Musculoskeletal trauma and orthopedic sx Flashcards
What is the most common cause of musculoskeletal injuries?
traumatic injury
What do traumatic injuries result in?
Fracture
Dislocation
Soft tissue injury
Fracture
a disruption or break in continuity of the structure of bone
Some fractures are secondary to disease processes (ie “fragility fractures”) - Cancer or osteoporosis
Dislocation
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)
Fracture classification
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)
What are the 7 different types of direction of fracture line?
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)
Manifestations of fractures
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 )
Care for fractures
If a fracture is suspected, immobilize extremity in position it was found
What does unnecessary movement cause for fractures?
Increases soft tissue damage
May convert a closed fracture into an open one
May create further injury to adjacent neurovascular structures
Fracture healing
- fracture hematoma (hematoma around bone ends)
- 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
- Callus formation (unorganized bone network of cartilage, Ca, phos.)
- Ossification
- Consolidation
- Remodeling (for loading stress after repair complete)
What are the overall goals for fracture care?
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)
Fracture reduction care
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
Fracture immobilization care
Casts
Immobilizers
External fixation
- metallic device
- applies traction or compresses fracture fragments
Internal fixation
- Pins, plates, rods
What is the risk of internal fixation?
Infection risk d/t harboring organisms
also foes not have blood flow to bring in immune response
What to note about broken bones with infants
Occur less frequently because of bony flexibility (if it does happen, it is because of abuse or malnutrition), very hard to break
Drug therapy for fractures
Varying degrees of pain and muscle spasm
Analgesics & Muscle relaxers
Tetanus-diptheria toxoid
Antibiotics
Nutritional therapy for fractures
Proper nutrition
Adequate energy for body to repair
What can we do to prevent complications?
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
Peripheral vascular assessment
colour, warmth, cap refill, peripheral pulses, edema
compare both ext
Peripheral neurological assessment
sensation
motor function
pain
compare both ext
Fracture complications
Direct:
Infection
Indirect
Fat embolism syndrome
Compartment Syndrome
VTE
Rhabdomyolysis
Hypovolemic Shock
Infection complication
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
Fat embolism syndrome complication
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
What are S and S of fat embolism?
- hypoxia
- Neurologic abnormalities
- petechial rash
hypoxia, anxiety, dyspnea, tachypnea, tachycardia, cyanosis, crackles
**petechiae are a distinguishing feature (clotting factors)
immobilization is KEY!
Compartment Syndrome Complication
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
Compartment syndrome manifestations
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
What are the 6 Ps of compartment syndrome?
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
What are common signs of myoglobinuria?
Dark reddish brown urine (BREAKDOWN OF PROTEINS)
Clinical manifestations associated with acute renal failure
Care for compartment syndrome
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)
Long term fracture complications
Joint stiffness or post-traumatic arthritis
Avascular necrosis
Altered union
Malunion
Delayed union
Non union
Take home message about fractures
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
Pelvic fractures
Associated with highest mortality
Often associated with intra-abdominal injury
Treatment depends on severity of injury
Can be extremely painful
Hip fractures
Require the longest hospital stays
Refers to a fracture of the proximal third of the femur
usually caused by osteoporosis
Clinical manifestations of hip fracture
External rotation
Muscle spasm
Shortening of the affected limb
Pain at fracture site
Care for surgical repair of hip fracture
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
Signs of prosthesis dislocation of hip are
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
Femur fractures
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
Stable Vertebral fractures
Stable: The fracture is unlikely to cause spinal cord damage
GOAL: keep good spinal alignment until union has been accomplished
Unstable vertebral fractures
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
Treatment of vertebral fractures
Pain mgmt, mobilization, and bracing
Mandibular fractures
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
What are post op care priorities for mandibular fractures?
Patent airway
Oral hygiene
Communication
Pain management
Adequate nutritions
Amputation: Ortho surgery
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)
What is the goal of amputation?
to preserve extremity length and function while removing all infected, pathological or ischemic tissues
Arthroplasty: Joint surgery
the reconstruction or replacement of a joint to relieve pain, improve or maintain ROM, and correct deformity
THA
provides significant relief of pain and improvement of function for pts w OA, RA, etc
TKA
Unremitting pain and instability as a result of severe destructive deterioration of the knee joint is the main indication for TKA
What are common complications for arthroplasty?
Infection r/t aerobic streptococci and VTE
Osteomyelitis
Severe infection of the bone, bone marrow and surrounding soft tissue
Most common organism is staph aureus
Direct (open wound) vs. indirect entry
Acute Clinical manifestations
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
Chronic clinical manifestations
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
Treatment for Osteomyelitis
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
