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NURS 412 > Musculoskeletal trauma and orthopedic sx > Flashcards

Musculoskeletal trauma and orthopedic sx Flashcards

1
Q

What is the most common cause of musculoskeletal injuries?

A

traumatic injury

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2
Q

What do traumatic injuries result in?

A

Fracture
Dislocation
Soft tissue injury

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3
Q

Fracture

A

a disruption or break in continuity of the structure of bone
Some fractures are secondary to disease processes (ie “fragility fractures”) - Cancer or osteoporosis

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4
Q

Dislocation

A

severe injury of the ligamentous structures around a joint that results in the complete displacement of the bone from its normal position (important to get it relocated quickly)

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5
Q

Fracture classification

A

Open or closed (is the skin broken?)
Complete or incomplete (is the break straight through the bone?)
Direction of fracture line (7 types)
Displaced or nondisplaced (are the two ends of the fracture separated?)
Anatomical location of fracture on involved bone (proximal, medial, distal)
Stable or unstable (stationary piece of periosteum)

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6
Q

What are the 7 different types of direction of fracture line?

A

Transverse (straight)
Spiral (twisted)
greenstick (incomplete fracture; one side split, one side bent)
comminuted (more than 2 fragments)
oblique (diagonal)
pathological (site of bone disease; cancer to bone)
stress fracture (site of repeated stress)

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7
Q

Manifestations of fractures

A

Edema & swelling
Pain & tenderness
Bruising
Muscle spasm
Deformity (may not be obvious)
Inability to bear weight on or loss of function
Abnormal movement
Crepitation (grating/crunching together of bony fragments)
Neurovascular changes
- Decreased sensation
- Numbness
Hypovolemic shock (longbones, highly vascular and are responsible for blood production )

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8
Q

Care for fractures

A

If a fracture is suspected, immobilize extremity in position it was found

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9
Q

What does unnecessary movement cause for fractures?

A

Increases soft tissue damage
May convert a closed fracture into an open one
May create further injury to adjacent neurovascular structures

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10
Q

Fracture healing

A
  1. fracture hematoma (hematoma around bone ends)
  2. Granulation tissue (osteoblasts are in granulated tissue which is man component of new bone called osteoid) - osteoids and osteoblasts can be seen in x-ray
  3. Callus formation (unorganized bone network of cartilage, Ca, phos.)
  4. Ossification
  5. Consolidation
  6. Remodeling (for loading stress after repair complete)
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11
Q

What are the overall goals for fracture care?

A

Anatomical realignment of bone fragments (reduction)
Immobilization to maintain realignment
Restoration of normal or near-normal function of injured parts (rehab after cast has been placed)

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12
Q

Fracture reduction care

A

Closed reduction
Nonsurgical, manual realignment of bone
fragments to previous anatomical position
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

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13
Q

Fracture immobilization care

A

Casts
Immobilizers

External fixation
- metallic device
- applies traction or compresses fracture fragments
Internal fixation
- Pins, plates, rods

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14
Q

What is the risk of internal fixation?

A

Infection risk d/t harboring organisms
also foes not have blood flow to bring in immune response

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15
Q

What to note about broken bones with infants

A

Occur less frequently because of bony flexibility (if it does happen, it is because of abuse or malnutrition), very hard to break

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16
Q

Drug therapy for fractures

A

Varying degrees of pain and muscle spasm
Analgesics & Muscle relaxers
Tetanus-diptheria toxoid
Antibiotics

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17
Q

Nutritional therapy for fractures

A

Proper nutrition
Adequate energy for body to repair

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18
Q

What can we do to prevent complications?

A

Neurovascular assessments are key (more than just CWMS)
Other assessments depend on type of fracture and stage of healing
Vital signs
Assessment for shock
Respiratory assessment
Skin integrity
Regaining maximum function
Achieving best cosmetic result

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19
Q

Peripheral vascular assessment

A

colour, warmth, cap refill, peripheral pulses, edema
compare both ext

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20
Q

Peripheral neurological assessment

A

sensation
motor function
pain

compare both ext

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21
Q

Fracture complications

A

Direct:
Infection

Indirect
Fat embolism syndrome
Compartment Syndrome
VTE
Rhabdomyolysis
Hypovolemic Shock

22
Q

Infection complication

A

Associated with open fractures and soft tissue injuries
Often related to high-energy trauma
Massive/ blunt soft tissue trauma often has more serious consequences than the fracture itself
Collaborative care:
- Aggressive surgical debridement
- Early sterile N/S lavage (washed)
- Extent of soft tissue injury determines whether the wound is closed or left open (vac dressing)
- IV antibiotics for 3-7 days

23
Q

Fat embolism syndrome complication

A

Presence of systemic fat globules from fractures distributed into tissues & organs after a traumatic skeletal injury
Fat globules –> occlusion of pulmonary vessels –> pulmonary edema, severe hypoxia & cardiovascular compromise
of the fat embolisms that come, 90% of them are longbone, then ribs, tibia and pelvis

24
Q

What are S and S of fat embolism?

A
  1. hypoxia
  2. Neurologic abnormalities
  3. petechial rash

hypoxia, anxiety, dyspnea, tachypnea, tachycardia, cyanosis, crackles
**petechiae are a distinguishing feature (clotting factors)

immobilization is KEY!

25
Q

Compartment Syndrome Complication

A

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
increased compartment content with decreased compartment size

26
Q

Compartment syndrome manifestations

A

Early recognition & treatment essential
- Ischemia can occur within 4 to 12 hours
Regular neurovascular assessments
May occur initially or may be delayed for several days
Urine output must be assessed because there is a possibility of muscle damage
- Myoglobin 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

27
Q

What are the 6 Ps of compartment syndrome?

A

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: ↑ in compartment
Pallor: Coolness, and loss of normal colour of extremity
Paralysis: Loss of function
Pulselessness: Diminished/absent peripheral pulses

28
Q

What are common signs of myoglobinuria?

A

Dark reddish brown urine (BREAKDOWN OF PROTEINS)
Clinical manifestations associated with acute renal failure

29
Q

Care for compartment syndrome

A

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 ↓ external circumferential pressures
Surgical decompression may be necessary (fasciotomy - cut in skin)

30
Q

Long term fracture complications

A

Joint stiffness or post-traumatic arthritis
Avascular necrosis
Altered union
Malunion
Delayed union
Non union

31
Q

Take home message about fractures

A

Ongoing assessments are key to the prevention of complications

Vital signs
Assessment of fracture site
Neurovascular assessments
Other: respiratory, cardiovascular, integument, neurological, etc.

Preventative interventions include:
- Maintaining adequate tissue perfusion
- Maintaining immobilization of fracture site
- Performing post-operative exercises
- Maintaining hydration and nutritional status (myoglobinuria)
- Preventing infection

32
Q

Pelvic fractures

A

Associated with highest mortality
Often associated with intra-abdominal injury
Treatment depends on severity of injury
Can be extremely painful

33
Q

Hip fractures

A

Require the longest hospital stays
Refers to a fracture of the proximal third of the femur
usually caused by osteoporosis

34
Q

Clinical manifestations of hip fracture

A

External rotation
Muscle spasm
Shortening of the affected limb
Pain at fracture site

35
Q

Care for surgical repair of hip fracture

A

If femoral head prosthesis (posterior approach), measures to prevent dislocation must be used x 6 weeks:
- Avoid extreme flexion
- Avoid crossing legs/ feet
- Avoid sitting up more than 90 degrees
Elevated toilet sets and chair alterations are helpful
Foam abduction pillow or pillows between legs
Avoid turning the patient on her affected side until the surgeon approves

36
Q

Signs of prosthesis dislocation of hip are

A

Sudden, severe pain
A lump in the buttock
Limb shortening
External rotation of the affected limb

Treatment for dislocation involves closed reduction under conscious sedation OR open reduction

37
Q

Femur fractures

A

Occurs with severe, direct force
Usually associated with damage to the adjacent soft tissue structures
Displacement of fracture fragments often results in considerable blood loss (1-1.5L)
Clinical manifestations are usually obvious

38
Q

Stable Vertebral fractures

A

Stable: The fracture is unlikely to cause spinal cord damage

GOAL: keep good spinal alignment until union has been accomplished

39
Q

Unstable vertebral fractures

A

Unstable: Ligamentous structures are significantly disrupted, dislocation of the vertebral structures may occur, leading to instability and injury to the spinal cord
Unstable fractures usually require surgery (aspen collar)
All spinal injuries are initially considered unstable until diagnostics confirm stability

40
Q

Treatment of vertebral fractures

A

Pain mgmt, mobilization, and bracing

41
Q

Mandibular fractures

A

Surgery: involves immobilization through wiring the jaws x 4-6 weeks
WIRE CUTTERS SHOULD ALWAYS BE WITH THE PATIENT
If the pt vomits/ chokes, the pt should:
- Bend his head over to the side to allow the vomitus to flow out of the mouth/ nose
- Allow the nurse to suction to clear the nose/ mouth

42
Q

What are post op care priorities for mandibular fractures?

A

Patent airway
Oral hygiene
Communication
Pain management
Adequate nutritions

43
Q

Amputation: Ortho surgery

A

Linked to PVD, atherosclerosis and vascular changes r/t diabetes
Amputation in younger patients usually r/t trauma
Vascular studies: arteriography, Doppler studies and venography
Phantom limb pain very common (60-100%)
Prosthesis fitting not possible until all edema is gone
Compression bandaging worn at all times (except bathing)

44
Q

What is the goal of amputation?

A

to preserve extremity length and function while removing all infected, pathological or ischemic tissues

45
Q

Arthroplasty: Joint surgery

A

the reconstruction or replacement of a joint to relieve pain, improve or maintain ROM, and correct deformity

46
Q

THA

A

provides significant relief of pain and improvement of function for pts w OA, RA, etc

47
Q

TKA

A

Unremitting pain and instability as a result of severe destructive deterioration of the knee joint is the main indication for TKA

48
Q

What are common complications for arthroplasty?

A

Infection r/t aerobic streptococci and VTE

49
Q

Osteomyelitis

A

Severe infection of the bone, bone marrow and surrounding soft tissue
Most common organism is staph aureus
Direct (open wound) vs. indirect entry

50
Q

Acute Clinical manifestations

A

Less than one month in duration
Systemic: fever, chills, night sweats, nausea, restlessness
Local: unrelieved pain – worse with movement, swelling, warmth at site, limited ROM

51
Q

Chronic clinical manifestations

A

Longer than one month – either a continuous problem or series of remissions and recurrences
Less systemic signs – continued local signs
Scar tissue forms (impenetrable to antibiotics)
Risk of septicemia, septic arthritis and unhealed fractures

52
Q

Treatment for Osteomyelitis

A

Dx:
Hx&Physical, Labs, cultures, biopsy, x-ray
Bone scan is the gold standard
Tx:
Vigorous and prolonged IV antibiotic therapy (only if bone ischemia has not occurred) – for 4-6 weeks at home, or up to 3-6 months (PICC or central line required).
Surgery – debridement, irrigation and suction
Amputation indicated in refractory cases

NURS 412 (21 decks)

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