CH 37 Fractures, Sprains, and Strains (Including Exemplars)

what’s a strain?

misuse or overuse of a tendon that causes it to over stretch

signs and symptoms of a strain (and sprain)

pain, decreased ROM, muscle spasms

what is a sprain?

an overstretched ligament with a possible tear

where are the most common areas for strains?

the hamstrings and the back

what is the most common type of sprain?

an inverted ankle sprain

diagnosis of a sprain needs…

an X ray or CT scan and an electromyographic exam (looks at electrical activity within muscles)

treatment for sprains

Rest
Ice
Compression
Elevation above heart level

what’s the most common cause of cervical strains/sprains?

whiplash (from car accidents) or abnormal posture

Where is pain located with cervical sprains/strains?

pain may not be immediately prominent, but becomes more intense and radiates to shoulder, scapula, and arm

• pins and needles and ↓ ROM may also be present due to affected nerves

What is used to diagnose cervical sprains/strains?

an MRI

how is cervical sprain/strain treated?

with pain relief, muscle relaxants, and cervical collar

Where do lumbar sprains/strains occur?

From L4-L5 or L5-S1

signs and symptoms of lumbar sprains/strains

sharp pain/tenderness upon palpation, ↓ & painful ROM, spasms, possible herniated disc

How to tell if there’s a herniated disc with lumbar strains/sprains?

look for Lasegue’s sign by performing straight leg test; if pain radiates down the leg past the knee during the straight leg raise test, = sciatic nerve irritation (or Lasegue’s sign)

treatment of lumbar sprains/strains

can use cold therapy for a couple of days, should have low activity/avoid activity that uses the spine, give muscle relaxants/NSAIDs

Closed complete fracture

fracture where the bone completely separates

Open compound fracture

fracture where the bone pierces/sticks out of skin

Incomplete fracture

fracture where the bone is not completely broken

compression fracture

fracture where bone is crushed, often seen in the vertebrae

Transverse fracture

a complete break but the pieces are close to each other

Comminuted fracture

multiple fractures in one bone

Stress fracture

a small crack in a bone caused by repetitive stress or overuse, common in athletes

most common in tibia, fibula, and metatarsals

Avulsion fracture

a fracture where a fragment of bone is torn away by a tendon or ligament

Greenstick fracture

usually seen in kids; an incomplete fracture that indicates abuse due to a twisting motion

Impacted fracture

splintered fracture where the pieces go into each other 

bone callus

a temporary bony tissue that forms at the site of a fracture during the healing process

what types of things can slow bone healing?

anti-inflammatory drugs, immunosuppressants (like steroids), poor nutrition, etc.

how long does it take for bone callus to show up on an Xray?

6 weeks

What are the ABCDEs of trauma?

Airway (with cervical spine protection)
Breathing

Circulation and hemorrhage control

Disability and neurological evaluation
Exposure and environmental control (what was pt exposed to, what happened, and what did they do at time of injury)

What is the nurse looking for during a musculoskeletal assessment?

Radiation of pain (to indicate nerve damage)

Color of the injury right after it happens (bright red)

Wound/wound drainage (in case bones come out of skin)

Deformity (partial or full loss of bone)

Sensation (to evaluate nerve damage)

Muscle strength (test by comparing it to the other side)

Crepitus in joints

passive ROM

muscle relaxed while examiner moves the joint

active ROM

patient moves muscle themself

what is used to diagnose fractures?

Xray, ultrasound (picks up nerve damage), DEXA (bone mineral density test to measure risk for fractures), CT, MRI, EMG (electromyogram measures electrical activity in response to nerve stimulation)

How are fractures treated?

Mostly self limiting, closed reduction (clinician puts a device on the outside of the limb to promote healing (like a metal brace/splint)), open reduction (clinician cuts skin to put hardware inside the person (ORIF = open reduction internal fixation); often done for hip fractures)

compartment syndrome

Where the site of injury has swelling/inflammation, causing a build-up in that compartment of the body; pt reports pain way greater than average for that injury

can cause ischemia, necrosis, functional impairment

has a weak distal pulse/pulselessness (want to check if there’s swelling)

If swelling continues, surgical intervention necessary

rhabdomyolysis

A serious syndrome caused by muscle injury, leading to the release of muscle cell contents into the bloodstream, which can result in kidney damage and other complications.

signs and symptoms of rhabdomyolysis

myalgia, weakness, myoglobinuria (urine that has myoglobin in it), and high CK level (creatine kinase level in the blood)

infection of fracture

could possibly be cellulitis or osteomyelitis

leads to sepsis; systemic problems include fever, chills, nausea, vomiting

what labs should the nurse look for to determine infection with a fracture?

↑ WBC, C-RP (c reactive protein produced by liver in response to inflammation), and ESR (sed rate),

fat embolism

when fat globules break off and enter bloodstream, eventually going to the lungs (usually happens due to trauma, and ↑ risk with long bone/pelvic fractures)

early signs of fat embolism

pulmonary dysfunction/breathing problems

how is risk of fat embolism reduced?

by taking care of the fracture w/in 24 hrs

delayed union

when fracture takes longer than expected to heal

Nonunion

when fracture has no chance of healing

Malunion

when the fracture has healed in an unacceptable position

what are the two ways a fracture can occur?

as a result of trauma (the cause is known, ex. maybe the pt fell)

or as a result of pathological condition (cause is unknown, ex. a kid playing soccer breaks his leg after the ball hits it, and ends up being weak bones due to bone cancer)

where is the most common fracture site for people with osteoporosis?

the femoral neck (hip)

what hip fracture site is more common in young people?

the femoral head, usually from trauma

intracapsular hip fracture

fractures occur within the hip joint capsule, often affecting the femoral head or neck

exrtacapsular hip fracture

fractures occur outside the hip joint capsule, typically involving the greater or lesser trochanter

what is used to diagnose hip fracture?

X ray

how is hip fracture treated?

• Immobilize pt in supine position

• Assess ABCDEs of trauma

• Give IV hydration cause probably NPO after surgery

• Likely receiving opioids for pain management after surgery

• Consult w orthopedist, neurologist and cardiologist

how is cyclobenzaprine classified?

skeletal muscle relaxant

therapeutic use of cyclobenzaprine

• relief of discomfort from acute, painful musculoskeletal conditions

• use adjunct to rest, PT, & OT

pharmacological action of cyclobenzaprine

• works in the CNS to stop reflexes that cause muscle spasms

• lyse spasms (spasmolytics)

• is thought to alter spinal/subcortical neurons

AEs of cyclobenzaprine

• CNS depression

• GI upset

• hypotension

• arrhythmias

• urinary frequency/urgency

• enuresis (involuntary urination, especially at night)

how is cyclobenzaprine administered?

orally, 1x/day

contraindications/precautions of cyclobenzaprine

(C)

• known allergy

• spasms from rheumatic disorders

(P)

• epilepsy

• cardiac dysfunction

• hepatic/renal dysfunction

• pregnancy/lactation

• conditions marked by muscle weakness

drug drug interactions of cyclobenzaprine

• CNS depressants

• Alcohol

nursing interventions of cyclobenzaprine

• provide heat, rest, NSAIDs

• withhold if signs of liver dysfunction occur

• monitor respiratory status

patient education for cyclobenzaprine

• drug may cause drowsiness/reduced psychomotor skills

• avoid driving and activities that require concentration

• avoid alcohol and CNS depressants because they can ↑ risk of sedation or AEs

what is being assessed for effectiveness of cyclobenzaprine?

improved spasms/pain relief