Musculoskeletal Problems of the Adult Client

Compression Fracture

bone compressed by another bone

Depressed Fracture

bone fragments driven downward

Compound Fracture (open)

bone is exposed to air through a break in the skin, and soft tissue injury and infection are common

Complete Fracture

bone is separated completely be a break into two parts

Comminuted Fracture

bone is splintered or crushed, creating numerous fractures

Extracapsular Fracture

break can occur at the greater trochanter or can be an intertrochanteric fracture

Spiral Fracture

break partially encircles the bone

Incomplete Fracture

fracture line does not extend through the full transverse width of the bone

Pathological (spontaneous) Fracture

fracture that results from a disease or condition

Syme's Amputation

most of the foot is removed, but the ankle remains

Closed reduction

nonsurgical intervention performed by manual manipulation -local or general anesthesia -cast may be applied

Stress Fracture

occurs in normal or abnormal bone exposed to repeated stress

Greenstick Fracture

one side of the bone is broken and the other is bent; these fractures occur most commonly in children

Impacted Fracture

part of the fractured bone is driven into another bone

Reduction

restores the bone to proper alignment

Closed Fracture (simple)

skin over the fractured area remains intact

Open Reduction

surgical intervention; fracture may treated with internal fixation devices

Transverse

the bone is fractured straight across

Oblique Fracture

the fracture line runs at an angle across the axis of the bone

Drop Arm Test

inability to maintain abduction of the arm at the shoulder used for rotator cuff tears/injuries

External Fixation

- use of an external frame to stabilize a fracture by attaching skeletal pins through bone fragments to a rigid external support - more freedom of movement than with traction -commonly used when massive tissue trauma is present

Skin Traction

-applied by elastic bandages or adhesive, foam boot (Buck's) or sling

Skeletal Traction

-applied mechanically to the bone with pins, wires, or tongs -aids in bone realignment but impairs mobility - 25- 40 lbs

Traction

-exertion of a pulling force applied in two directions to reduce and immobilize a fractures -provides proper bone alignment and reduces muscle spasms

Internal fixation

-follows an open reduction -application of screws, plates, pins, wires, or intramedullary rods to hold the fragments in alignment - may involve the removal of damaged bone and replacement with a prosthesis - provides immediate bone stabilization

Below-knee Amputation Interventions

-prevent edema -do not allow residual limb to hang over the edge of the bed - discourage long periods of sitting to lessen complications of knee flexion -place in prone position

Above-knee Amputation Interventions

-prevent internal or external rotation -place a sandbag along the outside of the thigh to prevent external rotation -place the client in a prone position throughout the day

Cervical Skin Traction

-relieves muscle spasms and compression in the upper extremities and neck - head of the bed elevated 30 to 40 degrees

Buck's (extension) Skin Traction

-used to alleviate muscle spasms and immobilize a lower limb by maintaining a straight pull on the limb with the use of weights -boot appliance is applied to attach to the traction -no more than 8- 10 lbs

The nurse has given the client instructions about crutch safety. Which statements indicate that the client understands the instructions? Select all that apply. 1. "I would not use someone else's crutches." 2. "I need to remove any scatter rugs at home." 3. "I can use crutch tips even when they are wet." 4. "I need to have spare crutches and tips available." 5. "When I'm using the crutches, my arms need to be completely straight.

1 2 4 "I would not use someone else's crutches." "I need to remove any scatter rugs at home." "I need to have spare crutches and tips available." The client needs to use only crutches measured for the client. When assessing for home safety, the nurse ensures that the client knows to remove any scatter rugs and to avoid walking on highly waxed floors. The tips need to be inspected for wear, and spare crutches and tips should be available if needed. Crutch tips should remain dry. If crutch tips get wet, the client needs to dry them with a cloth or paper towel. When walking with crutches, both elbows need to be flexed not more than 30 degrees when the palms are on the handle.

Which cast care instructions would the nurse provide to a client who just had a plaster cast applied to the right forearm? Select all that apply. 1. Keep the cast clean and dry. 2. Allow the cast 24 to 72 hours to dry. 3. Keep the cast and extremity elevated. 4. Expect tingling and numbness in the extremity. 5. Use a hair dryer set on a warm to hot setting to dry the cast. 6. Use a soft, padded object that will fit under the cast to scratch the skin under the cast.

1, 2, 3 Keep the cast clean and dry. Allow the cast 24 to 72 hours to dry. Keep the cast and extremity elevated. A plaster cast takes 24 to 72 hours to dry (synthetic casts dry in 20 minutes). The cast and extremity need to be elevated to reduce edema if prescribed. A wet cast is handled with the palms of the hand until it is dry, and the extremity is turned (unless contraindicated) so that all sides of the wet cast will dry. A cool setting on the hair dryer can be used to dry a plaster cast (heat cannot be used on a plaster cast because the cast heats up and burns the skin). The cast needs to be kept clean and dry, and the client is instructed not to stick anything under the cast because of the risk of breaking skin integrity. The client is instructed to monitor the extremity for circulatory impairment, such as pain, swelling, discoloration, tingling, numbness, coolness, or diminished pulse. The primary health care provider is notified immediately if circulatory impairment occurs.

A client is being discharged to home after application of a plaster leg cast. Which statement indicates that the client understands proper care of the cast? 1. "I need to avoid getting the cast wet." 2. "I need to cover the casted leg with warm blankets." 3. "I need to use my fingertips to lift and move my leg." 4. "I need to use something like a padded coat hanger end to scratch under the cast if it itches."

1. "I need to avoid getting the cast wet." A plaster cast must remain dry to keep its strength. The cast needs to be handled with the palms of the hands, not the fingertips, until fully dry; using the fingertips results in indentations in the cast and skin pressure under the cast. Air needs to circulate freely around the cast to help it dry; the cast also gives off heat as it dries. The client would never scratch under the cast because of the risk of altered skin integrity; the client may use a hair dryer on the cool setting to relieve an itch.

The nurse is caring for a client being treated for fat embolus after multiple fractures. Which data would the nurse evaluate as the most favorable indication of resolution of the fat embolus? 1. Clear mentation 2. Minimal dyspnea 3. Oxygen saturation of 85% 4. Arterial oxygen level of 78 mm Hg

1. Clear mentation An altered mental state is an early indication of fat emboli; therefore, clear mentation is a good indicator that a fat embolus is resolving. Eupnea, not minimal dyspnea, is a normal sign. Arterial oxygen levels need to be 80 to 100 mm Hg. Oxygen saturation needs to be higher than 95%

The nurse is caring for a client who has had spinal fusion, with insertion of hardware. The nurse would be most concerned with which assessment finding? 1. Temperature of 101.6° F (38.7° C) orally 2. Complaints of discomfort during repositioning 3. Old bloody drainage outlined on the surgical dressing 4. Discomfort during coughing and deep-breathing exercises

1. Temperature of 101.6° F (38.7° C) orally The nursing assessment conducted after spinal surgery is similar to that done after other surgical procedures. For this specific type of surgery, the nurse assesses the neurovascular status of the lower extremities, watches for signs and symptoms of infection, and inspects the surgical site for evidence of cerebrospinal fluid leakage (drainage is clear and tests positive for glucose). A mild temperature is expected after insertion of hardware, but a temperature of 101.6° F (38.7° C) should be reported.

A client being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm for extra support. The nurse responds, knowing that which would most likely result from this improper crutch measurement? 1. A fall and further injury 2. Injury to the brachial plexus nerves 3. Skin breakdown in the area of the axilla 4. Impaired range of motion while the client ambulates

2. Injury to the brachial plexus nerves Crutches are measured so that the tops are two to three finger widths from the axillae. This ensures that the client's axillae are not resting on the crutch or bearing the weight of the crutch, which could result in injury to the nerves of the brachial plexus. Although the conditions in options 1, 3, and 4 can occur, they are not the most likely result from resting the axilla directly on the crutches.

The nurse has conducted teaching with a client in an arm cast about the signs and symptoms of compartment syndrome. The nurse determines that the client understands the information if the client states that they will report which early symptom of compartment syndrome? 1. Cold, bluish-colored fingers 2. Numbness and tingling in the fingers 3. Pain that increases when the arm is dependent 4. Pain that is out of proportion to the severity of the fracture

2. Numbness and tingling in the fingers The earliest symptom of compartment syndrome is paresthesia (numbness and tingling in the fingers). Other symptoms include pain unrelieved by opioids, pain that increases with limb elevation, and pallor and coolness to the distal limb. Cyanosis is a late sign. Pain that is out of proportion to the severity of the fracture, along with other symptoms associated with the pain, is not an early manifestation.

The nurse is caring for a client with a diagnosis of gout. Which laboratory value would the nurse expect to note in the client? 1. Calcium level of 9.0 mg/dL (2.25 mmol/L) 2. Uric acid level of 9.0 mg/dL (540 mcmol/L) 3. Potassium level of 4.1 mEq/L (4.1 mmol/L) 4. Phosphorus level of 3.1 mg/dL (1.0 mmol/L)

2. Uric acid level of 9.0 mg/dL (540 mcmol/L) In addition to the presence of clinical manifestations, gout is diagnosed by the presence of persistent hyperuricemia. A normal value ranges from 2.7 to 8.5 mg/ dL (160-501 mcmol/L). Options 1, 3, and 4 indicate normal laboratory values. In addition, the presence of uric acid in an aspirated sample of synovial fluid confirms the diagnosis.

A client is complaining of low back pain that radiates down the left posterior thigh. The nurse would ask the client if the pain is worsened or aggravated by which factor? 1. Bed rest 2. Ibuprofen 3. Bending or lifting 4. Application of heat

3. Bending or lifting Low back pain that radiates down one leg (sciatica) is consistent with herniated lumbar disc. The nurse assesses the client to see whether the pain is aggravated by events that increase intraspinal pressure, such as bending, lifting, sneezing, and coughing, or by lifting the leg straight up while supine (straight leg-raising test). Bed rest, heat (or sometimes ice), and nonsteroidal anti-inflammatory drugs (NSAIDs) usually relieve back pain

A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse elevates the limb, applies an ice bag, and administers an analgesic, with little relief. Which problem may be causing this pain? 1. Infection under the cast 2. The anxiety of the client 3. Impaired tissue perfusion 4. The recent occurrence of the fracture

3. Impaired tissue perfusion Most pain associated with fractures can be minimized with rest, elevation, application of cold, and administration of analgesics. Pain that is not relieved by these measures needs to be reported to the primary health care provider because pain unrelieved by medications and other measures may indicate neurovascular compromise. Because this is a new closed fracture and cast, infection would not have had time to set in. Intense pain after casting is normally not associated with anxiety or the recent occurrence of the injury. Treatment following the fracture should assist in relieving the pain associated with the injury.

The nurse is assessing the casted extremity of a client. Which sign is indicative of infection? 1. Dependent edema 2. Diminished distal pulse 3. Presence of a "hot spot" on the cast 4. Coolness and pallor of the extremity

3. Presence of a "hot spot" on the cast Signs of infection under a casted area include odor or purulent drainage from the cast or the presence of "hot spots," which are areas of the cast that are warmer than others. The primary health care provider needs to be notified if any of these are noted. Signs of impaired circulation in the distal limb include coolness and pallor of the skin, diminished distal pulse, and edema.

The nurse is caring for a client who had an aboveknee amputation 2 days ago. The residual limb was wrapped with an elastic compression bandage, which has come off. Which immediate action would the nurse take? 1. Apply ice to the site. 2. Call the primary health care provider (PHCP). 3. Rewrap the residual limb with an elastic compression bandage. 4. Apply a dry, sterile dressing, and elevate the residual limb on one pillow.

3. Rewrap the residual limb with an elastic compression bandage. If the client with an amputation has a cast or elastic compression bandage that slips off, the nurse must wrap the residual limb immediately with another elastic compression bandage. Otherwise, excessive edema will form rapidly, which could cause a significant delay in rehabilitation. If the client had a cast that slipped off, the nurse would have to call the PHCP so that a new one could be applied. Elevation on one pillow is not going to impede the development of edema greatly once compression is released. Ice would be of limited value in controlling edema from this cause. If the PHCP were called, the prescription likely would be to reapply the compression dressing anyway

The nurse is evaluating a client in skeletal traction. When evaluating the pin sites, the nurse would be most concerned with which finding? 1. Redness around the pin sites 2. Pain on palpation at the pin sites 3. Thick, yellow drainage from the pin sites 4. Clear, watery drainage from the pin sites

3. Thick, yellow drainage from the pin sites The nurse would monitor for signs of infection such as inflammation, purulent (thick white or yellow) drainage, and pain at the pin site. However, some degree of inflammation, pain at the pin site, and serous drainage would be expected; the nurse would correlate assessment findings with other clinical findings, such as fever, elevated white blood cell count, and changes in vital signs. Additionally, the nurse would compare any findings to baseline findings to determine if there were any changes.

The nurse is conducting health screening for osteoporosis. Which client is at greatest risk of developing this problem? 1. A 25-year-old client who runs 2. A 36-year-old client who has asthma 3. A 70-year-old client who consumes excess alcohol 4. A sedentary 65-year-old client who smokes cigarettes

4. A sedentary 65-year-old client who smokes cigarettes Risk factors for osteoporosis include gender, being postmenopausal, advanced age, a low-calcium diet, excessive alcohol intake, being sedentary, and smoking cigarettes. Longterm use of corticosteroids, anticonvulsants, and/or furosemide also increases the risk.

The nurse has given instructions to a client who sustained a ligament injury who is returning home after knee arthroscopy. Which statement by the client indicates that the instructions are understood? 1. "I can resume regular exercise tomorrow." 2. "I can't eat food for the remainder of the day." 3. "I need to stay off the leg entirely for the rest of the day." 4. "I need to report a fever, redness around my incisions, or persistent drainage to my health care provider."

4. "I need to report a fever, redness around my incisions, or persistent drainage to my health care provider." After arthroscopy, the client usually can walk carefully on the leg once sensation has returned. The client is instructed to avoid strenuous exercise for the length of time prescribed by the surgeon. The client may resume the usual diet. Signs and symptoms of infection need to be reported to the primary health care provider

The nurse is admitting a client with multiple trauma injuries to the nursing unit. The client has a leg fracture and had a plaster cast applied. Which position would be best for the casted leg? 1. Elevated for 3 hours, then flat for 1 hour 2. Flat for 3 hours, then elevated for 1 hour 3. Flat for 12 hours, then elevated for 12 hours 4. Elevated on pillows continuously for 24 to 48 hours

4. Elevated on pillows continuously for 24 to 48 hours A casted extremity is elevated continuously for the first 24 to 48 hours to minimize swelling and promote venous drainage. Options 1, 2, and 3 are incorrect.

A client with a hip fracture asks the nurse what is involved with Buck's (extension) traction, which is being applied before surgery. The nurse would provide which information to the client? 1. Allows bony healing to begin before surgery and involves pins and screws 2. Provides rigid immobilization of the fracture site and involves pulleys and wheels 3. Lengthens the fractured leg to prevent severing of blood vessels and involves pins and screws 4. Provides comfort by reducing muscle spasms, provides fracture immobilization, and involves pulleys and wheels

4. Provides comfort by reducing muscle spasms, provides fracture immobilization, and involves pulleys and wheels Buck's (extension) traction is a type of skin traction often applied after hip fracture before the fracture is reduced in surgery. Traction reduces muscle spasms and helps immobilize the fracture. Traction does not allow for bony healing to begin or provide rigid immobilization. Traction does not lengthen the leg for the purpose of preventing blood vessel severance. This type of traction involves pulleys and wheels, not pins and screws.

A client with diabetes mellitus has had a right below-knee amputation. Given the client's history of diabetes mellitus, which complication is the client at most risk for after surgery? 1. Hemorrhage 2. Edema of the residual limb 3. Slight redness of the incision 4. Separation of the wound edges

4. Separation of the wound edges Clients with diabetes mellitus are more prone to wound infection, wound separation, and delayed wound healing because of the disease. Postoperative hemorrhage and edema of the residual limb are complications in the immediate postoperative period that apply to any client with an amputation. Slight redness of the incision is considered normal, as long as the incision is dry and intact.

The nurse witnessed a vehicle hit a pedestrian. The victim is dazed and tries to get up. A leg appears fractured. Which intervention would the nurse take? 1. Try to reduce the fracture manually. 2. Assist the victim to get up and walk to the sidewalk. 3. Leave the victim for a few moments to call an ambulance. 4. Stay with the victim and encourage the victim to remain still.

4. Stay with the victim and encourage the victim to remain still. With a suspected fracture, the victim is not moved unless it is dangerous to remain in that spot. The nurse would remain with the victim and have someone else call for emergency help. A fracture is not reduced at the scene. Before the victim is moved, the site of fracture is immobilized to prevent further injury.

Strain

excessive stretching of a muscle or a tendon

Sprains

excessive stretching or a tear of a ligament, usually caused by a twisting motion

Intracapsular Fracture

femoral head is broken within the joint capsule