Chapter 42: Management of Patients with Musculoskeletal Trauma

A closed Fracture: (simple fracture)

(simple fracture) is one that does not cause a break in the skin.

Medical management: Closed fracture reduction

(when there is no open wound) closed reduction is accomplished by bringing the bone fragments into anatomic alignment through manipulation and manual traction. The extremity is held in the aligned position while a cast, splint, or other device is applied. Reduction under anesthesia with percutaneous pinning may also be used. The immobilizing device maintains the reduction and stabilizes the extremity for bone healing. X-rays are obtained after reduction to verify that the bone fragments are correctly aligned Traction (skin or skeletal) may be used until the patient is physiologically stable to undergo surgical fixation.

Chart 42-2: Factors that Affect Fracture Healing **MUST KNOW***

***1. Age >40 years*** 2. Avascular necrosis -when there is not enough blood supply to the bone and to the tissue 3. Bone loss -extensive bone loss 4. Cigarette smoking 5. Comorbidities (e.g., diabetes, rheumatoid arthritis) ***6. Corticosteroids, nonsteroidal anti-inflammatory drugs**** 7. Extensive local trauma **8. Inadequate immobilization** -it wasn't mobilize 9. Infection 10. Local malignancy 11. Malalignment of the fracture fragments 12. Space or tissue between bone fragments 13. Weight bearing prior to approval -when they bear weight when they are told not to bear weight **14. Inadequate blood supply to the fracture site or adjacent tissue**

Prompting Physical Mobility

***1. Maintain neutral position of hip** prevents stress at the site of fixation 2. Use trochanter rolls Minimizes external rotation 3. Maintain abduction of hip Place pillow between legs when turning. 4. Isometric, quad-setting, and gluteal-setting exercises -Strengthens muscles needed for walking. 5. Use of trapeze -Strengthens shoulder and arm muscles necessary for use of ambulatory aids. 6. Use of ambulatory aids Prevents injury from unsafe use. 7. Consultation with physical therapy Amount of weight bearing depends on the patient's condition, fracture stability, and fixation device; ambulatory aids are used to assist the patient with non-weight-bearing and partial-weight-bearing ambulation.

How to prevent FES (fat embolism syndrome)

***Immediate immobilization of fractures*** -get the fracture immbolize and reduce as quickly as possible -including early surgical fixation minimal fracture manipulation, and adequate support for fractured bones during turning and positioning and maintenance of fluid and electrolyte balance are measures that may reduce the incidence of fat emboli. There is no specific treatment for FES; the treatment is supportive. Vasopressors, mechanical ventilation, and sometimes corticosteroids are used as supportive therapy

Nursing Interventions: Promote Wound Healing

***The residual limb must be handled gently and should be measured once every 8 to 12 hours*** postoperatively to assess for edema formation. Neurovascular assessments are also performed at these intervals, to ensure that there is adequate blood supply. The dressing is changed as prescribed and whenever soiled, using aseptic technique to prevent infection and possible osteomyelitis Application of consistent pressure to the residual limb reduces edema formation and helps to shape the residual limb so that it may fit a prosthetic. The wound should be assessed to ensure that it is healing and that there are no signs of infection (e.g., redness, purulent drainage), which can also hamper optimal prosthetic fit.

Collaborative Problems and Potential Complications

***you do your 6 Ps and you notify if you notice any signs of this:*** -Hemorrhage -Peripheral neurovascular dysfunction -DVT -Pulmonary complications -nurse are trying to prevent them, turn them, have them take deep breaths -Pressure ulcers -nurse job; we try to prevent it but get collaborative help if it happens

Stable Pelvic Fracture

**benign**- ***the pelvis can heal quickly from a stable fracture because of good blood supply*** -***Need a few days of bed rest (come with complications: paralytic ileus (can push fluids, give foods high in fiber, stool softeners), pressure ulcers, VTE, and PE, urinary retention (encourage fluids, want to get them on most natural position as possible)*** -Can have respiratory problems such as atelectasis and pneumonia (use deep breathing & incentive spirometer) Stable fractures of the pelvis include fracture of a single pubic or ischial ramus, fracture of ipsilateral pubic and ischial rami, fracture of the pelvic wing of the ilium (Duverney's fracture), and fracture of the sacrum or coccyx. If injury results in only a slight widening of the pubic symphysis or the anterior sacroiliac joint and the pelvic ligaments are intact, the disrupted pubic symphysis is likely to heal spontaneously with conservative management. Most fractures of the pelvis heal rapidly because the pelvic bones are mostly cancellous bone, which has a rich blood supply. ***Stable pelvic fractures are treated with a few days of bed rest and symptom management until discomfort is controlled.*** ***Fluids, dietary fiber, ankle and leg exercises, antiembolism stockings to aid venous return, logrolling, deep breathing, and skin care reduce the risk of complications and increase the patient's comfort.**** ***The patient with a fractured sacrum is at risk for paralytic ileus; therefore, bowel sounds should be monitored*** - the difference . The patient with a fracture of the coccyx experiences pain when sitting and when defecating. ***Sitz baths may be prescribed to relieve pain, and stool softeners may be given to ease defecation. *** As pain resolves, activity is gradually resumed with the use of assistive mobility devices. Early mobilization reduces problems related to immobility Rehabilitation focuses on the goal of full weight-bearing status by 3 months post injury

***Simple fracture***

- known as closed fracture a fracture that remains contained with no disruption of the skin integrity

Medical management: Open Fracture Reduction

-**We don't put a cast on it, because we don't put it over a open wound because it can cause infection** (when there is an open wound) Some fractures require open reduction. Through a surgical approach, the fracture fragments are anatomically aligned. Internal fixation devices (metallic pins, wires, screws, plates, nails, or rods) may be used to hold the bone fragments in position until solid bone healing occurs. These devices may be attached to the sides of bone, or they may be inserted through the bony fragments or directly into the medullary cavity of the bone Internal fixation devices ensure firm approximation and fixation of the bony fragments **Must assess:** -for infection -circulation -neurovascular status **must assess if surgeon nicked a blood artery or a nerve**

**Pathologic fracture**

-A fracture that occurs through an area of diseased bone ex: osteoproisis, bone cyst, pagets disease,bony metastasis, tumor this can occur without trauma or fall

Nursing Interventions: Relief of Pain

-Administer analgesic or other medications as prescribed -Changing position - placing a light sandbag on the residual limb to counteract the muscle spasm may improve the patient's level of comfort. -Alternative methods of pain relief: distraction, TENS unit (applies small electrical current and confuses the nerve endings) Evaluation of the patient's pain and responses to interventions is an important component of pain management. Patients who have amputations may begin to experience phantom limb pain soon after surgery. acetaminophen, NSAIDs, gabapentinoids, opioids, and ketamine (infusion). Epidural and perineural catheter analgesia may be used during and immediately after the operation. Opioid analgesics may be effective in relieving postoperative pain. In addition, beta-blockers may relieve dull, burning discomfort; anticonvulsants control stabbing and cramping pain; and tricyclic antidepressants may not only alleviate phantom limb pain but may also be prescribed to improve mood and coping ability

Relief of Pain

-Administer analgesics as prescribed -Use of Buck traction as prescribed reduce muscle spasms and provide comfort must pay attention to skin -Handle extremity gently good time to premedicate before you turn the patient -Support extremity with pillows and when moving -Positioning for comfort keep body in alignment -Frequent position changes -Alternative pain relief methods

Medical Management of Hip fracture

-Buck's extension traction, a type of temporary skin traction, was traditionally applied because it was believed to reduce muscle spasm, to immobilize the extremity, and to relieve pain. -must immobilize the fracture before going into surgery -Its efficacy had never been established in clinical trials, however, so its routine prescription is not advocated -. The goal of surgical treatment for hip fractures is to obtain a satisfactory fixation so that the patient can be mobilized quickly and avoid secondary medical complications. - Surgical treatment consists of (1) open or closed reduction of the fracture and internal fixation, (2) replacement of the femoral head with a prosthesis (hemiarthroplasty), or (3) closed reduction with percutaneous stabilization for an intracapsular fracture. -Surgical intervention is carried out as soon as possible after injury. The preoperative objective is to ensure that the patient is in as favorable a condition as possible for the surgery. -Displaced femoral neck fractures are treated as emergencies, with reduction and internal fixation performed within 24 hours after fracture. The femoral head is often replaced with a prosthesis if there is complete disruption of blood flow to the femoral head, which may cause AVN . -After general or spinal anesthesia, the hip fracture is reduced under x-ray visualization. A stable fracture is usually fixed with nails, a nail and plate combination, multiple pins, or compression screw devices -The orthopedic surgeon determines the specific fixation device based on the fracture site or sites. -Adequate reduction is important for fracture healing—the better the reduction, the better the healing. Total hip arthroplasty may be used in selected patients with intracapsular fractures

Medical management: Fracture reduction:

-Fracture reduction refers to restoration of the fracture fragments to anatomic alignment and positioning. Either closed reduction or open reduction may be used to reduce a fracture. The specific method selected depends on the nature of the fracture; however, the underlying principles are the same. Usually, the physician reduces a fracture as soon as possible to prevent loss of elasticity from the tissues through infiltration by edema or hemorrhage. In most cases, fracture reduction becomes more difficult as the injury begins to heal -Before fracture reduction and immobilization, the patient is prepared for the procedure; consent for the procedure is obtained, and an analgesic agent is given as prescribed. -Anesthesia may be given. The injured extremity must be handled gently to avoid additional damage.

Types of fractures:

-Fractures types are classified by location (e.g., proximal, midshaft, distal) and type. - Fractures are also described according to the degree of break (e.g., a greenstick fracture refers to a partial break) or the character of any fractured bone fragments (e.g., a comminuted fracture has more than two fragments).

Contusion what are the symptoms of contusion? How does a hematoma develop? Contusion is managed with price- what does each letter stand for?

-Soft tissue injury produced by blunt force. Examples: such as a blow, kick, or fall, causing small blood vessels to rupture and bleed into soft tissues (ecchymosis or bruising). Local symptoms include pain, swelling, and discoloration, ecchymosis A hematoma develops from bleeding at the site of impact, leaving a characteristic "black and blue" appearance. Contusions can be minor or severe, isolated or in conjunction with additional injuries (e.g., fracture). ***Local symptoms include pain, swelling, and discoloration.*** Lecture: Pt. on blood thinners, are very susceptible to bruises Contusions are managed with PRICE, an acronym that refers to protection, rest, ice, compression, and elevation Most contusions resolve in 1 to 2 weeks.

Treatment for dislocation:

-The affected joint needs to be immobilized at the scene and during transport to the hospital. -The dislocation is promptly reduced, and displaced parts are placed back in proper anatomic position to preserve joint function. -HOW DO WE KNOW? WE DO OUR 6PS!!! -Analgesia, muscle relaxants, and possibly anesthesia are used to facilitate closed reduction. -The joint is immobilized by splints, casts, or traction and is maintained in a stable position. -Neurovascular status is assessed at a minimum of every 15 minutes until stable. -After reduction, if the joint is stable, gentle, progressive, active and passive movement is begun to preserve ROM and restore strength. The joint is supported between exercise sessions.

Unstable Pelvic Fractures

-Treated in the EMERGENCY ROOM, LOOKING FOR BLEEDING VESSELS ex; big traumas -can puncture or lacerate blood vessels and internal organs Unstable fractures of the pelvis may result in rotational instability (e.g., the "open book" type, in which a separation occurs at the symphysis pubis with sacroiliac ligament disruption), vertical instability, or a combination of both. (Unstable pelvic fractures; trauma team comes in) -MUST GET THEM INTO OR Lateral or anteroposterior compression of the pelvis produces rotationally unstable pelvic fractures. Vertically unstable pelvic fractures occur when force is exerted on the pelvis vertically, as may occur when the patient falls onto extended legs or is struck from above by a falling object. Vertical shear pelvic fractures involve the anterior and posterior pelvic ring with vertical displacement, usually through the sacroiliac joint. There is generally complete disruption of the posterior sacroiliac, sacrospinous, and sacrotuberous ligaments. ****Immediate treatment in the ED for a patient with an unstable pelvic fracture includes stabilizing the pelvic bones and compressing bleeding vessels with a pelvic girdle, which is an external binding and stabilizing device.**** **(they are high risk for hemmorhagic shock; they need to be put on some type of fixator)** If major vessels are lacerated, the bleeding may be stopped through embolization using interventional radiology techniques prior to surgery. More than 10% of deaths in patients with unstable pelvic fractures occur because of frank hemorrhage Therefore, these patients are at risk for hemorrhagic shock. . When the patient is hemodynamically stable, treatment generally involves external fixation or ORIF. These measures promote hemostasis, hemodynamic stability, comfort, and early mobilization.

Clinical Manifestations of Fractures:

-acute pain - loss of function - deformity -shortening of the extremity -crepitus, - localized edema, ecchymosis (swelling and discoloration) Diagnosis by symptoms; radiography -Patient usually reports injury to area

Nursing Priorities for hip fractures:

-immobilize the fracture before we get them into surgery with pillows - they are going to have external fixator pins screw rods -hydration -respiratory support -circulation checks (the 6 ps) -skin assessment (especially if they are in bucks traction) -pain control -prevention of immobility complications -hx of chronic conditions and medications

**Greenstick fracture**

-most seen in young children Fracture in which one side of the bone is broken and the other side of the bone is bent

WHos at risk for hip fractures

-the older you are the more at risk -women who are going through menopause (low estrogen levels) -medications -osteoprosis

The Care of the Patient With an Amputation—Assessment

1. Before surgery, the nurse must assess the **neurovascular assessment** and functional status of the limb through history and physical assessment. If the patient has experienced a traumatic amputation, the nurse assesses the function and condition of the residual limb. 2. **The nurse also assesses the circulatory status and function of the unaffected limb.**Assess for signs and symptoms of infection. If infection or gangrene develops, the patient may have associated enlarged lymph nodes, fever, and purulent drainage. A culture and sensitivity test is obtained to determine the appropriate antibiotic therapy. 3. **The nurse evaluates the patient's nutritional status** and develops a plan for nutritional care in consultation with a dietitian or metabolic or nutrition support team, if indicated. **A diet with adequate protein and vitamins such as vitamin C is essential to promote wound healing.*** **-Pt. blood sugar may go up; they may need to have insulin** 4. **Any concurrent health problems (e.g., dehydration, anemia, cardiac insufficiency, chronic respiratory problems, diabetes)**need to be identified and treated so that the patient is in the best possible condition to withstand the surgical procedure. The use of corticosteroids, anticoagulants, vasoconstrictors, or vasodilators may influence management and prolong or delay wound healing. 5. **The nurse assesses the patient's psychological status.** Evaluation of the patient's emotional reaction to amputation is important. Grief responses to permanent alterations in body image, function, and mobility are likely. Professional counseling can help the patient cope in the aftermath of amputation surgery.

What are the 3 injuries in the musculoskeletal system?

1. Contusion 2. Strain 3. Sprain

Delayed Union Malunion Nonunion MUST KNOW

1. Delayed Union -occurs when healing does not occur within the expected time frame for the location and type of fracture. -Delayed union may be associated with distraction (pulling apart) of bone fragments, systemic or local infection, poor nutrition, or comorbidity (e.g., diabetes, autoimmune disease). -The healing time is prolonged, but the fracture eventually heals -**when the two ends of the bone do not heal quickly ** 2. Malunion -the healing of a fractured bone in a malaligned position **the two ends of the bone heal but in an incorrect postion/nonalignment ** 3. Nonunion -results from failure of the ends of a fractured bone to unite -**no matter what we do the two ends of the bone won't heal**

Nursing intervention: Resolving Grief and Enhancing Body Image

1. Encourage communication and expression of feelings -support groups can come in handy 2.. Create an accepting, supportive atmosphere -your nurse face should be accepting -have good eye contact -Your face should not show any disguest 3. Provide support and listen 4. Encourage to look at, feel, and care for the residual limb -you want them to look and feel their residual limb so that they can take care of it. 5. Help set realistic goals -walking before jogging on their prosthesis 6. Help resume self-care and independence 7. Referral to counselors and support groups -thats when we get social workers involved Concept Mastery Alert: The nurse can provide the following interventions to foster a positive self-image: encouraging the patient to care for the residual limb, allowing the expression of grief, and introducing the patient to local amputee support groups.

The Care of the Patient With Fracture of the Hip—Assessment

1. Health history and presence of coexistent problems 2. Pain 3. VS, respiratory status, LOC, and signs and symptoms of shock -6 Ps 4. Affected extremity including frequent neurovascular assessment 5. Bowel and bladder elimination; bowel sounds, I&O 6. Skin condition -ex: the sacrum 7. Anxiety and coping

Chart 42-1: The Patient with a closed fracture Education for the patient/caregiver

1. Name the procedure that was performed and identify any changes in anatomic structure or function as well as changes in ADLs, IADLs, roles, relationships, and spirituality. 2. Identify modification of home environment, interventions, and strategies (e.g., durable medical equipment, adaptive equipment) used in safely promoting effective recovery and rehabilitation. 3. Describe ongoing therapeutic regimen, including diet and activities to perform (e.g., exercises) and to limit or avoid (e.g., lifting weights, driving a car, contact sports). 4. Describe approaches to control swelling (e.g., elevate extremity to heart level).Consume a healthy diet to promote bone healing. -Observe prescribed weight-bearing and activity limits. -Participate in prescribed exercise regimen to maintain the health of unaffected muscles and those muscles now needed for safe transfer, mobility, etc. -If indicated, demonstrate safe use of mobility aid, assistive device, immobilizing device and transfer technique. -State the name, dose, side effects, frequency, and schedule for all prescribed therapeutic and prophylactic medications (e.g., antibiotics, analgesic agents). -Control pain with pharmacologic and nonpharmacologic interventions. -Report pain uncontrolled by elevation and analgesics (may be an indicator of impaired tissue perfusion or compartment syndrome). -State indicators of complications to report promptly to primary provider (e.g., uncontrolled swelling and pain; cool, pale fingers or toes; paresthesia; paralysis; signs of local and systemic infection; signs of venous thromboembolism; problems with immobilization device). -State possible complications of fractures (i.e., delayed union; nonunion; avascular necrosis; complex regional pain syndrome, formerly called reflex sympathetic dystrophy syndrome; heterotopic ossification). -Describe gradual resumption of normal activities when medically cleared, and discuss how to protect fracture site from undue stresses. -Relate how to reach primary provider with questions or complications. -State time and date of follow-up appointments, therapy, and testing. -Identify the need for health promotion, disease prevention, and screening activities.

The Care of the Patient With Fracture of the Hip—Interventions #2

1. Orient patient to and stabilize the environment -Short-term memory may be faulty in the older adult; frequent reorientation helps. 2.Provide for patient safety -Mechanism for securing assistance is available to patient; independent activities based on faulty judgment may result in injury. 3. Encourage participation in self-care Participation in routine activities promotes orientation and increases awareness of self. 4. Encourage coughing and deep breathing exercises 5. Ensure adequate hydration Liquefies respiratory secretions; facilitates expectoration. 6. Apply TED hose or SCDs as prescribed Compression aids venous blood return and prevents stasis. 7. Encourage ankle exercises Muscle exercise promotes circulation. 8. Patient and family teaching

Collaborative Problems and Potential Complications for amputation

1. Postoperative hemorrhage -Massive hemorrhage due to a loosened suture is a potentially life-threatening problem. The nurse monitors the patient for any signs or symptoms of bleeding and monitors the patient's vital signs and suction drainage. ***large tourniquet should be in plain sight at the patient's bedside so that if severe bleeding occurs, it can be applied to the residual limb to control the hemorrhage** 2. Infection -The nurse administers antibiotics as prescribed. The nurse must monitor the incision, dressing, and drainage for indications of infection (e.g., change in color, odor, or consistency of drainage; increasing discomfort) -infection always takes a few days 3. Skin breakdown -The nurse and the patient assess for breaks in the skin. Careful skin hygiene is essential to prevent skin irritation, infection, and breakdown. 4. Phantom limb pain -neuropathic pain -damage to a nerve; but the nerve still thinks the limb is there and it sends painful stimuli to the brain -Treatment: **Sandbag can be used on the residual limb** -mirror therapy; where they see the missing foot; and that will help the brain be aware the foot is not there 5. Joint contracture** (occur with above knee amputation; the joint they are talking about is the hip joint) -should NOT have them sit for an extended period of time -joint contracture happens when for example lower limb amputation is placed on the pillow causing flexion of the hip, should not elevate the residual limb because a flexion contracture may occur and cause them not to be straighten **The patient with AKA may need to lie prone 20 to 30 minutes, three times per day to avoid contracture***

HELPING THE PATIENT TO ACHIEVE PHYSICAL MOBILITY

1. Proper positioning of limb; avoid abduction, external rotation and flexion - **Proper positioning prevents the development of hip or knee joint contracture in the patient with a lower limb amputation.** **The patient with AKA may need to lie prone 20 to 30 minutes, three times per day to avoid contracture*** - if that hip contracts and they can't straight that limb they will not be able to use a prosthetic to walk** 2. Use of assistive devices 3. ROM exercises -making sure the other limbs are getting exercise 4. Muscle strengthening exercises -the stronger the other limbs can be the more ambulatory they can be 5. Pre-prosthetic care 6. Proper bandaging -we are using compression bandage to remove the edema 7. "Toughening" exercises -physical therapy will prepare the stump to be tough when a prosthetic is applied

Rehabilitation Needs

1. Psychological support -ex: support groups and help them to accept their body image 2. Prostheses fitting and use -limb needs to be condition that it can accept a prosthetic ***3. Physical therapy*** -lower limb ambutation; entire center gravity has been thrown off 4. Vocational or occupational training and counseling 5. Use a multidisciplinary team approach 6. Patient teaching

The Care of the Patient With an Amputation—Planning: Major goals

1. Relief of pain 2. Absence of altered sensory perceptions 3. Wound healing 4. Acceptance of altered body image 5. Resolution of grieving processes 6. Restoration of physical mobility 7. Absence of complications

Early Complications Of fractures

1. Shock 2. Fat embolism 3. Compartment syndrome 4. VTE, PE

The Care of the Patient With Fracture of the Hip—Interventions

1. Use aseptic (STERILE) technique with dressing changes -Avoids introducing infectious organisms. 2. Avoid or minimize use of indwelling catheters -Source of bladder infection -trying to stay away from osteomyeltitis/drains -increase risk of urinary retention 3. Supporting coping -Coping mechanisms modify disabling effects of stress; sharing concerns lessens the burden and facilitates necessary modification. 4. Provide and reinforce information -Encourage patient to express concerns -Support coping mechanisms -Encourage patient to participate in decision making and planning -Consult social services or other supportive services

malunion

: healing of a fractured bone in a malaligned position

Joint Dislocations: Dislocation & Subluxation (dont need to worry about subluxation) What can occur if dislocation and subluxation is not reduced immediantly?

A dislocation of a joint is a condition in which the articular surfaces of the distal and proximal bones that form the joint are no longer in anatomic alignment. ex: when the ball comes out of its socket A subluxation is a partial dislocation and does not cause as much deformity as a complete dislocation. In complete dislocation, the bones are literally "out of joint." Traumatic dislocations are orthopedic emergencies because the associated joint structures, blood supply, and nerves are displaced and may be entrapped with extensive pressure on them. ****If a dislocation or subluxation is not reduced immediately, avascular necrosis (AVN) may develop. AVN of bone is caused by ischemia, which leads to necrosis or death of the bone cells.**** (what we need to know) - this occurs when the nerves become compressed it is similar to compartment syndrome; nerve impulses are interrupted and damage -Do the 6ps!! (those 6 ps will tell us)

****Compression fractures***

A fracture in which bone has been compressed (vertebral fraction)

****Comminuted Fracture****

A fracture that bone has splintered into many fragments

**Stress fracture***

A fracture that results from repeated loading of bone and muscle

***Open fracture***

A fracture which damage also involves the skin or mucus membranes also known as a compound fracture

***Avascular necrosis of bone**** caused by Diagnostics Medical Manageent MUST KNOW!!

AVN occurs when the bone loses its blood supply and dies. It may occur after a fracture with disruption of the blood supply to the distal area. (when blood supply dries up) -HAPPENS WHEN WE DON'T IMMOBILIZE THE BONE AS SOON AS POSSIBLE It is also seen with prolonged high-dose corticosteroid therapy, radiation therapy, sickle cell disease, rheumatoid arthritis, and other diseases. The patient develops pain with movement that progresses to pain at rest. Diagnostics include history and physical examination with x-rays, CT scans, and bone scans. Medical management of AVN includes administration of NSAIDs, exercises, and limiting weight bearing of the affected region; however, total joint replacement is the definitive treatment when located in the hip or knee

Loss of Function

After a fracture, the extremity cannot function properly because normal function of the muscles depends on the integrity of the bones to which they are attached. Pain contributes to the loss of function. In addition, abnormal movement (false motion) may be present.

Immobilization

After the fracture has been reduced, the bone fragments must be immobilized and maintained in proper position and alignment until union occurs. Immobilization may be accomplished by external or internal fixation. Methods of external fixation include bandages, casts, splints, continuous traction, and external fixators

Patients with Amputations: Causes: Uses:

Amputation is the removal of a body part, often a digit or limb. The consequences of vascular disease, such as diabetes accounts for 54% of amputations, and trauma accounts for 45% of amputations. Causes: -Congenital -Traumatic -Conditions: progressive peripheral vascular disease, infection, or malignant tumor -get amputation because born of an deformity, or from a traumatic injury, or pt. has a disease process and can't save the limb (diabetes is the leading cause of nontraumatic amputation), infection (osteomyletis; if can't cure it then have to remove the limb) - amputation is the last resort to because it is the MOST SEVERE African Americans are at heightened risk of having amputations. It is estimated that nearly 2 million Americans have had some type of limb loss Uses: Amputation is used to relieve symptoms, to improve function, and to save or improve the patient's quality of life. -If the health care team communicates a positive attitude, the patient adjusts to the amputation more readily and actively participates in the rehabilitative plan, learning how to modify activities and how to use assistive devices for ADLs and mobility Below the knee amputation and below the elbows is preferred then above the knee

Compartment Syndrome

An anatomic compartment is an area of the body encased by bone or fascia (e.g., the fibrous membrane that covers and separates muscles) that contains muscles, nerves, and blood vessels. -***Swelling occurs that puts tremendous pressure on the muscles, the blood vessels, and on the nerves*** From lecture: ***Doesn't have to be caused from a split, brace, cast, can be from skin- can happen externally/internally*** -Can occur in the skin because of swelling or bleeding -externally in a cast or splint The human body has 46 anatomic compartments, and 36 of these are located in the extremities Compartment syndrome is characterized by the elevation of pressure within an anatomic compartment that is above normal perfusion pressure. **Compartment syndrome arises from an increase in compartment volume** (e.g., from edema or bleeding), a decrease in compartment size (e.g., from a restrictive cast), or aspects of both. ***When the pressure within an affected compartment rises above normal, perfusion to the tissues is impaired, causing cell death, which may lead to tissue necrosis and permanent dysfunction** Compartment syndrome occurs more frequently in young adults, and although it ***may take up to 48 hours for symptoms to present, it typically develops quickly,** within 6 to 8 hours after the initial injury or after fracture repair

**intra-articular fracture**

An intra-articular fracture extends into the joint surface of a bone. -**the joint gets damage** -Because each end of a long bone is cartilaginous, if the fracture is nondisplaced, x-rays will not always reveal the fracture because cartilage is nonradiopaque. MRI or arthroscopy will identify the fracture and confirm the diagnosis. The joint is stabilized and immobilized with a splint or cast, and no weight bearing is allowed until the fracture has healed. Intra-articular fractures often lead to posttraumatic arthritis

Hip Fractures

Annually, more than 250,000 adults older than 65 years of age sustain a hip fracture requiring hospitalization The 1-year mortality rate among these older adults is as high as 24% .Signs and symptoms: Weak quadriceps muscles, slowed reflexes, decreased bone tensile strength, general frailty due to age, and conditions that produce decreased cerebral arterial perfusion (transient ischemic attacks, anemia, emboli, cardiovascular disease, effects of medications) contribute to the incidence of falls, which are the major cause of hip fracture. Fractures of the neck of the femur may damage the vascular system that supplies blood to the head and the neck of the femur, and the bone may become ischemic. For this reason, AVN is common in patients with femoral neck fractures

QSEN flag;

Compartment syndrome is managed by maintaining the extremity at the heart level (not above heart level), and opening and bivalving the cast or opening the splint, if one or the other is present.

Deformity

Displacement, angulation, or rotation of the fragments in a fracture of the arm or leg causes a deformity that is detectable when the limb is compared with the uninjured extremity.

Fat Embolism Syndrome

Fat embolism syndrome (FES) describes the clinical manifestations that occur **when fat emboli enter circulation following orthopedic trauma, especially long bone (e.g., femur) fractures. ** ***almost always end up in the lungs, which can cause hypoxemia*** - want to review how blood enters the heart At the time of fracture, fat globules may diffuse from the marrow into the vascular compartment. The fat globules (i.e., emboli) may occlude the small blood vessels that supply the lungs, brain, kidneys, and other organs. the onset of symptoms is rapid, typically within 12 to 72 hours of injury ***FES occurs more frequently in males between the ages of 10 and 40 years after a traumatic injury. *** Although only a small percentage of patients who survive multitrauma have a diagnosis of FES by the time of hospital discharge (0.17% to 1.29%), fat emboli have been found in as many as 82% of trauma patient autopsies

Dislocation: Nursing management

From PP: Neurovascular Assessment and pain management The focus of nursing care is on frequent assessment and evaluation of the injury, including complete neurovascular assessment with proper documentation and communication with the primary provider. The patient and family members are educated regarding proper exercises and activities as well as danger signs and symptoms to look for, such as increasing pain (even with analgesic agents), numbness or tingling, and increased edema in the extremity. These signs and symptoms may indicate compartment syndrome; -if compartment syndrome is not identified and communicated to the primary provider, it may lead to disability or loss of the extremity

Heterotopic Ossification

Heterotrophic Ossification: **bone grows somewhere where it is not supposed to grow, like in the soft tissue*** Heterotopic ossification refers to benign bone growth in an atypical location, such as in the soft tissue Heterotopic ossification that is categorized as traumatic myositis ossificans usually develops in response to soft tissue trauma (e.g., contusion, sprain). It is characterized by pain and joint stiffness that causes decreased ROM. It typically occurs in young males after musculoskeletal sports injuries If significant ROM dysfunction persists, surgery may be indicated to remove the bone growth and restore function

Shock

Hypovolemic shock resulting from hemorrhage is ***more frequently noted in trauma patients with pelvic fractures and in patients with a displaced or open femoral fracture*** in which the femoral artery is torn by bone fragments. Treatment for shock consists of stabilizing the fracture to prevent further hemorrhage, restoring blood volume and circulation, relieving the patient's pain, providing proper immobilization, and protecting the patient from further injury and other complications ***must know the symptoms of hypovolemic shock***Signs & symptoms of shock: cool moist skin, rapid respirations, cyanosis, weak rapid thready pulse, low blood pressure, decreasing blood pressure, concentrated urine, confusion, pulse pressure (difference between systolic and diastolic)

Qsen Flag (promote wound healing)

If the cast or elastic dressing inadvertently comes off, the nurse must immediately wrap the residual limb with an elastic compression bandage. If this is not done, excessive edema will develop in a short time, resulting in a delay in rehabilitation. The nurse notifies the surgeon if a cast dressing comes off so that another cast can be applied promptly.

Qsen flag

Immediate postoperative bleeding may develop slowly or may take the form of massive hemorrhage resulting from a loosened suture. A large tourniquet should be in plain sight at the patient's bedside so that if severe bleeding occurs, it can be applied to the residual limb to control the hemorrhage. The nurse immediately notifies the surgeon in the event of excessive bleeding.

Emergency Management of fractures

Immediately after injury, if a fracture is suspected, **the body part must be immobilized** to prevent the bones rubbing against each other before the patient is moved. **Adequate splinting is essential.** MUST SPLINT THE BODY PART BEFORE YOU MOVE THE PATIENT. Joints proximal and distal to the fracture also must be immobilized to prevent movement of fracture fragments. Immobilization of the long bones of the lower extremities may be accomplished by bandaging the legs together, with the unaffected extremity serving as a splint for the injured one. In an upper extremity injury, the arm may be bandaged to the chest, or an injured forearm may be placed in a sling. **The neurovascular status distal to the injury should be assessed both before and after splinting to determine the adequacy of peripheral tissue perfusion and nerve function.** **With an open fracture, the wound is covered with a sterile dressing to prevent contamination of deeper tissues.** No attempt is made to reduce the fracture, even if one of the bone fragments is protruding through the wound. Splints are applied for immobilization In the ED, the patient is evaluated completely. The clothes are gently removed, first from the uninjured side of the body and then from the injured side. The patient's clothing may be cut away. The fractured extremity is moved as little as possible to avoid more damage.

Shortening of extremity

In fractures of long bones, there is actual shortening of the extremity because of the compression of the fractured bone. Sometimes, muscle spasms can cause the distal and proximal site of the fracture to overlap, causing the extremity to shorten

Sprain:

Injury to ligaments and supporting muscle fiber around a joint -**we sprain ligaments** Joint is tender, movement is painful, and edema -Disability, (not be able to use that joint well like before) -pain INCREASES during first 2-3 hours

Femoral Shaft Fracture

Internal fixation usually is carried out immediately. Intramedullary locking nail devices are typically used. Internal fixation permits early mobilization, which is associated with improved outcomes and recovery. -To preserve muscle strength, the patient is instructed to exercise the hip and the lower leg, foot, and toes on a regular basis. -Active muscle movement enhances healing by increasing blood supply and electrical potentials at the fracture site. -Prescribed weight-bearing limits are based on the type and location of the fracture and treatment approach. Physical therapy includes ROM and strengthening exercises, safe use of assistive devices, and gait training -Traction may be used until surgery can be performed. Skeletal traction is a temporary intervention, however, until such time as the patient is stable and may tolerate surgical intervention -Open femoral fractures require immediate and extensive irrigation and débridement in the operating suite (see previous discussion of treatment for open fractures). Depending on needs for continued débridement, intramedullary nailing may be delayed A common complication after fracture of the femoral shaft is restriction of knee motion. Active and passive knee exercises begin as soon as possible, depending on the stability of the fracture and knee ligaments. -Other complications in the immediate postoperative period can include hemorrhage, compartment syndrome, and neurovascular compromise. Long-term complications may include malrotation, malunion, delayed union, and nonunion

Localized Edema and Ecchymosis (localized swelling & discoloration)

Localized edema and ecchymosis occur after a fracture as a result of trauma and bleeding into the tissues. These signs may not develop for several hours after the injury or may develop within an hour, depending on the severity of the fracture.

Gerontologic Considerations

Older adults (particularly women) who have low bone density from osteoporosis and who tend to fall frequently have a high incidence of hip fracture. Stress and immobility related to the trauma predispose the older adult to atelectasis, pneumonia, sepsis, VTE, pressure ulcers, and reduced ability to cope with other health problems. Many older adults hospitalized with hip fractures exhibit delirium as a result of stress of the trauma, pain, unfamiliar surroundings, sleep deprivation, and medications. In addition, delirium that develops in some older adult patients may be caused by mild cerebral ischemia or mild hypoxemia. Other factors associated with delirium include responses to malnutrition, dehydration, infectious processes, mood disturbances, and blood loss. The same factors that may cause delirium may superimpose delirium on dementia in the older adult with a fractured hip, further complicating recovery. To prevent complications, the nurse must assess the older patient for chronic conditions that require close monitoring. Examination of the legs may reveal edema due to heart failure or absence of peripheral pulses from peripheral vascular disease. ***Similarly, chronic respiratory problems may be present and may contribute to the possible development of atelectasis or pneumonia*** . Coughing and deep-breathing exercises are encouraged. Frequently, older adults take cardiac, antihypertensive, or respiratory medications that need to be continued. The patient's responses to these medications should be monitored. Dehydration and poor nutrition may be present. At times, older adults who live alone cannot call for help at the time of injury. A day or two may pass before assistance is provided, and as a result, dehydration occurs. Nutritional status may have been poor prior to admission, so the nurse should monitor for complications of dehydration and poor nutrition (e.g., pressure ulcers, etc.). Nutritional supplements are effective in improving outcomes in older adults and should be incorporated into the plan of care . Muscle weakness may have initially contributed to the fall and fracture. Bed rest and immobility cause an additional loss of muscle strength unless the nurse encourages the patient to move all joints except the involved hip and knee. Patients are encouraged to use their arms and the overhead trapeze to reposition themselves. This strengthens the arms and shoulders, which facilitates walking with assistive devices.

Gerontologic Considerations (rib fractures)

Older adults sustaining rib fractures are at an increased risk for complications. Even in the presence of isolated rib trauma, hospital admission is recommended for the older adult with multiple rib fractures or for the older adult who cannot effectively cough and mobilize sputum Careful monitoring of respiratory status and encouraging the patient to mobilize early, and, for the bedfast patient, encouraging turning, coughing, and deep breathing and use of an incentive spirometer, can prevent respiratory complications

Nursing Management: Patients with open fractures

Open fractures have more complications then closed fractures In an open fracture, there is a risk for osteomyelitis, tetanus, and gas gangrene. The objectives of management are to prevent infection of the wound, soft tissue, and bone, and to promote healing of bone and soft tissue. Intravenous (IV) antibiotics are given upon the patient's arrival in the hospital along with intramuscular (IM) tetanus toxoid if needed Wound irrigation and débridement (removal of tissues and foreign material) are initiated in the operating room as soon as possible. The wound is cultured, and bone grafting may be performed to fill in areas of bone defects. The fracture is carefully reduced and stabilized by external fixation, and the wound is usually left open . If there is any damage to blood vessels, soft tissue, muscles, nerves, or tendons, appropriate treatment is implemented. With open fractures, primary wound closure is usually delayed, particularly with higher-grade fractures. Heavily contaminated wounds are left unsutured and treated with vacuum-assisted closures (VAC) to facilitate wound drainage. Wound irrigation and débridement may be repeated, removing infected and devitalized tissue and increasing vascularity in the region The extremity is elevated to minimize edema. Neurovascular status must be assessed frequently. Temperature is monitored at regular intervals, and the patient is monitored for signs of infection. Bone grafting may be necessary to bridge bone defects and to stimulate bone healing

PRICE: Nursing management

P: Protection- from further injury is accomplished through support of the affected area (e.g., sling) and/or splinting. R: Rest- prevents additional injury and promotes healing. I: Ice- Intermittent application of cold packs during the first 24 to 72 hours after injury produces vasoconstriction, which decreases bleeding, edema, and discomfort. ***Cold packs should not be in place for longer than 20 minutes at a time***, and care must be taken to avoid skin and tissue damage from excessive cold. ***(from VOPP: don't put ice pack directly on the skin, must have a cloth wrap around it)*** C: Compression: An **elastic compression bandage controls** bleeding, reduces edema, and provides support for the injured tissues. ex: Ace Bandage -make sure there is room, should be tight to compress but not too tight can cause compartment syndrome E: Elevation- Elevation at or just above the level of the heart controls the swelling Nonsteroidal anti-inflammatory drugs (NSAIDs) may be used for pain management The neurovascular status (circulation, motion, sensation) of the injured extremity is monitored at frequent intervals (e.g., every 15 minutes for the first 1 to 2 hours after injury) and then at lesser intervals (e.g., every 30 minutes) until stable.

Medical Management for compartment syndrome

Prompt management of acute compartment syndrome is essential. The surgeon needs to be notified immediately if neurovascular compromise is suspected. Delay in treatment may result in permanent nerve and muscle damage, necrosis, infection, rhabdomyolysis with acute kidney injury, and amputation If conservative measures do not restore tissue perfusion and relieve pain, a fasciotomy (surgical decompression with excision of the fascia) is indicated to relieve the constrictive muscle fascia. After fasciotomy, the wound is not sutured but is left open to allow the muscle tissues to expand; it is covered with moist, sterile saline dressings or with artificial skin. Alternatively, a vacuum dressing may be used to remove fluids and hasten wound closure. The affected arm or leg is splinted in a functional position and elevated to heart level, and prescribed intermittent passive ROM exercises are usually performed. In 2 to 3 days, when the swelling has resolved and tissue perfusion has been restored, the wound is débrided and closed (possibly with skin grafts) have the arm elevated at heart level, not above the heart level (above the heart level is used to manage edema)

Strain: Caused by: Symptoms of strain: Acute vs chronic strain

Pulled muscle injury to the muscle/tendon unit ex: strain your back (**we strain muscles**) -from overuse, overstretching, or excessive stress may cause strain Symptoms of strain: pain, edema, muscle spasm, ecchymosis (discoloration of the skin due to bleeding underneath)- not always present, and loss of function Strains can be categorized as acute or chronic and are graded along a continuum based on postinjury symptoms and loss of function. Acute strains can result from a single injurious incident; whereas, chronic strains result from repetitive injuries. Chronic strains can result from improper management of acute strains.

amputation

Removal of a body part, usually a limb or part of a limb

What are the Signs & symptoms of a traumatic dislocation?

Signs and symptoms of a traumatic dislocation include 1. acute pain 2. change in or awkward positioning of the joint 3. and decreased ROM. Bilateral assessment will make apparent the abnormality in the affected joint. X-rays confirm the diagnosis and reveal any associated fracture

A Opened fracture: (compound/complex fracture)

Skin wound extends to the bone An open fracture (compound, or complex, fracture) is one in which the skin or mucous membrane wound extends to the fractured bone

Should look over

Slide 24

QSEN Flag

Subtle personality changes, restlessness, irritability, or confusion in a patient who has sustained a fracture are indications for immediate arterial blood gas studies. Vopp: looking for them to oxygenate, and signs of fat embolism

Levels Of Amputation

The amputation of toes and portions of the foot can cause changes in gait and balance A Syme amputation (modified ankle disarticulation amputation) is performed most frequently for extensive foot trauma and aims to produce a durable residual limb that can withstand full weight bearing. Below-knee amputation (BKA) is preferred to above-knee amputation (AKA) because of the importance of the knee joint and the energy requirements for walking. Upper limb amputations are performed with the goal of preserving maximal functional length. The prosthesis is fitted early to ensure maximum function. A "staged" amputation used when gangrene and infection exist. Guillotine amputation (e.g., nonclosed residual limb) performed to remove necrotic and infected tissue. Wound is débrided and allowed to drain. Sepsis is treated with systemic antibiotics. After the infection has been controlled and patient's condition has stabilized, definitive amputation with skin closure is performed.

Clinical Manifestations of fat embolism

The classic triad of clinical manifestations of FES include: - hypoxemia** - neurologic compromise** -a petechial rash ** The typical first manifestations are pulmonary and include hypoxia, tachypnea, and dyspnea accompanied by tachycardia, substernal chest pain, low-grade fever, crackles, and additional manifestations of respiratory failure. Chest x-ray may show evidence of acute respiratory distress syndrome (ARDS) or it may be normal. Petechial rash may develop 2 to 3 days after the onset of symptoms. This rash is secondary to dysfunction in the microcirculation and/or thrombocytopenia and is typically located in nondependent regions (e.g., chest, mucous membranes) of the body. There may be varying degrees of neurologic deficits that can include restlessness, agitation, seizures, focal deficits, and encephalopathy

Qsen flag Complex regional Pain Syndrome

The nurse avoids using the affected extremity for blood pressure measurements and venipuncture in the patient with CRPS.

Nursing Management of compartment syndrome

The nurse should frequently assess pain and neurovascular status of the affected limb and report any negative changes that may suggest compartment syndrome immediately to the primary provider. The limb should be maintained in a functional position at the level of the heart to promote optimal blood flow. Pain management is essential and is accomplished with opioid analgesia, as prescribed. Careful assessment of intake and output and urinalysis could alert the nurse to the development of rhabdomyolysis . Education is necessary for those patients discharged to home-based or community settings with fractures and casts and should include recognition of the unique characteristics of acute compartment syndrome (increasing, refractory pain and neurovascular manifestations) and instructions when to contact the primary provider for emergent follow-up.

Acute Pain

The pain is continuous and increases in severity until the bone fragments are immobilized. Immediately after a fracture, the injured area becomes numb and the surrounding muscles flaccid. The muscle spasms that accompany a fracture begin shortly thereafter, within a few to 30 minutes, and result in more intense pain than the patient reports at the time of injury. **Can do traction to help with Muscle spasm** The muscle spasms can minimize further movement of the fracture fragments or can result in further bony fragmentation or malalignment

PROMOTING INDEPENDENT SELF-CARE

The patient is encouraged to be an active participant in self-care. The patient needs time to accomplish these tasks and must not be rushed. Practicing an activity with consistent, supportive supervision in a relaxed environment enables the patient to learn self-care skills. The patient and the nurse need to maintain positive attitudes and minimize fatigue and frustration during the learning process.

Nursing Management: Patients with closed Fractures

The patient with a closed fracture has no opening in the skin at the fracture site. The fractured bones may be nondisplaced or slightly displaced, but the skin is intact. The nurse educates the patient regarding the proper methods to control edema and pain It is important to educate about exercises to maintain the health of unaffected muscles and to increase the strength of muscles needed for transferring and for using assistive devices such as crutches, walkers, and special utensils. The patient is also educated to use assistive devices safely. Plans are made to help patients modify the home environment as needed and to ensure safety, such as removing floor rugs or anything that obstructs walking paths throughout the house. Patient education includes self-care, medication information, monitoring for potential complications, and the need for continuing health care supervision. Fracture healing and restoration of strength and mobility may take an average of 6 to 8 weeks, depending on the quality of the patient's bone tissue

Assessment and Diagnostic Findings

The patient with acute compartment syndrome reports deep, throbbing, unrelenting pain, which is unrelieved by medications, seems disproportional to the injury, and intensifies with passive ROM. Frequent assessment of neurovascular function after a fracture is essential and focuses on the "5 Ps": pain (does not get better with opiods, the pain will get worse not better) , pallor, pulselessness, paresthesias, and paralysis Paresthesia (burning or tingling sensation) is an early sign of nerve involvement. With continued nerve ischemia and edema, the patient experiences diminished sensation followed by complete numbness. Motor weakness may occur as a late sign of nerve ischemia. Motion is evaluated by asking the patient to flex and extend the wrist or plantar flex and dorsiflex the foot. No movement (paralysis) indicates nerve damage Peripheral circulation is evaluated by assessing color, temperature, capillary refill time, edema, and pulses. Cyanotic nail beds suggest venous congestion. Pallor or dusky and cold digits, prolonged capillary refill time, and diminished pulses suggest impaired arterial perfusion. Edema may obscure the function of arterial pulsation, and Doppler ultrasonography may be used to verify a pulse. Pulselessness is a very late sign of compartment syndrome A patient may not exhibit all, or even more than just one of the "five Ps"; therefore, pain assessment is most crucial in early recognition of acute compartment syndrome . Palpation of the muscle, if possible, reveals it to be swollen and hard with the skin taut and shiny. The orthopedic surgeon may measure tissue pressure by inserting a tissue pressure-monitoring device, such as a handheld direct injection device (e.g., Stryker Intra-Compartmental Pressure Monitor), into the muscle compartment (normal pressure is 8 mmHg or less) Nerve and muscle tissues deteriorate as compartment pressure increases. Prolonged pressure of more than 30 mmHg can result in permanent dysfunction

Qsen flag

The residual limb should not be placed on a pillow because a flexion contracture of the hip may result.

Pelvis Fractures

The sacrum, ilium, pubis, and ischium bones form the pelvis Signs and symptoms of pelvic fracture may include ecchymosis; tenderness over the symphysis pubis, anterior iliac spines, iliac crest, sacrum, or coccyx; local edema; numbness or tingling of the pubis, genitals, and proximal thighs; inability to bear weight without discomfort; severe back pain (retroperitoneal bleed); alterations in neurovascular status of lower extremities Trauma to the ureters, urethra, rectum, vagina; abdominal vascular trauma to veins (more common) and arteries; and neurologic trauma, particularly spinal column and cord injury, should be assessed as potential concomitant injuries hemorrhage and shock are two of the most serious consequences that may occur. Bleeding arises mainly from the laceration of veins and arteries by bone fragments and possibly from a torn iliac artery. The peripheral pulses, especially the dorsalis pedis pulses of both lower extremities, are palpated; absence of a pulse may indicate a tear in the iliac artery or one of its branches. Abdominal CT may be performed to detect intra-abdominal hemorrhage. and nuerovascular assessment, assess all the organs especially high impact trauma, spinal cord injuries, hemmorhage and shock can complicate things because the pelvis is very vascular. looking at peripheral pulses; that can indicate a tear in the artery

VTE (venous thromboembolism)

VTE, including DVT and PE, are associated with reduced skeletal muscle contractions and bed rest. Patients with fractures of the lower extremities and pelvis are at high risk for VTE. PE may cause death several days to weeks after injury. Disseminated intravascular coagulation (DIC) is a systemic disorder that results in widespread hemorrhage and microthrombosis with ischemia. Its causes are diverse and can include massive tissue trauma. Early manifestations of DIC include unexpected bleeding after surgery and bleeding from the mucous membranes, venipuncture sites, and gastrointestinal and urinary tracts. All open fractures are considered contaminated and are treated as soon as possible with copious irrigation, débridement, and IV antibiotics ( Surgical internal fixation of fractures carries a risk of infection. The nurse must monitor and instruct the patient regarding signs and symptoms of infection, including tenderness, pain, redness, swelling, local warmth, elevated temperature, and purulent drainage ***anyone who have fractures on the lower extremetieis are at risk for VTE & PE**; thats why they are given anticoagulants

Crepitus

When the extremity is gently palpated, a crumbling sensation, called crepitus, can be felt or may be heard. **grating sound** It is caused by the rubbing of the bone fragments against each other.

clinical manifestations of Hip Fractures

With fractures of the femoral neck, the leg is shortened, adducted, and externally rotated. The patient reports pain in the hip and groin or in the medial side of the knee. With most fractures of the femoral neck, the patient cannot move the leg without a significant increase in pain. The patient is most comfortable with the leg slightly flexed in external rotation. Impacted intracapsular femoral neck fractures cause moderate discomfort (even with movement), may allow the patient to bear weight, and may not demonstrate obvious shortening or rotational changes. With extracapsular femoral fractures of the trochanteric or subtrochanteric regions, the extremity is significantly shortened, externally rotated to a greater degree than intracapsular fractures, exhibits muscle spasm that resists positioning of the extremity in a neutral position, and has an associated area of ecchymosis. The diagnosis is confirmed by x-ray

What is the best diagnostic test to use to identify strain (tendon injury)?

X-rays do not reveal injuries to soft tissue or muscles, tendons, or ligaments, but magnetic resonance imaging (MRI) and ultrasound can identify tendon injury.

Fracture

a break in the continuity of a bone

Crepitus

a grating sound or sensation made by rubbing bony fragments together

Strain

a musculotendinous stress injury

PRICE:

acronym for protection, rest, ice, compression, elevation

Disarticulation

amputation through a joint

sprain

an injury to ligaments and muscles and other soft tissues at a joint

Cryotherapy

application of cold compresses or packets

Contusion

blunt force injury to soft tissue; bruise

Dislocation

complete separation of joint surfaces

avascular necrosis (AVN):

death of tissue secondary to a decrease or lack of perfusion; also called osteonecrosis

Complex Regional Pain Syndrome

from lecture: ***IT IS A TYPE OF NEUROPATHIC PAIN*** not nociceptive pain CRPS is a rare condition characterized by chronic pain in a limb, typically after an injury. **pain that is difficult to treat, just know that it can happen** Dysfunctional peripheral and central nervous system responses that mount an excessive response to the precipitating event (e.g., fracture, surgery) are thought to be the cause of the pain. Women are affected more often than men, and the average age of diagnosis is 40 years Two forms of CRPS exist: CRPS I (formerly called reflex sympathetic dystrophy) and CRPS II, also called causalgia, which is characterized by nerve injury Clinical manifestations of CRPS include severe burning pain, local edema, hyperesthesia, stiffness, discoloration, vasomotor skin changes (i.e., fluctuating warm, red, dry and cold, sweaty, cyanotic), and trophic changes that may include glossy, shiny skin, and changes in hair and nail growth. This syndrome is frequently chronic, with extension of symptoms to adjacent areas of the body. Dysfunction of the affected limb may also be manifested in CRPS. The diagnosis is made through the history and physical examination and ruling out other organic causes

Nonunion

nonunion: failure of fractured bones to heal together

Delayed Complications:

oDelayed union, malunion, and nonunion oAvascular necrosis of bone oComplex regional pain syndrome (CRPS) oHeterotrophic ossification

phantom limb pain:

pain perceived in an amputated section

Subluxation

partial separation of a joint

Delayed union

prolongation of expected healing time for a fracture

fracture reduction

restoration of fracture fragments into anatomic alignment

débridement:

surgical removal of contaminated and devitalized tissues and foreign material

arthroscope

surgical scope injected into the joint to examine or repair

Allograft

tissue harvested from a donor for use in another person

autograft:

tissue harvested from one area of the body and used for transplantation to another area of the same body

The Care of the Patient With an Amputation—Diagnoses/Analysis

v Acute pain v Impaired skin integrity v Disturbed body image v Grieving v Self-care deficit v Impaired physical mobility

Educating About Self-Care

vEncourage active participation in care -can they change their own wounds? vContinue support in rehabilitation facility or at home vFocus on safety and mobility