Musculoskeletal Nursing

Changes in older adult

- Loss of bone mass (in older women)
- Joint & disc cartilage dehydrates causing loss of flexibility
- Stooped posture, changing center of gravity
- Greater risk for falls
- Endocrine changes cause skeletal muscle atrophy
- Muscle tone decreases

Types of soft tissue trauma

- Contusion
- Sprain
- Strain

Contusion

- Bleeding into soft tissue
- Significant bleeding can cause a hematoma
- Swelling & discoloration (bruise)

Sprain

Ligament injury; excessive stretching of a ligament (twisting motion; overstretching or tear)

Strain

- Microscopic tear in the muscle
- May cause bleeding
- Aka "pulled muscle"
- Inappropriate lifting or sudden acceleration-deceleration

Treatment for Sprains & Strains

Rest (for 24-48 hrs)
Ice (20 min. q3-4h x 2 days)
Compression bandage (use ace bandage when elevating a sprain/strain)
Elevation & immobilization (done to increase venous return & decrease swelling)

Dislocation

A severe injury of the ligamentous structures that surround a joint which results in the complete displacement or separation of the joint surface

Subluxation

A partial or incomplete displacement of the joint

Which is considered an orthopedic emergency - dislocation or subluxation?

Dislocation

If a dislocation is not treated, can cause:

- Avascular necrosis
- Compartment syndrome

Define: Avascular necrosis

Death of bone tissue due to a lack of blood supply

Define: Compartment syndrome

Pressure builds up in the muscle and cuts off blood supply

Treatment of dislocation involves

- Involves reduction and immobilization of the affected joint
- Administration of analgesics for pain relief will be necessary
- After reduction, immobilization device is normally applied in order to prevent further injury

Rotator Cuff Injury

- Usually results from repetitive activity
- Shoulder pain; cannot initiate or maintain abduction of the arm at the shoulder

Tx of Rotator Cuff Injury

- Rest
- Sling will be applied to affected shoulder
- Anti-inflammatory meds
- After acute episode: gentle progressive exercise ordered; heating pad recommended prior to exercising joint

Bursitis

- Painful condition that affects the small, fluid-filled sacs (bursae) that cushion the bones, tendons and muscles near joints.
- Bursae become inflamed.
- Injury or overuse; usually repetitive motion

Tx of Bursitis

- Rest
- Ice
- Massage
- Compression wrap
- Anti-inflammatory agents
- Bursa cortisone injection

Nursing management of Bursitis

- Assess pain & perfusion
- Assist with mobilization
- Teach activity limitations

Meniscus serves as the

shock absorber of the knee

When does a meniscus injury occur?

Often from a fixed foot rotation in weight bearing with the knees flexed, during sports activities such as basketball or skiing.

Dx of meniscal injury

- Physical exam - pt hx
- MRI is ordered to confirm
- Surgical repair done arthroscopically

Carpal Tunnel Syndrome (CTS)

- Common condition in which the median nerve in the wrist becomes compressed, causing pain and numbness.
- Common repetitive strain injury via occupational or sports motions

Nonsurgical management of CTS includes

Drug therapy & immobilization
(possible surgical management)

Most common type of fracture

Fracture of the HIP

Who is at higher risk for hip fracture? Why?

Women at higher risk due to osteoporosis

Clinical manifestations of a hip fracture

- Severe pain at site
- Inability to move the leg voluntarily
- Shortening or external rotation of the leg

Classification of fractures

- Open
- Complete
- Incomplete
- Closed
- Comminuted

Open fracture

(compound or complex)
Break in tissue over site of the bone injury

Complete fracture

Break across entire cross-section of bone and often displaced

Incomplete fracture

(aka greenstick fracture)
Only part of the cross-section is broken

Closed fracture

(aka simple fracture)
Intact skin over site of injury

Comminuted fracture

Produces several bone fragments

Stages of Bone Healing

(1) Hematoma formation within 48-72 hours after injury
(2) Hematoma to granulation tissue
(3) Callus formation
(4) Osteoblastic proliferation
(5) Bone remodeling

When does completion of bone healing occur in the regular aged pt? The Older pt?

Healing completed within about 6-weeks.
In the older person, up to 6-months.

Emergency care of Fractures

- Check neurovascular status first
- Immobilize before moving client
- Sterile dressing for open wounds

Fracture complications:
Acute Compartment Syndrome

- Serious condition in which increased pressure within one or more compartments causes massive compromise of circulation to the area; insufficient blood supply to muscles and nerves
- Priority = Prevention of pressure buildup or fluid accumulation

After the onset of acute compartment syndrome, how long does it take for neuromuscular damage is irreversible?

Within 4-6 hr after onset

Frequent checking for the 5 P's:

- Pallor
- Pain (unrelieved with analgesics)
- Pulse (diminished or absent)
- Paresthesia (numbness/burning)
- Paralysis

Emergency care of Acute Compartment Syndrome

- Fasciotomy may be performed to relieve pressure.
- Pack & dress the wound after fasciotomy.

Possible results of Acute Compartment Syndrome

- Infection
- Motor weakness
- Volkmann's contractures

Volkmann's contractures

A deformity of the hand, fingers, and wrist caused by a lack of blood flow (ischemia) to the muscles of the forearm

Fracture complications:
Fat Embolism Syndrome

- Fat globules occlude small vessels of lungs, brain, kidneys, and other organs
- Characterized by neurologic dysfunction, pulmonary insufficiency, and petechial rash on chest, axilla, and upper arms

Principle risk factors for Fat Embolism Syndrome

Long bone fractures and other major trauma

What age group is most frequently affected by Fat Embolism Syndrome?

20-30 yo

Clinical manifestations of Fat Embolism Syndrome

- Hypoxia PaO2 less than 60 mmHg
- Tachycardia
- Deterioration in LOC (confusion, agitation)
- Respiratory distress responses
- Petechiae (pin-point red areas on chest, shoulders, axilla, mouth, conjunctival sac)

Respiratory distress responses seen with Fat Embolism Syndrome:

- Tachypnea
- Dyspnea
- Crackles
- Wheezes
- Precordial chest pain
- Copious thick white sputum

Measures to prevent fat embolism

- Immobilization fractures (early & stabilization)
- Gentle care
- Adequate hydration
- O2
- Be aware of those at high risk - those with long bone fx

Management of Fat Embolism

- O2
- Fluid replacement
- Mechanical ventilation
- Corticosteroids
- Vasoactive medications
- Maintain HgB
- Calm, supportive environment

Other complications of fractures

- Shock
- Venous thromboembolism
- Infection
- Ischemic necrosis
- Fracture blisters, delayed union, nonunion, and malunion

Percentage of persons with fat embolli that die

50%

What is important for the nurse to do in a pt with bone fx?

Monitor respiratory status every shift

Musculoskeletal Assessment - Fracture

- Change in bone alignment
- Alteration in length of extremity
- Change in shape of bone
- Pain upon movement
- Decreased ROM
- Crepitation
- Ecchymotic skin

How should the patient with a fx of the shoulder and/or upper arm be assessed?

The client should be assessed while in a sitting or standing position.
Support the affected arm to promote comfort.

How should the patient with a fx of distal areas of the arm be assessed?

The client should be in a supine position

How the should the patient with a fx of the lower extremities and pelvis be assessed?

The client should be in the supine position

Casts

Rigid device that immobilizes the affected body part while allowing other body parts to move

Cast materials include

Plaster, fiberglass, and polyester-cotton

Infection is a complication associated with casts. What are some the of manifestations?

- Musty, unpleasant odor over cast and/or at the ends of cast
- Drainage through cast or cast opening
- Sudden unexplained body temp elevation
- "Hot spot" felt over cast lesion
- May result in osteomyelitis

5 P's of circulatory checks

Pain
Paresthesia
Paralysis
Pulse
Pallor

Cast care (7)

1) Elevate extremity
2) Exercises (to unaffected side; isometric exercises to affected extremity)
3) Keep heal off mattress
4) Handle with palms of hands if cast wet
5) Turn every two hours until dry
6) Notify MD at once of wound drainage
7) Do not place

Patient teaching with cast (4)

1) Do not stractch under cast with a sharp object.
2) Do not get plaster cast wet.
3) Follow MD's orders for weight bearing.
4) PT will teach: crutch walking, limited weight bearing, transferring, etc.

Traction types

Manual - use of hands to exert pulling force
Skin - pulling force directly to the skin
Skeletal - traction forces directly to the bone

Purpose of traction (9)

1. Reduce, realign, and promote healing of fractured bones.
2. Decrease muscle spasm.
3. Immobilization
4. Treat deformities.
5. Rest joints.
6. Treat dislocations & subluxations.
7. Reduce deformities.
8. Prevent contractures.
9. Expand joint space.

Traction care (5)

1) Maintain correct balance between traction pull and counter traction force.
2) Care of weights
3) Skin inspection
4) Pin care
5) Assessment of neurovascular status

Care of client in T.R.A.C.T.I.O.N.

T - temperature
R - roped hang freely
A - alignment
C - circulation check (5 P's)
T - type and location of fracture
I - increase fluid intake
O - overhead trapeze
N - no weights on bed or floor

S&S of a Fractured Hip

- Increased pain, swelling
- Acute groin pain
- Shortening of the leg
- External rotation of the leg
- Restricted ability or inability to move leg

Buck's Extension Traction

- Used to decrease painful muscle spasms
- Form of skin traction to the LOWER LIMB
- Provides for straight pull through a single pulley attached to a crossbar at the foot of the bed
- The patient is usually not allowed to turn and must remain flat on his

Traction nursing care

- Neurovascular status *
this is done first
*
- Check color/cap refill
- Temperature
- Pulse
- Movement
- Sensation

Traction applied to an extremity puts pressure on which nerve?

Peroneal nerve, where it passes around the neck of the fibula to just below the knee

Pressure at the point of the peroneal nerve may cause:

Footdrop, leading to inability to dorsiflex the foot

The inability to plantarflex indicates damage to which nerve?

Tibial nerve

Nursing management of the pt with traction

- Positioning
- Strengthening exercises
- Potential complications

Musculoskeletal nursing care includes interventions such as:

- Promote comfort
- Assess infection
- Promote mobility
- Teach safety
- Vital signs
- Flotation, sheep skin
- Nutrition
- Vital signs
- Monitor elimination

Operative procedures for musculoskeletal fx

- Open reduction with internal fixation
- External fixation
- Postop care is similar to that for any surgery

Complications specific to fractures & musculoskeletal surgery

- Fat embolism
- Venous thromboembolism

Pin care for skeletal traction

Clean pin sites daily.
- 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 & cleaning