musculoskeletal system trauma

MUSCULOSKELETAL TRAUMA

JOFRED M. MARTINEZ, RN, MANUniversity of San Agustin Review CenterIloilo City, Philippines

Contusions, Strains and Sprains

CONTUSION STRAIN SPRAIN

Pathophysiology bleeding into soft tissue

stretching injury to a muscle or a muscle tendon unit

stretch and/or tear of one or more ligaments surrounding a joint

Etiology blunt force mechanical overloading

forces going in opposite directions

Manifestations swelling and discoloration of the skin

pain, limited motion, muscle spasms, swelling, and possible muscle weakness

loss of function, feeling of pop or tear, discoloration, pain, and rapid swelling

Grades of Sprain Severity

Grade Description Manifestation

1Mild

Overstretching or minimal tear of ligaments with no joint instability

Mild pain, swelling, tenderness Little or no bruising Minimal or no loss of joint function or ability

to bear weight

2Moderate

Partial tear of the ligament

Moderate pain, bruising, and swelling Mild to moderate joint instability, functional

disability Weight bearing difficult

3Severe

Complete tear or rupture of the ligament

Severe pain, swelling, and bruising Significant functional loss and joint instability Inability to bear weight

Grades of Sprain Severity


MANAGEMENT

Emergency care rest, ice, compression, and elevation for the first 24 to 48 hours

Diagnosis x-ray, magnetic resonance imaging (MRI)

Medications nonsteroidal anti-inflammatory drugs (NSAIDs)

Treatment immobilized with a cast or splintsurgery to repair the torn ligaments, muscle, or tendonsphysical therapy for rehabilitation

RICE Therapy

Action Interventions

Rest Decrease regular activities of daily living and exercise as needed.

Limit weight bearing on the injured extremity for 48 hours. If you use a cane or crutch to avoid weight bearing, use it on

the uninjured side so you can lean away from and relieve weight on the injured leg.

Ice To avoid cold injury or frostbite, apply an ice pack to the injured area for no more than 20 minutes at a time, four to eight times a day.

An ice bag, cold pack, plastic bag filled with crushed ice and wrapped in a towel, or a bag of frozen peas may be used.

RICE Therapy

Action Interventions

Compression Loosen the compression bandage if you experience numbness, tingling, or swelling distal to the injury, or if the distal extremity becomes cool or cyanotic (bluish-grey).

Elevation Keep the injured extremity elevated on a pillow above heart level to help reduce swelling and pain.

Nursing Care for Contusions, Sprains and Strains

Acute Pain

• Teach the patient to use RICE (rest, ice, compression, elevation) therapy to care for the injury.

Impaired Physical Mobility

• Teach the correct use of crutches, walkers, canes, or slings if prescribed.

• Encourage follow-up care.

Rotator Cuff Injuries, Knee Injuries and Joint Dislocation

ROTATOR CUFFINJURIES

KNEE INJURIES

JOINT DISLOCATION

Pathophysiology tendinitis, bursitis, and partial and complete muscle tears

ligament tears, meniscal injury, and patellar dislocation

bones are displacedout of their normal position and joint articulation is lost

Etiology repetitive use injury or degenerative changes

sports activities contact sports, disease of the joint, including infection, rheumatoid arthritis, paralysis, and neuromuscular diseases

Rotator Cuff Injuries

Knee Injuries

Joint Dislocation

Joint Trauma

ROTATOR CUFFINJURIES

KNEE INJURIES

JOINT DISLOCATION

Manifestations shoulder pain, limited ROM

immediate pain, a tearing or popping sensation, swelling

pain, deformity, and limited motion of the affected joint

Diagnosis history and physical assessmentx-ray and MRI

Treatment RICENSAIDsphysical therapysurgery

RICENSAIDsphysical therapysurgery

RICE, NSAIDsclose reductionmanual tractionsurgery

Joint Trauma

Nursing Care for Joint Trauma

History Taking

circumstances of injury if known;

pain, including location, character, timing, and activities or movements that aggravate or relieve it

history of prior musculoskeletal injuries;

chronic illnesses;

medications.

Nursing Care for Joint Trauma

Physical Assessment

Compare the position, color, size, and temperature of the affected joint to the corresponding unaffected joint.

Palpate for tenderness, crepitus, temperature, and swelling.

Instruct the patient or assist to move the joint through its normal range of motion, stopping and noting where pain is experienced.

When a joint dislocation is suspected, assess color, temperature, pulses, movement, and sensation of the limb distal to the affected joint.

Nursing Diagnosis and Interventions

Risk for Injury

• Monitor neurovascular status by assessing the 5 “P’s”: pain, pulses, pallor, paralysis, and paresthesia.

• Maintain immobilization as ordered after reduction.

Acute Pain

• Encourage use of an appropriate splint or joint immobilizer.

• Teach safe application of ice or heat to the affected joint as indicated.

• Instruct about using NSAIDs as ordered.


Preventing Dislocations

• Keep the knees apart at all times.

• Put a pillow between the legs when sleeping.

• Never cross the legs when seated.

• Avoid bending forward when seated in a chair.

• Avoid bending forward to pick objects on the floor.

• Use a high-seated chair and a raised toilet seat.

• Do not flex the hip to put on clothing.


Acute Pain

• Teach use of assistive devices such as a sling, crutches, or cane to reduce stress on the affected joint or minimize weight bearing.


• Refer to physical therapy for appropriate exercises.

• Suggest occupational therapy.

Repetitive Use Injuries

CARPAL TUNNEL SYNDROME

BURSITIS EPICONDYLITIS

Pathophysiology compressionof the median nerve

inflammation of a bursa

inflammation of the tendon to microvascular trauma

Etiology using computerspost menopausal women

constant friction between the bursa and the musculoskeletal tissue

tears, bleeding, andedema and calcification of the tendon




Manifestations pain, numbness and tingling of the thumb, index finger, and lateral ventral surface of the middle finger

hot, red, edematous, tender, and extension and flexion of the joint near the bursa produce pain

point tenderness, pain radiating down the dorsal surface of the forearm

Carpal Tunnel Syndrome

Bursitis

Epicondylitis




Diagnosis history and physical examinationPhalen’s testultrasound magnetic resonance imaging (MRI)electromyography (EMG)nerve conduction studies

history and physical examinationultrasound

magnetic resonance imaging (MRI)

Phalen’s Test

Tinel’s Sign




Emergency Management RICE in the first 24 to 48 hours

Medications NSAIDsnarcoticscorticosteroids

NSAIDsnarcotics

NSAIDsnarcoticscorticosteroids

Treatment Surgery

Carpal Tunnel Syndrome

Nursing Interventions for Repetitive Use Injuries

Acute Pain

• Ask the patient to rate the pain on a scale of 0 to 10 before and after any intervention.

• Encourage the use of immobilizers.

• Teach the patient to apply ice and/or heat as prescribed.

• Encourage use of NSAIDs as prescribed.

• Explain why treatment should not be abruptly discontinued.

Nursing Interventions for Repetitive Use Injuries


• Suggest interventions to alleviate pain (such as using an immobilizer and taking pain medications).

• Refer to a physical therapist for exercises.

• Suggest consultation with an occupational therapist.

Objective Health Assessment

Muscle Grading Scale

Scale Assessment Description

0 (No visible) contraction; paralysis

1 Can feel contraction of muscle but there is no movement of limb

2 Passive ROM

3 Full ROM against gravity

4 Full ROM against some resistance

5 Full ROM against full resistance

Traumatic Injuries of Bones


Etiology

• direct blow

• crushing force (compression)

• sudden twisting motion (torsion)

• severe muscle contraction

• stress or pathologic fracture

Fracture Classification

• open (compound) fracture

• closed (simple) fracture


• oblique fractures• spiral fractures• comminuted fractures


• avulsed fracture• impacted fracture• fissure fracture• greenstick fracture


• stable fracture

• unstable fracture


Manifestations • Deformity• Swelling• Pain/tenderness• Numbness• Guarding• Crepitus• Hypovolemic shock• Muscle spasms• Ecchymosis

Fracture Healing

Bone Injury

Fracture Healing

Fibrocartilaginous Callus Formation

Fracture Healing

Bony Callus Formation

Fracture Healing

Bone Remodelling

Fracture Complications

COMPARTMENT SYNDROME

Pathophysiology • pressure within this confined space constricts and entraps the structures within it

Manifestations • pain• normal or decreased peripheral pulse• cyanosis• tingling, loss of sensation (paresthesias)• weakness (paresis)• severe pain



Treatment • restrictive dressings are removed • bivalving• fasciotomy

Complication • Volkmann’s contracture

Fasciotomy


FAT EMBOLISM

Pathophysiology • fat globules lodge in the pulmonary vascular bed or peripheral circulation

Etiology • long bone fractures and other major trauma• hip replacement surgery

Manifestations • neurologic dysfunction• pulmonary insufficiency• petechial rash on the chest, axilla, and upper arms


FAT EMBOLISM

Treatment • early stabilization of long bone fractures• intubation and mechanical ventilation• fluid balance is closely monitored• corticosteroids


DEEP VEIN THROMBOSIS

Pathophysiology • blood clot forms along the intimal lining of a large vein, accompanied by inflammation of the vein wall

Etiology • venous stasis, or decreased blood flow• injury to blood vessel walls• altered blood coagulation

Manifestations • swelling, pain, tenderness, or cramping of the affected extremity


DEEP VEIN THROMBOSIS

Diagnosis • doppler ultrasonography• magnetic resonance imaging• venogram

Treatment • early immobilization of the fracture• early ambulation of the patient• prophylactic anticoagulation• antiembolism stockings and compression boots


INFECTION

Pathophysiology • Pseudomonas, Staphylococcus, or Clostridium organisms may invade the wound or bone

Complication • osteomyelitis


DELAYED UNION AND NONUNION

Pathophysiology • prolonged healing of bones beyond the usual time period• delayed union may lead to nonunion

Etiology • Injury-related: the type and location of facture and accompanying soft tissue injury

• System related: age, general health, immune status, chronic diseases, and smoking

Diagnosis • serial x-ray studies


DELAYED UNION AND NONUNION

Treatment • internal fixation and bone grafting• bone debridement• electrical or ultrasonic stimulation of the fracture site• growth hormone or parathyroid hormone stimulation


COMPLEX REGIONAL PAIN SYNDROME

Pathophysiology • pain receptors become sensitized to catecholamines, neurotransmitters associated with sympathetic nervous system activity

Etiology • female• older age

Diagnosis • history and physical examination• x-ray


COMPLEX REGIONAL PAIN SYNDROME

Manifestations • severe, diffuse, and burning pain • affected extremity is inflamed and edematous, later

becoming cool and pale• muscle wasting, skin and nail changes, and bone

abnormalities

Treatment • sympathetic nervous system blocking agent

Management for Fractures

Emergency Care

• Immobilizing the fracture

• Maintaining tissue perfusion

• Preventing infection

Diagnosis

• X-rays and bone scans

• Blood chemistry studies, complete blood count (CBC), and coagulation studies


Medications

• Antibiotics may be administered prophylactically

• Anticoagulants

• Stool softeners

• Antiulcer medications or antacids


Traction

• Manual traction


Traction

• Skin traction

Nursing Interventions for Patients in Skin Traction

• Frequently assess skin, bony prominences, and pressure points for evidence of pressure, shearing, or pending breakdown.

• Protect pressure sites with padding and protective dressings as indicated.

• Remove weights only if intermittent traction has been ordered to alleviate muscle spasm.


Traction

• Balanced suspension traction


Traction

• Skeletal traction

Skeletal Traction

Traction

• Balanced suspension traction

Skeletal Traction

Traction

• Buck’s extension traction

Skeletal Traction

Traction

• Head halter

Skeletal Traction

Traction

• Pelvic girdle

Skeletal Traction

Traction

• Buck’s extension traction

Skeletal Traction

Traction

• Bryant’s traction

Skeletal Traction

Traction

• Dunlop’s traction

Skeletal Traction

Traction

• Russel’s traction

Skeletal Traction

Traction

• Halo pelvic traction

Nursing Interventions for Patients in Skeletal Traction

• Never remove the weights.

• Frequently assess pin insertion sites and provide pin site care per policy.

• Report signs of infection at the pin sites, such as redness, drainage, and increased tenderness.

Nursing Interventions for Patients in Traction

Maintain the pulling force and direction of the traction:

• The patient’s weight provides counter traction.

• Center the patient on the bed; maintain body alignment with the direction of pull.

• Ensure that weights hang freely and do not touch the floor.

• Ensure that nothing is lying on or obstructing the ropes.

• Do not allow the knots at the end of the rope to come into contact with the pulley.


• Perform neurovascular assessments frequently.

• Assess for common complications of immobility, including pressure ulcer formation, renal calculi, deep venous thrombosis, pneumonia, paralytic ileus, and loss of appetite.

• If a problem is detected, assist in repositioning. Stabilize the fracture site during repositioning.

• Teach the patient and family about the type and purpose of the traction.


T - Temperature (Extremity, Infection)R - Ropes hang freelyA - AlignmentC - Circulation Check (5 P's)T - Type & Location of fractureI - Increase fluid intakeO - Overhead trapezeN - No weights on bed or floor


Casts


Casts

• Short arm

• Long arm


Casts

• Short leg

• Long leg


Casts

• Walking cast


Casts

• Hip spica cast


Casts

• Short leg hip spica cast


Pressure areas in casts

Nursing Interventions for Patients in Casts

• Perform frequent neurovascular assessments.

• Palpate the cast for “hot spots” that may indicate the presence of underlying infection.

• Promptly report increased or severe pain; changes in neurovascular status; or a hot spot or drainage on the cast.

Health Education for the Patient and Family

• Do not use a blow dryer to speed drying; do not cover the cast while it is drying.

• A sensation of warmth during drying is normal.

• Do not put anything into the cast.

• Keep the cast clean and dry; use plastic wrap as needed to protect it.

• If the cast is made of fiberglass, dry it with a blow dryer on the cool setting if it becomes wet.

Health Education for the Patient and Family

• Notify your doctor immediately if you develop increased pain, coolness, changes in color, increased swelling, and/or loss of sensation.

• A sling may be used to distribute the weight of the cast evenly around the neck.

• If crutches are used, arrange for physical therapist to teach correct crutch walking.

• When the cast is removed, an oscillating cast saw will be used.


Surgery

• open reduction and internal fixation (ORIF)


Surgery

• surgical fixation


Electrical Bone Stimulation

Nursing Care for Fractures

History Taking

• age

• history of traumatic event

• history of prior musculoskeletal injuries

• chronic illnesses

• medications (ask the older adult specifically about anticoagulants and calcium supplements).

Nursing Care for Fractures

Physical Assessment

• Pain with movement, pulses, edema, skin color and temperature, deformity, range of motion, touch.

• The 5 P’s of neurovascular assessment.


Acute Pain

• Monitor vital signs.


• Move the patient gently and slowly.

• Elevate the injured extremity above the level of the heart.

• Encourage distraction or other adjunctive methods of pain relief, such as deep breathing and relaxation.


Acute Pain

• Administer NSAIDs and pain medications as prescribed. For home care, explain the importance of taking pain medications before the pain is severe.


Risk for Peripheral Neurovascular Dysfunction

• Support the injured extremity above and below the fracture site when moving the patient.

• Assess the 5 P’s every 1 to 2 hours. Report abnormal findings immediately.

• Assess nail beds for capillary refill. If nails are too thick or discolored, assess the skin around the nail.

• Monitor the extremity for edema and swelling.

• Assess for deep, throbbing, unrelenting pain.



• Assess the ability to differentiate between sharp and dull touch and the presence of paresthesias and paralysis every 1 to 2 hours.

• Monitor the tightness of the cast. If the cast is tight, be prepared to assist the physician with bivalving.

• If compartment syndrome is suspected, assist the physician in measuring compartment pressure. Normal compartment pressure is 10 to 20 mmHg.


Bivalving



• Unless contraindicated, elevate the injured extremity above the level of the heart.

• Administer anticoagulant per physician’s order.


Risk for Infection

• For patients with skeletal pins, follow established guidelines for skeletal pin site care.

• Monitor vital signs and lab reports of WBCs.

• Use sterile technique for dressing changes.

• Assess the wound for size, color, and the presence of any drainage.

• Administer antibiotics per physician’s orders.



• Teach or assist patient with ROM exercises of the unaffected limbs.

• Teach isometric exercises, and encourage the patient to perform them every 4 hours.

• Encourage ambulation when able; provide assistance as necessary.

• Turn the patient on bed rest every 2 hours. If the patient is in traction, teach the patient to shift his or her weight every hour.

Amputation

Amputation

Causes of Amputation

• Peripheral vascular disease (PVD)

• Peripheral neuropathy

• Untreated infection

• Motor vehicle crashes or accidents involving machinery at work

• Combat-related trauma

• Frostbite, burns, or electrocution

Common Sites of Amputation

Amputation Complications

INFECTION

Pathophysiology • traumatic amputation has a greater risk of infection

Etiology • older patients, has diabetes mellitus, or suffers peripheral neurovascular compromise

Manifestations • local manifestations include drainage, odor, redness, and increased discomfort at the suture line.

• systemic manifestations include fever, an increased heart rate, a decrease in blood pressure, chills, and positive wound or blood cultures.


DELAYED HEALING

Pathophysiology • if infection is present or if the circulation remains compromised, delayed healing

Etiology • older patients, electrolyte imbalances, diet that lacks the proper nutrients, smoking, deep vein thrombosis and decreased cardiac output


CHRONIC STUMP PAIN

Pathophysiology • neuroma formation

Manifestations • severe burning pain

Treatment • medications• nerve blocks• transcutaneous electrical nerve stimulation (TENS)• surgical stump reconstruction


PHANTOM LIMB PAIN

Pathophysiology • pain in the amputated limb prior to its removal

Manifestations • tingling, numbness, cramping, or itching in the phantom foot or hand

Treatment • pain management• TENS• surgery


CONTRACTURES

Pathophysiology • abnormal flexion and fixation of a joint caused by muscle atrophy and shortening

Treatment • active or passive ROM exercises every 2 to 4 hours• postural exercises

Management for Amputation

Diagnosis

• Preoperative - Doppler flowmetry, segmental blood pressure determination, transcutaneous partial pressure oxygen readings, and angiography

• Postoperative - CBC, WBC, blood chemistries, and a vascular Doppler ultrasonography.


Medications

• analgesics

• antibiotics

• steroids

• H2 antagonists


Emergency Care

• Administer CPR as necessary, and control bleeding with direct pressure.

• Keep the person in a supine position with the legs elevated.

• Apply firm pressure to the bleeding area, using a towel or article of clothing.

• Wrap the amputated part in a clean cloth. If possible, soak the cloth in saline.


Emergency Care

• Put the amputated part in a plastic bag and put the bag on ice.

• Send the amputated part to the emergency department with the injured person, and be sure the emergency personnel know what it is.


Assessment

• Health history: Mechanism of injury, current and past health problems, pain, occupation, ADLs, changes in sensation in the feet, cultural and/or religious guidelines for handling the amputated part.

• Physical examination: Bilateral neurovascular status of the extremities, bilateral capillary refill time, skin over the lower extremities (discoloration, edema, ulcerations, hair, gangrene).


Acute Pain


• Splint and support the injured area.

• Unless contraindicated, elevate the stump on a pillow for the first 24 hours after surgery.

• Move and turn the patient gently and slowly.

• Administer pain medications as prescribed. A PCA pump may be ordered by the physician.


Acute Pain

• Encourage deep breathing and relaxation exercises.

• Reposition patient every 2 hours; turn from side to side and onto abdomen.


Risk for Infection

• Assess the wound for redness, drainage, temperature, edema, and suture line approximation.

• Take the patient’s temperature every 4 hours.

• Monitor WBC count.

• Use aseptic technique to change the wound dressing.

• Administer antibiotics as ordered.

• Teach the patient stump-wrapping techniques.


Risk for Impaired Skin Integrity

• Wash the stump with soap and warm water and dry thoroughly.

• Inspect the stump for redness, irritation, or abrasions.

• Massage the end of the stump, beginning 3 weeks after surgery.

• Expose any open areas of skin on the remaining part of the limb for 1 hour four times a day.

• Change stump socks and elastic wraps each day. Wash these in mild soap and water, and allow to completely dry before using.


Risk for Complicated Grieving

• Encourage verbalization of feelings, using open-ended questions.

• Actively listen and maintain eye contact.

• Reflect on the patient’s feelings.

• Allow the patient to have unlimited visiting hours, if possible.

• If desired by the patient, provide spiritual support by encouraging activities such as visits from a spiritual leader, prayer, and meditation.


Disturbed Body Image

• Encourage verbalization of feelings.

• Allow the patient to wear clothing from home.

• Encourage the patient to look at the stump.

• Encourage the patient to care for the stump.

• Offer to have a fellow amputee visit the patient.

• Encourage active participation in rehabilitation.



• Perform ROM exercises on all joints.

• Maintain postoperative stump shrinkage devices. (elastic bandages, shrinker socks, an elastic stockinette, or a rigid plaster cast).

• Turn and reposition the patient every 2 hours.

• Reinforce teaching by the physical therapist in crutch walking or the use of assistive devices.

• Encourage active participation in physical therapy.

References1. LeMone, P. et al. (2011). Medical-Surgical Nursing: Critical

Thinking in Client Care. 5th Edition. New Jersey: Pearson Education, Inc.

2. Smeltzer, S. C. et al. (2010). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. 12th Edition. Philadelphia: Lippincott Williams and Wilkins.

3. Williams. L. S. & Hopper, P. D. (2011). Understanding Medical-Surgical Nursing. 5th Edition. Philadelphia: F. A. Davis Company

musculoskeletal system trauma

Health & Medicine

joint instability mild

strains acute pain

ice bag

weight bearing

moderate joint instability

ligament moderate pain

loss of joint function

ligament severe pain