ch 62 musculoskeletal trauma & orthopedic surgey

Question 1

is a traumatic event resulting in fracture, dislocation, subluxation, and/or soft tissue injury

Answer 1

most common cause of musculoskeletal injury

Question 2

urge them to wear nonskid, hard-soled footwear and assess their living environment for safety risks (e.g., remove throw rugs, ensure adequate lighting, maintain clear paths to the bathroom for nighttime use)

Answer 2

reduce risk for falls, for elderly by

Question 3

sprains, strains, dislocations, and subluxations. They usually result from trauma.

Answer 3

Soft tissue injuries include

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sprains and strains, growth plate injuries, and repetitive motion injuries

Answer 4

younger patients sport injuries include

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abnormal stretching or twisting forces during vigorous activities. These injuries tend to occur around joints and in the spinal musculature.

Answer 5

Sprains and strains often result from

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is an injury to the ligaments surrounding a joint.

Answer 6

sprain

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a wrenching or twisting motion. Most occur in the ankle, wrist, and knee joints.

Answer 7

Sprains are usually caused by

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. 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.

Answer 8

A sprain is classified according to the degree of ligament damage

Question 9

s tears in only a few fibers, with mild tenderness and minimal swelling

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A first-degree (mild) sprain involve

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in partial disruption of the involved tissue with more swelling and tenderness.

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second-degree (moderate) sprain results

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is a complete tear of the ligament with moderate to severe swelling.

Answer 11

A third-degree (severe) sprain

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is an excessive stretching of a muscle and its fascial sheath, often involving the tendon

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strain

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the lower back, calf, and hamstrings.

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Most strains occur in the large muscle groups, including

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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.

Answer 14

Strains are classified as

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pain, edema, decreased function, and bruising. Continued use of the joint, tendon, or ligament makes pain worse.

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Manifestations of sprains and strains are similar. They include

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usually self-limiting. Full function generally returns within 3 to 6 weeks.

Answer 16

Mild sprains and strains are

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in which the ligament pulls loose a fragment of bone. The joint structure may become unstable, causing subluxation or dislocation
-hemarthrosis (bleeding into a joint space or cavity) or disruption of the synovial lining may occur.

Answer 17

severe sprain can cause an avulsion fracture,

Question 18

(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

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f an injury occurs, immediate care focuses on

Question 19

decrease local inflammation and pain for most musculoskeletal injuries.

Answer 19

RICE (Rest, Ice, Compression, Elevation) may

Question 20

cold therapy

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(cryotherapy)

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vasoconstriction in the soft tissue and reduces the transmission and perception of nerve pain impulses. 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.

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Cold causes

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edema and pain. We often use an elastic compression bandage.

Answer 22

Compression helps decrease

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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).

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elastic compression bandage

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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.

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bandage is too tight if there is

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circulation and helps resolve bruising and swelling.

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Muscle contraction improves

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is the complete displacement or separation of the articular surfaces of the joint.

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Dislocation

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is a partial or incomplete displacement of the joint surface.

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Subluxation

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around hip and shoulder sockets and the meniscus at the knee, play an important role in joint stability

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Fibrocartilage structures, such as the labrum

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forces on the joint that disrupt the surrounding soft tissue support structures.

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Dislocations typically result from

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the thumb, elbow, and shoulder.

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The joints most often dislocated in the upper extremity include

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anteriorly.

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shoulder most often dislocates

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are rare. They typically only happen after electrocution or seizure

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Posterior shoulder dislocations

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deformity.

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most obvious sign of a dislocation is

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local pain, tenderness, loss of function of the injured part, and swelling of soft tissues near the joint.

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Other manifestations of dislocated joint include

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open joint injuries, intraarticular fractures (within the joint), avascular necrosis (bone cell death from blood supply), and damage to adjacent nerves and blood vessels.

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Major complications of a dislocated joint are

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hemarthrosis or fat cells.

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joint may be aspirated to assess for

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a probable intraarticular fracture.

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Fat cells in the aspirate indicate

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an orthopedic emergency because it may be associated with significant vascular injury. The longer the joint is dislocated, the greater the risk for avascular necrosis.

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dislocation requires prompt attention. It is often considered

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avascular necrosis.

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femoral head of the hip joint is especially susceptible to

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to vascular injury and resulting ischemia

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Compartment syndrome may occur after dislocation due

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realign the dislocated part of the joint to its original anatomic position

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first goal of management of a dislocation is to

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(no incision)

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Closed reduction

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(joint visualized through surgical incision

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open reduction

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a brace, splint, or sling or by taping to allow torn ligaments and surrounding tissue to heal.

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After reduction, the extremity is immobilized by

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repeated dislocations because of damage or laxity to the previously mentioned structures

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patient who has dislocated a joint may be at greater risk for

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and cumulative trauma disorder are terms used to describe injuries resulting from prolonged force or repetitive movements and awkward postures

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Repetitive strain injury (RSI)

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repetitive trauma disorder, nontraumatic musculoskeletal injury, overuse syndrome (sports medicine), regional musculoskeletal disorder, and work-related musculoskeletal disorder.

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RSI is also called

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tendons, ligaments, and muscles, causing tiny tears that become inflamed.

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Repeated movements strain the

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musicians, dancers, butchers, grocery clerks, vibratory tool workers, and those who frequently use a computer mouse and keyboard.
-Competitive athletes and poorly trained athletes

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Persons at risk for RSI include

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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.
swimming, overhead throwing (e.g., baseball), weight lifting, gymnastics, tennis, skiing, and kicking sports (e.g., soccer) require repetitive motion. Overtraining compounds the effects of RSI.

Answer 50

Other factors related to RSI include

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pain, weakness, numbness, or impaired motor function.

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Symptoms of RSI include

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(the science that promotes efficiency and safety in the interaction of humans and their work environment).

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ergonomics

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compression of the median nerve, which enters the hand at the wrist through the narrow carpal tunnel

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Carpal tunnel syndrome (CTS) is caused by

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in the upper extremity.

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CTS is the most common compression neuropathy

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hobbies or work that require continuous wrist movement (e.g., musicians, carpenters, computer operators).

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Carpal tunnel syndrome (CTS) associated with

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by pressure from trauma or edema (due to 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

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CTS is often caused

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because of swelling that changes blood flow to the nerve and narrows the carpal tunnel

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Persons with diabetes, peripheral vascular disease (PVD), and RA have a higher incidence of CTS

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impaired sensation, pain, numbness, or weakness in the distribution of the median nerve
Numbness and tingling may awaken the patient at night. Shaking the hands often relieves these symptoms. Clumsiness in performing fine hand movements is common
-patient may have a positive Tinel’s sign and Phalen’s sign.

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Manifestations of CTS are

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can be elicited 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.

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Tinel’s sign (positive = CTS)

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can be elicited 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.

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Phalen’s sign (positive = CTS)

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6 months or if there is significant impairment to conduction on electromyography (EMG).

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Carpal tunnel release is generally done if symptoms last more than

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open release and endoscopic surgery

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types of carpal tunnel release surgery include

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an incision is made in the wrist and then the carpal ligament is cut to enlarge the carpal tunnel.

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open release surgery,

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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.

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Endoscopic carpal tunnel release is performed through

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the supraspinatus, infraspinatus, teres minor, and subscapularis muscles.

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rotator cuff is made up of 4 muscles in the shoulder:

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a gradual, degenerative process due to aging, repetitive stress (especially overhead arm motions), or injury to the shoulder.

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tear in the rotator cuff may occur as

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in swimming, weight lifting, and swinging a racquet (tennis, racquetball), often cause injury.

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In sports, repetitive overhead motions, such as (rotator cuff )

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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.

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rotator cuff can tear because of sudden

Question 69

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.

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Manifestations rotator cuff include

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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.

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drop arm test (rotator cuff)

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An x-ray alone is not helpful in the diagnosis. A tear can usually be confirmed by MRI.

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diagnosis of rotator cuff

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patient with a partial tear or cuff inflammation may be treated conservatively with rest, ice and heat, NSAIDs, corticosteroid injections into the subacromial space, ultrasound, and PT.

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Tx for rotator cuff

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(acromioplasty) to relieve compression of the rotator cuff during movement.
-shoulder immobilizer with an abduction pillow is typically used for 6 weeks after surgery to limit shoulder movement

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If the tear is extensive, part of the acromion may be surgically removed

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shoulder should not be immobilized for too long because “frozen” shoulder

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arthrofibrosis ( “frozen” shoulder )

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crescent-shaped pieces of fibrocartilage in the knee.

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menisci are

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the acromioclavicular (AC), sternoclavicular, and temporomandibular joints

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Menisci are also found in other joints, including

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ligament sprains common among athletes in sports such as basketball, football, soccer, and hockey.
-activities produce rotational stress when the knee is in varying degrees of flexion and the foot is planted or fixed

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Meniscus injuries are associated with

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shearing of the meniscus between the femoral condyles and tibial plateau, causing a torn meniscus

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blow to the knee can cause

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Older adults and people who have jobs that require squatting or kneeling are at

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risk for degenerative tears

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edema because most cartilage is avascular.

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Meniscus injuries alone do not usually cause significant

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localized tenderness, pain, and effusion . Pain occurs with flexion, internal rotation, and then extension of the knee (McMurray’s test). The patient may feel that the knee is unstable and often reports that the knee “clicks,” “pops,” “locks,” or “gives way.” Quadriceps atrophy is usually present if the injury has been present for some time.

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acutely torn meniscus may present with (sign/symp)

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repeated meniscus injury and chronic inflammation.

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Traumatic arthritis may occur from

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MRI can confirm the diagnosis before arthroscopy.

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diagnose Meniscus injuries

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patient’s age, occupation, sport activities, degree of knee pain, and dysfunction may affect the decision whether to have surgery.

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surgery Meniscus injuries based on

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ice application, 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.

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Initial care involves for Meniscus injuries

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, 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.

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After acute pain has decreased of Meniscus injuries

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progressive exercise therapy may improve neuromuscular function and muscle strength.8

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In older adults with degenerative meniscus tears,

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Surgical repair or excision of part of the meniscus

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(meniscectomy)

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Meniscal surgery is done by arthroscopy. Pain relief may include NSAIDs or other analgesics. Rehabilitation starts soon after surgery, including quadriceps and hamstring strengthening exercises and ROM. When the patient’s strength is back to its preinjury level, normal activities may be resumed.

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Tx after surgery

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anterior cruciate ligament (ACL)

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most commonly injured knee ligament is the

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noncontact injuries that occur when the athlete pivots, lands from a jump, or stops abruptly when running.

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ACL injuries are usually

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coming down on the knee, twisting, and hearing a pop, followed by acute knee pain and swelling

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Patients often report ACL injuries as

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a partial tear, a complete tear, or an avulsion (tearing away) from the bones that form the knee

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Injury to the ACL can result in

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A positive Lachman’s

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test suggests an ACL tear

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This test is done by flexing the knee 15 to 30 degrees and pulling the tibia forward while the femur is stabilized. The test is considered positive for an ACL tear if forward motion of the tibia occurs with the feeling of a soft or indistinct endpoint.

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Lachman’s test process

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MRI is often used to diagnose an ACL tear and coexisting conditions, including a fracture, meniscus tearing, and collateral ligament injuries.

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diagnose an ACL tear by

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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.

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Conservative treatment for an intact ACL injury includes

Question 98

physically active patients who have sustained severe injury to the ACL and meniscus.

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Reconstructive surgery is usually recommended for

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removed and replaced with graft tissue.
- prior level of physical functioning may take 6 to 8 months.

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In reconstruction, the torn ACL tissue is

Question 100

are closed sacs that are lined with synovial membrane and contain a small amount of synovial fluid

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Bursae are

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found at sites of friction, such as between tendons and bones and near the joints

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Bursae found

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(inflammation of the bursa) results from repeated or excessive trauma or friction, gout, RA, or infection.

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Bursitis

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warmth, pain, swelling, and limited ROM in the affected part.

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Symptoms of bursitis include

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the hands, elbows, shoulders, knees, and greater trochanters of the hip.

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Common sites of bursitis are

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Improper body mechanics, repetitive kneeling (carpet layers, coal miners, and gardeners), jogging in worn-out shoes, and prolonged sitting with crossed legs are

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common precipitating activities.leading to Bursitis

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Rest is often the only treatment needed.

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only treatment needed for Bursitis

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immobilized in a compression dressing or splint. Ice and NSAIDs can reduce pain and inflammation.9 Aspiration of the bursal fluid and intraarticular corticosteroid injection may be needed.

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affected part may be (Tx or Bursitis/ implementation)

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If the bursal wall has become thickened and continues to interfere with normal joint function,

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surgical excision (bursectomy) may be done if

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oral antibiotics, but usually need surgical incision and drainage

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Septic bursae may be treated with

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is a disruption or break in the continuity of bone

Answer 110

fracture

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a disease process, such as cancer or osteoporosis (pathologic fracture).

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Although traumatic injuries cause most fractures, some fractures are due to

Question 112

open or closed based on communication with the external environment

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Fractures are described as

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the skin is broken and bone exposed, causing soft tissue injury.

Answer 113

open fracture

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, the skin is intact over the site.

Answer 114

closed fracture

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complete or incomplete

Answer 115

fractures also described as

Question 116

he break goes completely through the bone.

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fracture is complete if t

Question 117

occurs partly across a bone shaft, but the bone is still intact.
-result of bending or crushing forces applied to a bone.

Answer 117

incomplete fracture

Question 118

the direction of the fracture line.

Answer 118

Fractures are identified according to

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linear, oblique, transverse, longitudinal, and spiral fractures

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Types fractures based on direction of fracture line include

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displaced or nondisplaced

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fractures can be classified as

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, the 2 ends of the broken bone are separated from each other and out of their normal positions.

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displaced fracture

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comminuted (more than 2 fragments) or oblique

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Displaced fractures are often (ex of types)

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the bone fragments stay in alignment

Answer 123

nondisplaced fracture,

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transverse, spiral, or greenstick

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Nondisplaced fractures are usually (ex of types)

Question 125

occurs in normal or abnormal bone that is subject to repeated stress, such as from jogging or running.

Answer 125

Stress fracture:

Question 126

a spontaneous fracture at the site of a diseased bone

Answer 126

Pathologic fracture:

Question 127

immediate localized pain, decreased function, and inability to bear weight or use the affected part. The patient guards and protects the extremity against movement. Obvious bone deformity may be present.

Answer 127

Manifestations fracture include

Question 128

1. Fracture hematoma
2. Granulation tissue
3. Callus formation
   4.Ossification
   5.Consolidation
4. Remodeling

Answer 128

Bone goes through a complex multistage healing process (union) that occurs in 6 stages:

Question 129

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

Answer 129

Fracture hematoma: (1st step in healing fracture)

Question 130

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.

Answer 130

Granulation tissue:(2nd step in healing fracture)

Question 131

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 primarily 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.

Answer 131

Callus formation ( 3rd step in healing fracture)

Question 132

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 the cast may be removed.

Answer 132

Ossification ( 4th step in healing fracture)

Question 133

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.

Answer 133

Consolidation (5th step in healing fracture)

Question 134

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 (Wolff’s law). 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.

Answer 134

Remodeling (6th step in healing fracture)

Question 135

granulation tissue.

Answer 135

hematoma converts to

Question 136

new blood vessels, fibroblasts, and osteoblasts

Answer 136

Granulation tissue consists of

Question 137

forms the basis for new bone substance

Answer 137

osteoid

Question 138

is primarily composed of cartilage, osteoblasts, calcium, and phosphorus

Answer 138

Callus

Question 139

air usually fills the small airways in lungs is replaced with something else. it can be either; fluid, pus, blood or water, a solid such as stomach contents or cells

Answer 139

lung consolidation

Question 140

new bone is built up as osteoclasts destroy dead bone

Answer 140

Callus formation

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Fracture heals in abnormal position in relation to midline of structure (type of malunion).

Answer 141

Angulation (complication of fracture healing)

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Fracture healing progresses more slowly than expected. Healing eventually occurs.

Answer 142

Delayed union (complication of fracture healing)

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Fracture heals in expected time but in unsatisfactory position. May cause deformity or dysfunction.

Answer 143

Malunion (complication of fracture healing)

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Deposition of calcium in muscle tissue at site of significant blunt muscle trauma or repeated muscle injury.

Answer 144

Myositis ossificans (complication of fracture healing)

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Fracture does not heal despite treatment. No x-ray evidence of callus formation.

Answer 145

Nonunion (complication of fracture healing)

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Type of nonunion occurring at fracture site in which a false joint is formed with abnormal movement at site.

Answer 146

Pseudoarthrosis (complication of fracture healing)

Question 147

New fracture occurs at original fracture site.

Answer 147

Refracture

Question 148

displacement and site of the fracture, blood supply, other local tissue injury, immobilization, and use of internal fixation devices (e.g., screws, pins)

Answer 148

Many factors influence the time needed for complete fracture healing. They include

Question 149

inadequate immobilization, excessive movement of fracture fragments, infection, poor nutrition, and systemic disease (e.g., diabetes)

Answer 149

Ossification may be slowed or even stopped by

Question 150

Fracture healing may not occur in the expected time (delayed union) or may not occur at all (nonunion).

Answer 150

Smoking increases fracture healing time. by

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(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.

Answer 151

overall goals of fracture treatment are

Question 152

• Manual traction
• Closed reduction
• Skeletal traction
• Open reduction

Answer 152

Management
Fracture Reduction (Realignment)

Question 153

• Casting or splinting
• Skeletal traction
• External fixation
• Internal fixation

Answer 153

Fracture Immobilization

Question 154

• Surgical debridement and irrigation
• Tetanus and diphtheria immunization
• Prophylactic antibiotic therapy

Answer 154

Open Fractures

Question 155

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.

Answer 155

Closed reduction

Question 156

the patient is under local or general anesthesia

Answer 156

Closed reduction is usually done while

Question 157

Traction, casting, splints, or orthoses (braces) may be

Answer 157

used after reduction to maintain alignment and immobilize the injured part until healing occurs. (closed reduction)

Question 158

is the correction of bone alignment through a surgical incision.

Answer 158

Open reduction

Question 159

internal fixation of the fracture with wires, screws, pins, plates, intramedullary rods, or nails

Answer 159

Open reduction usually includes

Question 160

type and location of the fracture, patient age, and concurrent disease

Answer 160

influence the decision to use open reduction

Question 161

are infection, complications associated with anesthesia, and effects of preexisting medical conditions (e.g., diabetes)
-facilitates early ambulation, thus decreasing the risk for complications related to prolonged immobility

Answer 161

main risks of open reduction

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is the application of a pulling force to an injured or diseased body part or extremity.

Answer 162

Traction

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(1) prevent or reduce pain and muscle spasm (e.g., whiplash, unrepaired hip fracture), (2) immobilize a joint or part of the body, (3) reduce a fracture or dislocation, and (4) treat a pathologic joint condition (e.g., tumor, infection).

Answer 163

Traction is used to

Question 164

(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.

Answer 164

Traction is also used to

Question 165

apply a pulling force on a fractured extremity to attain realignment while countertraction pulls in the opposite direction

Answer 165

Traction devices (work by)

Question 166

pulls in the opposite direction. in a traction

Answer 166

countertraction

Question 167

skin traction and skeletal traction

Answer 167

The most common types of traction are

Question 168

short-term treatment (48 to 72 hours) until skeletal traction or surgery is possible.

Answer 168

Skin traction is generally used for

Question 169

to help decrease muscle spasms in the injured extremity

Answer 169

Tape, boots, or splints are applied directly to the skin, mainly

Question 170

is a type of skin traction sometimes used for the patient with a hip, knee, or femur fracture

Answer 170

Buck’s traction

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heavier weights applied intermittently

Answer 171

Pelvic or cervical skin traction may require

Question 172

fractures of the femur, hip, and lower leg.

Answer 172

Balanced suspension skeletal traction. Most often used for

Question 173

align injured bones and joints or to treat joint contractures and congenital hip dysplasia

Answer 173

Skeletal traction is used to

Question 174

a long-term pull that keeps the injured bones and joints aligned

Answer 174

Skeletal traction provides

Question 175

a pin or wire into the bone, and weights are attached to align and immobilize the injured body part

Answer 175

To apply skeletal traction, the HCP inserts

Question 176

infection at the pin insertion site and the effects of prolonged immobility.

Answer 176

major complications of skeletal traction are

Question 177

balanced suspension traction

Answer 177

common type of skeletal traction is

Question 178

the correct positioning and alignment of the patient while the traction forces stay constant.

Answer 178

Fracture alignment skeletal traction depends on

Question 179

is supplied by the patient’s body weight or by weights pulling in the opposite direction.
-Elevating the end of the bed can help

Answer 179

Countertraction

Question 180

Keep the weights off the floor and moving freely through the pulleys.

Answer 180

Skeletal Traction must be maintained continuously.

Question 181

casts, braces, splints, immobilizers, and external and internal fixation devices.

Answer 181

Fracture immobilization is achieved with

Question 182

is a temporary immobilization device often applied after closed reduction

Answer 182

cast

Question 183

to perform many normal ADLs while providing enough immobilization to ensure stability.

Answer 183

cast allows the patient

Question 184

c the joints above and below a fracture. This restricts tendon and ligament movement, thus assisting with joint stabilization while the fracture heals

Answer 184

ast generally immobilizes

Question 185

natural (plaster of Paris) and fiberglass.

Answer 185

2 most common cast materials are

Question 186

they are lighter, relatively waterproof, and longer wearing than plaster of Paris.They also allow early weight bearing.

Answer 186

use fiberglass casts most often because

Question 187

contact casting in the treatment of diabetic foot ulcers

Answer 187

Plaster of Paris is now used primarily for

Question 188

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.

Answer 188

To apply a cast on an extremity, first

Question 189

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, so the patient may move around without difficulty. However, it is not strong enough for weight bearing until about 36 to 72 hours after application.

Answer 189

If using plaster of Paris (applying cast)

Question 190

submersion in cool or tepid water. Then they are molded to fit the torso or extremity.

Answer 190

Casts made of fiberglass or other synthetic materials (thermolabile plastic, thermoplastic resins, polyurethane) are activated by

Question 191

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.

Answer 191

If using plaster of Paris (applying cast)

Question 192

(1) sugar-tong splint, (2) posterior splint, (3) short arm cast, or (4) long arm cast

Answer 192

acute fracture or soft tissue injury of the upper extremity can be immobilized by using a

Question 193

is applied for acute wrist injuries or injuries that may result in significant swelling.

Answer 193

sugar-tong splint

Question 194

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.
-splinting material is wrapped with either elastic bandage or bias stockinette.

Answer 194

how sugar-tong splint placed

Question 195

early swelling in the fractured extremity.

Answer 195

sugar-tong posterior splint accommodates

Question 196

for the treatment of stable wrist or metacarpal fractures
-aluminum finger splint can be built into the short arm cast for treatment of phalangeal injuries.
-circular cast extending from the distal palmar crease to the proximal forearm
-cast immobilizes the wrist and allows unrestricted elbow motion.

Answer 196

short arm cast is often used

Question 197

for stable forearm or elbow fractures and unstable wrist fractures.
- 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.

Answer 197

long arm cast is often used

Question 198

elevation or use of a supportive sling. The hanging provides traction and maintains fracture alignment.

Answer 198

hanging arm cast is used for a proximal humerus fracture, avoid

Question 199

ensure the axillary area is well padded to prevent skin breakdown from direct skin-to-skin contact. Apply the sling carefully to avoid putting undue pressure on the neck.

Answer 199

sling is used,

Question 200

immobilization and support for stable spine injuries of the thoracic or lumbar spine.

Answer 200

body jacket brace is used for

Question 201

the chest and abdomen, extending from above the nipple line to the pubis

Answer 201

brace goes around

Question 202

After application of the brace, assess the patient for the development of

Answer 202

superior mesenteric artery syndrome (cast syndrome)

Question 203

condition occurs if the brace is too tight, compressing the superior mesenteric artery against the duodenum

Answer 203

superior mesenteric artery syndrome (cast syndrome)

Question 204

patient generally has 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).

Answer 204

superior mesenteric artery syndrome (cast syndrome) sign/symp

Question 205

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.

Answer 205

Treatment of cast syndrome includes

Question 206

a long leg cast, short leg cast, cylinder cast, or prefabricated splint or immobilizer.

Answer 206

Injuries to the lower extremity can be immobilized with

Question 207

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.

Answer 207

usual indications for a long leg cast are (lower extremity)

Question 208

stable ankle and foot injuries

Answer 208

short leg cast is used for (lower extremity)

Question 209

knee injuries or fractures. It extends from the groin to the malleoli of the ankle.

Answer 209

cylinder cast is used for

Question 210

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

Answer 210

Robert Jones dressing may be used

Question 211

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 (discussed on p. 1460) and 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.

Answer 211

After application of a lower extremity cast or dressing,

Question 212

type of immobilization is easy to apply and remove, which allows close observation of the affected joint for swelling and skin breakdown
-Depending on the injury, removal of the splint or immobilizer promotes ROM of the affected joint and faster return to function.

Answer 212

Prefabricated knee and ankle splints and immobilizers are

Question 213

for femur fractures in children to immobilize the affected extremity and trunk

Answer 213

hip spica cast is mainly used

Question 214

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).

Answer 214

hip spica cast covers

Question 215

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

Answer 215

external fixator

Question 216

used to apply traction or to compress fracture fragments and immobilize reduced fragments when the use of a cast or traction is not appropriate.

Answer 216

external fixator used to

Question 217

external device holds fracture fragments in place similar to a surgically implanted internal device.

Answer 217

external fixator similar to

Question 218

complex fractures with extensive soft tissue damage, correction of congenital bony defects, nonunion or malunion, and limb lengthening.
-used to try to salvage extremities that otherwise may require amputation.

Answer 218

External fixation is used mainly for

Question 219

surgically inserted to realign and maintain position of bony fragments

Answer 219

Internal fixation devices (pins, plates, intramedullary rods, metal and bioabsorbable screws) are

Question 220

stainless steel, vitallium, or titanium. Proper alignment and bone healing are evaluated regularly by x-rays.

Answer 220

nternal fixation metal devices are biologically inert and made from

Question 221

healing, especially with fracture nonunion or delayed union

Answer 221

Electrical bone growth stimulation can promote

Question 222

(1) increasing calcium uptake and the production of bone growth factors, (2) increasing collagen synthesis, and (3) promoting the growth of new blood vessels

Answer 222

mechanism of action of Electrical bone growth stimulation may include

Question 223

noninvasive, semi-invasive, and invasive

Answer 223

methods of electrical bone growth stimulation.

Question 224

use direct 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.

Answer 224

Noninvasive stimulators of electrical bone growth stimulation.

Question 225

an external power supply and electrodes that are inserted through the skin and into the bone.

Answer 225

Semi-invasive or percutaneous bone growth stimulators use

Question 226

a current generator in an IM or subcutaneous space. An electrode is implanted in the bone fragments.

Answer 226

Invasive stimulators of electrical bone growth require surgical implantation of

Question 227

carisoprodol (Soma), cyclobenzaprine, or methocarbamol (Robaxin), may be given to manage pain associated with muscle spasms.

Answer 227

Central and peripheral muscle relaxants, such as (drug therapy)

Question 228

the patient with an open fracture who has not been previously immunized or whose immunization is expired

Answer 228

Give tetanus and diphtheria toxoid or tetanus immunoglobulin to

Question 229

prophylactically before surgery

Answer 229

Bone-penetrating antibiotics, such as a cephalosporin (e.g., cefazolin), are used

Question 230

adequate protein (e.g., 1 g/kg of body weight), vitamins (especially B, C, and D), calcium, phosphorus, and magnesium.

Answer 230

patient’s dietary requirements must include

Question 231

tissue healing. Immobility and bone healing increase calcium needs.

Answer 231

Low serum protein and vitamin C deficiencies interfere with

Question 232

6 small meals. This helps avoid overeating that can cause abdominal pressure and cramping.

Answer 232

If immobilized in bed with skeletal traction or in a body jacket brace, the patient should eat

Question 233

thorough neurovascular assessment of the affected extremity, should be done

Answer 233

distal to the fracture site, is a primary concern.

Question 234

Poor positioning, physiologic responses to the traumatic injury, and application of a cast or constrictive dressing can

Answer 234

cause nerve or vascular damage, usually distal to the injury

Question 235

(excessive pain, pain with passive stretch of the affected extremity muscles, pallor, paresthesia, with late signs of paralysis and pulselessness).

Answer 235

compartment syndrome sign/symp

Question 236

dyspnea, chest pain, temperature elevation).

Answer 236

FES (fat embolism) sign/symp

Question 237

(color, temperature, capillary refill, peripheral pulses, edema) and
-peripheral neurologic assessment (sensation, motor function, pain).

Answer 237

neurovascular assessment consists of peripheral vascular assessment

Question 238

Pallor or a cool-to-cold extremity below the injury could
-delay in returning to its original color (greater than 3 seconds)

Answer 238

indicate arterial insufficiency.

Question 239

warm, cyanotic extremity could

Answer 239

indicate poor venous return.

Question 240

decreased or absent pulse distal to the injury can

Answer 240

indicate vascular dysfunction and insufficiency.

Question 241

(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).

Answer 241

Assess motor function by asking the patient to

Question 242

(peroneal nerve)

Answer 242

perform dorsiflexion

Question 243

(tibial nerve).

Answer 243

plantar flexion

Question 244

(fresh fruits and vegetables)

Answer 244

roughage

Question 245

bone demineralization due to reduced mobility

Answer 245

Renal stones can develop from

Question 246

a rise in urine pH and stone formation from calcium precipitation

Answer 246

Hypercalcemia from demineralization causes

Question 247

prolonged bed rest, resulting in orthostatic hypotension and decreased lung capacity

Answer 247

Rapid deconditioning of the cardiopulmonary system can occur from

Question 248

of the affected extremity is a classic assessment finding for a patient with unrepaired hip fracture.

Answer 248

External rotation

Question 249

(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 patient’s weight borne), (4) weight bearing as tolerated (based on patient’s pain and tolerance), and (5) full–weight-bearing ambulation (no limitations).

Answer 249

Ambulation occurs in different degrees of weight-bearing:

Question 250

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).

Answer 250

Devices for ambulation range from a cane-crutches

Question 251

(can relieve up to 40% of the weight normally borne by a lower limb)

Answer 251

cane

Question 252

(may allow for complete non–weight-bearing ambulation).

Answer 252

walker or crutches

Question 253

advanced at the same time or immediately after advance of the device. The uninvolved limb is advanced last.

Answer 253

The involved limb is usually (which foot goes first w/ walker or cane)

Question 254

opposite the involved extremity. (strong side)

Answer 254

Canes are held in the hand

Question 255

the neurovascular bundle that passes across the axilla.

Answer 255

A patient with inadequate upper limb strength or poorly fitted crutches bears weight at the axilla rather than at the hands. This can damage

Question 256

the transition from dependence to independence in performing simple ADLs.

Answer 256

Short-term rehabilitative goals address

Question 257

preventing problems associated with musculoskeletal injury

Answer 257

Long-term rehabilitative goals are aimed at

Question 258

direct or indirect

Answer 258

Complications of fractures may be

Question 259

problems with bone infection, bone union, and avascular necrosis.

Answer 259

Direct complications include

Question 260

compartment syndrome, VTE, fat embolism syndrome (FES), breakdown of skeletal muscle (rhabdomyolysis), and hypovolemic shock.

Answer 260

Indirect complications include

Question 261

a high rate of infection

Answer 261

Open fractures and soft tissue injuries have

Question 262

severe external forces.

Answer 262

open fracture usually results from

Question 263

anaerobic bacilli, such as Clostridium tetani.

Answer 263

Dying or contaminated tissue is an ideal medium for many common pathogens, including

Question 264

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)
-During surgery, the open wound may be irrigated with antibiotic solution.
-Antibiotic-impregnated beads also may be placed in the surgical site. Patients usually receive IV antibiotics for at least 3 days

Answer 264

Open fractures require aggressive surgical debridement. The wound is initially cleaned by

Question 265

is a condition in which swelling causes increased pressure within a limited space (muscle 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

Answer 265

Compartment syndrome

Question 266

the leg but can occur in any muscle group.

Answer 266

Compartment syndrome often involves

Question 267

(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.

Answer 267

Two basic causes of compartment syndrome are

Question 268

pressure to obstruct circulation and cause venous occlusion, which further increases edema

Answer 268

Edema can create enough

Question 269

Fractures of the distal humerus and proximal tibia are the

Answer 269

most common fractures associated with compartment syndrome.

Question 270

knee or leg surgery.

Answer 270

Compartment injury can also occur after

Question 271

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.

Answer 271

Prolonged pressure on a muscle compartment may result

Question 272

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).

Answer 272

sign/symp of compartment syndrome

Question 273

Pain unrelieved by drugs and out of proportion to the level of injury is one of the
-Paresthesia is also an early sign.

Answer 273

first signs of compartment syndrome.

Question 274

Pulselessness and paralysis are

Answer 274

later signs of compartment syndrome

Question 275

do not elevate the extremity above the heart. Similarly, do not apply cold compresses. They may cause vasoconstriction and worsen compartment syndrome.

Answer 275

NOT DO with compartment syndrome

Question 276

fasciotomy (surgical decompression) 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.

Answer 276

surgical decompression on compartment syndrome

Question 277

clot (thrombus) formation after a fracture, especially a hip fracture.

Answer 277

Veins of the lower extremities and pelvis are at great risk for

Question 278

total hip or total knee replacement surgery.

Answer 278

VTE may also occur after

Question 279

at least 10 to 14 days

Answer 279

prophylactic anticoagulant drugs should be given for (VTE SURGERY)

Question 280

(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)

Answer 280

most common agents used include (anticoagulant drugs for VTE)

Question 281

dorsiflex and plantar flex the ankle of an affected lower extremity against resistance and perform ROM exercises on the unaffected leg.

Answer 281

Besides wearing compression gradient stockings (antiembolism hose) or using intermittent pneumatic compression devices, the patient should

Question 282

(e.g., nosebleeds) or internal bleeding (e.g., tea-colored urine).

Answer 282

Monitor for signs of external bleeding (anticoagulant therapy)

Question 283

is characterized by fat globules entering the circulatory system from fractures.

Answer 283

Fat embolism syndrome (FES)

Question 284

collect in areas with abundant blood vessels, especially the lungs and brain.2

Answer 284

Fat embolism syndrome (FES) collect

Question 285

long bones, ribs, tibia, and pelvis.

Answer 285

fractures most often associated with FES are those of the

Question 286

total joint replacement, spinal fusion, liposuction, crush injuries, and bone marrow transplantation.

Answer 286

FES can also occur after

Question 287

, 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

Answer 287

According to the mechanical theory

Question 288

hormonal changes caused by trauma or sepsis stimulate systemic release of free fatty acids (e.g., chylomicrons) that form the fat emboli.

Answer 288

biochemical theory suggests

Question 289

acute respiratory distress syndrome (ARDS).

Answer 289

Fat emboli in the lungs cause hemorrhagic interstitial pneumonitis with signs and symptoms of

Question 290

chest pain, tachypnea, cyanosis, dyspnea, apprehension, tachycardia, and hypoxemia.
-Changes in mental status due to hypoxemia are common
-Petechiae on the neck, anterior chest wall, axilla, buccal membrane, and conjunctiva of the eye

Answer 290

Fat emboli in the lungs cause hemorrhagic interstitial pneumonitis with signs and symptoms of include

Question 291

include fat cells in blood, urine, or sputum; a decrease of PaO2 to less than 60 mm Hg; ST segment and T-wave changes on ECG; decreased platelet count and hematocrit; and high erythrocyte sedimentation rate (ESR)
-hest x-ray may show bilateral pulmonary infiltrates.

Answer 291

diagnosis of Fat emboli

Question 292

is a syndrome caused by the breakdown of damaged skeletal muscle cells

Answer 292

Rhabdomyolysis

Question 293

myoglobin into the bloodstream. Myoglobin precipitates and causes obstruction in renal tubules. This results in acute tubular necrosis and acute kidney injury (AKI).

Answer 293

Rhabdomyolysis breakdown causes the release of

Question 294

are dark reddish-brown urine and symptoms of AKI

Answer 294

Common signs Rhabdomyolysis

Question 295

is a fracture of the distal radius styloid process of the ulna may be involved as well.

Answer 295

Colles’ fracture

Question 296

the patient falls on an outstretched arm and hand.
-one of the most common types of fractures in adults.

Answer 296

Colles’ fracture injury usually occurs when

Question 297

over 50 years old whose bones are osteoporotic (fragility fracture)
-younger person with a Colles’ fracture caused by a low-energy force should be referred for an osteoporosis evaluation

Answer 297

Colles’ fracture most often occurs in patients

Question 298

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.

Answer 298

Symptoms Colles’ fracture include

Question 299

closed reduction of the fracture and application of a splint or cast. If displaced, the fracture is typically managed with open reduction and internal or external fixation.

Answer 299

Colles’ fracture is usually managed with

Question 300

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.

Answer 300

Encourage pt with Colles’ fracture

Question 301

among young and middle-aged adults.

Answer 301

Fractures involving the shaft of the humerus are common

Question 302

obvious displacement of the humeral shaft, shortened extremity, abnormal mobility, and pain.

Answer 302

The most common symptoms shaft of the humerus are

Question 303

radial nerve injury and injury to the brachial artery due to laceration, transection, or muscle spasm.

Answer 303

Complications associated shaft of the humerus include

Question 304

a hanging arm cast, shoulder immobilizer, sling and swathe (a type of immobilizer that prevents shoulder movement), or humeral cuff brace

Answer 304

Nonoperative treatment may include

Question 305

is typically used to stabilize mid-shaft humerus fractures.
-good option for nonoperative fracture management

Answer 305

humeral cuff brace

Question 306

minor to life threatening, depending on the mechanism of injury and associated vascular damage.

Answer 306

Pelvic fractures range from relatively

Question 307

s 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

Answer 307

Pelvic fractures may cause serious

Question 308

sepsis, FES, or VTE.

Answer 308

Patients may survive the pelvic injury, only to die from

Question 309

local swelling, tenderness, deformity, unusual pelvic movement, and bruising. Assess the neurovascular condition of the lower extremities and determine associated injuries.

Answer 309

Abdominal assessment may show (pelvic fract)

Question 310

x-ray and CT scan.

Answer 310

Pelvic fractures are diagnosed by

Question 311

external fixation alone or combined with ORIF (e.g., screws), often done emergently.
-Turn the patient only when ordered by the HCP

Answer 311

Complex or displaced fractures (e.g., open book fracture) need

Question 312

to a fracture of the proximal (upper) third of the femur, which extends 5 cm below the lesser trochanter

Answer 312

Hip fracture refers

Question 313

Fractures within the hip joint capsule are

Answer 313

intracapsular fractures.

Question 314

(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).

Answer 314

Intracapsular fractures are further identified by their specific locations:

Question 315

These fractures, which are often associated with osteoporosis and minor trauma, are called

Answer 315

fragility fractures.(Intracapsular fractures)

Question 316

outside the joint capsule.

Answer 316

Extracapsular fractures occur

Question 317

(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.

Answer 317

Extracapsular fractures occur either

Question 318

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.

Answer 318

Manifestations Extracapsular fractures include

Question 319

Initially the affected extremity may be immobilized with Buck’s traction
used for 24 to 48 hours to relieve painful muscle spasms.

Answer 319

hip fracture Tx

Question 320

(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. 62.19), and (4) total hip replacement (involves both the femur and acetabulum)

Answer 320

Surgical hip fracture options include

Question 321

(1) color, (2) temperature, (3) capillary refill, (4) distal pulses, (5) edema, (6) sensation, (7) motor function, and (8) pain.

Answer 321

Assess the patient’s extremity for

Question 322

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.

Answer 322

Decrease edema by

Question 323

(incision posterior to the midline of the greater trochanter down the femoral shaft), measures to prevent dislocation must be used

Answer 323

If hemiarthroplasty or total joint replacement was done by a posterior approach

Question 324

(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).

Answer 324

positions to be avoided with hemiarthroplasty or total joint replacement posterior approach

Question 325

(incision is made in the front of the hip with patient lying on the back), the hip muscles are left intact.

Answer 325

hemiarthroplasty or total joint replacement was done by an anterior approach

Question 326

motion and weight bearing are few. They typically include instructions to avoid hyperextension.

Answer 326

Precautions related to hemiarthroplasty or total joint replacement was done by an anterior approach

Question 327

Limited weight bearing is typically the
-until x-ray examination shows adequate healing, usually 6 to 12 weeks.
-Taking a tub bath and driving a car are not allowed for 4 to 6 weeks

Answer 327

only restriction for the patient who had ORIF of the hip fracture.

Question 328

nonunion, avascular necrosis, dislocation, and osteoarthritis (OA).

Answer 328

Complications associated with femoral neck fracture include

Question 329

affected leg may be shorter if the patient had an intertrochanteric fracture. A cane or shoe lift may be needed for safe ambulation.

Answer 329

intertrochanteric fracture. complications

Question 330

Sudden severe pain, a lump in the buttock, limb shortening, and external rotation

Answer 330

indicate prosthesis dislocation.

Question 331

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.

Answer 331

Tx prosthesis dislocation.

Question 332

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).
-Swimming and stationary cycling

Answer 332

Exercises to restore strength and tone in the quadriceps and muscles around the hip are essential

Question 333

jogging and tennis, because they may loosen the implant

Answer 333

avoid high-impact exercises and sports, such as

Question 334

(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.

Answer 334

Factors that increase the risk for a hip fracture in older adults include

Question 335

(1) gait and balance problems, (2) altered vision and hearing, (3) slowed reflexes, (4) orthostatic hypotension, and (5) medication use

Answer 335

Other factors that increase the older adult’s risk for falling include

Question 336

y (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.23

Answer 336

Homes can be made safer b

Question 337

Older adults may have low bone density (osteopenia) or osteoporosis, which

Answer 337

increases their risk for fragility fractures. (older adult)

Question 338

may be prescribed to decrease bone loss or increase bone density. This reduces the chance of fracture

Answer 338

bisphosphonate drug (e.g., alendronate [Fosamax])

Question 339

the fracture (e.g., from a motor vehicle crash or gunshot wound) often also damages the adjacent soft tissue. These injuries may be more serious than the bone injury.

Answer 339

femoral shaft fracture occurs from a severe direct force. The force exerted to cause t

Question 340

increased soft tissue damage.
-Considerable blood loss (1 to 1.5 L) can occur

Answer 340

Displacement of fracture fragments often causes

Question 341

transverse, spiral, comminuted, oblique, and open

Answer 341

most common types of femoral shaft fracture include

Question 342

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 associated with bone union, open fracture, and soft tissue damage.

Answer 342

femoral shaft fracture is marked by

Question 343

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.

Answer 343

Initial management of femoral shaft fracture involves

Question 344

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 because it reduces the hospital stay and complications associated with prolonged bed rest.

Answer 344

metal rod is placed into

Question 345

an open fracture.

Answer 345

External fixation may be used for (femur fracture)

Question 346

gluteal and quadriceps isometric exercises will promote and maintain strength in the affected extremity. Encourage the patient to perform ROM and strengthening exercises for all uninvolved extremities to prepare for ambulation.

Answer 346

After surgery, of femoral shaft fracture

Question 347

As a result, soft tissue damage, devascularization, and open fracture are common.
-common site for stress fracture.

Answer 347

causes tibial fracture (strong area)

Question 348

compartment syndrome, FES, delayed union or nonunion, and possible infection with an open fracture.

Answer 348

Complications of tibial fractures include

Question 349

is closed reduction followed by immobilization in a long leg cast

Answer 349

Recommended management for closed tibial fractures

Question 350

ORIF with intramedullary rods, plate fixation, or external fixation is
-emphasis of care is maintaining quadriceps strength.

Answer 350

Tx needed for complex fractures and those with extensive soft tissue damage of tibial fracture

Question 351

unlikely to move or cause spinal cord damage. This type of 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.

Answer 351

In a stable fracture, the fracture fragments are

Question 352

displacement by intact spinal ligaments.

Answer 352

Vertebral bodies are usually protected from

Question 353

motor vehicle crashes, falls, diving, or sports injuries.

Answer 353

Stable fractures of the vertebral column are usually caused by

Question 354

Instability and injury to the spinal cord may result (unstable fracture). These injuries generally require surgery.

Answer 354

unstable fracture

Question 355

fracture displacement, which can cause damage to the spinal cord

Answer 355

The most serious complication of vertebral fractures is

Question 356

patient usually has pain and tenderness in the affected region of the spine.

Answer 356

signs/symp of stable spine fracture

Question 357

(flexion angulation of thoracic vertebrae) known as a dowager’s hump

Answer 357

kyphotic deformity

Question 358

(extreme inward curve of lumbar spine) and cervical spine involvement are possible.

Answer 358

Lordosis

Question 359

spinal cord impingement and paraplegia. Bowel and bladder dysfunction may occur if there is interruption of the autonomic nervous system nerves or injury to the spinal cord.

Answer 359

Sudden loss of function below the fracture indicates

Question 360

is to keep the spine in good alignment until union is achieved. Many nursing interventions are aimed at assessing for spinal cord trauma
-Regularly evaluate vital signs and bowel and bladder function. Monitor the motor and sensory function of peripheral nerves distal to the injured region

Answer 360

verall goal in managing stable vertebral fractures

Question 361

pain medication followed by early mobilization and bracing. The patient’s mattress should be firm to support the spinal column, relax muscles, decrease edema, and prevent potential compression on nerve roots

Answer 361

Treatment stable vertebral fractures includes

Question 362

turning by moving the shoulders and pelvis together. The patient will need nursing help to learn the technique of logrolling

Answer 362

Teach the patient to keep the spine straight when

Question 363

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 evidence of neurologic deficit. The device gives extra support during healing and is used for a short period of time.

Answer 363

constructed orthotic device (e.g., thoracolumbar sacral orthosis [TLSO]),

Question 364

patients with stable vertebral compression fractures due to osteoporosis

Answer 364

Lightweight bracing (e.g., Jewett or Bähler-Vogt brace) may be used for

Question 365

vertebroplasty or balloon kyphoplasty.

Answer 365

Patients with osteoporosis also may be treated with 2 outpatient procedures:

Question 366

radioimaging to guide the injection of bone cement into a fractured vertebral body. When hardened, the cement stabilizes the vertebra and prevents further compression
- However, later compression fractures of adjacent vertebrae are a risk.

Answer 366

Vertebroplasty uses

Question 367

first inserting a balloon into the vertebral body and then inflating it. This creates a cavity that is filled with bone cement under low pressure to restore the height of the vertebral body.

Answer 367

Balloon kyphoplasty involves

Question 368

Kyphoplasty is now the
-due to the decreased incidence of bone cement leakage into nearby structures (e.g., colon, lung) compared to vertebroplasty.
- However, later compression fractures of adjacent vertebrae are a risk.

Answer 368

surgical treatment of choice for compression fractures

Question 369

wear a hard cervical collar. Some cervical fractures are immobilized by use of a halo vest

Answer 369

If the fracture is in the cervical spine, the patient may

Question 370

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.

Answer 370

halo vest (cervical fracture)

Question 371

(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

Answer 371

patient with a stable vertebral fracture is discharged after

Question 372

trauma, such as a motor vehicle crash, an assault, or a fall.

Answer 372

Any bone of the face can be fractured from

Question 373

patent airway and provide adequate ventilation

Answer 373

After facial injury it is critically important to establish and maintain a

Question 374

occur together.

Answer 374

Facial fractures and cervical spine injuries often

Question 375

the extent of the injury.

Answer 375

X-rays help determine

Question 376

between bone and soft tissue injury.

Answer 376

CT scanning helps distinguish

Question 377

and place a protective shield over the eye.

Answer 377

If an eye-globe rupture is suspected, stop

Question 378

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.

Answer 378

Signs of eye-globe rupture include

Question 379

trauma to the face or jaw.

Answer 379

Mandibular fracture may result from

Question 380

no bone displacement, or may involve loss of tissue and bone.

Answer 380

mandibular fracture may be simple, with

Question 381

to ensure the patient’s survival. Long-term treatment is sometimes needed to restore satisfactory appearance and function.

Answer 381

The mandibular fracture may need immediate treatment

Question 382

to correct an underlying alignment problem (malocclusion) that cannot be adjusted by orthodontics alone.
-mandible is resected during surgery and manipulated forward or backward to correct the occlusion problem

Answer 382

Mandibular fractures may be done therapeutically

Question 383

immobilization, usually by wiring the jaws (intermaxillary fixation).

Answer 383

Surgery for a mandibular fracture includes

Question 384

, 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

Answer 384

In a simple fracture with no loss of teeth

Question 385

(e.g., metal arch bars in the mouth or insertion of a pin in the bone). Bone grafting may be needed

Answer 385

If teeth are missing or bone is displaced, other forms of fixation may be needed

Question 386

are airway obstruction and aspiration of vomitus

Answer 386

Two potential problems in the immediate postoperative period (intermaxillary fixation)

Question 387

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 to all appointments and examinations away from the bedside

Answer 387

After surgery place the patient on (mandibular fraction)

Question 388

Liquid protein supplements may improve the patient’s 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.

Answer 388

diet for mandibular surgery post op

Question 389

is the removal of a body extremity by trauma or surgery.

Answer 389

amputation

Question 390

peripheral neuropathy that progresses to deep ulcers and gangrene

Answer 390

PVD w/ diabetes have

Question 391

trauma (e.g., motor vehicle crashes, farm-related injury). Battle injuries

Answer 391

Amputation in young people is usually due to

Question 392

thermal injuries, tumors, osteomyelitis, and congenital limb disorders.

Answer 392

Other common reasons for amputation include

Question 393

a weight-bearing residual limb (or stump).

Answer 393

closed amputation creates

Question 394

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

Answer 394

An anterior skin flap with dissected soft tissue padding covers

Question 395

is an amputation done through a joint.

Answer 395

Disarticulation

Question 396

is a form of disarticulation at the ankle.

Answer 396

syme’s amputation

Question 397

the surface of the residual limb is left uncovered with skin. This type of surgery is generally done to control actual or potential infection.
-wound is usually closed later by a second surgical procedure or closed by skin traction surrounding the residual limb.

Answer 397

After an open amputation (guillotine amputation),

Question 398

(measures blood flow in the arms or legs)

Answer 398

Plethysmography

Question 399

amputated limb may feel like it is still present after surgery. This phenomenon, termed

Answer 399

phantom limb sensation

Question 400

may be the best choice for older adults, patients with infection, or patients who have had amputations above the knee or below the elbow

Answer 400

delayed prosthetic fitting

Question 401

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.

Answer 401

temporary prosthesis may be used for

Question 402

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.

Answer 402

Patients are often extremely worried about phantom limb sensation bc

Question 403

patient may have shooting, burning, or crushing pain as well as feelings of coldness, heaviness, and cramping,

Answer 403

s/symp phantom limb sensation

Question 404

We do not know why looking in the mirror at the remaining limb would improve symptoms. The mirror is thought to give visual information to the brain, replacing sensory feedback expected from the missing limb. Mirror therapy may also improve patient function after a stroke.

Answer 404

Mirror therapy reduces symptoms in some patients (for phantom limb sensation)

Question 405

is hip flexion

Answer 405

most common and debilitating contracture

Question 406

have 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.

Answer 406

To prevent flexion contractures,

Question 407

the residual limb is shaped and molded for eventual prosthesis fitting

Answer 407

Proper bandaging ensures

Question 408

support soft tissues, reduce edema, hasten healing, and minimize pain. Compression also promotes residual limb shrinkage and maturation.

Answer 408

HCP usually orders a compression bandage to be applied right after surgery to

Question 409

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

Answer 409

prosthetist makes a

Question 410

from trauma

Answer 410

Because most upper extremity amputations result

Question 411

the below-the-elbow amputee.

Answer 411

Both immediate and delayed prosthetic fittings are possible for

Question 412

the above-the-elbow amputee. The usual functional prosthesis is the arm and hook.

Answer 412

Prosthetic fitting is delayed for

Question 413

to relieve chronic pain, improve joint motion, correct deformity and misalignment, and remove diseased cartilage.

Answer 413

goals of surgery are

Question 414

contraction with permanent limitation of motion may occur

Answer 414

If the joint problem is not corrected,

Question 415

remove inflamed tissue that is causing unacceptable pain or limiting ROM in RA

Answer 415

Synovectomy (removal of synovial membrane) is done to

Question 416

the elbow, wrist, and fingers. Synovectomy in the knee is done less often because knee joint replacement is usually done.

Answer 416

Common sites for Synovectomy surgery include

Question 417

removing a wedge or slice of bone to restore alignment (joint and vertebral) and to shift weight bearing, thus relieving pain

Answer 417

osteotomy involves

Question 418

kyphotic deformity in patients with ankylosing spondylitis
-Halo vests and body jacket braces are worn until fusion occurs (3 to 4 months).

Answer 418

Cervical osteotomy may be used to correct a

Question 419

some pain relief and improve motion in select patients with hip osteoarthritis (OA)

Answer 419

femoral osteotomy may provide

Question 420

also provides pain relief in some patients with knee instability or OA

Answer 420

Tibial osteotomy

Question 421

is the removal of debris, such as pieces of bone or cartilage (loose bodies) or osteophytes, from a joint using a fiberoptic arthroscope
-on the knee or shoulder
-compression dressing is applied after surgery. Weight bearing is permitted after knee arthroscopy.
-restricting activity for 24 to 48 hours

Answer 421

Debridement

Question 422

is the reconstruction or replacement of a joint to relieve pain, improve or maintain ROM, and correct deformity

Answer 422

Arthroplasty

Question 423

s most often done on patients with OA, RA, avascular necrosis, congenital deformities or dislocations, and other systemic problems.

Answer 423

Arthroplasty i

Question 424

surgical reshaping of the bones of the joints, replacement of part of a joint (hemiarthroplasty), and total joint replacement.

Answer 424

Types of arthroplasty include

Question 425

elbows, shoulders, fingers, wrists, ankles, and feet.

Answer 425

Arthroplasty is also available for

Question 426

significant relief of pain and improved function for patients with joint deterioration from OA, RA, and other conditions.
-treat hip fractures

Answer 426

Total hip arthroplasty (THA), or a total hip replacement, provides

Question 427

the ball-and-socket joint formed by the upper shaft of the femur and pelvis

Answer 427

THA, the prosthesis (implant) replaces

Question 428

polymethyl methacrylate, which bonds to the bone.

Answer 428

Both the ball-and-socket components can be cemented in place with

Question 429

longer stability by enabling ingrowth of new bone tissue into the porous surface coating of the prosthesis. Cementless devices are recommended for younger, more active patients and patients with good bone quality so that bone ingrowth into the components can be readily achieved.

Answer 429

may also be inserted without cement (cementless). Cementless THA may provide

Question 430

It preserves and reshapes the femoral head (ball) rather than replacing it as in THA.

Answer 430

alternative to hip replacement is hip resurfacing arthroplasty.

Question 431

Unrelieved pain and instability due to severe deterioration of the knee joint are the main reasons for

Answer 431

total knee arthroplasty (TKA), or a total knee replacement

Question 432

, a knee immobilizer or posterior plastic shell to maintain extension may be used during ambulation and at rest for about 4 weeks

Answer 432

If the patient is unable to perform a straight-leg raise (TKA)

Question 433

is used to restore function in the fingers of the patient with RA. Ulnar deviation often causes severe functional limitations of the hand.

Answer 433

A silicone rubber arthroplastic device

Question 434

restore function related to grasp, pinch, stability, and strength rather than to correct cosmetic deformity.

Answer 434

goal of hand surgery is primarily to

Question 435

, the patient is taught hand exercises, including flexion, extension, abduction, and adduction of the fingers.

Answer 435

Before surgery (hand surgery)

Question 436

severe pain because of RA, OA, avascular necrosis, or trauma.

Answer 436

Shoulder replacements are done in patients with

Question 437

may be done for pain and dysfunction caused by massive, irreparable, rotator cuff tears.

Answer 437

A specialized type of shoulder replacement, called a reverse total shoulder arthroplasty,

Question 438

the elbow is usually done first because a severely painful elbow interferes with the shoulder rehabilitation program.

Answer 438

If joint replacement is needed for both elbow and shoulder,

Question 439

indicated for RA, OA, trauma, and avascular necrosis.

Answer 439

Total ankle arthroplasty (TAA) is

Question 440

several fixed-bearing devices and a mobile-bearing cementless prosthesis. This device more closely imitates natural ankle function. (Ankle fusion is often done over arthroplasty because the result is more durable)

Answer 440

Available devices Total ankle arthroplasty include

Question 441

to change heel height. TAA achieves a more normal gait pattern.
-After surgery, the patient may not bear weight for 6 weeks.

Answer 441

fusion leaves the patient with a stiff foot and the inability

Question 442

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.

Answer 442

Arthrodesis

Question 443

the articular hyaline cartilage and adding bone grafts across the joint surface.

Answer 443

fusion is usually done by removing (Arthrodesis)

Question 444

wrist, ankle, cervical spine, lumbar spine, and metatarsophalangeal (MTP) joint of the great toe.

Answer 444

Common areas fused are

Question 445

are gram-positive aerobic streptococci and staphylococci.
-Infection may lead to pain and loosening of the prosthesis, generally requiring further surgery

Answer 445

most common causative organisms (after joint surgery)

Question 446

Give ordered anticoagulant medication, analgesia, and parenteral antibiotics. Pain management strategies may include epidural or intrathecal analgesia, femoral nerve block, patient-controlled IV analgesia, and oral opioids or NSAIDs

Answer 446

drug treatment joint surgery

Question 447

day of surgery and the INR and prothrombin times are measured daily.

Answer 447

If the patient is taking warfarin, therapy starts on the

Question 448

the morning after surgery

Answer 448

Therapy with LMWH (e.g., enoxaparin), apixaban, or rivaroxaban usually starts