Musculoskeletal Injuries: Key Considerations

• This will cover diagnostic criteria, assessment findings, nursing care, and medical treatment for musculoskeletal problems.

Fractures, Sprains and Strains

• Fractures are a disruption or break in the continuity of bone structure.
• Sprains involve injury to the ligamentous structures surrounding a joint and are often caused by a turning or wrenching motion, commonly affecting ankles, wrists, and knees, leading to joint instability.
• Strains are excessive stretching of a muscle, its fascial sheath, or a tendon, often affecting the lower back, calf, and hamstrings.
• Traumatic injuries are the majority cause of fractures.
• Diseases such as cancer or osteoporosis can cause secondary fractures.

Fracture Classification

• An open fracture involves the bone penetrating the skin, increasing the risk of infection.
• A closed fracture involves the skin remaining intact.
• A non-displaced fracture means that the bone is still aligned, and includes greenstick, spiral, and transverse fractures.
• A displaced fracture means that the bone is separated.

Fracture Clinical Manifestations

• Clinical manifestations that may be present are edema, swelling, pain, and tenderness.
• Loss of function, inability to bear weight or use are signs of a fracture.
• Muscle spasms may occur and the patient may guard the injured area.
• Deformity may or may not be present.
• Always immobilize if a fracture is suspected.

Fracture Treatment Goals

• Anatomic realignment (reduction) is the first goal.
• Fracture reduction can be achieved through closed reduction, open reduction, or traction.
• Immobilization is needed to maintain the alignment
• Restoration of normal or near-normal function completes the treatment goals

Fracture Reduction: Closed

• Closed reduction is a nonsurgical, manual realignment of bone fragments.
• Traction and countertraction are applied during close reduction
• Closed reduction is performed under local or general anesthesia.
• Immobilization follows, using traction, a cast, splint, or brace.

Fracture Reduction: Open

• Open reduction involves surgically correcting the alignment.
• Open reduction usually includes internal fixation (ORIF) using wires, screws, pins, plates, rods, or nails. Surgical incision is needed.
• Risk for infection is increased.
• Internal fixation is required.
• Early ROM of the joint is encouraged to prevent adhesions, and CPM machines are used.
• This process facilitates early ambulation

Fracture Reduction: Traction

• Traction involves applying a pulling force to attain realignment.
• Countertraction involves pulling in the opposite direction.
• Traction prevents pain and muscle spasms, immobilizes a joint or body part, reduces the fracture or dislocation and treats pathologic joint conditions like tumors or infections.
• Skin and skeletal traction are the two most common.

Skin Traction

• Skin traction is often utilized short-term, up to 48-72 hours until surgery is possible.
• In skin traction, tape, boots, or splints are applied directly to the skin to maintain alignment and reduce muscle spasms.
• Skin traction involve weights of 5 to 10 pounds.
• Assess the skin every 2-4 hours for prevention of breakdown where the traction device is placed.
• Skin traction is used for both children and adults

Skeletal Traction

• Skeletal traction is for long-term use.
• Skeletal traction aligns injured bones and joints or to treat joint contractures and congenital hip dysplasia
• In skeletal traction, a pin or wire is inserted into the bone to align and immobilize the injured body part.
• Skeletal traction's weight will range from 5 to 45 lbs, and there is a risk for infection.
• Pin care is essential
• Complications of immobility should be avoided.
• It is typically used in adults only.

Balanced Suspension Traction

• Proper patient position and alignment is mandatory.
• Constant traction forces must be sustained.
• Countertraction must be maintained, elevate the end of the bed.
• Traction weights should be kept off the floor and able to move freely through the pulleys.

Cast Care

• A cast is a temporary circumferential immobilization device that allows the patient to perform normal activities, while providing sufficient immobilization to ensure stability.
• Different materials are used.
• A cast typically incorporates joints above and below the fracture.
• To apply bandage the affected part with stockinette and padding.
• Immerse plaster of paris material in warm water, and mold around limb
• Cast should set in 15 minutes, and needs at least 24-72 hours to dry before weight bearing is allowed.
• Do not cover a cast while drying - air needs to circulate, and the trapped heat may burn the patient.
• No direct pressure should be applied to the cast during the drying period. Cover the edges with petals.
• Assess for circulation issues by looking for cyanosis in fingers and numbness and tingling.
• Frequent neurovascular assessments are needed, and provide patient and caregiver teaching.
• Apply ice for the first 24 hours, and elevate above the heart for first 48 hours.
• Exercise joints above and below the cast, and use a hair dryer on a cool setting for itching, and seek healthcare provider advice before getting it wet.
• Dry the cast thoroughly after getting wet.
• Report increasing pain despite elevation, ice and analgesic.
• Report swelling with pain and discolorations or movement
• Report burning or tingling under the cast, along with sores or a foul odor.
• Do not ice or elevate if compartment syndrome is suspected, get the cast wet, or remove the padding, insert objects inside the cast.
• Don't bear weight for 48 hours or cover cast with plastic for a prolonged period.

Lower Extremity Immobilization

• After immobilization elevate extremity above heart for 24 hours
• Do not place in dependent position due to increased edema
• Observe for signs of compartment syndrome
• Assess the 6 P's of compartment syndrome are pain, pressure, paresthesia, pallor, paralysis, pulselessness.

Compartment Syndrome

• Compartment syndrome involves swelling and increased pressure within a limited space (muscle compartment), which compromises the neurovascular function of tissues within that space resulting in tissue death.
• Compartment syndrome occurs in 38 compartments in upper and lower extremities.
• Compartment size decreases occur due to restrictive dressings, splints, casts, excessive traction or premature closure of the fascia.
• Compartment content increases are caused by bleeding, inflammation, edema, or IV infiltration.
• Edema causes pressure that obstructs circulation.
• Arterial flow is compromised which causes ischemia, then cell death, which leads to loss of function.
• Early recognition and treatment is essential.
• Ischemia can occur within 4 to 8 hours after onset.
• Prompt and accurate diagnoses are necessary.
• Notify of pain unrelieved by drugs, paresthesia, pulselessness, paralysis, and may require amputation.
• Do not elevate the extremity above the heart if compartment syndrome is suspected or apply cold compresses or ice.
• Treatment includes relieving pressure, surgical decompression (fasciotomy) or amputation.

Hip Fracture

• Hip fractures are more common in the elderly.
• Signs and symptoms include severe pain, tenderness, shortening of the affected extremity, muscle spasm, and external rotation.

The Nursing Management for Hip Fractures

• Assessment before surgery, during surgery and after, including neurovascular assessment.
• If medically unstable treat with Buck's traction, if stable use surgical repair with internal devices for fixation
• Anterior approach has fewer restrictions and more stable joint.
• Posterior approach has more mobility restrictions and less stable joint
• The priorities of postoperative care involve infection, atelactesis and PE (pulmonary embolism).
• Elevate leg to reduce edema, when moving to the non-operative side, use pillows, and avoid on surgical side.
• Physical therapy and exercise needed
• After surgery, clarify weight bearing status.
• Post surgery after posterior fixation (Hemiarthroplasty or THR) prevent dislocation: use elevated toilet seat, use chairs and shower.
• When sitting, walking, or lying use Keep hip is in a neutral, straight position.
• Report if severe pain, deformity, or loss of function happens.
• With dentist notify about having infection risk with prosthetics.
• Do not flex hip more than 90 degrees, adduct hip (abduction wedge), internally rotate hip, cross legs at knees or ankles, put on own shoes for 4 to 6 weeks, or sit on chairs without arms (anterior fixation Hemiarthroplasty or THR)
• For Hemiarthroplasty Avoid hyperextension.
• Restrictions of ORIF 6 to 12 weeks.
• Don't bathe in tub or driving for about 4 to 6 weeks weeks

Gerontological Considerations

• In hip fracture, eliminate tripping hazards, place railings on both sides of stairs, good lighting to prevent injuries and falls, and teach patients about calcium and vitamin D.

Spinal Fracture

• Stable fractures don't move so unlikely to damage spinal cord. But need pain meds and bracing.

Spinal Surgery - Post-operative care

• Properly align, log roll only with support between legs.
• Need enough staff to assist with the log roll.
• Numbness and tingling, loss of sensation (paresthesia), loss of bladder or bowel control are signs of neurologic impairment.

Amputation

• Amputation occurs because of vascular diseases or diabetes
• Diagnostic studies depend on the underlying reason.
• If an infection is present, check the WBC (5-10).
• Perform vascular studies to confirm with Arteriography, venography, ultrasound Doppler studies

Amputation - Collaborative care

• Collaborative care involves addressing the infection, chronic illness and preserving extremity length and function while removing infected, pathologic, or ischemic tissue.
• Assess for circulation to the incision site.
• With traumatic amputations, prepare the patient to have a period of phantom limb sensation, and to monitor for other complications. In some cases, a prosthesis is needed

Special Considerations

• The mirror is thought to provide visual information to the brain by replacing sensory feedback from the missing limb.

Osteoporosis and Osteoporotic Fractures

• They are more prevalent and occur at a younger age among people with IDD.
• Screen both male and female patients early in adulthood for osteoporosis. Seek advice from a radiologist regarding alternative methods to assess risk of fragility fractures.
• Reduce risk of osteoporosis through 1000-1200 mg daily of Calcium, Checking 25-hydroxyvitamin, supplement 600 or 800 daily
• Do weight bearing excercises, limit smoking, and exercise precautionary safety to preveent falls.

This lesson covers essential considerations for managing musculoskeletal injuries. It emphasizes the importance of blood flow to extremities, assessing for complications like cyanosis and nerve impairment. It also highlights the role of traction and weight distribution in treatment.