Musculoskeletal trauma

msklt

1. MUSCULOSKELETAL TRAUMA Linda H. Warren EdD RN MSN CCRN NUR 335

2. Objectives Identify common MOI associated with musculoskeletal trauma. Describe pathophysiological changes related to signs and symptoms. Discuss nursing assessment associated with MSKLT trauma patients. Identify appropriate nursing diagnosis and expected outcomes for pts. Plan appropriate interventions for patients with musculoskeletal trauma Evaluate the effectiveness of interventions for musculoskeletal trauma injuries.

3. Epidemiology 33 million injuries annually Approximately 8,000 deaths per year Single or multi-system injuries Concurrent injuries are common (ex: leg fracture w. head injury) Elderly at risk Poor balance Medication effects

4. A&P Musculoskeletal system: Bones Joints Tendons Ligaments Neurovascular system: Vessels Nerves

5. BONES: Types Compact / Spongy (cancellous) Classification Long (femur) Short (digits) Flat (sternum) Irregular (vertebrae) Structure Epiphysis Epiphyseal plate: growth plate, assess in children Diaphysis Medullary cavity: vascular Articular Cartilage Periosteum: bone covering, neurovascular

6. Medullary cavity contains marrow which makes RBCs and stores fat. Periosteum is neurovascular

7. JOINTS Fibrous Little or no movement Cartilaginous Slight movement Synovial Freely movable Arm, wrist, elbow

8. TENDONS & LIGAMENTS: Tendons Thick white fibrous Collagen fibers / tensile strength Extension / Flexion Ligaments Bands of fibrous connective tissue Elastic fibers provide stretch Stabilize joints Assist with movement Skeletal (striated) Muscle Voluntary muscles Fuse with tendon fibers Insert into bone Covered by fascia

9. Neurovascular Small blood vessels permeate bone and periosteum. Medullary Artery (I.O. access)** Nerves: Distributed through periosteum Accompany arteries Transmit impulses I.O. ACCESS SITES

10. PELVIS Weight bearing structure. Provides protection to lower abdominal viscera. Pelvic ring  formed by sacrum & two innominate bones. Stability maintained by ligaments. Venous Plexus: Highly vascular basin Tearing of vessels  catastrophic hemorrhage  hypovolemic shock Injury is concealed until bleeding is severe.

11. MOI: Intentional / Unintentional Blunt MVCs Pedestrian injury Falls Assaults (direct blows) Forced flexion / hyperextension Rotational / twisting forces Penetrating Gunshot / Stabbing / Blast Other Pathological Seizures (rigidity in tonic phase can cause fractures) Crush

12. Blood Loss / Hemorrhage: Femur: 1500 ml (venous plexus = highly vascular basin) Humeral: 750 ml CAUTION: significant blood loss may be concealed. Multiple Fractures: significant blood loss  s hock states (mostly hypovolemic) Neurological Deficits: Interrupted conduction pathways Nerve impulses blocked / diminished: due to compressed, torn, or lacerated nerves. Partial or complete loss of motor / sensory FX. Assess pulses above & below injury level for circulation.

13. Musculoskeletal Injuries

14. Soft Tissue Injuries

15. Soft Tissue Injuries Abrasion: Epidermal/dermal injuries (surface injuries) Caused by friction, rubbing or scraping. Rugburn, skid knee on pavement Avulsion: F ull thickness skin loss with resulting flap: unable to approximate wound edges. Trim skin edges to form a nice approximated wound edge for suturing. Degloving: Serious avulsion injury. Results from high energy shearing force. Tearing large amount of tissue from underlying vascular supply.

16. Contusions: Blood vessel rupture with bleeding soft tissues. Ecchymosis and hematoma. Localized pain and swelling Lacerations: OPEN WOUND Causes a tearing or splitting of skin from an external source. Punctures: MINIMAL BLEEDING Wound with a narrow opening that penetrates deep into soft tissue. Traps foreign material leading to infection. Foot punctures = high rate of infection. Keep puncture wound OPEN (prevent it from closing). Want puncture to heal from the inside out. Soft Tissue Injuries

17. MUSCLE STRAINS: Strain is a “muscle pull” Cause: overuse, overstretch, or excessive stress. Microscopic, incomplete muscle tear with bleeding into tissues. Soreness, sudden pain, local tenderness with muscle use or isometric contraction. “Overuse Syndrome:” Cumulative trauma disorder resulting from prolonged, repetitive forceful or awkward mvmts . Ex: carpal tunnel

18. Injury to ligaments. Caused by a wrenching or twisting motion. Torn ligament looses ability to stabilize joint Blood vessels rupture with edema Joint tenderness Painful movement X-Ray to r/o fracture SPRAINS:

19. R – REST I – ICE x 24 - 48 hours C – Compression E – Elevation

20. Neurovascular Assessment (5 P’s) Pain Pallor Pulses Paresthesia Paralysis ***Pain and paresthesia are often first indicators of fractures.

21. Musculoskeletal Trauma Dislocation: surfaces of bone are no longer in anatomic contact. Subluxation: partial dislocation of articulating surfaces. Avascular Necrosis: delay in reduction of a hip dislocation, Avascular necrosis of femoral head Hip dislocations should be reduced within 6-24 hrs. Immobilize affected joint Surgical reduction Analgesia Assess neurovascular status

22. Types of Fractures Compound (open): Skin integrity over or near fracture site is disrupted Closed: Skin integrity is intact Complete: Total disruption of bone continuity Incomplete: Incomplete disruption of bone continuity

23. Types of Fractures Comminuted Splintering of bone into fragments. Greenstick Bone buckles or bends. Fracture doesn’t go through entire bone. Common in children r/t immature bone formation. Impacted Distal and proximal sites wedged into each other (not overlapped). Displaced Proximal and distal fracture sites are out of alignment.

24. Clinical Manifestations of Skeletal Fractures: Pain / Tenderness Loss of function Deformity Shortening Crepitus (air, rice krispies under skin) Edema / Swelling Discoloration / Ecchymosis Muscle spasm Closed or Open Traction devices: form of immobilization Pelvic Fracture: stable vs. unstable Shock (hypovolemia) Multiple bone fractures cause a large amount of blood loss.

25. Emergency Management of Fractures: Immobilization Splinting Open Fracture Cover with clean sterile dressing. Reduction – “setting the bone” Closed reduction: manipulation or manual traction. Open reduction: surgical approach to set bones, involves internal fixation devices. Pressure areas Infection Pin-site care

26. Collaborative Management Anatomic realignment of bone fragments. Immobilization to maintain realignment. Restoration of normal or near-normal function. More prone to developing ARTHRITIS at fracture site.

27. Nursing Management Volume Replacement Fracture Stabilization Pressure Dressings (to stop bleeding) Five P’s Pain Pallor Pulse Paresthesia Paralysis ***Pain and paresthesia are often first indicators of fractures

28. Pelvic Fractures: Usually result of high energy traumas. unstable

29. Pelvic Fractures: The more fractures within the pelvis, the more unstable the injury is. Will require wiring.

30. Pelvic Fractures: High probability of hemorrhage into pelvic basin / venous plexus (highly vascular)

31. COMPLICATIONS of MUSCULOSKELETAL INJURIES

32. INFECTION: Irrigation (puncture wounds) Debridement Trimming edges of wound to allow for suturing. Tetanus Toxoid

33. Fat Embolism Long bone / Multiple fractures / Crush injuries Occurs 24-48 hrs after injury Young adults or elderly with proximal femur fractures. Fat in medullary cavity can be released… Fat globules diffuse into blood. Fat emboli occlude small vessels. Manifest 24-48 hrs after injury. S&S similar to pulmonary emboli Altered mental status, confusion Non-blancheable petechial rash No hemoptysis (not pulmonary)

34. Clinical Manifestations Hypoxia (altered ABG’s) Tachypnea Tachycardia Low grade fever Dysrhythmias Lipuria (fat in urine) S&S similar to PE (except no hemoptysis) Altered mental status (profound)

35. Management of Fat Emboli Fracture Immobilization Supplemental Oxygen Mechanical Ventilation Monitor CV status

36. Associated Vascular Compromise DVT Calf tenderness Redness Swelling Fever Positive Homan’s sign (toes flexed upwards causes pain) Treatment Early ambulation Anticoagulation Pneumatic compression devices Knee-high Foot

37. Pulmonary Embolus Obstruction of pulmonary tree or one of it’s branches Blood clot / thrombus Dyspnea / Tachypnea Chest pain Anxiety Fever Tachycardia Hemoptysis

38. Diagnostic Tests Chest x-ray Electrocardiogram ABGs Chest CT Spiral CT** VQ scan Pulmonary angiogram

39. Hemorrhage Hypovolemic (traumatic) shock resulting from loss of blood and extracellular fluid into damaged tissues. Occurs more often in fractures of: Femur (1500 mL blood loss) Pelvis Thorax Spine

40. Management of Hemorrhage Blood repletion Adequate splinting Pain relief Prevent further injury and complications Cardiac /respiratory / O 2 -sat monitoring Vascular status

41. OSTEOMYELITIS Infection of bone PATHO: Staphylococcus Aureus (s. aureus) Extension of soft tissue infection. Direct bone contamination from surgery, open fracture or traumatic injury (knife, gunshot). Hematogenous spread (blood-borne) from other sites of infection.

42. OSTEOMYELITIS Initial response to infection: Inflammation Increased vascularity  vasodilation  E dema 2-3 days: Thrombosis Ischemia Bone necrosis Chronic Infection

43. RISK FACTORS: Elderly Impaired immunity Long-term corticosteroid therapy (ex: COPD) Comorbidities Diabetes Rheumatoid Arthritis HIV/AIDS OSTEOMYELITIS

44. S&S: Septicemia Pyrexia (fever) Chills Tachycardia Malaise Pain Edema Warm extremity DIAGNOSIS: X-ray: Irregular calcification Bone necrosis Peri-ostial elevation r/t bone overgrowth & new bone formation. Radioisotope bone scan MRI Blood cultures (identify infectious organisms) Wound cultures OSTEOMYELITIS

45. GOAL: prevention! ABX: after collection of blood and wound cultures. Penicillin Cephalosporins (Ceftriaxone/Rocephin, Cefepime) Surgical Debridement: clean out dead tissue Implanted ABX CHRONIC: Sequestrectomy (remove part of bone) Wound irrigation MANAGEMENT of OSTEOMYELITIS:

46. MANAGEMENT of OSTEOMYELITIS:

47. AVASCULAR NECROSIS: Tissue death due to anoxia and diminished blood supply causing bone collapse. CAUSES: ETOH abuse (poor NX) Atherosclerosis Decompression sickness Steroid therapy Hip fracture at femoral neck Humoral fracture Jaw fracture Radiation therapy Malignant tumors (lymphomas)

48. AVASCULAR NECROSIS:

49. Diagnostics: X-ray MRI Treatment: Total hip replacement (THA) Bisphosphonates: Osteoporosis meds. Help to build bone. Bone Grafting MANAGEMENT of AVASCULAR NECROSIS:

50. CRUSH INJURIES: Cellular destruction & damage: neurovascular damage. Pelvis / both lower extremities: life-threatening Hemorrhage  Hypovolemic shock Tissue damage Destruction of muscle / bone tissue Fluid loss Compartment syndrome Infection Myoglobinuria / renal dysFX  rhabdomyolysis  AKI Loss of neurovascular FX DISTAL to injury.

51. COMPARTMENT SYNDROME: INCREASED PRESSURE inside a fascial compartment. Impaired capillary blood flow  CELLULAR ISCHEMIA. Internal Sources: Hemorrhage Edema Open or closed fractures Crush injuries External Sources: Skeletal traction Casts Air splints PASG’s

52. COMPARTMENT SYNDROME: Compression of nerves, blood vessels, muscle tissue. Ischemia of muscles and nerves. Pain disproportionate to injury. Loss of sensation, paresthesia Numbness and tingling may precede pain. Area: edematous / tense Increasing muscle weakness Pulselessness Elevated muscle compartment pressures Measured with needles .

53. Elevate extremity ABOVE level of the heart. Release restrictive devices: Casts Dressings Clothing SURGICAL INT: when conservative measures are unsuccessful in restoring tissue perfusion within 1 hour. Fasciotomy: LONGITUDINAL INCISION. Takes pressure off of muscle to prevent necrosis . MANAGEMENT of COMPARTMENT SYNDROME:

54. LONGITUDINAL INCISION**

55. Breakdown of muscle tissue that releases a damaging protein into the bloodstream. Muscle breakdown results in the release of a protein (myoglobin) into the blood. Myoglobin can damage the kidneys. Symptoms include dark, reddish urine, oliguria, weakness, and myalgia. Early TX with aggressive fluid replacement reduces the risk of AKI. RHABDOMYOLYSIS

56. RHABDOMYOLYSIS Associated with CRUSH INJURIES. Pt has been unresponsive for an UNKNOWN amt of time… be suspicious of rhabdomyolysis. SYSTEMIC EFFECTS: Hypotension Sepsis Shock Acute renal failure (AKI) High CK values (>50,000)

57. RHABDOMYOLYSIS Muscle destruction releases myoglobin. Myoglobin release  blockage of renal tubules  AKI Myoglobinuria Metabolic acidosis r/t elevated lactic acid levels. Hyperkalemia (K+ released from cells) Hypocalcemia Severe hyponatremia

58. #1: IVF Resuscitation Urine alkalization Osmotic diuresis (mannitol) Decrease in cast formation Cardiopulmonary support MANAGEMENT of RHABDOMYOLYSIS:

59. TRAUMATIC AMPUTATIONS: PARTIAL vs. COMPLETE: Complete: less active bleeding than with partial amputation. Partial: irregular tearing  more bleeding can occur. Exception: complete avulsive tearing injuries. “Preservation of Life Over Limb”  will resuscitate pt before saving limb. Guillotine amputations: precise edges Avulsive tearing injuries: irregular pattern & edges S&S: Pain Bleeding Hypovolemic shock

60. Relieve symptoms Improve functional status and QOL Surgical amputation is performed at the most distal point (want to preserve the joint) Site of amputation: Circulation: Circulatory status assessed Physical exam, Doppler studies, BP, PaO2 and angiography Functional usefulness TRAUMATIC AMPUTATIONS:

61. Conserve extremity length Preserve joints Fit with prosthesis Complications: Hemorrhage Infection Skin breakdown Phantom limb pain Joint contractures  keep pt mobile to prevent contractures The early the pt is mobilizing, the better off they are. Goal to get pt into rehab early on . TRAUMATIC AMPUTATIONS:

62. Elevate stump. Wrap stump in ace bandage (stump dressing). If the dressing becomes displaced, rewrap the stump… not an MD order, nursing can do it. Notify provider. Assess suture line on stump for infection or pressure/ irritation from prosthetic. Provide good skin care. Ensure prosthesis fits appropriately.

63. Musculoskeletal Trauma: Nursing Diagnoses Fluid volume deficit r/t hemorrhage. Impaired physical mobility r/t fracture, pain, external immobilization devices. Risk of infection r/t impaired skin integrity, contamination of wound. Impaired skin integrity r/t fracture, impaired mobility, pressure, shear, or friction. Pain Altered tissue perfusion Risk of injury Ineffective coping r/t loss of limb Altered body image