TRAUMATIC

INJURIES
 FRACTURE
Injury to one part of the musculoskeletal system results in
malfunction of adjacent muscles, joints, and tendons.
• A fracture is a complete or incomplete disruption in the continuity
of the bone structure and is defined according to its type and extent.
• Fractures occur when the bone is subjected to stress greater than
it can absorb.
• When the bone is broken, adjacent structures are affected,
resulting in soft tissue edema, hemorrhage into muscles and
joints, joint dislocations, ruptured tendons, severed nerves and
damaged blood vessels.
 FRACTURE- ETIOLOGY

•Excessive force applied to bones

•Direct force from a blow or muscle
contraction
•Bone infections, tumors, aging
 FRACTURE- CLASSIFICATION
1. Close or simple
– break has no
communication
outside
environment

- skin is intact
2. Open or compound fracture
– skin broken leading directly to fracture
 OPEN FRACTURE GRADING
Grade 1- wound is smaller than 1 cm; continuation is
minimal
Grade 2- wound is larger than 1 cm; continuation is
moderate
Grade 3- wound exceeds 6-8 cm; there is extensive
damage to soft tissue, nerve, and tendon; and there
is a high degree of contamination

Ref: J.Black, Medical Surgical Nursing, 7th Ed. Elsevier.2005

OPEN FRACTURE GRADING
OPEN FRACTURE GRADING
 FRACTURE- CLASSIFICATION
3. Complete
FRACTURE
- involves the complete section of the
bone, usually displaced or not in the
normal position
4. Incomplete
- involves a portion of the cross section of
the bone or maybe longitudinal
5. Pathological
- through an area of diseased bone
(osteoporosis, bone cyst and bone tumor)
 FRACTURE- PATTERN
1. Transverse
– break runs across the
bone
- 90 degrees angle to the
longitudinal axis of the
bone

2. Oblique
- break runs in slating
direction to the bone
FRACTURE- PATTERN
 FRACTURE- PATTERN
5. Impacted
– fractured end of the
bone are pushed into each
other

6. Compression
– fracture in which bone
has been compressed
- bone collapses on itself
usually in vertebral column
 FRACTURE- PATTERN
7. Depressed
– fracture in which
fragments are
driven inward
8. Greenstick
– fracture in which
one side of the bone
is broken and the
other side is bent
 FRACTURE- PATTERN
9. Avulsion
- fragment of the
bone pulled off by
the ligament or
tendon attachment

10. Fracture-
dislocation
- fracture complicated
by the bone being out
of the joint
 FRACTURE- PATTERN
10. Linear
- fracture line is intact
- caused by minor to
moderate force applied directly
to the bone

11. Burst fracture

- characterized by multiple
pieces of the bone
- often occurs at the bone
ends or in vertebrae
 FRACTURE- PATTERN
Longitudinal
fracture
- fracture line
extends in the
direction of the
bone’s longitudinal
axis
 FRACTURE – OTHER TYPES
1. Intracapsular
– within the capsule
2. Extracapsular
– outside the capsule
3. Intra articular
– in the joint
4.Proximal
- area near the point of
atttachment
 FRACTURE – OTHER TYPES

5. Medial
- middle or center
6. Distal
- farthest point of attachment
7. Epiphyseal
- fracture through the
epiphysis
 FRACTURE- CLINICAL MANIFESTATION
• The clinical signs and symptoms of a fracture may include the
following but not all are present in every fracture:
 The pain is continuous and increases in severity until the bone fragments are
immobilized.
Loss of function. After a fracture, the extremity cannot function properly
because normal function of the muscles depends on the integrity of the
bones to which they are attached.
Displacement, angulation, or rotation of the fragments in a fracture of the
arm or leg causes a deformity that is detectable when the limb is compared
with the uninjured extremity.
 There is actual shortening of the extremity because of the compression of
the fractured bone.
When the extremity is gently palpated, a crumbling sensation, called crepitus,
can be felt.
Localized edema and ecchymosis. Localized edema and ecchymosis occur
after a fracture as a result of trauma and bleeding into the tissues.
 FRACTURE- COMPLICATIONS
Hypovolemic shock resulting from hemorrhage is
more frequently noted in trauma patients with pelvic
fractures and in patients with displaced or open
femoral fractures.
Fat embolism syndrome. After fracture of long bones
and or pelvic bones, or crush injuries, fat emboli may
develop.
 Compartment syndrome. Compartment syndrome in
an extremity is a limb-threatening condition that
occurs when perfusion pressure falls below tissue
pressure within a closed anatomic compartment
 FRACTURE- ASSESSMENT AND DIAGNOSTIC FINDINGS
• Bone scans, tomograms, computed tomography (CT)/magnetic
resonance imaging (MRI) scans: Visualizes fractures, bleeding, and soft-
tissue damage; differentiates between stress/trauma fractures and
bone neoplasms.
• Arteriograms: May be done when occult vascular damage is
suspected.
• Complete blood count (CBC): Hematocrit (Hct) may be increased
(hemoconcentration) or decreased (signifying hemorrhage at the
fracture site or at distant organs in multiple trauma). Increased white
blood cell (WBC) count is a normal stress response after trauma.
• Urine creatinine (Cr) clearance: Muscle trauma increases load of Cr
for renal clearance.
• Coagulation profile: Alterations may occur because of blood loss,
multiple transfusions, or liver injury.
 FRACTURE- PRINCIPLES OF MANAGEMENT

a. In treating a fracture, the objectives of the

treatment are as follows:
(1) To regain and maintain the normal
alignment of the injured part.
(2) To regain normal function of the injured
part.
(3) To achieve the above objectives for the
patient in the shortest time possible.
 FRACTURE- PRINCIPLES OF MANAGEMENT
B The principles of fracture management are REDUCTION,
IMMOBILIZATION, and REHABILITATION.
• REDUCTION-Reduction is the process of restoring the bone ends (and any
fractured fragments) into their normal anatomical positions. This is
accomplished by open or closed manipulation of the affected area, referred
to as open reduction and close reduction.
Close reduction-is accomplished by bringing the bone ends into alignment by
manipulation and manual traction. Xrays are taken to determine the position
of the bones. A cast is normally applied to immobilize the extremity and
maintain the reduction.
Open reduction-a surgical opening is made, allowing the bones to be reduced
manually under direct visualization.
Frequently, internal fixation devices will be used to maintain the bone
fragments in reduction.
 FRACTURE- PRINCIPLES OF MANAGEMENT
• IMMOBILIZATION-Immobilization is necessary to maintain fracture
reduction until healing occurs. Immobilization may be accomplished by
external or internal fixation.
Internal fixation devices include pins, wires, screws, rods, nails, and plates. These
devices, attached to the sides of the bone or inserted through the bone,
provide internal immobilization of the bone.
External fixation includes casts, splints, and continuous traction.
• REHABILITATION- Rehabilitation is the regaining of strength and normal
function in the affected area. Specific rehabilitation for each patient will be
based upon the type of fracture and the methods of reduction and
immobilization used. The physician will generally consult with the physical
therapist to develop an individualized rehabilitation plan for each patient.
This plan is normally implemented and controlled by the physical therapy
department.
 FRACTURE- NURSING ASSESSMENT
Assessment of the fractured area includes the
following:
Close fracture. The patient with close fracture is
assessed for absence of opening in the skin at the
fracture site.
Open fracture. The patient with open fracture is
assessed for risk for osteomyelitis, tetanus, and gas
gangrene.
The fractured site is assessed for signs and symptoms
of infection
 FRACTURE – NURSING DIAGNOSIS
Based on the assessment data gathered, the
nursing diagnoses developed include:
• Acute pain related to fracture, soft tissue
injury, and muscle spasm.
• Impaired physical mobility related to
fracture.
• Risk for infection related to opening in the
skin in an open fracture.
 FRACTURE – MEDICAL MANAGEMENT
Management of a patient with fracture can belong to either
emergent or post-emergent.
• Immediately after injury, if a fracture is suspected, it is important to
immobilize the body part before the patient is moved.
• Adequate splinting is essential to prevent movement of fracture
fragments.
• In an open fracture, the wound should be covered with sterile
dressing to prevent contamination of the deeper tissues.
• Fracture reduction refers to restoration of the fracture fragments to
anatomic alignment and positioning and can be open or closed
depending on the type of fracture.
 DISLOCATION
A dislocation is the displacement of the normal association of the surface of
the bones that make up the joint.
Dislocations can be defined further as being partial or complete. A partial
dislocation is one in which the surfaces of the joint are not completely
separated. A complete dislocation is one in which the surfaces of the joint are
fully separated.
 A dislocation may occur in any bone joint. It may be traumatic, that is,
caused by an injury or violence, or the injury may be caused by
abnormal twisting or stretching. In addition, a dislocation may accompany a
fracture.
 Symptoms include pain and deformity at the joint, loss of movement,
swelling and discoloration around the joint, and even shock in severe cases.
DISLOCATION
 DISLOCATION TREATMENT
involves reduction and immobilization of the affected joint.
Administration of analgesics for pain relief will be necessary. After
reduction by the physician, an immobilization device is normally
applied in order toprevent further injury.
• Reduction. Your doctor might try gentle maneuvers to help your
bones back into position. Depending on the amount of pain and
swelling, you might need a local anesthetic or even a general
anesthetic before manipulation of your bones.
• Immobilization. After your bones are back in position, your doctor
might immobilize your joint with a splint or sling for several weeks.
How long you wear the splint or sling depends on the joint involved
and the extent of damage to nerves, blood vessels and supporting
tissues.
 DISLOCATION TREATMENT
Surgery. You might need surgery if your doctor can’t
move your dislocated bones into their correct positions
or if the nearby blood vessels, nerves or ligaments
have been damaged. Surgery may also be necessary if
you have had recurring dislocations, especially of your
shoulder.
• Rehabilitation. After your splint or sling is
removed, you’ll begin a gradual rehabilitation
program designed to restore your joint’s range of
motion and strength.
 DISLOCATION – NURSING MANAGEMENT
NURSING MANAGEMENT involves observation for complications and administration of
ordered medications. If the dislocation has involved a major joint, the patient will require the
same care and assistance given to any other immobilized patient.
• Rest your dislocated joint. Don’t repeat the action that caused the injury, and try to avoid
painful movements.
• Apply ice and heat. Putting ice on the injured joint helps reduce inflammation and pain.
Use a cold pack for 15 to 20 minutes at a time. For the first day or two, try to do this every
couple of hours during the day. After two or three days, when the pain and inflammation
have improved, hot packs or a heating pad may help relax tightened and sore muscles.
Limit heat applications to 20 minutes at a time.
• Take a pain reliever. Over-the-counter medications, such as ibuprofen (Advil, Motrin IB,
others), naproxen (Aleve) or acetaminophen (Tylenol, others), can help relieve pain.
• Maintain the range of motion in your joint. After one or two days, do some gentle exercises
as directed by your doctor or physical therapist to help maintain range of motion in your
injured joint. Total inactivity can cause stiff joints.
 SPRAIN
A sprain is an injury to a joint in which the ligaments, capsule, and
surrounding tissues are partially torn or severely stretched. This type of
injury is caused by wrenching or twisting the ligaments around the joint
beyond their normal range of movement.
A sharp pain is felt at the time of the injury, accompanied by a sensation
that there is no support in the injured joint. Rapid swelling and a
decrease or loss of function in the joint will occur.
A sprain is a complete or incomplete tear in the supporting ligaments
surrounding a joint.
Common locations include the ankle, knee, wrist, thumb, shoulder, neck
and lower back.
SPRAIN
 SPRAIN - DIAGNOSIS
During a physical, your doctor will examine your ankle, foot and
lower leg.
The doctor will touch the skin around the injury to check for points
of tenderness and move your foot to check the range of motion and
to understand what positions cause discomfort or pain. If the injury is
severe, your doctor may recommend one or more of the following
imaging scans to rule out a broken bone or to evaluate in more
detail the extent of ligament damage:
• X-ray. During an X-ray, a small amount of radiation passes
through your body to produce images of the bones of the ankle. This
test is good for ruling out bone fractures.
 SPRAIN
• Magnetic resonance imaging (MRI). MRIs use radio waves and
a strong magnetic field to produce detailed cross-sectional or 3-D
images of soft internal structures of the ankle, including ligament
scan take X-rays from many different angles and combine them
to make cross-sectional or 3-D images.
• CT scan- CT scans can reveal more detail about the bones of
the joint.
• CT Ultrasound. An ultrasound uses sound waves to produce
real-time images. These images may help your doctor judge the
condition of a ligament or tendon when the foot is in different
positions
 SPRAIN – MEDICAL MANAGEMENT
• Treatment of strains and sprains consists of resting and
elevating the affected part, applying cold and using a
compression bandage.
• The acronym RICE – Rest, Ice, Compression, Elevation is
helpful for remembering treatment intervention.
• Rest prevents additional injury and promotes healing.
• If the sprain is severe (torn muscle fibers and disrupted
ligaments), surgical repair or cast immobilization may be
necessary so that the joint will not lose its stability.
 SPRAIN- NURSING ASSESSMENT
NURSING ASSESSMENT/ sign and symptom
• Pain and discomfort, especially on joint
movement
• Edema, possibly ecchymoses
• Decreased joint motion and function
• Feeling of joint looseness with severe sprain
SPRAIN- NURSING DIAGNOSIS
• Acute pain
• Impaired mobility
• Risk for injury
 SPRAIN- NURSING INTERVENTION
1. Provide nursing care for a client who sustains a sprain
• Elevate or immobilize the affected joint, and apply ice packs immediately
• Assist with tape, splint or cast application, as necessary
• Prepare the client with a severe sprain for surgical repair or reattachment,
if indicated.
2. Provide nursing care for a client’s suffering muscle or tendon strain.
• Instruct the client to allow the muscle or tendon to rest and repair itself by avoiding use
for approximately week
and then by progressing activity gradually until healing is complete.
• Teach appropriate stretching exercises to be performed after healing to help prevent
reinjury.
• Prepare the client for surgical repair in severe injury.
3. Administer prescribed medications, which may include non-opioid analgesics.
 MUSCLE STRAIN
A strain is the result of overstretching or overexertion of muscles or
tendons so that some part of the musculature is stretched. A strain is
usually due to a sudden body movement or to overexertion. Upon
injury, pain or cramping will be felt.
Other symptoms include swelling, heat, redness, and loss or function
in the area of injury from excessively vigorous movement wherein
the muscles and tendons are overstretched.
A STRAIN is an overstretching injury to a muscle or tendon.
Commonly affected areas are the groin, hamstring, calf, shoulder,
and back muscles, and the Achilles tendons.
MUSCLE STRAIN
 MUSCLE STRAIN
NURSING ASSESSMENT/sign and symptom
• Edema
• Ecchymoses developing several days after injury
• Acute strain – pain may be sudden, severe, incapacitating.
• Chronic strain – gradual onset of soreness and tenderness

LABORATORY AND DIAGNOSTIC STUDY FINDINGS

• Radiographs are commonly done to rule out fracture or
dislocation.
• X-rays or lab tests are often not necessary, unless there was a
history of trauma or evidence of infection.
 MUSCLE STRAIN - MANAGEMENT
• Nonsteroidal anti-inflammatory drugs (NSAIDS) such as naproxen or ibuprofen
to reduce pain and improve your ability to move
around.
P-R-I-C-E
• Protect the strained muscle from further injury.
• Rest the strained muscle. Avoid the activities that caused the strain and other
activities that are painful.
• Ice the muscle area (20 minutes every hour while awake). Ice is a very effective
anti-inflammatory and pain-reliever.
Small ice packs, such as packages of frozen vegetables or water frozen in foam
coffee cups, applied to the area may help decrease inflammation.
• Compression can be gently applied with an Ace or other elastic bandage,
which can both provide support and decrease swelling. Do not wrap tightly.
 MUSCLE STRAIN – NURSING INTERVENTION

NURSING INTERVENTION-nursing intervention

includes placing the patient in a position of
comfort to lessen the tension and reduce
pressure.
Immobilization of the affected area will reduce
the pain and application of heat will usually
provide relief as well.
 OSTEOSARCOMA
Osteosarcoma is a type of cancer that produces immature
bone. It is the most common type of cancer that arises in
bones, and it is usually found at the end of long bones, often
around the knee. Most people diagnosed with osteosarcoma
are under the age of 25, and it is thought to occur more
often in males than females.
• Osteosarcomas range from low grade tumors that only
require surgery to high grade tumors that require an
aggressive treatment regimen. Patients with osteosarcoma
are best treated at a cancer center where an expert sarcoma
team and resources are available to provide specialized and
responsive care.
 OSTEOSARCOMA
CAUSES
• Scientists have not discovered the cause of most cases of
osteosarcoma. Osteosarcoma can develop as a result of radiation to an
area of the body. It can also be associated with specific genetic changes
and diseases.

THE SYMPTOMS
• Most people with osteosarcoma do not feel sick. Patients may have a
history of pain in the affected area and may have developed a limp. Often
the pain is thought to be related to muscle soreness or “growing pains,”
but it does not go away with rest. Many patients only see a doctor when
there is some sort of injury to the area or when the tumor weakens a bone
so much that it breaks (this is called a pathological fracture).
 OSTEOSARCOMA
A biopsy of the tumor, which provides a definite diagnosis based on the
characteristics of tumor tissue seen under a microscope. The biopsy will
• also show whether the tumor is high grade (highly malignant, which is the
case for most osteosarcomas) or low grade.
• There are two main types of biopsy: a needle aspiration and a surgical
biopsy. The location, incision and technical aspects of the biopsy can affect a
patient’s treatment options and outcome. Therefore, it is essential that the
biopsy is planned by a surgeon experienced with sarcomas.

The results of the biopsy and imaging studies provide physicians with an idea
of the “personality,” or stage, of the disease. Most patients are diagnosed
with high grade disease that does not appear to have spread throughout the
body.
 OSTEOSARCOMA- treatment

Surgery: During surgery, the tumor and some of the healthy tissue around it are
cut out of the affected bone. In most cases involving the arm or leg, surgery can
be done without amputation. This is called limb-salvage surgery. These
procedures may be possible in patients whose cancer has not spread beyond
its original site. Sometimes, artificial implants or bone taken from another part of
the body can be used to replace the bone that was removed during surgery.
• Chemotherapy: This is the use of drugs to kill cancer cells. Chemotherapy is
given before surgery to shrink the tumor. This is called neoadjuvant
chemotherapy and often takes about 3 months. Chemotherapy given after
surgery to kill any remaining cancer cells is called adjuvant chemotherapy. An
oncologist is a doctor who specializes in the treatment of patients who have
cancer. An oncologist has expertise not only in prescribing the dose and
schedule of these powerful drugs, but also in anticipating and reducing side
effects of cancer therapy.
 OSTEOSARCOMA- treatment

Radiation therapy: This is important in

osteosarcoma involving the spine, sacrum, skull,
face, and ribs. For osteosarcoma, a tumor that
makes bone, some patients are treated with bone-
seeking radiopharmaceuticals (samarium or
radium) that are taken up by the bone-forming
osteosarcoma cancer cells
NURSING ASSESSMENT -
• Encourage patient to discuss problem and course of
symptoms.
• Note patient and family’s understanding of the disease,
coping with the problem and management of pain.
• Palpate mass gently on physical examination.
• Note size and associated soft-tissue swelling, pain and
tenderness of the mass.
• Assess neuro-muscular status and range of motion extremity.
• Evaluate motility and ability to perform activities of daily
living
NURSING DIAGNOSIS
▪ Acute or chronic pain
▪ Risk for injury: pathologic fracture related to
tumor
▪ Ineffective coping
▪ Activity intolerance
NURSING INTERVENTION
• Provide quiet environment and calm activities to prevent or lessen pain.
• Provide comfort measure such as back rub, change position and use of heat
or cold application.
• Encourage diversional activities
• Administer analgesics as indicated to maximal dose as needed.
• Encourage the patient to increase fluid intake.
• Encourage rest periods to prevent fatigue.
• Provide accurate information about the situation, medication and
treatment.
• Assess muscle strength, gross and fine motor coordination.
• Provide pillows for cushion and support.
• Keep side rails up all the time.
 BONE TUMORS

benign bone tumors occur most often in people less than 30 years old. Most
are discovered in children, while their skeletons are still growing. These tumors
are often strongly influenced by the hormones that stimulate normal growth.
As a result, many benign tumors actually stop growing once a child reaches
skeletal maturity (i.e. when bones stop growing in length). This usually occurs
between the ages 14-16 in girls and the ages of 16-19 in boys.
Among the most common benign tumors involving bone are endochondroma,
osteochondroma, nonossifying fibroma, chondroblastoma, osteoid osteoma,
osteoblastoma, periosteal chondroma, giant cell tumor, and chondromyxoid
fibroma. Some conditions such as aneurysmal bone cyst, unicameral bone cyst,
and fibrous dysplasia are sometimes grouped with benign bone tumors. They
often require similar treatment, but are not truly tumors.
 BONE TUMORS- BENIGN

SYMPTOMS
A palpable lump or swelling can be the first sign of
a benign tumor. However, the most common sign is
persistent or increasing pain in the region of the
tumor. Sometimes tumors are discovered only
after a fracture occurs where the bone has been
weakened by the growth of the tumor.
 DIAGNOSING BONE TUMOR

DIAGNOSING BONE TUMOR

• Blood and urine tests

Your doctor may order tests, including blood or urine samples. A lab
will analyze these fluids to detect different proteins that may indicate
the presence of a tumor or other medical problems. An alkaline
phosphatase test is one common tool doctors use to diagnose bone
tumors. When your bone tissue is especially active in forming cells,
large quantities of this enzyme show up in your blood. This could be
because a bone is growing, such as in young people, or it could mean a
tumor is producing abnormal bone tissue. This test is more reliable in
people who’ve stopped growing.
 DIAGNOSING BONE TUMOR

Imaging tests

Your doctor will probably order X-rays to determine the size and exact location of the
tumor. Depending on the X-ray results, these other imaging tests may be necessary:
1. A CT scan is a series of detailed X-rays of the inside of your body that are taken
from several angles.
2. An MRI scan uses magnets and radio waves to provide detailed pictures of the
area in question.
3. In a positron emission tomography (PET) scan, your doctor will inject a small
amount of radioactive sugar into your vein. Since cancer cells use more glucose than
regular cells, this activity helps your doctor locate the site of the tumor.
4. An arteriogram is an X-ray of your arteries and veins.
5. A bone scan may also be needed
 DIAGNOSING BONE TUMOR

6. Biopsies
Your doctor may want to perform a biopsy. In this test, a
sample of the tissue that makes up your tumor will be
removed. The sample is examined in a laboratory under
a microscope. The main types of biopsies are a needle
biopsy and an incisional biopsy.
 BENIGN BONE TUMORS

How are benign bone tumors treated?

• If your tumor is benign, it may or may not require action.
Sometimes doctors just keep an eye on benign bone tumors to see if
they change over time. This requires coming back periodically for
follow-up X-rays.
• Bone tumors can grow, stay the same, or eventually disappear.
Children have a higher likelihood of having their bone tumors
disappear as they mature.
• However, your doctor may want to surgically remove the benign
tumor. Benign tumors can sometimes spread or transform into
malignant tumors. Bone tumors can also lead to fractures.
 OSTEOCHONDROMA
Osteochondroma is an overgrowth of cartilage
and bone that happens at the end of the bone
near the growth plate. Most often, it
affects the long bones in the leg, the
pelvis, or the shoulder blade.
Osteochondroma is the most common
noncancerous bone growth. It most often
occurs between ages 10 and 30. It affects
males and females equally.
 OSTEOCHONDROMA
SYMPTOMS
• A hard, mass that is painless and does not
move
• Lower-than-normal-height for age
• One leg or arm that is longer than the other
• Pressure or irritation with exercise
• Soreness of the nearby muscles
 OSTEOCHONDROMA
LABORATORY DIAGNOSIS
• X-ray. This test uses invisible electromagnetic energy beams
to make images of tissues, bones, and organs.
• CT scan. This test uses X-rays and computer technology to
make images (often called slices) of the body. A CT scan shows
detailed images of any part of the body, including the bones,
muscles, fat, and organs. CT scans are more detailed than
general X-rays.
• MRI. This test uses large magnets, radiofrequencies, and a
computer to make detailed images of organs and structures in
the body.
 OSTEOCHONDROMA
TREATMENT- Treatment for osteochondromas
varies depending on the size of the growth and
your symptoms. Treatment may include: 54
• Surgery to remove the mass- common in
patient
• Medicines to control pain