Unit # 4 Musculoskeletal Trauma and Orthopedic Surgery

A plaster splint is applied with an elastic bandage to the leg of a patient hospitalized with a fractured tibia in preparation for open reduction and internal fixation of the fracture. The patient complains of increasing pain in the affected leg and foot that is not relieved by loosening of the elastic bandage. The most appropriate action by the nurse is to: 1. Elevate the leg on two pillows. 2. Perform neurovascular assessment of the foot. 3. Notify the health care provider. 4. Apply ice over the fracture site.

Answer: 2 Rationale: Prompt, accurate diagnosis of compartment syndrome is critical. Prevention or early recognition is the key. Regular neurovascular assessments should be performed and documented on all patients with fractures, but especially those with injury of the distal humerus or proximal tibia or soft tissue disruption in these areas. Early recognition and treatment of compartment syndrome is essential to avoid permanent damage to muscles and nerves. One or more of the following six Ps are characteristic of compartment syndrome: (1) paresthesia(numbness and tingling); (2) pain distal to the injury that is not relieved by opioid analgesics and pain on passive stretch of muscle, traveling through the compartment; (3) pressure increases in the compartment; (4) pallor, coolness, and loss of normal color of the extremity; (5) paralysis or loss of function; and (6) pulselessness or diminished/absent peripheral pulses. Carefully assess the location, quality, and intensity of the pain (see Chapter 10). Evaluate the patient's level of pain on a scale of 0 to 10. Pain unrelieved by drugs and out of proportion to the level of injury is one of the first indications of impending compartment syndrome. Pulselessness and paralysis (in particular) are later signs of compartment syndrome. After completion of the neurovascular assessment, the nurse should notify the health care provider immediately of a patient's changing condition.

A patient is admitted to the emergency department with possible left lower leg fractures. The initial action be the nurse should be to: Elevate the left leg Splint the lower leg Obtain information about the tetanus immunization status Check the popliteal, dorsalis pedis, and posterior tibial pulses

Answer: Check the popliteal, dorsalis pedis, and posterior tibial pulses You'll want to check CMS prior to doing any interventions so that if the pulse is gone AFTER interventions, you know it is intervention related. Also, this is C (ABC's), and the others are not...

A patient who has had an open reduction and internal fixation (ORIF) of left lower leg fractures complains of constant severe pain in the leg, which is unrelieved by the prescribed morphine. Pulses are faintly palpable and the foot is cool. Which action should the nurse take next? Notify the health care provider Assess the incision for redness Reposition the left leg on pillows Check the patient's blood pressure

Answer: Notify the health care provider It's likely that the patient has developed compartment syndrome. The provider needs to be notified immediately as this is an emergency.

•incorporates joints above and below fracture. •Restricts tendinoligamentous movement •Assisting with joint stabilization while fracture heals •After immersion in water, plaster of Paris is wrapped and molded around affected part after bony prominences have been padded. •Do NOT use fingers - only the palms of the hands to avoid denting •Number of layers and technique determine strength of cast. •After cast is completely dry, it is strong and firm and can withstand stresses. •Plaster sets in 15 minutes. •Not strong enough for weight bearing until 24 to 72 hours •Fresh plaster should never be covered with a blanket. •During drying period §Cast should be kept dry and clean. §Direct pressure should be avoided. •Once thoroughly dry, edges may need to be petaled to avoid skin irritation.

Application of cast

•Inflammation of the bursa •Located at sites of friction •Carpet layers, joggers, infections, etc... Treatment •Rest is the main treatment •Ice •Compression with dressing •NSAIDs •Aspiration or removal of sac

BURSITIS

•Immobilization and support for stable spine injuries of thoracic or lumbar spine •After application, nurse assesses patient for cast syndrome. •Cast is applied too tightly. •Nursing assessment also includes •Observation of respiratory status •Bowel and bladder function •Areas of pressure over bony prominences •During time required for cast to dry, nurse should reposition patient every 2 to 3 hours. •This cast is applied around the chest and abdomen and extends from above the nipple line to the pubis. •With cast syndrome, the patient generally complains of abdominal pain, abdominal pressure, nausea, and vomiting. •Treatment includes gastric decompression with a nasogastric (NG) tube and suction. The cast may need to be removed or split.

Body Jacket (Brace)

•When traction is used, forces are usually exerted on distal fragment to obtain alignment with proximal fragment. •Buck's traction •Buck's traction is most commonly used for fractures of the hip and femur.

Buck's Traction

•Compression of the median nerve •Hobbies and occupations with lots of wrist action •Inflammation and edema •Women over men •S/S •Weakness, burning pain, numbness, impaired sensation, clumsiness •Shaking hand will relieve symptoms •Tinel's sign - tap the nerve •Phalen's sign - flex hand for 60 seconds •Both will elicit tingling over hand A, Wrist structures involved in carpal tunnel syndrome. B, Decompression of median nerve by incision through the transverse carpal ligament.

Carpal Tunnel Syndrome

•Open fractures require aggressive surgical debridement. •Extent of soft tissue damage determines whether •Wound will be closed at time of surgery •Drainage may be necessary •Skin grafting will be needed •The wound is initially cleansed by pulsating saline lavage in the operating room. •Gross contaminants are irrigated and mechanically removed. •Contused, contaminated, and devitalized tissues such as muscle, subcutaneous fat, skin, and fragments of bone are surgically excised (debridement). •During the postoperative phase, the patient will have antibiotics administered intravenously for 3 to 7 days.

Collaborative Care

•is most commonly associated with trauma, fracture (especially of the long bones), extensive soft tissue damage, and crush injury. •Elevated intracompartmental pressure within a confined myofascial compartment compromises neurovascular function of tissues within that space. •Causes capillary perfusion to be reduced below the level necessary for tissue viability •Is classified as acute, chronic/ exertional, or crush syndrome •38 compartments are located in the upper and lower extremities. •Depending on the patient's age and body mass index, the expected range of intracompartmental pressure readings is 0 to 10 mm Hg. •Readings of ≥30 mm Hg indicate compartment syndrome. •Picture: Volkmann's ischemic contracture of the forearm following acute compartment syndrome secondary to a supracondylar fracture of the humerus. Note the incision line of an unsuccessful fasciotomy.

Compartment Syndrome

•Majority heal without complication. •If death occurs, usually result of •Damage to underlying organs and vascular structures •Complications of fracture or immobility •May be either direct or indirect

Complications

•Machines can provide continuous passive motion (CPM) to various joints. •Helps prevent extraarticular and intraarticular adhesions •Results in faster reconstruction of subchondral bone plate, rapid healing of articular cartilage, and decreased complications

Continuous Passive Motion

•Problems with bone infection •Bone union Avascular necrosis

Direct Complications

•Complete displacement or separation of the joint •Usually a result of force •Thumb, elbow, shoulder •Hip, patella •Patella dislocates more in girls due to weaker quadriceps muscle •S/S •Deformity, shorter limb and internally rotated •Pain •Loss of function •swelling

Dislocation

•Stimulate bone healing •Electric currents modify cell mechanisms, causing bone remodeling. •Electrodes are placed over skin or cast and are used 10 to 12 hours each day. •The underlying mechanism for electrically induced bone remodeling remains unknown. It is thought to be related to negative electrical fields attracting positive ions such as calcium.

Electrical Stimulation and Pulsed Electromagnetic Fields (PEMFs)

•Metallic device •Composed of metal pins inserted into bone and attached to external rods •Applies traction or compresses fracture fragments •Immobilizes ↓ fragments when cast or other traction is not appropriate •External device holds fracture fragments in place similar to a surgically implanted internal device. •Attached directly to bone by percutaneous transfixing pins or wires A, Stabilization of hand injury. B, Stabilization of knee injury with pins in femur and tibia.

External Fixation

DRUG THERAPY REVIEW •Patients have varying degrees of pain associated with muscle spasms. •Involuntary reflexes result from edema and nerve injury following muscle injury. •Central and peripheral muscle relaxants may be prescribed. •Central and peripheral muscle relaxants include carisoprodol (Soma), cyclobenzaprine (Flexeril), and methocarbamol (Robaxin). •Side effects of muscle relaxants •Drowsiness •Lassitude •Headache •Weakness and fatigue •Blurred vision •Ataxia •Gastrointestinal upset •Ingestion of large doses of muscle relaxants may cause hypotension, tachycardia, or respiratory depression. •Hypersensitivity reactions may include skin rash or pruritus. •The possible habituating effects associated with long-term use and the potential for abuse must be carefully considered. •

FACTS

•Disruption or break in continuity of the structure of bone •Majority of fractures from traumatic injuries •Some fractures secondary to disease process •Cancer or osteoporosis

FRACTURES

•Presence of systemic fat globules from fracture that are distributed into tissues and organs after a traumatic skeletal injury •Contributory factor in many deaths associated with fracture •Fractures most often causing FES are those of long bones, ribs, tibia, and pelvis. •Known to occur following total joint replacement, spinal fusion, liposuction, crash injury, and bone marrow transplantation Two theories related to origin 1. Mechanical theory •Fat is released from marrow of injured bone. •Driven out by an increase in intramedullary pressure •Enters circulation through draining veins traveling to pulmonary capillaries, where it lodges •Fat droplets transverse capillary bed to enter systemic circulation, where they then embolize to other organs 2. Biochemical theory •Catecholamines released at time of trauma mobilize free fatty acids from adipose tissue. •Causes loss of chylomicron emulsion stability •Chylomicrons form large fat globules that eventually lodge in the lungs. •Biochemical change sets up an inflammatory response secondary to destabilization of free fatty acids. •Tissues most often affected •Lungs, Brain, Heart, Kidneys, Skin

Fat Embolism

fracture is an incomplete fracture with one side splintered and the other side bent

Greenstick fracture

•Femoral fractures •Immobilizes affected extremity and trunk securely •Includes two casts joined together •Body jacket cast •Long leg cast •The location of the femoral fracture will determine whether the thigh of the unaffected extremity will have to be immobilized to restrict rotation of the pelvis and possible hip motion on the side of the femoral fracture. •The hip spica cast extends from above the nipple line to the base of the foot (single spica) and may include the opposite extremity up to an area above the knee (spica and a half) or both extremities (double spica). •When the patient is positioned, the support bar joining the thighs must never be used to assist in moving because the bar can break and cause cast disruption. •Assess patient for same problems as body jacket cast. •Nurse should instruct patient in positioning activities required to get on and off bedpan. •Fracture bedpan may be used.

Hip Spica Cast

•bone is still in one piece but break occurs across the bone shaft

Incomplete

COLLABORATIVE CARE EXTERNAL FIXATION

Indications •Simple fractures and complex fractures with extensive soft tissue damage •Correction of bony defects (congenital) •Pseudoarthrosis •Nonunion or malunion •Limb lengthening •External fixation has many advantages over other fracture management strategies and is often employed in an attempt to salvage extremities that otherwise might require amputation. Infection control is critical. •Infection signaled by •Exudate •Erythema •Tenderness •Pain •Instruct patient and family on meticulous skin care. •Although each physician has a protocol for pin care cleaning, half-strength hydrogen peroxide with normal saline is often used.

•Blood vessels and nerve damage •Compartment syndrome •Deep vein thrombosis •Fat embolism •Traumatic or hypovolemic shock

Indirect Complications

•High incidence in open fractures and soft tissue injuries •Massive or blunt soft tissue injury often has more serious consequences than fracture. •Devitalized and contaminated tissue is an ideal medium for pathogens. •Treatment is costly in terms of •Extended nursing and medical care •Time for treatment •Loss of patient income •Osteomyelitis may become chronic.

Infection

Initial Assessment Initial Treatment

Initial Assessment •Subjective and objective data that should be obtained from an individual with a fracture are presented on p. 1475, Table 62-8. Initial Treatment •Review p. 1474, Table 62-7 for the emergency management of fracture • •Ongoing monitoring - for the remaining slides always ask yourself why are we doing this, what are we looking for? •

•Surgically inserted at time of realignment •Biologically inert metal devices used •Stainless steel •Vitallium •Titanium •Alignment evaluated by x-ray •Views of internal fixation devices to stabilize a fractured tibia and fibula. •

Internal Fixation

•Crescent shaped fibrocartilage in the knee •Associated with sprains of sports origin •Rotation causes the tear •Degenerative tears with squatting or kneeling •Minimal swelling •Pain on flexion, internal rotation, then extension (McMurray's test) •"click, pop, give way" •May see a weak quadriceps

Meniscus Injury

•Injury of the knee - common in football, soccer, and hockey •Warm up activities •Should be seen in 24 hours of injury •RICE •Knee immobilizer •Pain relief •Physical therapy to get back full flexion •Strengthening exercises •Meniscal Surgery •Tack or suture Arthroscopic views of the meniscus. A, Normal meniscus. B, Torn meniscus. C, Surgically repaired meniscus

Meniscus Injury

•Pivots, lands from a jump •Come down on knee, twist (Basketball) •Report a "pop" •Pain •Swelling •Knee feels unstable •Lachman's test •Flexing the knee and pulling the tibia forward while stabilizing the femur •Forward motion of the tibia with a soft endpoint

Noncontact Injury

bone is aligned and periosteum is intact

Nondisplaced fracture

NURSING AND COLLABORATIVE MANAGEMENT: CARPAL TUNNEL SYNDROME

Nursing Care and Collaborative Management •Splints to keep in slight extension •Wear to bed also •Stop the aggravating movements •Change jobs? •Surgery for symptoms >6 months •Same day surgery •Keyboard pads and mouse's •Steroid injections

Nursing Diagnoses Planning

Nursing Diagnoses •Risk for peripheral neurovascular dysfunction •Impaired physical mobility •Acute pain •Ineffective self-health management Planning •Overall goals •Have physiologic healing with no associated complications •Obtain satisfactory pain relief •Achieve maximal rehabilitation potential

is a spontaneous fracture at the site of a bone disease

Pathologic fracture

Sprains and strains what do you do?

RICE Immediate care after a sprain or strain injury includes the application of cold and compression to the injury to minimize swelling. Other actions should be taken after the ankle is wrapped with a compression bandage and ice is applied.

•Closed reduction or surgery •Local or conscious sedation •Immobilize for ligament to heal •Brace, splint •Gradual increase of ROM •Prevent dislocation or fracture •Pain control •Will be at risk for another dislocation in the future

Realignment

•Complex of 4 muscles that stabilize the humeral head •Normal aging •Repetitive stress •Trauma •Will notice shoulder weakness •Pain •Decreased ROM

Rotator Cuff Injury

•Ensures axillary area is well padded •Placement should not put undue pressure on posterior neck. •Encourage patient to move fingers and non-immobilized joints of the upper extremity.

Sling

What type of tissue injury is a sprain and strain?

Soft Tissue Injuries

•Partial of incomplete separation of the joint •Symptoms are less sever •Treatment is same with less healing time • •Major Complications of both: •Avascular necrosis •Neurovascular damage A shorter limb after a fall indicates a possible dislocation, which is an orthopedic emergency. Bruising, pain, and decreased range of motion also should be reported, but these do not indicate that emergent treatment is needed to preserve function.

Subluxation

•Acute wrist injuries •Injuries that result in significant swelling

Sugar-tong splint

•Molded to fit torso or extremity after being activated by submersion in cool or tepid water •Used more often because they are lightweight and relatively waterproof, and provides immediate immobilization •Still usually wrap the cast in a clean garbage bag for showers •Casting is a common treatment following closed reduction.

Synthetic Casting Materials

•Application of a pulling force to an injured or diseased part of body or extremity, while countertraction pulls in opposite direction •Purpose of any traction •Prevent or ↓ muscle spasm •Immobilize joint or part of body •↓ a fracture or dislocation •Treat a pathologic joint condition •Traction also indicated to •Provide immobilization to prevent soft tissue damage •Reduce muscle spasm associated with low back pain or cervical whiplash •Expand a joint space •During arthroscopic procedures •Before major joint reconstruction

Traction

•Veins of lower extremities and pelvis are highly susceptible to thrombosis. •Precipitating factors •Incorrectly applied cast or traction •Local pressure on a vein •Immobility •Venous thromboembolism (VTE) may also occur after total hip or total knee replacement surgery. •Aggravated by inactivity of muscles that normally assist in pumping action of venous blood •Instruct patient to •Wear compression gradient stockings •Prophylactic anticoagulant drugs may be ordered. •The patient's clinical manifestations and history are consistent with a pulmonary embolus, and the nurse's first action should be to ensure adequate oxygenation. The nurse should offer reassurance to the patient, but meeting the physiologic need for oxygen is a higher priority. The health care provider should be notified after the oxygen is started and pulse oximetry and assessment for fat embolus or venous thromboembolism (VTE) are obtained.

Venous Thromboembolism

•Temporary circumferential immobilization device •Allows patient to perform many normal activities of daily living •Cast materials are natural, synthetic acrylic, fiberglass-free, latex-free polymer, or a hybrid of materials.

casting

skin intact

clsoed fracture

is a fracture with more than two fragments. The smaller fragments appear to be floating.

comminuted fracture

break is completely through bone

complete fracture

two ends separated from one another

displaced fracture

fracture is a fracture in which the line of the fracture extends in an oblique direction

oblique

skin broken and bone and soft tissue exposed

open fracture

is a fracture in which the line of the fracture extends in a spiral direction along the shaft of the bone.

spiral fracture

is a fracture that occurs in normal or abnormal bone that is subject to repeated stress, such as from jogging or running. •

stress fracture

is a fracture in which the line of the fracture extends across the bone shaft at a right angle to the longitudinal axis.

transverse fracture

Factors Influencing Healing

•Age •Time required for healing increases with age •An example of the influence of age: an uncomplicated mid-shaft fracture of the femur heals in 3 weeks in a newborn and in 20 weeks in an adult. •Initial displacement •Site of fracture •Implants •Infection •Blood supply to area •Hormones •The ossification process may be arrested by inadequate reduction and immobilization, excessive movement of the fracture fragments, infection, poor nutrition, and systemic disease. •Fracture healing may •Not occur in the expected time •Delayed union •Not occur at all •Nonunion •Table 62-5 on p. 1470 summarizes complications of fracture healing.

Goals of Fracture Management

•Anatomic realignment of bone fragments •Immobilization to maintain realignment •Restoration of normal or near-normal function of injured parts •Table 62-6 on p. 1470 summarizes the collaborative care of fractures.

Cast Care DO'S

•Apply ice directly over fracture site for first 24 hours •Check with health care provider before getting fiberglass wet •Dry cast after exposure to water •Elevate extremity above level of heart for first 48 hours •Move joints above and below cast regularly •Report signs of possible problems to health care provider •Keep appointment to have fracture and cast checked

Clinical manifestations of fracture healing

•Bone goes through a remarkable reparative process of self-healing. •Fracture hematoma •initial 72 hours •Bleeding creates a hematoma, surrounding ends of fragments. •Hematoma is extravasated blood that changes from liquid to semisolid clot. •Granulation tissue •3 to 14 days post injury •Active phagocytosis absorbs products of local necrosis. •Hematoma converts to granulation tissue. •Granulation tissue produces basis for new bone substance (osteoid). •Granulation tissue consists of new blood vessels, fibroblasts, and osteoblasts. •Callus formation •end of second week •Minerals and new bone matrix are deposited in osteoid. •Unorganized bone network is formed and woven around fracture parts. •Callus is composed primarily of cartilage, osteoblasts, calcium, and phosphorus. • Evidence of callus formation can be verified by x-ray. •Ossification •Consolidation •As callus continues to develop, distance between bone fragments diminishes and eventually closes. •Ossification continues. •Can be equated with radiologic union •Radiologic union occurs when x-ray provides evidence of complete bony union. •This phase can occur up to a year following injury. •Remodeling • up to a year after injury •Excess bone tissue is reabsorbed. •Union is complete. •Gradual return to preinjury structural strength and shape occurs. •Bone remodels in response to physical loading stress. •Initially, stress is provided through exercise. •Weight bearing is gradually introduced. New bone is deposited in sites subjected to stress and resorbed at areas where there is little stress. •Radiologic union is present. • A, Bleeding at fractured ends of the bone with subsequent hematoma formation. B, Organization of hematoma into fibrous network. C, Invasion of osteoblasts, lengthening of collagen strands, and deposition of calcium. D, Callus formation: new bone is built up as osteoclasts destroy dead bone. E, Remodeling is accomplished as excess callus is reabsorbed and trabecular bone is laid down.

Preventing Complications

•Constipation can be prevented by •Increased activity •High fluid intake (>2500 mL/day) •Diet high in bulk and roughage •Warm fluids, stool softeners, laxatives, or suppositories may be necessary. •Maintain a regular time for elimination to promote bowel regularity. • Renal calculi •Can develop as a result of bone demineralization •Fluid intake of 2500 mL/day •Cranberry juice or ascorbic acid •Rapid deconditioning of cardiopulmonary system •Result of prolonged bed rest •Results in •Orthostatic hypotension •Decreased lung capacity •Risk for DVT and PE •Unless contraindicated, these effects can be diminished by having the patient sit on the side of the bed, allowing the patient's lower limbs to dangle over the bedside, and having the patient perform standing transfers. •When the patient is allowed to increase activity, assess for orthostatic hypotension.

COLLABORATIVE CARE FRACTURE REDUCTION for open reduction fracture

•Correction of bone alignment through surgical incision •Includes internal fixation with use of wires, screws, pins, plates, intramedullary rods, or nails •Type and location of fracture, age of patient, and presence of concurrent disease, as well as the outcome of attempted closed reduction by means of traction, may influence the decision to use open reduction. •ORIF facilitates early ambulation, which decreases the risk of complications related to prolonged immobility, and promotes fracture healing with gradually increasing increments of stress placed upon the affected joint and soft tissue structures. •Chief disadvantages •Possibility of infection •Complications associated with anesthesia •Effects of preexisting medical conditions •Early initiation of ROM of the joint •If open reduction with internal fixation (ORIF) is used for intraarticular fractures

•A cylinder cast is used for knee injuries or fractures.

•Cylinder cast

Assistive Devices

•Devices for ambulation range from a cane to a walker or crutches. •Involves balancing need for maximum stability and safety •Common gait patterns with assistive devices •Two-point gait •Four-point gait •Swing-to gait •Swing-through gait •The technique for using assistive ambulation devices varies. •The involved limb is usually advanced at the same time or immediately after advance of the device. The uninvolved limb is advanced last. •In almost all cases, the cane is held in the hand opposite the involved extremity. •Transfer belt should be placed around patient's waist to provide stability during learning stages. •Discourage patient from reaching for furniture or relying on another person for support. •With inadequate upper limb strength or poorly fitted crutches, the patient bears weight at the axilla rather than at the hands, endangering the neurovascular bundle that passes across the axilla. •If verbal coaching does not correct the problem, instruct the patient in another form of ambulation until strength is adequate (e.g., platform crutches, walker).

clinical manifestations of compartment syndrome

•Early recognition and treatment essential •Must notify the doctor •Ischemia can occur within 4 to 8 hours after onset. •Delay in diagnosis and treatment may lead to severe functional impairment. •Regular neurovascular assessments •May occur initially or may be delayed for several days • •Six Ps are characteristic of impending compartment syndrome. •Paresthesia: numbness and tingling •Pain: distal to injury that is not relieved by opioid analgesics and pain on passive stretch of muscle traveling through compartment •Pressure: ↑ in compartment •Pallor: coolness and loss of normal color of extremity •Paralysis: loss of function •Pulselessness: diminished/absent peripheral pulses •All of these are circulatory issues •Urine output must be assessed because there is a possibility of muscle damage. •Myoglobin released from damaged muscle cells precipitates as a gel-like substance. •Causes obstruction in renal tubules Large amounts of myoglobin may result in acute tubular necrosis. Acute tubular necrosis causes acute renal failure. Common signs of myoglobinuria Dark reddish brown urine Clinical manifestations associated with acute renal failure

Clinical manifestations of a fat embolism

•Early recognition crucial in preventing potentially lethal course •Most patients manifest symptoms 24 to 48 hours after injury. •Severe forms have occurred within hours of injury. •Fat globules transported to lungs cause a hemorrhagic interstitial pneumonitis. •Hemorrhagic interstitial pneumonitis produces signs and symptoms of acute respiratory distress syndrome (ARDS), such as chest pain, tachypnea, cyanosis, dyspnea, apprehension, tachycardia, and decreased partial pressure of arterial oxygen (PaO2). •Clinical course of fat embolus may be rapid and acute. •Patient frequently expresses a feeling of impending disaster. •In a short time skin color changes from pallor to cyanosis. •Patient may become comatose.

COLLABORATIVE CARE INJURIES TO LOWER EXTREMITIES AFTER CASTING

•Elevate extremity onto pillows above heart level for first 24 hours. •After initial phase, casted extremity should not be placed in a dependent position because of the possibility of excessive edema. •Observe for signs of pressure.

Nursing Management of Traction

•Fracture alignment depends on correct positioning and alignment while traction forces remain constant. •Forces must be pulling in opposite direction to prevent patient from sliding to end or side of bed. •Countertraction commonly supplied by patient's body weight or augmented by elevating end of bed •Imperative that nurse maintains traction constantly and does not interrupt weight applied to traction

CAST CARE DONT'S

•Get plaster cast wet •Remove any padding •Insert any objects inside cast •Bear weight on new cast for 48 hours •Not all casts are weight bearing •Cover cast with plastic for prolonged periods

•A Jones dressing is composed of bulky padding materials (absorption dressing and cotton sheet wadding), splints, and an elastic wrap or bias-cut stockinette.

•Jones dressing

•Treatment of stable forearm or elbow fracture and unstable wrist •Similar to short arm cast but extends to proximal humerus, restricting motion in wrist and elbow •The nurse should direct your care in supporting the extremity and reducing the effects of edema by maintaining extremity elevation with a sling. •However, when a hanging arm cast is used for a proximal humerus fracture, elevation or a supportive sling is contraindicated because hanging provides traction and maintains fracture alignment. •Plaster splints are applied over a well-padded forearm, beginning at the phalangeal joints of the hand, extending up the dorsal aspect of the forearm around the distal humerus, and then extending down the volar aspect of the forearm to the distal palmar crease.

•Long arm cast

•Indications •Unstable ankle fracture •Soft tissue injuries •Fractured tibia •Knee injuries •The cast usually extends from the base of the toes to the groin and gluteal crease.

•Long leg cast

How do you treat rotator cuff injury?

•Maintaining ROM •Increase abduction strength •Rest, ice and heat •NSAIDs •Corticosteroids injections •Physical Therapy •Before and after surgery •Surgery •Sling •Frozen shoulder Physical therapy after a rotator cuff repair begins on the first postoperative day to prevent "frozen shoulder." A shoulder immobilizer is used immediately after the surgery, but leaving the arm immobilized for several days would lead to loss of range of motion (ROM). The drop-arm test is used to test for rotator cuff injury, but not after surgery.

Interventions for compartment syndrome

•May be necessary to remove or loosen bandage or bivalve cast •Reduction in traction weight may ↓ external circumferential pressures. •Surgical decompression (e.g., fasciotomy) of the involved compartment may be necessary.

Clinical manifestations of a fracture

•Mechanism of injury associated with numerous signs and symptoms •Immediate localized pain •Decreased function •Inability to bear weight on or use affected part •Patient guards and protects extremity. •Crepitation •Edema and swelling •Ecchymosis •Deformity is the cardinal sign of fracture •Fracture may not be accompanied by obvious bone deformity. •Immobilize extremity if fracture is suspected. •Unnecessary movement •Increases soft tissue damage •May convert a closed fracture to open Read table 62-4 on page 1469

Postoperative Management

•Monitor vitals. •Perform frequent neurovascular assessments of affected extremity. •Minimize pain and discomfort through proper alignment and positioning. •Monitor limitations in movement. •Carefully observe dressings or casts for bleeding or drainage. •Significant ↑ in size of drainage area should be reported. •Measure and assess patency of system and volume of drainage.

Neurovascular Assessment

•Musculoskeletal injuries can cause changes in neurovascular status. •Causes of nerve or vascular damage •Application of a cast or constrictive dressing •Poor positioning •Physiologic responses •Neurovascular assessment should consist of a peripheral vascular assessment (color, temperature, capillary refill, peripheral pulses, and edema) and a peripheral neurologic assessment (sensation, motor function, and pain). •Remember to check CMS (Circulation, Motor, Sensation)

FAT EMBOLISM (FES) diagnosis

•No specific laboratory examinations are available. •Certain diagnostic abnormalities may be present. •Fat cells in blood, urine, or sputum •↓ platelet count and hematocrit levels •Prolonged prothrombin time •A chest x-ray may reveal areas of pulmonary infiltrate or multiple areas of consolidation. This is sometimes referred to as the white-out effect.

COLLABORATIVE CARE FRACTURE REDUCTION for closed reduction fracture

•Nonsurgical, manual realignment of bone fragments to previous anatomic position •Traction and countertraction manually applied to bone fragments to restore position, length, and alignment •Closed reduction is usually performed while the patient is under local or general anesthesia. •After reduction, traction, casting, external fixation, splints, or orthoses (braces) immobilize the injured part to maintain alignment until healing occurs.

Ambulation NURSING CARE

•Nurse may need to assist patient with lower extremity dysfunction. •Usually start mobility training when able to sit in bed, dangle feet over side •Degrees of weight-bearing ambulation •Non-weight-bearing ambulation •Touch-down/toe-touch weight-bearing ambulation •Partial-weight-bearing ambulation •Weight bearing as tolerated •Full-weight-bearing ambulation •Mobility training and instruction in the use of assistive aids (cane, crutches, walker) constitute major areas of responsibility for the physical therapist.

Preoperative Management

•Nurse should •Inform patients of •Immobilization •Assistive devices that will be used •Expected activity limitations after surgery •Assure patients that pain medication will be available •Skin preparation is very important. •The protocol for skin preparation varies among institutions and may be your responsibility. •Assist in cleansing skin. •Remove debris and hair to reduce infection.

NURSING MANAGMENT FOR TRACTION

•Nurse should inspect exposed skin regularly when slings are used with traction. •Pressure over bony prominence created by wrinkling sheets or bedclothes may cause pressure necrosis. •Persistent skin pressure may impair blood flow and cause injury to peripheral neurovascular structures. •The patient can lift the buttocks off the bed by using the unaffected leg without changing the affected-leg alignment. •Turning the patient will tend to move the leg out of alignment. •Disconnecting the traction will interrupt the weight needed to immobilize and align the fracture. •Observe skeletal traction pins for infection. •Pin care varies but usually includes regular removal of exudate, rinsing of pin sites, and drying of the area. •External rotation of hip can occur when skin traction is used on lower extremities. •Nurse can correct this position by placing a pillow, sandbag, or rolled-up draw sheet along greater trochanteric region of the femur. •Generally, the patient should be in the center of the bed in a supine position. Incorrect alignment can result in increased pain and nonunion or malunion. •To offset some of the problems associated with prolonged immobility, discuss specific patient activity with the health care provider. If exercise is permitted, encourage participation by the patient in a simple exercise regimen based on activity restrictions.

•Accommodates swelling in fractured extremity post injury

•Posterior splint

•Prefabricated knee and ankle splints and immobilizers are being used in many settings. •This type of immobilization, which permits close observation of the affected joint for signs of swelling and skin breakdown, is easy to apply and remove. •

•Prefabricated splint or immobilizer

Collaborative care for compartment syndrome

•Prompt, accurate diagnosis •Extremity should not be elevated above heart level. •Elevation may raise venous pressure and slow arterial perfusion. •Application of cold compresses may result in vasoconstriction and may exacerbate compartment syndrome. •Pain unrelieved by drugs and out of proportion to the level of injury is one of the first indications of impending compartment syndrome.

COLLABORATIVE CARE NUTRITIONAL THERAPY

•Proper nutrition is essential. •Adequate energy source needed to •Promote muscle strength and tone •Build endurance •Provide energy for ambulation and gait-training skills •Patient's dietary requirements must include •Ample protein (1 g/kg of body weight) •Vitamins (B, C, D) •Calcium •Phosphorus •Magnesium •Adequate fluid intake •2000 to 3000 mL/day •High-fiber diet with fruits and vegetables •For body jacket and hip spica cast patients: 6 small meals a day •To avoid over distention of the abdomen and place pressure on the tissues •Low serum protein levels and vitamin C deficiencies interfere with tissue healing. •Immobility and callus formation increase calcium needs. •Three well-balanced meals a day will usually provide the necessary nutrients. • •

Health Promotion

•Public should be taught to take appropriate safety precautions. •Personal actions known to reduce injury include regular use of seat belts, driving within posted speed limits, warming up muscles before exercise, use of protective athletic equipment (helmets and knee, wrist, and elbow pads), use of safety equipment at work, and not combining drinking and driving. •Nurses should advocate for personal actions to decrease injuries. •Warm-ups •Encourage moderate exercise to keep muscles strong and maintain balance. •Calcium and vitamin D intake

NURSING AND COLLABORATIVE MANAGEMENT: ACL INJURY

•RICE •NSAID's •Physical Therapy to maintain motion and muscle tone •Surgery •Removal and replaced with donor tissue •May take 6-8 months to recover •Higher risk of knee osteoarthritis later

•Treatment of stable wrist or metacarpal fracture •Circular cast extending from distal palmar area to proximal forearm •Provides wrist immobilization •Permits unrestricted elbow motion

•Short arm cast

•The short leg cast can be used for a variety of conditions but is primarily used for stable ankle and foot injuries.

•Short leg cast

Psychosocial Problems

•Short-term rehabilitative goals •Transition from dependence to independence in performing simple activities of daily living •Preserve or ↑ strength and endurance •Long-term rehabilitative goals •Prevent problems associated with musculoskeletal injury •See page 1478, table 62-10

•In place for longer periods •Used to align injured bones and joints or to treat joint contractures and congenital hip dysplasia •Provides a long-term pull that keeps injured bones and joints aligned •Physician inserts pin or wire into bone, either partially or completely, to align and immobilize injured body part. •Skeletal traction weight range: 5 to 45 pounds •Too much weight results in delayed union or nonunion. •The major disadvantages of skeletal traction are infection in the area of the bone where the skeletal pin is inserted and the consequences of prolonged immobility. •

•Skeletal traction

•Used for short-term treatment until skeletal traction or surgery is possible •Skin traction is generally used for 48 to 72 hours. •Tape, boots, or splints applied directly to skin to maintain alignment, assist in reduction, and help diminish muscle spasms in injured extremity •Traction weights 5 to 10 pounds •Pelvic or cervical skin traction may require heavier weights applied intermittently.

•Skin traction

FAT EMBOLISM (FES) treatment

•Treatment is directed at prevention. •Careful immobilization of a long bone fracture is probably the most important factor in prevention. •Management is essentially symptom related and supportive. •Treatment •Oxygen to treat hypoxia •Fluid resuscitation •Correction of acidosis •Replacement of blood loss •Encourage coughing and deep breathing. •The patient's clinical manifestations and history are consistent with a pulmonary embolus, and the nurse's first action should be to ensure adequate oxygenation. The nurse should offer reassurance to the patient, but meeting the physiologic need for oxygen is a higher priority. The health care provider should be notified after the oxygen is started and pulse oximetry and assessment for fat embolus or venous thromboembolism (VTE) are obtained. •Reposition the patient as little as possible before fracture immobilization or stabilization because of the danger of dislodging more fat droplets into the general circulation. •Use of corticosteroids to prevent or treat fat embolism is controversial.

•Related to bleeding, edema, chemical response to snakebite, or IV filtration

•↑ compartment size

•Resulting from restrictive dressing, splints, casts, excessive traction, or premature closure of fascia

•↓ compartment size