Musculoskeletal Disorders Second Degree Strain

Etiology  involves moderate stretching and or

partial tearing of the muscle or tendon
 Trauma- contusion, sprain and strain,  ss and sx include acute pain during
dislocation precipitating events, followed by
 Infection tenderness at the site with increase
 Metabolic disorders pain with passive ROM, edema, muscle
 Endocrine disorders spasm and ecchymosis
 Tumors
 Congenital Anomalies Third Degree Strain
 Neurologic disorders  severe or muscle or tendon stretching
 Psychologic disorders with rupturing and tearing of the
Contusion involve tissue
 A soft tissue injury produce by blunt  ss and sx include immediate pain
force (such as blow, kick or fall) causing described by tearing, snapping, burning,
muscle spasm, ecchymosis, edema, and
small blood vessels to rupture and
loss of function
bleed into soft tissues (results to
ecchymosis or bruising)
Sprain
 Hematoma develops from bleeding at
the site of impact leaving a dark and  Excessive stretching/tearing of the
blue appearance LIGAMENTS and tendons cause by
 Signs includes pain, swelling and twisting motion or hyperextension of a
discoloration joint (NAON, 2013)
 Resolve in 1-2 weeks  Ligament connects bone to bone and its
function is to stabilize a joint while
Strain permitting mobility. An injured ligament
 Excessive stretching, over use or causes joints instability (unsteadiness)
excessive stress or injury of Muscle or
Tendon (NAON, 2013) Degree or Grade of Sprains
First Degree/ Mild Grade Strain
Types  Tears in some fibers of the ligament and
Acute Strains mild localized hematoma formation
 result from abrupt and single injurious  Ss and sx include mild pain, edema, and
incident local tenderness
Chronic Strains
 results from repetitive injuries and from Second Degree/ Moderate Grade Sprain
improper management of acute strains  Partial tearing of the ligament
 Increased edema, tenderness, pain with
Degrees of Strains motion, joint instability and partial loss
of normal joint function
First Degree
 mild stretching of the muscle or tendon Third Degree/ Severe Grade Sprain
with no loss of ROM  Ligament is completely torn or ruptured
 ss and sx may include gradual onset of  It may also cause avulsion
palpation induce tenderness and mild  Severe pain, increase edema, and
muscle spasm abnormal joint motion
Causes
 most common causes of sprains are
falling, twisting, or experiencing trauma
to the joint.
 circumstances: Ankle — Walking or
exercising on an uneven surface,
landing awkwardly from a jump. Knee
— Pivoting during an athletic activity.
Diagnostic
X-ray
 to rule out bone injury because an
avulsion fracture ( bine fragment is
pulled away from the bone by a
tendon) may be associated with third
degree strain
 do not reveal injuries to soft tissues or
muscles, tendons or ligaments
MRI and Ultrasound
 can identify tendon injury
Management for SPRAIN, Strain , Contusion
P-Protect from further injury
 it is accomplish through support of the
affected area using slings and splinting
R-Rest
 prevents additional injury and promotes
healing
I-Ice.
 Intermittent application of cold packs
during the first 24-72 hours after injury
produces vasoconstriction which
decreases bleeding, edema and
discomfort
 Cold packs should be in place for more
than 20 minutes at a time to avoid skin
and tissue damage from excessive cold
(NAON, 2013)
C-Compression bandage
 Elastic compression bandage controls
bleeding, reduces edema, and provides
support for the injured tissues
E-Elevate the affected part
 Elevate or just the level of the heart
controls swelling
Other interventions
 Monitor neuro vascular status
(circulation, motion and sensation) of
the injured extremity (q15minutes for
the first 1-2 hours after injury ) and then
lesser at intervals.
 Documented and reported to the PHCP
if there are decrease sensation, motion
and increase in pain level should be
immediately to prevent compartment
syndrome
 L- Limit joint activity
 I- Immobilized the affected part if third
degree using splint, brace, and cast
 A- Administer NSAID’s and muscle
relaxant for pain management
JOINT DISLOCATION
 A condition in which the articular
surfaces of the distal and proximal
bones that forms that forms the joint
are not longer in anatomic position
 Displacement of the bone from its
normal joint position to the extent that
articulating surfaces loss contact.
Causes
 Trauma that forces a joint out of
place causes a dislocation
 Car accidents, falls, and contact sports
such as football are common causes of
this injury
Common Joint Dislocations
 Shoulder was the most prevalent site
of dislocation (50.6%),
 followed by fingers (10.1%),
 toes (7.6%),
 hip (7.3%), and elbow (6.5%).
Types
SUBLUXATION
 Partial disarticulation of the joint and
does not cause as much deformity as
complete dislocation
COMPLETE Dislocation
 The bones are literally out of the joint/
complete disarticulation of the joint

 Note: Traumatic Dislocations are
emergency because the associated joint
structures, blood supply, and nerves are
displaced and maybe entrapped with
extensive pressure on them
 If a dislocation or sublaxation is not
reduced immediately, it will result to
AVASCULAR NECROSIS, AVN of bone is
caused by ischemia leading necrosis or
dead bone cells
Signs and Symptoms
 Acute pain,
 Change or awkward positioning of the
joint
 Decrease ROM
 Bilateral assessment will make apparent
abnormality in the affected joint
compare to non affected
Diagnostic Test
X Ray- confirm the diagnosis and reveal any
associated fracture
Medical Management
 Immobilized the joint by splints, cast
and traction and maintained in stable
position. Immobilized the joint at the
scene and during transport in the
hospital
 Dislocation is promptly reduced and
displaced parts are place back in proper
anatomic position to preserve joint
function
 Analgesic and muscle relaxant and
anesthesia are use to facilitate closed
reduction
 After reduction, if the joint is stable,
gentle progressive, active and passive
movement is begun to preserve ROM
and restore strength
 Surgery
Nursing Interventions
 Assess level of pain and evaluation of
injury with complete neurovascular
assessment every 15 minutes until
stable
 Educate patient and family members
regarding proper exercises and
activities
 Educate on the danger signs such as
increasing pain uncontrolled with
analgesics, numbness or tingling and
increase edema in the extremities as
these are signs of Compartment
Syndrome. If CS is not identified and
communicated properly to PHCP, it may
lead to disability or loss of extremity
 Administer NSAIDS or analgesics
CONGENITAL HIP DISLOCATION
 Displacement of the head of the femur
from the acetabulum
INITIAL MANIFESTATION
• Limitation of abduction
Ortolani’s Click
 Palpable click dislocation
 Supine, bend the knees and place
thumb on bend knees and fingers at hip
point
 Bring femur 90 degrees to hip, then
abduct
Barlow’s test
• With infant on back, bend knees
• Affected knee will be lower because the
head of the femur dislocates towards
the bed of gravity.
• Additional skin folds with knees bent
Collaborative Management
• Position the hip in abduction with the
head of the femur in the acetabulum
• Traction and Casting
• Surgery
What is a bone fracture? 
Bone Fractures
 It’s a break or crack in a bone.
 Is a complete or incomplete disruption
in the continuity of bone and it is
defined according to its type and extent
 When the bone is broken, adjacent
structures are also affected which may
result to soft tissue edema, hemorrhage
into the muscles and joints, joints
 dislocations, rupture tendons, severed
nerves and damage blood vessels. Body
organs may be injured also by force that
cause the fracture or by fracture
fragments
Causes of Bone Fractures: it happens because
the bone can NOT withstand the force
 Trauma (fall, car accident, direct blows,
crushing forces etc.)
 Twisting (sports injury, abuse etc.)
 Extreme muscle contractions
 Diseases (bone cancer or osteoporosis)
NOTE
 Children tend to heal faster than adults
from bone fractures because the
periosteum (the dense fibrous
membrane covering the bones) is
stronger, more flexible, and thicker
than an adults.
 It can take anywhere from 3 to 12
weeks to heal from a bone fracture,
depending on the person’s age and
health status.
TYPES of FRACTURES
 Fractures types are classified by
location (proximal, distal, midshaft), and
type
 Are also described according to degree
of break (greenstick- partial break) or
character of any fractured bone
fragments
Fracture According to Broad Classification
Did it break through the skin? Open or closed
Closed Fracture (“Simple”)
 a fractured bone that does NOT
penetrate through the skin (skin
remains intact)
 it does not cause a break in the skin
Open Fracture (“Compound or Complex”)
 a fractured bone that breaks through
the ski, with or without protrusion of
the bone
Grades of Open Fractures (Halawi, Morhood,
2015)
Type 1- clean wound less than 1 cm long
Type 2- is a larger wound without extensive
soft tissue damage or avulsions ( an injury in
which a body structure is torn off by either
trauma or surgery)
Type 3- most severe with highly contaminated
and has extensive soft tissue damage. It is
accompanied by traumatic amputation
COMPLETE FRACTURE
 Periosteum and cortical tissue
completely broken on both sides of
bones
 Entire circumference of the bone is
impaired
INCOMPLETE FX/ Greenstick
 Bone broken, bent, but still securely at
one side
 One side of the bone is broken and the
other side is bent
 Affects cartilaginous bones and
common in children
Fracture According to Pattern
Transverse
 Breaks run across the bone
 A fracture that is straight across the
bone shaft
Spiral
 Breaks coil around the bone
 the fracture twists around the bone
shaft (from a twisting injury)
OBLIQUE
 Breaks runs in slanting direction
 the fracture is slanted across the
bone shaft
LONGITUDINAL
 Breaks run parallel with bone
Fracture According to Appearance
COMMINUTED
 Bone splintered into fragment
 3-more fragment
IMPACTED Common Fractures of Bones (Location)
 the fractured end bones are pushed COLLES’ FX
into each other  Fracture of distal radius
 a fracture in which a bone fragment is  complete fracture of the radius bone of
driven into another bone fragment the forearm close to the wrist resulting
in an upward (posterior) displacement
Linear Skull Fracture of the radius and obvious deformity.
 a break in a cranial bone resembling a
thin line, without splintering, Smith fracture
depression, or distortion of bone.  is a fracture of the distal radius.
 The radius is the larger of the two
COMPRESSION bones in the arm. The end of the
 Is one in which bone typically the radius bone toward the hand is
vertebra collapses itself called the distal end.
 The bone has been compressed
DEPRESSED Pott’s Fx
 Usually occurs in the skull with the • Fracture of bimalleolar
broken bone being driven inward ankle fractures
 A fracture in which bone has been
Clinical Manifestations
compressed
Acute pain/ Tenderness of the site
 Seen frequently in fractures of skull and
 Aggravated by motion (pain is
facial bones
continuous and increases ) so it should
be immobilized.
Other types of Fractures
Loss of function
 After a fracture the extremity cannot
Avulsion
function properly because the normal
 A fragment of a bone has been pulled
function of the muscles depends on the
away by a tendon and its attachment
integrity of bones to which they are
 occurs, the tendon or ligament pulls off
attached. Pain contributes to loss of
a piece of the bone.
function. False motion maybe present
 Avulsion fractures can occur anywhere
in the body, but they are more common
Deformity
in a few specific locations
 Displacement, angulation, or rotation of
Epiphyseal
the fragments in a fracture leg or arm
 Fracture through the epiphysis
causes a deformity that is detectable
Stress Fracture
when the limb is compared to uninjured
 A fracture that results from repeated
extremity
use of bone and muscle
 Ex: adduction and external rotation of
Pathologic
the hip in hip fracture
 A fracture that occurs through an area
of diseased bone like osteoporosis,
Shortening of the limb
osteomalacia, cancer and tumor
 Common In fracture long bones,
 Can occur without trauma or fall
because of the compression of the
Traumatic
fracture bone or spasm of muscles
 Due to injury
causing the distal and proximal site of
Fracture Dislocation
fracture to overlap causing the
 When a fracture is accompanied by a
extremity to shorten
bone out from the joint.
Crepitus
 Grating sounds as the end bones rub
together
Localized edema/ Ecchymosis
 Due to trauma and bleeding into the
tissues
 It may develop within an hour
depending on the severity of the
fracture
Bleeding from an open wound
 Due to severed blood vessels
“BROKEN”
Bruising over the site (discolored with swelling)
and pain
Reduced movement of extremity or muscle
Odd appearance (looks abnormal)
Crackling sounds due to bone fragments
rubbing together (crepitus)
Edema and erythema at the site
Neurovascular impairment…6 P’s (ischemia:
pain, pallor, paralysis, paresthesia,
pulselessness (late sign), poikilothermia)
Complications
 Hypovolemic shock-due to massive
bleeding
 Fat embolism- related to fracture
of the long bones leading to ARDS
 Tetanus.
Emergency Management
 The body part must be immobilized
immediately after the injury by
adequate splinting,. WHY is this
important to do? The goal is to help a
bone fracture heal properly by putting it
back in its original state (if it moves this
can cause improper healing). In
addition, it prevents more surrounding
tissue damage, bleeding, and pain
 Immobilization of the long bones in the
lower extremity by bandaging the legs
together.
 In upper extremity is injured, use
bandaged to the chest or use slings if
fore arm is injured
 Assess neurovascular status before and
after splinting to determine adequacy of
tissue perfusion and nerve function
 Stop bleeding, if present, by applying
pressure with a clean cloth
 If the fracture is an opened
“compound” fracture, cover with sterile
dressing to prevent contamination of
deep tissues
 No attempt is made to reduce fx if one
of the bone fragment is protruding
through the wound
 Apply ice wrapped in towel to the injury
to decrease swelling (want to prevent
excessive swelling due to the risk of
compartment syndrome).
 Clothes are gently remove from the
uninjured site first then from the
injured site or it can be cut away
Medical Management for Bone Fracture:
Bone reduction
 putting the fractured bone back in its
original state.
 Restore the fractured fragment to
anatomic alignment and positioning
either closed or open reduction to
reduce the fracture
 The physician reduce the fracture as
soon as possible to prevent loss of
elasticity from the tissues through
infiltration by edema or bleeding
Types
Closed reduction External Fixation
 Done by manual manipulation
followed by application of cast,
Pins, wires, screws are located
externally.
  fixture attached to the outside of the
skin that helps with bone healing (can
be adjusted…metal braces, screws)
Open reduction with Internal Fixation
 done surgically to put fractured bone
back in its original state and a fixation
device used:
 Internal fixation – the devices
attached directly to the bone using
pins, rods, plates, screws, nails to
hold the bone fragment in position
until bone healing occurs
 ensure firm fixation of bone fragment
Nursing Interventions of the Patient with
Reduction
 Monitor for disorientation and
confusion (elderly)- this may result from
stress, unfamiliar surroundings and
other
 Do neurovascular checks (CMS)
 Encourage the use of OHT to facilitate
movement
 Check dressings for bleeding and
infection
 Empty hemovac. Serousanguinos
drainage is normal
 Hemovac- is a wound drainage system.
Its purpose is to collect fluid from your
surgical area by the use of suction. By
removing this fluid, your surgical area
will be able to heal faster with less risk
of infection.
 Assess LOC. Bleeding causes altered
LOC
 Turn to un-operative side only- to
prevent pressure on the operative site
 Place 2 pillows between legs while
turning and when lying on the side
 Implement measure to prevent
thrombus formation (Elastic hose,
Dorsiflexion of the foot, Quadricept
setting and gluteal setting,
anticoagulant)
 Assist patient in getting in and out of
bed on first and second post op day
 Administer Analgesics
Cast (plaster or fiberglass) placed to keep
broken bone in place to allow it to heal. The
cast maintains the reduction and stabilizes
the extremity for bone healing
Things to remember about casts:
 Monitor for compartment syndrome:
6 P’s
 Monitor for infection: hotspots in the
cast, severe pain, fever
 Keep the cast and extremity
elevated above the heart level
(decreases swelling)
 Apply ice packs to the cast for the
first 2 days to decrease swelling
 Even drying for new cast by turning
every 2 hours
 Use palms of hand to handle (not
fingertips) with a new wet plaster
cast. WHY? Prevents dent formation
in the cast by handling with the
palms of hand, which can cause skin
breakdown overtime.
 Maintain skin integrity: petal the
cast….. use soft tape called moleskin
around the edge to prevent skin
breakdown
 Keep cast dry and never stick
anything inside to scratch an itch
Traction: aligns the bone with a constant steady
pulling action.
 Make sure the weights are hanging
freely and not on floor
 Never remove weights with a MD
order
 Pin care and monitor for infection
(odorous draining, redness, pain)
 Neurovascular status: 6 P’s
 Overhead trapeze bar to move
around in bed
What is Compartment Syndrome?
Compartment syndrome occurs when too much
pressure is exerted within the muscle
compartments found within the fascia.
This can occur when there is hemorrhaging
(bleeding) or swelling present after an injury,
like with a bone fracture (or with external
factors like a cast being too tight or traction). All
this can increase the pressure within the
compartments. As the pressure builds, this will
cut off the blood supply and nerve function to
this muscle. If not corrected within 6 hours, the
damage is permanent.
Remember from anatomy and physiology that
in the leg and arm there are individual
compartments grouped together (but separated
from one another) that contain bone, muscle,
nerves, and vessels. Each compartment usually
has it own muscle, nerve, and vessel supply.
Fascia is what keeps all these structures in place
and separated.
The important thing to remember about fascia
when talking about compartment syndrome is
that is does NOT expand when pressure
increases within a compartment (so there will
be no relief within the compartment from the
fascia).
Instead the pressure stays within the
compartment and causes blood vessel and
nerve function to become compromised
(diminished). So, ischemia is going to occur to
the muscle and distal extremity to the fracture.
Assess the 6 P’s:
Pain (early sign)
Paresthesia (can be an early sign too)
Pallor, Paralysis, Poikilothermia
Pulselessness (late sign)
Pain: worst with passive touch or movement,
elevating the limb, or any pressure, stretching
increases the pain. Pain medication is not
relieving it.
Paresthesia: patient may report it feels like the
extremity distal to the fracture feels like it is
falling asleep or a “pin and needle” sensation.
Can they feel you touch their
extremity? ALWAYS CHECK THE UNAFFECTED
EXTREMITY TO COMPARE!
Pallor: Extremity should be pink and have
normal capillary refill less than 2 seconds. In CS,
it may appear pale or dusky and have a capillary
refill greater than 2 seconds. ALWAYS CHECK
THE UNAFFECTED EXTREMITY TO COMPARE!
Paralysis: can the patient move the distal
extremity from the fracture or has the
movement decreased…this is a bad
sign! ALWAYS CHECK THE UNAFFECTED
EXTREMITY TO COMPARE!
Poikilothermia: This occurs when the affected
extremity distal from the fracture feels cooler to
the touch compared to the unaffected
extremity. The extremity can NOT regulate its
temperature.
Pulselessness: Always mark the pulses with a
black marker and have a Doppler available to
monitor the sound of the pulse. (this is a late
sign in compartment syndrome)
Nursing interventions for Compartment
Syndrome:
 keep the extremity AT HEART level
(NOT below….remember you want
to maintain arterial pressure and
elevating it above heart level will
cause more ischemia)
 loosen and remove restrictive items
 notify the physician
 perform neurovascular checks (6 P’s)
 prepare the patient for possible
bivalvement of the cast,
 reduction of weight in the traction, or
in severe cases fasciotomy.