N120 Week 4 Martin

Sprain

• Injury to a ligament around a joint

• Can be of a wrenching or twisting motion 

• S/S: Pain and swelling

• Can heal on its own

Strain

• excessive stretching of muscle or tendon 

• S/S: Pain and swelling

• Can heal on its own 

Sprain and Strain Treatment

• RICE (Rest, Ice, Compress, Elevate)

• Rest - limit physical activity on affected limb 

• Ice - ice affected area but alternate between heat and cold in 28 hours to reduce swelling 

• Compress - ACE wrap or brace to reduce swelling and provide more support 

• Elevate - above level of the heart

• Medications - use muscle relaxers and anti-inflammatories such as NSAIDs 

• Surgical - if rupture is severe, then repair may be needed

Dislocation

• can happen to anything that bends

• Complete displacement or separation of the articular surface of the joint 

• Simplified: when a bone pops out of its normal place in a joint

• Treatment: prompt attention due to vascular compromise

Subluxation

• partial or incomplete displacement of the joint

• Can pop out and back because it now has weaker support 

• Greater risk for another dislocation 

• Treatment: prompt medical attention is needed to perform a reduction (putting the joint back in place) to relieve pressure and restore blood flow if there’s a vascular compromise.

• This helps prevent permanent damage to tissues that aren’t getting enough oxygen due to poor circulation.

• Reduction - putting a dislocated or subluxed bone back into its normal place

  • Joint is out of place → do a reduction → joint goes back where it belongs 

• Vascular Compromise - blood isn’t flowing properly

Fractures

• a break in the continuity of the bone

• Cause: trauma or bone diseases

  • Examples: osteogenesis imperfecta, complications from chemo or radiology, osteoporosis, vitamin D malabsorption (Rickets)

• Highest incidence in 15-24 year old males

Open vs Closed 

• Closed - skin is intact 

• Open - skin is not intact

  • Increased risk for infection (osteomyelitis) 

  • Common infection is staph and is treated with cefazolin 

  • Common practice is to administer antibiotics before the infection can occur

Complete vs Incomplete

• Complete - fracture is completely broken off

  • It’s fully separated into two or more pieces

  • Clean break 

  • Example: A snapped bone that’s in two parts

• Incomplete - fracture did not break off completely 

  • This is also known as hairline fracture 

  • Bone cracks but doesn’t break all the way through

  • It’s still partially connected (think: still holding on)

  • Common in kids (ex. Greenstick fractures) 

Transverse

•  90 degree access or horizontal break 

Spiral

• usually complete break 

• Usually caused by another person and is a tell tale sign of abuse unless caused by bone disorders such as osteogenesis imperfecta or rickets

• A rounded break or spiral break (think twisting of bones due to rotational force)

Greenstick

•  Usually an incomplete break 

• Common in pediatrics 

• Will splinter but is intact (think of a stick that has been bent) 

Comminuted

• splinters to two to three pieces 

• Crushed or turned into dust 

• Usually occur in severe traumas such as car crashes or major falls (high impact trauma)

• Harder to heal and usually needs surgery 

• Usually considered a complete break 

Oblique

• break goes at an angle (slanted line) across the bone 

• Can be complete or incomplete 

• Often caused by a sharp, angled blow or bending with compression 

Pathological

•  caused by change in bone structure that is physiological

• Caused by a disease that weakens bones causing the bone to break easily sometimes with little or no trauma  

Stress

• occur slowly overtime due to repeated use or stress (not due to a big injury)

• Common in runners as tiny cracks form overtime

• Common in feet, shins or hips 

Displaced

• needs to be realigned before casting to heal

• Bone pieces are out of alignment 

• Bone needs to be realigned (reduced) before healing using a cast or with surgery 

Nondisplaced

• bone is still within anatomical alignment

• Bone is cracked or broken but it is still in the normal position 

• No realignment needed 

• Only need to be immobilized to heal 

Bruising

• blood present in subcutaneous tissue 

Crepitation

•  palpable or audible crunching or popping sensation (may or may not be seen) due to bone pieces rubbing 

Deformity

•  abnormal position of the extremity 

  • Limb looks bent, twisted, or out of place — not in normal alignment

Swelling

• from bleeding and disruption of soft tissue

• From bleeding and inflammation in the surrounding soft tissues

Loss of function

•  disruptions of bone or joint

• Can’t use the limb properly due to the broken bone or disrupted joint

Pain

• muscle spasms

• Caused by muscle spasms, swelling, or nerves near the break being irritated

• Note: Pain must not be treated with opioids unless pain is severe

  • If opioids are to be given, ideally no more than 24 hours after injury. Muscle relaxants or NSAIDs must be used afterwards

Muscle relaxants are most preferred because muscle around injury (where nerve endings are) can be relaxed

Mandible

• broken jaw

• Immobilize jaw by wiring it

• Concerns: airway

  • Always have scissors and suction ready at bedside to cut wiring if needed (experiencing n/v, trouble breathing etc.)

  • This is a risk vs benefits situation. Patient’s mandible may receive further damage, but airway is always priority

Pelvic

• unstable and may be a risk for internal bleeding 

• The pelvis has many blood vessels so a fracture can cause massive internal bleeding that may not be visible externally

  • Can even quickly lead to shock 

• Shifts can compromise (damage) surrounding tissue 

  • When bones shift out of place, they can cut, puncture or press on nearby structures 

  • Bladder, ureter, reproductive organs in females, intestines can be ruptured (perforation may occur) 

• Nothing can be inserted down there until rupture is confirmed absent

  • If there's an organ rupture, you could accidentally worsen the injury or cause infection

  • Always wait until imaging (like CT or ultrasound) shows no rupture or perforation

    • Perforation - a hole or tear in an organ or tissue.

Hip

• common injury in older adults

• Head of femur is normally broken 

• Death sentence for older adults due to complications that come after 

  • Delayed healing 

  • Immobility leading to pneumonia 

• Fall prevention is very important as it is common cause 

• Breaking femur requires a lot of force 

Spine

• can cause permanent irreversible damage

• Important to immobilize patient and keep them aligned (logroll only) 

• Do not move patient if suspected

• The spine protects the spinal cord, which controls movement and sensation. If a fracture affects the cord, it can cause:

  • Paralysis, Loss of sensation, Incontinence, Loss of reflexes

Fracture Reduction

• - restoration of alignment 

Closed Reduction

•  manual manipulation; manually moved back into place by a doctor through pulling ot adjusting the limb 

  • Anesthesia: local or generalized 

    • MAC anesthesia is usually preferred

    • Lidocaine is an option (local) but does not work as well as generalized anesthesia 

  • Can be performed bedside or in OR by orthopedic surgeon or ER attending

  • The nurse’s job is to monitor the patient afterwards

  • Once aligned, the bone is usually immobilized with a cast or splint

  • Used when the fracture is simple and the bones can be moved without opening the skin

Open Reduction

•  correction through surgery 

• The skin is cut open to visually see and fix the broken bone

• Associated with internal fixation (usage of pins, plates etc)

• Restores natural alignment while internal fixation allow for healing through immobilization 

• Concerns for infection especially when… 

  • The surgical site isn’t kept clean

  • The patient has a weak immune system

  • There's hardware (screws/plates) left inside — which bacteria can stick to

• Allow for early ambulation because… 

  • Bone is stabilized immediately 

  • Less movement at the fracture site can help with pain and healing 

  • Secured in place through surgery so patient can start moving earlier (under guidance) without worrying about their bones shifting 

    • Cannot be done with closed reduction because manual manipulation does not use internal hardware to secure bone into place, causing it to shift or move more when weight is applied 

Traction

•  use of weight/force in opposite direction 

• Note: Nurses are NOT allowed to adjust, add, remove or manipulate traction weights unless there is a specific order from the provider. Either way, let the provider do the manipulation 

Skin Traction

• Uses elastic or adhesive wraps

• Device needs to be kept clean

• Avoid use of powders or lotion under this device to maintain skin integrity 

Buck’s Traction

• commonly used for hip fractures

  • It uses a boot or wrap applied to the lower leg. A weight is attached by a rope and pulley system. This pulls the leg gently in a straight line

  • Temporarily stabilizes fractures of the hip, femur, or pelvis.

  • Reduces pain by stopping muscle spasms 

    • A good indication for effective traction is reduced pain

    • Assess for pain when patient is using a traction 

  • Keeps the leg straight and aligned until surgery

  • Key points:

    • Non-invasive as it does not use pinks or screws in the bone 

    • Usually used short term 

    • Leg should stay flat and in line with the body 

    • Not more than 5 pounds of weight should be applied

      Nursing Considerations:

  • Weights must hang freely over the edge of the bed and never touch the floor 

  • Check for skin breakdown 

  • Assess for neurovascular status such as color, warmth, sensation, movement and pulses 

  • Make sure the stays aligned 

  • Implement preventative measures for pressure ulcers or DVT 

  • Patient must be turned every 2 hours 

  • Pillows to keep heels off the bed 

  • Monitor peripheral pulse

  • Check temperature of skin

  • Weights should hang freely

  • Nurses aren't allowed to adjust weights unless emergency

Bryants

•  typically used on pediatric cases

Pelvic Skin Traction

• used to stabilize the vertebrae

• Also known as balanced suspension traction 

• Used to relieve low back, hip or leg pain and reduce muscle spasm

• Apply traction snugly over the hip and pelvis and iliac crest and attach weights 

• Patient position is important

• If patient complains of muscle spasms, realign the patient first 

  • If this does not work you can request for a muscle relaxant 

• The last resort is opioids

Russell’s Traction

• combination of Buck’s traction but with sling 

• Provides two directions of pull:

  • Upward pull at the knee

  • Horizontal pull at the lower leg 

• Directions of pull help with:

  • Stabilizing hip and knee 

  • Maintain proper alignment of the femur and lower leg

  • Reduce muscle spasms and pain 

• Used for femur and hip fractures and some knee injuries 

• Considerations:

  • Weights need to hang freely 

  • Keep sling under the knee centered and padded 

  • Monitor:

    • Skin integrity

    • Circulation

    • Sensation and movement 

  • Avoid letting the patient turn to the side as it can throw off alignment 

Differentiation between Buck’s and Russell’s

• Buck’s

  • Leg is straight

  • Pulls only in ONE direction 

  • Used for hip or femur fractures 

  • Helps reduce muscle spasms before surgery 

• Russell’s 

  • Knee is bent and supported by a sling 

  • Pulls in TWO directions 

  • Also for hip/femur fractures 

• Memory 

  • Buck’s = Straight leg, Single pull

  • Russell’s = Raised knee, Double pull

Skeletal Traction

• Screwed directly onto bone 

• More so for long term use for severe fractures

• Can support more weights than a skin traction

• Involves surgically inserting pins, wires or screws directly into the bone 

  • Weights are attached to these pins to pull bone into proper alignment  

  • Higher risk for infections due to opening created for metal pins or screws that allow pathogens directly into the body

    • Can lead to osteomyelitis 

  • Nursing Care

    • Pin care - clean daily to prevent infections 

    • Watch for signs of infections 

    • Check for neurovascular status 

    • Weights must hang freely 

    • Monitor for pressure injuries, constipation and DVT due to immobility

Traction Nursing Care

• Maintain correct balance between traction pull and counter traction force 

• Assess for complications of other organs

• Check equipment 

• Avoid manipulation of pins

• Maintain counter traction 

• Care for weights

  • Weights are ordered 

  • If adjustments are needed, call for the doctor. DO NOT do it yourself

• Inspect skin and provide skin care

• Pin care 

  • Serous drainage is fine but purulent drainage are not 

• Assess for neurovascular status (is the nerve and blood flow okay?) 

  • Look for 7Ps of Perfusion 

  • If pain is present 

    • Reposition patient as traction might have shifted causing pain

    • Administer medication but avoid opioids as much as possible

    • Muscle relaxants are preferred 

• Assist with toileting needs 

• Notes:

  • Ropes are at the center o􏰁 the wheel 􏰀rooves

  • Weights are equal on both sides and 􏰁ree han􏰀in􏰀

  • Ropes are secured between pins and weights

Pain (7 P’s)

• can be caused by anoxic/decrease oxygen being received by cells due to a decrease in blood flow

• May signal nerve damage or compartment syndrome

• Is it severe, unrelieved by meds, or worsens with movement?

• Is pain out of proportion? 

• Unresponsive to medication?

• Always obtain baseline data because it will help with making comparisons and guide interventions

Pallor (7 P’s)

• pale, white, gray or dusky skin

• Pale, cool, or blue skin = poor blood flow

Pulse or Pulselessness (7 P’s)

• can be due to weakened or lost blood flow

• Is a pulse present below the injury (e.g., dorsalis pedis, radial)?

• Assess distal to site of injury but this can also be challenging due to barriers like casts 

  • If this is the case, check for capillary refill instead

• Weak or absent = circulatory issue

Paresthesia (7 P’s)

•  tingling, numbness, or pins-and-needles sensation

• Early sign of nerve compression

• Usually means a nerve is being pinched, compressed, or irritated, often from:

  • Swelling

  • Tight casts or bandages

  • Fractures

  • Poor circulation

Paralysis (7 P’s)

•  weakness or loss of motor activity

• Complete/total paralysis should never happen

  • At most, patient must be able to wiggle their toes

• Can they move their fingers or toes?

• No movement may = nerve or muscle damage

Poikilothermia (7 P’s)

• cool skin temperature

• Is the affected limb cool to touch compared to the other side?

Pressure (7 P’s)

•  taut skin, edema

  • Patient may complain that cast is tight (usually a sign) 

  • Does the limb feel tight, swollen, or firm?

  • May be a sign of compartment syndrome where internal pressure builds up and cuts off circulation

Cast

• ridged device immobilize injury allows free movement of the body

• Can be made of plaster or fiberglass

• Plaster is older technology

• Cast Care:

  • Educate why, what how 

  • Apply ice directly over cast for the first 24 hours but avoid getting the cast wet 

    • To help reduce swelling and pain in the area right after the injury or casting

  • No sharp objects into cast 

    • Objects can scratch skin and lead to infection or even skin breakdown 

    • Harder to treat or even intervene because visualization is impeded

    • Infection can usually be detected through malodorous smell

    • Cold air through blow dryer can usually help with itching  

  • Prevent skin irritation by cleaning skin and assessing for signs of infection 

  • Attend to pain when reported 

  • Neurovascular checks are a must 

  • Encourage isometric exercises so function can be maintained 

• Interventions with wet cast 

  • Keep the cast and extremity elevated

  • Allow a wet cast 24-48 hours to dry

    • synthetic casts dry 20 mins

  • Handle a wet cast with the palms of the hand until dry

  • Turn the extremity unless contraindicated, so that all the sides of the cast will dry

Internal Fixation

•  follows an open reduction. Putting hardware inside the body to keep broken bones aligned and stable after surgery.

• Screws, plates, pins or nails are used 

• Removal of damaged bone 

  • If the bone is shattered or diseased, parts may be cut out

• Replacement with prosthesis 

  • If a joint or bone section is too damaged, it may be replaced with an artificial part (like in a hip replacement)

• For bone stabilization 

  • These devices keep the bone still and aligned while it heals

• Risk of infection 

  • Since it's a surgical procedure with hardware, there's a higher risk for wound infection, bone infection (osteomyelitis) especially if proper pin care or hygiene isn't followed

External Fixation

• external frame is utilized with multiple pins applied through the bone and attached to the external rods 

  • Used to salvage extremities 

  • Patient Education: do not manipulate external pins

    • Only allowed to clean pin sites 

  • Provides more freedom of movement than traction

• Note: casting and splinting are within nursing scope of practice as long as properly trained to do it (orthopedic nurses)

(#1) Compartment Syndrome

•  where swelling inside a muscle compartment increases pressure so much that blood cant flow, nerves can't function and tissue begins to die

  • Can lead to avascular necrosis 

  • Causes:

    • Soft tissue injury

    • Fracture

    • Tight casts or bandages

    • Severe burns  (due to swelling from fluid shifts)

  • Challenging to identify as similar to what is expected to be found for fractures especially during early signs 

    • Patient complaints: pain and swelling

      • Early signs look like normal fracture pain/swelling

    • Cast is a barrier to visualization 

      • Cast hides the swelling, so nurses must rely on patient complaints and careful assessment

    • Can happen 24 to 28 hours after injury

      • After 28 hours, it is no longer likely to be compartment syndrome 

  • Necrosis (tissue death) can begin just 4 to 6 hours after the onset of compartment syndrome.

    • When pressure builds up in a muscle compartment, it cuts off blood flow

    • Without oxygen, the muscle, nerves, and tissues start dying

    • The longer the pressure lasts, the more permanent the damage becomes

    • After 12+ hours: Damage may be irreversible

    • If not treated quickly → may lead to permanent disability or even amputation

  • Assessment: Watch for 7Ps 

  • Implementation

    • Notify physician immediately 

    • Obtain cast cutter and tono pen (to measure pressure)

    • DO NOT elevate 

    • NO cold compress 

• Treatment

  • Fasciotomy - a procedure in which the fascia is cut to relieve pressure in the muscle compartment 

    • Prepare for OR if pressure is greater than 30 mmHg 

    • Site is usually packed with sterile pads and gauze

    • Is not closed for five days 

  • Bivalving - to split (a cast) along one or two sides (to relieve pressure)

(#2) Fat Embolism

•  an embolism originating in the bone marrow that occurs after fracture 

  • Long bone or flat bones fractures are at the greatest risk 

  • Usually occur within 48 hours following the injury 

  • Embolism can be trapped anywhere

  • Diagnostic Clues

    • No specific lab test can be done 

    • Increased fat cells in blood, urine or sputum can be tested

    • Decreased PaO2 less than 60 mmHg due to poor oxygenation

      • Give patient O2 

      • Location of emboli does not matter because circulating O2 is going down 

    • Decreased platelet count and Hct 

    • ECG may show ST segment and T Wave from hypoxia

    • Chest x ray may show bilateral pulmonary infiltrates 

  • Assessment 

    • Early sign is confusion (most likely from hypoxia) 

    • Restless and altered LOC (from hypoxia)

    • Tachycardia, tachypnea and hypotension (compensation) 

    • Dyspnea 

    • Petechial rash over upper chest, neck and axillae conjunctiva 

      • Thrombotic emboli does not have this 

      • Usually a sign of decreased platelet count 

  • Implementation 

    • Notify physician immediately

    • Treat signs and symptoms

      • Respiratory - Support breathing by putting patient in O2 or mechanical ventilation 

      • Cardiac 

        • Give IV fluids 

        • Pulmonary vasodilators

        • Peripheral vasoconstrictors

        • Inotropic drugs (affects contraction strength of the heart)

      • Monitor cardiac status 

        • Check vitals such as HR, BP, RR, SpO2 

        • Monitor changes in ECG (ST segment and T wave)

        • Watch for tachycardia and hypotension

      • Medication

        • No research supporting the use of steroids, heparin or dextran

(#3) Osteomyelitis and Infection

• Difficult to treat 

• Can be caused by the interruption of the integrity of the skin, severe infection of the bone marrow and surrounding soft tissue 

• Types:

  • Indirect (20%) - Infection spreads from another part of the body via blood

    • Risk Factors in adults are age, debilitation, hemodialysis, sickle cell disease and IV drug use 

  • Direct (80%) - Infection comes from open wounds, fractures, or surgical sites

    • Can occur in open wounds as bacteria directly enters the bone

• Assessment

  • Fever

  • Pain (localized)

  • Erythema in the area surrounding fracture 

  • Bradycardia 

    • Can occur with sepsis or as later systemic response 

  • Elevated WBC 

  • Difficulty moving or baring weights 

• Implementation 

  • Aggressive IV antibiotics 

  • Physical or occupational therapy 

• Common on foot of diabetic patients

• Summary: bone infection that's hard to treat, usually needs IV antibiotics, and often shows up in diabetic feet or open wounds.

(#4) Venous Thrombosis - Pulmonary Embolism

• Assessment 

  • Restlessness and apprehension 

  • Dyspnea

  • Diaphoresis

  • Arterial blood gas exchange

  • An early sign is SOB 

• Implementation 

  • Notify physician if signs of emboli are present 

  • Prepare to administer anticoagulant therapy (thrombosis)

(#5) Pressure Ulcers

• Occurs because of the ischemia to the tissue bed from collapsed blood vessels

• Risk Factors 

  • Immobility

  • Moisture

  • Obesity

  • Nutrition

  • Shear Friction

  • Disease

  • Contractures

  • Increased body temperature

  • Impaired circulation 

  • Incontinence

  • Low diastolic pressure

  • Mental deterioration 

  • Pain

  • Prolonged surgery

• Sites - heels, sacrum, scapula, hips, elbows, ears

• Influenced by - intensity, time, tissue tolerance 

Braden Scale - sensory perception, moisture, activity, mobility, nutrition, and friction/shear