67
Musculoskeletal Trauma and
Orthopedic Surgery
Rebekah Filson
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Functional Ability
Infection
Mobility
Pain
Perfusion
Safety
LEARNING OUTCOMES
1.Discuss the etiology, pathophysiology, manifestations, and
interprofessional and nursing management of soft tissue
injuries.
2.Relate the sequence of events involved in fracture healing.
3.Compare closed reduction, casting, open reduction, and
traction in terms of purpose, complications, and nursing
management.
4.Assess the neurovascular condition of an injured extremity.
5.Explain common complications of a fracture and fracture
healing.
6.Describe the interprofessional and nursing management of
patients with various kinds of fractures.
7.Describe indications for and interprofessional and nursing
management of the patient with an amputation.
8.Describe types of joint replacement surgery.
9.Prioritize management of the patient having joint
replacement surgery.
KEY TERMS
amputation
arthrodesis
arthroplasty
bursitis
carpal tunnel syndrome (CTS)
compartment syndrome
debridement
dislocation
fat embolism syndrome (FES)
fracture
osteotomy
phantom limb sensation
repetitive strain injury (RSI)
sprain
strain
traction
The most common cause of musculoskeletal injury is a traumatic event resulting in fracture, dislocation, subluxation, and/
or soft tissue injury. Most of these injuries are not fatal. However, accidents are 1 of the top 3 causes of death for persons
ages 1 to 64 years.1 The costs in terms of pain, disability, and
expense are enormous. Nurses play a key role in teaching the
public about basic principles of safety and accident prevention.
This chapter discusses musculoskeletal problems resulting
from trauma and common orthopedic surgeries. After trauma
or surgery, the injured area is often immobilized while healing
occurs. We discuss the important role of the nurse in preventing
complications (e.g., pressure injuries, constipation, infection,
venous thromboembolism [VTE]) and promoting functional
ability in patients with fractures and orthopedic surgery.
1638
HEALTH PROMOTION
Teach people to take proper safety precautions to prevent injuries
while at home or work, driving, or taking part in sports (Box 67.1).
The morbidity from accidents can be reduced if people are aware
of environmental hazards, use proper safety equipment, and apply
safety and traffic rules. In the work setting, teach employees and
employers to use proper safety equipment and decrease workplace
hazards. Falls cause many musculoskeletal injuries in the home.
CHAPTER 67
BOX 67.1
HEALTH
Musculoskeletal Trauma and Orthopedic Surgery
PROMOTING POPULATION
Reducing the Risk for Musculoskeletal Injuries
• Wear seatbelts.
• Drive within posted speed limits.
• Avoid distracted driving (e.g., no texting, eating, talking on a cell phone).
• Do not drive under the influence of alcohol or drugs (prescribed or illicit).
• Warm up muscles before exercise.
• Use protective athletic equipment (helmets and knee, wrist, and elbow
pads).
• Use proper safety equipment at work.
BOX 67.2
HEALTH
PROMOTING POPULATION
Reducing Fall Risk
• Assess the living environment for safety risks.
• Wear functional, nonskid, hard-soled shoes.
• Avoid wet or slippery surfaces.
• Remove throw rugs and ensure adequate lighting in the home.
• Maintain clear paths to the bathroom for nighttime use.
Provide preventive teaching to high-risk persons (e.g., people with
gait instability, vision impairment) (Box 67.2).
Encourage people, especially older adults, to take part in
moderate exercise to help maintain muscle strength and balance. Table 67.1 describes ways to prevent common musculoskeletal problems in the older adult. Stress the importance of
adequate calcium and vitamin D intake for bone health.
SOFT TISSUE INJURIES
Soft tissue injuries include sprains, strains, dislocations, and subluxations. They usually result from trauma. As more people have
become involved in fitness programs or sports, the incidence of
soft tissue injuries has increased. Table 67.2 describes common
sports-related injuries. Sports injuries that often result in a visit
to the emergency department (ED) for younger patients include
sprains and strains, growth plate injuries, and repetitive motion
injuries.2
SPRAINS AND STRAINS
Sprains and strains often result from abnormal stretching or
twisting forces during vigorous activities. These injuries tend to
occur around joints and in the spinal muscles.
A sprain is an injury to the ligaments surrounding a joint.
Sprains are usually caused by a wrenching or twisting motion.
Most occur in the ankle, wrist, and knee joints.3 We classify
sprains according to the degree of ligament damage. A first-degree (mild) sprain involves tears in only a few fibers, with mild
tenderness and minimal swelling. A second-degree (moderate)
sprain results in partial disruption of the involved tissue with
more swelling and tenderness. A third-degree (severe) sprain is a
complete tear of the ligament with moderate to severe swelling.
1639
TABLE 67.1 PATIENT & CAREGIVER
TEACHING
Preventing Musculoskeletal Problems in Older
Adults
To prevent musculoskeletal problems, include the following instructions when
teaching older adults and their caregivers:
1.Use ramps in buildings and at street corners instead of steps to prevent falls.
2.Remove throw rugs from the home.
3.Treat pain and discomfort from osteoarthritis.
•Rest in positions that decrease discomfort.
•Use medication as prescribed for pain.
4.Use a walker or cane to help prevent falls.
5.Eat the amount and kind of foods needed to prevent weight gain. Obesity
adds stress to joints, which may predispose to osteoarthritis.
6.Get regular and frequent exercise.
•ADLs provide range-of-motion exercises. Tai Chi may be helpful.
•Hobbies (e.g., jigsaw puzzles, needlework, model building) exercise finger joints and prevent stiffness.
•Do daily weight-bearing exercise (e.g., walking) to improve bone health.
7.Use shoes with good support for safety and comfort.
8.Avoid sudden change in position. Rise slowly to a standing position to
prevent dizziness, falls, and fractures.
9.Do not walk on uneven surfaces and wet floors.
A strain is an excessive stretching of a muscle and its fascial
sheath, often involving the tendon. Most strains occur in the
large muscle groups, including the lower back, calf, and hamstrings. We classify strains as first degree (mild or slightly pulled
muscle), second degree (moderate or moderately torn muscle),
and third degree (severely torn or ruptured muscle). A defect
in the muscle may be apparent or palpated through the skin if
the muscle is torn. Because areas around joints are rich in nerve
endings, the injury can be very painful.
Manifestations of sprains and strains are similar. They include
pain, edema, decreased function, and bruising. Continued use
of the joint, tendon, or ligament makes pain worse. Edema
develops in the injured area because of the local inflammatory
response.
Mild sprains and strains are usually self-limiting. Full function generally returns within 3 to 6 weeks. X-rays may be done
to rule out a fracture. A severe sprain can cause an avulsion
fracture, in which the ligament pulls loose a fragment of bone.
The joint structure may become unstable, causing subluxation
or dislocation. At the time of injury, hemarthrosis (bleeding into
a joint space or cavity) or disruption of the synovial lining may
occur. Severe strains may need surgical repair of the muscle,
tendon, or surrounding fascia.
NURSING MANAGEMENT: SPRAINS AND
STRAINS
Implementation
Health Promotion
Warming up muscles before exercising and vigorous activity, followed by stretching, may significantly reduce the risk
for sprains and strains. Strength, balance, and endurance
1640
SECTION 12
TABLE 67.2
Problems Related to Movement and Coordination
Soft Tissue Injuries
Injury
Description
Treatment
Anterior cruciate ligament tear
Tearing of ligament by deceleration forces with pivoting or
odd positions of the knee or leg.
Entrapment of soft tissues and nerves under coracoacromial
arch of shoulder
Tearing or stretching of ligament. Usually occurs from
inversion, eversion, shearing, or torque applied to a joint.
Characterized by sudden pain, swelling, and instability
Injury to fibrocartilage discs in knee. Characterized by
popping, clicking, tearing sensation, effusion, and/or
swelling
Tear within muscle, tendons, or ligaments around shoulder
PT with rehabilitation, knee brace. If knee instability or further
injury, reconstructive surgery may be done.
NSAIDs. Rest until symptoms ↓, then begin gradual ROM and
strength exercises.
Rest, ice, elevation of extremity if possible, NSAIDs. Protect
affected extremity by use of brace. If symptoms persist,
surgical repair may be needed.
Rest, ice, elevation of extremity if possible, NSAIDs. Gradual
return to regular activities. If symptoms persist, MRI to assess
meniscus injury. Possible arthroscopic surgery.
If minor tear: rest, NSAIDs, and gradual mobilization with ROM
and strength exercises.
If major tear: surgical repair.
Rest, ice, NSAIDs, proper shoes. Gradual ↑ in activity. If pain
persists, x-ray to rule out tibial stress fracture
Impingement syndrome
Ligament injury
Meniscus injury
Rotator cuff tear
Shin splints
Tendonitis
BOX 67.3
HEALTH
Inflammation of periosteal bone (periostitis) along anterior
calf. Caused by improper shoes, overuse, or running on
hard pavement
Inflammation of tendon due to overuse or incorrect use
PROMOTING POPULATION
Health Impact of Physical Activity
• Helps with weight management
• Increases lean muscle and decreases body fat
• Helps maintain and improve bone mass
• Increases muscle strength, flexibility, and endurance
• Helps prevent high BP
• Reduces the risk for heart disease, diabetes, and colon cancer
• Enhances sense of well-being and reduces risk for depression
exercises are important (Box 67.3). Strength exercises that
involve working against resistance build muscle strength and
bone density. Balance exercises, which may overlap with some
strength exercises, help prevent falls. Endurance exercises
should start at a low level of effort and progress gradually to a
moderate level.
Acute Care
If an injury occurs, immediate care focuses on (1) stopping the
activity and limiting movement to the injured part, (2) applying ice packs to the injured area, (3) compressing the involved
area, (4) elevating the extremity, and (5) providing analgesia as
needed (Table 67.3). Most sprains and strains are treated in the
outpatient setting.
RICE (Rest, Ice, Compression, Elevation) may decrease
local inflammation and pain for most musculoskeletal injuries.
Movement should be restricted with the extremity rested as
soon as pain is felt. Unless the injury is severe, prolonged rest is
usually not needed.
There are several forms of cold therapy (cryotherapy).
Cold causes vasoconstriction in the soft tissue and reduces
the transmission and perception of nerve pain impulses.
Rest, ice, NSAIDs. Gradual return to sport activity. Protective
brace (orthosis) may be needed if symptoms recur.
These changes also reduce muscle spasms, inflammation, and
edema. Cold is most useful when applied immediately after an
injury has occurred and used for 24 to 28 hours. Apply ice no
more than 20 to 30 minutes at a time. Do not apply ice directly
to the skin.
Compression helps decrease edema and pain. We often use
an elastic compression bandage. It can be wrapped around the
injured part. To prevent edema and encourage fluid return,
wrap the bandage starting distally (at the point farthest from the
trunk of the body) and progress proximally (toward the trunk
of the body). The bandage is too tight if there is numbness or
tingling below the area of compression or pain or more swelling
occurs beyond the edge of the bandage. Leave the bandage in
place for 30 minutes, then remove it for 15 minutes. Use of an
elastic wrap may provide extra support during training, athletic,
and work activities.
Elevate the injured part above heart level, even during sleep,
for 24 to 48 hours to help mobilize excess fluid from the area
and prevent further edema. Mild analgesics and nonsteroidal
antiinflammatory drugs (NSAIDs) may be used to manage
patient discomfort.
After the acute phase (usually 24 to 48 hours), apply warm,
moist heat to the affected part to reduce swelling and provide
comfort. Heat applications should not exceed 20 to 30 minutes.
Allow a “cool-down” time between applications. Encourage the
patient to use the limb if the joint is protected by a cast, brace,
splint, or taping. Joint movement maintains nutrition to the cartilage. Movement helps prevent contracture (stiffening) of tendons and ligaments. Muscle contraction improves circulation
and helps resolve bruising and swelling.
Emphasize the importance of strength and conditioning
exercises to prevent reinjury. The physical therapist may help
with pain relief by using ultrasound or other interventions.
They can teach the patient exercises to improve flexibility and
strength.
CHAPTER 67
TABLE 67.3
Musculoskeletal Trauma and Orthopedic Surgery
1641
EMERGENCY MANAGEMENT
Acute Soft Tissue Injury
Cause
Assessment Findings
Interventions
•Crush injury
•Direct blows
•Falls
•Motor vehicle crashes
•Sports injuries
•Bruising
•↓ Movement with limited function or inability
to bear weight (lower extremity)
•↓ Pulse, coolness, capillary refill >2 sec
•↓ Sensation
•Edema
•Muscle spasms
•Pain, tenderness
•Pallor
•Shortening or rotation of extremity
Initial
•Ensure airway, breathing, and circulation.
•Perform neurovascular assessment of involved limb.
•Elevate involved limb.
•Apply compression bandage unless dislocation present.
•Apply ice packs to affected area.
•Immobilize affected extremity in the position found. Do not try to realign or
reinsert protruding bones.
•Anticipate x-rays of injured extremity.
•Give analgesia as needed.
•Give tetanus prophylaxis if there is an open fracture.
•Give antibiotic prophylaxis for open fracture, large tissue defects, or mangled
extremity injury.
Ongoing Monitoring
•Monitor for changes in neurovascular condition.
•
Implement weight-bearing restrictions as ordered for lower extremity
involvement.
•Anticipate compartment pressure monitoring if neurovascular assessment
changes and compartment syndrome suspected.
DISLOCATIONS
Dislocation is the complete displacement or separation of the
articular surfaces of the joint. Subluxation is a partial or incomplete displacement of the joint surface. Symptoms of subluxation
are similar to a dislocation but are less severe. Many structures contribute to joint stability. Injury to, or excessive laxity
of, ligaments is a major factor in dislocations or subluxations.
Weak or atrophied muscles can cause chronic joint instability.
Fibrocartilage structures, such as the labrum around hip and
shoulder sockets and the meniscus at the knee, play an important role in joint stability. Even small tears to these structures can
result in recurrent, chronic dislocations or subluxations.
Dislocations typically result from forces on the joint that disrupt the surrounding soft tissue support structures. The joints
most often dislocated in the upper extremity include the thumb,
elbow, and shoulder. The shoulder most often dislocates anteriorly. Posterior shoulder dislocations are rare. They typically only
happen after electrocution or seizure. In the lower extremity, the
hip is vulnerable to dislocation from severe trauma, often from
motor vehicle crashes (Fig. 67.1). The kneecap (patella) may dislocate because of a sharp, direct blow or after a sudden twisting
inward motion while the planted foot is pointed outward.
The most obvious sign of a dislocation is deformity. For
example, if the hip dislocates in a posterior (or backward) direction, the affected limb may be shorter and internally rotated.
Other manifestations include local pain, tenderness, loss of
function of the injured part, and swelling of soft tissues near the
joint. Major complications include open joint injuries, intraarticular fractures (within the joint), avascular necrosis (bone cell
death from blood supply), and damage to adjacent nerves and
blood vessels.
A
B
C
Fig. 67.1 Soft tissue injury of the hip. (A) Normal. (B) Subluxation (partial dislocation). (C) Dislocation.
X-rays can determine the extent of displacement. The joint
may be aspirated to assess for hemarthrosis or fat cells. Fat cells
in the aspirate indicate a probable intraarticular fracture.
Interprofessional and Nursing Care
A dislocation requires prompt attention. It is often considered
an orthopedic emergency because it may be cause significant
vascular injury. The longer the joint is dislocated, the greater the
risk for avascular necrosis. The femoral head of the hip joint is
especially susceptible to avascular necrosis. Compartment syndrome may occur after dislocation due to vascular injury and
resulting ischemia. Neurovascular assessment is critical.
The first goal of care of a dislocation is to realign the dislocated
part of the joint to its original anatomic position. Closed reduction
(no incision) may be done under local or general anesthesia or IV
moderate to deep sedation. Anesthesia is often needed to relax the
muscle so that the bones can be manipulated. Sometimes, open
reduction (joint visualized through surgery) may be needed. After
reduction, the extremity is immobilized by a brace, splint, or sling,
or by taping, to allow torn ligaments and surrounding tissue to heal.
1642
SECTION 12
Problems Related to Movement and Coordination
Nursing care includes pain management and support and
protection of the injured joint. After the joint has been reduced
and immobilized, motion is usually restricted. A monitored
rehabilitation program can prevent further instability and joint
problems. Gentle range-of-motion (ROM) exercises may be
done if the joint is stable and well supported. An exercise program slowly restores the joint to its original ROM without causing another dislocation. The patient should gradually return to
normal activities.
A patient who has dislocated a joint may be at greater risk
for repeated dislocations because of damage or laxity to the supporting structures. Activity restrictions may be imposed on the
affected joint to decrease the risk for repeated dislocations.
REPETITIVE STRAIN INJURY
Repetitive strain injury (RSI) and cumulative trauma disorder
are terms used to describe injuries resulting from prolonged
force or repetitive movements and awkward postures. RSI is
also called repetitive trauma disorder, nontraumatic musculoskeletal injury, overuse syndrome (sports medicine), regional musculoskeletal disorder, and work-related musculoskeletal disorder.
Repeated movements strain the tendons, ligaments, and muscles, causing tiny tears that become inflamed. We do not know
the exact cause of these disorders. No specific diagnostic tests
exist, and diagnosis is often difficult.
Persons at risk for RSI include musicians, dancers, butchers,
grocery clerks, vibratory tool workers, and those who frequently
use a computer mouse and keyboard. Competitive athletes and
poorly trained athletes may develop RSI. Swimming, overhead
throwing (e.g., baseball), weightlifting, gymnastics, tennis, skiing, and kicking sports (e.g., soccer) require repetitive motion.
Overtraining compounds the effects of RSI.
Other factors related to RSI include poor posture and positioning, poor workspace ergonomics, badly designed workplace
equipment (e.g., computer keyboard), and repetitive lifting of
heavy objects without sufficient muscle rest. Inflammation, swelling, and pain in the muscles, tendons, and nerves of the neck,
spine, shoulder, forearm, and hand may result. Symptoms of RSI
include pain, weakness, numbness, or impaired motor function.
RSI can be prevented through education and ergonomics (the
science that promotes efficiency and safety in the interaction of
humans and their work environment). For example, ergonomic
considerations for those who work at a desk and use a computer
include keeping the hips and knees flexed to 90 degrees with the
feet flat, keeping the wrist straight to type, having the top of the
computer monitor even with the forehead, and taking at least
hourly stretch breaks.
Treatment is supportive. Pain management includes heat or
cold therapy, NSAIDs, and rest. Physical therapy (PT) focuses
on strength and conditioning exercises. Teach the patient about
lifestyle changes and ways to modify equipment and/or activity.
CARPAL TUNNEL SYNDROME
Carpal tunnel syndrome (CTS) is caused by compression of
the median nerve. It enters the hand at the wrist through the
Median nerve
Volar carpal
ligament
Typical median
sensory innervation
Fig. 67.2 Wrist structures involved in carpal tunnel syndrome. Median
nerve distribution. Shaded areas show the locations of pain in carpal
tunnel syndrome. (From Buttaravoli P: Minor emergencies, ed 3, Philadelphia, 2012, Saunders.)
narrow carpal tunnel (Fig. 67.2). The carpal tunnel is formed
by ligaments and bones. CTS is the most common compression
neuropathy in the upper extremity. It is associated with hobbies
or work that require continuous wrist movement (e.g., musicians, carpenters, computer operators).
CTS is often caused by pressure from trauma or edema (from
inflammation of a tendon [tenosynovitis]), cancer, rheumatoid
arthritis (RA), or soft tissue masses, such as ganglia. Hormones
may be involved because CTS often occurs during the premenstrual period, pregnancy, and menopause. Persons with diabetes,
peripheral vascular disease (PVD), and RA have a higher incidence of CTS because of swelling that changes blood flow to the
nerve and narrows the carpal tunnel.4 Women are more likely than
men to develop CTS, possibly because of a smaller carpal tunnel.
Manifestations of CTS are impaired sensation, pain, numbness, or weakness in the distribution of the median nerve (Fig.
67.2). Numbness and tingling may awaken the patient at night.
Shaking the hands often relieves these symptoms. Clumsiness in
performing fine hand movements is common.
The patient may have a positive Tinel sign and Phalen sign.
Elicit Tinel sign by tapping over the median nerve as it passes
through the carpal tunnel in the wrist. A positive response is
a sensation of tingling in the distribution of the median nerve
over the hand. Test for Phalen sign by allowing the wrists to fall
freely into maximum flexion and maintain the position for longer than 60 seconds. A positive response is a sensation of tingling in the distribution of the median nerve over the hand. In
late stages, atrophy of the muscles around the base of the thumb
results in recurrent pain and eventual dysfunction of the hand.
Interprofessional and Nursing Care
To prevent CTS, teach employees and employers to identify risk
factors. Adaptive devices, such as wrist splints, may be worn
to hold the wrist in a slight extension and relieve pressure on
the median nerve. Special keyboard pads and computer mice
that help prevent repetitive pressure on the median nerve are
available for computer users. Other ergonomic changes include
workstation changes, change in body positions, and frequent
breaks from work activities.
CHAPTER 67
Musculoskeletal Trauma and Orthopedic Surgery
Care is directed toward relieving the underlying cause of the
nerve compression. Early symptoms can usually be relieved by
stopping the aggravating movement and by resting the hand
and wrist by immobilization in a hand splint. Splints worn at
night help keep the wrist in a neutral position. This may reduce
night pain and numbness. PT with hand and wrist exercises may
lessen symptom severity. A corticosteroid injection directly into
the carpal tunnel may give short-term relief. The patient may
need to consider a change in occupation because of discomfort
and sensory changes.
Carpal tunnel release is generally done if symptoms last
more than 6 months or if there is significant impairment to conduction on electromyography (EMG). Surgery involves severing the band of tissue around the wrist to reduce pressure on
the median nerve (Fig. 67.2). Surgery is done in the outpatient
setting using local anesthesia. The types of carpal tunnel release
surgery include open release and endoscopic surgery. In open
release surgery, an incision is made in the wrist and then the
carpal ligament is cut to enlarge the carpal tunnel. Endoscopic
carpal tunnel release is done through 1 or more small puncture
incisions in the wrist and palm. A camera is attached to a tube,
and the carpal ligament is cut. The endoscopic approach may
allow a faster recovery and cause less discomfort than traditional open release surgery.
Although symptoms may be relieved right after surgery,
full recovery may take months. After surgery, assess the hand’s
neurovascular status. Teach the patient about wound care and
assessments to perform at home.
ROTATOR CUFF INJURY
The rotator cuff is made up of 4 muscles in the shoulder: the
supraspinatus, infraspinatus, teres minor, and subscapularis
muscles. These muscles stabilize the humeral head in the glenoid fossa and assist with ROM of the shoulder and rotation of
the humerus.
A tear in the rotator cuff may occur as a gradual, degenerative
process due to aging, repetitive stress (especially overhead arm
motions), or injury to the shoulder. In sports, repetitive overhead motions, such as in swimming, weightlifting, and swinging
a racquet (tennis, racquetball), often cause injury. The rotator
cuff can tear because of sudden adduction forces applied to the
cuff while the arm is held in abduction. Other causes include
(1) falling onto an outstretched arm and hand, (2) a blow to the
upper arm, (3) heavy lifting, or (4) repetitive work motions.
Manifestations include shoulder weakness, pain, and
decreased ROM. The patient usually has severe pain when the
arm is abducted between 60 and 120 degrees (the painful arc).
A positive drop arm test is a sign of rotator cuff injury. In this
test, the arm is abducted 90 degrees, and the patient is asked
to slowly lower the arm to the side. If the arm falls suddenly,
rotator cuff injury is suspected. An x-ray is not helpful in the
diagnosis. MRI can usually confirm a tear.
The patient with a partial tear or cuff inflammation may
be treated with rest, ice, and heat, NSAIDs, corticosteroid
injections into the subacromial space, ultrasound, and PT. If
the patient does not respond to conservative treatment or if
1643
Acromion
Torn supraspinatus
muscle
Arthroscope
Biceps
tendon
Humerus
Subscapularis muscle
(located behind
the rib cage)
Fig. 67.3 A torn rotator cuff is repaired using arthroscopic surgery.
a complete tear is present, surgical repair may be done. Most
repairs are arthroscopic procedures done as an outpatient (Fig.
67.3). If the tear is extensive, part of the acromion may be surgically removed (acromioplasty) to relieve compression of the
rotator cuff during movement. A shoulder immobilizer with an
abduction pillow is typically used for 6 weeks after surgery to
limit shoulder movement. However, the shoulder should not be
immobilized for too long because “frozen” shoulder (arthrofibrosis) may occur. Pendulum exercises and other passive exercises typically begin the first postoperative day. Active PT starts
after 6 weeks of immobilization. Weight restrictions for lifting
are usually given. Full recovery may take 6 to 12 months.
MENISCUS INJURY
The menisci are crescent-shaped pieces of fibrocartilage in the
knee. Menisci are also found in other joints, including the acromioclavicular (AC), sternoclavicular, and temporomandibular
joints. Meniscus injuries are associated with ligament sprains
common among athletes in sports such as basketball, football,
soccer, and hockey.5 These activities produce rotational stress
when the knee is in varying degrees of flexion and the foot is
planted or fixed. A blow to the knee can cause shearing of the
meniscus between the femoral condyles and tibial plateau, causing a torn meniscus. Older adults and people who have jobs that
require squatting or kneeling are at risk for degenerative tears.5
Meniscus injuries alone do not usually cause significant
edema because most cartilage is avascular. However, an acutely
torn meniscus may present with local tenderness, pain, and
effusion (Fig. 67.4). Pain occurs with flexion, internal rotation,
and then extension of the knee (McMurray’s test). The patient
may feel that the knee is unstable. They often report that the
knee “clicks,” “pops,” “locks,” or “gives way.” Quadriceps atrophy
is usually present if the injury has been present for some time.
Traumatic arthritis may occur from repeated meniscus injury
and chronic inflammation.
MRI can confirm the diagnosis before arthroscopy. The
patient’s age, occupation, sport activities, degree of pain, and
dysfunction may affect the decision whether to have surgery.
1644
SECTION 12
Problems Related to Movement and Coordination
Tear of the anterior
cruciate ligament
A
A
Partial
B
Avulsion
C
Complete
Fig. 67.5 ACL injury. (A) Partial tear. (B) Complete tear. (C) Avulsion.
B
C
Fig. 67.4 Arthroscopic views of the meniscus. (A) Normal meniscus.
(B) Torn meniscus. (C) Surgically repaired meniscus. (A, From David
Lintner, MD, Houston, TX, www.drlintner.com. B and C, Courtesy Peter
Bonner, Placitas, NM.)
Interprofessional and Nursing Care
Most meniscus injuries are treated in an outpatient setting.
The acutely injured knee should be examined within 24 hours
of injury. Initial care involves ice, immobilization, and use of
crutches with weight bearing as tolerated. Using a knee brace or
immobilizer during the first few days after the injury protects
the knee and offers some pain relief.
After acute pain has decreased, PT can help the patient
regain knee flexion and muscle strength to aid in returning to
full function. Teach athletes to do warm-up exercises to reduce
the risk for sports-related injuries. In older adults with degenerative meniscus tears, progressive exercise therapy may improve
neuromuscular function and muscle strength.
Surgical repair or excision of part of the meniscus (meniscectomy) may be needed (see Fig. 67.4). Meniscal surgery is
done by arthroscopy. Pain relief may include NSAIDs or other
analgesics. Rehabilitation starts soon after surgery. PT includes
quadriceps and hamstring strength exercises and ROM. When
the patient’s strength is back to its preinjury level, they can
resume normal activities.
a complete tear, or an avulsion (tearing away) from the bones
that form the knee (Fig. 67.5).
A positive Lachman’s test suggests an ACL tear. This test is
done by flexing the knee 15 to 30 degrees and pulling the tibia
forward while stabilizing the femur. The test is positive for an
ACL tear if forward motion of the tibia occurs with the feeling
of a soft or indistinct endpoint. MRI can diagnose an ACL tear
and coexisting conditions, including a fracture, meniscus tear,
and ligament injuries.
Interprofessional and Nursing Care
Prevention programs can significantly reduce ACL injuries
in athletes. Conservative treatment for an intact ACL injury
includes rest, ice, NSAIDs, elevation, and ambulation as tolerated with crutches. If present, a tight, painful effusion may be
aspirated. A knee immobilizer or hinged knee brace may provide support. PT often helps the patient maintain knee joint
motion and muscle tone.
Reconstructive surgery is usually recommended for physically active patients who have sustained severe injury to the
ACL and meniscus. In reconstruction, the torn ACL tissue is
removed and replaced with graft tissue. ROM is encouraged
soon after surgery. The knee is placed in a brace or immobilizer.
Rehabilitation with PT is critical. Progressive weight bearing is
determined by the type of surgery. A safe return to the prior
level of function may take 6 to 8 months.
ANTERIOR CRUCIATE LIGAMENT INJURY
BURSITIS
Knee injuries account for more than 50% of all sports injuries.
The most commonly injured knee ligament is the anterior cruciate ligament (ACL). ACL injuries are usually noncontact injuries that occur when a person pivots, lands from a jump, or stops
abruptly when running. Patients often report coming down on
the knee, twisting, and hearing a pop, followed by acute knee
pain and swelling. The knee may feel unstable. Athletes usually
cannot continue playing. ACL injury can result in a partial tear,
Bursae are closed sacs that are lined with synovial membrane
and contain a small amount of synovial fluid. They are found at
sites of friction, such as between tendons and bones and near
the joints. Bursitis (inflammation of the bursa) results from
repeated or excessive trauma or friction, gout, RA, or infection.
Symptoms include warmth, pain, swelling, and limited ROM
in the affected part. Common sites are the hands, elbows, shoulders, knees, and greater trochanters of the hip. Improper body
CHAPTER 67
Musculoskeletal Trauma and Orthopedic Surgery
A
B
Transverse
Spiral
C
D
Greenstick
Comminuted
1645
Open fracture
Closed fracture
Fig. 67.6 Fracture classification by communication with the external
environment.
mechanics, repetitive kneeling (e.g., carpet layers, coal miners,
gardeners), jogging in worn-out shoes, and prolonged sitting
with crossed legs are common precipitating activities.
Try to determine and correct the cause of the bursitis. Rest
is often the only treatment needed. The affected part may
be immobilized in a compression dressing or splint. Ice and
NSAIDs can reduce pain and inflammation. Aspiration of the
bursal fluid and intraarticular corticosteroid injection may
be needed. If the bursal wall has become thickened and continues to interfere with normal joint function, surgical excision (bursectomy) may be done. Septic bursae may be treated
with oral antibiotics but usually need surgical incision and
drainage.
FRACTURES
Classification
A fracture is a disruption or break in the continuity of bone.
Traumatic injuries cause most fractures. Other fractures are due
to a disease process, such as cancer or osteoporosis (pathologic
fracture).
We classify fractures in several ways. Fractures are described
as open or closed based on communication with the external
environment (Fig. 67.6). In an open fracture, the skin is broken,
and bone exposed, causing soft tissue injury. An open fracture
usually results from severe external forces. In a closed fracture,
the skin is intact over the site.
We also describe fractures as complete or incomplete. A fracture is complete if the break goes completely through the bone.
An incomplete fracture occurs partly across a bone shaft, but the
bone is still intact. An incomplete fracture is often the result of
bending or crushing forces applied to a bone.
Fractures are identified by the direction of the fracture line.
Types include linear, oblique, transverse, longitudinal, and spiral fractures (Fig. 67.7).
Finally, we describe fractures as displaced or nondisplaced.
In a displaced fracture, the 2 ends of the broken bone are separated from each other and out of their normal positions.
Displaced fractures are often comminuted (more than 2fragments) or oblique (Fig. 67.7). In a nondisplaced fracture, the
bone fragments stay in alignment. Nondisplaced fractures are
usually transverse, spiral, or greenstick (Fig. 67.7).
E
F
Oblique
Pathologic
G
Stress
Fig. 67.7 Types of fractures. (A) Transverse fracture: the line of the fracture extends across the bone shaft at a right angle to the longitudinal
axis. (B) Spiral fracture: the line of the fracture extends in a spiral direction along the bone shaft. (C) Greenstick fracture: an incomplete fracture
with 1 side splintered and the other side bent. (D) Comminuted fracture:
a fracture with more than 2 fragments. The smaller fragments appear to
be floating. (E) Oblique fracture: the line of the fracture extends across
and down the bone. (F) Pathologic fracture: a spontaneous fracture at
the site of a diseased bone. (G) Stress fracture: occurs in bone that is
subject to repeated stress, such as from jogging or running.
Manifestations
Manifestations include immediate pain, decreased function,
and inability to bear weight or use the affected part (Table 67.4).
The patient guards and protects the extremity against movement. Obvious deformity may be present.
Fracture Healing
Bone goes through a complex multistage healing process, or
union (Fig. 67.8). Healing occurs in 6 stages:
1.Fracture hematoma: When a fracture occurs, bleeding creates a hematoma that surrounds the ends of the bone fragments. The hematoma is composed of extravasated blood
that changes from a liquid to a semisolid clot in the first 72
hours after injury.
2.Granulation tissue: During this stage, active phagocytosis
absorbs the products of local necrosis. The hematoma converts to granulation tissue. Granulation tissue (consisting
of new blood vessels, fibroblasts, and osteoblasts) forms the
basis for new bone substance (osteoid) during days 3 to 14
after injury.
3.Callus formation: As minerals (calcium, phosphorus, and
magnesium) and new bone matrix are deposited in the osteoid, an unorganized network of bone is formed and woven
about the fracture parts. Callus is mainly composed of cartilage, osteoblasts, calcium, and phosphorus. It usually appears
by the end of the second week after injury. An x-ray can show
evidence of callus formation.
1646
SECTION 12
TABLE 67.4
Problems Related to Movement and Coordination
Manifestations of Fracture
Manifestation
Significance
Bruising
Discoloration of skin from extravasation of May appear immediately after
blood in subcutaneous tissues.
injury and distal to injury.
Reassure patient that process
is normal, and discoloration
will resolve.
Crepitation
Grating or crunching of bony fragments,
May ↑ chance for nonunion if
causing palpable or audible crunching or bone ends are allowed to move
popping sensation.
excessively. Micromovement
of fragments (postfracture)
helps in osteogenesis (new
bone growth).
Deformity
Abnormal position of extremity or part
from original forces of injury and
action of muscles pulling fragment into
abnormal position. Seen as a loss of
normal bony contours.
Edema and Swelling
Disruption or penetration of skin or soft
tissues by bone fragments, or bleeding
into surrounding tissues.
Loss of Function
Disruption of bone or joint, preventing
functional use of limb or part.
Muscle Spasm
Irritation of tissues and protective
response to injury and fracture.
Pain and Tenderness
Muscle spasm due to involuntary reflex
action of muscle, direct tissue trauma,
↑ pressure on nerves, movement of
fracture fragments.
Classic sign of fracture. If
uncorrected, it may cause
problems with bony union
and restoration of function of
injured part.
Unchecked bleeding and
swelling in closed space can
occlude blood vessels and
damage nerves (e.g., ↑ risk for
compartment syndrome).
Fracture must be managed
properly to ensure restoration
of function to limb or part.
May displace nondisplaced
fracture or prevent it from
reducing spontaneously.
Prompt the patient to splint
muscle around fracture and
reduce motion of injured area.
4.Ossification: Ossification of the callus occurs from 3 weeks to
6 months after the fracture and continues until the fracture
has healed. Callus ossification is sufficient to prevent movement at the fracture site when the bones are gently stressed.
However, the fracture is still evident on x-ray. During this
stage of clinical union, the patient may be allowed limited
mobility, or we may remove the cast.
5.Consolidation: As callus continues to develop, the distance between bone fragments decreases and eventually
closes. Ossification continues and can be equated with
radiologic union, which occurs when an x-ray shows complete bony union. This phase can occur up to 1 year after
injury.
A
B
C
D
E
Fig. 67.8 Bone healing (schematic representation). (A) Bleeding at fractured ends of the bone with hematoma formation. (B) Organization of
hematoma into fibrous network. (C) Invasion of osteoblasts, lengthening of collagen strands, and deposition of calcium. (D) Callus formation:
new bone is built up as osteoclasts destroy dead bone. (E) Remodeling
is accomplished as excess callus is resorbed and trabecular bone is laid
down.
6.Remodeling: Excess bone tissue is resorbed in the last stage of
bone healing, and union is complete. Gradual return of the
injured bone to its preinjury structural strength and shape
occurs. Bone remodels in response to physical loading stress.
Initially, stress is provided through exercise. Weight bearing
is gradually introduced. New bone is deposited in sites subjected to stress and resorbed at areas of little stress.
Many factors influence the time needed for complete fracture healing. They include displacement and site of the fracture,
blood supply, other local tissue injury, immobilization, and use
of internal fixation devices (e.g., screws, pins). Ossification may
be slowed or even stopped by inadequate immobilization, excessive movement of fracture fragments, infection, poor nutrition,
and systemic disease (e.g., diabetes).6 Healing time for fractures
increases with age. For example, an uncomplicated midshaft
femur fracture heals in 3 weeks in an infant and in 20 weeks
in an adult. Smoking increases fracture healing time. Fracture
healing may not occur in the expected time (delayed union) or
may not occur at all (nonunion). Table 67.5 describes complications of fracture healing.
Interprofessional Care
The overall goals of fracture treatment are (1) anatomic realignment of bone fragments through reduction, (2) immobilization to maintain realignment, and (3) restoration of normal or
near-normal function of the injured part. Table 67.6 outlines the
management of fractures.
Fracture Reduction
Closed reduction. Closed reduction is the nonsurgical,
manual realignment of bone fragments to their anatomic
position. Traction and countertraction are manually applied to
the bone fragments to restore position, length, and alignment.
Closed reduction is usually done while the patient is under local
or general anesthesia. Traction, casting, splints, or orthoses
(braces) may be used after reduction to maintain alignment and
immobilize the injured part until healing occurs.
CHAPTER 67
TABLE 67.5
Healing
Musculoskeletal Trauma and Orthopedic Surgery
Complications of Fracture
Complication
Description
Angulation
Fracture heals in abnormal position in relation
to midline of structure (type of malunion).
Fracture healing progresses more slowly than
expected. Healing eventually occurs.
Fracture heals in expected time but in
unsatisfactory position. May cause
deformity or dysfunction.
Deposition of calcium in muscle tissue at
site of significant blunt muscle trauma or
repeated muscle injury.
Fracture does not heal despite treatment. No
x-ray evidence of callus formation.
Type of nonunion occurring at fracture site in
which a false joint is formed with abnormal
movement at site.
New fracture occurs at original fracture site.
Delayed union
Malunion
Myositis ossificans
Nonunion
Pseudoarthrosis
Refracture
TABLE 67.6
Fractures
1647
Interprofessional Care
Diagnostic Assessment
• H
istory and physical assessment
• X -ray
• C T scan, MRI
Management
Fracture Reduction
• M
anual traction
• C losed reduction
• S keletal traction
• O
pen reduction
Fracture Immobilization
• C asting or splinting
• S keletal traction
• E xternal fixation
• Internal fixation
Open Fractures
• S urgical debridement and irrigation
• T etanus and diphtheria immunization
• P rophylactic antibiotic therapy
Open reduction. Open reduction is the correction of bone
alignment through surgery. It usually includes internal fixation
of the fracture with wires, screws, pins, plates, intramedullary
rods, or nails. The type and location of the fracture, patient
age, and concurrent disease influence the decision to use open
reduction. The main risks of open reduction are infection,
complications of anesthesia, and effects of preexisting medical
conditions (e.g., diabetes). However, open reduction internal
fixation (ORIF) facilitates early ambulation, decreasing the risk
for complications related to prolonged immobility.
Traction. Traction is the application of a pulling force to an
injured or diseased body part or extremity. Traction is used to
(1) prevent or reduce pain and muscle spasm (e.g., whiplash,
unrepaired hip fracture), (2) immobilize a joint or part of
Fig. 67.9 Buck’s traction is most often used for fractures of the hip and
femur. (Courtesy Mary Wollan, RN, BAN, ONC, Spring Park, MN.)
the body, (3) reduce a fracture or dislocation, and (4) treat a
pathologic joint condition (e.g., tumor, infection). Traction can
also (1) provide immobilization to prevent soft tissue damage,
(2) promote active and passive exercise, (3) expand a joint space
during arthroscopic procedures, and (4) expand a joint space
before major joint reconstruction.
Traction devices apply a pulling force on a fractured extremity to attain realignment, while countertraction pulls in the
opposite direction. The most common types of traction are skin
traction and skeletal traction. Skin traction is generally used for
short-term treatment (48 to 72 hours) until skeletal traction or
surgery is possible. Tape, boots, or splints are applied directly
to the skin. They help decrease muscle spasms in the injured
extremity. Traction weights are usually 5 to 10 lb (2.3 to 4.5 kg).
Buck’s traction is a type of skin traction sometimes used for the
patient with a hip, knee, or femur fracture (Fig. 67.9). Pelvic or
cervical skin traction may require heavier weights applied intermittently. In skin traction, regular skin assessment is a priority because pressure points and skin breakdown may develop
quickly. Assess key pressure points every 2 to 4 hours.
Skeletal traction is used to align injured bones and joints or to
treat joint contractures and congenital hip dysplasia. It provides a
long-term pull that keeps the injured bones and joints aligned. To
apply skeletal traction, the HCP inserts a pin or wire into the bone,
and weights are attached to align and immobilize the injured body
part. Weight for skeletal traction ranges from 5 to 45 lb (2.3 to 20.4
kg). Too much weight can result in delayed union or nonunion.
The major complications of skeletal traction are infection at the
pin insertion site and the effects of prolonged immobility.
A common type of skeletal traction is balanced suspension
traction (Fig. 67.10). Fracture alignment depends on the correct positioning and alignment of the patient while the traction forces stay constant. For extremity traction to be effective,
forces must be pulling in the opposite direction (countertraction).
Countertraction is supplied by the patient’s body weight or by
weights pulling in the opposite direction. Elevating the end of the
bed can help. Traction must be maintained continuously. Keep
the weights off the floor and moving freely through the pulleys.
Fracture Immobilization
Fracture immobilization is achieved with casts, braces, splints,
immobilizers, and external and internal fixation devices.
1648
SECTION 12
Problems Related to Movement and Coordination
Short arm cast
Long arm cast
Long leg cast
Fig. 67.10 Balanced suspension skeletal traction. Most often used for
fractures of the femur, hip, and lower leg. (Courtesy Zimmer, Inc.)
Casts. A cast is a temporary immobilization device often
applied after closed reduction. A cast usually immobilizes the
joints above and below a fracture. This restricts tendon and
ligament movement, thus assisting with joint stabilization
while the fracture heals. A cast often allows the patient to
perform many normal ADLs while providing stability. The 2
most common cast materials are natural (plaster of Paris) and
fiberglass. We use fiberglass casts most often because they are
lighter, relatively waterproof, and longer wearing than plaster of
Paris.7 They also allow early weight bearing. Plaster of Paris is
used mainly for contact casting for treating diabetic foot ulcers.8
To apply a cast on an extremity, first cover the affected part
with stockinette that is cut longer than the extremity. Then
place cotton padding over the stockinette, with extra padding
for bony prominences. If using plaster of Paris, immerse it in
warm water and then wrap and mold it around the affected part.
The number of layers of plaster bandage and the technique of
application determine the strength of the cast. The plaster sets
within 15 minutes. It is not strong enough for weight bearing
until about 36 to 72 hours after application. The decision about
weight bearing is made by the HCP. Casts made of fiberglass
or other synthetic materials (thermolabile plastic, thermoplastic resins, polyurethane) are activated by submersion in cool or
tepid water. Then they are molded to fit the torso or extremity.
Leave a fresh plaster cast uncovered to allow air circulation.
Covering the cast allows heat to build up in the cast. This may
cause a burn and delay drying. Avoid direct pressure on the cast
during the drying period. Handle the cast gently with an open
palm to avoid denting the cast. Once the cast is thoroughly dry,
the rough edges may be petaled to minimize skin irritation.
Petaling also prevents plaster of Paris debris from falling into
the cast and causing irritation or pressure necrosis. Place several
strips (petals) of tape over the rough areas to ensure a smooth
cast edge.
Upper extremity injuries. An acute fracture or soft tissue
injury of the upper extremity can be immobilized by using a
(1) sugar-tong splint, (2) posterior splint, (3) short arm cast, or
Short leg cast
Fig. 67.11 Common types of casts.
(4) long arm cast (Fig. 67.11). The sugar-tong splint is applied
for acute wrist injuries or injuries that may result in significant
swelling. Splints are placed over a well-padded forearm,
beginning at the phalangeal joints of the hand, extending up
the dorsal aspect of the forearm around the distal humerus, and
then down the volar aspect of the forearm to the distal palmar
crease. The splinting material is wrapped with either elastic
bandage or bias stockinette. The sugar-tong posterior splint
adjusts for early swelling in the fractured extremity.
The short arm cast is often used to treat stable wrist or metacarpal fractures. An aluminum finger splint can be placed in
a short arm cast to treat finger injuries. The short arm cast is
a circular cast extending from the distal palmar crease to the
proximal forearm. This cast immobilizes the wrist and allows
unrestricted elbow motion.
The long arm cast is often used for stable forearm, elbow,
or unstable wrist fractures. It is similar to the short arm cast
but extends to the proximal humerus, restricting motion at the
wrist and elbow. Support the extremity and reduce edema by
elevating the extremity with a sling. When a hanging arm cast is
used for a proximal humerus fracture, avoid elevation or use of
a supportive sling. The hanging provides traction and maintains
fracture alignment.
When a sling is used, ensure the axillary area is well padded
to prevent skin breakdown from direct skin-to-skin contact.
Apply the sling carefully to avoid putting excess pressure on the
neck. Encourage movement of the fingers (unless contraindicated). This decreases edema by enhancing the pumping action
of blood vessels. Teach the patient to actively move joints of
the upper extremity if not immobilized to prevent stiffness and
contractures.
Vertebral injuries. The body jacket brace is used for
immobilization and support for stable spine injuries of the thoracic
or lumbar spine. The brace goes around the chest and abdomen,
CHAPTER 67
Musculoskeletal Trauma and Orthopedic Surgery
extending from above the nipple line to the pubis. After applying
a brace, assess the patient for superior mesenteric artery syndrome
(cast syndrome). This condition occurs if the brace is too tight,
compressing the superior mesenteric artery against the duodenum.
The patient may have abdominal pain, abdominal pressure,
nausea, and vomiting. Assess the abdomen for decreased bowel
sounds (there may be a window in the brace over the umbilicus).
Treatment of cast syndrome includes gastric decompression with
a nasogastric (NG) tube and suction. Assess respiratory status,
bowel and bladder function, and areas of pressure over the bony
prominences, especially the iliac crest. The brace may have to be
adjusted or removed if any complications occur.
Lower extremity injuries. Injuries to the lower extremity
can be immobilized with a long leg cast, short leg cast,
cylinder cast, or prefabricated splint or immobilizer. The usual
indications for a long leg cast are an unstable ankle fracture,
soft tissue injuries, a fractured tibia, and knee injuries. The
cast usually extends from the base of the toes to the groin and
gluteal crease. The short leg cast is used for stable ankle and foot
injuries. A cylinder cast is used for knee injuries or fractures. It
extends from the groin to the malleoli of the ankle. A Robert
Jones dressing may be used temporarily to limit mobility of
a joint. It is composed of soft padding materials (absorption
dressing and cotton sheet wadding), splints, and an elastic wrap
or bias-cut stockinette.
With a lower extremity cast or dressing, elevate the extremity above the heart on pillows for the first 24 hours. After that, a
casted extremity should not be placed in a dependent position, as
this may increase edema. After cast application, observe for signs
of compartment syndrome. Note increased pressure, especially in
the heel, anterior tibia, head of the fibula, and malleoli. Increased
pressure presents as pain or a burning feeling in these areas.
Prefabricated knee and ankle splints and immobilizers are
used in many settings. This type of immobilization is easy to
apply and remove. This allows us to observe the affected joint
for swelling and skin breakdown (Fig. 67.12). Depending on the
injury, removing the splint or immobilizer promotes ROM of
the affected joint and faster return to function.
The hip spica cast is mainly used for femur fractures in children to immobilize the affected extremity and trunk. It extends
from above the nipple line to the base of the foot (single spica)
and may include the opposite extremity up to an area above
the knee (spica and a half) or both extremities (double spica).
Assess the patient with a hip spica cast for the same problems
associated with the body jacket brace.
External fixation. An external fixator is composed of metal
pins and wires that are inserted into the bone and attached to
external rods to stabilize the fracture while it heals (Fig. 67.13). It
can be used to apply traction or to compress fracture fragments
and immobilize reduced fragments when the use of a cast or
traction is not appropriate. The external device holds fracture
fragments in place similar to a surgically implanted internal
device. External fixation is mainly used for complex fractures
with extensive soft tissue damage, correcting congenital bony
defects, nonunion or malunion, and limb lengthening.
External fixation is often used to try to salvage extremities that
otherwise may need amputation. Perform ongoing assessment
1649
Fig. 67.12 Knee immobilizer. (From Naples RM, Ufberg JW: Roberts
and Hedges’ Clinical procedures in emergency medicine and acute
care, Philadelphia, 2020, Elsevier.)
Fig. 67.13 External fixation of tibial fracture. (From Krettke C, Hawi N:
Skeletal trauma: basic science, management, and reconstruction, ed 6,
Philadelphia, 2020, Elsevier.)
for pin loosening and infection. Infection may require removing the device. Teach the patient and caregiver about meticulous
pin care. Although each HCP has a protocol for pin care cleaning, chlorhexidine is often used.9
Internal fixation. Internal fixation devices (pins, plates,
intramedullary rods, metal and bioabsorbable screws) are
surgically inserted to realign and maintain position of bony
fragments (Fig. 67.14). These metal devices are biologically inert
and made from stainless steel, vitallium, or titanium. Proper
alignment and bone healing are evaluated regularly by x-rays.
Electrical Bone Growth Stimulation
Electrical bone growth stimulation can promote healing, especially with fracture nonunion or delayed union. It stimulates
new bone, cartilage, and blood vessel formation.10 There are
noninvasive, semi-invasive, and invasive methods of electrical
bone growth stimulation. Noninvasive stimulators use direct
1650
SECTION 12
Problems Related to Movement and Coordination
We give tetanus and diphtheria toxoid or tetanus immunoglobulin to the patient with an open fracture when their
immunization status cannot be confirmed. Bone-penetrating
antibiotics, such as a cephalosporin (e.g., cefazolin), are given
prophylactically before surgery.
Fig. 67.14 Views of internal fixation devices to stabilize a fractured tibia
and fibula. (From Jeremy Lewis, MD, Albuquerque, NM.)
current or pulsed electromagnetic fields (PEMFs) to generate
a weak electrical current. Electrodes are typically in a band
applied over the patient’s skin or cast and worn 10 to 12 hours
each day, usually while the patient is sleeping. Semi-invasive or
percutaneous bone growth stimulators use an external power
supply and electrodes that are inserted through the skin and
into the bone. Invasive stimulators require surgical implantation of a current generator in an IM or subcutaneous space. An
electrode is implanted in the bone fragments.
Drug Therapy
Patients with fractures have varying degrees of pain. Muscle relaxants, such as carisoprodol (Soma), cyclobenzaprine, or methocarbamol, may be given to manage pain from muscle spasms.
TABLE 67.7
Nutrition Therapy
Proper nutrition helps ensure optimal soft tissue and bone healing. An adequate energy source promotes muscle strength and
tone, builds endurance, and provides energy for ambulation
and gait-training skills. The diet must include adequate protein
(e.g., 1 g/kg of body weight), vitamins (especially B, C, and D),
calcium, potassium, phosphorus, and magnesium. Low serum
protein and vitamin C deficiencies interfere with tissue healing.
Immobility and bone healing increase calcium needs.
A fluid intake of 2000 to 3000 mL/day promotes optimal
bladder and bowel function. Adequate fluid and a high-fiber
diet with fruits and vegetables prevent constipation. If immobilized in bed with skeletal traction or in a body jacket brace,
the patient should eat 6 small meals. This helps avoid overeating
that can cause abdominal pressure and cramping.
NURSING MANAGEMENT: FRACTURES
Assessment
Obtain a brief history of the traumatic episode, mechanism of
injury, and position in which the patient was found from the
patient or witnesses. As soon as possible, the patient should be
transported to an ED. There we do a thorough assessment and
start treatment (Table 67.7). Subjective and objective data that
EMERGENCY MANAGEMENT
Fractured Extremity
Cause
Assessment Findings
Interventions
Blunt Trauma
•Direct blow
•Fall
•Forced flexion or hyperextension
•Motor vehicle crash
•Pedestrian event
•Twisting force
•Bruising
Initial
•↓ Distal pulses
•Treat life-threatening injuries first.
•Deformity or unnatural position of •If unresponsive, assess circulation, airway, and breathing.
affected limb
•If responsive, monitor airway, breathing, and circulation.
•Edema
•Control external bleeding with direct pressure or sterile pressure dressing and eleva•Grating (crepitus)
tion of the extremity.
•Loss of function
•Assess neurovascular condition distal to injury before and after splinting.
•Muscle spasm
•Elevate injured limb if possible.
Penetrating Trauma
•Numbness, tingling
•Do not try to straighten fractured or dislocated joints.
•Blast
•Tenderness, pain
•Do not manipulate protruding bone ends.
•Gunshot
•Warmth at site
•Apply ice packs to affected area.
•Wound over injured site, exposure •Obtain x-rays of affected limb.
Other
of bone
•Give tetanus prophylaxis if there is a break in skin integrity.
•Pathologic condition
•Mark location of pulses to aid repeat assessment.
•Violent muscle contraction (sei•Splint fracture site, including joints above and below fracture site.
zures)
•Crush injury
Ongoing Monitoring
•Assess vital signs, level of consciousness, O2 saturation, neurovascular condition, pain.
•Assess for compartment syndrome (excessive pain, pain with passive stretch of
the affected extremity muscles, pallor, paresthesia, with late signs of paralysis and
pulselessness).
•Assess for FES (dyspnea, chest pain, temperature elevation).
CHAPTER 67
Musculoskeletal Trauma and Orthopedic Surgery
1651
TABLE 67.8 NURSING ASSESSMENT
Fracture
Subjective Data
Important Health Information
Health history: Traumatic injury, long-term repetitive forces (stress fracture),
bone or systemic diseases, prolonged immobility, osteopenia, osteoporosis
Medications: Corticosteroids (osteoporotic fractures); analgesics
Surgery or other treatments: First aid treatment of fracture, musculoskeletal
surgeries
General
Apprehension, guarding of injured site
Functional Health Patterns
Health perception–health management: Calcium and vitamin D supplementation
Activity-exercise: Loss of motion or weakness of affected part, muscle spasms
Cognitive-perceptual: Sudden and severe pain in affected area; numbness,
tingling, loss of sensation distal to injury; ongoing pain that increases with
activity (stress fracture)
Neurovascular
Paresthesia, absent or ↓ sensation, hypersensation
Objective Data
Cardiovascular
Reduced or absent pulse distal to injury, ↓ skin temperature, delayed capillary refill
Possible Diagnostic Findings
Identification and extent of fracture on x-ray, bone scan, CT scan, or
MRI
you should obtain from a person with a fracture are outlined in
Table 67.8.
If a fracture is suspected, immobilize the extremity in the
position in which it is found. Unnecessary movement increases
risk for damage to adjacent nerves and blood vessels. It may also
convert a closed fracture to an open fracture.
Neurovascular Assessment
Perform a thorough neurovascular assessment of the affected
extremity, distal to the fracture site. Musculoskeletal injuries
may cause changes in the neurovascular status of an injured
extremity. Poor positioning, physiologic responses to the
traumatic injury, and application of a cast or constrictive
dressing can cause nerve or vascular damage, usually distal
to the injury. Record clinical findings before fracture treatment. This way, if a problem occurs later, it will help determine if it was missed during the original assessment or a
result of treatment.
The neurovascular assessment consists of peripheral vascular
assessment (color, temperature, capillary refill, peripheral pulses,
edema) and peripheral neurologic assessment (sensation, motor
function, pain). Throughout the neurovascular assessment,
compare both extremities to obtain an accurate assessment.
Assess an extremity’s color (pink, pale, cyanotic) and temperature (hot, warm, cool, cold) around the injury. Pallor or a
cool-to-cold extremity below the injury could indicate arterial
insufficiency. A warm, cyanotic extremity could indicate poor
venous return. Next, assess capillary refill. A delay in returning
to its original color (greater than 3 seconds) can occur with arterial insufficiency.
Compare pulses on the unaffected and injured extremities to identify differences in rate or quality. This contralateral
evaluation is critical. A decreased or absent pulse distal to the
injury can indicate vascular problems and insufficiency. Assess
Musculoskeletal
Restricted or lost function of affected part; local bony deformities, abnormal
angulation; shortening, rotation, or crepitation of affected part; muscle
weakness
Skin
Lacerations, pallor and cool skin or bluish and warm skin distal to injury;
bruising, edema at fracture site
peripheral edema. Pitting edema may be present with severe
injury.
Assess ulnar, median, and radial nerve function to evaluate
sensation and motor innervation in the upper extremity. Assess
motor function by asking the patient to (1) abduct the fingers
(ulnar nerve), (2) oppose the thumb and small finger (median
nerve), and (3) flex and extend the wrist (or the fingers, if in a
cast) (radial nerve). In the lower extremity, assess the patient’s
ability to perform dorsiflexion (peroneal nerve) and plantar
flexion (tibial nerve). Evaluate sensory function of the peroneal
nerve by touching the web space between the big and second
toes. Stroke the plantar surface (sole) of the foot to assess sensory function of the tibial nerve.
The patient may report paresthesia (abnormal sensation [e.g.,
numbness, tingling]) and hypersensation or hyperesthesia.
Partial or full loss of sensation (paresis or paralysis) may be a
late sign of neurovascular damage. Teach the patient to immediately report any changes in sensation or the ability to move the
digits in the affected extremity.
Clinical Problems
Clinical problems for the patient with a fracture may include:
• Musculoskeletal problem
• Risk for infection
• Pain
Additional information on clinical problems and interventions for the patient with a fracture is presented in eNursing
Care Plan 67.1 (on the website for this chapter).
Planning
The overall goals are that the patient with a fracture will (1)
have healing with no associated complications, (2) have
acceptable pain relief, and (3) achieve maximal rehabilitation
potential.
1652
SECTION 12
Problems Related to Movement and Coordination
Implementation
Acute Care
Patients with fractures may be treated in an ED or an HCP’s
office and released to home care. They may need hospitalization
for varying amounts of time. Specific nursing measures depend
on the setting and type of treatment.
Preoperative care. If surgery is needed to treat a fracture,
patients must be prepared. In addition to the usual preoperative
nursing care (see Chapter 18), teach the patient about the
type of immobilization and assistive devices that will be used.
Discuss expected activity limitations after surgery. Assure them
that nursing staff will help meet their personal needs until they
can resume self-care. Review pain management strategies.
Postoperative care. In general, nursing care after surgery
involves monitoring vital signs and applying general principles
of postoperative nursing care (see Chapter 20). Perform
frequent neurovascular assessment of the affected extremity to
detect early and subtle changes. Follow any limitations related
to turning, positioning, and extremity support. Minimize pain
and discomfort through proper alignment and positioning.
Frequently observe dressings or casts for any signs of bleeding
or drainage. Report an increase in size of the drainage area
to the HCP. If a wound drainage system is in place, regularly
measure the volume of drainage and assess its character (e.g.,
bloody, purulent). Report increased or purulent drainage at
once to the HCP. Maintain the patency of any drainage systems,
using aseptic technique to avoid contamination.
Other nursing actions depend on the type of immobilization used. A blood salvage and reinfusion system may be used
to allow recovery and reinfusion of the patient’s own blood.
The blood is retrieved from a joint space or cavity; then the
patient receives this blood in the form of an autotransfusion.
Autotransfusion is discussed in Chapter 31.
Other measures. Patients often have reduced mobility
because of a fracture. Plan care to decrease risk for the many
possible complications of immobility. Prevent constipation by
increasing patient activity. Maintain high fluid intake (more
than 2500 mL/day unless contraindicated) and a diet high
in bulk and roughage (fresh fruits and vegetables). If these
measures are not effective in continuing the patient’s normal
bowel elimination pattern, give stool softeners, laxatives, or
suppositories. Maintain a regular time for elimination to
promote bowel regularity (Table 67.9).
Renal stones can develop from bone demineralization due to
reduced mobility. Hypercalcemia from demineralization causes
a rise in urine pH and stone formation from calcium precipitation. Unless contraindicated, maintain a fluid intake of 2500
mL/day to decrease the risk for stone formation. Renal stones
are discussed in Chapter 50.
Rapid deconditioning of the cardiopulmonary system can
occur from prolonged bed rest, resulting in orthostatic hypotension and decreased lung capacity. Unless contraindicated,
decrease these effects by having the patient sit on the side of
the bed, allowing their lower limbs to dangle over the bedside.
Have the patient perform standing transfers. When the patient
is allowed to increase activity, assess for orthostatic hypotension. Assess patients for signs of VTE. VTE is discussed in
Chapter 41.
TABLE 67.9 NURSING MANAGEMENT
Caring for the Patient With a Cast or Traction
•Perform neurovascular assessment on the affected extremity.
•Monitor pain intensity and give prescribed analgesics.
•Determine correct body alignment to enhance traction.
•Monitor skin integrity around cast and at traction pin sites.
•Monitor cast during drying for denting or flattening.
•Teach patient and caregiver about cast care or traction and measures to
prevent complications (e.g., ROM exercises).
•Assess for complications of immobility (e.g., constipation, VTE, kidney
stones, atelectasis) and develop a plan to minimize those complications.
•Supervise assistive personnel (AP):
•Position casted extremity above heart level as directed by RN.
•Apply ice to cast as directed by RN.
•Maintain body position and integrity of traction (if trained in this procedure).
•Help with passive and active ROM exercises.
•Notify RN about reports of pain, tingling, or decreased sensation in the
affected extremity.
Collaborate With Physical Therapist
•Assess current mobility and need for assistance.
•Teach safe ambulation with assistive device based on weight-bearing
restrictions.
•Establish exercise plan and teach patient to perform exercises safely.
•Coordinate PT with RN so that patient can receive timely analgesia.
•Discuss home environment with patient and identify modifications to promote safety (e.g., stair training).
Collaborate With Occupational Therapist
•Assess impact of patient’s condition on ability to perform ADLs.
•Teach use of assistive devices (e.g., long-handled reacher, shoe donner) to
promote self-care while maintaining activity restrictions.
Traction. When slings are used with traction, regularly
inspect exposed skin areas. Pressure over a bony prominence
created by wrinkled sheets or blankets may cause pressure
necrosis. Persistent skin pressure may impair blood flow and
cause injury to peripheral nerves and blood vessels. Assess
skeletal traction or external fixation pin sites for signs of
infection. Pin site care may vary. It often includes regularly
cleansing with chlorhexidine, rinsing with sterile saline, and
drying the area with sterile gauze.
External rotation of the affected extremity is a classic assessment finding for a patient with unrepaired hip fracture. If skin
traction is ordered before surgery, apply traction without trying
to reposition or realign the extremity. Movement of fracture fragments can occur during repositioning, causing increased pain
and possible nerve impingement. Keep the patient in the center of
the bed in a supine position to provide adequate countertraction.
If exercise is allowed, encourage patient participation in a
simple exercise program based on activity restrictions. Have the
patient perform frequent position changes, ROM exercises of
unaffected joints, deep-breathing exercises, and isometric exercises. These activities should be done several times each day.
Teach the patient to use the trapeze bar (if permitted) to raise
the body off the bed for linen changes and placement of the bedpan. Encourage and help the hospitalized patient to stay connected with friends and family by telephone or through social
media resources.
CHAPTER 67
Musculoskeletal Trauma and Orthopedic Surgery
TABLE 67.10 PATIENT & CAREGIVER
TEACHING
Cast Care
After a cast is applied, include the following instructions when teaching the
patient and the caregiver:
Do
1.Apply ice directly over fracture site for first 24 hr (avoid getting cast wet
by keeping ice in plastic bag and protecting cast with cloth).
2.Check with HCP before getting fiberglass cast wet.
3.Dry cast thoroughly if inadvertently exposed to water.
•Blot dry with towel.
•Use hair dryer on low setting until cast is thoroughly dry.
4.Elevate extremity above heart level for first 48 hr.
5.Regularly move joints above and below cast.
6.Use hair dryer on cool setting for itching inside the cast.
7.Report signs of possible problems to HCP:
•Increasing pain despite elevation, ice, analgesia.
•Swelling with pain and discoloration of toes or fingers.
•Pain during movement.
•Burning or tingling under cast.
•Sores or foul odor under cast.
8.Keep appointment to have fracture and cast checked.
Do Not
1.Get cast wet.
2.Remove any padding.
3.Insert any objects inside cast.
4.Bear weight on new cast for 48 hr (not all casts are made for weight
bearing; check with HCP when unsure).
5.Cover cast with plastic for prolonged periods.
Ambulatory Care
Cast care. Most uncomplicated fractures are treated in an
outpatient setting. Whatever the type of cast material, a cast
can interfere with circulation and nerve function if it is applied
too tightly or excess edema occurs after application. Frequent
neurovascular assessment of the immobilized extremity is
critical. Teach the patient to recognize and promptly report
tightness of the cast and areas of pressure or discomfort.
Explain the importance of elevating the extremity above heart
level to promote venous return and applying ice to control or
prevent edema during the initial phase. However, if you suspect
compartment syndrome, do not elevate the extremity above the
heart.
Patient and caregiver teaching is important to prevent complications. Table 67.10 describes patient and caregiver instructions for cast care. Teach the patient to exercise joints above and
below the cast. Tell the patient not to scratch or place anything
inside the cast because this may cause skin injury and infection.
For itching, direct a hair dryer on a cool setting under the cast.
Confirm the patient’s and caregiver’s understanding of these
instructions before discharge. A follow-up phone call is appropriate. Home care nursing visits may be needed, especially for
the patient with a body jacket brace.
The cast is typically removed in the outpatient setting.
Patients often fear being cut by the oscillating blade of the cast
1653
saw. Reassure the patient that damage to the skin is unlikely.
Teach the patient about possible changes in the appearance of
the extremity beneath the cast (e.g., dry, wrinkled skin; atrophied muscle; foul odor). The patient may be scared to use the
injured extremity after cast removal.
Ambulation. Know the overall goals of PT in relation to the
patient’s abilities, needs, and tolerance. The physical therapist
is responsible for mobility training and teaching about the
use of assistive aids (cane, crutches, walker). Reinforce these
instructions. The patient with lower extremity fractures usually
starts mobility training when able to sit in bed and dangle the
feet over the side. Work with the physical therapist to give
analgesia before a PT session.
When the patient begins to ambulate, know their
weight-bearing status and the correct technique if the patient
is using an assistive device. Ambulation occurs in different
degrees of weight-bearing: (1) non–weight-bearing (no weight
on the involved extremity), (2) touch-down/toe-touch weight
bearing (contact with floor for balance but no weight borne),
(3) partial–weight-bearing ambulation (25% to 50% of weight
borne), (4) weight bearing as tolerated (based on pain and tolerance), and (5) full–weight-bearing ambulation (no limitations).
Assistive devices. Devices for ambulation range from a
cane (can relieve up to 40% of the weight normally borne by
a lower limb) to a walker or crutches (may allow for complete
non–weight-bearing ambulation). The HCP decides which
device is best, balancing the need for maximum stability and
safety with the need for maneuverability in small spaces, such as
bathrooms. Discuss with the patient lifestyle requirements and
help select a device that allows the patient to feel most secure
and independent. The technique for using assistive ambulation
devices varies. The involved limb is usually advanced at the same
time or immediately after advance of the device. The uninvolved
limb is advanced last. Canes are held in the hand opposite the
involved extremity.
Place a transfer belt (gait belt) around the patient’s waist to
provide stability while teaching the patient how to use an assistive device. Discourage the patient from reaching for furniture
or relying on another person for support. A patient with inadequate upper limb strength or poorly fitted crutches bears weight
at the axilla rather than at the hands. This can damage the neurovascular bundle that passes across the axilla. If verbal coaching
does not correct the problem, teach the patient another form of
ambulation (e.g., walker) until strength is adequate.
Patients who must ambulate without weight bearing need
enough upper limb strength to lift their own weight at each step.
Because the muscles of the shoulder girdle and upper arm may
not be accustomed to this work, patients require focused training for this task. Push-ups, pull-ups using the overhead trapeze
bar, and weightlifting develop the triceps and biceps muscles.
Straight-leg raises and quadriceps-setting exercises strengthen
the quadriceps muscles.
Psychosocial concerns. Short-term rehabilitative goals
address the transition from dependence to independence in
performing simple ADLs. They are directed at preserving or
increasing strength and endurance. Long-term rehabilitative
goals are aimed at preventing problems from musculoskeletal
1654
SECTION 12
Problems Related to Movement and Coordination
TABLE 67.11
Problems Associated With Musculoskeletal Injuries
Problem
Description
Nursing Considerations
Atrophy
• ↓ Muscle mass occurs from disuse after prolonged immobilization.
• Loss of nerve function can cause muscle atrophy.
• Abnormal condition of joint characterized by flexion and fixation.
• Caused by atrophy and shortening of muscle fibers and ligaments or by loss of normal elasticity of skin over joint.
• Plantar-flexed position of the foot occurs when Achilles’s tendon in ankle shortens because it has been allowed to assume
an unsupported position.
• Peroneal nerve palsy (a compression neuropathy) can cause
footdrop and spinal nerve compression.
• Isometric strength exercises as able with immobilization device
helps reduce amount of atrophy.
• Muscle atrophy interferes with and prolongs rehabilitation process.
• Can be prevented by frequent position change, correct body alignment, active-passive ROM exercises several times a day.
• Intervention requires gradual progressive stretching of muscles or
ligaments in region of joint.
• For patient with long-term injuries, support foot in neutral position
to ↓ risk for footdrop.
• Once footdrop has developed, can significantly hinder ambulation
and gait training.
• May need splint to keep feet in neutral position.
• High-top athletic shoes may help. Apply at scheduled times to
keep feet in neutral position.
• Measures to ↓ intensity of muscle spasms are similar to actions for
pain management.
• Do not massage muscle spasms. Massage may stimulate muscle
tissue contraction that ↑ spasm and pain.
• Thermotherapy, especially heat, may reduce muscle spasm.
• Causes include incorrect positioning and alignment of extremity,
incorrect support of extremity, sudden movement of extremity,
immobilization device that is applied too tightly or incorrectly,
constrictive dressings, motion at fracture site.
• Determine causes of pain so that corrective action can be taken.
Contracture
Footdrop
Muscle spasms
Pain
• Caused by involuntary muscle contraction after fracture, muscle strain, or nerve injury.
• May last several weeks.
• Pain from muscle spasms is often intense and can last from
several seconds to several minutes.
• Common with fractures, edema, muscle spasm.
• May be mild to severe and described as aching, dull, burning,
throbbing, sharp, or deep.
injury (Table 67.11). During the rehabilitative phase, help
the patient adjust to any problems caused by the injury (e.g.,
separation from family, financial impact, loss of income from
inability to work, potential for disability). Assess patients for
posttraumatic stress disorder. This is especially important
if significant injury to others or fatalities occurred with the
incident.
The caregiver may have a key role in providing long-term
care. Teach the caregiver how to help with strength and endurance exercises, mobility, and promoting activities that enhance
the quality of daily living. Offer support and encouragement
while actively listening to the patient’s and caregiver’s concerns.
Evaluation
The expected outcomes are that the patient with a fracture will:
• Report satisfactory pain management
• Show proper care of cast or immobilizer
• Have uncomplicated bone healing
COMPLICATIONS OF FRACTURES
Most fractures heal without complications. Complications may
be direct or indirect. Direct complications include infection,
problems with bone union, and avascular necrosis. Indirect
complications include compartment syndrome, VTE, fat embolism syndrome (FES), breakdown of skeletal muscle (rhabdomyolysis), and hypovolemic shock. Most musculoskeletal injuries
are not life threatening. Death after a fracture is usually due to
damage to underlying organs and vascular structures or complications of the fracture or immobility. Open fractures, fractures
with severe blood loss, and fractures that damage vital organs
(e.g., lung, heart) are medical emergencies requiring immediate
attention.
Infection
Open fractures and soft tissue injuries have a high rate of
infection. Communication of the fracture site with the outside environment can contaminate the site with microorganisms or foreign bodies. Damage to the surrounding soft tissue
and blood vessels impairs the ability of defense mechanisms to
respond to microorganisms. Dying or contaminated tissue is an
ideal medium for many common pathogens, including anaerobic bacilli, such as Clostridium tetani. Measures to prevent infection and osteomyelitis are important.
Open fractures require surgical debridement. The wound
is cleaned by saline lavage in the operating room. Gross contaminants are irrigated and mechanically removed. Contused,
contaminated, and devitalized tissue (muscle, subcutaneous fat,
skin, and bone fragments) is surgically excised (debridement).
The wound may be irrigated with antibiotic solution. Antibioticimpregnated beads can be placed in the surgical site. Patients
usually receive IV antibiotics for at least 3 days.11 Surgical management and antibiotics have reduced the occurrence of infection. The amount of soft tissue damage determines if the wound
is closed at the time of surgery or if it needs repeat debridement,
closed suction drainage, and/or skin grafting.
Compartment Syndrome
Compartment syndrome is a condition in which swelling causes increased pressure within a limited space (muscle
CHAPTER 67
Musculoskeletal Trauma and Orthopedic Surgery
compartment). Because the fascia surrounding the muscle has
limited ability to stretch, continued swelling can cause pressure
that compromises the function of blood vessels and nerves in
the compartment. Capillary perfusion is reduced below a level
needed for tissue life. Compartment syndrome often involves
the leg but can occur in any muscle group.
There are 38 compartments in the upper and lower extremities. Two basic causes of compartment syndrome are (1)
decreased compartment size resulting from restrictive dressings, splints, casts, excessive traction, or premature closure of
fascia; and (2) increased compartment contents due to bleeding,
inflammation, edema, or IV infiltration.
Edema can create enough pressure to obstruct circulation
and cause venous occlusion, which further increases edema.
Arterial flow is eventually compromised, causing ischemia in
the extremity. As ischemia continues, muscle and nerve cells
are destroyed. Fibrotic tissue eventually replaces healthy tissue.
Contracture, disability, and loss of function can occur. Delays
in diagnosis and treatment may lead to irreversible muscle and
nerve ischemia. The extremity may become functionally useless
or severely impaired.
Compartment syndrome is usually due to fractures (especially of long bones), extensive soft tissue damage, and crush
injury. Distal humerus and proximal tibial fractures are the
most common ones associated with compartment syndrome.
Compartment injury can also occur after knee or leg surgery.
Prolonged pressure on a muscle compartment may result when
someone is trapped under a heavy object or a person’s limb is
trapped beneath the body because of response to drugs or alcohol.
Clinical Manifestations
Compartment syndrome may occur initially from the body’s
physiologic response to the injury, or it may be delayed for several days after the original insult or injury. Ischemia can occur
within 4 to 8 hours after the onset of compartment syndrome.
One or more of the “6 Ps” are specific to compartment
syndrome: (1) pain out of proportion to the injury that is not
managed by opioid analgesics, and pain on passive stretch of
muscle in the compartment; (2) increasing pressure in the compartment; (3) paresthesia (numbness and tingling); (4) pallor,
coolness, and loss of normal color of the extremity; (5) paralysis
or loss of function; and (6) pulselessness (decreased or absent
peripheral pulses).
Interprofessional Care
Prompt diagnosis of compartment syndrome is critical. Perform
regular neurovascular assessment on all patients with fractures,
especially those with injury of the extremities or soft tissue in
these areas. Early recognition and effective treatment of compartment syndrome are essential to avoid permanent damage to
muscles and nerves.
Carefully assess the location, quality, and intensity pain (see
Chapter 9). Pain unrelieved by drugs and out of proportion to
the level of injury is one of the first signs of compartment syndrome. Paresthesia is also an early sign. Notify the HCP immediately of these changes. Relieving the source of pressure (e.g.,
cast is cut [bivalved] or dressing loosened by order of the HCP)
1655
A
B
Fig. 67.15 (A) Fracture of the distal radius with distal forearm compartment syndrome. (B) Fasciotomy used to treat compartment syndrome.
(From Stevanovic MV, Sharpe F: Green’s operative hand surgery, ed 7,
Philadelphia, 2017, Elsevier.)
typically decreases pain and paresthesia and can avoid compartment syndrome. Reducing traction weight may decrease external pressures on the extremity. Pulselessness and paralysis are
late signs of compartment syndrome. Do not wait until these
late signs occur to contact the HCP. Amputation may be needed
due to prolonged ischemia.
With suspected compartment syndrome, do not elevate the
extremity above the heart. Similarly, do not apply cold compresses. They may cause vasoconstriction and worsen compartment syndrome.
Surgical decompression (e.g., fasciotomy) of the involved
compartment may be needed (Fig. 67.15). The fasciotomy site
is left open for several days to allow adequate soft tissue decompression. Infection resulting from delayed wound closure is a
potential problem after fasciotomy. In severe cases of compartment syndrome, amputation is done.
CHECK YOUR PRACTICE
Your 22-year-old male patient had a fall while rock climbing. He returned from
surgery 8 hours ago with a long leg cast placed for open fractures of the femur
and tibia. He continually reports pain that IV morphine does not seem to help.
• How will you assess his neurovascular condition?
• What signs and symptoms would suggest the development of compartment
syndrome?
• What is the most likely intervention if compartment syndrome is developing?
Venous Thromboembolism
Veins of the lower extremities and pelvis are at great risk for
clot (thrombus) formation after a fracture, especially a hip fracture. VTE may occur after total hip or total knee replacement
1656
SECTION 12
Problems Related to Movement and Coordination
surgery. In patients with limited mobility, inactivity of muscles
that normally help pump venous blood from the extremities to
the heart worsens venous stasis.
Because of the high risk for VTE in the orthopedic surgical
patient, prophylactic anticoagulant drugs should be given for
at least 10 to 14 days.12 The most common agents used include
(1) warfarin (Coumadin), (2) low-molecular-weight heparin
(LMWH) (e.g., enoxaparin [Lovenox], fondaparinux), (3) aspirin, or (4) a factor Xa inhibitor (e.g., rivaroxaban [Xarelto],
apixaban).12 Have the patient dorsiflex and plantar flex the
ankle of an affected lower extremity against resistance and perform ROM exercises on the unaffected leg. For upper extremity
injuries, have the patient flex and extend the wrist if not immobilized by a cast or splint and perform ROM exercises on the
unaffected arm. They may wear compression gradient stockings
(antiembolism hose) or using intermittent pneumatic compression devices.12 VTE is discussed in Chapter 41.
SAFETY ALERT
Anticoagulant Therapy
• Monitor for signs of bleeding (e.g., nosebleeds, hematuria).
• Teach patient signs of bleeding and what to do if bleeding occurs.
• Teach patient safe self-injection if taking an injectable anticoagulant after
discharge.
• Encourage patient to keep appointments for laboratory testing to monitor
effects of warfarin (if prescribed).
Fat Embolism Syndrome
Fat embolism syndrome (FES) is characterized by fat globules
entering the circulatory system from fractures. They collect
in areas with abundant blood vessels, especially the lungs and
brain. FES contributes to mortality from fractures. The fractures
most often associated with FES are those of the long bones, ribs,
tibia, and pelvis. FES can occur after joint replacement, burns,
pancreatitis, liposuction, crush injuries, and bone marrow
transplantation.13
Two theories about FES exist. According to the mechanical
theory, fat emboli originate from fat released from the marrow
of injured bone. The fat enters systemic circulation, where it
travels to other organs. As fat droplets become stuck in small
blood vessels, local ischemia and inflammation occur. The biochemical theory suggests hormonal changes caused by trauma
or sepsis stimulate systemic release of free fatty acids (e.g., chylomicrons) that form the fat emboli.
Clinical Manifestations
Early recognition of FES is crucial to prevent patient death.
Most patients have symptoms within 24 to 48 hours after
injury.13 Severe forms have occurred within hours of injury. Fat
emboli in the lungs cause hemorrhagic interstitial pneumonitis
with signs and symptoms of acute respiratory distress syndrome
(ARDS). These include chest pain, tachypnea, cyanosis, dyspnea, apprehension, tachycardia, and hypoxemia. These symptoms are caused by poor O2 exchange. Changes in mental status
due to hypoxemia are common. Petechiae on the neck, anterior
chest wall, axilla, and head may help discern FES from other
problems.13 They may appear due to intravascular thromboses caused by decreased oxygenation. However, not all patients
have petechiae. They may fade before they are noticed.
The clinical course of FES may be rapid and acute. In a short
time, skin color can change from pallor to cyanosis. The patient
may become comatose. No specific laboratory tests aid in the
diagnosis. However, certain abnormalities may be present.
These include fat cells in blood, urine, or sputum; a decrease
of PaO2 to less than 60 mm Hg; decreased platelet count and
hematocrit; and high erythrocyte sedimentation rate (ESR). The
ECG may show ST segment and T-wave changes. A chest x-ray
may show bilateral pulmonary infiltrates.
Interprofessional care. Management of FES is supportive and
related to managing symptoms. The patient needs appropriate
respiratory support (see Chapter 28). Administer O2 to treat
hypoxia. ECMO or mechanical ventilation may be an option if
a satisfactory PaO2 cannot be obtained. Some patients develop
pulmonary edema and/or ARDS, leading to increased mortality.
Most persons survive FES with few complications.
Cardiovascular problems are often managed with IV fluids,
pulmonary vasodilators, peripheral vasoconstrictors, and inotropic drugs. There is currently no research supporting the use
of steroids, heparin, or dextran in the treatment of FES.13
Preventing FES is important. Careful immobilization and
handling of a long bone fracture are the most important factors
in preventing FES. Reposition the patient as little as possible
before fracture immobilization or stabilization to decrease the
risk of dislodging fat droplets into the general circulation.
CHECK YOUR PRACTICE
You are caring for a 24-year-old male patient who had a femur fracture in a
motorcycle accident last night. He is scheduled for ORIF later today. While
doing your assessment, you notice that he seems very restless. You note some
axillary petechiae.
• What complication would you suspect is occurring?
• Why is this patient at risk for this complication?
• What is the most important intervention for a patient with this complication?
Rhabdomyolysis
Rhabdomyolysis is a syndrome caused by the breakdown of
damaged skeletal muscle cells. This breakdown causes the release
of myoglobin into the bloodstream. Myoglobin precipitates and
causes obstruction in renal tubules. This results in acute tubular necrosis and acute kidney injury (AKI). Because of possible
muscle damage, assess urine output. Common signs are dark
reddish-brown urine and symptoms of AKI (see Chapter 51).
TYPES OF FRACTURES
COLLES FRACTURE
A Colles fracture is a fracture of the distal radius. The styloid
process of the ulna may be involved as well. The injury usually
occurs when the patient falls on an outstretched arm and hand.
CHAPTER 67
R
Musculoskeletal Trauma and Orthopedic Surgery
1657
U
Fig. 67.16 Colles’ fracture. Fracture of the distal radius (R) and ulnar (U)
styloid from patient falling on the outstretched hand. (From Mettler FA:
Essentials of radiology, ed 2, Philadelphia, 2005, Saunders.)
It is one of the most common types of fractures in adults. It
most often occurs in patients over 50 years old whose bones are
osteoporotic (fragility fracture) (Fig. 67.16). A younger person
with a Colles’ fracture caused by a low-energy force should be
referred for an osteoporosis evaluation.
Symptoms include pain in the immediate area of injury, pronounced swelling, and dorsal displacement of the distal fragment (silver-fork deformity). This displacement appears as an
obvious deformity of the wrist. The major complication is vascular insufficiency from edema. CTS can be a later complication.
A Colles’ fracture is usually managed with closed reduction
of the fracture and applying a splint or cast. If displaced, the
fracture is typically managed with open reduction and internal
or external fixation. Nursing care includes frequent neurovascular assessment and measures to reduce edema. Provide support
and protect the extremity. Encourage active movement of the
thumb and fingers to reduce edema and increase venous return.
Teach the patient to perform active movements of the shoulder
to prevent stiffness or contracture.
Fig. 67.17 Humeral cuff brace. (Courtesy Matthew C. Price, MS, RN,
CNP, ONP-C, RNFA, Columbus, OH.)
freely when the patient is sitting or standing. Provide measures
to protect the axilla and prevent skin breakdown. Carefully
place absorbable composite dressing pads (e.g., ABD pads) in
the axilla. Change them twice daily or as needed. Skin or skeletal traction may be used for reduction and immobilization.
During the rehabilitative phase, an exercise program to
improve strength and motion of the injured extremity is important. Exercises should include assisted motion of the hand and
fingers. The shoulder can be exercised if the fracture is stable.
This helps prevent stiffness from frozen shoulder or fibrosis of
the shoulder capsule.
HUMERAL SHAFT FRACTURE
CLAVICULAR FRACTURE
Fractures involving the shaft of the humerus are common
among young and middle-aged adults. The most common
symptoms are obvious displacement of the humeral shaft, shortened extremity, abnormal mobility, and pain. Complications
include radial nerve injury and injury to the brachial artery due
to laceration, transection, or muscle spasm.
Treatment depends on the specific fracture location and displacement. Nonoperative treatment may include a hanging arm
cast, shoulder immobilizer, sling and swathe (a type of immobilizer that prevents shoulder movement), or humeral cuff brace
(Fig. 67.17).
The humeral cuff brace is typically used to stabilize mid-shaft
humerus fractures. Two pieces of molded plastic are fitted together
in a clam-shell configuration and held together with Velcro straps.
The humeral cuff brace is a good option for nonoperative fracture
management if the patient is at increased risk for complications.
When these devices are used, elevate the head of the bed to
assist gravity in reducing the fracture. Allow the arm to hang
The clavicle is a frequently broken bone in children and young
adults. Midshaft fractures account for 85% of all clavicle fractures. Injury is usually the result of a fall. Less often it happens from direct trauma to the bone. Common manifestations
include pain at the fracture site, with or without obvious deformity, and limited shoulder range of motion. The patient often
supports the affected side with the other hand and tilts the head
toward the side of the fracture.
Most patients do not need surgery. Surgery is usually done only
if the fracture is open. Treatment is aimed at maintaining comfort
with splinting, ice, and analgesics. PT includes early ROM and
strength exercises. Most clavicle fractures heal without complications. Contact sports should be avoided for 8 to 10 weeks.
PELVIC FRACTURE
Pelvic fractures range from relatively minor to life threatening,
depending on the mechanism of injury and associated vascular
1658
SECTION 12
Problems Related to Movement and Coordination
BOX 67.4 ETHICAL/LEGAL DILEMMAS
Entitlement to Treatment
Situation
D.C., a 35-year-old English tourist, was in a hang-gliding accident while
touring the United States. She was taken to the regional trauma center for
treatment of internal injuries, blood loss, and severe pelvic fractures. She has
become septic, is now in renal failure, and has ARDS. She has no health insurance. Despite a poor chance of survival, her husband and parents want all
possible measures to be taken.
Ethical/Legal Points for Consideration
• Federal law requires hospitals receiving federal funds through Medicare
and Medicaid to provide emergency evaluation and treatment to stabilize
patients (Emergency Medical Treatment and Active Labor Act [EMTALA]).
Once the patient is stabilized, they are under no obligation to continue
treatment and may transfer the patient to another facility.
• Discuss with the family treatment goals (e.g., recovery, survival, continued
biologic existence, nonabandonment of the patient) and what they mean
by wanting “everything done.” There is no legal or ethical obligation to
continue medical treatment when treatment goals cannot be met.
• Contact with the English consulate may result in collaboration to stabilize
the patient and transport her to England.
• Neither HCPs nor hospitals are required to provide medically futile care
(care that provides no benefit to the patient).
• Although her home country offers universal health care, D.C. assumed the
risk when engaging in a potentially dangerous activity and did not obtain
international health insurance coverage for her visit to a foreign country.
Discussion Questions
1. How can the nurse promote discussions with the family about treatment
goals for D.C.?
2. Are family members able to state D.C.’s wishes for her own care in such a
situation?
damage. They account for only 3% of adult fractures. Pelvic
fractures have a high mortality rate. They may cause serious
intraabdominal injury, including laceration and hemorrhage
of the urethra, bladder, or colon. They can cause acute pelvic
compartment syndrome. Paralytic ileus may occur after pelvic
fracture. Patients may survive the pelvic injury, only to die from
sepsis, FES, or VTE.
Abdominal assessment may show local swelling, tenderness,
deformity, unusual pelvic movement, and bruising. Assess the
neurovascular condition of the lower extremities and determine
associated injuries. Pelvic fractures are diagnosed by x-ray and
CT scan.
Treatment depends on the severity of the injury. Stable, nondisplaced fractures require little intervention. Ambulation with
weight bearing as tolerated is typically encouraged. Complex or
displaced fractures (e.g., open book fracture) need external fixation alone or combined with ORIF (e.g., screws), often done
emergently. Use extreme care in handling or moving the patient,
to prevent further injury. Because a pelvic fracture can damage
other organs, assess bowel and urinary elimination. Regularly
perform distal neurovascular assessment. Provide back care
with adequate help or while the patient is raised from the bed by
independent use of a trapeze (Box 67.4).
Subcapital Capital
Femoral neck
Intertrochanteric
Intracapsular
(within joint
capsule)
Subtrochanteric
Extracapsular
(outside joint
capsule)
Proximal one
third of femur =
hip
Fig. 67.18 Femur with location of various types of fracture.
HIP FRACTURE
Hip fractures are common in older adults. 95% of hip fractures
result from a fall.14 Many falls occur when getting in or out of
a chair or bed. Falls to the side are the most common type seen
in frail older adults. More than 300,000 patients are admitted to
hospitals each year because of a hip fracture. Up to 37% of those
patients die within 1 year of injury. Many older adults develop
disabilities that require long-term care. Women suffer 75% of
all hip fractures. In adults over 65 years old, hip fracture occurs
more often in women because of osteoporosis.
Older adults may have low bone density (osteopenia) or osteoporosis, which increases their risk for fragility fractures. Other
factors that increase the risk for a hip fracture in older adults
include (1) increased risk for falling due to an altered center
of gravity and inability to correct a postural imbalance, (2)
decreased fat and muscle to act as local tissue shock absorbers,
and (3) reduced skeletal strength. Other factors that increase the
older adult’s risk for falling include (1) gait and balance problems, (2) altered vision and hearing, (3) slowed reflexes, (4)
orthostatic hypotension, and (5) medication use.
Hip fracture refers to a fracture of the proximal (upper) third
of the femur, which extends 5 cm below the lesser trochanter
(Fig. 67.18). Fractures within the hip joint capsule are intracapsular fractures. Intracapsular fractures are further identified
by their specific locations: (1) capital (fracture of the head of
the femur), (2) subcapital (fracture just below the head of the
femur), and (3) transcervical (fracture of the femoral neck).
These fractures, which are often associated with osteoporosis
and minor trauma, are fragility fractures.
Extracapsular fractures occur outside the joint capsule. They
are either (1) intertrochanteric (in a region between the greater
and lesser trochanter) or (2) subtrochanteric (below the lesser
trochanter). Most are caused by severe direct trauma or a fall.
Clinical Manifestations
Manifestations include external rotation, muscle spasm, shortening of the affected extremity, and severe pain and tenderness
around the fracture site. Displaced femoral neck fractures may
disrupt blood supply to the femoral head, resulting in avascular
necrosis of the femoral head.
CHAPTER 67
Musculoskeletal Trauma and Orthopedic Surgery
A
B
C
D
1659
Fig. 67.19 Types of surgical repair for a hip fracture: (A) Closed reduction with percutaneous pinning. (B)
Intramedullary nail. (C) Sliding hip screw. (D) Hemiarthroplasty. (Courtesy Matthew C. Price, MS, RN, CNP,
ONP-C, RNFA, Columbus, OH.)
Interprofessional Care
Immediate surgery is the standard of care. Initially we may
immobilize the affected extremity with Buck’s traction (Fig.
67.9) if the patient’s physical condition needs stabilized before
they can have surgery. Buck’s traction may be used for 24 to 48
hours to relieve painful muscle spasms.
Surgical treatment allows for early mobilization and decreases
the risk for complications. The type of surgery depends on
the location and severity of the fracture and the person’s age.
Options include (1) closed reduction with percutaneous pinning (CRPP) (minimally invasive surgery to stabilize the femoral neck and head with screws), (2) repair with internal fixation
devices (e.g., hip compression screw, intramedullary devices),
(3) replacement of the femoral head with a prosthesis (partial
hip replacement or hemiarthroplasty, often used for fracture of
the femoral neck) (Fig. 67.19), and (4) total hip replacement
(involves both the femur and acetabulum) (Fig. 67.20).
NURSING MANAGEMENT: HIP FRACTURE
Implementation
Preoperative Care
In addition to the usual preoperative nursing care (see Chapter
18), we may do teaching in the ED. Most patients do not have an
extended preoperative period in which to receive instructions.
Many are older adults. When planning treatment of the hip
1660
SECTION 12
Problems Related to Movement and Coordination
TABLE 67.12 PATIENT & CAREGIVER
TEACHING
Posterior Hip Replacement
After a hip replacement by posterior surgical approach, include the following
instructions when teaching a patient and caregiver:
Do
•Use an elevated toilet seat.
•Place chair inside shower or tub and remain seated while washing.
•Use pillow between legs for first 6 weeks when lying on nonoperative side
or when supine.
•Keep hip in neutral, straight position when sitting, walking, or lying.
•Notify HCP at once if severe pain, deformity, or loss of function occurs.
•Discuss personal risk factors for prosthetic joint infection with HCP and dentist before dental work.
Fig. 67.20 Total hip replacement (arthroplasty) with cementless femoral prosthesis of metal alloy with plastic acetabular socket.
fracture, consider the presence of any chronic health problems
(e.g., diabetes, heart disease). We may have to delay surgery
briefly until the patient’s general health is stabilized. Begin to
consider discharge plans because the length of stay after surgery
will be no more than a few days.
Before surgery, severe muscle spasms can increase pain.
Analgesics or muscle relaxants, comfortable positioning (unless
contraindicated), and properly applied traction (if used) can
help to manage the spasms.
Postoperative Care
Similar principles of patient care apply to any surgical procedure for hip fractures. In the initial postoperative period, assess
vital signs, intake, and output. Monitor respiratory function and
encourage deep breathing and coughing. Assess pain and give
pain medication. Observe the dressing and incision for signs of
bleeding. See eNursing Care Plan 67.2 for the orthopedic surgical patient (available on the website for this chapter).
Neurovascular impairment is possible. Assess the extremity
for (1) color, (2) temperature, (3) capillary refill, (4) distal pulses,
(5) edema, (6) sensation, (7) motor function, and (8) pain.
Decrease edema by elevating the leg when the patient is in bed
or in a chair. Pain in the affected extremity can be reduced by
maintaining limb alignment with pillows between the patient’s
knees when turning the patient to the nonoperative side.
Encourage the patient to use the overhead trapeze bar and
the opposite side rail to help in position changes. Avoid turning the patient to the affected side unless approved by the HCP.
Have the patient exercise the unaffected leg and both arms.
Weight bearing on the involved extremity varies. Limited
weight bearing is typically the only restriction for the patient
who had ORIF of the hip fracture. The restriction continues
until x-rays show adequate healing, usually 6 to 12 weeks. Teach
the patient and caregiver about weight-bearing status after
surgery.
The physical therapist usually supervises exercises for the
affected extremity and ambulation when the HCP allows it.
The patient is usually out of bed the first postoperative day. A
Do Not
•Flex hip greater than 90 degrees (e.g., sitting in low chairs or toilet seats).
•Adduct hip (e.g., bring legs together at knees).
•Internally rotate hip (e.g., turn toward planted foot on affected side).
•Cross legs at knees or ankles.
•Put on own shoes or stockings without adaptive device (e.g., long-handled
shoehorn or stocking-helper) for 4–6 weeks.
•Sit on chairs without arms. The arms of chairs will help the patient rise to a
standing position.
physical therapist can teach the patient how to transfer out of
the bed to a chair. In collaboration with the physical therapist,
monitor the patient’s ambulation for proper use of crutches or
a walker. To be discharged home, the patient must show proper
use of crutches or a walker over a functional distance (about 150
ft). The patient must be able to transfer to and from a chair and
bed and to go up and down stairs.
If hemiarthroplasty or total joint replacement was done by
a posterior approach (incision posterior to the midline of the
greater trochanter down the femoral shaft), measures to prevent dislocation must be used (Table 67.12). Tell the patient and
caregiver about positions and activities that increase the risk for
dislocation (more than 90 degrees of flexion, adduction across
the midline [crossing of legs and ankles], internal rotation of
hip). Many daily activities reproduce these positions. These
include (1) putting on shoes and socks, (2) crossing the legs or
feet while seated, (3) assuming the side-lying position incorrectly, (4) standing up or sitting down while the hip is flexed
more than 90 degrees relative to the chair, and (5) sitting on low
seats, especially low toilet seats. Teach the patient to avoid these
activities until the soft tissue capsule around the hip has healed
enough to stabilize the prosthesis (usually at least 6 weeks).
Elevated toilet seats and chair alterations (e.g., raising the
seat with a folded blanket, keeping a straight back) are needed.
Avoid placing a soft pillow in a seat because sitting on it can
cause internal rotation. If a foam abduction wedge is ordered
to prevent joint dislocation, place it between the patient’s legs
(Fig. 67.21). Apply the top straps above the knee to avoid putting pressure on the peroneal nerve at the lateral tibial tubercle. Some HCPs want the patient to keep the abductor wedge in
place except when bathing or walking.
CHAPTER 67
Musculoskeletal Trauma and Orthopedic Surgery
1661
Ambulatory Care
Fig. 67.21 Maintaining abduction after total hip replacement. (Courtesy
Mary Wollan, RN, BAN, ONC, Spring Park, MN.)
If hemiarthroplasty or total joint replacement was done by
an anterior approach (incision is made in the front of the hip
with patient lying on the back), the hip muscles are left intact.
This approach provides a more stable hip in the postoperative
period with a lower rate of complications. Precautions related
to motion and weight bearing are few. They typically include
instructions to avoid hyperextension.
The patient may not take a tub bath or drive for 4 to 6 weeks.
An occupational therapist (OT) may teach the patient to use
assistive devices, such as long-handled shoehorns, sock assists,
and reachers or grabbers, to avoid bending over to pick up
something on the floor. The knees must be kept apart. Teach the
patient to never cross the legs or twist to reach behind.
Complications of femoral neck fracture include nonunion,
avascular necrosis, dislocation, and osteoarthritis (OA). The
affected leg may be shorter if the patient had an intertrochanteric
fracture. A cane or shoe lift may be needed for safe ambulation.
Sudden severe pain, a lump in the buttock, limb shortening, and external rotation indicate prosthesis dislocation. This
requires closed reduction with moderate to deep sedation or
open reduction under general anesthesia to realign the femoral
head in the acetabulum. If any of these signs occur (regardless
of the setting), keep the patient NPO in anticipation of surgical
intervention.
Help the patient and caregiver to adjust to restrictions and
dependence because of the hip fracture. Anxiety and depression can easily occur. Creative nursing care and awareness of
potential problems can help to prevent them. Tell the patient
and caregiver about community services that can help with
rehabilitation after hospital discharge.
Hospitalization averages 3 or 4 days. Older adults or patients
who live alone may require care in a subacute rehabilitation
unit, at a skilled nursing facility, or in an acute rehabilitation
facility for a few weeks before returning home. If the patient has
skilled nursing needs or is homebound for PT after discharge
from postacute care, the HCP may order follow-up home health
care.
Home care considerations include ongoing assessment of
pain management, monitoring for infection, and VTE prevention. If incision is closed with metal staples, they will be removed
at the HCP’s office. Teach the patient who is receiving an anticoagulant to report signs of bleeding to the HCP (see Chapter
41). Review how to administer an injectable anticoagulant (if
needed). Teach the patient receiving warfarin about required
laboratory testing.
Exercises to restore strength and tone in the quadriceps and
muscles around the hip are essential to improve function and
ROM. These include quadriceps setting (e.g., pressing the kneecap down), gluteal muscle setting (e.g., tightening the buttocks),
leg raises in supine and prone positions, and abduction exercises from the supine and standing positions (e.g., swinging the
leg out but never crossing midline). The patient continues these
exercises for many months after discharge. Teach the exercise
program to the caregiver who will be encouraging the patient
at home.
A physical therapist assesses ROM, ambulation, and adherence to the exercise program. The patient gradually increases
the number of exercise repetitions and may add ankle weights.
Swimming and stationary cycling may tone quadriceps and
improve cardiovascular fitness. Teach the patient to avoid
high-impact exercises and sports, such as jogging and tennis,
because they may loosen the implant.
A physical therapist or home care nurse may perform a home
assessment to identify hazards that may cause the patient to fall
again. Homes can be made safer by (1) eliminating tripping hazards (e.g., throw rugs, uneven surfaces), (2) adding grab bars
inside and outside the tub or shower, and beside the toilet, (3)
adding railings on both sides of the stairs, and (4) installing better lighting.14
Calcium and vitamin D supplementation are given to
patients with osteopenia or osteoporosis. A bisphosphonate
drug (e.g., alendronate) may be prescribed to decrease bone loss
or increase bone density. This reduces the chance of fracture.
Osteoporosis is discussed in Chapter 68.
Evaluation
CHECK YOUR PRACTICE
You are taking care of an 83-year-old patient who fell down the steps outside
her house while getting her mail. She was diagnosed with a femoral neck
fracture and Colles’ fracture. She is returning to the clinical unit after surgery.
She had a hemiarthroplasty for the femoral neck fracture and closed reduction
of the Colles’ fracture.
• Based on these injuries, what are some possible complications?
• How will you mobilize a patient with these injuries?
• What are your discharge concerns?
The expected outcomes are that the patient with a hip fracture will:
• Report satisfactory pain management
• Have uncomplicated bone healing
• Take part in exercise therapy
FEMORAL SHAFT FRACTURE
Because the femur can bend slightly to absorb stress, femoral shaft fracture occurs from a severe direct force. The force
exerted to cause the fracture (e.g., from a motor vehicle crash
1662
SECTION 12
Problems Related to Movement and Coordination
or gunshot wound) often also damages the adjacent soft tissue.
These injuries may be more serious than the bone injury. Young
adults have a high incidence of this type of fracture.
Displacement of fracture fragments often causes increased
soft tissue damage. Considerable blood loss (1 to 1.5 L) can
occur. The most common types of femoral shaft fracture include
transverse, spiral, comminuted, oblique, and open (Figs. 67.6
and 67.7).
A femoral shaft fracture is marked by pain, notable deformity and angulation, shortening of the extremity, and inability
to move the hip or knee. Complications include FES; nerve and
vascular injury; and problems with bone union, open fracture,
and soft tissue damage.
Initial management involves patient stabilization and fracture immobilization. Traction may be used as a temporary measure before surgery or in the patient unable to have surgery.
Placement of an intramedullary rod is the most common surgical treatment for femoral shaft fracture. The metal rod is placed
into the marrow canal of the femur. The rod passes across the
fracture to keep fragments in position. Plates and screws also
may be used. Internal fixation is preferred. It reduces the hospital stay and complications of prolonged bed rest. External fixation may be used for an open fracture.
After surgery, gluteal and quadriceps isometric exercises
promote and maintain strength in the affected extremity.
Encourage the patient to perform ROM and strength exercises
for all uninvolved extremities to prepare for ambulation. The
patient may be allowed to start non–weight-bearing activities
with an assistive device (e.g., walker, crutches). Full weight
bearing is usually restricted until x-rays show union of fracture
fragments. Teach the patient to follow the HCP’s instructions
for weight bearing.
TIBIAL FRACTURE
Although the tibia is vulnerable to injury because it lacks a
covering of anterior muscle, strong force is needed to cause a
fracture. As a result, soft tissue damage, devascularization, and
open fracture are common. The tibia is a common site for stress
fracture. Complications include compartment syndrome, FES,
delayed union or nonunion, and possible infection with an open
fracture.
Treatment for closed tibial fractures is closed reduction followed by immobilization in a long leg cast. ORIF with intramedullary rods, plate fixation, or external fixation is needed for
complex fractures and those with extensive soft tissue damage.
An emphasis of care is maintaining quadriceps strength.
Assess the neurovascular condition of the affected extremity
at least every 2 hours during the first 48 hours. Have the patient
perform active ROM exercises with the uninvolved leg and
the upper extremities to build the strength needed for crutch
walking. When the HCP has determined the patient is ready for
gait training, review principles of crutch walking introduced by
the physical therapist. The patient may be non–weight bearing
for 6 to 12 weeks, depending on healing. Home nursing visits
may be needed to monitor the patient’s progress if the patient
is homebound.
STABLE VERTEBRAL FRACTURE
In a stable vertebral fracture, the fracture fragments are unlikely
to move or cause spinal cord damage. This injury is often confined to the vertebral body (anterior part of the spinal column)
in the lumbar region. Sometimes it involves the cervical and
thoracic regions. Vertebral bodies are usually protected from
displacement by intact spinal ligaments. Stable fractures of the
vertebral column are usually caused by motor vehicle crashes,
falls, diving, or sports injuries. Patients with osteoporosis have
more than 700,000 vertebral compression fractures annually,
many of which are stable.
Most patients with stable fractures have only brief periods of
disability. If spinal ligaments are significantly disrupted, dislocation of the vertebrae may occur. Instability and injury to the
spinal cord may result (unstable fracture). These injuries often
require surgery. The most serious complication of vertebral
fractures is fracture displacement, which can cause damage to
the spinal cord (see Chapter 65). Although stable vertebral fractures are not associated with abnormal spinal cord pathology,
all spinal injuries should be considered unstable and potentially
serious until diagnostic tests determine the fracture to be stable.
The patient usually has pain and tenderness in the affected
region of the spine. There may be a kyphotic deformity (flexion
angulation of thoracic vertebrae) known as a dowager’s hump.
We can easily identify this deformity during the physical assessment (see Fig. 68.9). Lordosis and cervical spine involvement are
possible. Sudden loss of function below the fracture indicates
spinal cord impingement and paraplegia. Bowel and bladder
problems may occur if there is interruption of the autonomic
nervous system nerves or injury to the spinal cord.
The overall goal is to keep the spine in good alignment until
union is achieved. Many nursing interventions are aimed at
assessing for spinal cord trauma (see Chapter 65). Regularly
evaluate vital signs and bowel and bladder function. Monitor
the motor and sensory function of peripheral nerves distal to the
injured region. Report any decline in neurovascular condition.
Treatment includes pain medication followed by early mobilization and bracing. The mattress should be firm to support
the spinal column, relax muscles, decrease edema, and prevent
potential compression on nerve roots. Teach the patient to keep
the spine straight when turning by moving the shoulders and
pelvis together. The patient will need to learn to logroll. Several
days after the initial injury, the HCP may apply a specially constructed orthotic device (e.g., thoracolumbar sacral orthosis
[TLSO]), a jacket cast, or a removable corset if there is no neurologic deficit. The device gives extra support during healing. It
is used for a short period of time.
Lightweight bracing (e.g., Jewett or Bähler-Vogt brace) may
be used for patients with stable vertebral compression fractures
due to osteoporosis. Patients with osteoporosis may undergo
vertebroplasty or balloon kyphoplasty. Vertebroplasty uses
radioimaging to guide the injection of bone cement into a fractured vertebral body. When hardened, the cement stabilizes the
vertebra and prevents further compression. Balloon kyphoplasty
involves inserting a balloon into the vertebral body and then
inflating it. This creates a cavity that is filled with bone cement
CHAPTER 67
Musculoskeletal Trauma and Orthopedic Surgery
under low pressure to restore the height of the vertebral body.
Kyphoplasty is now the surgery of choice for compression fractures. This is due to the decreased incidence of bone cement
leakage into nearby structures (e.g., colon, lung) compared to
vertebroplasty. Patients have decreased pain almost at once with
these procedures. However, later compression fractures of adjacent vertebrae are a risk.
If the fracture is in the cervical spine, the patient may wear
a hard cervical collar. Some cervical fractures are immobilized
with a halo vest (see Fig. 65.8). This consists of a plastic jacket
or cast fitted about the chest and attached to a halo held in place
by skeletal pins inserted into the cranium. These devices immobilize the spine in the fracture area while allowing the patient
to ambulate.
The patient with a stable vertebral fracture is discharged
after (1) showing safe ambulation, (2) learning care of the cast
or orthotic device, and (3) stating ways to address safety and
security concerns related to the injury and treatment. Unstable
vertebral fractures and spinal cord injuries are the subject of
Chapter 65.
FACIAL FRACTURE
A person can fracture any bone of the face. Trauma, such as a
motor vehicle crash, assault, or fall, is a common cause. After
facial injury it is important to establish and maintain a patent
airway and provide adequate ventilation. Suctioning may be
needed to remove foreign material and blood. A surgically created airway (tracheostomy) may be needed if a patent airway
cannot be maintained.
Facial fractures and cervical spine injuries often occur
together. All patients with facial injuries should be treated as if
they have a cervical injury until proven otherwise by assessment
and CT scan or x-ray. Table 67.13 describes clinical manifestations of common facial fractures.
Related soft tissue injury often makes assessment of facial
injury difficult. Perform oral and facial assessments after we
have treated any life-threatening situations. Carefully assess
eye muscles and cranial nerves III, IV, and VI. X-rays help
determine the extent of the injury. CT scanning helps discern
between bone and soft tissue injury.
TABLE 67.13
Manifestations of Facial
Fracture
Manifestation
Frontal bone
Mandible
Rapid edema that may mask underlying fractures
Tooth fractures, bleeding, limited motion of
mandible
Segmental motion (instability) of maxilla and tooth
fracture at socket
Displacement of nasal bones, nosebleed (epistaxis)
Possible frontal sinus involvement, entrapment of
ocular muscles
Depression of cheek bone (zygomatic arch) and
entrapment of ocular muscles
Fractures
Maxilla
Nasal bone
Periorbital bone
Zygomatic arch
1663
Suspect injury to the eye when facial injury occurs, especially if the injury is near the orbit. If an eye-globe rupture is
suspected, stop and place a protective shield over the eye. Signs
of rupture include vitreous humor forced out of the eye. Brown
tissue (iris or ciliary body) may be seen on the surface of the
globe or penetrating through a laceration, with an off-center or
teardrop-shaped pupil.
Specific treatment depends on the site and extent of the facial
fracture and associated soft tissue injury. Immobilization or surgical stabilization may be needed. Maintain a patent airway and
adequate nutrition throughout the recovery period.
Be sensitive about changes in appearance that may occur
after facial fracture. Changes in appearance may be drastic.
Edema and discoloration subside with time, but soft tissue injuries can cause permanent scarring.
MANDIBULAR FRACTURE
Mandibular fracture may result from trauma to the face or jaw.
The fracture may be simple, with no bone displacement, or may
involve loss of tissue and bone. Mandibular fracture may need
immediate treatment to ensure the patient’s survival. Long-term
treatment is sometimes needed to restore satisfactory appearance and function.
Mandibular fractures may be done therapeutically to correct
an underlying alignment problem (malocclusion) that cannot be
adjusted by orthodontics alone. The mandible is resected during
surgery and manipulated forward or backward to correct the
occlusion problem.
Surgery includes immobilization, usually by wiring the jaws
(intermaxillary fixation). Internal fixation may be done with
screws and plates. In a simple fracture with no loss of teeth, the
lower jaw is wired to the upper jaw. Wires are placed around the
teeth, and then cross-wires or rubber bands are used to hold
the lower jaw tight against the upper jaw (Fig. 67.22). Arch bars
may be placed on the maxillary and mandibular arches of the
teeth. Vertical wires placed between the arch bars hold the jaws
together. If teeth are missing or bone is displaced, other forms
of fixation may be needed (e.g., metal arch bars in the mouth or
insertion of a pin in the bone). Bone grafting may be needed.
Immobilization is usually needed for only 4 to 6 weeks because
the fractures often heal rapidly.
Fig. 67.22 Intermaxillary
Denver, CO.)
fixation.
(Courtesy
R.A.
Weinstein,
1664
SECTION 12
Problems Related to Movement and Coordination
NURSING MANAGEMENT: MANDIBULAR
FRACTURE
Teach the patient before surgery about what is involved in the
surgery, how their face will look afterward, and changes caused
by the surgery. Reassure the patient about the ability to breathe
normally, speak, and swallow liquids. Hospitalization for respiratory monitoring is brief unless there are other injuries or
problems.
Postoperative care focuses on a patent airway, oral hygiene,
communication, pain management, and adequate nutrition.
Two potential problems in the immediate postoperative period
are airway obstruction and aspiration of vomitus. Because the
patient cannot open the jaws, an airway must be maintained.
Observe for signs of respiratory distress (e.g., dyspnea; changes
in rate, quality, and depth of respirations). After surgery place
the patient on the side with the head slightly elevated.
Tape a wire cutter or scissors (for rubber bands) to the head
of the bed. Send it with the patient when they are away from
the bedside. The wire cutter or scissors may be used to cut the
wires or elastic bands in case of an emergency requiring access
to the pharynx or lungs (e.g., cardiac arrest or respiratory distress). Keep a picture nearby showing the appropriate wires to
cut in an emergency. In some cases, cutting the wires may cause
the entire facial and upper jaw structure to shift or collapse and
worsen the problem. Keep a tracheostomy or endotracheal tray
available.
If the patient begins to vomit or choke, try to clear the mouth
and airway. Suction via the nasopharyngeal or oral route,
depending on the extent of injury and type of repair. An NG
tube can remove fluids and gas from the stomach to help prevent vomiting and aspiration. The NG tube can later be used as
a feeding tube. Antiemetics may be given. Teach the patient to
clear secretions and vomitus.
Oral hygiene is important. Teach the patient to remove food
debris by rinsing the mouth often, especially after meals and
snacks. Warm normal saline solution, water, or alkaline mouthwashes may be used. A syringe and soft irrigation catheter or a
Water Pik may be effective for thorough oral cleansing. Inspect
the mouth several times a day to see that it is clean. Use a tongue
depressor to retract the cheeks. Keep the lips, corners of the
mouth, and buccal mucosa moist. Cover any sharp edges of the
wires with dental wax to prevent irritation of the buccal mucosa.
Communication may be a problem, especially in the early
postoperative period. Establish an effective way of communicating before surgery (e.g., dry erase board, texting). The patient
can usually speak well enough to be understood within a few
days after surgery.
Adequate nutrition may be a challenge because the diet must
be liquid. The patient easily tires of sucking through a straw or
laboriously using a spoon. Work with the dietitian and patient
to plan a diet with adequate calories, protein, and fluids. Liquid
protein supplements may improve nutrition. The low-bulk,
high-carbohydrate diet and intake of air through the straw contribute to constipation and gas. Ambulation, prune juice, and
bulk-forming laxatives may help relieve these problems.
The patient is usually discharged with the wires in place.
Encourage the patient to share feelings about the changes in
appearance. Discharge teaching should include oral care, diet,
how to handle secretions, how and when to use wire cutters or
scissors, and when to notify the HCP.
AMPUTATION
An amputation is the removal of a body extremity by trauma
or surgery. About 2 million Americans live with limb loss.15
About 185,000 amputations occur each year in the United
States. Just over half are due to PVD and diabetes. These
patients often have peripheral neuropathy that progresses to
deep ulcers and gangrene. Trauma is the other major cause.
Injuries have affected over 1700 military veterans since 2003,
with several losing more than 1 limb.16 Other reasons for
amputation include thermal injuries, tumors, osteomyelitis,
and congenital limb disorders.
Diagnostic Studies
Diagnostic studies depend on the underlying reason for the
amputation (Table 67.14). An increased white blood cell (WBC)
count with abnormal differential may show infection. Vascular
tests such as arteriography, Doppler studies, and venography
give information about circulation in the extremity.
Interprofessional Care
Chronic illnesses and infection must be managed before an
amputation is done. The goal of surgery is to preserve the greatest extremity length and function while removing all infected,
pathologic, or ischemic tissue. Fig. 67.23 shows levels of amputation of upper and lower extremities. The type of amputation
TABLE 67.14
Amputation
Interprofessional Care
Diagnostic Assessment
• History and physical assessment
• Physical appearance of soft tissues
• Skin temperature
• Sensory function
• Quality of peripheral pulses
• Arteriography
• Venography
• Plethysmography (measures blood flow in the arms or legs)
• Transcutaneous ultrasonic Doppler recordings
Management
Medical
• Appropriate management of underlying disease
• Stabilize trauma victim
Surgical
• Residual limb management
• Immediate or delayed prosthesis fitting
Rehabilitation
• Coordination of prosthesis-fitting and gait-training activities
• Coordination of muscle-strength and PT programs
CHAPTER 67
Musculoskeletal Trauma and Orthopedic Surgery
Planning
Hemipelvectomy
Hip disarticulation
Shoulder
disarticulation
Short
above knee
Medium
Above elbow
(AEA)
Elbow
disarticulation
AKA
Long
Knee
disarticulation
Below elbow
(BEA)
Below knee (BKA)
Wrist
disarticulation
Syme’s amputation
Ray amputation
1665
Transmetatarsal
Fig. 67.23 Location and description of amputation sites of the upper
and lower extremities. AKA, Above-the-knee amputation.
depends on the reason for the surgery. A closed amputation creates a weight-bearing residual limb (or stump). An anterior skin
flap with dissected soft tissue padding covers the bony part of
the residual limb. The skin flap is sutured posteriorly so that the
suture line will not be in a weight-bearing area. Take special care
to prevent accumulation of drainage, which can cause pressure
and harbor bacteria that may cause infection.
Disarticulation is an amputation done through a joint. A
Syme’s amputation is a form of disarticulation at the ankle. After
an open amputation (guillotine amputation), the surface of the
residual limb is left uncovered with skin. This type of surgery
is generally done to control actual or potential infection. The
wound is usually closed later by a second surgery or closed by
skin traction surrounding the residual limb.
NURSING MANAGEMENT: AMPUTATION
Assessment
Assess for any preexisting illnesses. If amputation is planned or
elective, as for the patient with PVD, assess the patient’s general
health. Because most amputations are done for vascular problems, vascular and neurologic assessments are important (see
Chapters 35 and 60).
Clinical Problems
Clinical problems for the patient with an amputation may include:
• Impaired tissue integrity
• Pain
• Musculoskeletal problem
• Impaired role performance
• Negative self-esteem
The overall goals are that the patient with an amputation will (1)
have satisfactory pain management, (2) reach maximum rehabilitation potential (with the use of a prosthesis, if indicated),
(3) cope with the body image changes, and (4) make satisfying
lifestyle adjustments.
Implementation
Health Promotion
Control of illnesses, such as PVD, diabetes, chronic osteomyelitis, and pressure injuries, can eliminate or delay the need for
amputation. Teach patients with these problems to carefully
examine their lower extremities daily for signs of infection or
skin breakdown. If the patient cannot do this, the caregiver
should help. Teach the patient and caregiver to report changes
in the feet or toes to the HCP. These include decreased or
absent sensation, tingling, burning pain, cuts, or abrasions, and
changes in skin color or temperature.
Review safety precautions for people taking part in recreational activities and potentially hazardous work. This role is
important for the occupational health nurse.
Acute Care
Reasons for amputation and the rehabilitation potential depend
on a person’s age, diagnosis, occupation, personality, resources,
and support system. Be aware of the psychologic and social
implications of amputation. Body image problems related to
amputation often cause a patient to go through a grieving process. Use therapeutic communication to help the patient and
caregiver through this process and develop a realistic attitude
about the future.
Preoperative care. Reinforce information that the patient
and caregiver have received about reasons for the amputation,
proposed prosthesis, and mobility-training program. Help the
patient and caregiver understand the need for the amputation.
Assure them that rehabilitation can help with quality of life.
If the amputation is done emergently after trauma, patient
management is physically and emotionally more complicated.
To meet the patient’s educational needs, know the level of
amputation, type of dressings to be applied, and type of prosthesis to be used. Teach the patient to perform upper extremity
exercises, such as push-ups in bed or the wheelchair, to promote
arm strength for crutch walking and gait training. Discuss general postoperative nursing care. Review positioning, support,
and residual limb care. If a compression bandage will be used
after surgery, teach the patient about its purpose and how it
will be applied. If immediate prosthesis use is planned, discuss
general ambulation expectations. Tell the patient that the amputated limb may feel like it is still present after surgery. This phenomenon, termed phantom limb sensation, occurs in many
amputees.
Postoperative care. General care for the patient who had an
amputation depends largely on the patient’s age, general state
of health, and reason for the amputation. Monitor patients who
had an amputation due to a traumatic injury for posttraumatic
stress disorder because they may have had no time to prepare or
even take part in the decision to have a limb amputated.
1666
SECTION 12
Problems Related to Movement and Coordination
TABLE 67.15 PATIENT & CAREGIVER
TEACHING
Lower Extremity Amputation
Fig. 67.24 A double amputee fitted with prostheses. (Photo courtesy
US Army.)
Prevention and detection of complications are important
after surgery. Monitor vital signs. Assess dressings for hemorrhage. Use sterile technique during dressing changes to reduce
the risk for wound infection. If an immediate postoperative
prosthesis has been applied, carefully observe the surgical site.
If excess bleeding occurs, notify the HCP at once. Keep a tourniquet available for emergency use.
Proper bandaging ensures the residual limb is shaped and
molded for eventual prosthesis fitting (Fig. 67.24). The HCP
usually orders a compression bandage to be applied right after
surgery to support soft tissues, reduce edema, hasten healing,
and minimize pain. Compression also promotes residual limb
shrinkage and maturation. This bandage may be an elastic roll
applied to the residual limb or a residual limb shrinker, which is
an elastic stocking that fits tightly over the residual limb.
At first, the patient always wears the compression bandage
except during PT and bathing. Remove and reapply the bandage
several times daily. Take care to apply it snugly but not so tight as
to interfere with circulation. Wash and change shrinker bandages
daily. After the residual limb is healed, bandage it only when the
patient is not wearing the prosthesis. Teach the patient to avoid
dangling the residual limb over the bedside to decrease edema.
As the patient’s condition improves, the HCP and physical
therapist start and supervise an exercise program. We start
active ROM exercises for all joints as soon as possible after surgery. To prepare for mobility, the patient should increase triceps and shoulder strength for lower limb support. The patient
will need to learn to balance the altered body. The lost weight of
an amputated limb requires adaptation of proprioception and
coordination to prevent falls and injury.
Flexion contractures may delay rehabilitation. The most
common and debilitating contracture is hip flexion. Hip adduction contracture is rare. To prevent flexion contractures, have
After lower extremity amputation, include the following instructions when
teaching the patient and caregiver:
1.Inspect the residual limb daily for signs of skin irritation, especially redness, abrasion, and odor. Especially evaluate areas prone to pressure.
2.Stop using the prosthesis if irritation develops. Have the area checked
before resuming use of the prosthesis.
3.Wash the residual limb thoroughly each night with warm water and bacteriostatic soap. Rinse thoroughly and dry gently. Expose the residual limb
to air for 20 min.
4.Do not use lotions, alcohol, powders, or oil on residual limb unless prescribed by the HCP.
5.Wear only a residual limb sock in good condition and supplied by the
prosthetist.
6.Change residual limb sock daily. Launder in mild soap, squeeze, lay flat
to dry.
7.Use prescribed pain management techniques.
8.Perform ROM to all joints daily. Perform general strength exercises
(including for upper extremities) daily.
9.Do not elevate residual limb on a pillow.
10.Lay prone with hip in extension for 30 min, 3 or 4 times daily.
patients avoid sitting in a chair for more than 1 hour with hips
flexed or having pillows under the surgical extremity. Unless
contraindicated, patients should lie on their abdomen for 30
minutes 3 or 4 times each day and position the hip in extension
while prone.
Crutch walking starts as soon as the patient is physically able.
Follow orders for weight bearing carefully to avoid injury to the
skin flap and delay of tissue healing. Before discharge, teach the
patient and caregiver about residual limb care, ambulation, contracture prevention, recognition of complications, exercise, and
follow-up care (Table 67.15).
Ambulatory Care
Success of rehabilitation depends on the patient’s physical and
emotional health. Chronic illness and deconditioning can complicate rehabilitation. The patient’s previous ability to ambulate
may affect the extent of recovery. Physical and occupational
therapy must be a central part of the overall plan of care.
Prostheses
Appropriate timing for the use of a prosthesis depends on satisfactory healing of the residual limb and the patient’s general condition. The delayed prosthetic fitting may be the best choice for
older adults, patients with infection, or patients who had amputations above the knee or below the elbow (Fig. 67.25). A temporary
prosthesis may be used for partial weight bearing after sutures are
removed. If there are no problems, the patient can bear full weight
on a permanent prosthesis about 3 months after amputation.
Not all patients are candidates for prostheses. Using a prosthesis requires significant strength and energy for ambulation.
For example, walking with a below-the-knee prosthesis requires
40% more energy than walking on 2 legs. An above-the-knee
prosthesis requires 60% more. The seriously ill or debilitated
CHAPTER 67
Musculoskeletal Trauma and Orthopedic Surgery
1667
Start of second bandage
1
1
2
1
4
4
5
6
2
3
3
Fig. 67.25 Mirror therapy, a type of treatment that may reduce phantom limb sensation and pain. (US Navy photo courtesy Mass Communication Specialist Seaman Joseph A. Boomhower.)
1
patient may not have the upper body strength and energy
needed to use a lower extremity prosthesis. Mobility with a
wheelchair may be the most realistic goal for this patient.
When healing has occurred satisfactorily, and the residual
limb is well molded, the patient is ready for prosthesis fitting.
A prosthetist makes a mold of the residual limb and measures
landmarks for creation of the prosthesis. The molded limb
socket allows the residual limb to fit snugly into the prosthesis.
The residual limb is covered with a stocking to ensure good fit
and prevent skin breakdown. If the limb continues to shrink,
causing a loose fit, a new socket must be made. The patient
may need to have the prosthesis adjusted to prevent rubbing
and friction between the residual limb and socket. Excessive
movement of a loose prosthesis can cause severe skin irritation,
breakdown, and gait problems.
Artificial limbs become an integral part of the patient’s
changed body image. Teach the patient to clean the prosthesis
socket daily with mild soap and rinse thoroughly to remove irritants. Leather and metal parts of the prosthesis should not get
wet. Encourage the patient to have regular maintenance on the
prosthesis. Consider the condition of the patient’s shoe. A badly
worn shoe alters the gait and can damage the prosthesis.
Phantom Limb Sensations
Patients are often worried about phantom limb sensation
because they still perceive pain in the missing part of the limb.
As recovery and ambulation progress, phantom limb sensation and pain usually subside. However, the pain may become
chronic. The patient may have shooting, burning, or crushing
pain as well as feelings of coldness, heaviness, and cramping,
There is no one therapy for phantom limb sensation. Mirror
therapy and virtual reality treatment reduce symptoms in some
patients (Fig. 67.26). We think these therapies give visual information to the brain, replacing sensory feedback expected from
the missing limb.17
Upper Limb Amputation
An upper limb amputation is often more devastating than
for lower limb amputation. Despite technologic advances, we
5
1
5 4
6
6
7
7
8
1
5
9
6
7
Fig. 67.26 Bandaging for the above-the-knee amputation residual limb.
Figure-8 style covers progressive areas of the residual limb; 2 elastic
wraps used.
cannot replicate the movements and functional capacity of our
hands with upper extremity prostheses. The enforced dependency due to being 1-handed may be depressing and frustrating
to the patient. Because most upper extremity amputations result
from trauma, the patient likely had little time to adjust or be a
part of the decision-making process.
Both immediate and delayed prosthetic fittings are possible
for the below-the-elbow amputee. Prosthetic fitting is delayed
for the above-the-elbow amputee. The usual functional prosthesis is the arm and hook. A cosmetic hand is available but
has limited functional value. As with the lower limb prosthesis,
patient motivation and perseverance are major factors contributing to a satisfactory outcome.
Evaluation
The expected outcomes are that the patient with an amputation will:
• Accept changed body image and integrate changes into lifestyle
• Have no evidence of skin breakdown
• Have reduction or absence of pain
• Become mobile within limitations imposed by amputation
COMMON JOINT SURGERIES
Surgery plays a vital role in the treatment and rehabilitation of
patients with various joint problems. The goals of surgery are to
relieve chronic pain, improve joint motion, correct deformity
1668
SECTION 12
Problems Related to Movement and Coordination
and misalignment, and remove diseased cartilage. If the joint
problem is not corrected, contraction with permanent limitation of motion may occur. There will be limited joint motion
on physical assessment. Joint-space narrowing can be seen on
x-rays.
Partial hip
replacement
Total hip
replacement
TYPES OF JOINT SURGERIES
Synovectomy
Synovectomy (removal of synovial membrane) is done to
remove inflamed tissue that is causing unacceptable pain or
limiting ROM in RA. A synovectomy is best done early in
the disease process when there is minimal bone or cartilage
destruction. Removing the thickened synovium does not cure
RA. It may relieve symptoms temporarily. Common sites for
this surgery include the elbow, wrist, and fingers. Knee synovectomy is done less often because knee joint replacement is
usually done.
Osteotomy
An osteotomy involves removing a wedge or slice of bone to
restore alignment (joint and vertebral) and to shift weight bearing, thus relieving pain. Cervical osteotomy may be used to
correct a kyphotic deformity in patients with ankylosing spondylitis. Halo vests and body jacket braces are worn until fusion
occurs (3 to 4 months). Osteotomy is not effective in patients
with inflammatory joint disease. Femoral osteotomy may provide some pain relief and improve motion in select patients with
hip OA. Tibial osteotomy provides pain relief in some patients
with knee instability or OA.
Care of a patient who had an osteotomy is similar to that of
a patient with ORIF of a fracture at a comparable site. Internal
wires, screws and plates, bone grafts, or an external fixator usually fixes the bone in place.
Debridement
Debridement is the removal of debris, such as pieces of bone
or cartilage (loose bodies) or osteophytes, from a joint using a
fiberoptic arthroscope. This procedure is usually done on an
outpatient basis on the knee or shoulder. A compression dressing is applied after surgery. Weight bearing is permitted after
knee arthroscopy. Patient teaching includes monitoring for
signs of infection, managing pain, and restricting activity for
24 to 48 hours.
Arthroplasty
Arthroplasty is the reconstruction or replacement of a joint
to relieve pain, improve or maintain ROM, and correct deformity. Arthroplasty is most often done on patients with OA, RA,
avascular necrosis, congenital deformities or dislocations, and
other systemic problems. Types of arthroplasty include surgical
reshaping of the bones of the joints, replacement of part of a
joint (hemiarthroplasty), and total joint replacement. Around
1 million Americans have knee and hip replacement surgery
annually.18 Arthroplasty is also available for elbows, shoulders,
fingers, wrists, ankles, and feet.
Fig. 67.27 Types of hip replacements.
Total Hip Arthroplasty
Total hip arthroplasty (THA), or a total hip replacement, provides significant relief of pain and improved function for
patients with joint deterioration from OA, RA, and other conditions. THA is also used to treat hip fractures.
In THA, the prosthesis (implant) replaces the ball-andsocket joint formed by the upper shaft of the femur and pelvis (Fig. 67.27). Both the ball-and-socket components can
be cemented in place with polymethyl methacrylate, which
bonds to the bone. They may be inserted without cement
(cementless). Cementless THA may provide longer stability
by enabling growth of new bone tissue into the porous surface coating of the prosthesis. Cementless devices are better
for younger, more active patients and patients with good bone
quality as there is better bone growth into the components.
The nursing care for a patient who had a THA is discussed
in the section on nursing management of a patient with a hip
fracture.
Hip Resurfacing Arthroplasty
An alternative to THA is hip resurfacing arthroplasty. It preserves and reshapes the femoral head (ball) rather than replacing it as in THA. The resurfaced femoral head is then capped
by a metal prosthesis. Hip resurfacing may be an option for
patients younger than age 60 with larger frames. A small number of patients have a femoral neck fracture after hip resurfacing. This is not possible with THA. Metal ions may be released
into the bloodstream from the prosthesis. Patients may develop
sensitivity or allergy to these ions.19 Patients receiving a smaller
femoral head (including many women) have a higher failure
rate with a resurfaced implant when compared with patients
receiving THA.
Knee Arthroplasty
Unrelieved pain and instability due to severe deterioration of
the knee joint are the main reasons for total knee arthroplasty
(TKA) or a total knee replacement (Fig. 67.28). Partial arthroplasty can be done on a patient with OA limited to 1 part (compartment) of the knee.
CHAPTER 67
Musculoskeletal Trauma and Orthopedic Surgery
Femur
Patella
Femoral
component
Polyethylene
plastic surface
Stemmed
tibial plate
Tibia
Fig. 67.28 Knee arthroplasty components. Up to 3 bone surfaces can
be replaced in a total knee replacement. (Modified from Odom-Forren J:
Drain’s perianesthesia nursing, ed 7, St Louis, 2018, Elsevier.)
Right after surgery a compression dressing may be used to
immobilize the knee in extension. This dressing is removed
before discharge. If the patient is unable to perform a straightleg raise, a knee immobilizer or posterior plastic shell to maintain extension may be used during ambulation and at rest for
about 4 weeks.
After surgery, emphasis is on pain management and PT.
Managing pain is a primary nursing goal. Doing so decreases
the risk for complications and speeds the return to function.
Adequate analgesia should be ordered at discharge to allow the
patient to continue with the exercise program. Effective pain
management is key to achieving positive rehabilitation outcomes.
PT begins early with isometric quadriceps setting. Therapy
progresses to straight-leg raises and gentle ROM to increase
muscle strength and obtain 90-degree knee flexion. Ambulation
starts early with walking short distances, progressing to full
weight bearing. An active home exercise program involves progressive ROM with muscle strength and flexibility exercises.
After TKA, many patients with OA show significant improvement in mobility, motor function tests, and ability to complete
daily tasks.
Finger Joint Arthroplasty
A silicone rubber arthroplastic device is used to restore function in the fingers of the patient with RA. Ulnar deviation often
causes severe functional limitations of the hand. The main goal
of hand surgery is to restore function related to grasp, pinch,
stability, and strength rather than to correct cosmetic deformity.
Before surgery, the patient should learn hand exercises, including flexion, extension, abduction, and adduction of the fingers.
After surgery, the patient will have a bulk dressing. Keep
the hand elevated. Perform regular neurovascular assessment.
Monitor for signs of infection. Success of the surgery depends
largely on the postoperative treatment plan. An OT plays a key
role. After the dressing is removed, a guided splinting program
1669
is started. Patients wear splints while sleeping and do hand exercises at least 3 or 4 times a day for 10 to 12 weeks. Teach the
patient to avoid lifting heavy objects.
Elbow and Shoulder Arthroplasty
Elbow and shoulder replacements is not as common as other
arthroplasties. Shoulder replacements are done in patients with
severe pain because of RA, OA, avascular necrosis, or trauma.
A special type of shoulder replacement, called a reverse total
shoulder arthroplasty, may be done for pain and dysfunction
caused by massive, irreparable rotator cuff tears. Shoulder
replacement is usually considered if the patient has adequate
surrounding muscle strength and bone density.
Rehabilitation is longer and more difficult than with other
joint surgeries. If the patient needs elbow and shoulder joint
replacements, the elbow is usually done first because elbow pain
interferes with shoulder rehabilitation. Most patients have no
pain at rest or minimal pain with activity after elbow and shoulder arthroplasty. Functional improvements contribute to better
hygiene and increased ability to perform ADLs.
Ankle Arthroplasty
Total ankle arthroplasty (TAA) is indicated for RA, OA, trauma,
and avascular necrosis. Although TAA is not widespread, it is a
good alternative to fusion for treatment of severe ankle arthritis
in certain patients. Available devices include several fixed-bearing devices and a mobile-bearing cementless prosthesis. This
device more closely imitates natural ankle function.
Ankle fusion is preferred over arthroplasty because the result
is more durable. However, fusion leaves the patient with a stiff
foot and the inability to change heel height. TAA achieves a
more normal gait pattern. After surgery, the patient may not
bear weight for 6 weeks. They need to elevate the extremity to
reduce edema and maintain immobilization as directed by the
HCP.
Arthrodesis
Arthrodesis is the surgical fusion of a joint. This procedure
is done only if articular surfaces are too severely damaged or
infected to allow joint replacement or if reconstructive surgery
fails. Arthrodesis relieves pain and provides a stable but immobile joint. The fusion is usually done by removing the articular
hyaline cartilage and adding bone grafts across the joint surface.
The affected joint must be immobilized until bone healing has
occurred. Common areas fused are wrist, ankle, cervical spine,
lumbar spine, and metatarsophalangeal (MTP) joint of the big
toe.
Complications of Joint Surgery
Infection is a serious complication of joint surgery, especially
joint replacement surgery. The most common causative organisms are streptococci and staphylococci. Infection may lead to
pain and loosening of the prosthesis, often requiring further surgery. Measures to reduce infection include the use of specially
designed self-contained operating suites, operating rooms with
laminar airflow, and prophylactic antibiotic administration.
1670
SECTION 12
Problems Related to Movement and Coordination
VTE is a serious complication after joint surgeries, especially those involving the lower extremities. Provide prophylactic measures, such as anticoagulant drugs, use of intermittent
pneumatic compression devices, and early ambulation. Assess
patients for signs of VTE. VTE is discussed in Chapter 41.
NURSING AND INTERPROFESSIONAL
MANAGEMENT: JOINT SURGERY
Preoperative Care
The primary goal of preoperative assessment is to identify risk
factors for postoperative complications so we can implement
measures to promote optimal outcomes. A careful history
includes (1) medical diagnoses and complications, such as diabetes; (2) pain tolerance and management preferences; (3) current functional level and expectations after surgery; (4) current
social support; and (5) home care needs after discharge. The
patient should be free from infection, breaks in skin integrity,
and acute joint inflammation.
Preoperative teaching about the expected hospital course
and postoperative management at home is important for the
patient and caregiver. Explain postoperative care, including
early mobility, the need to maintain hydration, and VTE
prophylaxis. Assure the patient that analgesia will be available. A preoperative PT visit allows practice of postoperative
exercises and measurement for crutches or other assistive
devices. Provide opportunities for practice with assistive
devices.
If lower extremity surgery is planned, assess upper extremity muscle strength and joint function to determine the type of
assistive devices needed for ambulation and ADL performance.
Discuss ways to maximize the usefulness and longevity of the
prosthesis. Patients need to realize that recovery does not occur
rapidly. Talking with other people who have had joint arthroplasty may help the patient better understand the reality of
rehabilitation.
Begin discharge planning. Review the duration of the hospital stay and expected postoperative events so that the patient
and caregiver can prepare. Advanced planning helps to allow
for a discharge home. Assess the patient’s support. Identify their
care partner. Who is going to help the patient at home? Will
the patient need homemaker or meal services? It is preferable that the patient goes home after a total joint arthroplasty.
Discuss the safety and accessibility of the home environment
(e.g., throw rugs, cords). Are the bathroom and bedroom on
the first floor? Are door frames wide enough to accommodate a
walker? Discharge to a subacute or extended care facility should
be planned beforehand. The older patient may need to go to a
facility for a few weeks to regain independent living skills, if
there is no social support available.
Postoperative Management
Nursing care of the patient having orthopedic surgery is outlined in Table 67.16. Other nursing interventions are presented in eNursing Care Plan 67.2 (available on the website
TABLE 67.16 NURSING MANAGEMENT
Care of the Patient After Joint Surgery
•Perform neurovascular assessment on the affected extremity.
•Monitor pain intensity and give prescribed analgesics.
•Maintain correct body alignment.
•Provide wound care, including dressing changes.
•Assess for complications of immobility (e.g., constipation, VTE) and develop
a plan to minimize those complications.
•Assist with initial ambulation then help as needed.
•Assist patient, caregiver(s), and family in planning for discharge care.
•Supervise assistive personnel (AP):
•Record oral intake and output.
•Obtain vital signs and pulse oximetry.
•Aid patient with nutrition, elimination, and hygiene needs.
•Maintain body position and assist with ambulation.
•Help with passive and active ROM exercises.
•Notify RN about reports of pain, tingling, or decreased sensation in the
affected extremity.
Collaborate With Physical Therapist
•Assess current mobility and need for assistance.
•Teach safe ambulation with assistive device based on weight-bearing
restrictions.
•Establish exercise plan and teach patient to perform exercises safely.
•Coordinate PT with RN so that patient can receive timely analgesia.
•Discuss home environment with patient and identify modifications to promote safety.
for this chapter). The hospital stay after arthroplasty can be a
few hours after surgery to 2 days depending on preoperative
planning, postoperative course, and need for PT after surgery.
Many hip and knee replacement surgeries are done at ambulatory surgical centers. Same day surgery is a trend expected
to increase.
Regularly perform neurovascular assessment. Give ordered
analgesics. Assess patient comfort often during the postoperative period. Monitor for postoperative complications. Teach the
patient to report complications. Review signs of infection (e.g.,
fever, increased pain, drainage) and dislocation of the prosthesis
(e.g., pain, loss of function, shortening or malalignment of an
extremity).
Assess ROM at regular intervals to promote functional performance. In general, the affected joint is exercised, and we
encourage ambulation as early as possible. PT and ambulation
enhance mobility, build muscle strength, and reduce the risk for
VTE. Specific protocols vary according to the patient, type of
prosthesis, and HCP preference.
VTE risk reduction includes hydration, shorter surgery time, early mobility, and use of anticoagulant medications. Most prophylactic anticoagulant drugs are given for
at least 10 to 14 days.12 Some patients need therapy for up
to 35 days. If the patient is taking warfarin, therapy starts
on the day of surgery, and the INR and prothrombin times
are measured daily. Therapy with LMWH (e.g., enoxaparin),
apixaban, or rivaroxaban usually starts the morning after
surgery.
CHAPTER 67
Musculoskeletal Trauma and Orthopedic Surgery
1671
Case Study
Hip Fracture and Revision Arthroplasty
(© aronaze/
iStock.com.)
Patient Profile
M.C. is a 64-year-old man who had both hips replaced (left
6 years ago, right 2 years ago). He has a history of hypothyroidism. He was admitted to the ED after tripping over a short
retaining wall in his backyard while gardening. He landed on
his right side.
Subjective Data
• Acute, severe pain in right hip, unable to bear weight on right leg.
• Takes cholecalciferol (vitamin D3) 1000 IU every day without calcium supplement. States calcium upsets his stomach.
• Reports loss of about 30 lb in the last year through diet and exercise. Exercises 3 times a week.
• Lives in multilevel house with his wife. Bedrooms are on the second level.
• Has smoked ½ pack of cigarettes a day for the 30 years.
• Describes himself as “a very light social drinker.”
Interprofessional Care
• Revision of femoral part of his right total hip replacement with open reduction
of the femoral fracture and fixation with 3 wires
• Medications:
• IV morphine sulfate 2 mg IV every 3 hr as needed
• Cefazolin 1 gram IV every 8 hr for 24 hr
• Enoxaparin 40 mg subcutaneous daily for 4 weeks
• Calcium citrate 600 mg plus 800 IU vitamin D orally daily
• Levothyroxine (Synthroid) 125 mcg orally daily
• PT for transfers, gait, and stair training
• Occupational therapy for ADLs training
• Discharge planning based on mobility limitations and need for continued PT
and OT
Objective Data
• 5 ft, 9 in tall, 175 lb
Diagnostic Studies
• X-rays show periprosthetic right proximal femur fracture at the greater trochanter with loss of fixation in the femoral part of the THA
• Normal CBC, chest x-ray
• Serum calcium 8.1 mg/dL
Discussion Questions
1. Recognize: How do M.C.’s previous total joint surgeries affect his recovery
after this surgery?
2. Analyze: What are the most likely postoperative complications M.C. could
develop?
3. Analyze: In considering his patient profile, what issues can you identify that
may affect his bone healing?
4. Plan: As you plan care for M.C., what are the priority nursing interventions?
5. Prioritize: What is the interprofessional team’s top priority at this time?
6. Act: What do you need to assess to determine his readiness for discharge?
7. Safety: What safety precautions should we implement for M.C.?
8. Evaluate: Why is satisfactory pain management an important postoperative
nursing goal for M.C.?
9. Evaluate: What outcomes would indicate nursing care was effective?
Answers available at http://evolve.elsevier.com/Lewis/medsurg.
B R I D G E T O N C L E X E X A M I N A T I O N
The number of the question corresponds to the same-numbered
outcome at the beginning of the chapter.
1.The nurse in urgent care suspects an ankle sprain when a
patient describes
a. being hit by another soccer player during a game.
b. having ankle pain after sprinting around the track.
c. dropping a 10-lb weight on his lower leg at the health club.
d. twisting his ankle while running bases during a baseball game.
2.A patient with a humeral fracture is returning for a 4-week
checkup. The nurse explains that initial evidence of healing
on x-ray is indicated by
a. formation of callus.
b. complete bony union.
c. hematoma at the fracture site.
d. presence of granulation tissue.
SECTION 12
Problems Related to Movement and Coordination
3.A patient with a comminuted fracture of the tibia is to have
an open reduction with internal fixation (ORIF) of the fracture. The nurse explains that ORIF is indicated when
a. the patient cannot tolerate prolonged immobilization.
b. the patient cannot tolerate the surgery for a closed reduction.
c. other nonsurgical methods cannot achieve adequate
alignment.
d. a temporary cast would be too unstable to provide normal
mobility.
4.The nurse suspects a neurovascular problem based on assessment of
a. exaggerated strength with movement.
b. increased redness and heat below the injury.
c. decreased sensation distal to the fracture site.
d. purulent drainage at the site of an open fracture.
5.A patient with a stable, closed humeral fracture has a temporary splint with bulky padding applied with an elastic bandage. The nurse suspects early compartment syndrome when
the patient has
a. increasing edema of the limb.
b. muscle spasms of the lower arm.
c. bounding pulse at the fracture site.
d. pain when passively extending the fingers.
6.The nurse would monitor a patient with a pelvic fracture for
a. changes in urine output.
b. petechiae on the abdomen.
c. a palpable lump in the buttock.
d. sudden increase in blood pressure.
7.The nurse teaches the patient with an above-the-knee amputation that the residual limb should not be routinely elevated
because this position promotes
a. hip flexion contracture.
b. clot formation at the incision.
c. skin irritation and breakdown.
d. increased risk for wound dehiscence.
REFERENCES
1.Centers for Disease Control and Prevention (CDC): Leading
causes of death. Retrieved from https://www.cdc.gov/injury/wisqars/facts.html.
2.National Institute of Arthritis and Musculoskeletal and Skin
Diseases: Preventing sports injuries in youth: a guide for parents.
Retrieved from https://www.niams.nih.gov/Health_Info/Sports_
Injuries/child_sports_injuries.asp.
3.American Academy of Orthopaedic Surgeons (AAOS): Sprains,
strains, and other soft-tissue injuries. Retrieved from https://
www.orthoinfo.org/topic.cfm?topic=A00111.
4.Mayo Clinic: Carpal tunnel syndrome. Retrieved from https://
www.mayoclinic.org/diseases-conditions/carpal-tunnel-syndrome/basics/definition/con-20030332.
5.Mayo Clinic: Rotator cuff injury: diagnosis and treatment.
Retrieved from https://www.mayoclinic.org/diseases-conditions/
rotator-cuff-injury/symptoms-causes/syc-20350225.
8.A patient with osteoarthritis is scheduled for total hip arthroplasty. The nurse explains the purpose of this procedure is to
(select all that apply)
a. fuse the joint.
b. replace the joint.
c. prevent further damage.
d. improve or maintain ROM.
e. decrease the amount of destruction in the joint.
9.A patient is scheduled for total ankle replacement. The nurse
should tell the patient that after surgery he should avoid
a. lifting heavy objects.
b. sleeping on the back.
c. abduction exercises of the affected ankle.
d. bearing weight on the affected leg for 6 weeks.
1. d; 2. a; 3. c; 4. c; 5. d; 6. a; 7. a; 8. b, d; 9. d.
1672
For rationales to these answers and even more NCLEX review
questions, visit http://evolve.elsevier.com/Lewis/medsurg.
EVOLVE WEBSITE/RESOURCES LIST
http://evolve.elsevier.com/Lewis/medsurg
Review Questions (Online Only)
Key Points
Answer Keys for Questions
• Rationales for Bridge to NCLEX Examination Questions
• Answer Guidelines for Case Study
Student Case Studies
• Patient With Musculoskeletal Trauma
• Patient With Parkinson’s Disease and Hip Fracture
Nursing Care Plans
• eNursing Care Plan 67.1: Patient With a Fracture
• eNursing Care Plan 67.2: Patient Having Orthopedic Surgery
Concept Map Creator
Audio Glossary
Content Updates
6.Sheen JR, Garla VV: Fracture healing overview. Retrieved from:
https://www.ncbi.nlm.nih.gov/books/NBK551678/.
7.Swiontkowski MF: Cast and bandaging techniques. In Manual of
Orthopaedics, 8 ed, Wolters Kluwer, 2020.
8.American Orthopedic Foot and Ankle Society: Foot ulcers and
the total contact cast. Retrieved from https://www.aofas.org/
footcaremd/conditions/diabetic-foot/Pages/Foot-Ulcers-andthe-Total-Contact-Cast.aspx.
*9.Sáenz-Jalón M, Sarabia-Cobo CM, Bartolome ER, et al.: A randomized clinical trial on the use of antiseptic solutions for the
pin-site care of external fixators, J Trauma Nurs 27:146, 2020.
*10.Bhavsar MB, Han Z, DeCoster T, et al.: Electrical stimulation-based bone fracture treatment, if it works so well why do
not more surgeons use it? Eur J Trauma Emerg Surg 46:245,
2020.
11.Rupp M, Popp D, Alt V: Prevention of infection in open fractures: where are the pendulums now? Injury 51:S57,
2020.
CHAPTER 67
Musculoskeletal Trauma and Orthopedic Surgery
12.Bartlett MA, Mauck KF, Stephenson CR, et al.: Perioperative venous thromboembolism prophylaxis, Mayo Clin Proc 95:277, 2020.
13.Luff D, Hewson DW: Fat embolism syndrome, BJA Education
21:322, 2021.
14.CDC: Hip fractures among older adults. Retrieved from https://
www.cdc.gov/HomeandRecreationalSafety/Falls/adulthipfx.
html.
15.Amputee Coalition: Limb loss statistics. Retrieved from https://
www.amputee-coalition.org/limb-loss-resource-center/resources-by-topic/limb-loss-statistics/limb-loss-statistics.
*16.Armstrong AJ, Hawley CE, Darter B, et al.: Operation Enduring
Freedom and Operation Iraqi Freedom veterans with amputa-
1673
tion: an exploration of resilience, employment, and individual
characteristics, J Vocat Rehabil 48:167, 2018.
17.Erlenwein J, Diers M, Ernst J, et al.: Clinical updates on phantom limb pain, Pain Rep 6:e888, 2021.
*18.Singh JA, Yu S, Chen L, et al.: Rates of total joint replacement
in the United States: future projections to 2020–2040 using the
national inpatient sample, J Rheumatol 46:1134, 2019.
19.AAOS: Hip resurfacing. Retrieved from http://orthoinfo.aaos.
org/topic.cfm?topic=A00586.
*Evidence-based information for clinical practice.