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INTRODUCTION
Epidemiology
More than half of all hospital admissions because of trauma are patients with some type
of fracture, usually of the lower limb*.The elderly are at a particularly high risk of being
hospitalized for an extremity injury. Of those injuries sustained by passengers involved in
nonfatal motor vehicle crashes, 46% sustain pelvic fractures and 41% sustain femur
fractures. Drivers sustain femur fractures (65%), pelvic fractures (46%), and ankle
fractures (39%).0
The American Association of Orthopedic Surgeons reported an annual estimate of 32.7
million musculoskeletal injuries, which included 6.1 million fractures, 14.6 million
dislocations and sprains, 9.4 million open wounds, and 2.6 million other injuries.
Musculoskeletal injuries account for 8,000 deaths per year.
Musculoskeletal injuries can result from the application of both acceleration and
deceleration forces.
Injuries to the bone result from tension, compression, bending, and torsion type forces'
When there is enough force to fracture the shaft of a bone, this force may be transmitted
to the joints; for example, fractures of the shaft of the radius and ulna may be associated
with fractures to the wrist, elbow, and shoulder.
Falls are a frequent mechanism of injury, especially for the elderly. Elderly patients who
fall often sustain pelvic or lower extremity injuries. These injuries, even if not life
threatening, can seriously alter the elderly person's lifestyle and reduce his or her
functional independence. Underlying bone disease, such as osteoporosis or cancer
metastases, may predispose the patient to an extremity injury.
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Types of Injuries
Musculoskeletal injuries may be blunt or penetrating. They may involve bone, soft tissue,
muscles, nerves, and/or blood vessels. Injuries include fractures and/or dislocations of the
bone or joint, sprains, strains, ligamentous tears, tendon lacerations, and neurovascular
compromises.
Multiple fractures may result in significant blood loss, which can potentiate shock from
other injuries. Blood loss from pelvic fractures varies significantly based on the
mechanism of injury, type of fracture, the particular vessels injured, and whether there are
other intra-abdominal injuries.
Capillaries and cellular membranes can be disrupted or torn with all types of
musculoskeletal injuries. Blood from vascular disruption and intracellular fluid are
released into the area surrounding the injury.
Edema from fluid and blood accumulation can cause compression of surrounding
structures. Normal physiological mechanisms are activated to minimize damage caused
by these structural disruptions:
Initiation of the clotting system to decrease bleeding
Restoration of cellular membrane integrity to enhance fluid reabsorption
Increased collateral blood flow to promote healing
Bone or joint displacement can compress surrounding vessels and nerves, causing
pathophysiological changes distal to the injury. As arterial blood flow is obstructed, tissue
oxygenation decreases resulting in tissue ischemia and cellular death. During this
process, pain increases, pulses become more difficult to palpate, the limb becomes pale,
cyanotic and cool, and capillary refill time increases.
Neurologic Deficits
If nerves are compressed or lacerated, conduction pathways are interrupted and the relay
of nerve impulses are blocked or diminished. Nerve injury can result in diminished pain
sensation. Injury distal to a nerve may result in partial or complete loss of motor and
sensory function.
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Fractures
Fractures involve a disruption of bony continuity
Femur Fractures
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Femur fractures are a result of major trauma, such as falls, motor vehicle crashes,.
Fractures of the femoral neck are common after a fall in the elderly population.
Closed femur fractures can result in a collection of 1,000 to 1,500 ml of blood in the
thigh.
SIGNS AND SYMPTOMS
Pain and inability to bear weight
Shortening of the affected leg
Rotation internally or externally depending on the location of the fracture site in the
hip
Edema of the thigh
Deformity of the thigh
Evidence of hypovolemic shock
Pelvic Fractures
Pelvic fractures are classified as either stable or unstable. A stable fracture is defined as
"one that can withstand normal physiologic forces without abnormal deformation."" An
unstable fracture occurs when the pelvic ring is fractured in more than one place resulting
in two displacements on the ring; rotational
Open Fractures
All open fractures are considered contaminated because of the foreign materials and
bacteria that can be introduced into the wound. Any open fracture may result in an
infection. The risk of serious infection is greater with severe fractures. Infections can be
manifested by poor tissue healing, osteomyelitis, or sepsis.
Open fractures are graded from I to 111 according to the degree of skin and soft tissue
injury surrounding the fracture site. Grade III open fractures are further described by the
amount of nonviable tissue, injury to the periosteum, and vascular trauma.
SIGNS AND SYMPTOMS
Evidence of skin disruption (e.g., laceration or puncture) near or over the fracture
Protrusion of bone through open wounds
Pain
Neurovascular compromise
Bleeding may be minimal to severe
Amputations
Amputations may be partial or complete and usually involve the digits, distal half of the
foot, the lower leg, the hand, or the forearm. The axiom of saving "life over limb" is a
reminder to the trauma team to fully resuscitate the patient before managing the
amputation.
The following have been cited as indications for replantationl
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Multiple digits
Thumb
Wrist
Forearm
Pediatric patient (children typically, have a more positive outcome from replantation
procedures)
Amputations that are guillotine-type amputations have a better chance of being
successfully replanted as opposed to avulsive/tearing types of injuries. The decision to
replant should be made by a surgeon or replantation team, if available.
Complete amputations will have less active bleeding than partial amputations because of
retraction of the severed arteries. An exception is an avulsive type of complete
amputation, which can result in extensive bleeding.
Evidence of hypovolemic shock
Crush Injuries
Certain crush injuries, depending on the location of the injury, may be life-threatening
(e.g., pelvis and both lower extremities). Cellular destruction and damage to vessels and
nerves make crush injuries difficult to treat. Hemorrhage from the damaged tissue,
destruction of muscle and bone tissue, fluid loss resulting in hypovolemic shock,
compartment syndrome, and infection are sequelae associated with crush injuries. The
destruction of muscle tissue associated with release of myoglobin can result in renal
dysfunction.
SIGNS AND SYMPTOMS
Massively crushed pelvis or extremity (ies) with soft tissue swelling
Pain
Evidence of hypovolemic shock
Signs of compartment syndrome
Loss of neurovascular function distal to the injury
Compartment Syndrome
Compartment syndrome occurs as pressure increases inside a fascial compartment. This
results in impaired capillary blood flow and cellular ischemia. This occurs more
frequently in the muscles of the lower leg or forearm, but can involve any fascial
compartment. The increased pressure may be because of an internal source, such as
hemorrhage or edema, caused by open or closed fractures, or crush injuries. It
can also result from an external source, such as a cast, excessive traction, air splint, or
PASG. Nerves, blood vessels, and muscles can be compressed. If compartment syndrome
results in "prolonged" ischemia of the muscles and nerves, the patient may be left with a
limb that is painful and without function
SIGNS AND SYMPTOMS
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Pain disproportionate to the injury because of increased tissue pressures and ischemia
Sensory deficit (e.g., numbness, tingling, total loss of sensation)
Progressive muscle weakness
Tense, swollen area
PHYSICAL ASSESSMENT
Refer to Initial Assessment, for a description of assessment of the patient's airway,
breathing, circulation, and disability
Inspection
Observe general appearance of extremities
Note color, position, and obvious differences of injured extremity as compared to
uninjured extremity
Assess integrity of the injured area
Note protrusion of bone or any break in the skin
Assess for bleeding
Identify soft tissue damage, including edema, ecchymosis, contusions, abrasions,
avulsions, or lacerations
Assess for deformity and/or angulation of extremity
Palpation
Extremity assessment is described by the five Ps: pain, pallor, pulses, paresthesia, and
paralysis. This assessment relates to the neurovascular status of the injured extremity.
Assess the injured extremity and compare with an assessment of the opposite, uninjured
extremity.
Assess the five Ps
Pain
Carefully palpate the entire length of each extremity for pain. Determine location and
quality of pain. Ischemic pain is often described as burning or throbbing.
Pallor
Note color and temperature of injured extremity. Pallor, delayed capillary refill (> two
seconds), and a cool extremity indicate vascular compromise.
Pulses
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Palpate pulses proximal and distal to the injury for comparison. Then compare quality of
pulses with the opposite, uninjured extremity.
Paresthesia
Determine presence of abnormal sensations (e.g., burning, tingling, numbness)
• Paralysis
Assess motor function. The ability to move can be related to neurologic function.
Palpate the pelvis for pain or bony instability. Apply gentle pressure on the iliac crests
towards midline, noting any instability or increased pain. Gently press downward on the
symphysis pubis a fracture is suspected, carefully palpates the pelvis. Do not rock the
pelvis.
Note bony crepitus during palpation, which is a crackling sound produced by the
grating of the end of fractured bones.
DIAGNOSTIC PROCEDURES
Refer to Initial Assessment, for frequently ordered radiographic and laboratory studies
Additional studies for patients with musculoskeletal trauma are listed below.
Radiographic Studies
Anterior-posterior and lateral of injured extremity
Some fractures can 'only be seen from one radiographic angle; therefore, an oblique
view may be indicated. The film should include the joints immediately above and
below the injury.
• Angiography
Angiography may be indicated to identify tears or compressions in the arterial or
venous network the injured extremity.
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initiate infusion of lactated awake and alert,
Ringer's solution or normal age appropriate
saline Skin normal color,
• Administer blood, as warm, and dry
indicated Maintains hematocrit of
• splint injured extremity 30 ml/dl or hemoglobin of
12 to 14 g/dl or greater
Capillary refill time of <2
seconds
Physical mobility, impaired, Splint and immobilize The patient will experience
related to: affected extremity increased
Bone, soft tissue and/or Immobilize joints above mobility, as evidenced by:
nerve injury of extremity and below the deformity Ability to tolerate
• Pain Administer analgesia movement and increased
• Edema medications, as prescribed activity
External immobilization Use touch, positioning, or Willingness to move
devices relaxation techniques to affected part to degree
Limited range of motion give comfort allowed
of affected bone Maintenance of proper
body alignment
Infection, risk, related to: Obtain blood/wound The patient will be free
Impaired skin integrity cultures from infection, as
Contamination of wound Monitor vital signs evidenced by:
from Administer antibiotics, as Core temperature
initial injury or prescribed measurement of 36
instrumentation Keep wound clean and 37.5°C (98 - 99.5°F)
Invasive fixation devices apply White blood cell count
Interruption in perfusion dressing using aseptic within normal
Suppressed inflammatory technique limits
response Maintain aseptic technique Absence of signs of
Cover open wounds with a infection: redness,
sterile dressing swelling, purulent
Do not reposition drainage, odor, and
protruding tenderness
bone fragments
Prepare for definitive care
Stabilize impaled objects
Impaired skin integrity, risk, Assess skin integrity The patient will experience
related to: frequently absence or
Movement of fractured Keep skin dry resolution of impaired skin
bones Maintain aseptic/clean integrity, as
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Pressure, shear, friction technique, as appropriate evidenced by:
on skin Splinting, as indicated Maintenance of intact
and tissue skin overlying
Mechanical irritants: fracture
Fixation de- Absence of signs of
vices, splints, and casting irritation: redness,
material blanching, and itching
Impaired mobility
Effects of trauma/injury
agents
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Immobilize the joints above and below the deformity
Modify the splint to fit the fracture, if necessary
Reassess neurovascular status before and after immobilization. If neurovascular status
is compromised, reassess, remove, adjust, or reapply the splint.
Apply ice to reduce swelling and pain
Elevate the extremity above the level of the heart to reduce swelling and pain. If
compartment
Elevate the extremity above the level of the heart to reduce swelling and pain. If
compartment syndrome is suspected, then elevate to the level of the heart.
Administer analgesic medications, as prescribed
Consider regional analgesia. A femoral nerve block is frequently performed on patients
in many emergency departments in the United Kingdom and Australia.
Prepare for definitive stabilization. Traction, casting, internal or external fixation may
be indicated.
Prepare for conscious sedation, as prescribed (See Appendix 5)
Prepare for closed reduction, as indicated
Provide psychosocial support
Prepare patient for operative intervention, hospital admission or transfer, as indicated
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Elevate the stump
Splint the stump as needed
Remove gross dirt or debris
Keep the amputated part cool and wrap the part in a saline-moistened gauze, then place
in a sealed plastic bag, and finally place the bag in crushed ice and water. Do not allow
the part to freeze.
Prepare for radiographs of both the stump and the amputated part \ ~ '
Prepare patient for hospital admission, operative intervention, or transfer to a facility
with a replantation team, as indicated
Administer antibiotics, as prescribed
Administer tetanus prophylaxis, as indicated
NURSING INTERVENTIONS FOR THE PATIENT WITH A CRUSH
INJURY
Administer an intravenous crystalloid solution to increase urinary output and facilitate
excretion of myoglobin
Elevate the injured extremity above the level of the heart to reduce swelling and pain
Gently clean open wounds
Reassess
Urinary output
Presence of myoglobin in the urine
Motor and sensory function '
Prepare patient for surgical debridement, fasciotomy, and/or amputation
NURSING INTERVENTIONS FOR THE PATIENT WITH POSSIBLE
COMPARTMENT SYNDROME
Elevate the limb to the level of the heart to promote venous outflow and prevent
further swelling. Do not elevate the limb above the heart as this may decrease perfusion
to compromised extremity.
Assist with measurement of fascial compartment pressure, as indicated. Normal
pressure is > 10 mm Hg (1.3 KPa).20 A reading of > 35 to 45 mm Hg (4.7-6 KPa) is
suggestive of possible anoxia to muscles and nerves. 21
Prepare for fasciotomy, as indicated. A fasciotomy may prevent muscle and/or
neurovascular damage and loss of the limb.
Reassess and document neurovascular status on an ongoing basis. Communicate
changes to the physician immediately.
Evaluation and Ongoing Assessment
Refer to Chapter 3, Initial Assessment, for a description of the ongoing evaluation of the
patient's airway, breathing, circulation, and disability. Additional evaluations include:
Monitoring breathing effectiveness and rate of respiration
Tachpynea, rales, and wheezes may be indicators of fat embolus syndrome.
Reassess and document the five Ps
SUMMARY
Injuries of the extremities are usually not the first priority of care for the multiple trauma
patients. However, there is a high incidence of injuries to upper and lower extremities
that, although usually not life-threatening, can result in functional disability and/or loss,
and long-term rehabilitation.
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The proximity of vessels and nerves to musculoskeletal structures increases the risk of
neurovascular damage ranging from motor, sensory, or vascular deficits to paralysis
and/or hemorrhage, and shock.
Disruptions and fractures of the pelvis may result in significant blood loss because of
concurrent injury to the blood vessels in the pelvic cavity. Collaborate with members of
the trauma team to correct any life-threatening compromises to circulation.
During the secondary assessment, assess the extremities for indications of a fracture or
dislocation.
Intervene early to splint the suspected fracture and reassess neurovascular function both
before and after the application of any splinting device.
Timely identification and management of suspected musculoskeletal injuries, including
the use of pain control, splints, traction, and/or external fixation, contribute o improved
functional patient outcomes.
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