Musculoskeletal Trauma Flashcards
* Fractures * Fat embolic syndrome * Acute compartment syndrome * Complex regional pain syndrome
Functions of musculoskeletal system
- Framework
- Mobility
- Protection - ribs, skull
- Reservoir - fat in yellow marrow
- Hematopoiesis - red marrow producing blood cells
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
Classification
- Closed
- Open
- Complete
- Incomplete
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Occurs when bone continuity is completely interrupted (2 parts)
Complete
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Occurs when skin is broken (compound fx’s Grades I, II, or III)
Open
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Occurs when bone continuity is not completely interrupted
Incomplete
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Occurs when there is no break in skin (simple fx)
Closed
Common Types of Fractures
Depression Fracture
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These are produced by a loading force applied to the long axis of calcaneus bone; common for spinal cord injuries
Compression fracture
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
- While awaiting ORIF - placed on Buck’s traction to dec painful spasms
- ORIF surgery shouldn’t be confused for surgery for RA & OA
Internal Fixation
Bone Repair Cascade
- Hematoma formation (1-72 hrs post injury)
- Hematoma to granulation tissue (takes 3d - 2wks)
- Soft callus formation (takes ~3-6 wks post injury)
- Osteoblastic proliferation - hard callus forms (takes approx 3-8 wks)
- Bone remodeling (4-6 wks to a yr)
- Bone healing completed
- Note, time estimates are for a healthy young person
Risk Factors for Fx
Hormones
- Increased
> Thyroid
> Parathyroid
> Cortisol
- Decreased
> Sex hormones
> Growth hormones
Nutrition
> Calcium/phosphorous
> Vit D
> Protein
> Eating disorders
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
Manifestations
- Pain
- Impaired function
- Crepitus
- Deformity
- Shortening of limb
- Ecchymosis
- Edema, bruising
- Neurovascular changes
! Note, bone is very vascular
Diagnostics
- In addn to xray, CT & MRI
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- serum calcium
elevated or decreased with healing?
elevates
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- serum phosphorous
elevated or decreased with healing?
elevates
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- lactate dehydrogenase (LDH)
elevated or decreased with skeletal muscle trauma?
elevates
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- aspartate aminotransferase (AST)
elevated or decreased with skeletal muscle trauma?
elevates
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- creatinine phosphokinase (CPK)
elevated or decreased with muscle trauma?
elevates
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- myoglobin
elevated or decreased with skeletal muscle injury?
elevated
Reduction
- Closed
> Bring bone fragments in apposition
> Through manipulation; very painful & needs rx
> Manual traction
- Open
> Bring bone fragments in apposition
> Through surgical incision
Immobilization
Internal Fixation
- Intermedullary rod
- Compression nails
- Plates
- Screws
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
External Fixation utilized for…
- Comminuted fractures, grades II to III
- Bone loss
- Congenital defects affecting bone length
- 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
Immobilization Device
- Helps keep alignment of the bones
- Splint
- Ice can reduce swelling
- Consider perfusion & neurovascular checks when extremity is placed in dependent position
Fiberglass Synthetic Cast
- Preferred over plaster
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
Traction
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
Rehabilitation
- Early remobilization
- Decrease complication risks
Early complications requiring frequent assessment
- Hypovolemic shock
- Neurovascular compromise
- Loss of protective function (e.g., skull to brain; rib cage to lung)
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
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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
Compartment syndrome
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
- 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)
Clinical Diagnosis
6 P’s
* Pain (out of proportion to what is expected based on physical exam findings)
* Paresthesia
* Pallor
* Paralysis
* Pulselessness
* Poikilothermia
The 1st signs of compartment syndrome are numbness, tingling, & paresthesia
- also, pain is induced on passive ROM
Stryker Intra-Compartmental Pressure Monitor System
Etiology/Pathophysiology/Complications
- Pressure
- Inc tissue pressure
- Collapse of thin walled veins
- Dec capillary flow
- Cellular injury
- Inflammation
- More pressure
- Cellular hypoxia
- Rhabdomyolysis
- Necrosis
- Renal & multi-organ failure
- Loss of limb & life
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
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
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
Complications of compartment syndrome
! Neurological defects
! Myoglobinuric renal failure
! Volkmann contracture [ischemic contracture]
! Infection
! Amputation
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
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Circulating fat globules that cause multi-system dysfunction, mainly involving the lungs, brain, & skin
Are small & multiple, & so have widespread effects
Fat Embolism
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
Clinical manifestations within 24-48 hrs post injury - report immediately!
- Neurologic LOC changes
- Pulmonary changes
- Petechial rash - specific to fat emboli
Diagnostics
↑ or ↓ ESR ?
↑ or ↓ calcium levels?
↑ or ↓ RBCs & platelets?
↑ or ↓ serum lipase?
xray: snowstorm infiltrate
↑ ESR
↓ calcium levels
↓ RBCs & platelets
↑ serum lipase
The earliest manifestations of FES are low arterial oxygen level or hypoxemia, dyspnea, & tachypnea
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
Treatment
✓ Immobilization of fx
✓ Bed rest/gentle handling
✓ Support resp system
✓ Hydration
✓ Steroid
✓ Cardiac support
✓ Hemodynamic monitoring
✓ Pain & anxiety management
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
