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Chapter 54: 

Chapter 54 Care of Patients with Musculoskeletal Trauma

Classification of Fractures: 

Classification of Fractures A fracture is a break or disruption in the continuity of a bone. Types of fractures include: Complete Incomplete Open or compound Closed or simple Pathologic (spontaneous) Fatigue or stress Compression

Common Types of Fractures: 

Common Types of Fractures

Fracture : 

Fracture

Stages of Bone Healing: 

Stages of Bone Healing Hematoma formation within 48 to 72 hr after injury Hematoma to granulation tissue Callus formation Osteoblastic proliferation Bone remodeling Bone healing completed within about 6 weeks; up to 6 months in the older person

Stages of Bone Healing (Cont’d): 

Stages of Bone Healing (Cont ’ d)

Bone Formation and Growth: 

Bone Formation and Growth

Acute Compartment Syndrome : 

Acute Compartment Syndrome Serious condition in which increased pressure within one or more compartments causes massive compromise of circulation to the area Prevention of pressure buildup of blood or fluid accumulation Pathophysiologic changes sometimes referred to as ischemia-edema cycle

Muscle Anatomy: 

Muscle Anatomy

Emergency Care: 

Emergency Care Within 4 to 6 hr after the onset of acute compartment syndrome, neuromuscular damage is irreversible; the limb can become useless within 24 to 48 hr. Monitor compartment pressures. Fasciotomy may be performed to relieve pressure. Pack and dress the wound after fasciotomy.

Possible Results of Acute Compartment Syndrome: 

Possible Results of Acute Compartment Syndrome Infection Motor weakness Volkmann ’ s contractures Myoglobinuric renal failure, known as rhabdomyolysis Crush syndrome

Other Complications of Fractures: 

Other Complications of Fractures Shock Fat embolism syndrome — serious complication resulting from a fracture; fat globules are released from yellow bone marrow into bloodstream Venous thromboembolism Infection Chronic complications — ischemic necrosis (avascular necrosis [AVN] or osteonecrosis), delayed bone healing

Musculoskeletal Assessment: 

Musculoskeletal Assessment Change in bone alignment Alteration in length of extremity Change in shape of bone Pain upon movement Decreased ROM Crepitus Ecchymotic skin

Musculoskeletal Assessment (Cont’d): 

Musculoskeletal Assessment (Cont ’ d) Subcutaneous emphysema with bubbles under the skin Swelling at the fracture site

Special Assessment Considerations : 

Special Assessment Considerations For fractures of the shoulder and upper arm, assess patient in sitting or standing position. Support the affected arm to promote comfort. For distal areas of the arm, assess patient in a supine position. For fracture of lower extremities and pelvis, patient is in supine position.

Risk for Peripheral Neurovascular Dysfunction: 

Risk for Peripheral Neurovascular Dysfunction Interventions include: Emergency care — assess for respiratory distress, bleeding, and head injury Nonsurgical management — closed reduction and immobilization with a bandage, splint, cast, or traction

Casts : 

Casts Rigid device that immobilizes the affected body part while allowing other body parts to move Cast materials — plaster, fiberglass, polyester-cotton Types of casts for various parts of the body — arm, leg, brace, body

Casts (Cont’d): 

Casts (Cont ’ d) Cast care and patient education Cast complications — infection, circulation impairment, peripheral nerve damage, complications of immobility

Immobilization Device: 

Immobilization Device

Fiberglass Synthetic Cast: 

Fiberglass Synthetic Cast

Traction : 

Traction Application of a pulling force to the body to provide reduction, alignment, and rest at that site Types of traction — skin, skeletal, plaster, brace, circumferentialMM

Traction (Cont’d): 

Traction (Cont ’ d) Traction care: Maintain correct balance between traction pull and countertraction force Care of weights Skin inspection Pin care Assessment of neurovascular status

External Fixation Device: 

External Fixation Device

Operative Procedures: 

Operative Procedures Open reduction with internal fixation External fixation Postoperative care — similar to that for any surgery; certain complications specific to fractures and musculoskeletal surgery include fat embolism and venous thromboembolism

Procedures for Nonunion: 

Procedures for Nonunion Electrical bone stimulation Bone grafting Bone banking Low-intensity pulsed ultrasound (Exogen therapy)

Acute Pain: 

Acute Pain Interventions include: Reduction and immobilization of fracture Assessment of pain Drug therapy — opioid and non-opioid drugs

Acute Pain (Cont’d): 

Acute Pain (Cont ’ d) Complementary and alternative therapies — ice, heat, elevation of body part, massage, baths, back rub, therapeutic touch, distraction, imagery, music therapy, relaxation techniques

Risk for Infection: 

Risk for Infection Interventions include: Apply strict aseptic technique for dressing changes and wound irrigations. Assess for local inflammation. Report purulent drainage immediately to health care provider.

Risk for Infection (Cont’d): 

Risk for Infection (Cont ’ d) Assess for pneumonia and urinary tract infection. Administer broad-spectrum antibiotics prophylactically.

Impaired Physical Mobility: 

Impaired Physical Mobility Interventions include: Use of crutches to promote mobility Use of walkers and canes to promote mobility

Imbalanced Nutrition: Less Than Body Requirements: 

Imbalanced Nutrition: Less Than Body Requirements Interventions include: Diet high in protein, calories, and calcium; supplemental vitamins B and C Frequent, small feedings and supplements of high-protein liquids Intake of foods high in iron

Upper Extremity Fractures: 

Upper Extremity Fractures Fractures include those of the: Clavicle Scapula Husmerus Olecranon Radius and ulna Wrist and hand

Fractures of the Hip: 

Fractures of the Hip Intracapsular or extracapsular Treatment of choice — surgical repair, when possible, to allow the older patient to get out of bed Open reduction with internal fixation Intramedullary rod, pins, a prosthesis, or a fixed sliding plate Prosthetic device

Types of Hip Fractures: 

Types of Hip Fractures

Fractured Hip: 

Fractured Hip Assessment Leg shortened, abducted, externally rotated Pain Hematoma & Ecchymosis X-ray confirmation

Lower Extremity Fractures: 

Lower Extremity Fractures Fractures include those of the: Femur Patella Tibia and fibula Ankle and foot

Fractures of the Pelvis : 

Fractures of the Pelvis Associated internal damage the chief concern in fracture management of pelvic fractures Non–weight-bearing fracture of the pelvis Weight-bearing fracture of the pelvis

Compression Fractures of the Spine: 

Compression Fractures of the Spine Most are associated with osteoporosis rather than acute spinal injury. Multiple hairline fractures result when bone mass diminishes.

Compression Fractures of the Spine (Cont’d): 

Compression Fractures of the Spine (Cont ’ d) Nonsurgical management includes bedrest, analgesics, and physical therapy. Minimally invasive surgeries are vertebroplasty and kyphoplasty, in which bone cement is injected.

Amputations: 

Amputations Surgical amputation Traumatic amputation Levels of amputation Complications of amputations — hemorrhage, infection, phantom limb pain, neuroma, flexion contracture

Common Levels of Amputation: 

Common Levels of Amputation

Phantom Limb Pain: 

Phantom Limb Pain Phantom limb pain is a frequent complication of amputation. Patient complains of pain at the site of the removed body part, most often shortly after surgery. Pain is intense burning feeling, crushing sensation, or cramping. Some patients feel that the removed body part is in a distorted position.

Management of Pain: 

Management of Pain Phantom limb pain must be distinguished from stump pain because they are managed differently. Recognize that this pain is real and interferes with the amputee ’ s ADLs.

Management of Pain (Cont’d): 

Management of Pain (Cont ’ d) Opioids are not as effective for phantom limb pain as they are for residual limb pain. Other drugs include beta blockers, antiepileptic drugs, antispasmodics, and IV infusion of calcitonin.

Exercise After Amputation : 

Exercise After Amputation ROM to prevent flexion contractures, particularly of the hip and knee Trapeze and overhead frame Firm mattress Prone position every 3 to 4 hours Elevation of lower-leg residual limb controversial

Stump Care: 

Stump Care

Prostheses : 

Prostheses Devices to help shape and shrink the residual limb and help patient adapt Wrapping of elastic bandages Individual fitting of the prosthesis; special care

Complex Regional Pain Syndrome: 

Complex Regional Pain Syndrome A poorly understood complex disorder that includes debilitating pain, atrophy, autonomic dysfunction, and motor impairment Collaborative management — pain relief, maintaining ROM, endoscopic thoracic sympathectomy, and psychotherapy

Knee Injuries, Meniscus: 

Knee Injuries, Meniscus McMurray test Meniscectomy Postoperative care Leg exercises begun immediately Knee immobilizer Elevation of the leg on one or two pillows; ice

Knee Injuries, Ligaments: 

Knee Injuries, Ligaments When the anterior cruciate ligament is torn, a snap is felt, the knee gives way, swelling occurs, and stiffness and pain follow. Treatment can be nonsurgical or surgical. Complete healing of knee ligaments after surgery can take 6 to 9 months.

ACL injury: 

ACL injury

ACL repair: 

ACL repair

Tendon Ruptures: 

Tendon Ruptures Rupture of the Achilles tendon is common in adults who participate in strenuous sports. For severe damage, surgical repair is followed by leg immobilized in a cast for 6 to 8 weeks. Tendon transplant may be needed.

Dislocations and Subluxations: 

Dislocations and Subluxations Pain, immobility, alteration in contour of joint, deviation in length of the extremity, rotation of the extremity Closed manipulation of the joint performed to force it back into its original position Joint immobilized until healing occurs

Dislocations and Subluxations: 

Dislocations and Subluxations

Strains : 

Strains Excessive stretching of a muscle or tendon when it is weak or unstable Classified according to severity — first-, second-, and third-degree strain Management — cold and heat applications, exercise and activity limitations, anti-inflammatory drugs, muscle relaxants, and possible surgery

Sprains : 

Sprains Excessive stretching of a ligament Treatment of sprains: First-degree — rest, ice for 24 to 48 hr, compression bandage, and elevation (RICE) Second-degree — immobilization, partial weight bearing as tear heals Third-degree — immobilization for 4 to 6 weeks, possible surgery

Rotator Cuff Injuries: 

Rotator Cuff Injuries Shoulder pain; cannot initiate or maintain abduction of the arm at the shoulder Drop arm test Conservative treatment —NSAIDs , physical therapy, sling support, ice or heat applications during healing Surgical repair for a complete tear

Rotator Cuff Injuries: 

Rotator Cuff Injuries