Musculoskeletal Trauma Flashcards
* Fractures * Fat embolic syndrome * Acute compartment syndrome * Complex regional pain syndrome (38 cards)
1
Q
Functions of musculoskeletal system
- Framework
- Mobility
- Protection - ribs, skull
- Reservoir - fat in yellow marrow
- Hematopoiesis - red marrow producing blood cells
A
Classification of Fractures
- Fracture - break or disruption in continuity of a bone
- Types:
> Complete
> Incomplete
> Open or compound
> Closed or simple
> Pathologic (spontaneous), traumatic
> Fatigue or stress
> Compression
2
Q
Classification
- Closed
- Open
- Complete
- Incomplete
A
3
Q
?
Occurs when bone continuity is completely interrupted (2 parts)
A
Complete
4
Q
?
Occurs when skin is broken (compound fx’s Grades I, II, or III)
A
Open
5
Q
?
Occurs when bone continuity is not completely interrupted
A
Incomplete
6
Q
?
Occurs when there is no break in skin (simple fx)
A
Closed
7
Q
Common Types of Fractures
A
Depression Fracture
8
Q
?
These are produced by a loading force applied to the long axis of calcaneus bone; common for spinal cord injuries
A
Compression fracture
9
Q
Types of Hip Fractures
- Osteoporosis is greatest risk factor for hip fx’s
- Differentiate between hip & pelvis fx’s - proximal 1/3 of femur = hip fx
- Intracapsular puts pt @ risk for AVN of femoral head & can lead to pain & dec mobility
A
- While awaiting ORIF - placed on Buck’s traction to dec painful spasms
- ORIF surgery shouldn’t be confused for surgery for RA & OA
10
Q
Internal Fixation
A
Bone Repair Cascade
- Hematoma formation (1-72 hrs post injury)
- Hematoma to granulation tissue (takes 3d - 2wks)
- Soft callus formation (takes ~3-6 wks post injury)
- Osteoblastic proliferation - hard callus forms (takes approx 3-8 wks)
- Bone remodeling (4-6 wks to a yr)
- Bone healing completed
- Note, time estimates are for a healthy young person
11
Q
Risk Factors for Fx
Hormones
- Increased
> Thyroid
> Parathyroid
> Cortisol
- Decreased
> Sex hormones
> Growth hormones
Nutrition
> Calcium/phosphorous
> Vit D
> Protein
> Eating disorders
A
Activity
> Prolonged inactivity
> Inc risk taking behaviors
> Domestic violence
> Risk for falls
Diseases
> Neoplasms (e.g., multiple myeloma, 2° met from primary site)
> Paget’s dz
> Grave’s dz
> Hyperparathyroid
> Osteoporosis
> Diabetes
> Cushing’s
12
Q
Manifestations
- Pain
- Impaired function
- Crepitus
- Deformity
- Shortening of limb
- Ecchymosis
- Edema, bruising
- Neurovascular changes
! Note, bone is very vascular
A
Diagnostics
- In addn to xray, CT & MRI
13
Q
?
- serum calcium
elevated or decreased with healing?
A
elevates
14
Q
?
- serum phosphorous
elevated or decreased with healing?
A
elevates
15
Q
?
- lactate dehydrogenase (LDH)
elevated or decreased with skeletal muscle trauma?
A
elevates
16
Q
?
- aspartate aminotransferase (AST)
elevated or decreased with skeletal muscle trauma?
A
elevates
17
Q
?
- creatinine phosphokinase (CPK)
elevated or decreased with muscle trauma?
A
elevates
18
Q
?
- myoglobin
elevated or decreased with skeletal muscle injury?
A
elevated
19
Q
Reduction
- Closed
> Bring bone fragments in apposition
> Through manipulation; very painful & needs rx
> Manual traction
A
- Open
> Bring bone fragments in apposition
> Through surgical incision
20
Q
Immobilization
Internal Fixation
- Intermedullary rod
- Compression nails
- Plates
- Screws
A
External Fixation
- Fixator frames
- Non-rigid methods (slings, immobilizers)
- Traction
- Cast
- Pins are inserted through the skin into the bone. Pins are connected to an external framework. Allows for skin & CMS checks but needs care for pins & monitor pins q8-12h for signs of infection
- Normal in the first 48-72hrs to have serous, clear fluid of the pin sites
21
Q
External Fixation utilized for…
- Comminuted fractures, grades II to III
- Bone loss
- Congenital defects affecting bone length
A
- Minimized blood loss
- Keeps ends of bone aligned
- Screws on the device can be turned & rotated to lengthen traction on the extremity & over time bone growth occurs between the 2 ends of the bone
22
Q
Immobilization Device
- Helps keep alignment of the bones
- Splint
- Ice can reduce swelling
- Consider perfusion & neurovascular checks when extremity is placed in dependent position
A
Fiberglass Synthetic Cast
- Preferred over plaster
23
Q
Cast Care
- Inform/teach
- Neurovascular check
- Elevate limb/use sling
- Ice
- Assess & relieve pain/tightness
- Prevent resting on hard surface
- Assess for pressure ulcer
- Exercises
A
Traction
24
Q
Assess the following w/pts in traction (Carol P Smith)
- Continuous
- Alignment
- Resistance
- Opposing traction
- Line of pull
- Pulse
- Sensation
- Motion
- Interspaces
- Temperature
- Hue (color)
Also, keep in mind the 6 P’s
A
Rehabilitation
- Early remobilization
- Decrease complication risks
25
Early complications requiring ***frequent assessment***
* Hypovolemic shock
* Neurovascular compromise
* Loss of protective function (e.g., skull to brain; rib cage to lung)
Complications of Fractures
! Compartment syndrome
! Crush injury
! Fat embolism syndrome
! Venous thromboembolism
! Infection
! Chronic complications - ischemic necrosis, AVN, delayed bone healing
! Peripheral neurovascular dysfunction
! Pain
! Impaired physical mobility
26
?
Condition where circulation & function of tissues within a closed space are compromised by an increase of pressure in that space
Closed space: osteo-fascia area of muscle, nerve, & blood vessels
Compartment syndrome
27
Etiology of compartment syndrome
* Can happen from trauma, burns, infiltration of extravascular IV fluids, casting, lying on the ground for an extended period of time
- constriction of compartment
> closure of fascia defect
> scarring & contraction of skin or fascia, or both, due to burns
- increased fluid content in compartment
> fracture
> direct arterial trauma
> intra-compartmental hemorrhage
> burns
> muscle swelling d/t overexertion
> infiltration of exogenous fluid (IV needle slipped out of vein)
> fluid from capillaries (edema) 2° to bone or soft tissue trauma, burn toxins, venous or lymphatic obstruction
- external compression
> tight cast or dressing
> excessive or prolonged inflation of air splint
> prolonged compression of limb (as in alcohol or drug-induced metabolic or traumatic coma)
28
Clinical Diagnosis
6 P's
* Pain (out of proportion to what is expected based on physical exam findings)
* Paresthesia
* Pallor
* Paralysis
* Pulselessness
* Poikilothermia
***The 1st signs of compartment syndrome are numbness, tingling, & paresthesia***
- also, pain is induced on passive ROM
29
Stryker Intra-Compartmental Pressure Monitor System
30
Etiology/Pathophysiology/Complications
* Pressure
* Inc tissue pressure
* Collapse of thin walled veins
* Dec capillary flow
* Cellular injury
* Inflammation
* More pressure
* Cellular hypoxia
* Rhabdomyolysis
* Necrosis
* Renal & multi-organ failure
* Loss of limb & life
31
Rhabdomyolysis
A byproduct of skeletal injury, skeletal muscle injury; builds up in the bloodstream; can also build up in the urine (dipstick testing)
- Is possible w/trauma in general
Treatment of Compartment Syndrome
* Goal: dec tissue pressure, restore blood flow, preserve limb function
* Release compressive forces
* Limb @ heart lvl
* NO ICE - is vasoconstrictive
* Supplemental oxygen
* Maintain normotensive
! fasciotomy
32
Nursing Pitfalls
* Infrequent and/or inadequate observation of neurovascular status
* Inattention to pts complaints of pain, pain intensity & requests for pain medication
* Inattention to casts, splints, or dressings, which may be masking/exacerbating the problem
* Non-elevation of injured extremities to improve venous return (to reduce edema before compartment syndrome develops)
* Delayed or non-reporting of problems
Complications of compartment syndrome
! Neurological defects
! Myoglobinuric renal failure
! Volkmann contracture [ischemic contracture]
! Infection
! Amputation
33
Amputations
* Surgical
* Traumatic
* Levels of amputation
* Complications - hemorrhage, infection, phantom limb pain, neuroma, flexion contracture
* Postop nursing care
> Covered in depth in lecture re: peripheral vascular dz surgeries
34
?
Circulating fat globules that cause multi-system dysfunction, mainly involving the lungs, brain, & skin
Are small & multiple, & so have widespread effects
Fat Embolism
35
Prevention of Fat Emboli
* Minimal manipulation during reduction
* Adequate support when turning & repositioning
* Maintain F&E imbalance
* Early mobilization
> Medullary cavity of long bones store fat & a fx could result in the fat globules becoming emboli
Clinical manifestations within 24-48 hrs post injury - report immediately!
* Neurologic LOC changes
* Pulmonary changes
* Petechial rash - *specific to **fat** emboli*
36
Diagnostics
↑ or ↓ ESR ?
↑ or ↓ calcium levels?
↑ or ↓ RBCs & platelets?
↑ or ↓ serum lipase?
xray: snowstorm infiltrate
↑ ESR
↓ calcium levels
↓ RBCs & platelets
↑ serum lipase
37
The earliest manifestations of FES are low arterial oxygen level or hypoxemia, dyspnea, & tachypnea
Further Complications
* FES degradation into free fatty acids & CRP
* Resulting in capillary leakage - causes edema & swelling
* Lipid & plt aggregation & clot formation (petechiae)
* With FES, there are fatty emboli that are released & get trapped in the small capillary beds of different organs within the pulmonary system
* In other organs can get trapped, dec perfusion, & cause tissue death/organ death
38
Treatment
✓ Immobilization of fx
✓ Bed rest/gentle handling
✓ Support resp system
✓ Hydration
✓ Steroid
✓ Cardiac support
✓ Hemodynamic monitoring
✓ Pain & anxiety management
Nursing Diagnoses
* Acute Pain
* Impaired Physical Mobility
* Risk for Peripheral Neurovascular Dysfunction
* Risk for Infection
* Ineffective Tissue Perfusion
* Risk for Impaired Skin Integrity
* Deficient Fluid Volume
* Knowledge Deficit
