Musculoskeletal Trauma

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Musculoskeletal Trauma

• BY
• Deborah Cary, MSN
• Associate Professor
• Broward Community College

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ORTHOPEDIC TRAUMASOFT TISSUE INJURIES

• Contusions - bruise without a break in skin
• affects skin/subcutaneous tissue
• Strain - pull in a muscle, ligament or tendon
  caused by excessive stretch
• Sprain - a tear in a muscle, ligament, tendon

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Causes of injuries

• Contusions - due to a sudden, external pressure
  that tears the SC circulatory veins
• and capillaries resulting in bleeding in sc
• tissue
• bluish discoloration of the injured tissues
  with resulting edema.

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• Strain - cause is undue force to muscles,
• ligaments or tendons. Stretches fibers
• causing a temporary weakness,
• numbness. Weakness lasts 24-72 hrs
• ex a charley horse

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• Sprains - can affect portions of the bone in
• and around a joint.
• Affects ankles, wrists,
  fingers/toes
• 1st - 3rd degrees (marked edema, pain,
• hemorrhage and loss of function -
• full tearing (avulsion)

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FRACTURES

• Discontinuity or break in a bone
• Cause major trauma to musculoskeletal tissues
• Type of fx related to source or force of blow
• 6.2 million fx/yr 150,000 die from trauma

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FRACTURES

• Wrist (Colles)- most common due to falls
• Humerus - rx with casts
• use of swath/sling
• Clavicle - use of figure of eight bandage
• With upper extremity Fx - Elevate distal joints
  above proximal joints (Elbow above shoulder and
  wrist above elbow)

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Lower extremity Fractures

• Femur
• Tibia/ fibula
• Pelvic, pubic, coccygeal
• Ankle

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Medical Management Fractures

• Reduction via
• closed reduction with or without external
  fixation
• open reduction with internal fixation (ORIF)
  use of pins/wires
• casting
• traction - can be used along with open

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• Assess for breaks in skin (compound fx)
• If open wound, DSD -pressure if bleeding
• Keep person warm to prevent shock
• RICE rest, ice, compression, elevation
• Keep area immobilized
• If major trauma, suspect neck injury

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Nursing Management

• Initiate bedrest til injuries assessed
• Assess vitals - R/O life-threatening injury
• Assess for swelling, discoloration, abrasions,
  contusions or obvious deformity
• Assess neurovascular status hourly
• document color, temp, pulses, edema,
  presence of pain, sensory function, capillary
  refill - always compare to unaffected limb
• If casted - assess q 1-2hr initially, then q 4

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Management 2

• Special foam or alternating pressure mattress
• High protein, high carb diet if allowed
• Fluids to 3,000cc daily
• Turning sheet to relieve pressure on skin/bony
  prominences - prevent shearing force
• Bed making top to bottom

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Teaching

• Purposes for bedrest
• Purpose of position change q 2 hr
• Teach quadriceps, buttocks and triceps
• setting exercises to maintain strength (q4h)
  unaffected extremity

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Fracture Femur

• Young males in MVA - falls due to ETOH
• Sx - enlarged, deformed, painful thigh
• severe pain upon movement hip or knee
• dislocations common
• shock common due to blood loss
• Increasing diameter thigh indicates
  continuous bleeding (measure) - compare

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Types of Traction

• Skin- Velcro boot used (Bucks)
• Skeletal- Steinman pins, wires,tongs,screws
• (allows for longer tx time and heavier
  weights)
• Plaster -combines skeletal with a cast
• Brace - correction of alignment deformities
• Circumferential - use of a belt around body

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Types of Traction 2

• Upper Extremity
• Fx humerus with or without involvement of the
  shoulder/clavicle
• Skeletal tx (forearm flexed and extended
• 90 degrees from upper part of body)
• Plaster traction (pins inserted through the
  bone are fixed in the cast) Fx wrist

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Lower Extremity Traction

• Bucks extension - fx hip or femur pre-op
• prevention hip flexion contractures
• hip dislocation/spasms most common
• Russells traction - similar to above, but a
• sling under knee suspends leg
• fx hip or end of femur
• Balanced skin or skeletal traction - limb
  elevated in a Thomas splint with Pearsons
• attachment - fx femur or pelvis

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Traction 3

• Cervical halter - strap under chin
• Uses - cervical muscle spasms, strain/sprain
  and arthritis
• Cervical skeletal (halo brace, Crutchfield Tongs
  - fx cervical spine, muscle spasms
• Pelvic Belt-strap around hips at iliac crests is
• attached to weights at foot of bed - spasms
• Pelvic sling - wide strap around hips attached to
  overhead bar to keep pelvis off bed-pelvic fx

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Cast Care

• Explanation to patient
• Use palms of hands until dry
• Can use a hair dryer on low to hasten drying
• Petal the cast edges when dry
• Neurovascular checks!!

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Bucks Extension

• Used in any age - usually adults
• One or both legs
• Pre-op for hip fx
• Pulls contracted muscles/ relieves spasms
  in legs or back
• 5-7 weights ordered by MD
• Pt in recumbent position - HOB to 30degrees

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Nursing Management

• Weights hanging free
• Ropes on pulleys
• Body in straight alignment
• Foot plate or board to prevent footdrop

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Nursing Management 2

• fx, turn to UNAFFECTED side only
• Either side if no fx present
• Pillows to back and between legs when turn
• Assess CMS and burning under tape of boot
• Check heels for spongy feel - keep off bed

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Fractured Hip

• INCIDENCE
• Frail, elderly women - Caucasian,Asian
• Causes cerebral ischemia (ex TIA,
• syncope
• falls (occasionally inner ear problems
• balance (vestibular) disturbances
• Comorbidity cardiovascular,
• pulmonary complications due to bedrest

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Complications of all Fractures

• Acute Compartment Syndrome
• (Volkmanns Contracture)
• Fat Embolism
• Deep Vein Thrombosis (DVT)
• Infection
• Avascular Necrosis
• Delayed Union

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• Acute Compartment Syndrome
• Serious complication in which increased pressure
  within 1 or more compartments causes massive
  compromise of circulation to the area
• ISCHEMIA-EDEMA CYCLE
• Observe for edema, decreased sensation
• Assess lab tests Total Protein, Albumin
• ESR, WBC

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• Most common sites ACS are in lower leg
• and dorsal and volar compartments of
• forearm (Volkmans)
• Causes External (casts/ tight bulky
  dressings) Internal (blood or fluid accumulation)

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Fat Embolism

• Fat globules released from bone marrow into blood
• Long bone fx and multiple fx
• Older clients - fx hips risk and common in fx
  pelvis
• Earliest sx - AMS
• respiratory distress, tachycardia,
• tachypnea, fever Petechiae

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DEEP VEIN THROMBOSIS

• MOST COMMON COMPLICATION
• of lower extremity surgery or trauma
• Increased risk in smokers, obese, heart disease,
  hx of thromboembolic complications
• Increased incidence in older adults in lst 2-3
  days post-op
• Fx lower extremities/pelvis
• Prevention!!!!

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• Local venous stasis secondary to trauma or
• surgery (use of tourniquets in lower extremity
  injuries) increases risk of DVT
• Prevention- ROM, anticoagulants (heparin,
  lovenox), Sequential compression device,
• Antiembolism stockings, force fluids,
  insertion of Greenfield filter (IVC) pre-op

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Infection

• Cause - trauma to tissue
• implanted hardware
• (pins, screws, rods)
• organism of clostridium gangrene
  or tetanus
• Most common Staph
• Osteomyelitis bone with open fx and
• after repair

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Avascular Necrosis (AVN)

• Aseptic or ischemic necrosis (osteonecrosis)
• Blood supply disrupted leading to death of
• bone tissue
• Can occur after hip fx or any fx with bone
• displacement
• Hardware can interfere with circulation

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AMPUTATIONS

• CAUSES
• Peripheral Vascular Disease
• Gangrene
• Trauma
• Frostbite
• Electrical Burns
• Malignancy
• Chronic Osteomyelitis

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Nursing Considerations

• Traumatic - usually upper extremity
• Drastic reconstructive surgery
• Major body changes
• Altered physical mobility/ADL
• Psychological support pre/post-op
• Surgical site chosen is the most distal
  part that will heal successfully
• prosthetic fit best with BKA major advances in
  prostheses

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Nursing continued

• Gentle handling residual limb (stump)
• Control of edema via closed rigid dressing
• with cast or soft compression dressing
• Observe for hemorrhage - keep large
• tourniquet at bedside
• Pillows below stump for 48 hrs. only
• Phantom limb pain - with AKA
• SEE Table 61-15 in text pg. 1684

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Prostheses

• Fit when swelling subsides

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Crutch Walking

• Principle determine lifestyle and upper
• body strength
• Gait patterns two-point
• three- point
• four-point
• swing-to- gait
• swing-through
• Use transfer belt when ambulating
• Measurement