Chapter 51: Care of Patients with Musculoskeletal Trauma

Priority concepts applied in this chapter are MOBILITY and PERFUSION.

 Musculoskeletal trauma is one of the primary causes of disability, ranging from simple muscle strain to multiple
bone fractures with severe soft-tissue damage. 
 These injuries also affect SENSORY PERCEPTION and COMFORT because of pressure on nerve endings
from edema. In some cases, peripheral nerves are directly damaged as a result of musculoskeletal injury. 
 Amputations result in impaired tissue integrity and are often performed due to inadequate arterial PERFUSION
due to chronic disease. 
 Injury is a definable, correctable event with specific identifiable risks. 
 An important role in nursing is educating the public about how to prevent musculoskeletal trauma/other injuries. 

• Fractures
• A fracture is a break or disruption in the continuity of a bone that often affects MOBILITY and
causes impaired COMFORT. Classifications include:
•
1. Complete: break across the entire width 2pc
2. Incomplete: breaks only part of the bone
3. Open (compound:) skin is broken causes wound
4. closed (simple): does not break skin no wound
5. Fragility: (pathologic/spontaneous) after minimal trauma, the bone is weakened by
disease like bone cancer & osteoporosis
6. Fatigue or stress: results from strain and stress on bone
7. Compression: Produced by a loading force applied to a long axis of cancellous bone,
commonly on vertebra of older adults with osteoporosis extremely painful

 The primary cause of a fracture is trauma from a motor vehicle accident or fall, especially in older adults. . 
 Sports, vigorous exercise, and malnutrition are contributing factors. 
 Factors that affect healing include the severity of the trauma, the type of bone injured, type of management,
infections, and ischemic or avascular necrosis. 
 Hip fractures include those involving the upper third of the femur and are classified as intracapsular (within
the joint capsule) or extracapsular (outside the joint capsule). These types are further divided according to
fracture location. 
 After a hip repair, older adults frequently experience acute confusion or delirium. 
 The primary nursing concern is assessment and prevention of neurovascular dysfunction or compromise.
Marked neurovascular compromise will significantly decrease arterial PERFUSION. 

• 5 Stages of Bone Healing

1. (24-72 hr) hematoma forms

2. (3 days-2 w) granulation tissue promotes
fibrocartilage= foundation for bone healing
3. Vascular cell proliferation callus (nonbony
union) 3-6w
4. Callus -> bone (3-8w)
5. Consolidation and remodeling bone meet
mechanical demands (4-6w to 1y).
young, healthy adult bone, healing 4 to 6 weeks. older person complete healing often takes 3 to 6 months.
• Fractures of Specific Sites

• Upper extremity: Usually occurs in the distal radios

• Lower extremity: Most commonly affect the hip in older adults
• Hip fracture: pain in groin area, back of the knee and lower
back. Surgery
• Intracapsular: within joint capsule
• Extracapsular: outside of the joint capsule
• Open reduction internal fixation (ORIF): rods and pins
• Delirium after repair: monitor for falls, sleep, silent D.
• Abduction Pillows
• Straight leg exercise
• Ankle Tibia, fibula toes
• Chest:
• Rib or sternum concern: ASSESS Breathing!
• Can puncture heart, lungs, arteries & are at high risk for pneumonia
• Straining with deep breaths
• Pelvis
• Close to blood vessels and arteries, watch out for bleeding, shock (loss of blood),
check vital signs,
• Bladder and urine, hematuria, blood in stool
• Ultrasound: best/rapid bedside method to assess for bleeding
• Spine
• Painful back pain, associated with osteoporosis, metastatic bone cancer, multiple
myeloma.
• Treat with bead rest, nerve blocks, pain meds,
• Vertebroplasty:
Minimally invasive, bone cement is injected through the skin
directly into the fracture to provide stability and immediate pain
relief
• Kyphoplasty
Using a Balloon or cavity creating device to partially expand a
compressed vertebral body

Complications of Fractures

• Acute Compartment Syndrome (ACS) *chart 51-1

• Serious Limb-threatening condition in which increased pressure in one or more
compartments causes decreased PERFUSION and further ischemia results. 
• Assess for the “six Ps: pain, pressure, paralysis, paresthesia, pallor, and
pulselessness (rare or late stage). 
• SENSORY PERCEPTION deficits or paresthesia usually appear first.
o The most common sites are the compartments in the lower leg and forearm.
o Identify the patient at risk, and loosen bandages or request that the patient’s
cast be cut if neurovascular compromise is noted.
 • If ACS is suspected, notify the health care provider or immediately, and if possible,
implement interventions to relieve the pressure.
• Crush syndrome 
• any part of the body is crushed leading to shock and renal failure
• Rhabdomyolysis: muscle tissue breaks down and travels to the kidneys 
• Hemorrhage: leading to hypovolemic shock
• Fat embolism syndrome
• (FES), more common in those with a fractured hip or fractured pelvis, fat
globules are released into the bloodstream and clog small vessels, often in the
lungs, and impair PERFUSION, resulting in respiratory failure or death.
o The earliest manifestations of FES are a low arterial oxygen level
(hypoxemia), dyspnea, and tachypnea (increased respirations).
o When the lungs are affected, the complication may be misdiagnosed as a
pulmonary embolism from a blood clot.
• Venous thromboembolism: DVT, PE, PT at risk (cancer, obesity, heart disease, older etc)
• Infection: osteomyelitis
• Complex Regional Pain Syndrome (CRPS)
• Dysfunction of the central and peripheral nervous systems that leads to severe,
chronic pain. Common in hands and feet
• Triad of Symptoms
• Autonomic NS: color changes, temperature, sensitivity of skin, sweating,
edema
• Motor Symptoms: paresis, muscle spasms, loss of function
• Sensory Perception: intense burring pain becomes intractable
• Over time spotty diffuse osteoporosis can be seen on x-ray examination
• Timing is important for treatment, maintain ROM, Nerve Blocks, PT/OT

Priority Problems

• Acute pain
• Muscle spasms increased edema
• Decreased mobility
• Potential for neurovascular compromise
• The tissue has become impaired
• Potential for infection

Teaching

• Nutrition risk for osteoporosis

• Screening
• Fall prevention and home safety
• Drinking and driving causes motor accident

Assessment (assure comfort first)

• History
 • Events leading up to injury, Drug use, work, lifestyle

Assessment

• Physical
• Assess for the “six Ps: pain, pressure, paralysis, paresthesia, pallor, and
pulselessness (rare or late stage). Chart 51-3
• Check all body systems 
• Psychosocial
• Disrupted lifestyle with rehab and stress, depression. Nurse provides hope
the pain management will improve comfort level restore energy and return
to usual life
• Special considerations
• Check urine for blood, swelling, perfusion, skin integrity, check injury
side first and compare
• Diagnostic Assessment
• Laboratory assessment
• Hemoglobin and Hematocrit (H&H) =low (bleeding)
• Erythrocyte sediment rate (ESR) = high (soft tissue damage)
• WBC= high (infection)
• Calcium /phosphorus = high (healing)
• Imaging assessment
• X-ray= confirm diagnosis
• CT = detect fractures of complete structures
• MRI= soft-tissue damage

Managing Fractures
Nonsurgical management
◦ Closed reduction and immobilization:
• reduction means realigning the bone (closed fractures only) w/
Immobilization devices
• Splints are prefeed over a cast because it allows more room
• Fracture occurs= elevate the extremity and apply ice to reduce swelling
◦ Traction
• The application of a pulling force to part of the body to provide reduction,
alignment and rest. Also as a last resort to decrease muscle spasm (relives
pain) and prevent or correct deformity and tissue damage
◦ Physical therapy
◦ Medications
Immobilization Devices
◦ Short boot, long boot, splint
◦ Casts
• Wet plaster:
• Old needs 24hr to dry
• One finger
• Check fingers capillary refill
 • Bivalve: If cast is too tight
Cut it lengthwise into two equal pieces one half is inspected
and then it is held together by an elastic bandage wrap
• synthetic fiberglass it’s lighter and dries a lot quicker
• decreases risk of impaired tissue integrity
• Arm cast: elevate above heart to reduce swelling use sling
◦ Traction
• Uses bed frame (nurse can’t remove)
• Check vascular status/ skin every 8hr
• Skin: (5-10lb)
• Skeletal: uses weights (15-30lb) for longer time, check sight for
redness swelling, infection,
◦ External Fixation Device
• System in which pins and wires are inserted through the skin and affected
bone and then connected to a rigid external frame.
◦ Open reduction with internal fixation (ORIF)
• Surgery allows early mobility
• Open reduction: allows the surgeon to directly view the fracture
• internal fixation: uses metal pins, screws, rods, plates, or prostheses to
immobilize the fracture during healing
◦ Surgery use abduction pillows elevate the foot of the bed and reposition every 2
hours
Managing Acute Pain
◦ Drug therapy
• Opioids, non-opioids, PCA’s
◦ Complementary and alternative therapies
• Ice, imagery, distraction, elevating leg
Improving Physical Mobility
◦ Gait training
◦ Use of crutches
• 3 point crutch-
• Link: https://www.youtube.com/watch?v=AkCtAe0arQI
◦ Use of walkers and canes (need good upper body strength)
Prevent Neurovascular Dysfunction
◦ Assess for 6 Ps
Preventing Infection
◦ Assess for fever, WBCs, wound cultures, inflammation, purulent drainage
◦ Promote Adequate Nutrition
◦ Protein and calcium (bone and tissue healing)
◦ Iron (bone marrow)
◦ Stool softener (opioids)
Amputation
◦ Last Resort
◦ The higher the amputation the more energy required to move around
◦ Upper body interfere with ADLs more early prostatic replacement is vital (upper)
◦ Elective usually for disease
 Complications of amputation

• Infection, hemorrhage, contracture (you can’t straiten that part of the body)
• Flexion contractures = in PT with lower limb amp. Prevent with ROM, position
changes in early post op (don’t position PT in semi-fowlers all day)
• Phantom Limb Pain (PLP)
o Pain burning, crushing sensation, or cramping
o Some feel that the removed body part is in a distorted, uncomfortable
position
o More common on chronic limb pain than trauma amputation
o Beta Blockers, antiepileptic drugs, antispasmodics, massage relaxation, do
not use opioids

Mobility After Amputation

• ROM (flexion contractures no semi-F) sometimes prone but maintain elevation of

extremities
• Trapeze and overhead frame
• Prosthetics

“Stump” or Limb Care

• Custom fit for PT, teach care, cleaning sockets inserts liners
• Use a figure 8 wrapping – prevents blood flow restriction, shrinks edema,

Prevent Amputation

• Lifestyle modification:
• Weight exercise smoking, risky behaviors
• Stick to diabetic plan

Goals after amputation

• Make sure limb has good peripheral perfusion

• Pain is under control
• PT moves around independently
• Drainage no infection
• Positive self-esteem and lifestyle adaptation

Other Musculoskeletal Injuries

• Knee Injury
• MacMurray Test: clicking sound is a positive test
• PT need analgesics, my need an immobilizer
•
• Rotator Cuff injury
• Shoulder
 • Drop arm test: you cannot maintain abduction so arm drops =positive test
• Treatment: pain medication, NSAIDS, PT steroids
• Musculoskeletal Injuries
• Rice technique
R: rest. (splint if needed)
I: ice. (first 24-48hr) (heat after)
C: compression (24-48hr) (elastic wrap)
E: elevation (decrease swelling)