Musculoskeletal trauma and orthopedic sx

Question 1

What is the most common cause of musculoskeletal injuries?

Answer 1

traumatic injury

Question 2

What do traumatic injuries result in?

Answer 2

Fracture
Dislocation
Soft tissue injury

Question 3

Fracture

Answer 3

a disruption or break in continuity of the structure of bone
Some fractures are secondary to disease processes (ie “fragility fractures”) - Cancer or osteoporosis

Question 4

Dislocation

Answer 4

severe injury of the ligamentous structures around a joint that results in the complete displacement of the bone from its normal position (important to get it relocated quickly)

Question 5

Fracture classification

Answer 5

Open or closed (is the skin broken?)
Complete or incomplete (is the break straight through the bone?)
Direction of fracture line (7 types)
Displaced or nondisplaced (are the two ends of the fracture separated?)
Anatomical location of fracture on involved bone (proximal, medial, distal)
Stable or unstable (stationary piece of periosteum)

Question 6

What are the 7 different types of direction of fracture line?

Answer 6

Transverse (straight)
Spiral (twisted)
greenstick (incomplete fracture; one side split, one side bent)
comminuted (more than 2 fragments)
oblique (diagonal)
pathological (site of bone disease; cancer to bone)
stress fracture (site of repeated stress)

Question 7

Manifestations of fractures

Answer 7

Edema & swelling
Pain & tenderness
Bruising
Muscle spasm
Deformity (may not be obvious)
Inability to bear weight on or loss of function
Abnormal movement
Crepitation (grating/crunching together of bony fragments)
Neurovascular changes
- Decreased sensation
- Numbness
Hypovolemic shock (longbones, highly vascular and are responsible for blood production )

Question 8

Care for fractures

Answer 8

If a fracture is suspected, immobilize extremity in position it was found

Question 9

What does unnecessary movement cause for fractures?

Answer 9

Increases soft tissue damage
May convert a closed fracture into an open one
May create further injury to adjacent neurovascular structures

Question 10

Fracture healing

Answer 10

1. fracture hematoma (hematoma around bone ends)
2. Granulation tissue (osteoblasts are in granulated tissue which is man component of new bone called osteoid) - osteoids and osteoblasts can be seen in x-ray
3. Callus formation (unorganized bone network of cartilage, Ca, phos.)
4. Ossification
5. Consolidation
6. Remodeling (for loading stress after repair complete)

Question 11

What are the overall goals for fracture care?

Answer 11

Anatomical realignment of bone fragments (reduction)
Immobilization to maintain realignment
Restoration of normal or near-normal function of injured parts (rehab after cast has been placed)

Question 12

Fracture reduction care

Answer 12

Closed reduction
Nonsurgical, manual realignment of bone
fragments to previous anatomical position
Open reduction
Correction of bone alignment through
surgical incision
Includes internal fixation (ORIF) with use of
wires, screws, pins, plates, intramedullary
rods, or nails
Traction
Application of a pulling force to an injured
or diseased part of the body

Question 13

Fracture immobilization care

Answer 13

Casts
Immobilizers

External fixation
- metallic device
- applies traction or compresses fracture fragments
Internal fixation
- Pins, plates, rods

Question 14

What is the risk of internal fixation?

Answer 14

Infection risk d/t harboring organisms
also foes not have blood flow to bring in immune response

Question 15

What to note about broken bones with infants

Answer 15

Occur less frequently because of bony flexibility (if it does happen, it is because of abuse or malnutrition), very hard to break

Question 16

Drug therapy for fractures

Answer 16

Varying degrees of pain and muscle spasm
Analgesics & Muscle relaxers
Tetanus-diptheria toxoid
Antibiotics

Question 17

Nutritional therapy for fractures

Answer 17

Proper nutrition
Adequate energy for body to repair

Question 18

What can we do to prevent complications?

Answer 18

Neurovascular assessments are key (more than just CWMS)
Other assessments depend on type of fracture and stage of healing
Vital signs
Assessment for shock
Respiratory assessment
Skin integrity
Regaining maximum function
Achieving best cosmetic result

Question 19

Peripheral vascular assessment

Answer 19

colour, warmth, cap refill, peripheral pulses, edema
compare both ext

Question 20

Peripheral neurological assessment

Answer 20

sensation
motor function
pain

compare both ext

Question 21

Fracture complications

Answer 21

Direct:
Infection

Indirect
Fat embolism syndrome
Compartment Syndrome
VTE
Rhabdomyolysis
Hypovolemic Shock

Question 22

Infection complication

Answer 22

Associated with open fractures and soft tissue injuries
Often related to high-energy trauma
Massive/ blunt soft tissue trauma often has more serious consequences than the fracture itself
Collaborative care:
- Aggressive surgical debridement
- Early sterile N/S lavage (washed)
- Extent of soft tissue injury determines whether the wound is closed or left open (vac dressing)
- IV antibiotics for 3-7 days

Question 23

Fat embolism syndrome complication

Answer 23

Presence of systemic fat globules from fractures distributed into tissues & organs after a traumatic skeletal injury
Fat globules –> occlusion of pulmonary vessels –> pulmonary edema, severe hypoxia & cardiovascular compromise
of the fat embolisms that come, 90% of them are longbone, then ribs, tibia and pelvis

Question 24

What are S and S of fat embolism?

Answer 24

1. hypoxia
2. Neurologic abnormalities
3. petechial rash

hypoxia, anxiety, dyspnea, tachypnea, tachycardia, cyanosis, crackles
**petechiae are a distinguishing feature (clotting factors)

immobilization is KEY!

Question 25

Compartment Syndrome Complication

Answer 25

Elevated intracompartmental pressure within a confined myofascial compartment compromises the neurovascular function of tissues within that space - Capillary perfusion below level necessary for tissue viability increased compartment content with decreased compartment size

Question 26

Compartment syndrome manifestations

Answer 26

Early recognition & treatment essential - Ischemia can occur within 4 to 12 hours Regular neurovascular assessments May occur initially or may be delayed for several days Urine output must be assessed because there is a possibility of muscle damage - Myoglobin released from damaged muscle cells precipitates as a gel-like substance --> Causes obstruction in renal tubules - Large amounts of myoglobinemia may result in acute tubular necrosis --> Acute tubular necrosis causes acute renal failure

Question 27

What are the 6 Ps of compartment syndrome?

Answer 27

Paresthesia: Numbness and tingling Pain: Distal to injury that is not relieved by opioid analgesics and pain on passive stretch of muscle traveling through compartment Pressure: ↑ in compartment Pallor: Coolness, and loss of normal colour of extremity Paralysis: Loss of function Pulselessness: Diminished/absent peripheral pulses

Question 28

What are common signs of myoglobinuria?

Answer 28

Dark reddish brown urine (BREAKDOWN OF PROTEINS) Clinical manifestations associated with acute renal failure

Question 29

Care for compartment syndrome

Answer 29

Prompt, accurate diagnosis Extremity should not be elevated above heart level - Elevation may decrease venous pressure and slow arterial perfusion Application of cold compresses may result in vasoconstriction and exacerbate compartment syndrome May be necessary to remove or loosen bandage or bivalve cast Reduction in traction weight may ↓ external circumferential pressures Surgical decompression may be necessary (fasciotomy - cut in skin)

Question 30

Long term fracture complications

Answer 30

Joint stiffness or post-traumatic arthritis Avascular necrosis Altered union Malunion Delayed union Non union

Question 31

Take home message about fractures

Answer 31

**Ongoing assessments are key to the prevention of complications** Vital signs Assessment of fracture site Neurovascular assessments Other: respiratory, cardiovascular, integument, neurological, etc. Preventative interventions include: - Maintaining adequate tissue perfusion - Maintaining immobilization of fracture site - Performing post-operative exercises - Maintaining hydration and nutritional status (myoglobinuria) - Preventing infection

Question 32

Pelvic fractures

Answer 32

Associated with highest mortality Often associated with intra-abdominal injury Treatment depends on severity of injury Can be extremely painful

Question 33

Hip fractures

Answer 33

Require the longest hospital stays Refers to a fracture of the proximal third of the femur usually caused by osteoporosis

Question 34

Clinical manifestations of hip fracture

Answer 34

External rotation Muscle spasm Shortening of the affected limb Pain at fracture site

Question 35

Care for surgical repair of hip fracture

Answer 35

If femoral head prosthesis (posterior approach), measures to prevent dislocation must be used x 6 weeks: - Avoid extreme flexion - Avoid crossing legs/ feet - Avoid sitting up more than 90 degrees Elevated toilet sets and chair alterations are helpful Foam abduction pillow or pillows between legs Avoid turning the patient on her affected side until the surgeon approves

Question 36

Signs of prosthesis dislocation of hip are

Answer 36

Sudden, severe pain A lump in the buttock Limb shortening External rotation of the affected limb Treatment for dislocation involves closed reduction under conscious sedation OR open reduction

Question 37

Femur fractures

Answer 37

Occurs with severe, direct force Usually associated with damage to the adjacent soft tissue structures Displacement of fracture fragments often results in considerable blood loss (1-1.5L) Clinical manifestations are usually obvious

Question 38

Stable Vertebral fractures

Answer 38

Stable: The fracture is unlikely to cause spinal cord damage GOAL: keep good spinal alignment until union has been accomplished

Question 39

Unstable vertebral fractures

Answer 39

Unstable: Ligamentous structures are significantly disrupted, dislocation of the vertebral structures may occur, leading to instability and injury to the spinal cord Unstable fractures usually require surgery (aspen collar) All spinal injuries are initially considered unstable until diagnostics confirm stability

Question 40

Treatment of vertebral fractures

Answer 40

Pain mgmt, mobilization, and bracing

Question 41

Mandibular fractures

Answer 41

Surgery: involves immobilization through wiring the jaws x 4-6 weeks WIRE CUTTERS SHOULD ALWAYS BE WITH THE PATIENT If the pt vomits/ chokes, the pt should: - Bend his head over to the side to allow the vomitus to flow out of the mouth/ nose - Allow the nurse to suction to clear the nose/ mouth

Question 42

What are post op care priorities for mandibular fractures?

Answer 42

Patent airway Oral hygiene Communication Pain management Adequate nutritions

Question 43

Amputation: Ortho surgery

Answer 43

Linked to PVD, atherosclerosis and vascular changes r/t diabetes Amputation in younger patients usually r/t trauma Vascular studies: arteriography, Doppler studies and venography Phantom limb pain very common (60-100%) Prosthesis fitting not possible until all edema is gone Compression bandaging worn at all times (except bathing)

Question 44

What is the goal of amputation?

Answer 44

to preserve extremity length and function while removing all infected, pathological or ischemic tissues

Question 45

Arthroplasty: Joint surgery

Answer 45

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

Question 46

THA

Answer 46

provides significant relief of pain and improvement of function for pts w OA, RA, etc

Question 47

TKA

Answer 47

Unremitting pain and instability as a result of severe destructive deterioration of the knee joint is the main indication for TKA

Question 48

What are common complications for arthroplasty?

Answer 48

Infection r/t aerobic streptococci and VTE

Question 49

Osteomyelitis

Answer 49

Severe infection of the bone, bone marrow and surrounding soft tissue Most common organism is staph aureus Direct (open wound) vs. indirect entry

Question 50

Acute Clinical manifestations

Answer 50

Less than one month in duration Systemic: fever, chills, night sweats, nausea, restlessness Local: unrelieved pain – worse with movement, swelling, warmth at site, limited ROM

Question 51

Chronic clinical manifestations

Answer 51

Longer than one month – either a continuous problem or series of remissions and recurrences Less systemic signs – continued local signs Scar tissue forms (impenetrable to antibiotics) Risk of septicemia, septic arthritis and unhealed fractures

Question 52

Treatment for Osteomyelitis

Answer 52

Dx: Hx&Physical, Labs, cultures, biopsy, x-ray Bone scan is the gold standard Tx: Vigorous and prolonged IV antibiotic therapy (only if bone ischemia has not occurred) – for 4-6 weeks at home, or up to 3-6 months (PICC or central line required). Surgery – debridement, irrigation and suction Amputation indicated in refractory cases