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MUSCULOSKELETAL TRAUMA OBJECTIVES

Upon completion of this chapter/lecture, the learner should be able to:


1. Identify the common mechanisms of injury associated with musculoskeletal trauma.
2. Describe the path physiologic changes as a basis for signs and symptoms.
3. Discuss the nursing assessment of the patient with musculoskeletal trauma.
4. Based on the assessment data, identify appropriate nursing diagnoses and expected
outcomes associated with patients with musculoskeletal trauma.
5. Plan appropriate interventions for patients with musculoskeletal trauma.
6. Evaluate the effectiveness of nursing interventions for patients with specific types of
musculoskeletal trauma.

INTRODUCTION
Epidemiology
More than half of all hospital admissions because of trauma are patients with some type
of fracture, usually of the lower limb*.The elderly are at a particularly high risk of being
hospitalized for an extremity injury. Of those injuries sustained by passengers involved in
nonfatal motor vehicle crashes, 46% sustain pelvic fractures and 41% sustain femur
fractures. Drivers sustain femur fractures (65%), pelvic fractures (46%), and ankle
fractures (39%).0
The American Association of Orthopedic Surgeons reported an annual estimate of 32.7
million musculoskeletal injuries, which included 6.1 million fractures, 14.6 million
dislocations and sprains, 9.4 million open wounds, and 2.6 million other injuries.
Musculoskeletal injuries account for 8,000 deaths per year.

Mechanisms of Injury and Biomechanics


Musculoskeletal trauma can be sustained as a single system injury or in combination with
other systems. Injuries to the extremities are not usually considered the first priority.
Mechanisms of injury include motor vehicle crashes, assaults, falls, sports, leisure, or
home activities.
Differentiating between unintentional and intentional injury can be difficult. Abuse
should be considered as a possible cause of the injury. Suspicion of abuse should be
raised if the type or degree of injury does not correspond-to the history.

Musculoskeletal injuries can result from the application of both acceleration and
deceleration forces.
Injuries to the bone result from tension, compression, bending, and torsion type forces'
When there is enough force to fracture the shaft of a bone, this force may be transmitted
to the joints; for example, fractures of the shaft of the radius and ulna may be associated
with fractures to the wrist, elbow, and shoulder.
Falls are a frequent mechanism of injury, especially for the elderly. Elderly patients who
fall often sustain pelvic or lower extremity injuries. These injuries, even if not life
threatening, can seriously alter the elderly person's lifestyle and reduce his or her
functional independence. Underlying bone disease, such as osteoporosis or cancer
metastases, may predispose the patient to an extremity injury.

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Types of Injuries
Musculoskeletal injuries may be blunt or penetrating. They may involve bone, soft tissue,
muscles, nerves, and/or blood vessels. Injuries include fractures and/or dislocations of the
bone or joint, sprains, strains, ligamentous tears, tendon lacerations, and neurovascular
compromises.

Usual Concurrent Injuries


Bony extremity injuries may be associated with concurrent injury to nerves, arteries,
veins, or soft tissue. Suspect neurovascular injury with any injury to the bones of an
extremity. Severe pelvic fractures can be associated with injuries to pelvic organs and
large blood loss. Genitourinary injuries, especially to the bladder or the urethra in males,
can result from pelvic fractures. Depending on the mechanism of injury, bony injury of
the extremities may be associated with vertebral column injuries.

PATHOPHYSIOLOGY AS A BASIS FOR SIGNS AND SYMPTOMS


Blood Loss
Musculoskeletal trauma can be associated with large blood loss because of disruption of
arteries or veins in close proximity to bones. Up to 1,500 ml of blood can be lost from an
isolated femur fracture. A tibia or humeral fracture can lead to a blood loss up to 750 ml.

Multiple fractures may result in significant blood loss, which can potentiate shock from
other injuries. Blood loss from pelvic fractures varies significantly based on the
mechanism of injury, type of fracture, the particular vessels injured, and whether there
are other intra-abdominal injuries.
Capillaries and cellular membranes can be disrupted or torn with all types of
musculoskeletal injuries. Blood from vascular disruption and intracellular fluid are
released into the area surrounding the injury.
Edema from fluid and blood accumulation can cause compression of surrounding
structures. Normal physiological mechanisms are activated to minimize damage caused
by these structural disruptions:
• Initiation of the clotting system to decrease bleeding
• Restoration of cellular membrane integrity to enhance fluid reabsorption
• Increased collateral blood flow to promote healing
Bone or joint displacement can compress surrounding vessels and nerves, causing
pathophysiological changes distal to the injury. As arterial blood flow is obstructed,
tissue oxygenation decreases resulting in tissue ischemia and cellular death. During this
process, pain increases, pulses become more difficult to palpate, the limb becomes pale,
cyanotic and cool, and capillary refill time increases.

Neurologic Deficits
If nerves are compressed or lacerated, conduction pathways are interrupted and the relay
of nerve impulses are blocked or diminished. Nerve injury can result in diminished pain
sensation. Injury distal to a nerve may result in partial or complete loss of motor and
sensory function.

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Fractures
Fractures involve a disruption of bony continuity

Soft tissue injury


Disruption in the skin can result in a disturbance in fluid, electrolyte levels, or
temperature control. Any skin surface wound with loss of skin integrity provides an entry
for microorganisms. This can lead to infection, especially if necrotic tissue is present.
The following terms used to describe soft tissue injuries:
• Abrasion
An epidermal and dermal injury caused by a friction, rubbing, or scraping motion
• Avulsion
A full thickness skin loss or resultant flap in which the wound edges cannot be
approximated
• Degloving
A serious type of avulsion injury resulting from high-energy shearing forces that tear
large areas of skin and subcutaneous tissue away from the underlying vascular supply
• Contusion
Disruption of small blood vessels and extravasation of blood into the skin and/or mucous
membranes that does not interrupt the skin integrity
• Laceration
Open wound from external forces causing a tearing or splitting of the skin, involving the
dermis, epidermis, or underlying structures
• Puncture
Wound with a narrow opening that can penetrate deeply into the skin. Puncture wounds
bleed minimally and tend to trap foreign material that can lead to infection. Animal and
human bites can be considered puncture wounds and should be treated as contaminated
wounds."

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SELECTED MUSCULOSKELETAL INJURIES
Joint Injuries
A joint may become dislocated when the normal range of motion is exceeded. Joint
dislocations may be complicated by neurovascular compromise and associated fractures.
Delayed reduction of a hip dislocation can lead to a vascular necrosis (AVN) of the
femoral head and permanent disability.
." Dislocation of the knee requires immediate intervention since peroneal nerve injury
and compromises to the popliteal artery and vein may develop. Angiography is necessary
to diagnose vascular trauma.
SIGNS AND SYMPTOMS
•Pain
• Joint deformity
• Edema
• Inability to move the affected joint
• Abnormal range of motion
• Neurovascular compromise: distal pulses may be diminished or absent; sensory function
may be affected

Femur Fractures
Femur fractures are a result of major trauma, such as falls, motor vehicle crashes,.
Fractures of the femoral neck are common after a fall in the elderly population.
Closed femur fractures can result in a collection of 1,000 to 1,500 ml of blood in the
thigh.
SIGNS AND SYMPTOMS
• Pain and inability to bear weight
• Shortening of the affected leg
• Rotation internally or externally depending on the location of the fracture site in the hip
• Edema of the thigh
• Deformity of the thigh
• Evidence of hypovolemic shock

Pelvic Fractures
Pelvic fractures are classified as either stable or unstable. A stable fracture is defined as
"one that can withstand normal physiologic forces without abnormal deformation."" An
unstable fracture occurs when the pelvic ring is fractured in more than one place resulting
in two displacements on the ring; rotational

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SIGNS AND SYMPTOMS
•Pain
•Evidence of hypovolemic shock
•Shortening or abnormal rotation of the affected leg
• Genitourinary or intra-abdominal injury

Open Fractures
All open fractures are considered contaminated because of the foreign materials and
bacteria that can be introduced into the wound. Any open fracture may result in an
infection. The risk of serious infection is greater with severe fractures. Infections can be
manifested by poor tissue healing, osteomyelitis, or sepsis.
Open fractures are graded from I to 111 according to the degree of skin and soft tissue
injury surrounding the fracture site. Grade III open fractures are further described by the
amount of nonviable tissue, injury to the periosteum, and vascular trauma.
SIGNS AND SYMPTOMS
• Evidence of skin disruption (e.g., laceration or puncture) near or over the fracture
• Protrusion of bone through open wounds
•Pain
• Neurovascular compromise
• Bleeding may be minimal to severe

Amputations
Amputations may be partial or complete and usually involve the digits, distal half of the
foot, the lower leg, the hand, or the forearm. The axiom of saving "life over limb" is a
reminder to the trauma team to fully resuscitate the patient before managing the
amputation.
The following have been cited as indications for replantationl
• Multiple digits
• Thumb
• Wrist
• Forearm
• Pediatric patient (children typically, have a more positive outcome from replantation
procedures)
Amputations that are guillotine-type amputations have a better chance of being
successfully replanted as opposed to avulsive/tearing types of injuries. The decision to
replant should be made by a surgeon or replantation team, if available.

SIGNS AND SYMPTOMS


• Obvious tissue loss
• Pain
• Bleeding (may be minimal to severe) .

Complete amputations will have less active bleeding than partial amputations because of
retraction of the severed arteries. An exception is an avulsive type of complete
amputation, which can result in extensive bleeding.

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• Evidence of hypovolemic shock

Crush Injuries
Certain crush injuries, depending on the location of the injury, may be life-threatening
(e.g., pelvis and both lower extremities). Cellular destruction and damage to vessels and
nerves make crush injuries difficult to treat. Hemorrhage from the damaged tissue,
destruction of muscle and bone tissue, fluid loss resulting in hypovolemic shock,
compartment syndrome, and infection are sequelae associated with crush injuries. The
destruction of muscle tissue associated with release of myoglobin can result in renal
dysfunction.
SIGNS AND SYMPTOMS
• Massively crushed pelvis or extremity (ies) with soft tissue swelling
•Pain
• Evidence of hypovolemic shock
• Signs of compartment syndrome
• Loss of neurovascular function distal to the injury

Compartment Syndrome
Compartment syndrome occurs as pressure increases inside a fascial compartment. This
results in impaired capillary blood flow and cellular ischemia. This occurs more
frequently in the muscles of the lower leg or forearm, but can involve any fascial
compartment. The increased pressure may be because of an internal source, such as
hemorrhage or edema, caused by open or closed fractures, or crush injuries. It
can also result from an external source, such as a cast, excessive traction, air splint, or
PASG. Nerves, blood vessels, and muscles can be compressed. If compartment syndrome
results in "prolonged" ischemia of the muscles and nerves, the patient may be left with a
limb that is painful and without function
SIGNS AND SYMPTOMS
• Pain disproportionate to the injury because of increased tissue pressures and ischemia
• Sensory deficit (e.g., numbness, tingling, total loss of sensation)
•Progressive muscle weakness
• Tense, swollen area

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PHYSICAL ASSESSMENT
Refer to Initial Assessment, for a description of assessment of the patient's airway,
breathing, circulation, and disability
Inspection
• Observe general appearance of extremities
Note color, position, and obvious differences of injured extremity as compared to
uninjured extremity
•Assess integrity of the injured area
• Note protrusion of bone or any break in the skin
• Assess for bleeding
• Identify soft tissue damage, including edema, ecchymosis, contusions, abrasions,
avulsions, or lacerations
• Assess for deformity and/or angulation of extremity
Palpation
Extremity assessment is described by the five Ps: pain, pallor, pulses, paresthesia, and
paralysis. This assessment relates to the neurovascular status of the injured extremity.
Assess the injured extremity and compare with an assessment of the opposite, uninjured
extremity.
• Assess the five Ps
• Pain
Carefully palpate the entire length of each extremity for pain. Determine location and
quality of pain. Ischemic pain is often described as burning or throbbing.
• Pallor
Note color and temperature of injured extremity. Pallor, delayed capillary refill (> two
seconds), and a cool extremity indicate vascular compromise.
• Pulses
Palpate pulses proximal and distal to the injury for comparison. Then compare quality of
pulses with the opposite, uninjured extremity.
• Paresthesia
Determine presence of abnormal sensations (e.g., burning, tingling, numbness)
• Paralysis
Assess motor function. The ability to move can be related to neurologic function.
• Palpate the pelvis for pain or bony instability. Apply gentle pressure on the iliac crests
towards midline, noting any instability or increased pain. Gently press downward on the
symphysis pubis a fracture is suspected, carefully palpates the pelvis. Do not rock the
pelvis.
• Note bony crepitus during palpation, which is a crackling sound produced by the
grating of the end of fractured bones.
DIAGNOSTIC PROCEDURES
Refer to Initial Assessment, for frequently ordered radiographic and laboratory studies
Additional studies for patients with musculoskeletal trauma are listed below.
Radiographic Studies
• Anterior-posterior and lateral of injured extremity
Some fractures can 'only be seen from one radiographic angle; therefore, an oblique

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view may be indicated. The film should include the joints immediately above and
below the injury.
• Angiography
Angiography may be indicated to identify tears or compressions in the arterial or
venous network the injured extremity.

ANALYSIS, NURSING DIAGNOSES, INTERVENTIONS, AND EXPECTED


OUTCOMES
In addition to the nursing diagnoses outlined in Initial Assessment, the following nursing
diagnoses are potential problems for the patient with musculoskeletal injuries. Once a
patient has been assesses diagnoses can be defined as either actual or risk. An actual
nursing diagnosis is derived from a decision based on the patient's presenting signs and
symptoms. A risk nursing diagnosis is a judgment the nurse make based on a particular
patient's risk and potential for developing certain problems.

NURSING DIAGNOSIS INTERVENTION EXPECTED OUTCOME


Fluid volume deficit, Control any uncontrolled The patient will have an
related to bleeding by: applying direct effective circulating
• Hemorrhage pressure volume, as evidenced by:
over bleeding site; • Stable vital signs
elevating extremity; appropriate for age
applying pressure • Urine output of 1ml/kg/hr
over arterial pressure • Strong, palpable
sites peripheral pulses
• Cannulate two veins with • Level of consciousness,
large bore catheters and awake and alert,
initiate infusion of lactated age appropriate
Ringer's solution or normal • Skin normal color, warm,
saline and dry
• Administer blood, as • Maintains hematocrit of
indicated 30 ml/dl or hemoglobin of
• splint injured extremity 12 to 14 g/dl or greater
• Capillary refill time of <2
seconds

Physical mobility, Splint and immobilize The patient will experience


impaired, related to: affected extremity increased
• Bone, soft tissue and/or Immobilize joints above mobility, as evidenced by:
nerve injury of extremity and below the deformity • Ability to tolerate
• Pain Administer analgesia movement and increased
• Edema medications, as prescribed activity
• External immobilization Use touch, positioning, or • Willingness to move
devices relaxation techniques to affected part to degree
• Limited range of motion give comfort allowed

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of affected bone • Maintenance of proper
body alignment

Infection, risk, related to: Obtain blood/wound The patient will be free
• Impaired skin integrity cultures from infection, as
• Contamination of wound Monitor vital signs evidenced by:
from Administer antibiotics, as • Core temperature
initial injury or prescribed measurement of 36
instrumentation Keep wound clean and 37.5°C (98 - 99.5°F)
• Invasive fixation devices apply • White blood cell count
• Interruption in perfusion dressing using aseptic within normal
• Suppressed inflammatory technique limits
response Maintain aseptic technique • Absence of signs of
Cover open wounds with a infection: redness,
sterile dressing swelling, purulent
Do not reposition drainage, odor, and
protruding tenderness
bone fragments
Prepare for definitive care
Stabilize impaled objects

Impaired skin integrity, Assess skin integrity The patient will experience
risk, related to: frequently absence or
• Movement of fractured Keep skin dry resolution of impaired skin
bones Maintain aseptic/clean integrity, as
• Pressure, shear, friction technique, as appropriate evidenced by:
on skin Splinting, as indicated • Maintenance of intact skin
and tissue overlying
• Mechanical irritants: fracture
Fixation de- • Absence of signs of
vices, splints, and casting irritation: redness,
material blanching, and itching
• Impaired mobility
• Effects of trauma/injury
agents

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Planning and Implementation
Refer to Initial Assessment, for a description of the specific nursing interventions for
patients with compromises to airway, breathing, circulation, and disability.
• Control bleeding
• Splint and immobilize the affected extremity
• Splinting is indicated when there is evidence of the following:
• Deformity
• Pain
• Bony crepitus
• Edema
• Ecchymosis
• Circulatory compromise
• Open soft tissue injury
• Impaled object
• Paresthesia or paralysis
• Select an appropriate splint. Three types of splints are available:
• Rigid splints, such as cardboard, plastic devices or metal splints
• Soft splints, such as pillows, slings, or air splints
• Traction splints—applied for actual or suspected femur or proximal tibial fractures
• Remove jewelry or constricting items of clothing prior to immobilization
• Do not reposition protruding bone ends
• Avoid excessive movement of the fractured bone fragments. Any manipulation can
increase bleeding into the tissues, increase the risk of fat emboli, or convert a closed
fracture to an open fracture.
• Immobilize the joints above and below the deformity
• Modify the splint to fit the fracture, if necessary
• Reassess neurovascular status before and after immobilization. If neurovascular status is
compromised, reassess, remove, adjust, or reapply the splint.
• Apply ice to reduce swelling and pain

• Elevate the extremity above the level of the heart to reduce swelling and pain. If
compartment

• Elevate the extremity above the level of the heart to reduce swelling and pain. If
compartment syndrome is suspected, then elevate to the level of the heart.
• Administer analgesic medications, as prescribed
• Consider regional analgesia. A femoral nerve block is frequently performed on patients
in many emergency departments in the United Kingdom and Australia.
• Prepare for definitive stabilization. Traction, casting, internal or external fixation may
be indicated.
• Prepare for conscious sedation, as prescribed (See Appendix 5)
• Prepare for closed reduction, as indicated
• Provide psychosocial support

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• Prepare patient for operative intervention, hospital admission or transfer, as indicated

NURSING INTERVENTIONS FOR THE PATIENT WITH A PELVIC


FRACTURE
• Stabilize pelvic fractures
• Apply PASG to splint pelvic fractures, as indicated
• Wrap the pelvis in a folded sheet which is clamped or knotted at the front, as indicated
• Prepare for application of external fixator. Unstable pelvic fractures with severe blood
loss may require immediate stabilization with an external fixator.l3
• Assist with additional diagnostic radiographs, including cystogram, angiogram, or CT
scan of the pelvis, as ordered. Patients must be carefully monitored during angiography
and related therapeutic
embolization.
NURSING INTERVENTIONS FOR THE PATIENT WITH AN OPEN
WOUND
• Obtain a wound culture from an open fracture site
• Irrigate any wound, as indicated
• Cover open wounds with dry, sterile dressings. Avoid frequent dressing changes to
minimize the risk
of bacterial contamination.
• Administer antibiotics, as prescribed
• Inspect dressings frequently for continued bleeding
• Administer tetanus prophylaxis, as indicated
NURSING INTERVENTIONS FOR THE PATIENT WITH
ANAMPUTATION
• Control any active bleeding with pressure dressings and elevation. Avoid tourniquets or
clamps.
• Elevate the stump
• Splint the stump as needed
• Remove gross dirt or debris
• Keep the amputated part cool and wrap the part in a saline-moistened gauze, then place
in a sealed plastic bag, and finally place the bag in crushed ice and water. Do not allow
the part to freeze.
• Prepare for radiographs of both the stump and the amputated part \ ~'
• Prepare patient for hospital admission, operative intervention, or transfer to a facility
with a replantation team, as indicated
• Administer antibiotics, as prescribed
• Administer tetanus prophylaxis, as indicated
NURSING INTERVENTIONS FOR THE PATIENT WITH A CRUSH
INJURY
• Administer an intravenous crystalloid solution to increase urinary output and facilitate
excretion of myoglobin
• Elevate the injured extremity above the level of the heart to reduce swelling and pain
• Gently clean open wounds
• Reassess
• Urinary output

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• Presence of myoglobin in the urine
• Motor and sensory function ' •
• Prepare patient for surgical debridement, fasciotomy, and/or amputation
NURSING INTERVENTIONS FOR THE PATIENT WITH POSSIBLE
COMPARTMENT SYNDROME
• Elevate the limb to the level of the heart to promote venous outflow and prevent further
swelling. Do not elevate the limb above the heart as this may decrease perfusion to
compromised extremity.
• Assist with measurement of fascial compartment pressure, as indicated. Normal
pressure is > 10 mm Hg (1.3 KPa).20 A reading of > 35 to 45 mm Hg (4.7-6 KPa) is
suggestive of possible anoxia to muscles and nerves. 21
• Prepare for fasciotomy, as indicated. A fasciotomy may prevent muscle and/or
neurovascular damage and loss of the limb.
•Reassess and document neurovascular status on an ongoing basis. Communicate changes
to the physician immediately.
Evaluation and Ongoing Assessment
Refer to Chapter 3, Initial Assessment, for a description of the ongoing evaluation of the
patient's airway, breathing, circulation, and disability. Additional evaluations include:
• Monitoring breathing effectiveness and rate of respiration
Tachpynea, rales, and wheezes may be indicators of fat embolus syndrome.
• Reassess and document the five Ps

SUMMARY
Injuries of the extremities are usually not the first priority of care for the multiple trauma
patients. However, there is a high incidence of injuries to upper and lower extremities
that, although usually not life-threatening, can result in functional disability and/or loss,
and long-term rehabilitation.
The proximity of vessels and nerves to musculoskeletal structures increases the risk of
neurovascular damage ranging from motor, sensory, or vascular deficits to paralysis
and/or hemorrhage, and shock.
Disruptions and fractures of the pelvis may result in significant blood loss because of
concurrent injury to the blood vessels in the pelvic cavity. Collaborate with members of
the trauma team to correct any life-threatening compromises to circulation.
During the secondary assessment, assess the extremities for indications of a fracture or
dislocation.
Intervene early to splint the suspected fracture and reassess neurovascular function both
before and after the application of any splinting device.
Timely identification and management of suspected musculoskeletal injuries, including
the use of pain control, splints, traction, and/or external fixation, contribute o improved
functional patient outcomes.

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