UNIT 4 Nursing Care of Clients With Musculoskeletal Disorders

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

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.

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.

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

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?

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.

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

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

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)

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

Signs and Symptoms

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.

Fat Embolism Syndrome What to Look for: Manifestations of fat emboli occur within 24-72 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

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

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!

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

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

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.

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).

Muscle Spasm: 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 popiteal space Minimize compression Active & passive exercises as ordered Frequent change in position

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

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.

Avascular Necrosis

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% (1500-2000 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.

Potential Blood Loss Following Fractures (Liters) Humerus 1-2 Elbow .5-1.5 Forearm .5-1 Pelvis 1.5-4.5 Hip 1.5-2.5 Femur Knee 1-1.5 Tibia . 5-1.5 Ankle Spine/ribs 1-3 This is not what is expected but what is possible!

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

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)

Closed vs. Open Reduction

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.

External fixation

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

Open reduction and internal fixation of Comminuted mandibular fracture

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!

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.

Bivalving a Cast Window Cast

Cast Drying: Synthetic casts – dry approx. 20-30 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.

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.

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

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.

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

Compartmental Syndrome Swelling out of control

Compartment Syndrome Treatment Fasciotomy RELEASE PRESSURE RELIEF CUT OPEN

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) .

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

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

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

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

Volkmann’s Contracture

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.

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.

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.

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.

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

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

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

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

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

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

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

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% (1500-2000 ml) –obvious shock Stage IV over 40% (over 2000 ml)

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.

Potential Blood Loss Following Fractures (Liters) Humerus 1-2 Elbow .5-1.5 Forearm .5-1 Pelvis 1.5-4.5 Hip 1.5-2.5 This is not what is expected but what is possible! Femur 1-2 Knee 1-1.5 Tibia .5-1.5 Ankle .5-1.5 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.

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 48-72 hours post surgery.

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

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.

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.

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

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

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

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!

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

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.

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

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 25-40 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.

Thomas Splint Picture http://www.scribd.com/doc/12356898/Balance-Skeletal-Traction

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.

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.

Skin & Skeletal Traction Bucks

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

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.

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?

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

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

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

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

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.

Specific Fractures Hip Fractures Condylar fractures Pelvic fractures Patellar fractures Tibial & fibular fractures Foot fractures Upper extremities Please review Pages 607-619 for care of specific fractures

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.

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

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.

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

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.

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.

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.

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

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? ***

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.