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Ch.

42 Injuries

Muscloskeletal trauma occurs when the tissues are subjected to more force than they are able to
absorb. Soft tissue trauma is a common injury. The most common area for muscle strain is lower
back. The ankle is the most commonly sprained joint.

Contusion - is bleeding into soft tissue - also a bruise with soft swelling underneath it, where
there is blood underneath the tissues.

With some significant bruising you can have a hematoma develop, which is a huge clot that can
impair and compromise surrounding tissue.

Sprain -a ligament injury. A twisting motion that overstretches or tears the ligament. Graded
according to the extent of the damage. Grade 1 to grade 4. Grade 1 - overstretching of the
ligament with bleeding and inflammation. Grade 4 being where the bony attachment of the
ligament is broken away.

Strain - A microscopic tear in the muscle that causes bleeding into the tissues. A strain is less
severe than a sprain. A sprain is more traumatic, a strain is more of an annoyance injury.

Comparison of the two

A strain is a tear, local swelling, tenderness, sharp or dull pain, increased pain with muscle
contraction. Sprain - typically a ligament injury, with joint instability. Pain, swelling, discoloration,
and increased pain with joint use. If you flex the muscle and feel pain, it could just be a strain,
but if you flex a joint or twist your wrist and feel pain, it could be a sprain.

Treatment

Care for both is the same - use RICE. Rest, Ice, Compression, Elevation. Complications include
weakness of the area, tingling, numbness that can occur as swelling compromises the
surrounding tissues and nerves, inability to move distal to the injury. Similar to compartment
syndrome. Also assess circulatory status.

Fractures - break in the continuity of the bone. May result from a crushing force, which is known
as compression, Torsion (a twisting motion), a severe muscle contraction, a direct blow, or a
disease process (known as a pathological fracture). With fractures, there is a deformity not seen
with sprains or strains. You will see a deformity in the extremity.

Different types of fractures

Closed or simple fracture - the most common type.


Open or complex fracture - the skin is disrupted over the fracture.

Complete fracture - involves the entire width of the bone.

Incomplete fracture - only part of the bone is broken. It doesn't go all the way through.

Stable fracture - the bone is still aligned

Unstable - bone is out of alignment

The direction of the fracture is also used in classification, such as:

Oblique - a 45 degree angle

Spiral - spirals along the bone

Greenstick - along the lengthwise plane of the bone.

Healing

When a bone fractures, blood vessels tear and a hematoma forms between the fractured ends
and the bone surfaces. Bone and tissue damage cause a localized inflammatory response. Within
48 hours grannulation tissue is being formed and the hematoma begins to dissolve. Osteoblasts
promote new bone growth and osteoclasts remove the damage and excess bone. This process
continues for up to 2-3 months until everything is completely reformed.

Complications

Soft tissue injuries - a large amount of blood can be lost from a pelvis or femur fracture. Open
fractures can be complicated by infection or damaged nerve fibers. Circulation to the affected
bone may be impaired, causing necrosis. DVTs - which are clots in the extemities.

Compartment Syndrome occurs when pressure within one or more of the muscle compartments
compromises circulation, resulting in an ischemia-edema cycle. Capillaries dilate in an attempt to
pull oxygen into the tissue. However, increased capillary permability leads to edema from plasma
proteins leaking into the interstitial fluid space. Increased edema causes pressure on the nerve
endings, resulting in pain. Blood flow is further reduced and ischemia persists, resulting in
compromised neurovascular status. It may be caused by bleeding, edema, or external
compression. Nerve damage can occur within 30 minutes. Unless it's relieved, Compartment
Syndrome may lead to loss of the limb and sepsis. Develops within first 48 hours of injury.

Treatment consists of removing the compression source or a surgical procedure. So if a cast were
creating compartment syndrome they would remove the cast. If it were a burn, an escharotomy
or fasciotomy would be done.

Fat Embolism - occurs within 48 hours of a long bone fracture. Fat globules are released into the
vasculature of the bone marrow. They travel to the small blood vessels, resulting in acute
respiratory insufficiency. Symptoms are low O2 sat, changes in mental status, respiratory
distress, tachycardia, tachypnea, and fever. When a patient is having trouble breathing, they get
into a frantic panic mode. They have a combative, aggressive stance. That's one of the first signs
that something is wrong.

Cutaneous petechiae - associated only with fat embolus. These are pinpoint size subdural
hemorrhages that occur on the chest, neck, upper arms, and abdomen. Again, only with fat
emboli. Treatment includes oxygen for respiratory compromise, corticosteroids for edema,
vasopressers and fluid replacement for shock, as well as pain and antianxiety meds.

DVT (deep vein thrombosis) - formation of a blood clot within a large vein. It is the most
common complication following trauma, surgery, or disability related to immobility. Symptoms
include swelling, leg pain, tenderness or cramping. Clots can break loose and become emboli,
and then you'll have the same respiratory distress symptoms.

Delayed union - failure to heal within the expected time frame. This may be because it's not
healing correctly or not healing at all. This may cause pain and deformity. There's many different
reasons for this. Chronic disorders such as diabetes, where they are at risk for poor wound
healing.

Interventions/Emergency Care

The joints above and below the suspected fracture are typically immobilized. Pulses, color,
movement, and sensation of the extremity are checked before and after splinting. A reduction
may be necessary. The fracture must be reduced which means restored to its normal alignment.
A closed fracture requires external manipulation so for a patient with a broken leg, someone
would stabilize the leg above the break, somebody else would grab the foot. They may sedate
the patient. They would pull back on the foot and try to align that bone back into a stable
position. They may do conscious sedation or do a local anesthetic. With an open fracture that's
poking through the skin, that requires surgery. Afterward it would be immobilized.
Immobilization occurs many different ways.

Cast - rigid device used to immobilize broken bones and promote healing. A plaster or fiberglass
material is used over a thin padding. Observe for swelling, as it can lead to compartment
syndrome. If this occurs we have to cut the cast open and use velcro straps to keep it semi-
closed. Read over casts in both books.

Casting

Remember to educate the patient on what to do to keep it dry, if it is itching. Remember when
placing a cast you can't touch it with the tips of your fingers because you may make impressions.
That can cause increased pressure in certain areas, which could lead to compartment syndrome.

Traction - Muscle spasms can pull bone out of alignment after a fracture. Traction applies a
pulling force to return or maintain fractured bones to a normal position.
Manual traction - manually pullin on extremities, such as a reduction.

Skin traction - Pulling force is applied to the skin. Used intermittently.

Skeletal traction - Continuous force is applied directly to the bone. Pins are placed through the
skin. When performing skin care, one book says don't remove the crusting as it provides a
natural barrier. Another book says remove it, so what I'm going to say is follow policy according
to the facility where you work.

Halo - circles the head. A device that keeps the head in alignment with the spine. Make sure they
have a wrench readily available to release in case of nausea and vomiting.

Running traction or straight traction - The counter traction is provided by the client's body. These
are slings or splints.

Surgery may also be required to align and stabilize a fractured bone.

External fixation - simplest form of surgery. A frame is connected to pins that are inserted into
the bone.

Internal fixation/open reduction - they open up the area to visualize it, place pins directly under
the skin.

May also use analgesics, NSAIDS, stool softeners, antibiotics, muscle relaxants to provide care.

Hip Fracture - A break at the head, neck, or trochanteric regions of the femur. Fractures of the
head or neck are called intracapsular fractures. Extracapsular fractures occur in the trochanteric
region. There is an increased risk for poor healing with avascular necrosis when there are
fractures to the head or neck due to impaired blood supply. If the head or neck of the hip is
broken off, you can lose blood supply to the area and cause necrotic bone.

The increased number of fractures that occur in the older population are typically due to
decreased bone mass, decreased bone strength, slowed reflexes, or medications that affect
cognition and balance. Hip replacement procedure is done after a fracture to promote mobility,
decrease pain, and prevent complications. Some patients with fractures of the femoral head or
neck may also need prosthetics, which would be done in an orthoplasty procedure, where they
replace the hip. A total hip may be necessary if both the femoral head and hip socket must be
replaced.

Assess the color, temperature, movement, and sensation of the affected leg. Also report
shortening or internal rotation of the affected leg, as this can indicate dislocation.

Joint injuries

Joints are typically the weakest part of the skeleton. They can be damaged or injured in many
ways.
Dislocation - a separation of contact between two bones of a joint. The two types are:

Traumatic dislocation - usually via trauma.

Spontaneous dislocation - through a disease process.

Patient will have pain, change in the shape of the joint, and/or change in length of the extremity.

Manual traction may be used to reduce dislocation. They may need conscious sedation,
analgesics, muscle relaxants. Treatment consists of traction and RICE (rest, ice, compression,
elevation.)

Repetitive use injuries result from overuse or repeated stress on a joint, such as carpal tunnel
syndrome. This comes from frequent manipulation of the hands. Results from inflammation and
swelling in the structures of the wrist joint. The patient will experience numbness and tingling of
the thumb, index and middle finger. The hand is stated to fall asleep at night.

Bursitis - the bursa (pad-like sac that prevents friction between tissues) becomes inflammed,
causing tenderness and pain with joint movement.

Epicondylitis - inflammation of the tendon where it inserts into the bone. They will have joint
tenderness and pain radiating down the forearm.

Initial treatment is rest and immobilization with ice for the first 48 hours and heat every 4 hours.
NSAIDS or corticosteroids are also used.

Rotator cuff injuries - a group of muscles taht control arm movement. These disorders include
tendonitis, bursitis, and partial or complete muscle tears. Use rest, NSAIDS, physical therapy,
heat, or surgery.

Knee injuries - twisting of the knee joint. Use RICE, compression, restricted weight bearing, and
sometimes physical therapy.

Amputation - removal of a body part. PVD - peripheral Vascular Disease - is the primary reason
or cause of lower extremity amputations. Circulation is impaired to the lower extremities and
they become ischemic.

Trauma is the main cause of upper extremity amputation. Impaired blood flow and untreated
infection leads to gangrene which results in amputation. The level of amputation is determined
by the extent of tissue damage. BKA - below the knee, AKA - above the knee. Patients may use
prosthetics or compression dressings after surgery to control bleeding and edema. Potential
complications are infection, contractures, or phantom limb pain.

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