1. UNIT 4 Nursing Care of Clients With Musculoskeletal Disorders

2. This Class: Fractures: Types Management & complications
Traction (Skin and Skeletal)
Casts (Compartment Syndrome, Infection, Cast Syndrome)

3. Class Objectives:
Describe the anatomy and physiology of the musculoskeletal system including the significance of health history.
Discuss the significance of assessment and diagnosis of musculoskeletal problems including diagnostic tests.
Explain the pathophysiology, manifestations, complications & collaborative care of clients with fractures.
Describe the preventative health teaching needs of the client with a cast.
Describe the various types of traction and appropriate nursing care.

4. Class Objectives Cont’d:
Compare the nursing needs of the client undergoing a THR with those undergoing a TKR
Discuss the etiology, pathophysiology, prevention and management of clients with osteoporosis.
Identfy the causes and related nursing management of osteomalacia and Pagets’s disease.
Discuss the pathophysiology, manifestations, complications & collaborative care of clients with arthritis, gout, spinal cord deformities, septic arthritis.

5. Readings: Read in your text Chapters 66, 67, 68, & 69
Recommended readings
Bibliography list
Fractures

6. Fractures Read text content dealing with fractures
Know what a closed, open,displaced comminuted, impacted, & greestick fractures are.
Note the risk factors & levels of prevention r/t #
Review the stages of healing
Know neuromuscular assessment
What causes muscle spasm following #s and what are the consequences?

7. A fracture is “any disruption in the continuity of the bone, when more stress is placed on it than it can absorb”. (Black, Hawkes & Keene, 2001, p587).
When # occurs, muscles are also disrupted & pull fracture fragments out of position.
Adjacent structures are affected – soft tissue edema, hemorrhage, joint dislocations, ruptured tendons, severed nerves, damaged blood vessels
Large muscle groups create massive spasms, the proximal portion remains intact while the distal portion can be displaced in response to force and spasm.
The amount of force necessary depends on the characteristics of the person’s bone.
Examples of conditions that predispose people to #s include: osteoporosis, osteopenia (caused be steroid use or Cushing's syndrome), neoplasms, estrogen loss.

8. FRACTURES Fractured clavical
Bone almost penetrating skin at tip of red arrow

9. Classification of Fractures: (See Chart 69-1)
Open: (compound or complex) break in tissue over site of the bone injury
Complete: break across entire cross-section of bone & often displaced
Incomplete: (greenstick) though only part of the cross-section
Closed: (simple) intact skin over site of injury
Comminuted: produces several bone fragments
Open: break in tissue over site of the bone injury Grade I, II, or III
Complete: break across entire cross-section of bone & often displaced
Incomplete: though only part of the cross-section (greenstick)
Closed: intact skin over site of injury
Comminuted: produces several bone fragments

10. Simple: # remains contained, no skin break (closed)
Compound: # damage also involves the skin or mucous membranes (open)
Comminuted: bone has splintered into several fragments
Greenstick: one side of bone is broken and the other side is bent
Depressed: bone fragments are driven inward.
Types
Avulsion: # in which a fragment of bone has been pulled away by a ligament or tendon and its attachment.
Oblique: # occurs at an angle across the bone (less stable than a transverse)
Spiral: # twists around the shaft of the bone
Impacted: # in which a bone fragment is driven into another bone fragment.
Transverse: # across the bone
Compression: # # in which the bone has been compressed (Vertebral #s)

11. Physical Assessment may reveal:
Deformity (hemorrhage or spasm)
Shortening
Swelling
Ecchymosis
Muscle spasm
Pain, tenderness
Loss of function, altered mobility & crepitus
Neurovascular changes
shock

12. Signs and Symptoms

13. Complications Fat Embolism Syndrome
Fat globules (emboli) occlude small vessels of lungs, brain, kidneys, & other organs
Characterized by neurologic dysfunction, pulmonary insufficiency, and petechial rash on chest, axilla & upper arms
Long bone # & other major trauma ( such as THR) are the principle risk factors
Most frequently in young adults (20-30 years of age)
When a bone is fractured, pressure within the bone marrow rises & exceeds capillary pressure; fat globules leave the marrow & enter bloodstream, it may also be caused by the stress induced release of catecholamine, which causes the rapid immobilization of fatty acids. Once fat globules are released they travel to the brain, kidney, lung & other organs, occluding small blood vessels - - causing ischemia.

14. Fat Embolism Syndrome What to Look for:
Manifestations of fat emboli occur within hours but may be up to a week after injury:
Hypoxia PaO2 < 60 mm Hg
Tachypnea, tachycardia, pyrexia
Deterioration in LOC
Confusion , agitation
Respiratory distress response – tachypnea, dyspnea, crackles, wheezes, precordial chest pain, copious thick white sputum, tachycardia
petechiae: chest, shoulders, axilla, mouth, conjunctival sac

15. Fat Embolism: Prevention:
Immobilize fractures: early & gentle stabilization
Gentle care
Adequate hydration O2
Aware of those at high risk
Management:
Fluid replacement
Mechanical ventilation
Corticosteroids
Vasoactive medications
Maintain Hgb
Calm, supportive environment

16. Monitor Respiratory Status Every Shift.
Immobility increases risk for Atelectasis, DVT and Pulmonary Emboli.
Never ignore client's complaints.
Follow-through and check it out.
Fifty percent (50%) of persons with fat emboli die.
Nurse Alert!

17. Complications
Infection Musty, unpleasant odor over cast and/or at the ends of cast
Drainage through cast or cast opening
Sudden unexplained body temperature elevation
“Hot Spot” felt over cast lesion
May result in osteomyelitis

18. Interventions: Infection
Wash hands
Use aseptic technique when caring for wound and emptying drains
Culture drainage
Foley catheter care
Monitor temp
Report excessive drainage or inflammation to physician

19. Complications
Watch out for Deep Vein Thrombosis after skeletal or muscular injury/surgery!
Other Early Complications
Deep vein thrombosis (DVT), thromboembolism, and pulmonary embolus (PE) are associated with reduced skeletal muscle contractions and bed rest. Patients with fractures of the lower extremities and pelvis are at high risk for thromboembolism. Pulmonary emboli may cause death several days to weeks after injury. (See Chapter 31 for a discussion of DVT; Chapter 30 for discussion of thromboembolism, and Chapter 23 for discussion of PE).
Disseminated intravascular coagulopathy (DIC) includes a group of bleeding disorders with diverse causes, including massive tissue trauma. Manifestations of DIC include ecchymoses, unexpected bleeding after surgery, and bleeding from the mucous membranes, venipuncture sites, and gastrointestinal and urinary tracts. The treatment of DIC is discussed in Chapter 33.

20. Intervention: DVT/PE/FES
Client wears elastic stockings.
Teach leg exercises.
Observe for changes in mental status, chest pain and SOB.
Observe for swelling, redness and pain in legs (DO NOT MESSAGE).

21. Muscle Spasm:
Powerful involuntary muscle contractions shorten the flexor muscles & cause extreme pain. This may be triggered by hypoxia of muscle tissue.

22. What Helps? Bed cradle Heat Avoid heavy sedation
Avoid pressure in popiteal space
Minimize compression
Active & passive exercises as ordered
Frequent change in position

23. Fracture: Early Complications
Critical monitoring & assessment is imperative. Know assessment findings that may indicate one of the following early complications of fractures. Question waiting for a place to happen !!!!
Shock
Nerve damage, arterial damage
Infection
Cast syndrome
Compartmental Syndrome
Volkmann’s Contracture
Fat Embolism Syndrome
Deep Vein thrombosis & Pulmonary Embolism NB

24. Long-term Complications
Joint stiffness or post-traumatic arthritis
Avascular necrosis
Nonfunctional union after a fracture
Complex regional pain syndrome
Reaction to internal fixation device
A loss of the bone’s blood supply causes avascular necrosis (AN) - the bone dies & bone structure collapses . Femoral neck fractures which damage local blood vessels, increase the risk of avascular necrosis. Long term high dose steroids also increase risk. Symptoms of AN include pain & reduced ROM in affected joint. Heparin, Lasix & NSAIDs aren’t associated with AN.

25. Avascular Necrosis

26. Complications of Fractures:
Shock
Bones are very vascular. In combination with collateral damage to adjacent structures/vessels, the patient is at risk for hemorrhage.
Shock fully develops if a healthy client loses 1/3 of normal blood volume.
Blood loss:
15-30% (up to 1500 ml) -subtle signs
30-40% ( ml) –obvious shock
Over 40% (over 2000 ml)
1 unit of packed cells raises Hgb about 1 gram. Check with physician about expected normal loss.

27. Potential Blood Loss Following Fractures (Liters)
Humerus
1-2
Elbow
.5-1.5
Forearm
.5-1
Pelvis
Hip
Femur
Knee
1-1.5
Tibia
Ankle
Spine/ribs
1-3
This is not what is expected but what is possible!

28. See Text 1) Compartment Syndrome 2) Cast Syndrome 3) Infection
What?
How to recognize?
What should be done?

29. Fracture Reduction Closed reduction: usually done under anesthesia
Carried out through manual traction to move fracture fragments & restore bone alignment
Followed by immobilization device (cast)
Open Reduction: incision and realignment
Usually performed with internal fixation devices (screws, pins, plates, wires)

30. Closed vs. Open Reduction

31. Fracture Reduction Cont’d
External Fixation: maintain position for unstable fractures & for weakened muscles, allow for use of contiguous joints while affected part remains immobilized. Common sites include face & jaw, pelvis, fingers.
Traction: application of a pulling force to an injured body part or extremity while a counter-traction pulls in the opposite direction.

32. External fixation

33. Figure 27-3: Types of Internal Fixation Devices
Tension band wiring # phalanx
Compression plate & screws # femur
Intermedulary nail - femur

34. Open reduction and internal fixation of Comminuted mandibular fracture

35. CASTS
Review information learned in 2nd & 3rd year. At this point you should know
Types of casts
Why a cast may need to be Bi-valved
Drying & caring for a cast
Complications caused by casts …
Management of Casts & Braces
Importance of knowing weight bearing status
NB!

36. Windowing and Bivalving a Cast
Windows maybe cut in dried casts:
relieve pressure from abd. distension (body cast)
To prevent “Cast Syndrome”
To assess radial pulse (check circulation in a casted arm)
To inspect areas of discomfort or areas of suspected tissue damage
To remove drains or care for wounds.

37. Bivalving a Cast Window Cast

38. Cast Drying:
Synthetic casts – dry approx mins (clients feel the sensation of heat thus may feel hot).
Plaster casts set rapidly but take several hrs-days to completely dry (lg. cast).
Promote the circulation of warm, dry air around a damp cast to enhance moisture evaporation and speed drying process.
Heat occurs with early cast drying stages
Do not cover cast while drying, can place layers of towels underneath pillow to elevate cast to absorb dampness.
Green cast (damp cast)
Lg. cast avoid covering and to allow air to circulate
Never use heated hairdryer to dry cast.

39. Nerve Damage during casts/traction:
Traction applied to an extremity puts pressure on the peroneal nerve where it passes around the neck of the fibula to just below the knee.
Pressure at this point may cause footdrop, leading to inability to dorsiflex the foot.
Inability to plantarflex indicates damage to the tibial nerve.
The calf muscle is not affected & the temp of extremity doesn’t change.

40. Assess for complications following cast :
Compartment syndrome
Fat emboli
Infection
DVT
Cast syndrome

41. Complications of Fractures/Casts
Compartmental Syndrome:
Edema from a fracture causes an increase in compartmental pressure that decreases capillary blood perfusion.
When the local blood supply unable to meet tissue metabolic demands ischemia begins = compromised circulation.
Increase pressure in a confined space due to tight cast, edema or bleeding.

42. Complications of Fractures/Casts
Compartmental Syndrome:
Pulselessness: slow nail bed capillary refill (>3sec)
Skin pallor, blanching, cyanosis or coolness
Increasing pain, swelling,pain on passive motion, painful edema peripheral to cast.
Paresthesias (tingling, pricking), heightened sensation to touch, diminished sensitivity to touch (hypesthesia), anesthesia (numbness)
Motor paralysis to previous functioning muscles
Exam: What are the 4 classic signs/symptoms of a fracture? What is the associated vascular injury that may occur? 
Pain, loss of function, deformity, shortening, crepitus, swelling and discoloration. Complications that can occur with fractures: Shock, fat embolism syndrome, compartment syndrome, avascular necrosis of the bone
A compartmental syndrome is a condition in which increased pressure within a limited space compromises the circulation and function of the tissues within that space. This condition is a cause of major loss of function, limb and even life. It can result from trauma, prolonged recumbancy (in surgery or resulting from drugs or alcohol), or physical activity. It is common enough to affect thousands of individuals each year, yet rare enough that each physician may encounter it only once or twice during his or her career

43. Compartmental Syndrome Swelling out of control

44. Compartment Syndrome Treatment
Fasciotomy
RELEASE PRESSURE
RELIEF
CUT OPEN

45. Complications Cont’d
Figure 27-6: Cast Syndrome
Cast syndrome results from the compression of the duodenum between the aorta and the superior mesenteric artery. The external compression is usually caused by a tight body cast.
Black 2001, p. 601) .

46. Complications Cont’d Cast Syndrome: Bloating feeling
Prolonged nausea: repeated vomiting
Abdominal distension: vague abdominal pain
Shortness of breath
Untreated may lead to death!

47. Cast Syndrome
An abdominal flat-plate is ordered. If you diagnosed the cast syndrome, you correctly identified the clinical signs consistent with this syndrome.  This is due to an extrinsic compression of the third portion of the duodenum by the superior mesenteric artery

48. Other Complications Cont’d
Infection: Musty, unpleasant odor over cast and/or at the ends of cast
Drainage through cast or cast opening
Sudden unexplained body temperature elevation
“Hot Spot” felt over cast lesion
May result in osteomylitis

49. Complications Cont’d Volkmann’s Contracture:
A common complication of elbow fractures
Can result in unresolved compartment syndrome. Arterial blood flow decreases, leading to ischemia, degeneration & contracture of muscle
May lead to permanently stiff, claw-like deformity of arm & hand

50. Volkmann’s Contracture

51. Complications Cont’d NB FAT EMBOLISM:
Fat emboli occur when fat globules lodge in the pulmonary vascular bed or peripheral circulation. Fat embolism syndrome (FES) is characterized by neurologic dysfunction, pulmonary insufficiency, and petechial rash on chest, axilla & upper arms. Long bone # & other major trauma ( such as THR) are the principle risk factors
When a bone is fractured, pressure within the bone marrow rises & exceeds capillary pressure; fat globules leave the marrow & enter bloodstream, it may also be caused by the stress induced release of catecholamine, which causes the rapid immobilization of fatty acids. Once fat globules are released they travel to the brain, kidney, lung & other organs, occluding small blood vessels - - causing ischemia.

52. Fat Embolism: Beware!!
When a bone is fractured, pressure within the bone marrow rises & exceeds capillary pressure; fat globules leave the marrow & enter bloodstream, it may also be caused by the stress induced release of catecholamine, which causes the rapid immobilization of fatty acids. Once fat globules are released they travel to the brain, kidney, lung & other organs, occluding small blood vessels - - causing ischemia.

53. Fat Emboli: Fat globules within the
pulmonary arterioles. The globules stain reddish-orange. The cumulative effect of these globules is similar to a large pulmonary embolus, but the onset is usually 2 to 3 days following the initiating event, such as the trauma associated with bone fractures.

54. Monitor respiratory status every shift.
Nurse Alert:
Immobility increases risk for fat embolism, atelectasis, and pulmonary emboli. Never ignore client's complaints. Follow-through and check it out.
Fifty percent 50% of persons with fat emboli die.

55. WHAT TO LOOK FOR:
Manifestations of fat emboli occur within a few hours to weeks after injury:
deterioration in LOC
confusion , agitation
SOB
petechiae: Chest, axilla, mouth, conjunctival sac
atelectasis may result
signs of shock- tachycardia, tachypnea
Hypoxia Po2 < 60 mm Hg

56. Fat Embolism: Fat globulins released from long bone pelvis or multiple fractures
Prevention:
Immobilize fractures: early & gentle stabilization
Gentle care
Adequate hydration O2
Management: O2
Fluid replacement
Mechanical ventilation
Corticosteroids
Maintain Hgb

57. Complications Cont’d Neuro-vascular problems
Early detection may mean no or slight disability in the future. Assess carefully & knowingly!

58. Who is at Risk for Neurovascular Problems?
Those with/who:
External fixators
Interstitial edema/bleeding
Excessive exercise
Trauma to joint/limb
Casts, Splints, Constrictive Dressings
Medical Procedures (heart cath)
Traction
Spinal Surgery/injury
Tissue compression

59. KNOW the SIX Ps: Cast Assessment
Pain
Pallor
Paresthesia
Pulselessness
Paralysis
Polar
They alert you to problems!
Compartment Syndrome??
Infection??
Cast Syndrome??

60. Assess
Monitor neurovascular status of distal aspects of involved extremities in comparison with corresponding body part after the initial post op period & every 2 hours for the following 24 hours and every 4 to 12 hours thereafter (according to agency policy). Nurse Alert: Irreversible tissue death occurs in 4 to 12 hours.
Inspect color and temperature.
Monitor for edema caused by tissue trauma or venous stasis.
Assess capillary refill by pressing on toe or fingernail, releasing, and noting "pinking" on nail within 3 seconds

61. Complications Cont’d
Watch out for Deep Vein Thrombosis after skeletal or muscular injury/surgery!

62. Hemorrhage: Know what it means!
Stage I up to 15% (up to 750 ml)
Stage II 15-30% (up to 1500 ml) -subtle signs
Stage III 30-40% ( ml) –obvious shock
Stage IV over 40% (over 2000 ml)

63. Complications Cont’d Blood Loss in Fractures
Bones are very vascular. In combination with collateral damage to adjacent structures/vessels, the patient is at risk for hemorrhage.
Shock fully develops if a healthy client looses 1/3 of normal blood volume.
7 - 8% of body wt is blood. An adult has about 5.5 L of blood.
10% volume loss = tachycardia
30% loss affects B.P
1 unit of packed cells raises Hgb about 1 gram. Check with physician about expected normal loss.

64. Potential Blood Loss Following Fractures (Liters)
Humerus 1-2
Elbow
Forearm .5-1
Pelvis
Hip
This is not what is expected but what is possible!
Femur 1-2
Knee 1-1.5
Tibia
Ankle
Spine/
ribs 1-3
Check with surgeon to determine extent of expected blood loss
Interventions: Bleeding
Vitals q4h.
Assess for bleeding.
Report excessively low BP.

65. Watch for Blood loss post op For Example
In the client with a total hip replacement (THR) the total amount of drainage is usually less than 50 ml every 8 hours, it may be a bit more if the client received a plasma expander such as dextran.
Drains are usually removed within hours post surgery.

66. SPASM Muscle Spasms Interventions:
Powerful involuntary muscle contractions shorten the flexor muscles & cause extreme pain. This may be triggered by hypoxia of muscle tissue.
What helps?
Bed cradle
Heat
Avoid heavy sedation
Avoid pressure in popliteal space
Minimize compression
Active & passive exercises as ordered
Frequent change in position
SPASM

67. Interventions: Infection
Wash Hands.
Use aseptic technique when caring for wound and emptying drains.
Culture drainage.
Foley catheter care
Monitor temp.
Report excessive drainage or inflammation to physician.

68. Intervention: DVT/PE/FES
Client wears elastic stockings.
Teach leg exercises.
Observe for changes in mental status, chest pain and SOB.
Observe for swelling, redness and pain in legs (DO NOT MESSAGE).
Fat embolism is the most lethal complication of THR.

69. Interventions: Bleeding
Vitals q4h.
Assess for bleeding.
Report excessively low BP.

70. Intervention: Pain Management
Encourage client to report hip pain immediately.
Promote adequate rest through out the day.
Administer oral analgesics PRN.

71. Traction What is used traction for?
What is the difference between Skeletal & Skin traction?
What would the nurse assess for that is particular to each type?
Differentiate between the following types of traction & give an example of each:
Continuous & Intermittent
Running & Suspension
Skeletal/ Skin/ Cervical
Russell’s & Buck’s

72. Traction serves several purposes:
It aligns the ends of a fracture by pulling the limb into a straight position.
It ends muscle spasm.
It relieves pain.
It takes the pressure off the bone ends by relaxing the muscle.
important to know!

73. Skin Traction: http://www.youtube.com/watch?v=2ZEWz_Ps7vo
Apply traction to underlying bones and other structures (muscles).
Used :
1. with commercially prepared foam slings
2. by encircling a body part with a halter, corset or sling.
Counteraction is provided by a persons wt. when the bed is tilted away from the pull.
Skin Traction: Application of a pulling force directly to the skin through the use of strips, boots or foam splints. Skin traction bears a low longitudinal force load (5-7 lbs) which gives minimal effectiveness.
Temporarily should be used due to skin bkdn. NB

74. Buck’s SKIN TRACTION
Skin traction uses 5 to 7 pound weights attached to the skin to indirectly apply the necessary pulling force on the bone. If traction is temporary, or if only a light or discontinuous force is needed, then skin traction is the preferred treatment. Because the procedure is not invasive, it is usually performed in a hospital bed.
Bucks Traction: exerted by a straight pull on one or both legs. Can be used to immobilize a limb for a short time (# hip prior to surgery) or reduce muscle spasms.
Prefabricated boot used
Continuous traction unless otherwise stated by Dr.
If wt to be removed , manual traction applied until wts. Replaced.

75. Skeletal Traction:
Is accomplished by surgically inserting metal wires or pins thru distal bones to the # site or by anchoring metal tongs in the skull.
A traction bow is attached to wire or pin and traction force is applied .
Used to reduce unstable fractures of long bones

76. Balanced Skeletal Traction with Thomas Splint
Skeletal traction is performed when more pulling force is needed, or when the part of the body needing traction is positioned so that skin traction is impossible. Skeletal traction uses weights of pounds. It requires the placement of tongs, pins, or screws into the bone so that the weight is applied directly to the bone. This is an invasive procedure that is done in an operating room under general, regional, or local anesthesia.
Balanced suspension skeletal traction with Thomas leg splint. The patient can move vertically as long as the resultant line of pull is maintained.

77. Thomas Splint Picture

78. Balanced Skeletal Traction with Thomas Splint
Positioning the extremity so that the angle of pull brings the ends of the fracture together is essential. Weights must hang freely
Elaborate methods of weights, counterweights, and pulleys have been developed to provide the appropriate force, while keeping the bones aligned and preventing muscle spasm.
The patient's age, weight, and medical condition are all taken into account when deciding on the type and degree of traction.

79. Relative ease of use and ability to maintain comfort
Skin Traction
Advantage:
Relative ease of use and ability to maintain comfort
Disadvantage:
Wt required to maintain Normal body alignment or fracture alignment can not exceed 6 lbs per extremity.
Skeletal Traction
Advantage:
Increases mobility without threatening joint continuity. Easier to change linen, backcare
Disadvantage:
Need to use multiple wts makes client slide in bed more.

80. Skin & Skeletal Traction
Bucks

81. Risks
The main risks associated with skin traction are that the traction will be applied incorrectly, or that the skin will become irritated.
More risks associated with skeletal traction.
Bone inflammation.
Infection can occur at the pin sites.
Both types of traction have complications associated with long periods of immobility:
bed sores
reduced respiratory function
urinary & and circulatory problems
occasionally, fractures fail to heal
emotional toll of prolonged bedrest
Kidney/gallstones

82. More about traction
Positioning the extremity so that the angle of pull brings the ends of the fracture together is essential. Weights must hang freely
Elaborate methods of weights, counterweights, and pulleys have been developed to provide the appropriate force, while keeping the bones aligned and preventing muscle spasm.
The patient's age, weight, and medical condition are all taken into account when deciding on the type and degree of traction.

83. Check the four P's of traction maintenance:
Pounds: Inspect traction setup. Is the correct weight in place?
Pull: Is the direction of pull aligned with the long axis of affected bone?
Pulleys: Is the rope gliding smoothly over pulley?
Pressure: Are clamps and connections tight?

84. Assess, Assess, Assess
Assess client's knowledge of the reason for traction, including nonverbal behavior and responses.
Assess integrity and condition of skin over bony prominences and under devices in use.
Assess client's overall health condition, including degree of mobility, ability to perform ADLs, and current medical conditions.
Assess client's level of pain and need for analgesics before procedure begins.
Assess for respiratory dysfunction

85. USUAL PIN SITE CARE
With gloves remove gauze dressings from around pins
Inspect sites for drainage or inflammation.
Prepare supplies and apply new gloves.
Clean each pin site with NaCl by placing sterile applicator close to the pin and cleaning away from the insertion site. Dispose of applicator.
Continue process for each pin site.
Using a sterile applicator, apply a small amount of topical antibiotic ointment as ordered
Provide pin site care according to hospital policy/ Dr. orders.
Cover with a sterile 2 X 2 split gauze dressing or leave site open to air (OTA) as prescribed

86. More care for traction client
Assess level of discomfort and provide nonpharmacological and pharmacological relief as indicated.
Encourage active and passive exercises and use of unaffected extremities for ADLs.
Encourage us of trapeze bar for repositioning in bed.
Provide a fracture pan for elimination prn
Evaluate effectiveness of care & need for intervention

87. Care of the Client in Traction
When caring for a client in continuous, balanced, skeletal traction with a Thomas Splint what should the nurse know? Wow, what a question!
Consider skin, infection, personal care, ROM/exercises
Care of ropes, pulleys
What to do when transporting client/bed elsewhere

88. Nerve damage during traction
Traction applied to an extremity puts pressure on the peroneal nerve where it passes around the neck of the fibula to just below the knee.
Pressure at this point may cause footdrop, leading to inability to dorsiflex the foot.
Inability to plantarflex indicates damage to the tibial nerve.
The calf muscle is not affected & the temp of extremity doesn’t change.

89. Specific Fractures Hip Fractures Condylar fractures Pelvic fractures
Patellar fractures
Tibial & fibular fractures
Foot fractures
Upper extremities
Please review Pages for care of specific fractures

90. Sports Injuries Common Overuse injuries: Lower Extremities:
Stress fractures (common in tarsal bones)
Plantar fasciitis (damage of long ligament that attaches to the sole of the heal bone)
Shin splints (medial tibial area)
Patellar tendinitis (jumper’s knee)
Upper Extremities
Tennis elbow
Tendinitis (hand & wrist)
Strains & sprains
Over-use syndromes are common sports-related problems that arise from micro trauma that do not completely stop the affected person’s activities.
Strains: trauma to a muscle body or to the attachment to a tendon from over-strerching, overextension,, or misuse. May be acute or chrionic. Splinting, cold (first 24 to 48 hours) then heat (after 72 hours)
Sprains: overstress of ligaments, may be mild or severe. Treatment is physio to surgery.

91. Sports Injuries Cont’d
Rotator cuff tears
Shoulder muscle injury
Anterior cruciate ligament injuries
Tear of ACL
Meniscal injuries
Rotator cuff: NSAIDS,, strengthening physio, possible surgery
ACL: Arthroscopy is diagnostic as well as treatment
Meniscal: surgical

92. Arthroscopy Same day surgery.
Mostly preformed on knee and shoulder by use of a fibroptic arthoscope
Candidates for surgery are people who can flex their joint greater than fourty degrees and the joint is infection free.
Used for obtaining a Biopsy, assessing cartilage, removing loose bodies & trimming cartilage.
Infection is the major complication to arthroscopy.

93. Complications of Arthroscopy:
Infection
Blood in joint (hemarthrosis
Swelling
Synovial rupture
Joint injury
Thrombophlebitis.

95. By the time a person presents with complaints of numbness, paresthesias, pain, or motor deficit, nerve damage has progressed to the stage of larger fiber sensory and/or motor loss.
The median nerve shares confined space with nine flexor tendons as it travels through the carpal tunnel. Any condition which reduces that space is likely to cause CTS due to compression of the vulnerable median nerve.

96. Any solution which relieves pressure on the nerve and promotes circulation in the microvascular neural blood supply is likely to "cure" CTS and relieve its attendant symptoms of pain, etc.

97. DUPUYTREN'S CONTRACTURE
A painless thickening of the connective tissue in the palmar hand that can lead to difficulty extending the digits. Causes include hand trauma and genetic predisposition.
Painless nodule on the palm,
Cord-like bands across the palm & thickening of the lines of the palm, and curling (contracture) of the 4th and 5th digits.

98. Surgery is performed in some cases unresponsive to conservative measures such as (splinting, warm soaks, exercises).

99. Neurovascular Assessment:
Questions to Consider:
1. Discuss why neurovascular assessment is so important. Your answer should include consideration of the three components of neurovascular assessment: Circulation, Motor Function, & Sensation, as well as discussion of the 6Ps of neurovascular assessment.
2.Who is most at risk for problems of the peripheral nervous system/blood flow?
***

100. Explanation
A loss of the bone’s blood supply causes avascular necrosis (AN) - the bone dies & bone structure collapses . Femoral neck fractures which damage local blood vessels, increase the risk of avascular necrosis. Long term high dose steroids also increase risk. Symptoms of AN include pain & reduced ROM in affected joint. Heparin, Lasix &NSAIDs aren’t associated with AN.