Management of Patients

With Musculoskeletal
Trauma
A. Contusion is a soft tissue injury produced by
blunt force, such as a blow, kick, or fall.
>Many small blood vessels rupture and bleed
into soft tissues (ecchymosis, or bruising).
>A hematoma develops when the bleeding is
sufficient to cause an appreciable collection of
blood.
>Controlled with intermittent application of
cold.
>Most contusions resolve in 1 to 2 weeks.
Manifestations:
1. Pain
2. Swelling
3. Discoloration
B. Strain is a “muscle pull” caused by overuse,
overstretching, or excessive stress.
>Strains are microscopic, incomplete muscle tears
with some bleeding into the tissue.
Manifestations:
1. Soreness
2. Sudden pain
3. Local tenderness on muscle use and
isometric contraction.
C. Sprain is an injury to the ligaments
surrounding a joint that is caused by a
wrenching or twisting motion.
>The function of a ligament is to maintain
stability while permitting mobility.
>A torn ligament loses its stabilizing ability.
Manifestations:
1. Blood vessels rupture and edema occurs.
2. The joint is tender.
3. Movement of the joint becomes painful.
Management (RICE):
1. Rest prevents additional injury and promotes
healing.
2. Moist or dry cold applied intermittently for
20 to 30 minutes during the first 24 to 48
hours after injury produces vasoconstriction,
which decreases bleeding, edema, and
discomfort.
3. An elastic compression bandage controls
bleeding, reduces edema, and provides support
for the injured tissues.
4. Elevation controls the swelling.
D. Dislocation of a joint is a condition in which
the articular surfaces of the bones forming the
joint are no longer in anatomic contact. The
bones are literally “out of joint.”
Types of Joint Dislocation:
1. Congenital, or present at birth (most often
the hip).
2. Spontaneous or pathologic, caused by disease
of the articular or peri articular structures.
3. Traumatic, resulting from injury in which the
joint is disrupted by force.
Manifestations:
1. Pain
2. Change in contour of the joint.
3. Change in the length of the extremity.
4. Loss of normal mobility.
5. Change in the axis of the dislocated bones.
Medical Management:
1. Analgesia, muscle relaxants, and possibly
anesthesia are used to facilitate closed reduction.
2. The joint is immobilized by bandages, splints,
casts, or traction and is maintained in a stable
position.
3. Neurovascular status is monitored. After reduction,
if the joint is stable, gentle, progressive, active and
passive movement is begun to preserve range of
motion (ROM) and restore strength.
4. The joint is supported between exercise sessions.
SPORTS RELATED INJURIES:
A. Rotator cuff tears may result from an acute injury
or from chronic joint stresses.
Manifestations:
1. Pain
2. Limited ROM,
3. Some joint dysfunction, including muscle weakness.
4. Night pain
5. Unable to sleep
6. The patient is unable to perform over-the-head
activities.
Medical Management
1. Nonsteroidal anti-inflammatory drugs.
2. Rest with modification of activities.
3. Injection of a corticosteroid into the shoulder joint.
4. Progressive stretching, ROM, and strengthening
exercises.
5. Some rotator cuff tears require arthroscopic
débridement (removal of devitalized tissue).
6. Arthroscopic or open acromioplasty with tendon
repair.
B. Epicondylitis (Tennis Elbow) is a chronic,
painful condition that is caused by excessive,
repetitive extension, flexion, pronation, and
supination activities of the forearm.
> Activities contributing to the development of
epicondylitis include tennis, racket sports,
pitching, gymnastics, and repetitive use of a
screwdriver.
Manifestations:
1. The pain characteristically radiates down the
extensor (dorsal) surface of the forearm.
2. The patient may have a weakened grasp.
Medical Management:
1. Application of ice after the activity and
administration of NSAIDs, including COX-2
inhibitors, usually relieve the pain.
2. In some instances, the arm is immobilized in a
molded splint or cast.
3. Because of its degenerative effects on
tendons, local injection of a corticosteroid
is reserved for patients with severe pain who do not
respond to NSAIDs and immobilization.
C. Lateral and medial collateral ligament
injury - provide stability at the sides of the
knee.
> Injury to these ligaments occurs when the
foot is firmly planted and the knee is struck—
either medially, causing stretching and tearing
injury to the lateral collateral ligament, or
laterally, causing stretching and tearing injury
to the medial collateral ligament.
Manifestations:
1. The patient experiences pain.
2. Joint instability.
3. Inability to walk without assistance.
Medical Management
1. Emergency management includes RICE.
2. The joint is evaluated for fracture.
3. Hemarthrosis (bleeding into the joint) may
develop, contributing to the pain.
4. The joint fluid is aspirated to relieve
pressure.
Nursing Management:
1. The nurse provides patient teaching about
proper use of ambulatory devices, the healing
process, and activity limitation to promote
healing.
2. The nurse teaches the surgical patient about
pain management, medications (analgesics,
antibiotics), brace use, wound care, possible
complications (eg, altered neurovascular status,
infection, skin breakdown), and self-care.
D. The anterior cruciate ligament (ACL) and the
posterior cruciate ligament (PCL) injury:
> Injury occurs when the foot is firmly
planted, the knee is hyperextended, and the person
twists the torso and femur.
>The patient reports a pop or tearing sensation with this
twisting injury.
> Usually, the ACL is torn.
> The patient experiences pain, joint instability, and
pain with ambulation.
Medical Management:
1. Emergency management includes RICE.
2. The joint is evaluated for fracture.
3. Joint effusion and hemarthrosis require joint
aspiration and wrapping with a compression elastic
dressing.
4. Surgical ACL reconstruction includes tendon repair
with grafting and is performed as ambulatory
arthroscopic surgery.
5. Rehabilitation after surgery typically takes 6 to 12
months.
E. MENISCAL INJURIES
> In sports or accidents, twisting of the knee or
repetitive squatting and impact may result in
either tearing or detachment of the cartilage from
its attachment to the head of the tibia.
> If this happens during walking or running,
patients often describe their leg as “giving way”
under them.
> Patients may hear or feel a click in the knee when
they walk, especially when they extend the leg
that is bearing weight, as in going upstairs.
Medical Management:
> Initial conservative treatment includes
immobilization of the knee, use of crutches, anti-
inflammatory agents, analgesics, and
modification of activities to avoid those causing the
symptoms.
> If symptoms persist, the damaged cartilage is
surgically removed (meniscectomy) through a
procedure in which the surgeon uses an arthroscope
to visualize and repair the damage.
F. RUPTURE OF THE ACHILLES TENDON
> Traumatic rupture of the Achilles tendon, generally
within the tendon sheath, occurs during activities
when there is a sudden
contraction of the calf muscle with the foot fixed
firmly to the floor or ground.
> The patient experiences sharp pain and is unable to
plantar flex the foot.
> Immediate surgical repair of complete Achilles
tendon ruptures is usually recommended to obtain
satisfactory results.
> After surgery, a cast or brace is used to immobilize
the joint.
Fractures:
A fracture is a break in the continuity of bone and is
defined according to its type and extent.
> Fractures occur when the bone is subjected to stress
greater than it can absorb.
Specific Types of Fractures:
1. Avulsion: a fracture in which a fragment of bone has
been pulled away by a ligament or tendon and its
attachment.
2. Comminuted: a fracture in which bone has
splintered into several fragments.
3. Compound: a fracture in which damage also
involves the skin or mucous membranes; also called
an open fracture.
4. Compression: a fracture in which bone has been
compressed (seen in vertebral fractures).
5. Depressed: a fracture in which fragments are driven
inward (seen frequently in fractures of skull and
facial bones).
6. Epiphyseal: a fracture through the epiphysis.
7. Greenstick: a fracture in which one side of a bone is
broken and the other side is bent.
8. Impacted: a fracture in which a bone fragment is
driven into another bone fragment.
9. Oblique: a fracture occurring at an angle across the
bone (less stable than a transverse fracture).
10. Pathologic: a fracture that occurs through an area
of diseased bone (eg, osteoporosis, bone cyst, Paget’s
disease, bony metastasis,
tumor); can occur without trauma or a fall.
11. Simple: a fracture that remains contained; does not
break the skin.
12. Spiral: a fracture that twists around the shaft of the
bone.
13. Stress: a fracture that results from repeated loading
without bone and muscle recovery.
14. Transverse: a fracture that is straight across the
bone.
Open fractures are graded according to the
following criteria:
1. Grade I is a clean wound less than 1 cm long.
2. Grade II is a larger wound without extensive soft
tissue damage.
3. Grade III is highly contaminated, has extensive soft
tissue damage, and is the most severe.
Clinical Manifestations:
1. Pain - The pain is continuous and increases in
severity until the bone fragments are immobilized.
2. Loss of Function - After a fracture, the extremity
cannot function properly, because normal function of
the muscles depends on the integrity of the bones to
which they are attached.
3. Deformity - also results from soft tissue swelling.
4. Shortening - In fractures of long bones, there is
actual shortening of the extremity because of the
contraction of the muscles that are attached above
and below the site of the fracture.
>The fragments often overlap by as much as 2.5 to
5 cm (1 to 2 inches).
5. Crepitus - When the extremity is examined with the
hands, a grating sensation, called crepitus, can be felt.
It is caused by the rubbing of the bone fragments
against each other.
6. Swelling and discoloration
> Localized swelling and discoloration of the skin
(ecchymosis) occurs after a fracture as a result of
trauma and bleeding into the tissues.
Emergency Management of Fractures:
1. Immobilize the body part before the patient is
moved.
2. Adequate splinting, including joints adjacent to the
fracture, is essential.
3. In an upper extremity injury, the arm may be
bandaged to the chest, or an injured forearm may be
placed in a sling.
4. With an open fracture, the wound is covered with a
clean (sterile) dressing to prevent contamination of
deeper tissues.
Medical Management of Fractures:
1. Reduction - Reduction of a fracture (“setting” the
bone) refers to restoration of the fracture fragments to
anatomic alignment and rotation.
a. Closed Reduction. In most instances, closed
reduction is accomplished by bringing the bone
fragments into apposition (placing the ends in
contact) through manipulation and manual traction.
b. Open Reduction. Some fractures require open
reduction. Through a surgical approach, the fracture
fragments are reduced.
> Internal fixation devices (metallic pins, wires,
screws, plates, nails, or rods) may be used to hold the
bone fragments in position until solid bone
healing occurs.
2. Immobilization - may be accomplished by external
or internal fixation.
> Methods of external fixation include bandages,
casts, splints, continuous traction, and external
fixators.
> Metal implants used for internal fixation serve as
internal splints to immobilize the fracture.
3. MAINTAINING AND RESTORING FUNCTION
Reduction and immobilization are maintained as
prescribed to promote bone and soft tissue healing.
> Swelling is controlled by elevating the injured
extremity and applying ice as prescribed.
Nursing Management:
1. Patient with closed fractures - The nurse teaches
patients how to control swelling and pain
associated with the fracture and with soft tissue
trauma and encourages them to be active within the
limits of the fracture immobilization.
2. Patient with open fractures - In an open fracture,
there is risk of osteomyelitis, tetanus, and gas
gangrene.
> The objectives of management are to prevent
infection of the wound, soft tissue, and bone and to
promote healing of soft tissue and bone.
Early Complications:
1. Shock - Hypovolemic or traumatic shock resulting
from hemorrhage (both visible and nonvisible
blood loss) and from loss of extracellular fluid into
damaged tissues may occur in fractures of the
extremities, thorax, pelvis, or spine.
2. Fat embolism syndrome occurs most frequently in
young adults (typically those 20 to 30 years of age)
and elderly adults who experience fractures of the
proximal femur.
3. Compartment syndrome is a complication that
develops when tissue perfusion in the muscles is less
than that required for tissue viability.
This pain can be caused by
1. A reduction in the size of the muscle compartment
because the enclosing muscle fascia is too tight or
a cast or dressing is constrictive.
2. An increase in muscle compartment contents
because of edema or hemorrhage associated with a
variety of problems (eg, fractures, crush injuries).
Delayed Complications:
1. Delayed Union or non union
> Delayed union occurs when healing does not occur
at a normal rate for the location and type of fracture.
> Nonunion results from failure of the ends of a
fractured bone to unite.
- The patient complains of persistent discomfort
and abnormal movement at the fracture site
2. Complex regional pain syndrome (CRPS),
formerly called reflex sympathetic dystrophy
(RSD), is a painful sympathetic nervous
system problem. It occurs infrequently. When it does
occur, it is most often in an upper extremity after
trauma and is seen more
often in women.
3. Avascular necrosis occurs when the bone loses its
blood supply and dies.
> It may occur after a fracture with disruption of the
blood supply (especially of the femoral neck).
> It is also seen with dislocations, bone
transplantation, prolonged high-dosage corticosteroid
therapy, chronic renal disease, sickle cell anemia, and
other diseases.
> The devitalized bone may collapse or reabsorb.
4. Reaction to Internal fixation devices:
> Internal fixation devices may be removed after
bony union has taken place.
5. Heterotrophic ossification (myositis ossificans) is
the abnormal formation of bone, near bones or in
muscle, in response to soft tissue trauma after blunt
trauma, fracture, or total joint replacement.
Fractures of Specific Sites
A. CLAVICLE
Fracture of the clavicle (collar bone) is a common
injury that results from a direct blow to the shoulder
or a fall.
Manifestations:
1. Patient assumes a protective position.
2. Slumping the shoulders.
3. Immobilizing the arm to prevent shoulder
movements.
Treatment: (The treatment goal is to align the shoulder
in its normal position) by means:
1. Closed reduction
2. Immobilization
> A clavicular strap, also called a figure-of-eight
bandage may be used to pull the shoulders back,
reducing and immobilizing the fracture.
> A sling may be used to support the arm and to
relieve pain.
Nursing Management:
1. The nurse cautions the patient not to elevate the arm
above shoulder level until the ends of the bone have
united (about 6 weeks).
2. Encourages the patient to exercise the elbow, wrist,
and fingers as soon as possible.
3. When prescribed, shoulder exercises are performed
to obtain full shoulder motion.
4. Vigorous activity is limited for 3 months.
B. HUMERAL NECK
Fractures of the proximal humerus may occur
through either the anatomic or the surgical neck of
the humerus.
>The anatomic neck is located just below the humeral
head.
>The surgical neck is the region below the tubercles.
Manifestation:
1. Affected arm hanging limp at the side and supported
by the uninjured hand.
Medical Management:
1. The arm is supported and immobilized by a sling and
swathe that secure the supported arm to the trunk.
2. A soft pad is placed in the axilla to
absorb moisture and avoid skin breakdown.
3. These fractures require 6 to 10 weeks to heal, and the
patient should avoid vigorous activity (eg, tennis) for
an additional 4 weeks.
4.Residual stiffness, aching, and some limitation of
ROM may persist for 6 months or longer.
Immobilizers for proximal humeral fractures:
1. Commercial sling with immobilizing strap permits
easy removal for hygiene and is comfortable on the
neck.
3. Conventional sling and swathe.
3. Stockinette Velpeau and swathe are used when
there is an unstable surgical neck component.
Treatment:
1. Closed reduction
2. Open reduction with internal fixation.
3. Replacement of the humeral head with a prosthesis.
C. HUMERAL SHAFT
Fractures of the shaft of the humerus are most
frequently caused by:
(1) direct trauma that results in a transverse, oblique,
or comminuted
Fracture.
(2) an indirect twisting force that results in a spiral
fracture
Manifestation:
1. Wrist drop is indicative of radial nerve
injury.
Medical Management:
1. Initially, well-padded splints, overwrapped with an
elastic bandage, are used to immobilize the upper arm
and to support the arm in 90 degrees of flexion at the
elbow.
2. A sling or collar and cuff support the forearm. The
weight of the hanging arm and splints reduce the
fracture.
3. External fixators are used to treat open fractures of the
humeral shaft.
4. Functional bracing is another form of treatment used
for these fractures.
D. ELBOW
> Fractures of the distal humerus result from motor
vehicle crashes, falls on the elbow (in the extended or
flexed position), or a direct blow.
> These fractures may result in injury to the median,
radial, or ulnar nerves.
Manifestation:
1. Paresthesia
2. Signs of compromised circulation in the forearm and
hand.
Complications:
1. Volkmann’s ischemic contracture (a compartment
syndrome), which results from antecubital swelling
or damage to the brachial artery.
2. Damage to the joint articular surfaces.
3. Hemarthrosis (blood in the joint).
Management:
1. Prompt reduction and stabilization of the
distal humerus fracture.
2. If the fracture is not displaced, the arm is
immobilized in a cast or posterior splint with the
elbow at 45 to 90 degrees of flexion and in a sling for
4 to 6 weeks.
3. A displaced fracture is treated with open reduction
and internal fixation.
E. RADIAL HEAD
> Radial head fractures are common and are usually produced
by a fall on the outstretched hand with the elbow extended.
Management:
1. If blood has collected in the elbow joint (hemarthrosis), it is
aspirated to relieve pain and to allow early active elbow and
forearm ROM.
2. Immobilization for these undisplaced fractures is
accomplished with a splint.
3. The patient is instructed not to lift with the arm for
approximately 4 weeks.
4. If the fracture is displaced, surgery is required, with excision
of the radial head when necessary.
F. RADIAL AND ULNAR SHAFTS
> Fractures of the shaft of the bones of the forearm
occur most frequently in children.
> The radius or the ulna may be fractured at any
level.
Management:
1. If the fragments are not displaced, the fracture is
treated by closed reduction with a long arm cast
applied from the upper arm to the proximal palmar
crease.
2. The arm is elevated to control edema.
3.Frequent finger flexion and extension are encouraged
to reduce edema.
4. The fracture is immobilized for about 12 weeks;
during the last 6 weeks, the arm may be in a
functional forearm brace that allows exercise of the
wrist and elbow.
5. Lifting and twisting are avoided.
G. WRIST
> Fractures of the distal radius (Colles’ fracture) are
common and are usually the result of a fall on an open,
dorsiflexed hand.
Manifestations:
1. Deformed wrist
2. Radial deviation
3. Pain
4. Swelling
5. Weakness
6. Limited finger ROM
7. Numbness.
Management:
1. Closed reduction
2. Immobilization with a short arm cast.
3. The wrist and forearm are elevated for 48 hours after
reduction to control swelling.
Exercises to reduce swelling and prevent stiffness:
1. Hold the hand at the level of the heart.
2. Move the fingers from full extension to flexion. Hold
and release. (Repeat at least 10 times every hour when
awake.)
3. Use the hand in functional activities.
4. Actively exercise the shoulder and elbow, including
complete ROM exercises of both joints.
H. HAND
> Trauma to the hand often requires extensive
reconstructive surgery.
> The objective of treatment is always to regain
maximum function of the hand.
Management:
1. For an undisplaced fracture of the phalanx (finger bone),
the finger is splinted for 3 to 4 weeks to relieve pain and
to protect the
finger from further trauma.
2. Displaced fractures and open fractures may require open
reduction with internal fixation, using wires or pins.
I. PELVIS
Pelvic fractures are serious because at least two
thirds of affected patients have significant and multiple
injuries.
Manifestations:
1. Ecchymosis
2. Tenderness over the symphysis pubis, anterior iliac
spines, iliac crest, sacrum, or coccyx.
3. Local swelling.
4. Numbness or tingling of pubis, genitals,
and proximal thighs.
5. Inability to bear weight without discomfort.
Management:
1. The peripheral pulses of both lower extremities are
palpated; absence of pulses may indicate a torn iliac
artery or one of its branches.
2. Peritoneal lavage may be performed to detect intra-
abdominal hemorrhage.
3. The patient is handled gently to minimize further
bleeding and shock.
J. FEMUR
There is a high incidence of hip fracture among
elderly people, who have brittle bones from
osteoporosis (particularly women) and who tend to fall
frequently.
There are two major types of hip fracture:
1. Intracapsular fractures are fractures of the neck of
the femur. It may damage the vascular system that
supplies blood to the head and the neck of the femur,
and the bone may die.
2. Extracapsular fractures are fractures of the
trochanteric region (between the base of the neck and
the lesser trochanter of the femur) and of the
subtrochanteric region.
> Extracapsular intertrochanteric fractures have an
excellent blood supply and heal readily.
Clinical Manifestations:
1. With fractures of the femoral neck, the leg is
shortened, adducted, and externally rotated.
2. The patient complains of pain in the hip and groin or
in the medial side of the knee.
3. With most fractures of the femoral neck, the patient is
unable to move the leg without a significant increase
in pain.
4. The patient is most comfortable with the leg slightly
flexed in external rotation.
Management:
1. Open or closed reduction of the fracture and internal
fixation.
2. Replacement of the femoral head with a prosthesis
(hemiarthroplasty).
3. Closed reduction with percutaneous stabilization for
an intracapsular fracture.
Complications:
1. Neurovascular complications may occur from direct
injury to nerves and blood vessels or from increased
tissue pressure.
> Therefore, the nurse must monitor the
neurovascular status of the affected leg.
2. Deep vein thrombosis is the most common
complication.
> To prevent DVT, the nurse encourages intake of
fluids and ankle and
foot exercises.
3. Pulmonary complications are a threat to elderly
patients undergoing hip surgery.
> Deep-breathing exercises, a change of position at
least every 2 hours, and the use of an incentive
spirometer help to prevent respiratory complications.
4. Skin breakdown is often seen in elderly patients with
hip fracture.
> Proper skin care, especially on the heels, back,
sacrum, and shoulders, helps to relieve pressure.
5. Loss of bladder control (incontinence) may occur.
> In general, the routine use of an indwelling catheter
is avoided because of the high risk for urinary tract
infection.
> Because urinary retention is common after surgery,
the nurse must assess the patient’s voiding patterns.
6. Delayed complications of hip fractures include
infection, nonunion, avascular necrosis of the femoral
head (particularly with femoral neck fractures), and
fixation device problems (eg, protrusion of the fixation
device through the acetabulum, loosening of
hardware).
K. FEMORAL SHAFT
>Considerable force is required to break the shaft
of the femur in adults.
>Most femoral fractures are seen in young adults
who have been involved in a motor vehicle crash or
who have fallen from a high place.
Manifestations:
1. Enlarged, deformed and painful thigh.
2. Cannot move the hip or the knee.
Diagnostic Findings:
1. Assessment includes checking the neurovascular
status of the extremity, especially circulatory perfusion
of the lower leg and foot (popliteal, posterior tibial,
and pedal pulses and toe capillary refill time).
2. A Doppler ultrasound monitoring device may be
needed to assess blood flow.
Medical Management:
1. Skeletal traction or splinting is used to immobilize
fracture fragments until the patient is physiologically
stable and ready for open reduction and internal
fixation
procedures.
2. Internal fixation usually is carried out within a few
days after injury.
3. Compression plates and intramedullary nails may
need to be removed after 12 to 18 months due to
reaction or loosening.
4. Between 2 and 4 weeks after injury, when pain and
swelling have subsided, the patient is removed from
skeletal traction and placed in a cast brace.
5. An external fixator may be used if the patient has
experienced an open fracture, has extensive soft tissue
trauma, has lost bone, has an infection, or has hip and
tibial fractures.
Complications:
1. Restriction of knee motion.
2. Malunion
3. Delayed union or nonunion
4. Pudendal nerve palsy
5. Infection
L. TIBIA AND FIBULA
The most common fracture below the knee is one
of the tibia (and fibula) that results from a direct blow,
falls with the foot in a flexed position, or a violent
twisting motion.
Manifestations:
1. Pain
2. Deformity
3. Obvious hematoma
4. Considerable edema
Medical Management:
1. Most closed tibial fractures are treated with closed
reduction and initial immobilization in a long leg
walking cast or a patellar tendon–bearing cast.
> Partial weight bearing is usually
prescribed after 7 to 10 days.
> The cast is changed to a short leg cast or brace in 3
to 4 weeks, which allows for knee motion.
> Fracture healing takes 6 to 10 weeks.
2. Comminuted fractures may be treated with skeletal
traction, internal fixation with intramedullary nails or
plates and screws or external fixation.
3. Open fractures are treated with external fixation.
4. Distal fractures with extensive soft tissue damage heal
slowly and may require
bone grafting.
M. RIB
> Uncomplicated fractures of the ribs occur
frequently in adults and usually result in no
impairment of function.
Manifestations:
1. Fractures produce painful respiration.
2. The patient tends to decrease respiratory excursions.
3. Refrains from coughing.
As a result, tracheobronchial secretions are not
mobilized, aeration of the lung is
diminished, and a predisposition to pneumonia and
atelectasis results.
Management:
1. The nurse may splint the chest with her hands.
2. Occasionally, the physician administers intercostal
nerve blocks to relieve pain and to permit productive
coughing.
Other complications:
1. Flail chest
2. Pneumothorax
3. Hemothorax
N. THORACOLUMBAR SPINE
Fractures of the thoracolumbar spine may involve:
1. The vertebral body.
2. The laminae and articulating processes.
3. The spinous processes or transverse processes.

The T12 to L2 area of the spine is most vulnerable to

fracture.
Manifestations:
1. Acute tenderness
2. Swelling
3. Paravertebral muscle spasm.
4. Change in the normal curves or in the gap between
spinous processes.
5. Pain is greater with moving, coughing, or weight
bearing.
Medical Management:
1. Bed Rest - The head of the bed is elevated less than
30 degrees until the acute pain subsides (several
days).
2. Analgesics are prescribed for pain relief.
3. The patient is monitored for a transient paralytic
ileus caused by associated retroperitoneal hemorrhage.
4. A spinal brace or plastic thoracolumbar orthosis
may be applied for support during progressive
ambulation and resumption of activities.
Postoperative Management:
1. The patient may be cared for on the turning device or
in a bed with a firm mattress.
2. Progressive ambulation is begun a few days after
surgery, with the patient using a body brace orthosis.
3. Patient teaching emphasizes good posture, good
body mechanics, and, after healing is sufficient, back-
strengthening exercises.
AMPUTATION:
Amputation is the removal of a body part, usually an
extremity.
> Amputation is used to relieve symptoms, improve
function, and save or improve the patient’s quality of life.
Indications:
1. Progressive peripheral vascular disease (often a sequela
of diabetes mellitus).
2. Fulminating gas gangrene, trauma (crushing injuries).
3. Burns (frostbite and electrical burns).
4. Congenital deformities.
5. Chronic osteomyelitis, or malignant tumor.
Factors to determine the sites of Amputations:
1. Circulation in the part.
2. Functional usefulness.
Levels of Amputations:
1. A Syme amputation (modified ankle
disarticulation amputation) is performed most
frequently for extensive foot trauma and produces a
painless, durable extremity end
that can withstand full weight-bearing.
2. Below-knee amputations are preferred to above-knee
amputations because of the importance of the knee
joint and the energy requirements for walking.
3. Knee disarticulations are most successful with young,
active patients who are able to develop precise control
of the prosthesis.
4. When above-knee amputations are performed, all
possible length is preserved, muscles are stabilized and
shaped, and hip contractures are prevented for
maximum ambulatory potential.
5. A staged amputation may be used when gangrene and
infection exist.
Complications for Amputation:
1. Hemorrhage - Because major blood vessels have
been severed, massive bleeding may occur.
2. Infection - increases with contaminated wounds after
traumatic amputation.
3. Skin breakdown - Skin irritation caused by the
prosthesis may result in skin breakdown.
4. Phantom limb pain - is caused by the severing of
peripheral nerves.
5. Joint contracture - is caused by positioning and a
protective flexion withdrawal pattern associated with
pain and muscle imbalance.
Medical Management
1. Healing is enhanced by gentle handling of the residual
limb, control of residual limb edema through rigid or
soft compression dressings, and use of aseptic
technique in wound care to avoid infection.
2. A closed rigid cast dressing is frequently used to
provide uniform compression, to support soft tissues, to
control pain, and to prevent joint contractures.
3. A removable rigid dressing may be placed over a soft
dressing to control edema, to prevent joint flexion
contracture, and to protect the residual limb from
unintentional trauma during transfer activities.
4. A soft dressing with or without compression may be
used if there is significant wound drainage and
frequent inspection of the residual limb (stump) is
desired.
> An immobilizing splint may be incorporated in the
dressing.
> Stump (wound) hematomas are controlled with
wound drainage devices to minimize infection.
Rehabilitation
The multidisciplinary rehabilitation team:
1. Patient
2. Nurse
3. Physician,
4. Social worker
5. Psychologist
6. Prosthetist
7. Vocational rehabilitation worker
Nursing Interventions:
1. Relieving pain - Surgical pain can be effectively
controlled with opioid analgesics, nonpharmaceutical
interventions, or evacuation of the hematoma or
accumulated fluid.
2. Minimizing altered sensory perception - Amputees
may experience phantom limb pain soon after surgery
or 2 to 3 months after amputation. It occurs more
frequently may in above-knee amputations.
3. Promoting wound healing - The residual limb must be
handled gently. Whenever the dressing is changed,
aseptic technique is required to prevent wound
infection and possible osteomyelitis.
4. Enhancing body image - Amputation is a
reconstructive procedure that alters the patient’s body
image.
> The nurse encourages the patient to look at, feel, and
then care for the residual limb.
5. Helping the patient to resolve grieving - The loss of
an extremity (or part of one) may come as a shock
even if the patient was prepared preoperatively.
> The nurse acknowledges the loss by listening and
providing support.
6. Promoting independent self – care - Amputation of
an extremity affects the patient’s ability to provide
adequate self-care. The patient is encouraged to be an
active participant in self-care.
7. Helping the patient to achieve physical mobility -
Positioning assists in preventing the development of
hip or knee joint contracture in the patient with a lower
extremity amputation.
THANK YOU…