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Musculoskeletal Care Modalities. Managing care of the patient in Cast:  A rigid, external immobilizing device  Is used to: 1.Immobilize a reduced Fracture.

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Presentation on theme: "Musculoskeletal Care Modalities. Managing care of the patient in Cast:  A rigid, external immobilizing device  Is used to: 1.Immobilize a reduced Fracture."— Presentation transcript:

1 Musculoskeletal Care Modalities

2 Managing care of the patient in Cast:  A rigid, external immobilizing device  Is used to: 1.Immobilize a reduced Fracture ( allow the mobilization of the pt) 2.Correct a deformity 3.Apply uniform pressure to underlying soft tissue 4.Support and stabilize weakened Joint

3 Types of Casts: 1.Short arm cast 2.Long arm cast 2.Short leg cast 3.Long leg cast 3.Walking cast ( long or short) reinforced for strength 4.Body cast: encircle the trunk 5.Shoulder spica cast: a body jacket that enclosed the trunk and the shoulder and elbow 6.Hip spica cast: enclose the trunk and lower extremity ( double hip spica cast ( includes both legs

4 Casting Materials: Plaster: Rolls of plaster bandage, need 24 to 72 hrs to dry completely Nonplaster: Fiberglass cast ( lighter in wt, stronger, water resistant), has pores so diminish skin problems





9 Long-Arm and Short-Leg Cast and Common Pressure Areas

10 Teaching Needs of the Patient With a Cast  Prior to cast application Explain condition necessitating the cast Explain purpose and goals of the cast Describe expectations during the casting process: eg, the heat from hardening plaster  Cast care: keep dry; do not cover with plastic  Positioning: elevation of extremity; use of slings  Hygiene  Activity and mobility

11 Cont …  Explain exercises  Do not scratch or stick anything under the cast  Cushion rough edges  Report the following signs and symptoms: persistent pain or swelling; changes in sensation, movement, skin color, or temperature; and signs of infection or pressure areas  Required follow-up care  Cast removal

12 Nursing Process — Assessment of the Patient With a Cast  Prior to casting Perform general health assessment Evaluate emotional status Determine presenting signs and symptoms and condition of the area to be casted  Knowledge  Monitor neurovascular status and the potential for complications

13 Nursing Process — Diagnosis of the Patient With a Cast  Deficient knowledge  Acute pain  Impaired physical mobility  Self-care deficit  Impaired skin integrity  Risk for peripheral neurovascular dysfunction

14 Collaborative Problems/Potential Complications  Compartment syndrome  Pressure ulcer  Disuse syndrome  Delayed union or nonunion of fracture(s)

15 Interventions  Relieve pain Elevate to reduce edema Apply ice or cold intermittently Implement position changes Administer analgesics  Unrelieved pain may indicate compartment syndrome; discomfort due to pressure may require change of cast  Muscle setting exercises: see Chart 67-3  Patient teaching: see Chart 67-4

16 Interventions (cont.)  Heal skin wounds and maintain skin integrity Treat wounds to skin before the cast is applied Observe for signs and symptoms of pressure or infection Pad cast and cast edges  Patient may require tetanus booster  Maintain adequate neurovascular status Assess circulation, sensation, and movement Five “ P ’ s ” Notify physician at once of signs of compromise Elevate extremity no higher than the heart Encourage movement of fingers or toes every hour

17 Managing patient with an External fixator:  Are used to manage open fractures with soft tissue damage. They provide stable support for severe comminuted (crushed or splintered) fractures while permitting active treatment of damage soft tissue.  Nursing intervention:  Prepare the patient psychologically  Cover sharp points on the fixator or pins to prevent injuries  Elevate the extremity to reduce swelling  Assess neuromuscular status every 2 hrs  Assess pin site for sign of infection and loosening of the pin  Pin care  Encourage isometric and active exercise within the limit of tissue damage. Later the nurse help the patient to mobilize within the prescribed weight bearing limit  Teaching patient self care

18 External Fixation Devices (cont.)


20 Managing the patient in Traction:  Is used as short-term intervention until other modalities, such as external or internal fixation are possible.  Traction: is the application of a pulling force to a part of the body  Is used to minimize muscle spasm, to reduce fractures, align and immobilize fractures, to reduce deformity.  The effect of traction is evaluated by radioactive studies.

21 Traction (cont.)  All traction needs to be applied in two directions. The lines of pull are “ vectors of force. ” The result of the pulling force is between the two lines of the vectors of force.

22 Managing the patient in Traction (cont … ):  Principle of effective traction: 1.Countertraction must be maintained for effective traction 2.Must be continuous to be effective 3.Never interrupted 4.Weight are not removed 5.The patient must be in in good body alignment in the center of the bed 6.Ropes must be unobstructed 7.Weight must hang freely

23 Types of tractions: I. Skin traction: is used to control muscle spasm and to immobilize an area before surgery. No more than kg of traction should be used, pelvic traction 4.5 to 9 kg depending on the patient weight  Complications:  Skin breakdown, nerve pressure (drop foot), and circulatory impairment ( DVT)  Nursing interventions: 1.Ensuring effective traction 2.Monitor and managing potential complications

24 Skin Traction

25 Types of tractions (cont … ): II. Skeletal traction: applied directly to the bone by using metal pin or wires. Most frequently used to treat fracture of long bones and the cervical spine. Is a surgical procedure. Skeletal traction uses 7-12 kg, as the muscle relax the traction weight is reduced to prevent fracture dislocation and to promote healing  After removing the traction cast or splint are then used to support the healing bone.

26 Skeletal Traction

27 Nursing Interventions: 1.Maintaining effective traction: the nurse should not remove wt from skeletal traction unless life-threatening situation occurs 2.Maintaining positioning: such as the foot to prevent footdrop (planter flexion), inward and outward rotation. 3.Preventing skin breakdown 4.Monitoring neuromuscular status 5.Providing pin site care 6.Promoting exercise Assess sensation and movement Assess pulses, color capillary refill, and temperature of fingers or toes Assess for indicators of DVT Assess for indicators of infection

28 Joint Replacement:  Total Hip Replacement: Is the replacement of a severely damaged hip with an artificial joint  Indication: arrithritis, femoral neck fracture, failure of previous reconstructive surgeries, and problems resulting from congenital hip diseases.



31 Cont …  Nursing interventions: 1.Prevent dislocation: A.positioning the leg in abduction, B.don ’ t turn the patient in the affected side, C.never flex the hip more than 90 degree ( D.don ’ t elevate the head of the bed more than 60 degree E.protective positioning include maintaining abduction, avoiding internal and external rotation, hyperextension, and a cute flexion

32 Cont ……. 2. Monitoring wound drainage 3. Preventing DVT 4. Prevent infection 5. Teach patient self care 6. Continuing care

33 Total knee replacement: Indication: sever pain and functioning disabilities related to joint surfaces destroyed by arrithritis, bleeding into the joint  Nursing interventions: 1.Maintain the compressed bandage over the knee 2.Ice may be applied to decrease the swelling and bleeding 3.Encourage active flexion of the foot every hour 4.Prevent complications 5.Monitor drainage bag 6.Place the patient leg in continuous Passive motion device ( promote circulation and movement of the knee joint) 7.Weight bearing limits are prescribed. Patient can get out of the bed the evening of the surgery or the day after surgery


35 CPM Device

36 (chap 68) Management of patient with musculoskeletal disorders

37 Acute low Back pain:  Causes: 1.A cut lumbosacral strain, 2.unstable lumbosacral ligaments and weak muscles, 3.osteoarithritis of the spine, 4.spinal stenosis, intervertebral disk problems, 5.and unequal leg length. 6.Other causes include kidney diorders, pelvic problems, retroperitoneal tumors, abdominal aneurysims, obesity and stress.  L4-L5 and L5-S1 has the greatest degenrative changes

38 Clinical manifestations:  A cute or chronic back pain lasting more than 3 months without improvement)  Fatique  Pain radiating down the leg ( radiculopathy; Sciatica)  Patient ’ s gait, spinal mobility, reflexes, leg length, leg motor strength and sensory perception may altered

39 Cont …  Assessment and diagnostic findings:  Focused history and physical examination ( reflexes, sensory impairment, straight leg raising, muscle strength  X-ray of the spine, CT scan, MRI  Bone scan and blood study  Myelogram and dicogram  Electromyogram and nerve conduction studies  Medical management: Analgesia, rest, stress reduction and relaxation  Review the Nursing process

40 Positioning to Promote Lumbar Flexion

41 Proper and Improper Lifting Techniques

42 Proper and Improper Standing Postures

43 Carpal Tunnel Syndrome  Median Neuropathy at the Wrist is a medical condition in which the median nerve is compressed at the wristmedian nervewrist Irritation of the flexor tendon and median nerve Manifestations Numbness and tingling  Thumb  Index finger  Lateral ventral surface of the middle finger

44 Tinel ’ s Sign — Assessment of Carpal Tunnel Syndrome

45 Dupuytren ’ s Contracture

46 Carpal Tunnel Syndrome Risk Factors  Computer use  Jackhammer operation  Mechanical work  Gymnastics  Radial bone fracture history  Rheumatoid arthritis

47 possible treatments:  treating any possible underlying disease or condition, immobilizing braces, physiotherapy, massage therapy, medication  Ultimately, carpal tunnel release surgery may be required in which outcomes are generally good

48 Metabolic bone disorders: I.Osteoporosis:  Is characterized by a reduction in the total bone mass and a changes in bone structure which increases the tendency for fracture.  The rate of bone resorption is greater than the rate of bone formation, resulting in a reduced total bone mass.  The bones become porous, brittle, and fragile  Result in compression fractures of the thoracic and lumber spine, fractures of the neck, intertrochanteic region of the femur, and colle ’ s fracture of the wrist  Pathophysiology:  Loss of bone mass over time due to Aged-related loss: Decreased calcitonin, decreased estrogen ( which prevent bone breakdown), parathyroid hormone increases with age result in increase bone Resorption

49 Pathophysiology of Osteoporosis

50 Risk factors: see chart 68-7  Assessment and diagnostic findings:  Routine X-ray, and bone sonometer  Lab. Studies: Serum Ca, Serum Ph, urine calcium excretion, ESR  Medical Management:  Adequate balanced diet rich in calcium and Vit D  Regular weight bearing exercise promotes bone formation  Pharmacological therapy: Hormonal replacement therapy ( look for side effect of estrogen and progesterone replacement therapy which result in cancers … thus frequent breast examination is recommended )  Alendronate alternative to Hormonal replacement therapy: inhibiting osteoclast function and dedcreases bon loss  Calcitonin: suppress bone loss

51 Progressive Osteoporosis Bone Loss and Compression Fractures

52 Osteoporosis  Manifestations :  Loss of height  Progressive curvature of spine  Low back pain  Fractures of forearm, spine, hip  Development of “ dowager ’ s hump ” Dorsal kyphosis Cervical lordosis

53 Typical Loss of Height Associated With Osteoporosis and Aging

54 Prevention  Follow a balanced diet high in calcium and vitamin D throughout life  Use calcium supplements to ensure adequate calcium intake: take in divided doses with vitamin D  Regular weight bearing exercises: walking  Weight training stimulates bone mineral density (BMD)  See Chart 68-8

55 Musculoskeletal Infections: Osteomylitis  Is an infection of the bone through three ways ( extension of soft tissue infection, Direct bone contamination from bone surgery, Hematogenous spread (blood born).  More difficult to eradicate than soft tissue infection  Pathophysiology:  Staphylococcus aureus causes 70% to 80% of bone infection  Process of infection (inflammation, edema, thrombosis of the blood vessels result in ischemia with bone necrosis, which may progress to form bone abscess  Clinical manifestations: chills, high fever, rapid pulse, pain, swollen area, and tenderness and drainage  Assessment and diagnostic Findings:  X-ray (shows soft tissue swelling, later bone decalcification and necrosis), MRI, Lab test (leukocytosis, and increased ESR), wound and blood culture


57 Osteomyelitis  Deep sepsis after arthroplasty may be classified as follows:  Stage 1, acute fulminating: occurring during the first 3 months after orthopedic surgery; frequently associated with hematoma,drainage, or superficial infection  Stage 2, delayed onset: occurring between 4 and 24 months after surgery  Stage 3, late onset: occurring 2 or more years after surgery, usually as a result of hematogenous spread

58 Cont …..  Prevention: treat all sources of infection, Aseptic surgery, Prophylactic antibiotics, Aseptic postoperative care.  Medical management:  Pharmacological therapy: Intravenous antibiotic according to the wound culture  Surgical management: expose the bone surgically to remove infected and necrotic materials and irrigating the area with normal saline, direct application of antibiotics surgical (d é bridement).

59 Gout  also called metabolic arthritis) is a disease created by a buildup of uric acid)  Characterized by sudden, unexpected, burning pain, as well as swelling, redness, warmness, and stiffness in the affected joint. Low- grade fever may also be present.


61 Gout  Treat acute attacks before treatment to reduce serum uric acid levels  NSAIDs  Colchicine  Corticosteroids  Analgesics  Uricosuric  Allopurinol

62 Chapter 69 Management of Patients With Musculoskeletal Trauma

63 Injuries of the Musculoskeletal System  Contusion: soft tissue injury produced by blunt force  Pain,  swelling,  and discoloration: ecchymosis  Skin remains intact

64 Strain  pulled muscle-injury (stretching) to the musculocutaneous unit (muscle or muscle tendone.  Common sites: lower back and cervical.  Manifestations  Pain  Limited motion  Muscle spasms  Swelling  Muscle weakness  Ecchymosis

65 Sprain  injury to ligaments and supporting muscle fiber around a joint  Joint is tender  movement is painful;  edema,  disability,  and pain increase during the first 2 to 3 hours  Common sites: Ankle and knee

66 Management 1. X-ray may be done to rule out fracture. 2.Immobilize in splint, elastic wrap 3.Apply ice for first 24 hours. 4.Analgesics 5.Severe sprains may require surgical repair and/or cast immobilization. Nursing Interventions/Patient Education

67 Joint Dislocation  articular surfaces of the joint are not in contact  A traumatic dislocation is an emergency with pain change in contour, axis, and length of the limb and loss of mobility  Most common Shoulder Acromioclavicular joints  Subluxation Partial dislocation

68 Fractures:  Is a break in the continuity of bone and is defined according to type and extent  Occurs when the bone is subjected to stress greater than it can absorb.  Can cause by a direct blow, crushing force, sudden twisting motion, and extreme muscle contraction.

69 Types of fractures: 1.Complete fracture: break across the entire cross- section of the bone and is frequently displaced 2.Incomplete fracture: (green stick fracture) the break occur through only part of the cross-sectional of the bone 3.A comminuted fracture: fracture has several bone fragments 4.Closed fracture: simple fracture does not produce a break in the skin 5.Compound, complex fracture (open fracture): is one in which the skin or mucous membrane wound extends to the fracture bone

70 Cont …  Grade I: clean wound less than 1 cm  Grade II: larger wound without extensive soft tissue damage  Grade III: is highly contaminated, has extensive soft tissue damage, and is the most severe

71 Types of Fractures (cont.)


73 Types of Fractures

74 Manifestations of Fracture  Pain  Loss of function  Deformity  Shortening of the extremity  Crepitus  Local swelling and discoloration  Diagnosis by symptoms and x-ray  Patient usually reports an injury to the area

75 Emergency Management  Immobilize the body part  Splinting: joints distal and proximal to the suspected fracture site must be supported and immobilized  Assess neurovascular status before and after splinting  Open fracture: cover with sterile dressing to prevent contamination  Do not attempt to reduce the fracture

76 Medical Management  Reduction Closed Open  Immobilization: internal or external fixation  Open fractures require treatment to prevent infection Tetanus prophylaxis, antibiotics, and cleaning and debridement of wound Closure of the primary wound may be delayed to permit edema, wound drainage, further assessment, and debridement if needed

77 Three Phases of Fracture Healing  Inflammatory phase  Reparative phase: collagen formation and calcium deposition  Remodeling phase: 1. Excess callus is removed 2. New bone is laid down 3. Fracture site calcifies 4. Bone is reunited

78 Factors enhancing fracture healing: 1.Immobilize of fracture fragments 2.Maximum bone fragment contact 3.Sufficient blood supply 4.Proper nutrition 5.Exercise: wt bearing for long bone 6.Hormones: growth hormone, thyroid, calcitonin, Vit. D 7.Electric potential across fracture

79 Factors inhibiting fracture healing 1.Extensive local trauma, Bone loss, inadequate immobilization 2.Space/tissue between bone fragments, infection 3.Local malignancy, Metabolic bone disease 4.Irradiated bone (radiation necrosis) 5.Avascular necrosis 6.Intra-articular fracture 7.Age 8.Corticosteroids (inhibit the repair rate)

80 Fracture Complications  Early complications: 1.Shock: Hypovolemic or traumatic shock result from bleeding or from loss of extracellular fluid  Treatment: 1. Restoring blood volume and circulation 2. Releiving patient pain 3. Provide adequate splinting.

81 Compartment Syndrome 2.  develop when tissue perfusion in the muscles less than that required for tissue viability. Physiology  Entrapment of the blood vessels limits tissue perfusion  Results in edema within the compartment  Edema causes further pressure Early Manifestations  Deep Pain which is not controlled by opioids  Normal or decreased peripheral pulse Later Manifestations  Cyanosis  Paresthesias, paresis  Severe pain

82 Treatment  Interventions to alleviate pressure  Removal of the cast  Fasciotomy

83 3. Fat Embolism Syndrome  Pathophysiology  Bone fracture results in a rise of pressure in the bone marrow  Fat globules enter the bloodstream  Combine with platelets  Travel throughout the body  Occluding small blood vessels  Causes tissue ischemia

84 Fat Embolism Syndrome  Manifestations  Confusion  Changes in level of consciousness  Pulmonary edema  Impaired surfactant production  Atelectasis  ARDS

85 Fat Embolism Syndrome  Prevention  Early stabilization of long bone fracture. Treatment:  Intubation and mechanical ventilation  Fluid balance  Corticosteroids  Vasoactive medication to support the cardiovascular system and prevent hypotension.

86 4. Deep Vein Thrombosis  Manifestations  Swelling  Leg pain  Tenderness  Cramping  Some are asymptomatic  Diagnosis  Doppler ultrasound

87 Deep Vein Thrombosis  Treatment  Bed rest  Thrombolytic agents  Heparin  Vena cava filter  Thrombectomy  Prevention is the best treatment  Early immobilization of fractures  Early mobilization of the client

88 Cont ….. 5. DIC 6. Infection Delayed complications: 1.Delayed Union: Delay healing, which result from infection and distraction of bone fragment, poor nutrition 2.Nonunion: failure of the ends of the fractured bone to unite, pt complain of discomfort and abnormal movement at the fracture site. Managed by internal fixation or grafting Result from infection, interposition of tissue between the bone ends, inadequate immobilization, excessive space, and impaired blood supply

89 Cont …. 3. Avascular necrosis of the bone: Disruption of the blood supply, dislocation, bone transplantation, prolonged high doses of corticosteroids, chronic renal disease, sickle cell anemia. 4.Reaction to internal fixation device

90 Amputation  Partial or total removal of a body part  May be the result of an acute event or a chronic condition  Risk Factors  Peripheral vascular disease  Hypertension  Diabetes  Smoking  Peripheral neuropathy  Hyperlipidemia  Trauma

91 Amputation Pathophysiology  Interruption of blood flow  Circulation impairment  Edema development  Status ulcers develop/become infected  Development of gangrene

92 Amputation Types of Amputation  Above or below the elbow: arm amputation  Leg amputation Below the knee (BKA) Above the knee (AKA)  Open amputation (Guillotine)  Closed (flap) amputation



95 Amputation Post Amputation Care  Rigid or compression dressing is applied Prevents infection Minimize edema Complications  Infection  Delayed healing  Chronic stump pain  Contracture


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