Topic 10: Soft Tissue Injuries and Fractures (Ch 67)

soft tissue injuries

result from abnormal stretching or twitching forces during vigorous activities that tend to occur around joints in the spinal muscles; can be sprains or strains

sprains

Soft tissue injury is an injury to the ligaments surrounding a joint, usually caused by a wrenching or twisting motion, most often occurring in the ankle, wrist, and knee joints. classified based on the degree of ligament damage

1st degree/mild sprain

tears in only a few fibers of the ligament, presents with mild tenderness and minimal swelling

2nd degree/moderate sprain

sprain with partial disruption of the involved tissue with more swelling and tenderness

3rd degree/severe sprain

complete tear of the ligament with moderate to severe swelling

strains

an excessive stretching of a muscle and its facial sheath, often involving the tendon, most often occurring in the large muscle groups including the lower back, calf, and hamstrings

1st degree strain

mild or slightly pulled muscle

2nd degree strain

moderate or moderately torn muscle

3rd degree strain

severely torn or ruptured muscle

• pain

• edema

• decreased function

• bruising

• if mild is usually self-limiting and full function generally returns within 3-6 weeks, and X-rays may be done to rule out a function

what are the clinical manifestations of soft tissue injuries (sprains and strains)

• warm-up exercises to warm up muscles before exercising and vigorous exercise

• stretching

• Strength, balance, and endurance exercises are important

• use protective athletic equipment like helmets, knee/wrists/elbow pads

• use proper safety equipment at work

• wear seatbelt

• drive within posted speed limits

• do not drink under the influence of alcohol or drugs

• reduce fall risk:

  • assess living environment for safety risks

  • wear functional, nonskid, hard-soled shoes

  • avoid wet or slippery surfaces

  • remove throw rugs and ensure adequate lighting in the house

  • maintain clear paths to the bathroom for nighttime use

• older adults:

  • use ramps in building and at street corners instead of steps

  • fall risk precautions

  • treat pain and discomfort from OA

    • rest in positions that decrease discomfort

    • use meds as prescribed for pain

  • use a walker or cane to prevent falls

  • prevent obesity as extra weight adds stress to joints, which may predispose to OA

  • get regular and frequent exercise

    • ADLs, ROM, Tai Chi, hobbies to prevent finger joint stiffness like puzzles/sewing, daily weight bearing exercises like walking

  • use shoes with good support for safety and comfort

  • avoid sudden changes in position, rise slowly to a standing position to prevent dizziness, falls, and fractures

  • do not walk on uneven surfaces or wet floors

what are ways to prevent the risk or worsening of soft tissue injuries (sprains and strains)

• helps with weight management, maintains/improves bone mass, prevents high BP

• increases lean muscle, muscle strength, flexibility, and endurance

• decreases body fat

• reduces risk for heart disease, DM, colon cancer, and depression

• enhances sense of well-being

how does physical activity impact health positively

rest, ice, compression, elevate (RICE), provide analgesia and NSAIDs as needed to manage discomfort

what does acute care (first 24 hours) for after a soft tissue injury (sprain and strain) include that may decrease local inflammation and pain for most injuries

rest

acute care for soft tissue injuries: stop activity and limit movement to the injured part

ice (cryotherapy)

acute care for soft tissue injuries: cold therapy to the involved area for 24-48 hours for 20-30 minutes at a time that causes vasoconstriction in the soft tissue and reduces the transmission and perception of nerve pain impulses, reduces muscle spasms, inflammation, and edema; is most effective when applied immediately after an injury has occurs, do not apply directly to the skin

compression

acute care for soft tissue injuries: apply elastic bandage distal to proximal to prevent edema and encourage fluid return; should not be numbness/tingling before the area of compression/pain or swelling or beyond the edge of the bandage; leave in place for 30 minutes and then remove for 15; helps decrease edema and pain

elevate

acute care for soft tissue injuries: place the extremity above the heart for 24-48 hours to help mobilize excess fluid from the area and prevent further edema

• apply warm, moist heat to the affected part to reduce swelling and provide comfort, do not exceed 20-30 minutes

  • allow a cool-down time between applications

• encourage use of the limb if it is protected by a cast, brace, split, or taping as movement maintains nutrition to the cartilage, prevents contractures (stiffening) of tendons and ligaments, and muscle contraction improves circulation and helps resolve bruising and swelling

• need strength and conditioning exercises to prevent injury

what does care include 24-48 hours after the acute phase has passed for soft tissue injuries (sprains and strains)

• crush injury

• direct blows

• falls

• motor vehicle crashes

• sports injuries

what may cause acute soft tissue injury

• bruising

• decreased movement with limited function or inability to bear weight (lower extremity)

• decreased sensation, pulse, coolness, capillary refill > 2 seconds

• edema

• muscle spasms

• pain, tenderness

• pallor

• shortening or rotation of the extremity

What are common assessment findings of acute soft tissue injuries as a result of crush injuries, direct blows, falls, motor vehicle crashes, and sports injuries, etc

• ensure airway, breathing, circulation

• perform a neurovascular assessment of the involved limb

• elevate the involved limb

• apply a compression bandage unless a dislocation is present

• apply ice packs to the affected area

• immobilize the affected extremity in the position found, do not try to realign or reinsert protruding bones

• anticipate x-rays to the injured extremity

• give analgesia as needed

• give tetanus prophylaxis for open fractures, large tissue defects, or mangled extremity injuries

What are the initial interventions after an acute soft tissue injuries as a result of crush injuries, direct blows, falls, motor vehicle crashes, and sports injuries, etc

• monitor for changes in neurovascular condition

• implement weight-bearing exercises as ordered for the lower extremities

• anticipate comparison pressure monitoring if neurovascular assessment changes and compartment syndrome are suspected

What does ongoing monitoring after initial interventions include for acute soft tissue injuries as a result of crush injuries, direct blows, falls, motor vehicle crashes, and sports injuries, etc

fracture

a disruption or break in the continuity of bone MCC by traumatic injuries or diseases like cancer and osteoporosis

• open or closed

• complete or incomplete

• direction of the fracture line

• displaced or nondisplaced

how are fractures classified

open fracture

fracture in which skin is broken and the bone is exposed, causing soft tissue injury usually resulting from severe external forces

closed fractures

fractures in which the skin is intact over the site

complete fracture

fracture in which the break goes completely through the bone

incomplete fracture

fractures that occur partly across a bone shaft, but the bone is still intact, and often the result of bending or crushing forces applied to the bone

linear fracture

a fracture that breaks parallel to the bone’s long axis or shaft; a straight/clean break

oblique fracture

the line of the fracture extends across and down the bone

transverse fracture

the line of the fracture extends across the bone shaft at a right angle to the longitudinal axis

longitudinal fracture

a fracture that extends across the length of the bone shaft and is more irregular than just straight across

spiral fracture

the line of the fracture extends in a spiral direction along the bone shaft

greenstick fracture

incomplete fracture with one side splintered and the other side bent

comminuted fracture

fracture with more than 2 fragments, with the smaller fragments appearing to be floating

pathologic fracture

a spontaneous fracture at the site of diseased bone

stress fracture

fracture that occurs in bone that is subject to repeated stress such as from running

displaced fracture

fracture in which two ends of the broken bone are separated from each other and out of their normal position, and are often comminuted or oblique

nondisplaced fracture

fracture in which bone fragments stay in alignment and are usually transverse, spiral, or greenstick

• edema and swelling

• immediate pain and tenderness

• muscle spasms

• deformity

• contusion

• loss of function

• crepitation

• guarding and protection against movement

• inability to bear weight and/or use the effective part

• bruising immediately after injury and distal to injury (is normal and will resolve)

what are the clinical manifestations of fractures

edema and swelling

S/S of fractures in which unchecked bleeding and swelling in a closed space can occlude BVs and damage nerves, which increases the risk of compartment syndrome

splint the muscle around the fracture and reduce the motion of the injured area

what can a nurse recommend/do for a patient experiencing immediate pain and tenderness after suffering from a fracture

muscle spasms

sign of fracture that occurs due to irritation of tissues and a protective response to injury and fracture that may displace and nondisplaced fracture or prevent it from reducing spontaneously

deformity

classic sign of a fracture that is abnormal position of extremity or part from the original forces of injury and action of muscles pulling the fragments into an abnormal position, seen as a loss of normal bony contours, and if uncorrected, may cause problems with body union and restoration of function of the injured part

crepitation

S/S of fractures in which grating or crunching of bone fragments causes palpable or audible crunching or popping sensation, which may increase the chance of nonunion of bone ends that are allowed to move excessively

open fractured reduction

the correction of bone alignment through surgery that usually includes internal fixation of the fracture with wires, screws, pins, plates, intramedullary rods, or nails, which is influenced by the type and location of the fracture, patient’s age, and concurrent disease

• infection

• complications of anesthesia

• effects of preexisting medical conditions like DM

what are the risks associated with open fracture reduction

open reduction internal fixation (ORIF)

facilitates early ambulation, which decreases the risk for complications related to prolonged immobility

closed fracture reduction

the nonsurgical, manual realignment of bone fragments to their anatomic position that is usually done while the patient is under local or general anesthesia; often uses traction and traction devices to attain realignment

traction

the application of a pulling force to an injured or diseased body part or extremity used in closed reduction; MC skin and skeletal traction

• prevent/reduce pain and muscle spasms like whiplash or unrepaired hip fractures

• immobilize a joint or part of the body

• reduce a fracture or dislocation

• treat a pathological joint condition like a tumor or infection

• provide immobilization to prevent soft tissue damage

• promote active and passive exercise

• expand the joint space during arthroscopic procedures or before major joint reconstruction

what is traction used for

countertraction

pulls in the opposite direction of the pulling force of the traction

skin traction

traction that is generally used for short-term treatment (48-72 hours) until skeletal traction or surgery is available in which tape, boots, or splints are applied directly to the skin and help to decrease muscle spasms in the injrued extremity; weights are usually 5-10 lbs

Buck’s traction

type of skin traction that is sometimes used for the patient with a hip, knee, or femur fracture

• regular skin assessment because pressure points and skin breakdowns may develop quickly

• assess key pressure points every 2-4 hours

what are the nursing interventions for a patient with skin traction

skeletal traction

traction that is used to align injured bones and joints or to treat joint contractures and congenital dysplasia; provides a long-term pull that keeps the injured bones aligned.

The HCP inserts a pin/wire into the bone, and weights (5-45 lbs) are attached to align and immobilize the injured body part

balanced suspension traction

common skeletal traction that requires correct patient positioning and alignment with constant traction forces

• maintain countertraction, which is typically the patient’s own body weight

• elevate the end of the bed

• maintain a continuous traction

• keep weights off the floor and moving freely through pulleys

what are the nursing interventions for a patient with a balanced suspension traction

• When slings are used, regularly inspect exposed skin areas

• assess skeletal traction or external fixation pin sites for signs of infection

• pin site care may vary; usually clean with chlorhexidine, rinse with sterile saline, dry area with sterile gauze

• if exercise is allowed, encourage participation in a simple exercise-based program

• frequent positioning changes, ROM exercises of affected joints, deep breathing, and isometric exercises several times a day

• use a trapeze bar if permitted to raise the body off the bed for linen changes and placements of the bedpan

what are the nursing interventions for the use of traction

• casts

• braces

• splints

• immobilizers

• external and internal fixation devices

what is fracture immobilization obtained with

casts

Temporary immobilization devices are often applied after closed reduction that usually immobilizes the joints above and below a fracture, which restricts tendon and ligament movement, thus assisting with joint stabilization while the fracture heals. They often allow patients to perform many ADLs while providing stability/maintaining immobilization. commonly made of Plaster of Paris and Fiberglass

fiberglass

The material of casts that is most often used is lighter, relatively waterproof, and can be worn for longer

plaster of paris

Material of casts that is primarily used for contact casting for treating diabetic foot ulcers should be immersed in warm water and then wrapped/molded around the affected part. Left uncovered to allow air circulation. Covering allows heat to build up, causing burns and delayed drying. Avoid direct pressure. Handle gently with an open palm to avoid denting the case

• can interfere with circulation and nerve function if applied too tightly

• excess edema may occur after application

what are the complications of casts

• apply ice directly over the fracture site for the first 24 hours, avoid getting the cast wet by keeping the ice in a plastic bag and protecting the cast with a cloth

• check with HCP before getting fiberglass wet

• dry thoroughly if inadvertently exposed to water, lot dry with a towel, use hair dryer on low setting until cast is thoroughly dried

• elevate the extremity above heart level for the first 48 hours

• Regularly move joints above and below the cast

• do not put anything inside the cast, use a hair dryer on cool setting for itching inside the case

• educate on what to report to HCP

  • increasiing pain despite elevation, ice, and analgesia

  • swelling with pain and discoloration or toes or fingers

  • pain during movement

  • burning or tingling under the cast

  • sores or foul odor under the cast

• keep follow up appointment

• do not remove any padding

• do not bear weight on new cast for 48 hours, some not at al

• do not have with plastic for prolonged periods

what are the nursing interventions for a patient with a cast

external fixation

fracture immobilization method that is composed of metal pins and wires that are inserted into the bone and attached to external rods to stabilize the fracture while is heals; a long term process taht can be used to apply traction, compress fragments, and immobilized reduced fragment; used for complex fractures with extensive soft tissue damage, congenital bone defects, nonunion or malunion, limb lengthening, and in an attempt to save the extremity that may have required amputation;

NC: assess for pin loosening and infection. Patient teaching on pin site care

internal fixation

fracture immobilization method that is the surgical realignment of body fragments using devices to maintain the position of the fragments; pins, plates, rods, and screws are biologically inert and mad from stainless steel, vitallium, or titanium

x-ray evalv of proper alignment and bone healing

• Muscle relaxants may be given to manage pain from muscle spasms

  • Carisoprodol (Soma), cyclobenzaprine (Flexeril), methocarbamol (Robaxin)

• Tetanus, diphtheria toxoid, or tetanus immunoglobulin is given to a patient with an open fracture when immunization status is unknown

• bone penetrating antibiotics like cephalosporins are given prophylactically before surgery

what does drug therapy for a patient with a fracture include

• adequate protein, vitamins (especially vitamin C), calcium, potassium, phosphorus, magnesium to ensure optimal soft tissue and bone healing

• fluid intake of 2,000-3,0000 mL/day to promote optimal bladder/bowel function

• fluids and high fiber diet to prevent constipation

• if immobilized in bed with skeletal traction/body jacket brace, eat 6 small meals a day to avoid overeating that can cause abdominal pressure and cramping

what is appropriate nutrition therapy for a patient with a fracture

• brief history of the traumatic episode

• H&P

• Calcium and vitamin D supplementation

• Local bony deformities

• Peripheral vascular assessment:

  • Color: pink, pale, cyanotic

  • Temperature: hot, warm, cool, or cold around the injury

  • Capillary refill

  • Peripheral pulses: compare rate and quality B/L

  • Peipheral edema

• Peripheral neurological assessment:

  • Sensation

  • Motor function

  • Pain

what should assessment of a fracture include

arterial insufficiency

when performing a peripheral vascular assessment what can pallor/cool to touch and/or capillary refill > 3 seconds indicate

vascular problems and insufficiency

when performing a peripheral vascular assessment what can a decreased/absent peripheral pulses indicate

pitting edema

when performing a peripheral vascular assessment what type of edema may be present with severe edema

late sign of neurovascular damage

when performing a peripheral neurologic assessment what can partial/full loss of sensation indicate that should be reported immediately

• abduct the fingers to test the ulnar nerve

• oppose the thumb and small finger to test the median nerve

• flex and extend the wrist (or fingers if in a cast) to test the radial nerve

• dorsiflexion to test the peroneal nerve

• plantar flexion to test the tibial nerve

when performing a peripheral neurologic assessment how can the nurse assess motor function

• educate about the type of immobilization and assistive devices that will be used

• teach about expected activity limitations

• ensure that needs, including pain management, will be met

what does pre-op care for a patient with a fracture include

• monitor VS

• frequent neurovascular checks to detect early and subtle changes

• follow any limitation related to turning, positioning, and extremity support

• pain control through proper alignment, position, and analgesics

• frequently observe dressing or casts for any signs of bleeding or drainage

  • report an increase in the size of the drainage area to the HCP

• if a wound drainage system is used, regularly measure the volume of drainage and assess it

  • report increased/purulent drainage

  • maintain the functionality of drainage systems, using aseptic technique to avoid contamination

• reduce complications of immobility

• prevent constipation by increasing activity, maintaining high fluid intake, a diet high in bulk and fruits/veggies, stool softeners/laxatives, and having a regular time for elimination

• fluid intake of 2500 mL/day to prevent constipation and renal stone formation

• monitor for orthostatic hypotension and VTE

• collaborate with PT and OT

• supervise the AP

  • position the casted extremity above the heart

  • apply ice to the cast

  • maintain body position and integrity of traction if trained

  • help with passive and active ROM

  • notify the RN about reports of pain, tingling, or decreased sensation of the affected extremity

what does post-op care for a patient who suffered a fracture include