n325 msk

soft tissue injuries

sprains

• strains

• dislocations

• subluxations

sprain

abnormal twisting

• stretching of joint or spinal musculature

• injury to ligaments

  • can’t see ligaments on XRAY.. might need MRI

• commonly in the ankle or knee

• classified in grades

  • grade 1 = stretching/small tears

  • grade 2 = larger tears

  • grade 3 = complete tear

strains

muscle, fascial sheath, or tendon

• stretched or torn

• can palpate a torn muscle

• very painful

• firm but extremely tender

dislocations

a complete separation of bones in a joint

• most clear sign → deformity

• presentation: orthopedic emergency, chance of severe vascular damage

• complications: avascular necrosis → dislocation resulted in blood supply cut off to joints, compartment syndrome

• treatment: closed reduction, surgical open reduction, immobilization

• nursing interventions: PERFUSION ASSESSMENTS, pain relief, support of joint, protection of joint, restrict motion/gentle ROM, rehabilitation

sublaxations

a partial or incomplete dislocation where joint surfaces remain partially in contact, often slipping back into place

• bones in joint aren’t aligned properly but still in contact

• presentation: partial or incomplete displacement of joint, less severe

• treatment: closed reduction, surgical open reduction, immobilization but with less healing time

• nursing interventions: PERFUSION ASSESSMENTS, pain relief, support of joint, protection of joint, restrict motion/gentle ROM, rehabilitation

sprains/strains

strain = muscular tissue

• sprain = ligaments

• clinical manifestations

  • pain

  • edema → swelling

  • decrease in function/weakness

  • ecchymosis

  • spasms

• diagnostics

  • x-ray, MRI to r/o fracture or joint damage

• complications

  • joint structure is unstable → tearing of ligaments that hold bones together

  • avulsion fracture → ligament has disconnect some of the bone from itself, so if ligament is pulled so severely, it can pull some of the bone away

  • hemoarthrosis → blood in the joints, can cause dysfunction and pain

  • long-term instability

• interventions

  • prevention: stretching, warming up, strength training, balance training

  • treatment: stopping the activity, RICE (24-48 hours)

    • rest, ice, compression, elevate

  • pain relief → NSAIDs/acetaminophen, don’t give narcs

  • heat & movement > 48 hours

repetitive strain injuries (RSI)

• catch-all term for symptoms and signs located in the neck, upper back, shoulder, arm, elbow, hand, wrist, and fingers

• risks:

  • repetitive activities

  • high-intensity activity for long time w/o rest

  • poor posture/awkward position

  • computer use

  • overtraining for sports

• interventions:

  • correct precipitating factor

  • modify behvaior

  • pain management: NSAIDs, heat/cold application

  • rest

  • PT

  • ergonomics

  • lifestyle modifications

carpal tunnel syndrome

etiology: compression of median nerve

• most common neuropathy of UE

• risk factors:

  • female → hormone imbalances & smaller carpal tunnels

  • cancer → fluid shifts + hormone imbalances

  • RA → inflammation and swelling around carpal tunnel

  • ganglion cysts → little cysts that live on the joints, cause compression of median nerve

  • DM → impacts perfusion, impacts neurovascular process

  • PVD → impacts perfusion, impacts neurovascular process

  • continous wrist movement

• assessment:

  • weakness

  • burning pain

  • numbness

  • impaired sensation

  • tinel’s sign → tap on median nerve. positive response = sensation of tingling over the median nerve & shooting/tingling pain

  • phalen’s sign → allow wrist to fall freely and maintain position longer than 60 seconds. if compressed carpal tunnel → tingling of median nerve. see atrophy of thumb muscle and overall hand dysfunction

• interventions:

  • prevention: good ergonomics

  • TX: relieve cause

    • early: stop activity, modification, hand splint

    • later: cortisone injection for anti-inflammatory to decr inflammation around carpal tunnel, PTanti-inflammatory

    • >6 months: carpal tunnel release Sx.. done if symptoms are lasting more than 6 months or if there is significant impairment to median nerve. open release surgery.

fractures

• A partial or complete break in a bone

• etiology:

  • traumatic

  • pathologic → like cancer

fracture classifications

• open → open to environment and bone is exposed. traumatic force to cause this. infection risk is higher

• closed → not open to the environment

fracture extent

• complete

  • break goes completely through the bone

  • 2 sides are not connected

• incomplete

  • fracture is partly across bone shaft, but bone itself is still intact

  • fracture, but 2 ends of the bone are still connected

fracture displacement

• displaced

  • two ends of broken bone are separated from each other

  • out of normal position

  • more tissue injury than non-displaced

  • comminuted

    • fracture with more than 2 fragments

    • caused by crush injury

    • fragments are free floating

    • seen more in severe trauma and falls from great heights

    • very complicated and requires more healing

• non-displaced

  • bone fragments are in alignment

  • transverse: bone breaks in a straight line, perpendicular to its long axis

  • spiral: fracture line coils around the bone like a corkscrew

  • greenstick: incomplete bone break where bone bends and cracks on one side only. commonly occurs in children due to flexible bones

  • oblique: diagonal break across a bone’s long axis

  • stress: occurs in bones that are subjected to repeated stress

clinical manifestations of a fracture

• edema

  • cause: disruption/penetration through skin/soft tissues/bleeding

  • significance: occlude circulation, nerve damage, compartment syndrome

• pain

  • cause: trauma, spasm, pressure, movement of fracture

  • significance: reduction in motion

• spasm

  • cause: irritation and protection

  • significance: displacement

• deformity

  • cause: abnormal position

  • significance: signals fx, prevent union

• ecchymosis

  • cause: extravasation of blood

  • significance: distal to injury, resolves

• loss of function

  • cause: disruption

  • significance: address to preserve ability to restore function

• crepitation

  • cause: crunching of fragments

  • significance: possible non-union, micromovement = osteogenesis

fracture care goals

• REALIGN, IMMOBILIZE, RESTORE FUNCTION

• closed reduction

  • nonsurgical, manual realignment, traction, casting, splints, external fixation, braces

  • nothing broken thru skin

  • do the least invasive procedure first due to risks w post-op

• open reduction (ORIF)

  • surgical, internal fixation

  • disadvantages: risk for infection, anesthesia complications, comorbid disease

fracture healing steps

1. hematoma

• bleeding at the site

• creates semi-solid clot ~72 hrs after injury

• sanguineous drainage = bloody drainage

• 2. organization into fibrous network

  • good new blood vessels, osteoblasts to form basis for new bone substance

  • maintain immobilization so don’t break fibers

• 3. osteoblasts mobilize, calcium deposits

  • calcium and magnesium help new bone form

• 4. callus formation

  • temporary thickened structure of cartilage and bone forms to stabilize the break

• 5. remodeling

  • hard, temporary callus is replaced by strong bone

  • takes 3 days - 6 months to get through this.. comply w immobilization and instructions/limitations

  
  

fracture cast healing

• materials

  • plaster

    • cheaper, easier to mold

  • fiberglass

    • lightweight, stronger, water resistant, preferred

  • poly/cotton

  • 3-D printed

• allow for ADLs

• variations

  • short arm:

    • stable wrist and metacarpal

  • long arm:

    • stable forearm/elbow, unstable wrist

  • body jacket:

    • stable spine

    • monitor for cast syndrome (small bowel obstruction)

    • compression of mesenteric artery cuts off blood flow to bowel

    • severe pain, pressure, N/V to abdomen

• hip spica:

  • pelvis and one or both legs

• long leg:

  • tibia, femur

• short leg:

  • foot, ankle

• cylinder:

  • knee or lower leg

• jones dressing/jones cast dressing:

  • sterile foot dressing

fracture patient education

• do

  • elevate first 48 hours → decr swelling

  • watch for 6 P’s

  • apply ice in plastic bag

  • if gets wet → dry completely with a hair dryer on low

  • hair dryer cold and diphenhydramine for itching

  • move joints above/below cast

• do NOT

  • get cast wet (unless waterproof)

  • insert items into or remove parts

  • bear weight for 48 hours

  • stick anything into the cast (between cast and skin)

• other

  • pain meds:

    • muscle relaxants

    • NSAIDs

    • opioids

  • other meds (open fracture)

    • tetanus and diptheria

    • cephalosporins

  • nutrition

  • options for mobility

  • no smoking

what are the 6 P’s?

• pain

• paresthesia

• paralysis

  • nerves can’t transmit impulses

• pallor

  • poor capillary refill

• pulselessness

  • pulse is extremely weak

  • use doppler

• poikilothermia

  • tissue is cold

traction

• pulling force to affected area; counter-traction pulls in opposite direction

• pressure to distal to align with proximal

• also helps with healing → hematoma is forming and if can’t take to surgery soon, use this to start helping put bone in right area to promote healing

• purpose:

  • prevent/reduce pain, spasms

  • immobilize area

  • fx reduction

  • treat pathology

• types of traction:

  • skin traction

  • skeletal traction

  • external fixation

skin traction

• short-term treatment

• tape, boots, splints

• maintains alignment

• assists in reduction

• diminishes muscle spasms

• weights typically 5 or 10 pounds except pelvis

• ex) buck’s traction

  • dependent on positioning & alignment of patient - laying in bed of sitting up in chair

  • must keep traction forces on at all times → only time to remove is in life threatening/limb threatening situation

  • no weights touching floor → must hang freely

  • weight must move freely thru pulleys → no knots

skeletal traction

• longer treatment → maybe person can’t go get surgery for several weeks

• treats fractures, contractures (extreme tightening of muscle)

• wire/pin inserted into bone

• immobilizes

• weights = 5 to 45 pounds

  • attaching weight to wires/pins

  • can hold much more weight and be in place longer

• disadvantages:

  • infection, consequences of immobility

external fixation

• metal pins & wires inserted into bones

• attached to external rods

• provides stabilization while fracture heals

• used for complex fractures, bony defects, limb lengthening

• increased risk for infection

• requires pin care

  • hydrogen peroxide and gauze

complications of healing - infection

• high incidence

• devitalized/contaminated tissue is growth medium

  • anaerobic bacteria

  • leads to increased cost/risk for morbidity

• treatment:

  • aggressive surgical debridement

  • IV antibiotics for 7 days-6 weeks-6 months

• warmth, fever, swelling, purulent drainage, bright red erythema

complications of healing - union problems

• bones have not healed properly together

• if person is at high risk for this, surgeon may not operate

• nonunion (pseudoarthritis)

• malunion

• causes of delayed union and nonunion

  • poor blood supply

  • insufficient nutrients

  • insufficient immobilization

  • metabolic disorders: DM, PVD

  • smoking

complications of healing - compartment syndrome

• can be caused by fractures, severe trauma, casts that are too tight, tight dressings

• medical emergency

• etiology:

  • internal

    • hemorrhage

    • swelling

    • fluid

  • external

    • tight dressings

    • tight casts

• manifestations

  • 6 P’s

    • pain

    • pallor

    • pulselessness

    • paresthesia

    • poikilothermia

• interventions

  • do not elevate limb, keep at heart level → want to promote blood flow to the area

  • no cold packs → don’t wanna decr blood supply

  • remove or loosen bandages, split cast → don’t wanna worsen blood flow

  • monitor BP, prevent hypotension

  • O2 to maximize saturation

  • urgent surgical consult (fasciotomy)

    • cut into fascia and release pressure → allow room for swelling to occur

    • releases pressure on nerves and blood vessels

    • allows tissues to be perfused

    • high risk of infection → use antibiotics

    • assess for neurovascular intactness → get baseline and check frequently

complications of healing - VTE

• common causes

  • surgery → venous stasis causes clots and blood can’t go back to heart..

  • clot can travel to heart and lungs to be deadly

  • fracture of hip, pelvis, long bones

  • multiple trauma

  • immobility → muscles aren’t contracting → venous stasis, so no blood going back to heart

  • prior VTE

  • venous stasis

  • hypercoagulable state

    • could be from a med

  • endothelial injury

    • during surgery → vessels are cut

• S&S

  • thigh/calf pain or tenderness

  • UNILATERAL EDEMA

  • warm to touch

  • red streaks/discoloration

• general interventions:

  • prevent and treat

    • heparin/enoxaparin

    • early immobilization of fracture

    • early ambulation

    • compression stocking

    • SCDs - sequential compression devices

complications of healing - myositis ossificans

• calcification in soft tissue

• new bone forms in muscle tissue after injury - healing process occurs in wrong place

• usually from trauma

• tx:

  • ROM exercises to loosen area and maintain functionality

  • strengthening

  • ESWL (extracorporeal shockwave lithotripsy)

    • using shock waves to break apart bone tissue

• sx:

  • pain with movement

  • swelling

  • limited ROM

  • hard palpable lump in affected muscle/tissue

complications of healing - fat embolism

• embolisms can travel to heart and lungs and cause major issues

• release of fat globules that break off and enter bloodstream

• emboli = moving

• thrombus = stationary

  • once thrombus is broken off and starts moving, it becomes an emboli

• long bone break (tibia, femur, ribs, pelvis) leads to release of marrow

  • when breaks of long bones → incr risk of fat globules being released into the bloodstream

  • fat drop becomes stuck in small vessels → ischemia occurs at distal capillaries

• hormonal changes caused by trauma can stimulate release of free fatty acids

• can mimic other complications like pulmonary embolism

• can happen in young and old people

• factor in many fracture deaths

• risks:

  • total joint replacement

  • spinal fusion

  • liposuction

  • crush injuries

  • bone marrow transplan

• common MS causes:

  • multiple fx

  • fx of long bones

  • hip replacement

• S&S

  • 24-48 hours after fx

    • LOC changes - poor O2 exchange

    • confusion

    • restlessness

    • dyspnea

      • respiratory depression signs bc fat doesn’t belong in pulmonary vasculature of lungs

    • tachypnea

    • tachycardia

    • fever

    • petechiae

      • microhemorrhages → fat globules have landed in capillaries and caused breakage

    • hypoxia

• interventions

  • prevention is key

  • early stabilization of long bones

  • patient education at D/C

  • promote lung expansion

  • oxygen IVF

  • monitor respirations

  • TCBD, repositioning

  • possible intubation & mechanical ventilation

complications of healing - osteomyelitis

• severe infection: bone, marrow. periosteum

• usually see it a few months after surgical intervention

• infection in the bone

• etiology:

  • open fracture

  • prosthetics

  • periodontal disease, UTI, TB, puncture wounds, infectious pathogens

• risk factors:

  • trauma, open wounds, immunocompromised pts, vascular insufficiency, prosthetic devices

• manifestations

  • acute < 1 month

    • usually local

    • bone pain unrelieved by rest, increased with activity, swelling, tenderness, warmth, decreased ROM

  • chronic > 1 month

    • local and sytemic

    • fever, chills, night sweats, nausea, malaise

• diagnostics

  • history & physical

  • labs

    • WBCs, ESR, CRP

    • soft tissue or bone biopsy, blood/wound culture

    • x-rays, bone scans, MRI/CT

• interventions:

  • acute

    • IV ABs - long term course, 6 week to 6 months

    • surgical debridement

    • AB irrigation

    • AB acrylic beads implanted in bone

  • chronic

    • IV ABs

    • surgeries

      • incision/drainage

      • debridement

      • sequestrectomy

      • bone graft

      • amputation - sometimes the best, safest option

    • hyperbaric O2

complications of healing - avascular necrosis

• common MS causes:

  • interruption of blood supply to bone by fx → bone death, non healing

  • most common with long bones (hip, talus, femur at knee joint)

  • not an infection…

• S&S, Dx

  • pain

  • decreased sensation

  • MRI diagnosis

• general interventions:

  • surgery

  • sometimes bring in new bone

assessment of fracture

• compare affected side with contralateral side

• assess distal to fracture

• vascular assessment

  • if not neurovascularly attached - could have necrotic tissue

  • skin color → supposed to be pink

  • skin temp → supposed to be warm

  • pulse → supposed to be palpable

  • cap refill → supposed to have under 3 secs

• neuro assessment

  • movement

  • sensation

  • pain

    • neuro pain not gonna work w opioids

surgery: preoperative

• standard pre-op workup

• educate regarding immobilization device

• activity limitations

• assurance of assistance

• pain control available

• skin preparation

surgery: postoperative

• monitor VS

• NV checks

  • paralysis

  • paresthesia

  • pulse

  • cap refill

• monitor positioning

  • turning, moving

• monitor for compartment syndrome

• monitor for drainage & bleeding

• PT/OT

hip fractures

• super common in elderly

• 90% are fall-related

• by age 90:

  • 30% of females and 20% of males will have hip fx

• 30-50% die within a yr due to complications of fx, immobility

• potential long-term dsiability

• due to decr muscle strength, altered reflexes, and meds that incr fall risk

classification of hip fx

• intracapsular

  • within the joint capsule

  • higher risk of avascular necrosis

  • capital

  • subcapital

  • transcervical

• extracapsular

  • outside of joint capsule

  • intertrochanteric

  • sub trochanteric

• femoral neck

  • also incr risk of avascular necrosis

hip fracture manifestations

• external rotation

• muscle spasm → give muscle relaxants

• shortening of affected extremity

• severe pain & tenderness at site

hip fracture treament

• temp bucks traction

  • reduces spasms

• surgical repair

  • allows early mobilization

  • decreases risk of complications

hip fracture interventions

• preoperative

  • assess co-morbidities

  • muscle spasm reduction

  • teach

    • proper exercise unaffected side

    • overhead trapeze/handrail use

• postoperative

  • monitor VS, I&O

  • respiratory

  • monitor wound damage

  • assess extremity

hip fracture post-op care

• regular assessments:

  • Vs

  • Is&Os

  • respiratory

    • TCDB → turn cough deep breathe

    • post surg patient at high risk of pneumonia bc meds depress breathing, not moving around, not breathing deeply

    • fluid gets caught in lungs

  • pain

    • wanna get up and moving

    • pain meds can help

  • check dressing/site

• assess for complications:

  • hip dislocation

  • infection

  • bleeding

• positioning

  • OOB day of or day after surgery

  • avoid turning to affected side

  • overbed trapeze

  • abductor pillow

  • do not let leg cross midline

  • don’t cross legs or bend joints greater than 90 degree angles

• physical therapy

• placement needs

osteoarthritis pathophysiology

• cartilage destruction → wear and tear

• joint space narrows

• bone-on-bone

• crepitation

• osteophytes (bone spurs)

• joint pain, stiffness, decreased mobility, muscle atrophy

osteoarthritis characteristics

• chronic

• progressive

• degenerative

• unilateral, can progress to bilateral

  • if on one side, body compensates and eventually can affect other side

• non-systemic

  • localized inflammation/pain

  • shouldn’t be seeing it in places other than the joints

risk factors of osteoarthritis

• trauma

• inflammation

• joint instability

• mechanical stress

• skeletal deformities

• lack of exercise

• obesity

• aging

• drugs

osteoarthritis joints involved

• weight-bearing

  • hips

  • knees

  • spine

  • hands

osteoarthritis physical assessment

• morning stiffness that goes away within an hour

• joint pain - worsens as day goes on

  • early: goes away w rest

  • later: doesn’t go away w rest

• acute to chronic pain

• muscle spasms

• crepitus

• deformity (hands): bony growth at joint. debilitating and interferes with mobility

  • heberden’s nodes

  • bouchard’s nodes

• psychosocial changes r/t pain, disability

osteoarthritis diagnostics

• XRAY, MRI, CT

  • detect joint space narrowing, bony sclerosis, osteophyte formation

• bone scan

  • detects bone growth, regeneration

osteoarthritis assessment

• history

• physical

• impact on ability to perform ADLs

• pain management beliefs, practices

• physical exam of joints

  • compare with contralateral joint

osteoarthritis goals

• maintain or improve joint function

• not much else u can do to reverse other than joint replacement

• use joint protective measures

• achieve independence in self care and maintain optimal role function

• use drug and non-drug strategies to manage pain

osteoarthritis interventions

• medication

  • ASA

  • APAP

  • NSAIDs

  • topical creams

• non-pharm pain mgt

  • acupuncture

  • yoga

  • massage

  • guided imagery

• balance rest/activity

  • rest during acute inflammation

  • modify activities to decr joint stress

  • avoid prolonged standing, kneeling, squatting (knee OA)

• diet & exercise

  • dietary changes PRN

  • aerobic

  • ROM

  • quad strengthening

• assistive devices

  • splinting

  • support

  • cane/walker

• temperature therapy

  • ice for inflammation

  • heat for stiffness

osteoarthritis patient education

• pain mgt

• body mechanics

• corrective use of assistive devices

• joint protection and energy conservation

• nutrition

• weight and stress management

• exercise

osteoarthritis support

• assure deformity is not usual course of OA

• therapy, support groups

• community resources - www.arthritis.org

rheumatoid arthritis pathophysiology

• chronic, systemic autoimmune disease, inflammation of connective tissue in synovial joints

  • body attacks own cells

  • damage caused by inflammation

• all ethnic groups, across lifespan, peak 30-50 yo

• 1.3 million americans

• women > men (2-3x)

  • see higher incidence in women

• 1. precipitating event (antigen)

• 2. autoimmune response

• 3. inflammatory cascade

• 4. synovial inflammation

• 5. cartilage and bone damage

• 6. formation of rheumatoid nodules

• 7. systemic effects

rheumatoid arthritis S&S

• early

  • nonspecific

  • joint inflammation

  • fatigue

  • aching

  • morning stiffness - 1 hr or longer

  • low-grade fever bc immune system active and thinks something is wrong

• later

  • moderate to severe pain

  • joint softness, swelling

    • inflammatory process happening

    • red and swollen all the time

  • joint tenderness

  • muscle atrophy → weakness bc avoiding use of joint

  • systemic S&S

    • SQ nodules

    • osteoporosis

    • vasculitis

    • sjorgren’s syndrome

      • immune system attacks moisture-producing glands → causes dry eyes and mouth with more joint pain

  • joint deformities

    • boutonniere

    • swan neck

    • ulnar deviation

rheumatoid arthritis manifestations

• boutonniere deformity

• ulnar deviation

• swan neck deformity of fingers

• extra-articular manifestations

  • RA is a systemic disease → manifestations that happen outside of the joints

  • rheumatoid nodules

    • 25% RA

    • SQ, firm, nontender, usually on extensor surface joints

    • usually not removed bc they just come back

    • if in lungs, sclera, poorer prognosis

  • sjorgrens syndrome

    • secondary to RA or independent d/o

    • 10-15% RA

    • diminished lacrimal/salivary secretions

    • dry mouth, gritty, and burning eyes

    • decreased tearing and photosensitivity

rheumatoid arthritis diagnostics

• HPI and physical findings

• labs

  • WBC > 20k (mostly neutrophils)

  • + RF (rheumatoid factor) in 80%

  • elevated ESR (erythrocyte sedimentation rate), CRP (C-reactive protein)

    • inflammatory markers

    • when these are elevated → body is in process of systemic inflammation

  • ANA (anti-nuclear antibodies)

  • anti-CCP (anti-cyclic citrullinated peptides)

  • four of the following:

    • morning stiffness > 1 hr

    • swelling in 3+ joints

    • swelling in hand joints

    • symmetric joint swelling

    • erosions on hand x-rays

    • rheumatoid nodules

    • serum RF

rheumatoid arthritis interprofessional team goals

• prevent deformity

• decrease inflammation

• pain management

• maintain function

• increase mobility

rheumatoid arthritis interventions

• acute

  • drug therapy

  • medication teaching

  • rest

  • joint protection

  • lightweight splints

  • ROM exercises

  • occupational therapist

  • plan care around pain

• home care

  • stress management

  • balance nutrition

  • alternate rest with recovery

  • avoid total bed rest

  • modify activities to avoid overexertion

  • avoid flexion position

  • individualize exercise plan

rheumatoid arthritis meds

• NSAIDs & anti-inflammatory

  • APAP and ibuprofen

• DMARDs - disease modifying antirheumatic drugs

  • non-biologics

    • methotrexate → decreases progression of joint deformity and erosion

    • lower risk of toxicity. slows and helps suppress immune system

    • puts pt at risk of infections

    • avoid crowds

    • avoid illness

    • avoid ETOH

  • BRMs

    • modifies specific parts of immune system to help slow it down

    • most TNF blockers

    • etanercept (enbrel)

    • adalimumab (humira)

    • infliximab (remicade)

• flare-ups

  • corticosteroids

    • systemic

    • local: intraarticular steroids

    • immune suppression → incr risk of infection

  • NSAIDs

  • topical analgesics

• give immediately and consistently to slow disease progression and decrease risk of joint deformity

  • DMARDs

    • lessen joint erosions and deformity

    • chosen based on RA progression, functional level, lifestyle, cost

  • methotrexate

    • fewer sx in days to weeks, lower cost, fewer SEs

    • bone marrow suppression, hepatotoxicity, iatrogenic birth defects

    • lab monitoring: CBC, chem panel

• given when flare-ups/exacerbations occur

  • corticosteroids (provide sx relief and immune suppression)