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musculosketal

Musculosketal

by KatrinaMullens, Mar. 2015

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78 Cards in this Set

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	Assessing musculoskeletal Injuries is part of the	Secondary Survey
	Secondary Survey •Baseline assessment of neurovascular and motor status •Diagnostics: what to do	X-Rays, CT, Angiogram, MRI •Proper immobilization of affected extremities –Unstable pelvic ring disruption may require C-clamp application •Application of sterile dressings
	Assessment •Inspection	–Position of patient –Position of extremities –Bleeding / estimated blood loss –Obvious deformities –Open or closed fractures –Extremity color –Ecchymosis –Muscle spasm –Swelling
	Assessment •Palpation	–Pulse –Capillary refill –Range of motion - passive vs active –Sensation –Pain –Interruption in bone integrity –Crepitus –Temperature –Muscle spasm
	Assessment •Zone of injury	–Area affected by traumatic forces- –Damage to soft tissue structures is often greater than what it initially appears –Highly suspicious areas include joint above and joint below injury
	Assessment •Diagnostic studies	–Plain film radiographs-bone most common •Include the joint above and below –CT-soft tissue –Angiography-vessel damage –CT myelograms-weeks later-long term tissue damage –MRI
	Classification of Injuries	•Fractures •Dislocations-luxation-out of socket •Subluxations-almost out of socket-partial dislocation •Traumatic amputations •Soft tissue injuries – Skin – Muscles – Tendons-strain – Ligaments-sprain – Cartilage
	Extremity Fractures-no know	•Classification factors –Type of fracture line –Linear vs comminuted –Anatomic location –Type of displacement –Position of displacement in relation to other fragments –Open vs closed
	Classifications of Open Fractures Type I no know	–Wound less than 1 cm –Moderately clean, minimal contamination –Fracture-simple transverse or oblique with skin pierced by bone spike –Minimal soft tissue damage
	Classifications of Open Fractures Type II no know	–Wound greater than 1 cm –Moderate contamination –Fracture-moderate comminution/crush injury –Moderate soft tissue damage (flaps or avulsions)
	Classifications of Open Fractures Type III no know	–High degree of contamination –Fracture-severe communition and instability –Extensive soft tissue damage involving muscle, skin, and neurovascular structures – Traumatic amputation
	Classifications of Open Fractures Type III A no know	–Soft tissue coverage of fracture is adequate –Fracture-segmental of severely comminuted
	Classifications of Open Fractures Type III B no know	–Extensive injury to or loss of soft tissue, periosteal stripping, and exposure of bone –Massive contamination –Fracture-severe comminution
	Classifications of Open Fractures Type III C no know	–Any open fracture associated with arterial injury that must be repaired regardless of degree of soft tissue injury
	Disruption of Joint •Dislocation	–Articulating surfaces are no longer in contact
	•Subluxation	–Partial dislocation •Movement of extremity may be limited or impossible •Neurovascular compromise common –Careful assessment vital •Ligaments surrounding joint severely stretched or completely disrupted
	•Prompt immobilization essential	all disruption of joints
	Traumatic Amputations •Types	–Guillotine-clean cut –Crush- –Avulsion-yanked off
	Traumatic Amputations •Care for the amputated part	–Wrap amputated limb in sterile, saline moist gauze or towel –Place in plastic bag or container –Place the plastic bag or container on top of crushed ice and water in another plastic bag or an insulated cooling chest •Never place part in contact directly with ice •Do not freeze the amputated part –Transport part with the patient know–Consider ischemia time-detached from body
	Pelvic Fractures •Anteroposterior compression	Back hit –Symphysis pubis opens anteriorly –“Open Book” fracture –Generally stable fracture
	Pelvic Fractures •Lateral compression	Side hit •High-energy forces –Pelvis internally rotates due to direct pressure on one iliac crest –Generally stable fracture
	–Most common pelvic injury	•Lateral compression
	Pelvic Fractures •Vertical shear	land on feet-pelvic goes up –Unstable pelvic fracture –Bone and soft tissue •Sacrospinous and sacroiliac ligament injuries –Potential for large volume of blood loss
	Pelvic Fractures •Complex Pelvic Fracture	–Combination of powerful forces –Multiple fracture, dislocation, ligamentous injuries –Extremely unstable –High incidence of severe vascular injury
	Pelvic Fractures Management Principles what most important initial action	*Implementation of immobilization and splinting –Control blood loss –Preserve current neurovascular/motor functions –Prevents further injury –Restores neurovascular and lymphatic functions –Reduces soft tissue injury –Decreases pain
	Pelvic Fractures Management Principles •Immobilization/Splinting –Angulated fractures	• splinting in position found •Reassess neurovascular status frequently
	Pelvic Fractures Management Principles •Immobilization/Splinting –Pelvic ring disruptions	•Minimize further neurovascular injury •Caution with movement •Consider PASG (MAST) •Creative techniques •Use of C clamp or external fixator
	Pelvic Fractures Splinting Devices	•Thomas ring / Hare traction-femur / Sager traction devices-2 legs •Air splints •Vacuum splints •Pre-molded splints •Rigid padded object
	Pelvic Fractures Splinting Precautions	•Tissue ischemia –Splint too constrictive –Increased swelling after splint applied –Environmental changes and air splints •Pressure changes •Flight physiology principles
	Pelvic Fracture Splinting	•PASG: Pneumatic Anti-Shock Garment –First-aid used to treat hypovolemic shock –Contraindications-no with prego, brain/head injury(inc pressure)
	General Management •Principles and Complications	–Hypovolemia –Infection-pin care –Neurologic and vascular compromise –Pain management –Fat embolism–Pulmonary thromboembolism –Deep vein thrombosis –Crush syndrome
	Neurovascular Compromise	DEC Blood flow -dec tissue perfusion= ischemia= No oxygen delivered to the cells inc Capillary permeability=Edema inc pressure= No Oxygen= Cellular death within 6-8 hours= Irreversible damage locally and distally
	Neurovascular Compromise SIGNS	•Dislocations •Fractures •Pelvic injury •Brachial plexus injury •Reflex sympathetic dystrophy •Lumbosacral plexus injury •Compartment syndrome •Fat embolism syndrome •Deep vein thrombosis •Pulmonary thromboembolism •Crush syndrome
	_________- may be caused by any MS injury.	Neurovascular Compromise
	Neurovascular Compromise •Dislocations WITH_____=HIGH RISK	–Close proximity of nerves and blood vessels to the joint
	–Orthopedic emergency WHEN	•Bone is impinging on a vessel or nerve •Elbow, knee, and hip joints –Neurovascular compromise may lead to permanent injury if dislocation not reduced promptly
	Neurovascular Compromise •Fractures –Nerve or blood vessels are:	•Actually lacerated by bone fragments •Compressed from bone ends •Squeezed by edematous soft tissue •Stretched by disrupted bone fragments
	Neurovascular Compromise Pelvic injuries	–Disruption in bone or ligament
	Pelvic injuries •Can result in major source of _____ what to do	hemorrhage –Pelvis has a rich vascular supply GYN for female aggressive fluid/blood replacement
	Pelvic injuries •Pelvic ligament disruption tears and stretches nerves and nerve roots	–Lumbosacral plexus innervates pelvis and lower extremities, commonly injured
	Pelvic injuries –___________commonly lacerated IN Pelvic hemmor	Internal iliac artery
	Compartment Syndrome •Definition	Compartments are closed spaces containing muscle, nerves and vascular structures that are enclosed by fascia.
	-_______________ most commonly affected by compartment syndrome	•Lower leg and forearm
	Compartment Syndrome results when either	the internal contents or external sources cause an increase in compartment pressure to the point that microvascular circulation is compromised. This leads to ischemia of the muscle tissue.
	Compartment Syndrome •External causes	–Splints –Dressings –Positioning –Excessive skeletal traction –Eschar from burns
	Compartment Syndrome signs	• Formation of edema
	It is a misconception that _____ fractures cannot develop compartment syndrome.	open
	• Pressure > 30 – 40 mm Hg results in	muscle ischemia
	• Pressure > 55 – 65 mm Hg results in	irreversible muscle death 30 +
	know Compartment Syndrome •Signs and Symptoms	–Decrease two point discrimination –Localized, throbbing pain* •Disproportionate to actual injury •Unrelieved by narcotics* –Firm / taut / hard
	know Compartment Syndrome •Late Signs and Symptoms	–Paresthesia –Pulselessness –Paralysis
	Compartment Syndrome Neurovascular Compromise •Management	–Monitor for changes •Pulse quality •Edema •Skin color •Altered motor/sensory function –Appropriate splinting and positioning –Realignment of fractures; reduction dislocations –Maintain extremity in nondependent position but not above the level of the heart –Cooling –Pain management
	Compartment Syndrome Pain Management	•Immobilization / stabilization •Reduction •Administration of cooled packs •Narcotics •Muscle relaxants
	Deep Vein Thrombosis •Predisposing factors –Virchow’s triad	•Venous Stasis •Vascular Damage or Pathologic State •Hypercoagulability
	Deep Vein Thrombosis •Assessment	–Calf pain •“Homan’s sign” –Edema to area involved –Tachycardia –Fever –Skin color / temperature changes
	Deep Vein Thrombosis •Diagnostic studies	–Venograms –Doppler flow studies –Venous pressure measurement –Impedence plethysmography –Plasma D-dimer studies –MRI –CT
	Deep Vein Thrombosis •Prevention	–Early mobilization –Isometric exercises –Range of motion –Frequent change in position –Elastic stockings –Compression devices –Anticoagulation
	Deep Vein Thrombosis •Management of DVT	–Bedrest –Anticoagulation –Thrombolysis –Surgery
	Pulmonary Thromboembolism PTE def	Blood clot that is dislodged from a deep peripheral vein that circulates through the body to the right chambers of the heart and lodges in the pulmonary artery system.
	Pulmonary Thromboembolism •Assessment	–Sudden dyspnea or Shortness of breath –Substernal chest pain –Shock –Rapid shallow respirations –Pale, dusky, or cyanotic color –Bronchial breath sounds, crackles and pleural friction rub –Anxiety: “Feeling of impending doom” –Altered level of consciousness –Low grade fever
	Pulmonary Thromboembolism •Diagnostic studies	–ABGs –Labs •CBC, enzymes –Echocardiogram –CXR –Lung Scans (Ventilation-Perfusion) –CT scan –Pulmonary angiogram
	Pulmonary Thromboembolism •Management	–Oxygen therapy –Pulmonary care –Endotracheal intubation –Mechanical ventilation –Positioning –Pain control –Inotropic agents –Anticoagulation –Pulmonary embolectomy –Vena caval filter
	COMPARTMENT syndrome internal causes	–Increased volume –Increased capillary filtration –Trauma compressing or crushing mechanism –Open / closed fractures –Soft tissue / vascular Injury –Burns –Prolonged shock –Bleeding disorders –Contusions
	Crush Syndrome know •Rhabdomyolysis why? risk?	–Release of myoglobin and potassium –Acute tubular necrosis –Elevated potassium levels •Cardiac dysrhythmias •Cardiac arrest
	Critical Care Phase •Prevention	–Infection –Compartment syndrome –Fat embolism –Immobility related injuries
	Critical Care Phase •Predisposing factors for infection	–Devitalized muscle tissue –Dead space –Hematomas –Foreign bodies –Age –Nutritional status –Hemodynamic state –Pulmonary function –Co-morbidities
	Critical Care Phase •Recognition of infection	–Trends in vital signs/temperature –Labs •CBC w/diff and electrolytes –Wound site appearance/drainage •Amount –Consistency •Color •Odor
	Critical Care Phase •Management –Wound Care	•Irrigation and debridement •Wet to dry vs wet to wet dressings •Drainage of hematomas –JP drain; hemovac –Decrease risk of bacterial growth –Draining and reactivating suction •Pin site care •Antibiotic therapy
	Critical Care Phase •Management –Compartment syndrome	•Close monitoring of neurovascular status –Pulses •Location, strength, quality –Cap refill –Temperature –Skin color –Motor-sensory function –Immobilization/stabilization devices •Maintain extremity in nondependent position but not above the level of the heart •Cool packs to extremity
	Critical Care Phase •Management –Immobility related complications	•Muscle atrophy •Pulmonary complications •Vascular stasis •Skin breakdown •Fecal impaction •Renal calculi •Muscle wasting •Contractures
	Critical Care Phase •Complication preventive measures during immobility	–Chest physiotherapy –Frequent repositioning of patient •Specialized beds –Bowel regimens –Nutritional support –Adequate fluid intake –Range of motion exercises –Splinting to prevent contractures
	Intermediate Phase and Rehabilitation •Factors affecting bone healing dont know	Severity of fracture –Amount of bone or soft tissue loss –Loss of periosteum –Excessive motion at fracture site –Poor nutritional status –Smoking –Improper weight bearing –Decreased vascular supply
	no know Intermediate Phase and Rehabilitation •Grafting	–Bone grafting •Can decrease fracture healing time –Soft tissue grafting •Wound must be free of infection and devitalized tissue
	Intermediate Phase and Rehabilitation •Complications During Recovery –Mechanical failure of fixators	•Loosened components of external fixator device •Metal fatigue of the internal fixator device
	Intermediate Phase and Rehabilitation •Complications During Recovery –Impaired mobility	•Psychologically and physically devastating •Amputations •Extremity fractures •Pelvic fractures •Plexis injuries
	Intermediate Phase and Rehabilitation •Complications During Recovery –Chronic pain •Types of chronic pain	–Nociception –Central pain –Psychologic pain –Behavioral pain –Combination of all four •Treatment requires behavioral, psychological and analgesic therapy
	Patient and Family Education •Discharge preparation addresses	–Aseptic technique –Pin care –Dressing changes –Identification of infection –Weight bearing restrictions –Assistive devices –Follow-up appointments, contacts
	Crush Syndrome •Prolonged compression of body part patho	–Ischemia of muscle tissue –Third spacing of fluids –Edema –Increased compartment pressures –Impaired tissue perfusion –Neurovascular compromise –Infection

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