Musculoskeletal Care Modalities

Managing care of the patient in Cast: A rigid, external immobilizing device Is used to: Immobilize a reduced Fracture ( allow the mobilization of the pt) Correct a deformity Apply uniform pressure to underlying soft tissue Support and stabilize weakened Joint

Types of Casts: Short arm cast 2.Long arm cast Short leg cast 3.Long leg cast Walking cast ( long or short) reinforced for strength Body cast: encircle the trunk Shoulder spica cast: a body jacket that enclosed the trunk and the shoulder and elbow Hip spica cast: enclose the trunk and lower extremity ( double hip spica cast ( includes both legs

Casting Materials: Plaster: Rolls of plaster bandage, need 24 to 72 hrs to dry completely Nonplaster: Fiberglass cast ( lighter in wt, stronger, water resistant), has pores so diminish skin problems

Long-Arm and Short-Leg Cast and Common Pressure Areas

Teaching Needs of the Patient With a Cast Prior to cast application Explain condition necessitating the cast Explain purpose and goals of the cast Describe expectations during the casting process: eg, the heat from hardening plaster Cast care: keep dry; do not cover with plastic Positioning: elevation of extremity; use of slings Hygiene Activity and mobility

Cont… Explain exercises Do not scratch or stick anything under the cast Cushion rough edges Report the following signs and symptoms: persistent pain or swelling; changes in sensation, movement, skin color, or temperature; and signs of infection or pressure areas Required follow-up care Cast removal

Nursing Process—Assessment of the Patient With a Cast Prior to casting Perform general health assessment Evaluate emotional status Determine presenting signs and symptoms and condition of the area to be casted Knowledge Monitor neurovascular status and the potential for complications

Nursing Process—Diagnosis of the Patient With a Cast Deficient knowledge Acute pain Impaired physical mobility Self-care deficit Impaired skin integrity Risk for peripheral neurovascular dysfunction

Collaborative Problems/Potential Complications Compartment syndrome Pressure ulcer Disuse syndrome Delayed union or nonunion of fracture(s)

Interventions Relieve pain Elevate to reduce edema Apply ice or cold intermittently Implement position changes Administer analgesics Unrelieved pain may indicate compartment syndrome; discomfort due to pressure may require change of cast Muscle setting exercises: see Chart 67-3 Patient teaching: see Chart 67-4

Interventions (cont.) Heal skin wounds and maintain skin integrity Treat wounds to skin before the cast is applied Observe for signs and symptoms of pressure or infection Pad cast and cast edges Patient may require tetanus booster Maintain adequate neurovascular status Assess circulation, sensation, and movement Five “P’s” Notify physician at once of signs of compromise Elevate extremity no higher than the heart Encourage movement of fingers or toes every hour

Managing patient with an External fixator: Are used to manage open fractures with soft tissue damage. They provide stable support for severe comminuted (crushed or splintered) fractures while permitting active treatment of damage soft tissue. Nursing intervention: Prepare the patient psychologically Cover sharp points on the fixator or pins to prevent injuries Elevate the extremity to reduce swelling Assess neuromuscular status every 2 hrs Assess pin site for sign of infection and loosening of the pin Pin care Encourage isometric and active exercise within the limit of tissue damage. Later the nurse help the patient to mobilize within the prescribed weight bearing limit Teaching patient self care

External Fixation Devices (cont.)

Managing the patient in Traction: Is used as short-term intervention until other modalities, such as external or internal fixation are possible. Traction: is the application of a pulling force to a part of the body Is used to minimize muscle spasm, to reduce fractures, align and immobilize fractures, to reduce deformity. The effect of traction is evaluated by radioactive studies.

Traction (cont.) All traction needs to be applied in two directions. The lines of pull are “vectors of force.” The result of the pulling force is between the two lines of the vectors of force.

Managing the patient in Traction (cont…): Principle of effective traction: Countertraction must be maintained for effective traction Must be continuous to be effective Never interrupted Weight are not removed The patient must be in in good body alignment in the center of the bed Ropes must be unobstructed Weight must hang freely

Types of tractions: Nursing interventions: I. Skin traction: is used to control muscle spasm and to immobilize an area before surgery. No more than 2-3.5 kg of traction should be used, pelvic traction 4.5 to 9 kg depending on the patient weight Complications: Skin breakdown, nerve pressure (drop foot), and circulatory impairment ( DVT) Nursing interventions: Ensuring effective traction Monitor and managing potential complications

Skin Traction

Types of tractions (cont…): II. Skeletal traction: applied directly to the bone by using metal pin or wires. Most frequently used to treat fracture of long bones and the cervical spine. Is a surgical procedure. Skeletal traction uses 7-12 kg, as the muscle relax the traction weight is reduced to prevent fracture dislocation and to promote healing After removing the traction cast or splint are then used to support the healing bone.

Skeletal Traction

Nursing Interventions: Maintaining effective traction: the nurse should not remove wt from skeletal traction unless life-threatening situation occurs Maintaining positioning: such as the foot to prevent footdrop (planter flexion), inward and outward rotation. Preventing skin breakdown Monitoring neuromuscular status Providing pin site care Promoting exercise Assess sensation and movement Assess pulses, color capillary refill, and temperature of fingers or toes Assess for indicators of DVT Assess for indicators of infection

Joint Replacement: Total Hip Replacement: Is the replacement of a severely damaged hip with an artificial joint Indication: arrithritis, femoral neck fracture, failure of previous reconstructive surgeries, and problems resulting from congenital hip diseases.

Cont… Nursing interventions: 1.Prevent dislocation: positioning the leg in abduction, don’t turn the patient in the affected side, never flex the hip more than 90 degree ( don’t elevate the head of the bed more than 60 degree protective positioning include maintaining abduction, avoiding internal and external rotation, hyperextension, and a cute flexion

2. Monitoring wound drainage 3. Preventing DVT 4. Prevent infection Cont……. 2. Monitoring wound drainage 3. Preventing DVT 4. Prevent infection 5. Teach patient self care 6. Continuing care

Total knee replacement: Indication: sever pain and functioning disabilities related to joint surfaces destroyed by arrithritis, bleeding into the joint Nursing interventions: Maintain the compressed bandage over the knee Ice may be applied to decrease the swelling and bleeding Encourage active flexion of the foot every hour Prevent complications Monitor drainage bag Place the patient leg in continuous Passive motion device ( promote circulation and movement of the knee joint) Weight bearing limits are prescribed. Patient can get out of the bed the evening of the surgery or the day after surgery

CPM Device

Management of patient with musculoskeletal disorders (chap 68) Management of patient with musculoskeletal disorders

Acute low Back pain: Causes: A cut lumbosacral strain, unstable lumbosacral ligaments and weak muscles, osteoarithritis of the spine, spinal stenosis, intervertebral disk problems, and unequal leg length. Other causes include kidney diorders, pelvic problems, retroperitoneal tumors, abdominal aneurysims, obesity and stress. L4-L5 and L5-S1 has the greatest degenrative changes

Clinical manifestations: A cute or chronic back pain lasting more than 3 months without improvement) Fatique Pain radiating down the leg ( radiculopathy; Sciatica) Patient’s gait, spinal mobility, reflexes, leg length, leg motor strength and sensory perception may altered

Cont… Assessment and diagnostic findings: Focused history and physical examination ( reflexes, sensory impairment, straight leg raising, muscle strength X-ray of the spine, CT scan, MRI Bone scan and blood study Myelogram and dicogram Electromyogram and nerve conduction studies Medical management: Analgesia, rest, stress reduction and relaxation Review the Nursing process

Positioning to Promote Lumbar Flexion

Proper and Improper Lifting Techniques

Proper and Improper Standing Postures

Carpal Tunnel Syndrome Median Neuropathy at the Wrist is a medical condition in which the median nerve is compressed at the wrist Irritation of the flexor tendon and median nerve Manifestations Numbness and tingling Thumb Index finger Lateral ventral surface of the middle finger

Tinel’s Sign—Assessment of Carpal Tunnel Syndrome

Dupuytren’s Contracture

Carpal Tunnel Syndrome Risk Factors Computer use Jackhammer operation Mechanical work Gymnastics Radial bone fracture history Rheumatoid arthritis

possible treatments: treating any possible underlying disease or condition, immobilizing braces, physiotherapy, massage therapy, medication Ultimately, carpal tunnel release surgery may be required in which outcomes are generally good

Metabolic bone disorders: I.Osteoporosis: Is characterized by a reduction in the total bone mass and a changes in bone structure which increases the tendency for fracture. The rate of bone resorption is greater than the rate of bone formation, resulting in a reduced total bone mass. The bones become porous, brittle, and fragile Result in compression fractures of the thoracic and lumber spine, fractures of the neck, intertrochanteic region of the femur, and colle’s fracture of the wrist Pathophysiology: Loss of bone mass over time due to Aged-related loss: Decreased calcitonin, decreased estrogen ( which prevent bone breakdown), parathyroid hormone increases with age result in increase bone Resorption

Pathophysiology of Osteoporosis

Risk factors: see chart 68-7 Assessment and diagnostic findings: Routine X-ray, and bone sonometer Lab. Studies: Serum Ca, Serum Ph, urine calcium excretion, ESR Medical Management: Adequate balanced diet rich in calcium and Vit D Regular weight bearing exercise promotes bone formation Pharmacological therapy: Hormonal replacement therapy ( look for side effect of estrogen and progesterone replacement therapy which result in cancers… thus frequent breast examination is recommended ) Alendronate alternative to Hormonal replacement therapy: inhibiting osteoclast function and dedcreases bon loss Calcitonin: suppress bone loss

Progressive Osteoporosis Bone Loss and Compression Fractures

Osteoporosis Manifestations : Loss of height Progressive curvature of spine Low back pain Fractures of forearm, spine, hip Development of “dowager’s hump” Dorsal kyphosis Cervical lordosis

Typical Loss of Height Associated With Osteoporosis and Aging

Prevention Follow a balanced diet high in calcium and vitamin D throughout life Use calcium supplements to ensure adequate calcium intake: take in divided doses with vitamin D Regular weight bearing exercises: walking Weight training stimulates bone mineral density (BMD) See Chart 68-8

Musculoskeletal Infections: Osteomylitis Is an infection of the bone through three ways ( extension of soft tissue infection, Direct bone contamination from bone surgery, Hematogenous spread (blood born). More difficult to eradicate than soft tissue infection Pathophysiology: Staphylococcus aureus causes 70% to 80% of bone infection Process of infection (inflammation, edema, thrombosis of the blood vessels result in ischemia with bone necrosis, which may progress to form bone abscess Clinical manifestations: chills, high fever, rapid pulse, pain, swollen area, and tenderness and drainage Assessment and diagnostic Findings: X-ray (shows soft tissue swelling, later bone decalcification and necrosis), MRI, Lab test (leukocytosis, and increased ESR), wound and blood culture

Osteomyelitis Deep sepsis after arthroplasty may be classified as follows: Stage 1, acute fulminating: occurring during the first 3 months after orthopedic surgery; frequently associated with hematoma,drainage, or superficial infection Stage 2, delayed onset: occurring between 4 and 24 months after surgery Stage 3, late onset: occurring 2 or more years after surgery, usually as a result of hematogenous spread

Cont….. Prevention: treat all sources of infection, Aseptic surgery, Prophylactic antibiotics, Aseptic postoperative care. Medical management: Pharmacological therapy: Intravenous antibiotic according to the wound culture Surgical management: expose the bone surgically to remove infected and necrotic materials and irrigating the area with normal saline, direct application of antibiotics surgical (débridement).

Gout also called metabolic arthritis) is a disease created by a buildup of uric acid) Characterized by sudden, unexpected, burning pain, as well as swelling, redness, warmness, and stiffness in the affected joint. Low-grade fever may also be present.

Gout Treat acute attacks before treatment to reduce serum uric acid levels NSAIDs Colchicine Corticosteroids Analgesics Uricosuric Allopurinol

Management of Patients With Musculoskeletal Trauma Chapter 69 Management of Patients With Musculoskeletal Trauma

Injuries of the Musculoskeletal System Contusion: soft tissue injury produced by blunt force Pain, swelling, and discoloration: ecchymosis Skin remains intact

Strain pulled muscle-injury (stretching) to the musculocutaneous unit (muscle or muscle tendone. Common sites: lower back and cervical. Manifestations Pain Limited motion Muscle spasms Swelling Muscle weakness Ecchymosis

Sprain injury to ligaments and supporting muscle fiber around a joint Joint is tender movement is painful; edema, disability, and pain increase during the first 2 to 3 hours Common sites: Ankle and knee

Management 1. X-ray may be done to rule out fracture. 2. Immobilize in splint, elastic wrap 3. Apply ice for first 24 hours. 4. Analgesics Severe sprains may require surgical repair and/or cast immobilization. Nursing Interventions/Patient Education

Joint Dislocation articular surfaces of the joint are not in contact A traumatic dislocation is an emergency with pain change in contour, axis, and length of the limb and loss of mobility Most common Shoulder Acromioclavicular joints Subluxation Partial dislocation

Fractures: Is a break in the continuity of bone and is defined according to type and extent Occurs when the bone is subjected to stress greater than it can absorb. Can cause by a direct blow, crushing force, sudden twisting motion, and extreme muscle contraction.

Types of fractures: Complete fracture: break across the entire cross-section of the bone and is frequently displaced Incomplete fracture: (green stick fracture) the break occur through only part of the cross-sectional of the bone A comminuted fracture: fracture has several bone fragments Closed fracture: simple fracture does not produce a break in the skin Compound, complex fracture (open fracture): is one in which the skin or mucous membrane wound extends to the fracture bone

Cont… Grade I: clean wound less than 1 cm Grade II: larger wound without extensive soft tissue damage Grade III: is highly contaminated, has extensive soft tissue damage, and is the most severe

Types of Fractures (cont.)

Types of Fractures (cont.)

Types of Fractures

Manifestations of Fracture Pain Loss of function Deformity Shortening of the extremity Crepitus Local swelling and discoloration Diagnosis by symptoms and x-ray Patient usually reports an injury to the area

Emergency Management Immobilize the body part Splinting: joints distal and proximal to the suspected fracture site must be supported and immobilized Assess neurovascular status before and after splinting Open fracture: cover with sterile dressing to prevent contamination Do not attempt to reduce the fracture

Medical Management Reduction Closed Open Immobilization: internal or external fixation Open fractures require treatment to prevent infection Tetanus prophylaxis, antibiotics, and cleaning and debridement of wound Closure of the primary wound may be delayed to permit edema, wound drainage, further assessment, and debridement if needed

Three Phases of Fracture Healing Inflammatory phase Reparative phase: collagen formation and calcium deposition Remodeling phase: 1. Excess callus is removed 2. New bone is laid down 3. Fracture site calcifies 4. Bone is reunited

Factors enhancing fracture healing: Immobilize of fracture fragments Maximum bone fragment contact Sufficient blood supply Proper nutrition Exercise: wt bearing for long bone Hormones: growth hormone, thyroid, calcitonin, Vit. D Electric potential across fracture

Factors inhibiting fracture healing Extensive local trauma, Bone loss, inadequate immobilization Space/tissue between bone fragments, infection Local malignancy, Metabolic bone disease Irradiated bone (radiation necrosis) Avascular necrosis Intra-articular fracture Age Corticosteroids (inhibit the repair rate)

Fracture Complications Early complications: Shock: Hypovolemic or traumatic shock result from bleeding or from loss of extracellular fluid Treatment: 1. Restoring blood volume and circulation 2. Releiving patient pain 3. Provide adequate splinting.

Compartment Syndrome 2. develop when tissue perfusion in the muscles less than that required for tissue viability. Physiology Entrapment of the blood vessels limits tissue perfusion Results in edema within the compartment Edema causes further pressure Early Manifestations Deep Pain which is not controlled by opioids Normal or decreased peripheral pulse Later Manifestations Cyanosis Paresthesias, paresis Severe pain

Treatment Interventions to alleviate pressure Removal of the cast Fasciotomy

3. Fat Embolism Syndrome Pathophysiology Bone fracture results in a rise of pressure in the bone marrow Fat globules enter the bloodstream Combine with platelets Travel throughout the body Occluding small blood vessels Causes tissue ischemia

Fat Embolism Syndrome Manifestations Confusion Changes in level of consciousness Pulmonary edema Impaired surfactant production Atelectasis ARDS

Fat Embolism Syndrome Prevention Early stabilization of long bone fracture. Treatment: Intubation and mechanical ventilation Fluid balance Corticosteroids Vasoactive medication to support the cardiovascular system and prevent hypotension.

4. Deep Vein Thrombosis Manifestations Swelling Leg pain Tenderness Cramping Some are asymptomatic Diagnosis Doppler ultrasound

Deep Vein Thrombosis Treatment Bed rest Thrombolytic agents Heparin Vena cava filter Thrombectomy Prevention is the best treatment Early immobilization of fractures Early mobilization of the client

5. DIC 6. Infection Delayed complications: Cont….. 5. DIC 6. Infection Delayed complications: Delayed Union: Delay healing, which result from infection and distraction of bone fragment, poor nutrition Nonunion: failure of the ends of the fractured bone to unite, pt complain of discomfort and abnormal movement at the fracture site. Managed by internal fixation or grafting Result from infection, interposition of tissue between the bone ends, inadequate immobilization, excessive space, and impaired blood supply

Reaction to internal fixation device Cont…. 3. Avascular necrosis of the bone: Disruption of the blood supply, dislocation, bone transplantation, prolonged high doses of corticosteroids, chronic renal disease, sickle cell anemia. Reaction to internal fixation device

Amputation Partial or total removal of a body part May be the result of an acute event or a chronic condition Risk Factors Peripheral vascular disease Hypertension Diabetes Smoking Peripheral neuropathy Hyperlipidemia Trauma

Amputation Pathophysiology Interruption of blood flow Circulation impairment Edema development Status ulcers develop/become infected Development of gangrene

Amputation Types of Amputation Above or below the elbow: arm amputation Leg amputation Below the knee (BKA) Above the knee (AKA) Open amputation (Guillotine) Closed (flap) amputation

Figure 41–12 Common sites of amputation. A, The upper extremities Figure 41–12 Common sites of amputation. A, The upper extremities. B, The lower extremities. The surgeon determines the level of amputation based on blood supply and tissue condition.

Figure 41–12 Common sites of amputation. A, The upper extremities Figure 41–12 Common sites of amputation. A, The upper extremities. B, The lower extremities. The surgeon determines the level of amputation based on blood supply and tissue condition.

Amputation Post Amputation Care Rigid or compression dressing is applied Prevents infection Minimize edema Complications Infection Delayed healing Chronic stump pain Contracture

Figure 41–13 Stump dressings increase venous return, decrease edema, and help shape the stump for a prosthesis. With an above-knee amputation, a figure-eight bandage is started by bringing the bandage down over the stump and back up around the hips.