Alterations Related to Musculoskeletal Trauma

1. Alterations Related to Musculoskeletal Trauma Lisa M. Dunn MSN/Ed, RN, CCRN, CNE

2. 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

3. Common Types of Fractures

6. Question The patient with a history of osteoporosis is at high risk for developing what type of fracture? • Fatigue • Compound • Simple • Compression

7. 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

8. Stages of Bone Healing (Cont’d)

9. Exemplar: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

10. Muscle Anatomy

11. 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.

13. Question • A possible outcome for a patient who experienced a crush injury of his lower extremity may be: • Bradycardia • Hypotension • Rhabdomyolysis • Peripheral nerve injury

14. Question A possible outcome for the middle-aged male patient who has a tight cast on his left lower leg would be: • Fat embolism syndrome • Acute compartment syndrome • Venous thromboembolism • Ischemic necrosis

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

17. Exemplars: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] orosteonecrosis), delayed bone healing

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

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

22. Exemplar: 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

23. 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

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

27. Immobilization Device

28. Fiberglass Synthetic Cast

29. Question The best diagnostic test to determine musculoskeletal and soft tissue damage is: • Standard x-rays • Computed tomography (CT) • Magnetic resonance imaging (MRI) • Electromyography (EMG)

30. 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, circumferential

32. 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

33. External Fixation Device

34. 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

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

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

38. 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

39. 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.

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

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

42. 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

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

44. Exemplar: 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

45. Types of Hip Fractures

49. Exemplar: Lower Extremity Fractures • Fractures include those of the: • Femur • Patella • Tibia and fibula • Ankle and foot

50. Exemplar: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