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Med-Surg Ch 39

Musculoskeletal Trauma

Soft Tissue Trauma (2) Contusion (Bleeding into soft tissue, Blunt force, Bruise) and Hematoma (Contusion with large amount of bleeding)
Strain (common sites and manifestations) Stretching injury to a muscle or muscle-tendon unit caused by mechanical overloading. Most common sites: lower back, hamstrings. Manifestations: painful, swelling, muscle weakness, limited ROM
Sprain Excessive stretching of ligament. Ankle/knee. Ice 20min/time. NSAIDS. Treat: 1st degree (over stretched, RICE); 2nd degree (partial tear, immobilization, partial weight bearing); 3rd degree (complete tear, immobilization for 4-6 weeks, possible surgery)
Rotator Cuff Injury (Manifestations, Tests, and Treatments) M: Shoulder pain, increased at night, ROM, abduction, flexion limited, degenerative changes or trauma. Tests: Drop arm test (Cant raise arm above shoulder). Tx: NSAIDs, PT, Sling support, Ice /heat applications, Surgical repair, Immobilized for 4-6 wee
Knee injuries and Ligaments Ligament tears (ACL, MCL, may hear snap, knee swells almost instantly); Menisci injury (C-shaped plates/pads in knee); Patellar dislocation; Acute: Immediate pain, Tearing or popping, Knee “gives out”, Swelling; Treatment: nonsurgical or surgical
Joint Dislocation Dislocation (ends of bone are out of place); Subluxation (partial dislocation); Most common sites: shoulder and acromicoclavicular joints; May be congenital, traumatic, or pathologic
Joint Dislocation S/S: pain, deformity, ROM. Diagnosis: physical exam, X-ray. Care: Pain relief, Correction of dislocation, Prevention of complications. Treatment: Shoulder (Immobilize several wks, Sling), Hip dislocation (immediate care, Prevent necrosis of head of femur)
Joint Dislocation Prevention Avoid alcohol, Stretch/warm-up, Protective gear, Gun Safety
Repetitive Use Injury (3) Carpal tunnel syndrome, Bursitis, and Epicondylitis
Carpal tunnel syndrome Manifestations: Numbness and tingling of thumb, index finger, lateral ventral surface of middle finger. Interferes with sleep. Relieved by: Massage, Shaking hands and fingers. Weakness: inability to hold items or perform precise activities
Bursitis Inflammation of bursa sac (in synovial joints). Manifestations: Joint is tender, hot, red, edematous; pain with flexion or extension
Epicondylitis Tennis elbow, golfer’s elbow. Manifestations: tenderness and pain radiating down the dorsal surface of forearm
Diagnostics, Medications, and Treatments of Repetitive Use Injury Tests: Hx and Physical, Phalen test (Backs of hand together for 1min, numbness). Meds: NSAIDs, Corticosteroid injections. Tx: Immobilization (Ergonomic evaluations) or Surgery (resect ligament and enlarge carpel tunnel; remove calcium and scar tissue)
Fracture Any break in continuity of bone. Result from: Direct blow, Compression, Torsion (twisting), Stress/pathological (related to a disease process)
14 Fracture Terms (partial) Closed/simple (skin not broken), Open/compound (skin broken), Complete (Entire bone broken), Incomplete (Only part of bone broken), Oblique (Angle fracture), Spiral (all the way around), Avulsed (bone and other tissue pulled from the point of attachment)
14 Fracture Terms (partial) Greenstick (splinters), Communited (Breaks in many pieces), Compressed (Crushed), Impacted (Bone ends are forced into each other, jumping off of things), Depressed (Bone is forced inward), Stable (Not displaced, maintains alignment), Unstable (displaced)
Fracture Manifestations May be accompanied by soft tissue injuries involving muscles, arteries, veins, nerves, skin. May be alteration in circulation, sensation, swelling, pain. May be obvious deformity or fracture. May have felt the breakage of bone during the injury event.
Fracture Healing Phases Inflammatory phase (Swollen, may bleed; Collagen forms and allows calcium to be deposited). Reparative phase (Callus begins to form; Osteoblast/osteoclast). Remodeling phase (Starts molding back to normal shape; Callus removed)
Fracture Healing Time Uncomplicated fracture of arm or foot heals in 6 – 8 weeks. Fractured hip heals in 12 – 16 weeks.
Compartment Syndrome Usually within first 48 hours. Cause: Hemorrhage, edema, compression of nerves. S/S: pain, Paresthesias, dec reflexes and tissue perfusion, CAN LOSE LIMB, Pulses may be normal. Tx: split or removal of cast, Fasciotomy (incision into skin).
Fat Embolism Syndrome (FES) Fat lodges in pulmonary vascular or peripheral circulation. Often not diagnosed. S/S: Neurologic, Difficulty breathing/Rhonci/rail/ARDS, Thrombocytopenia (Petechial rash chest/axilla/upper arms), Usually 12-72hr after. Prevent by early stab long-bone fx.
Deep Vein Thrombosis (DVT) Prevent: Early immobilization of fracture, Early ambulation. Blood thinners, Prophylactic anticoagulation, Antiembolism stocking, Compression boots, Prompt diagnosis of DVT and adequate treatment. S/S: swelling, + Homan’s sign, 5 P's
Infection of Fracture Any complication decreasing blood supply increases risk. May result from contamination at time of injury or during surgery. May lead to: Pseudomonas, Staphylococcus or Clostridium, or osteomyelitis (infection of bone)
Delayed Union Prolonged healing of bones. Risk Factors: Poor nutrition, Inadequate immobilization, Prolonged reduction time (long time to put back into place), Infection, necrosis, age, Immunosuppression, Severe bone trauma. Detected by serial X-rays.
Non-Union Persistent pain and movement at fracture site. Treatments: Surgery (internal fixation, bone grafting), Debridement if infection present, Electrical stimulation, Growth hormone.
Reflex Sympathetic Dystrophy/Complex regional pain syndrome Poorly understood post-traumatic condition. Manifestations: persistent pain, hyperesthesias (^ feeling), swelling, changes in skin color, texture, temperature, decreased motion = muscle atrophy. Treatment includes sympathetic nerve block.
Emergency Care of a Fracture Immobilization (Try to keep normal anatomical alignment). Maintenance of tissue perfusion (5 P’s). Prevention of infection: Open? Cover with sterile dressing. Worst case… stop bleeding even if it’s not sterile.
Diagnostic Test for a Fracture History of incident and initial assessment. X-ray. CBC. Blood chemistries. Coagulation studies. Renal function: Myoglobunuria (Muscle breakdown, myoglobin released = clogs up kidneys).
Medications for a Fracture Pain and inflammation control (Opioids/NSAIDs). Medications to guard against ulcers. Stool softeners. Antibiotics. Anticoagulants.
Treatment for a Fracture Closed reduction (Cast, splint, traction) or Open reduction (Surgery)
Traction Acronym Temperature, Ropes hang freely, Alignment, Circulation check (5 P's), Type and location of fracture, Increase fluid intake, Overhead trapeze, No weights on bed or floor.
4 Kinds of Traction Manual, Skin, Balanced Suspension, and Skeletal
Manual Traction Physical pulling and realigning
Skin Traction AKA: Straight traction. Help control muscle spasms. Immobilize injury before and after surgery. Buck’s traction.
Balanced Suspension Traction More than one point of pull
Skeletal Traction Pins (clean 2-3/day), ex. halo, cannot be removed by a nurse!
Casting Rigid device immobilizes bones and promotes healing. Above/below fracture. Types: Plaster (48hrs to dry), Fiberglass (dries within 1hr). Assess for: Numbness, tingling, 5 P’s, hotspots (may indicate infection). Hairdryer on cool may help itching.
Fracture Surgery Direct visualization and repair. External fixator. Internal fixator (Open reduction internal fixation) (ORIF)
External Fixation Frame connected to pins inserted into long axis of bone. Maintains immobilization of fracture. Nurse: Clean pin sites with Peroxide and/or Triple antibiotic ointment, 2-3/day.
Internal Fixation Surgery. Open reduction internal fixation (ORIF), Involves reducing fracture and applying hardware (pins, nails, screws, or plates) to hold bones in place. Post-op: Hemovac, JP bulb, bowel sounds, PT, occupational therapy, early mobilization, TCDB.
Electrical Bone Stimulation Non-healing/slow healing fractures. Invasively or noninvasively. Contraindicated: In presence of infection, Upper extremities fracture in a pacemaker client.
Fx of Skull Displacement /depression. Pressure on brain = neurologic deficit. Surgical intervention.
Fx of Facial Bones Maintain airway. Severely displaced fractures: Open reduction, Internal fixation with wires or plates.
Fx of Spine Complication: spinal cord injury, paralysis. Displaced cervical fracture, reduced with manual or skeletal traction, brace application. May require surgical stabilization.
Fx of Clavicle Present in slumping position. Immobilize arm. Avoid shoulder movement. Clavicular strap or surgery.
Fx of Humerus Location determines treatment. Proximal: immobilization. Shaft: Hanging arm cast (Needs pulling force of gravity, Don’t rest or alleviate weight).
Fx of Elbow Non-displaced: splint/cast. Complications: Nerve/artery damage, hemarthrosis (bleed into joint). Volkmann’s contracture (arterial occlusion, muscle ischemia, pain). < sensation. < motor function: pressure on brachial artery/nerve, prevent muscle atrophy.
Fx of Radius or Ulna Casting or Surgery
Fx of Wrist/Hand Colles’s fracture: Fall on outstretched hands (catching themselves). Often treated with closed reduction, cast application.
Fx of Rib Simple: Analgesia, TCDB, splint. Serious rib fracture: Flail chest from multiple fractures, Paradoxical (inconsistent) breathing, may require ventilator, often requiring intubation and mechanical ventilation.
Fx of Pelvis Simple fracture, bed rest on a firm mattress. More than 2 fracture sites, Surgery with application of external fixator. Complications: hypovolemia, spinal injury, injury involving urinary or GI systems.
Fx of Femur Shaft S/S: Painful, deformed, edematous thigh, Inability to move hip or knee. Assess circulation to extremity! Complications: Hypovolemia, Fat embolism, Hip or knee dislocation. Treatment: Initially skeletal traction, Followed by external or internal fixation.
Hip Fractures Intracapsular: fractures of the head or neck of femur, greater risk of nonunion and avascular necrosis. Extracapsular: fractures of trochanter region. Cause greatest number of deaths and health problems.
Post Hip Fx... Hospital time? Home? Hospitalized for 1-2 weeks. Unable to return home after the fracture.
Manifestations of Hip Fx Pain. Shortening of affected leg. External rotation.
Treatment of Hip Fx Bucks traction. Surgery: Trochanter (ORIF using hardware to secure femur), Femoral neck/acetabulum (hemiarthroplasty or both total hip arthroplasty)
Total Hip Arthroplasty (THA) PT/OT. Prevention of DVT. Prevention of Anemia. Pre-emptive antibiotics. Cement vs. non cemented.
Preventing Dislocation/subluxation Post-op Maintain correct positioning at all times. Abduction pillow/wedges (not flex > 90 degrees). Turning. s/s of: pain, shortening of leg, external rotation
Preventing Thromboembolic Post-op Anti-embolic stockings. Sequential compression devices. Anticoagulants: Warfarin, LMWH (Lovenox). Exercises: Plantar flexion, Feet circles, Heel/Toe Exercises.
Watch for Infection VS and Incision site
Prevention of Bleeding/Anemia Post-Op Check site, drainage tubes. Surgeon generally removes first dressing/tubes in 24-48 hours. Monitor H&H and BP
Preventing Neurological Complications Post-Op Color, temp of extremity. Distal pulses. Cap refill. Movement. Sensation. Pain.
Activity Progression Post-Op OOB 1st day. Avoid hip flexion >90 degrees. Raised toilet seats. Straight back chairs. Weight bearing (PWB or FWB). Assistive devices.
Fx of Tibia/Fibula Common complications of fracture include, damage to perineal nerve or tibial artery, compartment syndrome, Hemarthroses, Ligament damage, Closed fracture. Reduction with casting.
Fx of Ankle/Foot Closed reduction and casting.
Risk of Peripheral Neurovascular Dysfunction Casts and Anticoagulants
How to Maintain Good Bone Health Weight-bearing exercise, avoiding obesity, adequate calcium intake. Screens for osteoporosis.
Amputation Partial or total removal of body part resulting from traumatic event or chronic condition.
Causes of Amputation PVD (peripheral vascular disease), diabetes, HTN, smoking, Osteomyelitis, Gangrene, Trauma/accident. Trauma.
2 Types of Amputation Open (guillotine) and Closed (flap).
Amputation Site Healing Immediate post-operative: assess circulation to stump. Compression dressing: Ace bandage in a conical shape to form stump, prevent edema, and infection; applied from distal to the proximal extremity.
Amputation Complications Infection: Local, Systemic. Delayed Healing: Nutrition, Poor blood flow, Decreased cardiac output (Chronic stump pain, phantom limb pain/sensation.
Amputation Treatments Medications (Dilaudid), Nerve blocks, Transcutaneous electrical nerve stimulation (TENS), Surgical stump reconstruction.
Contracture Abnormal flexion and fixation of joint. Common association with above the knee amputation. Interventions: Lying prone throughout day, Active and passive ROM, Avoid prolonged sitting.
Prostesis Types: level of amputation, occupation and life style. Pneumatic device: fits over stump, allows early ambulation, decreased postoperative swelling.
Created by: nimeggs