1. Caring for Clients with Musculoskeletal Trauma
VN 86
Bakersfield College

2. Introduction
Musculoskeletal Trauma occurs when tissues are subjected to more force than they are able to absorb.
Example: A fall, a step off a curb, being tackled, a motor vehicle crash
Can range from mild to severe:
1. Soft tissue injury
2, Fracture
3. Complete amputation
May affect surrounding tissues.
A bone fracture can affect the function of muscles, tendons and ligaments that attach to it.

3. MS Trauma Older adults are at higher risk for MS trauma due to falls.
Nurses job to:
1. Assessment of home for potential hazards- lighting, hand rails, throw rugs and clutter, bath mats and grab bars in bathrooms are necessary.
2. Shoes that will decrease the risk of slipping

4. Soft Tissue Trauma
Sprains, strains and soft tissue damage are common injuries.
The ankle is the most commonly sprained joint.
The lower back and cervical spine are the most common sites for muscle strains.
Contusion- simplest MS injury. Bleeding into the soft tissue from blunt force.
Sprain- ligament injury caused by a twisting motion that overstretches or tears the ligament. Grades 1,2,3 and 4.
Strain- microscopic tear in the muscle that causes bleeding into the tissues. The muscle was forced to extend past it’s elasticity.

5. Interdisciplinary Care Soft tissue trauma
X-ray to rule out fracture.
MRI to further evaluate.
Treatment- Measures to decrease swelling, alleviate pain and encourage rest and healing.
Avoid using injured area
May need a splint
Ice first 48 hrs, then heat
Compression dressing
Elevation
NSAID, analgesics including narcotics may be needed.
Health promotion- discussion

6. Nursing Interventions
Promote comfort, prevent further injury and allow healing.
RICE
Do not attempt to move an injured joint beyond the point of comfort.
If fracture is suspected immobilize the joint
Especially important with cervical spine fracture
Palpate for swelling, warmth, tenderness, deformity and crepitus.
Check capillary refill, pulses, movement and sensation distal to the injury.

7. Nursing Process Potential Nursing diagnosis:
1. Impaired tissue integrity rt trauma
Goal: patient will demonstrate progressive healing of tissue from date.
2. Acute pain rt tissue trauma
Goal: patient will have pain level of 1-3 on a scale of 1-10 during my shift.

8. Fractures A break of a bone.
Vary in severity depending on location and type of fracture.
Types of Fractures:
See text
The direction of the fracture line is used to classify fractures.
Closed
Open
Comminuted
Compression
Impacted
Depressed
Spiral
Greenstick

9. Fracture Clinical Manifestations
Fractures accompanied by soft tissue injuries that involve muscles, blood vessels, nerves or skin.
CM- Deformity Complications
Swelling, Bleeding- hypovolemic shock
Ecchymosis Infection
Pain peripheral nerve damage
Tenderness blood flow disruption
Numbness necrosis, blood vessel damage
Crepitus immobility
Muscle spasm DVT, compartment syndrome, fat emboli

10. Fracture Healing Osteoblasts promote new bone formation
Osteoclasts migrate to the repair site to remove damaged and excess bone in the callus.
Callus- connects bone fragments and splints the fracture, it’s a stage in fracture
Video on fracture
Healing time varies with the individual.
Uncomplicated fracture of the arm or foot can heal in 6 to 8 weeks. Vertebra- 12weeks, hip weeks.

11. Interdisciplinary Care Fracture
Fractures require prompt treatment
May need to be reduced- Normal alignment of bone is restored. Immobilization as soon as possible.
Nursing Interventions-
Immobilization, pulses, color movement and sensation before and after splinting and throughout shift.
Closed Reduction- External manipulation is used to reposition the bone. Conscious sedation used.
Open Reduction- Completed in the OR. The bone is exposed and realigned. Screws may be used to maintain position.

12. Care of Fractures continued
Casts- rigid device used to immobilize broken bones and promote healing. Plaster or fiberglass.
Muscle spasms can pull bones out of alignment after a fracture.
Traction- applies a straightening or pulling force to return or maintain the fractured bones in normal position.
1. Manual Traction- applied by physically pulling on the extremity. Reduce a fracture or dislocation.
2. Skin Traction- (straight traction)applies the pulling force through the client’s skin. Non-invasive and is relatively comfortable for the client. Example: Buck’s traction.

13. Traction continued
The Most common type of Skin Traction is Buck’s Traction- Used to immobilize the leg before surgery to repair a hip or proximal femur fracture.(NCLEX)
3. Balanced suspension Traction- Uses more than one force of pull to raise and support the injured extremity off the bed and maintain it’s alignment. Increases mobility while maintaining bone position.
4. Skeletal Traction- Pulling force is applied directly through pins inserted into the bone. Risk for infection is greater than other types.

14. Surgery and Fractures
1. External fixation is the simplest form of surgery used to immobilize a fracture. This uses a external fixator and a frame connected to pins inserted into the bone. The pins require care similar to that of skeletal traction pins. The client is monitored for infection, and frequent neurovascular assessment is performed.
2. Internal fixation- surgery called an open reduction and internal fixation (ORIF). Fracture is directly reduced and a nail, screws, plates and screws or pins are inserted to hold the bones in place. Open fractures and hip fractures are repaired with ORIF.

15. Nursing Care Fractures
Priorities for Nursing care:
Prevent complications
Managing pain
Impaired mobility
Health Promotion- Fractures
Use safety equipment
Adequeate daily calcium
Regular exercise
Discussion Older Adults and hip fractures!!!!!

16. Nursing Care Fractures
Assessment Potential Complications Fractures:
Increasing pain or pain that is not relieved by analgesia may indicate a complication such as compartment syndrome or infection.
Numbness, tingling, changes in sensation or changes in movement distal to the fracture may indicate nerve damage or compartment syndrome.
Impaired circulation- cool, pale extremity with weak or absent pulses.
Edema, warmth and a bluish or purple tinge may indicate venous venous pooling.

17. Nursing Diagnosis
1. Risk for or ineffective peripheral tissue perfusion r/t altered bone integrity or surgical procedure.
Goal: Circulation will remain effective.
2. Acute pain r/t altered bone integrity.
3. Impaired physical mobility r/t altered bone integrity.

18. Hip Fracture Causes: Decreased bone mass and muscle strength
Slowed reflexes
Medications that can affect cognition or balance
Osteoporosis and loss of bone mass- spontaneous hip fracture, minor trauma can lead to hip fracture.
Leads to loss of independence and restricted activity and death
Break of the femur at the head, neck or trochanteric region.
Most common neck or trochanteric region.
Diagnosed by history and physical and x-ray.
Buck’s traction is applied to reduce muscle spasm until OR.

19. Hip Fracture 340,000 people/year, 50% 85 yr and older.
ORIF or hip replacement is completed
Femoral head or neck is fractured a prosthesis is inserted to replace the femoral head= arthroplasty.
Femoral head and acetabulum replaced= total hip replacement.
Video

20. Hip Fracture Nursing
1. Maintaining circulation to the injured extremity
2.Preventing infection
3. Making pain tolerable
4. Increasing mobility
1. Risk for ineffective peripheral tissue perfusion r/t fracture and swelling
2.Risk for infection r/t altered bone integrity
3. Acute pain r/t fracture and muscle spasms
4. Impaired physical mobility r/t bed rest and fracture

21. Joint Trauma and Injury
Joints are the weakest part of the skeleton.
Can be injured when subject to stretching or twisting.
Ligaments, tendons and muscles that support the joint may be stretched or torn, joint cartilage may be damaged, the joint itself can be dislocated.
Dislocation- is separation of contact between two bones of a joint.
Dislocations are due to sudden force or joint disease.
Shoulder and hip dislocation are the most common

22. Repetitive Use Injuries
Result from overuse of or repeated stress on a joint without adequate recovery time.
Common Types:
Carpal tunnel syndrome, bursitis, and epicondylitis.
Significant disability and lost work time.
Carpal tunnel syndrome-work related injury results from inflammation and swelling of structures in the wrist joint. Result is the tunnel narrows, compressing and irritating the median nerve. Numbness and tingling of the thumb, index finger and middle finger of the affected hand develop.

23. Bursitis
Inflammation of the bursa, which is a pad sac that prevents friction between tissues such as ligaments, tendons and bone. Bursae in the shoulder, hip, leg and elbow may become inflamed, causing local tenderness and pain with movement.
Epicondylitis- also called tennis elbow or golfer’s elbow. Inflammation of a tendon where it inserts into the bone. Repeated trauma causes it along with bleeding and inflammation of the tendon. Point tenderness, pain radiating down the forearm and history of repetitive use.

24. Repetitive Use Injury Diagnosed by history and physical exam.
History will reveal an occupational risk or frequent participation in activities such as tennis, golf, softball, or baseball.
Phalen’s test- When Carpal tunnel syndrome is suspected.
Initial Treatment- rest and immobilization, splint and ice for hrs. Heat after, NSAID, cortisone into joint. What about corticosteroids and diabetes?
Surgery for CTS.

25. Rotator Cuff and Knee Injury
Shoulder injuries result from rotator cuff being injured.
Repetitive use or degenerative changes of involved tissue
CM- shoulder pain which is worse at night or lying on the involved shoulder, motion may be limited
Diagnosed by h&p, x-ray, MRI. Treatment is conservative. May need surgery.
Knee Injury- ligament tears, meniscal injury, patellar dislocation seen with sports injury.
CM-acute injury with immediate pain, tearing sensation or popping. Swelling common. X-ray and MRI complete DX.
Joint rest with RICE, Physical therapy, surgery.

26. Nursing Care Joint Trauma Repetitive Use Injury
Primary focus is education!!!
Detailed assessment detailed information about known trauma, circumstances of injury, pain. Examiniation.
Acute Pain
Impaired physical mobility
Psychosocial also.

27. Amputation Partial or total removal of a body part.
May be completed to treat types of diseases like bone cancer, may be the result of a chronic condition such as peripheral vascular disease or diabetes.
May be due to trauma.
Devestating to the client!
Significant physical and psychosocial effects on the client and family
Adapting will take time and significant effort.
Pheripheral vascular disease is the major cause of lower extremity amputation. Peripheral neuropathy puts clients at risk.

28. Pathophysiology
Impaired blood flow along with untreated infection can cause tissue death and lead to amputation.
PVD- circulation to the extremites is impaired. This leads to edema and tissue damage. Healing is impaired (why?)
Thus minor injuries and stasis ulcers can become infected.
Bacteria tend to proliferate.
Peripheral neuropathy- loss of sensation leads to unrecognized injury and infection.
Level of amputation is determined by the extent of tissue damage and healthy tissue. Joints try to be reserved for better function. See textbook.

29. Amputation Complications: Infection Delayed healing Contractures
Infection- Older, diabetes, PVD higher risk.
Nursing- assessment, skin care, aseptic technique, turning, deep breathing and coughing.
Look for delayed healing in the clients with PVD, diabetes and who are older along with poor nutrition and smoking.

30. Amputation
Contractures- abnormal flexion and fixation of a joint caused by muscle atrophy and shortening. Common with amputations. Measures to prevent: discussion.
Phantom Limb Pain- Tingling, numbness or itching of the amputated limb. Cause unknown may be caused by trauma to the nerves serving the amputated part. Pain clinic comprehensive pain management program.
Open and closed amputation
Prosthetist- prosthetic options.

31. Nursing Care Amputation
Potential complications- vitals, urine output, pain not relieved by analgesics or change in pain character or location.
Assessment of wound and dressing- bright red, or later redness, swelling purulent drainage or hematoma.
Nursing Diagnosis:
Risk for infection
Acute pain
Impaired physical mobility
Disturbed body image

32. Amputations Video Amputation video