to rule out bone injury.
MRI and Ultrasound can identify tendon injury
What is a sprain?
An injury to the ligaments and tendons that surround a joint. Caused by a twisting motion or hypererxtension of a joint
Disability and Pain increase during first 2-3 hours
Ligaments connect
bone to bone
Tendons connect
muscle to bone
Function of a ligfament is to
stabilize a joint while permititng mobility
First-Degree/Mild Grade Sprain results from
tears in some fibers of the ligament and mild, localized hematoma formation
First-Degree/Mild Grade Sprain Manifestations include
Mild pain, edema, and local tenderness
Second-Degree/Moderate Grade Sprain involves
partial tearing of the ligament
Second-Degree/Moderate Grade Sprain manifestations include
increased edema, tenderness pain with motion, joint instability, and partial loss of normal joint function
Third-Degree/Severe Grade Sprain occurs when
a ligament is completely torn or ruptured. May also cause avulsion of the bone
Third-Degree/Severe Grade Sprain symptoms
severe pain, increased edema, and abnormal joint motion
How is (P)RICE accomplished?
Through support of the affected area and/or splinting
How is P(R)ICE accomplished?
Rest prevents additional injury and promotes healing
How is PR(I)CE accomplished?
Intermittent application of cold packcs during the first 24-72 hours after injury produces vasoconstriction, which decreases discomfort
Ice packs should not be placed for longer than 20 minutes
How is PRI(C)E accomplished?
Elastic compression bandage controls bleeding, reduces edema, and provides support for ithe injured tissues
How is PRIC(E) accomplished?
Elevation at or just above the level of the heart controls teh swelling
What is a dislocation?
Dislocation of a joint is a condition in which the articular surfaces of the distal and proximal bones that form the joint are no longer in anatomic alignment
What is a subluxation?
A partial dislocation that does not cause as much deformity as a complete dislocation
A sprian is what type of injury?
Tissue injury. You get swelling and you get bleeding into the tissue. That is where the bruising comes from
What is a traumatic dislocation?
An emergency with pain change in contour, axis, and length of the limb and loss of mobility
If a dislocation or subluxation is not reduced immediately, what may develop?
Avascular Necrosis (AVN).
AVN of bone is caused by ischemia, which leads to necrosis or death of the boen cells
Signs and Symptoms of a traumatic dislocation include
acute pain, change in or awkward positioning of the joint, and decreased ROM.
XRays conform the diagnosis and reveal any associated fracture
Dislocation: What is used to facilitate closed reduction?
Analgesia, muscle relaxants, and possibly anesthesia
Dislocation: The joint is immobilized by
splints , casts, or traction and is maintained in a stbale position
Dislocation: Neurovaascular status is assessed at a minimum of
every 15 minutes until stable
Dislocation: Danger Signs and Symptoms to look out for include
increasing pain, numbness or tingling, and increased edema in the extremity.
Where does a DVT occur?
In the actual vessel itself. DVT will be on bed rest for a day ro two and will be given a anticoagulant in order to break it down
For All Knee Ligaments, TEndons, and Menisci, what should you do?
PRICE.
What should you do when you sprain a knee?
Place it in a brace. No matter what is injured, you want to place it in a brace
What can you teach a patient to assess for neurovascular wise?
Wiggle fingers, Feel numbness? Warm? Feel Pain? Check for Pulse. Assess Capillary Refillq
Every joint has
tendons
What is a fracture?
A complete or incomplete disruption in the continuity of boen structure and is defined according to its type and extent
Fractures occur when
the bone is subjected to sress greater than it can absorb
Fractures may be caused by
direct blows, crushing forces, sudden twisting motions, and extreme muscle contractions
When the bone is broken, adjacent structres are also affected which may result in
soft tissue edema, hemorrhage into the muscles and joints, joint dislocations, reuptured tendons, severed nerves, adn damaged blood vessels
What is a closed (simple) fracture?
It is one that does not cause a brek in the skin
What is an open fracture (compound, or complex)
One in whicht he skin or mucous membrane would extends to the fractured bone
What is a Type I open wound?
Clean wound less than 1 cm long
What is a Type II open wound?
Larger wound without extensive soft tissue damage or avulsions
What is a Type III open wound?
Highly contaminated and has extensive soft tissue damage. May be accompanied by traumatic amputation and is the most severe
What is a intra-articular fracture?
Extends into the joint surface of a bone.
CLinical signs and symptoms of a fracture include
acute pin, loss of function, deformity, shortening of the extemity, crepitus, and localized edema and ecchymosis
Fractures: PAin is continuous and icnreases in severity until the boen fragments are
immobilized
Fractures: Immediately after a fracture, injured area becomes
numb and the surrounding muscles flaccid
Fractures: Muscle spasms that accompany a fracture begin
shortly thereafter, whthin a few to 30 minutes and result in more intesne pain
Fractures: sometimes muscle spasms can cause the distal and proximal site of the fracture to
overlap , causing the extremity to shorten
What is crepitus?
A crumbling sensation that can be felt or may be heart. It is caused by the rubbing of bone fragments against each other
Fractures: Localized edema and ecchymosis occur after a fracture as a result of
trauma and bleeding into the itissues. The signs may not develop for several hours
What is a Avulsion Fractures:
A fracture in which a fragment of bone has been pulled away by a tendon and its attaachment
What is a Comminuted Fractures:
A fracture in which bone has splintered into several fragments
What is a COmpression Fractures:
A fracture in which bone has been compressed (seen in vertebral fractures)
What is a Depressed Fractures:
A fracture in which fragments are drive inward (seen frequently in fractures of skull and facial bones)
What is Epiphyseal Fractures:
A fractures through the epiphysis
What is a Greenstick Fractures:
A fracture in which one side of a boen is broken and the other side is bent
What is a Impacted Fractures:
A fracture in which a bone fragment is driven into another bone fragment
What is a Oblique Fractures:
A fracture occuring at an angle across the bone (lesss stabele than a transverse fracture
What is a Open Fractures:
A fracture in which damage also involves the skin or mucous membranes, also called a compound fracture
What is a Pathologic Fractures: q
A fracture that occurs through an area of diseased bone ; can occur without trauma or fall
What is a Simple Fractures:
A fracture that remains ontained with no didsruption of the skin integrity
What is a Spiral Fractures:
A fracture that twists around the shaft of the bone
What is a Stress Fractures:
A fracture that results from repeated laoding of bone and muscle
What is a Transverse Fractures:
A fracture that is straight across the bone shaft
Immediately after a fracture, the body part must be
immobilized
Joints proximal and distal to the fracture also must be
immobilized to prevent movement of fracture fragments
With an open fracture the wound is covered with
a sterile dressing to prevent contamination of deeper tissues
What is a Fracture Reduction?
Restoration of the fracture fragemnts to anatomic alignment and positioning. Closed Reduction or Open Reduction may be used to reduce fracture
Closed Reduction is accomplished by
bringing the bone fragments into anatomic alignment through manipulation and manual traction
Closed Reduction: Extremity is held in the aligned position while
a cast, splint, or other device is applied
Closed Reduction: What is used after to verify that the bone fragments are correctly aligned?
X-Rays
Closed Reduction: What may be used until patient is physiologically stable to undergo surgical fixation?
Traction (Skin or Skeletal)
What is a Open Reduction?
Through a surgical approach, the fracture fragments are anatomically aligned. Internal fixation devices may be used to hold the bone fragments in position.
When does Immobilization occur?
After the fracture has been reduced and maintained in proper position and alignment
Immobilization may be accomplished by
external or internal fixation.
Methods of external fixation include
bandages, casts, splints, continuous traction, and external fixators
Fracture: Edema is controlled by
elevating the injured extremity and applying ice as prescribed
Fracture: What Neurovascular status do we keep an eye on?
Circulation, motion, and sensation
Fracture: How can you test to see if you have an infection?
You can perform a WBC count, SED Rate, and Temperature
Closed Fracture: Healing and Restoration of strength and mobility may take
an average of 6-8 weeks
In an open fracture, there is a risk for
osteomyelitis, tetanus, and gas gangrene
Open Fracture: What is given upon patients arrival?
Intravenous ANtibiotics along with Intramuscular Tetanus Toxoid is needed
Open Fracture: What is initiated in the operating room as soon as possible?
Wound irrigation and debridement
Open Fracture: Heavily contaminated wounds are left
unsultured and treated with vacuum-assited closures (VAC) to facilitate wound drainage
Open Fracture: Extremity is elevated to eliminate
edema
Factors that impair fracture healing include
Inadequate fracture immobilization
Inadequate Blood Supply To the Fracture Site
Multiple Trauma
Extensive Bone Loss
Infection
Corticosteroiods
Older Age
Fracture: Hypovolemic shock resulting from hemorrhage is more frequently noted in
trauma patients with pelvic fractures and in patients with a displaced or open femoral fracture in which the femoral artery is torn by bone fragemnts
Fracture: Treatment for shock consists of stablizing
the fracture to prevent further hemorrhage, restoring blood volume and circulation, relieving the patients pain, providing proper immobilization, and protecting the patient from further injury
What is Fat Embolism Syndrome? (FES)
This describes the clinical manifestations that occur when fat emboli enter circulation following orthopedic trauma, especially long bone fractures
How does Fat Embolism Syndrome occur?
Fat globules may diffuse from the marrow into the vascular compartment. They may occlude the small blood vessels that supply the lungs, brian, kidneys, and other organs
Fat Embolism Syndrome onset of symptoms?
Rapid, within 12-72 hours.
Clinical Manifestations of Fat Embolism Syndrome?
Hypoxemia
Neurologic Compromise
Petechial Rash
Typical first manifestations of FES are
Pulmonary and includ ehypoxia, tachypnea, and dyspnea acompained by tachycarida, chest pain, fever, crackles.
FES: Petechial Rash may develop
2-3 days after the onset of symptoms
FES: Petechial Rash is secondary to
dysfunction in the microcirculation and/or thrombocytopenia and is typically located in nondependent regions
FES: Neurologic Deficits can include
Restlessness, agitation, seizures, focal deficits, and encephalopathy
What may reduce the incidence of fat emboli?
Immediate Immobilization
Minical Fracture Manipulation
Adequate support for fractured bones
FES: What can be used as supportive therapy?
Vasopressors, Mechanical Ventilation, and Sometimes Corticosteroids
What is Compartment Syndrome characterized by?
Elevation of pressure within an anatomic compartment that is above normal perfussion pressure
COmpartment Syndrome arises from an increase in
compartment volume, (from edema or bleeding), a decrease in compartment size, or aspects of both
Compartment Syndrome: WHen the pressure within an affected compartment rises above normal,
perfusion to the tisseus in impaired, causing cell death, which may lead to tissue necrosis and permanent dysfunction
The patient with acute Compartment Syndrome reports
deep, throbbing, unrelenting pain, which is unrelieved by medications, and intesifies with passive ROM
What are the five P’s
Pain Pallo Pulselessness Paresthesias (Burning or Tingling Sensation) Paralysis
Compartment Syndrome: Peripheral Circulation is elevated by assessing
color, temperature, capillary refill time, edema, and pulses
Compartment Syndrome: Cyanotic nail beds suggest
venous congestion
Compartment Syndrome: Pallor or dusky and cold digits, prolonged capillary refill time, and dimished pulses suggest
impaired arterial perfusion.
Compartment Syndrome: Palpation of the muscle reveals it to be
swollen and hard, with the skin taut and shiny
Compartment Syndrome: Normal pressure in muscle?
8 mmHg or less. Prolonged pressure of mor than 30 mmHg can result in permanent dysfunction
Compartment Syndrome: Delaying treatment may result in
permanent nerve and muscle damage
Necrosis
infection
Rhabdomolysis with acute kidney injury and amputation
Compartment Syndrome: If conservative measures do not restore tissue perfusion and relieve pain, what is done?
Fasciotomy (Surgical Decompression with excision of the fascia) is indicated to relieve the constrictive muscle fascia
Compartment Syndrome: After fasctiotomy, wound is left
not sutured but is left open to llow the muscle tissues time to expand
Compartment Syndrome: Wound covered with
moist, sterile salien dressings or with artifical skin
Compartment Syndrome: Affected arm or leg is splinted ina functional position and at a
elevated heart level
Compartment Syndrome: After 2-3 days when swelling has resolved
wound is debrided and closed (possibly with skin grafts0
Compartment Syndrome: Pain management accomplished with
opioid analgesia
What is Disseminated Intracascular Coagulation (DIC)?
A systemic disorder that results in widespread hemorrhage and microthrombosis with ischemia
Early manifestations of DIC include
unexpected bleeding afer surgery and bleeding from the mucous membranes, venipuncture sites, and GI and urinary tracts
Delayed union occurs when
healing does not occur within the expected time frame for hte location and type of fracture
Nonunion results from
failure of the ends of the fractured bones to unite
What is Malunion?
Healing of fractured bones in a malaligned positioned
Fractures: Nonsurgical Treatment Modalities include
Ultrasound Stimulation
Electrical Bone Stimulation and shold be used everyday to be most effective
Fractures: Surgical Interventions include
Bone Frafts
Internal and External Fixation
Fractures: Cortical Bone is used for
Structual Strength
Fractures: Cancellous Bone used for
Osteogenesis
Fractures: Corticocancellous bone used for
strength and rapid incorporation
Fractures: Bivalving Cast: May need to
open up the cast in order to relieve some of the pressure. When in the cast, you would assess the Five P’s
Amputation: IF the health care team communicates a positive atittude, the patient
adjusts to the amputation more readily and actively particpates in the rehabilitative plan, learning how to modify activites
Amputation: May be
congenital or traumatic or caused by conditions such as progressive peripheral vascular disease, infection, or malignant tumor
Amputation: Is used to relieve
symptoms, improve function, and improve quality of life
Amputation: The parts most likely to be amputated are
legs, and the leading cause is because of diabetes. Its because of neuropathy and CVD
What is a syme Amputation?
Performed most frequently for extensive foot trauma. Saves the heel in order for them to have balance
Amputation: Complications?
Hemorrhage Infection Skin Breakdown Phantom Limb Pain Joint Contracture
Phantom limb pain is caused by severing of
peripheral nerves
Amputation: Joint contracture caused by
positioning and a protctive flexion withdrawal pattern associated with pain and muscle imbalance
Amputation: Rigid dressing removed several days after surgery for
wound inspecion, and is then replaced to control edema
Amputation: Edema is better controlled with
semi-rigid dressings for certain types of amputations
Amputation: If infection or gangrene develops, the patient may have associated
enlarged lymph nodes
FEver
Purulent Drainage
Amputation: Diet with what is essential to promote wound healing?
Adequate Protein and Vitamins
Amputation: Some Nursing Diagnosis?
Acute Pain RT Amputation
Impaired Skin Integrity RT Surgical Amputation
Distrubted Body Image RT Amputation
Impaired Physical Mobility RT Amputation
Amputation: Potential COmplications include?
Hemorrhage
Infection
Skin Breakdown
Amputation: Major goals of the patient may include
Relief of Pain
Wound Healing
Acceptance of Altered Body Image
Resolution of the Grieving Process
Amputation: What can be done to improve paitents level of comfort?
Changing the patietns position or placing a light sandbag on the residual limb to counteract the muscle spasm
Amputation: Surigcal pain can be effectively controlled with
opioid analgesics
Amputation: Phantom Pain feels like
the limb is being crushed, cramped, or twisted in an abnormal position
Sometimes accompanied by numbness, tingling, or burning sensations
Amputation: Perioperatively, patient may be managed with
Acetaminophen
NSAIDS
GABAPENTINOIDS
Opioids
Ketamine
Amputation: What may be used during and immediately after the operative?
Epidural and Perineural Catheter Analgesia
Amputation: What may be effective in relieving postoperative pain?
Opoid Analgesics
Amputation: What may releive dull, burning discomfort?
Beta-Blockers
Amputation: What controls stabbing and cramping pain?
Anticonsulsants
Amputation: What may be prescribed to alleviate phantom limb pain and to improve mood and coping ability?
Tricyclic Antidepressants
Amputation: What should be done every 8-12 hours postoperatively?
Measure the limb to assess for edema formation
Amputation: Why should the residual limb not be placed on a pillow?
Flexion contracture of the hip may result
Patient with AKA may need to lie
prone 20-30 minutes 3x per day to avoid contractures
Amputation: ROM excercies include
hip and knee exercises for patients with BKAs and hip exercises for patietns with AKAs
Amputation: Resolving Grief and Enhancing Body Image
Encourage Communication
Create Accepting Atmosphere
Provide Support
Help Pt Set Goals
Help Pt Resume Self-Care
Amputation: Avoid what type of movements?
Avoid abduction, external rotation, and flexion
Amputation: You shoudl turn
frequently , prone positioning if possible
Amputation: “Preprosthetic CarE”
Proper bandaging, massage, and toughening of the residual limb
Amputation: With the Upper Limb Amputation, exercises should be focused on
shoulders.
Amputation: Bandaging supports the soft tissue and minimizes the formation of
edema while the residual limb is in the dependent position
Amputation: Educating About Self-Care
Encourage active participation in care
Continue support in rehabilitation facilitiy or at home
Focus on safety and mobility
Potential Complications of Fractures?
Hemorrhage Peripheral Neurovascular Dysfunction DVT Pulmonary Emboli/Pneumonia Pressure Ulcers
