Chapter 69: Management of Patients With Musculoskeletal Trauma

When joint manipulation is unsuccessful for a client, he is taken to surgery for surgical repair of his hip injury. He is brought to the ICU where you practice nursing for postoperative recovery. In addition to the regular assessments prescribed by policy, what assessment is completed every 30 minutes for several hours? a) Neurological b) Neurovascular c) Orientation d) Head-to-toe

Neurovascular Explanation: The nurse should perform neurovascular assessments every 30 minutes for several hours, and then at least every 2 to 4 hours for the next 1 or 2 days to detect complications.

A nurse is caring for a client who underwent a total hip replacement. What should the nurse and other caregivers do to prevent dislocation of the new prosthesis? a) Prevent internal rotation of the affected leg. b) Keep the hip flexed by placing pillows under the client's knee. c) Use measures other than turning to prevent pressure ulcers. d) Keep the affected leg in a position of adduction.

Prevent internal rotation of the affected leg. Explanation: The nurse and other caregivers should prevent internal rotation of the affected leg. However, external rotation and abduction of the hip will help prevent dislocation of a new hip joint. Postoperative total hip replacement clients may be turned onto the unaffected side. The hip may be flexed slightly, but it shouldn't exceed 90 degrees. Maintenance of flexion isn't necessary.

Which of the following is a term used to describe a soft tissue injury produced by a blunt force? a) Sprain b) Hematoma c) Contusion d) Strain

Contusion Explanation: A contusion is a soft tissue injury produced by blunt force, such as a blow, kick, or fall, that results in bleeding into soft tissues (ecchymosis, or bruising). A hematoma develops when the bleeding is sufficient to form an appreciable solid swelling. A strain, or a "pulled muscle," is an injury to a musculotendinous unit caused by overuse, overstretching, or excessive stress. A sprain is an injury to the ligaments and supporting muscle fibers that surround a joint often caused by a trauma, wrenching or twisting motion.

A client presents to the emergency department with an open fracture. What is the first action the nurse should take? a) Assess the client's vital signs and determine allergies. b) Cover the exposed bone with sterile dressing. c) Perform a neurovascular assessment of the affected extremity. d) Assist the physician with reduction of the fracture.

Cover the exposed bone with sterile dressing. Explanation: The exposed bone should be covered with a sterile dressing to protect the deeper tissues from contamination.

Which of the following is a factor that inhibits fracture healing? a) Vitamin D b) Maximum bone fragment contact c) Local malignancy d) Exercise

Local malignancy Explanation: Factors that inhibit fracture healing include local malignancy, bone loss, and extensive local trauma. Factors that enhance fracture healing include proper nutrition, vitamin D, exercise, and maximum bone fragment contact.

A client undergoes a total hip replacement. Which statement made by the client indicates to the nurse that the client requires further teaching? a) "The occupational therapist is showing me how to use a sock puller to help me get dressed." b) "I'll need to keep several pillows between my legs at night." c) "I need to remember not to cross my legs. It's such a habit." d) "I don't know if I'll be able to get off that low toilet seat at home by myself."

"I don't know if I'll be able to get off that low toilet seat at home by myself." Explanation: The client requires additional teaching if he is concerned about using a low toilet seat. To prevent hip dislocation after a total hip replacement, the client must avoid bending the hips beyond 90 degrees. The nurse should instruct the client to use assistive devices, such as a raised toilet seat, to prevent severe hip flexion. Using an abduction pillow or placing several pillows between the legs reduces the risk of hip dislocation by preventing adduction and internal rotation of the legs. Teaching the client to avoid crossing the legs also reduces the risk of hip dislocation. A sock puller helps a client get dressed without flexing the hips beyond 90 degrees.

A client is treated in the emergency department for acute muscle strain in the left leg caused by trying a new exercise. During discharge preparation, the nurse should provide which instruction? a) "Apply ice packs for the first 24 to 48 hours, then apply heat packs." b) "Apply heat packs for the first 24 to 48 hours." c) "Apply heat packs for the first 24 hours, then apply ice packs for the next 48 hours." d) "Apply ice packs for the first 12 to 18 hours."

"Apply ice packs for the first 24 to 48 hours, then apply heat packs." Explanation: The nurse should instruct the client to apply ice packs to the injured area for the first 24 to 48 hours to reduce swelling and then apply heat to increase comfort, promote reabsorption of blood and fluid, and speed healing. Applying ice for only 12 to 18 hours may not keep swelling from recurring. Applying heat for the first 24 to 48 hours would worsen, not ease, swelling. Applying ice 48 hours after the injury would be less effective because swelling already has occurred by that time.

If a dislocation is not treated promptly, tissue death due to anoxia can occur. This would be documented as which of the following? a) Heterotopic ossification b) Osteomyelitis c) Subluxation d) Avascular necrosis (AVN)

Avascular necrosis (AVN) Explanation: If a dislocation is not treated promptly, AVN, tissue death due to anoxia and diminished blood supply, and nerve palsy may occur. Subluxation is a partial dislocation of the articulating surfaces. Heterotopic ossification is the abnormal formation of bone, near bones or in muscle, in response to soft tissue trauma after blunt trauma, fracture, or total joint replacement. Osteomyelitis is an acute or chronic inflammation of the bone caused by infection.

In a patient with a dislocation, the nurse should initially perform neurovascular assessments a minimum of every 15 minutes until stable. Which of the following complications do the assessments help the nurse to monitor in the patient? a) Compartment syndrome b) GI bleeding c) Ganglion cysts d) Carpal tunnel syndrome

Compartment syndrome Explanation: The nurse should initially perform neurovascular assessments a minimum of every 15 minutes until stable in a patient with a dislocation to assess for compartment syndrome. It is a complication associated with dislocation. A patient with a dislocation does not experience an increased risk of complications such as GI bleeding, carpal tunnel syndrome, or ganglion cysts.

A 13-year-old client is brought to the emergency department. The client's mother reports that the client was struck with a baseball bat on his upper arm while diving for a pitched ball. After diagnostic tests are completed, the physician reassures the mother that her son's humerus is not broken but he has suffered another type of injury. What type of injury would you expect the physician to diagnose? a) Sprain b) Strain c) Contusion d) Subluxation

Contusion Explanation: A contusion is a soft tissue injury resulting from a blow or blunt trauma.

A client who suffers an injury in a local high school hockey game presents with left shoulder pain. The client cannot move the left arm, and the left shoulder is lower than the right shoulder. The nurse recognizes the client most likely has a: a) Clavicle fracture b) Dislocated elbow c) Dislocated shoulder d) Cervical injury

Dislocated shoulder Explanation: Clinical manifestations of a dislocated shoulder include pain, lack of motion, feeling of an empty shoulder socket, and uneven posture.

A 39-year-old client has been brought to the ED by his teammates. The client was fielding a fly ball, fell, and injured his hip. He cannot place weight on the leg and is in significant pain. After radiographs indicated intact but malpositioned bones, what would you expect the physician to diagnose? a) Fracture b) Strain c) Sprain d) Dislocation

Dislocation Explanation: In joint dislocation, radiographic films show intact yet malpositioned bones.

A client with arterial insufficiency undergoes below-knee amputation of the right leg. Which action should the nurse include in the postoperative care plan? a) Maintaining the client on complete bed rest b) Elevating the stump for the first 24 hours c) Removing the pressure dressing after the first 8 hours d) Applying heat to the stump as the client desires

Elevating the stump for the first 24 hours Explanation: Stump elevation for the first 24 hours after surgery helps reduce edema and pain by increasing venous return and decreasing venous pooling at the distal portion of the extremity. Bed rest isn't indicated and could predispose the client to complications of immobility. Heat application would be inappropriate because it promotes vasodilation, which may cause hemorrhage and increase pain. The initial pressure dressing usually remains in place for 48 to 72 hours after surgery.

A client with a fracture develops compartment syndrome that requires surgical intervention. The nurse would most likely prepare the client for which of the following? a) Amputation b) Joint replacement c) Bone graft d) Fasciotomy

Fasciotomy Explanation: Surgical treatment of compartment syndrome is achieved with a fasciotomy, a surgical incision of the fascia and separation of the muscle to relieve pressure and restore tissue perfusion. Bone graft, joint replacement or amputation may be done for a client who experiences avascular necrosis.

The nurse assesses subtle personality changes, restlessness, irritability, and confusion in a patient who has sustained a fracture. The nurse suspects which complication? a) Fat embolism syndrome b) Hypovolemic shock c) Reflex sympathetic dystrophy syndrome d) Compartment syndrome

Fat embolism syndrome Explanation: Cerebral disturbances in the patient with fat embolism syndrome include subtle personality changes, restlessness, irritability, and confusion. With compartment syndrome, the patient complains of deep, throbbing, unrelenting pain. With hypovolemic shock, the patient would have a decreased blood pressure and increased pulse rate. Clinical manifestations of reflex sympathetic dystrophy syndrome include severe, burning pain, local edema, hyperesthesia, muscle spasms, and vasomotor skin changes.

When evaluating for hypovolemic shock, the nurse should be aware of which of the following clinical manifestations? a) Hypertension b) Bradycardia c) Bounding pulse d) Hypotension

Hypotension Explanation: The nurse should be alert to a weak pulse (thread), decreased blood pressure, decreased urine output, rapid, shallow respirations, and elevated heart rate.

The nurse should include which intervention in the postoperative care plan? a) Keeping a pillow between the client's legs at all times b) Turning the client from side to side every 2 hours c) Maintaining the client in semi-Fowler's position d) Performing passive range-of-motion (ROM) exercises on the client's legs once each shift

Keeping a pillow between the client's legs at all times Explanation: After hip pinning, the client must keep the affected leg abducted at all times; placing a pillow between the legs reminds the client not to cross the legs and to keep the leg abducted. Passive or active ROM exercises shouldn't be performed on the affected leg during the postoperative period because this could damage the operative site and cause hip dislocation. Most clients should be turned to the unaffected side, not from side to side. After hip pinning, the client must avoid acute flexion of the affected hip to prevent possible hip dislocation; therefore, semi-Fowler's position should be avoided.

Which of the following is an inaccurate clinical manifestation of a fracture? a) Lengthening b) Deformity c) Pain d) Crepitus

Lengthening Explanation: Clinical manifestations of a fracture include crepitus, deformity pain, shortening, and loss of function.

Which nursing intervention is appropriate for minimizing muscle spasms in the client with a hip fracture? a) Assist the client with use of a trapeze. b) Maintain the internal fixator. c) Apply a soft compression dressing. d) Maintain Buck's traction.

Maintain Buck's traction. Explanation: Buck's traction decreases pain, muscle spasm, and external rotation by immobilizing the hip fracture.

Which nursing intervention is essential in caring for a client with compartment syndrome? a) Wrapping the affected extremity with a compression dressing to help decrease the swelling b) Starting an I.V. line in the affected extremity in anticipation of venogram studies c) Keeping the affected extremity below the level of the heart d) Removing all external sources of pressure, such as clothing and jewelry

Removing all external sources of pressure, such as clothing and jewelry Explanation: Nursing measures should include removing all clothing, jewelry, and external forms of pressure (such as dressings or casts) to prevent constriction and additional tissue compromise. The extremity should be maintained at heart level (further elevation may increase circulatory compromise, whereas a dependent position may increase edema). A compression wrap, which increases tissue pressure, could further damage the affected extremity. There is no indication that diagnostic studies would require I.V. access in the affected extremity.

A client sustains an injury to the ligaments surrounding a joint. The nurse identifies this as which of the following? a) Fracture b) Strain c) Sprain d) Contusion

Sprain Explanation: A sprain is an injury to the ligaments surrounding a joint. A strain is an injury to a muscle when it is stretched or pulled beyond its capacity. A contusion is a soft tissue injury resulting from a blow or blunt trauma. A fracture is a break in the continuity of a bone.

Which of the following may occur if a client experiences compartment syndrome in an upper extremity? a) Subluxation b) Callus c) Volkmann's contracture d) Whiplash injury

Volkmann's contracture Explanation: If compartment syndrome occurs in an upper extremity, it may lead to Volkmann's contracture, a clawlike deformity of the hand resulting from obstructed arterial blood flow to the forearm and hand. A whiplash injury is a cervical spine sprain. Callus refers to the healing mass that occurs with true bone formation after a fracture. Subluxation refers to a partial dislocation.

The post-amputation client is seen by the home health nurse. One client outcome included preventing exposure to infection. Which finding would indicate to the nurse that this outcome was met? a) Decreased need for pain medication b) Absence of fever c) Decreased activity tolerance d) Increased participation in self- care

Absence of fever Explanation: Fever would be an indication of infection.

A 45-year-old softball player arrives at the emergency department following his injury while sliding into a base during a game. After his examination and radiographs, the physician diagnoses muscle strain and prescribes appropriate treatment. What does the physician mean with the term "strain"? a) Stretched or pulled beyond capacity b) Subluxation of a joint c) Injuries to ligaments surrounding a joint d) Injury resulting from a blow or blunt trauma

Stretched or pulled beyond capacity Explanation: A strain is an injury to a muscle when it is stretched or pulled beyond its capacity.

Choice Multiple question - Select all answer choices that apply. A bone graft may be used for which of the following reasons? Select all that apply. a) Improvement of motion b) Defect filling c) Stimulation of bone healing d) Joint stabilization e) Reduction of a fracture

• Joint stabilization • Defect filling • Stimulation of bone healing Explanation: A bone graft is used for joint stabilization, defect filling, or stimulation of bone healing. Tendon transfer is used for improving motion. Either closed or open reduction may be used to reduce a fracture.

Which assessment findings would cause the nurse to suspect compartment syndrome after casting of the leg? a) Warm, pink foot and ability to move toes of affected leg b) Low-grade fever, dyspnea, tachycardia, and crackles c) Increased capillary refill and bounding pulses in affected leg d) Complaints of numbness and tingling in toes of affected leg

Complaints of numbness and tingling in toes of affected leg Explanation: Numbness and tingling indicate nerve ischemia and edema, suggesting development of compartment syndrome.

A 39-year-old softball player has been brought to the ED by his teammates. The client was fielding a fly ball, fell, and injured his hip. He cannot place weight on the leg and is in significant pain. After radiographs indicate intact yet malpositioned bones, what repair would you expect the physician to perform? a) Analgesia and immobilization b) Joint manipulation and immobilization c) Heat and immobilization d) Ice and immobilization

Joint manipulation and immobilization Explanation: The physician manipulates the joint or reduces the displaced parts until they return to normal position, then immobilizes the joint with an elastic bandage, cast, or splint for several weeks.

A 17-year-old high school junior was involved in a motor-vehicle collision and brought to the ED via squad. His left arm was severely traumatized in the accident and he was taken immediately to surgery. He is admitted to the ICU where you practice nursing and the physician has ordered close monitoring for compartment syndrome. What musculoskeletal structure does compartment syndrome affect? a) Nerve b) All options are correct c) Bone d) Ligament

Nerve Correct Explanation: Compartment syndrome affects nerve innervation, leading to subsequent palsy (decreased sensation and movement).

A nurse suspects that a client with a recent fracture has compartment syndrome. Assessment findings may include: a) body-wide decrease in bone mass. b) inability to perform active movement and pain with passive movement. c) a growth in and around the bone tissue. d) inability to perform passive movement and pain with active movement.

inability to perform active movement and pain with passive movement. Explanation: With compartment syndrome, the client can't perform active movement, and pain occurs with passive movement. A body-wide decrease in bone mass is seen in osteoporosis. A growth in and around the bone tissue may indicate a bone tumor.

Which discharge instruction should a nurse give a client who's had surgery to repair a hip fracture? a) "Don't flex your hip more than 60 degrees, don't cross your legs, and have someone help you put your shoes on." b) "Don't flex your hip more than 120 degrees, don't cross your legs, and have someone help you put your shoes on." c) "Don't flex your hip more than 90 degrees, don't cross your legs, and have someone help you put your shoes on." d) "Don't flex your hip more than 30 degrees,

"Don't flex your hip more than 90 degrees, don't cross your legs, and have someone help you put your shoes on." Explanation: Falls in the home cause most injuries among the elderly. Elderly clients should take measures to decrease the clutter that can contribute to falls, such as removing objects such as throw rugs from the floor. Elderly clients should also install grab bars in the shower and next to the toilet. The threat of fire makes burglar bars on every window impractical.

Which of the following terms refers to a fracture in which one side of a bone is broken and the other side is bent? a) Avulsion b) Oblique c) Greenstick d) Spiral

Greenstick Explanation: A greenstick fracture is a fracture in which one side of a bone is broken and the other side is bent. A spiral fracture is a fracture twisting around the shaft of the bone. An avulsion is the pulling away of a fragment of bone by a ligament or tendon and its attachment. An oblique is a fracture occurring at an angle across the bone.

Elderly clients who fall are most at risk for which injuries? a) Cervical spine fractures b) Pelvic fractures c) Wrist fractures d) Humerus fractures

Pelvic fractures Explanation: Elderly clients who fall are most at risk for pelvic and lower extremity fractures. These injuries are devastating because they can seriously alter an elderly client's lifestyle and reduce functional independence. Wrist fractures usually occur with falls on an outstretched hand or from a direct blow. Such fractures are commonly found in young men. Humerus fractures and cervical spine fractures aren't age-specific.

Which of the following may occur if a client experiences compartment syndrome in an upper extremity? a) Volkmann's contracture b) Callus c) Subluxation d) Whiplash injury

Volkmann's contracture Explanation: If compartment syndrome occurs in an upper extremity, it may lead to Volkmann's contracture, a clawlike deformity of the hand resulting from obstructed arterial blood flow to the forearm and hand. A whiplash injury is a cervical spine sprain. Callus refers to the healing mass that occurs with true bone formation after a fracture. Subluxation refers to a partial dislocation.

Which of the following are general nursing measures for a patient with a fracture reduction? a) Promoting intake of omega-3 fatty acids b) Encourage participation in ADLs c) Examining the abdomen for enlarged liver or spleen d) Assisting with intake of immune-enhancing tube feeding formulas

Encourage participation in ADLs Explanation: General nursing measures for a patient with a fracture reduction include administering analgesics, providing comfort measures, encouraging participation with ADLs, promoting physical mobility, preventing infection, maintaining skin integrity, and preparing the patient for self-care. Omega-3 fatty acids have no implications on the diet of a patient with a fracture reduction. The nurse should not examine the abdomen for enlarged liver or spleen since fracture reduction treatment does not affect these organs. It is unlikely that a patient with a fracture reduction will be prescribed immune-enhancing tube feeding formulas.

A client undergoes hip-pinning surgery to treat an intertrochanteric fracture of the right hip. The nurse should include which intervention in the postoperative care plan? a) Keeping a pillow between the client's legs at all times b) Maintaining the client in semi-Fowler's position c) Turning the client from side to side every 2 hours d) Performing passive range-of-motion (ROM) exercises on the client's legs once each shift

Keeping a pillow between the client's legs at all times Explanation: After hip pinning, the client must keep the affected leg abducted at all times; placing a pillow between the legs reminds the client not to cross the legs and to keep the leg abducted. Passive or active ROM exercises shouldn't be performed on the affected leg during the postoperative period because this could damage the operative site and cause hip dislocation. Most clients should be turned to the unaffected side, not from side to side. After hip pinning, the client must avoid acute flexion of the affected hip to prevent possible hip dislocation; therefore, semi-Fowler's position should be avoided.