this simple lecture about nursing care of patient traumatic musculoskeletal disorders is helpful for undergrad students

1. MANAGEMENT OF PATIENTS WITH
MUSCULOSKELETAL TRAUMA
Teaching Group

2. LEARNING OBJECTIVES
On completion of this chapter , the student will:
1. Identify the signs and symptoms of an acute fracture.
2. Describe common treatment modalities for fractures
3. Discuss the prevention and management of immediate
and delayed complications of fractures.
4. Use the nursing process as a framework for care of the
older adult patient with a fracture of the hip.
5. Apply the nursing process as a framework for care of the
patient with an amputation.

3. Fractures
 Fracture :complete or incomplete disruption in the
continuity of bone .
 Occur when bone is subjected to stress greater than it can
absorb
 Caused by direct blows, crushing forces, sudden twisting
motions, and extreme muscle contractions
 When bone is broken, adjacent structures affected ,
resulting in soft tissue edema, hemorrhage into the muscle
and joints , joint dislocations, ruptured tendons, severed
nerves and blood vessels damaged

4. TYPES OF FRACTURES
 Complete
 Incomplete
 Closed or simple
 Open or compound/complex
 Grade I
 Grade II
 Grade III

5. TYPES OF FRACTURES (CONT.)

6. TYPES OF FRACTURES (CONT.)

7. TYPES OF FRACTURES

8. 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

9. 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

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

11. TECHNIQUES OF INTERNAL FIXATION

12. NURSING MANAGEMENT OF THE PATIENT
WITH A CLOSED FRACTURE
- Instruct for proper methods to control edema and pain ( elevate
extremity to heart level, take analgesics as prescribed)
- Teach exercises to maintain the health of unaffected muscles to
increase the strength of muscles needed for transferring and for
using assistive devices such as crutches, walkers, and special
utensils
- Teach how to use assistive devices safely
- Plans made to help patients modify the home environment as
needed to ensure safety such as removing floor rugs or
obstructing walking paths
- Self care , medication information, monitoring potential
complications

13. NURSING MANAGEMENT OF THE PATIENT
WITH OPENED FRACTURE
- Administer IV antibiotics immediately upon the patient’s
arrival in the hospital along with tetanus toxoid if needed
- Initiate wound irrigation and debridement in operating room .
- Wound is cultured and bone grafting may be performed to fill
areas of bone defects
- Elevate the extremity to minimize edema
- Assess neurovascular status frequently

14. FRACTURE HEALING
 Factors that Enhance Fracture Healing
- Immobilization of fracture fragments
- Maximum bone fragment contact
- Sufficient blood supply
- Proper nutrition
- Exercises
- Hormones
- Electric potential across fracture

15. FRACTURE HEALING (CONT.)
 Factors that Inhibit Fracture Healing
- Extensive local trauma
- Bone loss
- Weight bearing prior to approval
- Infection
- Inadequate immobilization
- Local malignancy
- Age
- Corticosteroids

16. COMPLICATIONS OF FRACTURES
 Shock
 Fat embolism
 Compartment syndrome
 Delayed union and nonunion
 Vascular necrosis
 Reaction to internal fixation devices
 Complex regional pain syndrome (CRPS)
 Heterotrophic ossification

17. EARLY COMPLICATIONS
 Shock
- Hypovolemic shock resulting from hemorrhage noted in
trauma patients with pelvic fracture in which the femoral
artery is torn by bone fragments
- Treatment consists of stabilizing the fracture to prevent
further hemorrhage, resorting blood volume and
circulation, relieving the patient's pain, providing proper
immobilization and protecting the patient from further
injury and other complication s

18. EARLY COMPLICATIONS (CONT.)
 Fat Embolism Syndrome
- May develop after long bone or pelvic bone fracture , or
crush injuries
- Most frequently in adults younger than 40 years of age and
in men
- More common in patients with multiple fracture
- At the time of fracture, fat globules may diffuse from the
marrow into the vascular compartment , which may
occlude the small blood vessels that supply the lungs, brain,
kidneys and other organs
- Onset is rapid, 12-48 hours of injury but may occur up to
10 days after injury

19. EARLY COMPLICATIONS (CONT.)
 Fat Embolism Syndrome
 Clinical Manifestations
- Hypoxia, tachypnea, tachycardia and pyrexia
- Respiratory distress response includes tachypnea, dyspnea,
crackles , wheezes, precordial chest pain, cough, large
amounts of thick white sputum and tachycardia
- Acute respiratory distress syndrome and heart failure may
develop
- Systemic embolization, patient appears pale, petechiae,
fever greater than 39.5 °C, free fat in urine , acute tubular
necrosis and renal failure may develop

20. EARLY COMPLICATIONS (CONT.)
 Fat Embolism Syndrome
 Prevention and Management
- Immediate immobilization of fracture including early surgical
fixation, minimal fracture manipulation and adequate support
for fractured bones during turning and positioning .
- maintenance of fluid and electrolyte balance
- Respiratory support is provided with high flow oxygen
- PEEP may be used to prevent or treat pulmonary edema
- Corticosteroids
- Vasopressor medications
- I/O

21. EARLY COMPLICATIONS (CONT.)
 Compartment Syndrome
- Compartment syndrome is a limb threatening condition
occurs when perfusion pressure falls below tissue pressure
within a closed anatomic compartment
- Involves sudden and severe decrease in blood flow to tissues
distal to an area of injury that results in ischemic necrosis
- Patient complains of deep, throbbing, unrelenting pain,
which continues to increase despite the administration of
opioids and seems out of proportion to injury
- Pain occurs or intensifies with passive ROM

22. `

24. EARLY COMPLICATIONS (CONT.)
 Compartment Syndrome
- Assessment and Diagnostic Findings
- 5 Ps: pain, paralysis, paresthesia , pallor, pulselessness
- Doppler ultrasonography
- Palpate muscles
- Surgeon may measure tissue pressure , prolonged pressure of
more than 30 mm Hg can result in compromised
microcirculation

25. EARLY COMPLICATIONS (CONT.)
 Compartment Syndrome
- Medical Management
- Notify surgeon immediately
- Fasciotomy ( surgical decompression with excision of fascia ) is
indicated to relieve constrictive muscle fascia
- Wound not sutured , left open to allow muscle tissues to expand,
covered with moist , sterile saline dressings or artificial skin
- Affected part splinted, positon and elevated to heart level ,
passive ROM exercises performed every 4-6 hors
- In 3-5 days , when swelling resolved and tissue perfusion
restored , wound is debrided and closed

26. CROSS SECTIONS OF ANATOMIC COMPARTMENTS

27. WICK CATHETER USED TO MONITOR COMPARTMENT
PRESSURE
This link shows how to measure compartment syndrome
https://www.youtube.com/watch?v=XXp0EtKtlF8

28. AMPUTATION
 Amputation : removal of a body part
 Amputation may be congenital, traumatic, or due to
conditions such as progressive peripheral vascular
disease, infection, or malignant tumor
 Amputation is used to relieve symptoms, improve
function, and save the person's life
 The health care team needs to communicate a positive
attitude to facilitate acceptance and participation in
rehabilitation

29. LEVELS OF AMPUTATION

33. REHABILITATION NEEDS
 Psychological support
 Prosthesis fitting and use
 Physical therapy
 Vocational/occupational training and counseling
 Use a multidisciplinary team approach
 Patient teaching: see Chart 69-6

34. COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS

35. MONITORING AND MANAGING POTENTIAL
COMPLICATIONS
 Monitor VS and suction drainage for signs of
bleeding
 Assess by systems ( respiratory , hematological, GI,
GU, skin) for problems associated with immobility(
atelectasis, pneumonia, DVT, PE)
 Administer antibiotics as prescribed
 Monitor incision, dressing and drainage for signs of
infection
 Assess breakdown of skin
 Use of residual limb sock

37. NURSING PROCESS—ASSESSMENT OF THE PATIENT WITH AN
AMPUTATION
 Assess neurovascular status and function of
affected extremity or residual limb and of
unaffected extremity
 Assess for signs and symptoms of infection
 Determine nutritional status
 Assess concurrent health problems
 Determine psychological status and coping

38. NURSING PROCESS—DIAGNOSIS OF THE PATIENT WITH AN
AMPUTATION
 Acute pain
 Risk for disturbed sensory perception
 Disturbed body image
 Ineffective coping
 Risk for anticipatory or dysfunctional
grieving
 Self-care deficit
 Impaired physical mobility

39. NURSING PROCESS—PLANNING THE CARE OF THE PATIENT
WITH AN AMPUTATION
 Major goals include
 Relief of pain
 Absence of altered sensory perceptions and wound
healing
 Acceptance of altered body image
 Resolution of grieving processes
 Restoration of physical mobility
 Absence of complications

40. INTERVENTIONS
 Relief of pain
 Administer analgesic or other medications as prescribed
 Change position
 Put a light sandbag on residual limb
 Alternative methods of pain relief: distraction; TENS
unit
 Pain may be an expression of grief and altered body image
 Promote wound healing
 Handle limb gently
 Aseptic technique
 Provide residual limb shaping

41. Resolving Grief and Enhancing Body Image
 Encourage communication and expression of feelings
 Create an accepting, supportive atmosphere
 Provide support and listen
 Encourage the patient to look at, feel, and care for the
residual limb
 Help the patient set realistic goals
 Help the patient resume self-care and independence
 Provide referral to counselors and support groups

42. Achieving Physical Mobility
 Provide proper positioning of limb; avoid abduction,
external rotation, and flexion
 Turn the patient frequently; use prone position if possible
 Use assistive devices
 Implement ROM exercises
 Implement muscle strengthening exercises
 Provide “preprosthetic care”: proper bandaging, massage,
and “toughening” of the residual limb