Chapter 62: Carin for Clients with traumatic musculoskeletal injuries

fractured femur

A fractured femur commonly occurs in car accidents but may also occur in falls from ladders or other high places or in gunshot wounds

nursing management of fractured femur

Because the client is confined to bed, the nurse implements measures to prevent complications of immobility and inactivity The nurse positions the client and in line with pull exerted by the traction the nurse cleans pin sites with a prescribed agent to prevent infection

medical and surgical management of fractured femur

Fractures of the femur usually are treated initially with some form of traction to prevent deformities and soft tissue injury Skeletal traction or an external fixator is used to align the fracture in preparation for future reduction of the fracture occurred in the lower 2/3rds of the femur once the femur is aligned a spica cast may be used to maintain the corrected position

nursing management of hip fractures

Most clients with a fractured hip are older adults and are prone to complications After surgery the nurse implements measures to prevent skin breakdown, wound infection, pneumonia, constipation, urinary retention, muscle atrophy, and contractures The client usually has a wound drain in place for one to 2 days after surgery The nurse monitors the drain and administers antibiotics as prescribed The nurse must show the client how to use the overhead trapeze safely for independent movement and activity Place a trochanter roll besides the hip to maintain a neutral position so that the repaired hip stays in place Place abductor pillows between the client's legs when turning the client side to side If I hit prosthesis has been inserted the nurse instructs the client to avoid a adduction of the affected leg until it is healed The client must use of abductor pillows at all times Soon after surgery the nurse or physical therapist assists the client to transfer from the bed to a chair The chair must have an elevated seat, either with this structure or with pillows so that the client does not flex the hips Beyond the 90° The client usually requires much encouragement and assistance Eventually the client progresses to ambulating with a walker Before discharge the nurse needs to explore ways to ensure safety in the clients home to avoid future injuries and falls

Assessment findings for hip fractures

The client reports severe pain that increases with leG movement The pain frequently radiates to the knee and the client may have a sensation of pressure in the outer aspect of the hip A large blood loss may accompany trochanteric fRaCtures leading to hypovolemic shock There may also's be extensive bruising an swelling in the hip, groin, & thigh Femoral neck fractures are intracapsular so bleeding is more likely to be contained within the joint capsule radiographic studies reveal the exact location of the fracture, which maybe within or outside the joint capsule

medical and surgical management of fracture

The goal is to reestablish functional continuity of the bone Treatment includes one or more methods: traction closed or open reduction internal or external fixation cast application the treatment method depends on many factors, including the first aide given, the location and severity of the break, and the age and overall physical condition of the client

fractured hip

Usually a hip fracture affects the proximal end of the femur This type of fracture commonly results from a fall and it occurs more frequently in older adults with osteoporosis Usually the falls are not very tramatic, what the clients condition contributes to the resulting fracture fractures may occur in the femoral neck, between the trochanters, or below the trochanters

nursing management for fracture

When caring for the client with a fracture, the nurse assesses for neurovascular and systemic complications If the client is in traction, the nurse gives simple and direct explanations about the traction and its purpose The nurse points out activities are allowed and not allowed and identifies approximate duration of the restrictions When traction is discontinued, the nurse prepares the client for further treatment, such as casting skin and muscles The nurse reassures the client that with gradual exercise and use, muscles will regain strength and tone, and joints will be flexible

deformity

a break may cause an extremity to bend to backward or to assume another unusual position

volkmann's contracture

a claylike deformity of the hand resulting from obstructed arterial blood flow to the forearm and hand client is unable to extend his or her fingers and complains of unrelenting pain, particularly if attempting to stretch the hand

ganglion cyst

a cystic mass that develops near tendon sheaths and joints of the wrist form through defects in the tendon sheath or joint capsule and occurs commonly in women younger than 50 experience pain and tenderness in affected area

impacted fracture

a fracture in which a bone fragment is driven into another bone fragment

compression fracture

a fracture in which bone has bee compressed (seen in vertebral fractures)

commented fracture

a fracture in which bone has splintered into several fragments

compound fracture

a fracture in which damage also involves the skin or mucous membranes

depressed fracture

a fracture in which fragments are driven inward (seen frequently in fractures of skull and facial bones)

greenstick fracture

a fracture in which one side of a bone is broken and the other side is bent

oblique fracture

a fracture occurring at an angle across the bone (less stable than transverse)

transverse fracture

a fracture that is straight across the bone

pathologic fracture

a fracture that occurs through an area of diseased bone (bone cyst, page's disease, bony metastasis, tumor) can occur without trauma or fall

simple fracture

a fracture that remains contained; doesn't break the skin

epiphyseal fracture

a fracture through the epiphysis

spiral fracture

a fracture twisting around the shaft of the bone

open tendon repair

a lager incision is used to repair and reattach the tendon

Tinel's sign

a test that elicits tingling, numbness, and pain for clients with carpal tunnel syndrome the examiner percusses (taps) the median nerve, located on the inner aspect of the wrist, to elicit this response

nursing management of dislocations

administer prescribed analgesics elevate and immobilize the affected limb apply cold packs to the injury perform neuromuscular assessments every 30 min for several hours and then at least 2-4 hour for next couple days to detect complications like compartment syndrome

General nursing measures for fracture include:

administering pain medication, providing comfort, assisting with ADLs, preventing constipation, promoting physical mobility, preventing infection, maintaining skin integrity, and preparing client for self-care

injuries to upper and lower extremities can be treated by

applications of cold (ice) and heat exercise steroidal anti-inflammatory medications local injection of corticosteriods analgesics NSAIDs rest in many cases clients with injuries of the shoulder or other portions of the upper extremity are referred for physical therapy

medical and surgical management for sprains, contusion, strains

apply ice/chemical cold pack to the area to reduce swelling and relive pain for the first 24-48 hours Elevate the part and compress w/an elastic bandage PRICE (protect, rest, ice, compress, elevate) after 2 days when swelling is no longer likely to increase, applying heat reduces pain and receives local edema by improving circulation full use of the injured joint is discouraged temporarily NSAIDs ease discomfort continued trauma during healing can result in a permanently unstable joint or the formation of adhesions that may limit full ROM a removable splint or light cast is applied for several weeks soft cervical collar limits motion if the client has a neck sprain

surgical procedures for rotator cuff tear

arthorschopgic tendon repair open tendon repair removal of bone spur tendon transfer shoulder replacement

treatment of ganglion cysts

aspiration of the ganglion corticosteroid injection and surgical excision

types of fractures

avulsion commented compound depressed epiphyseal green stick impacted oblique pathologic simple spiral transverse

ligament injuries

both occur as a result of traumatic injury injuries can occur to the lateral or medial collateral knee ligaments (these ligaments provide stability to the sides of the knee) or to the ACL or PCL injury to the ligaments of the knee happens when the client is standing firmly and receives a blow or twists in a different direction when hyperextending the knee the client experiences pain, instability of the joint, and ambulatory difficulty when the ACL/PCL tear the client may report a popping sound or tearing sensation menisci can become injured, disrupting the stability of the leg when flexed or extended

rotator cuff

made up of 4 muscles and their tendons that connect the proximal humerus, clavicle, and scapula which in turn connect with the sternum and ribs

fracture

break in the bone may affect tissues or organs near the bones as well

rotator cuff injuries

can occur as a result of a traumatic injury or from chronic overuse or irritation of the shoulder joint a tear (or more than one) occurs in a tendon connecting the rotten muscles to the head of the humerus tears are differentiated as partial/full thickness clients experience pain with movement and limited mobility of the shoulder and arm they especially have difficulty with activities that involve stretching their arms above their heads (or complete) many clients find that the pain is worse at night and that they are unable to sleep on the affected side the diagnosis is based on physical exam--generally there s tedernesson the acromioclavicular joint radiography, arthography, ultrasound and MRI can evaluate the extent of the rotator cuff tear and any soft tissue injury

assessment findings of dislocations

client often reports hearing a popping sound hen the dislocation occurs another common complaint is the joint suddenly gave out implying that it became unstable or nonsupportive if the dislocation results from trauma, the client usually experiences considerable pain from the injury and/or the resultant muscle spasm on inspection, the structural shape is altered. a depression may be noted about the joints circumference indicating that the bones above and below are no longer aligned if it affects an extremity the arm or leg may be shorter than its unaffected counterpart and as a result the displacement ozone of the articulating bones ROM is limited X-rays show intact yet malpositoned bones arthography/artrhoscopy may reveal damage to other structures in the joint capsule

various complications of fractures

compartment syndrome thromboembolism fat embolism delayed healing nonunion malunion infection avascular necrosis

avascular necrosis

death of bone from an insufficient blood supply

palsy

decreased sensation and movement

medical/surgical management for ligament and meniscal injuries

depends on the extent of injury initial treatment involves immobilizing the joint and limiting weight bearing physician may recommend NSAIDs as well as the use of ice during the first 48 hours surgical procedures involve repair of the ligaments and tendons inovlved an arthrocentesis may be done for diagnostic purposes and to provide symptomatic relief through draining of bloody fluid arthroscopy is done to determine what the meniscal tear involves for torn menisci the surgeon removes the damaged cartilage (MENISCECTOMY) recovery is generally complete within 3-12 moths depending on the nature of the injury and the type of surgery

several types of tendinitis that commonly occur as a result of repeated sports/work activities:

epicondylitis ganglion cyst carpal tunnel syndrome

removal of bone spur

excess bone is removed and tendons are repaired, through a small incision

strains result from:

excessive stress, overuse, or overstretching small blood vessels in the muscle may rupture, and the muscle fibers sustain tiny tears

types of sprains

first degree second degree third degree

types of strain

first degree second degree third degree

treatment of musculoskeletal trauma involves:

immobilization of the injured area until it has healed requires preventing further injury and complications

third degree sprain

ligament is torn/ruptured completely with possible detachment of a fragment of bone (AVULSION FRACTURE) hematoma formation which contributes to the severe pain, edema, and abnormal joint movement

diagnostic findings of carpal tunnel syndrome

in carpal tunnel syndrome results of electromyography, which relies on a. mild electrical current to stimulate a nerve, show a delay in motor response in muscles innervated by the median nerve other tests are: Tinel's sign and Phalen's sign the examiner percusses the median nerve, lo

tendinitis

inflammation of a tendon caused by overuse

assessment findings of sprains, strains, and contusions

injured area becomes painful immediately and swelling follows person avoids full weight bearing or using the injuries area ecchymosis may appear the joint may be unstable until it heals diagnosis made by exam of affected part and symptoms X-rays may show a larger than usual joint space and rule to or confirm an accompanying fracture MRI done to determine extent of the injury orthography demonstrates asymmetry in the joint as a result of the damaged ligaments arthroscopy can tell you the amount of trauma in the joint capsule

strain

injury to a muscle when it is stretched or pulled beyond its capacity injuries to the ligaments surrounding the joint

medical and surgical management for hip fractures

intracapsular hip fractures are prone to nonunion and avascular necrosis from the disrupted blood supply The fractured head and neck may be removed and replaced with a metal device such as an Austin Moore or Thompson prosthesis This procedure is referred to as HEMIARTHROPLASTY The bone heals around the metallic device which in the meantime holds the bone together The bone is united immediately and clients are mobilized much earlier than they are with traction

phalens sign

involves having the client flex the wrist for 30 seconds to determine if pain or numbness occurs and if it does occur then this is a positive sign for carpal tunnel syndrome

second degree sprain

involves partial tearing of the ligament with edema, pain with motion, joint instability, and some loss of function

first degree sprain

involves stretching of the ligament fibers characterized by mild edema, tenderness, and pain if the joint is moved

compartment syndrome

involves the compression of nerves and blood vessels due to swelling within the enclosed space created by the fascia that separates groups of muscles

meniscal injuries

menisci can become injured, disrupting the stability of the leg when flexed or extended both occur as a result of traumatic injury occur with twisting of the knee or repeated squatting clients report that their knees gave away or buckled and the clients may experience a click in their knees as they ambulate the knee sometimes locks because the cartilage moves as it tears and prevents full flexion and extension a MRI is done initially to assess the extent of the injury

first degree strain

mild stretching of muscle or tendon, casing some edema and muscle spasm no real loss of function pain occurs with full ROM

spasm

muscles near fractures involuntarily contract may cause a limb to shorten, when the fracture involves a long bone

dislocations

occur when the articular surfaces of a joint are no longer in contact shoulder, hip, and knee are commonly affected

ruptured achilles tendon

occurs secondary to trauma as the client engages in an activity, the calf muscle contracts suddenly while the foot is grounded firmly in place there is often a loud pop and the client experiences severe pain and inability to plantar flex the affected foot the client usually requires surgical repair for complete healing to ocur following surgery the client wears a cast or brace for 6-8 weeks physical therapy. is necessary for the client to regain mobility, strength, and full ROM the nurse teaches the client about activity restrictions, the use of ambulatory aids, and pain management

pain

one of the most consistent symptoms of having a fracture is pain, which may be severe. attempts to move the part and or pressure o over the fracture contribute to increased pain

signs and symptoms of a fracture vary depending on the type and location. they may include the following

pain loss of function deformity false motion crepitus edema spasm

subluxation

partial dislocation

second degree strain

partial tearing of muscle or tendon leading to inability to bear weight, limited motion, edema is present, and muscle tenderness, and muscle spasms and ecchymosis (bruising)

medical and surgical management of dislocations

physician manipulates the joint or reduces the displaced parts until they return to normal position then immobilizes the joint for several weeks client may receive a local/general anesthetic before the manipulation is performed some dislocations may require surgery either to correct the dislocation or to repair the damage caused by the injury

after surgical management for ligament and meniscal injuries

physician will immobilize the joint prescribe NSAIDs recommend the application of cold therapy physical rehabilitation includes: exercises gradual weight bearing use of any ambulatory devices

any client who is inactive during healing is prone to

pneumonia thrombophlebitis pressure sores UTI renal calculi constipation muscle atrophy weight gain depression

Nursing management

provides information about medications if the client is taking NSAIDs the nurse stresses to take these medications with food if corticosteroid injections are ordered he or she explains what the client can expect and mentions that the injection itself may cause some discomfort show clients how to use and care for prescribed splints ad perform related ROM exercises some clients find that hand exercises are less painful if performed with the hand under warm water exploring ways to perform ADLs or alter job responsibilities to relieve stress and reduce injury to joints.

avulsion fracture

pulling away of a fragment of bone by a ligament or tendon and its attachment

arthroscopic tendon repair

reattach the tendon to the bone arthroscopically

shoulder replacement

referred to as reverse shoulder arthroplasty; the socket portion of the articifical joint is placed on the humerus and the ball part of the joint is placed on the scapula

tendon transfer

replace torn tendons with a nearby tendon---open procedure

key teaching points

rest the joint in a position that reduces stress support the affected arm joint on pillows apply cold for the first 24-48 hours to reduce swelling and pain gradually increase joint movement avoid working or lifting above shoulder level. don't push objects with the arm joint, particularly the shoulder perform ROM and strengthening exercises as prescribed by the physician or physical therapist

treatment of carpal tunnel

resting hands the possible and splinting the hand and wrist NSAIDs and periodic injections of a corticosteroid preparation may relieve the inflammation and discomfort if conservative treatment fails then surgery to release the pressure of the ligament on the median nerve may be performed

third degree strain

severe muscle and/or tendon tearing, causing severe pain, muscle spasm, ecchymosis, edema and loss of function

assessment findings of fractured femur

severe pain, swelling, and ecchymosis may be seen the client usually cannot move the hip or knee if a compound fracture has occurred, an open wound or a protrusion of bone is see X-rays show the type and location of the fracture

frequent sites of injury and pain in the extremities are

shoulder elbow wrist knee ankle

loss of function

skeletal muscular function depends on intact bone

contsuion

soft tissue injury resulting from a blow or blunt trauma injury is confined to the soft tissues and doesn't affect musculosekteal structure many small blood vessels rupture, causing ecchymosis or a hematoma (collection of blood) applying cold packs helps to alleviate local pain, swelling and bruising usually resolves w/in 2 weeks

treatment for epicondylitis

splinting to rest and support the joint structures corticosteroids may be injected locally

whiplash injury

sprain of the cervical spine

diagnostic findings of fractures

stress fractures may not be apparent radiographically for a few weeks a bone scan usually can identify a non displaced or stress fracture before radiographic changes are evident in some cases an MRI may be necessary

sprains result from

sudden, unusual movement or stretching around a joint which is common with falls or other accidental injuries

evidence of soft tissue injury

swelling coolness numbness tingling pale/dusky color of the distal tissue X rays show intact but malpositioned bones

edema

swelling usually is greatest directly over the fracture

epicondylitis

tennis elbow a painful inflammation of the elbow occurs when the tendons of the medial or lateral radial and ulnar epicondyles sustain damage the injury follows excessive pronation and supination of the forearm such as that while playing tennis, pitching ball, or rowing clients report pain radiating down the dorsal surface of the forearm and a weak grasp

carpal tunnel syndrome

term for a group of symptoms located in the carpal tunnel of the wrist, which is a narrow, inelastic canal through which the carpal tendons and median nerve pass results from reptile wrist motion that traumatizes the tendon sheath or ligaments in the carpal canal the trauma produces swelling that compresses the median nerve against the transverse carpal ligament those affected the duo be in occupations that perform repetitive hand movements describe pain or burning in one or both hands, which may radiate to the forearm and shoulder in severe cases pain tends to be more prominent at night and early in the morning shaking hands may reduce the pain by promoting movement of edematous fluid from the carpal tunnel sensation may be lost or reduced in the thumb, index, middle, and portion of the ring finger the client may be unable to flex the index and middle fingers to make a fist flexion of the wrist usually causes immediate pain and numbness

crepitus

the grating sound of bone ends moving over one another may be audible (this term also refers to a popping sound caused by air trapped in soft tissue)

patho and etiology of dislocations

the injury may disrupt local blood supply to structures such as the joint cartilage causing degeneration, chronic pain, and restricted movement COMPARTMENT SYNDROME may also develop; the syndrome affects nerve innervation leading to subsequent PALSY; if compartment syndrome occurs in an upper extremity it may lead to VOLKMAN'S CONTRACTURE if there is an insufficient amount of collagen during the repair stage then the end result is that the ligaments have less strength and are instable, leading to recurrent dislocations of the same joint

lateral or medial collateral knee ligaments

these ligaments provide stability to the sides of the knee

what causes dislocations

trauma diseases of a joint result in dislocations when the ligament supporting a joint are torn, stretched or relaxed

false motion

unnatural motion occurs at the site of the fracture

treatment of rotator cuff tear

use of NSAIDs (initial treatment) advise the client to modify their activities and to rest the joint physicians may recommend corticosteroid injections into the shoulder joint, with progressive passive and active exercises and streching depending on the type of surgery, clients have to immobilize the shoulder for several days to several or more weeks, and then undergo physical therapy for several weeks to months the client will have full recovery postoperatively within 6-12 months

patho and etiology

when force applied to a bone exceeds maximum resistance, the bone breaks sudden direct force from a blow or fall causes most fractures some result from indirect force like a strong muscle contraction during a seizure a few fractures result from underlying weakness created by bone infections, bone tumors, or more bone resorption than production for 10 to 40 minutes after bone breaks the muscles around the bone flaccid then they go into spasm often increasing deformity and interfering with the vascular and lymphatic circulations the tissue surrounding the fracture swells from hemorrhage and edema healing begins when blood in the area clots and a fibrin network forms between the broken bone ends osteoblasts which proliferate in the clot, increase the secretion of an enzyme that restores the alkaline pH calcium is deposited and true bone forms. The healing mass is called the CALLUS. It holds the ends of the bone together but cannot endure strain. bone repair is a local process about one year feeling must pass before bone regains its former structural strength, becomes well consolidated and remodeled, and possesses fat and marrow cells

areas most subject to sprains

wrist elbow knee ankle