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NUR 202 Week 2 > Musculoskeletal Trauma > Flashcards

Musculoskeletal Trauma Flashcards

* Fractures * Fat embolic syndrome * Acute compartment syndrome * Complex regional pain syndrome

1
Q

Functions of musculoskeletal system

  • Framework
  • Mobility
  • Protection - ribs, skull
  • Reservoir - fat in yellow marrow
  • Hematopoiesis - red marrow producing blood cells
A

Classification of Fractures

  • Fracture - break or disruption in continuity of a bone
  • Types:
    > Complete
    > Incomplete
    > Open or compound
    > Closed or simple
    > Pathologic (spontaneous), traumatic
    > Fatigue or stress
    > Compression
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2
Q

Classification

  • Closed
  • Open
  • Complete
  • Incomplete
A
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3
Q

?

Occurs when bone continuity is completely interrupted (2 parts)

A

Complete

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4
Q

?

Occurs when skin is broken (compound fx’s Grades I, II, or III)

A

Open

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5
Q

?

Occurs when bone continuity is not completely interrupted

A

Incomplete

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6
Q

?

Occurs when there is no break in skin (simple fx)

A

Closed

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7
Q

Common Types of Fractures

A

Depression Fracture

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8
Q

?

These are produced by a loading force applied to the long axis of calcaneus bone; common for spinal cord injuries

A

Compression fracture

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9
Q

Types of Hip Fractures

  • Osteoporosis is greatest risk factor for hip fx’s
  • Differentiate between hip & pelvis fx’s - proximal 1/3 of femur = hip fx
  • Intracapsular puts pt @ risk for AVN of femoral head & can lead to pain & dec mobility
A
  • While awaiting ORIF - placed on Buck’s traction to dec painful spasms
  • ORIF surgery shouldn’t be confused for surgery for RA & OA
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10
Q

Internal Fixation

A

Bone Repair Cascade

  1. Hematoma formation (1-72 hrs post injury)
  2. Hematoma to granulation tissue (takes 3d - 2wks)
  3. Soft callus formation (takes ~3-6 wks post injury)
  4. Osteoblastic proliferation - hard callus forms (takes approx 3-8 wks)
  5. Bone remodeling (4-6 wks to a yr)
  6. Bone healing completed
  • Note, time estimates are for a healthy young person
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11
Q

Risk Factors for Fx

Hormones
- Increased
> Thyroid
> Parathyroid
> Cortisol

  • Decreased
    > Sex hormones
    > Growth hormones

Nutrition
> Calcium/phosphorous
> Vit D
> Protein
> Eating disorders

A

Activity
> Prolonged inactivity
> Inc risk taking behaviors
> Domestic violence
> Risk for falls

Diseases
> Neoplasms (e.g., multiple myeloma, 2° met from primary site)
> Paget’s dz
> Grave’s dz
> Hyperparathyroid
> Osteoporosis
> Diabetes
> Cushing’s

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12
Q

Manifestations

  • Pain
  • Impaired function
  • Crepitus
  • Deformity
  • Shortening of limb
  • Ecchymosis
  • Edema, bruising
  • Neurovascular changes

! Note, bone is very vascular

A

Diagnostics

  • In addn to xray, CT & MRI
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13
Q

?

  • serum calcium

elevated or decreased with healing?

A

elevates

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14
Q

?

  • serum phosphorous

elevated or decreased with healing?

A

elevates

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15
Q

?

  • lactate dehydrogenase (LDH)

elevated or decreased with skeletal muscle trauma?

A

elevates

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16
Q

?

  • aspartate aminotransferase (AST)

elevated or decreased with skeletal muscle trauma?

A

elevates

17
Q

?

  • creatinine phosphokinase (CPK)

elevated or decreased with muscle trauma?

A

elevates

18
Q

?

  • myoglobin

elevated or decreased with skeletal muscle injury?

A

elevated

19
Q

Reduction

  • Closed
    > Bring bone fragments in apposition
    > Through manipulation; very painful & needs rx
    > Manual traction
A
  • Open
    > Bring bone fragments in apposition
    > Through surgical incision
20
Q

Immobilization

Internal Fixation
- Intermedullary rod
- Compression nails
- Plates
- Screws

A

External Fixation
- Fixator frames
- Non-rigid methods (slings, immobilizers)
- Traction
- Cast

  • Pins are inserted through the skin into the bone. Pins are connected to an external framework. Allows for skin & CMS checks but needs care for pins & monitor pins q8-12h for signs of infection
  • Normal in the first 48-72hrs to have serous, clear fluid of the pin sites
21
Q

External Fixation utilized for…

  • Comminuted fractures, grades II to III
  • Bone loss
  • Congenital defects affecting bone length
A
  • Minimized blood loss
  • Keeps ends of bone aligned
  • Screws on the device can be turned & rotated to lengthen traction on the extremity & over time bone growth occurs between the 2 ends of the bone
22
Q

Immobilization Device

  • Helps keep alignment of the bones
  • Splint
  • Ice can reduce swelling
  • Consider perfusion & neurovascular checks when extremity is placed in dependent position
A

Fiberglass Synthetic Cast

  • Preferred over plaster
23
Q

Cast Care

  • Inform/teach
  • Neurovascular check
  • Elevate limb/use sling
  • Ice
  • Assess & relieve pain/tightness
  • Prevent resting on hard surface
  • Assess for pressure ulcer
  • Exercises
A

Traction

24
Q

Assess the following w/pts in traction (Carol P Smith)

  • Continuous
  • Alignment
  • Resistance
  • Opposing traction
  • Line of pull
  • Pulse
  • Sensation
  • Motion
  • Interspaces
  • Temperature
  • Hue (color)

Also, keep in mind the 6 P’s

A

Rehabilitation

  • Early remobilization
  • Decrease complication risks
25
Q

Early complications requiring frequent assessment

  • Hypovolemic shock
  • Neurovascular compromise
  • Loss of protective function (e.g., skull to brain; rib cage to lung)
A

Complications of Fractures

! Compartment syndrome
! Crush injury
! Fat embolism syndrome
! Venous thromboembolism
! Infection
! Chronic complications - ischemic necrosis, AVN, delayed bone healing
! Peripheral neurovascular dysfunction
! Pain
! Impaired physical mobility

26
Q

?

Condition where circulation & function of tissues within a closed space are compromised by an increase of pressure in that space

Closed space: osteo-fascia area of muscle, nerve, & blood vessels

A

Compartment syndrome

27
Q

Etiology of compartment syndrome

  • Can happen from trauma, burns, infiltration of extravascular IV fluids, casting, lying on the ground for an extended period of time
  • constriction of compartment
    > closure of fascia defect
    > scarring & contraction of skin or fascia, or both, due to burns
A
  • increased fluid content in compartment
    > fracture
    > direct arterial trauma
    > intra-compartmental hemorrhage
    > burns
    > muscle swelling d/t overexertion
    > infiltration of exogenous fluid (IV needle slipped out of vein)
    > fluid from capillaries (edema) 2° to bone or soft tissue trauma, burn toxins, venous or lymphatic obstruction
  • external compression
    > tight cast or dressing
    > excessive or prolonged inflation of air splint
    > prolonged compression of limb (as in alcohol or drug-induced metabolic or traumatic coma)
28
Q

Clinical Diagnosis

6 P’s
* Pain (out of proportion to what is expected based on physical exam findings)
* Paresthesia
* Pallor
* Paralysis
* Pulselessness
* Poikilothermia

A

The 1st signs of compartment syndrome are numbness, tingling, & paresthesia
- also, pain is induced on passive ROM

29
Q

Stryker Intra-Compartmental Pressure Monitor System

A
30
Q

Etiology/Pathophysiology/Complications

  • Pressure
  • Inc tissue pressure
  • Collapse of thin walled veins
  • Dec capillary flow
  • Cellular injury
A
  • Inflammation
  • More pressure
  • Cellular hypoxia
  • Rhabdomyolysis
  • Necrosis
  • Renal & multi-organ failure
  • Loss of limb & life
31
Q

Rhabdomyolysis

A byproduct of skeletal injury, skeletal muscle injury; builds up in the bloodstream; can also build up in the urine (dipstick testing)
- Is possible w/trauma in general

A

Treatment of Compartment Syndrome

  • Goal: dec tissue pressure, restore blood flow, preserve limb function
  • Release compressive forces
  • Limb @ heart lvl
  • NO ICE - is vasoconstrictive
  • Supplemental oxygen
  • Maintain normotensive

! fasciotomy

32
Q

Nursing Pitfalls

  • Infrequent and/or inadequate observation of neurovascular status
  • Inattention to pts complaints of pain, pain intensity & requests for pain medication
  • Inattention to casts, splints, or dressings, which may be masking/exacerbating the problem
  • Non-elevation of injured extremities to improve venous return (to reduce edema before compartment syndrome develops)
  • Delayed or non-reporting of problems
A

Complications of compartment syndrome

! Neurological defects
! Myoglobinuric renal failure
! Volkmann contracture [ischemic contracture]
! Infection
! Amputation

33
Q

Amputations

  • Surgical
  • Traumatic
  • Levels of amputation
  • Complications - hemorrhage, infection, phantom limb pain, neuroma, flexion contracture
  • Postop nursing care

> Covered in depth in lecture re: peripheral vascular dz surgeries

A
34
Q

?

Circulating fat globules that cause multi-system dysfunction, mainly involving the lungs, brain, & skin

Are small & multiple, & so have widespread effects

A

Fat Embolism

35
Q

Prevention of Fat Emboli

  • Minimal manipulation during reduction
  • Adequate support when turning & repositioning
  • Maintain F&E imbalance
  • Early mobilization

> Medullary cavity of long bones store fat & a fx could result in the fat globules becoming emboli

A

Clinical manifestations within 24-48 hrs post injury - report immediately!

  • Neurologic LOC changes
  • Pulmonary changes
  • Petechial rash - specific to fat emboli
36
Q

Diagnostics

↑ or ↓ ESR ?

↑ or ↓ calcium levels?

↑ or ↓ RBCs & platelets?

↑ or ↓ serum lipase?

xray: snowstorm infiltrate

A

↑ ESR

↓ calcium levels

↓ RBCs & platelets

↑ serum lipase

37
Q

The earliest manifestations of FES are low arterial oxygen level or hypoxemia, dyspnea, & tachypnea

A

Further Complications

  • FES degradation into free fatty acids & CRP
  • Resulting in capillary leakage - causes edema & swelling
  • Lipid & plt aggregation & clot formation (petechiae)
  • With FES, there are fatty emboli that are released & get trapped in the small capillary beds of different organs within the pulmonary system
  • In other organs can get trapped, dec perfusion, & cause tissue death/organ death
38
Q

Treatment

✓ Immobilization of fx
✓ Bed rest/gentle handling
✓ Support resp system
✓ Hydration
✓ Steroid
✓ Cardiac support
✓ Hemodynamic monitoring
✓ Pain & anxiety management

A

Nursing Diagnoses

  • Acute Pain
  • Impaired Physical Mobility
  • Risk for Peripheral Neurovascular Dysfunction
  • Risk for Infection
  • Ineffective Tissue Perfusion
  • Risk for Impaired Skin Integrity
  • Deficient Fluid Volume
  • Knowledge Deficit

NUR 202 Week 2 (2 decks)

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