Musculoskeletal Problems: Nursing Management

Soft Tissue Injuries (Often from trauma or sports)

• Include sprains, strains, dislocations, and subluxations.

Sprain

• Injury to the ligamentous structures surrounding a joint, often due to wrenching or twisting.

• Commonly affects the ankle, wrist, and knee.

• Degrees of sprain:

  • First degree (mild): Tears in a few fibers with tenderness and swelling.

  • Second degree (moderate): Partial disruption of tissue with tenderness and swelling.

  • Third degree (severe): Complete tear of the ligament with pain and moderate to severe swelling.

Strain

• Excessive stretching of a muscle, fascial sheath, or tendon (connects muscle to bone at each end).

• Commonly affects the low back, calf, and hamstring.

• Degrees of strain:

  • First degree (mild): Slightly pulled muscle.

  • Second degree (moderate): Moderately torn muscle.

  • Third degree (severe): Severely torn or ruptured muscle; may have a palpable defect.

Clinical Manifestations – Sprain & Strain

• Usually self-limiting (as they heal, symptoms go away), with full function returning in 3-6 weeks.

  • Pain: Aggravated with continued use.

  • Edema: Localized inflammatory response.

  • Decreased function.

  • Contusion.

• Potential Complications:

  • Avulsion fracture (sprain so bad it breaks off part of bone and need surgical repair), hemarthrosis (blood within joint space).

  • X-ray often done in severe injuries to rule out fracture.

  • Severe strains may need surgical repair.

Nursing Management

• RICE

  • Rest: Stop activity and limit movement.

  • Ice: Apply ice compress to the area.

    • 20-30 mins on and 20-30 minutes off (never put ice pack directly on skin)

    • After 24 hours → switch to heat to encourage circulation and healing

  • Compression: Compress the involved extremity (ace wrap).

  • Elevation: Decreases local inflammation.

    • Do NOT put in a dependent position.

    • Elevate above heart.

• NSAIDs, acetaminophen (Tylenol).

• Heat after 24 hours.

• Motion.

• Health Promotion:

  • Warm-up prior to exercise, stretching after exercise.

  • Strength exercises increase muscle strength and bone density.

  • Balance exercises prevent falls.

Dislocation and Subluxation

• Dislocation: Complete displacement or separation of the articular surfaces of the joint.

• Subluxation: Partial or incomplete displacement of the joint surface.

• Most often affects the thumb, elbow, shoulder, hip, and patella.

• Risk Factors: Injury, excessive laxity of ligaments, weak or atrophied muscles.

• Clinical Manifestations: Deformity, loss of function, pain, tenderness, edema.

Interprofessional Care – Subluxation/Dislocation

• Considered an orthopedic emergency due to risk of neurovascular compromise and avascular necrosis and compartment syndrome

• First goal – realignment!!

  • Closed (most common) or open reduction.

  • Pain relief.

  • Immobilization: Brace, splint, tape, sling, or cast.

• Support/protect injured joint to reduce the increased risk for subsequent dislocation.

• Frequent neurovascular assessment (circulation, motion, sensation).

  • Assessment: Cap refill, ROM (movement of nearby extremities but NOT the one affected)

Fractures

• Disruption or break in the continuity of the bone.

• Etiology:

  • Traumatic (most common).

    • Car accident

    • Fell

    • Climbed latter and fell off

  • Pathologic

    • Related to a disease process (ex. Osteoporosis w/out trauma)

  • Stress

    • Repeated use of said bone (Ex. Runners, obese people)

• Classification:

  • Open or closed.

  • Complete or incomplete.

  • Direction of Fracture Line: Linear, longitudinal, oblique, transverse, spiral.

  • Non-displaced (transverse, spiral, greenstick) or displaced (comminuted or oblique).

    

Clinical Manifestations

• Immediate, localized pain

• Decreased function

• Inability to bear weight or use affected part

• Ecchymosis/Contusion

  • 27:43 LISTEN TO LECTURE!!!!

• Deformity

• Edema

• Muscle spasm

• Crepitation

  • Rice crispy sound (from bone rubbing against each other)

Stages of Bone Healing

1. Hematoma

   1. Bone marrow → blood producing tissue → surrounds end of bone fragments → changes to semisolid clot in first 72 hours after injury → ecchymosis (bruising might be seen)

2. Granulation Tissue

   1. Bl

3. Callus Formation

4. Ossification

5. Consolidation

6. Remodeling

Interprofessional Care

• Fracture reduction

  • Closed reduction = nonsurgical, manual realignment

  • Open reduction = surgical realignment, often with internal fixation (ORIF)

  • Traction = application of a pulling force

    • Skin (tape/boot/splint) or skeletal (pin or wire in bone with weights)

• Fracture immobilization

  • Braces, splints

  • Casting; temporary circumferential immobilization

  • Fixators (internal or external)

  • Traction (reduces pain)

• Open fracture

  • Surgical debridement with immunizations & antibiotics

Interprofessional Care - Pain Management (Multi-modal approach)

• Muscle relaxants

  • Examples: carisoprodol (Soma), cyclobenzaprine (Flexeril), or methocarbamol (Robaxin)

• Opioid analgesics

  • Morphine, dilaudid

• Neuropathic agents

  • Gabapentin

• NSAIDs

Interprofessional Care - Nutrition Therapy

• Adequate Protein (1g/kg body weight, daily)

• Vitamins B, C, D

• Minerals Ca, K, Phos, Mag

• Avoid constipation related to prolonged immobilization

• Fluid intake 2-3L/day

  • Except HF and dialysis patients

• High fiber diet with fruits and vegetables

Cast Care

• Keep Dry

• Do not stick things in it

• Do not pull out the padding

  • Go back to doctor if padding is coming out due to risk of skin breakdown.

• Elevate extremity above heart level for 48 hours

• Maintain distal and proximal ROM

• Monitor pain and neurovascular function

• Common Complaints

  • Itching – use hair dryer on cool or gently smack it.

  • Change in lifestyle

Traction

• Traction care:

  • Maintain correct balance between traction pull and counter traction force

    • If patient slides down in bed, pull patient back up.

  • Care of weights

  • Skin inspection

    • Q2H turns

  • Pin care (skeletal traction)

    • Straw-color or yellowish drainage is okay

Neurovascular Assessment

• (circulation, motion, sensation)

  • Peripheral vascular assessment

    • Color, temp, cap refill, pulses, edema

  • Peripheral neurologic assessment

    • Sensation, motion, pain

• Acronym: 5 P’s (bilateral comparison)

  • Pain

  • Paresthesia

  • Paralysis

  • Pulses

  • Pallor

Fracture Complications

• Direct complications (bone itself is the problem/localized complication):

  • Infection/Osteomyelitis

  • Non-Union

    • Bone doesn’t heal.

  • Avascular Necrosis

• Indirect complications:

  • Compartment Syndrome

  • Fat Embolism Syndrome (FES)

  • VTE

  • Rhabdomyolysis

  • Hypovolemic shock

Osteomyelitis

• Infection of the bone, marrow, & surrounding tissue

• Dependent upon:

  • Severity of fracture

  • Severity of soft tissue injury

  • Degree of bacterial contamination

  • Presence of underlying vascular insufficiency

• Indirect Entry (hematogenous spread)

  • Blunt trauma (young)

  • Respiratory & GU infections (older)

  • Diabetic’s

• Direct Entry

  • Penetrating wounds/fractures/Implants

Pathophysiology

• Microorganism growth causes increased pressure in the limited bone space causing vascular compromise & ischemia of periosteum

• Infection spreads to bone cortex, marrow cavity causing devascularization & necrosis

• Area of dead bone separates from living bone forming sequestra

• Area of remaining periosteum with blood supply forms new bone; involucrum

• Antibiotics & WBC’s have difficulty reaching the reservoir of bacteria

Clinical Manifestations

• Acute Infection < 1 month in duration

  • Local

    • Bone pain that worsens with activity; unrelieved by rest

    • Redness, warmth, swelling, restrictive movement

  • Systemic

    • Fever, chills, night sweats, malaise

• Chronic Infection > 1 month duration

  • Continuous persistent problem with exacerbations & remissions

  • Same local manifestations as acute

  • Systemic manifestations may be reduced

  • Eventual amputation may be necessary if bone destruction is extensive

Treatment

• Bone or Tissue biopsy to define causative organism

  • Skin flora; staph epi/staph aureus

  • Aerobic, anaerobic, septic

• IV antibiotic therapy

• Surgical debridement

  • Required for open fractures

  • Implantation of acrylic bead antibiotic chains

  • Removal of orthopedic prosthetic device

Compartment Syndrome

• An increased pressure within enclosed osteofascial space that reduces capillary perfusion below level necessary for tissue viability; the underlying mechanism is:

  • increased volume within space

  • decreased space for contents

  • combination of both

• Most often occurs in the leg but can occur in other areas

• BUE and BLE contain 38 separate compartments

Pathophysiology

• Decreased space

  • Restrictive dressings, splints, casts, excessive traction

• Increased volume

  • Bleeding, inflammation, edema, IV infiltration

• Edema creates enough pressure to obstruct circulation, compromising arterial blood flow

  • Tissue ischemia

  • Muscle & nerve cell destruction

  • Fibrotic tissue replaces healthy tissue

• Irreversible muscle & nerve ischemia resulting in functional loss

Etiology

• Often related to:

  • Fractures (tibia and distal humerus)

  • Soft tissue damage (ex. blunt force trauma)

  • Crush Injury

• Can occur as a complication of orthopedic surgery or immobilization devices (casts, splints, etc.)

• May be related to an extremity being stuck underneath the body r/t EtOH intoxication or drug OD.

Clinical Manifestations

• 6 P’s

  • Pain (out of proportion to injury) 1st sign

  • Pressure

  • Paresthesia early sign

  • Pallor

  • Paralysis late sign

  • Pulselessness late sign

• Laboratory tests

  • CPK

  • Urine myoglobin

  • Be alert for acute kidney injury

  • Dark reddish-brown urine

Treatment

• Lower extremity to the level of the heart

• Remove anything restrictive (cast/splint); Split all dressings down to the skin

• Do NOT apply cold compresses

• Fasciotomy if continued clinical findings and/or elevated compartment pressure

Rhabdomyolysis

• Excessive breakdown of damaged skeletal muscle cells

• Myoglobin released in bloodstream

• Creatine Protein Kinase (CPK)

• Myoglobin obstructs renal tubules

• Risk for Acute Kidney Injury (AKI)

• Clinical Manifestations:

  • Dark, reddish-brown urine

  • Oliguria

  • Weakness in affected muscles

  • May also have pain in those muscle areas

• Treatment:

  • Aggressive IV hydration

  • Monitor Intake and Output, Renal Function

  • PT may be necessary depending on muscles involved

Fat Embolism Syndrome (FES)

• Fat globules enter the circulatory system from fractures.

• Collect in vascular areas (lungs, brain)

• Commonly occurs from fractures to long bones, ribs, tibia, pelvis; may also be seen after joint replacement, pancreatitis, burn injuries, and crush injuries

FES - Pathophysiology

• Exact pathophysiology unknown – two theories exist:

  • Theory I

    • Fat is released from the marrow of injured bone

    • Fat enters systemic circulation

    • Embolizes to organs: lungs, brain

    • Produces localized ischemia & inflammation

  • Theory II

    • Hormonal changes caused by trauma or sepsis stimulate the release of free fatty acids (chylomicrons) which form emboli

Triad of FES

• Usually occurs 24-48 hours post-injury

  1. Hypoxemia

     • Dyspnea, cyanosis, chest pain

     • Tachycardia, tachypnea

  2. Neurological abnormalities

     • Memory loss, restlessness

     • Fever, headache

  3. Petechial rash

     • Neck, anterior chest, axilla, head, conjunctiva

     • Only occurs in some patients; fades quickly

FES: Interdisciplinary Care

• Prevention!!

  • Immobilization of long bone fractures

  • Minimal repositioning prior to fracture stabilization

• Acute Care Management:

  • Treat Hypoxia

  • Treat Hypotension

• Care often managed in the ICU setting

Hip Fracture

• Fracture of proximal (upper 1/3) of the femur which extends 5 cm below the lesser trochanter.

  • Intracapsular fracture

    • Within the hip joint capsule

    • Common in older adults

    • 95% due to fall

      • (>300,00) hospitalizations

      • 37% die within a year

    • Women

      • Suffer 75% of all hip fractures

      • Over age 65 due to osteopenia or osteoporosis

Hip Fracture Types

• Intracapsular – occurs within the hip joint capsule

  • Capital – head of femur

  • Subcapital – just below the head of the femur

  • Transcervical – femoral neck

    • Fragility fractures

    • Associated with osteoporosis and minor trauma

• Extracapsular – occurs outside joint capsule

  • Intertrochanteric – between greater and lesser trochanter

  • Subtrochanteric – below lesser trochanter

Hip Fracture Manifestations and Treatment

• Clinical manifestations

  • External rotation

  • Muscle spasm

  • Shortening of affected extremity

  • Severe pain and tenderness around fracture site

• Displaced femoral neck fracture may lead to avascular necrosis of femoral head

• Initial treatment

  • Immobilization with Buck’s traction to relieve muscle spasms (used for 24-48 hours) if medically unstable

    • Surgical Options:

      • Closed reduction with percutaneous pinning (CRPP)

      • Repair with internal fixation devices (ORIF)

      • Replacement of femoral head—hemiarthroplasty

      • THA/THR (femur and acetabulum)

Hip Fracture Complications

• Complications of Hip Fracture (femoral neck)

  • Nonunion, avascular necrosis, osteoarthritis, shorter leg

  • Dislocation: sudden, severe pain, lump in buttock, limb shortening, and external rotation

  • Keep patient NPO in anticipation of surgery

    • Closed reduction with sedation

    • Open reduction under general anesthesia

Joint Surgery

• Emphasis on THA and TKA

• Types of Joint Surgeries

  • Synovectomy

    • Removal of synovial membrane

    • Most common in RA

  • Osteotomy

    • Remove bone to restore alignment

    • To relieve pain in severe arthritis, kyphosis

  • Debridement

    • Removal of debris (loose bone/cartilage – usually in a joint)

  • Arthroplasty

    • Reconstruction or replacement of a joint

    • To relieve pain, improve ROM, or correct deformity

Arthroplasty - Overview

• Done for patients with OA, RA, avascular necrosis, congenital deformities, dislocations, or fractures.

• May include surgical reshaping, partial replacement (hemiarthroplasty), or total joint replacement.

• Common procedures and abbreviations:

  • Total Hip Arthroplasty (THA) or Total Hip Replacement

  • Total Knee Arthroplasty (TKA) or Total Knee Replacement

  • Total Shoulder Arthroplasty (TSA)

• 1 million Americans have THA or TKA each year!!

Complications of Joint Surgery

• Infection

  • Common organisms: gram-positive streptococci and staphylococci

  • May loosen prosthesis, cause deep infection (osteomyelitis), and cause significant pain. Patient may need surgery revision.

  • Prophylaxis:

    • -In the OR: self-contained OR suites, laminar airflow

    • -Prophylactic antibiotics (pre-/intra-/post-op)

• VTE: Prevention is key!

  • Early ambulation

  • Anticoagulants or Antiplatelets, starting in hospital and continued at home

  • Intermittent pneumatic compression (SCDs)

  • Compression socks (“ted hose”)

• Prosthesis Dislocation

  • S/s = pain, loss of function, shortening or malalignment of an extremity

Joint Surgery: Interprofessional Management

• Early mobilization = day of surgery!

  • Check weight-bearing orders (WBAT, etc.)

• Hydration (IV and then PO)

• VTE prophylaxis

  • Anticoagulants: heparin subQ, LMWH, apixaban (Eliquis), or rivaroxaban (Xarelto)

  • Antiplatelets: ASA

  • SCDs and/or Ted hose

• Infection prophylaxis

  • IV antibiotics

  • Maintain surgical dressing

• Neurovascular assessments

• Pain management: Multimodal analgesia

  • Preop: femoral nerve block

  • Postop: opioids, NSAIDS, neuropathic agents, muscle relaxants

• May consider epidural, intrathecal, or PCA for severe pain

• PT/OT visit with practice of exercises and use of assistive devices

  • Coordinate analgesia with therapy time

• Maintain correct anatomical alignment

  • Post THA = avoid bending at the hip past 90°, twisting their leg in or out, and crossing their legs.

  • Post TKA = initially immobilized in extension, do not cross legs at knees or ankles.

• General Surgical Care

  • Post-op Vital Signs

  • Bowel Regimen

  • Pulmonary Hygiene (Incentive Spirometry, deep breathing, and coughing)

  • Dressing care as ordered

  • Monitor for bleeding and s/s of infection

Joint Surgery: Discharge Considerations

• Subacute rehabilitation or acute rehabilitation

  • May be inpatient or at skilled nursing facility (SNF)

• Home health care with PT/OT

• Ambulatory Care, education:

  • Pain management (opioid education), monitor for infection, prevent VTE

  • Patient teaching: bleeding precautions with anticoagulant

  • Home safety to prevent falls

  • Discuss the risk of infection related to the prosthetic joint with a dentist or surgeon

Ambulatory Care, Movement Restrictions for THA:

• Do:

  • Use elevated toilet seat

  • Remain seated on chair in shower or tub

  • Keep hip in neutral, straight position when sitting, walking, or lying

  • Notify surgeon immediately if severe pain, deformity, or loss of function occurs

• Do Not:

  • Flex hip greater than 90 degrees

  • Adduct hip

  • Internally rotate hip

  • Cross legs at knees or ankles

  • Put on own shoes for 4 to 6 weeks

  • Sit on chairs without arms