NURS 342

Unit IV

Management of Patients
With
Musculoskeletal Trauma

Contusions, Strains, and

Sprains
Contusion is a soft tissue injury
Strain is a pulled muscle from
overuse, overstretching, or excessive
stress
Sprain is an injury to ligaments
surrounding a joint
RICE

Joint Dislocations
Subluxation is a partial dislocation of
the articulating surfaces
Medical Management is immobilization
Nursing Management

provide

comfort
neurovascular status
protect joint

Sports-Related Injuries
Rotator Cuff Tears
Epicondylitis (Tennis Elbow)
Lateral and Medial Collateral Ligament
Injury
Anterior and Posterior Cruciate
Ligament Injury
Meniscal Injuries
Rupture of the Achilles Tendon

Fractures: Specific Types

Complete
Incomplete

e.g. Greenstick
Comminuted
Closed (Simple)
Open (Compound/Complex
Grade

I, Grade II, Grade III

Types of Fractures (cont.)

Types of Fractures (cont.)

Types of Fractures

Manifestations of Fracture

Pain
Loss of function
Deformity
Shortening of the extremity
Crepitus
Local swelling and discoloration
Diagnosis by symptoms and x-ray
Patient usually reports an injury to the area

Emergency Management

Immobilize the body part

Splinting: joints distal and proximal to the
suspected fracture site must be supported and
immobilized
Assess neurovascular status before and after
splinting
Open fracture: cover with sterile dressing to
prevent contamination
Do not attempt to reduce the fracture

Medical Management

Reduction

Closed

Open

Immobilization: internal or external fixation

Maintaining and restoring function

Open fractures require treatment to prevent infection
Tetanus prophylaxis, antibiotics, and cleaning and
debridement of wound
Closure of the primary wound may be delayed to permit
edema, wound drainage, further assessment, and
debridement if needed

Techniques of Internal Fixation

Question
Is the following statement True or False?
Testing for crepitus can produce further
tissue damage and should be avoided.

Answer
True
Testing for crepitus can produce further
tissue damage and should be avoided.

Nursing Management: Patients with

closed (simple) fractures

Assessment: include neurovascular assessment, pain,

activity limitations, patient knowledge, and home
environment and support
Goal is to have patient return to usual activities as soon
as possible
Patient teaching is a primary intervention as the patient
will usually be cared for in the home setting
See Chart 43-1, p. 1163

Complications of Fractures

Factors that affect fracture healing: see Chart 43-2

Shock
Fat embolism
Compartment syndrome
Delayed union and nonunion
Avascular necrosis
Reaction to internal fixation devices
Complex regional pain syndrome (CRPS)
Heterotrophic ossification

Complications of Fractures

Factors that affect fracture healing: see Chart 43-2

Shock
Fat embolism
Compartment syndrome
Delayed union and nonunion
Avascular necrosis
Reaction to internal fixation devices
Complex regional pain syndrome (CRPS)
Heterotrophic ossification

Cross-Sections of Anatomic
Compartments

Wick Catheter Used to Monitor

Compartment Pressure

Question
Is the following statement True or False?
Avascular necrosis is prolongation of
expected healing time for a fracture.

Answer
False
Avascular necrosis is death of tissue
secondary to poor perfusion and
hypoxemia. Delayed union is prolongation
of expected healing time for a fracture.

Bone Healing Stimulator

Rehabilitation Related to
Specific Fractures

Clavicle

Use of claviclar strap (figure 8) or sling

Exercises
Limitation of activities
Do not elevate arm above shoulder for approximately
6 weeks

Humeral neck and shaft fractures

Slings and bracing

Activity limitations and pendulum exercises

Fracture of Clavicle and

Immobilization Device

Prescribed Shoulder Exercises

(Clavicle Fractures)

Immobilizers for Proximal

Humeral Fractures

Functional Humeral Brace

Rehabilitation Related to
Specific Fractures

Elbow fractures
Monitor regularly for neurovascular compromise and
signs of compartment syndrome
Consider potential for Volkmann's contracture: see Chart
43-3.
Encourage active exercises and ROM to prevent limitation
of joint movement after immobilization and healing (4 to 6
weeks for nondisplaced, casted) or after internal fixation
(about 1 week)
Colles fracture
Early functional rehabilitation exercises
Active motion exercises of fingers and shoulder

Rehabilitation Related to Specific

Fractures (cont.)
Pelvic fractures

Management depends upon type and extent of fracture

and associated injuries

Stable fractures are treated with a few days bed rest

and symptom management
Early mobilization reduces problems related to immobility

Hip fracture
Surgery is usually done to reduce and fixate the fracture.

Care is similar to that of a patient undergoing other

orthopedic surgery or hip replacement surgery

Pelvic Bones

Stable Pelvic Fractures

Unstable Pelvic Fractures

Fracture of the Femur

Risk factors
Types of hip fracture

Regions of the Proximal Femur

Assessment of Hip Fracture

Shortened leg
Adducted
Externally rotated
Pain at hip and groin or medial knee
Immobilized due to pain
Most comfortable with leg slightly flexed in
external rotation
X-ray confirms fracture
Gerontological considerations

Assessment of Hip Fracture

Shortened leg
Adducted
Externally rotated
Pain at hip and groin or medial knee
Immobilized due to pain
Most comfortable with leg slightly flexed in
external rotation
X-ray confirms fracture
Gerontological considerations

Medical/Surgical Management

Skin traction (Bucks Extension)

Surgical treatment to fixate for enabling
mobility

Open/closed reduction of fracture and internal

fixation
Replacement of femoral head with prosthesis
(hemiarthroplasty)
Closed reduction with percutaneous
stabilization for an intracapsular fracture

Examples of Internal Fixation for

Hip Fractures

Collaborative Problems/Potential
Complications

Hemorrhage

Peripheral neurovascular dysfunction

DVT

Pulmonary complications

Pressure ulcers

Nursing ProcessAssessment of the

Patient With Fracture of the Hip

Health history and presence of concomitant problems

Pain
VS, respiratory status, LOC, and signs and symptoms of
shock
Affected extremity including frequent neurovascular
assessment
Bowel and bladder elimination, bowel sounds, and I&O
Skin condition
Anxiety and coping

Nursing ProcessDiagnosis of the

Patient With Fracture of the Hip

Acute pain

Impaired physical mobility

Impaired skin integrity

Risk for impaired urinary elimination

Risk for ineffective coping

Risk for disturbed thought processes

Stretch Spica Wrap

Nursing ProcessPlanning the Care of

the Patient With Fracture of the Hip

Major goals include pain relief; achievement of

a pain-free, functional, and stable hip; healed
wound; maintenance of normal urinary
elimination pattern; use of effective coping
mechanisms; an oriented patient who
participates in decision making; and absence
of complications

Relief of Pain

Administer analgesics as prescribed

Use of Bucks traction as prescribed

Handle extremity gently

Support extremity with pillows and when moving

Position for comfort

Provide frequent position changes

Provide alternative pain relief methods

Promoting Physical Mobility

Maintain neutral position of hip

Use trochanter rolls
Maintain abduction of hip
Implement isometric, quad-setting, and
gluteal- setting exercises
Use trapeze
Use ambulatory aids
Consult with physical therapy

Interventions

Use aseptic technique with dressing changes

Avoid/minimize use of indwelling catheters
Support coping

Provide and reinforce information

Encourage the patient to express concerns
Support coping mechanisms
Encourage the patient to participate in decision
making and planning
Consult social services or other supportive services

Interventions (cont.)

Orient patient to and stabilize the environment

Provide for patient safety
Encourage participation in self-care
Encourage coughing and deep breathing
exercises
Ensure adequate hydration
Apply TED hose or SCDs as prescribed
Encourage ankle exercises
Provide patient and family teaching

Postoperative Nursing
Management

Pain management
Preventing general surgical complications
Repositioning the patient
Promoting Strengthening exercise
Monitoring and Managing Potential
Complications
Health Promotion

Rehabilitation Related to Specific

Fractures

Hip fracture

Care is similar to that of a patient

undergoing other orthopedic surgery or hip
replacement surgery

Femoral Fractures

Rehabilitation Related to
Specific Fractures

Femoral shaft fractures

Lower leg, foot, and hip exercises to preserve

muscle function and improve circulation
Early ambulation stimulates healing
Physical therapy, ambulation, and weight bearing
are prescribed
Active and passive knee exercises are begun as
soon as possible to prevent restriction of knee
movement

Rehabilitation Related to
Specific Fractures (cont.)

Uncomplicated rib fractures

Chest strapping is not used

Encouraged to cough and deep breathe

Rehabilitation Related to
Specific Fractures

Thoracolumbar spine fractures

Usually treated conservatively with limited
bed rest
Avoid sitting
Progressive ambulation
Emphasize good posture and body
mechanics
Implement back strengthening exercises

Rehabilitation of Patients with

Amputation

Amputation may be congenital, traumatic, or due

to conditions such as progressive peripheral
vascular disease, infection, or malignant tumor.
Amputation is used to relieve symptoms,
improve function, and save the person's life.
The health care team needs to communicate a
positive attitude to facilitate acceptance and
participation in rehabilitation.

Question
Is the following statement True or False?
Phantom limb pain is perceived in the
amputated limb.

Answer
True
Phantom limb pain is perceived in the
amputated limb.

Rehabilitation Needs

Psychological support
Prostheses fitting and use
Physical therapy
Vocational/occupational training and
counseling
Use a multidisciplinary team approach
Patient teaching

Nursing Process: The Care of the Patient

with an AmputationAssessment

Neurovascular status and function of

affected extremity or residual limb and of
unaffected extremity
Signs and symptoms of infection
Nutritional status
Concurrent health problems
Psychological status and coping

Nursing Process: The Care of the Patient

with an AmputationDiagnoses

Acute pain
Risk for disturbed sensory perception
Disturbed body image
Ineffective coping
Risk for anticipatory or dysfunctional grieving
Self-care deficit
Impaired physical mobility

Collaborative
Problems/Complications

Postoperative hemorrhage
Infection
Skin breakdown

Nursing Process: The Care of the Patient

with an AmputationPlanning

Major goals may include relief of pain,

absence of altered sensory perceptions,
wound healing, acceptance of altered
body image, resolution of grieving
processes, restoration of physical mobility,
and absence of complications.

Interventions

Relief of pain
Administer analgesic or other medications as prescribed
Changing position
Putting a light sand bag on residual limb
Alternative methods of pain relief- distraction, TENS unit
Note: Pain may be an expression of grief and altered body
image
Promoting wound healing
Handle limb gently
Residual limb shaping

Resolving Grief and Enhancing

Body Image

Encourage communication and expression of feelings

Create an accepting, supportive atmosphere
Provide support and listen
Encourage patient to look at, feel, and care for the
residual limb
Help patient set realistic goals
Help patient resume self-care and independence
Referral to counselors and support groups

Achieving Physical Mobility

Proper positioning of limb; avoid abduction, external

rotation and flexion
Turn frequently; prone positioning if possible
Use of assistive devices
ROM exercises
Muscle strengthening exercises
Preprosthetic care; proper bandaging, massage, and
toughening of the residual limb