chapter 37 management of pts with musculoskeletal trauma

Injuries of the musculoskeletal system ***

• contusion: soft tissue injury produced by blunt force

  • pain swelling and discoloration: ecchymosis

• strain: pulled muscle injury to the musculotendinous unit

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

• Sprain: injury to ligaments and supporting muscle fiber around a joint

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

• dislocation: articular surfaces of the joint are not in contact

  • a traumatic dislocation is an emergency with pain change in contour, axis, and length of the lib of mobility

• subluxation: partial or incomplete dislocation

  • does not cause as much deformity as a complete dislocation

management of soft tissue injuries ***

RICE

• rest

• ice

• compression

• elevation

immobilize

types of fractures 1

closed or simple

no break in the skin

wound extends to the bone

• grade I: 1 cm long clen wound

• Grade II: larger wound without extensive damage

• Grade III: highly contaminated, extensive soft tissue injury, may have amputation

intra- articular

• extends into the joint surface of a bone

manifestations of fracture

• acute pain

• loss of function

• deformity

• shortening of the extremity

• crepitus

• local swelling and discoloration

• diagnosis by symptoms and radiography

• patients usually reports an injury to the area

emergency management

• immobilize the body part

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

• assess neurovascular status before and after splinting

• open fracture: cover with sterile dressing to prevent contamination

• do not attempt to reduce the fracture

surgeons or paramedics reduce the fracture

medical management of fracture

• fracture reduction: restoration of the fracture fragments to anatomic alignment and positioning

closed

• uses manipulation and manual traction

• traction may be used (skin or skeletal)

open

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

immobilization

• external (cast, splints) or internal fixations

factors that affect fracture healing

• inadequate fracture immobilization

• inadequate blood supply to the fracture site or adjacent tissue

• multiple trauma

• extensive bone loss

• infection

• poor adherence to prescribed restrictions

• malignancy - cancer that metastasized to bone

• certain medications (corticosteroids)

• age >40 yrs

• comorbidities ( diabetes, rheumatoid arthritis)

lack of care someone not going to the ER in high poverty areas

complications of fractures

early complications

• shock severe fracture

• fat embolism

• compartment syndrome

• VTE, PE

delayed complications

• delayed union, malunion, nonunion

• avascular necrosis of bone

• complex regional pain syndrome (CRPS)

• heterotrophic ossification

rehabilitation related to specific fractures ** ( CLAVICLE)

clavicle

• use of clavicular strap or sling

• exercises for elbow, wrist fingers asap

• do not elevate arm above for 6 weeks

humeral neck and shaft fractures

• slings and bracing

• activity limitations until adequate period of immobilization

rehabilitation related to specific fractures #2 ** (ELBOW)

elbow fractures

• monitor regularly for neurovascular compromise and signs of compartment syndrome

• potential for Volkmann contracture

• active exercises and ROM are encouraged to prevent limitation of joint movement after immobilization and healing (4-6 weeks for nondisplaced casted) or after internal fixation (about 1 week)

• radial, ulnar, wrist and hand fractures

• early functional rehabilitation exercises

• active motion exercises of fingers and shoulders

rehabilitation related to specific fractures #3 (PELVIC)

• pelvic fractures

• management depends on type and extent of fracture and associated injuries

• stable fractures are treated with a few days of bed rest and symptom management

• early mobilization reduces problems related to immobility

hip fractures

• surgery is usually done to reduce and fixate the fracture

• care is similar to that of a patient undergoing other orthopedic surgery or hip replacement surgery

rehabilitation r/t specific fractures #4 (femoral shaft)

femoral shaft fractures

• lower leg, foot, and hip exercises to preserve muscle function and improve circulation

• early ambulation stimulates healing

• physical therapy, ambulation and weight bearing are prescribed

• active and passive knee exercises are begun as soon as possible to prevent restriction of knee movement

assessment of the pt with a brace, splint or cast #1 **

Before application

• general health assessment

• emotional status

• presenting signs and symptoms and condition of the area

• monitoring of neurovascular status and for potential complications

• treat lacerations and abrasions before cast, brace, splint

• provide information about the purpose of treatment

• prepare patient for application by explaining procedure

know when to use a brace v splint

assessment with brace, splint or cast #2

• assessing for neurovascular changes using 5 Ps

• pain

• pallor

• pulselessness

• paresthesia

• paralysis

• monitoring and treating pain

• describe exact site, character and intensity of pain

• treat with elevation, ice packs, and analgesics

once they have one of the devices put on know pts at risk for using a brace splint or cast

potential complications of the patient with a brace splint or cast #1

acute compartment syndrome

• serious complication occurs from increased pressure in a confined space

• compromised blood flow

• ischemia and irreversible damage can occur within hours

• clinical assessment of 5 Ps is the early indicator

• treatment: notify physician cast may be removed and emergent surgical fasciotomy may be necessary

potential complications of the pts with a brace, splint or cast #2

pressure injuries: caused by inappropriately applied cast

lower extremity sites most susceptible

patient reports painful “hotspot” and tightness

Dx: may cut window in the cast for inspection and access

treatment: dressing applied over exposed skin

disuse syndrome: muscle atrophy and loss of strength (frozen shoulder)

• treatment: isometric exercises, muscle setting exercises

education needs of the pt with a cast, brace or splint #1

what they need to do to care for themselves

• impact of injury to physiologic functioning (ADL, IADL)

• activity exercise rest

• medications

• techniques for cast drying

• controlling of swelling and pain

• care of minor skin irritation

  • pad rough edges with tape or moleskin

  • blow with the hair dryer to relieve itching

  • do not stick foreign objects into the cast

education needs of the pt with a cast, brace, or splint #2

s&s

• signs and symptoms to report:

• persistent pain or swelling

• changes in sensation, movement, skin color, or temperature

• signs of infection or pressure areas

• required follow up care

• required follow up care

• cast removal and after care

external fixator device

if someone has pins or rods understand pin care and how to clean it

• used to manage open fractures with soft tissue damage

• provide support for complicated or comminuted fractures

• patient requires reassurance because of appearance of device

• discomfort is usually minimal, and early mobility may be anticipated with these devices

• elevate to reduce edema

• monitor for signs and symptoms of complications, including infection

• pin care

• patient education

traction 1

• the application of pulling force to a part of the body

• purposes

  • reduce muscle spasms

  • reduce align and immobilize fractures

  • reduce deformity

  • increase space between opposing forces

• used as a short term intervention until other modalities are possible

application of weights that cause a pulling force on certain part of the body

use it for a pt having severe muscle spasms, if someone is paraplegic,

types of traction

skin traction

• bucks extension traction

skeletal traction

• thomas leg splint

traction #2

• all traction to be applied in two directions

• the lines of pull are “vectors of force” the result of the pulling force is between the two lines of the vectors of force

applied in 2 directions

principles of effective traction

• whenever traction is applied, a counterforce must be applied. frequently the patients body weight and positioning in bed supply the counterforce

• traction must be continuous to reduce and immobilize fractures

• skeletal traction is never interrupted

• weights are not removed unless intermittent traction is prescribed

• any factor that reduces pull must be eliminated

• ropes must be unobstructed and weights must hang freely

• knots or the footplate must not touch the foot of the bed

suspension skeletal traction with Thomas leg splint

combination of bucks traction and skeletal

bucks most common one point of pulling

complicated leg up moving verything at same time

nursing interventions for the patient in skin traction #1

• proper application and maintenance of traction

• monitor for complications of breakdown, nerve damage and circulatory impairment

  • inspect skin at least three times a day

  • palpate traction tapes to assess for tenderness

  • assess sensation and movement

  • assess pulses, color, capillary refill, and temperature of finger or toes

  • assess for indicators of DVT

  • assess for indicators of infection

nursing interventions for the pt in skeletal traction #2

• evaluate traction apparatus and patient position

• maintain alignment of body

• report pain promptly

• trapeze to help with movement

• assess pressure points in skin at least every 8 hours

• regular shifting of position

• special mattresses or other pressure reduction devices

• perform active foot exercises and leg exercises every hour

nursing interventions for the patient in skeletal traction #2

• anti-embolism sticking’s, compression devices or anticoagulant therapy may be prescribed

• pin care

• exercises to maintain muscle tone and strength

nursing management of patients in traction

• assessing anxiety

• assisting with selfcare

• monitor and manage complications

  • atelectasis and pneumonia

  • constipation

  • anorexia

  • urinary stasis

  • infection

  • VTE

assessment of the patient with fracture of the hip *

• health hx and presence of concomitant problems

• pain

• vs, respiratory status, LOC, and signs and symptoms of shock

• affected extremity including frequent neurovascular assessment

• bowel and bladder elimination, bowel sounds I&O

• skin condition

• anxiety and coping

collaborative problems and potential complications for the pt with a hip fracture *

• hemorrhage

• peripheral neurovascular dysfunction

• skin breakdown

• loss of bladder control

• delayed: infection, nonunion (fracture that fails to heal), AVN (avascular necrosis, bone tissue dies)

planning and goals for the patient with fractured hip *

• relief of pain

• achievement of pain free functional and stable hip

• healed wound

• maintenance of normal urinary elimination pattern

• use of effective coping mechanisms

• remains oriented and participates indecision making

• absence of complications

common sports related injuries

• fracture: clavicle, wrist, ankle, metatarsal stress

• dislocations: shoulder and elbow

• sprains: wrist ankle

• knee: sprain, strain and meniscal tears

prevention of sports related injuries

• use of proper equipment, running shoes for runners, wrist guards for skaters and so on

• effective training and conditioning specific for the person and the sport

• stretching

• hydration

• proper nutrition

occupation related injuries

• nursing ranked top 10 occupations most involved

• common injuries include

  • strains, sprains, tears

  • cuts, lacerations, contusions, bruises

• prevention measures may include

• safe patient handling training and proper use of equipment

• correct use of body mechanics

amputation

may be congenital or traumatic or caused by conditions such as progressive peripheral vascular disease, infection, malignant tumor, trauma

performed to control pain or disease process, improve function, and improve quality of life

health care team needs to communicate a positive attitude to facilitate patient acceptance and participation in rehabilitation

assessment of the patient with an amputation

neurovascular and functional status of affected extremity or residual limb and of unaffected extremity

signs and symptoms of infection

nutritional status - foods to promote healing

concurrent health problems psychological status, grief and coping

collaborative problems and potential complications of the patient with an amputation

• postoperative hemorrhage

• infection

• skin breakdown

• phantom limb pain

• joint contracture

planning and goals for the patient with an amputation

major goals:

• relief of pain

• wound healing

• acceptance of altered body image

• resolution of grieving process

• independence in self care

• restoration of physical mobility

• absence of complications

nursing interventions for the patient with an amputation #1 (pain)

relieving pain

• administer analgesic or other medications as prescribed

• changing position

• putting a light sandbag on residual limb

• alternative methods of pain relief: distraction, TENS unit

Promoting wound healing

• handle limb gently

• residual limb shaping

nursing intervention for the patient with an amputation #2 (resolving grief)

resolving grief and enhancing body image

• encourage expression of feelings

• create an accepting supportive atmosphere

• provide support and listen

• encourage patient to look at feel and care for the residual limb

• help patient resume self care and independence

• referral to counselors and support groups

nursing interventions for the patient with an amputation #3 ( self care)

promoting self care

• encourage active participation in care

• continue support in rehabilitation facility or at home

• focus on safety and mobility

nursing intervention for the pt with amputation #4 ( physical mobility)

assisting the patient to achieve physical mobility

• proper positioning of limb, avoid abduction, external rotation and flexion

• turn frequently, prone positioning if possible

• use of assistive device

• ROM exercises

• muscle strengthening exercises

• prepprosthetic care - proper bandaging massage and toughening of the residual limb