Chapter 63: Nursing Management: Musculoskeletal Trauma and Orthopedic Surgery The most common cause of musculoskeletal injuries is a traumatic event resulting in fracture, dislocation, and associated soft tissue injuries. Nurses have an important role in public education about the basic principles of safety and accident prevention. SOFT-TISSUE INJURIES: A sprain is an injury to tendinoligamentous structures surrounding a joint, usually caused by wrenching or twisting motion. A strain is an excessive stretching of a muscle and its fascial sheath. It often involves the tendon. Symptoms of sprains and strains are similar and include pain, edema, decrease in function, and contusion. Mild sprains and strains are usually self-limiting, with full function returning within 3 to 6 weeks. Severe strains may require surgical suturing of muscle and surrounding fascia. RICE (rest, ice, compression, elevation) can decrease inflammation and pain for most of these injuries. Stretching and warm-up prior to exercising and before vigorous activity significantly reduces sprains and strains. DISLOCATION: Dislocation is a severe injury of the ligamentous structures that surround a joint. The most obvious sign is deformity, also local pain, tenderness, loss of function of injured part, and swelling of soft tissues in joint region. Requires prompt attention with the dislocated joint first realigned in its original anatomic position. Extremity then is immobilized by bracing, taping, or using a sling to allow torn ligaments and tissue time to heal. SUBLUXATION Subluxation is a partial or incomplete displacement of the joint surface. Manifestations are similar to a dislocation but are less severe. Treatment is similar to a dislocation, but subluxation may require less healing time. Nursing care of subluxation or dislocation is directed toward pain relief and support and protection of injured joint. REPETITIVE STRAIN INJURY: Repetitive strain injury (RSI) is a cumulative traumatic disorder resulting from prolonged, forceful, or awkward movements. RSI can be prevented through education and ergonomics. Treatment includes identifying the precipitating activity, modification of activity, pain management with heat/cold application, drugs, rest, physical therapy for strengthening and conditioning, and lifestyle changes. CARPAL TUNNEL SYNDROME: Carpal tunnel syndrome (CTS) is caused by compression of the median nerve, which enters the hand through the narrow confines of the carpal tunnel. CTS is often caused by pressure from trauma or edema caused by inflammation of tendon (tenosynovitis), rheumatoid arthritis, or soft tissue masses. Signs are weakness (especially in thumb), burning pain, and numbness. Holding the wrists for 60 seconds produces tingling and numbness over the distribution of the median nerve, a positive Phalen’s test. Prevention involves educating employees and employers to identify risk factors. Early symptoms usually relieved by stopping the aggravating movement and by placing hand and wrist at rest by immobilizing them in a hand splint. Injection of a corticosteroid drug directly into carpal tunnel may provide some relief. If CTS continues, median nerve may need to be surgically decompressed. Rehabilitation can last up to 7 weeks. ROTATOR CUFF INJURY: Rotator cuff injury may occur gradually from aging, repetitive stress, or injury to the shoulder while falling. Manifestations include shoulder weakness and pain and decreased range of motion. Conservative treatment involves rest, ice and heat, NSAIDs, corticosteroid injections into joint, and physical therapy. Surgery may be done with complete tear or no improvement with conservative therapy. MENISCUS INJURIES: Meniscus injuries are associated with ligament sprains that commonly occur in athletes. Pain is elicited by flexion, internal rotation, and then knee extension. Surgery may be indicated for a torn meniscus. Proper stretching may make the patient less prone to meniscal injury when a fall or twisting occurs. BURSITIS: Bursitis results from repeated or excessive trauma or friction, rheumatoid arthritis, or infection. Manifestations are warmth, pain, swelling, and limited ROM in the affected part. Rest is often the only treatment needed for bursitis. FRACTURE: Fracture is a disruption or break in the continuity of the bone structure. Traumatic injuries account for the majority of fractures. Fractures are often described according to 1) type, 2) communication or noncommunication with the external environment, and 3) anatomic location. Signs include immediate localized pain, decreased function, and inability to bear weight or use affected part. Obvious bone deformity may not be present. Fractures require nursing assessments of the peripheral vasculature (color, temperature, capillary refill, peripheral pulses, and edema) and neurologic systems (sensation, motor function, and pain). Treatment goals are anatomic realignment of bone fragments, immobilization to maintain realignment, and restoration of function. Lower extremity injuries are often immobilized by casts, dressings, or splints/immobilizers. The majority of fractures heal without complications, which include bone infection, avascular necrosis, compartment syndrome, venous thrombosis, fat embolism, and shock. Nursing care involves comfort measures for pain, maintenance of nutrition, and prevention of complications associated with immobility. A Colles’ fracture is a fracture of the distal radius. Usually managed by closed manipulation, by immobilization by splint or a cast, or, if displaced, by internal or external fixation. Fractures involving the shaft of the humerus are a common injury among young and middle-aged adults. If surgery is done, skin or skeletal traction may be used for reduction and immobilization. Pelvic fractures range from benign to life threatening depending on mechanism of injury and associated vascular insult. Physical examination demonstrates local swelling, tenderness, deformity, unusual pelvic movement, and ecchymosis on abdomen. Treatment depends on the injury severity and ranges from limited intervention to pelvic sling traction, hip spica casts, external fixation, and open reduction. HIP FRACTURES: Hip fractures are common in older adults. Manifestations are external rotation, muscle spasm, shortening of affected extremity, and severe pain in region of fracture. Surgical repair is preferred for managing intracapsular and extracapsular fractures. After surgery—in addition to teaching on how to prevent prosthesis dislocation—the nurse should place a large pillow between patient’s legs when turning, avoid extreme hip flexion, and avoid turning the patient on affected side until approved by surgeon. The nurse assists both the patient and family in adjusting to restrictions and dependence imposed by hip fracture. AMPUTATION: Older persons have the highest incidence of amputation due to effects of peripheral vascular disease, atherosclerosis, and diabetes. Indications for amputation include circulatory impairment resulting from a peripheral vascular disorder, traumatic and thermal injuries, malignant tumors, and infection of the extremity. Goal of surgery is to preserve extremity length and function while removing all infected, pathologic, or ischemic tissue. Goals for the nurse are that the patient will have pain relief from the underlying health problem, satisfactory pain control, maximum rehabilitation potential, and ability to cope with the body image changes. JOINT REPLACEMENT SURGERY: Joint replacement surgery is the most common orthopedic operation performed on older adults. Surgery is aimed at relieving pain, improving joint motion, correcting deformity and malalignment, and removing intraarticular causes of erosion. Types of joint surgeries include synovectomy, osteotomy, debridement, and arthroplasty. Arthrodesis is the surgical joint fusion which may be done if articular surfaces are too damaged or infected to allow joint replacement or for reconstructive surgery failures. Postoperatively, neurovascular assessment is performed to assess nerve function and circulatory status. Anticoagulation therapy, analgesia, and antibiotics are administered. Ambulation is encouraged as early as possible to prevent immobility complications. Patient discharge teaching includes instructions on reporting complications, including infection and dislocation of the prosthesis (e.g., pain, loss of function, shortening or malalignment of an extremity). Chapter 64: Nursing Management: Musculoskeletal Problems OSTEOMYELITIS: Osteomyelitis is a severe infection of bone, bone marrow, and surrounding soft tissue. Infecting microorganisms can invade by indirect or direct entry. After entering the blood, they lodge in an area of bone and grow which results in increased pressure, eventually leading to bone ischemia. Once ischemia occurs, the bone dies. Chronic osteomyelitis is a continuous, persistent problem or a process of exacerbations and remission. Acute symptoms are fever, night sweats, malaise, and constant bone pain. Some immobilization of affected limb (e.g., splint, traction) is indicated to decrease pain. The patient is frequently on bed rest in the early stages of the acute infection. Vigorous and prolonged IV antibiotic therapy is treatment of choice for acute osteomyelitis. Oral antibiotics, hyperbaric oxygen therapy, and surgery may be prescribed for chronic disease. SARCOMA: Most primary bone cancer is called sarcoma. Sarcomas can also develop in cartilage, muscle fibers, fatty tissue, and nerve tissue. Common types are osteogenic sarcoma, chondrosarcoma, Ewing’s sarcoma, and chordoma. Osteochondroma: Osteochondroma is a primary benign bone tumor characterized by overgrowth of cartilage and bone near end of the bone at the growth plate. Manifestations include painless, hard, and immobile mass, one leg or arm longer than other, and pressure or irritation with exercise. No treatment necessary if asymptomatic. If patient has pain or neurologic symptoms due to compression, surgical resection is usually done. Nursing care does not differ significantly from the care given to patients with a malignant disease of any other body system. Osteogenic Sarcoma: Osteogenic sarcoma (osteosarcoma) is a primary bone tumor that is extremely aggressive and rapidly metastasizes to distant sites. Manifestations are usually associated with gradual onset of pain and swelling, especially around the knee. Preoperative (neoadjuvant) chemotherapy is used to decrease tumor size. Limb-salvage procedures are considered when there is a clear 6- to 7-cm margin surrounding the lesion. Metastatic Bone Cancer: The most common type of malignant bone tumor occurs as a result of metastasis from a primary tumor. Metastatic bone lesion is commonly found in vertebrae, pelvis, femur, humerus, or ribs. Metastasis to bone may be suspected in patients with local bone pain and past cancer history. Treatment may be palliative and consists of radiation and pain management. LOW BACK PAIN: Low back pain is common, affecting about 80% of adults during their lifetime. Acute low back pain is usually associated with activity that causes undue stress (often hyperflexion) on the lower back. If muscle spasms and pain are not severe, treatment includes avoiding activities that aggravate pain, analgesics, muscle relaxants, massage and back manipulation; and heat and cold compresses. Most acute cases spontaneously improve. Chronic low back pain causes include degenerative disk disease, lack of physical exercise, prior injury, obesity, and structural and postural abnormalities. Treatment can include weight reduction, analgesics, rest periods, heat or cold application, and exercise and activity to keep muscles and joints mobilized. Surgery may be indicated for severe chronic low back pain that is not responding to conservative care. INTERVERTEBRAL LUMBAR DISK DAMAGE: Structural degeneration of the lumbar disk is often caused by degenerative disk disease (DDD). This is a normal process of aging, and results in intervertebral disks losing their elasticity, flexibility, and shock-absorbing capabilities. An acute herniated intervertebral disk (slipped disk) can be the result of DDD or repeated stress and spinal trauma. Radicular pain, which radiates down buttock and below the knee, generally indicates disk herniation. Treatment initially is at least 4 weeks of conservative therapy including drug therapy, limitation of spinal movement with brace or corset, local heat or ice, ultrasound and massage, transcutaneous electrical nerve stimulation, and epidural steroid injections. If there is no improvement, various surgical techniques may be used. Postoperative nursing interventions focus on maintaining proper alignment of the spine at all times until healing has occurred. Once symptoms subside, back strengthening exercises are begun twice a day and encouraged for a lifetime. FOOT DISORDERS: Most of the pain and disability is attributed to improperly fitting shoes, which cause toe crowding and inhibition of normal foot muscle movement. The older adult is prone to foot problems because of poor circulation, atherosclerosis, and decreased sensation in lower extremities. Therapy includes analgesics, shock-wave therapy, icing, physical therapy, alterations in footwear, stretching, warm soaks, orthotics, ultrasound, and corticosteroid injections. If there is no relief, then surgery may be done. OSTEOMALACIA: Osteomalacia is a rare condition of adult bone associated with vitamin D deficiency, resulting in decalcification and softening of bone. Common features are localized bone pain, difficulty rising from a chair, and walking. Care is directed toward correction of vitamin D deficiency. Vitamin D3 (cholecalciferol) and vitamin D2 (ergocalciferol) can be supplemented. Calcium salts or phosphorus supplements may also be prescribed. Exposure to sunlight (and ultraviolet rays) is also valuable, along with weight-bearing exercise. OSTEOPOROSIS: Osteoporosis is a chronic, progressive metabolic bone disease characterized by low bone mass and structural deterioration of bone tissue. Bones can eventually become so fragile that they cannot withstand normal mechanical stress. At least 10 million persons in the United States (80% are women) have osteoporosis. Risk factors are female sex, increasing age, family history of osteoporosis, white or Asian race, small stature, early menopause, sedentary lifestyle, and insufficient dietary calcium. People may not know they have osteoporosis until their bones become so weak that a sudden fall causes a hip or vertebral fracture. Collapsed vertebrae may initially be manifested as back pain, loss of height, or spinal deformities such as kyphosis or severely stooped posture. Dual-energy x-ray absorptiometry (DEXA) studies are used in diagnosis and to assess the treatment effectiveness. Collaborative care focuses on proper nutrition, calcium supplementation, exercise, prevention of fractures, and drugs. PAGET’S DISEASE: Paget’s disease is a skeletal bone disorder in which there is excessive bone resorption followed by replacement of normal marrow by vascular, fibrous connective tissue. The etiology is unknown, although a viral cause has been proposed. Initial manifestations are usually insidious development of bone pain (may progress to severe intractable pain), fatigue, and progressive development of a waddling gait. Pathologic fracture is the most common complication. X-rays may demonstrate that the normal contour of the affected bone is curved and the cortex is thickened and irregular. Care is usually limited to symptomatic and supportive care and correction of secondary deformities by either surgical intervention or braces. GERONTOLOGIC CONSIDERATIONS: METABOLIC BONE DISEASES: Metabolic bone diseases increase the possibility of pathologic fractures. The nurse must use extreme caution when patient is turned or moved. It is important to keep the patient as active as possible to retard demineralization of bone resulting from disuse or extended immobilization.