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)

Isaac Amankwaa

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.
Isaac Amankwaa

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.

Isaac Amankwaa

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
Isaac Amankwaa

Causes of fracture
Direct blow
Crushing force
Sudden twisting motion
Extreme muscle contraction

Isaac Amankwaa

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

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Table 6.1

COMMON TYPES OF FRACTURES

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Table 6.1

COMMON TYPES OF FRACTURES

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Table 6.1

COMMON TYPES OF FRACTURES

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Table 6.1

Isaac Amankwaa

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.
Isaac Amankwaa

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 patients 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.

Isaac Amankwaa

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 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
Isaac Amankwaa

HEALING OF FRACTURE
Bone 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

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Figure 6.14

FACTORS ENHANCING FRACTURE HEALING

1.

2.
3.
4.
5.

6.

Immobilization of the fracture

fragments
Maximum bone fragment contact
Sufficient blood supply
Proper nutrition
Exercise-Weight-bearing for long
bones
Hormones-growth hormone, thyroid,
calcitonin, insulin, vitamins A and D,
anabolic steroids.
Isaac Amankwaa

Factors Inhibiting Fracture

Healing

Extensive local trauma

Bone loss
Inadequate immobilization
Space/tissue between bone
fragments
Infection
Local malignancy
Metabolic bone diseases (e.g.
Pagets disease)
Isaac Amankwaa

Factors Inhibiting Fracture

Healing

Irradiated bone (radiation necrosis)

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

Isaac Amankwaa

Complications of
fracture

Early complications include:

Shock

Nerve damage, arterial damage

Infection

Cast syndrome

Compartmental Syndrome

Fat Embolism Syndrome

Deep Vein thrombosis & Pulmonary Embolism

Isaac Amankwaa

Long-term Complications
Joint stiffness or post-traumatic
arthritis
Avascular necrosis
Nonfunctional union after a
fracture
Complex regional pain syndrome
Reaction to internal fixation
device
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Avascular 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
Isaac Amankwaa

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.
Isaac Amankwaa

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
Isaac Amankwaa

Principles for fracture

management

The management process is a threestep process:

Reductionsetting the bone; refers to

restoration of the fracture fragments
into anatomic position and alignment.
Immobilizationmaintains reduction
until bone healing occurs
Rehabilitationregaining normal
function of the affected part.
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Fracture Reduction
Fracture fragments brought into their
pre-injury position.
It consists of pulling the broken bone
ends to correct alignment and regain
continuity.(Bone setting)

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FRACTURE REDUCTION

Reduction is necessary only if there

is some displacement of the
fragment.

It is carried out as soon as possible

to achieve satisfactory alignment

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Methods of fracture
reduction

Includes;
1.
Closed manipulative
reduction
2.
Open (Internal )reduction
3.
Traction

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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
Isaac Amankwaa

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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Closed vs. Open Reduction

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 tractionforce 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.

Isaac Amankwaa

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

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Nail
Plates
Screws
Wires
Rods
Metal implants used
for internal fixation
serve as internal
splints to immobilize
the fracture.

Alignment &
Immobilization

External Fixation (advantages)

1.

2.
3.

4.

Permits rigid support of severely

comminuted open fractures, infected
non-unions, and infected unstable
joints.
Facilitates wound care
Allows early function of muscles and
joints.
Allows early patient comfort
Isaac Amankwaa

External fixation

The method is
used mainly in the
management of
open fractures
with severe softtissue damage.
Common sites
include face &
jaw, pelvis,
fingers.
Isaac Amankwaa

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.
Isaac Amankwaa

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
Isaac Amankwaa

CASTING MATERIALS

Non-plaster

Plaster (P.O.P)

Referred to as fiberglass casts, are lighter in

weight, stronger, water resistant, and durable.
are porous and therefore diminish skin
problems.
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

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
Isaac Amankwaa

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 clients temperature

Isaac Amankwaa

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

Isaac Amankwaa

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
Isaac Amankwaa

Windowing and Bivalving

of cast

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

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Bivalving a cast

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Bivalving a Cast
Cast

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Window

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 floor
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Indications for traction

To reduce fractures
Immobilization of an area
before surgery
Control and relieve of painful
muscle spasm
stretching adhesions
correct deformities
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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.

Bucks traction (bucks extension)

2.

Russels traction (balanced traction)

3.

Bryants traction

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Bucks 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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Russels 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
Isaac Amankwaa

Skeletal traction

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
Isaac Amankwaa

Comparison of skin and skeletal

traction
Skin traction

Skeletal traction

Advantage:
Relative ease of use and
ability to maintain comfort
Disadvantage:
Wt required to maintain
Normal body alignment or
fracture alignment can not
exceed 6 lbs per extremity.

Advantage:
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

Isaac Amankwaa

Check the four Ps 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?
Isaac Amankwaa

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
Isaac Amankwaa

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
Isaac Amankwaa

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
Isaac Amankwaa

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
relaxation.
Isaac Amankwaa