Musculoskeletal Disorders: Strains, Sprains, Fractures, and Related Care
Musculoskeletal Disorders
Key Terms
Arthritis: Inflammation of a joint.
Avascular Necrosis: Death of bone tissue due to a lack of blood supply.
Fasciotomy: A surgical incision through the fascia to relieve pressure, often in cases of compartment syndrome.
Hyperuricemia: An excess of uric acid in the blood.
Rhabdomyolysis: A severe and potentially fatal condition involving the breakdown of muscle fibers, leading to the release of muscle fibers into the bloodstream.
Synovitis: Inflammation of the synovial membrane, which lines joints.
Ischemia: An inadequate blood supply to an organ or part of the body, especially the heart muscles.
Poikilothermia: The inability to regulate one's body temperature; the skin temperature of the affected limb closely matches the ambient temperature. It's one of the "6 Ps" indicating neurovascular compromise.
Core Concepts
Comfort
Mobility
Teaching and Learning
Strains
Definition
A soft tissue injury where a muscle or tendon is excessively stretched.
Causes
Falls
Excessive exercise
Lifting heavy items
Types
Mild: Minimal inflammation with swelling and tenderness.
Moderate: Involves partial tearing of muscle or tendon fibers, causing pain and inability to move the affected part.
Severe:
A muscle or tendon is ruptured.
Separation of muscle from muscle.
Separation of tendon from muscle.
Separation of tendon from bone.
Causes severe pain and disability.
Treatment/Interventions (R.I.C.E. method and medication)
Rest: Stop using the injured part to prevent further injury. Use crutches for leg/knee/ankle/foot injuries, and splints for arm/elbow/wrist/hand injuries.
Ice: Apply for 20 minutes, 4 times daily, to decrease swelling and pain. Helps stop internal bleeding of injured capillaries and blood vessels by causing vasoconstriction. Apply for the first 24 hours.
Compression: Used to support the area and decrease swelling, hastening healing. Use an elasticized bandage, compression sleeve, or cloth.
Elevation: Elevate the injured part above the level of the heart to decrease swelling and pain.
Heat: After swelling stops (usually after the first 24 hours), apply heat for 15 to 30 minutes, 4 times daily, to increase blood flow.
Activity Limitation: Rest is crucial.
NSAIDs (Nonsteroidal Anti-inflammatory Drugs): Such as Ibuprofen (Motrin). Take with food to prevent GI upset.
Muscle Relaxants: May be used.
Surgical Repair: Severe strains may require surgical intervention.
Sprains
Definition
Excessive stretching of ligaments.
Causes
Twisting during sports
Exercise
Falls
Treatments
Mild sprain (tearing of a few ligaments): RICE and NSAIDs.
Moderate sprains (more fibers torn, but joint remains stable): May need immobilization with a brace or cast.
Severe sprain (causes instability of the joint): Usually requires surgery for tissue repair or grafting. Pain and inflammation restrict activity.
Patient Safety
Use lifting devices (e.g., draw sheets, mechanical moving devices) to prevent injury to both patients and healthcare providers.
Avoid pulling up on a patient's arms to prevent patient injury.
Dislocations
Definition
The ends of the bone have moved out of their normal position within a joint.
Causes
Trauma
Rheumatoid arthritis
Osteoporosis (brittle bones)
Can be genetic
Signs & Symptoms
Severe pain
Loss of range of motion (ROM)
Joint deformity
Treatment
Keep the affected joint immobile.
Apply ice.
Seek immediate medical treatment.
Do not move joints: This is crucial as blood vessels, muscles, and nerves could be damaged.
Fractures
Definition
A break in a bone.
Causes
Trauma: Direct impact or injury.
Pathological (from disease process):
Osteoporosis
Bone cancer
Malnutrition
Certain medications
Carbonated beverages (interfere with calcium absorption)
Types of Fractures
Complete Fractures: Bone completely breaks into two or more pieces. Can be life-threatening if sharp bone fragments sever blood vessels and nerves.
Incomplete Fractures: Bone does not divide completely into two.
Displaced Fracture: Bone ends are out of alignment.
Closed Fracture (Simple Fracture): Does not break the skin.
Open Fracture (Compound Fracture): Breaks the skin, posing an increased risk of infection.
Phases of Bone Healing
Clot formation (Hematoma): Blood clots form at the fracture site shortly after injury.
Fibroblasts and osteoblasts arrive: Within days, new capillaries, fibroblasts, and osteoblasts enter the clot.
Fibrocartilage callus forms: A soft callus of fibrocartilage forms, splinting the broken bone.
New bone forms (Bony Callus): Osteoblasts begin to form cancellous bone, converting the fibrocartilaginous callus into a bony callus.
Bone remodeling: The bony callus remodels over time until the bone is intact and restored to its original shape. Repair and healing are completed.
Signs & Symptoms
Pain
Decreased range of motion
Limb rotation
Deformity, shortening of limb
Swelling
Bruising
Crepitation (a grating sound or sensation)
Diagnostics
X-ray
Computed tomography (CT) scan
Emergency Treatment
Splint it as it lies! Do not attempt to straighten or realign.
Seek immediate medical attention.
Observe for respiratory arrest, bleeding, and head or spine injury.
Therapeutic Goals
Realignment of bone ends (Reduction): Restoring the bone to its anatomical position.
Immobilization: Preventing movement of the fractured bone to allow healing.
Preserving vessels, tendons, ligaments, and muscles.
Preventing deformity or further injury.
Management
Closed Reduction for Simple Fractures:
Manual realignment of bone ends.
Analgesia and/or sedation administered before the procedure.
Healthcare provider pulls on the bone, and alignment is confirmed with an X-ray.
Followed by elastic wrap or splints.
Perform neurovascular checks hourly.
Casts: Provide stronger support than splints. COMPLICATION: Compartment Syndrome (see below).
Traction: Application of a pulling force.
Skin Traction (e.g., Buck's traction): Applied to the skin, typically using 5-10 lb weights.
Skeletal Traction: Involves pins, wires, or tongs inserted directly into the bone, using 20-40 lbs of weight, which must hang freely at all times.
Urgent Management of Fractures (Summary of immediate care)
Immobilize the limb. If movement is necessary, support above and below the fracture.
Apply splints and padding above and below the fracture. If bleeding, apply pressure.
Use the opposite limb for immobilization (e.g., tie fractured leg to the other leg).
Monitor for warmth, circulation, and movement distal to the fracture.
For open fractures, cover protruding bone with a sterile dressing, if possible.
Do not straighten or realign a fractured extremity.
Transport to hospital for medical care.
Open Reduction with Internal Fixation (ORIF)
Process
Bone ends are reduced (realigned) by direct visualization through a surgical incision.
Held together with internal fixation devices (e.g., plates, screws, rods).
Hip fracture is most common for older adults requiring ORIF.
ORIF often allows for early ambulation while the bone is healing.
Internal Fixation Devices
Examples: Side plate and screw combination device for intertrochanteric hip fracture, side plate and screw fixation for radial fracture.
These devices remain after healing but may need removal from ankle or long bones due to loosening or pain.
Post-surgery, keep the limb in alignment.
Preoperative Care for Fracture Surgery
Preoperative Labs:
PT/INR & PTT for coagulation studies.
Complete Blood Count (CBC) to check for abnormalities.
Basic Metabolic Panel (BMP) to assess electrolyte abnormalities.
CHG (Chlorhexidine Gluconate) Bath: Bath using wipes impregnated with chlorhexidine. Warm wipes in a warmer; do not use on face or perineal area.
Informed Consent: Confirm that it has been signed and is in the chart.
NPO (Nil Per Os) after midnight: Nothing by mouth to prevent aspiration during anesthesia.
Hip Fracture Post-op Interventions
Pain Control Priority:
Acetaminophen 1000mg every 6 hours for the first 24 hours (do not exceed 4g/day total from all sources).
Hydrocodone/acetaminophen 5/325mg for breakthrough pain.
Ibuprofen 400mg every 4 hours.
Neurovascular Checks: Monitor every 2 hours for the 6 P's.
Limb Alignment: Keep the limb in alignment; use an abductor wedge (ensure the knee faces the ceiling).
Turning: Use log roll technique to turn the patient.
Incentive Spirometer: Perform 10 times an hour to prevent pneumonia.
Deep Breathing and Coughing: To prevent pulmonary complications.
Monitor for Bleeding:
Low blood pressure may indicate internal bleeding.
Monitor the surgical site for external bleeding from the incision.
Hip Fracture Education (Do's & Don'ts for successful recovery after hip replacement)
DO's:
While lying on your back, keep a pillow between your legs to prevent knees from touching.
Use a walker, crutches, or cane for ambulation until advised by the doctor.
Sit on a high chair (higher than knee height).
Use raised toilet seats and adjust bed height.
DON'Ts:
Avoid crossing and twisting your legs.
Avoid bending from your waist more than 90 degrees.
Don't drive until your doctor advises.
Avoid turning your back on your operated leg.
Interventions for Internal Fixation
Monitor for pain and administer analgesics, especially before physical therapy.
Perform neurovascular checks, looking for the 6 P's (Pain, Paresthesia, Pallor, Paralysis, Pulselessness, Poikilothermia).
Use a fracture bedpan if needed for ease and comfort.
Apply thigh-high compression stockings or sequential compression devices (SCDs) to prevent deep vein thrombosis (DVT).
Administer anticoagulants (e.g., heparin or enoxaparin subcutaneously).
Remind the patient to practice exercises of the fractured extremity.
Promote early ambulation.
External Fixation
Use Cases
Used when bone damage is severe, such as crushed or splintered fractures, or if the bone has many breaks.
After reduction, pins are held in place by an external metal frame to prevent bone movement.
Also allows for visualization of soft tissue damage that requires additional treatment.
Interventions
Inspect pin sites and dressings for signs of infection (priority): Look for warmth, redness, heat, edema, drainage, pain.
Provide pin-site care per agency policy: Strict aseptic technique is essential due to the pins creating a pathway for pathogens.
Monitor the patient's mobility with the external fixation device in place.
Collaborate with other disciplines to educate patients on safe ambulation and transfers with EF devices.
Splints, Casts, Traction (Specific Details)
Splints
Used for immobilizing a limb to allow for healing.
Can be an elastic wrap.
Monitor for swelling; perform neurovascular checks hourly, looking for the 6 P's.
Traction
A pulling force with a prescribed weight, holding bone fragments in place for proper alignment.
Buck's Traction (Skin Traction): Uses 5-10 lb weights. Used for hip fractures to relieve muscle spasms and stabilize until surgery.
Skeletal Traction: Uses pins, wires, or tongs inserted into the bone, with 20-40 lbs of weight. Weights must hang freely at all times.
Casts
Provide stronger support than splints for fractured bones.
Made of plaster or fiberglass.
Heat is produced as casts dry.
Plaster casts take 24-72 hours to dry.
Fiberglass casts take about 2 hours to dry.
Monitor for Compartment Syndrome (when the cast becomes too tight).
If too tight, a cast must be cut (bivalved) with a cast saw to relieve pressure immediately.
If a wound is present or an odor is detected, a window opening is cut to treat the wound. If no wound, the window should be closed.
Cast Nursing Interventions (Box 46.2)
Neurovascular checks every 2 hours for 24 hours, then 4 times a day.
Check for cast tightness; assess if the patient can move their digits.
During drying, keep the limb elevated to prevent swelling and support the cast on soft surfaces (e.g., pillows) to prevent indentations and facilitate air circulation.
Avoid covering the cast, as this can impede drying and lead to heat buildup.
Monitor for "hot spots" which may indicate pressure areas or infection under the cast.