67
Musculoskeletal Trauma and
Orthopedic Surgery
Rebekah Filson
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Functional Ability Perfusion
Infection Safety
Mobility
Pain
LEARNING OUTCOMES
1. Discuss the etiology, pathophysiology, manifestations, and 6. Describe the interprofessional and nursing management of
interprofessional and nursing management of soft tissue patients with various kinds of fractures.
injuries. 7. Describe indications for and interprofessional and nursing
2. Relate the sequence of events involved in fracture healing. management of the patient with an amputation.
3. Compare closed reduction, casting, open reduction, and 8. Describe types of joint replacement surgery.
traction in terms of purpose, complications, and nursing 9. Prioritize management of the patient having joint
management. replacement surgery.
4. Assess the neurovascular condition of an injured extremity.
5. Explain common complications of a fracture and fracture
healing.
KEY TERMS
amputation fat embolism syndrome (FES)
arthrodesis fracture
arthroplasty osteotomy
bursitis phantom limb sensation
carpal tunnel syndrome (CTS) repetitive strain injury (RSI)
compartment syndrome sprain
debridement strain
dislocation traction
The most common cause of musculoskeletal injury is a trau- venous thromboembolism [VTE]) and promoting functional
matic event resulting in fracture, dislocation, subluxation, and/ ability in patients with fractures and orthopedic surgery.
or soft tissue injury. Most of these injuries are not fatal. How-
ever, accidents are 1 of the top 3 causes of death for persons
ages 1 to 64 years.1 The costs in terms of pain, disability, and
HEALTH PROMOTION
expense are enormous. Nurses play a key role in teaching the Teach people to take proper safety precautions to prevent injuries
public about basic principles of safety and accident prevention. while at home or work, driving, or taking part in sports (Box 67.1).
This chapter discusses musculoskeletal problems resulting The morbidity from accidents can be reduced if people are aware
from trauma and common orthopedic surgeries. After trauma of environmental hazards, use proper safety equipment, and apply
or surgery, the injured area is often immobilized while healing safety and traffic rules. In the work setting, teach employees and
occurs. We discuss the important role of the nurse in preventing employers to use proper safety equipment and decrease workplace
complications (e.g., pressure injuries, constipation, infection, hazards. Falls cause many musculoskeletal injuries in the home.
1638
, CHAPTER 67 Musculoskeletal Trauma and Orthopedic Surgery 1639
BOX 67.1 PROMOTING POPULATION TABLE 67.1 PATIENT & CAREGIVER
HEALTH TEACHING
Reducing the Risk for Musculoskeletal Injuries Preventing Musculoskeletal Problems in Older
Adults
• Wear seatbelts.
• Drive within posted speed limits. To prevent musculoskeletal problems, include the following instructions when
• Avoid distracted driving (e.g., no texting, eating, talking on a cell phone). teaching older adults and their caregivers:
• Do not drive under the influence of alcohol or drugs (prescribed or illicit). 1. Use ramps in buildings and at street corners instead of steps to prevent falls.
• Warm up muscles before exercise. 2. Remove throw rugs from the home.
• Use protective athletic equipment (helmets and knee, wrist, and elbow 3. Treat pain and discomfort from osteoarthritis.
pads). • Rest in positions that decrease discomfort.
• Use proper safety equipment at work. • Use medication as prescribed for pain.
4. Use a walker or cane to help prevent falls.
5. Eat the amount and kind of foods needed to prevent weight gain. Obesity
adds stress to joints, which may predispose to osteoarthritis.
BOX 67.2 PROMOTING POPULATION 6. Get regular and frequent exercise.
HEALTH • ADLs provide range-of-motion exercises. Tai Chi may be helpful.
Reducing Fall Risk • Hobbies (e.g., jigsaw puzzles, needlework, model building) exercise fin-
ger joints and prevent stiffness.
• ssess the living environment for safety risks.
A • Do daily weight-bearing exercise (e.g., walking) to improve bone health.
• Wear functional, nonskid, hard-soled shoes. 7. Use shoes with good support for safety and comfort.
• Avoid wet or slippery surfaces. 8. Avoid sudden change in position. Rise slowly to a standing position to
• Remove throw rugs and ensure adequate lighting in the home. prevent dizziness, falls, and fractures.
• Maintain clear paths to the bathroom for nighttime use. 9. Do not walk on uneven surfaces and wet floors.
Provide preventive teaching to high-risk persons (e.g., people with A strain is an excessive stretching of a muscle and its fascial
gait instability, vision impairment) (Box 67.2). sheath, often involving the tendon. Most strains occur in the
Encourage people, especially older adults, to take part in large muscle groups, including the lower back, calf, and ham-
moderate exercise to help maintain muscle strength and bal- strings. We classify strains as first degree (mild or slightly pulled
ance. Table 67.1 describes ways to prevent common musculo- muscle), second degree (moderate or moderately torn muscle),
skeletal problems in the older adult. Stress the importance of and third degree (severely torn or ruptured muscle). A defect
adequate calcium and vitamin D intake for bone health. in the muscle may be apparent or palpated through the skin if
the muscle is torn. Because areas around joints are rich in nerve
endings, the injury can be very painful.
SOFT TISSUE INJURIES
Manifestations of sprains and strains are similar. They include
Soft tissue injuries include sprains, strains, dislocations, and sub- pain, edema, decreased function, and bruising. Continued use
luxations. They usually result from trauma. As more people have of the joint, tendon, or ligament makes pain worse. Edema
become involved in fitness programs or sports, the incidence of develops in the injured area because of the local inflammatory
soft tissue injuries has increased. Table 67.2 describes common response.
sports-related injuries. Sports injuries that often result in a visit Mild sprains and strains are usually self-limiting. Full func-
to the emergency department (ED) for younger patients include tion generally returns within 3 to 6 weeks. X-rays may be done
sprains and strains, growth plate injuries, and repetitive motion to rule out a fracture. A severe sprain can cause an avulsion
injuries.2 fracture, in which the ligament pulls loose a fragment of bone.
The joint structure may become unstable, causing subluxation
or dislocation. At the time of injury, hemarthrosis (bleeding into
SPRAINS AND STRAINS
a joint space or cavity) or disruption of the synovial lining may
Sprains and strains often result from abnormal stretching or occur. Severe strains may need surgical repair of the muscle,
twisting forces during vigorous activities. These injuries tend to tendon, or surrounding fascia.
occur around joints and in the spinal muscles.
A sprain is an injury to the ligaments surrounding a joint.
Sprains are usually caused by a wrenching or twisting motion. NURSING MANAGEMENT: SPRAINS AND
Most occur in the ankle, wrist, and knee joints.3 We classify STRAINS
sprains according to the degree of ligament damage. A first-de-
gree (mild) sprain involves tears in only a few fibers, with mild Implementation
tenderness and minimal swelling. A second-degree (moderate) Health Promotion
sprain results in partial disruption of the involved tissue with Warming up muscles before exercising and vigorous activ-
more swelling and tenderness. A third-degree (severe) sprain is a ity, followed by stretching, may significantly reduce the risk
complete tear of the ligament with moderate to severe swelling. for sprains and strains. Strength, balance, and endurance
,1640 SECTION 12 Problems Related to Movement and Coordination
TABLE 67.2 Soft Tissue Injuries
Injury Description Treatment
Anterior cruciate ligament tear Tearing of ligament by deceleration forces with pivoting or PT with rehabilitation, knee brace. If knee instability or further
odd positions of the knee or leg. injury, reconstructive surgery may be done.
Impingement syndrome Entrapment of soft tissues and nerves under coracoacromial NSAIDs. Rest until symptoms ↓, then begin gradual ROM and
arch of shoulder strength exercises.
Ligament injury Tearing or stretching of ligament. Usually occurs from Rest, ice, elevation of extremity if possible, NSAIDs. Protect
inversion, eversion, shearing, or torque applied to a joint. affected extremity by use of brace. If symptoms persist,
Characterized by sudden pain, swelling, and instability surgical repair may be needed.
Meniscus injury Injury to fibrocartilage discs in knee. Characterized by Rest, ice, elevation of extremity if possible, NSAIDs. Gradual
popping, clicking, tearing sensation, effusion, and/or return to regular activities. If symptoms persist, MRI to assess
swelling meniscus injury. Possible arthroscopic surgery.
Rotator cuff tear Tear within muscle, tendons, or ligaments around shoulder If minor tear: rest, NSAIDs, and gradual mobilization with ROM
and strength exercises.
If major tear: surgical repair.
Shin splints Inflammation of periosteal bone (periostitis) along anterior Rest, ice, NSAIDs, proper shoes. Gradual ↑ in activity. If pain
calf. Caused by improper shoes, overuse, or running on persists, x-ray to rule out tibial stress fracture
hard pavement
Tendonitis Inflammation of tendon due to overuse or incorrect use Rest, ice, NSAIDs. Gradual return to sport activity. Protective
brace (orthosis) may be needed if symptoms recur.
These changes also reduce muscle spasms, inflammation, and
BOX 67.3 PROMOTING POPULATION edema. Cold is most useful when applied immediately after an
HEALTH injury has occurred and used for 24 to 28 hours. Apply ice no
Health Impact of Physical Activity more than 20 to 30 minutes at a time. Do not apply ice directly
• elps with weight management
H to the skin.
• Increases lean muscle and decreases body fat Compression helps decrease edema and pain. We often use
• Helps maintain and improve bone mass an elastic compression bandage. It can be wrapped around the
• Increases muscle strength, flexibility, and endurance injured part. To prevent edema and encourage fluid return,
• Helps prevent high BP wrap the bandage starting distally (at the point farthest from the
• Reduces the risk for heart disease, diabetes, and colon cancer trunk of the body) and progress proximally (toward the trunk
• Enhances sense of well-being and reduces risk for depression of the body). The bandage is too tight if there is numbness or
tingling below the area of compression or pain or more swelling
occurs beyond the edge of the bandage. Leave the bandage in
exercises are important (Box 67.3). Strength exercises that place for 30 minutes, then remove it for 15 minutes. Use of an
involve working against resistance build muscle strength and elastic wrap may provide extra support during training, athletic,
bone density. Balance exercises, which may overlap with some and work activities.
strength exercises, help prevent falls. Endurance exercises Elevate the injured part above heart level, even during sleep,
should start at a low level of effort and progress gradually to a for 24 to 48 hours to help mobilize excess fluid from the area
moderate level. and prevent further edema. Mild analgesics and nonsteroidal
antiinflammatory drugs (NSAIDs) may be used to manage
Acute Care patient discomfort.
If an injury occurs, immediate care focuses on (1) stopping the After the acute phase (usually 24 to 48 hours), apply warm,
activity and limiting movement to the injured part, (2) apply- moist heat to the affected part to reduce swelling and provide
ing ice packs to the injured area, (3) compressing the involved comfort. Heat applications should not exceed 20 to 30 minutes.
area, (4) elevating the extremity, and (5) providing analgesia as Allow a “cool-down” time between applications. Encourage the
needed (Table 67.3). Most sprains and strains are treated in the patient to use the limb if the joint is protected by a cast, brace,
outpatient setting. splint, or taping. Joint movement maintains nutrition to the car-
RICE (Rest, Ice, Compression, Elevation) may decrease tilage. Movement helps prevent contracture (stiffening) of ten-
local inflammation and pain for most musculoskeletal injuries. dons and ligaments. Muscle contraction improves circulation
Movement should be restricted with the extremity rested as and helps resolve bruising and swelling.
soon as pain is felt. Unless the injury is severe, prolonged rest is Emphasize the importance of strength and conditioning
usually not needed. exercises to prevent reinjury. The physical therapist may help
There are several forms of cold therapy (cryotherapy). with pain relief by using ultrasound or other interventions.
Cold causes vasoconstriction in the soft tissue and reduces They can teach the patient exercises to improve flexibility and
the transmission and perception of nerve pain impulses. strength.
, CHAPTER 67 Musculoskeletal Trauma and Orthopedic Surgery 1641
TABLE 67.3 EMERGENCY MANAGEMENT
Acute Soft Tissue Injury
Cause Assessment Findings Interventions
• Crush injury • Bruising Initial
• Direct blows • ↓ Movement with limited function or inability • Ensure airway, breathing, and circulation.
• Falls to bear weight (lower extremity) • Perform neurovascular assessment of involved limb.
• Motor vehicle crashes • ↓ Pulse, coolness, capillary refill >2 sec • Elevate involved limb.
• Sports injuries • ↓ Sensation • Apply compression bandage unless dislocation present.
• Edema • Apply ice packs to affected area.
• Muscle spasms • Immobilize affected extremity in the position found. Do not try to realign or
• Pain, tenderness reinsert protruding bones.
• Pallor • Anticipate x-rays of injured extremity.
• Shortening or rotation of extremity • Give analgesia as needed.
• Give tetanus prophylaxis if there is an open fracture.
• Give antibiotic prophylaxis for open fracture, large tissue defects, or mangled
extremity injury.
Ongoing Monitoring
• Monitor for changes in neurovascular condition.
• Implement weight-bearing restrictions as ordered for lower extremity
involvement.
• Anticipate compartment pressure monitoring if neurovascular assessment
changes and compartment syndrome suspected.
DISLOCATIONS
Dislocation is the complete displacement or separation of the
articular surfaces of the joint. Subluxation is a partial or incom-
plete displacement of the joint surface. Symptoms of subluxation
are similar to a dislocation but are less severe. Many struc-
tures contribute to joint stability. Injury to, or excessive laxity
of, ligaments is a major factor in dislocations or subluxations.
Weak or atrophied muscles can cause chronic joint instability. A B C
Fibrocartilage structures, such as the labrum around hip and Fig. 67.1 Soft tissue injury of the hip. (A) Normal. (B) Subluxation (par-
tial dislocation). (C) Dislocation.
shoulder sockets and the meniscus at the knee, play an import-
ant role in joint stability. Even small tears to these structures can
result in recurrent, chronic dislocations or subluxations. X-rays can determine the extent of displacement. The joint
Dislocations typically result from forces on the joint that dis- may be aspirated to assess for hemarthrosis or fat cells. Fat cells
rupt the surrounding soft tissue support structures. The joints in the aspirate indicate a probable intraarticular fracture.
most often dislocated in the upper extremity include the thumb,
elbow, and shoulder. The shoulder most often dislocates anteri- Interprofessional and Nursing Care
orly. Posterior shoulder dislocations are rare. They typically only A dislocation requires prompt attention. It is often considered
happen after electrocution or seizure. In the lower extremity, the an orthopedic emergency because it may be cause significant
hip is vulnerable to dislocation from severe trauma, often from vascular injury. The longer the joint is dislocated, the greater the
motor vehicle crashes (Fig. 67.1). The kneecap (patella) may dis- risk for avascular necrosis. The femoral head of the hip joint is
locate because of a sharp, direct blow or after a sudden twisting especially susceptible to avascular necrosis. Compartment syn-
inward motion while the planted foot is pointed outward. drome may occur after dislocation due to vascular injury and
The most obvious sign of a dislocation is deformity. For resulting ischemia. Neurovascular assessment is critical.
example, if the hip dislocates in a posterior (or backward) direc- The first goal of care of a dislocation is to realign the dislocated
tion, the affected limb may be shorter and internally rotated. part of the joint to its original anatomic position. Closed reduction
Other manifestations include local pain, tenderness, loss of (no incision) may be done under local or general anesthesia or IV
function of the injured part, and swelling of soft tissues near the moderate to deep sedation. Anesthesia is often needed to relax the
joint. Major complications include open joint injuries, intraar- muscle so that the bones can be manipulated. Sometimes, open
ticular fractures (within the joint), avascular necrosis (bone cell reduction (joint visualized through surgery) may be needed. After
death from blood supply), and damage to adjacent nerves and reduction, the extremity is immobilized by a brace, splint, or sling,
blood vessels. or by taping, to allow torn ligaments and surrounding tissue to heal.
Musculoskeletal Trauma and
Orthopedic Surgery
Rebekah Filson
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Functional Ability Perfusion
Infection Safety
Mobility
Pain
LEARNING OUTCOMES
1. Discuss the etiology, pathophysiology, manifestations, and 6. Describe the interprofessional and nursing management of
interprofessional and nursing management of soft tissue patients with various kinds of fractures.
injuries. 7. Describe indications for and interprofessional and nursing
2. Relate the sequence of events involved in fracture healing. management of the patient with an amputation.
3. Compare closed reduction, casting, open reduction, and 8. Describe types of joint replacement surgery.
traction in terms of purpose, complications, and nursing 9. Prioritize management of the patient having joint
management. replacement surgery.
4. Assess the neurovascular condition of an injured extremity.
5. Explain common complications of a fracture and fracture
healing.
KEY TERMS
amputation fat embolism syndrome (FES)
arthrodesis fracture
arthroplasty osteotomy
bursitis phantom limb sensation
carpal tunnel syndrome (CTS) repetitive strain injury (RSI)
compartment syndrome sprain
debridement strain
dislocation traction
The most common cause of musculoskeletal injury is a trau- venous thromboembolism [VTE]) and promoting functional
matic event resulting in fracture, dislocation, subluxation, and/ ability in patients with fractures and orthopedic surgery.
or soft tissue injury. Most of these injuries are not fatal. How-
ever, accidents are 1 of the top 3 causes of death for persons
ages 1 to 64 years.1 The costs in terms of pain, disability, and
HEALTH PROMOTION
expense are enormous. Nurses play a key role in teaching the Teach people to take proper safety precautions to prevent injuries
public about basic principles of safety and accident prevention. while at home or work, driving, or taking part in sports (Box 67.1).
This chapter discusses musculoskeletal problems resulting The morbidity from accidents can be reduced if people are aware
from trauma and common orthopedic surgeries. After trauma of environmental hazards, use proper safety equipment, and apply
or surgery, the injured area is often immobilized while healing safety and traffic rules. In the work setting, teach employees and
occurs. We discuss the important role of the nurse in preventing employers to use proper safety equipment and decrease workplace
complications (e.g., pressure injuries, constipation, infection, hazards. Falls cause many musculoskeletal injuries in the home.
1638
, CHAPTER 67 Musculoskeletal Trauma and Orthopedic Surgery 1639
BOX 67.1 PROMOTING POPULATION TABLE 67.1 PATIENT & CAREGIVER
HEALTH TEACHING
Reducing the Risk for Musculoskeletal Injuries Preventing Musculoskeletal Problems in Older
Adults
• Wear seatbelts.
• Drive within posted speed limits. To prevent musculoskeletal problems, include the following instructions when
• Avoid distracted driving (e.g., no texting, eating, talking on a cell phone). teaching older adults and their caregivers:
• Do not drive under the influence of alcohol or drugs (prescribed or illicit). 1. Use ramps in buildings and at street corners instead of steps to prevent falls.
• Warm up muscles before exercise. 2. Remove throw rugs from the home.
• Use protective athletic equipment (helmets and knee, wrist, and elbow 3. Treat pain and discomfort from osteoarthritis.
pads). • Rest in positions that decrease discomfort.
• Use proper safety equipment at work. • Use medication as prescribed for pain.
4. Use a walker or cane to help prevent falls.
5. Eat the amount and kind of foods needed to prevent weight gain. Obesity
adds stress to joints, which may predispose to osteoarthritis.
BOX 67.2 PROMOTING POPULATION 6. Get regular and frequent exercise.
HEALTH • ADLs provide range-of-motion exercises. Tai Chi may be helpful.
Reducing Fall Risk • Hobbies (e.g., jigsaw puzzles, needlework, model building) exercise fin-
ger joints and prevent stiffness.
• ssess the living environment for safety risks.
A • Do daily weight-bearing exercise (e.g., walking) to improve bone health.
• Wear functional, nonskid, hard-soled shoes. 7. Use shoes with good support for safety and comfort.
• Avoid wet or slippery surfaces. 8. Avoid sudden change in position. Rise slowly to a standing position to
• Remove throw rugs and ensure adequate lighting in the home. prevent dizziness, falls, and fractures.
• Maintain clear paths to the bathroom for nighttime use. 9. Do not walk on uneven surfaces and wet floors.
Provide preventive teaching to high-risk persons (e.g., people with A strain is an excessive stretching of a muscle and its fascial
gait instability, vision impairment) (Box 67.2). sheath, often involving the tendon. Most strains occur in the
Encourage people, especially older adults, to take part in large muscle groups, including the lower back, calf, and ham-
moderate exercise to help maintain muscle strength and bal- strings. We classify strains as first degree (mild or slightly pulled
ance. Table 67.1 describes ways to prevent common musculo- muscle), second degree (moderate or moderately torn muscle),
skeletal problems in the older adult. Stress the importance of and third degree (severely torn or ruptured muscle). A defect
adequate calcium and vitamin D intake for bone health. in the muscle may be apparent or palpated through the skin if
the muscle is torn. Because areas around joints are rich in nerve
endings, the injury can be very painful.
SOFT TISSUE INJURIES
Manifestations of sprains and strains are similar. They include
Soft tissue injuries include sprains, strains, dislocations, and sub- pain, edema, decreased function, and bruising. Continued use
luxations. They usually result from trauma. As more people have of the joint, tendon, or ligament makes pain worse. Edema
become involved in fitness programs or sports, the incidence of develops in the injured area because of the local inflammatory
soft tissue injuries has increased. Table 67.2 describes common response.
sports-related injuries. Sports injuries that often result in a visit Mild sprains and strains are usually self-limiting. Full func-
to the emergency department (ED) for younger patients include tion generally returns within 3 to 6 weeks. X-rays may be done
sprains and strains, growth plate injuries, and repetitive motion to rule out a fracture. A severe sprain can cause an avulsion
injuries.2 fracture, in which the ligament pulls loose a fragment of bone.
The joint structure may become unstable, causing subluxation
or dislocation. At the time of injury, hemarthrosis (bleeding into
SPRAINS AND STRAINS
a joint space or cavity) or disruption of the synovial lining may
Sprains and strains often result from abnormal stretching or occur. Severe strains may need surgical repair of the muscle,
twisting forces during vigorous activities. These injuries tend to tendon, or surrounding fascia.
occur around joints and in the spinal muscles.
A sprain is an injury to the ligaments surrounding a joint.
Sprains are usually caused by a wrenching or twisting motion. NURSING MANAGEMENT: SPRAINS AND
Most occur in the ankle, wrist, and knee joints.3 We classify STRAINS
sprains according to the degree of ligament damage. A first-de-
gree (mild) sprain involves tears in only a few fibers, with mild Implementation
tenderness and minimal swelling. A second-degree (moderate) Health Promotion
sprain results in partial disruption of the involved tissue with Warming up muscles before exercising and vigorous activ-
more swelling and tenderness. A third-degree (severe) sprain is a ity, followed by stretching, may significantly reduce the risk
complete tear of the ligament with moderate to severe swelling. for sprains and strains. Strength, balance, and endurance
,1640 SECTION 12 Problems Related to Movement and Coordination
TABLE 67.2 Soft Tissue Injuries
Injury Description Treatment
Anterior cruciate ligament tear Tearing of ligament by deceleration forces with pivoting or PT with rehabilitation, knee brace. If knee instability or further
odd positions of the knee or leg. injury, reconstructive surgery may be done.
Impingement syndrome Entrapment of soft tissues and nerves under coracoacromial NSAIDs. Rest until symptoms ↓, then begin gradual ROM and
arch of shoulder strength exercises.
Ligament injury Tearing or stretching of ligament. Usually occurs from Rest, ice, elevation of extremity if possible, NSAIDs. Protect
inversion, eversion, shearing, or torque applied to a joint. affected extremity by use of brace. If symptoms persist,
Characterized by sudden pain, swelling, and instability surgical repair may be needed.
Meniscus injury Injury to fibrocartilage discs in knee. Characterized by Rest, ice, elevation of extremity if possible, NSAIDs. Gradual
popping, clicking, tearing sensation, effusion, and/or return to regular activities. If symptoms persist, MRI to assess
swelling meniscus injury. Possible arthroscopic surgery.
Rotator cuff tear Tear within muscle, tendons, or ligaments around shoulder If minor tear: rest, NSAIDs, and gradual mobilization with ROM
and strength exercises.
If major tear: surgical repair.
Shin splints Inflammation of periosteal bone (periostitis) along anterior Rest, ice, NSAIDs, proper shoes. Gradual ↑ in activity. If pain
calf. Caused by improper shoes, overuse, or running on persists, x-ray to rule out tibial stress fracture
hard pavement
Tendonitis Inflammation of tendon due to overuse or incorrect use Rest, ice, NSAIDs. Gradual return to sport activity. Protective
brace (orthosis) may be needed if symptoms recur.
These changes also reduce muscle spasms, inflammation, and
BOX 67.3 PROMOTING POPULATION edema. Cold is most useful when applied immediately after an
HEALTH injury has occurred and used for 24 to 28 hours. Apply ice no
Health Impact of Physical Activity more than 20 to 30 minutes at a time. Do not apply ice directly
• elps with weight management
H to the skin.
• Increases lean muscle and decreases body fat Compression helps decrease edema and pain. We often use
• Helps maintain and improve bone mass an elastic compression bandage. It can be wrapped around the
• Increases muscle strength, flexibility, and endurance injured part. To prevent edema and encourage fluid return,
• Helps prevent high BP wrap the bandage starting distally (at the point farthest from the
• Reduces the risk for heart disease, diabetes, and colon cancer trunk of the body) and progress proximally (toward the trunk
• Enhances sense of well-being and reduces risk for depression of the body). The bandage is too tight if there is numbness or
tingling below the area of compression or pain or more swelling
occurs beyond the edge of the bandage. Leave the bandage in
exercises are important (Box 67.3). Strength exercises that place for 30 minutes, then remove it for 15 minutes. Use of an
involve working against resistance build muscle strength and elastic wrap may provide extra support during training, athletic,
bone density. Balance exercises, which may overlap with some and work activities.
strength exercises, help prevent falls. Endurance exercises Elevate the injured part above heart level, even during sleep,
should start at a low level of effort and progress gradually to a for 24 to 48 hours to help mobilize excess fluid from the area
moderate level. and prevent further edema. Mild analgesics and nonsteroidal
antiinflammatory drugs (NSAIDs) may be used to manage
Acute Care patient discomfort.
If an injury occurs, immediate care focuses on (1) stopping the After the acute phase (usually 24 to 48 hours), apply warm,
activity and limiting movement to the injured part, (2) apply- moist heat to the affected part to reduce swelling and provide
ing ice packs to the injured area, (3) compressing the involved comfort. Heat applications should not exceed 20 to 30 minutes.
area, (4) elevating the extremity, and (5) providing analgesia as Allow a “cool-down” time between applications. Encourage the
needed (Table 67.3). Most sprains and strains are treated in the patient to use the limb if the joint is protected by a cast, brace,
outpatient setting. splint, or taping. Joint movement maintains nutrition to the car-
RICE (Rest, Ice, Compression, Elevation) may decrease tilage. Movement helps prevent contracture (stiffening) of ten-
local inflammation and pain for most musculoskeletal injuries. dons and ligaments. Muscle contraction improves circulation
Movement should be restricted with the extremity rested as and helps resolve bruising and swelling.
soon as pain is felt. Unless the injury is severe, prolonged rest is Emphasize the importance of strength and conditioning
usually not needed. exercises to prevent reinjury. The physical therapist may help
There are several forms of cold therapy (cryotherapy). with pain relief by using ultrasound or other interventions.
Cold causes vasoconstriction in the soft tissue and reduces They can teach the patient exercises to improve flexibility and
the transmission and perception of nerve pain impulses. strength.
, CHAPTER 67 Musculoskeletal Trauma and Orthopedic Surgery 1641
TABLE 67.3 EMERGENCY MANAGEMENT
Acute Soft Tissue Injury
Cause Assessment Findings Interventions
• Crush injury • Bruising Initial
• Direct blows • ↓ Movement with limited function or inability • Ensure airway, breathing, and circulation.
• Falls to bear weight (lower extremity) • Perform neurovascular assessment of involved limb.
• Motor vehicle crashes • ↓ Pulse, coolness, capillary refill >2 sec • Elevate involved limb.
• Sports injuries • ↓ Sensation • Apply compression bandage unless dislocation present.
• Edema • Apply ice packs to affected area.
• Muscle spasms • Immobilize affected extremity in the position found. Do not try to realign or
• Pain, tenderness reinsert protruding bones.
• Pallor • Anticipate x-rays of injured extremity.
• Shortening or rotation of extremity • Give analgesia as needed.
• Give tetanus prophylaxis if there is an open fracture.
• Give antibiotic prophylaxis for open fracture, large tissue defects, or mangled
extremity injury.
Ongoing Monitoring
• Monitor for changes in neurovascular condition.
• Implement weight-bearing restrictions as ordered for lower extremity
involvement.
• Anticipate compartment pressure monitoring if neurovascular assessment
changes and compartment syndrome suspected.
DISLOCATIONS
Dislocation is the complete displacement or separation of the
articular surfaces of the joint. Subluxation is a partial or incom-
plete displacement of the joint surface. Symptoms of subluxation
are similar to a dislocation but are less severe. Many struc-
tures contribute to joint stability. Injury to, or excessive laxity
of, ligaments is a major factor in dislocations or subluxations.
Weak or atrophied muscles can cause chronic joint instability. A B C
Fibrocartilage structures, such as the labrum around hip and Fig. 67.1 Soft tissue injury of the hip. (A) Normal. (B) Subluxation (par-
tial dislocation). (C) Dislocation.
shoulder sockets and the meniscus at the knee, play an import-
ant role in joint stability. Even small tears to these structures can
result in recurrent, chronic dislocations or subluxations. X-rays can determine the extent of displacement. The joint
Dislocations typically result from forces on the joint that dis- may be aspirated to assess for hemarthrosis or fat cells. Fat cells
rupt the surrounding soft tissue support structures. The joints in the aspirate indicate a probable intraarticular fracture.
most often dislocated in the upper extremity include the thumb,
elbow, and shoulder. The shoulder most often dislocates anteri- Interprofessional and Nursing Care
orly. Posterior shoulder dislocations are rare. They typically only A dislocation requires prompt attention. It is often considered
happen after electrocution or seizure. In the lower extremity, the an orthopedic emergency because it may be cause significant
hip is vulnerable to dislocation from severe trauma, often from vascular injury. The longer the joint is dislocated, the greater the
motor vehicle crashes (Fig. 67.1). The kneecap (patella) may dis- risk for avascular necrosis. The femoral head of the hip joint is
locate because of a sharp, direct blow or after a sudden twisting especially susceptible to avascular necrosis. Compartment syn-
inward motion while the planted foot is pointed outward. drome may occur after dislocation due to vascular injury and
The most obvious sign of a dislocation is deformity. For resulting ischemia. Neurovascular assessment is critical.
example, if the hip dislocates in a posterior (or backward) direc- The first goal of care of a dislocation is to realign the dislocated
tion, the affected limb may be shorter and internally rotated. part of the joint to its original anatomic position. Closed reduction
Other manifestations include local pain, tenderness, loss of (no incision) may be done under local or general anesthesia or IV
function of the injured part, and swelling of soft tissues near the moderate to deep sedation. Anesthesia is often needed to relax the
joint. Major complications include open joint injuries, intraar- muscle so that the bones can be manipulated. Sometimes, open
ticular fractures (within the joint), avascular necrosis (bone cell reduction (joint visualized through surgery) may be needed. After
death from blood supply), and damage to adjacent nerves and reduction, the extremity is immobilized by a brace, splint, or sling,
blood vessels. or by taping, to allow torn ligaments and surrounding tissue to heal.
