Musculoskeletal trauma and Ortho Surgery Flashcards
What are the structures of the musculoskeletal system?
bones joints muscle cartilage ligaments and tendons fascia bursae
What blood test would you do in relation to the musculoskeletal system?
rheumatoid factor (RF) erythrocyte sedimentation rate (ESR) antinuclear antibody (ANA) uric acid C-reactive protein (CRP) creatinine kinase (CK) potassium
What are the types of injuries when it comes to the musculoskeletal system?
sprain
strain
dislocation
subluxation
What are the clinical manifestations of strains/sprains?
pain edema decreased function contusion usually self-limiting
What is the nursing care for sprains and strains?
R -rest
I - ice
C - compression
E - elevation
What is the nursing care for dislocation and subluxation?
dislocation - needs prompt attention
need reduction then immobilization
put in an IV for pain meds and sedation
What are complications of dislocation and subluxation?
avascular necrosis
compartment syndrome
open joint injuries
fractures
What are sports related injuries to the musculoskeletal system?
cartilage - knee meniscus
ligaments - ACL
rotator cuff injury
bursitis patellar dislocation
What is the nursing care of various sports injuries?
conservative treatments: rest, ice, heat, NSAIDS, corticosteroid injections, PT
surgical repair may be necessary
RICE
What is a fracture?
a break or disruption in the continuity of a bone
What are the classifications of fractures?
open compound closed complete incomplete
What are signs & symptoms of fractures?
edema and swelling pain and tenderness muscle spasm deformity echymosis or contusion loss of function crepitation
What is the etiology of fractures
Trauma cars, motorcycles, horses, falls, etc Bone disease cancer osteoporosis
What are the classifications of fractures?
pathologic
fatigue/stress fractures
compression fractures
What diagnostic studies do you perform for fractures?
simple x-ray
CT scan - complex structures as hip, pelvis and spine
Bone Scan - small bone fractures of fractures from stress or disease
shows inflammatory process well
What does the nursing assessment for a fracture entail?
History of what happens = MOI (mechanism of injury) Other history Medical Allergies Occupation Nutrition
What does the neurovascular assessment of a fracture entail?
5 P's Pain Pulses Paresthesia Pallor Paralysis
How do you immobilize a fracture?
Splints (always check circulation before and after splinting
What are the goals of medical treatment for fractures
anatomic realignment of bone fragments (reduction)
Immobilization to maintain realignment
Restoration of normal or near normal function of injured part
What are the different stages of healing in fractures?
Fracture hematoma - immediately after fracture, bleeding & edema occur. Within 72 hours.
Granulation tissue - phagocytosis occurs
Callus formation
Ossification 2-3 weeks after break, a permanent callus of woven bone forms
Consolidation - callus continues to develop decreasing the distance between the bone fragments
Remodeling - union is complete
Wat are the different methods for reducing a fracture?
closed reduction
open reduction
traction
What is the collaborative care needed for fractures?
Fracture reduction - closed reduction or open reduction Traction - skin, skeletal Casts External Fixation Internal Fixation
What does a closed reduction of a fracture entail?
Nonsurgical realignment of the bones Its painful General or local anesthesia is used "Conscious sedation" X-ray to confirm alignment Casting
What do we need to know about casts?
Temporary circumferential immobilization device
Common treatment following closed reduction
Immobilization above and below the joint restricts movement to allow healing
Pad bony prominences
Multiple types
Plaster of Paris - avoid direct pressure to cast,
sets within 15 minutes, no weight bearing 48
hours
Synthetic materials - much lighter
If in a spica cast or one that goes around the abdomen there is a hole to assess bowl sounds (put on stool softeners and H2 receptors)
What can you not do with a cast?
get cast wet
remove any padding
insert objects inside the cast
bear weight on new cast for 48hrs (not all casts are made for weight bearing; check with HCP when unsure)
Cover cast with plastic for prolonged periods
What can you do with a cast?
Apply ice directly over fracture site for 1st 24 hours
Check with HCP before getting fiberglass cast wet
Dry cast thoroughly after exposure to water
blot dry with towel
use hair dryer on low setting until cast is thoroughly dry
Elevate extremity above level of heart for 1st 48hrs
Move joints above and below cast regularly
Use hair dryer on cool setting for itching
Report signs of possible problems to HCP
Increasing pain
Swelling associated with pain and discoloration of toes or fingers
Pain during movement
Burning or tingling under cast
Sores or foul odor under the cast
Keep appointment to have fracture and cast checked
What does an open reduction of a fracture entail?
It’s a surgical procedure
There is an incision over the fracture site
Internal fixation with the use of wires, screws, pins, plates, intramedullary rods or nails
Usually with open (compound) fractures
What is internal fixation of a fracture?
Placement of internal hardware to “fix” the fragments in place
Using
rods, pins, nails, screws, metal plates
Promotes early mobility
Preferred for older adults
What is an open reduction/internal fixation (ORIF)?
A surgical Incision to correct bone alignment
Use of wires, screws, pins nails or rods
What is external fixation of a fracture?
Similar to internal fixation, but pins inside the bone are attached to a frame outside the body
With extensive soft tissue damage or infection, external fixation allows easy access to the site and facilitates wound care
Allows early mobility while relieving pain
Pin track infection occurs in about 10%
What is traction?
Application of a pulling force to an injured or diseased part of the body/extremity while countertraction pulls in the opposite direction
What are the goals of traction?
Prevent/reduce pain/spasms
Immobilize a joint or a part of the body
Reduce the fracture or dislocation
Treat a pathologic joint condition
What are the different types of traction?
Skin - uses light weights short term tape, boots or splints Skeletal - heavier weights used longer pins or wires inserted into the bone
What is buck’s traction most commonly used for?
used for fractures of the hip and femur
What is the nursing care required for a patient in traction?
Assist in set up Don't remove weights without an order Weights should hang freely Inspect skin a minimum of every 8 hours Watch areas with pins, wires screws Assess neurovascular status of affected body part
What are complications of traction?
impaired circulation inadequate bone alignment skin breakdown soft tissue injury pin track infection (10%) osteomyelitis
What are the pharmacological treatment of fractures?
Muscle relaxants Carisoprodol (Soma) Cyclbenzaprine (Flexaril) Methocarbamol (Robaxin) Tetanus and antibiotics for an open fracture Pain medications
What is the nutritional therapy needed for a fracture?
Ample protein (1g/kg of body weight) Vitamins (B,C,D) Calcium Phosphorus Magnesium Needed to: Promote muscle strength and tone Build endurance Provide energy for ambulation and gait-training skills Adequate fluid intake 2-3L/day High fiber diet with fruits and vegetables If in a body cast (6 small meals a day)
What are goals for patients with fractures?
Have physiologic healing without associated complications
Obtain satisfactory pain relief
Achieve maximal rehab potential
Anatomic realignment of bone fragments
Immobilization to maintain realignment
Restoration of normal or near-normal function of injured parts
What are causes of slow healing with fractures?
Inadequate immobilization Excess movement Poor alignment Infection Poor nutrition
What are complications of fractures?
Acute compartment syndrome
Shock
Fat emboli
Venous Thromboembolism
What is compartment syndrome?
Compartments have increased pressure compromising nerves and circulation
Resulting in pressure on nerve endings and reduced blood flow
Two sources of pressure
decreased compartment size from casts, splints or dressings
increased compartment content
Relatively rare
MEDICAL EMERGENCY
Ischemia in 4-12 hours
Limb useless or limb loss within 24-48 hours
What are the symptoms of compartment syndrome?
Ischemia occurs
Increased pain
change in color
paresthesia
How do you treat compartment syndrome?
fasciotomy
What are the 6 p’s of compartment syndrome?
Paresthesia Pain Pressure Pallar Paralysis Pulselessness
What is shock in relation to fractures?
bone is vascular
femur fracture-patient can lose 1L of blood
Large blood volume loss associated with fractures
How do you treat shock?
fluids
blood replacement
What is a venous thromboembolism?
Includes:
DVT - deep vein thrombosis
PE - pulmonary emboli
Most common complication of lower extremity surgery or trauma
Aggravated by inactivity of muscles that normally assist in pumping action of venous blood
Hpw dp ypi prevent and treat DVTs?
anticoagulants
compression devices - TEDS, sequential stockings
early ambulation
ROM exercises
What is Fat Embolism Syndrome
Fat globules are released from exposed marrow into blood stream
May migrate to lungs
Too large to pass through pulmonary circulation
Lodge in capillaries
Break down into fatty acids
What are the signs and symptoms of fat embolism syndrome?
Most patients manifest symptoms 24-48 hours after injury Respiratory distress is first Tachycardia Tachypnea Fever Confusion Decreased LOC Petechiae over neck, upper arms, chest or abdomen
How do you treat fat embolism syndrome?
prevention fluid resuscitation encourage coughing and deep breathing gentle handling oxygen ventilatory support diuretics for pulmonary edema corticosteroids (controversial)
What are the diagnostic studies performed prior to amputation?
Arteriogram: x-ray exam with the use of contrast material to visualize the blood flow to the arteries; invasive procedure
Venogram: x-ray exam with the use of contrast material to visualize the blood flow to veins; invasive procedure
Doppler studies: can detect the arterial and venous blood flow patterns; non-invasive procedure
What are the clinical indications for amputation?
circulatory impairment
traumatic or thermal injuries
malignant tumors
widespread infection of extremity
What nursing care is provided for amputation patients?
prevention and detection of problems assess dressing, change as indicated infection, bleeding compression bandages pain control psychosocial issues prosthetic fitting
What nursing care needs to be provided for prosthesis and wound care after amputation?
Prevention of infection is paramount
PT and OT to assist in ADL’s
Wrapping stump correctly for reducing edema to help prepare for prosthesis
What are the overall goals of amputation?
Preserve extremity length and function while removing all infected, pathologic, or ischemic tissue
Relief from underlying health problems
Satisfactory pain control
Reach maximal rehabilitation potential with prosthesis (if indicated)
Cope with body image change
Make satisfying lifestyle adjustments
Keep chronic health problems under control (diabetes, COPD)
What are nursing implications of amputation?
Health promotion:
Control of the causative illness such as:
PVD, DM, pressure ulcers
Psychologic and Social implications
Allow the patient to go through the grieving process
Pre-operative management
Post-operative management
What are complications of amputations?
hemorrhage infection phantom limb pain flexion contractures psychosocial issues
What do we need to know about infection in relation to fractures and amputation?
body’s defense interrupted
superficial wound infection to deep wound
clostridial infection - gangrene
osteomyelitis - bone infection - open fracture
How do you treat infection in relation to fractures and amputation?
prevention
debridement
surgery
antibiotics
Where can hip fractures occur?
Intracapsular head and neck of hip Extracapsular trochanteric area Femoral neck Intertrochanteric Common in elderly due to falls
How do you treat hip fractures?
bucks traction
ORIF rods, pins, prosthesis, plates
If femoral head or neck fractured-may need prosthetic device implanted
Total hip replacement
Gemur fractures
usually result of major trauma
patient can lose up to 1-1.5L of blood in thigh
Pelvis fracture
stable or unstable
patient can lose up to 2-3 L of blood
Compression fractures
vertebral fractures
associated with osteoporosis
bone mass diminishes
What are the medical and nursing interventions for fractures?
always check ABC's first visualize area of concern Assess Immobilize/splint Non-surgical interventions (closed reduction - moderate sedation) Surgical interventions
What are the nursing diagnoses for fractures?
acute pain risk for peripheral neurovascular dysfunction impaired physical mobility risk for infection impaired nutrition potential for elimination disturbances
What is the nursing care required for fractured?
concern for blood loss pain control mobility-need to know do's and don'ts neurovascular assessment incision assessment nutrition and elimination
