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Musculoskeletal disorders
FRACTURES:
A traumatic injury interrupting bone continuity
Types:
2. Open, compound, complicated fractures – involve trauma to surrounding tissue and a break in the
skin
Patterns of Fracture
5. Comminuted fractures – produce several breaks of the bone, producing splinter fragments
6. Spiral (torsion) fractures – involve a fracture twisting around the shaft of the bone
8. Oblique fractures – occur at an angle across the bone (less than a transverse)
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Etiology:
Potential Complications
a. Fat embolism syndrome – release of fat globules from the bone marrow into the
circulation after fracture
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Fasciotomy: incision of the skin into the fascia of the muscle compartment allows for
tissue expansion and restores blood flow by relieving pressure on microcirculation
c. Delayed union, Nonunion (non-healing 4-6 months after initial injury), and fibrous union
of the fracture side
f. Cast syndrome
Implementation
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1. Assess pain
• rate scale
• take action: use nonpharmacologic interventions like relaxation technique, massage and
guided imagery
• Assess various locations, including radial, brachial, pedal, posterior tibial, popliteal, and
femoral pulses. Always mark pulses with an X.
• Document pulse strength using a scale of 0 to 4+: 0, no pulse; 1+, weak; 2+, normal; 3+,
strong; 4+, bounding
• Determine whether the client can ascertain dull or sharp touch sensation
• Determine whether the client can move and lift the affected extremity
• Ascertain whether the client can push the affected extremity against pressure
• Determine whether the client’s extremity feels cool or has a bluish color
• Elevate the injured extremity above the level of the client’s heart for the first 24 hours as
ordered
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• Apply cold packs as ordered for 15-20 minutes intermittently the 1st 24 hours –
vasoconstricting effects of cold retard extravasation of blood and lymph (edema) and suppress
pain
• After 24 hours, apply mild heat (15-30 minutes, 4 times daily) – to promote absorption
c. Promote mobility
• Assist the client with active and passive range of motion exercises for unaffected body parts to
help maintain function
d. Prevent infection
• Instruct the client in and have him demonstrate safe transfer, ambulating and sitting techniques
to prevent further injury from the immobilization
f. Promote the client’s participation in self-care activities within limitation of the injury and
treatment regimen
g. Minimize anxiety
Assessment Findings
a. Pain
b. Edema (due to localization of serous fluid at the fracture site and extravasation of blood into
surrounding tissues.
c. Tenderness
d. Abnormal movement and crepitus (grating sound heard when fractured limb is moved)
e. Loss of function
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g. Visible deformity (caused by muscle spasms leading to limb shortening, a rotational deformity, or
angulation)
Nursing Assessment
• Ask patient how the fracture occurred - mechanism of injury important in determining possible associated
injuries.
• Ask patient to describe location, character, and intensity of pain to help determine possible source of
discomfort.
• To aid in evaluation of neurovascular status ask patient to describe sensations in injured extremity.
• To assess functional mobility observe patient's ability to change position.
• Note patient's emotional status and behavior - indicators of ability to cope with stress of injury.
• Assess patient's support system; identify current and potential sources of support, assistance, and
caregiving.
• Review findings on past and present health status to aid in formulating care plan.
NURSING ALERT
Change in behavior or cerebral functioning may be an early indicator of cerebral
anoxia from shock or pulmonary or fat emboli.
Nursing Diagnosis
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Nursing Interventions
• Monitor vital signs as frequently as clinical condition indicates, observing for hypotension, elevated pulse,
widening pulse pressure, cold clammy skin, restlessness, pallor.
• Watch for evidence of hemorrhage on dressings or in drainage containers.
• Review laboratory data; report abnormal values.
• Administer prescribed fluids/blood to maintain circulating volume.
• Monitor intake and output.
• Evaluate changes in mental status and restlessness that may indicate hypoxia.
• Review diagnostic evaluation data - especially ABG values and chest X-ray.
• Position to enhance respiratory effort. Report any sudden or progressive changes in respiratory status.
• Encourage coughing and deep breathing to promote lung expansion and
diminish pooling of pulmonary secretions.
• Monitor pulse oximetry. Administer oxygen as prescribed.
• Maintain cervical spine precautions if spinal injury is suspected.
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NURSING ALERT
Monitoring the neurovascular integrity of the injured extremity is essential.
Development of compartment syndrome (increased tissue pressure causing hypoxemia)
leads to permanent loss of function in 6 to 8 hours. This situation must be identified and
managed promptly.
Relieving Pain
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• Methods
o Closed reduction
o Principles:
Ma. Elena I. Momongan, R.N.
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b. Avoid friction
• Types:
a. Skin traction: weights attached to adhesive, which is applied to the skin
Longitudinal force load: 5-7 lbs
Bryant’s traction – both lower limbs extended vertically; used to align fractured femurs in
young children
Indication: Femoral fractures, hip injuries (for children below 4 years old)
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Russel traction: balanced traction in which the lower leg is supported in a hammock –
attached to a rope and pulleys on a Balkan frame
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• Assess for pain, deformity, swelling, motor and sensory function, and circulatory status of the affected
extremity.
• Assess skin condition of the affected extremity, under skin traction and around skeletal traction, as well as
over body prominences throughout the body.
• Assess traction equipment for safety and effectiveness.
o The patient is placed on a firm mattress.
o The ropes and the pulleys should be in alignment.
o The pull should be in line with the long axis of the bone.
o Any factor that might reduce the pull or alter its direction must be
eliminated.
Weights should hang freely.
Ropes should be unobstructed and not in contact with the bed or
equipment.
Help the patient to pull himself or herself up in bed at frequent
intervals.
o The amount of weight applied in skin traction must not exceed the
tolerance of the skin. The condition of the skin must be inspected
frequently.
o Cover exposed sharp ends of skeletal pins with cork or other pin covering to
protect patient and caregivers from injury.
• Assess emotional reaction to condition and traction.
• Assess understanding of the treatment plan.
NURSING ALERT
Traction is not accomplished if the knot in the rope or the footplate is touching the
pulley or the foot of the bed or if the weights are resting on the floor. Never remove the
weights when repositioning the patient who is in skeletal traction because this will
interrupt the line of pull and cause the patient considerable pain.
Nursing Diagnoses
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Nursing Interventions
• Encourage active exercise of uninvolved muscles and joints to maintain strength and function. Dorsiflex
feet hourly to avoid development of footdrop and aid in venous return.
• Encourage deep breathing hourly to facilitate expansion of lungs and movement of respiratory secretions.
• Auscultate lung fields twice per day.
• Encourage fluid intake of 2,000 to 2,500 mL daily.
• Provide balanced high-fiber diet rich in protein; avoid excessive calcium intake.
• Establish bowel routine through use of diet and stool softeners, laxatives, and enemas, as prescribed.
• Prevent pressure on the calf, and evaluate twice daily for the development of thrombophlebitis.
• Check traction apparatus at repeated intervals - the traction must be continuous to be effective, unless
prescribed as intermittent, as with pelvic traction.
NURSING ALERT
Every complaint of the patient in traction should be investigated immediately to prevent injury.
• Assess motor and sensory function of specific nerves that might be compromised.
o Peroneal nerve - have patient point great toe toward nose; check sensation on dorsum of foot;
presence of footdrop.
o Radial nerve - have patient extend thumb; check sensation in web between thumb and index finger.
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• Determine adequacy of circulation (eg, color, temperature, motion, capillary refill of peripheral fingers
or toes).
• Report promptly if change in neurovascular status is identified.
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b. Endoprosthetic replacement
d. Open Reduction with External fixation device- when fractures accompany soft
tissue injury
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CASTS
• A cast is an immobilizing device made up of layers of plaster or fiberglass (water-
activated polyurethane resin) bandages molded to the body part that it encases.
• Purposes
• To immobilize and hold bone fragments in reduction
• To apply uniform compression of soft tissues
• To permit early mobilization
• To correct and prevent deformities
• To support and stabilize weak joints
• Types of Casts
a. Short-arm Cast
Extends from below the elbow to the proximal palmar crease.
b. Gauntlet Cast
Extends from below the elbow to the proximal palmar crease, including the thumb
(thumb spica).
c. Long-arm Cast
Extends from upper level of axillary fold to proximal palmar crease; elbow usually
immobilized at right angle.
d. Short-leg Cast
Extends from below knee to base of toes.
e. Long-leg Cast
Extends from upper thigh to the base of toes; foot is at right angle in a neutral position.
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f. Body Cast
Encircles the trunk stabilizing the spine.
g. Spica Cast
Incorporates the trunk and extremity.
Shoulder spica cast - a body jacket that encloses trunk, shoulder, and elbow.
Hip spica cast - encloses trunk and a lower extremity.
o Single hip spica - extends from nipple line to include pelvis and extends to
include pelvis and one thigh.
o Double hip spica - extends from nipple line or upper abdomen to include
pelvis and extends to include both thighs and lower legs.
One-and-a-half hip spica - extends from upper abdomen, includes one entire leg,
and extends to the knee of the other.
Complications of Casts
• Pressure of cast on neurovascular and bony structures causes necrosis, pressure sores, and nerve palsies.
• Compartment syndrome - trauma or surgery affecting an extremity will produce swelling (result of
hemorrhage from bone and surrounding tissue and of tissue edema).
Vascular insufficiency and nerve and muscle compression due to unrelieved swelling can cause
irreversible damage to an extremity.
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• Immobility and confinement in a cast, particularly a body cast, can result in multisystem
problems.
o Nausea, vomiting, and abdominal distention associated with cast syndrome (superior mesenteric
artery syndrome, resulting in diminished blood flow to the bowel), adynamic ileus, and possible
intestinal obstruction.
o Acute anxiety reaction symptoms (ie, behavioral changes and autonomic responses - increased
respiratory and heart rate, elevated blood pressure, diaphoresis) associated with confinement in a
space.
o Thrombophlebitis and possible pulmonary emboli associated with immobility and ineffective
circulation (eg, venous stasis).
o Respiratory atelectasis and pneumonia associated with ineffective respiratory effort.
o Urinary tract infection (UTI) - renal and bladder calculi associated with urinary stasis, low fluid
intake, and calcium excretion associated with immobility.
o Anorexia and constipation associated with decreased activity.
o Psychological reaction (eg, depression) associated with immobility, dependence, and loss of
control.
Nursing Assessment
• Assess neurovascular status of the extremity with a cast for signs of compromise.
o Pain.
o Swelling.
o Discoloration - pale or blue.
o Cool skin distal to injury.
o Tingling or numbness (paresthesia).
o Pain on passive extension (muscle stretch).
o Slow capillary refill; diminished or absent pulse.
o Paralysis.
• Carefully assess for positioning and potential pressure sites of the casted extremity
• Assess cardiovascular, respiratory, and GI systems for possible complications of immobility.
• Assess psychological reaction to illness, cast, and immobility.
Nursing Interventions
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• Elevate the extremity on cloth-covered pillow above the level of the heart. Keep the heel off the mattress.
• Avoid resting cast on hard surfaces or sharp edges that can cause denting or flattening of the cast and
consequent pressure sores.
• Handle moist cast with palms of hands.
• Turn patient every 2 hours while cast dries.
• Assess neurovascular status hourly during the first 24 hours, then less frequently as condition warrants and
swelling resolves. Observe for signs of circulatory impairment:
o hot spots – areas of the cast feels warmer than the other
sections – may indicate infection or necrosis
numbness or tingling
unrelieved pain
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NURSING ALERT
Cast syndrome (superior mesenteric artery syndrome) is a rare sequela of body cast
application, yet it is a potentially fatal complication. It is important to teach patients
about this syndrome because this can develop as late as several weeks after cast
application
Complications
o Clinical manifestations:
o Respiratory distress - tachypnea, hypoxemia, crackles, wheezes,
acute pulmonary edema
o Mental disturbances - irritability, restlessness, confusion,
disorientation, stupor, coma due to systemic embolization, and
severe hypoxia
o Fever
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NURSING ALERT
Restlessness, confusion, irritability, and disorientation may be the first signs of fat
embolism syndrome. Confirm hypoxia with arterial blood gas (ABG) analysis. Young
adults (ages 20 to 30) and older adults (ages 60 to 70) with multiple fractures or
fractures of long bones or pelvis are particularly susceptible to development of fat
emboli.
Amputation
a. Removal of a body part as a result of trauma or surgical intervention
c. Types:
• Nursing Care:
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3. Elevate stump for 12-24 hours to decrease edema; remove pillow after
this time for functional alignment and prevent contractures
4. Provide stump care
b. When wound is healed, wash stump daily, avoiding use of oils which might cause
macerations
c. Apply pressure to the end of the stump with progressively firmer surfaces to toughen stump
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• Place a bedboard under the mattress for uniform support of the body.
• Support the curves of the cast with cloth-covered flexible pillows prevents cracking and flat spots
while cast is drying.
o Place three pillows crosswise on bed for body cast.
o Place one pillow crosswise at the waist and two pillows lengthwise for affected leg for
spica cast. If both legs are involved, use two additional pillows.
• Encourage the patient to maintain physiologic position by:
o Using the overhead trapeze.
o Placing good foot flat on bed and pushing down while lifting himself or herself up on the
trapeze.
o Avoiding twisting motions.
o Avoiding positions that produce pressure on groin, back, chest, and abdomen.
Turning
• Move the patient to the side of the bed using a steady, even pulling motion.
• Place pillows along the other side of the bed - one for the chest and two (lengthwise) for the legs.
• Instruct the patient to place arms at side or above head.
• Turn the patient as a unit. Avoid twisting the patient in the cast.
• Turn the patient toward the leg not encased in plaster or toward the unoperated side if both legs are
in plaster.
o One nurse stands at other side of bed to receive the patient's shoulders.
o Second nurse supports leg in plaster while the third nurse supports the patient's back as he
or she is turned.
Ma. Elena I. Momongan, R.N.
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o Turn the patient in body cast to a prone position twice daily - provides postural drainage of
bronchial tree; relieves pressure on back.
• Keep the cast level by elevating the lumbar sacral area with a small pillow when the head of the
bed is elevated.
NURSING ALERT
Do not grasp cross bar of spica cast to move the patient. The purpose of the bar is to maintain the
integrity of the cast.
Hygienic Care
Skin Care
• Inspect skin for signs of irritation:
o Around cast edge.
o Under cast - pull skin taut and inspect under cast, using a flashlight for
illumination.
• Reach up under cast, and massage accessible skin.
• Protect the toes from the pressure of the bedding.
Exercise
• Instruct patient to actively exercise every joint that is not immobilized and to perform isometric
exercises (contract muscles without moving joint) of those immobilized to maintain muscle
strength and to prevent atrophy.
• Tell patient to perform hourly when awake:
Ma. Elena I. Momongan, R.N.
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o Leg cast - Push down on the popliteal (knee) space, hold it, relax, repeat. Move toes back
and forth; bend toes down, then pull them back.
o Arm cast - Make a fist, hold it, relax, repeat. Move shoulders.
Cast Care
• Advise to avoid getting cast wet, especially padding under cast - causes skin breakdown as plaster
cast becomes soft.
• Warn against covering a leg cast with plastic or rubber boots because this causes condensation and
wetting of the cast.
• Instruct to avoid weight bearing or stress on plaster cast for 24 hours.
• Instruct to report to health care provider if the cast cracks or breaks; instruct the patient not to try
to fix it.
• Teach how to clean the cast:
o Remove surface soil with slightly damp cloth.
o Rub soiled areas with household scouring powder.
o Wipe off residual moisture.
CRUTCH INSTRUCTIONS
General Information: When using your crutches, beware of ice or snow under your crutch tips. Be careful on wet
or waxed floors, smooth cement floors, and small rugs. Take care not to trip over telephone and extension cords,
toys, or pets. Avoid crowds.
Instructions:
1. Walking:
· Place both crutches in front of you at the same time. Put them about 1 inch in front and 6 to 8 inches to
the side of your toes.
· Lean on your hands, not your underarms. The top of the crutches should hit about 2 inches below your
underarm.
· Keep your elbows bent as you use the crutches. Keep your injured leg off the floor by bending your
knee.
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· Take a step with your crutches. Then, swing your uninjured foot between the crutches landing heel first.
· Face the stairs. Put the crutches close to the first step.
· Push on the crutches with your elbows straight and put your uninjured leg on the first step.
· Stand with the toes of your uninjured leg close to the edge of the step.
· Bend the knee of your uninjured leg. Slowly lower both crutches onto the next step.
· Lean on your crutches. Slowly lower your uninjured leg on to the same step.
· Place both crutches under the other arm when using a railing.
4. Sitting in a Chair:
· Turn and back up to the chair until you feel the edge of it against the back of your legs. Keep your
injured leg forward.
· Remove your crutches from under your arms. Sit while bending your uninjured knee. Hold the chair so
it doesn’t move out from under you.
· Sit on the edge of your chair. Put your uninjured foot close to the chair.
· Push up with your hands using the crutches or arms of the chair. Put your weight on your uninjured foot
as you get up.
· Keep your injured leg bent at the knee and off the floor.
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It takes some coordination to get around on crutches. To make sure you use your crutches correctly, please
read these instructions and follow them carefully.
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1. Make sure the chair is stable and will not roll or slide—and it must have arms and back support.
2. Stand with the backs of your legs touching the front of the seat.
3. Place both crutches in one hand, grasping them by the handgrips.
4. Hold on to the crutches (on one side) and the chair arm (on the other side) for balance and stability
while lowering yourself to a seated position—or raising yourself from the chair if you're getting up.
Managing Stairs Without Crutches
The safest way to go up and down stairs is to use your seat—not your crutches.
To go up stairs:
1. Seat yourself on a low step.
2. Move your crutches upstairs by one of these methods:
To go down stairs:
1. Seat yourself on the top step.
2. Move your crutches downstairs by sliding them to the
lowest possible point on the stairway—then continue
to move them down as you progress down the stairs.
3. In the seated position, reach behind you with both
arms.
4. Use your arms and weight-bearing foot/leg to lift
yourself down one step.
5. Repeat this process one step at a time. (Remember to
move the crutches to the bottom of the staircase if
you haven't already done so.)
Don't look down. Look straight ahead as you normally do when you walk.
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Don't put any weight on your foot if your doctor has so advised.
Do call your foot and ankle surgeon if you have any questions or difficulties.
Measurement of crutches:
• The top of the crutches should be at least two finger widths deep from the armpit (make sure the shoulders
are relaxed).
• When the arm is hanging straight down, the hand piece should be at the level of the wrist.
• Hold the top part of the crutch firmly between the chest and the inside of the upper arm. Do not allow the
top of the crutch to push up into the armpit. It is possible to damage nerves and blood vessels with constant
pressure. Support the weight with the hands on the hand rests. The hand rests should be padded.
• When standing still, it will be safer to stand with the crutches slightly ahead and apart. Remember, do not
let the top of the crutches push up into the armpit; stand straight.
Sit to stand:
• Make sure to keep the crutches nearby so they can be reached when needed.
• Hold the hand grips of both crutches in one hand. Use the crutches with one hand and the side of the chair
with the other hand. Make sure the chair is stable. If necessary, have someone stand behind you.
• Stretch the "bad" leg out straight.
• Push on chair, crutches, and the "good" leg; stand up.
• Keep the weight off the "bad" leg. Balance. Place the crutches in place for walking.
Stand to sit:
Ma. Elena I. Momongan, R.N.
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Stairs:
• Use one crutch and the stair rail if present (only if the railing is stable and there is someone to carry the
other crutch). Use two crutches if there is no stair rail.
• It does not matter which side the stair rail is on.
• If both crutches can be held in one hand safely, you can use both crutches on one side and the railing on the
other.
Up stairs:
• Walk close to the first stair and hold onto the stair rail.
• Hold onto the rail with one hand and the crutch with the other hand.
• Push down on the stair rail and the crutch and step up with the "good" leg.
• If not allowed to place weight on the "bad" leg, hop up with the "good" leg.
• Bring the "bad" leg and the crutches up beside the "good" leg.
• Remember, the "good" leg goes up first and the crutches move with the "bad" leg.
Down stairs:
Precautions:
• Take care on slick or wet surfaces (i.e., the kitchen and bathroom).
• Be careful of throw rugs; they should be taken up.
• Never hop around holding on to furniture; it may slide or fall.
• Keep the crutches near you so they are always in reach.
• Wear low-heeled shoes that will not slip off (i.e., sneakers).
• For the first few days, a strong belt may be worn to allow someone to assist you.
• Be careful of ramps or slopes, as it is a little harder to walk.
• If falling, throw the crutches out to the side and use your arms to break your fall. To get up, get into a
sitting position. Back up to a stool or low chair. Put your hands backwards on to the chair. Bend the "good"
leg up. Pull with your hands and push with the "good" leg to get up onto the chair.
• If not allowed to take weight on the "bad" leg, hop up with the "good" leg.
• Do not remove any parts from your crutches, including the rubber tips.
Helpful hints:
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