Management of patients with

musculoskeletal trauma and problems

Dr. Sameer Agarwal

Orthopaedics
Khoula Hospital
 Topics
• Fracture
• Joint dislocation
• Contusion, sprains and strain
• Osteomyelitis
• Low back pain
• Amputation
 OBJECTIVES
• Causes, clinical manifestation, diagnostic tests,
management and care.

• Care modalities

• Patient education program.

• Rehabilitation
 ORTHOPAEDICS
• 1840, French orthopédique,
from orthopédie,
• French physician Nicholas
Andry (1658-1742), from
• Greek orthos "straight,
correct"
• paideia "rearing of children,"
from pais (genitive paidos)
"child" (see pedo- ).
206 bones in the human body
Basic Bone structure
Joints
Basic anatomy
 Sprains
• Stretching, partial or
complete tearing of
ligaments
• Typically occur when
joint overextended
• Ankles, knees, wrists,
fingers
• Swelling, pain,
bruising
• Inability to use joint
 Strains
• Tearing of muscle or
tendon
• Occurs due to
overstretching
• Causes pain, swelling
and sometimes inability
to use muscle
• Can be prevented by
avoiding overexertion,
good body mechanics,
sports safety
 Care for Musculoskeletal Injuries
• Proper care vs identifying the type of injury

• Assume any injury to an extremity includes a

bone fracture.

• The general care for injuries to muscle, bone

and joints includes following R.I.C.E.
 R.I.C.E.
• Rest: do not move or straighten the injured
area.
• Ice: apply ice to the injured area for periods of
20 minutes.
• Compression: with a firmly wrapped bandage
• Elevation: do not elevate the injured part if it
causes more pain.
Many fancy terms
 Splinting
• A method of immobilizing an injured
extremity
• ONLY : to move or transport a patient to
higher center
• Splinting does not cause more pain.
 Types of Splints
• Soft splints
• folded blankets, towels, pillows and a sling.
• Rigid splints
• include boards, metal strips and folded magazines or
newspapers.
• Use a triangular bandage to secure the rigid or soft
splinting material in place
• Anatomic splints
• an uninjured body part to immobilize an injured area.
• You can use tape to secure an uninjured finger to the
injured
 Head, Neck and Back Injuries
• These injuries may cause an unintentional
death or life-long neurologic damage.
• If you suspect that a person has a head, neck
or back injury, tell him/her to respond verbally
to any questions you ask and to avoid nodding
or shaking his/her head.
• Goal is to minimize movement
 Care for Head/Neck/Back
• Minimize movement of the head, neck, and
back
– by placing your hands on both sides of the
person’s head.
– Maintain an open airway.
– Let the person remain in the position in which you
found him/her until advanced medical personnel
arrive and take over.
• Monitor the ABC’s
 Fracture
• A disruption or break in the continuity of the
structure of bone

• Traumatic injuries account for the majority of

fractures
 Description

• Described and classified according to:

– Type
– Anatomic location
– Communication or non communication with
external environment
Description of fractures
 Compression fx
• Specific to the vertebral
body collapses, anterior
aspect is reduced in
height.
• From trauma or
demineralization of bone
(old age).
 Burst fx
C - 1 (atlas)
• C1 ring is broken,
fragments move
outward.
• Football injuries, heavy
object dropped on head.
 Pediatric fractures
• 1. Greenstick (torus) -
incomplete fx, bones
more flexible, bends &
fractures only outer
edge.
• 2. Epiphyseal -
fractures located at
the site of an
epiphysis.
Classification by Fracture Location
 Description

• Described and classified according to:

– Appearance, position, and alignment of the
fragments
– Classic names
– Stable or unstable
 Description

• Closed (also called simple)

• Open (also called compound)

Classification by Communication with
External Environment
 Description

• Stable fractures
– Occur when a part of the periosteum is
intact across the fracture
OR
– External or internal fixation has rendered
the fragments stationary
 Description

• Unstable fractures

-Grossly displaced

-Poor fixation
 Clinical Manifestations
– Immediate localized pain
– Loss of Function
– Inability to bear weight or use affected part
– Guarding
– May or may not see obvious bone
deformity
Fracture Healing
 Collaborative Care
• Overall goals of treatment:
– Anatomic realignment of bone fragments
(reduction)
– Immobilization to maintain alignment
(fixation)
– Restoration of normal function

• 3 ‘R’ s
 Collaborative Care - Fracture Reduction
• Closed reduction
– Nonsurgical, manual realignment
• Open reduction
– Correction of bone alignment through a
surgical incision
 Fracture Reduction (Closed)
• Traction (with simultaneous counter-traction)
– Application of pulling force to attain
realignment
• Skin traction (short-term: 48-72 hrs.)
• Skeletal traction (longer periods)
• Manipulation under anesthesia
• To control pain and overcome muscle spasm
 Collaborative Care
Fracture Immobilization
• Traction
Application of a pulling force to an injured
part of the body while counter traction pulls
in the opposite direction

• Purpose of traction:
– Prevent or reduce muscle spasm
– Reduction
– Immobilization
– Treat a pathologic condition
 Collaborative Care
Fracture Immobilization
• Casts
– Circumferential
immobilization device
– Common following
closed reduction
 Collaborative Care
Fracture Immobilization
• External fixation
• device composed of pins that are inserted into
the bone and attached to external rods
Open fractures external fixation
 Collaborative Care
Fracture Immobilization
• Internal fixation
Pins, plates, intramedullary rods, and screws
Surgically inserted at the time of realignment
 Nursing Management
Nursing Assessment for Fractures
• AMPLE history
 Nursing Management
Nursing Assessment
• Neurovascular assessment
– Color and temperature
• cyanotic and cool/cold: arterial insufficiency
• Blue and warm: venous insufficiency
– Capillary refill (< 2 sec)
– Peripheral pulses (↓ indicates vascular
insufficiency)
 Nursing Management
Nursing Diagnoses
• Risk for peripheral neurovascular dysfunction
• Acute pain
• Risk for infection
• Assessment of fall risk
• Decubitus ulcer policy
• Prolonged immobilization
• DVT prophylaxis
 Nursing Management
Nursing Diagnoses
• Ineffective therapeutic regimen management
– Analgesia
– Antibiotic prophylaxis(treatment)
– Thromboprophylaxis
– Medication for co-mobidities
– Non prescription medication
 Nursing Management
Nursing Implementation
• General post-op care
– Assess dressings/casts for bleeding/drainage

– Prevent complications of immobility

• Measures to prevent constipation
• Frequent position changes/ ambulate as permitted
• ROM exercises of unaffected joints
• Deep breathing
• Isometric exercises
 Nursing Management-Traction
Nursing Implementation
Ensure: • Weights must hang freely
• No frayed ropes, loose • Appropriate body
knots alignment
• Ropes in pulley grooves – Inspect skin
• Pulley clamps fastened • Around slings
securely • Around pins
 Nursing Management
Nursing Implementation: Cast care
• Casts can cause neurovascular complications if
– Too tight
– Edematous
• Frequent neurovascular checks
• Ice and elevation during early phase
 Complications of Fractures-Infection
• Open fractures and soft tissue injuries have 
incidence
• Osteomyelitis can become chronic
– Open fractures require aggressive surgical
debridement
– Post-op IV antibiotics till wound closure
(prophylactic)
 Complications of Fractures
Compartment Syndrome
• elevated intra-compartmental pressure
• within a confined compartment
• capillary perfusion to be reduced below a level
necessary for tissue viability
 Complications of Fractures
Compartment Syndrome
• Two basic etiologies create compartment
syndrome:
– Decreased compartment size (dressings,
splints, casts)
– Increased compartment content (bleeding,
edema)
 Complications of Fractures
Compartment Syndrome
• Clinical Manifestations Six Ps
1. Pain (unrelieved by narcotics)
3. Pressure (Tense tight compartment)
4. Pallor (loss of normal color, coolness)
5. Paresthesia (unrelieved by narcotics)
6. Paralysis
7. Pulselessness (decreased/absent pulses)
 Complications of Fractures
Compartment Syndrome
• Clinical Manifestations
– Six Ps:
• Patient may present with one or all of the
six Ps
• Compare extremities

DO NOT WAIT FOR ALL SIX Ps TO

APPEAR
 Complications of Fractures
Compartment Syndrome
• Clinical Manifestations Late
– Absence of peripheral pulse = ominous late
sign
– Myoglobinuria
• Dark reddish-brown urine
 Complications of Fractures
Compartment Syndrome
• Collaborative Care
– Prompt, accurate diagnosis is critical
– Early recognition is the key
– Do not apply ice or elevate above heart
level
 Complications of Fractures
Compartment Syndrome
• Collaborative Care
– Remove/loosen the bandage and bivalve
the cast
– Reduce traction weight
– Maintain vitals (avoid hypotension)
– O2 inhalation
– Inform the team promptly
– Surgical decompression (fasciotomy)
 Complications of Fractures
Venous Thrombosis
• Veins of the lower extremities and pelvis are
highly susceptible to thrombus formation
after fracture, especially
• hip fracture
• Pelvis fractures
• Spine fractures
• Polytrauma
 Complications of Fractures
Venous Thrombosis
• Precipitating factors:
– Venous stasis caused by incorrectly applied
casts or traction
– Local pressure on a vein
– Immobility
• Prevent with anticoagulant medications
 Complications of Fractures
Fat Embolism Syndrome (FES)
• Characterized by the presence of fat globules
in tissues and organs after a traumatic skeletal
injury
 Complications of Fractures
Fat Embolism Syndrome (FES)
• Fractures that most often cause FES:
– Long bones
– Ribs
– Tibia
– Pelvis
 Complications of Fractures
Fat Embolism Syndrome (FES)
• Tissues most often affected:
– Lungs
– Brain
– Heart
– Kidneys
– Skin
 Complications of Fractures
Fat Embolism Syndrome (FES)
• Clinical Manifestations
– Usually occur 24-48 hours after injury
– Interstitial pneumonitis
• Produce symptoms of ARDS
 Complications of Fractures
Fat Embolism Syndrome (FES)
• Clinical Manifestations
– Symptoms of ARDS:
• Chest pain
• Tachypnea
• Cyanosis
•  PaO2
 Complications of Fractures
Fat Embolism Syndrome (FES)
• Clinical Manifestations
– Symptoms of ARDS:
• Dyspnea
• Apprehension
• Tachycardia
 Complications of Fractures
Fat Embolism Syndrome (FES)
• Clinical Manifestations
– Rapid and acute course
– Feeling of impending disaster
– Patient may become comatose in a short
time
 Complications of Fractures
Fat Embolism Syndrome (FES)
• Collaborative Care
– Treatment directed at prevention
– Careful immobilization of a long bone
fracture
• Most important preventative factor
 Complications of Fractures
Fat Embolism Syndrome (FES)
• Collaborative Care (treatment)
– Symptom management
– Fluid resuscitation
– Oxygen
– Reposition as little as possible
 Fracture of the Hip
• Fracture of proximal third of femur
• Common in the elderly
• More frequent in women than men.
• Up to 35% of clients will die within the first
year
 Fracture of the Hip
• Intracapsular fractures:
– Occur within hip joint capsule
• Extrascapular fractures
– Intertrochanteric: between greater and lesser
trochanter
– Subtrochanteric: below lesser trochanter
 Clinical Manifestations
• External rotation of affected leg
• Muscle spasm
• Shortening of the affected extremity
• Severe pain and tenderness in region of
fracture
 Collaborative Care
• Surgical repair is preferred
– Allows for early mobilization and decreases the
risk of major complications.
• traction may be utilized preoperatively to
decrease painful muscle spasms.
 Nursing Diagnosis
• Risk for peripheral neurovascular dysfunction
• Acute pain
• Risk for impaired skin integrity
• Impaired physical mobility
 Post-Operative Care
• General post-op care (V/S, DB & C, etc.)
• Neurovascular checks
• Prevent external rotation (sandbags, pillows)
 Preventing Dislocation of Femur Head
Prosthesis
• Do Not
– Flex hip greater than 90 degrees.
– Place hip in adduction
– Allow hip to internally rotate
– Cross legs
 Preventing Dislocation of Femur Head
Prosthesis
• Do
– Use elevated toilet seat
– Use chair in shower/tub
– Use pillow between legs when on “good” side or
supine (for 8 weeks post-op)
– Keep hip in neutral position when sitting, walking
and lying.
– Notify surgeon if severe pain, deformity, or loss of
function
 Dislocation
• Definition:
• complete and persistent displacement of joint

• Pathology
• Part of the supporting joint capsule and some of
its ligaments disrupted.
 Deformity of a limb
• Clinical indication of dislocation
 Types of dislocation
• Congenital
– Developmental Dysplasia of Hips
– Congenital dislocation of knee
– Arthrogryposis multiplex
• Acquired
1. Traumatic
2. Pathological e.g. TB hip, Septic Arthritis
3. Paralytic e.g. Poliomyelitis, cerebral palsy, etc
4. Inflammatory disorders, rheumatoid arthritis,etc
 Dislocation
• No joint is immune from dislocation
• Most commonly occur in the following joints.
• Shoulder
• Hip
• Elbow
• Metacarpophalengeal joint
• Facet joint dislocation in cervical spine.
• Acromiclavicular joint dislocation.
Investigations- Xrays
 Complication
1. Acute: Injury to peripheral nerve and vessels
2. Chronic: Unreduced dislocation
Recurrent dislocation
Traumatic osteoarthritis
Joint stiffness
Avascular necrosis
Myositis ossificans
 Caution !
• Excessive force should not be used in close
reduction.
• Forceful manipulation may lead to fracture.
• Interposition of soft tissue, bony fragment or
buttonhole in capsule may make close
reduction impossible.
 Remember
• It is an orthopedic emergency.
• Reduction should be quick and prompt.
• Reduction should always be under G/A or
sedation.

Fracture Dislocation
Lot of swelling Swelling is less
Some restriction of Movements grossly restricted
movements
 Osteomyelitis
• Infection of the
– Bone
– Bone marrow
– Surrounding soft tissue
• Caused by a variety of microorganisms
• Most common infecting microorganism –
staph. aureus
 Clinical Manifestations
Acute Osteomyelitis

• Initial infection
–Infection of <1 month in duration
–Both systemic and local
 Clinical Manifestations
Acute Osteomyelitis
• Systemic
- Fever
– Unwell
• Local
– Constant bone pain that worsens with activity
– Swelling, tenderness, warmth at infection site
– Restricted movement of affected part
– Later signs: drainage from sinus tracts
 Diagnostic Studies
• Bone or soft tissue biopsy
– Definitive way to determine causative
microorganism
• Patient’s blood and/or wound culture
– Frequently positive for presence of microorganism
• Lab Studies
– WBC
– Erythrocyte sedimentation rate (ESR)
 Radiologic Studies
• Radiologic signs
 Usually do not appear until 10 days to weeks after
start of clinical symptoms
• Radionuclide bone scans
 Helpful in diagnosis and usually positive in areas
of infection
• Magnetic resonance imaging (MRI)
• Computed tomography (CT)
 Help identify extent of infection, including soft
tissue involvement
 Collaborative Care
Acute Osteomyelitis
• Vigorous and prolonged intravenous (IV)
antibiotic therapy
– Treatment of choice for acute osteomyelitis
– As long bone ischemia has not occurred
– Cultures or bone biopsy should be done if possible

• Delaying antibiotic treatment may require

surgical debridement and decompression
 Collaborative Care
Chronic Osteomyelitis
• Adults with chronic osteomyelitis --6 to 8
weeks of IV antibiotics

• Oral antibiotics may be given after acute IV

therapy to ensure resolution of infection

• Monitoring patient’s response

 Nursing Implementation
• Ambulatory and home care

– Importance of continuing antibiotics after

symptoms have subsided should be stressed

– Periodic nursing visits provide support and

decrease anxiety

– Frequent dressing changes for open wounds

 Septic arthritis
• Acute inflammation of joint
• Caused by microorganism
• May mimic acute OM
• May result from acute OM
• More common in extremes of age
 Acute OM vs Septic arthritis
Osteomyelitis Septic arthritis
• Subacute onset of limp / • Acute onset of limp / non-
non-weight bearing / refusal weight bearing / refusal to
to use limb use limb
• Localised pain and pain on • Pain on movement and at
movement rest
• Tenderness • Limited range / loss of
• Soft tissue redness / swelling movement
may not be present & may • Soft tissue redness / swelling
appear late often present
• +/- Fever • Fever
 Back Pain
• 2nd most common cause for opd visit
• 60-80% of population will have lower back
pain at some time in their lives
• Each year, 15-20% will have back pain
• Most common cause of disability for persons <
45 years
• 1% of US population is disabled
• Costs to society: $20-50 billion/year
 Causes of Low Back Pain
• Lumbar “strain” or “sprain” • Spondylolysis, diskogenic low
– 70% back pain or other instability
• Degenerative changes – 10% – 2%
• Herniated disk – 4% • Traumatic fracture - <1%
• Osteoporosis compression • Congenital disease - <1%
fractures – 4% • Cancer – 0.7%
• Spinal stenosis – 3% • Inflammatory arthritis – 0.3%
• Spondylolisthesis – 2% • Infections – 0.01%
 Pathophysiology
• Elastic rod constructed of rigid units (vertebrae) and
flexible units (intervertebral disks)

• Flexibility with protection

• Truncal muscles help stabilize the spine

 Clinical manifestations
• Acute < 3 months
• Chronic > 3 months without improvement
• Radiculopathy
• Neurological deficits
• Paraspinal muscle spasm
 Red Flags
• History of cancer • Major Trauma
• Unexplained weight • Osteoporosis
loss • Fever
• Intravenous drug use • Back pain at rest or at
• Prolonged use of night
corticosteroids • Bowel or bladder
• Older age dysfunction
 Medications
• Anti-inflammatory medications (NSAID’s):
– Beneficial; no differences; watch side-effects
• Narcotic Pain Relievers:
– No more effective than NSAID’s
– Many side effects
• Muscle Relaxants (ie. Flexeril®):
– Can decrease pain and improve mobility
– 70% with drowsiness/dizziness
 Exercise & Bed Rest
• Advice to stay active:
– ‘There is no evidence that advice to stay active is
harmful for either acute low back pain or
sciatica.’
• One or two days of bed rest if necessary
• Light activity, avoiding heavy lifting, bending
or twisting (ie. walking)
• No data on any particular exercises
 Other Modalities
• Back Brace/Corset/Lumbar Support:
• Traction:
• Injections: Inconclusive evidence
• TENS:
• Hot/Cold:
• Ultrasound:
 Role of X-rays (Radiology)
• Usually unnecessary and not helpful
• Plain X-ray:
– Age>50 years
– No improvement after 6 weeks
– Other worrisome findings
• MRI:
– After 6 weeks if have sciatica
 Injections
• Epidural injections:
– Insufficient and conflicting evidence
• Facet joint injections:
-conflicting evidence
• Local/Trigger point injections:
– Possibly some benefit
 Surgery
• Discectomy improves pain in short term.

• Microdiscectomy similar to standard

discectomy.

• Automated percutaneous discectomy and

laser discectomy both less effective.
 Prevention
• Exercise:
– Aerobic, back/leg strengthening

• Back braces and education about proper

lifting techniques are partially effective

• ? weight loss and smoking cessation

• Improved self esteem
AMPUTATION
Amputation
“Surgical removal of limb
or part of the limb
through a bone or
multiple bones”

Disarticulation
“Surgical removal of
hole limb or part of the
limb through a joint”
 Epidemiology

• Age- common in 50-75 yrs of age

traumatic- common in young age
• Sex- aprox. 75% male
25% female
• Limb- aprox. 85% - lower limb
15% -- upper limb
• Etiology: Traumatic
Diabetic, ischaemic
 DDD
• Dead:
• Dangerous:
• Damn nuisance:
Open
Guillotine
modified guillotine
Closed amputation
revised
planned
Level of Amputation
 Complications

Hematoma

Infection

Phantom Necrosis

Contractures

Neuroma
• Prompt, uncomplicated wound healing
• Control of edema
• Control of Postoperative pain
• Prevention of joint contractures
• Rapid rehabilitation
Care of the Stump

– keep the stump clean, dry, and free from infection at

all times.
– If fitted with a prosthesis, you should remove it before
going to sleep.
– Inspect and wash the stump with mild soap and warm
water every night, then dry thoroughly and apply
talcum powder.
– do not use the prosthesis until the skin has healed.
– The stump sock should be changed daily, and the
inside of the socket may be cleaned with mild soap.
 Rehabilitations
1. Residual Limb
Shrinkage and Shaping
2. Limb Desensitization
3. Maintain joint range of
motion
4. Strengthen residual
limb
5. Maximize Self reliance
6. Patient education:
Future goals and
prosthetic options
IT IS A REPLACEMENT Or
SUBSTITUTION OF A
MISSING OR A DISEASED
PART
 Take Home message
Strain and spains
• Proper care more important than anatomic
diagnosis
• RICE
– Rest
– Ice
– Compression
– Elevation
• Analgesia
 Take home message - Fractures
• Fracture management • Awareness of 5 P
– Reduction – Pain
– Retention – Pulseless
– Rehabilitation – Pallor
• AMPLE history – Paresthesia
– Allergies – Paralysis
– Medication • Avoid Complications
– Past medical history – Compartment syndrome
– Last meal – Fat embolism
– Events around injury – DVT
– Infection
 Take Home message-Backpain
• Most common orthopaedic complaint
• Aware of RED flag symptoms
• Acute vs chronic backpain
• Majority are better in 6 weeks-3months
• Lifestyle modifications are effective
• Injections and surgery has definite role
• Prolonged bed rest and use of braces are
counterproductive
 Take Home message-Amputation
• DDD
– Dead, Deadly, Damn nuisance
• Avoid immediate and late postoperative
complications
• Facilitate early and rapid rehabilitation
• Teach and supervise the care of stump
Any thing else?