VN 86 BAKERSFIELD COLLEGE

Caring for Clients with Musculoskeletal Trauma

Introduction

Musculoskeletal Trauma occurs when tissues are subjected to more force than they are able to absorb.

Example: A fall, a step off a curb, being tackled, a motor vehicle crash

Can range from mild to severe: 1. Soft tissue injury 2, Fracture 3. Complete amputation May affect surrounding tissues. A bone fracture can affect the function of muscles, tendons and

ligaments that attach to it.

MS Trauma

Older adults are at higher risk for MS trauma due to falls.

Nurses job to:1. Assessment of home for potential hazards-

lighting, hand rails, throw rugs and clutter, bath mats and grab bars in bathrooms are necessary.

2. Shoes that will decrease the risk of slipping

Soft Tissue Trauma

Sprains, strains and soft tissue damage are common injuries.

The ankle is the most commonly sprained joint. The lower back and cervical spine are the most common sites

for muscle strains. Contusion- simplest MS injury. Bleeding into the soft tissue

from blunt force. Sprain- ligament injury caused by a twisting motion that

overstretches or tears the ligament. Grades 1,2,3 and 4. Strain- microscopic tear in the muscle that causes bleeding

into the tissues. The muscle was forced to extend past it’s elasticity.

Interdisciplinary Care Soft tissue trauma

X-ray to rule out fracture.MRI to further evaluate.Treatment- Measures to decrease swelling,

alleviate pain and encourage rest and healing. Avoid using injured areaMay need a splintIce first 48 hrs, then heatCompression dressingElevationNSAID, analgesics including narcotics may be

needed.Health promotion- discussion

Nursing Interventions

Promote comfort, prevent further injury and allow healing.

RICEDo not attempt to move an injured joint beyond the

point of comfort.If fracture is suspected immobilize the joint Especially important with cervical spine fracturePalpate for swelling, warmth, tenderness,

deformity and crepitus. Check capillary refill, pulses, movement and

sensation distal to the injury.

Nursing Process

Potential Nursing diagnosis:1. Impaired tissue integrity rt traumaGoal: patient will demonstrate progressive

healing of tissue from 0700-1900 date.2. Acute pain rt tissue traumaGoal: patient will have pain level of 1-3 on a

scale of 1-10 during my shift.

Fractures

A break of a bone.Vary in severity depending on location and type of

fracture.Types of Fractures:See textThe direction of the fracture line is used to classify

fractures.ClosedOpenComminutedCompression Impacted DepressedSpiralGreenstick

Fracture Clinical Manifestations

Fractures accompanied by soft tissue injuries that involve muscles, blood vessels, nerves or skin.

CM- Deformity ComplicationsSwelling, Bleeding- hypovolemic shockEcchymosisInfectionPain peripheral nerve damageTenderness blood flow disruptionNumbness necrosis, blood vessel damageCrepitus immobilityMuscle spasm DVT, compartment syndrome, fat

emboli

Fracture Healing

Osteoblasts promote new bone formationOsteoclasts migrate to the repair site to remove

damaged and excess bone in the callus.Callus- connects bone fragments and splints the

fracture, it’s a stage in fracture Video on fractureHealing time varies with the individual. Uncomplicated fracture of the arm or foot can heal

in 6 to 8 weeks. Vertebra- 12weeks, hip- 12-16 weeks.

Interdisciplinary Care Fracture

Fractures require prompt treatmentMay need to be reduced- Normal alignment of bone

is restored. Immobilization as soon as possible.Nursing Interventions-Immobilization, pulses, color movement and

sensation before and after splinting and throughout shift.

Closed Reduction- External manipulation is used to reposition the bone. Conscious sedation used.

Open Reduction- Completed in the OR. The bone is exposed and realigned. Screws may be used to maintain position.

Care of Fractures continued

Casts- rigid device used to immobilize broken bones and promote healing. Plaster or fiberglass.

Muscle spasms can pull bones out of alignment after a fracture.

Traction- applies a straightening or pulling force to return or maintain the fractured bones in normal position.

1. Manual Traction- applied by physically pulling on the extremity. Reduce a fracture or dislocation.

2. Skin Traction- (straight traction)applies the pulling force through the client’s skin. Non-invasive and is relatively comfortable for the client. Example: Buck’s traction.

Traction continued

The Most common type of Skin Traction is Buck’s Traction- Used to immobilize the leg before surgery to repair a hip or proximal femur fracture.(NCLEX)

3. Balanced suspension Traction- Uses more than one force of pull to raise and support the injured extremity off the bed and maintain it’s alignment. Increases mobility while maintaining bone position.

4. Skeletal Traction- Pulling force is applied directly through pins inserted into the bone. Risk for infection is greater than other types.

Surgery and Fractures

1. External fixation is the simplest form of surgery used to immobilize a fracture. This uses a external fixator and a frame connected to pins inserted into the bone. The pins require care similar to that of skeletal traction pins. The client is monitored for infection, and frequent neurovascular assessment is performed.

2. Internal fixation- surgery called an open reduction and internal fixation (ORIF). Fracture is directly reduced and a nail, screws, plates and screws or pins are inserted to hold the bones in place. Open fractures and hip fractures are repaired with ORIF.

Nursing Care Fractures

Priorities for Nursing care:Prevent complicationsManaging painImpaired mobilityHealth Promotion- FracturesUse safety equipmentAdequeate daily calciumRegular exerciseDiscussion Older Adults and hip fractures!!!!!

Nursing Care Fractures

Assessment Potential Complications Fractures:Increasing pain or pain that is not relieved by

analgesia may indicate a complication such as compartment syndrome or infection.

Numbness, tingling, changes in sensation or changes in movement distal to the fracture may indicate nerve damage or compartment syndrome.

Impaired circulation- cool, pale extremity with weak or absent pulses.

Edema, warmth and a bluish or purple tinge may indicate venous venous pooling.

Nursing Diagnosis

1. Risk for or ineffective peripheral tissue perfusion r/t altered bone integrity or surgical procedure.

Goal: Circulation will remain effective.

2. Acute pain r/t altered bone integrity.3. Impaired physical mobility r/t altered bone

integrity.

Hip Fracture

Causes: Decreased bone mass and muscle strengthSlowed reflexesMedications that can affect cognition or balanceOsteoporosis and loss of bone mass- spontaneous hip

fracture, minor trauma can lead to hip fracture.Leads to loss of independence and restricted activity and

deathBreak of the femur at the head, neck or trochanteric

region.Most common neck or trochanteric region.Diagnosed by history and physical and x-ray.Buck’s traction is applied to reduce muscle spasm until OR.

Hip Fracture

340,000 people/year, 50% 85 yr and older.ORIF or hip replacement is completedFemoral head or neck is fractured a prosthesis is

inserted to replace the femoral head= arthroplasty.

Femoral head and acetabulum replaced= total hip replacement.

Video

Hip Fracture Nursing

1. Maintaining circulation to the injured extremity2.Preventing infection3. Making pain tolerable4. Increasing mobility1. Risk for ineffective peripheral tissue perfusion

r/t fracture and swelling2.Risk for infection r/t altered bone integrity3. Acute pain r/t fracture and muscle spasms4. Impaired physical mobility r/t bed rest and

fracture

Joint Trauma and Injury

Joints are the weakest part of the skeleton.Can be injured when subject to stretching or twisting.Ligaments, tendons and muscles that support the joint

may be stretched or torn, joint cartilage may be damaged, the joint itself can be dislocated.

Dislocation- is separation of contact between two bones of a joint.

Dislocations are due to sudden force or joint disease.

Shoulder and hip dislocation are the most common

Repetitive Use Injuries

Result from overuse of or repeated stress on a joint without adequate recovery time.

Common Types:Carpal tunnel syndrome, bursitis, and epicondylitis.Significant disability and lost work time.Carpal tunnel syndrome-work related injury

results from inflammation and swelling of structures in the wrist joint. Result is the tunnel narrows, compressing and irritating the median nerve. Numbness and tingling of the thumb, index finger and middle finger of the affected hand develop.

Bursitis

Inflammation of the bursa, which is a pad sac that prevents friction between tissues such as ligaments, tendons and bone. Bursae in the shoulder, hip, leg and elbow may become inflamed, causing local tenderness and pain with movement.

Epicondylitis- also called tennis elbow or golfer’s elbow. Inflammation of a tendon where it inserts into the bone. Repeated trauma causes it along with bleeding and inflammation of the tendon. Point tenderness, pain radiating down the forearm and history of repetitive use.

Repetitive Use Injury

Diagnosed by history and physical exam.History will reveal an occupational risk or frequent

participation in activities such as tennis, golf, softball, or baseball.

Phalen’s test- When Carpal tunnel syndrome is suspected.

Initial Treatment- rest and immobilization, splint and ice for 24-48 hrs. Heat after, NSAID, cortisone into joint. What about corticosteroids and diabetes?

Surgery for CTS.

Rotator Cuff and Knee Injury

Shoulder injuries result from rotator cuff being injured.Repetitive use or degenerative changes of involved tissueCM- shoulder pain which is worse at night or lying on the

involved shoulder, motion may be limitedDiagnosed by h&p, x-ray, MRI. Treatment is conservative.

May need surgery.Knee Injury- ligament tears, meniscal injury, patellar

dislocation seen with sports injury.CM-acute injury with immediate pain, tearing sensation

or popping. Swelling common. X-ray and MRI complete DX.

Joint rest with RICE, Physical therapy, surgery.

Nursing Care Joint Trauma Repetitive Use Injury

Primary focus is education!!!Detailed assessment detailed information about

known trauma, circumstances of injury, pain. Examiniation.

Acute PainImpaired physical mobilityPsychosocial also.

Amputation

Partial or total removal of a body part.May be completed to treat types of diseases like bone

cancer, may be the result of a chronic condition such as peripheral vascular disease or diabetes.

May be due to trauma.Devestating to the client!Significant physical and psychosocial effects on the

client and familyAdapting will take time and significant effort.Pheripheral vascular disease is the major cause of

lower extremity amputation. Peripheral neuropathy puts clients at risk.

Pathophysiology

Impaired blood flow along with untreated infection can cause tissue death and lead to amputation.

PVD- circulation to the extremites is impaired. This leads to edema and tissue damage. Healing is impaired (why?)

Thus minor injuries and stasis ulcers can become infected.

Bacteria tend to proliferate.Peripheral neuropathy- loss of sensation leads to

unrecognized injury and infection.Level of amputation is determined by the extent of

tissue damage and healthy tissue. Joints try to be reserved for better function. See textbook.

Amputation

Complications:InfectionDelayed healingContracturesInfection- Older, diabetes, PVD higher risk.Nursing- assessment, skin care, aseptic technique,

turning, deep breathing and coughing.Look for delayed healing in the clients with

PVD, diabetes and who are older along with poor nutrition and smoking.

Amputation

Contractures- abnormal flexion and fixation of a joint caused by muscle atrophy and shortening. Common with amputations. Measures to prevent: discussion.

Phantom Limb Pain- Tingling, numbness or itching of the amputated limb. Cause unknown may be caused by trauma to the nerves serving the amputated part. Pain clinic comprehensive pain management program.

Open and closed amputationProsthetist- prosthetic options.

Nursing Care Amputation

Potential complications- vitals, urine output, pain not relieved by analgesics or change in pain character or location.

Assessment of wound and dressing- bright red, or later redness, swelling purulent drainage or hematoma.

Nursing Diagnosis:Risk for infectionAcute painImpaired physical mobilityDisturbed body image

Amputations

VideoAmputation videohttp://www.youtube.com/watch?v=XFb2fXPZi

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