Care of client

with musculoskeletal injury

or disorder

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What can go wrong

Fractures

Hip
Mandible

Degenerative joint disease

Osteoporosis
Herniated disc
Amputation

CONCEPTS: FRACTURES
Reduction/Realignment
Immobilization
Nursing care
Prevention and early
detection:

complication

Realignment=Reduction

Correct bone alignment goal:

restore injured part to normal or
near-normal function
Closed vs. open reduction
Open reduction = surgery

Immobilization:
to maintain alignment

Cast
Traction
External fixation
Internal fixation

CASTS

Casts

External, circumferential
Thermochemical reaction = warmth
Nursing care:

No weight bearing 24-72 hours

flat hands
Elevate
Neuro-vascular checks

CASTS

Cast: Client/Family
Teaching

Keep dry
No foreign objects in cast
No weight bearing until MD order
(at least 48 hour)
Elevate above heart (48 hours)
Signs of problems to report

Pain, tingling, burning

Sores, odor

External fixation

Metal pins inserted into bone

Pins attach to external rods
Nursing care:

Assess for s/s infection

Teach pin care: H2O2+ H2o
Open reduction: assess incision
Elevate
Neurovascular checks

EXTERNAL FIXATION

Internal Fixation

Pins, plates, screws surgically

inserted
Nursing care:

Assess incision site

MD orders: activity, weight bearing,
ROM,
Assess s/s infection; temp. q 2-4 hours
Neurovascular checks:

5 Ps

INTERNAL FIXATION

Traction

Pulling forces: traction +

countertraction
Purpose(s):

Prevent or reduce muscle spasm

Immobilization
Reduce a fracture
Treat certain joint conditions

Types of Traction

Skin

Bucks
Russells
Bryants (babies cry with Bry)

Skeletal
Balanced suspension
(Lewis, 1660-1661)

Nursing
Concerns/Interventions

Assess neurovascular status

Assess skin (bony prominences,
under elastic wraps, etc.)
Assess pin sites (skeletal tx)
Maintain correct body alignment
Weights hang freely
Hazards of immobility

TRACTION

SKIN TRACTION

BUCKS TRACTION

SKELETAL TRACTION

Nursing Diagnoses

Neurovascular dysfunction, risk for

Acute pain, R/T edema, muscle
spasms, movement of bones
Infection, risk for
Impaired skin integrity, risk for
Impaired physical mobility

Complications of Fractures

Compartment syndrome
Fat embolism
Venous thrombosis
Infection

COMPARTMENT
SYNDROME

FACIOTOMY
wound is left open
If no
improvement,
amputation

Hip Fracture

In 1999 (USA) hip fractures resulted

in approximately 338,000 hospital
admissions

Up to 25% of community-dwelling
older adults who sustain hip
fractures remain institutionalized for
at least a year

Hip Fractures

One-third of older women who

fracture their hip will die within a
year because of lengthy
convalescence that makes them
susceptible to complications, like
lung and bladder infections.

The Lancet 1999;353:878-82

Fracture of hip
Types of hip fractures (Lewis pg.
1675):

Intracapsular

Capital
Subcapital
Transcervical

Extracapsular

Intertrochanteric
Subtrochanteric

ORIF
vs
Total Hip
Open reduction/internal
fixation:

pins, screws, plate(s)

Total hip:

endoprosthesis replace
femoral head

Internal fixation =
immobilization

Nursing Care

Risk for peripheral neurovascular

dysfunction
Pain
Impaired mobility:

Prevent thrombus
Safety
Constipation

Risk for impaired skin integrity:

Immobility
Incision

Femoral head prosthesis

(total hip)

Prevent dislocation:

Do not flex > 90 degrees

No internal rotation (toes to ceiling)
Maintain abduction
Do not position on operative side
Patient teaching:

Precautions for 6-8 weeks

Notify dentist: prophylactic antibiotics
Lewis: pg. 1678

Fracture of mandible

Trauma vs. Therapeutic

Immobilization: wiring, screws,
plate(s)
Nursing care:

Airway (Cutter with client)

Oral hygiene
Nutrition
Communication

What can go wrong

Fractures

Hip
Mandible

Degenerative joint disease

Osteoporosis
Herniated disc
Amputation

Degenerative Joint
Disease:
Osteoarthritis

Not normal part of aging process

Cartilage destruction:

Trauma
Repetitive physical activities
Inflammation
Certain drugs (corticosteroids)
Genetics

Assessment

Location, nature, duration of pain

Joint swelling/crepitus
Joint enlargement
Deformities
Ability to perform ADLs
Risk factors
Weight (history of obesity)

Nursing Interventions

Pain management
Rest with acute pain; exercise to
maintain mobility
Splint or brace
Moist heat
Alternative therapies

TENS, acupuncture, therapeutic touch

Surgical management: total

joint arthroplasty
(replacement)

Elbow, shoulder, hip, knee, ankle, etc.

Pre-operative teaching:

What to expect (CPM, abduction pillow,

drains, compression dressing, etc.)
Postoperative exercises: quad sets, glute
sets, leg raises, abduction exercises
Pain management:

PCA
Use of pain scale

Total Joint Arthroplasty

Post-operative care:

5 Ps
Observe for bleeding
Pain management
Knee: CPM
Check incision for s/s infection

Total Joint Arthroplasty

Postoperative Care
Prevent:

Dislocation
Skin breakdown
Venous thrombosis (DVT)

TED/Sequential compression
Anticoagulants
Exercises: plantar flexion, dorsiflexion, circle
feet, glute & quad sets

Osteoporosis

Primary often women postmenopause

Secondary corticosteroids, immobility,
hyperparathyroidism
Bone demineralization = decreased
bone density
Fractures:

Wrist
Hip
Vertebral column

Silent disease

Dowagers hump (kyphosis)

Pain
Compression fractures
Spontaneous fractures
X-ray can not detect until > 25%
calcium in bone is lost
Diagnosis: bone density ultrasound

Interventions

Hormone replacement
Calcium & vitamin D
Calcitonin, Fosamax, Actonel, Evista
Avoid alcohol and smoking
Daily weight bearing, sustained
exercise (walking, bike)
Safety in home (throw rugs, pets, etc.)

What can go wrong

Fractures

Hip
Mandible

Degenerative joint disease

Osteoporosis
Herniated disc
Amputation

Location of PPT on Web is

below

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