Musculoskeletal Trauma and Orthopedic Surgery Flashcards
Most common cause of musculoskeletal Injuries:
Traumatic injuries result in:
- fracture
- dislocation
- soft tissue injury
Fracture
a disruption or break in continuity of the structure of bone
Dislocation
severe injury of the ligamentous structures around a joint that results in the complete displacement of the bone from its normal position
- immediate action is relocation
Fragility fractures
Fracture secondary to disease processes
- cancer or osteoporosis
- force exerted on a bone that shouldn’t normally break the bone but does
Fractures are described and classified according to: (6)
- open or closed
- complete or incomplete
- direction of fracture line
- displaced or nondisplaced
- anatomical location of fracture or involved bone
- stable or unstable
Types of Fractures (7)
- Transverse
- Spiral (twisting force)
- Greenstick (one side fractured, the other bent - common in kids)
- Comminuted (two or more fragments)
- Oblique (horizontal direction)
- Pathological (cancer eats away at bone)
- Stress
Fracture classification according to location
- proximal third - towards core
- middle third
- distal third
Fractures: Clinical Manifestations (10)
- Edema & swelling - can cause compressure of nerves and vessels feeding the distal limb
- Pain & tenderness
- Bruising
- Muscle spasm (often seen with fractured hip)
- Deformity (may not be obvious)
- Inability to bear weight on or loss of function
- Abnormal movement
- Crepitation (air in the tissue)
- Neurovascular changes - decreased sensation, numbness
- Hypovolemic shock (femur fracture - 1-1.5L of blood loss)
Femur Fracture: Immediate care
If a fracture is suspected, immobilize extremity in position it was found
Unnecessary movement: (3)
- increases soft tissue damage
- may convert a closed fracture into an open one
- may create further injury to adjacent neurovascular structures
Fracture Healing: First two stages
Bone goes through remarkable reparation process of self-healing:
- fracture hematoma
- Granulation tissue
Overall Goals of Fracture Treatment: (3)
- Anatomical realignment of bone fragments (reduction)
- Immobilization to maintain realignment
- Restoration of normal or near-normal function of injured parts
Fracture Reduction: Closed Reduction
- nonsurgical, manual realignment of bone fragments to previous anatomical position
- done under conscious sedation
- post-reduction x-ray
Fracture Reduction: Open reduction
- correction of bone alignment through surgical incision
- includes internal fixation (ORIF) with use of wires, screws, pins, plates, intramedullary rods, or nails
Traction
Application of a pulling force to an injured or diseased part of the body or extremity while counter-traction pulls in opposite direction
Fracture Immobilization
- Casts
- Immobilizers
Casting is done after reduction. Patient’s need to check circulation - swelling occurs
External Fixation
Metallic device
Applied traction or compresses fracture fragments
Internal Fixation
Pins, plates, rods
Drug therapy
- Varying degrees of pain and muscle spasm
- Analgesics & muscle relaxers
- Tetanus-diptheria toxoid -
- Antibiotics - consider the kind
Nutritional therapy
- Proper nutrition
- Adequate energy for body to repair
Collaborative Care: Preventing Complications - Assessments (5)
- Neurovascular assessments are key (more than just CWMS)
Other assessments depend on type of fracture and stage of healing - Vital signs
- Assessment for shock (femur patient’s)
- Respiratory assessment
- Skin integrity
Goals of Collaborative Care (3) Surgical Goals (3)
Preventing complications
Regaining maximum function - early mobilization
Achieving best cosmetic result
Reduction - closed, open
Immobilization - cast, immobilizer, internal or external fixation, traction
Restore function
Neurovascular Assessment - peripheral vascular (5) and neurological assessment (3)
Peripheral Vascular Assessment
- colour
- warmth
- capillary refill
- peripheral pulses
- edema
Peripheral Neurological Assessment
- sensation
- motor function
- pain
COMPARE BOTH EXTREMITIES!!
Ambulatory & Home Care Cast Care: DO (7)
- Apply ice directly over fracture site for first 24 hours
- Dry cast after exposure to water
- Elevate extremity above level of heart for first 48 hours
- Use hair dryer on cool setting for itching
- move joints above & below cast regularly
- report signs of possible problems
- keep appointment to have fracture & cast checked
Ambulatory & Home Care Cast Care: DON’T
- Get plaster cast wet or remove any padding
- Insert any objects inside cast or bear weight on new cast for 48 hours
- Cover cast with plastic for prolonged periods
Fracture Complications Direct and Indirect (6)
- Infection (Direct)
- Fat embolism syndrome (ID)
- Compartment Syndrome (ID)
- VTE (ID)
- Rhabdomyolysis (ID)
- Hypovolemic Shock (ID)
Direct: Infection
- which fractures?
- Associated with open fractures and soft-tissue injuries - where there has been significant damage and blood flow is impeded
- Often related to high-energy trauma
- Massive/blunt soft tissue trauma often has more serious consequences than the fracture itself
Infection: Collaborative Care (4)
- Aggressive surgical debridement
- Early sterile N/S lavage
- Extent of soft tissue injury determines whether the wound is closed or left-open (vac dressing)
- IV antibiotics for 3-7 days
Indirect: Fat Embolism Syndrome
- What is it?
- Most frequent cause?
Presence of systemic fat globules from fractures distributed into tissues & organs after a traumatic skeletal injury
Happens 1- 3 days after
- Fat globules -> occlusion of pulmonary vessels -> pulmonary edema, severe hypoxia & cardiovascular compromise
Most often fractures of long bones (90%), ribs, tibia, & pelvis
Signs & Symptoms of Fat Embolism (9) and Key prevention
hypoxia, anxiety, dyspnea, tachypnea, tachycardia, cyanosis, crackles
Neurologic abnormalities
- petechiae around the neck are a distinguishing feature
Prevention is KEY through immobilization of long bone fractures
Indirect: Compartment Syndrome
- what is it?
Elevated intracompartmental pressure within a confined myofascial compartment compromises the neurovascular function of tissues within that space
- capillary perfusion below level necessary for tissue viability - ischemia occurs
Compartment Syndrome: Etiology
- decreased compartment size (restrictive dressings, splints, casts, excessive traction or premature closure of fascia)
- increased compartment content (bleeding, edema, chemical response or intravenous infiltration)
Compartment Syndrome: Early Recognition
Early Recognition & treatment essential
- ischemia can occur within 4-12 hours
Regular neurvascular assessments
May occur initially or may be delayed for several days
Classic Sign - pain that is not commensurate with injury. given morphine and still in extreme pain
Compartment Syndrome: Clinical Manifestations - 6 Ps
- Paresthesia - numbness and tingling
- Pain - distal to injury that is not relieved by opioid analgesics and pain on passive stretch of muscle traveling through compartment
- Pressure - increased in compartment
- Pallor - coolness, and loss of normal colour of extremity
- Paralysis - loss of function
- Pulselessness - diminished/absent peripheral pulses
Compartment Syndrome: Clinical Manifestations - Urine Output
- signs of myoglobinuria
- Urine output must be assessed because there is a possibility of muscle damage
- Myglobin released from damaged muscle cells precipitates as a gel-like substance - causes obstruction in renal tubules
- large amounts of myoglobinemia may result in acute tubular necrosis. Acute tubular necrosis causes acute renal failure
- Common signs of myoglobinuria:
Dark reddish brown urine - clinical manifestations associated with acute renal failure
Compartment Syndrome: Collaborative Care
- Prompt accurate diagnosis
- Extremity should NOT be elevated above heart level - elevation may decrease venous pressure and slow arterial perfusion
- Application of cold compresses may result in vasoconstriction and exacerbate compartment syndrome
- May be necessary to remove or loosen bandage or bivalve cast
- Reduction in traction weight may decreased external circumferential pressures
- Surgical decompression may be necessary (Fasciotomy)
Long Term Fracture Complications (3)
- joint stiffness or post-traumatic arthritis
- avascular necrosis
- altered union (malunion, delayed union, non union)
Take Home Message: Assessments
Ongoing assessments are key to the prevention of complications
- Vital signs
- Assessment of fracture site
- Neurovascular assessments
- Respiratory, cardiovascular, integument, neurological
Fractures: Preventative Interventions Include: (5)
- Maintaining adequate tissue perfusion
- maintaining immobilization of fracture site
- Performing post-operative exercises
- Maintaining hydration and nutritional status
- Preventing infection
