Exam 4: Musculoskeletal (Fractures/Casts/Amputations/Osteomyelitis) Flashcards
Fracture
A disruption or break in the continuity of the structure of bone.
Major cause of fractures include
Traumatic (most common) Pathological Fracture (d/t disease process)
Classification of Fracture according to type:
- Avulsion
- Comminuted
- Displaced
- Greenstick
- Impacted
- Interarticular
- Longitudinal
- Oblique
- Pathologic
- Spiral
- Stress
- Transverse
Avulsion Fracture
Due to pulling effect of tendon or ligament
Comminuted Fracture
More than one fragments
Displaced fracture
Overriding the other bone fragment, shortening the length of the bone.
Greenstick Fracture
Incomplete with one side splintered and the other bent
Impacted Fracture
More than one bone is driven into each other.
Interarticular Fracture
Extending into the articulate surface of the bone.
Longitudinal Fracture
Incomplete with fracture running in a longitudinal axis.
Oblique Fracture
Fracture line extended in an oblique direction.
Pathologic Fracture
Spontaneous at the site of bone disease
Spiral Fracture
Spiral direction along the shaft (twisted)
Stress Fracture
Area of repeated stress
Transverse Fracture
Line of fracture extends across the bone at a right angle.
Classification of Fracture According to: Communication or non-communication to the external environment
- Open fracture
2. Closed frature
Classification of Fracture According to: Anatomic Position or The Involved Bone
- Proximal
- Medial
- Distal
Classification of Fractures According to Stability
- Stable
2. Unstable
Stable Fracture
Intact periosteum
Fragments are stationary
Unstable Fracture
Grossly displaced site of poor fixation
Clinical Manifestations of Fractures
- Localized pain
- Decrease in function of affected limb
- Inability to bear weight or use of the affected part
- Guarding against movement
- May or may not have deformity or shortening of a limb
- Crepitation
- Muscle Spasm
Collaborative Care Goals for Fractures
- anatomic realignment of bone fragments
- immobilization to maintain realignment
- restoration of function
Types of Fracture Reductions
- Close Reduction
- Open Reduction
Close Reduction
- Non surgical manual realignment
- Traction and counter traction is applied.
Open Reduction
- Use of surgical incision.
- Use of internal fixation such as wire plates, screw, pin rods and nails.
Traction
Devices that apply pulling forces on the fractured extremities while counter traction pulls in the opposite direction.
Skin traction
Is temporary for about 48-72 hours
Skeletal Traction
Pins and wires are placed into the bone -long term
Common Types of Traction’s
- Buck’s Traction
- Russel’s Traction
- Bryant’s Traction
Buck’s Traction
Used for hip, knee, femur or back fracture.
Russel’s Traction
Used for femur or hip
Bryant’s Traction
Used for small children (under 2 years or <30 lbs in weight) for femur and hip joints.
Review other types of traction’s, its indications and nursing implications in
Chapter 61 pp. 1660-1661
Cast
Is a temporary circumferential immobilization device applied after close reduction.
How do you care for a new cast?
- do not cover with blanket (to allow it to dry quickly)
- do not subject to wetness or soiling
- handle by palm rather than fingertips (fingertips apply more pressure)
- petal edges when dry
- assess circulation and sensation in affected extremity extremity
- do not insert anything between the cast and the skin
- support the extremity
- reduce swelling by elevation
What should you assess for in patients with a new cast?
Cast syndrome
Cast Syndrome includes
Abdominal pain
Pressure
Nausea/Vomiting
Types of Casts
- Sugar-tong splint
- Short arm splint
- Long arm cast
- Body jacket cast
- hip spica cast
Sugar-tong splint
Used for acute wrist injuries.
May allow space for swelling to occur.
Short arm splint
Used in stable wrist or metacarpal fracture.
Provides an unrestricted elbow motion.
Long arm cast
- Used for stable forearm or elbow fracture and unstable wrist fracture.
- Restricts wrist and elbow.
Body jacket cast
- Used for stable spine injuries and thoracic lumbar spine.
- Extended above the nipple line down to the pubis.
- Window is left by the umbilicus.
Hip spica cast
Used for femoral Fracture to immobilize the affected extremities and trunk.
Fixators
Metallic devise composed of metal pins and plates inserted into the bone to stabilize the fracture while it heals.
External Fixation
For simple fractures - temporary.
External Fixation Nursing Care
Assess for loosening and infections.
Meticulous pin site care should be done.
Internal Fixation
Uses pins, palates, rods and screws surgically inserted during realignment reduction - can be permanent.
Drug Therapy for Fractures
- Muscle relaxant for pain d/t spasm (soma, flexeril, robaxin)
- Analgesia
- ATB (cephalosporin)
- Tetanus (diphtheria toxoid or immunoglobulin)
Nutritional Therapy for Fractures
- ample protein (1gm/kg of body weight): to rebuild bone and muscle tissue
- vitamins D, B, C, calcium
- adequate fluid intake
- high fiber
- six small meals for patients in body casts (d/t risk for cast syndrome)
Colles’ Fracture
Fracture of the distal radius.
One of the most common fracture in adults.
Colles’ Fracture usually happens when
An individual tries to break a fall with an outstretched hand
Treatment for Colles’ Fracture includes
- Immobilization, splint, cast, external fixation
- Elbow is immobilized to prevent supination and pronation
- Decrease edema
- Neurovascular assessment
- Encourage movement of thumb and fingers
Hip Fracture
- Common among older adults.
- By age 80, 1 out of 5 will have hip fracture.
- Fracture of the proximal third of the femur.
Intracapsular fracture
Occurs within the hip joint (femoral neck)
Fractures of the hips are associated with
Osteoporosis and minor trauma
Clinical Manifestations of Hip Fractures
- External rotation of affected limb
- Muscle spasm
- Shortening of affected extremity
- Severe pain and tenderness in the region of the fracture
Collaborative Care for Fractures
- surgical repair is the preferred method of treatment
- buck’s traction while awaiting surgery (24-48 hours max)
Nursing Therapeutics for Fractures: Preoperative Management
- Stabilize general health
- Analgesic or muscle relaxant
- Health teaching such as exercise, use of gadgets, transfer and ambulation, weight bearing
Nursing Therapeutics for Fractures: Postoperative Management
- (ORIF) monitor VS, I&Os, respiratory activities (deep breathing and coughing), Pain Management, bleeding and signs of infection
- decrease pain by positioning for proper alignment by keeping pillows or abductor splint between knees when turning patient.
When can patient’s ambulate post surgery?
ambulation by 1st or 2nd day by PT, use of crutch or walker
How can you prevent external rotation?
Use of sandbag to prevent external rotation
Discharge of patient post op
- to discharge home, pt must demonstrate safety
- may need rehabilitation for few weeks before returning home.
When can patients begin weight bearing post operatively?
Until x ray shows adequate healing (about 6-12 weeks)
Health Teachings to Prevent Hip Prosthesis Dislocation
- Place a large pillow between patient’s leg when turning
- Keep leg abductor splints on the patient except when bathing
- Avoid hip flexion
- Avoid turning the patient on the affected side until approved by the surgeon.
Amputation
Removal of a limb, part or organ usually by surgery or mechanical force or trauma.
Indications for Amputations
- Circulatory Impairments
- Peripheral Vascular Disorders
- Traumatic Injuries
- Thermal Injuries
- Malignant Tumors
- Uncontrolled or widespread infections of the limb
- Congenital Disorders
Collaborative Care/Nursing Therapeutics Goal for Amputations
Preserve extremity length as necessary
Health Promotion for Amputations: Monitor
Changes of the extremity involved such as:
- skin color changes
- decrease or absence of sensation
- pulsation/presence of adequate circulation
Amputations: Preoperative Management
o Reinforce information: reason for amputation, proposed prosthesis, mobility training program
o Discuss about phantom limb sensation
Amputations: Postoperative Management
o Assess, monitor VS and dressing
o Maintain *STERILE technique on wound dressing changes
o Pain Management
Amputations: Acute Interventions
- Notify surgeon immediately if bleeding occurs
- Prosthetic fitting
- Involve PT and OT services
- Monitor flexion contracture (hip flexion)
- Bandaging of the residual limb for proper prosthesis fitting
- Compression bandage applications
- Minimized edema of the ritual limb
- Active ROM
Osteomyelitis
a severe infection of the bone, bone marrow and surrounding tissues
Osteomyelitis is most often caused by
Staphylococcus aureus
Limited supply of blood to the bone can cause
Limited amount of antibodies to the infection site -> more time for bacteria to multiply
Causes of Osteomyelitis include
Indirect Entry: -Blunt Trauma -Vascular Insufficiency (DM) Direct Entry: -Open wounds -Foreign bodies (implant or orthopedic prosthetic devices)
Common Sites for Osteomyelitis
Pelvis
Tibia
Vertebrae
Pathophysiology of Osteomyelitis
- Predisposing or precipitating factors (entrance of microorganisms)
- Lodge to area with slow circulation
- Microorganism multiplies
- Increase pressure in the bone area
- Ischemia/vascular compromise
- Infection to the bone cortex
- Cortical devascularization
- Spread to other parts
Clinical Manifestations of Osteomyelitis: Localized
o Bone pain o Swelling o Tenderness o Warmth in site o Restricted movement o Drainage (serosanguinous to purulent drainage)
Clinical Manifestations of Osteomyelitis: Systemic
o Fever o Night sweats o Chills o Restlessness o Nausea and malaise
Diagnostic Studies of Osteomyelitis
- Bone tissue biopsy (biopsy is a histologic study) – identifies atypical cells, malignancy
- Blood and wound culture
- CBC
- Radiologic
- MRI/CT Scan
Collaborative Care for Osteomyelitis
- Vigorous prolonged IV antibiotic therapy
- Culture and bone biopsy prior to ABT
- Surgical debridement and decompression
- Discharge patient home on rehab on ABT
- Bone Graft (helps restore blood flow)
- Amputation
Nursing Management of Osteomyelitis: Health Promotion
o Control infection
o Educate about osteomyelitis
o Report symptoms
Acute Interventions for Osteomyelitis include
o Immobilization d/t pain o Care of handling of affected limb o Monitor pain control o Handle soiled dressing carefully and use sterile technique o Good body alignment and frequent position changes (prevents complications associated with immobility) o Bed rest o Prevent complication of immobility o Monitor ABT therapy side effects o Emotional support
Ambulatory Care for Osteomyelitis
o Continue ABT
o Care of access device
o Dressing change
Sequestrum
- Dead bone
- May also be a reservoir for microorganisms that spread systemically -> lungs and brain
Involucrum
- new bone (makes it difficult for successful antibiotic therapy)
- Antibiotics and WBC have difficult time reaching sequestrum
Fracture of the Pelvis
Life-threatening
Highest mortality rate (d/t increase bleeding)
Clinical Manifestations of the Pelvis include
- Abdominal swelling
- Tenderness
- Deformity
- Unusual pelvic movement
- Ecchymosis on the abdomen
Pelvic Fracture: Assess
Neurovascular status (CMS) of lower extremities X-ray studies demonstrate fractures
Complications of Pelvic Fractures
- Intraabdominal injury
- Paralytic ileus
- Hemorrhage
- Laceration of urethra,bladder and colon
- Sepsis
- FES
- Thromboembolism (DVT)
- Acute pelvic compartment syndrome
Open book fracture (antero-posterior compression)
- Pelvis is pulled apart
- usually caused by high speed motor vehicular accident or skiing
- can cause life threatening hemorrhage
Closed book fracture (lateral compression)
Lateral force impact
Treatment for Stable, Nondipslaced Pelvic Fractures
Only requires conservative therapy:
- Immobility, bed rest for up to 6 weeks
- Early ambulation is encouraged
Treatment for more complex pelvic fractures include:
- Pelvic sling traction
- Skeletal traction
- External fixation
- Open reduction
- Or combination of methods
A displaced pelvic fracture may require
ORIF
More Treatment for Pelvic Fractures include
- Careful handling and moving of patients (turn patient only by physician older)
- Assess bowel and urinary function
- Assess distal neurovascular status
- Provide back care when patient is raised from bed by independent use of trapeze or with adequate assistance
- Restrict weight bearing on affected side until bone is healed
- May use walker to distribute weight bearing between upper and lower extremities
