Nursing Care of Clients With Musculoskeletal Disorders

1. Nursing Care of Clients With Musculoskeletal Disorders

2. This Class: • Fractures: Types • Management & complications • Traction (Skin and Skeletal) • Casts (Compartment Syndrome, Infection, Cast Syndrome)

3. Class Objectives: • Describe the anatomy and physiology of the musculoskeletal system including the significance of health history. • Discuss the significance of assessment and diagnosis of musculoskeletal problems including diagnostic tests. • Explain the pathophysiology, manifestations, complications & collaborative care of clients with fractures. • Describe the preventative health teaching needs of the client with a cast. • Describe the various types of traction and appropriate nursing care.

4. Class Objectives Cont’d: • Compare the nursing needs of the client undergoing a THR with those undergoing a TKR • Discuss the etiology, pathophysiology, prevention and management of clients with osteoporosis. • Identfy the causes and related nursing management of osteomalacia and Pagets’s disease. • Discuss the pathophysiology, manifestations, complications & collaborative care of clients with arthritis, gout, spinal cord deformities, septic arthritis.

5. Readings: • Read in your text Chapters 66, 67, 68, & 69 • Recommended readings • Bibliography list • Fractures

6. Fractures • Read text content dealing with fractures • Know what a closed, open,displaced comminuted, impacted, & greestick fractures are. • Note the risk factors & levels of prevention r/t # • Review the stages of healing • Know neuromuscular assessment • What causes muscle spasm following #s and what are the consequences?

7. A fracture is “any disruption in the continuity of the bone, when more stress is placed on it than it can absorb”. (Black, Hawkes & Keene, 2001, p587). • When # occurs, muscles are also disrupted & pull fracture fragments out of position. • Adjacent structures are affected – soft tissue edema, hemorrhage, joint dislocations, ruptured tendons, severed nerves, damaged blood vessels • Large muscle groups create massive spasms, the proximal portion remains intact while the distal portion can be displaced in response to force and spasm.

8. FRACTURES

9. Classification of Fractures: (See Chart 69-1) • Open: (compound or complex) break in tissue over site of the bone injury • Complete:break across entire cross-section of bone & often displaced • Incomplete: (greenstick) though only part of the cross-section • Closed: (simple) intact skin over site of injury • Comminuted: produces several bone fragments

11. Physical Assessment may reveal: • Deformity (hemorrhage or spasm) • Shortening • Swelling • Ecchymosis • Muscle spasm • Pain, tenderness • Loss of function, altered mobility & crepitus • Neurovascular changes • shock

12. Signs and Symptoms

13. ComplicationsFat Embolism Syndrome • Fat globules (emboli) occlude small vessels of lungs, brain, kidneys, & other organs • Characterized by neurologic dysfunction, pulmonary insufficiency, and petechial rash on chest, axilla & upper arms • Long bone # & other major trauma ( such as THR) are the principle risk factors • Most frequently in young adults (20-30 years of age)

14. Fat Embolism Syndrome What to Look for: • Manifestations of fat emboli occur within 24-72 hours but may be up to a week after injury: • Hypoxia PaO2 < 60 mm Hg • Tachypnea, tachycardia, pyrexia • Deterioration in LOC • Confusion , agitation • Respiratory distress response – tachypnea, dyspnea, crackles, wheezes, precordial chest pain, copious thick white sputum, tachycardia • petechiae: chest, shoulders, axilla, mouth, conjunctival sac

15. Fat Embolism: Prevention: • Immobilize fractures: early & gentle stabilization • Gentle care • Adequate hydration • O2 • Aware of those at high risk Management: • O2 • Fluid replacement • Mechanical ventilation • Corticosteroids • Vasoactive medications • Maintain Hgb • Calm, supportive environment

16. Monitor Respiratory Status Every Shift. • Immobility increases risk for Atelectasis, DVT and Pulmonary Emboli. • Never ignore client's complaints. • Follow-through and check it out. • Fifty percent (50%) of persons with fat emboli die. Nurse Alert!

17. Complications • InfectionMusty, unpleasant odor over cast and/or at the ends of cast • Drainage through cast or cast opening • Sudden unexplained body temperature elevation • “Hot Spot” felt over cast lesion • May result in osteomyelitis

18. Interventions: Infection • Wash hands • Use aseptic technique when caring for wound and emptying drains • Culture drainage • Foley catheter care • Monitor temp • Report excessive drainage or inflammation to physician

19. Complications Watch out for Deep Vein Thrombosis after skeletal or muscular injury/surgery!

21. Muscle Spasm: • Powerful involuntary muscle contractions shorten the flexor muscles & cause extreme pain. This may be triggered by hypoxia of muscle tissue.

22. What Helps? • Bed cradle • Heat • Avoid heavy sedation • Avoid pressure in popiteal space • Minimize compression • Active & passive exercises as ordered • Frequent change in position

23. Fracture: Early Complications Critical monitoring & assessment is imperative. Know assessment findings that may indicate one of the following early complications of fractures. Question waiting for a place to happen !!!! Shock Nerve damage, arterial damage Infection Cast syndrome Compartmental Syndrome Volkmann’s Contracture Fat Embolism Syndrome Deep Vein thrombosis & Pulmonary Embolism NB

24. Long-term Complications • Joint stiffness or post-traumatic arthritis • Avascular necrosis • Nonfunctional union after a fracture • Complex regional pain syndrome • Reaction to internal fixation device

25. Avascular Necrosis

26. Complications of Fractures: Shock • Bones are very vascular. In combination with collateral damage to adjacent structures/vessels, the patient is at risk for hemorrhage. • Shock fully develops if a healthy client loses 1/3 of normal blood volume. Blood loss: • 15-30% (up to 1500 ml) -subtle signs • 30-40% (1500-2000 ml) –obvious shock • Over 40% (over 2000 ml) • 1 unit of packed cells raises Hgb about 1 gram. Check with physician about expected normal loss.

27. Potential Blood Loss Following Fractures (Liters) This is not what is expected but what is possible!

28. See Text • 1) Compartment Syndrome • 2) Cast Syndrome • 3) Infection • What? • How to recognize? • What should be done?

29. Fracture Reduction • Closed reduction: usually done under anesthesia • Carried out through manual traction to move fracture fragments & restore bone alignment • Followed by immobilization device (cast) • Open Reduction: incision and realignment • Usually performed with internal fixation devices (screws, pins, plates, wires)

30. Closed vs. Open Reduction Open Reduction

31. Fracture Reduction Cont’d • External Fixation: maintain position for unstable fractures & for weakened muscles, allow for use of contiguous joints while affected part remains immobilized. Common sites include face & jaw, pelvis, fingers. • Traction: application of a pulling force to an injured body part or extremity while a counter-traction pulls in the opposite direction.

32. External fixation

33. Figure 27-3: Types of Internal Fixation Devices Tension band wiring # phalanx Compression plate & screws # femur Intermedulary nail - femur

34. Open reduction and internal fixation of Comminuted mandibular fracture

35. CASTS • Review information learned in 2nd & 3rd year. At this point you should know • Types of casts • Why a cast may need to be Bi-valved • Drying & caring for a cast • Complications caused by casts … • Management of Casts & Braces • Importance of knowing weight bearing status NB!

36. Windowing and Bivalving a Cast • Windows maybe cut in dried casts: • relieve pressure from abd. distension (body cast) • To prevent “Cast Syndrome” • To assess radial pulse (check circulation in a casted arm) • To inspect areas of discomfort or areas of suspected tissue damage • To remove drains or care for wounds.

37. Bivalving a Cast Window Cast

38. Cast Drying: • Synthetic casts – dry approx. 20-30 mins (clients feel the sensation of heat thus may feel hot). • Plaster casts set rapidly but take several hrs-days to completely dry (lg. cast). • Promote the circulation of warm, dry air around a damp cast to enhance moisture evaporation and speed drying process. • Heat occurs with early cast drying stages • Do not cover cast while drying, can place layers of towels underneath pillow to elevate cast to absorb dampness. • Green cast (damp cast) • Lg. cast avoid covering and to allow air to circulate • Never use heated hairdryer to dry cast.

39. Nerve Damage during casts/traction: • Traction applied to an extremity puts pressure on the peroneal nerve where it passes around the neck of the fibula to just below the knee. • Pressure at this point may cause footdrop, leading to inability to dorsiflex the foot. • Inability to plantarflex indicates damage to the tibial nerve. • The calf muscle is not affected & the temp of extremity doesn’t change.

40. Assess for complications following cast : • Compartment syndrome • Fat emboli • Infection • DVT • Cast syndrome

41. Complications of Fractures/Casts Compartmental Syndrome: • Edema from a fracture causes an increase in compartmental pressure that decreases capillary blood perfusion. • When the local blood supply unable to meet tissue metabolic demands ischemia begins = compromised circulation. • Increase pressure in a confined space due to tight cast, edema or bleeding.

42. Complications of Fractures/Casts • Compartmental Syndrome: • Pulselessness: slow nail bed capillary refill (>3sec) • Skin pallor, blanching, cyanosis or coolness • Increasing pain, swelling,pain on passive motion, painful edema peripheral to cast. • Paresthesias (tingling, pricking), heightened sensation to touch, diminished sensitivity to touch (hypesthesia), anesthesia (numbness) • Motor paralysis to previous functioning muscles

43. Compartmental SyndromeSwelling out of control

44. Compartment Syndrome Treatment Fasciotomy RELEASE PRESSURE RELIEF CUT OPEN

45. Complications Cont’d Figure 27-6: Cast Syndrome Cast syndrome results from the compression of the duodenum between the aorta and the superior mesenteric artery. The external compression is usually caused by a tight body cast. Black 2001, p. 601) .

46. Complications Cont’d Cast Syndrome: • Bloating feeling • Prolonged nausea: repeated vomiting • Abdominal distension: vague abdominal pain • Shortness of breath • Untreated may lead to death!

47. Cast Syndrome An abdominal flat-plate is ordered. If you diagnosed the cast syndrome, you correctly identified the clinical signs consistent with this syndrome.  This is due to an extrinsic compression of the third portion of the duodenum by the superior mesenteric artery

48. Other Complications Cont’d Infection:Musty, unpleasant odor over cast and/or at the ends of cast • Drainage through cast or cast opening • Sudden unexplained body temperature elevation • “Hot Spot” felt over cast lesion • May result in osteomylitis

49. Complications Cont’d Volkmann’s Contracture: A common complication of elbow fractures • Can result in unresolved compartment syndrome. Arterial blood flow decreases, leading to ischemia, degeneration & contracture of muscle • May lead to permanently stiff, claw-like deformity of arm & hand

50. Volkmann’s Contracture