musculoskeletal trauma

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musculoskeletal trauma
2011-12-10 18:36:24
musculoskeletal trauma

musculoskeletal trauma
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  1. Fracture
    break or disruption in the continuity of a bone
  2. Types of fractures
    • complete - break across entire width of bone
    • incomplete - break in only part of a bone
    • open or compound - skin over bone is broken
    • closed or simple - doesn't break skin
    • pathologic - spontaneous - fractures because of trauma to bone that has weakened it - osteoporosis, paget's, rickets
    • fatigue/stress - most common in athletes
    • compression - loading force applied to long axis of a bone - vertebral most common
  3. Stages of bone healing
    • 1. hematoma formation within 48-72 hrs after injury
    • 2. hematoma turns into granulation tissue
    • 3. callus formation
    • 4. osteoblastic proliferation - bone building
    • 5. bone remodeling
    • 6. bone healing completed within about 6 weeks (up to 6 months in elderly)
  4. Acute compartment syndrome
    • serious condition in which increased pressure within one or more compartments causes massive compromise of circulation to the area
    • ischemia-edema cycle
  5. Pathophysiology of compartment syndrome
    • most commonly affects lower leg/arm
    • swelling/edema in the compartment and pressure builds, impairing circulation and nerves
    • can occur within 6-8 hrs of injury and up 24 hrs later
    • fascia is an inelastic tissue that surrounds groups of muscles, blood vessels and nerves so the swelling in the compartment is unable to expand
  6. Signs of acute compartment syndrome - with fracture injury
    • the 6 P's
    • Pain
    • Pressure
    • Paralysis
    • Paresthesia
    • Pallor
    • Pulselessness
  7. Emergency care for compartment syndrome
    • within 4-6 hrs of onset, neuromuscular damage is irreversible; limb can become useless within 24-48 hrs
    • monitor compartment pressures
    • fasciotomy may be performed to relieve pressure
    • pack and dress wound after fasciotomy
  8. Possible complications/results of compartment syndrome
    • infection
    • motor weakness
    • Volkmann's contractures - shortening of muscle fibers that affect the forearm
    • myoglobinuric renal failure (rhabdomylosis)
    • crush syndrome
  9. Crush syndrome - related to fractures
    caused by crushing injury that compresses one or more compartments resulting in hemorrhage and edema
  10. S/S of crush syndrome
    • hypovolemia
    • hyperkalemia
    • rhabdomylosis
    • acute tubular necrosis - dark brown urine
    • muscle weakness and pain
  11. Treatment of crush syndrome
    • fluids - hypovolemia
    • diuretics - hyperkalemia
    • dopamine
    • kayexhalate - hyperkalemia
  12. Other complications of fractures (not compartment or crush syndrome)
    • hypovolemic shock
    • fat embolism syndrome
    • venous thromboembolism
    • infection
    • chronic complications - ischemic necrosis, delayed union
  13. Fat embolism syndrome
    • serious complication resulting from a fracture
    • fat globules are released from yellow bone marrow into blood stream
    • may go the lung - appears to be a pulmonary emboli but it's fat, not blood
  14. When assessing site of a possible fracture:
    • change in bone alignment
    • alteration in extremity length
    • change in shape of bone
    • pain upon movement
    • decreased ROM
    • crepitus
    • ecchymotic skin
    • subQ emphysema with bubbles under the skin
    • swelling
    • assess neuro status
  15. What are some special assessment considerations for fractures of the shoulder/upper arm; distal areas of arm; lower extremities and pelvis?
    • 1. sitting or standing assessment
    • 2. supine
    • 3. supine
  16. Fracture management
    • reduction or realignment of bone ends for proper healing
    • immobilization
  17. Immobilization of fractures
    • casts
    • - if there is drainage under the cast, mark it so the care team can keep track of changes
    • - check distal areas for color, warmth, sensation, pulses and cap. refill
    • - complications: infection, circulation impairment, peripheral nerve damage, complications of immobility
    • traction
    • - application of pulling force to the body to provide reduction, alignment and rest at the site
    • - maintain correct balance between traction pull and countertraction force
    • - never put the weights on the floor; never move them without a doctor's order
    • - perform skin assessments
    • - clean pins with chlorohexadine
    • - perform frequent neuro checks
  18. Operative procedures to reduce fractures
    • open reduction with internal fixation (ORIF)
    • external fixation
  19. Operative procedures for nonunion of bone after a fracture
    • electrical bone stimulation
    • bone grafting
    • bone banking
    • low-intensity pulsed ultrasound
  20. Interventions for relieving pain r/t fracture
    • reduction and immobilization of fracture
    • pain assessments
    • opioid and non-opioid drugs
    • RICE
    • massage
    • baths
    • distraction
    • relaxation
  21. Interventions to prevent infection r/t fracture
    • strict aseptic technique for dressing changes/wound irrigations
    • assess for inflammation
    • report purulent drainage immediately
    • assess for pneumonia and UTI
    • prophylactic antibiotics
  22. Interventions for impaired physical mobility r/t fracture
    • crutches
    • walkers
    • canes
    • exercises in bed
  23. Interventions for imbalanced nutrition r/t fracture
    • diet high in protein, calories, and calcium
    • supplemental vitamins B and C
    • frequent, small feedings and supplements of high-protein liquids (especially elderly)
    • intake of foods high in iron
  24. Most common wrist/hand fracture
    Colles' fracture
  25. Treatment of choice for hip fractures
    • surgical repair - so the elderly patient can get out of bed
    • ORIF
  26. Is the femur more commonly casted or uncasted after it's fractured?
    seldom casted because of muscle spasms - repaired ORIF
  27. What is the chief concern with fractures of the pelvis?
    associated internal damage
  28. What are most compression fractures of the spine associated with?
    osteoporosis - multiple hairline fractures result when bone mass diminishes
  29. Nonsurgical management of compression fractures of the spine
    • bedrest
    • analgesics
    • physical therapy
  30. Surgical management of compression fractures of the spine
    vertebroplasty or kyphoplasty
  31. Types of amputation
    • surgical - planned b/c of severe infection
    • traumatic - accidental
  32. Complications of amputation
    • hemorrhage
    • infection
    • phantom limb pain
    • neuroma
    • flexion contracture
  33. Phantom limb pain
    • complaints that the body hurts below the site of amputation; feel like the body part is positioned abnormally; occurs early after amputation and fades with time
    • pain is intense, burning feeling, crushing sensation or cramping
  34. Management of phantom limb pain
    • must be distinguished from stump pain because treatment is different
    • handle the residual limb carefully
    • Beta blockers, antiepileptic drugs, antispasmodics, calcitonin and/or neurontin
    • opioids do not work!!
  35. Exercise after amputation
    • ROM to prevent flexion contractures
    • trapeze and overhead frame on bed to aid with movement
    • firm mattress
    • prone position q3-4hr to move limb differently and take pressure off bony prominences
    • elevation of lower-leg residual limb
  36. Stump care
    wrap it correctly
  37. Prostheses post-amputation
    • devices to help shape and shrink the residual limb and help patient adapt to walk or have some use in arm
    • individual fitting and special care
  38. Complex regional pain syndrome
    • can result from a musculoskeletal injury
    • poorly understood complex disorder that includes debilitating pain, atrophy, autonomic dysfunction and motor impairment
    • collaborative management - pain relief, maintaining ROM, endoscopic sympathectomy (cutting the nerves) and psychotherapy
  39. Meniscectomy post-op care
    • leg exercises begin immediately
    • knee imobilizer
    • elevation of leg on one or two pillows
    • ice
  40. Torn ligaments
    • when the ACL is torn, a snap is felt, the knee gives way, swelling occurs and stiffness and pain follow
    • treatment can be nonsurgical or surgical
    • complete healing of knee ligaments after surgery can take 6-9 months - generally knee is immobilized; client on crutches
  41. Tendon ruptures
    • rupture of Achilles tendon is common in adults who participate in strenuous sports
    • surgical repair and leg immobilization for 6-8 weeks is required for severe damage
    • tendon replacement may be needed
  42. Dislocations/Subluxations
    • pain, immobility, alteration in contour of joint, deviation in length of extremity and rotation of extremity
    • closed manipulation of the joint performed to force it back into original position
    • joint is immobilized until healing occurs
  43. Strain
    • excessive stretching of muscle or tendon when it is weak or unstable
    • classified according to severity
    • management - RICE; antiinflammatory meds, muscle relaxants, possible surgery
  44. Sprain
    • excessive stretching of a ligament
    • first degree - RICE
    • second degree - immobilization, partial weight bearing as tear heals
    • third degree - immobilization for 4-6 weeks, possible surgery
  45. Rotator cuff injuries
    • shoulder pain; cannot initiate or maintain abduction of the arm at the shoulder
    • drop arm test - can't raise their arm above head
    • conservative treatment - NSAIDs, PT, sling support, ice/heat
    • surgical repair for complete tear