Management Of Clients With Musculoskeletal Disorders

Management of Clients with Musculoskeletal Disorders 1. Review functions of the musculoskeletal system to include: support, locomotion, protection, mineral storage, hematopoiesis, and heat production. 2. What does the musculoskeletal system consist of? a. Bones, joints, muscles, and ligaments 3. Discuss common musculoskeletal problems to include: pain, altered mobility, neurovascular compromise, and infection. a. Pain – all who have fx, sprain, and dislocation have pain b. Altered mobility – loss or decrease in mobility due to pain or inability to move extremity c. Neurovascular compromise - Altered sensations or sensory disturbances frequently associated with musculoskeletal problems. d. Infection – Occurs mostly with compound fractures where the skin has been damage along with the bone 4. When a client is immobilized, what are potential complications related to the major body systems (hazards of immobility)? a. Weakened muscles, joint contractor, and deformity pg165 5. Define neurovascular compromise. a. Altered sensations or sensory disturbances frequently associated with musculoskeletal problems. 6. What causes neurovascular compromise? a. Failure to treat traumatic dislocations promptly 7. Define compartment syndrome. Pg2084 a. A complication that develops when tissue perfusion in the muscles is less than that required for tissue viability. 8. Define musculoskeletal traumatic injuries to include: contusion, strain, and sprain. Pg 2076 a. Contusion – soft tissue injury produced by blunt force. Many small blood vessels rupture bleed into soft tissue resulting in development of hematoma. b. Strain – a muscle pull caused by overuse overstretching or excess stress. They are microscopic incomplete muscle tears with some bleeding into the tissues. c. Sprain – an injury to the ligaments surrounding a joint that is caused by a wrenching or twisting motion. 9. Discuss RICE (rest, ice, compress, and elevate) as a management technique for musculoskeletal injuries. a. Rest prevents additional injury and promotes healing. Ice produces vasoconstriction, which decreases bleeding, edema, and discomfort. Compression bandage controls bleeding, reduces edema, and provides support, and elevation controls swelling pg2076 10. Define subluxation. Pg2076 a. Partial separation or dislocation of joint surfaces. 11. Define avascular necrosis. a. Tissue death due to anoxia and diminished blood supply 12. Define fracture. a. A break in the continuity of a bone pg2076 13. Discuss types of fractures to include: complete, incomplete, simple (closed), and compound (open). Pg 2079

a. Complete – involves a break across the entire cross section of the bone and is frequently displaced b. Incomplete – the break occurs through only part of the cross section of bone. c. Simple (closed) – a fracture that remains contained does not break the skin d. Compound (open) – a fracture in which damage also involves the skin or mucous membranes 14. The specific types of fractures include: greenstick, transverse, oblique, spiral, comminuted, depressed, compression, pathological, avulsion, and epiphyseal. Pg2081 a. Greenstick – a fracture in which one side of the bone is broken and the other side is bent b. Transverse – fracture straight across the bone c. Oblique – fracture occurring at an angle across the bone less stable than a transverse d. Spiral – a fracture that twists around the shaft of the bone e. Comminuted – a fracture in which bone has splintered into several fragments f. Depressed – fracture in which fragments are driven inward, seen in skull and facial bone g. Compression – a fracture in which bone has been compressed, seen in vertebral fractures h. Pathological – a fracture that occurs through an area of diseased bone, can occur without trauma or a fall i. Avulsion – a fracture in which a fragment of bone has been pulled away by a ligament or tendon and its attachment. j. Epiphyseal – a fracture through the epiphysis 15. The clinical manifestations of a fracture include: pain, loss of function, false motion, deformity/shortening, crepitation, and swelling/discoloration. 16. Discuss emergency management in relation to a fracture. a. Important to immobilize the body part before the patient is moved. If injured patient must be removed before splints are applied the extremity is supported above and below the fracture site to prevent rotation and angular motion. With an open fracture the wound is covered with a clean sterile dressing to prevent contamination of deeper tissues. The fractured extremity is moved as little as possible to avoid injury. 17. The goals of fracture treatment include: reduction, immobilization, and rehabilitation. 18. Reduction includes: closed reduction, traction, and open reduction and internal fixation (ORIF). 19. Immobilization may involve: external devices, internal devices, physiological splinting, and traction 20. Discuss nursing interventions to assist the client during rehabilitation. a. Elevate extremities to decrease swelling b. Frequent neurovascular checks c. Control patient anxiety d. Assist with ADL’s to increase independence e. Promote circulation f. Medicate prior to PT g. Isometric exercises h. Maintain reduction and immobilization 21. What are some inhibiting and enhancing factors of fracture healing? Pg2083 a. Enhancing: i. Immobilization of fracture fragments

ii. Maximum bone fragment contact iii. Sufficient blood supply iv. Proper nutrition v. Exercise: weight baring for long bones vi. Hormones: growth hormone, thyroid, calcitonin, Vit. D, anabolic steroids vii. Electric potential across fracture b. Inhibiting i. Extensive local trauma ii. Bone loss iii. Inadequate immobilization iv. Space or tissue between bone fragments v. Infection vi. Local malignancy vii. Metabolic bone disease viii. Irradiated bone ix. Avascular necrosis x. Intra-articular fracture xi. Age xii. Corticosteroids 22. List the stages of fracture healing: inflammation, cellular proliferation, callous formation, ossification, and remodeling.

23. Discuss the complications of fractures: hypovolemic shock, fat embolism syndrome, compartment syndrome, thromboembolism, infection, and delayed complications. a. Hypovolemic shock – Results from hemorrhage and loss of extracellular fluid into damage tissues and may occur in fractures of the extremities, thorax, pelvis, or spine. b. Fat embolism Syndrome (FES) – Fat emboli may develop following fracture of long bone or pelvis, multiple fractures, or crush injuries, most frequently seen in young adults and elderly adults who experience fractures of the proximal femur, at the time of the fracture fat globules may move in the blood because marrow pressure Is greater than capillary pressure, the fat globules occlude small BV that supply the lungs, brain, kidney, and other organs. Onset is rapid usually within 24-72 hours, but may occur up to a week after the injury. c. Compartment syndrome – is a complication that develops when tissue perfusion in the muscles is less than that required for viability, the patient will complain of a deep throbbing unrelenting pain, which is not controlled by opiods. The forearm and leg muscle compartments are involved most frequently. Permanent function can be lost if the anoxic situation continues for longer than six hours. d. Thromboembolism – patients with fractures of the lower extremities and pelvis are at high risk for thromboembolism. e. Infection – all open fractures are considered contaminated and surgical internal fixation of fractures carries the risk for infection. Monitor for and teach patient to monitor for s/s of infection including: tenderness, pain, redness, swelling, local warmth, elevated temp, and purulent drainage. Must be treated promptly f. Delayed complications – i. Delayed union – occurs when healing does not occur at a normal rate for the location and type of fracture.

ii. Delayed non-union – results from failure of the ends of the fractured bones to unite iii. Delayed Avascular Necrosis of bone – Avascular necrosis occurs when the bone losses its blood supply and dies. It may occur after a fracture with disruption of the blood supply especially of the femoral neck. Also seen with dislocations, bone transplantation, prolonged high dosage corticosteroid therapy, chronic renal disease, and sickle cell anemia. Treatment generally consists of attempts to revitalize the bone with bone grafts, prosthetic replacement, or arthrodesis iv. Delayed reaction to internal fixation devices – pain, and decreased function are prime indicators that a problem has developed, may include mechanical failure, material failure, corrosion of the device, allergic response to the metallic alloy, and osteoporotic remodeling adjacent to the fixation device. v. Delayed complex regional pain syndrome – it is a painful sympathetic nervous system problem that occurs infrequently. When it does occur it is most often in an upper extremity after trauma and seen most often in women. This syndrome is frequently chronic with extension of symptoms to adjacent areas of the body. Disuse muscle atrophy and bone deossification occur with persistence of CRPS. vi. Delayed heterotrophic ossification – this is the abnormal formation of bone, near bones or in muscle, in response to soft tissue trauma after blunt trauma, fracture, or total joint replacement. 24. What are the clinical manifestations of FES and how is it managed a. Presenting features include i. Hypoxia ii. Tachypnea iii. Tachycardia iv. Pyrexia b. Management i. Immediate immobilization of fracture ii. Minimal fracture manipulation iii. Adequate support for fractured bones during turning and positioning iv. Maintenance of fluid electrolyte balance 25. Define intracapsular and extracapsular hip fractures a. Intracapsular – Fracture of neck of femur b. Extracapsular – Fracture of trochanteric region 26. What are the clinical manifestations of a hip fracture? a. Femoral Neck fracture i. Pain with movement ii. Leg shortened, adducted, externally rotated iii. Ecchymosis iv. C/O slight pain in groin or medial side of knee v. Unable to move leg without significant increase in pain b. Impacted Femoral neck fracture i. Moderate discomfort ii. May allow weight bearing iii. May not demonstrate obvious shortening or rotational changes c. Extracapsular Femoral Fractures i. Extremity significantly shortened ii. Externally rotated greater degree than intracapsular fracture

iii. Exhibits muscle spasm- resists positioning of extremity in neutral position iv. Large hematoma or area of ecchymosis 27. Discuss Buck’s traction and surgical treatments in medically managing a hip fracture (open reduction and internal fixation (ORIF), hemiarthroplasty, and total hip arthroplasty (THA). a. Buck’s Traction – skin traction to the lower leg where the pull is exerted in one plane when partial or temporary immobilization is desired, used to proved immobility of fractures to the proximal femur before surgical fixation. b. ORIF – Excision of damaged and diseased tissue, repair of damaged structures, removal of loose bodies, arthroplasty (replacement of all of the joint surfaces), arthrodesis (immobilizing fusion of a joint). c. Hemiarthroplasty – is the replacement of the head of the femur with prosthesis and is usually reserved for fractures that cannot be satisfactorily reduced or securely nailed, or to avoid complications of non-union and avascular necrosis of the head of the femur. d. THA – The replacement of a severely damaged hip with an artificial joint. 28. Discuss the major post-operative complications associated with a hip fracture to include: DVT, infection, dislocation, hemorrhage, neurovascular deficit, and pneumonia. a. DVT – incidence of DVT is 45%-70%. The peak occurrence is 5-7 days after surgery. About 20% of patients with DVT development pulmonary emboli. Nurse must institute preventative measures and monitor patient closely for the development of DVT and pulmonary emboli. The patient is encouraged to consume adequate amounts of fluid, to perform ankle and foot exercises hourly while awake, to use elastic stockings, and sequential compression devices, and to transfer out of bed and ambulate with assistance beginning on the first post-op day. Lo-dose heparin is usually prescribed as prophylaxis. b. Infection – is serious complication of THA and may necessitate removal of the implant. All efforts are undertaken to minimize the occurrence of infection. Prophylactic antibiotics are prescribed, acute infections may occur within three months after surgery, and are associated with progressive superficial infections or hematoma, delayed surgical infections may appears 4-24 months after surgery. c. Dislocation – Maintenance of the femoral head component in the acetabular cup is essential. The nurse teaches the patient to position the leg in abduction; the use of an abduction splint keeps the hip in abduction, when turning patient in bed the operative hip must be kept in abduction. Patients hip is never flexed more than 90 degrees; the nurse does not elevate the head of the bed more than 60 degrees. d. Hemorrhage – if excessive blood loss is anticipated of THA, and autotransfusion drainage system may be used to decrease the need for homologous blood transfusion. e. Neurovascular deficit – neurovascular checks must be made 3 times per day f. Pneumonia – nurse monitors breath sounds and encourages death breathing and coughing exercises, if signs of resp problems develop, nurse reports immediately to physicians 29. Be familiar with the purposes of using braces, splints, and soft immobilizers. a. Braces – are used to provide support, control movement, and prevent additional injury, for long term use b. Splints – may be used for conditions that do not require rigid immobilization, for those in which swelling may be anticipated, and for those that require special skin care.

c. Soft immobilizers – used to support an injured body part, the extremity is wrapped with elastic bandage then secured in a padded, contoured, canvas, immobilizer. 30. Discuss the purpose of casting and cast care. a. A cast is a rigid external immobilizing device that is molded to the contours of the body, the purpose of the cast is to immobilize a body part in a specific position and to apply uniform pressure on incased soft tissue. b. Cast care i. Describe techniques to promote cast drying ii. Describe approaches to control swelling and pain iii. Report pain uncontrolled by elevation and by analgesics iv. Demonstrate ability to transfer v. Use mobility aids safely vi. Avoid excessive use of injured extremity vii. Manage minor irritations from cast viii. Demonstrate exercises to promote circulation and minimize disuse syndrome ix. Report complications to physician promptly x. Describe care of extremity following cast removal 31. What are external fixators? What must the nurse include in “pin care?” a. External fixators are used to manage open fractures with soft tissue damage. b. Pin care i. Cleaning each pin site separately 3x a day with cotton tipped applicators soaked in sterile saline solution ii. Crusts should not form at the pin site iii. If signs of infection are present or if the pins or clamps seem loose nurse notifies physician 32. What is the purpose of the continuous passive motion (CPM) machine? a. To increase range of motion, circulation, and healing. Of the knee joint 33. What is a re-infusion device (Stryker drain)? a. Autotransfusion drainage system may be used to decrease the need for homologous blood transfusions 34. Know the crutch walking gaits to include: 4-point, 2-point, 3-point, swing-through, and swing-to. Also, how does one go up and down the stairs on crutches? Pg 171 a. 4-point – partial weight baring, both feet, maximal support provided requires constant shift of weight. b. 2-point – Partial weight baring, both feet, less support, faster than 4-point c. 3-point – non-weight baring, requires good balance, requires arm strength, a faster gait, can use with walker. d. Swing-through – weight baring, requires arm strength, requires coordination and balance, most advanced gait e. Swing-to – weight baring, both feet, provides stability, requires arm strength, can use with walker. f. Stairs i. Up – advance the stronger leg first up to the next step, next advance the crutches and weaker extremity (note strong leg goes up first and down last) ii. Down – walk forward as far as possible on the step, next advance crutches to lower step, the weaker leg is advanced first then the stronger one, this allows the stronger extremity to share the work of raising and lowering the body weight with the arms. 35. List the purposes of traction to include:

a. Minimizing muscle spasms b. Reducing, aligning, and immobilizing fractures c. Increasing space between opposing surfaces within a joint d. Preventing soft tissue damage 36. What are the principles of traction? a. Whenever traction is applied counter traction must be used to achieve affective traction. Usually patients body weight and bed position adjustments supply the needed counter traction. b. Traction must be continous to be affective c. Skeletal traction is NEVER interrupted d. Weights are not removed unless intermittent traction is prescribed. e. Any factor that might reduce the affective pull or alter its resultant line of pull must be eliminated i. Patient must be in good body alignment in center of bed ii. Ropes must be unobstructed iii. Weights must hang free and not rest on the bed or floor iv. Knots in the rope or the foot plate must not touch the pulley or the foot of the bed 37. Define the two methods of traction: skin and skeletal a. Skin – Is used to control muscle spasm and to immobilize an area before surgery, accomplished by using a weight to pull on traction tape or on a foam boot attached to the skin. b. Skeletal – Is applied directly to the bone, it is applied by use of a metal pin or wire that is inserted through the bone distal to the fracture, avoiding nerves, blood vessels, muscles, tendons, and joints. Tongs applied to the head are fixed in the skull to apply traction that immobilizes cervical fractures. 38. What is Buck’s traction used for? a. It is used to provide immobility after fractures of the proximal femur before surgical fixation 39. What is the purpose of skin and skeletal cervical traction? a. Skin cervical – is used to occasionally treat neck pain. AKA cervical head halter b. Skeletal Cervical – immobilize cervical fractures 40. When is pelvic traction used? a. Is sometimes used to treat back pain. AKA pelvic belt 41. What are examples of suspension tractions? a. Thomas Splint w/ Pearson attachment b. Russell’s c. Dunlop’s d. Halo Vest 42. What is balanced suspension traction with Thomas splint and Pearson attachment specifically used for? a. Used for skeletal traction with fractures of the femur 43. What nursing care is essential in caring for a client in skin or skeletal traction? a. This includes: i. Maintaining effective traction, ii. Proper body positioning, iii. Skin care, iv. Neurovascular assessment, v. Pin-site care,

vi. Exercises, and vii. Measures to prevent nerve pressure.