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1. Medical Surgical II
Unit I. Musculoskeletal disorders
Time allowed : 6 hrs
BY: Wondwossen Yimam (Msc.N)
1

2. Unit I. Musculoskeletal disorders
Caring for patients with soft
tissue injuries
&
Caring for patients with joint
& connective tissue disorders
2

3. I/ SOFT TISSUE INJURIES
SPRAIN
Is an injury to ligaments and other soft tissues at a joint
Caused by a wrenching or twisting motion
There are three grades of sprain
A/ First degree sprain:-
Caused by tearing a few ligament fibers
B/ Second degree sprain:-
Caused by tearing more ligament fibers
C/ Third degree sprain:-
Occurs when a ligament is completely torn
It is manifested by severe pain, tenderness, increased edema,
and abnormal joint motion
3

4. S & Sx of Sprain
• Pain
• Tenderness
• Swelling
• Discoloration
DX
• Complete Hx taking
• P/E
• X-ray
4

5. General management of sprain
Mnemonic “ A RICE”
A= Anti pain
R = Rest
- Prevent additional injury and promote healing
I = Immobilize
- Applying an elastic compressive bandage to control
bleeding, reduce edema and provide support for
injured tissue
– Monitoring the neuromuscular status
– Surgical repair or cast application
– Splinting may be used to prevent injury
5

6. General management of sprain---
C = Cold
o Apply intermittently for 20-30 minutes during the first 24-
48 hours after injury produces vasoconstriction, which
decrease bleeding, edema and discomfort
o After 24-48 hours after injury heat may be applied
intermittently (for 15-30 minutes, 4 times a day) to
relieve muscle spasm and to promote vasodilatation,
absorption and repair
E = Elevate the part above the level of the heart
o Elevation control swelling
6

7. STRAIN
= Strains are microscopic, incomplete muscle tears with
some bleeding in to the tissue
= Is a "muscle pull" due to overuse, overstretching or
excessive stress
= Commonly strains occur on the back muscles due to
improper lifting techniques
-S&SX
-DX Similar to sprain
-Mgt
7

8. There are three grades of strain
A/ First degree strain:-
Caused by tearing a few muscle fibers
B/ Second degree strain:-
Caused by tearing more muscle fibers
C/ Third degree strain:-
The most severe type
Significant pain , muscle spasm, eccymosis, edema
& loss of function
Its management is similar to sprain
8

9. JOINT DISLOCATION
Defn:- Is a displacement of a bone end from the joint.
A subluxation is a partial dislocation of the articulating surfaces
Luxation is total separation of the bone from its socket.
Dislocation may be:-
• Traumatic due to injury in which the joint is disrupted by force
• Congenital (present at birth, due to some mal development) hip
• Pathologic or spontaneous due to disease at articular or
periarticular structures
9

10. The S/SXS of traumatic dislocation
o Pain upon movement
o Tenderness to touch
o Change in contour of joints (swelling)
o Change in the length of extremity
o Loss of normal mobility
o Change in the axis of the dislocated bones
( Obvious deformity)
10

11. Management of dislocation
Goal of treatment
Relieve pain Ex. Meperidine 75-100 mg
Reduce dislocation
Prevent further dislocations
General management
ARICE +
• Anti- pain
• Rest
• Apply splint & immobilize the part
• Elevate the part
• Prevent complications
• Refer for surgical repair
• Assess neurovascular status before and after reduction,
including strength of the pulse, capillary refill time, sensation,
movement, pain, and color of the skin 11

12. II. Joint & connective tissue disorders
OSTEOARTHRITIS
Defn:-Degenerative joint disease or osteoartherosis
Risk Factors for osteoarthritis
• Increased age • Obesity
• Previous joint damage
• Repetitive use (occupational or recreational) • Anatomic
deformity
• Genetic susceptibility
Characteristics of osteoarthritis
Cause: Mechanical wear & tear on joints
= Cartilage destruction with bone spur growth, degenerative
= Most common than RA
Age: Common in elderly
Gender: Common in both F & M (1:1)
< 50 yrs = M>F >50yrs = F>M 12

13. Osteoarthritis---
Characteristics of osteoarthritis---
Onset: Slow over years
S&Sxs: -Begins in a single joint
-Joint pain with little or no swelling
-Pain with activity (pain decrease at rest)
= Movement increase pain
• In advanced cases, pain also may be present during rest
- Asymmetrical/Symmetrical/ involvement
- Morning stiffness lasts < 30 mins
- Whole body symptoms are not present
- Affects large joints
- Effusions are not common
- Common in obese pts
13

14. Osteoarthritis---
Characteristics of osteoarthritis---
Nodules : Bouchard’s & Heberden’s nodes
Severity : Less severe than RA
DX:- Non definitive Lab test, X-ray, RF negative, normal ESR
RX: No Rx halts the degenerative process but slow the progression
- Nutrition, Yoga, Glucosamine(500 BID) + Chondroitin (400 BID)
- Joint rest, Wt reduction, Avoidance of joint overuse, Passive & Active
exercises.
- Avoid activities that overload the joint
- Use brace or splints and orthotic devices
o Assistive devices: stocking helpers, built-up eating utensils, pickup sticks,
and raised toilet seats
- Well fitted shoes
- Local moist heat/Cold/
- Intraarticular steroids, analgesics and anti-inflammatory
- Arthroplastic surgery/ Joint replacement/
By: Wondwossen Yimam (Msc.N)
Wollo University

15. Rheumatoid Arthritis
Defn: Chronic , progressive, systemic, inflammatory
process that affects primarily synovial joints due to
autoimmune reaction
Characteristics of RA---
Cause: Unknown, predisposing factors include
autoimmune process, food allergies, hereditary and viral
infections
Age: Begin any time in life
Gender: F>M (3:1)
Most crippling
Onset: Relatively rapid (week to months)
15

16. Rheumatoid Arthritis---
Seven criteria must be met to diagnose RA
appropriately:
1.Morning joint stiffness lasting more than 1 hour
before disappearing
2. Involvement of three or more joint areas
3. Arthritis of hand joints
4. Symmetric joint involvement
5. Presence of rheumatoid nodules
6. Elevated rheumatoid factor
7. Radiographic changes 16

17. Rheumatoid Arthritis---
Characteristics of RA---
S&Sxs: -Painful joints, swollen & stiff
-Symmetrical involvement
-Movement decreases pain (pain at rest)
-Morning stiffness lasts > an hour(60 mins)
-Whole body symptoms are present
(Low grade fever, wt loss , fatigue)
- Affects both small and large joints
- Effusions are common
-Usually patients are not obese
17

18. Rheumatoid Arthritis---
Characteristics of RA---
Nodules :- Present especially on extensor surfaces
(Rheumatoid nodules)
- May develop on sclera, heart, skin, lungs, etc
- May develop Sjogren’s (felty) syndrome
- May develop Raynaud’s phenomenon
- Boutonnière’s deformities of hands
Severity : More severe than osteoarthritis
DX:- X-ray, RF positive, Wbcs ESR, Rbcs, C3 & C4
Arthrocentesis:-Cloudy, milky,dark yellow synovial fluid, low
glucose level than serum
RX: NSAIDS, Steroids, Methotroxate ,Immunosuppressants
(Azathioprine 1.5-2.5mg/kg/d po) ,& Antimalarial
(Chloroquine)
18

19. NSAIDS
• Oxaprozin 1200 mg /d
• Piroxicam 20 mg/d
• Meloxicam 15 mg/d COX-2-Selective Agents
• Celecoxib 400 mg BID COX-2-Selective Agents
• Sulindac 150 mg BID
• Ibuprofen 400 mg BID
• Indomethacin 25 mg TID
• Diclofenac 50 mg TID
• Colchicine 0.6 mg TID
19

20. Rheumatoid Arthritis---
RX:
- NSAIDS
- Steroids ( Not good for osteoarthritis)
- Chrysotherapy (use of medicinal gold salts)
- DISEASE MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS)
Ex. Methotroxate 7.5-20 mg once /wk
- BIOLOGIC RESPONSE MODIFIERS ( TNF alpha antagonists)
- Glucosamine 500 mg BID + Chondroitin 400 mg BID for 30 – 90
days
- Well fitted shoes
- Heat/Ice packs( osteoarthritis)
- Cold ( RA)
- ROM exercises
- Massages
- Salicylate ointments
- Surgery (Joint replacement, arthrodesis, osteotomy)
20

21. Boutonnière’s deformities of hands
21

22. Osteomyelitis
Defn:- It is an acute or a chronic infection of the bone or bone
marrow.
Causes
- Bacterial contamination (from open wound)
(Staphylococcus aureus (90%), Streptococcus pyogenes,
Pseudomonas aeruginosa, Escherichia coli, Neisseria
gonorrhoeae, Haemophilus influenzae, and Salmonella typhi)
- Hematogenic osteomyelitis
- Inadequate antimicrobial therapy or lack of response to
treatment
Common sites
Metaphyseal area in long bones (femur, tibia, humerus, and
vertebrae )
22

23. Osteomyelitis---
Signs and symptoms
• Pain and pressure; heat, edema, and tenderness
• Associated systemic signs and symptoms include
chills, fever, malaise, nausea, and tachycardia
• The affected limb may be sore with use
• An open, draining area may appear
23

24. Osteomyelitis---
Diagnosis
• Patient history, bone scan, MRI, physical examination,
X-rays of the involved bone, culture of the drainage,
WBC count and ESR
Treatment
• An antibiotic is administered I.V. in large doses after
blood cultures are taken
• Aspirin
• TAT 3000 IU
• After antibiotic therapy is completed, the bone is
surgically scraped to clear away the dead bone and
residue of infection
24

25. Osteomyelitis---
Treatment---
• Bone grafts may be used to aid bone healing and
prevent fracture
• Tubes or catheters may be inserted to flush the site
with an antibiotic to clear any residual organisms
• An external fixates may be placed above and below
the osteomyelitic site to decrease the possibility of
bone fracture
• Surgery to drain infection may be necessary
• Immobilization of the infected bone may be necessary
using a cast, traction, or bed rest
25

26. Osteomyelitis---
Nursing interventions
• Monitor the type and amount of pain to determine
the disease’s status
• Administer an antibiotic, an analgesic, or tetanus
toxoid or antitoxin as prescribed
• Administer I.V. fluids to maintain hydration
• Perform neurovascular checks, and monitor vital
signs
• Use strict aseptic technique when required; the
patient is more susceptible to additional infection or
nosocomial infection
26

27. Osteomyelitis---
Nursing interventions
• Help the patient achieve a comfortable position to
relieve pressure on the affected tissues
• Encourage the patient to perform ROM exercises for
all unaffected tissues and joints to maintain strength
• Teach the patient how to use an ambulatory aid (or
arm sling)
• Discuss concerns about types of treatment
• Provide and encourage diversionary activities to help
the patient maintain a positive outlook
27

28. Osteoporosis
Defn:- It is a systemic disease in which bone
density and bone mass decrease because of a
disturbance in the balance between bone
resorption and bone deposition
• Common after 30 yrs, but progresses rapidly in
postmenopausal women; 70% of women older
than age 45 have osteoporosis
28

29. Osteoporosis---
Causes:-
Menopausal decreases in estrogen, family history,
immobility, insufficient intake of Ca++ and vitamin
D, alcohol use, smoking, corticosteroid use, and
caffeine intake, etc
Patients with osteoporosis are susceptible to
fractures (particularly of the femur, radius, and
ulna) and compression or crush injuries of the
vertebrae
29

30. Osteoporosis---
Signs and symptoms
◆ Pain may affect the lower back or thoracic spinal
area
◆ A loss of height (> 2 cm or 0.78 inches)
◆ Spinal Kyphosis (“dowager’s hump”)
◆ A minor twist or turn can cause a sudden fracture
(Fragility fracture, especially of the hip or spine)
◆ Numbness or tingling in arms or legs may occur
30

31. Osteoporosis---
Diagnosis
Patient history, P/E, and CT scans
Serum Ca++ > 10.5 mg/dl
Treatment
◆ Elemental Calcium intake is increased to 1,000-1500 mg daily
◆ Estrogen(0.625 mg) and progesterone are prescribed to restore
hormonal balance
◆ Calcitonin 4 units/kg BID
◆ Bisphosphonates (Ex. Alendronate 10-70 mg /d)
◆ Oral vitamin D
o Calcitriol (0.5 µg/day) If kidney not functioning or
o Calcidiol (1000 IU/day) or
o Vit D3 100-200 u/d
◆ Sodium fluoride , weekly androgenic anabolic steroids, thiazides
◆ Back or neck supports are used to prevent stress fractures
◆ Active exercises are encouraged to help retain calcium in the bones
31

32. Osteoporosis---
Nursing interventions
◆ Monitor the amount and type of pain to determine
its extent
◆ Give an analgesic
◆ Teach the patient how to use an ambulatory aid to
maintain mobility, and apply a neck or back support,
if ordered
◆ Teach the patient about dietary sources of calcium
(dairy products ,cereals (oats, beans) ,juices, green
leafy vegetables, etc
◆ Don’t give Alendronate with Al2(OH)3 PO ,it binds
phosphate and promote excretion through GI
◆ Moderate weight bearing exercise
32

33. Osteoporosis---
Nursing interventions---
◆ Discuss how to ensure a safe home environment to
decrease the risk of falls, for example, by removing
loose rugs and avoiding long uncovered electrical
cords
◆ Encourage the patient to participate in active,
weight-bearing exercises, such as walking and
swimming, to maintain calcium in bones and preserve
muscle strength
◆ Encourage the patient to modify lifestyle choices by
avoiding smoking, alcohol, caffeine, and carbonated
beverages, and increasing protein intake.
33

34. Gout
Defn:- Genetic defect of purine metabolism
(metabolic disorder) resulting in hyperuricemia
( > 7.5 mg/dl)
• Gout commonly begins in one joint, most often the
big toe joint, but it may spread to more joints
• It often affects foot, ankle, knee, hand, wrist and
elbow joints
34

35. Gout---
Hyperuricemia (> 7.5 mg/d )

Monosodium urate crystal deposition

Urate crystals in the joints

An inflammation of joints Gout

Repeated accumulation of sodium urate crystals in the
periphery of the body (toes, hands, ear)

Kidney stones (renal urate lithiasis)

Chronic disease
35

36. Gout---
Causes
Primary gout:- high levels of uric acid from either increased
production or decreased excretion of uric acid. EX.
Starvation, excessive intake of fish, organ meat, hereditary
• Secondary gout:- HPN, RF, DM, hypothyroidism ,hypo/hyper
parathyroidism, pernicious anemia, hemolytic anemia,
glycogen storage disease, psoriasis, renal insufficiency,
leukemia, use of thiazide diuretics, chronic renal disease,
myeloproliferative disease, hemoglobinopathies, cancer
chemotherapy, and multiple myeloma
Prevalence : M:F(9:1) PR = 5%
36

37. Gout---
Risk factors
• A family history of gout
• Drinking too much alcohol
• Being overweight or overeating
• Joint injury or surgery
• Certain medical conditions (e.g., high blood pressure,
diabetes, kidney disease)
• Certain medicines (e.g., fluid tablets (diuretics), cancer
therapy)
• Crash dieting or fasting
• Not drinking enough fluids
• Eating certain foods that increase uric acid in the blood.
• Older age
37

38. Gout---
Risk factors---
• Lead intoxication
• Medications:-Low dose salicylates, thiazide diuretics,
cytotoxic drugs, diazepam, ethambutol ,nicotinic acid,
, niacin, pyrazinamide, & cyclosporine. In most cases,
these drugs block uric acid secretion in the kidney.
• Metabolic acidosis (Ex. ketoacidosis, lactic acidosis)
D/DX
Septic arthritis, osteomyelitis, pseudo gout, bursitis,
cellulitis, RA
38

39. Gout---
Signs and symptoms
• A gout attack usually comes on suddenly, often
overnight.
• Common symptoms include: Joint inflammation,
with swelling, redness and heat
• An extremely tender and painful joint, which is
sensitive to touch – sometimes even the weight
of a bed sheet can cause severe pain.
39

40. Gout---
Signs and symptoms---
• If gout is not managed correctly, the time between
attacks may get shorter, attacks may last longer and
more joints may be affected
• Repeated gout attacks can permanently damage
joints and also lead to kidney problems
• Gout symptoms are most often felt in the large joint
of the big toe, but can affect other joints such as:
Ankle, Heel, Knee ,Achilles tendon, Wrist, Finger,
Elbow, etc
40

41. Gout---
Diagnostic tests
• Increased serum uric acid levels > 7.5 mg/d
• Increased WBC- in acute phase
• Increased ESR- in acute phase
• Analysis of synovial fluid- urate crystals
• Monosodium urate crystals confirms the diagnosis.
• Joint fluid has an elevated WBC count with neutrophils
predominating
• X-ray ( cystic changes, punched-out lytic lesions with
overhanging bony edges, and soft-tissue calcified masses)
41

42. Gout---
Stages of Gout
Stage 1 – Asymptomatic Hyperuricemia
• Elevated levels of uric acid , No symptoms of gout,
Treatment usually not necessary
• Most people will have elevated levels of uric acid for many
years before their first attack. Many people with elevated
uric acid will never have an attack.
• The risk of an attack increases as the uric acid level
increases
42

43. Stages of gout---
Stage 2 – Acute Gout Attack
• A gout attack awakens someone at night by intense
pain, redness and swelling in the joint
• Pain goes away (even without treatment) after 3 to 10
days
• Another gout attack may not occur for months or years
• In 50% of the initial attacks, the meta -
tarsophalangeal joint of the great toes is involved,
commonly known as podagra , but the feet, ankles,
and knees are also commonly affected
43

44. Stages of gout---
Stage 3 – Intercritical gout
Symptom -free period between attacks (for months or
year pts feel well)
• Joints functioning normally
• Unfortunately, if ignored, this phase is frequently
followed by continued attacks of gout
• Despite a lack of symptoms, there is ongoing
inflammation
• A low level of inflammation may be associated
with risks for heart disease and stroke
44

45. Stages of gout---
Stage 4 – Chronic Tophaceous Gout
• Tophi =Accumulation of sodium urate crystals in
soft tissues
• Tophi can form anywhere in the body, commonly
involved sites are the olecranon bursa, fingers,
wrists, and sometimes the helix of the ear
• With proper medical attention and treatment,
most gout patients will not progress to this
advanced, disabling stage
RX:- Allopurinol, Colchicine
45

46. Gout---
Foods that can increase uric acid levels
• Although there is little scientific evidence about the
influence of diet on gout, there is some evidence
that eating meat or seafood can contribute to gout
• Large amounts of meat, especially red meat
• Liver, kidney, brains, heart
• Seafood
• Foods containing yeast (e.g, beer )
• Beans, peas, lentils, oatmeal
• Mushrooms, cauliflower, spinach
46

47. Gout---
Self care
• An ice pack may ease pain until medicines start to
work.
• During a gout attack, protect and rest the inflamed
joint. Lift up the joint whenever possible to reduce
swelling.
• Limit alcohol. Avoid drinking a lot of alcohol at one
time
• Drink enough water (3-4 litre) every day
• Eat regular, healthy meals, including plenty of fruit,
vegetables and grains
• Limit foods high in fat, sugar or salt
• Limit or avoid foods that trigger your gout
• Keep to a healthy weight
47

48. Gout---
RX
A/ Gout reliever
- Medicines that reduce pain and swelling are used to
relieve gout attacks. Ex. NSAIDS, Steroids
- They should be started at the first sign of symptoms
and taken until the attack has settled or for as long as
directed by your doctor
B/Gout preventer
- Gout preventer medicines help to prevent gout
attacks, by lowering uric acid blood levels. They can
help existing uric acid crystals to dissolve, stop new
crystals forming and prevent kidney problems.
48

49. Gout---
A/ Relieving attacks---
• NSAIDS (Ex. Diclofenac, Ibuprofen, Indomethacin 50 mg
TID for 48 hrs then 25 mg TID) are the medicines most
commonly prescribed by doctors to relieve a gout
attack.
• Colchicine ( 0.6mg TID) for acute phase, decrease urate
crystal deposition = Give on empty stomach
• Corticosteroids (EX.Prednisolone) are sometimes used
instead
• Aspirin should not be used for pain relief during a gout
attack, as the doses needed for pain relief can increase
the uric acid level in blood
49

50. Gout---
B/ Preventing attacks
Uricosuric agents
A/ Allopurinol (Xantine oxidase inhibitor)
200-300mg/d (most common)
– To decrease uric acid level
Starting dose:-
CrCl > 90 mL/minute = 300 mg/day
CrCl 60–90 mL/minute = 200 mg/day
CrCl 30–60 mL/minute = 100 mg/day
CrCl less than 30 mL/minute = 50 mg/day
• Adjust dosage based on follow-up uric acid levels;
maximum 800 mg/day
50

51. Gout---
B/ Preventing attacks---
Uricosuric agents
B/ Probenecid 500mg-2gm/d Second line
• Is a uricosuric agent that blocks the tubular
reabsorption of uric acid, increasing its excretion.
Starting dose 250 mg PO bid; may increase to 1000 mg
PO bid
• A ‘gout preventer’ must be taken regularly every day,
whether or not you have any symptoms
• A ‘gout preventer’ will not relieve the symptoms of a
gout attack and if ‘preventer’ treatment is started
during an attack, it can make gout symptoms worse
51

52. Gout---
Preventing attacks---
• Treatment with a ‘gout preventer’ is usually life
long. If treatment is stopped suddenly, gout may
worsen
• Xanthine oxidase inhibitors and uricosuric agents
can be combined if serum urate levels are not
reduced below 6 mg/dL on a single agent
52

53. General MGT for gout
Palliative interventions
• High fluid intake
• Low purine diet
• Limit alcohol
• Rest the affected joint, Elevate the inflamed joint
with pillows, above the level of the heart
• Wt reduction
• Cold application
• Regular monitoring of serum uric acid
• Perform passive ROM of the joints bid
• Provide psychosocial support
• Teach the family members
53

54. NSAIDS for Gout
• Ibuprofen 600 to 800 mg PO QID
• Indomethacin 50 mg PO TID
• Piroxicam 40 mg PO once daily
• Sulindac 200 mg bid × 7 to 10 days
• Celecoxib 200 mg PO BID
• Meloxicam 7.5–15 mg PO once daily
• Colchicine 0.6 mg PO every hour for up to 3 doses, then 0.6 mg
1–2 times daily if desired before antihyperuricemic
Local corticosteroids
Methylprednisolone 10–40 mg × 1 dose by intra-articular injection
Systemic corticosteroids
• Prednisone 40–60 mg PO once daily × 3 days, then decrease by
10 mg every 3 days
54

55. Fracture
• It is simply defined as a break in the bone
Causes
o Trauma: a major cause for fracture e.g. Fall,
motor accident
o Disease process : a fracture resulting from a
disease is called pathological fracture
E.g. Cancer, malnutrition, osteoporosis
• The commonest fracture is hip fracture that
resulted from osteoporosis especially in the
middle aged women
55

56. Fracture---
Types
Displaced Vs non displaced fracture
• Displaced: A fracture where the bone is separated
into two complete pieces
• Non-displaced: An incomplete fracture where the
bone is not completely separated
Open Vs closed fractures
• Open fracture: is a fracture that breaks the
continuity of the skin
N.B. Open fracture is prone to infection
• Closed fracture: Does not disrupt the skin integrity
56

57. Fracture---
• Avulsion: Piece of bone is torn away, while still
attached to a ligament or tendon
• Comminuted: Bone splintered or shattered into
numerous fragment, often occur in crushing injury
• Impacted: Fracture with one end wedged into the
opposite end or into the fractured fragment
• Greenstick: Bone is bent and fractures on the outer
area of the bend & often seen in children
= Break in only one cortex of the bone
57

58. Fracture---
• Spiral: Fracture curves around the shaft of the
bone
• Longitudinal: Fracture occurs along the length of
the bone
• Transverse: Bone fractured horizontally
• Depressed: Bone pushed inward, often seen with
skull and facial fracture
58

59. Fracture---
Sign & symptoms
• Tenderness, Pain
• Pts with hip fracture complain of pain the groin area
and of the knee – i.e referred pain
• Shortening of affected limb- common in displaced
fractures result of muscle contraction
• Limb rotation or deformity
• Decreased Range of motion (ROM)
• Ecchymosis (bruising)
• Crepitus
59

60. Fracture---
Diagnostic test
• X-ray, CT – scan to detect fracture of complex
area such as hip fracture
• MRI: to determine damage to surrounding soft
tissue
• Hematocrit /hemoglobin: For patient
experiencing moderate to severe bleeding
• Serum calcium level: may be inquired by
physician b/c calcium is important in bone
healing.
60

61. Fracture---
Fracture management
• Make the victim comfortable, ABC
• Stop bleeding
• Treat for shock
• Treat for fracture (check for head or spinal injury )
• Reassure the casualty, + “A RICE”
• Prevent any movement
• Immobilize the part (, splint/immobilizer/, cast, traction
& external fixation)
• Assess paleness, cold skin, numbness, tightness and
tingling sensation
• Give support ( cold compress, elevate the part)
• Arrange transportation
• Anti pain 61

62. Fracture---
Purposes of immobilization
- Prevent further injury
- Promote healing/circulation
- Reduce pain/spasm
- Correct a deformity
Complications of fracture
A/ Hemorrhage:- bone is highly vascular
B/ Infection- common in open fracture
C/ Thromboembolitic complications
D/ Acute compartment syndrome (ACS)
E/ Fat Embolism Syndrome (FES)
62

63. Fracture---
Acute Compartment Syndrome
Defn: is a buildup of pressure within muscle compartment(s) that
can cause serious circulatory obstruction resulting in tissue
ischemia and possibly necrosis
Early symptoms of acute compartment syndrome
 Increasing pain- Not relieved even by narcotics
 Pain exacerbated by active movement rather than passive
 Decreased sensation follows before ischemia becomes
severe
 The Six “P” s appear with severe acute compartment
syndrome
1.Pain ( severe, non stopping) 2. Parasthesia
3. Paralysis 4. Pallor 5. Pulselessness 6.
Poikilothermia(Coldness)
63

64. Fracture---
Treatment of acute compartment syndrome (ACS)
• By removing source of pressure Ex. cast
• Fascioctomy incision in to the fascia that
enclose the compartment to relieve the
constrictive muscle fascia
• Renal failure is a potentially fatal complication
of ACS
64

65. Fracture---
Fat Embolism Syndrome (FES)
= A condition in which small fat globules are
released from yellow bone marrow into the
blood stream
• Globules travel to the lung fields causing
respiratory complications
• Long bones especially the femoral shaft
• When pts have multiple fractures
• Elderly pts with fractured hip are at high risk
for Fat embolism Syndrome
• FES can occur after 72 hrs late from the time of
initial injury 65

66. Fracture---
Fat Embolism Syndrome (FES)
Sign and symptoms
• Altered mental status
• Low arterial oxygen level (PaO2 ,< 60 mmHg) and
then pt experiences:
- Tachycardia - Fever - High blood pressure
- Severe respiratory distress (tachypnea,dyspnea,
crackles, wheezes, precordial chest pain, cough,&
large amounts of thick white sputum
- Patechiae (measles like rush) in the upper body
66

67. Fracture---
• Fat embolism syndrome occurs most frequently in young adults
(20 - 30 years) and elderly adults who experience fractures of
the proximal femur
Action that must be taken if Fat Embolism Syndrome is
suspected
• Promote oxygen
• Maintain bed rest and keep movement of extremity to a
minimum
• Elevation of the extremity to the heart level, release of
restrictive devices (dressings or cast), or both
• Prepare pt for a chest x-ray examination or lung scan
• Adequate support for fractured bones during turning and
positioning, and maintenance of fluid and electrolyte balance
• Steroids to treat the inflammatory lung reaction and to control
cerebral edema
• Morphine for pain and anxiety
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68. Amputation
• An amputation is removal or excision of part or
whole of a limb, usually an extremity.
• Amputation is used to relieve symptoms, improve
function, and save or improve the patient’s quality
of life.
Causes
- Progressive peripheral vascular disease (DM)– most
common
- Fulminating gas gangrene
- Malignant tumors
- Trauma (crushing injuries, burns, frostbite, electrical
burns)
- Congenital deformities
- Chronic osteomyelitis 68

69. Amputation---
Complications of amputation
• Edema, skin breakdown caused by the
prosthesis
• Bleeding
• Infection
• Ischemic necrosis
• Flexion contracture/ joint contracture
• Chronic pain- phantom limb pain, psychogenic,
neuromas, etc.
• Phantom limb pain is caused by the severing of
peripheral nerves
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70. Amputation---
Medical management
• The objective of treatment is to achieve healing
of the amputation wound, the result being a
non tender residual limb (stump) with healthy
skin for prosthesis use.
• Healing is enhanced by gentle handling of the
residual limb, control of residual limb edema
through rigid or soft compression dressings, and
use of aseptic technique in wound care to avoid
infection.
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71. THANK YOU!
Diversity is our beauty
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