GENER C.

SIBAL, RN,MD,FPOA
MUSCULOSKELETAL: Traumatic Orthopedic Disorders

I. A. Types of Traumatic Injuries

1. Soft Tissue Injuries
a. Sprain - rupture (excessive stretching) of ligaments

b. Strain - rupture (excessive stretching) of muscles or tendons

c. Contusion or bruise - injury due to a blunt force

2. Soft & Bony or Osseous Tissue Injuries

a. Dislocation - complete disruption of a joint so that the articular surfaces are no longer in
contact

normal elbow joint dislocated elbow joint

b. Subluxation - minor disruptions of joints where articular contact still remains

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 normal elbow joint subluxated elbow joint

c. Fracture - break in the continuity of a bone

normal elbow joint fractured ulna

d. Traumatic Amputation - complete un/intentional non-surgical severance of a body part

B. Clinical Signs and Symptoms of Fracture

1) pain and tenderness
2) loss of function
3) deformity
4) attitude
5) abnormal mobility and crepitus
6) neurovascular injury
7) radiographic findings

C. Fracture Types and Patterns

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 a) based on the mechanism of injury -

b) based on the fracture type

1) closed or simple - skin is intact
2) open or compound - skin is breached
3) greenstick - usually in children; only 1 side is broken, the other is bent
4) incomplete - only 1 side is broken (adult)
5) complete - bone is separated into 2 parts
6) comminuted - with 3 or more fragments
7) oblique
8) spiral
9) transverse - fractured straight across

D. Fracture Treatment: Methods and Principles / Nursing Interventions

1. Casting
- application of plaster-of-Paris or a synthetic (fiberglass) material to a body part for the
purpose of immobilization
- the cast serves to hold the broken bone in place to allow for healing even when the client is
up and about
- to be effective, the cast should include both joints above and below the fracture line
- 3 methods of application: (historically)
a. skin-tight cast (Böhler)
- POP applied directly to the skin without any intervening padding
- rarely used today, if ever
- adv.: provides the most efficient form of immobilization
disadv.: greatest danger of pressure sore & circulatory embarassment
difficult to remove because hair becomes incorporated with the cast
b. Bologna cast (emanated from Rizzoli Institute / advocated by Charnley)
- with generous amounts of cotton wadding applied to the limb followed by compressive
effect of POP (applied with “just the right amount of tension”)
c. Third Way
- stockinette, then sheet wadding, then POP

2. Traction - utilized when reduction through the use of a cast is impossible

a. Skin
- named after Gurdon Buck hence the term “Buck’s traction (although he never invented it
nor did he ever claim to have done so)
- traction weight must only be 5 to 7 lbs.
- aside from immobilization and fracture reduction, it can also relieve muscle spasm
b. Skeletal
- was first achieved with the use of tongs
- as we know it today, the bone is transfixed with a pin (Fritz Steinmann hence Steinmann

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 pin)
- K-wire (Kirschner), a smaller diameter pin, was used for some time because it offered less
trauma to the soft and bony tissues but when applied for prolonged periods, it had a
propensity to cut through bone - so… back to Steinmann pin
- can apply traction weights of up to 10% of the person’s body weight

3. Fracture Reduction
a. Closed
- attempts to achieve adequate or acceptable alignment of the fracture fragments; it is
neither necessary, nor, in some cases, desirable to achieve an anatomical reduction
* reasons for reducing a fracture (Lloyd Griffiths):
- to ensure recovery of function of the limb where that is threatened by displacement of
the fracture
- to prevent or delay degenerative changes in joints (particularly weight-bearing joints)
which will result from persisting deformity
- to minimize the deforming effect of injury
b. Open - (by surgery) indications:
- when closed methods have failed
- when it is known from experience that closed methods will be ineffective
- when articular surfaces are fractured and are displaced
- when the fracture is secondary to tumor metastasis
- when there is an associated neurovascular injury
- when multiple injuries are present
- where continued confinement to bed is undesirable
- when the cost of treatment may be substantially reduced
4. Fixation
a. Internal
- through the use of screws, wires, plates, intramedullary rods and nails, pins, spinal fixation
devices
- some will be removed after some time; some will be left within the body until death

screws cerclage wire semi-tubular plates

pins spine fixation device

hip prostheses

etc. etc. etc.

b. External

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 - for fracture fixation
> unstable fractures
> extensive soft tissue injury
- for limb lengthening (Ilizarov)
> bone loss
> aesthetic

Ilizarov limb lengthening technique

external fixators - for fracture fixation

E. Spine Injuries
- nursing interventions:
> turn patient side to side every 2 hrs.
> turn the patient as one unit e.g. logrolling

F. Hip Fracture in the Elderly

- 2 types:
1) intracapsular - femoral neck fracture
- patient needs to have surgery (e.g. partial hip replacement)
2) extracapsular - intertrochanteric fracture / (subtrochanteric fracture)
- patient may be treated conservatively (e.g. skin or skeletal traction / skillful neglect) or
surgically (dynamic compression screw fixation / partial hip replacement)
- post-op care:
> limb positioning: depends on the surgical approach (“surgical approach” refers to whether
the hip joint capsule was entered anteriorly or posteriorly)
* if anterior approach - limb should be maintained in internal rotation
* if posterior approach - limb should be maintained in external rotation
> turning patients - turn client fom back to unaffected side (do not position the client on the
affected side)
> ensure that hip flexion does not exceed 60 to 80 degrees; head of bed may be elevated to
30 to 45 degrees (only for meals)
> maintain leg abduction to prevent internal/external rotation; use trochanter roll to prevent
external rotation
> avoid low chairs when out of bed; instruct the clients not to cross legs; avoid bending over

G. Complications of Fractures: Immediate and Delayed

1. Compartment Syndrome
- a condition in which the circulation and function of tissues within a closed space are
compromised by an increased pressure within that space
- S/Sx: 4 Ps - Pain / Pallor / Paralysis / Pulselessness
although none is pathognomonic, pain is the most important
best indicator: tissue pressure measurement
- a surgical emergency (fasciotomy)
- results in permanent neurovascular damage if not relieved in 4 to 6 hrs.
* the normal tissue pressure within closed compartments is approximately 0 mmHg
> pressures of within 10 to 30mmHg of a patient’s diastolic blood pressure - there will
inadequate tissue perfusion and relative ischemia
> if the pressure within a compartment equals or exceeds the patient’s diastolic blood
pressure - there will be no effective tissue perfusion

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 * Instructions for measuring intracompartmental pressure (Whitesides technique)

1. Clean and prep the area of the extremity to be evaluated.
2. Assemble your 20cc syringe with the plunger at the 15cc
mark and connect to an open end of the 4-way
stopcock (see diagram).
3. Connect sterile plastic IV extension tube and an
18-gauge needle on another end of stopcock and a
second IV extension tube to opposite end of stopcock
(see diagram) to a blood pressure manometer (see
diagram).
4. Insert the tip of the 18-gauge needle into the saline bag
and open the stopcock to allow flow through the
needled IV tubing only. Aspirate the saline without
bubbles into approximately half of the length of the
extension tube. Turn the 4-way stopcock to close off
this tube so that the saline is not lost during transfer of
the needle.
5. Insert the 18-gauge needle into the muscle of the
compartment in which the tissue pressure is to be
measured.
6. Turn the stopcock so that the syringe is open to both
extension tubes forming a “T” connection as shown in
the diagram. This produces a closed system in which
the air is free to flow into both extension tubes as the
pressure within the system is increased.
7. Increase the pressure in the system gradually by slowly
depressing the plunger of the syringe while watching
the saline/air meniscus. The mercury manometer will
rise as the pressure within the system rises. When the
pressure in this system has just surpassed tissue
pressure sorrounding the needle, a small amount of
saline will be injected into the tissue and the meniscus
will be seen to move. When the column moves, stop the
pressure on the syringe plunger and read the level of
the manometer. The manometer reading at the time the
saline column moves is the tissue pressure in mmHg.

OR… JUST USE THIS…

Stryker STIC (soft tissue intracompartment) Monitor

intermuscular septae fasciotomy post-op wound care

2. Cast Syndrome
- results from obstruction of the third portion of the duodenum by the superior mesenteric
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 artery leading to high intestinal obstruction
- associated with the use of hyperextension body jackets which were used to treat spinal
fractures in the past
- presently, the typical presentation is abdominal pain, distension and vomiting following
application of a spica cast
- treatment:
> nasogastric tube suction and IV fluid for 3 to 4 days
> occassionally these symptoms may become intractable and may require surgery
consisting of a side to side duodenojejunostomy

3. Fat Embolism
- usually seen in long bone fractures / after reaming
- restlessness, altered mental staus, dyspnea, tachypnea, tachycardia
- petechial rash over the chest, axilla, neck
- NI: notify MD immediately
High-Fowler’s position

4. Plaster Sores (Cast Pressure Ulcers)

- pressure sores result from skin necrosis caused by localized pressure from the inner aspect
of the cast
- they occur over prominent bony areas, from ridges formed in the plaster during improper
application and from foreign bodies placed under the cast
- this is the reason why only the palms of the hands are used to hold a wet cast - so as not to
create inward projections resulting from imprints of fingertips which later on harden and
cause pressure on the skin (the resulting skin lesion is very much similar to a bedsore)
- note for foul odor and/or moist areas on the cast - this may point to a unseen weeping lesion
* these pressure ulcers may occur with little or no pain

bedsore (plaster sores have the same appearance as this)

5. Malunion / Delayed Union / Non-union

Malunion
- fracture healing in a non-acceptable angulation

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 Non-union
- refers to an arrest of the healing process and the formation of a
typical pseudoarthrosis or a fibrous union in which the bone
ends are either osteoporotic and atrophied, or sclerotic

Delayed union
- one that takes longer than the average for a given bone injury
to heal

6. Heterotopic Ossification or Myositis Ossificans

- generally occurs in a muscle (or adjacent to a muscle) near bone
- if it occurs, it will become apparent radiographically within 3 to 4 weeks after the initial injury

7. Osteomyelitis
- infection of the bone
- suppurative process in bone caused by a pyogenic organism
- types of osteomyelitis (Waldvogel) - based on the pathogenesis
a. hematogenous osteomyelitis
b. osteomyelitis secondary to a contiguous focus of infection
c. osteomylitis from direct inoculation of bacteria at the time of injury or surgery
- this is the type most frequently associated with fractures

typical skin appearance of osteomyelitis typical radiographic picture of osteomyelitis

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