Orthopedic and Musculoskeletal Fundamentals

Musculoskeletal System Injuries

Common Injuries to the Musculoskeletal System
Sprains
Strains
Fractures
Devices and Equipment Used to Treat Bone Injuries
Casts
Cervical tong devices
External fixators
Halo traction devices
Musculoskeletal Injury Assessment: 5 Ps
Pain
Pulse
Paresthesia
Paralysis
Pallor
Sprains and Strains
The Difference Between Sprains and Strains
A strain is a soft tissue injury that involves the muscles. It is tear in the muscle that
causes bleeding in the tissue. Strain can result from overuse, excessive stretching or
stress. It presents with abrupt soreness, pain, and local tenderness that exacerbates with
use of the affected area or during an isometric contraction
A sprain is a soft tissue injury of the ligaments. Its characterized by vessel rupture,
edema, swelling, and tissue bleeding. Sprains are caused by an excessive wrenching or
twisting motion. Pain and disability worsens 2 to 3 hours after injury onset as a result of
cumulative inflammation. It presents with joint tenderness, pain upon movement, and
edema (Altizer, 2005)
Treatment for Sprains and Strains: RICE
R: Rest the affected area to allow healing
I: Ice. Applied intermittently for 20 to 30 minutes during the first 24 to 48 hours after
the injury to decrease pain, inflammation, and bleeding
C: Compression. A bandage is applied to control edema and give support
E: Elevation. Reduces inflammation of the affected area (Altizer, 2005)
Patient Teaching for Sprains and Strains
Prevent skin injury (ice burn) by not applying ice directly to the injury site. Use a barrier
such as a towel or cloth to layer over the ice pack
Wrap the compression bandage to the proper pressure in order to not cut off circulation
Heat may be applied for intervals of 15 to 30 minutes, up to four times a day after the
initial 48 to 72 hours, when the acute inflammatory stage is complete. Heat is used to
relieve muscle spasm, encourage vasodilation, and promote healing
An over-the-counter (OTC) nonsteroidal anti-inflammatory drug (NSAID) may be used for
pain control (if not contraindicated). For severe pain, the provider may prescribe a
stronger drug for pain (Altizer, 2005)
Fractures
Common Causes of a Fracture
Trauma, from violent injury, occupation injuries, motor vehicle accidents, and other causes
Overuse, such as athletic injuries
Diseases of the bone, such as osteoporosis, which can lead to a pathological fracture
How Fractures are Classified
Location of the fracture
Open or closed break
Pattern of the fracture
Source of the fracture (in the case of pathological fracture)

Types of Fractures
Greenstick: most common in children, an incomplete fracture in which the bone is
stretched but remains intact
Incomplete: non-open fracture (non-exposed) that doesnt extend all the way through the
bone and doesnt shatter, such as a hairline fracture
Stable fracture: the broken ends of the bone line remain aligned
Open, compound fracture: the bone is exposed to the environment. The skin is pierced by
the bone or a separate blow breaks the skin at the time of the fracture. the bone may or
may not be visible. Open fractures are common in severe trauma from motor vehicle
accidents
Pathological: weakness from a disease, such as osteoporosis
Transverse fracture: a horizontal fracture line
Oblique fracture: an angled fracture pattern
Comminuted fracture: the bone shatters into three or more pieces
Bone Fracture Types Mnemonic: Go C3PO (from Star Wars)
G: Greenstick
O: Open
C(1): Complete
C(2): Closed
C(3): Comminuted
P: Partial
O: Other
Standard Treatments for Fractures
Cast: placement of a plaster or fiberglass material to stabilize the bone, such as
a functional cast, or brace
External fixation
Open reduction: surgical process of stabilizing the bone prior to applying a device to
promote healing
Traction: equipment used to immobilize the bone and stabilize it
Fracture Treatment: PRICE
Pressure
Rest
Ice
Compression
Elevation
Cast Immobilizations
What is Cast Immobilization?
Cast immobilization involves the placement of a plaster or fiberglass material to stabilize
the bone to promote healing
Plaster casts are white in color
Fiberglass casts come in a variety of colors, patterns, and designs
Common Types of Casts
Short casts: short arm casts, short leg casts
Long casts: long arm casts
Spica casts: shoulder spica casts, unilateral hip spica casts, one and one-half hip
spica casts, bilateral long leg hip spica casts, short leg hip spica casts
Cylinder casts: arm cylinder casts, leg cylinder cast
Minerva cast
Abduction boot cast
Care for Cast Immobilization
A cast should be kept clean and dry
Rough edges are filed down or petaled with tape to prevent scratches and irritation to the
skin
Assess for circulation by checking the skin characteristics

Control edema to reduce the risk of compartment syndrome

Foul odors should not protrude from the cast
Lotion should not be used in the skin under the cast
No objects should be placed in the cast: this is especially important to teach children
External Fixation
Two Main Components of External Fixation
A surgical procedure called an open-reduction is performed to set the bone
During the procedure, the surgeon uses devices known collectively as external fixators
Through skin incisions, the devices are attached to the bone from the outside of the skin
Metal pins are placed either side of the injured bone to hold it in place and securely anchor
the external fixator (Bell, 2008)
What are External Fixators?
External fixators are devices that include metal screws, wires, and plates. External fixators are
surgically placed in order to promote orthopedic healing while optimizing mobility. They
are used to stabilize, correct the alignment or change the bone position, and to correct cartilage
deformities (Bell, 2008).
Infection and External Fixation
Pins are used to secure the external fixators to the bone pierce the skin, thereby
introducing the risk of infection (Bell, 2008)
Cellulitis from Staphylococcus aureus is the most frequently occurring infection associated
with fixation treatment
Most infections are superficial but necrotizing infections, such as osteomyelitis, may occur
in severe cases
The Three Main Categories of Nursing Care for External Fixation
Assessment
Monitoring
Cleaning
Nursing Assessment for Internal and External Fixation
Assessment relies upon strong nursing skills and knowledge
Its vital to understand the difference between symptoms related to the normal healing
process, such as inflammation and pain, and those that indicate infection
The nurse must differentiate between reaction, colonization and infection
Nursing Care for Internal and External Fixation
Monitor for signs of infection, such as drainage and hot spots
Administer antibiotics to treat infections such as cellulitis, as ordered. Most antibiotics are
administered orally
Skeletal Traction
What is Skeletal Traction?
A non-surgical method that uses gravity, weights, or position
This is performed to temporarily immobilize or stabilize a broken bone in order to gradually
realign it
Forms of Skeletal Traction
Bucks traction
Cervical tong
Halo traction
Bucks Traction
Bucks traction is a method used to immobilize a fracture
Its designed to promote comfort by reducing muscle spasms
Skeletal Traction Care Mnemonic: TRACTION
Temperature of extremity is assessed for signs of infection
Ropes hang freely
Alignment of body
Circulation check (5 Ps)
Type and location of fracture
Increase fluid intake

Overhead trapeze
No weights on bed or floor
Nursing Care for Traction
Assess for skin breakdown, neurovascular, elimination and diversional activities
Remove at least 3 times per day to perform skin care and assess for breakdown
Cervical Tong Device
Cervical Tong
Used to realign the spinal cord in order to provide relief of symptoms following a cervical
injury
Weights must be handing free in order to pull the device taught
Nursing Considerations for Cervical Tong
Maintain weights
Assess for skin breakdown due to increased pressure
Cleaned by hydrogen peroxide at least once per shift
Cleaning the Halo Tong
The tong site is inspected for sings of infection of skin breakdown

A cotton swab applicator is soaked in sterile water or saline solution

The cotton swab applicator is used to gently remove the exudate, crust, and debris around
the tong site
Clean cotton swab applicators are used upon each are to prevent contamination
This procedure is performed every eight hours for the first week following insertion of tong
device (University of Toledo, April 2, 2013)
Halo Traction
What is Halo Traction?
Halo traction is used to immobilize a patients head and neck following a cervical fracture. Halos
are a type of harness or vest thats secured by a brace with the shape of an angels halo. Its
positioned on the patients head to reduces preoperative spinal misalignment while stabilizing
the cervical spine fracture and providing for ongoing immobilization. The halo vest is typically
used for 12 weeks, but duration can vary. Halos do not use weights; rather, theyre secured by
spikes that are drilled into the skull (Saro, Anthony, Magtoto., & Mauceri, 2010).
How Halo Traction is Applied
The upper portion of the vest is placed at the superior aspect of the scapulae (top of the shoulder
blade) and the opening in the posterior vest is placed in line with the spine. The upper edge of
the anterior vest exposes around 2 inches of the sternal notch. The four upright bars are
attached to the anterior and posterior joints (back portions) of the vest with the bolts positioned
on the outside while keeping the access to the posterior pins open. The thoracic bands are slid
into anterior vest and then locked into place. The shoulder straps are attached and the clamps
are tightened once the patients head is positioned into the proper alignment. The halo wrench is
secured onto the front of the vest or the upright bars (Saro, Anthony, Magtoto., & Mauceri, 2010).
Components of Halo Traction Apparatus
Halo ring, halo wrench, and halo crown
Skull pins
Anterior and posterior vest
Vest lining, made from a sheepskin-like material
Four upright bars
Thoracic bands and clamps
Two transverse bars (Saro, Anthony, Magtoto., & Mauceri, 2010)
Halo Traction Application Equipment
Torque wrench or torquing caps
Positioning pads
A spoon: removed after the halo crown is in place (Saro, Anthony, Magtoto., & Mauceri,
2010)
Contraindications of Halo Crown
Skull fractures
Chest trauma

Obesity
Advanced age (Saro, Anthony, Magtoto., & Mauceri, 2010)
Possible Complications of Halo Traction
Pin site infections
Pin loosening or dislodgement
Skin breakdown
Swallowing issues
Dural tears (Saro, Anthony, Magtoto., & Mauceri, 2010)
Nursing Considerations for Halo Traction
Risk of infection: as this is a highly invasive treatment, the patient is at risk for infection.
One of the most serious risks include meningitis
Positioning: when assisting the surgeon with halo crown placement, the patient must be
log-rolled after the spoon is removed. Ensure that proper positioning is used when
performing all nursing tasks
Care and cleaning: provide for halo pin and vest care
Provide for assessment of neurological, bowel, and bladder function, swallowing, skin, and
positioning of the device
If cardiopulmonary resuscitation is needed, the anterior portion of the halo vest will need
to be removed to perform chest compressions. This is achieved by loosening the two bolts
through the red emergency washers with the halo wrench, located on the anterior portion
of the vest. expose the sternum by releasing the straps and rotating the anterior portion of
the vest away from the body. Perform compressions with the patient in supine, lying on the
posterior portion of the vest
Teaching: the patient and family or caregiver requires a high level of education to prepare
for discharge. This include regular follow-up visits for monitoring and pin tightening and
teaching on care and cleaning of the pins. Educate the patient and caregiver on the signs
of pin site complications, such as infection can develop (Saro, Anthony, Magtoto., &
Mauceri, 2010)
Nursing Assessment for Halo Traction
Assess the vest placement to ensure that breathing is not constricted
Assess the pin sights for signs of loosening and infection, such as redness, swelling,
discharge, unusual drainage, and tracking
Assess alignment to ensure that it remains secure and stable
Assess for signs of skin breakdown, especially around the spike spots and under the vest
Assess neurological function, both sensory and motor, and examine the spinal cord
Assess motor, bowel, and bladder function
Assess swallowing function and monitor for signs of dysphagia
Patient Education for Halo Traction
Assistance will be required for many daily activities while the halo traction is in place
Bathing and grooming: do not take a shower when using halo traction, as this increases
the risk for infection. Sponge baths are used instead. Shampoo hair regularly to keep the
vest clean and reduce the risk of infection This is performed in supine by placing towel or
plastic bag along back and shoulders to protect the vest. Position the head gently by
suspending it beyond the top of the mattress to and place a basin under the head to catch
the water
Sleeping: the head should be supported with a small pillow when sleeping at night
Dressing: special alterations or oversized clothing may be necessary during placement
Vest care: clean the vest in a lateral supine position
Fracture Complications
Potential Complications of a Fracture
Hardware failure
Refracture
Malunion and nonunion
Osteomyelitis
Compartment syndrome

The 6 Ps of Compartment Syndrome

1. Pain on passive stretch of the compartment
2. Paresthesia along dermatomal patterns
3. Pulselessness
4. Pallor of the extremity
5. Polar or poikilothermia
6. Paralysis of the affected limb