Management of Patients with Musculoskeletal Trauma, Osteomyelitis, Septic Arthritis

contusion is a

soft tissue injury produced by blunt force

contusion symptoms

oPain, swelling, and discoloration: ecchymosis

contusion can be

minor or severe, isolated or in conjunction with additional injuries (e.g., fracture

Contusions can limit

joint range of motion (ROM) near the injury, and the injured muscle may feel weak and stiff

Most contusions resolve in

1 to 2 weeks; severe contusions may take longer to heal.

strain is a

Pulled muscle injury to the musculotendinous unit, injury to a muscle or tendon from overuse, overstretching, or excessive stress.

strain symptoms

oPain, edema, muscle spasm, ecchymosis, and loss of function are on a continuum graded first, second, and third degree

a first degree strain is a

mild stretching of the muscle or tendon with no loss of ROM.

first degree strains signs and symptoms

•gradual onset of palpation-induced tenderness and mild muscle spasm.

a second degree strain involves

involves moderate stretching and/or partial tearing of the muscle or tendon.

second degree strain signs and symptoms

•include acute pain during the precipitating event, followed by tenderness at the site with increased pain with passive ROM (PROM), pain with weight bearing, edema, significant muscle spasm, and ecchymosis.

a third degree strain is a

severe muscle or tendon stretching with rupturing and complete tearing of the involved tissue.

signs and symptoms of a third degree strain

immediate pain described as tearing, snapping, or burning, muscle spasm, ecchymosis, edema, and loss of function.

with a third degree strain what should be obtained

An x-ray should be obtained to rule out bone injury, because an avulsion fracture (in which a bone fragment is pulled away from the bone by a tendon) may be associated with a third-degree strain

xrays do not reveal

•injuries to soft tissue or muscles, tendons, or ligaments, but magnetic resonance imaging (MRI) and ultrasound can identify tendon injury.

sprain is a

injury to ligaments and supporting muscle fiber around a joint

sprain symptoms

oPain (may increase with motion), edema, tenderness; severity graded according to ligament damage and joint stability

A Grade I sprain is

stretching or slight tearing in some fibers of the ligament and mild, localized hematoma formation.

Sprain - A Grade I manifestations include

mild pain, edema, and local tenderness.

A Grade II sprain is

more severe and involves partial tearing of the ligament

A Grade II sprain manifestations include

increased pain with motion, edema, tenderness, joint instability, ecchymosis, and partial loss of normal joint function.

A Grade III sprain is a

complete tear or rupture of the ligament. A Grade III sprain may also cause an avulsion of the bone.

•A Grade III sprain

severe pain, edema, tenderness, ecchymosis, and abnormal joint motion. (joints bend in ways they shouldn't be)

dislocation is a

: articular surfaces of the joint are not in contact

Dislocation Symptoms

oA traumatic dislocation is an emergency with pain change in contour, axis, and length of the limb and loss of mobility

most common dislocation

shoulder and hips,

dislocation needs to be

put in back in place, normally relieves the pain, rest the joint

Acute traumatic dislocations are

orthopedic emergencies because the associated joint structures, blood supply, and nerves are displaced and may be entrapped with extensive pressure on them.

If a dislocation or subluxation is not

reduced immediately, avascular necrosis (AVN) may develop (bone is not getting enough blood flow) . AVN of bone is caused by ischemia, which leads to necrosis or death of the bone cells.

subluxation is a

partial or incomplete dislocation

subluxation symptoms

oDoes not cause as much deformity as a complete dislocation

Management of Soft Tissue Injuries

vRICE

oRest

oIce

oCompression

oElevation

vImmobilize

. Intermittent application of cold or ice packs during the first 24 to 72 hours after injury produces

vasoconstriction, which decreases bleeding, edema, and discomfort.

. Cold packs should

not be in place for longer than 20 minutes at a time, and care must be taken to avoid skin and tissue damage from excessive cold

. An elastic compression bandage controls

bleeding, reduces edema, and provides support for the injured tissues

Elevation at or just above the level of the heart controls the

swelling

If the sprain or strain is the most severe grade or degree, immobilization by a

splint, brace, or cast may be necessary so that the joint will not lose its stability

). Nonsteroidal anti-inflammatory drugs (NSAIDs) may be prescribed for

pain

The neurovascular status, a type of focused assessment of the neurologic (motor and sensory) and vascular function of the injured extremity, is monitored at frequent intervals

15 minutes for the first 1 to 2 hours after injury) and then at lesser intervals (e.g., every 30 minutes) until stable

Decreases in sensation or motion and increases in pain level should be

documented and reported to the patient's primary provider immediately so that acute compartment syndrome can be prevented.

Immobilize dislocation at the scene and

take to hospital to be reduced to proper alignment. ROM used to preserve function once joint is stable.

types of fractures

vClosed or simple

vOpen or compound/complex

vIntra-articular

closed or simple

oNo break in the skin, deformity in bone

first aid for closed fracture

is immobilize limb at it is and get them to a hospital

vOpen or compound/complex Grade I:

oWound extends to the bone

vOpen or compound/complex

o1 cm long clean wound

vOpen or compound/complex Grade 11

larger wound without extensive damage

vOpen or compound/complex Grade III

: highly contaminated, extensive soft tissue injury, may have amputation

intraarticular

extends into the joint surface of a bone, affects mobility

avulsion

a fracture in which fragment of bone has been pulled away by a tendon and its attachment

comminuted

a fracture in which the bine has splintered into several fragments

compression

a fracture in which bone has been compressed (common in vertebral fracture)

Depressed

a fracture in which fragments are driven inward (seen frequently in facial and skull bones)

Epiphyseal

fracture through the epiphyseal

impacted

a fracture in which a bone fragment is driven into another bone fragment

Oblique

a fracture that remains contained with no disruption of the skin integrity

open

a fracture that damages the skin or mucosa also called a compund fracture

pathologic

a fracture that occurs through an area of diseased bone (such as osteoporosis) can occur without trauma or fall

Green sticik

a fracture in which one side of a bone is broken and the other side is bent

Manifestations of Fracture

vAcute pain

vLoss of function

vDeformity

vShortening of the extremity- common in legs

vCrepitus- bones rub against eachother

vLocal swelling and discoloration

diagnosis of fracture by

symptoms and radiography

Patient usually reports an

injury to the area

Emergency Management of Fracture

vImmobilize the body part

vSplinting: joints distal and proximal to the suspected fracture site must be supported and immobilized

vAssess neurovascular status before and after splinting

vOpen fracture: cover with sterile dressing to prevent contamination

vDo not attempt to reduce the fracture (put it back into place)

make sure is blood flow to

limb

make sure splint

isn't too tight

Fracture reduction:

: restoration of the fracture fragments to anatomic alignment and positioning

Medical Management of Fracture closed

oUses manipulation and manual traction

oTraction may be used (skin or skeletal)

Skin traction

on something outside of the limb holding it in place

Skeletal traction-

put pins in bones and attach weights

Medical Management of Fracture open

oInternal fixation devices hold bone fragment in position (metallic pins, wires, screws, plates)

closed and open reduction doesn't matter if the fracture is

opened or closed

Open Reduction Internal Fixation (ORIF)

surgically put the bone back in place, like a hip fracture

closed reduction

using plain traction and pulling and manipulating

immobilization

oExternal (cast, splints) or internal fixations

after medical management of fracture

immobilize and possible cast

plaster cast important considerations

know that it takes 24-48 hrs to dry, not at full strength, feel warm up is normal, don't wrap it, don't rest on hard surface

what should you always check for any type of casting

circulation

compartment syndrome common signs

if your pt starts complaining of pain that can't be explained, surgical emergency

Factors that Affect Fracture Healing

vInadequate fracture immobilization

vInadequate blood supply to the fracture site or adjacent tissue

vMultiple trauma

vExtensive bone loss

vInfection

vPoor adherence to prescribed restrictions

vMalignancy

vCertain medications (e.g., corticosteroids)

vAge >40 years

vComorbidities (e.g., diabetes, rheumatoid arthritis)

vEarly complications of fractures

oShock

oFat embolism

oCompartment syndrome

oVTE, PE- embolism from immobilization/vasculature

In an open fracture, there is a risk for

osteomyelitis (i.e., infection of the bone), tetanus, and gas gangrene

for prevention of infection they will give them

Intravenous (IV) antibiotics are given upon the patient's arrival in the hospital along with intramuscular (IM) tetanus toxoid as indicated

shock can be

hypovolemic or traumatic

Hypovolemic or traumatic shock resulting from hemorrhage is more frequently noted in trauma patients with

pelvic fractures and in patients with a displaced or open femoral fracture in which the femoral artery is torn by bone fragments

Fat embolism syndrome (FES) describes the clinical manifestations that occur when

fat emboli enter circulation following orthopedic trauma, especially long bone (e.g., femur) and pelvic fractures, more common in closed fracatures than open

The fat globules (e.g., emboli) may

occlude the small blood vessels that supply the lungs, brain, kidneys, and other organs.

a fat embolism is a

medical emergency

fat embolism onset of symptoms is

rapid, typically within 24 to 72 hours of injury, but may occur up to a week after injury

diagnosis for FES

There are no universal criteria for diagnosis of FES; diagnosis relies on clinical suspicion based upon the classic triad of symptoms and imaging findings

FES triad

hypoxemia, neurologic compromise, petechial rash

compartment syndrome

An anatomic compartment is an area of the body encased by bone or fascia (e.g., the fibrous membrane that covers and separates muscles) that contains muscles, nerves, and blood vessel

compartment syndrome what happens is

The pressure increases inside so bad, or putting cast on to night causes necrosis of the muscle and vasculature, emergency, cast needs to come off, will have a fasciotomy

vDelayed complications of fractures

oDelayed union, malunion, and nonunion

oAvascular necrosis of bone

oComplex regional pain syndrome (CRPS)

oHeterotrophic ossification

oDelayed union, malunion, and nonunion

-takes to long or edges don't heal together - may need grafts to heal

Avascular necrosis of bone

damage to the vascular of the bone, kill the bone cells

CRPS

disproportionate pain in the affected limb that may cause disuse of limb, hurts so bad they stop using the limb leading to muscle atrophy

Heterotrophic ossification

bone growing in places where it shouldn't

Most nursing care is based on help

restore function and supportive care.

Rehabilitation Related to Specific Fractures #1 clavicle

oUse of clavicular strap or sling

oExercises for elbow, wrist, fingers asap

oDo not elevate arm above shoulder for approximately 6 weeks

vHumeral neck and shaft fractures

oSlings and bracing

oActivity limitations until adequate period of immobilization