Mobility: Strains, Sprains, Fractures, Carpal Tunnel Syndrome, and Back Pain

STRAINS AND SPRAINS

• Occur from sporting injuries, accidents at home, work, and during recreation.
• A strain is an injury to muscle or tendon tissue, graded as 1st, 2nd, and 3rd degree.
• A sprain is an injury to ligaments, also graded as 1st, 2nd, and 3rd degree.

Clinical Manifestations

• Pain, limited function, swelling, and bruising.

Management

• Diagnosis based on history and physical examination.
• Confirmed by radiography, ultrasound, or MRI.
• Treatment for 1st and 2nd degree strains/sprains: RICE (Rest, Ice, Compression, Elevation).
• 3rd degree strains may require surgical repair of the torn tendon or muscle.
• 3rd degree sprains may need arthroscopic surgical repair with graft.

RICE

*Rest the injured extremity up to 72 hours.
*Ice applied for no longer than 30 minutes three to five times per day for 24 to 72 hours.
*Compression by means of an Ace wrap.
*Elevate the affected area

• NSAIDs are usually prescribed to minimize pain and inflammation.

FRACTURES

• Often occur in the young and the elderly population due to porous bones and areas of weakness.
• Associated with Cushing’s syndrome, osteoporosis, osteogenesis imperfecta, neoplasms, anorexia, and Paget’s disease.
• A fracture is defined as a disruption, or break, in the continuity of a bone.

Types of Fractures

• Complete: The disruption spans across the width of the bone.
• Incomplete: The disruption occurs through part of the bone cortex.
• Closed (simple): Fracture is contained within the skin.
• Open (compound): Disruption in which pieces of bone protrude through the skin.
  • Grade I: Presence of a puncture wound, minimal injury to soft tissues, and vasculature remains intact.
  • Grade II: Puncture wound, fragments or broken bone, moderate skin and muscle contusions, and significant wound contamination.
  • Grade III: Severe damage to soft tissue, nerves, muscles, and blood vessels. Fracture site is considered highly contaminated and contains numerous comminuted fractures.
• Other types: Transverse, Linear, Oblique, Spiral, Greenstick, Comminuted, Nondisplaced, Displaced

Clinical Manifestations - Assessment

• Pain due to muscle spasms or tissue damage.
• Decrease in function.
• Deformity.
• Limb shortening, crepitation (grating sensation).
• Edema.
• Bruising.

Management

• History of how the injury occurred.
• Physical assessment.
• Confirmation by radiography or CT.
• Narcotics and anti-inflammatory medications are effective in controlling pain and inflammation.
• Closed reduction: Nonsurgical treatment where fractured bone segments are manually manipulated and realigned.
• Open reduction: Surgical repair of fractures that includes an open reduction with internal fixation (ORIF) or external fixation.

TRACTION

• Traction is the application of a pulling force to a part of the body to provide bone reduction or decrease muscle spasm.

Types of Traction

• Skeletal Traction: Uses pins to attach to weights that keep the fracture aligned. Keep body alignment, ensure weight is always applied, monitor skin integrity, monitor pin sites for redness, swelling drainage, provide pin care as prescribed.
• Skin Traction: Uses elastic bandages or boot to apply traction. Commonly used for lower extremities. Good skin care is essential. Ensure weight is always applied.

Nursing Alert

1. Weights are not removed or manipulated without a PCP’s order.
2. Weights should be freely hanging at all times.
3. Inspect the skin at least every 8 hours for signs of irritation or inflammation.
4. Assess neurovascular status of the affected body part to detect impaired perfusion and tissue integrity. If severe pain, diminished pulse, pallor, poor ROM, notify PCP immediately.
5. The patient’s circulation is typically monitored every hour for the first 24 hours after traction is applied and every 4 hours thereafter.

COMPLICATIONS

• Compartment syndrome
• Neurovascular compromise
• VTE (Venous Thromboembolism)
• Fat embolism

Acute Compartment Syndrome

Fat Embolism

Nursing Care

• Monitor for the 5 “P”s of impaired circulation:
  • Pain
  • Paresthesia
  • Pallor
  • Pulselessness
  • Paralysis
• Keep elevated
• Ice for 24-48 hours
• Patient Teaching:
  • Elevation
  • Not putting anything inside cast
  • Cooling measures
  • Symptoms of compartment syndrome

CARPAL TUNNEL SYNDROME

• Most frequent compression neuropathy of hands.
• Women are 4-5 times more likely than men.
• Repetitive wrist motions elicit inflammation of the tendons and ligaments which compresses the median nerve causing sharp pain, numbness, and tingling of the hand.
• Higher occurrences are noted in patients who have jobs requiring repetitive motions of the hands such as computer operators, musicians, construction workers, and factory workers.
• Symptoms initially occur intermittently at night, then progress if not treated.

Risk Factors

• Repetitive stress injuries
• Inflammatory conditions
• Osteoarthritis
• Rheumatoid arthritis
• Sports that require holding an object while flexing wrist (Golf, Tennis)

Clinical Manifestations

• Pain in the hand with wrist flexion
• Painful tingling of the first 3 fingers
• Weak pinch
• Clumsiness
• Difficulty with fine motor tasks
• Phalen’s test: paresthesia within 60 seconds of flexion
• Tinel’s sign: paresthesia caused by direct pressure on the nerve

Medical Management

• Conservative:
  • Anti-inflammatory medications
  • Splinting
• Surgical:
  • Relief of compression (Cutting or laser)

Surgical Intervention

• Carpal tunnel release surgery is often performed as an outpatient procedure to decrease pressure on the median nerve.
  • Open release: creates a 2-inch incision in the wrist allowing visualization. The transverse carpal ligament is then cut to enlarge the carpal tunnel.
  • Endoscopic procedure: creates two half-inch incisions to allow visualization via an endoscopic camera. As in the open release, the ligament is cut to enlarge the carpal tunnel.

Nursing Care

• Monitor sensation
• Neurovascular checks
• Finger range of motion
• Administer pain medication
• Monitor swelling at site
• Patient Teaching:
  • Take NSAIDs with food
  • Wear splints
  • Elevate hands to reduce swelling
  • Report an increase in pain after surgery

Nursing Care Prevention

• Focus on ergonomics – specially designed wrist rest devices, geometrically designed keyboards, chair height appropriate for good posture.
• Take breaks when performing repetitive stress and stay relaxed.
• Stretch fingers and wrists during work hours

LOW BACK PAIN

• 2nd most common neurological ailment.
• Equally affects men and women
• Spinal degeneration is loss of normal structure and function of the spine decreasing support of facet joints.
• Spinal stenosis of foramina and canals may apply pressure on the spinal cord and nerve roots.
• At least 60% to 80% of the population will have an episode at least once in their lifetime. Low back pain (LBP) often occurs between the ages of 30 and 50 with an annual cost of $50 billion per year on treatment alone.

Types

• Acute: Lasts less than 3 months
• Chronic: Lasts greater than 3 months
• Recurrent: Subsequent episodes that may increase in intensity

Causes and Risk Factors

• Degenerative disk disease
• Obesity
• Injury or stress to lower back
• Occupations requiring heavy lifting
• Sitting or standing for long periods of time
• Changes in supportive structures of the spine – spinal stenosis, osteoarthritis, osteoporosis then changes to actual spine- scoliosis
• Vascular changes – arteriosclerosis (diminishes blood supply to the spinal cord)

Clinical manifestations

• Pain may be exacerbated by movement
• Muscle spasms may limit mobility
• Decrease in flexibility and stamina
• Constipation

Management

• History, physical exam, and neurological testing like Electromyography, nerve conduction testing, x-rays, CT, MRI, bone scans, myelograms
• Treated using medications and physical therapy
• Interventional therapy: nerve blocks with local anesthetics, steroids, and narcotics injected into affected areas
• Transcutaneous electrical nerve stimulation (TENS): mild electrical impulses are sent along nerve fibers to block pain signals to the brain.
• Surgery

Management - Medications

*Depends on the type of back pain:
*Acute
* NSAIDs
* Acetaminophen
* Muscle relaxants
* Oral steroids
*Chronic
* NSAIDs
* Opioids
* Antidepressants
*Alternative therapies include ice and/or heat applications, deep heat therapy,
*Water therapy, exercise, and weight reduction.
*Surgery

Complementary and Alternative Therapies

• Chiropractic or spinal manipulation
• Acupuncture
• Guided imagery
• Massage therapy
• Weighted traction
• Interdisciplinary healthcare team
• Dietary
• Physical therapy
• Occupational therapy
• Home health
• Community resources