Musculoskeletal Trauma

Donna Peters

Important Facts
Leading cause of death in people under 40

Musculoskeletal trauma occurs in 85% of those patients

experiencing trauma 80,000 suffer permanent disability each year from trauma

Etiology
Direct blow or trauma to the bone

Crushing force
Sudden twisting motion Extreme muscle contraction Pathologic conditions: osteoporosis, drug use, tumors,

decalcification

Musculoskeletal Injuries
Contusion

Strain
Sprain Dislocation/Subluxation

Fracture

Contusion
Definition - Soft tissue trauma with no damage to MS

structure. Cause rupture of blood vessels resulting in a hematoma S/S - Pain, Swelling, ecchymosis, limited ROM Rx - RICE

Strain
Definition excessive stretching of muscle

Cause rupture of blood vessels in muscle

S/S - Pain, muscle soreness, edema Rx - RICE

Sprain
Definition injury of ligament surrounding the joint

Cause joint stretched beyond normal ROM resulting in loss

of stability of the joint. Avulsion fx may occur. S/S - Pain, Rapid Swelling, Joint tenderness, limited ROM Rx X-ray, RICE, casting, surgery

RICE
Rest

Ice
Compress Elevate

24 48 hours
After 48 hours- heat

Dislocation
Subluxation - is a partial dislocation

Dislocation out of joint

Rx
Assessment

RICE
Reduction Open Closed

Other Injuries
Repetitive Strain injury

Rotator cuff
Meniscus injury Carpal Tunnel Syndrome (CTS)
compression neuropathy
Phalens sign Tinels sign

Classification of Fractures
Closed vs open

Complete vs incomplete
Stable (nondisplaced) vs unstable (displaced) Greenstick Compression Impacted Depressed Spiral Comminuted

Bone Healing
Bone Injury

Callus Formation
Bony Callus Formation Bone Remodeling

 Granulation tissue

Callus formation
Ossification (3wks 6mo)

Factors Influencing Bone Healing Positive

Immobilization

Timely correction of Displacement

Application of Ice Adequate amounts of growth hormone, V-D and calcium Adequate blood supply Absence of infection Moderate activity level prior to injury

Factors Influencing Bone Healing Negative Factors

Delay in correction of displacement

Open fracture
Presence of foreign body Immuno-compromised Decrease circulation Malnutrition Osteoporosis Advanced Age

Clinical Manifestations of Fx
Deformity

Swelling
Pain/ guarding Numbness Crepitus Muscle Spasm Ecchymosis Hypovolemic Shock

Assessment of Trauma The 5 Ps

Pain

Pallor
Pulselessness Paresis Paralysis

Complications of Trauma
Soft tissue damage

Hemorrhage
Ruptured tendons Severed nerves Damaged blood vessels Body organ injuries

Medical Intervention

Closed Reduction
Manual manipulation

Manual traction
Skin traction
Bucks Extension

Russell Traction

Skeletal traction

Bone Healing Stimulator

Traction

Purpose
Maintain Anatomical Alignment

Minimize Muscle Spasm

Reduce Fractures/ deformities Immobilize Fractures Stretch Adhesions

Classifications
Straight
pulls in one direction towards the longitudinal axis of the bone

Vectored
applied in two different directions

Balanced Suspension
applied to elevate extremity

Types
Manual

Skin
Skeletal

Types of Skin Traction

Bucks Extension

Russell
Bryants Cervical Pelvic

Bucks
This traction exerts a straight pull on arm or leg.

Between 5 8 lbs
Temporary

Contraindications
Dermatitis

Impaired circulation
Varicose ulcers Peripheral neuropathies

Complications
Allergic reaction to tape

Irritation of skin
Peroneal nerve palsy Circulation impairment

Pressure sores

Skeletal Traction
Pulling force directly to the bones by metal pins, screws or

tongs Weight 15 to 25 pounds Requires pin care Impaired skin integrity

Risk for infection

Types of Skeletal Traction

Crutchfield

Long Bone

Types of Skeletal Traction

Crutchfield

Long Bone

Nursing Intervention
Assess traction frequently

Maintain proper body alignment

Neurovascular assessment q 1 2 h Monitor for complications

Assist with ADL

Diversional Therapy

Nursing Diagnosis: Knowledge Deficit R/T nature of traction

Patient verbalizes understanding of traction
Explain type and purpose
Turn q 2 h Instruct on proper body alignment

ROM QID

Pain
Patient reports pain as 3/1-10
Assess pain level q 2 4 h
Medicate as ordered Monitor for complication i.e. DVT, compartment syndrome

Teach relaxation

External Fixation Device

Definition
A device of metal percutaneous pins that are attached to an

external frame. Placed above and below the fracture Provides

Comfort
early mobility active exercise above and below injury

Indications
Compound fracture Comminuted fractures Leg lengthening Access to open wounds Joint fusion After skeletal traction to

allow mobility

Assessments
Pin sites

Frame
5 Ps Wound site

Risk for infections

Patient remains free from infection
Assess q 1 2 h then 2 4 h
Assess wound for drainage Pin assessment

Monitor for infection

Monitor for migration of device Check the integrity of the frame

Fracture Immobilization
External Fixation
Bandages
Casts Splints

Internal Fixation
Open Reduction Internal Fixation (ORIF) Screws Nails Plate/rods

Casts
Rigid immobilizing device

Encompasses a joint above and below

Plaster vs. fiberglass

Purpose
Immobilize fracture / subluxations

Correct deformities
Support of weakened
joint, ligament sprains, tears, tendon, nerve and arterial repair

Amputation

Plaster of Paris Casts

Advantages
Inexpensive Strong durable

Disadvantage
Chemical reaction Heat increases edema Slow drying

Wrinkles and denting

Cannot get wet Cannot clean

Fiberglass
Advantages
Dries quickly Can get wet Light

Disadvantage
Expensive Easier to get off

Application
Assess skin should be clean and dry, note any lesions

Protect skin with tubular stockinette/ padding bony

structures Protect from rough edges

Complications
Neurovascular compromise

Cast compartment syndrome

Cast syndrome Tissue necrosis / Infection

Hemorrhage
Nerve Damage

Cast Removal
To change cast or splint

Assess complications
Healing of injury Emergency removal

Knowledge Deficit R/T treatment Regimen

Expected outcome:
Patient describes care of cast

Nursing Interventions
Isometric exercises Active/passive ROM Itching cool hair dryer

by discharge

Notify MD if Pain Numbness Poor color Unable to move toes Stain, odor or heat

Pain
Expected Outcome
Patient states pain free No numbness

Nursing Interventions
Assess pain q 1 2 h Elevate cast Apply ice

Administer analgesic
Monitor for complications

Orthopedic Complications
Complications Following Fractures

Hypovolemic Shock
Assessments
Decreased BP/Tachycardia
Tachypnea Skin cool/clammy

Restlessness
Decreased LOC

Hypovolemic Shock: Management

Keep patient warm
Splint fractures to prevent blood loss Monitor VS

Oxygen
Monitor Hbg/Hct Replace fluids

Fat Embolism: Assessment

Headache

Drowsiness
Irritabiltiy/Confusion/Agitation Sense of impending doom Tachycardia Tachypnea, Wheezing, use of Accessory muscles Petechiae

Fat Embolism: Management

Oxygen Coughing, Deep Breathing Heparin/Aspirin

Bedrest

Compartment Syndrome: Assessment

Deep, Throbbing, Unrelenting Pain

Pain not relieved by narcotics

Swelling Numbness and Tingling Paresis/Paralysis Loss of distal pulse, cyanotic nailbeds

Compartment Syndrome: Management

Prevention
Elevate limb above heart
Apply ice Remove restrictive dressing

Measure intracompartment pressure

8 norm 30 - 40 mm Hg abnormal

Wick Catheter Used to Monitor Compartment Pressure

Question
Tell whether the following statement is true or false. A hallmark sign of acute compartment syndrome is pain that occurs or intensifies with passive ROM.

Answer
True. Rationale: A hallmark sign of compartment syndrome is pain that occurs or intensifies with passive ROM. This pain can be caused by (1) a reduction in the size of the muscle compartment because the enclosing muscle fascia is too tight or a cast or dressing is constrictive or (2) an increase in compartment contents because of edema or hemorrhage.

Deep Vein Thrombosis: Assessment

Reddness Heat Swelling

Tenderness/Cramping/Pai

n Loss of Function Homens sign

Doppler / Venogram

Deep Vein Thrombosis: Management

Heparin/Lovenox Bedrest Thrombolytic agents Vena Cava Filter Thrombectomy

Infection: Assessment
Malaise/fever

Pain/tenderness of bone
Redness/swelling Difficulty weight bearing

Wound drainage

Infection: Management
Immobilization

C/S Wound
Antibiotics: pencillin, methacillin,vanco Pain Medication

Heat application

Joint Stiffness/Contractures
Joint Stiffness/Contracture

Malunion
Ruptured Tendons Severed nerves Avascular Necrosis

Case Study
A 59 year old right knee replacement with severe pain.

Received oxycontin at 8p and 2 percocets at 10p. Now at 11:30 p patient remains in severe pain. What assessments would your make?

Assessments Findings
Edema

Heat
Erythema Swelling of right leg

Suture site clean.

T-99.2; P-98; R-22 and BP 130/82. Any other assessments you would like to include?

Other Assessments
Neurovascular assessment

Homens

Your patient suffered a fractured femur. Which of the following would you tell your nursing assistant to report immediately?
A.
B. C. D.

Complaints of pain Patient is confused Blood Pressure is 136/88 Patient voided using fracture bedpan

You are caring for a pt with a fxulnar, which assessment should you report immediately ?
A. B. C. D.

Complaints of pain and pressure Cast is dry and intact Skin is pink and warm to touch Patient can move all fingers and thumb