Musculoskeletal Trauma
Day 2
Chapter 42
Risk Factors
• Elderly
Elderly Home Safety
•
•
•
•
Lighting
Rugs
Clutter
Shoes
Soft Tissue Injury
• Contusion 
– Ecchymosis
•
•
•
•
Black & Blue
Purple
Brown
Yellow
• Hematoma
Sprain
• S&S
–
–
–
–
–
Ligament injury
Pain
Joint Instability
Edema, discoloration
h pain with movement
• D/T
– Twisting
Strain
• S&S
–
–
–
–
Muscle tear
Pain
Edema
h pain with muscle
contraction
Dx
• X-ray
• MRI
Tx Goal
•
•
•
•
i swelling
i pain
h rest
h healing
Tx
• Rest
• Ice
– 48 hrs
• Heat
– > 48 hrs
• Compression dressing
• Elevate
Tx
• Support
–
–
–
–
Knee immobilizer
Sling
Crutches
Walker
Meds
• NSAIDs
• Analgesics
– Narcotic
Mr. Rayne Inspain is prescribed NSAID’s
due to a grade 2-3 ankle sprain. What
would you teach Mr. Inspain about this
medication
A. Take as needed with food
B. Take regularly with food
C. Take as needed on an empty stomach
D. Take regularly on an empty stomach
Small Group Activity
• Generate a list of questions to assess
John age 44 injured ankle.
What are the 5 cardinal S&S of
inflammation?
•
•
•
•
•
Pain
Redness
Swelling / edema
Loss of function
Heat
Assessment
• Assess
• Palpate
–
–
–
–
–
Edema
Heat
Pain
Deformity
Crepitus
•
•
•
•
Cap refill
Pulses
Mobility
Sensation
Report Complications
•
•
•
•
•
Numbness
Tingling
Weakness
i mobility
Cool / pale
Fracture
• Break in the continuity
of a bone.
Type of Fractures
Closed
• Intact skin
Open
• Broken skin
Type of Fractures
Comminuted
• Broken into many pieces
Compression
• Crushed
Type of Fractures
Impacted
• Ends forced together
Depressed
• Pressed inward
Type of Fractures
Spiral
• Twisted
Greenstick
• Incomplete break
Fracture Healing Process
•
•
•
•
•
•
Fx 
Hematoma 
Inflammatory response 
Clotting 
Phagocytosis 
Osteoblasts 
– Bone Matrix
• Weight bearing 
• Osteocytes 
• Remodeling
Manifestations of Fracture
•
•
•
•
•
•
•
Deformity
Edema, ecchymosis
Pain
Immobility
Numbness
Crepitus
Muscle spasm
Casts
• Rigid external
immobilizing device
• Molds to the contours
of the body
Casts
• Purpose
–
–
–
–
Immobilize
Correct deformity
Apply uniform pressure
Support
Types of casts
• Short arm cast
Types of casts
• Long-arm cast
Types of casts
• Short-leg cast
Types of casts
• Long-leg cast
Types of casts
• Walking cast
Types of casts
• Body Cast
Types of casts
• Shoulder-spica cast
Types of casts
• Hip spica cast
Fiberglass Casts
• Cool-water activated
• Hardens in minutes
• Exothermic reaction
Fiberglass Casts
• Light weight
• Water resistant
• Waterproof?
Fiberglass casts – NURSING care!
• Warn!
This is going to get
really warm – it wont
burn you but it might
be a little
uncomfortable.
Fiberglass casts – NURSING care!
• Don’t dent!
Waterproof Fiberglass casts –
NURSING care!
• Drain
• Dry
Plaster casts
Pros +
Cons -
• i$
• h mold
• i Durability
• h drying time
Plaster Casts
• Cold water activated
• Exothermic reaction
• Rigid
– 15-20 minutes
• Fully dry
– 24-72 hrs
• Will plaster casts soon
be a thing of the past?
Plaster Cast Warning!
• Do not cover while
drying
Splints
• Indications
– Not require rigid
immobilization
– Swelling
– Skin care
– Short term
Splint – NURSING care
• Well padded
• P Circulation
Braces
• Indications
–
–
–
–
Support
Control movement
Prevent additional injury
Long term
General Nursing Management of a
Client
in a Cast, Splint or Brace
• Before applied:
– Assessment
•
•
•
•
•
Holistic
Skin
Swelling
Neurovascular (5P’s)
Pain
– Educate
General Nursing Management of a
Client
in a Cast, Splint or Brace
• NURSING ALERT!
• A patient’s unrelieved pain must be
immediately reported to the physician to
avoid possible paralysis and necrosis.
General Nursing Management of a
Client
in a Cast, Splint or Brace
• Pain assessment
–
–
–
–
Elevate
Ice
Analgesic
Immobilize
PAIN
Pressure
ulcers
Compartment
syndrome
General Nursing Management of a
Client
in a Cast, Splint or Brace
• NURSING ALERT!
• The nurse must never ignore complaints
of pain form the patient in a cast because
of the possibility of problems, such as
impaired tissue perfusion or pressure
ulcer formation.
General Nursing Management of a
Client
in a Cast, Splint or Brace
• ROM to every joint not
immobilized!
General Nursing Management of a
Client
in a Cast, Splint or Brace
When was your
• Skin care
– Treat skin before cast is
applied
• Clean
• Tx per order
last Tetanus
booster?
General Nursing Management of a
Client
in a Cast, Splint or Brace
• Tetanus booster
– q10 yrs
– If dirty
• > 5 yrs
General Nursing Management of a
Client
in a Cast, Splint or Brace
• Skin care
– With cast
• Observe
– S&S of infection
– Purulent drainage
– Odor
I wonder if I
should report this
to the doctor?
General Nursing Management of a
Client
in a Cast, Splint or Brace
• Neurovascular Status
Monitoring & Managing
Potential Complications
• Which of the following type of modality
is most likely to cause complications?
A. Brace
B. Cast
C. Splint
WHY?
Monitoring & Managing
Potential Complications
1.Compartment Syndrome
2.Pressure ulcers
3.Disuse syndrome
Compartment Syndrome
• Pathophysiology
–h Pressure + limited space 
–i circulation
–Compression of nerves
Compartment Syndrome
• S&S
– PAIN!
• passive ROM
• Not relieve with opiods
–
–
–
–
Paresthesia
Pulselessness
Pallor
Paralysis
Compartment Syndrome
• Management
– Notify MD STAT
– Bivalve the cast
– Elevate at heart level
Compartment Syndrome
• NURSING ALERT!
• Compartment Syndrome is managed by
maintaining the extremity at the heart
level (not above heart level), and
bivalving the cast.
Pressure Ulcers
• Pathophysiology
– Pressure 
– Tissue anoxia 
– Ulcer
Pressure Ulcer
• S&S
– Pain
– Warm area on cast
– Drainage
• Stain
• Odor
Pressure Ulcer
• Tx
– Remove, bivalve or
window cast
– If window:
• replace & secure with
compression dressing
• To prevent “window
edema”
Disuse syndrome
• Prevention
– Isometric exercises
– Qhr
Arm slings
• Distribute weight
Crutches
• Indications
– Partial weight bearing
– Non-weight bearing
Crutches
• Requirement for use
– Good balance
– Strong upper body
– Erect posture
Crutches: Adjust
• Length
– 5 cm below axilla
– -40 cm from height
• Hand grip
– 20 – 30o elbow flexion
Crutches
• Down Stairs
1. Crutches
2. Affected leg
3. Unaffected leg
Crutches
• Up stairs
1. Unaffected leg
2. Crutches & affected
Crutches & Stairs
Unaffected
leg
goes
up first
and
down last.
Cane
• Hold on unaffected side
1. Cane forward
2. Affected leg to cane
3. Stronger leg advances
Walker
• Most stable
Transfer from bed to W/C
• W/C
– Parallel to bed
– Un-affected side
– Locked
• Procedure
– Stand
– Pivot
– Sit
Cast removal • Cast cutter
– Vibrations
• Padding cut with
scissors
Cast removal
• Prepare the client
– Skin dry & scaly
• Wash & lube
– Stiff
• Support
– Atrophy
– Weak
• Exercises
• Elevate
Small Group Questions
1. You are giving a client discharge instructions
regarding his new plaster long-leg cast. What do
you teach him about cast drying?
2. What will you teach your client about controlling
swelling and pain?
3. What will you tell the client he needs to report
to the physician immediately?
4. What techniques will you teach the client about
managing minor skin irritation?
5. What will you teach the client to minimize the
complication of disuse syndrome?
Traction
• Applying a pulling force
Traction
• Purpose
–
–
–
–
i muscle spasms
Reduce
Immobilize
i deformity
Traction Rules
•
•
•
•
•
•
•
Continuous
Never interrupted
Do not remove weights
Good body alignment
Unobstructed ropes
Weights free hanging
Knots not touch pulley
Types of traction
• Skin Traction
• Skeletal Traction
Skin traction
• Purpose
– Control muscle spasms
– Immobilize ā surgery
Skin traction
• Weight pulls on “boot”
attached to skin
• Extremities
– 4.5 – 8 lb.
• Pelvis
– 10 – 20 lb.
Skin traction
• Examples
– Buck’s traction
• Lower leg
Skin Traction: Nursing management
• Ensure effective
traction
– No wrinkles or slipping
of the boot
– Proper position
– Do not twist
Skin traction: Management
• Skin breakdown
– Asses skin
– Provide back care
– Special mattress
Skin traction: Management
• Nerve damage
– Avoid pressure on the
peroneal nerve 
– Footdrop =
Skin traction: Management
• Circulatory Impairment
– Asses circl. w/in
• 15 min.
– Assess circl.
• q1-2 hr.
– Enc. exercises q1hr
• Assessment:
–
–
–
–
–
Peripheral pulses
Color
Cap. Refill
Temp.
S&S or DVT
•
•
•
•
Unilateral calf tenderness
Warm
Red
Swelling
Skeletal Traction
• Applied directly to the
bone via
– Pins, wires or tongs
• Indications
– Femur
– Tibia
– Cervical spine
Skeletal traction:
• Procedure
– Pins inserted during
surgery
– Attached to traction
Skeletal traction: Management
• Maintaining effective
traction
– P apparatus
– Eval. pt position
Traction: Nursing Management
• NURSING ALERT!
• The nurse must never remove weights
from skeletal traction unless a lifethreatening situation occurs. Removal of
the weights completely defeats their
purpose and may result in injury to the
patient.
Skeletal traction: Management
• Maintain position
– Foot = plantar flexion
– No rotation
Skeletal traction: Management
• Prevent skin breakdown
–
–
–
–
–
Protect elbows & heel
Trapeze
Asses for redness
Back care
Pressure reducing
mattress
How would you change the bedding of
a patient with skeletal leg traction?
A. Remove the traction and change the linen
B. Turn the patient onto their left side and change
the linen on the right side of the bed, then roll
the patient over the linen to his right side and
finish making the bed on the left side.
C. One nurse changes the linen from the bottom of
the bed upward
D. Two nurses change the linen from the top of the
bed downward.
Skeletal traction: Management
• Monitoring
neurovascular status
– P q1hr until stable then
q4hr
– ROM unaffected limb
– Isometric exercises
– Anti-embolism stocking
– Compression devises
– Anti-coagulant therapy
Skeletal traction: Management
• Pin care
– Infection prevention 
osteomyelitis
– 1st 48hrs cover with
sterile drsging
– Clean pins bid
Joint Replacement
• Indications
– Pain
– Disability
• Caused by
– Joint degeneration
– Fractures
Arthroplasty
• Surgical removal of a
diseased joint &
• Replacement with
prosthetic or artificial
components
Common joint repairs
• Hip
• Knees
• Fingers
Total knee Arthroplasty
• Involves replacement of
– Distal femoral
component
– Tibial plate
– Patellar button
Unicondylar Knee replacement
• When only one
compartment of the
joint is diseased
Unicondylar Knee replacement
Total Hip Arthroplasty
• Replacement of
– Acetabular cup
– Femoral head
– Femoral stem
Hemiarthroplasty
• Refers to
– ½ joint replacement
• Fx of the femoral neck
can be treated with the
replacement of the
femoral component
only
General Nursing interventions
• Pre-op
–
–
–
–
Health
P risk factors for DVT
P neurovascular status
P infection
Pre-OP
• Review labs
Mr. Hip Located is scheduled for a total hip
replacement in the morning. Upon reviewing his lab
results you note the following. What would the correct
interpretation of these results be?
•
•
•
•
•
•
RBC = 4.1 million/mm3
WBC = 7,000/mm3
Hgb = 10 g/dL
Hct = 37%
BUN = WNL
Serum Creatinine = WNL
A.
B.
C.
D.
Infection
Dehydration
Anemic
Renal failure
Mrs. Canta Bendaney is scheduled for a total knee
replacement in the morning. Upon reviewing her lab
results you note the following. What would the correct
interpretation of these results be?
•
•
•
•
•
•
RBC = 6.5 million/mm3
WBC = 7,000/mm3
Hgb = 19 g/dL
Hct = 52%
BUN = elevated
Serum Creatinine = WNL
A.
B.
C.
D.
E.
Infection
Dehydration
Anemic
Hemorrhaging
Renal failure
Mrs. Olden Ugaly is scheduled for a Arthroplasty in the
morning. Upon reviewing her lab results you note the
following. What would the correct interpretation of
these results be?
•
•
•
•
•
•
RBC = 6.5 million/mm3
WBC = 14,000/mm3
Hgb = 15 g/dL
Hct = 37%
BUN = WNL
Serum Creatinine = WNL
A.
B.
C.
D.
Infection
Dehydration
Anemic
Renal failure
General Nursing interventions
• Inform
– Autologous blood
donation
– Post op environment
Intraprocedure:
• General or spinal
anesthesia
Intraprocedure: Arthroplasty
• Replace with artificial
joint
Intraprocedure: Arthroplasty
• Artificial joints have a
limited life span
– 10 – 20 years
Intraprocedure: Hip Arthroplasty
• May or may not be
“cemented” in place
• If not
– Bone grows into the
prosthesis to stabilize it
– Weight bearing is
delayed several weeks
until femoral shaft has
grown into prothesis
Post-procedure: Arthroplasty
• Older adult > risk of
complications
–
–
–
–
–
–
Resp. Infection
DVT
Hematoma/hemorrhage
Infection
PE
Wound dehiscence
Post-procedure: Arthroplasty
• Meds as Rx
– Analgesics
• Opiods
• NSAID’s
– Antibiotics
– Anticoagulants
• Aspirin
• Heparin
• Warfarin / Coumadin
Post-procedure: Arthroplasty
• Monitor neurovascular
status
– CMS
– 5 P’s
Post-procedure: Arthroplasty
• Monitor for S&S
– Bleeding
– Hypovolemia
What V/S changes would you indicate
post-OP bleeding?
• Pulse
– h
• B/P
–i
Post-procedure: Arthroplasty
• Monitor for bleeding
– dressing
• Bleeding
• Drainage
– Lab values
What laboratory results indicate
bleeding / hypovolemia?
A. Decreased Hgb
B. Elevated Hct
C. Decreased Na+
D. Elevated BUN
Blood transfusions
• Hgb < 9 g/dL
Post Procedure: Arthroplasty
Preventing DVT’s
• Monitor for S&S of PE
– Acute onset of dyspnea
– Tachycardia
– Chest pain
Post Procedure: Arthroplasty
Preventing DVT’s
•
•
•
•
•
•
Anticoagulant Rx
Anti-embolic stockings
Compression device
Ankle exercises
Early mobilization
P.T. & O.T.
Post-procedure: Knee Arthroplasty
• Continuous passive
motion machine
– h movement
– i scar tissue
Post-procedure: Knee Arthroplasty
• Limit flexion of the knee
–  contractures
– No knee gatch
– No pillow under knees
Post-procedure: Knee Arthroplasty
• Ice
–  i swelling
Post-procedure: Hip Arthroplasty
• Early Ambulation
– Transfer from unaffected
side into reclining W/C
Post-procedure: Hip Arthroplasty
• Weight bearing status is
determined by the orthopedic
surgeon
Post-procedure: Hip Arthroplasty
Cemented
• Usually partial / full weight
bearing as tolerated
Non-cemented
• Usually only partial weight
bearing for a few weeks
Preventing Dislocation of the Hip
Prosthesis
• Position
–
–
–
–
Supine
HOB slightly h
Hip/leg neutral position
Abduction device
• Turn only to unaffected
side
Preventing Dislocation of the Hip
Prosthesis
Do not turn the client to the
operative side  hip dislocation!
Preventing Dislocation of the Hip
Prosthesis
DO
DONT
•
•
•
•
•
•
•
•
Elevated seat
Straight chair w/ arms
Abduction pillow
Externally rotate toes
Flex hip > 90o
Low chairs
Cross legs
Internally rotate toes
S&S of Hip Dislocation
•
•
•
•
Pain
“pop”
Internal rotation
Shortened
Arthroplasty education
• Physical Therapy
Arthroplasty education
• S&S of infection
– 5 cardinal S&S
– Purulent drainage
– Care of incision
Arthroplasty education
• S&S of
– DVT
• Swelling
• Redness
• Calf pain
– PE
• SOB
• Chest pain
– Bleeding
Knee Arthroplasty education
• Dislocation
UNCOMMON
• Limited
– Kneeling
– Deep knee bends
Hip Arthroplasty education
• Prevent dislocation
• Arrange for home
modifications