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Common Musculoskeletal problems

4 main common problems in Musculoskeletal - Pain (subjective) – as a nurse we need to respect the pain in your client. Pain is subjective and everyone experiences pain differently. Maybe you have medicated the client, but there could be other issues going on such as underlying infection and this may be the reason that their pain is not fully relieved by medication. o Bone (deep, dull pain) o Muscular (associated with movement, achy pain, soreness) o Fracture (sharp, intense, eases with immobilization {always immobilize above and below the break}) o Infectious process (steadily increasing, throbbing pain, meds don’t work) – before sending these patients home they need to be taught the signs and symptoms of infection and they also need to know that they need to be sure and call the doctor if after taking their PO antibiotic that the pain is not being relieved but getting worse. This is a sign of a possible pending infection o Joint (pain upon movement, throbbing pain, limited mobility) o Nerve pressure (Sharp radiating, prickling sensation) – if something is pressing on a nerve, it is going to be painful. For example if someone has a lower back injury or someone who has osteoarthritis of L4 & L5, they have a lot of pain in the back area, but they might also be experiencing pain in the lower extremities. - Infection - Altered mobility – a “healthy body” is an “active body”. - Neurovascular compromise During am assessment always ask the patient what their pain level is. We are required to document whether the patient is in pain and what the pain level is in our nurses notes. Functions of Musculoskeletal system - Support – strong and sturdy framework - Locomotion – muscles are attached to bone allowing for movement - Protection – vital organs - Mineral Storage – Calcium, phosphorus, magnesium, fluoride - Hematopoiesis – production of blood cells, in flat bones (sternum, ileum area of pelvis, vertebrae, ribs) - Heat production – Movement and muscle contraction to help maintain body temp Made up of: - Bones - Muscles - Tendons – connect muscle to bone. - Ligaments – connect bone to bone - Joints - Bursae – baglike sac in connective tissue of joint. - Intact nerves are required to send impulse to muscle to move bone Bone stays healthy and strong by walking and moving around. They go through a chemical action, that helps to build strong bones. Bones are in a constant state of turnover and breakdown.

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Common Musculoskeletal problems

“What A Pathetic Picture He Makes, The Blood Clotting In His Veins, The Lime Draining From His Bones, The Feces Stacking Up In His Colon, The Flesh Rotting From His Seat, The Urine Leading From His Distended Bladder, And The Spirit Evaporating From His Soul.” Richard Asher, British Medical Journal, 1947 72 year old female in the hospital due to a THA – total hip arthroplasty – What are the potential complications related to the major body systems, and how will you intervene? - Respiratory o #1 RF – pneumonia  TCDB  Incentive Spirometer  S&S  Rales  Low grade temp  ↓Breath sounds  ↑ respiratory rate  Phlegm – productive cough We want to prevent fluid from pooling in this patient’s lungs and developing pneumonia. Most of the patients that die within the first year of a THA, or a fracture procedure die from pneumonia o Fat embolism – clot traveled to the lungs - Cardiovascular o #1 – DVT – due to venous stasis from immobility (if you suspect DVT, tell this patient that they do not need to get up – call the doctor)  ROM exercises – q hour while pt is awake - no adduction, hyperflexion, anything > 90 degrees  Elastic compression stockings/plexi-pulses –make sure these are on and working - take off and check skin daily – Brunner says 2/day for 20 minutes each  Adequate hydration – make sure post op that IV is flowing at the correct rate and make sure that as soon as the client is able to drink that they are getting plenty of fluids. A well hydrated patient will be at less risk of getting a thrombus.  Early immobilization  Heparin/Lovenox  Check platelets – HOLD <100,000  If you don’t have the lab work – assess for overcoagulation o Bleeding o Bruising gums  Avg dose – 30-40 mg / 24 hrs  Age start @ 12-24 hrs after surgery  Good Nursing – check to make sure anticoag therapy is ordered postop  Aspirin has no apparent effect in preventing DVT in orthopedic pt.  Check Homan’s q 4 hrs - while doing this, you are also checking the nerves  Check pulses distal to area  Assess skin temp  Measure calf 2/day  No large pillows under affected leg – puts pressure on popliteal bv 2

Common Musculoskeletal problems

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 Change positions  Monitor body temp o Orthostatic Hypotension o Infiltration – check IV site o Shock – Hypovolemia – due to excessive blood loss during or after surgery  S&S  ↑ pulse rate – tachycardia – this usually appears first  ↓BP  Urine <30cc/hr  Restless  Mental changes  ↓ H&H  Check dressing  Check drains – make sure the bulb is compressed – helps w/suction  1st 8 hours postop - <250 is ok - >250 Call Dr!!  1st 24 hours postop – 200-500 cc  By 48 hrs – should diminish <25cc Metabolic o Arrhythmias – due to IV K+ - check lab values (3.5-5) o Hypercalemia (with immobility)  Check lab values (9-10.5)  Calcitonin – Calcimar (given when a patient is hypercalcemic – pulls calcium back into the bones)  Given by IM, Subq  S/E o Flushing o GI upset o Urinary frequency Musculoskeletal – Immobility (if joint is inflamed typically want to rest the joint) o ROM  Isotonic  Isometric o TED, plexi-pulse o Gluteal & Quad setting – squeezing & holding buttocks and quads o Ankle pumps o Maintain neutral position of extremity o Use trochanter rolls – prevents external rotation o Place pillow between legs when turning o Instruct and assist in position changes and transfers o Encourage use of trapeze o Instruct and supervise safe ambulation within limitations of weight-bearing prescription Integumentary – RF skin breakdown – pressure ulcers o TCDB at least q 2 hrs o Watch bony prominences o Monitor vitals 3

Common Musculoskeletal problems

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Aseptic dressing changes Assess wound appearance and character of drainage Full body assessment Skin care to pressure points Support heal off mattress EARLY INTERVENTION

Genitourinary – RF urinary retention and Urinary tract infections o Check for patency of Foley, I&O o Always clarify w/Dr before leaving in a catheter o Encourage voiding q 3-4 hrs o Assist w/positioning – fracture bedpans o Large amounts of milk should not be given to ortho pts who are on bed rest – increases RF kidney stones - Gastrointestinal o Constipation  Stool softeners, laxatives, suppositories, enemas  Diet high in fiber & fluids o Anorexia  Find pts food preferences – as appropriate – within the therapeutic diet o Paralytic Ileus  S&S  No bowel sounds  Abdominal distention o May need bowel rest Neurovascular Compromise - Altered sensations or sensory disturbances that are frequently associated with Musculoskeletal problems - Clients often experience paresthesia (tingling) and numbness. - Loss of function can result from impaired nerves and circulatory structures. - Volkmann’s contracture – compromise of the forearm. Some type of compromise in the vascular bed that did not get proper intervention and mobility is lost. They could be paralyzed and not able to use the lower forearm. - Compromise typically occurs often in the forearm and the calves or lower part of the leg. What causes Neurovascular compromise? - Soft tissue swelling or direct trauma - Leads to pressure on nerves or circulatory structures - Swelling, the major concern, leads to impaired tissue perfusion. Make sure to keep elevated. - Diminished sensory and motor function - Swelling in confined space may result in compartment syndrome. The doctor must be called for compartment syndrome. We are talking about broken bones or injuries, but this can also happen with a thrombus or an infiltrated IV. The doctor could possibly have to do a fasciotomy. This is where they go in and make a little incision into the fascia to relieve some of the pressure on the nerves. The fascia is not elastic and it won’t give. Neurovascular Assessment - Experiencing any abnormal sensations or numbness? - When did it begin? Is it getting worse? -

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Common Musculoskeletal problems

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Experiencing pain? What their pain level is? – Sometimes repositioning helps Color of the part distal to the affected area? Is it pale, dusky, cyanotic? Rapid capillary refill? Distal pulses palpable? Motor component of nerve intact? If they can move it, it is intact. Ability to move the affected part? If have a patient with a cast on the arm, want to go in and make sure they can flex and extend fingers. Constrictive devices or clothing causing nerve or vascular compression? o If pt is in Buck’s traction – yes, you can take them out to check – get somebody to help you support the extremity o Ace bandage – yes, you can take that off to assess Edema present? Symptoms decrease by elevating the affected part? (Elevating should decrease swelling) A lot of times elevating the extremity will do a world of good in helping their level of pain.

COMPARTMENT SYNDROME - Occurs when there is an increase of tissue pressure within a closed anatomical space that compromises circulation and tissue function. We are going to know this is going on because that patient has unrelieved pain. The doctor has ordered a couple of Percocet, the nurse gave them and the patient got no relief. - A complication that develops when tissue perfusion in the muscles is < than that required for tissue viability - Increased tissue pressure within a limited space (cast, muscle compartment) – it compromises circulation - Usually seen in calf, forearm – this is why it is very important to flex and extend feet and fingers - S&S o Deep, throbbing, unrelenting pain – not controlled by opioids – can be caused by:  Reduction in size of muscle because fascia is too tight or cast or dressing is constrictive  Increase in muscle compartment contents because of edema, hemorrhage o Decreased cap refill o Inability to move affected part o Diminished distal pulses o Paresthesia – burning or tingling sensation – early signs o Numbness – early signs o Motor weakness – late sign o No movement – nerve damage o Pain caused by passive stretching the muscle o Hard, swollen muscle upon palpation - Permanent function can be lost if continues > 6 hrs - Assessment o Freq checks after fracture o Evaluate motion o Evaluate circulation – color, temp, cap refill, swelling, pulses  Swelling (edema) – reduced tissue perfusion  Cyanotic nail beds – venous congestion  Pale, dusky, cold fingers/toes or long cap. Refill – diminished arterial perfusion o Pulses – may need Doppler – edema may obscure sound 5

Common Musculoskeletal problems

o Pulselessness – not a sign of Compartment Syndrome – sign of artery occlusion o Palpation of muscles o Measure tissue pressure – insert tissue pressure measuring device – Normal 8 or < -

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TX o Prompt management!! o Call DR if suspected o Elevate to heart level o Release any restrictive devices (dressings or cast) If conservative measures don’t work in 1 hour o Fasciotomy  DR performs  Cutting the edge of the fascia to relieve the pressure  Afterward, wound is not sutured, but is left open to permit the muscle tissues to expand  Cover w/moist, sterile saline dsg  Splint in a functional position  Elevate  PROM q 4-6 hrs  3-5 days after swelling has gone down – wound is debrided and closed o Bi-Valved Cast  Experienced nurse can do this  Cast is cut in half long ways  Maintain proper alignment  Elevate no higher than heart

TRAUMATIC INJURIES - Contusions o Ecchymosis or bruising o Usually caused by blunt force (blow, kick, fall) - Strains o Over use of the muscle – stretching – stress o Tendons are affected o “Pulled muscle” - Sprains o More force is involved o Involves ligaments – ligament connects bone to bone o This is more serious – it surrounds a JOINT o A torn ligament loses it’s stabilizing ability o X-ray to rule out bone injury o Avulsion fracture - a bone fragment is pulled away by a ligament or tendon Management - RICE o REST o ICE – moist or dry cold – 20-30 min intermittently for first 24-48 hrs - avoid skin damage o COMPRESSION – Ace bandage 6

Common Musculoskeletal problems

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o ELEVATION – controls swelling If Sprain in severe – surgery or cast immobilizer Monitor neurovascular frequently AFTER 24-48 hrs (after inflammation stage) – heat may be applied – 15-30 min intermittently – relieves Muscle spasm and promote vasodilatation, absorption, and repair ROM – 2-5 days – depending on severity Severe sprains – 1-3 wks of immobility may be required

Joint Dislocations - Subluxation – out of joint - When articular surface of the bones forming the joint are no longer in anatomic contact - Joint dislocations may be congenital, traumatic, or patholigical diseases - Traumatic dislocation – orthopedic emergencies – associated joint structures, blood supply, and nerves are Distorted and severely stressed - Avascular Necrosis – tissue death due to anoxia and diminished blood supply – if the dislocation is not treated Promptly - S&S o Pain o Change in contour of joint o Change in length of extremity o Loss of normal mobility o Change in axis of dislocated bones - X-ray confirms - Management o Immobilized affected joint while being transported to hospital o Analgesia o Muscle relaxers o Possible anesthesia – to facilitate closed reduction o Immobilized w/bandages, splints, casts, traction o Monitor neurovascular o ROM - support joint between exercise sessions -

PREVENTION OF INJURIES o Know the proper way to lift – use good body mechanics o Bend at the knees – not the back o Carry loads close to the body o Should not twist when reaching for something or carrying something o Don’t bend down or reach up high unnecessarily o Watch where you walk o Stretch o Relax

FYI o The femur is referred to as the long bone. It is the longest and strongest bone of the body. In the long bone, the red marrow is replaced by yellow marrow. This becomes an issue if someone breaks this bone, they are at risk for fat embolism syndrome, because that area is replaced by fatty marrow and once it breaks the fat globules can spill out into the bloodstream. 7

Common Musculoskeletal problems

o Compartment Syndrome – the calf area and forearm are two common sites for compartment syndrome to occur. • Peroneal nerve is important to know – it is a common nerve to be affected with compartment syndrome because of its anatomical position. So when checking to see if a person can dorsiflex their foot, we are checking to see if they have an intact peroneal nerve. • If there are issues a doctor will come in and do a fasciotomy. This is where the doctor will go in and cut right into the edge of the fascia. The fascia is a sheath that is wrapped on the outer part of the muscle compartment. The fascia is a connective tissue, it is not elastic. With the fasciotomy, they will go in and make a very superficial incision in order to give that area some room to expand, so there will be no clamping down on the nerves which may cause paralysis. They will cover this incision with some sterile 4 x 4’s dipped in saline. They will not bind this incision back up. Scenario Mrs. Ed is 36 years old has had Open Reduction of a right tibial fracture. Two days post-op they have come back and put her in a long leg cast. She is complaining of “tightness across her knee”, she also is complaining of discomfort at the top of her cast on her posterior thigh. Her toes on the effected leg are slightly swollen. She can dorsiflex all five of her toes, although she complains that they are numb. She is also complaining of being tired of being in the bed. One of the first things we want to do is make sure that the extremity is elevated. We will also check capillary refill and pedal pulses. Check the color of the toes. We need to find out when the last pain medication was given. We want to check the previous assessment data. The numbness is a cause of concern and needs to be watched closely. If after the extremity is elevated and it is not resolved, the nurse should call the doctor on this one because she is saying that she is feeling tightness across the knee and this may be saying that the cast is too tight. Fractures - Good sites for RBC production – flat bones o Torso area – rib cage, sternum o Iliac crest o Scapula - Femur – longest and strongest bone -has fat marrow – if it breaks, fat can mix w/platelets – form a clot – R/F fat embolus - You have just received a patient from pacu w/a long leg cast due to a fractured tibia – prioritize nursing interventions 1. Take vitals 2. Elevate cast on pillow 3. Neurovascular assessment 4. Assess cast for dryness, drainage, and sharp edges (if cast is still not dry, handle the cast with the palms of the hands) 5. Teach isometric exercises (isometric exercises are done where muscle groups are tensed and then relaxed, do not have to move a body part. These are in contrast to isotonic exercises which are to move). Quadricep setting would be a good isometric exercise to do. With quadriceps setting, you would tell the patient to press the back of the knee flat and dorsiflex their foot up. 8

Common Musculoskeletal problems

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A fracture is a break in the continuity of bone Occurs when the bone is subjected to stress greater than what it is able to absorb Caused by direct blows, crushing force, sudden twisting motions, and even extreme muscle contractions When bone is broken, adjacent structures are affected – results in: o Soft tissue edema o Hemorrhage into muscles and joints o Joint dislocations o Ruptured tendons o Severed nerves o Damaged blood vessels Body organs – can be injured o By the force o By the fragments from the fracture

Types of fractures – depends on degree of break or skin integrity - Complete fracture o Break across entire cross-section of bone o Frequently displaced (removed from normal position) - Incomplete fracture o Break occurs through only part of the cross-section of bone o Greenstick fracture - Comminuted fracture – one that produces several bone fragments - Closed fracture o Simple fracture o Doesn’t cause a break in the skin - Open fracture o Compound/complex fracture o Coming out of skin o Tx w/external fixation – not a surgical procedure – allows healing Specific types of fractures – pg. 2081 for pictures - Avulsion – fragment of bone has been pulled away by a ligament or tendon and its attachment - Comminuted o Bone has splintered into several fragments (3 or more) o Treatment w/external fixation – not a surgical procedure – allows healing – this gives the bone some support while limiting mobility - Compound o Damage also involves skin or mucous membrane o Open fracture - Compression o Bone has been compressed o Seen in vertebral fractures o Usually back or neck (arthritis or back problems) o The doctor will go in and do a decompression laminectomy to relieve the pressure - Depressed 9

Common Musculoskeletal problems

o Fragments are driven inward o Seen in fracturs of skull and facial bones o Tx – will have to de-compress – r/f ↑icp - Epiphyseal o 1. Fracture through epiphysis – growth plate o 2. Seen in children o 3. May affect their growth - Greenstick o 1. One side of a bone is broken, the other side is bent o 2. Incomplete fracture - Impacted – bone fragment is driven into another bone fragment - Oblique o Occurring at an angle across the bone o Less stable than a transverse fracture - Pathologic o Occurs through an area of diseased bone (osteoporosis, bone cyst, paget’s disease, bony metastasis, cancer) o Can occur without trauma or a fall - Simple o Remains contained o Doesn’t break skin - Spiral o Twists around the shaft of the bone o Seen in child abuse - Stress – results from repeated loading without bone and muscle recovery - Transverse o Straight across the bone o Complete fracture Manifestations – vary according to type and location of fracture, amount of soft tissue damage, and strength of the muscle attachment – diagnosis is based on s&s, physical signs, x-ray - Pain o Continuous – increases in severity of the pain until bone fragments are immobilized. In other words if someone comes to you and they seem to have broken their arm and they want you to look at it, we do not need to take their arm and pull it out to look at it. This may cause more vascular bed damage. If they break their arm they are probably going to hold it to their body, this is called physiological splinting. We want them to do this and keep in this position until they get to the ER. o The muscle spasm that accompanies fracture is a type of natural splinting designed to minimize further movement of the fracture fragments - Loss of function o Can’t function properly o Abnormal movement may be present – unnatural movement - Deformity o Either visible or palpable o Compare with other limb o Causes soft tissue swelling - Shortening 10

Common Musculoskeletal problems

o Seen in long bone fractures o We see this particularly with a hip fracture, they can have the shortening of an extremity from 1 to 3 inches. o There is actual shortening of the extremity because of the contraction of the muscles that are attached above and below the site of fracture o May overlap as much as 1-2 inches - Crepitus o When examined w/hands – a grating sensation can be felt o Caused by rubbing of bone fragments together o Caution: testing for crepitus can produce further tissue damage – should be avoided - Swelling/discoloration o Swelling & ecchymosis – result of trauma and bleeding into tissues o May not develop for several hours after injury Emergency management - Immobilize immediately after injury where a fracture is suspected – don’t move unless it has been immobilized - If injured pt must be removed from car before splints can be applied – support extremity above and below fracture site - Long bones immobilization – accomplished by bandaging the legs together – the unaffected leg serves as a splint - Upper extremity injury – the arm may be bandaged to the chest, or place in sling - Assess neurovascular status below injury – determines tissue perfusion and nerve function – palpate pulses - Open fracture – cover wound w/clean (preferable sterile) dressing (we don’t want further debris in it) - don’t reduce the fracture if a portion is protruding through the wound - apply splints - Er o Pt is evaluated completely o Clothes are gently removed - 1st from uninjured side, then injured – may have to cut away clothing o The fractured extremity is moved as little as possible Goals of medical management – think rehab from day one 1. Reduction o Immobilize the body part immediately – support above and below o “Setting the bone” or reduction  Putting back into alignment and rotation  The method depends on the nature of the fracture  Dr will do as soon as possible  Becomes more difficult once healing begins  Pre-reduction • Get permission • Give analgesic as prescribed • Anesthesia may be administered • Handle extremity gently to avoid more damage o Types  Closed reduction 11

Common Musculoskeletal problems

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Bringing the bone fragments together through manipulation and manual traction • Extremity is held in place while dr applies a cast, splint • Percutaneous pinning may be used – anesthesia is needed • X-ray to confirm alignment • Traction – skin or skeletal – used until patient is stable and able to withstand surgical fixation  Open reduction • Surgical procedure • Internal fixation devices – pins, screws, plates, nails, rods – used to hold the bone fragments in place until solid bone healing occurs 2. Immobilization o Held in correct position and alignment until healing union occurs o Accomplished by:  External fixation – bandages, casts, splints, continuous traction, external fixators (2025). External fixator is assembled where it is above and below the area that is injured. The hardware and cross wires need to be cleaned to help avoid infection. Typically they are cleaned with some ½ strength peroxide and maybe put some betadine on them. They leave them open to are then put some tiny gauze on them. This is considered standard nursing care on an orthopedic unit when someone has this type of equipment on.  Internal fixation – metal implants  Physiologically splinting – where they hold it themselves  Traction (as a nurse you need to make sure that they are in traction correctly, are the weights where they need to be, are the ropes tied securely to the weights, is the patient positioned in the bed correctly) 3. Rehab o To maintain and restore function o Promotes bone and soft tissue healing o Swelling?  Elevate injured extremity  Apply ice as prescribed o Neurovascular status monitored (circulation, movement, sensation) frequently – call dr if compromise is noted o Restlessness, anxiety, discomforts?  Reassurance  Position changes  Pain relief strategies – including analgesics o Isometric & muscle-setting exercises – minimizes disuse atrophy and promotes circulation pg 2021 o Encourage participation in ADL’s – promotes independent functioning and ↑ selfesteem o Gradual resuming of activities o Internal fixation – doctor determines the amount of movement, weight-bearing stress, and level of activity

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Common Musculoskeletal problems

FYI -- When you go in to make your assessment of these patients make sure that you get the activity status. In other words, are they full weight bearing? Are they partial weight bearing? You need to know this. Healing factors - Enhances o Immobilization of fracture o Maximum bone fragment contact o Sufficient blood supply o Proper nutrition o Exercise – weight bearing for long bones o Hormones – growth hormone, thyroid, calcitonin, vit d, anabolic steroids -

Impedes o Extensive local trauma – location of bone involved, severity of fracture  Arm – 3 months to heal (from point of break through rehab)  Leg – 6 months to heal  A child will heal more quickly, they are growing a lot, they have an increase osteoblastic activity where the bone cells are really building. In contrast, the older person has an increase in osteoclasts. Remember the “B” in osteoblasts means building. We gave up to until about age 30 to 35 to build strong bones.  Flat bones are more vascular (sternum, pelvis, scapula) so they heal more quckly.  End of long bones heal more quickly than due midshaft due to the spongy tissue & vascular supply. o Bone loss o Swelling – edema will impede healing, this is why it is so important to keep these extremities elevated. If you get swelling down in the lower part of the extremity and the circulation is not full, it is not going to supply all of the nutrition that the damaged area needs. o Inadequate immobilization o Space or tissue between bone fragments o Infection – look at pt’s history (If a person comes in and they have broken their hip and they have diabetes, cardiac conditions and other things going on, then obviously this patient is going to heal slower). o Local malignancy o Metabolic bone disease – paget’s o Radiation necrosis o Avascular necrosis o Age – elderly heal more slowly  Osteoblasts – builds (“building is a blast”)  Osteoclasts – breaks down (“clasts means cast”) o Corticosteroids – inhibit the repair rate – slows down healing (If on prednisone for say osteoarthritis, this is going to slow down healing,) With corticosteroids these patients are at high risk of infection as well o Intra-articular fracture – blood supply – edema impedes healing 13

Common Musculoskeletal problems

STAGES OF BONE HEALING - Hematoma & Inflammation o Bleeding into injured tissue o Hematoma is formed o Inflammation, pain, swelling is present o Inflammation stage lasts several days - Angiogenesis & Cartilage Formation o Cellular proliferation is when the fibroblasts and osteoblasts begin to be laid down o Blood vessels and cartilage overlie the fracture - Cartilage Calcification o Chondrocytes in the cartilage callus form matrix vesicles o These regulate calcification of the cartilage o Enzymes in the matrix vesicles prepare the cartilage for calcium release and deposit - Cartilage Removal o The calcified cartilage is invaded by blood vessels o Becomes reabsorbed by chondroblasts and Osteoclasts o Replaced by woven bone similar to the growth plate - Bone Formation o Minerals continue to deposit until bone is firmly reunited o Ossification takes 3-4 mos in adult long bones - Remodeling o Remodeling the new bone into the former structural arrangement o May take months to years **The type of bone fractured, the adequacy of blood supply, the surface contact of the fragments, and the general health of the person influences the rate of fracture healing. **Adequate immobilization is essential until there is x-ray evidence of bone formation w/ossification. COMPLICATIONS OF FRACTURES - Shock – hypovolemic (blood volume is lost) o Will have to replace the volume o Can be visible or non-visible loss o With broken bones you can hemorrhage o Can occur in the fracture of  Extremities (femur) – large quantities  Thorax  Pelvis – large quantities  Spine o Treatment  Restore volume  Relieve pain  Splinting  Protect from injury and other complications - FES – Fat Embolism Syndrome (rare but can be fatal) o Fracture of long bone, pelvis, multiple fractures, crush injuries o More in young adults – 20-30 years old 14

Common Musculoskeletal problems

o Also in elderly – usually femur fracture o The bone breaks, the globules from the fat marrow spill out into bloodstream → form and emboli that occlude the small blood vessels that supply lungs, brain, kidney, & other organs o Onset of S&S is rapid – 24-48 hrs – can occur up to a week after injury o If this is possibly beginning to occur, the patient will begin to get short of breath, a little restless and irritable. You want to call the doctor right away and tell him what is going on, get some ABG’s o S&S  Hypoxia • Mental changes • HA • Mild agitation • Confusion to delirium and coma  Respiratory distress • Tachypnea • Dyspnea • Crackles • Wheezes • Precordial chest pain • Cough • Large amounts of thick white sputum  Tachycardia  Pyrexia – temp > 103  ABG – O2 < 60 – early resp alkalosis, late resp acidosis  Chest x-ray – shows snowstorm  ARDS, Pulmonary Edema, Heart Failure will develop  Pale skin  Petachiae – in buccal membranes, conjunctival sacs, hard palate, over chest and axillary folds  Free fat in urine if emboli reaches kidneys – kidney failure may develop o Sudden mental changes in someone w/a fracture – do immediate ABG’s o Prevention & Management  Immediate immobilization, minimal fracture manipulation, always adequately support for fractured bones during turning and positioning  Fluid &Electrolyte balances  Monitor High RF pts • Adults – 20-30 years old w/long bone, pelvic, or multiple fractures or crush injuries • Elderly w/femur fractures  O2 at high concentrations – immediately – respiratory failure is the most common cause of death – need to be where they can get adequate respiratory support.  Corticosteroids – treatment inflammatory lung reaction & to control cerebral edema  Vasoconstrictor meds – to prevent hypotension, shock, pulmonary edema  I&O 15

Common Musculoskeletal problems

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 Morphine for pain and to reduce anxiety if on ventilator  Provide calm reassurance  Recognize early S&S & call DR!!!  Important to institute O2 early!!! Compartment Syndrome Thromboembolism – throwing a clot Infection – due to open fractures & internal fixation devices DIC – Disseminated Intravascular Coagulation o From massive tissue trauma o Will be in ICU o S&S  Ecchymosis  Unexpected bleeding after surgery  Bleeding from mucous membranes, IV sites, Gastrointestinal & urinary tracts DVT PE – Pulmonary Embolus Delayed Union o Healing doesn’t occur at a normal rate for the location and type of fracture o Associated w/pulling apart of bone fragments, infection, poor nutrition, DM, autoimmune ds. o It eventually heals Nonunion o Failure of ends to unite o C/O a persistent discomfort and abnormal movement at fracture site o Factors:  Infection at site  Interposition of tissue between the bone ends  Inadequate immobilization or manipulation that disrupts callus formation  Excessive space between fragments (bone gap)  Limited bone contact  Impaired blood supply resulting in avascular necrosis o False joint may develop at site o Commonly occurs w/fractures of middle third of humerus, lower third of tibia, and elderly peoples femur neck o Tx  Internal fixation – stabilizes and ensures contact  Bone grafting  Electrical bone stimulation  Or a combo of all  Pt may become frustrated w/prolonged therapy – provide emotional support  Encourage compliance w/tx regimen  Periodic x-rays to check on progression of healing  Bone graft care will include: • Pain management • Monitor for infection @ donor and recipient sites • Patient education 16

Common Musculoskeletal problems

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Avascular Necrosis – bone loses its blood supply and dies Reaction to Internal Fixation Devices - Pain & decreased function – a problem has developed – device is removed Mal-Union – unites, but not where you wanted it to

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