WKU Med Surg Exam 3

what are the priority concepts for the musculoskeletal system

mobility and perfusion

what are the interrelated concepts for the musculoskeletal system

- pain: especially with ischemia

- tissue integrity

- sensory perception

- infection

what is a fracture

a break or disruption in continuity of a bone that affects mobility and comfort

how are fractures classified by

1. the extent of the break: complete or incomplete

2. the extent of soft tissue damage: open/ compound or closed/ simple

3. the cause: fragility/ patho/ spont, stress/ fatigue, compression

what is a complete fracture

bone is broken into 2 or more separate pieces

what are the different kinds of complete fractures

- nondisplaced/ aligned

- displaced/ misaligned

what is the tx option for a nondisplaced/ aligned complete fracture

splint or cast

what is the tx option for a displaced/ misaligned complete fracture

surgery (needs to be stabilized)

what is an incomplete fracture

bone is partially cracked but not completely broken

what is an open/ compound fracture

when a broke breaks and the bone fragments protrude through the skin or the skin is open and you can see the bone

what is a closed/ simple fracture

broken but no wound

what is a fragility/ pathological/ spontaneous fracture

occurs when bone breaks very easily due to weakened structure (ex: osteoporosis, osteogenesis, cancerous conditions)

what is a fatigue/ stress fracture

repetitive motion/ stress that tire muscles and place more pressure on the bones causing them to break

what is a compression fracture

bone is crushed or flattened in appearance due to a significant force or pressure

how long is the typical healing process of fractures depending on the pt

6-8 wks

what are the stages of bone healing

1. hematoma

2. hematoma to granulation tissue

3. soft callus formation

4. osteoblastic proliferation

5. bone remodeling

what occurs in the first stage of bone healing when a hematoma forms

happens immediately after a fracture to serve as a foundation for healing and provider of nutrients for healing

what occurs in the second stage of bone healing when a hematoma turns into granulation tissue

happens after a few days post injury and is rich in collagen and supplies the injured site with new blood vessels

what occurs in the third stage of bone healing when a soft callus forms

happens a couple wks post injury and acts as a soft structure that allows mobility and a foundation for healing and stabilization

what occurs in the fourth stage of bone healing when osteoblastic proliferation occurs

osteoblasts begin to replace soft callouses starting around a couple of wks-mths post injury

what occurs in the fifth stage of bone healing when bone remodeling occurs

the structure of the bone is more refined and strengthened through mobility

what are some acute complications of fractures

- venous thromboembolism

- infection

- acute compartment syndrome (ACS)

- fat embolism syndrome (FES)

what is acute compartment syndrome

occurs when too much pressure is exerted within the muscle compartments found within the fascia (often due to swelling or bleeding) compromises blood flow and can lead to muscle and nerve damage if not taken care of quickly

what causes the s/s of ACS

arise from reduce blood flow and sensory deficits

what are the s/s of ACS

- extreme pain (especially during passive muscle stretching) that is disproportionate to injury and is not relieved by normal analgesics that intensifies the longer the injury is prolonged

- paresthesia, paralysis

- pale skin

- diminished pulses

- feeling of the affected area is very tense

what are the most common causes of ACS

crush injuries

how do you tx ACS

fasciotomy: using general anesthesia, cuts only through the fascia are made over affected area to reduce pressure and are left as open wounds to help decrease pressure

what is a FES

fat globule from yellow bone marrow that travels and lodges within a blood vessel

what type of fractures most commonly cause fat embolism syndrome
when does it occur?
s/s

long bone fractures & pelvic area
12-48 hours after fracture

desaturation, stroke-like s/s (decreased LOC, irritable), brown, non-palpable macular rash (late sign)

what are some chronic complications of fractures

- avascular necrosis

- delayed bone healing

- chronic regional pain syndrome (CRPS)

what is avascular necrosis

blood flow to bone is interrupted and bone tissue dies and starts to develop tiny fractures and eventually collapses

what joint most commonly collapses due to avascular necrosis

hip

what is the classic sign of avascular necrosis

crescent sign: bone starts chipping away and causes an increased space between bone and the joint making it more likely to collapse

what are the s/s of avascular necrosis

- reduced ROM

- joint pain

what is delayed bone healing

results from poor blood supply, infections, or inadequate nutrition

who is/what makes you at greater risk for delayed bone healing

• poor blood supply

• infection

• high-energy fractures

• nonunion fractures (bone fails to heal completely)

• malunion fracture (bone heals in deformed position)

• older adults

• patients with conditions that degrade the bone (ex: osteoporosis)

what are some different types of fractures seen with delayed bone healing

nonunion and malunion

what is a nonunion fracture with delayed bone healing

bone fails to completely heal

what is a malunion fracture with delayed bone healing

bone heals in a deformed position

what is CRPS

long lasting pain that usually affects a limb after injury

what causes CRPS

unknown but it is an altered pain pathway

what is Chronic Regional Pain Syndrome characterized by

- severe pain

- swelling

- pt experiences changes in skin or temp in the affected area

when assessing a pt with a fracture, when is the best time to take a hx on them

after they have been made comfortable

what things should be asked/ assessed for when collecting a hx

- determine type of injury

- ask about events leading to injury

- obtain drug use and alcohol consumption hx

- medical hx

- ask about occupational and recreational activities

what do you monitor postop for hip fractures

• Monitor for acute confusion because of anesthesia

• Monitor for fat embolism syndrome -> High risk (decreased LOC, stroke-like s/s)

• Abduction devices, SCDs, etc

s/s of sinusoidal obstructive sydnrome

abd swelling, weight gain, portal htn (ascites, varices, edema), ruq pain, jaundice not present initially but may occur if liver damage severe

what things should you assess for in your physical assessment of someone with a fracture

- assess all body systems for life threatening complications especially for head, neck, etc trauma

- internal hemorrhage especially for trauma around major vessels (do neuro and vascular checks)

- organ Function

- swelling, bruising, perfusion, skin integrity

- change in bone alignment or deformities (crepitus, internal or external rotation, shortening)

if someone has a fracture, where is it most important to do a neurovascular check on them

distal to injury

what things should be a part of/ should assess when doing a neurovascular check

- skin color

- skin temp

- movement

- sensation

- pulses

- pain: should only be localized and need to get them some relief

what is someone with a fractures psychosocial assessment dependent on

- extent of the injury

- possible complications

- coping ability

- availability of support systems

what should you reassure someone who has had a fracture to help with their psychosocial needs

appropriate pain management will be used

what lab tests need to be done when someone has a fracture to help dx

- Hgb

- Hct

- ESR

- WBC

- serum calcium

- serum phosphorus

what imaging assessments need to be done when someone has a fracture to help dx

- xrays

- CT for complex fractures (ex: hip, pelvis, compression fractures of spine)

- MRI (shows soft tissue damage)

what are some things you should anticipate and help prevent when someone has a fracture

- acute pain due to broken bone(s), soft tissue damage, muscle spasm, and edema

- decreased mobility due to pain, muscle spasm, and soft tissue damage

- potential for neurovascular compromise r/t impaired tissue perfusion

- potential for infection due to a wound caused by an open fracture

what are some interventions you should implement when it comes to taking care of someone with a fracture

- managing acute pain

- increasing mobility

- preventing and monitoring for neurovascular compromise

- preventing infection

what are the expected outcomes of managing acute pain for someone with a fracture

pt states adequate pain control after fracture reduction and immobilization

what is the first priority when doing emergency fracture care

ABCs and lifesaving care

what is the second priority when doing emergency fracture care

head to toe assessment

after completing a head to toe assessment when providing emergency fracture care, what should you do next

- remove clothing, inspect area while supporting the area above and below level of injury

- apply direct pressure if bleeding is present

- remove jewelry on affected extremity

- keep patient warm and supine

- assess neurovascular status distal to fracture

- immobilize extremity

- cover open areas with sterile dressing

- add ice to affected to help reduce swelling and alleviate pain

once a pt in an emergency fracture care situation is stabilized, what things can you do

- manage pain with short term IV (20 or 18 G and may need 1 or more IVs) opioids, NSAIDS, and regional nerve blocks

- bone reduction

- immobilization

- always assess and reassess to prevent neurovascular compromise

what are some different nonsurgical managements for acute pain regarding a fracture

closed reduction and immobilization

what is a closed reduction used for

common for displaced fractures or dislocations

how is a closed reduction performed

using moderate sedation a physician manipulates the bone back into alignment and then stabilizes it with a splint or cast to keep it in alignment

what things do you need to consider/ have when a closed reduction is being performed

- maintain airway

- large bore IV fluids

- crash cart nearby

- reversal meds if sedation gets too heavy

- cardiac monitoring

what are some different immobilization devices

- bandages

- splints

- boot

- cast

- skin traction

how do splints, orthopedic boots/ shoes, and casts provide optimal stability

extend to the joints above and below the fracture site to ensure optimal stability

what do need to assess when applying splints, orthopedic boots/ shoes, and casts

assess neurovascular status before and after reducing and immobilizing a fracture to prevent neurovascular compromise

what is the most common material used for casting and immobilization

fiberglass synthetic material

why is fiberglass synthetic material used commonly for casts

dries quicker than traditional plaster

what should you teach pts about making sure a fiberglass synthetic cast is fitted right

slide 1 finger between cast/ skin bc if too tight can cause ACS or decrease circulation

what should you do if casting becomes too tight or if the casts integrity is compromised

should see their provider immediately to remove the cast or do a bivalve maneuver where you cut 2 holes into the sides of the cast to reduce pressure

if someone has a wound underneath a cast, what should be done

a window should be cut to observe and care for the wound

what needs to be used to protect the skin from the rigid surface of a cast

cast padding

what things should you teach a pt with a cast

- teach s/s of infection and atrophy

- teach them never to put anything in their cast

what is skin traction

noninvasive device used to relive muscle spasms and pain, and helps prevent skin breakdown

how does skin traction work

uses a light weight as its pulling force (5-10 lbs) and should not touch the floor to stabilize the skin and joints especially with leg fractures

what are some examples of skin tractions

velcro boot/ halter

what is a skeletal traction

device that helps with pain and muscles spasms by putting a pin through a distal bone and applying a 15-30 lb weight to stabilize/ straighten a joint/ extremity

what is a running traction

pulling force in straight line with body where it is resting on the bed

what is a disadvantage of running tractions

moving the pt or bed position can alter alignment w/ pulling force (supine is best)

what is balanced suspension traction

keeps extremity elevated and aligned for complex injuries

how does a balanced suspension traction work

maintained by pulleys and devices that allow the pt to move freely and still maintain alignment

what is important to know about the weights used in tractions

- should not ever be removed unless physician tells you to

- should be freely hanging at all times

- teach everyone not to mess with it

what things should you look out for and do when it comes to taking care of someone with tractions

- maintain correct body alignment

- monitor neurovascular status at least q1h for first 24 hrs, then q4h

- pain management

- inspect skin (q8h), ropes, knots, pulleys, and correct weight consistency

if someone needs surgery for a fracture, what things should you teach the pt

what to expect before and after

what are the different procedures that can be done for fractures

internal and external fixation

what is an internal fixation device

reduced fracture and then hold the bones together with metal; for complicated fractures (open reduction ex)

what is external fixation device

screws inserted above or below fracture site that uses an external device to help keep the bone stable (open reduction ex)

what are the advantages of a external fixation device

- minimal blood loss

- allows for early ambulation and exercise to promote healing

what are the disadvantages of a external fixation device

increased risk for pin site infection which can lead to osteomyelitis

what do you need to do post op for someone after a surgery for fractures

- pain management

- reducing infection

how often and what do you need to assess at the pin site for an external fixation device

assess q8-12h for drainage, color, s/s of infection

what findings are normal post op external fixation device after 48-72 hrs

clear fluid drainage and weeping and crusting

what do you need to follow when taking care of external pin sites

follow agency protocol

what are some interventions you can do to increase mobility in someone with a fracture

- help increase and promote mobility

- prevent complications of decreased mobility

- physical and/ or occupational therapy

- use of crutches, knee walker scooter, walker, cane

what is the expected outcome of increasing mobility for someone after a fracture

- the pt w/ a fracture is expected to increase physical mobility and be free of complications associated w/ mobility

- move purposefully in the environment independently w/ or w/out an ambulatory device unless restricted by traction or other modality

what are some interventions to prevent and monitor for neurovascular complications in someone with a fracture

perform neurovascular assessments frequently before and after fracture tx

what are the expected outcomes for preventing and monitoring for neurovascular complications in someone with a fracture

the pt with a fracture is expected to have no compromise in neurovascular status as evidenced by adequate perfusion, mobility, and sensory perception

what are some interventions to preventing infection in someone with a fracture

- when caring for a pt w/ an open fracture use aseptic technique for dressing changes and wound irrigations

- immediately notify provider if you observe inflammation and purulent drainage

what are the expected outcomes when preventing infections in someone with a fracture

the pt w/ a fracture is expected to be free of wound or bone infection as evidenced by no fever, no increase in WBC count, and negative wound culture (if wound present)