|Mean LOS:||8.5 days|
|Description:||SURGICAL: Hip and Femur Procedures, Except Major Joint With Major CC|
|Mean LOS:||5.6 days|
|Description:||SURGICAL: Major Shoulder or Elbow Joint Procedure With CC or Major CC|
|Mean LOS:||5.7 days|
|Description:||MEDICAL: Fracture, Sprain, Strain, and Dislocation Except Femur, Hip, Pelvis, and Thigh With Major CC|
The bony skeleton provides the supporting framework for the human body. Its 206 bones are subject to many stressors, which may result in fractures. Fractures vary in complexity and potential harm to the body. Simple fractures occur with no break from the bone to the outside of the body, whereas compound fractures have an external wound, thus creating contamination of the fracture. Complete fractures occur when bone continuity is completely interrupted, whereas partial fractures (incomplete) interrupt only a portion of bone continuity. Fractures can be classified by fragment position or fracture line (Table 1).
|Fragment position||Angulated||Bone fragments are at an angle to each other|
|Avulsed||Bone fragments are pulled from normal position by muscle spasms, muscle contractions, or ligament resistance|
|Comminuted||Bone breaks into many small pieces|
|Displaced||Bone fragments separate and are deformed|
|Impacted||A bone fragment is forced into another bone or bone fragment|
|Nondisplaced||After the fracture, two sections of the bone maintain normal alignment|
|Overriding||Bone fragments overlap, thereby shortening the total length of the bone|
|Segmental||Bone fractures occur in two areas next to each other with an isolated section in the center|
|Fracture line||Linear||Fracture line is parallel to the axis of the bone|
|Longitudinal||Fracture line extends longitudinally but not parallel to the axis of the bone|
|Oblique||Fracture line crosses the bone at a 45-degree angle to the axis of the bone|
|Spiral||Fracture line coils around the bone|
|Transverse||Fracture line forms a 90-degree angle to the axis of the bone|
Alcohol consumption is an important cofactor when it is associated with trauma. Acute alcohol intoxication may compound a head or musculoskeletal injury by masking the effects of pain and immobility. In addition, it may modify the patient’s ability to tolerate multiple traumas by having a direct cardiodepressant effect. Profound hypotension and bradycardia may result from acute blood loss in the patient with musculoskeletal injury who has been drinking heavily.
Many complications can occur as a result of musculoskeletal trauma. Arterial damage and bleeding can lead to hypovolemic shock. Nonunion of bones, avascular necrosis, bone necrosis, and peripheral nerve damage can lead to lasting deformities and disabilities. Rhabdomyolysis (destruction of skeletal muscle) can lead to renal failure, and bone injury can lead to fat emboli. Infection is the most common complication of trauma and can lead to sepsis and septic shock.
Traumatic injuries can be intentional (assaults, gunshot wounds, stab wounds) or unintentional (falls, motor vehicle crashes [MVCs]). Multiple traumas that result from an MVC often involve several systems of the body and musculoskeletal injury. Falls and MVCs account for a high percentage of the fractures seen today. Children at play take falls as a matter of course and only occasionally suffer fractures. Their most common fractures are of the clavicle. Adults who fall more often fracture a hip or wrist. Osteoporosis increases the likelihood of fractures from a fall; it even sometimes causes a fracture from a slight shift in the body’s position, which then results in a fall, rather than the reverse.
There are no known genetic considerations.
Gender, ethnic/racial, and life span considerations
Multiple musculoskeletal traumas can occur at any time in life—no one is exempt. However, young adults are most at risk. MVCs are the leading cause of death for those ages 4 to 34. Serious industrial accidents are more common in young men, and multiple injuries from falls are especially a problem in older women.
Fractures occur at all ages, with their incidence increasing with age. Osteoporosis, which occurs in many women past menopause and in men somewhat later in life, accounts for the vulnerability to fractures of those past midlife. Fractures in elderly people are often of the wrist, hip, and vertebrae. Healing occurs much more rapidly in the young, and the elderly are more at risk for complications of immobility from both the fracture and its treatment. The high death rate of the elderly within a year after a broken hip is largely from complications of immobility. There are no known racial or ethnic considerations.
Global health considerations
Internationally, falls from heights of less than 5 meters are the leading cause of injury overall, and MVCs are the next most frequent cause. MVCs are the ninth leading cause of death globally. Muscular skeletal injury often results from both falls and MVC.
Determine the details of the immediate injury. Question the patient if possible, relatives if present, and any witnesses, including bystanders, the police, and the life squad. Note that the obvious injuries may not be the most serious ones. For example, a leg injury may be evident, whereas the pelvic fracture caused by force to the knee or leg during a car crash may be more serious. Obtain information from family or friends about the usual health status. Determine the past medical history, with particular attention to life span considerations such as pregnancy, chronic diseases such as diabetes and hypertension, and patterns of substance abuse.
Common symptoms are pain, angulation (bone fractures are at an angle to each other), shortening or deformation of limbs, open wounds, bleeding from wounds or into tissues (ecchymosis), swelling, and muscle spasms. In the immediate trauma resuscitation, assessment and treatment are merged. Always of first priority is the assessment and management of airway, breathing, and circulation (ABCs). Neurological status becomes part of that initial assessment, because the patient is often in a compromised state of consciousness. Monitor the vital signs every 15 minutes or more often until the patient is stabilized. The patient may demonstrate a wide range of blood pressures and heart rates depending on age, degree of blood loss, baseline vital signs, and degree of alcohol intoxication.
During the physical examination, handle the patient carefully and be aware that any fractures can be made more serious by the manipulation caused by examination. If the cervical spine is injured, movement can lead to lifelong disability. Broken ribs may not initially pose a serious problem for the patient, but with rough handling, they may become displaced and cause damage to the pleura and lungs. Manipulation of broken bones also causes increased pain and blood loss. Inspect the patient thoroughly for evidence of fractures, including angulation or shortening of limbs, open wounds, and changes in color from the rest of the body. Note any swelling or muscle spasms of the limbs, which may indicate injuries not apparent initially. Palpate any areas suspected of injury, noting the contour of surrounding bones. Check the range of motion of all joints, listening for crepitus and noting any signs of pain from the patient during the examination, but do not move an obviously injured extremity to test for range of motion. Complete a neurovascular examination, checking pulses, capillary refill, and response to sharp and dull pain stimuli.
The patient with serious musculoskeletal injury is usually seen in the emergency department and is often in hypovolemic shock. As the patient becomes conscious, the effect of the trauma may be overwhelming; alternatively, the patient may have no memory of the trauma and be distraught to find herself or himself in the hospital. The older patient who has fallen and suffered a broken hip often becomes confused from the trauma. As the situation becomes clearer, the fear of hospitalization and becoming dependent on others poses a real problem. The patient may deny having a fracture or may not realize that fracture and a broken bone are synonymous.
The sudden nature of multiple trauma presents serious psychological stressors to the patient, family, and significant others. Often, the victim is young and healthy; parents become extremely anxious, angry, guilty, and even despairing when their child is injured and they cannot protect him or her from danger. Peers often rally to support a classmate; their numbers may overwhelm the visiting area and the hospital’s resources. A careful assessment of the family’s and peer’s response to trauma is important if interventions are to be constructive.
|Test||Normal Result||Abnormality With Condition||Explanation|
|Urine myoglobin||Negative||Positive; > 20 ng/mL||Myoglobin is a heme-containing, oxygen-binding protein that is present in striated and nonstriated skeletal and cardiac muscle; it is released into the interstitium fluid after injury to a muscle|
|X-rays, computed tomography scan, magnetic resonance imaging depending on location of injury||Intact bones, soft tissues, and joints||Visualization of number and location of fractures||Identifies extent and degree of injury|
Other Tests: Blood alcohol level, urine toxic screen, complete blood count, coagulation studies, type- and cross-matching for blood
Primary nursing diagnosis
DiagnosisPain (acute or chronic) related to inflammation and swelling of the tendon
OutcomesComfort level; Pain control behavior; Pain: Disruptive effects; Pain level
InterventionsPain management; Analgesic administration; Positioning; Teaching: Prescribed activity/exercise; Teaching: Procedure/treatment; Teaching: Prescribed medication
Planning and implementation
In the emergency situation, planning and implementation are related to the priorities of ABCs and neurological status. Unless the musculoskeletal injury is threatening the patient’s circulation because of bleeding, management of musculoskeletal injuries usually occurs after the patient is stabilized. When a musculoskeletal injury interrupts a bone or joint, the trauma causes severe muscle spasms that lead to pain, angulation (abnormal formation of angles by the bones), and overriding of the ends of the bones. These complications need to be managed immediately to prevent increased soft tissue injury, decreased venous and lymphatic return, and edema. If the patient has any exposed soft tissue or bone, cover the area with a wet, sterile saline dressing. Prevent reentry of a contaminated bone into the wound if possible.
Early immobilization of the extremity at the trauma scene—which is actually the first step in trauma rehabilitation—preserves the function and prevents further injury. Immobilization limits muscle spasm, decreases angulation and injury from the overriding bone ends, and prevents closed fractures from becoming open fractures. Traction may also be applied to align bone ends in a close-to-normal position. This procedure restores circulatory, nerve, and lymphatic function and limits tissue injury and swelling. Generally, immobilization devices that are applied before the patient is admitted to the hospital are left in place until x-rays are performed.
When the fracture is confirmed by diagnostic testing, the bone is reduced by restoring displaced bone segments to their normal position. When the physician restores the bone to normal alignment, venous and lymphatic return improves, as does soft tissue swelling. The orthopedist may perform a closed reduction in which she or he manually manipulates the bones to restore alignment. When closed reduction is not possible, a surgical (open) reduction is performed. The method of reduction depends on the grade, type, and location of the fracture.
External fixation devices are now being used frequently for many fractures that would until recently have been treated with traction. External fixation, such as the Hoffmann device, is a metal system of rods designed to maintain alignment of fracture fragments. The patient requires less immobilization and therefore usually suffers fewer of the hazards of immobility. Use the device itself to position limbs, unless it is being used to stabilize a pelvic fracture. External fixation devices may also cause complications, however. Some patients react to them with local irritation, and a few develop infections. Monitor the area every 8 hours while the patient is hospitalized and clean it according to hospital protocol. The most common method is with half-strength hydrogen peroxide. Use of povidone-iodine (Betadine) or Neosporin ointment around the pins after cleansing may also be indicated to prevent infection.
|Medication or Drug Class||Dosage||Description||Rationale|
|Narcotic analgesia||Varies with drug||Codeine, morphine sulfate, meperidine hydrochloride||Relieves pain|
Other Drugs: Antibiotics, antispasmodics
Follow the priorities of pain management, emotional support to cope with a sudden threat to health status, and prevention of complications. Pain may be caused by ineffective use of some treatment methods for fractures. Casts, traction, and fixation devices, once applied, should not cause pain. Improperly padded casts or ones that have been damaged may cause irritation and pressure to the casted area. Skin traction that causes friction also leads to impaired skin integrity. If the patient has soft tissue wounds that require treatment, a window in the cast may be needed. Maintain the functional integrity of the cast with attention to both immobilization of the fracture and prevention of further damage to the tissues.
Pain that seems extreme when a patient is casted or in skeletal traction may signal the advent of a compartment syndrome, a condition in which an edematous extremity is constricted by the cast. The patient complains of a burning sensation or other paresthesia. Edema may be present; pulses ordinarily remain intact. Even in the presence of substantial edema, the use of ice is contraindicated because of the danger of increased neurovascular compromise. The surgeon may bivalve the cast, remove the traction, or perform a fasciotomy.
The patient and family need a great deal of support to cope with a serious injury. Allow time each day to listen to concerns, discuss the patient’s progress, and explain upcoming procedures. If the patient is a young trauma patient, you may need to work out a schedule with the patient’s friends so that they can see the patient but also allow the patient adequate rest. Young adults enjoy diversional activities such as watching television and videos and listening to CDs and the radio. Older patients may experience depression and loss if the injury has long-term implications about their self-care. Consult with social workers and advanced practice nurses if the patient’s anxiety or fear is abnormal. If the patient is a heavy drinker or was intoxicated at the time of injury, encourage the patient to evaluate his or her drinking patterns and the link between drinking and injury. If needed, refer the patient appropriately for a full evaluation for substance abuse.
Immobilization involving the whole person, rather than one extremity, requires aggressive prevention of the hazards of immobility. Motivate and educate the patient in order to help her or him anticipate and prevent complications. Delayed healing of either wound or bone may occur as a complication of the patient’s status at the time of the fracture or as a result of immobility. Encourage a balanced diet with foods that promote healing, such as those that contain protein and vitamin C. Stimulation of the affected area by isometric and isotonic exercises also helps promote healing. Instruct the patient in those techniques, which may not initially seem possible to her or him. They provide a partial substitute for the stimulation to bone remodeling that is otherwise provided by weight bearing. Remember the design adage that is also useful in orthopedics: Form follows function.
Evidence-Based Practice and Health Policy
Talsnes, O., Hjelmstedt, F., Dahl, O.E., Pripp, A.H., & Reikerås, O. (2011). Clinical and biochemical prediction of early fatal outcome following hip fracture in the elderly. International Orthopaedics, 35(6), 903–907.
- Overall 3-month mortality was 19.5% for a sample of 302 patients over age 75 who were surgically treated for hip fracture.
- Mortality was higher among patients with troponin T levels above 0.04 µg/L compared to patients with troponin levels less than 0.04 µg/L (p = 0.003). In fact, high troponin levels increased the risk of mortality by 6.1 times (95% CI, 6 to 23.1; p = 0.008).
- Creatinine kinase was also higher among patients who died compared to patients who survived (p = 0.001).
- Physiological response: Adequacy of ABCs; vital signs; serial monitoring of neurological status; urine output; body weight
- History of injury, description, forces applied to the body during the trauma
- Response to treatment/medications: Pain, mobility, range of motion, muscle spasm, response to surgery, tolerance to nutrition
- Presence and response to traction and immobilization devices
- Complications: Infection, bleeding, anxiety, lack of mobility
Discharge and home healthcare guidelines
Ascertain that the patient is alert and able to care for himself or herself within the limitations that are imposed by treatment of the fracture (e.g., cast or external fixation device) or has adequate home care available. Make sure the patient and family understand any care that is needed for casts or fixation devices. Arrange with social service for the purchase or rental of any supplies, such as crutches, wheelchairs, or home health devices. Teach the patient the hazards of immobility, the symptoms of complications, and when to seek assistance from a healthcare provider. Teach the patient about the route, dosage, mechanism of action, and side effects of all medications. Make sure the patient understands the basic components of a healthy diet. Explore with the patient the effects of drinking and drug use on long-term health and well-being. Remind the patient that rates of reinjury are very high in those who continue to drink alcohol excessively. Determine that the patient has adequate transportation home and for follow-up appointments.