Musculoskeletal Problems: Fractures, Injuries & Treatment PDF

Musculoskeletal Problems Chapters 67,68  Know the diagnostic criteria, usual assessment findings, nursing care and medical treatment for… Fractures, sprains, strains: management & complications Compartment syndrome Traction Amputation Diagnostic studies-X-ray, CT, MRI, ESR, R...

Musculoskeletal Problems Chapters 67,68  Know the diagnostic criteria, usual assessment findings, nursing care and medical treatment for… Fractures, sprains, strains: management & complications Compartment syndrome Traction Amputation Diagnostic studies-X-ray, CT, MRI, ESR, RF, CRP, Duplex venous Doppler  Soft Sprain Tissue – Injury Injuries: to ligamentous Strains structures & Sprains surrounding a joint, usually caused by a turning or wrenching motion (ankles, wrists, knees) ligaments supporting joints are injured joint instability Strain – excessive stretching of a muscle, in its fascial sheath, or a tendon. (large muscle groups: lower back, calf, hamstrings) overuse or over stretching of muscles Nursing management: Sprains and strains Acute injury CMS checks capillary refill pulses color numbness tingling RICE (rest, ice, compression, elevation) Pain medication/X-ray and identifies bonehmaffathfieling Ambulatory and home care-elevate & ice (ice not longer than 20 minutes, and not applied directly to skin) for 24-48…then moist heat  Fractures Disruption or break in continuity of structure of bone Majority of fractures from traumatic injuries Some fractures secondary to disease process Cancer or osteoporosis m break down LEG and makesbone comesthrough morethe s bone brittle Copyright © 2014 by Mosby, an imprint of Elsevier Inc.  Classification Open= penetrates skin Closed= skin intact Non-displaced = bone aligned greenstick, spiral, transverse Displaced= bone separated Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Classification According to Type Copyright © 2014 by Mosby, an imprint of Elsevier Inc. KW , a 21-year-old man, is brought to ED following injury to his left leg during a basketball game. The EMS immobilized the leg at the scene. KW rates his pain as a 9 on a scale of 0-10. For what other clinical manifestations associated with a fracture will you assess KW? Copyright © 2014 by Mosby, an imprint of Elsevier Inc.  Clinical Manifestations d Edema and swelling Pain and tenderness Decreased or loss of function Loss of function: Inability to bear weight or use Guarding Muscle spasm due to inflammed bone around the fracture May or may not have deformity Immobilize if suspect fracture!!!!  Goals of Fracture Treatment Anatomic realignment (reduction) Fracture reduction: Closed reduction, open reduction, traction Immobilization to maintain alignment Restoration of normal or near-normal function  Fracture Reduction: Closed Closed Reduction Closed reduction Nonsurgical, manual realignment of bone fragments Traction and countertraction applied Under local or general anesthesia https://www.youtube.com/watch?v=cVt4VI2Kotc Immobilization afterwards Traction, cast, splint, or brace Also see: Nursing Management: Caring for the Patient with a Cast or Traction in ©the Copyright textbook 2014 by Mosby, an imprint of Elsevier Inc.  Case Study Jupiterimages/Pixland/Thinkstock KW is scheduled for an immediate debridement and open reduction/repair of these fractures. How will you explain the planned treatment to KW? Prep bone will be mended with hardware Copyright © 2014 by Mosby, an imprint of Elsevier Inc.  Fracture Reduction: Open Open Open Reduction reduction - Correction of alignment Usually includes internal fixation (ORIF) of the fracture with the use of wires, screws, pins, plates, rods, or nails Surgical incision Risk for infection biggest concern Internal fixation Early ROM of joint to prevent adhesions CPM machines Facilitates early ambulation prevents long term fractureCopyright © 2014 by Mosby, an imprint of Elsevier Inc. Open fracture reduction  Internal Fixation Copyright © 2014 by Mosby, an imprint of Elsevier Inc.  more common for crushed External Fixation injuries Metal pins and wires attached to external rods Applies traction, compresses fragments and immobilizes Immobilizes and holds fracture fragments in place Nursing management: assess for pin loosening and infection, patient teaching, pin site care Copyright © 2014 by Mosby, an imprint of Elsevier Inc.  Fracture Reduction: Traction or diseased Traction – Application of a pulling force to an injured or diseased part of the body or extremity to attain realignment Countertraction – pulls in the opposite direction Purpose 1. Prevent or ↓ pain and muscle spasm. 2. Immobilize joint or part of body. 3. Reduce fracture or dislocation. 4. Treat a pathologic joint condition (Tumor or infection). 2 most common is skin and skeletal traction Copyright © 2014 by Mosby, an imprint of Elsevier Inc.  Fracture Reduction: Skin Traction Short-term (48-72 hours) until surgery possible noninvasive allows for pain relief Tape, boots, or splints applied directly to skin to maintain alignment, reduce muscle spasms Traction weights 5 to 10 pounds Skin assessment every 2-4 hours for prevention of breakdown imperative Children and adults Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Fracture Reduction: Skeletal Traction Long-term Used to align injured bones and joints or to treat joint contractures and congenital hip dysplasia Pin or wire inserted into bone to align and immobilize the injured body part. Weights 5 to 45 lbs needs to be ordered Risk for infection Pin care Complications of immobility weight provides Adults only cation Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Balanced Suspension short term Traction weight Skeletal Traction Requires correct patient position and alignment with constant traction forces Maintain countertraction. Elevate end of bed Maintain continuous traction Keep weights off the floor and moving freely through the pulleys Copyright © 2014 by Mosby, an imprint of Elsevier Inc.  Case Study Jupiterimages/Pixland/Thinkstock KW returns to the orthopedic unit following an open reduction and fixation of his leg fracture. His left leg has a cast on it that is secured with an Ace wrap KW ask how long will it take for his leg to heal? long time Copyright © 2014 by Mosby, an imprint of Elsevier Inc.  Bone Healing (Fig. 62-8) Copyright © 2020 by Elsevier, Inc. All rights reserved. 21  Fracture Immobilization Cast Temporary circumferential immobilization device Allows patient to perform many normal ADLs while providing sufficient immobilization to ensure stability Made of various materials Typically incorporates joints above and below fracture  Fracture Application of a Cast Immobilization Affected part covered with stockinette and padding Plaster of paris material immersed in warm water, wrapped, and molded Set in 15 minutes. Needs 24-72 hours before weight bearing Do not cover – air cannot circulate, heat builds up in the cast that may cause a burn, and drying is delayed No direct No direct pressure pressure on cast during dryingduring on cast period; petal edges Copyright © 2014 by Mosby, an imprint of Elsevier Inc.  Case Study Jupiterimages/Pixland/Thinkstock It is elevated above the level of his heart. The surgeon has written an order for hourly neurovascular checks. What will that assessment include? T Copyright © 2014 by Mosby, an imprint of Elsevier Inc.  Neurovascular Assessment aka CMS Assessment Peripheral vascular Color and temperature Capillary refill Pulses Edema Peripheral neurologic Sensation and motor function impaired circulation Pain pain can be due to Copyright © 2014 by Mosby, an imprint of Elsevier Inc.  Case Study What type of medication would you expect the health care provider to order for K.W. postoperatively? What vaccination should he have received in the ED if he were not up-to-date? Tetanus and ask him about other vaccines needed What will you teach about his nutritional needs r/t bone healing? Eat more cat protein and do not overdue rehabilitation KW recuperates well and is scheduled for discharge. What will you teach KW regarding cast care? Copyright © 2014 by Mosby, an imprint of Elsevier Inc.  d Cast Care Frequent neurovascular assessments Patient and caregiver teaching Apply ice for first 24 hours Elevate above heart for first 48 hours Exercise joints above and below cast Use hair dryer on cool setting for itching Check with health care provider before getting wet  Cast Care Do Dry thoroughly after getting wet Report increasing pain despite elevation, ice, and analgesia Report swelling associated with pain and discoloration OR may need to release the cast movement Report burning or tingling under cast Report sores or foul odor under cast  Cast Care Do not: Ice or Elevate if compartment syndrome suspected (could make it worse) Get plaster cast wet Remove padding Insert objects inside cast Bear weight for 48 hours Cover cast with plastic for prolonged period  Lower Extremity Immobilization Elevate extremity above heart x 24 hrs. Do not place in a dependent position d/t increase edema Observe for signs of compartment syndrome 6 P’s r oomomtcuh Pain swelling Increased pressure Paresthesia numbness and tingling Pallor to distal area Paralysis not being able to pulselessness no blood circulating to the distal move Copyright © 2014 by Mosby, an imprint of Elsevier Inc.  a n I se ling p Compartment Syndrome Swelling and increased pressure within a limited space (muscle compartment) Compromises neurovascular function of tissues within that space 38 compartments in upper and lower extremities if these swell too much CMS and tissue problems https://www.youtube.com/watch?v=GnN UqfQYMAo Copyright © 2014 by Mosby, an imprint of Elsevier Inc.  Compartment Syndrome Two basic causes: ↓ Compartment size : resulting from restrictive dressings, splints, casts, excessive traction, or premature closure of fascia ↑ Compartment contents: resulting from bleeding, inflammation, edema, or IV infiltration Edema causes pressure that obstructs circulation Arterial flow compromised → ischemia → cell death → loss of functionCopyright © 2014 by Mosby, an imprint of Elsevier Inc.  Compartment Syndrome Clinical Manifestations 0 indicates fluid Early recognition and treatment essential is truing to get out of swollen May occur initially with injury or may be delayed area several days Ischemia can occur within 4 to 8 hours after onset. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.  Compartment Syndrome Collaborative care Prompt accurate diagnoses (neurovascular assessments) Early signs: Notify of pain unrelieved by drugs and out of proportion to injury Paresthesia is also an early sign Relieving the source of pressure may prevent progression Late signs:cardiac arrest tissue death Pulselessness Paralysis  Compartment Syndrome If compartment syndrome suspected: Do not elevate extremity above heart Do not apply cold compresses or ice Treatment: Relieve pressure Surgical decompression (fasciotomy) Amputation  Fracture of the Hip Isate to undergo anesthesia More common in what age and gender? Gst Signs & Sx? severe pain & tenderness, shortening of affected extremity, muscle spasm, external rotation Nursing Management: pre-op, intra-op, post-op assessment including neurovascular assessment Medical Management: Buck’s traction if medically unstable or Surgery if stable with internal fixation devices Types of Surgical Repair for a Hip Fracture Copyright © 2020 by Elsevier, Inc. All rights reserved. 37 Internal Fixation  Nursing Management Hip Fracture Anterior approach—fewer restrictions, more stable joint, fewer complications smoother recovery Posterior approach—more mobility restrictions, less stable joint more limitations this is the outcome Post operative priorities of care: Infection Hospital Acquired pneumonia Atelectasis  Nursing Management of Hip fractures Postoperative care Elevate leg to reduce edema Maintain limb alignment with pillows when turning to non-operative side (avoid operative side unless HCP approved) keep hips in a more Trapeze neutral position Physical therapy Exercise Clarify weight bearing status need this to get the patient out of bed  Nursing Implementation Hip Fracture Hemiarthroplasty or THR by posterior approach Prevent dislocation Do: Use elevated toilet seat Remain seated on chair in shower or tub Keep hip in neutral, straight position when sitting, walking or lying Notify surgeon immediately if severe pain, deformity, or loss of function occurs Discuss risk of infection related to prosthetic joint with dentist or surgeon  Nursing Implementation Hip Hemiarthroplasty or THR Fracture by posterior approach Prevent dislocation Do Not: Flex hip greater 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 Sit on chairs without arms  Nursing Implementation Hemiarthroplasty or THR Hipby Fracture anterior approach Fewer precautions Avoid hyperextension Weight bearing ORIF: restricted 6 to 12 weeks must not be taking narcotics and be No bathing in tub or driving for 4 to 6 weeks mobile enough to Occupational therapist for assistive devices react when driving Physical therapist for exercise and ambulation Gerontologic Considerations Hip Fracture Causes? Prevention methods T  6 Safety measures Home safety Eliminate tripping hazards Add grab bars in and out of shower and beside toilet Railings on both sides of stairs Good lighting External hip protectors Calcium and Vitamin D Bisphosphonate drugs  Spinal Stable spinal fractures Fracture – the fracture or the fragment is not likely to move or cause spinal cord damage. Most patients experience only brief periods of disability Could result in serious spinal injury, so… Consider all spinal fractures to be unstable __ Keep spine in good alignment until union has been accomplished Evaluate VS regularly Evaluate bowel and bladder function new incontinence of urine or bowels Monitor sensory status of peripheral nerves Give pain medication  d g Spinal surgery-post op care Proper alignment: Log rolling only with support between legs Enough staff to assist? CMS checks Assess for CSF leakage— severe headache, clear or slightly yellow e drainage from incision Assess for signs of neurologic impairment Numbness tingling, loss of sensation (paresthesia), paresthesia loss of loss of bladder or bladder bowel control or  Amputation Clinical indications Diagnostic studies depends on the underlying reason Infection->check WBC (5-10), Vascular studies look at blood flow to the veins Arteriography, venography, ultrasound Doppler studies Collaborative care: Address the infection and chronic illness before amputation Goal of surgery: Preserve extremity length & function while removing infected, pathologic, or ischemic tissue Amputation Sites do not need to memorize  Nursing Management Nursing implementation Health promotion Treat underlying problem to delay or eliminate the need for amputation Patient/family education Acute intervention: education about peri-op care Pre-op care: educate about phantom limb sensation – occur in many amputees Emergent or planned? Post-op care- traumatic emergent amputation🡪 monitor for PTSD, monitor VS, hemorrhage, infection Need for prosthesis?—immediate or delayed? May know in aplanned prosthesis often not immediate Traumatic Amputations  Mirror therapy for phantom limb pain The mirror is thought to provide visual information to the brain, replacing the sensory feedback expected from the missing limb.  RN LPN UAP Perform neurovascular Check color, temperature, Position casted extremity assessments on affected extremity cap refill and pulses distal to above heart level Assess for clinical manifestations cast Apply ice to cast as of compartment syndrome Mark circumference of any directed by RN Monitor cast during drying for drainage on cast Maintain body position denting or flattening Monitor skin integrity around and integrity of traction Teach patient and caregiver about cast at traction connections (after being trained and cast care and complications of Pad cast edges and traction evaluated in this casting connections to prevent skin procedure) Determine correct body alignment irritation Assist patient with passive to enhance traction Monitor pain level and and active ROM Instruct patient and caregiver ROM administer prescribed Notify RN about patient exercises analgesics complaints of pain, Assess for complications Notify RN if changes in pain tingling or decreased associated with immobility or if pain persists after sensation in affected Develop plan to minimize prescribed analgesics are extremity complications associated with administered immobility fracture  Osteoporosis and Osteoporotic Fractures in IDD Osteoporosis and osteoporotic fractures are more prevalent and occur at a younger age among people with IDD than among those in the general population Screen both male and female patients for osteoporosis starting in early adulthood Seek advice from a radiologist regarding alternative methods to assess risk of fragility fractures if the patient cannot be assessed using the usual nuclear BMD test, such as by assessing the patient’s forearm only Canadian Consensus Guidelines, 2018  Osteoporosis and Osteoporotic Fractures in IDD What can be done to reduce risk of osteoporosis and its complications? Diet that includes Calcium (1000-1200 mg daily) Checking 25-hydroxyvitamin D levels and supplementing as necessary – 600 IU-800 IU daily Encourage weight bearing exercises Avoid smoking Limit alcohol intake Safety precautions to avoid falls Long term Antiepileptic drug use increases risk for Osteoporosis Women with IDD post menopausal , which can happen at a younger age Escude, 2019