Musculoskeletal & Fractures, Amputations Flashcards
______ is composed of cells, protein matrix, and mineral deposits
Bone
Three basic cell types of bone are?
Osteoblasts
Osteocytes
Osteoclasts
–bone forming cells, secrete bone forming cells
osteoblasts
mature bone cells, help with bone maintenance
osteocytes
bone absorption cells, dissolving and reabsorbing bone
osteoclasts
t/f: bone development happens more rapidly in a kids than an adult, and the bone healing process is better in kids
true
bone regrowth slows at ____ years of age
physical activity helps bone growth
20
t/f: nutrient absorption is really important
hormones are really important for bone growth
true
______ = Bone formation
Osteogenesis
____________ _________ and _________ __________ – acts to stimulate bone formation and remodeling
Physical activity, weight bearing
Good diet is necessary for bone health – ______ mg of calcium is needed every day to maintain bone health
1500
___________ ____________happens in four areas:
Bone marrow
Bone cortex
Periosteum
External soft tissue
Fracture healing
t/f: a fracture is a break
true
Bone marrow –where ______ are formed
osteoblasts
Bone cortex –where new ______ are formed
osteons
Periosteum –where _________ _________ or ___________ _________ is formed, formed through intramembranous ossification this happens peripheral to the fracture, where cartilage is formed through endochondral ossification
hard callous or fibrous tissue
Periosteum –where _________ _________ or __________ __________ is formed, formed through intramembranous ossification this happens peripheral to the fracture, where cartilage is formed through endochondral ossification
hard callous or fibrous tissue
________ _______ tissue –the tissue around the bone near the break where a bridging callous forms and it provides ____________ to the fractured bones
External soft
stability
There are ____ stages of healing are there in bone healing.
six
Stage 1: ______________ Formation
Stage 2: Hematoma to ___________ Tissue
Stage 3: _______ Formation
Stage 4: ___________ Proliferation
Stage 5: Bone _____________
Stage 6: Bone __________ Completed
Stage 1: Hematoma Formation
Stage 2: Hematoma to Granulation Tissue
Stage 3: Callus Formation
Stage 4: Osteoblastic Proliferation
Stage 5: Bone Remodeling
Stage 6: Bone Healing Completed
__________ ___ _____________ ______________–painful, forms within 72 hours, bleeding cuz bones vascular, vasoconstriction occurs, cytokines are released and they trigger angiogenesis which is the growth of new blood vessels,
Stage 1: Hematoma Formation
Stage __: Hematoma to __________ Tissue -__ _____ to ___ _____after the injury, granulation tissue invades the hematoma and starts forming fibrocartilage which is like the building block
Stage 2: Hematoma to Granulation Tissue
2 days to 2 weeks
________ __ __________ ____________due to vascular and cellular proliferation, fracture site will be surrounded by new vascular tissue called a _____
Stage 3: Callus Formation
callus
__________ ____ _________________ ________________ callous reabsorbed and transformed into bone, in __ __ ___ ______
Stage 4: Osteoblastic Proliferation
3 to 8 weeks
4-6 weeks after breaking a bone and can continue for a year, dead bone or necrotic bone is being removed by osteoclasts and reshaping of the new bone occurs
Stage 5: Bone Remodeling
Bone Healing Completed
Stage 6:
_______________ ______________ break across the ________ cross-section of the bone
Complete fracture
entire
__________________ ______________ (green-stick) a break through only part of the ______________ of bone
Incomplete fracture
cross-section
– produces several bone fragments
Comminuted fracture
__________________ _________ caused by a loading _________ applied to the long axis of cancellous bone (vertebrae)
Compression fracture
force
____________ ______________ one that does not cause a break in the skin
Closed fracture – (simple fracture)
_________________ _____________ bone alignment is altered or disrupted
Displaced fracture
_____________ __________ the skin or mucous membrane wound extends to the fractured bone
Open fracture (compound or complex fracture)
_____________ __________ (spontaneous or pathologic) occurs after ________trauma to a bone weakened by disease
Fragility Fracture
minimal
___________ _______________-due to excessive strain or stress on a bone
Fatigue (stress) Fracture
Open fractures are graded according to the following criteria:
______ __ less than 1 cm long
Grade I
Open fractures are graded according to the following criteria:
______ __ without extensive soft tissue damage
Grade II
Open fractures are graded according to the following criteria:
_________ ____ extensive soft tissue damage
Grade III
Acute pain
Loss of function
Deformity
_____________ of extremity
Crepitus
Local swelling and ___________
Pain is continuous and increases until the fragments are immobilized
MANIFESTATIONS: fractures
Shortening
discoloration
Ensure emergency care for airway, breathing, and circulation is not needed OR call 911 OR provide this care
Immobilize the body part before moving the patient
Splint adequately – including joints both proximal and distal to the injury
Pain management -opioids for a bit but as short as possible
management for a fracture
regional nerve blocks
is a shot in a bone
__________ – “setting the bone” – restoration of the fracture fragments to proper alignment and rotation
Reduction
____________ __________ – bringing the bone fragments into opposition through manipulation and manual traction
Use of moderate ________
X-ray confirmation
Will then ____________ with orthotic device, cast, splint, __________
Closed reduction
sedation
immobilize, bandage
____________ ___________ surgical procedure using internal fixation devices – screws, pins, wires, etc
Open reduction
Immobilize a reduced fracture
___________ a deformity
Apply uniform pressure to underlying soft tissue
Support and ________ weak joints
What does a cast do?
Correct
stabilize
______________ below the elbow to the palmar crease and secured around the base of the thumb – if the thumb is included can be also known as a thumb-spica or gauntlet cast
Short-arm
__________ from axillary fold to proximal palmar fold – elbow is usually immobilized at a _________ angle
Long-arm
right
______________ from below the knee to base of toes with foot flexed at a right angle in a neutral position
Short-leg
_________ From junction of the upper and middle third of the ______ to base of toes – knee may be slightly _____________
Long-leg
thigh
flexed
____________ ______ short or long-leg reinforced for strength
Walking cast
______ ____ encircles the trunk
Body cast
_________ ______body jacket that encloses trunk and shoulder and elbow
Shoulder spica
______ _______ encloses trunk and lower extremity – double hip includes both legs
Hip spica
body cast
shoulder spica
HIP spica
in what age demographic are hip spicas seen?
children
what are casts usually made out of?
nonplaster or fiberglass
Which casting material is ligher?
fiberglass
t/f: heat is given off and can in some instances be uncomfortable when applying the cast
true
t/f: you will not wait for swelling to go down before casting
false
make sure you don’t put the cast on too tight bc it can cut off circulation
patient education: keep dry, don’t take off, don’t shove things in there bc it can cause a wound,
cast should provide support but not increase pain
for first couple of days, does the pain get worse or better?
can you feel their pulse? capillary refill ? –make sure its not too tight
assessment for casts
What are the 5 Ps for neurovascular assessment with casts?
Pain
Pulse
Pallor
Paresthesia
Paralysis
t/f: Fractures may require weeks even months to heal
true
What are the two categories of complications?
early
delayed
What are the the early complications that can occur with a fracture?
Shock
Fat embolism syndrome
Compartment syndrome
Thromboembolic complications – Deep vein thrombosis (DVT) and pulmonary embolus (PE)
DIC (Disseminated Intravascular Coagulation)
DIC –body clots and your body overreacts and you bleed out
increased pressure in a confined space can cause __________ –compromised blood flow, ischemia, irreversible nerve and tissue damage,
-the 5 Ps are important, unrelenting pain is a sign
can also happen if your body is swelling
compartment syndrome
what is the hallmark sign of compartment syndrome?
PASSIVE RANGE OF MOTION INTENSIFIES PAIN
pressure ulcer from cast
causes tissue anoxia and then goes to an ______. patient will complain of a hot spot and that it really hurts, cast may feel warmer, may drain, may be stinky
ulcer
Pain and tightness in area
Warm area on cast (underlying tissue erythema)
Skin breakdown
Drainage and odor
Can be extensive loss of tissue
Monitor for ______________ development
To inspect area – may have to window the cast
SIGNS AND SYMPTOMS: pressure ulcer
pressure ulcer
encourage them to use their muscles so they don’t get this, wiggle fingers and toes etc
Potential complications – Disuse Syndrome
disuse syndrome
While in cast – teach patient to tense or contract muscles (isometrics without moving the part)
Helps reduce muscle atrophy and maintain muscle strength
Leg cast – teach to “push down” the knee
Arm cast – make a fist
Muscle-setting exercises – to maintain muscles used for walking
disuse syndrome nursing interventions
delayed union of fractures
potential complication
Knowledge of the treatment regimen
Relief of pain
Improved physical mobility
Achievement of maximum level of self-care
Healing of trauma-associated lacerations and abrasions
Maintenance of neurovascular function
Absence of complications
goals
Have patient indicate where and describe intensity and character
In most cases – elevate, apply cold packs as ordered, and pain med.
The unrelieved pain level must be immediately reported to the physician to avoid possible paralysis and necrosis
pain interventions
systemic signs of infection
odor from cast
purulent drainage staining cast
observe patient for these things with pain assessment
______ natural response to trauma - may complain that the cast is too tight
Vascular insufficiency & nerve compression due to unrelieved swelling can lead to compartment syndrome
Edema
Circulation
Motion
Sensation of the affected extremity –assess fingers or toes of casted extremity and compare them to the other extremity
assessments for neurovascular in a cast
The five “P’s of neurovascular compromise and compartment syndrome to assess are?
Pain
Pallor
Pulse
Parathesis
Paralysis
Often hypovolemic shock due to _______
blood loss
Can happen when a patient has sustained major injuries such as a long bone fracture
Can progress into ____ ________________ ___________which can lead to multisystem failure
It is believed that the ____ emboli leads to occlusion to microvasculature triggering an inflammatory response resulting in multisystem complications
Fat embolism
Fat Embolism Syndrome
(FES)
major trauma leads to cascade of inflammation which leads to ______ which goes to the vascular system which also causes a systemic inflammatory response. in the lungs it can cause acute respiratory syndrome, nervous system can cause occluded stuff and cerebral edema. morbidity and mortality are super high and can happen in up to 90% of people with severe trauma
fat embolism
resp distress, delirious, LOC change, unusual skin rashes (capillary rash on upper torso), tachycardic, fever, changes in renal function, retinal changes (petichia), jaundice (affects liver), acute drop in hemoglobin, low levels of platelets, ESR is elevated [lots of inflammation], can start having seizures.
s/s: of fat embolism
what are the treatments for a fat embolism?
Treatments: supportive care, theres not really a treatment, just have to fix things as they come. may use corticosterioids for inflammation.
______ ______ __________ when a blood clot (thrombus) forms in one or more of the deep veins in the body
Deep Vein Thrombosis
_______________ _______ sudden blockage in a lung artery; often caused by a blood clot that travels to the lung from a vein in the leg
Pulmonary Embolus
Delayed:
Delayed union and nonunion
Avascular necrosis
Complex regional pain
syndrome
Heterotopic ossification- -abnormal bone formation, a random bone in some place, may be more common in a trauma
complications
Move about as normally as possible – avoid excessive use of injured extremity – avoid wet, slippery floors or sidewalks
Perform prescribed exercises regularly
Elevate casted extremity to heart level frequently –avoids swelling
Do not scratch skin under cast
Cushion rough edges
Keep cast dry but don’t cover with plastic or rubber – unless taking a shower
When cast is dry - teach:
Persistent pain
Swelling that doesn’t respond to elevation
Changes in sensation, decreased ability to move fingers or toes
Changes in skin color and temperature
Report a broken cast to the physician – do not try to fix it yourself
Cast removal:
Removed with a vibrating cast cutter
Padding is cut with scissors
Skin will be dry and scaly – use lotion
What do you need to tell them to report ?
Arm cast – will be one-handed – can have fatigue; weight of cast may increase fatigue – may need extra rest
Elevate to control swelling
May use sling
*Watch for signs of cyanosis, swelling and inability to move fingers
patient care for cast
Impaired circulation in the arm can lead to ______________________ – a specific type of compartment syndrome
Obstructed arterial blood flow to forearm and hand
can’t extend fingers
has abnormal sensation
unrelenting pain; pain with passive stretching
diminished circulation – permanent damage develops within a few hours – do frequent neurovascular checks
Volkman’s contracture
Causes a degree of immobility
Support leg on pillows to heart level – control swelling
Ice-packs over fracture site for 1 or two days
Lay down a couple times /day & elevate
Observe carefully for color, temp, & capillary refill
long leg cast care
Monitor for cast syndrome – happens as a result of psychological and physiological responses to confinement
Cracking or denting is prevented by support on a firm mattress with waterproof pillows until cast is dry
Position pillows next to each other
– close – as spaces between pillows allow
the damp cast to sag
No pillow under the head of a patient in a body cast while drying as it will cause pressure on their chest
Turn patient – log roll – every two hours to relieve pressure and allow cast to dry
It takes at least three people to turn – use palms of hands to support properly
The stabilizing abduction bar (located usually about the knees) should never be used to turn
Turn to prone position twice a day – postural drainage of bronchial tree and relieve pressure on back
Usually use fracture bed pans
Perineal area must be large enough for hygienic care
care for body or spica cast
The application of a pulling force to part of the body
traction
minimize muscle spasms
reduce, align, & immobilize fractures
reduce deformities
increase space between opposing surfaces
uses for traction
Effects of _________ are evaluated with x-rays
Usually short term intervention
traction
Usually, the patient’s weight and bed position apply the needed counter ______
traction
______ must be continuous
Skeletal ______ is never interrupted (UNLESS NEED CPR)
Weights are never removed unless intermittent _______ is prescribed
principles for traction
Traction 3x
The patient must be in good body alignment in the center of the bed when ______ is 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
traction
Control muscle spasms
Immobilize an area before surgery
______ ___________ is accomplished by using a weight to pull on ______ tape or on a foam boot attached to the skin
Skin traction
traction
No more than ______ (4.5 to 8 lbs) of traction for an extremity and ______ (10 to 20 lbs) depending on the weight of the patient
2 to 3.5 kg, 4.5 to 9 kg
______ _____________ _________
unilateral or bilateral to lower leg
- Used to immobilize fractures of the proximal femur before surgical fixation
- Before traction is applied – observe for abrasions and circulatory disturbances
- One nurse elevates and supports the leg & another places boot with heel in boot heel unilateral or bilateral to lower leg
bucks extension traction
Bucks extension traction
- Secure velcro strap around leg
- Avoid excessive pressure over the malleolus and proximal fibula to prevent pressure ulcers and nerve damage
- Older adults are at greater risk for complications due to sensitive, fragile skin
considerations/care for bucks extension traction
Skin breakdown Prevention:
Remove foam boots to inspect skin, ankle, and achilles tendon 3x/day – 2nd nurse is necessary to support the extremity during inspection and skin care
Palpate area of tapes for tenderness – daily
Provide back care every 2 hours
Use special mattress overlays
Nerve damage:
Regularly assess sensation and motion
Immediately investigate any complaints of a burning sensation under traction, bandage, or boot
Immediately report altered sensation or impaired motor function
Circulatory impairment:
Following application of traction – assess circulation of foot or hand within 15 to 30 minutes and then every 1 to 2 hours
Assessment consists of:
Peripheral pulses, color, capillary refill and temperature
Indicators of DVT, including unilateral calf tenderness, warmth, redness and swelling
Encourage patient to perform active foot exercises every hour – while awake
complications/prevention interventions for traction
Traction is applied directly to the bone by a metal pin or wire (Steinman pin, Kirschner wire) inserted through the bone, distal to the fracture
To immobilize cervical fractures: tongs are applied to the head (Gardner-Wells or Vinke tongs) affixed to skull
skeletal traction
skeletal traction
Skeletal uses ________
7 to 12 kg
Overbed frame is used with trapeze to help movement
When discontinued, extremity is gently supported while weights are removed. Pin is cut close to skin and removed by physician
skeletal traction
Always check the traction apparatus
Never remove weights unless a life-threatening situation occurs
Maintain alignment of patient’s body
Position foot to avoid footdrop
May support foot in a neutral position by using various orthopedic devices (foot supports)
interventions for traction
Elbows may become sore from pushing while trying to reposition
Also use the heel of the unaffected leg to push up
Trapeze is best– pt can raise themselves off the bed for sheet change, bedpan, etc
skin breakdown measures for traction
Assess every hour at first & then every 4 hours
Remind pt to inform nurse of any changes in sensation
Assess for DVT
Do active flexion-extension ankle exercises and isometric contraction of calf muscles
neurovascular assessment for people in traction
Temperature
ropes hang freely
alignment
circulation check (5 ps)
type and location of fracture
increase fluid intake
overhead trapeze
no weights on bed or floor
care of client in traction
Avoid infection & development of osteomyelitis
Covered with sterile gauze for first 48 hours
Assess frequently
Inspect every day for signs of a reaction
Inspect ______ at least every 8 hours
pin site
Reduce anxiety
Achieve a maximum level of comfort
Achieve maximum amount of self-care
Encourage exercise and maintain positioning
interventions for a client in traction
Pressure ulcers
Pneumonia
Constipation & anorexia
Urinary stasis & infection
Venous thromboembolism
monitor for these during traction
Removal of a body part
Usually an extremity
amputation
Often from progressive peripheral vascular disease
amputation
gangrene, trauma (crushing injuries), burns, frostbite, electrical burns, congenital deformities, chronic osteomyelitis, or a malignant tumor
potential causes of amputation
relieve symptoms
to improve function
save or improve the life of the patient
why amputations are performed
Level of amputation = ___________________
most distal point that will heal successfully
Hemorrhage
Infection
skin breakdown
phantom limb pain
joint contracture
Phantom limb pain is caused by the severing of peripheral nerves
Neuroma
potential complications from amputation
massage the remaining part of the limb to help with phantom limb pain. _____ unit can also be used for phantom limb pain, local anesthesia can also be used. ______ is also really encouraged to help.
TENS, Activity
joint contracture: continue moving all joints to prevent that which can form a ______ which is a tumor consisting of damaged nerve cells (often seen in upper body amputations rather than lower ones more often) can be removed surgically but pain is often worse after surgery if it comes back
neuroma
Relief of pain absence of altered sensory perceptions
wound healing
acceptance of altered body image
resolution of the grieving process
independence in self-care
restoration of physical mobility
absence of complications
goals for amputation
low self esteem, inability to cope
impaired skin integrity
risk for infection
risk for ineffective tissue perfusion
impaired physical mobility
potential complications from amputation after the fact
ROM, encourage them to do prescribed exercise, refer to physical therapy, refer to occupational therapy, provide stump care on a regular basis, measure circumference of the stump to make sure its not swelling, instruct patient to lie in a prone position at least twice a day as tolerated which prevents contracture of the hip,
care for amputation
t/f:
make sure youre not putting a pillow under the stump all the time bc it can cause permanent flexion
true
When should you begin exercise?
Why exercise the remaining limb?
What factors should be considered to determine type of prothesis?
things to consider after amputation
