CHAPTER 51 Care of Patients with Musculoskeletal Trauma

NANDA-I nursing diagnoses: Fractures

1. Acute Pain related to one or more fractures, soft-tissue damage, muscle spasm, and edema (NANDA-I) 2. Potential for neurovascular compromise related to tissue edema and/or bleeding 3. Risk for Infection related to a wound caused by an open fracture (NANDA-I) 4. Impaired Physical Mobility related to need for bone healing and/or pain (NANDA-I)

Chart 51-4 Emergency Care of the Patient with an Extremity Fracture

1. Assess the patient's airway, breathing, and circulation, and perform a quick head-to-toe assessment. 2. Remove the patient's clothing (cut if necessary) to inspect the affected area while supporting the area above and below the injury. Do not remove shoes because this can cause increased trauma. 3. Remove jewelry on the affected extremity in case of swelling. 4. Apply direct pressure on the area if there is bleeding and pressure over the proximal artery nearest the fracture. 5. Keep the patient warm and in a supine position. 6. Check the neurovascular status of the area distal to the fracture, including temperature, color, sensation, movement, and capillary refill. Compare affected and unaffected limbs. 7. Immobilize the extremity by splinting; include joints above and below the fracture site. Recheck circulation after splinting. 8. Cover any open areas with a dressing (preferably sterile).

Splints and Orthopedic Boots/Shoes: Fractures-Managing Acute Pain

A commercial immobilizer may be used to keep the bone in place during healing. Because upper extremity bones do not bear weight, splints may be sufficient to keep bone fragments in place for a closed fracture. Thermoplastic, a durable, flexible material for splinting, allows custom fitting to the patient's body part. Splints for lower extremities are also custom-fitted using flexible materials and held in place with elastic bandages (e.g., ACE wrap). When possible, splints are preferred over casts to prevent complications. Splints also allow room for extremity swelling. Orthopedic shoes may be used to support the injured area during healing. For ankles or the lower part of the leg, padded orthopedic boots supported by multiple Velcro straps to hold the boot in place may be used. These devices are especially useful when the patient is allowed to bear weight.

Fractures

A fracture is a break or disruption in the continuity of a bone that often affects mobility and sensory perception.

Classification of Fractures

A fracture is classified by the extent of the break: • Complete fracture. The break is across the entire width of the bone in such a way that the bone is divided into two distinct sections. • Incomplete fracture. The fracture does not divide the bone into two portions because the break is through only part of the bone. A fracture is described by the extent of associated soft-tissue damage as open (or compound) or closed (or simple). The skin surface over the broken bone is disrupted in a compound fracture, which causes an external wound. A simple fracture does not extend through the skin and therefore has no visible wound. Fractures are described by their cause. A pathologic (spontaneous) fracture occurs after minimal trauma to a bone that has been weakened by disease. A fatigue (stress) fracture results from excessive strain and stress on the bone. This problem is commonly seen in recreational and professional athletes. Compression fractures are produced by a loading force applied to the long axis of cancellous bone. They commonly occur in the vertebrae of older patients with osteoporosis and are extremely painful.

Assessment: Carpal Tunnel Syndrome

A medical diagnosis is often made based on the patient's history and report of hand pain and numbness and without further assessment. Ask about the nature, intensity, and location of the pain. Patients often state that the pain is worse at night as a result of flexion or direct pressure during sleep. The pain may radiate to the arm, shoulder and neck, or chest. May also have paresthesia (painful tingling). Sensory changes usually occur weeks or months before motor manifestations. Several tests for abnormal sensory findings. Phalen's wrist test, sometimes called Phalen's maneuver, produces paresthesia in the median nerve distribution (palmar side of the thumb, index and middle fingers, and half of the ring finger) within 60 seconds due to increased internal carpal pressure. The patient is asked to relax the wrist into flexion or to place the back of the hands together and flex both wrists at the same time. The Phalen's test is positive in most patients with CTS. The same sensation can be created by tapping lightly over the area of the median nerve in the wrist (Tinel's sign). If the test is unsuccessful, a blood pressure cuff can be placed on the upper arm and inflated to the patient's systolic pressure (tourniquet). Causes pain and tingling. Motor changes in CTS begin with a weak pinch, clumsiness, and difficulty with fine movements. These changes progress to muscle weakness and wasting. Test for pinching ability and ask the patient to perform a fine-movement task, such as threading a needle. Strenuous hand activity worsens the pain and numbness. Observe the wrist for swelling. Gently palpate the area and note any unusual findings. Autonomic changes may be evidenced by skin discoloration, nail changes (e.g., brittleness), and increased or decreased hand sweating.

Sprains

A sprain is excessive stretching of a ligament. Twisting motions from a fall or sports activity typically cause the injury. Sprains are also classified according to severity. Pain and swelling result from ligament injuries. The treatment for mild (first-degree) sprains includes RICE (rest, ice, compression, elevation). Second-degree sprains require immobilization, such as elastic bandage and an air stirrup ankle brace or splint, and partial weight bearing while the tear heals. For severe ligament damage (third-degree sprain), immobilization for 4 to 6 weeks is necessary. Arthroscopic surgery may be done, particularly for chronic joint instability.

Strains

A strain is excessive stretching of a muscle or tendon when it is weak or unstable. Strains are sometimes referred to as muscle pulls. Falls, lifting a heavy item, and exercise often cause this injury. Strains are classified according to their severity: • A first-degree (mild) strain causes mild inflammation but little bleeding. Swelling, ecchymosis (bruising), and tenderness are usually present. • A second-degree (moderate) strain involves tearing of the muscle or tendon fibers without complete disruption. Muscle function may be impaired. • A third-degree (severe) strain involves a ruptured muscle or tendon with separation of muscle from muscle, tendon from muscle, or tendon from bone. Severe pain and disability result from severe strains. Management usually involves cold and heat applications, exercise, and activity limitations. May prescribe anti-inflammatory drugs to decrease inflammation and pain. Muscle relaxants may also. Third-degree strains, surgical repair of the ruptured muscle or tendon may be needed.

Knee Injuries 1

A tendon rupture in a knee is cared for in the same manner as a tendon rupture in the wrist. Chart 51-8 lists general emergency measures for sports-related injuries. All patients require frequent neurovascular monitoring. Trauma to the knee results in internal derangement, a broad term for disturbances of an injured knee joint. When surgery is required to resolve the problem, most surgeons prefer to perform the procedure through an arthroscope when possible. Patellofemoral pain syndrome (PFPS), or "runner's knee", is the most common diagnosis in patients who have knee pain. It occurs most often in people who are runners or who overuse their knee joints. Describe pain as being behind or around their patella (knee cap) in one or both knees. Swelling is not common although stiffness may be present, especially when the knee is flexed. Management usually involves rest, physical therapy, bracing or splinting, and mild analgesics. For patients who have pain lasting for more than 12 months, arthroscopic surgery. With a torn meniscus (medial or lateral) typically has pain, swelling, and tenderness in the knee. A clicking or snapping sound can often be heard when the knee is moved. For a locked knee resulting from the tear, the treatment may be manipulation followed by splinting or casting for 3 to 6 weeks. If the problem recurs, a partial or total meniscectomy is performed through an arthroscope. The surgeon threads a cutting device through the arthroscope for removal of the torn cartilage while the knee is irrigated. The surgeon may use a laser during the procedure, depending. Bulky pressure dressing is applied after the procedure, and the affected leg is wrapped in elastic bandages.

Tendinopathy

Achilles tendon-related injuries (tendinopathy). Rupture of the Achilles tendon is common in adults who participate in strenuous sports or in women who wear high heels. Can also occur after taking fluoroquinolone antibiotics, such as levofloxacin (Levaquin) and ciprofloxacin (Cipro). In the older adult, quadriceps tendon rupture may occur from a fall down several steps. Most cases of Achilles tendinopathy can be treated with RICE (see Chart 51-8): • Rest • Ice • Compression • Elevation The use of NSAIDs, and changes in activity and shoes may be helpful. Ultrasound treatments may also be effective. As a last resort, the tendon is surgically repaired and the leg is immobilized in a cast or brace for at least 6 to 8 weeks. If the tendon is beyond repair, a tendon transplant (also known as tendon reconstruction) may be performed. A tendon is removed from one part of the body and transplanted to the affected area, or a cadaver donor.

Community-Based Care: Amputation

After the sutures or staples are removed, the patient begins residual limb care. A home care nurse may be needed to teach the patient and/or family how to care for the limb and the prosthesis if it is available (Chart 51-7). The limb should be rewrapped 3 times a day with an elastic bandage applied in a figure-eight manner (see Fig. 51-13). For many patients, a shrinker stocking or sock is easier to apply. After the limb is healed, it is cleaned each day with the rest of the body during bathing with soap and water. Teach the patient and/or family to inspect it every day for signs of inflammation or skin breakdown.

Health Promotion and Maintenance: Fractures

Airbags and seat belts have decreased the number of severe injuries and deaths, but they have increased the number of leg and ankle fractures, especially in older adults. Health teaching should also focus on other risks for musculoskeletal injury, including: • Osteoporosis screening and self-management education • Fall prevention • Home safety assessment and modification, if needed • Dangers of drinking and driving • Drug safety (prescribed, over-the-counter, and illicit) • Older adults and driving • Helmet use when riding bicycles, motorcycles, all-terrain vehicles (ATVs), and skateboards

Types of Amputation

Amputations may be elective or traumatic. Most are elective and are related to complications of peripheral vascular disease and arteriosclerosis. Diabetes mellitus is often an underlying cause. Amputation is considered only after other interventions have not restored circulation. Sometimes referred to as limb salvage procedures (e.g., percutaneous transluminal angioplasty [PTA]). Traumatic amputations most often result from accidents or war and are the primary cause of upper extremity amputation.

Amputations

An amputation is the removal of a part of the body. The loss is complete and permanent and causes a change in body image and self-esteem.

Compression Fractures of the Spine

Are associated with osteoporosis, metastatic bone cancer, and multiple myeloma. Compression fractures result when trabecular or cancellous bone within the vertebra becomes weakened and causes the vertebral body to collapse. The patient has severe pain, deformity (kyphosis), and occasional neurologic compromise. Nonsurgical management includes bedrest, analgesics, nerve blocks, and physical therapy to maintain muscle strength. Vertebral compression fractures (VCFs) that remain painful and impair mobility may be surgically treated with vertebroplasty or kyphoplasty. These procedures are minimally invasive techniques in which bone cement is injected through the skin (percutaneously) directly into the fracture site to provide stability and immediate pain relief. Kyphoplasty includes the additional step of inserting a small balloon into the fracture site and inflating it to contain the cement and to restore height to the vertebra. They can be done with moderate sedation or general anesthesia. IV ketorolac (Toradol) may be given before the procedure to reduce inflammation. Large-bore needles are placed into the fracture site using fluoroscopy or CT guidance. Then the deflated balloon is inserted through the needles and inflated in the fracture site, and the cement is injected. Teach the patient to report any signs or symptoms of infection from puncture sites. Remind him or her to not soak in a bath for 1 week, use analgesics as needed, resume activity.

Physical Assessment/Clinical Manifestations: Fractures

Assess all major body systems first for life-threatening complications, including head, chest, and abdominal trauma. Some fractures can cause internal organ damage resulting in hemorrhage. When a pelvic fracture is suspected, assess vital signs, skin color, and level of consciousness for indications of possible hypovolemic shock. Check the urine for blood. If the patient cannot void, suspect that the bladder or urethra has been damaged. Moderate to often severe pain!! Vertebral compression factures are also extremely painful. Patients with a fractured hip may have groin pain or pain referred to the back of the knee or lower back. Pain is usually due to muscle spasm and edema. Fractures of the shoulder and upper arm, the physical assessment is best done with the patient in a sitting or standing position, if possible, so that shoulder drooping or other abnormal positioning can be seen. Support the affected arm and flex the elbow to promote comfort during the assessment. For more distal areas of the arm, perform the assessment with the patient in a supine position so that the extremity can be elevated to reduce swelling. Place the patient in a supine position for assessment of the legs and pelvis. A patient with an impacted hip fracture may be able to walk for a short time after injury. Look for a change in bone alignment. The bone may appear deformed, a limb may be internally or externally rotated, and/or one or more bones may also be dislocated. Observe for extremity shortening or a change in bone shape. If the skin is intact (closed fracture), the area over the fracture may be ecchymotic (bruised) from bleeding into the underlying soft tissues. Subcutaneous emphysema, the appearance of bubbles under the skin because of air trapping, may be present

Chronic Complications

Avascular necrosis and delayed bone healing are later complications. Blood supply to the bone is disrupted causing decreased perfusion and death of bone tissue. This problem is most often a complication of hip fractures or any fracture in which there is displacement of bone. Surgical repair of fractures also can cause necrosis because the hardware can interfere with circulation. Patients on long-term corticosteroid therapy, such as prednisone, are also at high risk for ischemic necrosis. Delayed union is a fracture that has not healed within 6 months of injury. Some fractures never achieve union; that is, they never completely heal (nonunion). Others heal incorrectly (malunion). Common in tibial fractures. If bone does not heal, he or she typically has chronic pain and immobility from deformity.

Action Alert

Be sure that the patient's heels are up off the bed at all times. Inspect the heels and other high-risk bony prominence areas every 8 to 12 hours. Delegate turning and repositioning every 1 to 2 hours to unlicensed assistive personnel (UAP), and supervise this nursing activity.

Considerations for Older Adults: Bone Healing

Bone healing is often affected by the aging process. Bone formation and strength rely on adequate nutrition. Calcium, phosphorus, vitamin D, and protein are necessary for the production of new bone (see Chapter 50). For women, the loss of estrogen after menopause decreases the body's ability to form new bone tissue. Chronic diseases can also affect the rate at which bone heals. For instance, peripheral vascular diseases, such as arteriosclerosis, reduce arterial circulation to bone. Thus the bone receives less oxygen and fewer nutrients, both of which are needed for repair.

Hypovolemic Shock

Bone is very vascular. Therefore bleeding is a risk with bone injury. In addition, trauma can cut nearby arteries and cause hemorrhage, resulting in rapidly developing hypovolemic shock.

Health Promotion and Maintenance: Carpal Tunnel Syndrome

Both men and women in the labor force are experiencing increasing numbers of RSIs. Occupational health nurses have played an important role in ergonomic assessments and in the development of ergonomically designed furniture and various aids to decrease CTS and other musculoskeletal injuries. U.S federal and state legislation has been passed to ensure that all businesses, including health care organizations (HCOs), provide ergonomically appropriate workstations for their employees(OSHA).

Carpal Tunnel Syndrome(chronic, acute is rare)

Carpal tunnel syndrome (CTS) is a common condition in which the median nerve in the wrist becomes compressed, causing pain and numbness. The carpal tunnel is a rigid canal that lies between the carpal bones and a fibrous tissue sheet. A group of tendons surround the synovium and share space with the median nerve in the carpal tunnel. When the synovium becomes swollen or thickened, this nerve is compressed. Affects the first three fingers of the hand and the palmar aspect of the fourth (ring) finger. Wrist flexion causes nerve impingement and extension causes increased pressure in the lower portion of the carpal tunnel. Excessive hand exercise, edema or hemorrhage into the carpal tunnel, or thrombosis of the median artery can lead to acute CTS. Patients with hand burns or a Colles' fracture of the wrist are particularly at risk for this problem. Synovitis (inflammation of the synovium) occurs in patients with rheumatoid arthritis (RA). The hypertrophied synovium compresses the median nerve. In other chronic disorders such as diabetes mellitus, inadequate blood supply can cause median nerve neuropathy or dysfunction. Most common type of repetitive stress injury (RSI). People whose jobs require repetitive hand activities such as pinching or grasping during wrist flexion (e.g., factory workers, computer operators, jackhammer operators) are predisposed to CTS. It can also result from overuse in sports activities such as golf, tennis, or racquetball. CTS may be a familial or congenital problem that manifests in adulthood. Space-occupying growths such as ganglia, tophi, and lipomas can also result. Women, especially those older than 50 years, are much more at risk. CTS is beginning to be found in children and adolescents as a result of the increased use of computers and handheld devices.

Knee Injuries 2

Check the surgical dressing for bleeding and monitor vital signs after the patient is admitted to the same-day surgical unit. Perform neurovascular checks qh. The patient begins exercises immediately after surgery to strengthen the leg, prevent venous thromboembolism, and reduce swelling. Quadriceps setting, in which the patient straightens the leg while pushing the knee against the bed, is done in sets of 10 or more. Straight-leg raises are also performed. ROM exercises are usually not started for several days. Provider often requests a knee immobilizer. Elevate the leg on one or two pillows according to the physician, and apply ice to reduce postoperative swelling. Full weight bearing is restricted for several weeks. The patient is usually discharged from the hospital with crutches in less than a day. Cruciate and collateral ligaments in the knee are predisposed to injury. Most common ligament injury is an anterior cruciate ligament (ACL) tear. Women have ACL tears more often. Proper athletic shoes and learning how to land when jumping can help prevent. When the ACL is torn, the patient feels a snap and the knee gives way because of ACL laxity. Within hours, the knee is swollen, stiff, and painful. Examination by the health care provider shows positive ligament laxity. The diagnosis of an ACL tear is best confirmed by MRI. Exercises, bracing, and limits on activities while the ligament heals may be sufficient. If medical management is not effective or the tear is severe, surgery. Surgeon repairs the tear by reattaching the torn portions of the ligament through arthroscopy. The leg is placed in a brace or immobilizer. If the ligament cannot be repaired, reconstructive surgery may be performed with autologous grafts. A ligament from another part of the body is used to replace the torn knee ligament. Another option is artificial knee implants such as the GORE-TEX ligament. Complete healing of knee ligaments after surgery can take 6 to 9 months or longer. These patients may use a continuous passive motion (CPM) machine.

Action Alert

Check to ensure that any type of cast is not too tight, and frequently monitor neurovascular status—usually every hour for the first 24 hours after application if the patient is hospitalized. You should be able to insert a finger between the cast and the skin. Teach the patient to apply ice for the first 24 to 36 hours to reduce swelling and inflammation.

Closed Reduction and Immobilization: Fractures-Managing Acute Pain

Closed reduction is the most common nonsurgical method for managing a simple fracture. While applying a manual pull, or traction, on the bone, the health care provider moves the bone ends so that they realign. Moderate sedation and/or analgesia is used. Monitor the patient's oxygen saturation (and possibly end-tidal carbon dioxide [EtCO2] level) to ensure adequate rate and depth of respirations during the procedure. An x-ray confirms that the bone ends are approximated (aligned) before the bone is immobilized, and a splint is usually applied.

Action Alert

Collaborate with the prosthetist to teach the patient about prosthesis care after amputation to ensure its reliability and proper function. These devices are custom made, taking into account the patient's level of amputation, lifestyle, and occupation. Proper teaching regarding correct cleansing of the socket and inserts, wearing the correct liners, assessing shoe wear, and a schedule of follow-up care is essential before discharge. This information may need to be reviewed by the home care nurse.

Acute Compartment Syndrome

Compartments are areas in the body in which muscles, blood vessels, and nerves are contained within fascia. Fascia is an inelastic tissue that surrounds groups of muscles, blood vessels, and nerves in the body. Acute compartment syndrome (ACS) is a serious condition in which increased pressure within one or more compartments reduces circulation to the area. Common compartment sites: the lower leg (tibial fractures) and forearm. Changes of increased compartment pressure are sometimes referred to as the ischemia-edema cycle. Capillaries within the muscle dilate, which raises capillary (arterial) pressure and venous pressure (Hershey, 2013). Capillaries become more permeable because of the release of histamine by the ischemic muscle tissue, and venous drainage decreases. As a result, plasma proteins leak into the interstitial fluid space and edema occurs. Edema increases pressure on nerve endings and causes pain. Perfusion to the area is reduced, and further ischemia results. Sensory perception deficits or paresthesia generally appears before changes in vascular or motor signs. The color of the tissue pales, and pulses begin to weaken but rarely disappear. The affected area is usually palpably tense, and pain occurs with passive motion. Not treated, cyanosis, tingling, numbness, paresis, necrosis, and severe pain can occur. Fracture is present in 75% of all cases of ACS. Tight, bulky dressings and casts are examples of external pressure. Blood or fluid accumulation in the compartment is a common source of internal pressure. The injury or trauma causing the problem is above the compartment involved, which decreases blood flow to the more distal area of injury. Can also occur in those with severe burns, extensive insect bites or snakebites, or massive infiltration of IV fluids. Resulting from compartment syndrome include infection, persistent motor weakness in the affected extremity, contracture, and myoglobinuric renal failure. In extreme cases, amputation. Infection from necrosis may become severe enough that amputation of the limb is needed. Motor weakness from injured nerves is not reversible, and the patient may require an orthotic device for assistance in mobility. Volkmann's contractures of the forearm, which can begin within 12 hours of the pressure increase, result from shortening of the ischemic muscle and from nerve involvement.

Complex Regional Pain Syndrome

Complex regional pain syndrome (CRPS), formerly called reflex sympathetic dystrophy (RSD), is a poorly understood dysfunction of the central and peripheral nervous systems that leads to severe, chronic pain. CRPS most often results from fractures or other traumatic musculoskeletal injury and commonly occurs in the feet and hands. In some cases, specific nerve injuries are present, but in others, no injury. Abnormalities of the autonomic nervous system (changes in color, temperature, and sensitivity of skin over the affected area, excessive sweating, edema), motor symptoms (paresis, muscle spasms, loss of function), and sensory perception symptoms (intense burning pain that becomes intractable [unrelenting]). Over time, spotty and diffuse osteoporosis can be seen on x-ray examination. Timing of diagnosis is important because the syndrome is more difficult to treat when diagnosed in the later stages.

Promoting Mobility: Fractures-Improving Physical Mobility

Crutches are the most commonly used ambulatory aid for many types of lower extremity musculoskeletal trauma. Crutches are not often used for older adults. Walkers and canes are preferred for the older adult. Crutches can cause upper extremity bursitis or axillary nerve damage if they are not fitted. There should be two to three finger-breadths between the axilla and the top of the crutch when the crutch tip is at least 6 inches (15 cm) diagonally in front of the foot. The crutch is adjusted so that the elbow is flexed no more than 30 degrees when the palm is on the handle. A walker is most often used by the older patient who needs additional support for balance. A cane is sometimes used if the patient needs only minimal support for an affected leg. The straight cane offers the least support. A hemi-cane or quad-cane provides a broader base for the cane and therefore more support. The cane is placed on the unaffected side and should create no more than 30 degrees of flexion of the elbow. The top of the cane should be parallel to the greater trochanter of the femur or stylus of the wrist.

Joint Dislocation

Dislocation of a joint occurs when the ends of two or more bones are moved away from each other. If the dislocation is not complete, the joint is partially dislocated, or subluxed. It can occur in any diarthrodial (synovial) joint but is most common in the shoulder, hip, knee, and fingers. The typical manifestations of dislocation are: • Pain • Decreased mobility • Alteration in contour of the joint • Deviation in length of the extremity • Rotation of the extremity The health care provider performs a closed reduction of the joint and moves the joint surfaces back into their normal anatomic position. The patient requires light anesthetic or moderate sedation. The joint is immobilized by a cast, splint, brace, or immobilizer until healing occurs. Recurrent dislocations are common in the knee and shoulder. For this problem, the joint may be fixed with wires or other device to prevent further displacement. A cast, splint, or traction is applied for 3 to 6 weeks.

Levels of Amputation(Fig. 51-12)

Elective lower extremity (LE) amputations are performed much more frequently than upper extremity amputations. The loss of any or all of the small toes presents a minor disability. Loss of the great toe is significant because it affects balance, gait, and "push off" ability during walking. Midfoot amputations and the Syme amputation are common procedures for peripheral vascular disease. In the Syme amputation, most of the foot is removed but the ankle remains. The advantage of this surgery over traditional amputations below the knee is that weight bearing can occur without the use of a prosthesis and with reduced pain. An intense effort is made to preserve knee joints with below-the-knee amputation (BKA). When the cause for the amputation extends beyond the knee, above-knee or higher amputations are performed. Hip disarticulation, or removal of the hip joint, and hemipelvectomy (removal of half of the pelvis with the leg) are more common in younger patients than in older ones who cannot easily handle the cumbersome prostheses required for ambulation. The higher the level of amputation, the more energy is required for mobility. These higher-level procedures are typically done for cancer of the bone, osteomyelitis, or trauma as a last resort. An amputation of any part of the upper extremity is generally more incapacitating than one of the leg. Early replacement with a prosthetic device is vital for the patient with this type of amputation.

Procedures for Nonunion: Fractures-Managing Acute Pain

Electrical bone stimulation may be successful. This procedure is based on research showing that bone has electrical properties that are used in healing. A noninvasive, external electrical bone stimulation system delivers a small continuous electrical charge directed toward the non-healed bone. There are no known risks with this system, although patients with pacemakers cannot use this device on an arm. Implanted direct-current stimulators are placed directly in the fracture site and have no external apparatus. A bone graft may also replace diseased bone or increase bone tissue for joint replacement. In most cases, chips of bone are taken from the iliac crest or other site and are packed or wired between the bone ends to facilitate union. Allografts from cadavers may also be used. Bone banking from living donors is becoming increasingly popular. If qualified, patients undergoing total hip replacement may donate their femoral heads to the bank for later use as bone grafts for others. One of the newest modalities for fracture healing is low-intensity pulsed ultrasound (Exogen therapy). Used for slow-healing fractures or for new fractures as an alternative to surgery, ultrasound treatment has had excellent results. The patient applies the treatment for about 20 minutes each day. It has no contraindications or adverse effects.

Self-Management Education: Fractures

Encourage patients and their families to ensure adequate foods high in protein and calcium that are needed for bone and tissue healing. For patients with lower extremity fractures, less weight bearing on long bones can cause anemia. The red bone marrow needs weight bearing to simulate red blood cell production. Encourage foods high in iron content. Teach the patient to take a daily iron-added multivitamin (take with food to prevent possible nausea).

Fat Embolism Syndrome

Fat embolism syndrome (FES) is another serious complication in which fat globules are released from the yellow bone marrow into the bloodstream within 12 to 48 hours after an injury or other illness. Globules clog small blood vessels that supply vital organs, most commonly the lungs, and impair organ perfusion. The embolized fat degrades into free fatty acids and C-reactive protein, which results in capillary leakage, lipid and platelet aggregation, and clot formation. Patients with fractured hips have the highest risk, but FES is also common in those with fractures of the pelvis within 24 to 72 hours after injury or surgery. The earliest manifestations of FES are a low arterial oxygen level (hypoxemia), dyspnea, and tachypnea (increased respirations). Headache, lethargy, agitation, confusion, decreased level of consciousness, seizures, and vision changes may follow. Nonpalpable, red-brown petechiae—a macular, measles-like rash—may appear over the neck, upper arms, and/or chest. This rash is a classic manifestation but is usually the last sign to develop. Abnormal laboratory findings include: • Decreased Pao2 level (often below 60 mm Hg) • Increased erythrocyte sedimentation rate (ESR) • Decreased serum calcium levels • Decreased red blood cell and platelet counts • Increased serum level of lipids The chest x-ray often shows bilateral infiltrates but may be normal. The chest CT often reveals a patchy distribution of opacities. An MRI of the brain can show evidence of neurologic deficits from hypoxemia. FES can result in respiratory failure or death, often from pulmonary edema.

Emergency Care: Fractures-Managing Acute Pain

First call 911 and assess for airway, breathing, and circulation (ABCs, or primary survey). Provide lifesaving care if needed before being concerned about the fracture. If cardiopulmonary resuscitation (CPR) is needed, ensure circulation first, followed by airway and breathing. Cut away clothing from the fracture site, and remove any jewelry. Control any bleeding by direct pressure on the area and digital pressure over the artery above the fracture. To prevent shock, place the patient in a supine position and keep him or her warm. After a head-to-toe assessment (secondary survey) and patient stabilization, pain is managed with IV opioids such as fentanyl, hydromorphone (Dilaudid), or morphine. Cardiac monitoring for patients who are older than 50 years is established before drugs. The prehospital or emergency team immobilizes the fracture by splinting. An air splint or any object or device that extends to the joints above and below the fracture to immobilize it can be used as a splint. Sterile gauze is placed loosely over open areas to prevent further contamination of the wound. Bone reduction, or realignment of the bone ends for proper healing, is accomplished by a closed method or an open (surgical) procedure. In some cases, dislocated bones are also reduced, such as when the distal tibia and fibula are dislocated. Immobilization is achieved by the use of bandages, casts, traction, internal fixation, or external fixation.

Emergency Care-Traumatic Amputation: Amputation

First call 911. Assess the patient for airway or breathing problems. Examine the amputation site, and apply direct pressure with layers of dry gauze or other cloth, using clean gloves if available. Many nurses carry gloves and first aid kits. Elevate the extremity above the patient's heart to decrease the bleeding. Do not remove the dressing to prevent dislodging the clot. The fingers are the most likely part to be amputated and replanted. The current recommendation for prehospital care is to wrap the completely severed finger in dry sterile gauze (if available) or a clean cloth. Put the finger in a watertight, sealed plastic bag. Place the bag in ice water, never directly on ice, at 1 part ice and 3 parts water. Avoid contact between the finger and the water to prevent tissue damage. Do not remove any semidetached parts of the digit.

Promoting Mobility and Preparing for Prosthesis: Amputation 1

For patients with AKAs or BKAs, teach range-of-motion (ROM) exercises for prevention of flexion contractures, particularly of the hip and knee. A trapeze and an overhead frame aid in strengthening the arms and allow the patient to move independently in bed. Teach the patient how to perform range-of-motion exercises. Be sure to turn the patient every 2 hours, or teach the patient to turn independently. Move the patient slowly to prevent muscle spasms A firm mattress is essential for preventing contractures with a leg amputation. Assist the patient into a prone position every 3 to 4 hours for 20- to 30-minute periods if tolerated and not contraindicated. This position helps prevent hip flexion contractures. Instruct the patient to pull the residual limb close to the other leg and contract the gluteal muscles of the buttocks for muscle strengthening. After staples are removed, the physical therapist may begin resistive exercises. Teach the patient how to push the residual limb down toward the bed while supporting it on a soft pillow at first. Then instruct him or her to continue this activity using a firmer pillow and then progress to a harder surface. This activity helps prepare the residual limb for prosthesis and reduces the incidence of phantom limb pain and sensation. Inspect the residual limb daily to ensure that it lies completely flat on the bed. The patient often sees a certified prosthetist-orthotist (CPO) so that planning can begin for the postoperative period. Arrangements for replacing an arm part are especially important so that the patient can achieve self-management. The patient being fitted for a leg prosthesis should bring a sturdy pair of shoes to the fitting. The prosthesis will be adjusted to that heel height.

Stages of Bone Healing

Fractures heal in five stages that are a continuous process and not single stages. • In stage one, within 24 to 72 hours after the injury, a hematoma forms at the site of the fracture because bone is extremely vascular. • Stage two occurs in 3 days to 2 weeks when granulation tissue begins to invade the hematoma. This then prompts the formation of fibrocartilage, providing the foundation for bone healing. • Stage three of bone healing occurs as a result of vascular and cellular proliferation. The fracture site is surrounded by new vascular tissue known as a callus (within 3 to 6 weeks). Callus formation is the beginning of a nonbony union. • As healing continues in stage four, the callus is gradually resorbed and transformed into bone. This stage usually takes 3 to 8 weeks. • During the fifth and final stage of healing, consolidation and remodeling of bone continue to meet mechanical demands. This process may start as early as 4 to 6 weeks after fracture and can continue for up to 1 year, depending on the severity of the injury and the age and health of the patient. Young, healthy adult bone, healing takes about 4 to 6 wks. Complete healing often takes 3 months or longer in people who are older than 70 years. Other factors also affect healing. Examples include the severity of the trauma, the type of bone injured, how the fracture is managed, infections at the fracture site, and ischemic or avascular necrosis (AVN), also called osteonecrosis.

Other Fractures of the Lower Extremity

Fractures of the lower two thirds of the femur usually result from trauma, often from a motor vehicle crash. A femur fracture is seldom immobilized by casting because the powerful muscles of the thigh become spastic, which causes displacement of bone ends. Extensive hemorrhage can occur with femur fracture. Treatment is ORIF with nails, rods, or a compression screw. In a few cases in which extensive bone fragmentation or severe tissue trauma is found, external fixation may be employed. Healing time for a femur fracture may be 6 months or longer. 1069Skeletal traction, followed by a full-leg brace or cast, may be used in nonsurgical treatment. Trauma to the lower leg most often causes fractures of both the tibia and the fibula, particularly the lower third, and is often referred to as a "tib-fib" fracture. The major treatment techniques are closed reduction with casting, internal fixation, and external fixation. If closed reduction is used, the patient may wear a cast for 6 to 10 wks. Delayed union is not unusual with this type of fracture. Internal fixation with nails or a plate and screws, followed by a long-leg cast for 4 to 6 weeks, is another option. When the fractures cause extensive skin and soft-tissue damage, the initial treatment may be external fixation, often for 6 to 10 weeks, usually followed by application of a cast. Ankle fractures are described by their anatomic place of injury. For example, a bimalleolar (Pott's) fracture involves the medial malleolus of the tibia and the lateral malleolus of the fibula. The small talus that makes up the rest of the ankle joint may also be broken. An ORIF is usually performed using two incisions—one on the medial (inside) aspect of the ankle and one on the lateral (outer) side. Several screws or nails are placed into the tibia, and a compression plate with multiple screws keeps the fibula in alignment. Weight bearing is restricted until the bone heals. Treatment of fractures of the foot or phalanges (toes) is similar to that of other fractures. Phalangeal fractures may be more painful but are not as serious as most other types of fractures. Crutches are used for ambulation if weight bearing is restricted, but many patients can ambulate while wearing an orthopedic shoe or boot.

Upper Extremity Fractures 1

Fractures of the proximal humerus, particularly impacted or displaced fractures, are common in the older adult. An impacted injury is usually treated with a sling or other device for immobilization. A displaced fracture often requires ORIF with pins or a prosthesis. Humeral shaft fractures are generally corrected by closed reduction and a hanging-arm cast or splint. If necessary, the fracture is repaired surgically (with an intramedullary rod or metal plate and screws) or with external fixation. The distal radius fracture (DRF), which occurs in both younger and older adults. Younger adults experience this injury from high-energy (high-impact) trauma as a result of motor vehicle crashes and sports. Older adults, particularly women with osteopenia, typically have low-impact DRFs as a result of falls. Names are used to classify DRFs, including Colles' and Smith fractures. A Colles' fracture can occur when a person attempts to break a fall by landing on the heel of the hand when the wrist is extended. The resulting deformity is often called a "dinner fork" injury (Fig. 51-8). Seen less commonly, a Smith fracture occurs from a fall on a flexed wrist.

Fractures of the Chest and Pelvis

Fractures of the ribs or sternum. The major concern with rib and sternal fractures is the potential for puncture of the lungs, heart, or arteries by bone fragments or ends. Assess airway, breathing, and circulation status first for any patient having chest trauma! Fractures of the lower ribs may damage underlying organs, such as the liver, spleen, or kidneys. These fractures tend to heal on their own without surgical intervention. Requires analgesia. Also have a high risk for pneumonia because of shallow breathing caused by pain on inspiration. Encourage them to breathe normally if possible. Because the pelvis is very vascular and is close to major organs and blood vessels, associated internal damage is the major focus in fracture management. After head injuries, pelvic fractures are the second most common cause of death from trauma. Falls are the most common cause in older adults. The major concern related to pelvic injury is venous oozing or arterial bleeding. Loss of blood volume leads to hypovolemic shock. Assess for internal abdominal trauma by checking for blood in the urine and stool and by monitoring the abdomen for the development of rigidity or swelling. The trauma team may use peritoneal lavage, CT scanning, or ultrasound for assessment of hemorrhage. Ultrasound used also. When a non-weight-bearing part of the pelvis is fractured, such as one of the pubic rami or the iliac crest, treatment can be as minimal as bedrest on a firm mattress or bed board. This type of fracture can be quite painful, and the patient may need stool softeners to facilitate bowel movements because of hesitancy to move. Well-stabilized fractures usually heal in 2 months. A weight-bearing fracture, such as multiple fractures of the pelvic ring creating instability or a fractured acetabulum, necessitates external fixation or ORIF or both. Progression to weight bearing depends on the stability of the fracture after fixation. Some patients can fully bear weight within days of surgery, whereas others managed with traction may not be able to bear weight for as long as 12 weeks. For complex pelvic fractures with extensive soft-tissue damage, external fixation may be required.

Laboratory Assessment: Fractures

Hemoglobin and hematocrit levels may often be low because of bleeding caused by the injury. If extensive soft-tissue damage is present, the erythrocyte sedimentation rate (ESR) may be elevated, which indicates the expected inflammatory response. If this value and the white blood cell (WBC) count increase during fracture healing, the patient may have a bone infection. During the healing stages, serum calcium and phosphorus levels are often increased as the bone releases these elements into the blood.

Fractures of the Hip 1

Hip fracture is the most common injury in older adults and one of the most frequently seen injuries. Over half of older adults experiencing a hip fracture are unable to live independently, and many die within the first year. Hip fractures include those involving the upper third of the femur and are classified as intracapsular (within the joint capsule) or extracapsular (outside the joint capsule). The area of the femoral neck, disruption of the blood supply to the head of the femur is a concern, which can result in ischemic or avascular necrosis (AVN) of the femoral head. AVN causes death and necrosis of bone tissue and results in pain and decreased mobility. This problem is most likely in patients with displaced fractures. Osteoporosis is the biggest risk factor for hip fractures.

Postoperative Care: Fractures-Managing Acute Pain

IV ketorolac (Toradol) is often given in the postanesthesia care unit (PACU) or soon after discharge to the post-surgical area to reduce inflammation and pain. Aggressive pain management starts as soon as possible. For patients with an external fixator, pay particular attention to the pin sites for signs of inflammation or infection. In the first 48 to 72 hours, clear fluid drainage or weeping is expected. Monitor the pin sites at least every 8 to 12 hours for drainage, color, odor, and severe redness, which indicate inflammation and possible infection. The Ilizarov technique of circular external fixation is sometimes used to treat new fractures (closed, comminuted fractures and open fractures with bone loss), as well as malunion or nonunion of fractures. It may also be used to treat congenital bone deformities, especially in "little people". The circular external fixation device is used to gently pull apart the cortex of the bone and stimulate new bone growth. Unlike the traditional fixator, the Ilizarov external fixator promotes rotation, angulation, lengthening, or widening of bone to correct bony defects and allows for healing of any soft-tissue defect. If the device is being used for filling bone gaps, teach the patient how to manually turn the four-sided nuts (also called clickers) up to 4 times a day. Daily distraction rates vary, but 1 mm daily is common.

Action Alert

If the patient reports PLP, recognize that the pain is real and should be managed promptly and completely! It is not therapeutic to remind the patient that the limb cannot be hurting because it is missing. To prevent increased pain, handle the residual limb carefully when assessing the site or changing the dressing.

History: Fractures

In severe pain, delay the interview until he or she is more comfortable. Then ask about the cause of the fracture. Incisional injuries, as from a knife wound, and crush injuries cause hemorrhage and decrease blood flow to major organs. Acceleration or deceleration injuries cause direct trauma to the spleen, brain, and kidneys when these organs are moved from their fixed locations in the body. Shearing and friction damage the skin and cause a high level of wound contamination. A forward fall often results in Colles' fracture of the wrist because the person tries to catch himself or herself with an outstretched hand. Knowing the mechanism of injury also helps determine whether other types of injury are. A drug history, including substance use, is important regardless of the patient's age. DUI/DWI A medical history may identify possible causes of the fracture. Ask about the patient's occupation and recreational activities.

Upper Extremity Fractures 2

Initial nursing interventions for a patient with a DRF include: • Removing jewelry on the affected hand and wrist before edema worsens • Performing a neurovascular assessment of the affected UE • Immobilizing the affected wrist and hand • Elevating the affected UE • Applying ice to the affected area • Managing pain The most common treatment for a DRF is closed reduction. The health care provider realigns the bone ends while the patient is moderately sedated. A splint is applied and held in place with an elastic bandage. The splint may be replaced several days later with a cast after edema decreases. Complicated DRFs, an ORIF with pins and plates may be performed. The patient may have surgery in an ambulatory care or same-day surgical setting using general anesthesia, a peripheral nerve block, or a combination. Block is often given as a single injection of levobupivacaine (Chirocaine) or bupivacaine (Marcaine), which provides pain relief for 12 to 20 hrs. Teach patients having a peripheral nerve block (e.g., supraclavicular block) that temporarily they will not be able to move their affected arm. Also observe, report, and document signs and symptoms of pneumothorax, including tachypnea, decreased breath sounds, or respiratory distress. Assess for nerve compression, especially the radial and median nerves. Be sure to perform frequent neurovascular assessment with special attention to the presence of decreased sensory perception (e.g., numbness) or decreased movement. Fractures of the metacarpals and phalanges (fingers) are usually not displaced, which makes their treatment less difficult. etacarpal fractures are immobilized for 3 to 4 weeks. Phalangeal fractures are immobilized in finger splints for 10 to 14 days.

Health Promotion and Maintenance: Amputation

Lifestyle habits like maintaining a healthy weight, regular exercise, and avoiding smoking can help prevent chronic diseases like diabetes and poor blood circulation. Tight blood glucose control. Teach young male adults the importance of taking safety precautions to prevent injury at work and to avoid speeding or driving while drinking alcohol. An increasing number of young women also tend to speed and drive while drinking, which endangers themselves and others around them.

Critical Rescue

Monitor for early signs of ACS. Assess for the "six Ps" including pain, pressure, paralysis, paresthesia, pallor, and pulselessness (rare). Pain is increased even with passive motion and may seem out of proportion to the degree of injury. Analgesics that had controlled pain become less effective. Numbness and tingling or paresthesias are often one of the first signs of the problem. The affected extremity then becomes pale and cool as a result of decreased arterial perfusion to the affected area. Capillary refill is an important assessment of perfusion but may not be reliable in an older adult because of arterial insufficiency. Losses of movement and function and decreased pulses or pulselessness are late signs of ACS! Fortunately, ACS is not common, but it creates an emergency situation when it does occur.

Physical Assessment/Clinical Manifestations: Amputation

Monitor neurovascular status in the affected extremity that will be amputated. When the patient has peripheral vascular disease, check circulation in both legs. Assess skin color, temperature, sensation, and pulses in both affected and unaffected extremities. Capillary refill can be difficult to determine in the older adult related to nail condition. In this situation, the skin near the nail bed can be used. Capillary refill may not be as reliable. Observe for discoloration of the skin, edema, ulcerations, presence of necrosis, and hair distribution on the lower extremities.

Nonsurgical Management: Carpal Tunnel Syndrome

NSAIDs are the most commonly prescribed drugs for the relief of pain and inflammation. Physician may inject corticosteroids directly into the carpal tunnel. If the patient responds to the injection, several additional weekly or monthly injections are given. Teach him or her to take NSAIDs with or after meals to reduce gastric irritation. A splint or hand brace may be used to immobilize the wrist during the day, during the night, or both. Many patients experience temporary relief with these devices. The occupational therapist places the wrist in the neutral position or in slight extension. Laser or ultrasound therapy may also be helpful. Some patients report fewer symptoms after beginning yoga or other exercise routine.

Nonsurgical Management: Fractures-Managing Acute Pain

Nonsurgical management includes closed reduction and immobilization with a bandage, splint, cast, or traction. For some small, closed incomplete bone fractures in the hand or foot, reduction is not required. Immobilization with an orthotic device or special orthopedic shoe or boot may be the only management. The primary nursing concern is assessment and prevention of neurovascular dysfunction or compromise. Assess the patient's neurovascular status every hour for the first 24 hours and every 1 to 4 hours thereafter, depending on the injury. Patient usually reports discomfort that is unrelieved by analgesics if the bandage, splint, or cast is too tight. Elevate the fractured extremity higher than the heart, and apply ice for the first 24 to 48 hours as needed to reduce edema.

Considerations for Older Adults

Older adults may not have a temperature elevation even in the presence of severe infection. An acute onset of confusion (delirium) often suggests an infection in the older adult patient.

Operative Procedures: Fractures-Managing Acute Pain

Open reduction with internal fixation (ORIF) is one of the most common methods of reducing and immobilizing a fracture. External fixation with closed reduction is used when patients have soft-tissue injury (open fracture). Because ORIF permits early mobility, it is often the preferred surgery. Open reduction allows the surgeon to directly view the fracture site. Internal fixation uses metal pins, screws, rods, plates, or prostheses to immobilize the fracture during healing. The surgeon makes one or more incisions to gain access to the broken bone(s) and implants one or more devices. A cast, boot, or splint is placed to maintain immobilization. After the bone achieves union, the metal hardware may be removed. External fixation is a system in which pins or wires are inserted through the skin and affected bone and then connected to a rigid external frame. The system may be used for upper or lower extremity fractures or for fractures of the pelvis, especially for open fractures when wound management is needed. After a fixator is removed, the patient may be placed in a cast or splint. External fixation has several advantages over other surgical techniques: • There is minimal blood loss compared with internal fixation. • The device allows early ambulation and exercise of the affected body part while relieving pain. • The device maintains alignment in closed fractures that will not maintain position in a cast and stabilizes comminuted fractures that require bone grafting. In open fractures, in which skin and tissue trauma accompany the fracture, the device permits easy access to the wound while the bone heals. This method is usually preferred over the use of a window in a cast for wound care. A disadvantage of external fixation is an increased risk for pin site infection. Pin site infections can lead to osteomyelitis

Chart 51-1 Key Features Compartment Syndrome

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Chart 51-2 Key Features Pulmonary Emboli: Fat Embolism Versus Blood Clot Embolism

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Chart 51-3 Assessment of Neurovascular Status in Patients with Musculoskeletal Injury

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TABLE 51-1 Types of Casts Used for Musculoskeletal Trauma

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TABLE 51-2 Types of Traction Used for Musculoskeletal Trauma

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Action Alert

Patients who have an ORIF are at risk for hip dislocation or subluxation. Be sure to prevent hip adduction and rotation to keep the operative leg in proper alignment. Regular pillows or abduction devices can be used for patients who are confused or restless. If straps are used to hold the device in place, check the skin for signs of pressure. Perform neurovascular assessments to ensure that the device is not interfering with arterial circulation or peripheral nerve conduction.

Action Alert

Patients with one or more fractured ribs have severe pain when they take deep breaths. Monitor respiratory status, which may be severely compromised from pain or pneumothorax (air in the pleural cavity). Assess the patient's pain level and manage pain before continuing the physical assessment.

What should you INTERPRET and how should you RESPOND to a patient with impaired mobility and sensory perception as a result of acute musculoskeletal trauma?

Perform and interpret focused physical assessment findings, including: • ABC (airway, breathing, circulation) ability (first action!) • Pain intensity and quality • Vital signs • Neurovascular assessment ("circ check") Respond by: • First, establishing ABCs if problem exists • If skin is not intact, covering wound with dry, sterile dressing, if available, using clean cloth as an option; applying pressure to proximal pulse if patient is bleeding; for traumatic amputation, applying direct pressure to the residual body part • Implementing measures to prevent hypovolemic shock if patient is bleeding, including having patient lie flat, keeping him or her warm, and elevating the bleeding part • Splinting the extremity (in community setting) to prevent movement and further damage • If in hospital setting, assisting health care provider in splinting • Providing pain control interventions by drug therapy as soon as possible • Providing emotional assurance for the patient by being present and comforting

Interventions: Fractures-Preventing and Monitoring for Neurovascular Compromise

Perform neurovascular (NV) assessments (also known as "circ checks" or CMS assessments) frequently before and after fracture treatment. Patients who have extremity casts, splints with elastic bandage wraps, and open reduction with internal fixation (ORIF) or external fixation are especially at risk for NV compromise. If blood flow to the distal extremity is impaired, the patient reports increased pain and decreased sensory perception and movement. At risk for acute compartment syndrome. Early recognition of the signs and symptoms of ACS can prevent loss of function or loss of a limb. Identify patients who may be at risk, and monitor them closely. ACS can begin in 6 to 8 hours after an injury or take up to 2 days to appear. If it is suspected, notify the health care provider immediately, and if possible, implement interventions to relieve the pressure. For example, for the patient with tight, bulky dressings, loosen the bandage or tape. Compartment pressure may be monitored on a one-time/continuous basis with a handheld device. If ACS is verified, the surgeon may perform a fasciotomy, or opening in the fascia, by making an incision through the skin and subcutaneous tissues into the fascia of the affected compartment. Some surgeons use negative pressure wound therapy (e.g., Wound Vac) over a fasciotomy to decrease edema until the wound is closed. For other patients, a skin graft may be used

Chart 51-6 Nursing Care for Patients Having Vertebroplasty or Kyphoplasty

Provide preoperative care including: • Check the patient's coagulation laboratory test results; platelet count should be more than 100,000/mm3. • Make sure that all anticoagulant drugs were discontinued as requested by the physician. • Assess and document the patient's neurologic status, especially extremity movement and sensation. • Assess the patient's pain level. • Assess the patient's ability to lie prone for at least 1 hour. • Establish an IV line, and take vital signs. Provide postoperative care including: • Place the patient in a flat supine position for 1 to 2 hours or as requested by the physician. • Monitor and record vital signs and frequent neurologic assessments; report any change immediately to the physician. • Apply an ice pack to the puncture site if needed to relieve pain. • Assess the patient's pain level, and compare it with the preoperative level; give mild analgesic as needed. • Monitor for complications such as bleeding at the puncture site or shortness of breath; report these findings immediately if they occur. •Assist the patient with ambulation. Before discharge, teach the patient and family the following: • The patient should avoid driving or operating machinery for the first 24 hours because of drugs used during the procedure. • Monitor the puncture site for signs of infection, such as redness, pain, swelling, or drainage. • Keep the dressing dry, and remove it the next day. • The patient should begin usual activities, including walking the next day, and should slowly increase activity level over the next few days.

Promoting Mobility and Preparing for Prosthesis: Amputation 2

Several devices help shape and shrink the residual limb in preparation for the prosthesis. Rigid, removable dressings are preferred because they decrease edema, protect and shape the limb, and allow easy access to the wound for inspection. The Jobst air splint, a plastic inflatable device, is sometimes used for this purpose. One of its disadvantages is air leakage and loss of compression. Wrapping with elastic bandages can also be effective in reducing edema, shrinking the limb, and holding the wound dressing in place. Reapply the bandages every 4 to 6 hours or more often if they become loose. Figure-eight wrapping prevents restriction of blood flow. Decrease the tightness of the bandages while wrapping in a distal-to-proximal direction. After wrapping, anchor the bandages to the highest joint, such as above the knee for BKAs. One of the most important developments in lower extremity prosthetics is the ankle-foot prosthesis, such as the Flex-Foot for more active amputees.

Physical Therapy: Fractures-Managing Acute Pain

Some patients who have an ORIF for one or more ankle fractures may begin therapy when the incisional staples or Steri-Strips are removed and an orthopedic boot is fitted. Based on the initial evaluation, the PT performs gentle manipulative exercises to increase range of motion. The therapist may also begin to help the patient with laterality, a concept to help the brain identify the injured foot from the uninjured foot. In mirror-box therapy for an injured foot, the patient covers his or her affected foot while looking at and moving the uninjured foot in front of the mirror. The brain perceives the foot in the mirror as the injured foot. Stimulation by touch also helps the brain acknowledge the injured foot. The PT teaches the patient to have someone frequently touch the injured area and use various materials and objects against the skin to desensitize it. These interventions decrease the risk for complex regional pain syndrome. Weight bearing begins about 6 weeks after surgery, the PT teaches the patient how to begin with toe-touch or partial weight bearing using crutches or a walker. Muscle strengthening exercises of the affected leg help with ambulation. PT also assists with pain control and edema reduction by using ice/heat packs, electrical muscle stimulation ("e-stim"), and special treatments such as dexamethasone iontophoresis. Iontophoresis is a method for absorbing dexamethasone, a synthetic steroid, through the skin near the painful area to decrease inflammation and edema. A small device delivers a minute amount of electricity via electrodes that are placed on the skin. Electrical current increases the ability of the skin to absorb the drug from a topical patch.

Surgical Management: Carpal Tunnel Syndrome

Surgery can relieve the pressure on the median nerve by providing nerve decompression. Whatever the cause of nerve compression, the surgeon removes it either by cutting or by laser. The most common surgery is the endoscopic carpal tunnel release (ECTR). In this procedure, the surgeon makes a very small incision through which the endoscope is inserted. The surgeon then uses special instruments to free the trapped median nerve. May have a longer period of postoperative pain and numbness compared with recovery from open carpal tunnel release (OCTR). Monitor vital signs and check the dressing carefully for drainage and tightness. Surgeon may require that the patient's affected hand and arm be elevated above heart level for several days to reduce postoperative swelling. Check the neurovascular status of the fingers every hour, and encourage the patient to move them frequently. Offer pain medication, and assure him or her that a prescription for analgesics will be provided before discharge. Hand movements, including lifting heavy objects, may be restricted for 4 to 6 weeks. Can expect weakness and discomfort for weeks or perhaps months. Teach him or her to report any changes in neurovascular status, including increased pain. Remind the patient and family that the surgical procedure might not be a cure. For instance, synovitis may recur.

Preoperative Care: Fractures-Managing Acute Pain

Surgical intervention may be needed to realign the bone for the healing process. Teach the patient and family what to expect during and after the surgery. The preoperative care for a patient undergoing orthopedic surgery is similar to that for anyone having surgery with general or epidural anesthesia.

Action Alert

Swelling at the fracture site is rapid and can result in marked neurovascular compromise due to decreased arterial perfusion. Gently perform a thorough neurovascular assessment, and compare extremities. Assess skin color and temperature, sensation, mobility, pain, and pulses distal to the fracture site. If the fracture involves an extremity and the patient is not in severe pain, check the nails for capillary refill by applying pressure to the nail and observing for the speed of blood return. If nails are brittle or thick, assess the skin next to the nail. Checking for capillary refill is not as reliable as other indicators of perfusion. Chart 51-3 describes the procedure for a neurovascular assessment, which evaluates circulation, movement, and sensation (sensory perception) (CMS function).

Considerations for Older Adults

Teach older adults about the risk factors for hip fracture including physiologic aging changes, disease processes, drug therapy, and environmental hazards. Physiologic changes include sensory changes such as diminished visual acuity and hearing; changes in gait, balance, and muscle strength; and joint stiffness. Disease processes like osteoporosis, foot disorders, and changes in cardiac function increase the risk for hip fracture. Drugs, such as diuretics, antihypertensives, antidepressants, sedatives, opioids, and alcohol, are factors that increase the risks for falling in older adults. Use of three or more drugs at the same time drastically increases the risk for falls. Throw rugs, loose carpeting, inadequate lighting, uneven walking surfaces or steps, and pets are environmental hazards that also cause falls. The older adult with hip fracture usually reports groin pain or pain behind the knee on the affected side. In some cases, the patient has pain in the lower back or has no pain at all. However, the patient is not able to stand. X-ray or other imaging assessment confirms the diagnosis.

Diagnostic Assessment: Amputation

Tests are performed to assess for viability of the limb based on blood flow. One procedure is measurement of segmental limb blood pressures, which can also be used by the nurse at the bedside. In this test, an ankle-brachial index (ABI) is calculated by dividing ankle systolic pressure by brachial systolic pressure. A normal ABI is 0.9 or higher. Blood flow in an extremity can also be assessed by other noninvasive tests, including Doppler ultrasonography or laser Doppler flowmetry and transcutaneous oxygen pressure (TcPO2). The ultrasonography and laser Doppler measure the speed of blood flow in the limb. The TcPO2 measures oxygen pressure to indicate blood flow in the limb and has proved reliable for predicting healing.

Patient-Centered Collaborative Care: Complex Regional Pain Syndrome

The first priority of management is pain relief. Many classes of drugs may be used to manage the intense pain. These include topical analgesics, antiepileptic drugs, antidepressants, corticosteroids, bisphosphonates, and analgesics. Assist in maintaining adequate ROM and function. The skin of a patient with CRPS tends to alternate between warm, swollen, and red to cool, clammy, and bluish. Skin care needs to be gentle with minimal stimulation. Peripheral or spinal cord neurostimulation using an external or internal implanted device delivers electrical pulses to block pain from getting to the brain where pain is perceived. The external or acupuncture method requires weekly sessions or a short-term continuous trial before the device is surgically implanted. Complications of implantable neurostimulators include spinal cord damage from hematoma or edema formation or neurological. A chemical sympathetic nerve block may be used. This procedure can be done by an IV infusion of phentolamine (Regitine), a drug that blocks sympathetic receptors, or by injecting an anesthetic agent next to the spine to block sympathetic nerves. Minimally invasive surgical sympathectomy, or cutting of the sympathetic nerve branches via endoscopy through a small axillary incision, may be required. Topical skin adhesive is used to close the very small incision.

Drug Therapy: Fractures-Managing Acute Pain

The health care provider commonly prescribes opioid and non-opioid analgesics, anti-inflammatory drugs, and muscle relaxants. Meperidine (Demerol) should never be used for older adults because it has toxic metabolites that can cause seizures and other complications. Most hospitals no longer use this drug for patients of any age. Oxycodone and oxycodone with acetaminophen (Percocet) are common oral opioid drugs that are very effective for most patients with fracture pain. NSAIDs are given to decrease associated tissue inflammation. Severe or multiple fractures, patient-controlled analgesia (PCA) with morphine, fentanyl, or hydromorphone (Dilaudid) is used. Constipation is a common side effect of opioid therapy, especially for older adults. Assess for frequency of bowel movements, and administer stool softeners as needed. Encourage fluids and activity as tolerated. Some patients experience a long-term, intense burning pain and edema that are associated with complex regional pain syndrome (CRPS).

Imaging Assessment: Fractures

The health care provider requests standard x-rays to confirm a diagnosis of fracture. These reveal the bone disruption, malalignment, or deformity. The CT scan is useful in detecting fractures of complex structures, such as the hip and pelvis. It also identifies compression fractures of the spine. MRI is useful in determining the amount of soft-tissue damage that may have occurred.

Cultural Considerations

The incidence of lower extremity amputations is greater in black and Hispanic populations because the incidence of major diseases leading to amputation, such as diabetes and arteriosclerosis, is greater in these populations (Lowe & Tariman, 2008). Limited access to health care or lack of health insurance for these minority groups may also play a major role in limb loss. Language barriers may also be an obstacle to seeking health care providers.

Rotator Cuff Injuries 1

The musculotendinous, or rotator, cuff of the shoulder functions to stabilize the head of the humerus in the glenoid cavity during shoulder abduction. Young adults usually sustain a tear of the cuff by substantial trauma, such as may occur during a fall, while throwing a ball, or with heavy lifting. Older adults tend to have small tears related to aging, repetitive motions, or falls, and the tears are usually painless. Has shoulder pain and cannot easily abduct the arm at the shoulder. When the arm is abducted, he or she usually drops the arm because abduction cannot be maintained (drop arm test). Pain is more intense at night and with overhead activities. Partial-thickness tears are more painful that full-thickness tears, but full-thickness tears result in more weakness and loss of function. Muscle atrophy is common, and mobility reduced. Diagnosis is confirmed with x-rays, MRI, ultrasonography, and/or CT.

Assessing Tissue Perfusion and Managing Pain: Amputation

The nurse's primary focus is to monitor for signs indicating that there is sufficient tissue perfusion and no hemorrhage. The skin flap at the end of the residual (remaining) limb should be pink in a light-skinned person and not discolored (lighter or darker than other skin pigmentation) in a dark-skinned patient. The area should be warm but not hot. Assess the closest proximal pulse for presence and strength, and compare it with that in the other extremity. If the patient has bilateral vascular disease, however, comparison of limbs may not be accurate. Use a Doppler device to determine if the affected side is being perfused. Pain as always. Some patients also report pain in the missing body part (PLP). Be sure to determine which type the patient has. Opioid analgesics are not as effective for PLP as they are for residual limb pain. IV infusions of calcitonin (Miacalcin, Calcimar) during the week after amputation can reduce phantom limb pain. For instance, beta-blocking agents such as propranolol (Inderal, Apo-Propranolol , Detensol) are used for constant, dull, burning pain. Antiepileptic drugs such as pregabalin (Lyrica) and gabapentin (Neurontin) may be used for knifelike or sharp burning pain. Antispasmodics such as baclofen (Lioresal) may be prescribed for muscle spasms or cramping. Some patients improve with antidepressants. PT often use massage, heat, transcutaneous electrical nerve stimulation (TENS), and ultrasound therapy for pain control.

Casts 1: Fractures-Managing Acute Pain

The physician or orthopedic technician may apply a cast to hold bone fragments in place after reduction. A cast is a rigid device that immobilizes the affected body part while allowing other body parts to move. It also allows early mobility and reduces pain. Although its most common use is for fractures, a cast may be applied for correction of deformities (e.g., clubfoot) or for prevention of deformities. Fiberglass is the most common material used. Fiberglass can dry and become rigid within minutes and decreases the risk for skin breakdown. Plaster is used less today. Requires application of a well-fitted stockinette under the material. If the stockinette is too tight, it may impair circulation. If it is too loose, wrinkles can lead to the development of pressure ulcers. Padding is applied over the stockinette, followed by wet plaster rolls wrapped around the extremity or other body part. The cast feels hot because an immediate chemical reaction occurs, but it soon becomes damp and cool. This type of cast takes at least 24 hours to dry, depending on the size and location of the cast. A wet cast feels cold, smells musty, and is grayish. The cast is dry when it feels hard and firm, is odorless, and has a shiny white appearance. A window is cut in the cast so that a wound can be observed and cared for. The piece of cast removed to make the window must be retained and replaced after wound care to prevent localized edema in the area. This is most important when a window is cut from a cast on an extremity. Tape or elastic bandage wrap may be used to keep the "window" in place. A window is also an access for taking pulses, removing wound drains, or preventing abdominal distention when the patient is in a body or spica cast. If the cast is too tight, it may be cut with a cast cutter to relieve pressure or allow swelling. Provider may choose to bivalve the cast (i.e., cut it lengthwise into two equal pieces) if bone healing is almost complete. Either half of the cast can be removed for inspection or for provision of care. The two halves are then held in place by a wrap.

Traction: Fractures-Managing Acute Pain

Traction is the application of a pulling force to a part of the body to provide reduction, alignment, and rest. It is also used as a last resort to decrease muscle spasm (thus relieving pain) and prevent or correct deformity and tissue damage. In running traction, the pulling force is in one direction and the patient's body acts as countertraction. Moving the body or bed position can alter the countertraction force. Balanced suspension provides the countertraction so that the pulling force of the traction is not altered when the bed or patient is moved. The two most common types of traction are skin and skeletal traction. Skin traction involves the use of a Velcro boot (Buck's traction) (Fig. 51-5), belt, or halter, which is usually secured around the affected leg. The primary purpose of skin traction is to decrease painful muscle spasms that accompany hip fractures. A weight is used as a pulling force, which is limited to 5 to 10 pounds. In skeletal traction, screws are surgically inserted directly into bone (e.g., Halo traction). These allow the use of longer traction time and heavier weights—usually 15 to 30 pounds (6.8 to 13.6 kg). Skeletal traction aids in bone realignment. Pin site care is an important part of nursing management to prevent infection. If the patient reports severe pain from muscle spasm, the weights may be too heavy or the patient may need realignment. Report the pain to the health care provider if body realignment fails to reduce the discomfort. Assess neurovascular status of the affected body part to detect circulatory compromise and tissue damage.

Rotator Cuff Injuries 2

Treat the patient with partial-thickness tears conservatively with NSAIDs, intermittent steroid injections, physical therapy, and activity limitations while the tear heals. Physical therapy treatments may include ultrasound, electrical stimulation, ice, and heat. Not responsive to conservative treatment in 3 to 6 months or for those who have a complete (full-thickness) tear, the surgeon repairs the cuff using mini-open or arthroscopic procedures. An interscalene nerve block may be used to extend analgesia for an open repair. If a peripheral nerve block is used, remind the patient that the arm will feel numb and cannot be moved for up to 20 or more hours. Observe, report, and document complications of respiratory distress and neurovascular compromise. After surgery the affected arm is usually immobilized for several weeks. Pendulum exercises are started on the third or fourth postoperative day and progress to active exercises in about 2 weeks. Patients then begin rehabilitation in the ambulatory care occupational therapy department. Teach them that they may not have full function for several mo.

Fractures of the Hip 2

Treatment of choice is surgical repair by ORIF, when possible, to reduce pain and allow the older patient to be out of bed and ambulatory. Skin (Buck's) traction may be applied before surgery to help decrease pain associated with muscle spasm. An ORIF may include an intramedullary rod, pins, prostheses (for femoral head or femoral neck fractures), or a compression screw. Epidural or general anesthesia is used. Occasionally a patient will be so debilitated that surgery cannot be done. In these cases, nonsurgical options include pain management and bedrest for healing. Patients usually receive IV morphine after admission to the emergency department and PCA morphine or epidural analgesia after surgery. In some cases, a femoral nerve block may also be performed. Meperidine (Demerol) should not be used due to its toxic metabolites that can cause seizures and other adverse drug events, especially in the older adult. After a hip repair, older adults frequently experience acute confusion, or delirium. They may pull at tubes or the surgical dressing or attempt to climb out of bed, possibly falling and causing self-injury. Other patients stay awake all night and sleep during the day. Keep in mind that some patients have a quiet delirium. Monitor the patient frequently to prevent falls. The patient begins ambulating with assistance the day after surgery to prevent complications associated with immobility (e.g., pressure ulcers, atelectasis, venous thromboembolism). Early mobility and ambulation also decrease the chance of infection and increase surgical site healing.

Preventing Infection: Amputation

Typically prescribes a broad-spectrum prophylactic antibiotic. May be continued for patients with traumatic amputations or for those who have open wounds on the residual limb. The initial pressure dressing and drains are usually removed by the surgeon 36 to 48 hours after. Inspect the incision or wound for signs of infection. Record the appearance, amount, and odor of drainage, if present. The surgeon may want the incision open to air until staples or sutures are removed or may want the residual limb to have a continuous soft or rigid dressing made of fiberglass. A soft dressing is secured by an elastic bandage wrapped firmly around the residual limb.

Interventions: Fractures-Preventing Infection

Use clean or aseptic technique for dressing changes and wound irrigations. Immediately notify the health care provider if you observe inflammation and purulent drainage. Other infections, such as pneumonia and urinary tract infection, may occur several days after the fracture. Monitor the patient's vital signs every 4 to 8 hours because increases in temperature and pulse often indicate systemic infection. Provider prescribes one or more broad-spectrum antibiotics prophylactically and performs surgical débridement of any wounds as soon as possible. First-generation cephalosporins, clindamycin (Cleocin), and gentamycin are commonly used. In addition to systemic antibiotics, local antibiotic therapy through wound irrigation is commonly prescribed. Negative pressure wound therapy (e.g., vacuum-assisted closure [VAC] system) as a method of increasing the rate of wound healing for open fractures. This device allows quicker wound closure, which decreases the risk for infection. FDA approved the use of recombinant human bone morphogenetic protein-2 (rhBMP-2) for tibial and spinal fractures. This implanted genetically engineered substance increases wound healing, decreases hardware failure, and decreases the risk for infection.

Promoting Body Image and Lifestyle Adaptation: Amputation

Use of the word stump for referring to the remaining portion of the limb (residual limb) continues to be controversial. Some rehabilitation specialists who routinely work with amputees believe the term is appropriate because it forces the patient to realize what has happened and promotes adjustment to the amputation. Assess the patient to determine what term he or she prefers. Some patients behave euphorically (extremely happy) and seem to have accepted the loss. Do not jump to the conclusion that acceptance has occurred. He or she may verbalize acceptance but refuse to look at the area during a dressing change. This inconsistent behavior is not unusual and should be documented and shared with other health care team members.

Venous Thromboembolism

Venous thromboembolism (VTE) includes deep vein thrombosis (DVT) and its major complication, pulmonary embolism (PE). It is the most common complication of lower extremity surgery or trauma and the most often fatal complication of musculoskeletal surgery. Factors that make patients with fractures most likely to develop VTE include: • Cancer or chemotherapy • Surgical procedure longer than 30 minutes • History of smoking • Obesity • Heart disease • Prolonged immobility • Oral contraceptives or hormones • History of VTE complications • Older adults (especially with hip fractures)

Action Alert

When moving a patient with a wet plaster cast, handle it with the palms of the hands to prevent indentations and resulting areas of pressure on the skin. Turn the patient every 1 to 2 hours to allow air to circulate and dry all parts of the cast. Be sure to remind unlicensed assistive personnel (UAP) and the family that the cast is wet and requires special handling. If the health care provider requests that the cast be elevated to reduce swelling, use a cloth-covered pillow instead of one encased in plastic, which could cause the cast to retain heat and prevent drying. Elevation of the casted extremity reduces edema but may impair arterial circulation to the affected limb. Therefore performing a neurovascular assessment of the limb distal to (below) the cast is very important.

Action Alert

When patients are in traction, weights usually are not removed without a prescription. They should not be lifted manually or allowed to rest on the floor. Weights should be freely hanging at all times. Teach this important point to UAP on the unit, to other personnel such as those in the radiology department, and to visitors. Inspect the skin at least every 8 hours for signs of irritation or inflammation. When possible, remove the belt or boot that is used for skin traction every 8 hours to inspect under the device.

Casts 2: Fractures-Managing Acute Pain

With an arm cast, teach him or her to elevate the arm above the heart to reduce swelling. Ice may be prescribed. The arm is supported with a sling placed around the neck to alleviate fatigue. For many wrist fractures, a splint is used to immobilize the area instead of a cast to accommodate for edema. A leg cast allows mobility and requires the patient to use ambulatory aids such as crutches. A cast shoe, sandal, or boot that attaches to the foot or a rubber walking pad attached to the sole of the cast assists in ambulation. Teach the patient to elevate the affected leg on several pillows to reduce swelling and to apply ice for the first 24 hours or as prescribed. With a plaster cast, warn the patient about the heat that will be felt immediately after the wet cast is applied. Do not cover the new cast. Allow for air-drying. Inspect it at least once every 8 hours for drainage, cracking, crumbling, alignment, and fit. Plaster casts act like sponges and absorb drainage, whereas synthetic casts act like a wick pulling drainage away from the drainage site. Padding can also absorb wound drainage. Immediately report to the health care provider any sudden increases in the amount of drainage or change in the integrity of the cast. After swelling decreases, it is not uncommon for the cast to become too loose and need replacement. Assess for infection, circulation impairment, and peripheral nerve damage. Infection most often results from the breakdown of skin under the cast (pressure necrosis). If pressure necrosis occurs, the patient typically reports a very painful "hot spot" and may be felt outside the cast. Teach the patient or family to smell the area for mustiness or an unpleasant odor as a sign of infection. Fever may develop. Circulation impairment causing decreased perfusion and peripheral nerve damage can result from tightness of the cast. Teach the patient to assess for circulation at least daily, including the ability to move the area distal to the extremity, numbness, and increased pain. Assess for complications of immobility, such as skin breakdown, pneumonia, atelectasis, thromboembolism, and constipation. Before the cast is removed, inform the patient that the cast cutter will not injure the skin but that heat may be felt. Prolonged immobilization, a joint may become contracted, usually in a fixed state of flexion. Osteoarthritis and osteoporosis may develop from lack of weight bearing. Muscle can also atrophy from lack of exercise during prolonged immobilization of the affected body part, usually an extremity.

Infection

Wound infections are the most common type of infection resulting from orthopedic trauma. They range from superficial skin infections to deep wound abscesses. Infection can also be caused by implanted hardware. Clostridial infections can result in gas gangrene or tetanus and can prevent the bone from healing properly. Bone infection, or osteomyelitis, is most common with open fractures in which skin integrity is lost and after surgical repair of a fracture.

Complications of Fractures

• Acute compartment syndrome • Crush syndrome • Hypovolemic shock • Fat embolism syndrome • Venous thromboembolism • Infection • Chronic complications, such as ischemic necrosis and delayed union

Chart 51-7 Home Care Assessment The Patient with a Lower Extremity Amputation in the Home

• Assess the residual limb for: 1 Adequate circulation 2 Infection 3 Healing 4 Flexion contracture 5 Dressing/elastic wrap • Assess the patient's ability to perform ADLs in the home. • Evaluate the patient's ability to use ambulatory aids and to care for the prosthetic device (if available). • Assess the patient's nutritional status. • Assess the patient's ability to cope with body image change.

Key Points: Psychosocial Integrity

• Be aware that patients with severe musculoskeletal trauma may have a prolonged hospitalization and recovery period. • For patients with severe trauma or amputation, assess coping skills and encourage verbalization. • Recognize that the patient having an amputation may need to adjust to an altered lifestyle; however, new custom prosthetics improve mobility. • Help the patient with an amputation or other musculoskeletal trauma and family to set realistic expected outcomes and take one day at a time.

Chart 51-9 Health Promotion Activities to Prevent Carpal Tunnel Syndrome

• Become familiar with federal and state laws regarding workplace requirements to prevent repetitive stress injuries such as carpal tunnel syndrome (CTS). • When using equipment or computer workstations that can contribute to developing CTS, assess that they are ergonomically appropriate, including: 1 Specially designed wrist rest devices 2 Geometrically designed computer keyboards 3 Chair height that allows good posture • Take regular short breaks away from activities that cause repetitive stress, such as working at computers. • Stretch fingers and wrists frequently during work hours. • Stay as relaxed as possible when using equipment that causes repetitive stress.

Key Points: Safe and Effective Care Environment

• Collaborate with physical and occupational therapists for care of patients with extremity fractures to improve mobility and muscle strength. • Collaborate with the prosthetist, physical and occupational therapists, psychologist, and sex therapist or intimacy coach for care of patients with amputations to improve mobility, muscle strength, ADLs, and self-image.

Chart 51-8 Emergency Care of Patients with Sports-Related Injuries

• Do not move the victim until spinal cord injury is ascertained. • Rest the injured part; immobilize the joint above and below the injury by applying a splint if needed. • Apply ice intermittently for the first 24 to 48 hours (heat may be used thereafter). • Elevate the affected limb to decrease swelling. • Use compression for the first 24 to 48 hours (e.g., elastic wrap). • Always assume the area is fractured until x-ray studies are done. • Assess neurovascular status in the area distal to the injury.

What might you NOTICE if the patient has impaired mobility and sensory perception as a result of acute musculoskeletal trauma?

• Extremity swelling, bleeding, bruising, shortening, malalignment, and/or rotation • Report of severe pain • Break in skin integrity • Report of decreased or unusual sensation in extremity • Inability or decreased ability to move extremity • Difficulty breathing (rib trauma) • Severe kyphosis (compression fractures)

Complications of Amputation

• Hemorrhage • Infection • Phantom limb pain • Neuroma • Flexion contractures Major blood vessels are severed, which causes bleeding. If the bleeding is uncontrolled, the patient is at risk for hypovolemic shock and possibly death. Infection can occur in the wound or the bone (osteomyelitis). The older adult who is malnourished and confused is at the greatest risk because excreta may soil the wound and/or constant picking. Sensation is felt in the amputated part immediately after surgery and usually diminishes over time. When this sensation persists and is unpleasant or painful, it is referred to as phantom limb pain (PLP). The patient reports pain in the removed body part shortly after surgery, usually after an above-the-knee amputation (AKA). The pain is often described as intense burning, crushing, or cramping. Some patients report that the removed part is in a distorted, uncomfortable position. They experience numbness and tingling, referred to as phantom limb sensation, as well as pain. Others state that the most distal area of the removed part feels as if it is retracted into the residual limb end. Pain is triggered by touching the residual limb or by temperature or barometric pressure changes, concurrent illness, fatigue, anxiety, or stress. Routine activities such as urination can trigger the pain. Neuroma—a sensitive tumor consisting of damaged nerve cells—forms most often in amputations of the upper extremity but can occur anywhere. The patient may or may not have pain. It is diagnosed by sonography. Surgery to remove the neuroma may be performed, but it often regrows and is more painful than before the surgery. Nonsurgical modalities include peripheral nerve blocks, steroid injections, and cognitive therapies such as hypnosis. Flexion contractures of the hip or knee are seen in patients with amputations of the lower extremity. This complication must be avoided so that the patient can ambulate with a prosthetic device. Proper positioning and active range-of-motion exercises help prevent this complication.

Chart 51-5 Care of the Extremity After Cast Removal

• Remove scaly, dead skin carefully by soaking; do not scrub. • Move the extremity carefully. Expect discomfort, weakness, and decreased range of motion. • Support the extremity with pillows or your orthotic device until strength and movement return. • Exercise slowly as instructed by your physical therapist. • Wear support stockings or elastic bandages to prevent swelling (for lower extremity).

Evaluation: Outcomes of Fractures

• States that he or she has adequate pain control • Has adequate blood flow to maintain tissue perfusion and function • Is free of infection • Is free of physiologic consequences of impaired mobility • Ambulates or moves independently with or without an assistive device (if not restricted by traction or other device)

Key Points: Health Promotion and Maintenance

• Teach people to avoid musculoskeletal injury by treating or preventing osteoporosis (see Chapter 50), being cautious when walking to prevent a fall, wearing supportive shoes, avoiding dangerous sports or activities, and decreasing time spent doing repetitive stress activities, such as using a computer keyboard. • Several community organizations, such as the Amputee Coalition of America, are available to help patients and their families cope with the loss of a body part. • Teach patients and their family members and significant others how to care for casts or traction at home. • Reinforce teaching for ambulating with crutches, walkers, or canes. • Provide special care for older adults with hip fractures, including preventing heel pressure ulcers and promoting early ambulation to prevent complications of immobility. • Teach exercises to patients with leg amputation to prevent hip flexion contractures.