MusculoSkeletal Trauma

1. MusculoSkeletal Trauma

2. Traumatic Injuries • Contusion: A blow or blunt force which causes local bleeding under the skin • Sprains: Wrenching or hyperextension of a joint • Whiplash: Injury at cervical spine caused by hyperextension • Strains: Microscopic muscle tears as a result of overstretching muscles and tendons

3. Traumatic Injuries • Contusions • Medical management/nursing interventions • Elevate injured area • Cold compresses for 15-20 minutes intermittently for 12-36 hours • Compressive dressings and/or splint • Surgery

4. Traumatic Injuries • Dislocations • Etiology/pathophysiology • Temporary displacement of bones from their normal position • Usually involve tearing of the joint capsule • Subluxations – partial or incomplete dislocations • Usually involve stretching of the joint capsule

5. Traumatic Injuries • Dislocations cont. • Clinical manifestations/assessment • Erythema; discoloration • Edema • Pain • Limitation of movement • Deformity or shortening of the extremity • Neurovascular assessment

6. Traumatic Injuries • Dislocations • Medical Management • Closed reduction • Open reduction

7. Traumatic Injuries • Dislocations cont. • Nursing Interventions • Goals: • Reduction of edema and discomfort • Immobilization of injured part • Patient education

8. Traumatic Injuries • Carpal Tunnel Syndrome • Etiology/pathophysiology • Compression of the median nerve between the carpal ligament and other structures • Predisposing factors • Obese, middle-aged women • Employment in occupations involving repetitious motions of the fingers and hands

9. Figure 44-40 (From Thompson, J.M., et al. [2002]. Mosby’s clinical nursing. [5th ed.]. St. Louis: Mosby.) A, Wrist structures involved in carpal tunnel syndrome. B, Decompression of median nerve.

10. Traumatic Injuries • Carpal tunnel syndrome • Clinical Manifestations/Assessment • Burning pain or tingling in the hands • Inability to grasp or hold small objects • Edema of the hand, wrist, or fingers • Muscle atrophy • Depressed appearance at the base of the thumb on palm side

11. Traumatic Injuries • Carpal tunnel syndrome • Diagnostic tests • Physical exam— • Deficits in sensory mapping along median nerve innervation pathways • + Tinel’s sign (light tapping over nerve to illicit pins and needles sensation in nerve distribution area) • Edema of fingers • + Phalen’s test – hold wrists against each other in forced palmar flexion for 1 minute  numbness/tingling • Electromyogram – shows weakened muscle response to stimulation • MRI – shows compression and flattening of median nerve

12. Traumatic Injuries • Carpal Tunnel Syndrome cont. • Medical Management • Immobilizer • Hydrocortisone injection into carpal tunnel • Elevate extremity • ROM exercises • Surgery (decompression of median nerve)

13. Traumatic Injuries • Carpal Tunnel Syndrome cont. • Nursing Considerations: • Educate patient re: ergonomic equiptment • Application of immobilizer • Elevate affected area • ROM exercises

14. Traumatic Injuries • Carpal Tunnel cont. • Nursing Considerations cont. • If surgery required, post op interventions: • ↑ for 24 hrs • Implement and evaluate active thumb and finger motion • Administer analgesics • Monitor for s/sx infection • CMS checks q 1-2 hrs x 24 hrs.

15. Traumatic Injuries • Herniation of Intervertebral Disk • (Herniated Nucleus Pulposus) • Etiology/pathophysiology • Rupture of the fibrocartilage surrounding an intervertebral disk, releasing the nucleus pulposus that cushions the vertebrae above and below • Lumbar and cervical herniations are most common • May occur from lifting, twisting, trauma, or degenerative changes

16. Figure 44-41 (From Thibodeau, G.A., Patton, K.T. [1997]. The human body in health and disease. [2nd ed.]. St. Louis: Mosby.) Sagittal section of vertebrae showing both normal and herniated disks.

18. Traumatic Injuries • Herniation of Intervertebral Disk cont. • Clinical manifestations/assessment • Lumbar • Low back pain that radiates over the buttock following the sciatic nerve pathway → numbness and tingling in affected leg • Cervical • Neck pain, headache, and neck rigidity

19. Traumatic Injuries • Herniation of Intervertebral Disk cont. • Diagnostic tests: To determine nerve involvement • CAT scan • Myelography • EMG (electromyelography) • Complete hx. • Physical Exam

20. Traumatic Injuries • Herniation of Intervertebral Disk cont. • Medical Management • Usually a 4 week course of conservative Tx. • Braces, corset, or belt • Local heat or ice • US and massage • TENS use • Bedrest/activity per MD orders • Pain medication • Muscle relaxants

21. Traumatic Injuries • Herniation of Intervertebral Disc cont. • Medical Management cont. • Physical therapy • Traction • Surgery • Laminectomy, spinal fusion, diskectomy, chemonucleolysis

22. Laminectomy • Removal of part of the vertebrae • Done to remove pressure on spinal nerves • Performed to treat: • Traumatic cord injury • Herniated disks • Spinal tumors

23. Laminectomy • Preoperative care • VS and neurological status checks to establish baselines • Preoperative teaching about procedure • Postoperative care • Ongoing assessment of neurological status • Promote healing of operative site

24. Laminectomy • Postoperative care cont. • Assess movement, strength, ROM • Assess ability to localize sensory stimuli • Elastic stockings on lower legs • ROM – QID unless indicated otherwise by MD or PT • Incentive spirometer, cough,deep breathe q 2h

25. Laminectomy • Post Operative Care cont. • Physical Therapy • Advance from sitting to ambulating with assistance as ordered • Ensure use of back brace as ordered –usually continually at first with decreasing frequency as muscle strength returns • Maintain bed flat or only slightly elevated to reduce strain on operative site • Maintain good alignment-back straight, avoid twists, turns when getting out of bed

26. Laminectomy • Postoperative care • Maintain soft collar for cervical laminectomy • Encourage position changes q 2h • Change dressing aseptically • Check dressing for blood or cerebrospinal fluid (CSF) • Medicate for pain or spasms as needed • Bowel Care

27. AMPUTATION

28. Amputations • Extensive laceration of arteries or nerves • Diseases such as malignant tumors, infections, peripheral vascular disorders • Extensive osteomyelitis, or congenital disorders • In severe trauma situations, may be performed to save a client’s life • Recent advances have allowed replantation

29. Amputations • Replantation • If severed limb is kept sterile and moist in plastic bag filled with ice water (dry ice should not be used) • The part should be protected from direct contact with ice) • Amputation of long bones anemia • Traumatic or surgical amputation  serious blood loss • Malignant bone tumors  metastasize via bloodstream

30. Amputations • Medical Management • Measures to restore circulating blood volume • Control pain • Prevent wound infection • Perform plastic surgical repair to facilitate use of prosthesis • Maintain adequate urinary output

31. Amputations • Surgical Management • Necessity and type of amputation • Level of amputation (open, closed) • Potential for rehabilitation • Type of prosthesis and rehabilitation program

32. Nursing Process- Assessment • Subjective Data • Pain • Sensations felt on extremity amputated • Emotional status • Severe pain may indicate hematoma or excessive pressure • Phantom limb pain may be confused with incisional pain and will decrease as inflammation subsides

33. Nursing Process- Assessment • Objective Data • Color and temperature of the skin • Pulse • Responses to limb movement • Unaffected extremity should also be assess for function and circulation

34. Amputations • Postoperative Nursing Interventions • Aimed at: prevention of deformities • Coordinate with Physical Therapy! • Raise foot of bed to elevate extremity • Encourage movement • Place in prone position at least two times a day • Teach strengthening exercises • Elastic wraps to shape residual extremity • Assess for respiratory complications

35. Amputations • Phantom Limb Pain • Pain felt in the missing extremity as if it were still present • Occurs because the nerve tracks that register pain in the amputated area continue to send messages to the brain • Considered “normal” physiologic response • Nursing Intervention: aimed at effective pain management

36. Amputations • Pharmacological Interventions: • Narcotic analgesics, eventually non-narcotic • Antibiotic therapy for infection • For persistent severe phantom pain: • Infiltration (injection) of stump with procaine • Sympathetic nerve block

37. Amputations • Diet • Balanced diet with adequate vitamins and protein • Elderly patients may require special diets

38. Amputations • Activity • Postoperative positioning of the stump will be determined by the surgeon • Client should be encouraged to spend time in the prone position • One to two days following surgery client may begin bed exercises • Ambulation begins in physical therapy and progresses according to prosthesis situation

39. Correct method of bandaging amputation stump.

40. Below the knee amputation

41. Temporomandibular Joint Disease/Disorder (TMD)

42. TMD • Temporomandibular joint is the articular surface between the mandible and the temporal bones of the skull • Hinge and gliding joint

44. TMD/TMJ • Commonly referred to as TMJ by the general public • Collection of conditions affecting TM joint and/or muscles of mastication • Over 10 million people in U.S. affected • 90% seeking treatment are females

45. TMD/TMJ • Causes for TMD include: • Trauma • Stress • Teeth clenching or grinding (bruxism) • Joint diseases such as rheumatoid arthritis or osteoarthritis

46. TMD/TMJ • Common symptoms include: • Clicking or crepitus when jaw moves • Popping when chewing or talking • Radiating pain in the face, neck, shoulders • Jaw may lock as a result of muscle spasm

47. TMD/TMJ • Medical Management • Moist heat to promote muscle relaxation • Cold therapy to reduce muscle spasms • Analgesics or nonsteroidal anti-inflammatory drugs • Bite plate to prevent teeth clenching or grinding • Splints may be necessary

48. TMD/TMJ • Surgical Management • Arthroscopy or surgery to reshape the joint if no response to medical treatment

49. TMD/TMJ • Diet • A soft diet allows the jaw and muscles to relax • Chewing gum is not advised