Orthopedic Trauma

CHAPTER 37 Orthopedic Trauma



Denise Ramponi, CRNP, MSN, CEN, NP-C, RN-C, APRN Mary Jo Cerepani, CRNP, MSN, CEN



MAJOR TOPICS



General Strategy


Assessment

Analysis: Differential Nursing Diagnoses/Collaborative Problems

Planning and Implementation/Interventions

Evaluation and Ongoing Monitoring

Documentation of Interventions and Patient Response

Age-Related Considerations

Specific Soft Tissue Injuries


Contusions/Hematomas

Strains and Sprains

Specific Injuries of Bony Skeleton


Dislocations

Fractures

Traumatic Amputations

Specific Life-Threatening Complications Associated with Orthopedic Injuries


Hemorrhage from Fractures

Fat Embolism Syndrome

Compartment Syndrome

Septic Arthritis

Osteomyelitis

Splinting and Assistive Walking Devices


Splints

Assistive walking devices


I. GENERAL STRATEGY


The aim in caring for the patient with an orthopedic emergency is to restore and preserve function.



A. Assessment




1. Primary and secondary assessment/resuscitation (see Chapters 1 and 31)


2. Focused assessment


a. Subjective data collection

1) History of present injury/chief complaint
a) Trauma
(1) Mechanism of injury (see Chapter 30)
(a) Onset of symptoms

(b) Duration of symptoms

(c) Blunt or penetrating injury forces

(d) Motor vehicle crash

(e) Falls

(f) Power tool injury

(2) Precipitating factors: preexisting injuries, associated symptoms, medical problems

(3) Aggravating factors

b) Pain: PQRST (see Chapter 9)

c) Associated symptoms
(1) Changes in neurovascular function

(2) Ability to bear weight

(3) Range of motion

(4) Weakness versus pain as presenting symptom

d) Swollen areas
(1) Onset

(2) Size

(3) Location

(4) Symptoms: pain, tenderness, numbness, weakness

e) Effort to relieve symptoms
(1) Home remedies

(2) Alternative therapies

(3) Medications
(a) Prescription

(b) Over-the-counter/herbal

2) Past medical history
a) Current or preexisting diseases/illness
(1) Anemia, bleeding, coagulation disorder

(2) Cardiovascular disease (indication of peripheral vascular disease)

(3) Diabetes mellitus (associated with peripheral neuropathy, decreased microcirculation)

(4) Arthritis: degenerative or rheumatoid

(5) Acute inflammatory diseases

(6) Paget’s disease: localized areas of bone destruction followed by replacement with overdeveloped, light, soft, porous bone and associated with deformities such as thickening of portions of the skull and bending of weight-bearing bones; cause unknown

(7) Use of medications that predispose to fractures (e.g., phenytoin sodium and corticosteroids)

(8) Disorders associated with peripheral nerve injury (Box 37-1)

(9) Prior injury or surgery of affected extremity

(10) Preexisting disabilities, metabolic disorders

(11) Osteopenia or osteoporosis

(12) Infections: septic arthritis or osteomyelitis in children
(a) Streptococcal infections

(b) Urinary tract infections

(c) Upper respiratory tract infections

(d) Ear infections

(e) Other infectious disorders

b) Recent injury or problem with affected extremity

c) Pregnancy: swelling precipitates overuse syndromes; prone to falls with pelvic ligament laxity

d) Smoking history

e) Substance and/or alcohol use/abuse

f) Last normal menstrual period: female patients of childbearing age

g) Vitamin deficiency

h) Current medications
(1) Prescription

(2) Over-the-counter/herbal

i) Allergies

j) Immunization status

3) Psychological/social/environmental factors
a) Stress factors
(1) Lifestyle

(2) Precipitating events

(3) Possible/actual assault, abuse, or intimate partner violence situations (see Chapter 3)

b) Ability to perform activities of daily living

c) Household or domicile residence factors
(1) Single, living alone

(2) Stairs

b. Objective data collection

1) General appearance
a) Level of consciousness, behavior, affect

b) Vital signs

c) Gait

d) Hygiene

e) Odors

f) Level of distress/discomfort

2) Inspection
a) Comparison: examine both sides of body to visualize symmetry, contour, size, alignment
(1) Valgus: deformity of distal portion of joint that is angulated away from midline of body (e.g., knock-knees, hallux valgus)

(2) Varus: deformity of distal portion of joint that is angulated toward midline of body (e.g., bowleg and pigeon-toe)

b) Skin and soft tissue
(1) Color changes and hair loss associated with peripheral vascular disease

(2) Soft tissue swelling or ecchymosis

(3) Gross deformities: associated with arthritis, tumors, swelling

(4) Muscle mass: hypertrophy and atrophy

(5) Scars indicative of previous injury, surgery, invasive procedures, intravenous (IV) drug abuse

c) Joints
(1) Deformity (e.g., nodules in fingers, toes, knees)

(2) Swelling (e.g., inflammation, infection, trauma)

(3) Redness (e.g., inflammation associated with infection, cellulitis, and gouty arthritis)

(4) Range of motion (passive and active)

(5) Rotation: position of joint, extremity, ability to rotate internally or externally

d) Peripheral vasculature
(1) Peripheral nerve assessment (see Chapter 24, Table 24-1)

(2) Skin for acute pallor; chronic cyanosis, pigmentation, circulatory changes

(3) Amount and distribution of hair

(4) Skin ulcers

(5) Veins for distention: unilateral versus bilateral

3) Palpation/percussion
a) Skin and soft tissue
(1) Temperature and texture

(2) Swelling and pitting edema

b) Quality of arterial pulses: brachial, radial, ulnar (overlying tissue may obscure, patency determined by Allen’s test); femoral, popliteal, posterior tibial, and dorsalis pedis (may be congenitally absent or may branch higher in ankle); presence of pulse does not rule out arterial injury

c) Grading of pulse quality (Table 37-1)

d) Capillary refill test (Box 37-2)

e) Muscle tone (Box 37-3)

f) Muscle strength (Box 37-4)

g) Deep tendon reflexes (Table 37-2)

h) Joints
(1) Temperature

(2) Pain or tenderness with palpation

(3) Crepitation with movement

(4) Passive range of motion (done by examiner)

(5) Joint laxity and stability (varies with each joint)

i) Bones
(1) Tenderness along length

(2) Resistance to deforming force

(3) Deformity, crepitus, tenderness

3. Diagnostic procedures


a. Laboratory studies (Table 37-3)

1) Complete blood count (CBC) with differential

2) Erythrocyte sedimentation rate (ESR)

3) Arterial blood gases (ABGs)

4) Blood cultures

5) Urinalysis; pregnancy test in female patients of childbearing age

b. Imaging studies

1) Radiographic films provide data on bone and joint changes; useful for diagnosing open joint injuries (air visible in joint space); standard imaging studies for acute fractures and dislocations; do not show soft tissue disorders except swelling

2) Computed tomography (CT) used for diagnosis
a) Fractures involving articular surfaces (e.g., tibial plateau, calcaneus, talus)

b) Fracture/dislocations that are difficult to visualize or too dangerous to manipulate (e.g., pelvis for complex fractures, sacrum, acetabulum)

c) Fracture of scapula, carpal bones, tarsal bones; dislocations of humeral and femoral heads, radioulnar or sternoclavicular joints

d) Stress fractures

e) Bony changes, metastatic processes

3) Angiography: used to diagnose and treat vascular injuries, prevent hemorrhage, and relieve ischemia; useful for recognizing and selectively embolizing major bleeding vessels through an arterial catheter and injuries of extremities with suspected vascular involvement (e.g., knee dislocations or penetrating wounds)

4) Magnetic resonance imaging (MRI): indicated for soft tissue disorders such as ligamentous injury, meniscal damage, tendon ruptures, muscle tears, tumors and hematomas, spinal structures, infection, degenerative disorders

5) Bone scans: helpful in the identification of occult fractures and metastatic disease

6) Arthroscopy: used to evaluate injury to joint structures

7) Doppler sonography: assessment of arterial flow

a. Other studies

1) 12- to 15-lead electrocardiogram (ECG)


Box 37-1 DISORDERS ASSOCIATED WITH PERIPHERAL NERVE INJURY




Alcoholism


Sudden significant weight loss


Carcinomatous neuropathy


Diabetic peripheral neuropathy


Previous trauma


Acute extremity compression


Table 37-1 GRADING OF PULSE QUALITY





















Grade Description
0 No pulse
1 Weak and easily obliterated with pressure
2 Difficult to palpate but easy to feel once located
3 Easily palpated and considered normal
4 Strong and bounding


Box 37-2 CAPILLARY REFILL TEST




Used when unable to palpate pulses because of casts, splints, dressings


Is nonspecific measure of tissue perfusion, which can be affected by multiple factors


Normal time for color to return after blanching is 2 seconds or less



Box 37-3 MUSCLE TONE




Decreased as a result of musculoskeletal, neurologic, metabolic, or infectious disorders and/or fatigue


Increased as a result of spasms, injury, cramps, tremors (associated with electrolyte disorders, neurologic conditions, and infections such as tetanus)



Box 37-4 MUSCLE STRENGTH




Assess range of motion before muscle strength because muscular contraction may produce enough pain to inhibit further examination


1. Ask patient to resist movement or move against resistance

2. Strength is subjectively graded by examiner on scale ranging from 1 to 5

3. All findings are recorded and used as a baseline

4. Grading of muscle strength

0: Paralysis, no muscular contraction detected

1: Only slight contractility and no joint motion

2: Active movement, full range of motion with gravity eliminated

3: Active movement, full range of motion against gravity

4: Active movement, full range of motion against gravity and some resistance

5: Active movement, full range of motion against full resistance

Table 37-2 DEEP TENDON REFLEXES*























Grading of Reflexes
Grade Description
0 No reflex
+1 Less than normal
+2 Average
+3 Stronger than average
+4 Intense (clonus)

* Assess major reflexes: biceps, brachioradialis, triceps, patellar knee jerk, Achilles tendon.


Table 37-3 LABORATORY STUDIES TO AID DIAGNOSIS OF ORTHOPEDIC CONDITIONS

































Test Examples
Alkaline phosphatase level Increased with healing fractures, metabolic bone disease, osteoporosis, and metastatic tumors of bone
Calcium level

Increased with metastatic bone cancer, dehydration, Paget’s disease


Decreased with hypoparathyroidism, advanced osteomalacia, and rickets

Creatine kinase level Increased in dehydration, hyperthyroidism, renal failure, and rhabdomyolysis
Phosphorus level Increased in bone metastases and hypoparathyroidism
Alanine aminotransferase (ALT), aspartate aminotransferase (AST) Increased in myositis
Uric acid level Increased in gout, multiple myeloma, and acute tissue destruction as a result of starvation or excessive exercise
C-reactive protein Increased in acute inflammatory changes and rheumatoid arthritis
Antinuclear antibodies Positive in rheumatoid arthritis, systemic lupus erythematosus, and polymyositis
Serum rheumatoid factor Positive in rheumatoid arthritis and some chronic inflammatory diseases


B. Analysis: Differential Nursing Diagnoses/Collaborative Problems




1. Acute pain


2. Activity intolerance


3. Risk for falls/injury


4. Anxiety/fear


5. Impaired skin integrity


6. Ineffective tissue perfusion


7. Risk for infection


8. Deficient knowledge



C. Planning and Implementation/Interventions




1. Determine priorities of care


a. Maintain airway, breathing, and circulation (see Chapters 1 and 31)

b. Provide supplemental oxygen as indicated

c. Establish IV access for administration of crystalloid fluids/blood products/medications as needed

d. Obtain and set up equipment and supplies

e. Prepare for/assist with medical interventions

f. Administer pharmacologic therapy as ordered

2. Relieve anxiety/apprehension


3. Allow significant others to remain with patient if supportive


4. Educate patient and significant others



D. Evaluation and Ongoing Monitoring (see Appendix B)




1. Continuously monitor and treat as indicated


2. Monitor patient response/outcomes and modify nursing care plan as appropriate


3. If positive patient outcomes are not demonstrated, reevaluate assessment and/or plan of care



E. Documentation of Interventions and Patient Response




F. Age-Related Considerations




1. Pediatric


a. Growth or development related

1) Child’s bone structure different from adult’s; children considered skeletally immature

2) Skeleton of infant and young child is largely cartilaginous
a) Bones narrow and flexible

3) Periosteum is thicker and resists disruption
a) Provides circulation and nutrients to bone

b) Allows bone to be more elastic and resists fracture
(1) Greenstick: shaft of bone (diaphysis) fractured on one side, but cortex intact on other side

(2) Torus: compression fracture of the bone at the junction of the metaphysis and diaphysis causing “buckling”; patient often presents with pain but no deformity

4) Children have open epiphyses (growth plate) until after adolescence; this area is more susceptible to trauma; fractures to the epiphysis constitute one third of all fractures and are described according to Salter-Harris classification system (Fig. 37-1)

5) Child’s ligaments are more resistant than epiphyses to trauma
a) Dislocations rare

b) Fractures often accompany dislocation

c) Sprains (ligamental tears) unusual in young children but do occur in adolescents

6) General appearance
a) Observe legs while child is walking
(1) Infants have bowlegged (genu varum) appearance from birth to 2 or 3 years

(2) Infants tend to evert feet and walk on inner aspects of feet

(3) Between 18 and 36 months, child may appear knock-kneed (genu valgum)

(4) Normal leg configuration should be present at approximately 6 to 7 years

b) Feet appear flatfooted
(1) Medial longitudinal arch normally obscured by fat pads until approximately 2 years

(2) Arch better visualized when child not weight bearing (e.g., when seated or on tiptoes)

c) Child may normally walk with in-toeing (pigeon-toed)
(1) Rotational alignment of legs changes as skeleton matures, producing spontaneous correction

(2) Pathologic changes may be produced by disorders of feet, lower legs, and hips

b. “Pearls”

1) Fractures result from significant force: history should be appropriate for pattern of injury

2) Warning flags to consider child maltreatment: fracture in infant younger than 1 year, spiral fracture, unwitnessed or unexplained injury, fractures in various healing stages, history of other fractures, fracture that does not fit mechanism of injury stated

3) Approximately 25% of fractures in children younger than 3 years caused by nonaccidental trauma

4) Torus/buckle fractures unique to children

5) Pulling injury to arm can result in “nursemaid’s elbow” (subluxation of the radial head) in child commonly seen between 2 to 3 years of age

6) Limping: uncommon in children; suspect hip disorder if found

7) Unwillingness to bear weight requires further investigation

2. Geriatric


a. Aging related

1) Loss of bone minerals and mass
a) Regeneration prolonged

b) Bones become more brittle

c) Loss of vertebral body height results from compression that occurs with normal aging and leads to kyphosis

2) Muscles lose ability to regenerate new fibers to replace ones lost because of age (atrophy)
a) Decreased muscular strength and endurance, shuffling gait

b) Longer contraction time and tendency to fatigue more easily, which may cause muscle tremors, even at rest

b. “Pearls”

1) Joint stiffness and degenerative changes contribute to decreased mobility

2) Posture affected by age-related changes

3) Gait affected by posture, balance, strength, and flexibility

4) Changes in feet common
a) Foot size decreases because of loss of subcutaneous fat

b) Skin is drier; corns and calluses form at pressure points; epidermis thins and loses natural moisture

c) Decreased circulation from peripheral vascular disease may delay healing; venous stasis or arterial occlusion produces ulceration

d) Toenails thicken, affecting shoe fit

e) Bunion and toe overlapping or underriding may occur

5) Osteoporosis promotes fractures, especially in vertebral bodies, ribs, proximal femur

6) Osteoarthritis (degeneration of movable joints) affects mostly weight-bearing joints of knees, vertebrae, small joints of hand and feet

7) Rheumatoid arthritis (e.g., systemic disease of connective tissue resulting in joint inflammation) produces swelling, stiffness, ankylosis, redness, warmth of joints

8) Pathologic fracture may be caused by other chronic diseases

9) Paget’s disease
a) Metabolic disease that causes excessive bone resorption and deposits

b) Middle-aged and elderly men primarily affected

c) Affected bones tend to fracture easily

image

FIGURE 37-1 Salter-Harris classification of pediatric fractures.


(From Simon, R. R., & Koenigsknecht, S. J. [2001]. Emergency orthopedics (4th ed.). New York: McGraw-Hill.)




II. SPECIFIC SOFT TISSUE INJURIES


The soft tissue of the extremities includes the skin, muscles, tendons, ligaments, nerves, and blood vessels. Injuries may occur with or without a bony injury, and in some cases it is difficult to determine the diagnosis. A careful clinical examination, along with radiologic studies to rule out skeletal trauma, is necessary to identify the problem. Certain disorders may result from chronic overuse and may not have an acute history of injury.



A. Contusions/Hematomas


A contusion is a closed wound in which a ruptured blood vessel has hemorrhaged into the surrounding tissues. The blood may form a hematoma if bleeding is sufficient and has been contained. This can result from blunt external forces or exertional stresses. Symptoms may include swelling, discoloration, and tenderness. Populations at risk are those involved in physical activities, sports, or abusive relationships and patients who are taking anticoagulant therapy or who have a history of clotting disorders.




1. Assessment


a. Subjective data collection

1) History of present injury/chief complaint
a) Direct blow to affected area

b) Object of contact

c) Onset of swelling, discoloration

d) Therapies initiated to relieve symptoms

2) Past medical history
a) Current or preexisting diseases/illness
(1) Peripheral vascular disease

(2) Clotting factor deficiencies

b) Medications (e.g., anticoagulants, antiplatelet agents)

c) Allergies

d) Immunization status

b. Objective data collection

1) Physical examination
a) General appearance
(1) Mild to moderate distress/discomfort

b) Inspection
(1) Skin discoloration reflecting age of contusion (Box 37-5)

(2) Size

(3) Location
(a) Extension of ecchymosis to dependent areas over time (e.g., lower leg ecchymosis spreads to foot)

c) Palpation
(1) Area tenderness

2) Diagnostic procedures
a) CBC with platelet count to rule out significant blood loss and thrombocytopenia as possible cause of bleeding

b) Coagulation profile (prothrombin time [PT], partial thromboplastin time [PTT], international normalized ratio [INR]) to rule out coagulopathy

c) Radiographs to rule out associated fractures

2. Analysis: differential nursing diagnoses/collaborative problems


a. Acute pain

b. Activity intolerance

c. Impaired skin integrity

d. Risk for infection

e. Deficient knowledge

3. Planning and implementation/interventions


a. Prepare for/assist with medical interventions

1) Splint extremity to protect from further injury or iatrogenic injury and for pain reduction

2) Apply pressure dressing to decrease hemorrhage and swelling

b. Administer pharmacologic therapy as ordered

1) Non-narcotic analgesics

2) Narcotics

c. Educate patient and significant others

1) Rest and elevate affected extremity to minimize bleeding and edema formation

2) Apply cold packs to stimulate vasoconstriction
a) Use for 20 minutes at a time, four times per day, for the first 2 to 3 days

b) Wrap cold pack to protect skin from cold and further injury

3) Apply and remove compressive dressing

4) Use physical assistive devices (e.g., cane, crutches, walker)

4. Evaluation and ongoing monitoring (see Appendix B)


a. Pain relief


Box 37-5 SKIN DISCOLORATION REFLECTING AGE OF CONTUSION




24 to 48 hours after injury: Area tender and swollen; ecchymosis may not appear; reddish blue or purple color may take up to several days to appear, depending on location of injury, distance of injured blood vessels from skin surface, and amount of bleeding


5 to 7 days: Color begins changing on periphery, proceeding toward center; takes on greenish tint


7 to 10 days: Yellow tint


10 to 14 days or longer: Brown


2 to 4 weeks: Clears



B. Strains and Sprains


Injuries to the structures around a joint are usually caused by excessive stretch or sudden force. This results in pulling on the structures, which causes tears in muscle and/or tendon. A sprain is the stretching, separation, or tear of a supporting ligament, and a strain is the separation or tear of a musculotendinous unit from a bone. Injury may result in pain, inability to weight bear fully, and swelling of the affected area. Sprains and strains are rare in small children, whose epiphyseal plates are still open and more vulnerable to forces. Athletes and obese patients resuming physical fitness are at risk for these types of injuries. Both strains and sprains are classified based on the amount of damage (Box 37-6).



Box 37-6 DEGREE OF SPRAINS/STRAINS




First degree: Minor tear in the fibers; minimal swelling, minor discomfort, absent or minor ecchymosis


Second degree: Partial tear; joint intact; more severe swelling, visible ecchymosis


Third degree: Complete disruption of ligament; joint may be open; minimal to severe swelling; resultant separation of muscle from muscle, muscle from tendon, or tendon from bone




1. Assessment


a. Subjective data collection

1) History of present injury/chief complaint
a) Sudden stretching, twisting, or excessive force to joint (e.g., popping sound may be heard or felt)

b) Pain (see Chapter 9): in joint (i.e., ranges from localized to severe and disabling; may be aggravated by movement, muscle tension, weight bearing)

2) Past medical history
a) Current or preexisting diseases/illness
(1) Rheumatoid arthritis predisposes to tendon rupture because of associated deformity changes

(2) Steroid injections are associated with tendon rupture; may result from injection itself or excessive volume within tendon sheath

b) Injury, surgery, or problems with joint

c) Medications

d) Allergies

e) Immunization status

b. Objective data collection

1) Physical examination
a) General appearance
(1) Gait: possible alteration

(2) Mild to moderate distress/discomfort

b) Inspection
(1) Swelling, deformity of affected area

(2) Ecchymosis

c) Palpation
(1) Tenderness over affected area

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Nov 8, 2016 | Posted by in NURSING | Comments Off on Orthopedic Trauma

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