Orthopedics for nurses

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Management of patients with musculoskeletal trauma and problems

Management of patients with musculoskeletal trauma and problems

Dr. Sameer AgarwalOrthopaedicsKhoula Hospital

TopicsFractureJoint dislocationContusion, sprains and strainOsteomyelitisLow back painAmputation

OBJECTIVESCauses, clinical manifestation, diagnostic tests, management and care.

Care modalities

Patient education program.

Rehabilitation

ORTHOPAEDICS1840, French orthopdique, from orthopdie,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

Covering the bone is a dense, fibrous membrane known as the periosteum. The endosteum is a thin, vascular membrane that covers the marrow cavity.Red bone marrow, located mainly in the sternum, ilium, vertebrae, and ribs in adults, is responsible for producing red blood cells, white blood cells, and platelets through a processcalled hematopoiesis.

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Joints

The junction of two or more bones is called a joint (articulation).There are three basic kinds of joints: synarthrosis, amphiarthrosis, and diarthrosis joints.Synarthrosis joints are immovable (eg, the skull sutures). Amphiarthrosis joints (eg, the vertebral joints and the symphysis pubis) allow limited motion.Diarthrosis joints are freely movable jointsThere are several types of diarthrosis joints: Examples are Ball-and-socket joints and Hinge joints.

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Basic anatomy

SprainsStretching, partial or complete tearing of ligamentsTypically occur when joint overextendedAnkles, knees, wrists, fingersSwelling, pain, bruising Inability to use joint

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StrainsTearing of muscle or tendonOccurs due to overstretchingCauses pain, swelling and sometimes inability to use muscleCan be prevented by avoiding overexertion, good body mechanics, sports safety

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Care for Musculoskeletal InjuriesProper 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.

Giving proper care is more important than identifying the type of injuryInitial care is the same whether the injury is a fracture, dislocation, sprain or strain.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.

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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

SplintingA method of immobilizing an injured extremityONLY : to move or transport a patient to higher centerSplinting does not cause more pain.

If you have to splint:Splint an injury in the position in which you findSplint the injured area and the joints or bones above and below the injury site.Check for circulation (feeling, warmth, and color) before and after splinting.

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Types of SplintsSoft splintsfolded 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 placeAnatomic 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 InjuriesThese 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/BackMinimize movement of the head, neck, and back by placing your hands on both sides of the persons 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 ABCs

FractureA 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:TypeAnatomic locationCommunication or non communication with external environment

Description of fractures

Compression fxSpecific to the vertebral body collapses, anterior aspect is reduced in height.From trauma or demineralization of bone (old age).

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Burst fxC1 ring is broken, fragments move outward. Football injuries, heavy object dropped on head.

C - 1 (atlas)

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Pediatric fractures1. Greenstick (torus) - incomplete fx, bones more flexible, bends & fractures only outer edge.2. Epiphyseal - fractures located at the site of an epiphysis.

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Classification by Fracture Location

Description

Described and classified according to:Appearance, position, and alignment of the fragmentsClassic namesStable or unstable

Description

Closed (also called simple)

Open (also called compound)

Classification by Communication withExternal Environment

Description

Stable fracturesOccur when a part of the periosteum is intact across the fractureORExternal or internal fixation has rendered the fragments stationary

Description

Unstable fractures

-Grossly displaced

-Poor fixation

Clinical ManifestationsImmediate localized painLoss of FunctionInability to bear weight or use affected partGuardingMay or may not see obvious bone deformity

Fracture Healing

Fracture hematoma (d/t bleeding, edema)Granulation tissue osteoid (3 14 days post injury)Callus formation (minerals deposited in osteoid)Ossification (3 wks 6 mos)Consolidation (distance between fragments decreases closes).Remodeling (union completed; remodels to original shape, strength)31

Collaborative CareOverall goals of treatment:Anatomic realignment of bone fragments (reduction)Immobilization to maintain alignment (fixation)Restoration of normal function

3 R s

Collaborative Care - Fracture ReductionClosed reductionNonsurgical, manual realignmentOpen reductionCorrection of bone alignment through a surgical incision

Fracture Reduction (Closed)Traction (with simultaneous counter-traction)Application of pulling force to attain realignmentSkin traction (short-term: 48-72 hrs.)Skeletal traction (longer periods)Manipulation under anesthesiaTo control pain and overcome muscle spasm

Collaborative Care Fracture ImmobilizationTractionApplication of a pulling force to an injured part of the body while counter traction pulls in the opposite directionPurpose of traction:Prevent or reduce muscle spasmReductionImmobilizationTreat a pathologic condition

Collaborative Care Fracture ImmobilizationCastsCircumferential immobilization deviceCommon following closed reduction

Collaborative Care Fracture ImmobilizationExternal fixation device composed of pins that are inserted into the bone and attached to external rods

Open fractures external fixation

Collaborative Care Fracture ImmobilizationInternal fixationPins, plates, intramedullary rods, and screwsSurgically inserted at the time of realignment

Nursing Management Nursing Assessment for FracturesAMPLE history

Nursing Management Nursing AssessmentNeurovascular assessmentColor and temperaturecyanotic and cool/cold: arterial insufficiencyBlue and warm: venous insufficiencyCapillary refill (< 2 sec)Peripheral pulses ( indicates vascular insufficiency)

Nursing Management Nursing DiagnosesRisk for peripheral neurovascular dysfunctionAcute painRisk for infectionAssessment of fall riskDecubitus ulcer policyProlonged immobilizationDVT prophylaxis

Nursing Management Nursing DiagnosesIneffective therapeutic regimen managementAnalgesiaAntibiotic prophylaxis(treatment)ThromboprophylaxisMedication for co-mobiditiesNon prescription medication

Nursing Management Nursing ImplementationGeneral post-op careAssess dressings/casts for bleeding/drainage

Prevent complications of immobilityMeasures to prevent constipationFrequent position changes/ ambulate as permittedROM exercises of unaffected jointsDeep breathingIsometric exercises

Nursing Management-TractionNursing ImplementationEnsure:No frayed ropes, loose knotsRopes in pulley groovesPulley clamps fastened securely

Weights must hang freelyAppropriate body alignmentInspect skinAround slingsAround pins

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Nursing Management Nursing Implementation: Cast careCasts can cause neurovascular complications ifToo tightEdematousFrequent neurovascular checksIce and elevation during early phase

Complications of Fractures-InfectionOpen fractures and soft tissue injuries have incidenceOsteomyelitis can become chronicOpen fractures require aggressive surgical debridementPost-op IV antibiotics till wound closure (prophylactic)

Complications of FracturesCompartment Syndromeelevated intra-compartmental pressure within a confined compartment capillary perfusion to be reduced below a level necessary for tissue viability

Complications of FracturesCompartment SyndromeTwo basic etiologies create compartment syndrome:Decreased compartment size (dressings, splints, casts)Increased compartment content (bleeding, edema)

Complications of FracturesCompartment SyndromeClinical Manifestations Six PsPain (unrelieved by narcotics)3. Pressure (Tense tight compartment)Pallor (loss of normal color, coolness)Paresthesia (unrelieved by narcotics)ParalysisPulselessnes