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JOFRED M.

MARTINEZ, RN, MAN


University of San Agustin Review Center
Iloilo City, Philippines

MUSCULOSKELETAL TRAUMA

Contusions, Strains and Sprains


CONTUSION
Pathophysiology bleeding into

soft tissue

STRAIN

SPRAIN

stretching injury to a
muscle or a muscle
tendon unit

stretch and/or tear of


one or more ligaments
surrounding a joint

Etiology

blunt force

mechanical
overloading

forces going in opposite


directions

Manifestations

swelling and
discoloration of
the skin

pain, limited motion,


muscle spasms,
swelling, and possible
muscle weakness

loss of function, feeling


of pop or tear,
discoloration, pain, and
rapid swelling

Contusions, Strains and Sprains

Contusions, Strains and Sprains

Contusions, Strains and Sprains

Grades of Sprain Severity


Grade
Description
Overstretching or
1
Mild

Mild pain, swelling, tenderness


minimal tear of ligaments Little or no bruising
with no joint instability
Minimal or no loss of joint function or ability
to bear weight

Partial tear of the


Moderate ligament

3
Severe

Manifestation

Moderate pain, bruising, and swelling


Mild to moderate joint instability, functional
disability
Weight bearing difficult

Complete tear or rupture Severe pain, swelling, and bruising


of the ligament
Significant functional loss and joint instability
Inability to bear weight

Grades of Sprain Severity

Contusions, Strains and Sprains


MANAGEMENT
Emergency care

rest, ice, compression, and elevation for the first 24 to


48 hours

Diagnosis

x-ray, magnetic resonance imaging (MRI)

Medications

nonsteroidal anti-inflammatory drugs (NSAIDs)

Treatment

immobilized with a cast or splint


surgery to repair the torn ligaments, muscle, or tendons
physical therapy for rehabilitation

RICE Therapy
Action
Rest

Ice

Interventions
Decrease regular activities of daily living and exercise as
needed.
Limit weight bearing on the injured extremity for 48 hours.
If you use a cane or crutch to avoid weight bearing, use it on
the uninjured side so you can lean away from and relieve
weight on the injured leg.
To avoid cold injury or frostbite, apply an ice pack to the
injured area for no more than 20 minutes at a time, four to
eight times a day.
An ice bag, cold pack, plastic bag filled with crushed ice and
wrapped in a towel, or a bag of frozen peas may be used.

RICE Therapy
Action
Compression

Elevation

Interventions
Loosen the compression bandage if you experience
numbness, tingling, or swelling distal to the injury, or if the
distal extremity becomes cool or cyanotic (bluish-grey).
Keep the injured extremity elevated on a pillow above heart
level to help reduce swelling and pain.

Nursing Care for Contusions, Sprains and Strains


Acute Pain
Teach the patient to use RICE (rest, ice, compression, elevation)
therapy to care for the injury.
Impaired Physical Mobility
Teach the correct use of crutches, walkers, canes, or slings if
prescribed.
Encourage follow-up care.

Rotator Cuff Injuries, Knee Injuries and Joint Dislocation


ROTATOR CUFF
INJURIES
Pathophysiology tendinitis, bursitis,

and partial and


complete muscle
tears

Etiology

KNEE
INJURIES

JOINT
DISLOCATION

ligament tears, bones are displaced


meniscal injury, out of their normal position
and patellar
and joint articulation is lost
dislocation

repetitive use injury sports activities contact sports, disease of


or degenerative
the joint, including
changes
infection, rheumatoid
arthritis, paralysis, and
neuromuscular diseases

Rotator Cuff Injuries

Knee Injuries

Joint Dislocation

Joint Trauma
ROTATOR CUFF
INJURIES

KNEE
INJURIES

Manifestations

shoulder pain,
limited ROM

Diagnosis

history and physical assessment


x-ray and MRI
RICE
RICE
RICE, NSAIDs
NSAIDs
NSAIDs
close reduction
physical therapy physical therapy
manual traction
surgery
surgery
surgery

Treatment

immediate pain, a
tearing or popping
sensation, swelling

JOINT
DISLOCATION
pain, deformity, and
limited motion of the
affected joint

Joint Trauma

Joint Trauma

Nursing Care for Joint Trauma


History Taking
circumstances of injury if known;
pain, including location, character, timing, and activities or
movements that aggravate or relieve it
history of prior musculoskeletal injuries;
chronic illnesses;
medications.

Nursing Care for Joint Trauma


Physical Assessment
Compare the position, color, size, and temperature of the
affected joint to the corresponding unaffected joint.
Palpate for tenderness, crepitus, temperature, and swelling.
Instruct the patient or assist to move the joint through its normal
range of motion, stopping and noting where pain is experienced.
When a joint dislocation is suspected, assess color, temperature,
pulses, movement, and sensation of the limb distal to the
affected joint.

Nursing Diagnosis and Interventions


Risk for Injury
Monitor neurovascular status by assessing the 5 Ps: pain,
pulses, pallor, paralysis, and paresthesia.
Maintain immobilization as ordered after reduction.
Acute Pain
Encourage use of an appropriate splint or joint immobilizer.
Teach safe application of ice or heat to the affected joint as
indicated.
Instruct about using NSAIDs as ordered.

Nursing Diagnosis and Interventions


Preventing Dislocations
Keep the knees apart at all times.
Put a pillow between the legs when sleeping.
Never cross the legs when seated.
Avoid bending forward when seated in a chair.
Avoid bending forward to pick objects on the floor.
Use a high-seated chair and a raised toilet seat.
Do not flex the hip to put on clothing.

Nursing Diagnosis and Interventions

Nursing Diagnosis and Interventions


Acute Pain
Teach use of assistive devices such as a sling, crutches, or cane to
reduce stress on the affected joint or minimize weight bearing.
Impaired Physical Mobility
Refer to physical therapy for appropriate exercises.
Suggest occupational therapy.

Repetitive Use Injuries


CARPAL TUNNEL
SYNDROME
Pathophysiology compression

of the median
nerve

Etiology

using computers
post menopausal
women

BURSITIS
inflammation of a
bursa
constant friction
between the bursa
and the
musculoskeletal
tissue

EPICONDYLITIS
inflammation of the
tendon to
microvascular trauma
tears, bleeding, and
edema and
calcification of the
tendon

Repetitive Use Injuries


CARPAL TUNNEL
SYNDROME
Manifestations

pain, numbness
and tingling of the
thumb, index
finger, and lateral
ventral surface of
the middle finger

BURSITIS

EPICONDYLITIS

hot, red, edematous,


tender, and extension
and flexion of the
joint near the bursa
produce pain

point tenderness,
pain radiating down
the dorsal surface of
the forearm

Carpal Tunnel Syndrome

Bursitis

Epicondylitis

Repetitive Use Injuries


CARPAL TUNNEL
SYNDROME
Diagnosis

history and physical


examination
Phalens test
ultrasound
magnetic resonance
imaging (MRI)
electromyography (EMG)
nerve conduction studies

BURSITIS

EPICONDYLITIS

history and physical examination


ultrasound
magnetic resonance imaging (MRI)

Phalens Test

Tinels Sign

Repetitive Use Injuries


CARPAL TUNNEL
SYNDROME
Emergency
Management
Medications

Treatment

BURSITIS

EPICONDYLITIS

RICE in the first 24 to 48 hours

NSAIDs
narcotics
corticosteroids

NSAIDs
narcotics
Surgery

NSAIDs
narcotics
corticosteroids

Carpal Tunnel Syndrome

Nursing Interventions for Repetitive Use Injuries


Acute Pain
Ask the patient to rate the pain on a scale of 0 to 10 before and
after any intervention.
Encourage the use of immobilizers.
Teach the patient to apply ice and/or heat as prescribed.
Encourage use of NSAIDs as prescribed.
Explain why treatment should not be abruptly discontinued.

Nursing Interventions for Repetitive Use Injuries


Impaired Physical Mobility
Suggest interventions to alleviate pain (such as using an
immobilizer and taking pain medications).
Refer to a physical therapist for exercises.
Suggest consultation with an occupational therapist.

Objective Health Assessment

Muscle Grading Scale


Scale
0

Assessment Description
(No visible) contraction; paralysis

Can feel contraction of muscle but there is no movement


of limb
Passive ROM

Full ROM against gravity

4
5

Full ROM against some resistance


Full ROM against full resistance

Traumatic Injuries of Bones

Traumatic Injuries of Bones


Etiology
direct blow
crushing force (compression)
sudden twisting motion (torsion)
severe muscle contraction
stress or pathologic fracture

Fracture Classification
open (compound) fracture
closed (simple) fracture

Fracture Classification
oblique fractures
spiral fractures
comminuted fractures

Fracture Classification

avulsed fracture
impacted fracture
fissure fracture
greenstick fracture

Fracture Classification
stable fracture
unstable fracture

Traumatic Injuries of Bones


Manifestations
Deformity
Swelling
Pain/tenderness
Numbness
Guarding
Crepitus
Hypovolemic shock
Muscle spasms
Ecchymosis

Fracture Healing

Bone Injury

Fracture Healing

Fibrocartilaginous Callus Formation

Fracture Healing

Bony Callus Formation

Fracture Healing

Bone Remodelling

Fracture Complications
COMPARTMENT SYNDROME
Pathophysiology
Manifestations

pressure within this confined space constricts and entraps


the structures within it
pain
normal or decreased peripheral pulse
cyanosis
tingling, loss of sensation (paresthesias)
weakness (paresis)
severe pain

Fracture Complications
COMPARTMENT SYNDROME

Fracture Complications
COMPARTMENT SYNDROME
Treatment

restrictive dressings are removed


bivalving
fasciotomy

Complication

Volkmanns contracture

Fasciotomy

Fracture Complications
FAT EMBOLISM
Pathophysiology

fat globules lodge in the pulmonary vascular bed or


peripheral circulation

Etiology

Manifestations

long bone fractures and other major trauma


hip replacement surgery
neurologic dysfunction
pulmonary insufficiency
petechial rash on the chest, axilla, and upper arms

Fracture Complications
FAT EMBOLISM
Treatment

early stabilization of long bone fractures


intubation and mechanical ventilation
fluid balance is closely monitored
corticosteroids

Fracture Complications
DEEP VEIN THROMBOSIS
Pathophysiology

blood clot forms along the intimal lining of a large vein,


accompanied by inflammation of the vein wall

Etiology

Manifestations

venous stasis, or decreased blood flow


injury to blood vessel walls
altered blood coagulation
swelling, pain, tenderness, or cramping of the affected
extremity

Fracture Complications
DEEP VEIN THROMBOSIS
Diagnosis

doppler ultrasonography
magnetic resonance imaging
venogram

Treatment

early immobilization of the fracture


early ambulation of the patient
prophylactic anticoagulation
antiembolism stockings and compression boots

Fracture Complications
INFECTION
Pathophysiology
Complication

Pseudomonas, Staphylococcus, or Clostridium organisms may


invade the wound or bone
osteomyelitis

Fracture Complications
DELAYED UNION AND NONUNION
Pathophysiology

prolonged healing of bones beyond the usual time period


delayed union may lead to nonunion

Etiology

Injury-related: the type and location of facture and


accompanying soft tissue injury
System related: age, general health, immune status, chronic
diseases, and smoking

Diagnosis

serial x-ray studies

Fracture Complications
DELAYED UNION AND NONUNION
Treatment

internal fixation and bone grafting


bone debridement
electrical or ultrasonic stimulation of the fracture site
growth hormone or parathyroid hormone stimulation

Fracture Complications
COMPLEX REGIONAL PAIN SYNDROME
Pathophysiology

pain receptors become sensitized to catecholamines,


neurotransmitters associated with sympathetic nervous
system activity

Etiology

Diagnosis

female
older age
history and physical examination
x-ray

Fracture Complications
COMPLEX REGIONAL PAIN SYNDROME
Manifestations

severe, diffuse, and burning pain


affected extremity is inflamed and edematous, later
becoming cool and pale
muscle wasting, skin and nail changes, and bone
abnormalities

Treatment

sympathetic nervous system blocking agent

Management for Fractures


Emergency Care
Immobilizing the fracture
Maintaining tissue perfusion
Preventing infection
Diagnosis
X-rays and bone scans
Blood chemistry studies, complete blood count (CBC), and
coagulation studies

Management for Fractures

Management for Fractures


Medications
Antibiotics may be administered prophylactically
Anticoagulants
Stool softeners
Antiulcer medications or antacids

Management for Fractures


Traction
Manual traction

Management for Fractures


Traction
Skin traction

Nursing Interventions for Patients in Skin Traction


Frequently assess skin, bony prominences, and pressure points
for evidence of pressure, shearing, or pending breakdown.
Protect pressure sites with padding and protective dressings as
indicated.
Remove weights only if intermittent traction has been ordered to
alleviate muscle spasm.

Management for Fractures


Traction
Balanced
suspension
traction

Management for Fractures


Traction
Skeletal traction

Skeletal Traction
Traction
Balanced
suspension
traction

Skeletal Traction
Traction
Bucks
extension
traction

Skeletal Traction
Traction
Head halter

Skeletal Traction
Traction
Pelvic girdle

Skeletal Traction
Traction
Bucks
extension
traction

Skeletal Traction
Traction
Bryants
traction

Skeletal Traction
Traction
Dunlops
traction

Skeletal Traction
Traction
Russels traction

Skeletal Traction
Traction
Halo pelvic
traction

Nursing Interventions for Patients in Skeletal Traction


Never remove the weights.
Frequently assess pin insertion sites and provide pin site care per
policy.
Report signs of infection at the pin sites, such as redness,
drainage, and increased tenderness.

Nursing Interventions for Patients in Traction


Maintain the pulling force and direction of the traction:
The patients weight provides counter traction.
Center the patient on the bed; maintain body alignment with the
direction of pull.
Ensure that weights hang freely and do not touch the floor.
Ensure that nothing is lying on or obstructing the ropes.
Do not allow the knots at the end of the rope to come into
contact with the pulley.

Nursing Interventions for Patients in Traction


Perform neurovascular assessments frequently.
Assess for common complications of immobility, including
pressure ulcer formation, renal calculi, deep venous thrombosis,
pneumonia, paralytic ileus, and loss of appetite.
If a problem is detected, assist in repositioning. Stabilize the
fracture site during repositioning.
Teach the patient and family about the type and purpose of the
traction.

Nursing Interventions for Patients in Traction


T - Temperature (Extremity, Infection)
R - Ropes hang freely
A - Alignment
C - Circulation Check (5 P's)
T - Type & Location of fracture
I - Increase fluid intake
O - Overhead trapeze
N - No weights on bed or floor

Management for Fractures


Casts

Management for Fractures


Casts
Short arm
Long arm

Management for Fractures


Casts
Short leg
Long leg

Management for Fractures


Casts
Walking cast

Management for Fractures


Casts
Hip spica cast

Management for Fractures


Casts
Short leg hip
spica cast

Fracture Complications

Pressure areas in casts

Nursing Interventions for Patients in Casts


Perform frequent neurovascular
assessments.
Palpate the cast for hot spots that may
indicate the presence of underlying
infection.
Promptly report increased or severe pain;
changes in neurovascular status; or a hot
spot or drainage on the cast.

Health Education for the Patient and Family


Do not use a blow dryer to speed drying; do not cover the cast
while it is drying.
A sensation of warmth during drying is normal.
Do not put anything into the cast.
Keep the cast clean and dry; use plastic wrap as needed to
protect it.
If the cast is made of fiberglass, dry it with a blow dryer on the
cool setting if it becomes wet.

Health Education for the Patient and Family


Notify your doctor immediately if you develop increased pain,
coolness, changes in color, increased swelling, and/or loss of
sensation.
A sling may be used to distribute the weight of the cast evenly
around the neck.
If crutches are used, arrange for physical therapist to teach
correct crutch walking.
When the cast is removed, an oscillating cast saw will be used.

Management for Fractures


Surgery
open reduction and
internal fixation (ORIF)

Management for Fractures

Management for Fractures


Surgery
surgical fixation

Management for Fractures


Electrical Bone Stimulation

Nursing Care for Fractures


History Taking
age
history of traumatic event
history of prior musculoskeletal injuries
chronic illnesses
medications (ask the older adult specifically
about anticoagulants and calcium
supplements).

Nursing Care for Fractures


Physical Assessment
Pain with movement, pulses, edema, skin color and
temperature, deformity, range of motion, touch.
The 5 Ps of neurovascular assessment.

Nursing Diagnosis and Interventions


Acute Pain
Monitor vital signs.
Ask the patient to rate the pain on a scale of 0 to 10 before and
after any intervention.
Move the patient gently and slowly.
Elevate the injured extremity above the level of the heart.
Encourage distraction or other adjunctive methods of pain relief,
such as deep breathing and relaxation.

Nursing Diagnosis and Interventions


Acute Pain
Administer NSAIDs and pain medications as prescribed. For
home care, explain the importance of taking pain medications
before the pain is severe.

Nursing Diagnosis and Interventions


Risk for Peripheral Neurovascular Dysfunction
Support the injured extremity above and below the fracture site
when moving the patient.
Assess the 5 Ps every 1 to 2 hours. Report abnormal findings
immediately.
Assess nail beds for capillary refill. If nails are too thick or
discolored, assess the skin around the nail.
Monitor the extremity for edema and swelling.
Assess for deep, throbbing, unrelenting pain.

Nursing Diagnosis and Interventions


Risk for Peripheral Neurovascular Dysfunction
Assess the ability to differentiate between sharp and dull touch
and the presence of paresthesias and paralysis every 1 to 2
hours.
Monitor the tightness of the cast. If the cast is tight, be prepared
to assist the physician with bivalving.
If compartment syndrome is suspected, assist the physician in
measuring compartment pressure. Normal compartment
pressure is 10 to 20 mmHg.

Nursing Diagnosis and Interventions


Bivalving

Nursing Diagnosis and Interventions


Risk for Peripheral Neurovascular Dysfunction
Unless contraindicated, elevate the injured extremity above the
level of the heart.
Administer anticoagulant per physicians order.

Nursing Diagnosis and Interventions


Risk for Infection
For patients with skeletal pins, follow established guidelines for
skeletal pin site care.
Monitor vital signs and lab reports of WBCs.
Use sterile technique for dressing changes.
Assess the wound for size, color, and the presence of any
drainage.
Administer antibiotics per physicians orders.

Nursing Diagnosis and Interventions


Impaired Physical Mobility
Teach or assist patient with ROM exercises of the unaffected
limbs.
Teach isometric exercises, and encourage the patient to perform
them every 4 hours.
Encourage ambulation when able; provide assistance as
necessary.
Turn the patient on bed rest every 2 hours. If the patient is in
traction, teach the patient to shift his or her weight every hour.

Amputation

Amputation
Causes of Amputation
Peripheral vascular disease (PVD)
Peripheral neuropathy
Untreated infection
Motor vehicle crashes or accidents
involving machinery at work
Combat-related trauma
Frostbite, burns, or electrocution

Common Sites of Amputation

Amputation Complications
INFECTION
Pathophysiology

traumatic amputation has a greater risk of infection

Etiology

older patients, has diabetes mellitus, or suffers peripheral


neurovascular compromise
local manifestations include drainage, odor, redness, and
increased discomfort at the suture line.
systemic manifestations include fever, an increased heart
rate, a decrease in blood pressure, chills, and positive
wound or blood cultures.

Manifestations

Amputation Complications
DELAYED HEALING
Pathophysiology

if infection is present or if the circulation remains


compromised, delayed healing

Etiology

older patients, electrolyte imbalances, diet that


lacks the proper nutrients, smoking, deep vein
thrombosis and decreased cardiac output

Amputation Complications
CHRONIC STUMP PAIN
Pathophysiology

neuroma formation

Manifestations

severe burning pain

Treatment

medications
nerve blocks
transcutaneous electrical nerve stimulation (TENS)
surgical stump reconstruction

Amputation Complications
PHANTOM LIMB PAIN
Pathophysiology

pain in the amputated limb prior to its removal

Manifestations

tingling, numbness, cramping, or itching in the


phantom foot or hand
pain management
TENS
surgery

Treatment

Amputation Complications
CONTRACTURES
Pathophysiology
Treatment

abnormal flexion and fixation of a joint caused by


muscle atrophy and shortening
active or passive ROM exercises every 2 to 4 hours
postural exercises

Management for Amputation


Diagnosis
Preoperative - Doppler flowmetry,
segmental blood pressure determination,
transcutaneous partial pressure oxygen
readings, and angiography
Postoperative - CBC, WBC, blood
chemistries, and a vascular Doppler
ultrasonography.

Management for Amputation


Medications
analgesics
antibiotics
steroids
H2 antagonists

Management for Amputation


Emergency Care
Administer CPR as necessary, and control bleeding with direct
pressure.
Keep the person in a supine position with the legs elevated.
Apply firm pressure to the bleeding area, using a towel or article
of clothing.
Wrap the amputated part in a clean cloth. If possible, soak the
cloth in saline.

Management for Amputation

Management for Amputation


Emergency Care
Put the amputated part in a plastic bag and put the bag on ice.
Send the amputated part to the emergency department with the
injured person, and be sure the emergency personnel know
what it is.

Management for Amputation


Assessment
Health history: Mechanism of injury, current and past health
problems, pain, occupation, ADLs, changes in sensation in the
feet, cultural and/or religious guidelines for handling the
amputated part.
Physical examination: Bilateral neurovascular status of the
extremities, bilateral capillary refill time, skin over the lower
extremities (discoloration, edema, ulcerations, hair, gangrene).

Nursing Diagnosis and Interventions


Acute Pain
Ask the patient to rate the pain on a scale of 0 to 10 before and
after any intervention.
Splint and support the injured area.
Unless contraindicated, elevate the stump on a pillow for the first
24 hours after surgery.
Move and turn the patient gently and slowly.
Administer pain medications as prescribed. A PCA pump may be
ordered by the physician.

Nursing Diagnosis and Interventions


Acute Pain
Encourage deep breathing and relaxation exercises.
Reposition patient every 2 hours; turn from side to side and onto
abdomen.

Nursing Diagnosis and Interventions


Risk for Infection
Assess the wound for redness, drainage, temperature, edema,
and suture line approximation.
Take the patients temperature every 4 hours.
Monitor WBC count.
Use aseptic technique to change the wound dressing.
Administer antibiotics as ordered.
Teach the patient stump-wrapping techniques.

Nursing Diagnosis and Interventions


Risk for Impaired Skin Integrity
Wash the stump with soap and warm water and dry thoroughly.
Inspect the stump for redness, irritation, or abrasions.
Massage the end of the stump, beginning 3 weeks after surgery.
Expose any open areas of skin on the remaining part of the limb
for 1 hour four times a day.
Change stump socks and elastic wraps each day. Wash these in
mild soap and water, and allow to completely dry before using.

Nursing Diagnosis and Interventions


Risk for Complicated Grieving
Encourage verbalization of feelings, using open-ended questions.
Actively listen and maintain eye contact.
Reflect on the patients feelings.
Allow the patient to have unlimited visiting hours, if possible.
If desired by the patient, provide spiritual support by
encouraging activities such as visits from a spiritual leader,
prayer, and meditation.

Nursing Diagnosis and Interventions


Disturbed Body Image
Encourage verbalization of feelings.
Allow the patient to wear clothing from home.
Encourage the patient to look at the stump.
Encourage the patient to care for the stump.
Offer to have a fellow amputee visit the patient.
Encourage active participation in rehabilitation.

Nursing Diagnosis and Interventions


Impaired Physical Mobility
Perform ROM exercises on all joints.
Maintain postoperative stump shrinkage devices. (elastic bandages,
shrinker socks, an elastic stockinette, or a rigid plaster cast).
Turn and reposition the patient every 2 hours.
Reinforce teaching by the physical therapist in crutch walking or the
use of assistive devices.
Encourage active participation in physical therapy.

References

1. LeMone, P. et al. (2011). Medical-Surgical Nursing: Critical


Thinking in Client Care. 5th Edition. New Jersey: Pearson
Education, Inc.
2. Smeltzer, S. C. et al. (2010). Brunner & Suddarths Textbook of
Medical-Surgical Nursing. 12th Edition. Philadelphia: Lippincott
Williams and Wilkins.
3. Williams. L. S. & Hopper, P. D. (2011). Understanding MedicalSurgical Nursing. 5th Edition. Philadelphia: F. A. Davis Company