Musculoskeletal Trauma Management PDF

Management of Patients with Musculoskeletal Trauma Dr. Ola Sukkarieh Injuries of the Musculoskeletal System  Contusion: soft tissue injury produced by blunt force  Pain, swelling, and discoloration: ecchymosis  Strain: Pulled muscle injury to the musculotendinous unit...

Management of Patients with Musculoskeletal Trauma Dr. Ola Sukkarieh Injuries of the Musculoskeletal System  Contusion: soft tissue injury produced by blunt force  Pain, swelling, and discoloration: ecchymosis  Strain: Pulled muscle injury to the musculotendinous unit  Pain, edema, muscle spasm, ecchymosis, and loss of function are on a continuum graded first, second, and third degree  Sprain: injury to ligaments and supporting muscle fiber around a joint  Pain (may increase with motion), edema, tenderness; severity graded according to ligament damage and joint stability  Dislocation: articular surfaces of the joint are not in contact  A traumatic dislocation is an emergency with pain change in contour, axis, and length of the limb and loss of mobility  Subluxation: partial or incomplete dislocation  Does not cause as much deformity as a complete dislocation Q1  What is a contusion?  A musculotendinous injury  Blunt force injury to soft tissue  A break in the continuity of a bone  An injury to ligaments and other soft tissues at a joint Answer  B. Blunt force injury to soft tissue  Rationale: A contusion is a soft tissue injury produced by blunt force, such as a blow, kick, or fall, causing small blood vessels to rupture and bleed into soft tissues (ecchymosis or bruising). A hematoma develops from bleeding at the site of impact, leaving a characteristic “black and blue” appearance. Management of soft tissues injury  RICE  Rest  Ice  Compression  Elevation  Immobilize Types of fracture  Closed or simple  No break in the skin  Open or compound/complex  Wound extends to the bone  Grade I: 1 cm long clean wound  Grade II: larger wound without extensive damage  Grade III: highly contaminated, extensive soft tissue injury, may have amputation  Intra-articular  Extends into the joint surface of a bone Manifestations of a Fracture  Acute pain  Loss of function  Deformity  Shortening of the extremity  Crepitus  Local swelling and discoloration  Diagnosis by symptoms and radiography  Patient usually reports an injury to the area Emergency Management of a Fracture  Immobilize the body part  Splinting: joints distal and proximal to the suspected fracture site must be supported and immobilized  Assess neurovascular status before and after splinting  Open fracture: cover with sterile dressing to prevent contamination  Do not attempt to reduce the fracture Medical Management of a Fracture  Fracture reduction: restoration of the fracture fragments to anatomic alignment and positioning  Closed  Uses manipulation and manual traction  Traction may be used (skin or skeletal)  Open  Internal fixation devices hold bone fragment in position (metallic pins, wires, screws, plates)  Immobilization  External (cast, splints) or internal fixations Figure 37-3 Techniques of internal fixation. A. Plate and six screws for a transverse or short oblique fracture. B. Screws for a long oblique or spiral fracture. C. Screws for a long butterfly fragment. D. Plate and six screws for a short butterfly fragment. E. Medullary nail for a segmental fracture. Factors that affect fracture healing  Inadequate fracture immobilization  Inadequate blood supply to the fracture site or adjacent tissue  Multiple trauma  Extensive bone loss  Infection  Poor adherence to prescribed restrictions  Malignancy  Certain medications (e.g., corticosteroids)  Age >40 years  Comorbidities (e.g., diabetes, rheumatoid arthritis)  Early Complications of Fractures  VTE (DVT & PE): associated with bed rest& fractures of the lower extremities and pelvis  Shock: Hypovolemic from hemorrhage in trauma patients with pelvic fractures and with a displaced or open femoral fracture in which the femoral artery is torn by bone fragments.  Fat embolism: At the time of fracture, fat globules may diffuse from the marrow into the vascular compartment; onset within 24 to 72 hours of injury  Acute Compartment syndrome: An anatomic compartment is an area of the body encased by bone or fascia (e.g., the fibrous membrane that covers and separates muscles) that contains muscles, nerves, and blood vessels. When the pressure within an affected compartment rises above normal, perfusion to the tissues is impaired, causing cell death, which may lead to tissue necrosis and permanent dysfunction  increase in compartment volume (e.g., from edema or bleeding)  decrease in compartment size (e.g., from a restrictive cast), or aspects of both. A. Cross-section of normal lower leg with muscle compartments. B. Cross-section of lower leg with compartment syndrome.  Delayed Complications of Fractures  Delayed union, malunion, and nonunion:  Delayed union occurs when healing does not occur within the expected timeframe for the location and type of fracture but eventually heals. (e.g. (pulling apart) of bone fragments, systemic or local infection, poor nutrition, or comorbidity (e.g., diabetes, autoimmune disease).  Nonunion is an incomplete healing of a fracture and results from failure of the ends of a fractured bone to unite  malunion is the healing of a fractured bone in a malaligned (deformed) position  Avascular necrosis of bone: bone loses its blood supply and dies; leads to bony collapse and destruction of the associated joint. progressive, and the patient develops pain with movement that progresses to pain at rest.  fracture with disruption of the blood supply to the distal area.  prolonged high-dose corticosteroid therapy, exposure to radiation, rheumatoid arthritis, and other diseases; chronic alcohol use and cigarette smoking  Heterotrophic ossification: Heterotopic ossification refers to benign bone growth in an atypical location, such as in the soft tissue. Common in young athletes Heterotopic ossification can be conceptualized as a tissue repair process gone awry and is a common complication of trauma and surgery. It develops in response to soft tissue trauma (e.g., contusion, sprain). characterized by pain and joint stiffness that causes decreased ROM. It typically occurs in young males after musculoskeletal sports injuries. Q  Is the following statement true or false?  Avascular necrosis is prolongation of expected healing time for a fracture. Answer  False  Rationale: Avascular necrosis is death of tissue secondary to poor perfusion and hypoxemia. Delayed union is prolongation of expected healing time for a fracture Rehabilitation Related to Specific Fractures #3 Pelvic fractures  Management depends on type and extent of fracture and associated injuries  Stable fractures are treated with a few days of bed rest and symptom management  Early mobilization reduces problems related to immobility Hip fracture  Surgery is usually done to reduce and fixate the fracture  Care is similar to that of a patient undergoing other orthopedic surgery or hip replacement surgery Examples of Internal Fixation for Hip Fractures Rehabilitation Related to Specific Fractures #4 Femoral shaft fractures  Lower leg, foot, and hip exercises to preserve muscle function and improve circulation  Early ambulation stimulates healing  Physical therapy, ambulation, and weight bearing are prescribed  Active and passive knee exercises are begun as soon as possible to prevent restriction of knee movement Assessment of the Patient with a Brace, Splint, or Cast #1  Before application  General health assessment  Emotional status  Presenting signs and symptoms and condition of the area  Monitoring of neurovascular status and for potential complications  Treat lacerations and abrasions before cast, brace, splint  Provide information about the purpose of treatment  Prepare patient for application by explaining procedure Assessment of the Patient With a Brace, Splint, or Cast #2 Assessing for neurovascular changes using “5 Ps”  Pain  Pallor  Pulselessness  Paresthesia  Paralysis Monitoring and treating pain  Describe exact site, character, and intensity of pain  Treat with elevation, ice packs, and analgesics Q  Is the following statement true or false?  A patient’s unrelieved pain should be reported to the provider 30 minutes after administered pain medication. Answer  False  Rationale: A patient’s unrelieved pain must be immediately reported to the provider to avoid possible paralysis and necrosis. Potential Complications of the Patient with a Brace, Splint, or Cast #1 Acute Compartment Syndrome:  Serious complication  Occurs from increased pressure in a confined space  Compromises blood flow  Ischemia and irreversible damage can occur within hours  Clinical assessment of 5 Ps; pain is the early indicator  Treatment: Notify physician, cast may be removed, and emergent surgical fasciotomy may be necessary Potential Complications of the Patient with a Brace, Splint, or Cast #2 Pressure Injuries: caused by inappropriately applied cast  Lower extremity sites most susceptible  Patient reports painful “hotspot” and tightness  Dx: May cut window in the cast for inspection and access  Treatment: dressing applied over exposed skin Disuse Syndrome: muscle atrophy and loss of strength  Treatment: Isometric exercises, muscle setting exercises Potential Complications of the Patient with a Brace, Splint, or Cast #2 Controlling of swelling and pain  medications and elevate Care of minor skin irritation  Pad rough edges with tape or moleskin  Blow with hair dryer to relieve itching  Do not stick foreign objects into the cast Education Signs and symptoms to report:  Persistent pain or swelling,  Changes in sensation, movement, skin color, or temperature  Signs of infection or pressure areas Required follow-up care Cast removal and after care External Fixator Devices  Used to manage open fractures with soft tissue damage  Provide support for complicated or comminuted fractures  Patient requires reassurance because of appearance of device  Discomfort is usually minimal, and early mobility may be anticipated with these devices  Elevate to reduce edema  Monitor for signs and symptoms of complications, including infection  Pin care  Patient education External Fixator Traction  Traction in its purest sense, is the action of pulling or drawing. It is still used every day to manipulate and reduce fractures.  The advent of improved technology has meant that more fractures are now treated operatively with intramedullary nails, or plates and screws, so traction is used less frequently as a treatment modality than in the past.  However, it can still be used as a temporary measure to provide pain relief, reduce blood loss and shock while definitive treatment is planned.  treated with traction at home (children/young people, for example), to avoid lengthy inpatient stays Traction Purposes  Reduce muscle spasms  Reduce, align, and immobilize fractures  Reduce deformity  Increase space between opposing forces Used as a short-term intervention until other modalities are possible All traction needs to be applied in two directions. The lines of pull are “vectors of force.” The result of the pulling force is between the two lines of the vectors of force Principles of effective traction  Whenever traction is applied, a counterforce must be applied. Frequently, the patient’s body weight and positioning in bed supply the counterforce NURISNG INTERVENTIONS  Traction must be continuous to reduce and immobilize fractures  Skeletal traction is never interrupted  Weights are not removed unless intermittent traction is prescribed  Any factor that reduces pull must be eliminated  Ropes must be unobstructed, and weights must hang freely  Knots or the footplate must not touch the foot of the bed Q  Is the following statement true or false?  The nurse must never remove weights from skeletal traction unless a life-threatening situation occurs. Answer  True  Rationale: The nurse must never remove weights from skeletal traction unless a life-threatening situation occurs. Removal of the weights completely defeats their purpose and may result in injury to the patient. Nursing Interventions for traction  Proper application and maintenance of traction  Monitor for complications of skin breakdown, nerve damage, and circulatory impairment  Inspect skin at least three times a day  Palpate traction tapes to assess for tenderness  Assess sensation and movement  Assess pulses, color, capillary refill, and temperature of fingers or toes  Assess for indicators of DVT  Assess for indicators of infection  Special mattresses or other pressure reduction devices  Perform active foot exercises and leg exercises every hour Nursing interventions  Assessing anxiety  Assisting with self-care  Monitor and manage complications  Atelectasis and pneumonia  Constipation  Anorexia  Urinary stasis  Infection  VTE Amputation  Maybe congenital or traumatic or caused by conditions such as progressive peripheral vascular disease, infection, malignant tumor, trauma  Performedto control pain or disease process, improve function, and improve quality of life  Health care team needs to communicate a positive attitude to facilitate patient acceptance and participation in rehabilitation Assessment of patient with an amputation  Neurovascular and functional status of affected extremity or residual limb and of unaffected extremity  Signs and symptoms of infection  Nutritional status  Concurrent health problems  Psychological status, grief, and coping  Phantom limb pain is perceived in the amputated limb (or section) and is caused by the severing of peripheral nerves. Nursing care of amputation  Assisting the patient to achieve physical mobility  Proper positioning of limb; avoid abduction, external rotation and flexion  Turn frequently; prone positioning if possible  Use of assistive devices  ROM exercises  Muscle‐strengthening exercises  “Preprosthetic care”; proper bandaging, massage, and “toughening” of the residual limb