Musculoskeletal disorders & trauma

• osteomyelitis patho: invasion of bone and surrounding tissue by a bacterial pathogen; aka infection of the bone
• risk factors for osteomyelitis: open fracture or trauma, surgical wounds/devices/puncture wounds, diabetes, immunosuppression, long bones, and anyone with poor circulation
• clinical manifestations of osteomyelitis: pain NOT relieved by rest (**), swelling, tenderness and warmth at site, fever, chills, malaise
• medical treatment for osteomyelitis: antibiotic treatment (PICC line placed for 6 weeks of IV antibiotics), pain management, and surgical debridement
• complications of osteomyelitis: sepsis, amputation, squamous cell carcinoma
• physical assessment of osteomyelitis: vitals (temperature, pulse, BP), pain, wound assessment (redness, heat, purulent drainage, pain, and edema), and neurovascular assessment (pain, pallor, pulselessness, paralysis, parasthesia, pressure)
• labs for osteomyelitis: WBC, ESR, and CRP all ELEVATED
• interventions for osteomyelitis: apply thermal therapy as ordered (heat improves blood flow to the area), ROM (above and below the infected site), education for safe movement, nutrition support (high protein, high calcium, high vitamin D, C, and zinc), home health referral
• teaching for osteomyelitis: pain management, long term antibiotic therapy (increased risk for c diff), and nutrition
• hip replacement:

  • hip surfacing - preserving the femoral bone; leaves the joint but replace the ball of the femur
  • total hip replacement - replacement of socket and ball
• complications of joint replacement: hypotension, bleeding, hypovolemia, wound site infection, DVT (prophylaxis treatment before surgery), and PE (secondary to the DVT)
• joint replacements are at a HIGH risk for DVT/PE
• physical assessment for joint replacement: pain, neurovascular (pain, pallar, pulselessness, pressure, paralysis), and wound/drainage
• labs for joint replacement: CBC (looking for infection - WBC and bleeding - H/H)
• interventions for joint replacements: administer medications as ordered (give pain medications 30 minutes BEFORE physical therapy), wound care (sterile and surgeon does first one), early mobilization (up within 24 hours), anti embolic stockings, continuous passive ROM machine, and proper positioning and turning schedule
• teaching for joint replacements: preoperative teaching and postoperative teaching (taking pain meds as prescribed, anticoagulation teaching, bleed precautions while on anticoagulants)
• fractures: disruption or break in the continuity of bone; open and closed; ORIF - open reduction and internal fixation
• clinical manifestations of fractures: pain, swelling, loss of function, deformity, medical treatment (non surgical - closed reduction OR surgical - open reduction (internal fixation - screws/nails and external fixation - pins))
• complications of fractures: neurovascular compromise, venous thromboemboli (high risk for blood clot), fat embolism (causes PETECHIAE wherever it lands), traumatic rhabdomyolysis (leads to kidney failure and red/rusty urine), hypovolemia, infection, and malunion/nonunion
• what is the common sign of a fat embolism?

  petechiae
• what is the common sign of rhabdomyolysis?

  red and rusty colored urine
• compartment syndrome: increased pressure in the compartment causing compression of nerves and blood vessels; if untreated they will lose the limb
• treatment for compartment syndrome?

  fasciotomy
• physical assessment for fractures: vitals (BP - shock, temperature - infection), physical assessment (6 Ps), verify proper positioning, urine appearance (red and rusty - rhabdomyolysis), I&Os, respiratory assessment (fat emboli), skin (petechiae)
• labs for fractures: CBC (infection or bleeding), electrolytes (K+, Ph - low, and Ca+ - high), renal function (BUN/Cr will go up after injury/trauma but make sure it doesnt get worse), myoglobin (protein in muscle and when damaged it gets released into bloodstream causing high protein in blood)
• interventions for fractures: maintain pulmonary hygiene, wound/pin care, elevation, apply ice, ROM exercises, repositioning, provide hydration and nutrition
• cast care:

  • assess every ho urs for first 24 hours
  • handle with palms NOT fingers while wet
  • elevate limb
  • one finger wiggle room between cast skin
  • monitor for drainage and skin abrasions
• pin care:

  • clean with chlorhexidine every shift
  • one swab for each pin
  • monitor drainage (COCA)
  • report signs of infection
• interventions for casts: treatment process (takes bones around 6 weeks to heal), overview of healing process, consume adequate calories and minerals (protein, vitamin D), appropriate use of analgesics, wound care, exercise and ambulation, self care activities
• amputations: severing, or removal, of part of the body; traumatic or elective
• complications of amputations: hemorrhage, infection, contractures, phantom limb pain (real pain; treat with gabapentin), neuromas
• interventions for amputations: vitals (hypotension, infection), pulses, pain, and wound/incision cite
• labs for amputations: CBC (H/H, WBC)
• key points:

  • meticulous skin care and infection prevention is key for all bones related injuries
  • adjustment to temporary or permanent loss of limb use is necessary for safety
  • monitor for complications - fat emboli (petechiae), osteomyelitis, DVT, rhabdomyolysis (red, rusty urine)