MUSCULOSKELETAL CARE MODALITIES

Management of musculoskeletal problems includes the use of casts, traction, artificial joint replacement and surgery. Health teaching is crucial for better prognosis of the applied care modalities. Nursing care plan is essential to maximize the effectiveness of these treatments modalities and to prevent potential complication associated with each of the interventions. The patient is thought to manage his or her care at home an how to safely resume activities.

Managing Care of the Patient with Cast

CAST A rigid external immobilizing device that is molded to

the contours of the body.

Purposes of the cast are:

To immobilize a body part in a specific position To apply uniform pressure on encased soft tissueTo immobilize a reduced fractureTo correct deformity To support and stabilize weakened joints

¤ Types of Cast ¤ Short arm cast –extends from below the

elbow to the palmar crease, secured around the base of the thumb. If the thumb is included it is known as a thumb spica or gauntlet cast.

Long arm cast –extends from the upper level of the axillary fold to the proximal palmar crease. The elbow usually is immobilized at a right angle.

Short leg cast –extends from below the knee to the base of the toes. The foot is flexed at a right angle in a neural position.

Long leg cast –extends from the junction of the upper and middle third of the thigh to the base of the toes. The knee may be slightly flexed.

Walking cast –a short or long leg cast reinforced for strength.

Body cast –encircles the trunk.

Shoulder spica cast –a body jacket that encloses the trunk and the shoulder and elbow.

Hip spica cast –encloses the trunk and a lower extremity. A double hip spica cast includes both the legs.

¤ Casting Materials ¤

Nonplaster

Generally referred to as fiberglass casts, these water-activated polyurethane materials have the versatility of plaster but are lighter in weight, stronger, water resistant, and durable.

Are porous and therefore diminish skin problems. They do not soften when wet, which allows for hydrotherapy when appropriate.

When wet they are dried with a hair drier on a cool setting to prevent skin breakdown.

They are used for nondisplaced fractures with minimal swelling and for long – term wear.

Plaster

Traditional cast Rolls of plaster bandage are wet in cool water and

applied smoothly to the body Increasing warmth is felt Plaster casts need to be exposed to allow maximum

dissipation of the heat and that most casts cool after about 15 mins.

Managing the Patient With Splints and Braces

Contoured splints of plaster or pliable thermoplastic

May be used for conditions that do not require rigid immobilization

For those in which welling may be anticipated For those that require special skin care

Nursing considerations:

The splint needs to immobilize and support the body part in a functional positionThe splint must be well padded to prevent pressure, skin abrasion, and skin breakdownThe splint is over wrapped with an elastic bandage applied in a spiral fashion and with pressure uniformly distributed so that the circulations not restricted.The nurse frequently assesses the neurovascular status and skin integrity of the splinted extremity.The nurse provides skin care and makes adjustments for swelling.

Braces (orthoses)

Provided for long term use Are used to provide support, control movement and

prevent additional injury are custom fitted to various parts of the body may be constructed of plastic materials, canvas, leather

or metal the orthotist adjust the brace for positioning, fit and

motion

Nursing considerations:

helps the patient learn to apply the brace and to protect the skin from irritation and breakdownassesses neurovascular integrity and comfort when the patient is wearing the brace, encourages the patient to wear the brace as prescribedreassures the patient that minor adjustments of the brace by the orthotist will increase comfort and minimize problems associated with its long-term use

Managing the Patient With an External Fixator

External Fixators

Are used to manage open fractures with soft tissue damage

Provide stable support for severe comminuted fractures while permitting active treatment of damaged soft tissue

Fractures is reduced, aligned, and immobilized by a series of pins inserted in the bone

Pin position is maintained through attachment to a portable frame

It facilitates patient comfort, early mobility and active exercise of adjacent uninvolved joints

Complications related to disuse and immobility are minimized

Nursing considerations:

Prepare the patient psychologically for application of the external fixator.

Reassure that the discomfort associated with the device is minimal and that early mobility is anticipated promotes acceptance of the device.

Extremity is elevated at the applied area to reduce swelling

Sharp points on the fixator or pins are covered to prevent device induced injury

Monitor the neurovascular status every 2 to 4 hours and assess each pin for redness, drainage, tenderness, pain and loosening of pin.

Be alert for potential problems caused by pressure from the device on the skin, nerves or blood vessels and for the development of compartment syndrome

Pin care must be observed which typically includes cleaning each pin site separately three times a day with cotton-tipped applicators soaked in sterile saline solution.

If the pins or clamps seem loose or sign of infection is noted, notify the physician immediately.

Managing the Patient in Traction

Traction Is the application of a pulling force to a part of the

body. Used primarily as a short – term intervention until other

modalities such as external or internal fixation are possible

This reduces the risk of disuse syndrome and minimizes the length of hospitalization

Purposes of traction:to minimize muscle spasmsto reduce, align and immobilize fracturesto reduce deformityto increase space between opposing surfaces

☼Principles of Effective Traction ☼

Whenever traction is applied, countertraction(a force acting in the opposite direction) must be used to achieved effective traction.

Traction must be continuous to be effective in reducing and immobilizing fractures.

Skeletal traction is never interrupted.

Weights are not removed unless intermittent traction is prescribed.

Any factor that might reduce the effective pull or alter its resultant line of pull must be eliminated:

The patient must be in good body alignment in the center of the bed when traction is applied.

Ropes must be unobstructed Weihts must hang free and not rest on the

bed or floor. Knots in the rope or the footplate must not

touch the pulley or the foot of the bed.

¤ Types of Traction ¤

Straight or running traction Applies the pulling force in a straight line with the

body part resting on the bed. Buck’s extension traction is an example.

Balanced suspension traction Supports the affected extremity off the bed and

allows for some patient movement without disruption of the line of pull.

Traction may be applied as:

Skin Traction Applied to the skin or directly to the bony

skeleton.

Used to control muscle spasms and to immobilize and area before surgery.

Accomplished by using a weight to pull on traction tape or on a foam boot attached to the skin.

No more than 2 to 3.5kg of traction can be used on an extremity.

Types of skin traction used for adults include:

Buck’s extension (applied to the lower leg)

Cervical head halter (occasionally used to treat neck pain)

Pelvic belt (sometimes used to treat back pain)

Nursing interventions:Avoid wrinkling and slipping of the traction bandage and to maintain countertraction.

Proper positioning must be maintained to keep the leg in a neutral position.

Assist the client in shifting position.

Assess for sensitivity of skin and fragility especially in adults.

Assess circulatory impairment on the affected area.

Encourages the patient to perform active foot exercises every hour when awake.

Skeletal Traction Applied directly to the bone

Used occasionally to treat fractures of the femur, the tibia and the cervical spine.

Local anesthesia is administered at the insertion site and periosteum.

The surgeon makes a small skin incision and drills the sterile pin or wire through the bone.

The patient feels pressure during this process and possibly pain when the periosteum is penetrated.

Frequently uses 7 to 12 kg to achieve the therapeutic effect.

Thomas splint with a Pearson attachment is frequently used with skeletal traction for fractures of femur.

Nursing Interventions:Maintain effective traction by checking the apparatus to see that ropes are in the wheel grooves of the pulleys, the knots in the rope are tied securely.

Maintain positioning by maintaining body alignment in traction as prescribed to promote an effective line of pull.

Prevent skin breakdown.

Monitor neurovascular status.

Provide pin site care.

Managing the Patient Undergoing Orthopedic Surgery

¤ Orthopedic Surgery ¤

Open reduction The correction and alignment of the fracture after

surgical dissection and exposure of the fracture.

Internal fixation the stabilization of the reduced fracture by the use of

metal screws, plates, nails, and pins

Arthroplasty The repair of joint problems through the operating

arthroscope (an instrument that allows the surgeon to operate within a joint without a large incision) or through open joint surgery.

Hermiarthroplasty The replacement of one of the articular surfaces (e.g.

in a hip hermiarthroplasty, the femoral head and neck are replaced with a femoral prosthesis-the acetabulum is not replaced).

Joint arthroplasty or replacement The replacement of joint surfaces with metal or

synthetic materials.

Total joint arthroplasty or replacement the replacement of both articular surfaces within a

joint with metal or synthetic materials

Meniscectomy the excision of damaged joint fibrocartilageAmputation the removal of a body part

Bone graft

the placement of bone tissue (autologous or homologous grafts) to promote healing, to stabilize, or to replace diseased bone.

Tendon transfer the movement of tendon insertion to improve

function.

Fasciotomy The incision and diversion of the muscle fascia to

relieve muscle constriction, as in compartment syndrome, or to reduce fascia contracture.

Nursing Process: Preoperative care of the Patient Undergoing Orthopedic Surgery

Goals: includes relief of pain, adequate

neurovascular function, health promotion, improved mobility and positive self-esteem

Nursing Interventions:♥ assessment of patient is focused on hydration

status, current medication history, and possible infection.

♥ Assess the skin, mucous membranes, vital signs, urinary output and laboratory value

♥ relieving painimmobilize fractured bone to lessen discomfortelevate edematous extremity to promote venous return

ice, if prescribed relieves swelling and directly reduces discomfort by diminishing nerve impulseadministered analgesic as prescribed to control the acute painalternative methods of pain includes:

distraction focusing guided imagery quiet environment backrubs

♥ maintaining adequate neurovascular functionnurse must frequently assess neurovascular status like color, temperature, capilliary refill, pulses, edema, pain,sensation, motion of the extremity and document the findings.If circulation is compromised:

Notify the physician Elevate the extremity Release constricting wraps or casts as

prescribed.

♥ promoting healthassess nutritional status and hydrationif patient has diabetes, is elderly and frail or I the victim of multiple trauma, special fluid and nutritional provisions may be necessarycoughing, deep breathing and use of the incentive spirometer are practiced preoperatively for improved respiratory functionsmoking should be stoppedcleans the skin with soap and water before surgery

♥ improving mobility

elevate and adequately support edematous extremities with pillows.Encourage movements within limits of therapeutic immobility.

♥ helping the patient maintain self-esteempromotes trusting relationship for patient to express concerns and anxieties and helps them examine their feelings about changes in self-conceptclarifies any misconceptions helps them work through modifications needed to adapt to alterations in physical capacityreestablish positive self-esteem.

Expected Outcomes:

♥ reports relief of pain

♥ exhibits adequate neurovascular function

♥ promotes health

♥ maximizes mobility within the therapeutic limits

♥ expresses positive self-esteem

Nursing Process: Postoperative care of the Patient Undergoing Orthopedic Surgery

Goals: includes relief of pain, adequate neurovascular function,

health promotion, improved mobility, positive self-esteem and absence of complications.

Nursing Interventions:♥ Reassess the patient’s needs in relation to pain,

neurovascular status, health promotion, mobility and self-esteem.

♥ Monitored closely tissue perfusion because edema and bleeding into the tissue can compromise circulation and result in compartment syndrome.

♥ Notes the prescribed limits on mobility and assess the patient’s understanding of the mobility restrictions.

♥ Changes in patient’s pulse rate, respiratory rate or color may indicate pulmonary or cardiovascular complications.

♥ Assess for calf swelling, tenderness, warmth, redness and positive Homans’ sign which is an indicative of thromboembolic disease.

♥ Relieving of painPatient-controlled analgesia(PCA) and epidural analgesia may be prescribed to control pain.In intramuscular and oral analgesics are prescribe PRN, instructs the patient to requests before the pain becomes severe.

Elevation of the operative extremity and application of cold, if prescribed help to control edema and pain.Portable suction of the wound decreases fluid accumulation and hematoma formation.

♥ Maintaining adequate neurovascular functionMonitor the neurovascular status of the involved body part and notifies the physician promptly of any indications of diminished tissue perfusion.Encourage patient to perform muscle-setting, ankle and calf-pumping exercises hourly while awake to enhance circulation.

♥ Maintaining healthA well-balanced diet with adequate protein and vitamins is needed for wound healing.Large amount of milk should not be given to orthopedic patient who are on bed rest,however, because this adds to the calcium pool in the body and requires that the kidneys excrete more calcium, which increases the risk for urinary calculi.Monitor for pressure ulcer.Turning, washing and drying the skin and minimizing pressure over bony prominences re necessary to avoid skin breakdown.

♥ Improving physical mobilityMetal pins, screws, rods, and plates used for internal fixations are designed to maintain position of the bone until ossification occurs.Physical therapists tailors the exercise program to the individual patient’s need with a goal of returning of the patient’s highest level of function in the shortest time possible.Rehabilitation involves progressive increases in the patient’s activities and exercises

♥ Maintaining self-esteemNurse continues the plan of preoperative care.

♥ Monitoring and managing potential complicationsNurse monitors the signs and symptoms of hypovolemic shock: increased pulse rate, decrease blood pressure, urine output less than 30cc per hour, restlessness, and change in mentation, thirst, decreased hemoglobin and hematocrit and notify the physician immediately.

Evaluation Outcomes:

♥ Reports decreased level of pain

♥ Exhibits adequate neurovascular function

♥ Promotes health

♥ Maximizes mobility within the therapeutic limits

♥ Expresses positive self-esteem

♥ Exhibits absence of complications