Muskuoloskeletal System CS

Nursing Care of Clients With Musculoskeletal

Disorders

Lecturer: Isaac Amankwaa

Outline Fractures: Types Management & complications Traction (Skin and Skeletal) Casts (Compartment Syndrome,

Infection, Cast Syndrome)

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Class Objectives: Describe the anatomy and physiology of the

musculoskeletal system including the significance of health history.

Discuss the significance of assessment and diagnosis of musculoskeletal problems including diagnostic tests.

Explain the pathophysiology, manifestations, complications & collaborative care of clients with fractures.

Describe the preventative health teaching needs of the client with a cast.

Describe the various types of traction and appropriate nursing care.

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Fracture Definition

A Fracture is a break in the continuity of a bone, separating it into two or more parts that may be accompanied by injury of surrounding soft tissue producing swelling and discoloration.

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Fracture ctd When # occurs, muscles are also

disrupted & pull fracture fragments out of position.

Adjacent structures are affected – soft tissue edema, hemorrhage, joint dislocations, ruptured tendons, severed nerves, damaged blood vessels

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Causes of fracture

Direct blow Crushing force Sudden twisting motion Extreme muscle contraction

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Types of Fracture Open: (compound or complex) break in

tissue over site of the bone injury

Complete: break across entire cross-section of bone & often displaced

Incomplete: (greenstick) through only part of the cross-section

Closed: (simple) intact skin over site of injury

Comminuted: produces several bone fragment

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COMMON TYPES OF FRACTURES

Table 6.1

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COMMON TYPES OF FRACTURES

Table 6.1

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COMMON TYPES OF FRACTURES

Table 6.1

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COMMON TYPES OF FRACTURES

Table 6.1

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PHYSIOLOGICAL RESPONSES

Local Response Blood vessels within the bone, the

periosteum and surrounding tissues are torn, resulting in haemorrhage and the formation of a haematoma.

The periosteum at the site may be stripped away from the underlying bone tissue, interrupting the blood supply into the area and thus contributing to the death of bone cells.

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PHYSIOLOGICAL RESPONSES Systemic Response

The client suffers some degree of shock which is influenced by the severity of the injury, the amount of soft tissue damage, associated disorders or multiple injuries and the patient’s age and general condition at the time of injury.

In addition there is also the psychological dimension to consider as different people respond to different ways to same injury.

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Clinical Manifestations Deformity (hemorrhage or spasm) Shortening Swelling Muscle spasm Pain, tenderness Loss of function, altered mobility &

crepitus Neurovascular changes shock

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Signs and SymptomsSigns and Symptoms

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Diagnostic Investigations X-ray examination to confirm location

and direction of fracture line. Signs and symptoms Magnetic resonance imaging (MRI) Angiography with blood vessel injury Differential diagnostic studies with

pathological fracture Nerve conduction and

electromyogram studies with nerve injury

Blood studies e.g. Complete blood count

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HEALING OF FRACTUREBone is different from many of the

specialized tissues because of its ability to

regenerate and hence restore the continuity Haematoma formation Granulation tissue formation Callous formation Ossification Remodeling and Consolidation

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Stages of Healing a Fracture

Figure 6.14Isaac Amankwaa

FACTORS ENHANCING FRACTURE HEALING

1. Immobilization of the fracture fragments

2. Maximum bone fragment contact3. Sufficient blood supply 4. Proper nutrition5. Exercise-Weight-bearing for long

bones6. Hormones-growth hormone, thyroid,

calcitonin, insulin, vitamins A and D, anabolic steroids.

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Factors Inhibiting Fracture Healing

Extensive local trauma Bone loss Inadequate immobilization Space/tissue between bone

fragments Infection Local malignancy Metabolic bone diseases (e.g.

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Factors Inhibiting Fracture Healing

Irradiated bone (radiation necrosis) Avascular necrosis Age (elderly persons heal more slowly) Corticosteroids (inhibit the repair rate) Denervation

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Complications of fracture Early complications include:

Shock Nerve damage, arterial damage Infection Cast syndrome Compartmental Syndrome Fat Embolism Syndrome Deep Vein thrombosis & Pulmonary

Embolism

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Long-term Complications Joint stiffness or post-traumatic

arthritis Avascular necrosis Nonfunctional union after a

fracture Complex regional pain syndrome Reaction to internal fixation

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Avascular NecrosisAvascular Necrosis

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Emergency mgt of fractures Immediately immobilize affected limb. Unless there is bleeding apply splints

and padding (above and below fracture site) directly over the clothing.

If bleeding is present visualization may be necessary before pressure can be applied where bleeding is originating.

Keep patient covered to preserve body heat

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Emergency mgt of fractures If the fractured extremity is a leg

bone, the unaffected extremity can be used as a splint by bandaging both legs together.

An arm can be bandaged to the chest or put into a sling to minimize further tissue damage

Assess color, warmth, circulation, and movement (CWCM) of the limb distal to the fracture.

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Emergency mgt of fractures Open fractures require the

protruding bone be covered with a clean (sterile preferred) dressing.

Do not attempt to “straighten” or realign the fractured extremity. Move the affected limb as little as necessary.

Transport to an emergency department as soon as possible

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Principles for fracture management The management process is a

three-step process: Reduction—setting the bone; refers

to restoration of the fracture fragments into anatomic position and alignment.

Immobilization—maintains reduction until bone healing occurs

Rehabilitation—regaining normal function of the affected part.

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Fracture fragments brought into their pre-injury position.

It consists of pulling the broken bone ends to correct alignment and regain continuity.(Bone setting)

Fracture Reduction

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Reduction is necessary only if there

is some displacement of the

fragment.

It is carried out as soon as possible

to achieve satisfactory alignment

FRACTURE REDUCTION

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Methods of fracture reduction

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Includes;1. Closed manipulative

reduction2. Open (Internal )reduction3. Traction

Methods of fracture Reduction

Closed Reduction Minimal manipulation carried out to

bring bone fragments into contact. Afterwards a cast, bandage or splint is

applied to immobilize, support and protect the part.

The procedure may require administration of anesthesia/analgesia

X-rays are taken before and after the procedure to ensure correct alignment

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Methods of reduction Open reduction

Bone fragments are directly visualized. Internal fixation devices are used to hold

bone fragments in position until solid bone healing occurs

Examples of internal fixation devices include metal pins, wires, screws, plates, nails and rods.

The devices may be removed when bone is healed.

After closure of the wound, splints or casts may be used for additional stabilization and support.

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Open Reduction

Closed vs. Open ReductionClosed vs. Open Reduction

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Traction Pulling force applied to accomplish

and maintain reduction and alignment Used for fractures of long bones. Techniques

Skin traction—force applied to the skin using foam rubber, tape.

Skeletal traction-force applied to the bony skeleton directly, using wires, pins, or tongs placed into or through the bone.

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Immobilization or fixation This follows reduction It involves holding the bone fragments in

correct position and alignment until union has had time to take place.

Immobilization may be accomplished externally with external fixation devices

(e.g. cast, splint, brace), traction, or external fixators; or

internally with metal plates, pins, screws and nails, alone or in combination with bone grafts or prosthetic implants

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Immobilization or fixation External Fixation

External fixation is a technique of fracture immobilization in which a series of transfixing pins is inserted through bone and attached to a rigid external metal frame.

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Immobilization or fixation External fixation devices

include: Splint Brace Cast External Fixator Traction Bandage

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FRACTURES - METHODS FOR MAINTAINING IMMOBILIZATION

Internal devices Nail Plates Screws Wires Rods Metal implants used

for internal fixation serve as internal splints to immobilize the fracture.

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Alignment & Immobilization

External Fixation (advantages)1. Permits rigid support of severely

comminuted open fractures, infected non-unions, and infected unstable joints.

2. Facilitates wound care3. Allows early function of muscles and

joints.4. Allows early patient comfort

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External fixation The method is

used mainly in the management of open fractures with severe soft-tissue damage.

Common sites include face & jaw, pelvis, fingers.

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Open Reduction &Internal fixation

The bone ends are realigned (reduced) by direct visualization through a surgical incision (open reduction [OR]).

The bone ends are held in place by internal fixation (IF) devices

Internal fixation devices include metal pins, wires, screws, plates, nails, rods

After closure of the wound, splints or casts may be used for additional stabilization and support.

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Types of Internal Fixation Devices

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Open reduction and internal fixation of Comminuted mandibular fracture

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Differences between Internal fixation and external fixation

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Immobilization or fixation

Casts Cast is a substance made into a rigid

material to immobilize support and protect a broken bone or correct deformities.

Purpose of cast Immobilization prevention or correction of deformity to realign bone promotion of healing

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CASTING MATERIALS Non-plaster

Referred to as fiberglass casts, are lighter in weight, stronger, water resistant, and durable.

are porous and therefore diminish skin problems.

Plaster (P.O.P) The traditional cast Rolls of plaster bandage are wet in cool water

and applied smoothly to the body. A crystallizing reaction occurs, and heat is

given off polyester-cotton

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Types of cast Short arm cast

Extends from below the elbow to the palmar crease

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Types of cast Long arm cast

Extends from the upper level of the axillary fold to the proximal palmar crease

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Types of cast Short leg cast

Extends from below the knee to the base of the toes. The foot is flexed at a right angle in a neutral position.

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Types of cast Long leg cast

Extends from the junction of the upper and middle third of the thigh to the base of the toes. The knee may be slightly flexed

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SHORT & LONG CASTS

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BODY / SPICA CASTS

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POLYESTER/FIBERGLASS

Nursing care of pt in cast

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The nurse: Keep the cast and extremity elevated Allows a wet cast 24 to 48 hours to dry

(synthetic casts dry in 20 minutes) Handle a wet cast with the palms of the

hand until dry Turn the extremity unless

contraindicated, so that all sides of the wet cast will dry

Heat can be used to dry the cast. The cast will change from a dull to a shiny substance when dry

Nursing care of pt in cast The nurse:

Examine the skin and cast for pressure areas Monitor the extremity for circulatory impairment

such as pain, swelling, discoloration, tingling, numbness, coolness, or diminished pulse

Notify the physician immediately if circulatory compromise occurs

Prepare for bivalving or cutting the cast if circulatory impairment occurs

Petal the cast; maintain smooth edges around the cast to prevent crumbling of the cast material

Monitor the client’s temperature

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Nursing care of pt in cast The nurse:

Monitor for the presence of a foul odor, which may indicate infection

Monitor drainage and circle the area of drainage on the cast

Monitor for warmth on the cast. Monitor for wet spots, which may indicate a need for drying, or the presence of drainage under the cast

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Nursing care of pt in cast The Nurse

If an open draining area exists on the affected extremity, a cut-out portion of the cast or a window will be made by the physician

Instruct the client not to stick objects inside the cast

Teach the client to keep the cast clean and dry

Instruct the client on isometric exercises to prevent muscle atrophy

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Windows maybe cut in dried casts: relieve pressure from abd. distension (body

cast) To prevent “Cast Syndrome” To assess radial pulse (check circulation in a

casted arm) To inspect areas of discomfort or areas of

suspected tissue damage To remove drains or care for wounds

Windowing and Bivalving of cast

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Bivalving a cast

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Bivalving a Cast Window Cast

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Potential complications of cast Hidden bleeding Neurovascular compromise Hidden infection from wound Skin breakdown

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Other complications of cast

Fat emboli Infection DVT Cast syndrome

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Traction Traction is the mechanism by

which a steady pull is placed on a part or parts of the body.

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Purposes of traction

It aligns the ends of a fracture by pulling the limb into a straight position.

It ends muscle spasm. It relieves pain. It takes the pressure off the bone

ends by relaxing the muscle.

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Terminologies Counter traction. pulling force equal and

opposite the traction weights Traction: is the application of a pulling

force Trapeze: an overhead patient helping

device to promote mobility in bed.

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Principles of effective traction

Traction must be continuous to be effective

Skeletal traction is never interrupted. Weights are not removed unless

intermittent traction is prescribed. The patient must be in good body

alignment Ropes must be unobstructed Weights must hang free and not rest on

the bed or floorIsaac Amankwaa

Indications for traction

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To reduce fractures Immobilization of an area

before surgery Control and relieve of painful

muscle spasm stretching adhesions correct deformities

Contraindications Patients with structural diseases

secondary to tumor or infection, Acute strains, sprains and

inflammation conditions Malignancy Aneurysm

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Types of traction Straight or running traction

applies the pulling force in a straight line with the body part resting on the bed.

E.g. Bucks extension traction

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Types of traction Balanced suspension traction

supports the affected extremity off the bed and allows for some patient movement without disruption of the line of pull

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Methods of applying traction Traction may be applied to

the skin (skin traction) or directly to the bony skeleton

(skeletal traction).

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Skin Traction Application of a pulling force

directly to the skin through the use of strips, boots or foam splints.

Apply traction to underlying bones and other structures (muscles).

It is used temporally due to skin breakdown

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Forms of skin traction

1. Buck’s traction (buck’s extension)

2. Russel’s traction (balanced traction)

3. Bryant’s traction

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Buck’s SKIN TRACTION

The traction is exerted by a straight pull on one or both legs.

Can be used to immobilize a limb for a short time (# hip prior to surgery) or reduce muscle spasm

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Russel’s traction (balanced traction)

Has an additional overhead pulley system with the leg supported by a sling.

The pull is up & toward the foot of the bed.

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Bryant's Traction

It is used to immobilize a fracture of the femur in children who weigh less than 18.2 kg.

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Skeletal Traction: Is accomplished by surgically

inserting metal wires or pins thru distal bones to the # site or by anchoring metal tongs in the skull.

A traction bow is attached to wire or pin and traction force is applied .

Used to reduce unstable fractures of long bones

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• Skeletal traction is performed when • more pulling force is needed, or • when the part of the body needing traction is

positioned so that skin traction is impossible. • It requires the placement of tongs, pins, or screws

into the bone so that the weight is applied directly to the bone.

• This is an invasive procedure that is done in an operating room under general, regional, or local anesthesia

Skeletal traction

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Comparison of skin and skeletal traction

Skin tractionAdvantage:•Relative ease of use and ability to maintain comfortDisadvantage:•Wt required to maintain Normal body alignment or fracture alignment can not exceed 6 lbs per extremity.

Skeletal tractionAdvantage:–Increases mobility without threatening joint continuity. Easier to change linen, backcare

Disadvantage:

Need to use multiple wts makes client slide in bed more.

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Bucks

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Risk associated with skin traction Bone inflammation. Infection can occur at the pin sites. Both types of traction have complications

associated with long periods of immobility: bed sores reduced respiratory function urinary & and circulatory problems occasionally, fractures fail to heal emotional toll of prolonged bedrest Kidney/gallstones

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Check the four P’s of traction maintenance

Pounds: Inspect traction setup. Is the correct weight in place?

Pull: Is the direction of pull aligned with the long axis of affected bone?

Pulleys: Is the rope gliding smoothly over pulley?

Pressure: Are clamps and connections tight?

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USUAL PIN SITE CARE With gloves remove gauze dressings from

around pins Inspect sites for drainage or inflammation. Prepare supplies and apply new gloves. Clean each pin site with NaCl by placing sterile

applicator close to the pin and cleaning away from the insertion site. Dispose of applicator.

Continue process for each pin site. Using a sterile applicator, apply a small

amount of topical antibiotic ointment as ordered

Provide pin site care according to hospital policy/ Dr. orders.

Cover with a sterile 2 X 2 split gauze dressing or leave site open to air (OTA) as prescribed

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More care for traction client Assess level of discomfort and provide

nonpharmacological and pharmacological relief as indicated.

Encourage active and passive exercises and use of unaffected extremities for ADLs.

Encourage use of trapeze bar for repositioning in bed.

Provide a fracture pan for elimination prn

Evaluate effectiveness of care & need for intervention

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Care of the Client in Traction• When caring for a client in continuous,

balanced, skeletal traction with a Thomas Splint what should the nurse know? Wow, what a question!

• Consider skin, infection, personal care, ROM/exercises

• Care of ropes, pulleys• What to do when transporting

client/bed elsewhere

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Relieving Pain Initiate activities to prevent or modify pain.

Assist patient with pain-reduction technique, e.g. guided imagery

Immobilize injured part. Position patient in correct alignment. Reposition patient with slow and steady

motion; use additional personnel as needed. Elevate painful extremity to diminish venous

congestion. Apply heat or cold modalities as prescribed.

Heat versus cold is controversial. Modify environment to facilitate rest and

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