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.

INTRODUCTIONEpidemiologyMore 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%).0The 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 BiomechanicsMusculoskeletal 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 InjuriesMusculoskeletal 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 InjuriesBony 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 SYMPTOMSBlood LossMusculoskeletal 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 healingBone 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 DeficitsIf 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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FracturesFractures involve a disruption of bony continuity

Soft tissue injuryDisruption 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:• AbrasionAn epidermal and dermal injury caused by a friction, rubbing, or scraping motion• AvulsionA full thickness skin loss or resultant flap in which the wound edges cannot be approximated • DeglovingA 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• ContusionDisruption of small blood vessels and extravasation of blood into the skin and/or mucous membranes that does not interrupt the skin integrity• LacerationOpen wound from external forces causing a tearing or splitting of the skin, involving the dermis, epidermis, or underlying structures• PunctureWound 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 INJURIESJoint InjuriesA 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 FracturesFemur 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 FracturesPelvic 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 FracturesAll 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

AmputationsAmputations 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 InjuriesCertain 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 SyndromeCompartment 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. Itcan 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 functionSIGNS 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 ASSESSMENTRefer to Initial Assessment, for a description of assessment of the patient's airway, breathing, circulation, and disabilityInspection • Observe general appearance of extremitiesNote 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 extremityPalpationExtremity 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• PainCarefully palpate the entire length of each extremity for pain. Determine location and quality of pain. Ischemic pain is often described as burning or throbbing.• PallorNote color and temperature of injured extremity. Pallor, delayed capillary refill (> two seconds), and a cool extremity indicate vascular compromise.• PulsesPalpate pulses proximal and distal to the injury for comparison. Then compare quality of pulses with the opposite, uninjured extremity.• ParesthesiaDetermine presence of abnormal sensations (e.g., burning, tingling, numbness)• ParalysisAssess 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 PROCEDURESRefer to Initial Assessment, for frequently ordered radiographic and laboratory studiesAdditional studies for patients with musculoskeletal trauma are listed below.Radiographic Studies

• Anterior-posterior and lateral of injured extremitySome 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.

• AngiographyAngiography may be indicated to identify tears or compressions in the arterial or venous network the injured extremity.

ANALYSIS, NURSING DIAGNOSES, INTERVENTIONS, AND EXPECTED OUTCOMESIn 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 OUTCOMEFluid volume deficit, related to• Hemorrhage

Control any uncontrolled bleeding by: applying direct pressure

over bleeding site; elevating extremity; applying pressureover arterial pressure sites

• Cannulate two veins with large bore catheters and initiate infusion of lactated Ringer's solution or normal saline• Administer blood, as indicated

• splint injured extremity

The patient will have an effective circulatingvolume, as evidenced by:• Stable vital signs appropriate for age• Urine output of 1ml/kg/hr• Strong, palpable peripheral pulses• Level of consciousness, awake and alert,

age appropriate• Skin normal color, warm, and dry• Maintains hematocrit of 30 ml/dl or hemoglobin of 12 to 14 g/dl or greater

• Capillary refill time of <2 seconds

Physical mobility, impaired, related to:• Bone, soft tissue and/or nerve injury of extremity• Pain• Edema• External immobilization devices• Limited range of motion

Splint and immobilize affected extremityImmobilize joints above and below the deformityAdminister analgesiamedications, as prescribedUse touch, positioning, or relaxation techniques to give comfort

The patient will experience increasedmobility, as evidenced by:• Ability to tolerate movement and increased activity• Willingness to move affected part to degree allowed

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of affected bone • Maintenance of proper body alignment

Infection, risk, related to:• Impaired skin integrity• Contamination of wound from

initial injury or instrumentation

• Invasive fixation devices• Interruption in perfusion• Suppressed inflammatory

response

Obtain blood/wound culturesMonitor vital signsAdminister antibiotics, asprescribedKeep wound clean and applydressing using aseptictechniqueMaintain aseptic techniqueCover open wounds with asterile dressingDo not reposition protrudingbone fragmentsPrepare for definitive careStabilize impaled objects

The patient will be free from infection, asevidenced by:• Core temperature measurement of 36

37.5°C (98 - 99.5°F)• White blood cell count within normal

limits• Absence of signs of infection: redness,

swelling, purulent drainage, odor, andtenderness

Impaired skin integrity, risk, related to:• Movement of fractured bones• Pressure, shear, friction on skin

and tissue• Mechanical irritants: Fixation de-

vices, splints, and casting material

• Impaired mobility• Effects of trauma/injury agents

Assess skin integrity frequentlyKeep skin dryMaintain aseptic/cleantechnique, as appropriateSplinting, as indicated

The patient will experience absence orresolution of impaired skin integrity, asevidenced by:• Maintenance of intact skin overlying

fracture• Absence of signs of irritation: redness,blanching, and itching

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Planning and ImplementationRefer 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 PELVICFRACTURE• 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 therapeuticembolization.NURSING INTERVENTIONS FOR THE PATIENT WITH AN OPENWOUND• 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 riskof bacterial contamination.• Administer antibiotics, as prescribed• Inspect dressings frequently for continued bleeding• Administer tetanus prophylaxis, as indicatedNURSING INTERVENTIONS FOR THE PATIENT WITHANAMPUTATION• 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 indicatedNURSING INTERVENTIONS FOR THE PATIENT WITH A CRUSHINJURY• 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 amputationNURSING INTERVENTIONS FOR THE PATIENT WITH POSSIBLECOMPARTMENT 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 AssessmentRefer 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 respirationTachpynea, rales, and wheezes may be indicators of fat embolus syndrome.• Reassess and document the five Ps

SUMMARYInjuries 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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