Care of client with musculoskeletal injury

or disorder

What can go wrong

Fractures Hip Mandible

Degenerative joint disease Osteoporosis Herniated disc Amputation

CONCEPTS: FRACTURESReduction/RealignmentImmobilizationNursing carePrevention and early detection:

complication

Realignment=Reduction

Correct bone alignment goal: restore injured part to normal or near-normal function

Closed vs. open reduction Open reduction = surgery

Immobilization:to maintain alignment

Cast Traction External fixation Internal fixation

CASTS

Casts

External, circumferential Thermochemical reaction = warmth Nursing care:

No weight bearing 24-72 hours “flat hands” Elevate Neuro-vascular checks

CASTS

Cast: Client/Family Teaching

Keep dry No foreign objects in cast No weight bearing until MD order

(at least 48 hour) Elevate above heart (48 hours) Signs of problems to report

Pain, tingling, burning Sores, odor

External fixation Metal pins inserted into bone Pins attach to external rods Nursing care:

Assess for s/s infection Teach pin care: ½ H2O2+ ½ H2o Open reduction: assess incision Elevate Neurovascular checks

EXTERNAL FIXATION

Internal Fixation

Pins, plates, screws surgically inserted

Nursing care: Assess incision site MD orders: activity, weight bearing,

ROM, Assess s/s infection; temp. q 2-4 hours Neurovascular checks:

5 “P’s”

INTERNAL FIXATION

Traction

Pulling forces: traction + countertraction

Purpose(s): Prevent or reduce muscle spasm Immobilization Reduce a fracture Treat certain joint conditions

Types of Traction

Skin Buck’s Russell’s Bryant’s (“babies cry with Bry”)

Skeletal Balanced suspension(Lewis, 1660-1661)

Nursing Concerns/Interventions

Assess neurovascular status Assess skin (bony prominences,

under elastic wraps, etc.) Assess pin sites (skeletal tx) Maintain correct body alignment Weights hang freely Hazards of immobility

TRACTION

SKIN TRACTION

BUCK’S TRACTION

SKELETAL TRACTION

Nursing Diagnoses

Neurovascular dysfunction, risk for Acute pain, R/T edema, muscle

spasms, movement of bones Infection, risk for Impaired skin integrity, risk for Impaired physical mobility

Complications of Fractures

Compartment syndrome Fat embolism Venous thrombosis Infection

COMPARTMENT SYNDROME

FACIOTOMY – wound is left open

If no improvement, amputation

Hip Fracture

In 1999 (USA) hip fractures resulted in approximately 338,000 hospital admissions

Up to 25% of community-dwelling older adults who sustain hip fractures remain institutionalized for at least a year

Hip Fractures

One-third of older women who fracture their hip will die within a year because of lengthy convalescence that makes them susceptible to complications, like lung and bladder infections.

The Lancet 1999;353:878-82

Fracture of hip

Types of hip fractures (Lewis pg. 1675): Intracapsular

Capital Subcapital Transcervical

Extracapsular Intertrochanteric Subtrochanteric

ORIFvs

“Total Hip”Open reduction/internal fixation: pins, screws, plate(s)

Total hip: endoprosthesis – replace

femoral head

Internal fixation = immobilization

Nursing Care

Risk for peripheral neurovascular dysfunction

Pain Impaired mobility:

Prevent thrombus Safety Constipation

Risk for impaired skin integrity: Immobility Incision

Femoral head prosthesis (total hip) Prevent dislocation:

Do not flex > 90 degrees No internal rotation (toes to ceiling) Maintain abduction Do not position on operative side Patient teaching:

Precautions for 6-8 weeks Notify dentist: prophylactic antibiotics Lewis: pg. 1678

Fracture of mandible

Trauma vs. Therapeutic Immobilization: wiring, screws,

plate(s) Nursing care:

Airway (Cutter with client) Oral hygiene Nutrition Communication

What can go wrong

Fractures Hip Mandible

Degenerative joint disease Osteoporosis Herniated disc Amputation

Degenerative Joint Disease:Osteoarthritis

Not normal part of aging process Cartilage destruction:

Trauma Repetitive physical activities Inflammation Certain drugs (corticosteroids) Genetics

Assessment

Location, nature, duration of pain Joint swelling/crepitus Joint enlargement Deformities Ability to perform ADL’s Risk factors Weight (history of obesity)

Nursing Interventions

Pain management Rest with acute pain; exercise to

maintain mobility Splint or brace Moist heat Alternative therapies

TENS, acupuncture, therapeutic touch

Surgical management: total joint arthroplasty

(replacement)

Elbow, shoulder, hip, knee, ankle, etc. Pre-operative teaching:

“What to expect” (CPM, abduction pillow, drains, compression dressing, etc.)

Postoperative exercises: quad sets, glute sets, leg raises, abduction exercises

Pain management: PCA Use of pain scale

Total Joint Arthroplasty

Post-operative care: 5 P’s Observe for bleeding Pain management Knee: CPM Check incision for s/s infection

Total Joint Arthroplasty Postoperative Care

Prevent: Dislocation Skin breakdown Venous thrombosis (DVT)

TED/Sequential compression Anticoagulants Exercises: plantar flexion, dorsiflexion, circle

feet, glute & quad sets

Osteoporosis Primary – often women postmenopause Secondary – corticosteroids, immobility,

hyperparathyroidism Bone demineralization = decreased

bone density Fractures:

Wrist Hip Vertebral column

Silent disease

Dowager’s hump (kyphosis) Pain Compression fractures Spontaneous fractures X-ray can not detect until > 25%

calcium in bone is lost Diagnosis: bone density ultrasound

Interventions

Hormone replacement Calcium & vitamin D Calcitonin, Fosamax, Actonel, Evista Avoid alcohol and smoking Daily weight bearing, sustained

exercise (walking, bike) Safety in home (throw rugs, pets,

etc.)

What can go wrong

Fractures Hip Mandible

Degenerative joint disease Osteoporosis Herniated disc Amputation