Acute Care of The Musculoskeletal System

Surgical Orthopedic Conditions & Complications

•Fracture Management

•Cast Care

•Osteomyelitis

•Compartment Syndrome

•Fat embolus

•Scoliosis

Fracture:

A disruption (crack) or break in the structure of a bone

•Majority of ___ from traumatic injuries

Some fractures are secondary to a disease process like

Cancer or Osteoporosis

Fractures can be Classified Four Ways:

Open or Closed

Complete or Incomplete

Based on the direction of fracture line

Displaced or Non-displaced

Open Fracture:

Skin is broken- bone is exposed and causing soft tissue injury

Closed fracture:

Skin is not broken- No bone exposed

What has more risk for infection, closed or open fracture?

• Open fracture: The broken bone penetrates the skin, or there’s a wound that communicates with the fracture site.

  • This exposes the bone and deep tissues to bacteria from the external environment.

  • The risk of infection (osteomyelitis or soft tissue infection) increases significantly.

  • Immediate irrigation, debridement, and antibiotics are required

  • -As a for a Closed fracture: The skin remains intact, so there’s no direct exposure of the fracture site to the outside environment.

• Infection risk is much lower, though it can occur secondarily (e.g., after surgery or in immunocompromised patients).

Complete Fracture:

break is completely through bone

Incomplete fracture:

bone is still in one piece

DISPLACED Fractures:

Two ends separated from one another

(pulled out of normal alignment)

NON-DISCPLACED Factures:

bone is aligned, and periosteum is intact

(still normal alignment)

Fractures: Clinical Manifestations

•pain at (or near) the site of the injury

•difficult or impossible to move normally (decreased or absent range of motion (ROM))

•loss of power (inability to weight bear)

•deformity (obvious/ non-obvious)

•abnormal mobility

•tenderness

•swelling

•discoloration and bruising

•Possible overt bleeding (open fracture)

Immobilize extremity in the position in which it is found if fracture is suspected!

Unnecessary movement of a fractures:

Increases soft tissue damage & may convert closed fracture to open

Nursing care with a fracture 

•Control external bleeding with (careful) direct pressure (sterile, if possible)

•Splint joints above and below fracture sites

•Check neurovascular status distal to injury before and after splinting

•Elevate injured limb if indicated

•Do not attempt to straighten fractured or dislocated joint

•Do not manipulate protruding bone ends

•Apply ice packs to affected area

•Obtain X-rays of affected area

•Administer tetanus and diphtheria prophylaxis (if required)

•Mark location of pulses to facilitate repeat assessment

•Splint fracture site

Interprofessional goals with fractures

•Anatomical Realignment of Bone Fragments (Reduction)

•Immobilization to maintain alignment

•Restoration of normal or near normal functioning (Healing time increases as age increases)

•Pain management and therapeutic support 

Closed Reduction:

Non-Surgical, manual realignment of bone. Done often under light sedation/pain control. Casting/traction applied to maintain alignment

Open Reduction:

Surgical bone alignment though surgical incision. Often includes internal/EXTERNAL fixation with use of wires, screws, pins (hardware) PIN CARE

Traction:

application of pulling forces to an injured extremity- Can be skin traction or skeletal traction.

•Prevent or reduce muscle spasms

•Immobilize joint or part of body

•Reduce a fracture or dislocation

TRACTION care

•Success depends on correct positioning and alignment while traction forces remain constant

•Forces must be pulling in opposite direction to prevent patient from sliding to the end or side of the bed

•Countertraction commonly supplied by patient’s body weight or augmented by elevating end of bed

•Imperative that nurse maintains traction constantly and does not interrupt weight applied to traction; ensure weights stay off the floor

Skin Traction

•Used for short-term treatment until skeletal traction or surgery is possible

•Tape, boots, or splints applied directly to skin to maintain alignment, assist in reduction, and decrease muscle spasms

Skeletal Traction

•In place for longer periods: Provides a long-term pull that keeps injured bones and joints aligned

•Health care provider inserts pin or wire into bone, either partially or completely, to align and immobilize injured body part

Splint:

A temporary (less than 2 weeks) semi-circumferential immobilization device applied in acute injury. It allows joint stability while also allowing for swelling

Cast:

Temporary circumferential immobilization device commonly used after closed reductions or orthopedic surgeries to properly immobilize the affected bone- immobilization above and below the joint restricts tendon and ligament movement

Patient education for casts 

•Casts are not fully hardened for 24-72 hrs

•Once dry; edges may need to be “petalled” to avoid skin irritation

•Weight bearing vs. non-weight bearing/ Assistive Devices

•Bathing Considerations

•Discuss signs & symptoms of compartment syndrome

•NEVER INSERT OBJECTS!

if cast gets slight wet on mistake, pt can

use a hair dryer on a light setting to dry cast.

NOTHING should be inserted.

Neurovascular Assessment, Peripheral Vascular Assessment

color, temperature, capillary refill, peripheral pulses, edema

5 Ps for the neuro assessment 

Pain, Pulse,Pallor, Paresthesia, Paralysis

Pediatric considerations

•Children tend to heal Faster than adults

•Consider the mechanism of injury

•Is injury from trauma (fall, accident, etc.)?

•Is injury from twisting/push (consider abuse)?

•Is injury consistent with child’s development?

•Is fracture associated with injury (consider healed fracture, pathologic fracture)?

Mandatory Reporting for

any Suspected Child Abuse:

Do not need to prove, but unusual injury/injury not consistent with development warrants referral to CPS

Cast Care Education DOs

•Apply ice directly over the fracture site for first 24 hrs (Avoid getting cast wet)

•Check with HCP before getting fiberglass cast wet

•Dry cast thoroughly after accidental 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 first 48 hrs

•Move joints above and below cast regularly

•Use Hairdryer on cool setting for itching

•Report Signs of possible complications to HCP

•Increased pain despite elevation, ice, & analgesia

•Swelling associated with pain and discoloration of toes or fingers

•Pain during movement

•Burning or tingling under cast

•Sores or foul odor under cast

•Keep appointment to have facture & cast checked

Cast Care Education DONTs

•Get plaster cast wet

•Remove any padding

•Insert any objects inside cast

•Bear weight on new cast for 48 hrs (not all casts are made for weight bearing; Check with HCP if unsure)

•Cover cast with plastic if it will be wet for long periods of time

Indirect Complications

•Compartment Syndrome

•DVT

•Fat Embolism

•Rhabdomyolysis (breakdown of skeletal muscle)

•Hypovolemic Shock

Direct Complications

•Osteomyelitis (higher risk with open fractures)

•Avascular Necrosis

•Contractures

Indirect complications def

These occur as a result of the body’s response to the injury or its treatment, not from the trauma itself. They may develop days or weeks later.

Direct complications def

These are complications that result directly from the injury itself — the damage occurs at the time of the trauma or as an immediate consequence of it.

Examples for direct complications

• Damage to nearby structures:

  • Nerve injury (e.g., radial nerve palsy in humeral shaft fracture)

  • Blood vessel injury (e.g., popliteal artery damage in knee dislocation)

• Infection: Especially in open fractures

• Fracture blisters or skin necrosis due to direct trauma

• Loss of limb (amputation) in severe crush injuries

🧠 Think: Direct = caused by the initial injury.

Examples of indirect complications 

• Fat embolism syndrome

• Deep vein thrombosis (DVT) or pulmonary embolism

• Compartment syndrome

• Shock (especially hypovolemic)

• Tetanus

• Joint stiffness or muscle contractures

• Reflex sympathetic dystrophy (Complex Regional Pain Syndrome)

🧠 Think: Indirect = secondary effects of injury or its management.

osteomyelitis

•Severe infection of the bone, marrow & surrounding soft tissues

•Infection by two different means

•Due to bone anatomy (nerve, haversian canal, blood supply) infection is very difficult to treat

•High Risk Individuals: Weak Immune System (HIV, Immunocompromised)

•Poor blood Circulation due to uncontrolled Diabetes

osteomyelitis s&s

Inflammation

fever

weakness

Indirect osteomyelitis

Spread to bone  via blood

Direct osteomyelitis

•Open wound, penetrating trauma, foreign body (prosthetic implant)

common causes of osteomyelitis

Staph & Strep

Indirect Spread of Osteomyelitis:

IV Drug Use/Contaminated Needles/ Hemodialysis / Infected tooth/dental extraction

Direct Spread/Contiguous of Osteomyelitis:

Trauma/Foreign Body Puncture-Open fracture, bone exposed to external structures/ Orthopedic Surgery, prosthetic device or hardware/ Cellulitis/chronic skin ulcers/animal bite

DIABETIC FOOT ULCER is a Source of

OSTEOMYELITIS

Osteomyelitis: Acute Phase

•Microorganism grows in bone where circulation is slow

•Increase pressure within the rigid bone leads to ischemia & vascular compromise of the periosteum (the painful part)

•Eventually causes devascularization, necrosis, bone death

•Infected portion of dead bone surrounded by purulent drainage (think of a walled off abscess) Very difficult for Antibiotics to penetrate!

•Can serve as a reservoir for spread to other tissues (Heart valves, joints, overlying muscle, other bone etc.)

Clinical Manifestations Osteomyelitis: chronic Phase

•Systemic Signs of infection (Fevers, chills, night sweats, nausea, malaise)

•Local Manifestations (bone pain, swelling, tenderness, warmth at site)

•Labs: Elevated White Blood Cell Count, Elevated inflammatory Markers (ESR), possible + blood cultures

•Imaging: Xray-Thickening of the cortical bone/periosteum, loss of bone architecture/ MRI-Gold standard for evaluation of Osteomyelitis

Osteomyelitis: chronic Phase

•10-30% of acute Osteomyelitis becomes Chronic

•Lasting months-years

Osteomyelitis: Nursing Management

•Antibiotic Therapy: Targeted to pathogen (based on bone culture)

•IV antibiotic therapy often continued for 4-6 weeks but may extend to 3-6 months

•Surgical Debridement should be expected with Antibiotic treatment

•Nursing Management IV Antibiotics

•Antibiotic associated complications

•Medical Monitoring of antibiotic Therapy (nephrotoxic, audio toxic)

•Regional, antibiotic irrigation

Pain Assessment PQRSTU

• P – Provocation / Palliation

• Q – Quality / Quantity

• R – Region / Radiation

• S – Severity / Scale

• T – Timing

• U – Understanding / “You”

Compartment Syndrome

•Elevated intra-compartmental pressure within a confined myofascial compartment compromises neurovascular function of tissues within that space

•Compartment swelling compromises blood circulation, nerves, & tendons (causing severe/non-viable tissue perfusion)

•Causes capillary perfusion to be reduced below the level necessary for tissue viability

•Most often involves the leg (but can occur in arm, shoulder)

LIMB THREATENING EMERGENCY

Compartment Syndrome→ Decreased compartment size due to:

•Restrictive dressings, splints, casts, orthopedic traction

•Increased compartment contents

•Bleeding & edema

•Edema can create enough pressure to impede venous & arterial flow resulting in ISCHEMIA

•Delay in identifying syndrome can result in IRREVERSIBLE loss of function or loss of limb

Compartment Syndrome: Diagnosis, may occur as

physiological response to injury or delayed (several days) after initial injury

6 Ps

Pain, Pallor, Paresthesia, Paresthsia, Pressure, Paralysis, Pulselessness

EARLY SIGNS for Compartment Syndrome

•Pain-Distal to injury, pain out of proportion to expected

•Pallor-coolness, loss of normal color of limb (cap refill delayed)

LATE SIGNS for Compartment Syndrome

•Paresthesia-numbness, tingling (nerve impaired)

•Pressure-increased pressure in compartment (tight)

•Paralysis-loss or decreased function (motor)

•Pulselessness- diminished or absent peripheral pulses

Compartment Syndrome: Nursing Care

Report Clinical symptoms to Provider! This is an emergency!

•Educate patients on signs and symptoms (cast care & education)

•Prevention & early recognition is key (Time is limb)

Compartment Syndrome: Patient Care

•Pain Management

•Loosen any dressings, anticipate cast bivalve/split

•Do not elevate limb above level of heart (this will decrease perfusion further)

•Do not apply cold compress  (vasoconstriction will decrease perfusion further)

•Urine Output: Possibility of muscle damage- myoglobin released from damaged muscle cells precipitates as a gel-like substance- Causes obstruction in renal tubules

Compartment Syndrome: Surgical Decompression

•May be necessary to remove or loosen bandage or split cast (bifurcation)

•Fasciotomy: Surgical procedure to open fascial layer of limb compartment to allow for swelling and edema. Restores vascular and nerve compression. Goal is to prevent need for amputation.

•Incision is left open for swelling to subside

FAT Embolus

•Presence of systemic fat globules from fracture that are distributed into tissues and organs after a traumatic skeletal injury

•Contributory factor in many deaths associated with fracture

•most often fractures of long bones, ribs, tibia, and pelvis

•Early recognition is crucial in preventing a potentially lethal course

•Most patients manifest symptoms 24–48 hours after injury

•Fat globules transported to lungs cause respiratory compromise

•Severe cases have occurred within hours of injury

•The clinical course of fat embolus may be rapid and acute

•The patient frequently expresses a feeling of impending disaster

•In a short time, skin color changes from pallor to cyanosis

•The patient may become comatose

•No specific laboratory examinations are available

•Certain diagnostic abnormalities may be present

•Treatment is directed at prevention

•Careful immobilization of a long bone fracture is the most important factor in prevention *danger of dislodging more fat droplets into the general circulation.

•Management is essentially symptom related and supportive Respirator

•signs & symptoms of acute respiratory distress syndrome (ARDS), such as chest pain, tachypnea, cyanosis, dyspnea, apprehension, tachycardia, and hypoxia

signs & symptoms FE

acute respiratory distress syndrome (ARDS), such as chest pain, tachypnea, cyanosis, dyspnea, apprehension, tachycardia, and hypoxia

Treatment for fat embolus

directed at prevention

What is a Fat Embolus

is a fat droplet that enters the bloodstream and blocks blood vessels, usually after a fracture of a long bone (like the femur, pelvis, or tibia).

🧠 In simple terms:

When a large bone breaks, fat from the bone marrow leaks into the blood.
These tiny fat globules can travel to the lungs, brain, or skin, causing a serious condition called Fat Embolism Syndrome (FES).

Scoliosis

Deformity resulting from lateral S-shaped curvature of the thoracic and lumbar spine

Scoliosis Etiology:

•Idiopathic/congenital (most common- 80 %)

•Degenerative (asymmetric disk degeneration)

•Dislocation

•Osteomalacia (brittle bone due to low vitamin D)

Minor Scoliosis

Causes some degree of cosmetic spinal curvature, mild back pain

Severe Scoliosis:

Causes severe curvature and alteration in respiratory, cardiac, and musculoskeletal complications

Adams-Forward Bend test:

Screening test used to screen for scoliosis in child/adolescents

Scoliometer:

Used to evaluate the degree of curvature. Ruler & air bubble level

Scoliosis: Screening

Adams-Forward Bend test

Scoliometer

Scoliosis: Clinical Manifestations

•Uneven Shoulders

•One shoulder blade that appears more prominent than the other

•Uneven waist

•One hip higher then the other

•One side of the rib cage jutting forward

•A prominence on one side of the back when bending forward

•Often part of a child/adolescent wellness exam, but often missed

External Bracing

•Custom external bracing designed to be worn 20-23 hours per day

•Encourages proper curvature/alignment

•Primary intervention, best used during adolescents (growing)

Spinal Fusion & Internal Fixation

•Surgical intervention when bracing failed or for severe cases

•Spinal hardware can pose risk of infection

•Surgical intervention when growing completed

Scoliosis: Intervention

External Bracing, Spinal Fusion & Internal Fixation