Musculoskeletal Trauma Management

Chapter 37: Musculoskeletal Trauma Management

Pre-Assessment: Musculoskeletal Trauma

  • Case Study: A patient with a femur fracture presents with severe pain unrelieved by IV opioids.

    • Additional findings: Pallor, cool skin, and diminished pulses in the affected extremity.

    • Priority Action: Notify the health care provider immediately.

Impaired Mobility: Hazards Assessment

  • Components to assess:

    • Vital signs

    • Pain level

    • Neurovascular status

    • Muscle strength

    • Range of Motion (ROM)

    • Functional ability

  • Risk Factors:

    • Age

    • Comorbidities

    • Nutritional status

  • Complications due to impaired mobility:

    • Pressure injuries

    • Muscle atrophy

    • Venous Thromboembolism (VTE)

    • Pneumonia

    • Constipation

    • Urinary stasis

    • Psychological effects

Impaired Mobility: Prevention

  • Position Changes: Every 2 hours, repositioning with proper body alignment, and utilize support surfaces.

  • Exercise Program: Implement isometric, ROM, and muscle-setting exercises for uninvolved extremities to maintain function.

  • Circulation Support: Include compression devices, anticoagulants, ankle pumps, and adequate hydration.

    • Early mobilization and progressive activity as tolerated are essential to prevent complications of immobility.

Musculoskeletal System: Physical Assessment

  • Inspection:

    • Observation for:

      • Deformity

      • Swelling

      • Bruising

      • Skin integrity

      • Alignment of extremities

    • Compare bilateral findings for symmetry.

  • Palpation:

    • Feel for tenderness, warmth, crepitus, edema, muscle spasms.

    • Note abnormalities or points of localized pain.

  • Range of Motion (ROM):

    • Active and passive ROM assessment for all affected and adjacent joints.

    • Identify limitations, pain, or instability.

  • Muscle Strength:

    • Evaluate muscle strength against resistance using a grading scale (0-5 scale).

    • Note any weakness, paralysis, or atrophy.

  • Neurovascular Status:

    • Check:

      • Pulses

      • Capillary refill

      • Skin color and temperature

      • Sensation (light touch, pain)

      • Motor function distal to the injury.

  • Pain Assessment:

    • Assess pain location, intensity, quality, and aggravating/alleviating factors using a pain scale for objective measurement.

  • A comprehensive assessment is crucial for guiding diagnostic and management decisions. Vital signs differentiate between stable and unstable patients.

Contusions, Strains, and Sprains: Assessment

  • Contusions (Bruises):

    • Soft tissue injury from blunt force.

    • Symptoms include ecchymosis, pain, swelling, and limited joint ROM.

    • Typically resolve within 1-2 weeks.

  • Strains (Muscle/Tendon):

    • 1st degree: mild stretching, no ROM loss.

    • 2nd degree: partial tear; pain with movement.

    • 3rd degree: complete tear; immediate pain.

  • Sprains (Ligaments):

    • Grade I: mild stretching, minimal pain.

    • Grade II: partial tear; joint instability.

    • Grade III: complete tear; severe dysfunction.

Contusions, Strains, and Sprains: Management

  • Rest: Prevent additional injury and promote healing.

  • Ice: Apply ice for 20-minute intervals for 24-72 hours to reduce bleeding and edema.

  • Compression: Use elastic bandages to control bleeding and provide support.

  • Elevation: Keep affected area at or above heart level to control swelling.

  • Diagnostics: X-rays to rule out fractures; MRI or ultrasound for soft tissue injuries.

Splints and Braces

  • Splints:

    • Provide noncircumferential immobilization, allowing for swelling.

    • Easily removed for wound care.

    • Types include: Sugar-tong, posterior, volar.

  • Braces:

    • Support and control movement.

    • Custom-fitted for long-term use.

    • Types include: Functional, hinged, rigid.

    • Materials: Plastic, metal, fabric.

  • Patient Education: Instructions on application/removal, skin care, and activity restrictions.

Casts: Types and Application

  • Fiberglass Casts:

    • Material: Water-activated polyurethane resin with fiberglass knit fabric.

    • Lightweight compared to plaster casts.

    • Stronger and more durable, can be made waterproof.

    • Dries rapidly (minutes to hours), allowing better air circulation.

    • More expensive than plaster casts.

  • Plaster Casts:

    • Material: Plaster of Paris bandages, heavier than fiberglass casts.

    • prone to cracking or breaking, not water-resistant.

    • Takes 24-72 hours to fully dry and harden.

    • Close molding to the body for unstable fractures.

    • Less radiolucent, obscuring fracture lines on X-ray.

    • Less expensive than fiberglass casts.

  • The choice between casts is based on fracture type, activity level, and cost.

Casts: Nursing Care

  • Neurovascular Assessment: Use the 6 P's: Pain, Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia; Check every 1 hour for the first 24 hours, then every 4 hours until stable.

  • Cast Care:

    • Handle wet casts with palms, allow to dry completely (24-48h).

    • Keep cast clean and dry; petal rough edges.

  • Complication Prevention:

    • Elevate extremity to heart level.

    • Encourage active ROM of uninvolved joints.

    • Isometric exercises of muscles beneath the cast.

    • Report unrelieved pain, cool or pale digits, numbness, or tingling immediately.

Assistive Devices: Types

  • Crutches:

    • Types: Axillary or forearm; varied weight-bearing capabilities.

  • Walkers:

    • Types: Standard or rolling; provide maximum stability.

  • Canes:

    • Types: Single or multi-point; provide balance and minimal support.

  • Device selection depends on the patient's strength, balance, and coordination.

Assistive Devices: Patient Education

  1. Proper Sizing:

    • Crutches: 2-3 finger widths below axilla with 30° elbow flexion.

    • Walker: Height at wrist crease with elbows flexed at 30°.

  2. Gait Training:

    • Learn correct walking patterns based on weight-bearing ability; practice on flat ground before stair use.

  3. Safety Measures:

    • Inspect devices regularly; use non-skid tips; remove home hazards.

    • Advise on proper footwear and avoiding wet surfaces.

Joint Dislocations: Assessment

  • Clinical Manifestations:

    • Symptoms include acute pain at the joint, visible deformity, decreased ROM, joint instability, and possible neurovascular compromise.

  • Complications:

    • Risks include neurovascular injury, recurrent dislocation, avascular necrosis, post-traumatic arthritis, and ligamentous damage.

  • Diagnostics:

    • Use X-rays to confirm dislocation and identify associated fractures; labs include CBC and coagulation studies if surgical intervention is anticipated.

Joint Dislocations: Management

  • Initial Stabilization:

    • Immobilize the joint, assess neurovascular status, and provide analgesia.

  • Reduction:

    • Prompt closed reduction under sedation/anesthesia to restore alignment.

  • Post-Reduction Care:

    • Immobilization with splint/sling, neurovascular checks every 15 minutes until stable.

  • Rehabilitation:

    • Engage in progressive ROM exercises, strengthening program, and joint protection.

    • Patient education on danger signs (increased pain, numbness, tingling, increased edema), proper exercises, and follow-up care.

Fractures: Types and Assessment

  • Types of Fractures:

    • Definitions include closed vs. open, complete vs. incomplete, transverse, oblique, spiral, comminuted, impacted, and intra-articular.

  • Assessment Findings:

    • Indicators include pain, swelling, deformity, loss of function, crepitus, shortening, ecchymosis, and neurovascular changes.

Fractures: Diagnostic Studies

  • Imaging:

    • X-rays: Initial assessment with multiple views; CT scan for complex or intra-articular fractures; MRI for soft tissue damage or occult fractures; bone scan for stress fractures or infections.

  • Laboratory Tests:

    • CBC for baseline and blood loss monitoring; coagulation studies for pre-surgical screening; electrolytes for fluid/electrolyte balance; calcium and vitamin D for bone health.

  • Neurovascular assessment is critical to identify potential complications.

Fractures: Complications

  • Compartment Syndrome:

    • Increased pressure within a muscle compartment can lead to nerve and muscle damage; requires immediate intervention.

  • Fat Embolism Syndrome (FES):

    • Fat globules released into the bloodstream from the bone marrow, often post long bone fractures; can cause respiratory distress, neurological changes, and petechial rash.

  • Osteomyelitis:

    • Severe bone infection, common with open fractures due to bacterial contamination; can lead to chronic pain and destruction.

  • Avascular Necrosis (AVN):

    • Bone tissue death due to interrupted blood supply; common in femoral head or scaphoid fractures.

  • Malunion/Nonunion:

    • Malunion: fracture heals in abnormal position; Nonunion: fracture fails to heal fully, leaving a persistent gap.

  • Venous Thromboembolism (VTE):

    • Involves DVT and PE; increased risk due to immobility and tissue trauma, especially lower extremity fractures.

Hip Fractures: Assessment

  • Risk Factors:

    • Advanced age (>65), osteoporosis, female gender, previous falls, medications affecting balance, cognitive impairment.

  • Clinical Presentation:

    • Symptoms include hip/groin pain, external rotation of the leg, shortened leg, inability to bear weight, limited ROM with pain.

Hip Fractures: Nursing Care

  1. Preoperative Care:

    • Manage pain, perform neurovascular assessments, position with a pillow between legs, establish NPO status, and provide IV hydration.

  2. Postoperative Care:

    • Monitor vital signs, manage pain, wound assessment, neurovascular checks, prevent VTE, early mobilization, avoid hip flexion beyond 90 degrees.

  3. Rehabilitation:

    • Progressive weight bearing as prescribed, use assistive devices, engage in physical therapy, and focus on fall prevention.

  • Monitoring for Complications: Watch for infection, dislocation, VTE, pneumonia, and delirium.

Discussion: Prioritizing Assessment in Musculoskeletal Trauma

  • Initial Assessment Principles:

    • Airway: Identify scenarios such as facial trauma and cervical spine injuries; interventions include jaw-thrust maneuver and airway clearance.

    • Breathing: Understand indirect effects on breathing and signs of respiratory distress requiring attention.

    • Circulation: Recognize indicators of compromised circulation and assess for neurovascular compromise distal to the injury site.

    • Applying ABCs: Use specific case scenarios to frame assessment priorities relevant to airway, breathing, and circulation.

Prioritizing Assessment in Musculoskeletal Trauma: Answers

  1. Airway Concerns:

    • Compromise may occur with facial trauma, cervical spine injuries, or altered consciousness; interventions involve airway management while maintaining spinal immobilization.

  2. Breathing Impact:

    • Severe injuries can affect breathing through pain, rib fractures, or significant blood loss; monitor for tachypnea and signs of respiratory distress.

  3. Circulation Indicators:

    • Assess for signs such as pallor, cool skin, tachycardia, and altered mental status; neurovascular status assessed via the 6 P's: Pain, Pallor, Pulses, Paresthesia, Paralysis, Poikilothermia.

  4. ABCs Application:

    • For an open fracture case, prioritize airway, breathing, circulation, and only after addressing these would attention shift to limb injury. Perform hemorrhage control, cover wounds, and assess neurovascular status.

Internal Fixation: Types of Devices

  • Devices include screws, plates, nails/rods, wires, pins, and compression devices.

External Fixation

  • Indications:

    • For open fractures with soft tissue damage, infected fractures, severe comminuted fractures, and limb lengthening procedures.

  • Components:

    • Pins or wires inserted into bone, external frame/rods, and clamps connecting pins to the frame.

Discussion: Prioritizing Concerns of Internal vs. External Fixation

  • Primary considerations include advantages/disadvantages, nursing priorities post-surgery, preferred method usage, and long-term rehabilitation goals.

Prioritizing Concerns of Internal vs. External Fixation: Answers

  1. Internal Fixation Advantages/Disadvantages:

    • Advantages: Direct stabilization, early mobilization, improved cosmetic outcome, lower infection risk post-surgery.

    • Disadvantages: Requires surgery, risk of implant failure or infection, anesthesia complications.

  2. External Fixation Preference:

    • Preferred in open fractures with significant soft tissue damage or infection, and allows direct wound care and observation.

  3. Nursing Priorities for Internal Fixation:

    • Focus on pain management, wound care, monitoring for infection, and early mobilization as per surgeon orders.

  4. Nursing Priorities for External Fixation:

    • Emphasize pin site care and early partial mobilization.

  5. Long-term Rehabilitation Goals:

    • Internal fixation focuses on restoring function as healing progresses, while external fixation emphasizes managing the device and achieving bone union.

External Fixation: Nursing Care

  1. Pin Site Care:

    • Maintain aseptic technique and assess for infection; frequency based on protocol.

  2. Neurovascular Assessment:

    • Monitor circulation, sensation, and movement, reporting changes immediately.

  3. Patient Education:

    • Discuss frame care, weight-bearing restrictions, pin site care, and signs of infection; provide psychological support for body image concerns.

Skin Traction vs. Skeletal Traction

  • Skin Traction:

    • Applies pulling force to skin/soft tissues via tapes or straps; suitable for short-term immobilization or muscle spasm reduction.

  • Skeletal Traction:

    • Involves pin placement in bone; used for long-term immobilization with higher weight application and does align bones effectively.

Traction: Nursing Care

Skin Traction Nursing Care

  • Skin Assessment:

    • Inspect skin under traction devices; monitor for pressure and irritation.

  • Traction Maintenance:

    • Check alignment and weight application.

  • Complication Prevention:

    • Perform neurovascular checks and ROM exercises for uninvolved joints.

Skeletal Traction Nursing Care

  • Pin Site Care:

    • Clean meticulously and assess for infection.

  • Traction Maintenance:

    • Ensure correct weight and alignment of equipment.

  • Complication Prevention:

    • Perform regular neurovascular checks, promote mobility of uninvolved joints, and monitor for DVT.

Amputation: Types and Causes

  • Types:

    • Upper extremity: Finger, hand, below/above elbow.

    • Lower extremity: Toe, foot, below/above knee.

    • Disarticulation: Through joint.

  • Causes:

    • Trauma, peripheral vascular disease, diabetes mellitus, malignancy, congenital deformities.

Amputation: Nursing Care

  1. Preoperative Care:

    • Psychological preparation, baseline assessment, pain management, and lab work (CBC, coagulation studies, electrolytes, glucose).

  2. Immediate Postoperative Assessment:

    • Focus on ABCs and neurovascular assessment, monitoring for hemorrhage.

  3. Ongoing Postoperative Care:

    • Manage residual limb positioning, dressing, pain control, and monitor for infection and edema.

  4. Rehabilitation:

    • Plan for residual limb wrapping/shaping, strengthening exercises, and prosthetic fitting; provide psychological support for body image changes and grief process.

Patient Education: Key Points

  • Injury Care: Follow RICE protocol, partake in medication management, wound care, and activity restrictions.

  • Warning Signs: Recognize increasing pain, numbness/tingling, color changes, fever, drainage, swelling.

  • Follow-up Care: Schedule appointments, rehabilitation plans, and home exercise programs.

  • Prevention: Focus on fall prevention, proper body mechanics, bone health, and safety measures.

Musculoskeletal Trauma Case Study: John Doe

  • Scenario: A 45-year-old male presents with a severe left leg injury due to a fall from a ladder.

  • Subjective Data:

    • Reports "excruciating" pain rated 8/10; heard a "pop".

  • Objective Data:

    • Vital signs: BP 142/92 mmHg, HR 105 bpm, RR 22 breaths/min, Temp 98.4°F, SpO2 97%.

    • Left leg: Obvious deformity, swelling, ecchymosis.

    • Neurovascular: Weak distal pulses, capillary refill >3 seconds, decreased sensation, unable to move foot.

  • Critical Thinking Questions:

  1. Immediate concern: Compartment Syndrome due to neurovascular findings.

  2. Correlation of vital signs: Elevated BP and HR reflect pain and physiological stress.

  3. Top three nursing interventions: Immobilize extremity, administer pain medication, position leg at heart level.

Musculoskeletal Trauma Case Study: Answers

  1. Immediate Concern: Compartment Syndrome, indicated by impaired circulation and nerve function.

  2. Vital Signs Correlation: Reflect acute pain response; prompt pain management is necessary.

  3. Nursing Interventions:

    • Immobilize the injured extremity with a splint, administer analgesia for severe pain, position left leg at heart level for monitoring and prevention of escalation.

Key Takeaways: Assessment and ABCs

  • Prioritize ABCs: Always ensure airway, breathing, and circulation are managed first in trauma.

  • Thorough assessment: Conduct rapid primary and detailed secondary assessments to identify life-threatening issues.

  • Neurovascular vigilance: Carry out meticulous assessments to detect signs of compromise like Compartment Syndrome.

  • Continuous monitoring: Regularly assess vital signs, pain levels, and neurovascular status to determine patient stability and intervention effectiveness.