Interventions for Clients Interventions for Clients with Musculoskeletal with Musculoskeletal

TraumaTrauma

Classification of Classification of FracturesFractures

A fracture is a break or A fracture is a break or disruption in the continuity of a disruption in the continuity of a bone.bone.

Types of fractures include:Types of fractures include:– CompleteComplete– IncompleteIncomplete– Open or compoundOpen or compound– Closed or simpleClosed or simple– Pathologic (spontaneous)Pathologic (spontaneous)– Fatigue or stress Fatigue or stress – CompressionCompression

Stages of Bone HealingStages of Bone Healing

Hematoma formation within 48 to 72 Hematoma formation within 48 to 72 hr after injuryhr after injury

Hematoma to granulation tissueHematoma to granulation tissue Callus formationCallus formation Osteoblastic proliferationOsteoblastic proliferation Bone remodelingBone remodeling Bone healing completed within about Bone healing completed within about

6 weeks; up to 6 months in the older 6 weeks; up to 6 months in the older personperson

Acute Compartment Acute Compartment Syndrome Syndrome

Serious condition in which increased pressure within Serious condition in which increased pressure within one or more compartments causes massive one or more compartments causes massive compromise of circulation to the areacompromise of circulation to the area

Prevention of pressure buildup of blood or fluid Prevention of pressure buildup of blood or fluid accumulationaccumulation

Pathophysiologic changes sometimes referred to as Pathophysiologic changes sometimes referred to as ischemia-edema cycleischemia-edema cycle

Emergency CareEmergency Care Within 4 to 6 hr after the onset of acute Within 4 to 6 hr after the onset of acute

compartment syndrome, neuromuscular damage is compartment syndrome, neuromuscular damage is irreversible; the limb can become useless within 24 irreversible; the limb can become useless within 24 to 48 hr.to 48 hr.

Monitor compartment pressures.Monitor compartment pressures. Fasciotomy may be performed to relieve pressure.Fasciotomy may be performed to relieve pressure. Pack and dress the wound after fasciotomy.Pack and dress the wound after fasciotomy.

Other Complications of Other Complications of FracturesFractures

ShockShock Fat embolism syndrome: serious complication Fat embolism syndrome: serious complication

resulting from a fracture; fat globules are resulting from a fracture; fat globules are released from yellow bone marrow into released from yellow bone marrow into bloodstreambloodstream

Venous thromboembolismVenous thromboembolism InfectionInfection Ischemic necrosisIschemic necrosis Fracture blisters, delayed union, nonunion, and Fracture blisters, delayed union, nonunion, and

malunionmalunion

Musculoskeletal Musculoskeletal AssessmentAssessment

Change in bone alignmentChange in bone alignment Alteration in length of extremityAlteration in length of extremity Change in shape of boneChange in shape of bone Pain upon movementPain upon movement Decreased ROMDecreased ROM CrepitationCrepitation Ecchymotic skinEcchymotic skin Subcutaneous emphysema with Subcutaneous emphysema with

bubbles under the skinbubbles under the skin Swelling at the fracture siteSwelling at the fracture site

Risk for Peripheral Risk for Peripheral Neurovascular Neurovascular

DysfunctionDysfunction Interventions include:Interventions include:

– Emergency care: assess for Emergency care: assess for respiratory distress, bleeding and respiratory distress, bleeding and head injuryhead injury

– Nonsurgical management: closed Nonsurgical management: closed reduction and immobilization with a reduction and immobilization with a bandage, splint, cast, or tractionbandage, splint, cast, or traction

Casts Casts Rigid device that immobilizes the affected body part Rigid device that immobilizes the affected body part

while allowing other body parts to movewhile allowing other body parts to move Cast materials: plaster, fiberglass, polyester-cottonCast materials: plaster, fiberglass, polyester-cotton Types of casts for various parts of the body: arm, Types of casts for various parts of the body: arm,

leg, brace, bodyleg, brace, body Cast care and client educationCast care and client education Cast complications: infection, circulation Cast complications: infection, circulation

impairment, peripheral nerve damage, complications impairment, peripheral nerve damage, complications of immobilityof immobility

Traction Traction Application of a pulling force to the Application of a pulling force to the

body to provide reduction, body to provide reduction, alignment, and rest at that sitealignment, and rest at that site

Types of traction: skin, skeletal, Types of traction: skin, skeletal, plaster, brace, circumferentialplaster, brace, circumferential

Traction care: Traction care: – Maintain correct balance Maintain correct balance

between traction pull and between traction pull and countertraction forcecountertraction force

– Care of weightsCare of weights– Skin inspectionSkin inspection– Pin carePin care– Assessment of neurovascular Assessment of neurovascular

statusstatus

Operative ProceduresOperative Procedures

Open reduction with internal Open reduction with internal fixation fixation

External fixationExternal fixation Postoperative care: similar Postoperative care: similar

to that for any surgery; to that for any surgery; certain complications certain complications specific to fractures and specific to fractures and musculoskeletal surgery musculoskeletal surgery include fat embolism and include fat embolism and venous thromboembolismvenous thromboembolism

Acute PainAcute Pain Interventions include:Interventions include:

– Reduction and immobilization of fractureReduction and immobilization of fracture– Assessment of painAssessment of pain– Drug therapy: opioid and nonopioid drugsDrug therapy: opioid and nonopioid drugs– Complementary and alternative therapies: ice, Complementary and alternative therapies: ice,

heat, elevation of body part, massage, baths, heat, elevation of body part, massage, baths, back rub, therapeutic touch, distraction, imagery, back rub, therapeutic touch, distraction, imagery, music therapy, relaxation techniquesmusic therapy, relaxation techniques

Risk for InfectionRisk for Infection Interventions include:Interventions include:

– Apply strict aseptic technique for dressing Apply strict aseptic technique for dressing changes and wound irrigations.changes and wound irrigations.

– Assess for local inflammationAssess for local inflammation– Report purulent drainage immediately to health Report purulent drainage immediately to health

care provider.care provider.– Assess for pneumonia and urinary tract infection.Assess for pneumonia and urinary tract infection.– Administer broad-spectrum antibiotics Administer broad-spectrum antibiotics

prophylactically.prophylactically.

Impaired Physical Impaired Physical MobilityMobility

Interventions include:Interventions include:– Use of crutches to promote mobilityUse of crutches to promote mobility– Use of walkers and canes to Use of walkers and canes to

promote mobilitypromote mobility

Imbalanced Nutrition: Imbalanced Nutrition: Less Than Body Less Than Body RequirementsRequirements

Interventions include:Interventions include:– Diet high in protein, calories, and Diet high in protein, calories, and

calcium, supplemental vitamins B calcium, supplemental vitamins B and Cand C

– Frequent small feedings and Frequent small feedings and supplements of high-protein liquidssupplements of high-protein liquids

– Intake of foods high in ironIntake of foods high in iron

Upper Extremity Upper Extremity FracturesFractures

Fractures include those of the:Fractures include those of the:– ClavicleClavicle– ScapulaScapula– HumerusHumerus– OlecranonOlecranon– Radius and ulnaRadius and ulna– Wrist and handWrist and hand

Lower Extremity Lower Extremity FracturesFractures

Fractures include those of the:Fractures include those of the:– FemurFemur– PatellaPatella– Tibia and fibulaTibia and fibula– Ankle and footAnkle and foot

Fractures of the HipFractures of the Hip

Intracapsular or extracapsular Intracapsular or extracapsular Treatment of choice: surgical Treatment of choice: surgical

repair, when possible, to allow repair, when possible, to allow the older client to get out of bedthe older client to get out of bed

Open reduction with internal Open reduction with internal fixationfixation

Intramedullary rod, pins, a Intramedullary rod, pins, a prosthesis, or a fixed sliding prosthesis, or a fixed sliding plateplate

Prosthetic device Prosthetic device

Fractures of the Pelvis Fractures of the Pelvis Associated internal damage the chief concern in Associated internal damage the chief concern in

fracture management of pelvic fracturesfracture management of pelvic fractures Non–weight-bearing fracture of the pelvisNon–weight-bearing fracture of the pelvis Weight-bearing fracture of the pelvisWeight-bearing fracture of the pelvis

Compression Fractures Compression Fractures of the Spineof the Spine

Most are associated with osteoporosis Most are associated with osteoporosis rather than acute spinal injury.rather than acute spinal injury.

Multiple hairline fractures result when Multiple hairline fractures result when bone mass diminishesbone mass diminishes

Nonsurgical management includes Nonsurgical management includes bedrest, analgesics, and physical bedrest, analgesics, and physical therapy.therapy.

Minimally invasive surgeries are Minimally invasive surgeries are vertebroplasty and kyphoplasty, in vertebroplasty and kyphoplasty, in which bone cement is injected.which bone cement is injected.

AmputationsAmputations Surgical amputationSurgical amputation Traumatic amputationTraumatic amputation Levels of amputationLevels of amputation Complications of amputations: hemorrhage, Complications of amputations: hemorrhage,

infection, phantom limb pain, problems associated infection, phantom limb pain, problems associated with immobility, neuroma, flexion contracturewith immobility, neuroma, flexion contracture

Phantom Limb PainPhantom Limb Pain

Phantom limb pain is a frequent Phantom limb pain is a frequent complication of amputation.complication of amputation.

Client complains of pain at the site Client complains of pain at the site of the removed body part, most of the removed body part, most often shortly after surgery.often shortly after surgery.

Pain is intense burning feeling, Pain is intense burning feeling, crushing sensation or cramping.crushing sensation or cramping.

Some clients feel that the Some clients feel that the removed body part is in a removed body part is in a distorted position.distorted position.

Management of PainManagement of Pain Phantom limb pain must be Phantom limb pain must be

distinguished from stump pain distinguished from stump pain because they are managed because they are managed differently.differently.

Recognize that this pain is real and Recognize that this pain is real and interferes with the amputee’s interferes with the amputee’s activities of daily living.activities of daily living.

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Management of PainManagement of Pain

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Some studies have shown that Some studies have shown that opioids are not as effective for opioids are not as effective for phantom limb pain as they are phantom limb pain as they are for residual limb pain.for residual limb pain.

Other drugs include intravenous Other drugs include intravenous infusion calcitonin, beta infusion calcitonin, beta blockers, anticonvulsants, and blockers, anticonvulsants, and antispasmodics.antispasmodics.

Exercise After Exercise After Amputation Amputation

ROM to prevent flexion contractures, ROM to prevent flexion contractures, particularly of the hip and kneeparticularly of the hip and knee

Trapeze and overhead frameTrapeze and overhead frame Firm mattressFirm mattress Prone position every 3 to 4 hoursProne position every 3 to 4 hours Elevation of lower-leg residual limb Elevation of lower-leg residual limb

controversial controversial

Crush SyndromeCrush Syndrome Can occur when leg or arm injury includes multiple Can occur when leg or arm injury includes multiple

compartmentscompartments Characterized by acute compartment syndrome, Characterized by acute compartment syndrome,

hypovolemia, hyperkalemia, rhabdomyolysis, and hypovolemia, hyperkalemia, rhabdomyolysis, and acute tubular necrosisacute tubular necrosis

Treatment: adequate intravenous fluids, low-dose Treatment: adequate intravenous fluids, low-dose dopamine, sodium bicarbonate, kayexalate, and dopamine, sodium bicarbonate, kayexalate, and hemodialysishemodialysis

Complex Regional Pain Complex Regional Pain SyndromeSyndrome

A poorly understood complex A poorly understood complex disorder that includes debilitating disorder that includes debilitating pain, atrophy, autonomic pain, atrophy, autonomic dysfunction, and motor impairmentdysfunction, and motor impairment

Collaborative management: pain Collaborative management: pain relief, maintaining ROM, relief, maintaining ROM, endoscopic thoracic endoscopic thoracic sympathectomy, and sympathectomy, and psychotherapy.psychotherapy.

Knee Injuries, MeniscusKnee Injuries, Meniscus

McMurray testMcMurray test Meniscectomy Meniscectomy Postoperative carePostoperative care Leg exercises begun Leg exercises begun

immediatelyimmediately Knee immobilizerKnee immobilizer Elevation of the leg on one Elevation of the leg on one

or two pillows; ice.or two pillows; ice.

Knee Injuries, LigamentsKnee Injuries, Ligaments

When the anterior cruciate When the anterior cruciate ligament is torn, a snap is felt, ligament is torn, a snap is felt, the knee gives way, swelling the knee gives way, swelling occurs, stiffness and pain follow.occurs, stiffness and pain follow.

Treatment can be nonsurgical or Treatment can be nonsurgical or surgical.surgical.

Complete healing of knee Complete healing of knee ligaments after surgery can take ligaments after surgery can take 6 to 9 months.6 to 9 months.

Tendon RupturesTendon Ruptures Rupture of the Achilles tendon is common in adults Rupture of the Achilles tendon is common in adults

who participate in strenuous sports.who participate in strenuous sports. For severe damage, surgical repair is followed by leg For severe damage, surgical repair is followed by leg

immobilized in a cast for 6 to 8 weeks.immobilized in a cast for 6 to 8 weeks. Tendon transplant may be needed.Tendon transplant may be needed.

Dislocations and SubluxationsDislocations and Subluxations Pain, immobility, alteration in contour of joint, Pain, immobility, alteration in contour of joint,

deviation in length of the extremity, rotation of the deviation in length of the extremity, rotation of the extremityextremity

Closed manipulation of the joint performed to force Closed manipulation of the joint performed to force it back into its original positionit back into its original position

Joint immobilized until healing occursJoint immobilized until healing occurs

Strains Strains Excessive stretching of a muscle or tendon when it is Excessive stretching of a muscle or tendon when it is

weak or unstableweak or unstable Classified according to severity: first-, second-, and Classified according to severity: first-, second-, and

third-degree strainthird-degree strain Management: cold and heat applications, exercise Management: cold and heat applications, exercise

and activity limitations, anti-inflammatory drugs, and activity limitations, anti-inflammatory drugs, muscle relaxants, and possible surgerymuscle relaxants, and possible surgery

Sprains Sprains

Excessive stretching of a ligamentExcessive stretching of a ligament Treatment of sprains:Treatment of sprains:

– first-degree: rest, ice for 24 to 48 hr, first-degree: rest, ice for 24 to 48 hr, compression bandage, and elevationcompression bandage, and elevation

– second-degree: immobilization, second-degree: immobilization, partial weight bearing as tear healspartial weight bearing as tear heals

– third-degree: immobilization for 4 to third-degree: immobilization for 4 to 6 weeks, possible surgery6 weeks, possible surgery

Rotator Cuff InjuriesRotator Cuff Injuries Shoulder pain; cannot initiate or maintain abduction Shoulder pain; cannot initiate or maintain abduction

of the arm at the shoulderof the arm at the shoulder Drop arm testDrop arm test Conservative treatment: nonsteroidal anti-Conservative treatment: nonsteroidal anti-

inflammatory drugs, physical therapy, sling support, inflammatory drugs, physical therapy, sling support, ice or heat applications during healingice or heat applications during healing

Surgical repair for a complete tearSurgical repair for a complete tear