Care of Patient with Musculoskeletal DisordersBryan Mae H. Degorio, RN, MAN

I. Fractures

Is a disruption or break in the continuity of the structure of the bone.

Occurs when the stress placed on the bone is greater that the bone can absorb

Fracture maybe caused by direct blow, crushing forces, sudden twisting motion and extreme muscle contraction When the bone is broken- adjacent structure are also affected resulting in soft tissue edema, hemorrhage into the muscles and joint dislocation, ruptured tendons, severed nerves and damage blood vessels. Types of Fractures:

1. Complete Fracture- involves a break across the entire section of the bone and is frequently displaced

2. Incomplete Fracture- involves the break through a part of the cross section of the bone

3. Closed Fracture

- is the one that does not cause break in the skin

4. Open Fracture

- is the one in which the skin or mucus membrane is disrupted

5. Pathologic Fracture- through an area of diseased bone Pattern of Fractures

1. Greenstick Fracture- one side of the bone is broken and the other side is bent

2. Transverse

- a fracture that is straight across the bone

3. Oblique

- an angle across the bone4. Spiral

- twist around the shaft of the bone

5. Comminuted

- a fracture in which the bone has splintered into several fragments

6. Depressed

- fragments area are driven inward (commonly seen in skull and facial bones)

7. Compression

- bone collapse in on itself (seen in vertebral fractures)

8. Avulsion

- bone fragment has been pulled away by a tendon attachment9. Impacted

- bone fragments is driven into another bone fragment Manifestations:

1. Pain Is continuous and increasing in severity until the bone fragment is immobilized

The spasm of the surrounding muscles serve as a temporary splints to minimize further movement of the fracture limb.

2. Loss of function

The normal function of the muscle depends on the integrity of the bone to which they are attached.

Pain may also contribute to the loss of function

3. Deformity

Due to displacement, angulation, or rotation of the fragments in the fracture as seen as loss of normal bony contour. It can be detected by comparing the injured limb with the uninjured limb.

Deformity can also be due to the soft tissue swelling

4. Shortening

Is due to the contraction of the muscles that are attached below and above the fracture site.

The fragments overlap by as much as 2.5-5 cm (1-2 inches)

5. Crepitus

Is a grating sensation felt when bone fragments are rubbed against each other.

Note: testing for crepitus may produce further damage to the area.

6. Swelling and discoloration (ecchymosis) Due to trauma and bleeding in the tissue These may develop for several hours after injury.

Management:

A. Goals of Fracture Treatment:

Anatomic realignment of the bone fragment

Immobilization to maintain realignment

Restoration of normal or near normal function of the injured part

B. Three step processes in managing bone fracture:1. Reduction- refers to the restoration of the fragments into anatomic position and alignment (pls. refer to your notes on the general management of client with musculoskeletal disorders)

a. Closed reduction- is a non-surgical, manual realignment of the bone. Traction and counter traction maybe applied.

b. Open reduction- is the correction of bone alignment through a surgical incision. It includes internal fixation of the fracture with the use of wires, screws, pins, plates, intermedullary rods or nails.

2. Immobilization- maintaining reduction until bone healing occurs.

a. It can be achieved with use of casts, splints and tractions.

3. Rehabilitation- regaining normal function of the affected part.

C. Drug Therapy1. Central and peripherally acting muscle relaxant can be given to relieve the pain associated with muscle spasm.

a. It includes: carisoprodol (Soma), cyclobenzaprine (Flexeril) and methocarbamol (Robaxin)

2. Tetanus immunoglobulins may also be given for those who has not been previously immunized.

D. Nutritional therapy

1. Dietary therapy should include ample protein (1g/kg of body weight), vitamins (B, C and D) and calcium, phosphorus and magnesium to ensure optimal soft tissue and bone healing.

Complications of Fracture:

A. Compartment Syndrome: Is a condition in which elevated intracompartment pressure within a confined myofacial compartment compromises the neurovascular function of tissue within the space. Possible causes:

a. A reduction in the size of the muscle compartment because the enclosing muscle fascia is too tight or a cast or dressing is constrictive.b. An increase in the muscle compartment content because of the edema or hemorrhage associated with variety of problems (ex: fractures and crush injuries)

As a result, the pressure within the muscle compartment may increase to such an extent as to decrease circulation to the area causing nerve and muscle anoxia and necrosis.

Assessment and Diagnostics:

a. Neurovascular assessment:

paresthesia, unrelenting pain, and hypoesthesia and possible numbness to the area.

motion is evaluated by asking the patient to move his toes or fingers

paralysis may indicate nerve damage

peripheral circulation can be assessed by color, temperature, capillary refill time, swelling and pulses

b. There is a deep, throbbing and unrelenting pain which is greater than expected and is not controlled by opioids.

Management:

a. Physician must be notified immediately when suspecting for neurovascular compromise.

b. Elevate the extremities at the level of the heart, release of restrictive dressing (dressing or cast) or both.

c. If conservative management do not restore the tissue perfusion and relieve pain within 1 hour, a fasciotomy compression with excision of the fibrous membrane that covers and maybe needed to relieve the constrictive muscle.

B. Fat Embolism Syndrome Is characterized by the presence of the systemic fat lobules from factures that are distributed into the tissues and organs after a traumatic skeletal injury. Theories of the development of FES:

a. Mechanical theory- fat is released from the marrow of the injured bone and is driven out into the circulation by the increase intramedullary pressure causing it to lodge in the pulmonary circulation.

b. Biochemical theory- catecholamines are released at the time of trauma mobilizing free fatty acid from the adipose tissue causing the loss of chylomicron emulsion stability. Chylomicrons form large fat globules that eventually lodge in the lungs.

Manifestations:

a. Hemorrhagic interstitial pneumonitis that produces signs and symptoms of ARDS such as chest pain, tachypnea, cyanosis, dyspnea, apprehension, tachycardia and decreases partial pressure of arterial oxygen

Management:

a. The management is directed to prevention:

immediate immobilization, minimal movement of the fracture, adequate support for the fractured bone and maintaining fluid and electrolyte balance.

b. Respiratory support

Administration of oxygen in high concentration.

Controlled-volume ventilation with positive end-expiratory pressure may be used to prevent or treat pulmonary edema. Corticosteroid to treat inflammatory lung reaction and cerebral edema

Morphine maybe given to relive acute pain and anxiety

Vasoactive medication can be given to prevent shock and hypotension