Interventions for clients with musculoskeletal trauma
Musculoskeletal injury is one of the primary causes of disability in the
FRACTURES
 |
I OVERVIEW
A fracture is a break or disruption in the continuity of a bone. Fractures can occur anywhere in the body and at any age. All fractures have the same basic pathophysiologic mechanism and nursing management, regardless of fracture type or location.
1 Pathophysiology
K CLASSIFICATION OF FRACTURES
A fracture is classified by the extent of the break as follows: Complete fracture. The break is across the entire width of the bone in such a way that the bone is divided into two distinct sections.
Incomplete fracture. The fracture does not divide the bone into two portions, because the break is through only part of the bone.
A fracture is described by the extent of associated soft-tissue damage as open (or compound) or closed (or simple). The skin surface over the broken bone is disrupted in a compound fracture, which causes an external wound. These fractures are often graded to define the extent of tissue damage. Grade I is the least severe injury, and skin damage is minimal. In grade II, an open fracture is accompanied by skin and muscle contusions. The most severe injury is grade III, in which there is damage to skin, muscle, nerve tissue, and blood vessels; the wound is more than 2.4 to
Figure 52-1 illustrates common types of fractures. The nurse needs to be familiar with the differences in these types because they often dictate the specific nursing care required for the client.
In addition to being identified by type, fractures are characterized by their cause. A pathologic (spontaneous) fracture occurs after minimal trauma to a bone that has been weakened by disease. For example, a client with bone cancer or osteoporosis can easily sustain a pathologic fracture. A fatigue or stress fracture results from excessive strain and stress on the bone. Compression fractures are produced by a loading force applied to the long axis of cancellous bone. They commonly occur in the vertebrae of clients with osteoporosis.
K STAGES OF BONE HEALING
When a bone is broken, the body immediately begins the healing process to repair the injury and restore the body’s equilibrium. Within 48 to 72 hours after the injury, a hematoma forms at the site of the fracture because bone is extremely vascular. Blood supply to and within the bone usually diminishes because of the injury, which causes an area of bone necrosis. The dead cells prompt migration of fibroblasts and osteoblasts to the fracture site as part of the inflammatory process. This prompts the formation of fibrocartilage, providing the foundation for bone healing (within 3 days to 2 weeks).
As a result of vascular and cellular proliferation, the fracture site is surrounded by new vascular tissue known as a callus (within 2 to 6 weeks). Callus formation is the beginning of a nonbony union. As healing continues, the callus is transformed from a loose, fibrous tissue into bone (within 3 weeks to 6 months). Excess callus is resorbed. During the final phase of healing, consolidation, and remodeling, bone continues to be resorbed and deposited in response to stress, reshaping to meet mechanical demands. This process may start as early as 6 weeks after fracture and can continue for up to 1 year. Figure 52-2 summarizes the stages of bone healing.
In young, healthy adult bone, healing takes about 6 weeks. In the older person who has reduced bone mass, healing time is lengthened; complete healing often takes 3 to 6 months. Other factors that affect healing include the severity of the trauma, the type of bone injured, inadequate immobilization, infections at the fracture site, and avascular necrosis (AVN).
CONSIDERATIONS FOR OLDER ADULTS
CIS Healing can be affected by a number of factors in addition to the aging process. Bone formation and strength rely on adequate nutrition. Calcium, phosphorus, vitamin D, and protein are necessary for the production of new bone (see Chapter 53). For women, the loss of estrogen after menopause is detrimental to the body’s ability to form new bone tissue. Concurrent diseases can also affect the rate at which bone heals. For instance, peripheral vascular diseases, such as arteriosclerosis, reduce arterial circulation to bone; thus the bone receives less oxygen and lesser amounts of nutrients, both of
which are needed for repair.
|
|
|
■ COMPLICATIONS OF FRACTURES
Regardless of the type or location of the fracture, several limb and life-threatening complications can result from the injury. The nurse must be able to recognize the clinical manifestations of impending complications so that treatment can be started immediately. In some cases, careful monitoring and assessment can prevent these complications.
ACUTE COMPARTMENT SYNDROME. Compartments are sheaths of inelastic fascia that support and partition muscles, blood vessels, and nerves in the body. Acute compartment syndrome (ACS) is a serious condition in which increased pressure within one or more compartments causes massive compromise of circulation to the area. The most common sites for ACS are the compartments in the lower leg and the dorsal and volar compartments of the forearm.
The pressure to the compartment can be from an external or internal source. Tight, bulky dressings and casts are examples of external pressure. Blood or fluid accumulation is a common source of internal pressure. ACS is not limited to clients with musculoskeletal problems; clients with severe burns, extensive insect bites, or massive infiltration of intravenous (IV) fluids are also susceptible to compartment syndrome. In these situations, edema increases pressure in one or more compartments.
PATHOPHYSIOLOGIC CHANGES. The primary patho-physiologic changes of increased compartment pressure are sometimes referred to as the ischemia-edema cycle. Capillaries within the viable muscle dilate, which raises capillary pressure. Capillaries become more permeable because of the release of histamine by the ischemic muscle tissue. As a result, plasma proteins leak into the interstitial fluid space, and edema occurs. Edema causes pressure oerve endings and subsequent pain. Blood flow to the area is reduced, and further ischemia results. Sensory deficits (e.g., paresthesia) generally appear before changes in vascular or motor signs. The color of the tissue pales, and pulses begin to weaken but rarely disappear; the affected area is usually palpably tense, and pain can be elicited with passive motion of the extremity. If the condition is not treated, cyanosis, tingling, numbness, paresis, and severe pain occur. Chart 52-1 summarizes the sequence of pathophysiologic events in compartment syndrome and the associated clinical assessment findings.
ACS is not common, but it creates an emergency situation when it does occur. Within 4 to 6 hours after the onset of compartment syndrome, neuromuscular damage is irreversible. The limb can become useless in 24 to 48 hours.
In some cases, clients at especially high risk for ACS are monitored by an invasive procedure. Compartment pressures can be monitored on a one-time basis with a handheld device with a digital display, or they can be monitored continuously. Continuous monitoring requires placement of a wick or slit-tip catheter connected to a transducer and is recommended for comatose or unresponsive at-risk clients.
If ACS is verified, the surgeon may perform a fasciotomy by making an incision through the skin and subcutaneous tissues into the fascia of the affected compartment. This procedure relieves the pressure in order to restore circulation to the affected area. No consensus exists on what pressure requires fasciotomy (normal = 0 to
POSSIBLE RESULTS OF COMPARTMENT SYNDROME. Specific problems resulting from compartment syndrome include infection, persistent motor weakness in the affected extremity, contracture, and myoglobinuric renal failure. In extreme cases, amputation may be necessary.
Infection from the necrotic tissue may become severe enough that amputation of the limb is warranted. Motor weakness from injured nerves is not reversible, and the client may require braces or other orthotic devices for assistance in movement. Volkmann’s contractures, which can begin within 12 hours of the pressure increase, result from shortening of the ischemic muscle and from nerve involvement.
Myoglobinuric renal failure (rhabdomyolysis) is a potentially fatal complication of compartment syndrome. It commonly occurs when large or multiple compartments are involved. Injured muscle tissues release myoglobulin (muscle protein) into the circulation, where it can occlude the distal convoluted tubule and precipitate acute renal failure. Although the exact pathophysiologic mechanisms are unknown, it is suspected that myoglobulin has a direct toxic effect on the kidney. Damaged muscle cells also release potassium, which cannot be excreted because of the renal failure. The resulting hyperkalemia may cause cardiac dysrhythmias.
SHOCK. Bone is quite vascular; therefore there is a risk of bleeding with bone injury. In addition, trauma can sever adjacent arteries and cause hemorrhage; consequently, hypovo-lemic shock can develop rapidly. (The pathophysiology of hy-povolemic shock is described in Chapter 37.)
FAT EMBOLISM SYNDROME. Fat embolism syndrome (
The release of fat emboli is most likely with fractures of long bones or multiple fractures, although a break in any bone with sufficient bone marrow content can cause the complication. The problem can occur at any age or in either sex, but young men between ages 20 and 40 years and older adults between ages 70 and 80 years are at the greatest risk. The older client with a fractured hip has the highest risk, but
Several theories have been offered to explain how fat is released from the bone marrow. The metabolic theory proposes that the elevated concentration of catecholamines as a result of trauma causes mobilization of free fatty acids, which leads to platelet aggregation and the formation of fat globules. The mechanical theory suggests that the pressure within yellow bone marrow is greater than capillary pressure, and therefore fats are released directly from the bone. In either case, the fat globules are deposited in small blood vessels that supply the major organs of the body, most commonly the lungs.
The earliest manifestation of
Laboratory findings in
• Decreased serum calcium levels
• Decreased red blood cell and platelet counts
• Increased serum lipase level
These changes in blood values are poorly understood, but they aid in diagnosis of the condition.
Fat embolism usually occurs within 48 hours of the fracture and can result in respiratory failure or death, often from pulmonary edema. When the lungs are affected, the complication may be misdiagnosed as a pulmonary embolism from a blood clot (Chart 52-2).
THROMBOEMBOLITIC COMPLICATIONS. Deep vein thrombosis (DVT) often develops in people who are immobile because of trauma, surgery, or disability. It is the most common complication of lower extremity surgery or trauma and the most often fatal complication of musculoskeletal surgery. A person who smokes, is obese, has heart disease, or hasdure relieves the pressure in order to restore circulation to the affected area. No consensus exists on what pressure requires fasciotomy (normal = 0 to
a history of thromboembolitic complications is at an increased risk for DVT. The incidence of life-threatening em-bolic conditions is highest in older adults, particularly during the first 2 to 3 days after musculoskeletal surgery.
Certain fracture sites are more often associated with life-threatening thrombi. For example, DVT that leads to pulmonary embolism is more likely to develop in clients with fractures of the lower extremities and pelvis. Local venous stasis secondary to trauma or surgical procedures (e.g., use of tourniquets in lower extremity injuries) increases the chance of DVT in clients with musculoskeletal trauma. A further discussion of DVT is found in Chapter 36.
INFECTION. Any time there is trauma to tissues, the body’s defense system is disrupted. Wound infections are the most common type of infection resulting from orthopedic trauma; they range from superficial skin infections to deep wound abscesses. Infection can also be caused by implanted hardware used to repair a fracture surgically, such as pins, plates, or rods. Clostridial infections can result in gas gangrene or tetanus and can prevent the bone from healing properly.
Bone infection, or osteomyelitis, is most common with open fractures in which skin integrity is lost and after surgicalrepair of a fracture (see Chapter 53). For clients experiencing this type of trauma, the risk of hospital-acquired (nosocomial) infections is increased.
AVASCULAR NECROSIS. Avascular necrosis (AVN)
is sometimes referred to as aseptic or ischemic necrosis or os-teonecrosis. Blood supply to the bone is disrupted, which results in the death of bone tissue. AVN is most often a complication of hip fractures, or any fracture in which there is displacement of bone. Surgical repair of fractures also can lead to AVN because the hardware can interfere with circulation.
FRACTURE BLISTERS. Fracture blisters are associated most commonly with high-energy fractures and twisting injuries in the lower extremities. Extensive tissue edema allows fluid to move into the weakened space between the epidermis and the dermis. The increased colloidal osmotic pressure then pulls more fluid into the space. Fracture blisters can lead to wound infection and delayed fracture treatment, which may then contribute to potential nonunion. Nursing measures that can assist in preventing or minimizing fracture blisters include maintaining proper immobilization before definitive treatment, and elevation to limit edema.
DELAYED
Delayed union describes a fracture that has not healed within 6 months of injury. Some fractures never achieve union; that is, they never completely heal (nonunion); others heal incorrectly (malunion). These problems are most common in clients with tibial fractures, fractures for which a number of different treatment techniques have been used (e.g., cast, traction), and pathologic fractures.
I Etiology
The primary cause of a fracture is trauma from a motor vehicle accident or fall. The trauma experienced may be a direct blow to the bone or an indirect force from muscle contractions or pulling forces on the bone. Sports, vigorous exercise, and malnutrition are contributing factors. Bone diseases, such as osteoporosis, increase the risk of a fracture in older adults.
1 Incidence/Prevalence
The incidence of fractures depends on the location of the injury. Rib fractures are the most common type in the adult population. Femoral shaft fractures occur most often in young and middle-aged adults. The incidence of proximal femur (hip) fractures is highest in older adults. Humeral fractures are common in adults; the older the person, usually the more proximal the fracture. Wrist (Colles’) fractures are typically seen in middle and late adulthood
► COLLABORATIVE MANAGEMENT
|
I* Assessment
I HISTORY
The nurse collects data to determine the cause of the fracture, which helps in developing an individualized plan of care for the client.
PRECEDING EVENTS. The nurse asks the client to recall the specific events up to the time of the injury. Some type of force, such as incisional, crush, acceleration or deceleration, shearing, or friction, leads to most musculoskeletal injuries. As a result, several body systems are often affected.
Incisional (as from a knife wound) and crush injuries cause hemorrhage and disrupt blood flow to major organs. Acceleration or deceleration injuries cause direct trauma to the spleen, brain, and kidneys when these organs are moved from their fixed locations in the body. Shearing and friction damage the skin and cause a high level of wound contamination.
By asking about the events leading to the injury, the nurse can determine which forces have been experienced and therefore which body systems or parts of the body to assess. For example, a forward fall often results in Colles’ fracture of the wrist because the person tries to catch himself or herself with an outstretched hand. Knowing the mechanism of injury also helps the nurse determine whether other types of injury, such as head and spinal cord injury, may be present.
OTHER HISTORY. A medication history, including substance abuse (recreational drug use), is important regardless of age. For example, a young adult may have had an excessive amount of alcohol, which contributed to a motor vehicle accident or to a fall at the work site. Many older adults also consume alcohol and an assortment of prescribed and over-the-counter drugs, which can cause dizziness and loss of balance.
A medical history elicits possible causes of the fracture and gives clues as to how long it will take for the bone to heal. Certain diseases, such as bone cancer and Paget’s disease, cause pathologic fractures that often do not achieve union.
The nurse asks about the client’s occupation and recreational activities. Some occupations are more hazardous than others; for instance, construction work is potentially more physically dangerous than office work. Certain hobbies and recreational activities are also extremely hazardous (e.g., skiing and in-line skating). Contact sports, such as football and ice hockey, often result in musculoskeletal injuries, including fractures. Other activities do not have such an obvious potential for injury but can cause fractures nonetheless. For instance, daily jogging and frequent marching in a band can lead to fatigue fractures
Because inadequate nutrition contributes to fractures and can inhibit bone healing, the nurse takes a complete diet history. Health promotion counseling is a major focus for comprehensive health care today
PHYSICAL ASSESSMENT/CLINICAL MANIFESTATIONS
BODY SYSTEM ASSESSMENT. The client with a fracture often sustains trauma to other body systems. Consequently, the nurse assesses all major body systems first for life-threatening complications, including head, thoracic, and abdominal injuries. The assessment of these areas is described elsewhere in this text.
MUSCULOSKELETAL ASSESSMENT. When inspecting the site of a possible fracture, the nurse observes for a change in bone alignment. The bone may appear deformed, or a limb may be internally or externally rotated. Accompanying these deviations may be an alteration in the length of the extremity (usually a shortening) or a change in bone shape. The nurse asks the client to move the involved body part. If pain is elicited, the movement is stopped immediately. Range of motion (ROM) is typically decreased. When the affected part is moved, the nurse may hear crepitation, a continuous grating sound created by bone fragments.
The nurse also observes the skin for integrity. If the skin is intact (closed fracture), the area over the fracture may be ec-chymotic (bruised) from bleeding into the underlying soft tissues. Subcutaneous emphysema, the appearance of bubbles under the skin because of air trapping, is not uncommon but is seen later.
Swelling at the fracture site is rapid and can result in marked neurovascular compromise. Therefore the nurse performs a thorough neurovascular assessment and compares the injured area with its symmetric counterpart. Skin color and temperature, sensation, mobility, pain, and pulses are assessed distal to the fracture site. If the fracture involves an extremity, the nurse checks the nails for capillary refill by applying pressure to the nail and observing for the speed of blood return. If nails are brittle or thick, the skin adjacent to the nail is assessed. Chart 52-3 describes the procedure for a neurovascular assessment, which evaluates circulation, movement, and sensation.
For an open fracture, the nurse determines the degree of soft-tissue damage and the amount of overt bleeding. The area may be lightly palpated for tenderness, but a sterile glove is worn if the skin is disrupted.
Clients often complain of moderate to severe pain at the site of the fracture or in an adjacent or distal area. For example, clients with a fractured hip may have groin pain or pain referred to the back of the knee. Pain is usually due to muscle spasm and edema, which result from the fracture. In clients with one or more fractured ribs, severe pain occurs when deepbreaths are taken. The nurse assesses respiratory status, which may be severely compromised from pain or pneumothorax (air in the pleural cavity).
SPECIAL ASSESSMENT CONSIDERATIONS. For fractures of the shoulder and upper arm, the physical assessment is best done with the client in a sitting or standing position, if possible, so that shoulder drooping or other abnormal positioning can be seen. The nurse supports the affected arm and flexes the elbow to promote comfort during the assessment. For more distal areas of the arm, the assessment is done with the client in a supine position so that the extremity can be elevated to reduce swellingThe nurse places the client in a supine position for assessment of the lower extremities and pelvis. A client with an impacted hip fracture may be able to walk for a short time after injury, although this is not recommended. The client with any type of hip fracture has pain and decreased ROM in the hip.
Some fractures can cause internal organ damage, resulting in hemorrhage. When a pelvic fracture is suspected, the nurse assesses vital signs, skin color, and the level of consciousness for indications of possible hypovolemic shock. The urine is checked for blood, which indicates damage to the urinary system, often the bladder. If the client is unable to void, the nurse suspects damage to the urethra.
i PSYCHOSOCIAL ASSESSMENT
The psychosocial status of a client with a fracture depends on the extent of the injury and other complications. Hospitaliza-tion is usually not required for a single, uncomplicated fracture, and the client may return to usual daily activities within a few days. Healing is usually complete in a young adult in 4 to 6 weeks.
In contrast, a client suffering multiple trauma can be hospitalized for weeks and may undergo many surgical procedures and other treatments. For these clients, disruptions in lifestyle can create a high level of stress.
The stresses that result from a chronic condition affect relationships between the client and family members or significant others. The nurse assesses the client’s feelings about himself or herself as a person and asks about how he or she coped with previously experienced stressful events. Body image and sexuality may be altered by deformity, treatment modalities for fracture repair, and/or long-term immobilization
B LABORATORY ASSESSMENT
No special laboratory tests are available for assessment of fractures. The client’s hemoglobin level and hematocrit are often low because of bleeding caused by the injury. If extensive soft-tissue damage accompanies the fracture, the erythro-cyte sedimentation rate (ESR) may be elevated, which indicates the expected inflammatory response. If the ESR increases during fracture healing, the client may have a bone infection. During the healing stages, serum calcium and phosphorus levels are often increased as the bone releases these elements into the blood.
■ RADIOGRAPHIC ASSESSMENT
The health care provider orders standard x-ray studies and to-mograms to confirm a diagnosis of fracture. These reveal the bone disruption, malalignment, or deformity. If the x-ray film does not show a fracture but the client is symptomatic, the x-ray study is usually repeated with additional views.
The computed tomography (CT) scan is useful in detecting fractures of complex structures, such as the hip and pelvis. It also identifies compression fractures of the spine.
i OTHER DIAGNOSTIC ASSESSMENT
The health care provider may order a bone scan (with tech-netium or gallium) for help in detecting certain types of fractures, particularly pathologic fractures. It is impossible for fractures of small bones or occult fractures to be visualized by conventional x-ray studies as early as by a bone scan. In addition, the bone scan can better determine fracture complications, such as delayed bone healing, nonunion, infection, and avascular necrosis (AVN).
Magnetic resonance imaging (MRI) is useful in determining the amount of soft-tissue damage that may have occurred with the fracture. It is also helpful in visualizing vertebral and skull fractures.
!• Analysis
■ COMMON NURSING DIAGNOSES AND COLLABORATIVE PROBLEMS
The following are commoursing diagnoses for clients with fractures:
1. Risk for Peripheral Neurovascular Dysfunction related
to bone and soft-tissue trauma and immobility
2. Acute Pain related to bone disruption, soft-tissue dam
age, muscle spasm, and edema
3. Risk for Infection related to bone trauma and soft-tissue
damage
4. Impaired Physical Mobility related to pain
5. Imbalanced Nutrition: Less Than Body Requirements
related to additional metabolic need for healing of bone
and soft tissues
K ADDITIONAL NURSING DIAGNOSES AND COLLABORATIVE PROBLEMS
In addition to the commoursing diagnoses, clients with fractures may have one or more of the following:
Activity Intolerance related to pain and impaired mobility Constipation related to prolonged immobility (particularly in older adults)
• Ineffective Coping related to prolonged immobility, hos-
pitalization, and/or lifestyle changes
Compromised Family Coping related to prolonged hos-
pitalization and/or lifestyle changes
• Deficient Diversional Activity related to prolonged hos-
pitalization and rehabilitation
Anticipatory Grieving related to altered lifestyle 1 Self-Care Deficit related to pain and immobility
• Disturbed Body Image related to deformity and/or treat
ment modality
• Sexual Dysfunction related to pain and immobility
Disturbed Sleep Pattern related to chronic pain and/or
prolonged hospitalization
Fear related to possible nursing home placement and/or death (particularly in older adults)
1 Impaired Skin Integrity and Impaired Tissue Integrity related to bone injury
The following collaborative problems may be appropriate for clients with severe fractures:
Potential for Acute Compartment Syndrome
■ Potential for Hypovolemic Shock
1 Potential for Fat Embolism Syndrome Potential for Thromboembolitic Complications
• Potential for Avascular Necrosis
4 Potential for Delayed Healing, Malunion, or Nonunion
!• Planning and Implementation
K RISK FOR PERIPHERAL NEUROVASCULAR DYSFUNCTION
noo PLANNING: EXPECTED OUTCOMES. The client with a fracture is expected to have sufficient blood flow for adequate oxygen and nutrient delivery to tissues, especially distal to the fracture site, as indicated by strong distal peripheral pulses, brisk capillary refill, normal skin color, and intact muscle function.
INTERVENTIONS. A fracture can occur anywhere. The nurse provides emergency interventions until medical treatment in a hospital is available.
EMERGENCY CARE. A fracture may be accompanied by multiple injuries to vital organs. Therefore the nurse first assesses the client for respiratory distress, bleeding, and head injury. If any of these is present, the nurse provides lifesaving care before being concerned about the fracture.
The fracture injury is then assessed (Chart 52-4). If the person is clothed, the nurse or another person trained in first aid cuts away clothing from the fracture site for best visualization. Bleeding is controlled by direct pressure on the area and digital pressure over the proximal artery nearest the fracture. At the same time, to prevent shock, the nurse checks vital signs, places the client in a supine position, and keeps him or her warm with coverings. The nurse also:
Inspects the fracture site for intactness of skin, swelling, and deformity (e.g., shortening and rotation) • Palpates the area lightly to determine temperature (coolness), decreased sensation, and blanching Assesses distal pulses by comparing affected and unaffected extremities, if applicable
■ Assesses for motor function by asking the client to move an area distal to the fracture (e.g., if a femoral fracture is suspected, he or she is asked to move the ankle and foot on the affected side; the upper portion of the leg remains immobilized)
To prevent further damage, reduce pain, and increase circulation, the nurse immobilizes the area of the fracture by splinting. Any object or device that extends to the joints above and below the fracture can be used as a splint. At the scene of an accident, the nurse may need to improvise by using available materials, such as a board. If the skin is broken, the nurse loosely applies a clean (preferably sterile) cloth to prevent further contamination of the wound. Neurovascular assessment is rechecked following splinting.
In the emergency department, physician’s office, or clinic, fracture management begins with reduction and immobilization of the fracture:
• Reduction, or realignment of the bone ends for proper
healing, is accomplished by a closed method (e.g., trac
tion) or an open (surgical) procedure.
• Immobilization is achieved by the use of bandages,
casts, traction, internal fixation, or external fixation.
The health care provider selects the treatment method on the basis of the type, location, and extent of the fracture. These interventions prevent further injury and reduce discomfort. The nurse is responsible for maintaining these devices and for assessing, preventing, and intervening for complications that can result from their use.
CRITICAL THINKING CHALLENGE
A 30-year-old man arrives at your emergency department via ambulance. He was the driver of a motorcycle involved in a collision with a sport utility vehicle (SUV). Paramedics report that the client was hit from the side; the bike fell on him, and he was trapped underneath the SUV. Initial reports from the ambulance en route describe an individual in shock with a mangled left leg below the knee and a left wrist fracture. The client was wearing a helmet at the time of the crash.
• What information given above is helpful in predicting other
injuries this client may have sustained?
• What are the priority assessments you should perform when
he arrives at the hospital?
• What assessments of the leg injury will determine the type
and grade of the fracture?
• What initial assessments of the injured leg should you
perform?
NEUROVASCULAR MONITORING
. The nurse performs a neurovascular assessment (Chart 52-5) at frequent intervals if the client is admitted to the hospital, depending on the severity and extent of the fracture and agency policy. The nurse pays particular attention to early signs and symptoms of acute compartment syndrome (ACS) by doing a thorough pain assessment. The client with early ACS typically complains of severe, diffuse pain that is not relieved by analgesics; pain during passive motion is greater than pain during active motion. If the client presents with this complaint, the nurse notifies the health care provider immediately.
NONSURGICAL MANAGEMENT. Nonsurgical management typically involves closed reduction and immobilization with a bandage, splint, cast, or traction. For each modality, the nurse’s primary concern is assessment and prevention of neurovascular dysfunction or compromise.
CLOSED REDUCTION. Closed reduction is the most commoonsurgical method for managing a simple fracture. While applying a manual pull, or traction, on the bone, the health care provider manipulates the bone ends so that theyrealign. Anesthesia or analgesia may be used during this procedure to minimize pain. An x-ray verifies that the bone ends are approximated before the bone is immobilized.
Bandages and Splints. For certain areas of the body, such as the scapula and clavicle, an elastic bandage or commercial mobilizer may be used to immobilize the bone during healing. Because upper extremity bones do not bear weight, splints may be sufficient to keep bone fragments in place. Figure 52-3 illustrates the use of a wrist splint for fracture immobilization. Thermoplast, a durable, flexible material for splinting, allows custom fitting to the client’s body part.
The nurse’s primary responsibility is to assess the area distal to the bandage or splint for neurovascular compromise. The client usually complains of increased discomfort that is not relieved by analgesics if the splint or bandage is too tight. The nurse reinforces the need for elevation as appropriate and teaches how to assess for circulatory changes. The client is reminded to keep the device as dry and clean as possible to prevent skin breakdown and infection.
Caste. For more complex fractures or fractures of the lower extremity, the physician or orthopedic technician applies a cast to hold bone fragments in place after reduction. A cast is a rigid device that immobilizes the affected body part while allowing other body parts to move. A cast also allows early mobility and reduces pain. Although its most common use is for fractures, a cast may be applied for correction of deformities (such as clubfoot) or for prevention of deformities (such as those seen in some clients with rheumatoid arthritis).
Cast Materials. Several types of materials are used to make casts. The traditional plaster of Paris (anhydrous calcium sulfate) cast requires application of a well-fitted stockinette under the material. If the stockinette is too tight, it may impair circulation; if it is too loose, wrinkles can lead to the development of pressure ulcers and subsequent skin breakdown. Padding is applied over the stockinette, followed by wet plaster rolls wrapped around the extremity or other body part. The cast feels hot because an immediate chemical reaction occurs, but it soon becomes damp and cool. This type of cast takes 24 to 72 hours to dry, depending on the size and location of the cast. A wet cast feels cold, smells musty, and is grayish. The cast is dry when it feels hard and firm, is odorless, and has a shiny white appearance.
On occasion, the plaster cast may have rough edges, which can crumble and cause skin irritation. To resolve this problem, the nurse petals the cast if the underlying stockinette does not cover the edges of the cast. Small strips of tape are placed over the rough edges to protect the skin. If the skin under the cast was disrupted, the health care provider, orthopedic technician, or specially trained nurse cuts a window into the cast so that the wound can be observed and cared for. A window is also an access for taking pulses, removing wound drains, or relieving abdominal distention when the client is in a body or spica cast.
If the cast is too tight, it may be cut with a cast cutter to relieve pressure or allow tissue swelling. The physician may choose to bivalve the cast (cut it lengthwise into two equal pieces) if bone healing is almost complete. The nurse can remove either half of the cast for inspection or for provision of care. The two pieces are then reunited by an elastic bandage wrap.
Synthetic materials for casts include fiberglass and polyester-cotton knit (Figure 52-4). These materials are lighter than plaster and require minimal drying time. Fiberglass casts are dry in 10 to 15 minutes and can bear weight 30 minutes at ter application. Polyester-cotton knit casts take 7 minutes to dry and can withstand weight bearing in approximately 20 minutes. Some health care providers use synthetic casts for upper extremities and plaster of Paris casts for lower extremities because plaster casts can bear more weight for a longer time.
Types of Casts. Casts can be generally divided into four main groups: arm casts, leg casts, cast braces, and body or spica casts. Table 52-1 describes specific casts that are used for various parts of the body.
When a client is in bed with an arm cast, a sling is used to elevate the arm above the heart to reduce swelling. The hand should be higher than the elbow. Ice may be ordered for the first 24 to 48 hours. When the client is out of bed, the arm is supported with a sling placed around the neck to alleviate fatigue caused by the weight of the cast. The sling should distribute the weight over a large area of the shoulders and trunk, not just the neck. Some health care providers prefer that after the first few days in an arm cast, particularly a short-arm cast, the client not use a sling, to encourage normal movement of the mobile joints and enhance bone healing.
A leg cast permits mobility and requires the client to use ambulatory aids, such as crutches. A cast shoe, sandal, or boot that attaches to the foot or a rubber walking pad attached to the sole of the cast assists in ambulation (if weight bearing is allowed) and helps prevent damage to the cast. The affected leg is elevated on several pillows to reduce swelling, and ice is applied for the first 24 hours or as ordered.
A cast brace enables the client to bend unaffected joints while the fracture is healing. The fracture must show signs of healing and minimal tissue edema before application of this cast. Two cylindric casts are made and connected by a hinge to allow joint movement. As healing occurs, the casts may be removed and replaced with a soft brace. Commercial immo-bilizers, which serve the same function as a cast brace, are available and may be used in some cases.
A body cast encircles the trunk of the body; a spica cast encases a portion of the trunk and one or two extremities. A client with either of these casts presents a special challenge for nursing care. Potential complications related to severe impairment in mobility include the following:
• Skin breakdown
• Respiratory dysfunction, such as pneumonia and atelec-
tasis
Constipation
• Joint contractures
Cast syndrome (superior mesenteric artery syndrome), an uncommon but serious complication, is most often seen in orthopedic clients who have been placed in a hip spica or body cast. Partial or complete upper intestinal obstruction results in classic symptoms: abdominal distention, epigastric pain, nausea, and vomiting. The vomiting often occurs after meals, and clients may have normal bowel sounds. Partial obstruction occurs initially from compression of the third portion of the duodenum between the superior mesenteric artery and the aorta. This progresses to complete obstruction from duodenal edema caused by continued vomiting and distention. Placing a window in the abdominal portion of the cast or bivalving the cast may be sufficient to relieve pressure on the duodenum. Management of intestinal obstruction is the same as for any client with this complication (see Chapter 57).
Cast Care. Before the cast is applied, the nurse explains the purpose of the cast and the procedure for its application.
With a plaster cast, it is particularly important for the nurse to warn the client about the heat that will be felt immediately after the wet cast is applied. The new cast is not covered; this facilitates air-drying.
When a client with a wet plaster cast is moved and turned, the nurse handles the cast with the palms of the hands to prevent indentations and resultant areas of pressure on the skin. The client is turned every 1 to 2 hours to allow air to circulate and dry all parts of the cast. If the client is hospitalized, the nurse or assistive nursing personnel places a sign at the head of the bed as a reminder that the cast is wet and requires special handling. If the health care provider orders that the cast be elevated to reduce swelling, a cloth-covered pillow is used instead of one encased in plastic, which could cause the cast to retain heat and prevent drying. Elevation of the casted extremity reduces edema but may impair arterial circulation to the affected limb. Uniform support is needed while the cast is drying to prevent development of pressure points.
For preventing contamination by urine or feces, the perineal area of a dry long leg or body cast is encased in a plastic, protective covering. Fracture pans are preferred over traditional bedpans because they are smaller and more comfortable for the client. Care is taken to prevent spillage onto the cast.
The nurse checks to ensure that the cast is not too tight and frequently monitors the client’s neurovascular status, usually every hour for the first 24 hours after application (see Chart 52-3 for a description of the procedure and normal findings). The nurse should be able to insert a finger between the cast and the skin. Ice may be applied for the first 24 to 36 hours to reduce swelling and inflammation.
Once the plaster cast is dry, it is inspected at least once every 8 hours for drainage, cracking, crumbling, alignment, and fit. Areas of drainage on the cast should be measured and documented, although there is no direct relationship between the amount of cast drainage and the amount of drainage from the wound. Plaster casts act like sponges and absorb drainage, whereas synthetic casts act like a wick, pulling drainage away from the drainage site. Padding can also absorb wound drainage. Drainage on any cast should always be measured and documented in the client record; however, sources disagree on whether drainage should be circled on the cast, because it may increase anxiety. The nurse immediately reports sudden increases in the amount of drainage or a change in the integrity of the cast to the health care provider. After swelling decreases, it is not uncommon for the cast to become too loose and need replacement. If the client is not admitted to the hospital, he or she is given instructions regarding cast care, as discussed later under Community-Based Care, p. 1141.
Cast Complications. During hospitalization, the nurse assesses for other complications resulting from casting that canbe serious and life threatening, such as infection, circulation impairment, and peripheral nerve damage. If the client returns home after cast application, the client and family are taught how to monitor for these complications and when to notify the health care provider.
Infection most often results from the breakdown of skin under the cast (pressure necrosis). If pressure necrosis occurs, the client typically complains of a very painful “hot spot” under the cast, and the cast may feel warmer in the affected area. The nurse smells the area for mustiness or an unpleasant odor that would indicate infected material. If the infection progresses, a fever may develop.
Circulation impairment and peripheral nerve damage can result from constriction of the cast. The nurse performs frequent neurovascular assessments, as described in Chart 52-
The client with a cast may be immobilized for a prolonged period, depending on the extent of the fracture and the type of cast. The nurse assesses for complications of immobility, such as skin breakdown, pneumonia, atelectasis, thromboem-bolism, and constipation. Before the cast is removed, the nurse informs the client that the cast cutter will not injure the skin but that heat may be felt during the procedure.
Because of prolonged immobilization, a joint may become contracted, usually in a fixed state of flexion, or degenerative arthritis may develop from lack of weight bearing, which is necessary for cartilage viability. Muscle can also atrophy from lack of exercise during prolonged immobilization of the affected body part, usually an extremity.
CRITICAL THINKING CHALLENGE Following initial assessment in the emergency department, your client who was injured in the motorcycle accident has a closed reduction of the wrist fracture and application of a long-arm cast. He is alert and oriented when he arrives on the orthopedic unit.
• What assessment should you perform to evaluate the neu
rovascular status of the client’s injured arm?
• What is a potential cause of compartment syndrome in this
client’s fractured arm?
• What symptoms would raise suspicion of compartment
syndrome?
Traction. Traction is the application of a pulling force to a part of the body to provide reduction, alignment, and rest. Traction can also decrease muscle spasm (thus relieving pain) and prevent or correct deformity and tissue damage. A client in traction is usually hospitalized longer, but in some cases home care is possible even for skeletal traction. Mechanical traction can be either of the following:
Continuous, as in fracture treatment • Intermittent, for relief of muscle spasm in other types of musculoskeletal/neurologic trauma, such as cervical nerve root compression
Traction may also be classified as running traction or balanced suspension. In running traction, the pulling force is in one direction and the client’s body acts as countertraction.
Moving the body or bed position can alter the countertraction force. Balanced suspension provides the countertraction, so that the pulling force of the traction is not altered when the bed or client is moved. This allows for increased client movement and facilitates care.
Types of Traction. Traction is typically one of five types: skin traction, skeletal traction, plaster traction, brace traction, or circumferential traction. Skin traction involves the use of a Velcro boot (Buck’s traction) (Figure 52-5), belt, or halter, which is secured around a body part. The primary purpose of skin traction is to decrease painful muscle spasms that accompany fractures. The weight used as a pulling force is limited (5 to
In skeletal traction, pins (e.g., Steinmann), wires (e.g., Kirschner), tongs (e.g., Crutchfield), or screws are surgically inserted directly into bone. These allow the use of longer traction time and heavier weights (usually 15 to
Plaster traction combines skeletal traction and a plaster cast. A brace traction device exerts a pull for correction of alignment deformities. Circumferential traction uses a belt around the body, such as pelvic traction for low back problems. Table 52-2 describes commonly used types of traction for various parts of the body.
Traction Care. The nurse may set up or assist in the setup of traction. In larger or specialty hospitals or units, orthopedic technicians may set up traction. Once traction is applied, the nurse is responsible for maintaining the correct balance between traction pull and countertraction force. Weights are not usually removed without an order; they are not usually lifted manually or allowed to sit on the floor. Weights should be freely hanging at all times. The nurse teaches this important point to staff members on the unit and to other personnel, such as in the radiology department.
The skin should be inspected at least every 8 hours for signs of irritation or inflammation. When possible, the nurse removes the belt or boot that is used for skin traction every 8 hours to inspect under the device
When skeletal traction is used, the nurse pays particular attention to the points of entry of pins, wires, or screws for signs of inflammation or infection. A small amount of clear fluid drainage (“weeping”) is expected. Most health care providers prefer that the nurse perform pin care every day. No standardized method or protocol for pin care has been established throughout the
The nurse is responsible for checking traction equipment to ensure its proper functioning. All ropes, knots, and pulleys are inspected at least every 8 hours for loosening, fraying, and positioning. The nurse checks the weight for consistency with the health care provider’s order. At times, the health care provider or qualified technician changes the weight without notifying the nurse or modifying the written order; the nurse contacts the person responsible for a new order for confirmation of the change. Sometimes one of the weights is accidentally displaced by a staff member or visitor who bumps into it. The nurse replaces the weights if they are not correct and notifies the health care provider or orthopedic technician.
If the client complains of severe pain from muscle spasm, the weights may be too heavy or the client may need realignment. The nurse reports the pain to the health care provider if body realignment fails to reduce the discomfort. The nurse also assesses the neurovascular status of the affected body part to detect circulatory compromise and subsequent tissue damage. For clients with casts, circulation is usually moni tored every hour for the first 24 hours after traction is applied and every 4 hours thereafter (see Chart 52-3).
PЈ CONSIDERATIONS FOR OLDER ADULTS
2123 Older clients often have peripheral vascular disease, connective tissue disease, and/or diabetes. Therefore they are at high risk for problems caused by skin or skeletal traction because of inadequate circulation and sensation. Traction of any type is not the ideal treatment for the older client, because it necessitates a prolonged period of immobilization; serious complications can result, such as pneumonia and pulmonary emboli. Abrasions, ulcers, and other skin problems should be reported to the health care provider. Care must be taken to avoid pressure on the bony prominences and superficial nerves. Pressure on the peroneal nerve at the point where it passes around the neck of the fibula must also be avoided, or footdrop could occur.
SURGICAL MANAGEMENT. For some types of fractures, casts and traction are not appropriate or sufficient treatment techniques. Surgical intervention may be needed to realign the bone for the healing process.
PREOPERATIVE CARE.
For stabilizing the fracture, the client may be placed in traction before surgery. This procedure is typical for managing a fractured hip when Buck’s traction may be used preoperatively (see Figure 52-5). The nurse teaches the client and family or significant others what to expect during and after the surgery. The preoperative care for a client undergoing musculoskeletal surgery is similar to that for any client preparing for surgery with general or epidural anesthesia. (See Chapter 17 for a thorough discussion of preoperative nursing care.)
OPERATIVE PROCEDURES. Open reduction with internal fixation (ORIF) is a common method of reducing and immobilizing a fracture. When this method is not feasible, external fixation with closed reduction is used. Although the nurse does not decide which surgical technique is used, the nurse’s understanding of the procedures enhances client teaching and care.
Open Reduction with Internal Fixation. ORIF permits early mobilization. Consequently, it is often the preferred surgical method for an older adult who is susceptible to the complications of immobility.
Open reduction allows the surgeon direct visualization of the fracture site. Internal fixation uses pins, screws, rods, plates, and/or prostheses to immobilize the fracture during healing. The surgeon makes an incision to gain access to the broken bone and implants the device. After the bone achieves union, the hardware may be removed, depending on the location and type of fracture (e.g., fractured ankle). Specific types of internal fixation devices are discussed later under Fractures of Specific Sites, p. 1142.
External Fixation. An alternative modality for the initial management of fractures is the external fixation apparatus, as shown in Figure 52-6. After fracture reduction, the physician makes small percutaneous incisions so that pins may be implanted into the bone. All pins are self-drilling. The pins are held in place by an external metal frame to prevent bone movement.
Advantages and Disadvantages. External fixation has several advantages over other immobilization techniques: There is minimal blood loss in comparison with internal fixation.
The Hex-Fix external fixation system for tibial fractures. (Courtesy Smith & Nephew, Inc., Orthopaedics Division,
The device allows early ambulation and exercise of the affected body part while relieving painThe device maintains alignment in closed fractures that will not maintain position in a cast and stabilizes comminuted fractures that require bone grafting. In open fractures, in which skin and tissue trauma accompanies the fracture, the device permits easy access to the wound and promotes healing. This method is often preferred over the use of a window in a cast for wound care.
A disadvantage of external fixation is pin tract infection. Pin tract infections can lead to osteomyelitis, which is serious and difficult to treat (see Chapter 51). For prevention of these infections, some agencies have a pin care procedure that is performed several times a day. The procedure is similar to that described earlier for skeletal traction pins (see Traction Care, p. 1136). As with skeletal traction, the need for special cleaning of the pins and the area around the pins is controversial. Regardless of whether pin care is done, the nurse inspects the pin sites at least daily for severe redness, swelling, and purulent drainage.
Care of the Client with an External Fixator. As with any fracture treatment, the nurse assesses the neurovascular status of the extremity distal to the fracture. External fixators may be used for an extremity or for fractures of the pelvis. External fixation is not definitive treatment for fractures. After a fixator is removed, the client may be placed in a cast until healing is complete.
The client with an external fixator may experience a disturbed body image. The frame may be large and bulky, and the affected area may have massive tissue damage with dressings. The nurse is sensitive to this possibility in planning care.
CRITICAL THINKING CHALLENGE
Following evaluation in the emergency department, the client injured in the motorcycle accident is sent to the operating room for removal of his ruptured spleen, ORIF of an unstable pelvic fracture, and application of an external fixator to the grade III comminuted fracture of his left tibia and fibula.
What are the advantages of external fixation for treating
fractures of the tibia and fibula?
• What assessments of the external fixator should you per
form frequently?
• Your client tells you that when the fixator is removed, his leg
will be completely healed and he will be able to bear weight
completely. What does this statement indicate about the
client’s understanding of the role of external fixation in frac
ture management?
For suggested answer guidelines, go to §jWV,: http://www.wbsaunders.com/SIMON/lggy/.
Circular External Fixation. The Ilizarov technique of circular external fixation is sometimes used to treat new fractures (closed, comminuted fractures and open fractures with bone loss), as well as malunion or nonunion of fractures. It may also be used to treat congenital bone deformities, especially in children. This procedure originated in
A circular external fixation device stimulates bone growth. Unlike the traditional fixator, the Ilizarov external fixator promotes rotation, angulation, shortening, lengthening, and/or widening of bone while allowing healing of the soft-tissue defect. The nursing care of the client with this device is similar to the care of the client with other external fixation systems
except in one major regard: if the device is being used for filling bone gaps, using bone transport or distraction, the client must be taught how to manually turn the four-sided nuts (clickers), usually four times a day, unless he or she has an automated device. Daily distraction rates vary among clients, but 1 mm/day is common. Screening and teaching are particularly important because the client adjusts and cares for the apparatus for a prolonged time.
POSTOPERATIVE CARE. The postoperative care for a client undergoing ORIF or external fixation is similar to that provided for any client undergoing surgery (see Chapter 19). However, because bone is a vascular, dynamic body tissue, the client is at risk for certain complications specific to fractures and musculoskeletal surgery. These problems (e.g., fat embolism and deep vein thrombosis [DVT]) are discussed earlier under Complications of Fractures, pp. 1127-1129.
PROCEDURES FOR NONUNION. Some surgical repairs are not successful, because the bone does not heal. Several additional options are available to the surgeon to promote bone union, such as electrical bone stimulation, bone grafting, and the newest therapy, ultrasound fracture treatment.
For selected clients, electrical bone stimulation may be successful. This procedure is based on research showing that bone has inherent electrical properties that are used in healing. The exact mechanism of action is unknown. Several types of devices have been developed. A noninvasive system uses magnetic coils applied on the skin or over a cast to deliver a pulsed magnetic field. There are no known risks with this system, although clients with pacemakers cannot use this device on an upper extremity. Implanted direct-current stimulators are placed directly in the fracture site and have no external apparatus. Both systems require about 6 months of treatment, and weight bearing is at the discretion of the health care provider.
Another method of treating nonunion is bone grafting. A bone graft may also replace diseased bone or increase bone tissue for joint replacement. In most cases, chips of bone are taken from the client’s iliac crest or other site and are packed or wired between the bone ends to facilitate union. Allografts from cadavers may also be used. These grafts are frozen or freeze-dried and stored under sterile conditions in a bone bank, usually in a hospital.
Bone banking from living donors is becoming increasingly popular. If qualified, clients undergoing total hip replacement may donate their femoral heads to the bank for later use as bone grafts for other clients. Careful screening ensures that the bone is healthy and that the donor has no communicable disease. The bone cannot be donated without the client’s written consent.
One of the newest modalities for fracture healing is low-intensity pulsed ultrasound (also called Exogen therapy). Used for slow-healing fractures or for new fractures as an alternative to surgery, ultrasound treatment has yielded excellent results. The client applies the treatment for about 20 minutes each day. It has no contraindications or adverse effects.
1 ACUTE PAIN
Hi PLANNING: EXPECTED OUTCOMES. The client with a fracture is expected to experience a reduction or alleviation of pain as indicated by the absence of or a decrease inreported pain, no changes in vital signs, and no facial expressions of pain.
INTERVENTIONS. The nonsurgical or surgical management of fractures through reduction and immobilization helps reduce pain and prevents neurovascular injury. The client often requires drug therapy and other pain relief measures.
DRUG THERAPY. Musculoskeletal pain related to soft-tissue damage, bone disruption, and muscle spasm is one of the most severe types of pain that can be experienced. The client often has the pain for a prolonged time, which makes pain management difficult. The health care provider commonly prescribes opioid analgesics, anti-inflammatory drugs, and muscle relaxants.
For clients with chronic, severe pain, opioid and nonopi-oid drugs are alternated or given together to manage pain both centrally and peripherally. The nurse and client mutually decide on the best times for the strong pain relievers to be administered (e.g., before a complex dressing change and at bedtime). The nurse observes the client carefully for the effectiveness of the medication and its side effects. An early sign of acute compartment syndrome (ACS) is often the sudden inability of pain medication to relieve pain. Chapter 7 discusses the various methods of pain management, including epidural analgesia and patient-controlled analgesia.
COMPLEMENTARY AND ALTERNATIVE THERAPIES.
With chronic, severe pain, the client cannot depend solely on drugs for relief. The nurse uses temporary pain relief measures, such as ice or heat, depending on the cause of the pain. If swelling causes pressure on the affected area, ice and elevation of the affected body part may be appropriate. Muscle spasms are best relieved by application of heat and massage. Other physical measures include a warm, soothing bath, a back rub, and the use of therapeutic touch.
If these measures are not effective in reducing pain, the nurse may use distraction, imagery, or music therapy as alternatives. The nurse teaches relaxation techniques, such as deep breathing, for use during periods of severe pain. Chapters 4 and 7 discuss these techniques in detail.
Wi RISK FOR INFECTION
PLANNING: EXPECTED OUTCOMES. The client with a fracture is expected to be free of a wound or bone infection.
INTERVENTIONS. When caring for a client with a fracture, particularly an open fracture, the nurse uses strict aseptic technique for dressing changes and wound irrigations. Signs and symptoms of local inflammation with purulent drainage are reported immediately to the physician. Other infections, such as pneumonia and urinary tract infection, may occur days after the fracture. The nurse or assistive nursing personnel monitors the client’s vital signs every 4 to 8 hours; increases in temperature and pulse often indicate systemic infection.
For most clients with an open fracture, the health care provider prescribes one or more broad-spectrum antibiotics prophylactically. This treatment is especially important for fractures requiring surgical repair
m IMPAIRED PHYSICAL MOBILITY
Ml PLANNING: EXPECTED OUTCOMES. The client with a fracture is expected to be free of consequences of impaired mobility and independent in ambulation and mobility, such as transferring from bed to chair.
INTERVENTIONS. The interventions necessary for this diagnosis can be grouped into two types: those that help prevent complications of impaired mobility and those that help increase mobility.
PREVENTION OF COMPLICATIONS. The nurse plays a vital role in preventing and assessing complications in immobilized clients with fractures. Additional information about nursing care for preventing problems associated with immobility is found in Chapter 10 and earlier in this chapter in the discussion of specific complications under Complications of Fractures, pp. 1127-1129.
1 CONSIDERATIONS FOR OLDER ADULTS
e risk of each complication related to impaired mobility is dramatically increased if surgery is performed. Older clients are at the greatest risk; physiologic changes and prolonged immobility predispose them to these complications.
PROMOTION OF MOBILITY. The use of crutches or a walker increases mobility and assists in ambulation. The client may progress to use of a cane.
CRUTCHES. Crutches are the most commonly used ambulatory aid for many types of musculoskeletal trauma (e.g., fractures, sprains, and amputations). In most agencies, the physical therapist fits the client for crutches and teaches him or her how to ambulate with them on flat surfaces and stairs. The nurse’s role may be to reinforce the instructions and evaluate whether the client is using the crutches correctly. However, in emergency department and ambulatory settings nurses routinely teach clients how to use crutches.
Walking with crutches requires strong upper extremities, balance, and coordination. For this reason, crutches are not used as often for older adults.
The therapist pads the tips and axillary bars of the crutches; padding prevents the tips from slipping and the bars from damaging the axillae. To prevent pressure on the axillary nerve, there should be two to three finger breadths between the axilla and the top of the crutch when the crutch tip is at least
There are several types of gaits for walking with crutches. The most common one for musculoskeletal injury is the three-point gait, which allows minimal weight bearing on the affected leg.
CANE. A cane is sometimes used if the client needs only minimal support for an affected leg. The straight cane offers the least support. A hemi-cane or quad-cane provides a broader base for the cane and therefore more support. The cane is placed on the unaffected side and should create no more than 30 degrees of flexion of the elbow. The top of the cane should be parallel to the greater trochanter of the femur.
K IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS
PLANNING: EXPECTED OUTCOMES. The client with a fracture is expected to maintain an adequate dietary intake to promote healing and prevent complications.
INTERVENTIONS. Nursing interventions focus on meeting the client’s nutritional needs. The dietitian assesses the client’s food likes and dislikes and collaborates with him or her to plan meals that are both appealing and nutritional. For promotion of bone and tissue healing, the client needs a high-protein, high-calorie diet. Supplements of vitamins B and C are also required for tissue nutrition. Clients with fractures may be immobilized for extended periods; thus they are predisposed to hypocalcemia, which results in loss of calcium from bone and in subsequent bone fragility. The nurse teaches the client to increase intake of foods high in calcium, particularly milk and milk products if they are tolerated.
A negative nitrogen balance can develop 7 to 10 days after injury in an immobilized client because of an increase in ca-tabolism without compensatory protein intake. The nurse offers frequent small feedings and supplements of high-protein liquids, such as Ensure or Carnation Instant Breakfast preparations. Milk shakes are an excellent protein and calorie supplement, as well as a source of calcium.
Because of less weight bearing on long bones, the immobilized client with a fracture often becomes anemic. Blood loss from the injury or reparative surgery contributes to the anemic state. The nurse encourages intake of foods high in iron content. The health care provider may prescribe an oral iron supplement. It is not uncommon for the client to receive a daily multivitamin with iron.
II Community-Based Care
The client with an uncomplicated fracture is usually discharged to home from the emergency department. Older adults with hip or other fractures or clients with multiple trauma are hospitalized and then often transferred to a rehabilitation setting or to a long-term care facility for rehabilitation or permanent residence. To ensure continuity of care, the case manager or the discharge planner in the hospital communicates the plan of care to the health care agency receiving the client.
K HEALTH TEACHING
The client with a fracture may be discharged from the hospital, emergency department, office, or clinic with a bandage, splint, cast, or external fixator. The nurse provides verbal and written instructions on the care of these devices. Chart 52-6 describes care of the affected extremity after removal of the cast.
The client may also need to continue wound care at home. The nurse teaches the client and caregiver how to assess and dress the wound to promote healing and prevent infection. The client is taught how to recognize complications (see Complications of Fractures, p. 1127) and when and where to seek professional health care should complications occur.
Additional educational needs depend on the type of fracture and fracture repair. Care of external fixators and casts is discussed earlier under Cast Care (p. 1134) and External Fixation (p. 1138).
K HOME CARE MANAGEMENT
If the client is discharged to home, the nurse or case manager assesses the home environment for structural barriers to mobility, such as stairs.
Ј71 CONSIDERATIONS FOR OLDER ADULTS
BUS A home assessment is particularly important for older clients. A cast is bulky and requires room for maneuvering and ambulating. In collaboration with the therapy team, the nurse instructs the client and family or significant others to remove scatter rugs and other items that can contribute to falls. The rooms should not be cluttered with furniture, so that the client can maneuver with crutches, a walker, or a cane. An elevated toilet seat or shower chair may be needed to promote independence in toileting.
Wi. HEALTH CARE RESOURCES
The nurse identifies potential or actual problems in the hospital and arranges for follow-up care at home. For example, professional counseling for depression may need to continue after discharge from the hospital. A social worker may need to help the client apply for funds to pay medical bills. If there is severe bone and tissue damage, the nurse must be realistic and help the client understand the long-term nature of the recovery period, particularly if he or she experiences a major complication, such as infection, while in the hospital. Multiple treatment techniques and surgical procedures required for complications can be mentally and emotionally draining for the client and family. A vocational counselor may be needed to help the client seek a different type of job, depending on the nature of the fracture.
The client with a severe injury and multiple treatment modalities may need follow-up care in the home by a home care nurse. An older or incapacitated client may need assistance with activities of daily living (ADLs), which is provided by home care aides. The nurse in the hospital anticipates the client’s needs and arranges for these services, usually with the assistance of the case worker or discharge planner.
It is extremely important for the hospital nurse to communicate the client’s needs to the nurse or aide who will care for the client at home. A physical therapist may come to the home, or the client may go to a clinic, hospital, or private office for follow-up physical therapy after discharge from the hospital. An occupational therapist assists with retraining in the home environment for ADLs; adaptations in the home enable the client to be independent.
In addition to individual follow-up, it is the nurse’s responsibility to participate in community education about injury prevention. Injury ranked fifth as the leading cause of death in 1996 and since 1980 has remained the leading cause of death between ages 1 and 44.
The cost to individuals and society at large is enormous (see the Cost of Care box on p. 1142). For every death due to injury, there are 16 hospitalizations and 400 outpatient visits. Each year, about 90,000 people sustain injuries serious enough to cause long-term disability. Injury is a definable, correctable event with specific identifiable risks. It is imperative that nurses be active in educating the public on prevention of injury through programs that highlight the major risk factors: alcohol, illicit drugs, and firearms among the young, and falls in older adults (see also Chapter 51).
H Evaluation: Outcomes
Mi The nurse evaluates the care of the client with a fracture on the basis of the identified nursing diagnoses and collaborative problems. The expected outcomes include that the client:
• Maintains adequate tissue perfusion as indicated by
strong distal peripheral pulses, brisk capillary refill, nor
mal skin color, and intact muscle formation
• Reports that pain is reduced or alleviated
Does not acquire an infection of the bone or soft tissues
Independently ambulates with or without ambulatory aids and provides self-care Does not experience consequences of immobility Maintains an adequate nutritional intake, as evidenced by bone and soft-tissue healing
Fractures of Specific Sites
I UPPER EXTREMITY FRACTURES 1 Fractures of the Clavicle
Fractures of the clavicle typically result from a fall on an outstretched hand, a fall on the shoulder, or a direct injury. Most clavicular fractures are self-healing; a splint or bandage is used for immobilization. Complicated fractures, although uncommon, may require open reduction with internal fixation (ORIF) by pins, wires, or screws.
I Fractures of the Scapula
Scapular fractures are not common and are usually caused by direct impact to the area. Serious internal trauma, including pneumothorax, pulmonary contusion, and fractured ribs, can accompany these fractures.
The shoulder is immobilized with a sling and swathe or a shoulder immobilizer until the fracture heals, usually in 2 to 4 weeks. Intra-articular neck and glenoid fractures may require surgical intervention with plate and screw fixation.
I Fractures of the Humerus
Fractures of the proximal humerus, particularly impacted or displaced fractures, are common in the older adult. An impacted injury is usually treated conservatively, with a sling for immobilization. A displaced fracture often requires ORIF with pins or a prosthetic device.
Humeral shaft fractures are generally corrected by closed reduction and application of a hanging-arm cast or splint. If necessary, the fracture is repaired surgically (with an in-tramedullary rod or metal plate and screws) or with external fixation. Nonunion of the bone and radial nerve palsy are frequent complications of this fracture. Bone grafting facilitates union; prolonged splinting is necessary while the radial nerve regenerates.
A direct blow to the condyles of the distal humerus can cause either or both condyles to fracture, usually in a T- or Y-shaped configuration. The most serious complication is damage to the brachial or mediaerve. Condylar fracture is usually treated by ORIF with a series of screws, although skeletal traction and casting can be used.
1 Fractures of the Olecranon
Fractures of the olecranon are relatively common in adults and typically result from a fall on the elbow. Many are successfully treated by closed reduction and application of a cast. The healing process usually takes more than 2 months, and several additional months may be needed before full use of the elbow is achieved. ORIF is performed for displaced fractures, and a splint is worn during the healing phase.
i Fractures of the Radius and Ulna
Forearm fractures of the ulna without accompanying injury to the radius are rare. As with other fractures of long bones, closed reduction with casting may be the appropriate treatment. If the fracture is displaced, ORIF with intramedullary rods or plates and screws is required.
|
□ |
WOMEN’S HEALTH CONSIDERATIONS Colles’ fracture, or distal radius fracture, is common among older adults (particularly women); it results most often from a fall on an open hand. The distal radius has a large percentage of cancellous bone, the type that is initially affected by osteoporosis. Chapter 51 describes osteoporosis, or loss of bone mass, in detail. The options for reduction and immobilization include splinting, casting, plaster-and-pin fixation, or external fixation with a frame. External fixation may be used even with soft tissue damage.
Fractures of the Wrist and Hand
One or more of the bones in the wrist and hand can break, but the most common fracture is of the carpal scaphoid bone in young adult men. This is also one of the most misdiagnosed fractures because it is poorly visualized on an x-ray film. Closed reduction and casting for 6 to 12 weeks is the treatment of choice. If the bone does not heal, open reduction and bone grafting are performed.
Fractures of the metacarpals and phalanges are usually not displaced, which makes their treatment less difficult than that of other fractures. Metacarpal fractures are immobilized for 3 to 4 weeks. Phalangeal fractures are immobilized in finger splints for 10 to 14 days
LOWER EXTREMITY FRACTURES
■ Fractures of the Hip
Hip fractures include those involving the upper third of the femur and are classified as intracapsular (within the joint capsule) or extracapsular (outside the joint capsule). These types are further divided according to fracture location
CONSIDERATIONS FOR OLDER ADULTS
BaiB Hip fractures occur most often in older persons, particularly women who have osteoporosis. Repair of hip fracture is rapidly becoming the most common surgical procedure for people older than 85 years of age. As many as one third of older clients who sustain a hip fracture die within 1 year of injury from medical complications caused by the fracture or by immobility that occurs after the fracture. Approximately 50% cannot return home or live independently after the fracture (Lappe, 1998). Because of the poor prognosis of clients experiencing hip fractures, public education on osteoporosis and fracture prevention is crucial. Studies suggest that older, thin, Caucasian women are at the most risk for hip fracture (see the Evidence-Based Practice for Nursing box above)
Falls cause most hip fractures; impaction or displacement, especially of the femoral neck, often results. If the degree of osteoporosis is so severe that it prevents surgical intervention, the client may be incapacitated for the remainder of his or her life.
The treatment of choice is surgical repair, when possible, to allow the older client to get out of bed. Buck’s traction may be applied before surgery, which should be scheduled within 24 hours of injury if at all possible. Depending on the exact location of the fracture, open reduction with internal fixation (ORIF) may include an intramedullary rod, pins, a prosthesis, or a fixed sliding plate (such as a compression screw). The client with a compression screw can usually ambulate a few days after surgery and has a decreased chance of infection and nonunion, in comparison with clients for whom other procedures are used. If the femoral neck or head is fractured, a prosthetic device is implanted. Depending on the age of the client and prior mobility status, the surgeon replaces the femoral head only (
Hip fractures are common. Nurses in all health care settings need to know how to care for the special needs of the older adult with a hip fracture (see the Client Care Plan on p. 1145). The care is similar to that needed by older clients undergoing total hip replacement (see Chapter 21).
i Fractures of the Femur
Fractures of the lower two thirds of the femur usually result from trauma (often from a motor vehicle accident). A femoral fracture is seldom immobilized by casting, because the powerful muscles of the thigh become spastic, which causes displacement of bone ends. Extensive hemorrhage is associated with femoral fracture.
Skeletal traction, followed by a cast brace or hip spica cast, is the typical nonsurgical treatment. Surgical treatment is ORIF with nails, rods, or a compression screw. In a few cases, external fixation may be employed. Healing time for a femoral fracture may be 6 months or longer.
i Fractures of the Patella
Like most other fractures, patellar fractures result from direct impact. The surgeon typically repairs the fracture by closed reduction and casting or internal fixation with screws.
■ Fractures of the Tibia and Fibula
Trauma to the lower leg most often causes fractures of both the tibia and the fibula, particularly the lower third (“tib-fib” fractures). The three basic treatment techniques are closed reduction with casting, internal fixation, and external fixation. If closed reduction is used, the client wears a cast for at least 8 to 10 weeks. Delayed union is not unusual with this type of fracture. Internal fixation with nails or a plate and screws, followed by a long leg cast for 4 to 6 weeks, is another option. When the fractures cause extensive skin and soft-tissue damage, the initial treatment may be external fixation, often for 6 to 10 weeks. This is usually followed by application of a cast until the fracture is completely healed.
P Fractures of the Ankle and Foot
Ankle fractures are described by their anatomic place of injury. For example, a bimalleolar (Pott’s) fracture involves the medial malleolus of the tibia and the lateral malleolus of the fibula. Because of the instability of the ankle joint, the fracture can result from supination and eversion, pronation and abduction, or pronation and eversion. These forces generally create spiral, transverse, or oblique breaks, which are oftendifficult to treat and present problems in healing. A combination of closed and open techniques may be used, depending on the severity and extent of the fracture. An arthrodesis (fusion) may be needed if the bone does not heal.
Treatment of fractures of the foot or phalanges is similar to that of other fractures, with either closed or open reduction. Phalangeal fractures are more painful than, but not as serious as, most other types of fractures.
■ FRACTURES OF THE RIBS AND STERNUM
Chest trauma may cause fractures of the ribs or sternum; the most commonly fractured ribs are numbers 4 through 8. The major concern with rib and sternal fractures is the potential for puncture of the lungs, heart, or arteries by bone fragments or ends. Fractures of the lower ribs may damage underlying organs, such as the liver, spleen, or kidneys. These fractures tend to heal spontaneously without surgical intervention. The client is often uncomfortable during the healing process and requires analgesia.
I FRACTURES OF THE PELVIS
Because the pelvis is very vascular and close to major organs and blood vessels, associated internal damage is the chief concern in fracture management. After head injuries, pelvic fractures are the second most common cause of death from trauma. In young adults, pelvic fractures typically result from motor vehicle accidents or falls from buildings; falls are the most common cause in older adults. The major concern related to pelvic injury is venous oozing or arterial bleeding. Loss of blood volume leads to hypovolemic shock.
Internal abdominal trauma is assessed by checking for the presence of blood in the urine and stool and by watching theabdomen for the development of rigidity or swelling. The trauma team may use peritoneal lavage, computed tomography (CT) scanning, or ultrasound (the newest diagnostic modality) for assessment of hemorrhage. Ultrasound is non-invasive, rapid, reliable, and cost-effective, and it can be done at the bedside in real time.
There are many classification systems for pelvic fractures. A system that is particularly useful for nurses divides fractures of the pelvis into two broad categories: non-weight-bearing fractures and weight-bearing fractures.
When a non-weight-bearing part of the pelvis is fractured, such as one of the pubic rami or the iliac crest, treatment can be as minimal as bedrest on a firm mattress or bed board. This type of fracture can be quite painful, and the client may need stool softeners to facilitate defecation because of hesitancy to move. Well-stabilized fractures usually heal in 2 months.
A weight-bearing fracture, such as multiple fractures of the pelvic ring creating instability or a fractured acetabulum, necessitate external fixation and/or open reduction with internal fixation (ORIF). Less commonly used now are skeletal traction or double-hip spica casts. Progress to weight bearing depends on the stability of the fracture following fixation. Some clients may fully bear weight within days of surgery, whereas others managed with traction may not bear weight for as long as 12 weeks.
I FRACTURES AT OTHER SITES
Because the skull and vertebral column protect the brain and spinal cord, these fractures are described in Chapter 43. The nurse must be aware of the special care required for these clients because of possible neurologic damage resulting from these fractures. Fractures of the mandible or nose and other facial trauma are discussed elsewhere in the text
AMPUTATIONS
I OVERVIEW
An amputation is the removal of a part of the body. The nurse recognizes that the psychosocial ramifications of the procedure are often more devastating than the physical impairment that results. The loss experienced is complete and permanent and causes a change in body image and often in self-esteem. As with other types of loss, the client can be expected to progress through phases of the grieving process.
■ Pathophysiology
1 SURGICAL AMPUTATION
Amputations range from removal of part of a digit to removal of nearly half the entire body. The surgeon performs an amputation by one of two methods: open (or guillotine) method or closed (or flap) method.
The open method is used for clients who have, or are likely to develop, an infection. The wound remains open, and drains allow exudate to escape from the site until the infection clears. The surgeon may suture the skin flaps over the wound at a later time. In the closed technique, the surgeon pulls the skin flaps over the bone end and sutures them in place as part of the amputation procedure. One or more drains are typically inserted.
In either the closed or open method, the surgeon attempts to preserve as much of the part as possible and to keep major joints intact for maximal postoperative mobility.
■ TRAUMATIC AMPUTATION
Not all amputations are surgically planned. Some, classified as traumatic amputations, occur when a body part is severed unexpectedly (e.g., by a chain saw). Because the amputated part in these clients is usually healthy, attempts to replant it may be made.
One of the most likely replantations involves one or more digits. The current recommendation for prehospital care is that the severed digit be wrapped in a cool, dry cloth and moistened with normal saline, if possible, or bottled water. The digit should then be placed in a sealed plastic bag. The bag is placed in ice water, never directly on ice. Contact between the digit and the water is avoided to prevent tissue damage. Any semidetached parts of the digit should not be removed.
|
■ LEVELS OF AMPUTATION
LOWER EXTREMITY. Lower extremity amputations are performed much more frequently than upper extremity amputations. Five types of lower extremity amputations may be performed (Figure 52-11).
The loss of any or all of the small toes presents a minor disability. Loss of the great toe is significant because it affects balance, gait, and “push off’ ability during walking. Midfoot amputations (e.g., the Lisfranc amputation and the Chopart amputation) and the Syme amputation are common procedures for peripheral vascular disease. In the Syme amputation, most of the foot is removed but the ankle remains. Theadvantage of this surgery over traditional amputations below the knee is that weight bearing can be accomplished without use of a prosthesis and without pain.
An intense effort is made to preserve knee joints with below-knee amputation (BKA) rather than above-knee amputation (AKA). When the cause for the amputation extends beyond the knee, however, above-knee or higher amputations are performed. Hip disarticulation, or removal of the hip joint, and hemipelvectomy procedures are more common in younger clients than in older clients, who cannot easily handle the cumbersome prostheses required for ambulation. The higher the level of amputation, the more energy is required for ambulation. These higher-level procedures are typically done for cancer of the bone, osteomyelitis, or trauma. Hemicorporectomy (hemipelvectomy and translumbar amputation) is a rare radical procedure performed as a last resort for cancer.
UPPER EXTREMITY. Fewer than 10% of all amputations are upper extremity amputations. An amputation of any part of the upper extremity is generally more incapacitating than one of the leg. The arms and hands are necessary for activities of daily living (ADLs), such as feeding, bathing, dressing, and driving a car. As much length as possible is saved to maintain function. Early replacement with a prosthetic device is vital for the client with this type of amputation.
Bi COMPLICATIONS OF AMPUTATIONS
The following are common complications of elective or traumatic amputations:
• Hemorrhage
• Infection
• Phantom limb pain
• Problems associated with immobility
• Neuroma
• Flexion contractures
HEMORRHAGE. When a person loses part or all of an extremity either by surgery or by trauma, major blood vessels are severed, which causes bleeding. If the bleeding is uncontrolled, the client is at risk for hypovolemic shock and possibly death.
INFECTION. As with any surgical procedure or trauma, infection can occur in the wound or the bone (osteomyelitis). The older adult who is debilitated and confused is at the greatest risk because excreta may soil the wound, or the client may remove the dressing and pick at the incision.
PHANTOM LIMB PAIN. Phantom limb pain (PLP) is
a frequent complication of amputation. Most clients experience phantom limb sensation in the early postoperative period. Sensation is perceived in the phantom foot or hand and diminishes over time. When phantom limb sensation persists and is unpleasant or painful, it is referred to as PLP. PLP is more common in clients who have experienced chronic limb pain before surgery and rare in those who experience traumatic amputations.
No one theory explains or predicts PLP. Three theories are being researched:
Peripheral nervous system theory
Central nervous system theory
* Psychologic theory
The peripheral nervous system theory implies that sensations remain as a result of severing peripheral nerves during the amputation. The central nervous system theory states that PLP results from a loss of inhibitory signals that are usually generated through afferent impulses from the amputated limb. When many sensory fibers are destroyed by amputation, the loss of inhibitory influences allows repetitive neural activity, which results in pain. Neither of these physiologic theories completely explains PLP. Most likely, a psychologic component helps predict and explain this phenomenon. Stress, anxiety, and depression often worsen or trigger an episode of PLP but are not likely to be the causative factors.
When experiencing PLP, the client complains of pain in the removed body part, most often shortly after surgery. The pain is often described either as an intense burning or crushing sensation or as cramping. Some clients say they feel as if the removed part is in a distorted, uncomfortable position; they experience numbness and tingling (sometimes called phantom limb sensation), as well as pain.
Some clients report that the most distal area of the removed part feels as if it is retracted into the residual limb end. For most clients, the pain is triggered by touching the residual limb, by temperature or barometric pressure changes, by concurrent illness, by fatigue, or by emotional stress. Routine activities, such as urination, can trigger the pain in other clients. If pain is long-standing, especially if it existed before the amputation, any stimulus can cause it, including touching any part of the body.
PROBLEMS ASSOCIATED WITH IMMOBILITY.
Because the client experiences reduced mobility as a result of surgery, the complications of atelectasis, pneumonia, throm-boembolism, and skin breakdown can readily occur. These problems are discussed earlier under Complications of Fractures, p. 1127.
NEUROMA. Neuroma—a sensitive tumor consisting of nerve cells found at severed nerve endings—forms most often in amputations of the upper extremity but can occur anywhere.
FLEXION CONTRACTURES. Flexion contractures of the hip or knee are seen in clients with amputations of the lower extremity. This complication must be avoided so that the client can ambulate with a prosthesis.
S Etiology
Most knowledge about amputations was obtained during World War II, when trauma ofteecessitated a loss of one or more body parts. Today, with highly sophisticated microsurgery for revascularization of tissues, amputations related to trauma are less likely to be needed. Limb salvage procedures, such as those described in Chapter 51 (under Surgical Management in the section on malignant bone tumors), have reduced the need for amputation.
Traumatic amputations most often result from accidents. A person may be cleaning lawn mower blades or a snow blower
without disconnecting the machine. A motor vehicle or industrial machine accident may also cause an amputation.
Ј73 CONSIDERATIONS FOR OLDER ADULTS
fiufflThe primary indication for surgical amputation is ischemia from peripheral vascular disease in the older client (see Chapter 36). The rate of lower extremity amputation, for example, is much greater among clients with diabetes than among other clients because of peripheral neuropathy and peripheral vascular disease (Spollett, 1998). In addition, these older diabetic clients have visual, cardiac, and kidney problems. A client with an amputation of one leg because of poor circulation will often have an amputation of the other leg within 5 years. Older adults of advanced age may not be candidates for prostheses because of the energy required for ambulation. The more proximal the amputation in the lower extremity, the more energy required for ambulation.
I Incidence/Prevalence
Surgical amputations are not as common as they were in the past, because the success rates of revascularization and limb salvage techniques have improved over the last 30 years. However, more than 100,000 amputations are performed yearly in the
The typical client undergoing the procedure is a middle-aged or older man with diabetes and a lengthy history of smoking. The client most likely has failed to care for his feet properly, which has resulted in a nonhealing, infected foot ulcer and possibly gangrene.
The second largest group with amputations consists of young men who experience motorcycle or other vehicular accidents or who are injured at work by industrial equipment. These men may either experience a traumatic amputation or undergo a surgical amputation because of a severe crushing injury and massive soft-tissue damage.
CULTURAL CONSIDERATIONS
■^s- The incidence of lower extremity amputations is greater in the African-American and Hispanic populations because the incidence of major diseases leading to amputation, such as diabetes and arteriosclerosis, is greater in this population. Limited access to care for these minority groups may also play a major role in limb loss (Spollett, 1998).
Wh COLLABORATIVE MANAGEMENT
I* Assessment
m PHYSICAL ASSESSMENT/CLINICAL. MANIFESTATIONS
When the client has peripheral vascular disease, the nurse’s primary concern preoperatively is to assess circulation in other parts of the body The nurse assesses skin color, temperature, sensation, and pulses in both affected and unaffected extremities. Capillary refill is evaluated by applying pressure to the nail bed and waiting for the brisk return of normal color. In the older adult, however, this test may be difficult to do because the nails may be thick and opaque. In this situation, the skiear the nail bed can be assessed (see Chart 52-3).
K PSYCHOSOCIAL ASSESSMENT
People react differently to the loss of a body part. The nurse needs to be aware that an amputation of a portion of one finger can be traumatic to the client; therefore the loss must not be underestimated. The client undergoing an amputation faces a complete, permanent loss. The nurse assesses the client’s psychologic preparation for a planned amputation and expects him or her to experience the grieving process. Adjustment to a traumatic, unexpected amputation is often more difficult than accepting a planned one. The young client may be bitter, hostile, and uncooperative. In addition to loss of a body part, the client may lose a job, the ability to participate in favorite recreational activities, or a social relationship if the other person cannot accept the body change. Chapter 9 discusses the nursing assessment for a client experiencing loss.
The client is faced with an altered self-concept. The physical alteration that results from an amputation affects body image and self-esteem. For example, a client may think that an intimate relationship with a mate is no longer possible. An older adult may feel a loss of independence. The nurse assesses the client’s feelings about himself or herself to identify areas in which he or she needs emotional support.
The nurse tries to determine the client’s willingness and motivation to withstand prolonged rehabilitation after the amputation. Asking questions about how the client has dealt with previous life crises can provide clues. The client’s willingness to change careers or other activities is also determined. Adjustment to the amputation and rehabilitation is less difficult if the client is willing to make necessary changes.
In addition to assessing the client’s psychosocial status, the nurse assesses the family’s or significant others’ reaction to the surgery. The family’s response usually correlates directly with the client’s progress during recovery and rehabilitation. The family can be expected to grieve for the loss and must be allowed to adjust to the change in the client.
The nurse also assesses the client’s coping abilities and helps him or her to identify personal strengths and weaknesses. The nurse ascertains that the client’s religious or spiritual beliefs have been determined, because certain groups require that the amputated body part be stored for later burial with the rest of the body or be buried now.
|
» DIAGNOSTIC ASSESSMENT
Routine preoperative x-ray studies, such as a chest x-ray, are done as appropriate for any client undergoing surgery. The surgeon determines which tests are performed to assess for viability of the limb. A large number of noninvasive techniques are available to assist the physician in this evaluation. For complete accuracy, the health care provider does not rely on any single test.
One procedure is measurement of segmental limb blood pressures, which can also be used by the nurse at the bedside. In this test, an ankle-brachial index (ABI) is calculated by dividing ankle systolic pressure by brachial systolic pressure. A normal ABI is greater than or equal to 1.
Blood flow in an extremity can also be assessed by many other noninvasive tests, including Doppler ultrasonography, laser Doppler flowmetry, and transcutaneous oxygen pressure (TcPO2). The ultrasonography measures the velocity of blood flow in the limb. The TcPO, measures oxygen pressure to indicate blood flow in the limb. Angiography is the most com monly used invasive method; however, it is not helpful in predicting healing of amputations. Transcutaneous oxygen pressure has proved reliable for predicting healing.
■» Interventions
Clients undergoing amputation today are not confined to a wheelchair. Advancements in the design of prosthetics have enabled clients to become independent in ambulation. Therefore complications from extended bedrest are not common, even for older adults.
ASSESSMENT OF TISSUE PERFUSION. The nurse’s primary focus is to monitor for signs indicating that there is sufficient tissue perfusion but no hemorrhage. The skin flap at the end of the residual limb should be pink in a light-skinned person and not discolored (lighter or darker than other skin pigmentation) in a dark-skinned client. The area should be warm but not hot. The nurse assesses the closest proximal pulse for strength and compares it with that in the other extremity. If the client has bilateral vascular disease, however, comparison of limbs is not an accurate way of measuring blood flow.
MANAGEMENT OF PAIN. Phantom limb pain (PLP) must be distinguished from stump pain, since they are managed differently. Pain management related to stump pain is not unlike that for any client in pain (see Chapter 7). If the client complains of PLP, the nurse recognizes that the pain is real. It is not therapeutic for the nurse to remind the client that the limb cannot be hurting, because it is missing. To prevent increased pain, the nurse handles the residual limb carefully when assessing the site or changing the dressing.
DRUG THERAPY. Some studies have shown that opioids are not as effective for PLP as they are for residual limb pain. The health care provider prescribes medication on the basis of the type of PLP the client experiences. For instance, beta-blocking agents such as propranolol (Inderal, Apo-Propranolol4*1, Deten-sol4>) are used for constant, dull burning. Anticonvulsants, such as phenytoin (Dilantin) and carbamazepine (Tegretol), may be used for knifelike pain; antispasmodics such as baclofen may be prescribed for muscle spasms or cramping.
COMPLEMENTARY AND ALTERNATIVE THERAPIES.
More than 50 treatments for PLP have been used worldwide. Transcutaneous electrical nerve stimulation (TENS) has had the most consistent pain relief rates. Other treatment measures include the following:
• Ultrasound therapy
• Massage
Exercises
> Biofeedback
■ Distraction therapy
• Hypnosis
Psychotherapy
PREVENTION OF INFECTION. The surgeon typically prescribes broad-spectrum prophylactic antibiotics for several days postoperatively. The initial pressure dressing and drains are usually removed by the surgeon 48 to 72 hours after surgery. The nurse:
Inspects the wound site for signs of inflammation (e.g.,
redness and swelling)
* Monitors the healing process
* Records the characteristics of drainage, if present
” Changes the soft dressing every day until the sutures are removed
The below-the-knee limb may be casted in the operating room for protection, prevention of edema, and prevention of knee contractures. On the third postoperative day, a window is opened in the distal end of the cast to inspect the suture line.
PROMOTION OF AMBULATION. The nurse or health care provider consults with a physical therapist to initiate exercises as soon as possible after surgery. If the amputation is a planned one, the therapist often works with the client before surgery to start muscle strengthening exercises and to evaluate the need for aids, such as crutches. If the client can be instructed preoperatively in the use of these devices, learning how to ambulate after surgery is facilitated.
EXERCISE. For clients with above-knee amputations (AKAs) or below-knee amputations (BKAs), the nurse teaches range-of-motion (ROM) exercises for prevention of flexion contractures, particularly of the hip and knee. A trapeze and an overhead frame, as shown in Figure 52-12, aid in strengthening the upper extremities and allow the client to move independently in bed.
A firm mattress is essential for preventing contractures with a lower extremity amputation. The nurse assists the client into a prone position every 3 to 4 hours for 20- to 30-minute periods. This position may be uncomfortable initially, but it is necessary to prevent hip flexion contractures. The nurse instructs the prone client to pull the residual limb close to the other leg and contract the gluteal muscles of the buttocks. For BKAs, the nurse also teaches the client to push the residual limb down toward the bed while supporting it on a pillow. After the sutures are removed, the physical therapist may begin resistive exercises with a “sling-and-spring” apparatus, which can also be used at home
Elevation of a lower leg residual limb on a pillow while the client is in a supine position is controversial. Some practitioners advocate avoiding this procedure at all times because it promotes hip or knee flexion contracture. Others allow elevation for the first 24 hours to reduce swelling and subsequent discomfort. The nurse inspects the residual limb daily to ensure that it lies completely flat on the bed.
PROSTHESES. For an elective amputation, the nurse arranges for the client to see a certified prosthetist-orthotist (CPO) so that planning can begin for the client’s postoperative needs. Arrangements for replacing an upper extremity are especially important so that the client can provide self-care. Some clients are fitted with a temporary prosthesis at the time of surgery. Other clients, particularly older clients with vascular disease, are fitted after the residual limb has healed.
The client being fitted with a lower extremity prosthesis should bring a sturdy pair of shoes to the fitting. The prosthesis will be adjusted to that heel height.
PREPROSTHETIC CARE. Several devices help shape and shrink the residual limb in preparation for the prosthesis. Rigid, removable dressings are preferred because they decrease edema, protect and shape the limb, and allow easy access to the wound for inspection. The Jobst air splint, a plastic inflatable device, is sometimes used for this purpose. This device is usually inflated to
Wrapping with elastic bandages can be effective in reducing edema, shrinking the limb, and holding the wound dressing in place. Most surgeons prefer elastic bandages over a shrinker sock, although it is easier for the client to apply a sock than to wrap elastic bandages.
For wrapping to be effective, the nurse reapplies the bandages every 4 to 6 hours or more often if they become loose. Figure-eight wrapping prevents restriction of blood flow. Thenurse decreases the tightness of the bandages while wrapping in a distal-to-proximal direction. After wrapping, the nurse anchors the bandages to the most proximal joint, such as above the knee for BKAs (Figure 52-13).
PROSTHESIS APPLICATION. The design of and materials for prostheses have improved dramatically over the years. Computer-assisted design and manufacturing (CAD-CAM) is now available for a custom fit. One of the biggest developments in lower extremity prosthetics is the ankle-foot prosthesis. The Flex-Foot is used by more active amputees.
PROMOTION OF BODY IMAGE. The client often experiences feelings of inadequacy as a result of losing a body part, especially the older adult who was in poor health before surgery. If possible, the nurse arranges for the client to meet with a rehabilitated amputee. If the client is older, an older amputee is the ideal person with whom the client should interact.
Use of the word stump for referring to the remaining portion of the limb is controversial. Clients have reported feeling as if they were part of a tree when the term was used. However, some rehabilitation specialists who routinely work with amputees believe the term is appropriate because it forces the client to realize what has happened and enhances adjustment to the amputation. This discussion uses residual limb instead.
The nurse assesses the client’s verbal and nonverbal references to the affected area. Some clients behave euphorically and seem to have accepted the loss. The nurse should not jump to the conclusion that acceptance has occurred. The client is asked to describe his or her feelings about changes in body image and self-esteem. The client may verbalize acceptance but refuse to look at the area during a dressing change
This inconsistent behavior is not unusual and should be noted by the nurse.
PROMOTION OF LIFESTYLE ADAPTATIONS. The client may believe that it will be impossible to return to a previous lifestyle, including intimate relationships, his or her job, and recreational activities. With advancements in prostheses, many clients can return to their jobs and other activities. Professional athletes who use prostheses are quite successful in sports. Clients with amputations ski, hike, bowl, and participate in other physically demanding activities. More than 20,000 amputees in the
If a job or career change is necessary, the nurse consults with a social worker for evaluation of the client’s other skills that could be used in another capacity. A supportive family or significant other is important for the client’s adjustment to this change. The client may also think that an intimate relationship is no longer possible because of physical changes. The nurse works with the sexual partner to help in the client’s adjustment to the amputation. Professional assistance from a sex counselor or psychologist may be needed.
The nurse helps the client to set realistic goals and to take one day at a time. He or she is helped to recognize personal strengths, which are emphasized and taken into account in setting goals. If the goals are not realistic, frustration and disappointment may dampen the client’s motivation during rehabilitation. Basic principles of rehabilitation are discussed in Chapter 10.
the hospital stay, the nurse helps the client to identify strong support systems on which he or she can rely after discharge. The home care or rehabilitatiourse reinforces this supporting information.
R HOME CARE MANAGEMENT
The client with a lower extremity amputatioeeds to have enough room at home to maneuver a wheelchair if the leg prosthesis is not yet available. He or she must be able to use toileting facilities and have access to areas necessary for self-care, such as the kitchen. Structural changes may be required before the client goes home.
m HEALTH CARE RESOURCES
For the older adult or for the client with an extensive amputation, such as a hemipelvectomy, the case manager or discharge planner arranges for follow-up care in the home by a home care nurse (Chart 52-7). Physical therapy may continue in the home or on an ambulatory care basis.
The client with an upper extremity amputation may need occupational therapy to relearn activities of daily living (ADLs). The nurse or case manager also makes arrangements for vocational or family counseling, as needed. Some clients are discharged to a rehabilitation facility for 2 to 3 weeks for these services. Chapter 10 describes the rehabilitation phase of health care in detail. The nurse teaches the client to explore support groups for amputees that may be available in the client’s community.
H Community-Based Care
The client is discharged directly to home or to a rehabilitation facility, depending on the extent of the amputation. In the few cases in which rehabilitation is not feasible (e.g., for a debilitated, confused older client), he or she may be discharged to a long-term care facility. The case manager or discharge planner coordinates this transfer.
K HEALTH TEACHING
After the sutures are removed (several weeks after surgery), the client begins residual limb care. The home care nurse teaches the client how to care for the residual limb and how to care for the prosthesis if it is available. The limb should be rewrapped three times a day with an elastic bandage applied in a figure-eight manner (see Figure 52-13) by the client or family member. After the residual limb is healed, it is cleaned each day with the rest of the body during bathing with soap and water, and it is inspected for signs of inflammation or skin breakdown.
Prostheses require special care for ensuring their reliability and proper function, and the prosthetist plays an important role in the rehabilitation team effort. Prostheses are custom made, taking into account the client’s level of amputation, lifestyle, and occupation. Proper teaching regarding correct cleansing of the socket and inserts, wearing the correct liners, assessing shoe wear, and a schedule of follow-up care is essential before discharge.
A client who seemed to adjust to the amputation during hospitalization may realize that it is difficult to cope with the loss after discharge from the hospital. The nurse in the hospital setting should tell the client that this can happen. During
CRUSH SYNDROME
When multiple compartments in the leg or arm are injured, crush syndrome (CS) can occur. CS is a potentially life-threatening, systemic complication after a severe crush injury. Its pathophysiologic mechanism is similar to that of acute compartment syndrome (see p. 1127).
Specific causes of CS include the following:
• Prolonged use of a pneumatic antishock garment (PASG)
or military antishock trousers (MAST) (For this reason,
these devices are seldom used today.)
• Wringer-type injuries
• Natural disasters, such as earthquakes
• Work-related injuries, such as being trapped under heavy
equipment or material
FOCUSED ASSESSMENT of
The Client with a Lower Extremity Amputation in the Home
Assess the residual limb for:
• Adequate circulation
• Infection
• Healing
• Flexion contracture
• Dressing/elastic wrap
Assess the client’s ability to perform activities of daily living
(ADLs) in the home. Evaluate the client’s ability to use ambulatory aids and care
for the prosthetic device (if available). Assess the client’s nutritional status. Assess the client’s ability to cope with body image change.
Drug/alcohol overdose, when one or more limbs may be
compressed by body weight for a prolonged time
Regardless of the cause, CS is characterized by the following:
• Acute compartment syndrome
• Hypovolemia
• Hyperkalemia
Rhabdomyolysis (myoglobulin release from skeletal muscle into the bloodstream)
Acute tubular necrosis (ATN) resulting from hypovolemia and rhabdomyolysis
Nursing assessments include signs and symptoms of hypovolemia, hyperkalemia, and compartment syndrome. Treatments focus on preventing acute tubular necrosis secondary to myoglobin release and cardiac dysrhythmias related to hyperkalemia. Adequate IV fluids, diuretics, and low-dose dopamine to enhance renal perfusion may be ordered. An output of 100 to 200 ml/hr is the goal. Sodium bicarbonate is given to treat aci-dosis. Kayexalate may reduce serum potassium adequately, but hemodialysis may be required if potassium levels remain high or renal failure occurs.
COMPLEX REGIONAL PAIN SYNDROME ._
Complex regional pain syndrome (CRPS) (less commonly called reflex sympathetic dystrophy syndrome [RSDS]) is a poorly understood complex disorder that includes pain, trophic changes, autonomic dysfunction, and motor impairment (most notably muscle paresis). It is probably caused by an abnormally hyperactive sympathetic nervous system. It most often results from traumatic injury and commonly occurs in the feet and hands (Aprile, 1998).
The syndrome tends to progress through three classic stages. In stage 1, which lasts 1 to 3 months, the client complains of locally severe, burning pain; edema; vasospasm; and muscle spasm. Over the next 3 months, clients in stage 2 have more severe, diffuse pain and edema, muscle atrophy, and spotty osteoporosis, as shown on x-ray examination. In stage 3, the final stage, the client presents with marked muscle atrophy, intractable (unrelenting) pain, severely limited mobility of the affected area, contractures, and marked, diffuse osteoporosis. Timing of diagnosis is important, since the syndrome is more difficult to treat when diagnosed in the later stages.
The first priority of management is pain relief. Nurses play an important role in pain management, which includes drug therapy and an array of nonpharmacologic modalities. Chapter 7 discusses pain management in detail.
In collaboration with the physical and occupational therapist, the nurse also assists in maintaining adequate range of motion (ROM). The skin of a client with CRPS tends to alternate between warm, swollen, and red to cool, clammy, and bluish. Skin care needs to be gentle, with minimal stimulation.
The nurse assists the client in coping with CRPS. Psychotherapy may be indicated. The RSDS Association is available to help clients organize or locate support groups and other resources for clients with this syndrome.
In addition to the bone and muscle problems already discussed, trauma can cause cartilage, ligament, and tendon in jury. Many musculoskeletal injuries are the result of participation in sports or other strenuous physical activities. These injuries have become so common that large metropolitan hospitals have sports medicine clinics and physicians who specialize in this field.
Although the specific types of injury are numerous, this chapter includes only the most common ones seen by the nurse in a hospital or ambulatory care setting. The principles of injury to one part of the body are analogous to those of similar injuries in other parts. For example, a tendon rupture in a knee is cared for in the same manner as a tendon rupture in the wrist. Chart 52-8 lists general emergency measures for sports-related injuries.
Because the knee is most often injured, it is discussed as a typical example of other areas of the body. Trauma to the knee results in internal derangement, a broad term for disturbances of an injured knee joint. When surgery is required to resolve the problem, most surgeons prefer to perform the procedure through an arthroscope when possible. A general description of arthroscopy is presented in Chapter 50.
Knee Injuries: Meniscus
1 OVERVIEW
There are two semilunar cartilaginous structures, or menisci, in the knee joint: the medial meniscus and the lateral meniscus. These pads act as shock absorbers, but they can tear. Tearing is usually a result of twisting the leg when the knee is flexed and the foot is placed firmly on the ground. The medial meniscus is much more likely to tear than the lateral meniscus because it is less mobile. Internal rotation causes a tear in the medial meniscus; external rotation causes a tear in the lateral meniscus.
Tears can be anterior or posterior, longitudinal or transverse. In the medial meniscus, a longitudinal tear, or “bucket handle” injury, often causes the knee to lock; that is, the torn cartilage jams between the femur and the tibia and prevents extension of the knee. Surgery is often required for this type of injury. In transverse tears, the knee does not lock, and surgery may not be required.
Wt COLLABORATIVE MANAGEMENT
The client with a torn meniscus typically has pain, swelling, and tenderness in the knee. A clicking or snapping sound can often be heard when the knee is moved.
A common diagnostic technique is the McMurray test. The examiner flexes and rotates the knee and then presses on
BEST PRACTICE/or
Emergency Care of Sports-Related Injuries
|
Do not move the victim until spinal cord injury is ascertained (see Chapter 45 for assessment of spinal cord injury).
Immobilize the injured part; immobilize the joint above and below the injury by applying a splint. Apply ice intermittently for the first 24-48 hours (heat may be used thereafter). Elevate the affected limb to decrease swelling. Always assume the area is fractured until x-ray studies are done. Assess neurovascular status in the area distal to the injury.
the medial aspect while slowly extending the leg. The test result is positive if clicking is palpated or heard. A negative finding, however, does not rule out a tear.
For a locked knee, the treatment may be manipulation followed by casting for 3 to 6 weeks. If the problem recurs, a partial or total meniscectomy is performed. An open menis-cectomy requires a surgical incision for removal of all or part of the meniscus and is rarely performed. Most surgeons prefer to remove only the affected portion, which can be accomplished through an arthroscope during a closed meniscectomy as a same-day surgical procedure. As described in Chapter 50, an arthroscope is a metal tubular instrument used for examination or surgery of joints. One or more small incisions (less than V4 inch [0.6 cm] long) are made in the knee for insertion of the arthroscope. The surgeon threads a cutting device through the arthroscope for removal of the torn cartilage while the knee is irrigated with saline or lactated Ringer’s solution, depending on the type of equipment used. The surgeon may use a laser during the procedure, depending on the type and severity of the injury. A bulky pressure dressing is applied after the procedure, and the affected leg is wrapped in elastic bandages.
As for any postoperative client, the nurse checks the surgical dressing for bleeding and monitors vital signs after the client is readmitted to the unit. The nurse performs circulation checks, as outlined in Chart 52-3, usually every hour for the first few hours and then every 4 hours.
The client begins leg exercises immediately after surgery to strengthen the leg, prevent thrombophlebitis, and reduce swelling. Quadriceps setting, in which the client straightens the leg while pushing the knee against the bed, is done in sets of 10 or more. Straight-leg raises are also performed as soon as the client awakens from anesthesia. Range-of-motion (ROM) exercises are usually not started for several days.
To prevent the client from bending the affected knee, the physician may order a knee immobilizer, such as the one shown in Figure 52-14. The nurse elevates the leg on one or two pillows according to the physician’s preference and applies ice to reduce postoperative swelling. Full weight bearing is restricted for several weeks, depending on the amount of cartilage removed. The client is usually discharged from the hospital with crutches in less than 23 hours.
Knee Injuries: Ligaments
I OVERVIEW
The cruciate and collateral ligaments in the knee are predisposed to injury, often from sports or vehicular accidents. The anterior cruciate ligament (ACL) is the most commonly torn ligament in the knee. Athletes often experience ACL injuries during skiing or gymnastics.
When the ACL is torn, the person feels a snap; the knee gives way because of ACL laxity. Within hours, the knee is swollen, stiff, and painful.
Wr COLLABORATIVE MANAGEMENT
Physical examination by the health care provider shows positive ligamentous laxity. The diagnosis of ACL deficiency is confirmed by x-ray studies, magnetic resonance imaging (MRI), or assessment with an arthrometer (an instrument for measuring the amount of tibial displacement
Treatment may be nonsurgical or surgical, depending on the severity of the injury and the anticipated activity of the client. Exercises, bracing, and limits on activities while the ligament heals may be sufficient. If medical management is not effective, surgery may be needed.
The surgeon repairs the tear by reattaching the torn portions of the ligament, and the leg is placed in a cast. If the ligament cannot be repaired, reconstructive surgery may be performed with the use of autologous grafts. Since the early 1980s, the Food and Drug Administration (FDA) has approved several artificial knee ligaments. The Gore-Tex ligament is a permanent implant. A ligament augmentation device is used temporarily while the autograft heals. Both of these materials can be implanted through an arthroscope.
Complete healing of knee ligaments after surgery can take 6 to 9 months or longer. Nursing management is similar to the care of any client in a cast, which is described earlier in this chapter under Cast Care, p. 1134.
Tendon Ruptures
Rupture of the Achilles tendon is common in adults who participate in strenuous sports. In the older adult, quadriceps tendon rupture may occur from a fall down several steps. For severe damage, the tendon is surgically repaired and the leg is immobilized in a cast for 6 to 8 weeks. If the tendon is beyond repair, a tendon transplant (also known as tendon reconstruction) is performed. A tendon is removed from one part of the body and transplanted to the affected area. The nursing care for these clients is similar to that discussed earlier for a client with a cast
Dislocation of a joint occurs when the articulating surfaces are no longer in proximity. If the dislocation is not complete, the joint is partially dislocated, or subluxed. Dislocation can occur in any diarthrodial (synovial) joint but is common in the shoulder, hip, knee, and fingers. This injury is most often the result of trauma but can be congenital or pathologic (resulting from joint disease, such as arthritis).
The typical manifestations of dislocation are as follows:
1 Pain
• Immobility
• Alteration in contour of the joint
• Deviation in length of the extremity
• Rotation of the extremity
The health care provider performs a closed manipulation, or reduction, of the joint and forces it back into its original position while the client is anesthetized or under conscious sedation. The joint is immobilized by a cast or immobilizer until healing occurs.
Recurrent dislocations are common in the knee and shoulder. For this problem, the joint is fixed with wires to prevent further displacement; a cast, splint, or traction is applied for 3 to 6 weeks.
Strains
A strain is excessive stretching of a muscle or tendon when it is weak or unstable. Strains are sometimes referred to as muscle pulls. Falls, lifting of heavy items, and exercise often cause this injury.
Strains are classified according to their severity:
• A first-degree (mild) strain causes mild inflammation
but little bleeding. Swelling, ecchymosis, and tenderness
are usually present.
• A second-degree (moderate) strain involves tearing of
the muscle or tendon fibers without complete disruption.
Muscle function may be impaired.
• A third-degree (severe) strain involves a ruptured muscle
or tendon with separation of muscle from muscle, tendon
from muscle, or tendon from bone. Severe pain and dis
ability result from severe strains.
Management usually involves cold and heat applications, exercise, and activity limitations. The health care provider may prescribe anti-inflammatory drugs to decrease inflammation and pain. Muscle relaxants may also be used. In third-degree strains, surgical repair of the ruptured muscle or tendon may be necessary.
Sprains
A sprain is excessive stretching of a ligament. Twisting motions from a fall or sports activity typically precipitate the injury. Sprains are classified according to severity:
• A first-degree (mild) sprain involves tearing of a few
fibers of a ligament. Function of the joint is not impaired.
• In a second-degree (moderate) sprain, more fibers are
torn, but stability of the joint remains intact.
• A third-degree (severe) sprain causes marked instability
of the joint.
Pain and swelling characterize ligament injuries. The treatment for mild (first-degree) sprains is minimal:
• Rest
5 Use of ice for the first 24 to 48 hours
• Application of a compression bandage for a few days to
reduce swelling and provide joint support
Elevation
Second-degree sprains require immobilization (elastic bandage and Air Stirrup ankle brace, splint, or cast) and partial weight bearing while the tear heals. For severe ligament damage (third-degree sprain), immobilization for 4 to 6 weeks is necessary. Surgery may be recommended, particularly for chronic instability, as discussed earlier under Knee Injuries: Ligaments, p. 1153.
For more specific client education, refer to the Clinical Pathway on p. 1833.
Rotator Cuff Injuries
The musculotendinous, or rotator, cuff of the shoulder functions to stabilize the head of the humerus in the glenoid cavity during shoulder abduction. The rotator cuff typically undergoes degenerative changes as one gets older. Young adults usually sustain a tear of the cuff by substantial trauma, such as may occur during a fall, while throwing a ball, or with heavy lifting. Older adults tend to have small tears related to aging, repetitive motions, or falls.
Clients with a torn rotator cuff have shoulder pain and cannot initiate or maintain abduction of the arm at the shoulder. When the arm is abducted, the client usually drops the arm because abduction cannot be maintained (drop arm test).
The health care provider usually treats the client conservatively with nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy, sling support, and ice/heat applications while the tear heals.
For clients who do not respond to conservative treatment or for those who have a complete tear, the surgeon repairs the cuff. After surgery, the affected arm is usually immobilized in a sling for several weeks. Pendulum exercises are started on the third or fourth postoperative day and progress to active exercises in about 2 weeks. If the surgery is extensive, the client’s arm may be immobilized for a longer time before exercises begin.
