MS Trauma Questions Flashcards by Kelsey Klipfel

A female patient with osteoporosis comes to the ED after falling suddenly while opening her car door. She said it felt as though her “leg gave way” and caused her to fall. What type of fracture does this patient likely have?
A.Pathologic (spontaneous)
B.Spiral
C.Impacted
D.Incomplete

Answer: A

How well did you know this?

Not at all

Perfectly

break or disruption in continuity of a bone that often affects mobility and sensory perception

Fracture

How well did you know this?

Not at all

Perfectly

Break is across the entire width of the bone; bone is divided into two distinct sections

Classified by extent of the break: Complete

How well did you know this?

Not at all

Perfectly

Break is only through part of the bone

Classified by extent of the break: Incomplete

How well did you know this?

Not at all

Perfectly

skin surface over the broken bone is disrupted and causes an external wound

Classified by the extent of associated soft-tissue damage: Open or compound

How well did you know this?

Not at all

Perfectly

does not extend through the skin and therefore has no visible wound

Classified by the extent of associated soft-tissue damage: Closed or simple

How well did you know this?

Not at all

Perfectly

Occurs after minimal trauma to a bone that has been weakened by disease: Pagets, osteoporosis

Classified by the cause of fractures: Pathologic (spontaneous)

How well did you know this?

Not at all

Perfectly

Results from excessive strain and stress on the bone

Classified by the cause of fractures: Fatigue (stress)

How well did you know this?

Not at all

Perfectly

Produced by a loading force applied to the long axis of cancellous bone
Commonly occur in the vertebrae of older patients with osteoporosis
Compressing force

Classified by the cause of fractures: Compression

How well did you know this?

Not at all

Perfectly

24 to 72 hours after the injury
Hematoma forms at the site of the fracture because bone is extremely vascular

Stages of bone healing: Stage 1

How well did you know this?

Not at all

Perfectly

3 days to 2 weeks after injury
Granulation tissue begins to invade the hematoma
Formation of fibrocartilage
Foundation for bone healing

Stages of bone healing: Stage 2

How well did you know this?

Not at all

Perfectly

3-6 weeks
Fracture site is surrounded by new vascular tissue known as a callus
Callus formation is the beginning of a non-bony union occurs
Result of vascular and cellular proliferation

Stages of bone healing: Stage 3

How well did you know this?

Not at all

Perfectly

3-8 weeks
Callus is gradually resorbed and transformed into bone

Stages of bone healing: Stage 4

How well did you know this?

Not at all

Perfectly

From 4-6 weeks up to 1 year
Bone remodeling
Length of time depends on the severity of the injury and the age and health of the patient
In young, healthy adult bone, healing takes about 4 to 6 weeks
Extent injury can lengthen time
Healing time is lengthened in older adults
3 months or longer

Stages of bone healing: Stage 5

How well did you know this?

Not at all

Perfectly

A 30 year-old patient who is hospitalized for repair of a fractured tibia and fibula is experiencing altered mental status. Which complication related to the injury might the patient be experiencing?
A.Hypovolemic shock
B.Fat embolism
C.Acute compartment syndrome
D.Pneumonia

Answer: B

How well did you know this?

Not at all

Perfectly

Fat embolism syndrome
Acute compartment syndrome
Crush syndrome
Hypovolemic shock
Venous thromboembolism
Infection
Chronic complications

Complications of fractures

How well did you know this?

Not at all

Perfectly

Fat globules are released from the yellow bone marrow into the bloodstream within 12 to 48 hours after an injury or illness
Globules clog small blood vessels that supply vital organs and impair organ perfusion
Early signs
Petechiae is a classic manifestation, but is usually the last sign to develop
Can result in respiratory failure or death, often from pulmonary edema

Fat embolism syndrome

How well did you know this?

Not at all

Perfectly

Altered mental status (earliest sign)
Increased respirations, pulse, and temperature
Chest pain
Dyspnea
Crackles
Low arterial oxygen level

Early signs - Fat embolism syndrome

How well did you know this?

Not at all

Perfectly

Increased pressure within one or more compartments reduces circulation to the area
Relieve pressure
Pressure can be from an external or internal
Complication:
Early signs of acute compartment syndrome
Late signs

Acute compartment syndrome

How well did you know this?

Not at all

Perfectly

tight, bulky dressings and casts

External - Acute compartment syndrome

How well did you know this?

Not at all

Perfectly

blood or fluid accumulation

Internal - Acute compartment syndrome

How well did you know this?

Not at all

Perfectly

Infection
Persistent motor weakness
Contracture
Myoglobinuric renal
Amputation in extreme cases

Complication: - Acute compartment syndrome

How well did you know this?

Not at all

Perfectly

pressure, paresthesia, pallor, paralysis,

Early signs of acute compartment syndrome - Acute compartment syndrome

How well did you know this?

Not at all

Perfectly

pain, cyanosis, decreased pulses, pulselessness (rare), necrosis

Late signs - Acute compartment syndrome

How well did you know this?

Not at all

Perfectly

Systemic complication Results from severe or prolonged pressure, hemorrhage and edema after a severe fracture or crush injury Myoglobin is released into circulation, where it can occlude the distal renal tubules and result in kidney failure Rhabdomyolysis: myoglobulin in the bloodstream Priority of care is to prevent Acute Tubular Necrosis

Crush syndrome

From blood loss

Hypovolemic shock

DVT and PE

Venous thromboembolism

Superficial skin wound infections Deep wound abscesses Bone infection (osteomyelitis) - IV antibiotics Clostridial infections can lead to gas gangrene or tetanus and may result in a loss of an extremity

Infection

From loss of blood supply to the bone

Chronic complications - Ischemic necrosis

Fracture that has not healed within 6 months of injury

Chronic complications - Delayed union

A patient has a fracture of the right wrist. What is an early sign that indicates this patient may be having a complication? A.Patient loses ability to wiggle fingers without pain B.Fingers are cold and pale; capillary refill is sluggish C.Pain is severe and seems out of proportion to injury D.Patient reports numbness and tingling

Answer: D AN EARLY SIGN

History Clinical manifestations Lab Imaging

Assessment

Mechanism of injury Medical history (Hx of DM, osteoporosis, CKD) Drug history (including substance abuse)

History

Depends on the specific traumatic event Moderate to severe pain Edema Ecchymosis (bruising) Check for neurovascular compromise

Clinical manifestations

could be rapid and result in neurovascular compromise; acute compartment syndrome

Edema

Bleeding into the underlying soft tissues

Ecchymosis (bruising)

Skin color and temperature – distal to the injury Movement Sensation – any numbness or tingling (paresthesia) Pulses - distal to the fracture site Capillary refill (least reliable) - compromised from other things as well need know baseline Pain

Check for neurovascular compromise

No special laboratory tests are available for assessment of fractures Hemoglobin and hematocrit Erythrocyte sedimentation rate (ESR) may be elevated Increased WBC Elevated serum calcium and phosphorus

Lab

Low because of bleeding caused by the injury

Hemoglobin and hematocrit - Lab

Indicates inflammatory response

Erythrocyte sedimentation rate (ESR) may be elevated - Lab

Indicates bone infection

Increased WBC - Lab

During healing, bone releases these elements into the blood

Elevated serum calcium and phosphorus - Lab

X-rays: tells if have fracture; gold standard to look at fractures CT MRI

Imaging

Useful for fractures of complex structures, e.g., joints, spine, pelvis

Useful in determining the amount of soft tissue injury

MRI

Acute pain related to one or more fractures, soft-tissue damage, muscle spasm, and edema - quite bit pain pain Risk for neurovascular compromise related to tissue edema and/or bleeding - precandent over pain Risk for infection related to a wound caused by an open fracture Impaired physical mobility related to need for bone healing and/or pain - not weight bearing for awhile

Priority nursing diagnoses and collaborative probs

Keep her warm and in a supine position Check the neurovascular status of the area distal to her fracture Immobilize and elevate the extremity above the heart level Partial splint therapy Ice (24 to 48 hours) Drug therapy Not walk until know what going on

What care would you expect for treatment of her fracture?

pain, pallor, pulse, paresthesia, paralysis

Check the neurovascular status of the area distal to her fracture

Assess ABC’s and perform a quick head-to-toe assessment Remove clothing from the fracture site - swelling Remove jewelry on the affected extremity Apply direct pressure on the area if there is bleeding Keep the patient warm and in a supine position Check the neurovascular status of the area distal to the fracture Immobilize the extremity Cover any open areas with a dressing

Emergency care of the patient with an extremity fracture

temperature, color, sensation, movement, and capillary refill compare the affected and unaffected limbs

Check the neurovascular status of the area distal to the fracture

preferably sterile

Cover any open areas with a dressing

The nurse is reviewing the orders for a patient who was admitted for 24-hour observation of a leg fracture. A cast is in place. Which order should the nurse question? A.Oxycodone PO PRN for pain B.Neurovascular assessments every 8 hours C.CBC and BMP in the morning D.Regular diet as tolerated

Answer: B Done more often; assess often

Closed reduction and immobilization with a bandage, splint, cast, or traction Cast care Arms, legs, braces, and body or spica casts. Depending on what pat did Prevent neurovascular dysfunction or compromise Elevate extremity higher than the heart Ice for the first 24 to 48 hours Drug therapy Improve physical mobility and prevent complications of impaired mobility Prevent infection

Nonsurgical management

For small, closed incomplete bone fractures in the hand or foot, reduction is not required

Closed reduction and immobilization with a bandage, splint, cast, or traction

Four primary groups of casts

Cast care

Primary nursing concern Assess the neurovascular status every hour for the first 24 hours and then every 1-4 hours

Prevent neurovascular dysfunction or compromise

Opioid and non-opioid analgesics, anti-inflammatory drugs, muscle relaxants Meperidine (Demerol) should never be used for older adults because it has toxic metabolites that can cause seizures and other complications

Drug therapy

Involve PT/OT for exercise and inpt/outpt therapy

Improve physical mobility and prevent complications of impaired mobility

Proper wound care IV antibiotics depending on type fracture or wounds Wound vacuum-assisted closure system - VAC: depending on size wound area; heal from inside out; prevent osteomyelitis

Prevent infection

A nurse cares for four patients in casts on the orthopedic unit. Which patient should the nurse prepare for a window procedure? A.Patient in a full leg cast, toes slightly cool, takes ibuprofen for pain B.Patient developed pressure ulcer under the cast C.Patient in a partial cast, toes slightly swollen and warm D.Patient whose cast became soiled with urine

Answer: B Window: cut out little piece of cast to look at it - eventually replace it - diff areas of compression getting

If needed to realign the bone for the healing process Open reduction with internal fixation (ORIF) most common method of reducing and immobilizing a fracture

Surgical management

Open reduction Internal fixation External fixation

Open reduction with internal fixation (ORIF) most common method of reducing and immobilizing a fracture

Allows the surgeon to directly view the fracture site

Open reduction

Uses metal pins, screws, rods, plates, or prostheses to immobilize the fracture during healing After the bone achieves union, the metal hardware may be removed, depending on the location and type of fracture Might take out hardware

Internal fixation

Pins or wires are inserted through the skin and affected bone and then connected to a rigid external frame increased risk for pin site infection - good pin care

External fixation

related to complications of peripheral vascular disease, arteriosclerosis

Amputations: Types: Elective

often result of accidents

Amputations: Types: Traumatic

Toe Mid-foot Syme Below-knee Above-knee

Levels of amputation for lower extremities

most of the foot is removed, but the ankle remains

Syme

Hemorrhage - traumatic Infection - can be sig Phantom limb pain Neuroma Flexion contractures

Complications of amputations

More common in patients who had chronic limb pain before surgery and less common in those who have traumatic amputations; elective amputations Sensation is felt in the amputated part immediately after surgery and usually diminishes over time If sensation persists and is unpleasant or painful, it is referred to as phantom limb pain

Phantom limb pain - Complications of amputations

Sensitive tumor consisting of damaged nerve cells more common in upper extremity amputations

Neuroma - Complications of amputations

Hip or knee flexion contractures are seen in patients with amputations of the lower extremity

Flexion contractures - Complications of amputations

Emergency care for traumatic amputations Assess tissue perfusion Manage pain Prevent infection Promote mobility and preparation for prosthesis - want them up and moving Promote body image and lifestyle adaptation - some psychological concerns: talk about that with them

Interventions

Stop the bleeding, stabilize the patient Wrap the amputated part (finger, hand, toe) in a clean or sterile cloth Place it in a water tight sealed plastic bag Place the bag in ice water – but never amputated part directly on ice Avoid contact between the body part and the water to prevent tissue damage

Emergency care for traumatic amputations - Interventions

After surgical closure, the skin flap at the end of the remaining limb should be pink in a light-skinned person and not discolored in a dark-skinned patient Tissue should be warm, but not hot - not show signs of infection Sig edema

Assess tissue perfusion - Interventions

Pain medications per HCP IV infusions of calcitonin (Miacalcin, Calcimar) during the week after amputation can reduce phantom limb pain - talk to them about it; not dismiss pain Massage Heat TENS unit Ultrasound therapy per PT - vibration to deliver heat

Manage pain - Interventions

Which of the following statements identifies the patient as at highest risk for musculoskeletal trauma? A.“I removed my area rugs at home so that I don’t trip over them” B.“My mother had osteoporosis, so I am very careful when I ride my motorcycle” C.“I don’t drink alcohol if I have to drive” D.“I always wear my helmet when I ride my bicycle.”

Answer: B Fam history and ride motorcycle

Health teaching should focus on: - SAFETY Airbags and seatbelts Osteoporosis screening and self-management Fall prevention Home safety assessment and modification, if needed; rugs, not as many steps Dangers of drinking and driving Drug safety (prescribed, OTC, illicit) Older adults and driving - ensure safe to cont that Helmet use when riding bicycles, motorcycles, all-terrain vehicles (ATVs), and skateboards

Health promotion and maintenance