Musculoskeletal Injuries (Fractures)

Abduction pillow?

-A certain kind of pillow used to immobilize a patient's legs just after hip surgery. -Prevent dislocation. -They help to prevent adduction beyond the midline of the body -It is made of a large, thick piece of foam shaped like an acute triangle.

Dislocation?

-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.* -A traumatic dislocation is an emergency with pain change in contour, axis, and length of the limb and loss of mobility

Soft tissue injuries?

-Contusion -Strain -Sprain -Dislocation

Complications from Hip Surgery?

-Hip surgery patients are at high risk for infection it is important to monitor for fever, as well as redness and warmth at the site. -Older adults are at high risk for Venous Thromboembolism's (*DVT and PE*) after a hip fracture and this is the reason for prophylactic anticoagulation and the sequential compression devices are ordered for all of these patients. -At risk for *skin breakdown*, due to pain and immobility these patients don't want to move it is important to be sure you as the nurse are repositioning them when they are not ambulating and monitoring their bony prominences for skin breakdown. -At high risk for *hospital acquired pneumonia* the use if *incentive spirometers* or teaching them to turn cough and deep breath is important for nursing to include in the plan of care.

Factors that inhibit fracture healing?

-Inadequate fracture immobilization -Inadequate blood supply to the fracture site or adjacent tissue -Multiple trauma -Extensive bone loss -Infection -Poor adherence to prescribed restrictions -Malignancy -Certain medications (e.g., corticosteroids) -Older age Some disease processes (e.g., rheumatoid arthritis)

Strain?

-Injury to a muscle or tendon from overuse, overstretching, or excessive stress may cause strain. (*Pulled muscle*). •*Pain, edema, muscle spasm, ecchymosis (bruise), and loss of function* are on a continuum graded first, second, and third degree. 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.

PRICE acronym

-Protection -Rest -Ice -Compression -Elevation -Immobilize -Anti-inflammatory medications

Contusion?

-Soft tissue injury produced by blunt force such as a blow, kick, or fall, causing small blood vessels to rupture and bleed into soft tissues. -Pain, swelling, and ecchymosis (discoloration; bruise)

Delayed complications of fractures?

1. *Delayed union*: occurs when healing does not occur within the expected time frame for the location and type of fracture. 2. *Malunion*: healing of a fractured bone in a misaligned position. 3. *Nonunion*: failure of the ends of a fractured bone to unite. 4. *Necrosis* of bone: occurs when the bone loses its blood supply and dies. 5. *Complex regional pain syndrome* (CRPS): rare condition characterized by chronic pain in a limb, typically after an injury.

Early complications of fractures?

1. *Hypovolemic shock* resulting from hemorrhage; frequent in trauma patients with femoral fracture that tore femoral artery. 2. A *fat embolism* is a piece of fat that lodges within a blood vessel and causes a blockage of blood flow. Commonly occur after fractures to the long bones of the lower body. Fat emboli may occlude the small blood vessels that supply the lungs, brain, kidneys, and other organs. Happens within 12 to 72 hours of injury. 3. *Compartment syndrome.* 4. Patients with fractures of the lower extremities are at high risk for Venous Thromboembolism (VTE). Either a *DVT* (in the deep veins of the leg or groin) or *PE* (travels in the circulation, lodging in the lungs).

What are fractures?

A fracture is a complete or incomplete disruption in the continuity of bone structure and is defined according to its type and extent. Fractures occur when the bone is subjected to stress greater than it can absorb. Fractures may be caused by direct blows, crushing forces, sudden twisting motions, and extreme muscle contractions. When the bone is broken, adjacent structures are also affected, which may result in soft tissue edema, hemorrhage into the muscles and joints, joint dislocations, ruptured tendons, severed nerves, and damaged blood vessels. Body organs may be injured by the force that caused the fracture or by fracture fragments.

Sprain?

A sprain is an injury to the *ligaments and tendons* that surround a *joint.* It is caused by a twisting motion or hyperextension (forcible) of a joint. Joint is *tender*, and *movement is painful*, edema; disability and pain increases during the first *2 to 3 hours*

Amputation?

Amputation is performed at the *most distal point* that will heal successfully. The objective of surgery is to *conserve as much limb length* as needed to preserve function and possibly to achieve a good prosthetic fit. Preservation of knee and elbow joints is desirable. Example: 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.

Complications of amputation surgery?

Because major blood vessels have been severed, *hemorrhage* may occur. *Infection* is a risk with all surgical procedures. The risk of infection increases with contaminated wounds after traumatic amputation. Skin irritation caused by the prosthesis may result in *skin breakdown*. *Phantom limb pain*, which is pain perceived in the amputated section, is caused by the severing of peripheral nerves. *51% to 85%* will have this happen and it may occur as soon as right after surgery. The nurse acknowledges these feelings as real and encourages the patient to verbalize when in pain so that effective treatment may be given *Joint contracture* is caused by positioning and a protective flexion withdrawal pattern associated with pain and muscle imbalance.

What is compartment syndrome?

Compartment syndrome is a painful condition that occurs when *pressure within the muscles builds to dangerous levels.* This pressure can decrease blood flow, which prevents nourishment and oxygen from reaching nerve and muscle cells which can *impair fracture healing and result in muscle damage* and other complications (see below). 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. 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, and amputation.* *It is important to remember to check capillary refill* on an extremity that is splinted, braced, or casted to prevent the development of compartment syndrome.

Nursing Interventions/Considerations for a Post Total Hip Surgery Replacement?

During the first *24 to 48 hours*, relief of pain and prevention of complications are important, and *continuous neurovascular assessment* is essential. The nurse encourages *deep breathing* and *dorsiflexion and plantar flexion* exercises every 1 to 2 hours. Preventing Dislocation of Hip Prosthesis: -Correct positioning using *splint, wedge, pillows.* -Keep hip in *abduction* when turning, *adduction* when transferring. -Limited flexing of the hip; <90 degrees. Mobility and ambulation: -Patients usually begin *ambulation within 24-48 hrs* after surgery using walker or crutches. -Weight bearing as prescribed by the physician. Prevention of infection: -Remove drain within 24 to 48 hours -Strict hygiene practices -*At risk for up to 24 months* -Prophylactic antibiotic may be given Prevention of DVT: -Appropriate prophylaxis (action taken to prevent disease), -Instituting preventive measures, and -Monitoring the patient closely for clinical signs of the development of DVT and PE. Assessments: Watch their dressings for any signs of bleeding while checking the limb for neurovascular dysfunction. *Neurovascular assessment* includes color, temperature, capillary refill, edema, pulses, ability to move, and sensations in the affected limb

Clinical manifestations of fractures include?

Pain, loss of function, deformity, shortening, crepitus (crackling or grating sound caused by bones rubbing against each other), localized edema and ecchymosis. 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 30 minutes, and result in more intense pain than the patient reports at the time of injury. The muscle spasms can minimize further movement of the fracture fragments or can result in further bony fragmentation or malalignment

Patient education after hip surgery?

These patients will need to be educated about precautions, and prepared for rehabilitation. Physical therapy is needed to rehabilitate mobility back to baseline. Hip precautions: -*Limited flexion* is maintained during transfers and when sitting. When the patient is initially assisted out of bed, an *abduction splint or pillows* are kept between the legs. -*Orthopedic chairs with arm rests, semi-reclining chairs, and raised toilet seats* are used to minimize hip joint flexion. -When sitting, the patient's hips should be higher than the knees. -The patient's affected leg should *not be elevated when sitting*. The patient may flex the knee. -The nurse educates the patient about protective positioning, which includes *maintaining abduction and avoiding internal and external rotation, hyperextension, and acute flexion.* -*At no time should the patient cross their legs or bend at the waist past 90 degrees.* -Occupational therapists can provide the patient with devices to assist with dressing below the waist. -These precautions can stay in place for up to 4 months.

Risk factors for hip fractures due to falls?

Transient ischemic attacks, Anemia, Emboli, Cardiovascular disease, Effects of medications.

How does old age contribute to falls that cause hip fractures?

Weak quadriceps muscles, Slowed reflexes, Decreased bone tensile strength, General frailty due to age.

Femoral neck 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.* The patient cannot move the leg without a significant increase in pain and the patient is *most comfortable* with the leg slightly flexed in external rotation. Most fractures of the femoral neck lead to the *total hip arthroplasty (THA)* it is the replacement of a severely damaged hip with an *artificial joint.*

Frequent assessment of neurovascular function after a fracture is essential and focuses on the "five Ps". What are these?

pain, pallor, pulselessness, paresthesias, and paralysis