Disorder of Musculoskeletal

System

Set by Minichil G
2022
 Learning Objectives

After the end of this session, you will be able to:

 Describe the parts of the MS and its function
 Explain the assessment technique of MS
 List the common MS disorders
 Explain the possible cause, clinical presentation, Dx
modality for each MS disorders.
 Manage each MS disorder by using medical and
nursing approach
 Assessment of the MS
 History

 Physical Examination
 Inspect and palpate

 Perform a head to toe assessment

 The special procedure is the assessment of joint

and muscle movement
 Assessment…

Gait: ask the patient to walk

Posture: kyphosis, lordosis, scoliosis
Muscular palpation
Joint palpation
Range of motion (ROM): active & passive
Muscle strength: examined against the
examiner hand
 Diagnostic Procedures

1. X-ray studies: to determine bone density, texture,

erosions, fractures, & joint structure.
2. CT scan: Can reveal tumors of the soft tissues, or
injuries to the ligaments & tendons.
3. MRI: used to detect abnormalities of soft tissues
such as muscles, tendons, cartilage & nerves.
 Diagnostic Procedures(cont’d…)
4. Arthrocentesis (synovial fluid aspiration)
 Performed to obtain synovial fluid for
examination or to relieve pain.
 Helpful in the diagnosis of rheumatoid
arthritis, other inflammatory arthropathies.
5.Biopsy:- performed to determine the structure
and composition of bone, muscle and
synovium.
 6. Arthroscopy

 Flexible fiberoptic endoscope used to view

joint structures and tissues
 Used to identify:
 Torn tendon and ligaments
 Inflammatory joint changes
 Damaged cartilage
 7. Bone Marrow Aspiration

 Usually involves aspiration of the marrow to

diagnose diseases like leukemia, aplastic
anemia.
 Usual site is the sternum and iliac crest
Diagnostic Procedures(cont’d…)

8. Blood chemistry studies

 Serum calcium level
 Uric acid

9. Serologic study – Rheumatoid factor

10. CBC
 Rheumatoid Arthritis ( RA )
Learning objectives
At the end of this lesson the student will be able to:
 Define Rheumatoid arthritis
 Describe the etiology and pathogenesis of RA
 Identify the clinical features of Rheumatoid arthritis
 Explain the Dx method of RA
 Manage a patient with Rheumatoid arthritis
 Describe prognostic factors for Rheumatoid arthritis
Definition
 Rheumatoid arthritis (RA) is a symmetric,
inflammatory, peripheral polyarthritis of
unknown etiology
 Usually involving peripheral joints in a
symmetrical distribution
 The potential of the synovial inflammation to
cause cartilage damage, bone erosion and
subsequent changes in joint integrity is the hall
mark of the diseases
Etiology:
 The cause of RA remains unknown
 Genetic factors
 The presence of HLA-DR4 allogen is
associated with high incidence of RA.
 Infectious agent:
 May play a role in triggering an autoimmune
reaction
Epidemiology
 The prevalence of RA is approximately 0.8 in
the population
 Women are more affected than men with F: M
ratio of 3:1
 The prevalence increases with age
 Clinical Features
• Typical "classic" RA
 The disease onset is usually insidious, with
the predominant symptoms being pain,
stiffness, and swelling of many joints
Articular ( joint ) manifestations
 Result from persistent inflammatory synovitis

 Pain , swelling and tenderness of involved joints ,

aggravated by movement
 Joint stiffness (Morning stiffness)

 Symmetrical small joint involvement is typical for

RA
• Extraarticular features
 Rheumatoid nodules

 Most common features of extraarticular

diseases
 Found in 20-25 % of patients

 Firm subcutaneous masses typically are

found in areas on periarticular structures
 Rheumatoid vasculitis

 Skin: cutanous ulceration , dermal necrosis

 Digital gangrene

 Visceral infarction
 Eye involvement

 Keratoconjuctivitis is seen in 10 -15 % of

rheumatoid arthritis patients

 Lungs

 Pleuritis and pleural effusion may be seen is

some patients
 Interstial fibrosis

 Rheumatoid nodules may appear on the lung,

single or multiple
 Heart

 Asymptomatic pericardits is fund in 50% of

patients on autopsy.

 It is often associated pleural effusion.

 Hematologic features

 Anemia of chronic diseases

 Thrombocytosis

 Chronic RA with splenomegaly and neutropenia,

with an occasional thrombocytopenia and
anemia.
• Constitutional symptoms

 Like weight loss, fever, anorexia and fatigue

are common complaints

 Diagnostic approach for RA

 Proper history taking and Physical examination

 CBC
 ESR is often raised indicating chronic
inflammation
 Rheumatoid factor positive
 It is typically present in 60 - 80% of patients
 Radiographic findings
 American revised Criteria for Having RA
 Morning stiffness: lasting > 1 hr
 Arthritis of three or more joint areas
 Arthritis of hand joints: wrist, MCP and PIP
 Symmetrical arthritis
 Rheumatoid nodules: subcutaneous nodules
over bony prominences
 Serum rheumatoid factor positive
 Radiologic changes : periarticular bony erosion
and other findings
Note: Interpretation

 Four of seven (>4/7) criteria are required to

classify a patient as having Rheumatoid

arthritis

 Patients with two or more criteria, the clinical

diagnosis of RA is not excluded

 Management
Goals of therapy

1. Short term : controlling pain and reducing

inflammation without causing undesired side

effects

2. Long term: preservation of joint function and the

ability to maintain life-style

 First line Treatment: NSAIDs

 Aspirin, Ibuprofen, diclofenac, indometacin

may be used

 Dose: Aspirine 900 mg PO TID, Ibuprofen 400

mg PO BID or Diclofenac 50 mg PO BID or TID

• Second line treatment

 Low dose oral corticosteroids have potent

anti-inflammatory effect
• Third line:
 Disease modifying antirheumatic drugs- or slow
acting antirheumatic drugs
 Methotrexate is the most frequently DMARD
used, which is relatively rapidly acting
 Dose: given low dose: 7.5-30 mg once weekly
Non pharmacologic therapy
1) Patient education
 The chronicity of the diseases
 Rest and exercise
 Patients should be advised to rest or splint
acutely involved joints
 Exercise is advised to strengthen muscle
surrounding involved joints , when the
arthritis is resolved
2) Physiotherapy to reduce disability
• Assessment of response:

 Resolution of symptoms: reduction or

disappearance of joint pain, stiffness and
swelling
 Functional status: ability of the patient to
perform daily activities and living
 Laboratory: anemia may be corrected and ESR
declines
Sign of poor prognostic factors
 Many persistently inflamed joints
 Poor functional status
 Rheumatoid factor positivity
 HLA-DR4 positivity
 Extra-articular diseases
 Persistently elevated acute phase reactants
( ESR, C-reactive protein )
 Radiologic evidence of erosion
GOUT ARTHRITIS
Learning objectives
At the end of this session, you will be able to:
 Define Gout
 Describe the etiology and pathogenesis of Gout
 Identify the clinical features of Gout
 Make the diagnosis method of Gout
 Discuss the management principles of different
types Gout
What Is Gout?
 Gout is a kind of arthritis caused by a buildup of
uric acid crystals in the joints
 Uric acid is a breakdown product of purines that
are part of many foods we eat
 An abnormality in handling uric acid and
crystallization of these compounds in joints can
cause attacks of painful arthritis
 Serum uric acid concentration above 7 mg/dl.
 Elevation of serum uric acid alone is not sufficient
for the diagnosis of gout; only 10 % of patients
with hyperuricemia develop gout
 Etiology
• Patients with elevated serum uric acid are mainly
due to
1) Overproduction
 Account for 10 % of patients.
 The urinary excretion of urate is >1000 mg/day
 Uric acid overproduction may be :-
a) Primary:- purine pathway enzyme defect
b) Secondary:- cellular destruction associated with
alcohol use, hematologic malignancies , chronic
hemolysis , or cancer chemotherapy
2. Under secretion of Uric acid
 Account for 90 % of patients
 Decreased renal excretion of uric acid is the
underlying reason for hyperuricemia
 Urinary excretion of uric acid is < 700 mg/dl
a) Drugs: Diuretics , alcohol , Aspirin interfere
with tubular handling of urate
b) Renal diseases
• Conditions associated with Gout
 Obesity: serum uric acid level rises

 Diabetes mellitus:- more common

 Hypertension: is more common in gout

patients
 Hyperlipidemia
 Clinical Features
 Usually, only one joint is affected initially, but

polyarticular acute gout can occur in subsequent

episodes

 The metatarsophalangeal joint of the first toe often is

involved, but tarsal joints, ankles, and knees also are

affected commonly
 Gouty arthritis frequently begins at night with
dramatic joint pain and swelling.
 Joints rapidly become warm, red, and tender,
with a clinical appearance that often mimics
that of cellulitis.
 Early attacks tend to subside spontaneously
within 3–10 days
• Several events may precipitate acute gouty arthritis:

 Dietary excess

 Trauma

 Surgery

 Excessive ethanol ingestion

 Hypouricemic therapy, and

 Serious medical illnesses such as myocardial infarction

and stroke
 Diagnostic work up

 Clinical presentation

 Serum uric acid value

 Synovial fluid analysis: demonstration of urate

crystals
 Radiologic findings
 Management

 Asymptomatic hyperuricemia: no need for

treatment, other than correction of the
underlying causes
 Acute gouty arthritis : drug treatment of acute
gouty arthritis is most effective when started
early after the symptoms begin
• Colchicine
 Has anti-inflammatory effect

 Dose: 0.6 mg is given every hr until the relief

of symptoms
 It may also be given intravenously during
acute attack in patients who cannot take PO
medication.
• NSAID:-

 Are used in high but quickly tapered dose

 Drugs like Aspirin that affect uric acid clearance

should be avoided.
 Indomethacine: 25-50 mg PO TID

 Ibuprofen: 800 mg Po TID

 Diclofenac: 25-50 mg PO TID

 Corticosteroids:

 Oral glucocorticoids: Prednisolone, 30-50

mg/day as the initial dose and tapered over 5-

7 days.

 Intraarticular injections
• Uricosuric agents (probenicide)
 This drugs facilitate the renal excretion of uric
acid.
 It can be used in patients who excrete less
than 700 mg of uric acid daily, who have
normal renal function
 Dose: Probenicide 200 mg PO Bid increased
gradually as needed up to 2 gm
• Xanthine Oxide inhibitors (allopurinol)

 This drug competitively inhibits xanthine

oxidase.
 This drug is preferred in patients with urate
excretion greater than 1000 mg/day, creatinin
clearance < 30 ml/min
 Dose: 300 mg single morning dose initially and
may be increased up to 800 mg if needed.
Osteomyelitis
 An infection of bone that leads to tissue

destruction

 Can be caused by a wide variety of bacteria

(including mycobacteria) and fungi and may

be associated with viral infections

CLASSIFICATION
 Two major osteomyelitis classification

 Based on the duration of illness (acute versus

chronic)
 The mechanism of infection (hematogenous
or secondary to a contiguous focus of
infection)
 Hematogenous osteomyelitis
 Occurs more commonly in children than adults
 Long bones are most often affected
 Adults the vertebrae are the most common site
 Contiguous osteomyelitis
 Setting of trauma and related surgery
 Secondary to decubitus ulcers and infected total
joint
 Usually seen in individuals with diabetes
mellitus.
• PATHOPHYSIOLOGY
 Osteomyelitis can occur as a result :-

 Hematogenous spreeding

 Contiguous spread of infection to bone from

adjacent soft tissues and joints, or
 Direct inoculation of infection into the bone as a
result of trauma or surgery
 Hematogenous osteomyelitis is usually
monomicrobial, while osteomyelitis due to
contiguous spread or direct inoculation is
usually polymicrobial
 Predisposing factors
 Prosthetic joint implants and stabilization
devices
 Trauma is also a common cause of infection
 Bacteremia
 Poor arterial and venous supply
 Host factors such as diabetes - impaired
immunity with hyperglycemia, loss of
sensation, vascular disease
CLINICAL MANIFESTATIONS
 Acute osteomyelitis typically presents with
 Dull pain at the involved site, with or without
movement
 Local findings (tenderness, warmth, erythema
and swelling) and systemic symptoms (fever,
rigors)
 Fever (40 to 80 percent)
Localized pain (56 to 95 percent)
Decreased mobility (50 to 84 percent)
• Chronic osteomyelitis may present

 Pain, erythema, or swelling

 Sometimes in association with a draining sinus

tract

 The presence of a sinus tract is pathognomic of

chronic osteomyelitis.
 Diagnosis method
 The white blood cell count was elevated in
only 35 %
 The erythrocyte sedimentation rate (ESR)
was initially elevated (≥20 mm/h) in 92 % of
patients (mean 45 mm/h).
 The serum C-reactive protein (CRP)
concentration was elevated in 98 % on
admission.
 Joint fluid analysis

 Gram staining

 Culture

 Biopsy

 Radiological Finding
 Management

 Osteomyelitis frequently requires

 Both surgical therapy for debridement of

necrotic material together with antimicrobial

therapy for eradication of infection.

• Duration of treatment

 4- to 6-week course of IV therapy reasonable

• Surgery

 Drain area infected

 Remove diseased tissue and bone

 Remove any objects that are foreign

 Limb amputation
Complications
 Loss of full function of the bone or supporting
tissues
 Fractures are more likely with progressive
disease.
 Local spread and dissemination of infection
 May lead to malignant transformation into
squamous cell carcinoma or sarcoma
Septic Arthritis
 Septic arthritis is also known as infectious
arthritis, and is usually caused by bacteria, or
fungus.
 The condition is an inflammation of a joint
that's caused by infection.
 Typically, septic arthritis affects one large joint
in the body, such as the knee or hip.
 Less frequently, septic arthritis can affect
multiple joints.
What Causes Septic Arthritis?
 Septic arthritis usually is caused by bacteria
that spread through the bloodstream from
another area of the body
 It can also be caused by a bacterial infection
from an open wound or an opening from a
surgical procedure
• Septic arthritis can be caused by bacteria, viruses, and

fungi.

 The most common causes of septic arthritis are bacteria,

including S. aureus and H. influenzae

 In certain "high-risk" individuals, other bacteria may cause

septic arthritis, such as E. coli and Pseudomonas spp

 Neisseria gonorrhoeae in sexually active young adults

 Mycobacterium tuberculosis.
 Fungi that can cause septic arthritis include

Histoplasma, Coccidioides, and Blastomyces.

 Viruses that can cause septic arthritis include

hepatitis A, B, and C, parvovirus B19, herpes viruses,

HIV
Who's at Risk for Septic Arthritis?

 Young children and elderly adults

 People with open wounds

 People with a weakened immune system and those

with pre-existing conditions such as cancer, diabetes,
and immune deficiency disorders

 In addition, previously damaged joints have an

increased likelihood of becoming infected.
What Are the Symptoms of Septic Arthritis?
 Symptoms of septic arthritis usually come on rapidly
with intense pain, joint swelling, and fever.
 Septic arthritis symptoms may include:
 Chills
 Fatigue and generalized weakness
 Inability to move the limb with the infected joint
 Severe pain in the affected joint, especially with
movement
 Swelling (increased fluid within the joint)
 Warmth (the joint is red and warm to touch because of
increased blood flow
How Is Septic Arthritis Diagnosed?

 A procedure called arthrocentesis is commonly

used to make an accurate diagnosis of septic
arthritis.

 Synovial fluid analysis

 X-rays are typically done to look for joint
damage.
 Blood tests can also be used to monitor
inflammation
 MRI scanning is sensitive in evaluating joint
destruction but is less useful in the early
stages .
What's the Treatment for Septic Arthritis?

• Septic arthritis treatments include using a

combination of powerful antibiotics as well as

draining the infected synovial fluid from the

joint
Is the Infected Fluid Drained?

 Drainage of the infected area is critical for

rapid clearing of the infection.

 Drainage is performed by removing the fluid

with a needle and syringe

 Caring for a patient with soft tissue
injuries
• They are usually caused by trauma.
1. Contusions
 It is a soft tissue injury produced by blunt
force, such as a blow, kick, or fall.
 Many small blood vessels rupture and bleed
into soft tissues (ecchymosis, or bruising).
 Significant bleeding can cause a hematoma
 Soft tissue injuries…
Contusions

• Symptoms (pain, swelling, and discoloration).

• Most contusions resolve in 1 to 2 weeks.

 Soft tissue injury…
2. Sprains
• It is an injury to ligaments and other soft
tissues at a joint.
– Caused by
Twisting motion
Overstretching or tear
• Sprained ankles are most common, which
occurs when the foot turns inwards which is
called inversion and causes extreme tension in
the ligaments of the ankle.
 Grades
• Sprain classification
Grade 1: some stretching
and damage to the fibers
that compose the ligament.
Grade 2: A partial tearing
causes extra looseness
when the joint is moved in
specific ways.
Grade 3: The ligament is
completely torn and causes
the joint to be
nonfunctional.
 Sign and symptom of Sprain
• Swelling

• Tenderness

• Pain upon motion

• Discoloration
 It might be difficult to differentiate a sprain
from a closed fracture with out an X-ray.
 Soft tissue injury…

3. Strain
 “Pulled muscle”
 Microscopic tear in the muscle
 May cause bleeding
Causes:
– Lack of pre- exercise before doing sport activity
– Lifting of heavy weight
– Inappropriate lifting or sudden acceleration
– The most common one is back strain.
• Signs and symptoms
– Pain (sudden sharp pain at the site of the injury)
– Spasm of muscles
– Difficulty in moving the affected parts
– Localized swelling
 Management of Soft Tissue Injury
/Trauma
 Rest
 Ice for first 24 - 48 hours- produces vasoconstriction,
which decrease bleeding, edema and discomfort.
- Intermittent application of cold
 Compression with bandage controls bleeding,
reduces edema.
 Elevation to increase venous return and decrease
swelling
 Splint to support extremities and limit movement.
Management of Soft Tissue Trauma…
 After 24-48 hours after injury heat may be
applied intermittently (for 15-30 minutes, 4
times a day) to relieve muscle spasm and to
promote vasodilatation, absorption and
repair
 NSAIDs
 Checking the neuromuscular status
 Surgical repair for third degree sprain or strain
 Joint Dislocations

Defn:- Is a displacement of a bone end from the

joint
– A subluxation is a partial dislocation of the
articulating surfaces.
Dislocation may be:-
• Traumatic due to injury in which the joint is
disrupted by force.
• Congenital (present at birth, due to some mal
development).
• Pathologic or spontaneous due to disease at
articular or periarticular structures.
 Joint Dislocations…
• Traumatic dislocations are orthopedic
emergencies b/se the associated joint
structures, blood supply, and nerves are
distorted and severely stressed.
• If the dislocation is not treated promptly,
avascular necrosis (tissue death due to
hypoxia and diminished blood supply) and
nerve palsy may occur.
Signs and symptoms of dislocation
– acute pain,
– change in positioning of the joint,
– Shortening of the extremity,
– loss of normal mobility,
– Deformity
X-rays confirm the diagnosis and
demonstrate any associated fracture.
 Management
The affected joint needs to be immobilized
while the patient is transported to the
hospital.
Immobilize by bandages, splints, casts, or
traction and is maintained in a stable position
Promptly reduced
Analgesia and possibly anesthesia are used to
facilitate closed reduction.
 Management…
Assess neurovascular status before and after
reduction, including strength of the pulse,
capillary refill time, sensation, movement,
pain, and color of the skin.
After reduction, if the joint is stable, gentle,
progressive, active and passive movement is
begun to preserve range of motion (ROM) and
restore strength.
 Management…

• Nursing care is directed at providing comfort,

evaluating the patient’s neurovascular status,
and protecting the joint during healing.

• The nurse teaches the patient how to manage

the immobilizing devices and how to protect
the joint from re injury.
 Fractures
 Any disruption/ break in the continuity of bone,
when more stress is placed on it than it can absorb”.
 When its occurs, muscles are also disrupted & pull
fracture fragments out of position
 Adjacent structures are affected – soft tissue edema,
hemorrhage, joint dislocations, ruptured tendons,
severed nerves, damaged blood vessels
 Large muscle groups create massive spasms, the
proximal portion remains intact while the distal
portion can be displaced in response to force and
spasm.
Causes

 Direct blow

 Crushing force (compression)

 Sudden twisting motions (torsion)

 Severe muscle contraction

 Disease (pathologic fracture)

 Classification of Fractures
Closed or open
Simple or compound
Complete or incomplete
Stable or unstable
Direction of the fracture line
 Oblique
 Spiral
 Lengthwise plane (greenstick)
 Types of Fracture
Simple: # remains contained, no skin break
(closed)
Compound: # damage also involves the skin or
mucous membranes (open)
Comminuted: bone has splintered into several
fragments
Greenstick: one side of bone is broken and
the other side is bent
Depressed: bone fragments are driven inward.
 Cont…
 Avulsion: # in which a fragment of bone has been
pulled away by a ligament or tendon and its
attachment.
 Oblique: # occurs at an angle across the bone
(less stable than a transverse)
 Spiral: # twists around the shaft of the bone
 Impacted: # in which a bone fragment is driven
into another bone fragment.
 Transverse: # across the bone
 Compression: # in which the bone has been
compressed (Vertebral #s)
Types of Fractures(cont’d…)
Types of Fractures(cont’d…)
 Common sites for fractures

• The following bones are commonly break

– Upper arm (humerus)

– Forearm (radius/ulna)

– Wrist

– Lower leg (tibia/fibula)

– Ankle
 Clinical Manifestations
 Pain
 loss of function
 Deformity
 Shortening of the extremity
 Crepitus (a grating sensation palpation)
 Swelling and discoloration.
 False movement
Note: all of these clinical manifestations may not
present in every fracture.
 Stages of Bone Healing
 The process of fracture healing (bone healing) stages:
1. Hematoma formation:-blood collects in the
periosteal sheath or adjacent tissues within 48 to
72hr after injury fastens the broken ends together.
2. Granulation tissue formation:-
 Fibroblasts;- invade the hematoma forming a fibrin
meshwork
 Osteoblasts;- invade the fibrous union to make it
firm;
 Blood vessels will develop from capillary buds.
 These all form a granulation tissue.
 Cont…
3. Callus formation:-osteoblasts form an
unorganized network of bone (callus) that is
woven about the fracture parts.
 Callus is formed mainly by deposition of
minerals (calcium and phosphorous).
 It begins to appear by the end of the first week
after injury.
 The callus unites and helps to stabilize the
fragments
 Not strong enough to bear weight or withstand
stress.
 Cont….
4. Ossification (consolidation)
 Begins with in 2-3 weeks after the fracture
and continues until the fracture heals.
 Stage where restructuring of callus takes
place.
 Collagenous fibrous net work is produced that
become impregnated with mineral salts
(calcium and phosphate) to form bone tissue.
 5. Remodeling
The final stage of fracture healing.
 Excess callus is reabsorbed and the union is
completed.
 Osteoclasts are responsible for this action

 Bone healing completed within about 6 weeks

up to 6 months in the older person
Bone Healing(cont’d…)
A. Fracture hematoma
B. Granulation tissue
C. Callus formation
(minerals deposited in
osteoid)
D. Consolidation
E. Remodeling
 Management of fracture
 Analgesics

 Antibiotics – when an open fracture has

occurred or surgical intervention is necessary.
 Tetanus anti toxoid – in case of open fracture

 Vitamin (especially vit B & C), calcium , iron ,

protein, fluid & fiber diet.
The overall goal of fracture management:-
 To reduce the fracture by realigning the
fracture
 To maintain the fragments in correct
alignment through immobilization
 To restore function
 Immediate management of fracture

Prevent movements of the injured parts

Immobilization by preserving correct body
alignment
Elevation of the injured part(if possible)
Application of cold packs
Observation for changes in color, sensation,
circulation and temperature of the injured
part.
 Immediate management …

If a fragment of bone is protrude, cover the

entire wound with sterile dressing
Do not attempt to cleanse the wound
Don’t replace any bone fragment
Reassure and calm the causality
Refer for subsequent management
 Splint Applications

 Splints are devices applied to parts of a body

especially on the arms, leg, and trunk to
immobilize the injured part when a fracture is
suspected or diagnosed.
 Splints are used to;

• Prevent further injury

• Decrease pain

• Decrease the likely hood of developing shock.

 Principles of splint application
 Splints can be made from the locally available
materials. E.g. splint can be made from a straight stick,
pillows, blankets or other hard boards or cartons.
 During splint application
– Splints should involve the adjacent joint
– Splints should be well padded in between the splint
and the skin, specially on the bony prominences,
– Pads should extend above the ends of the splint
 Principles of splint application…

– Do not hold splints to tight; it may result in

compartment syndrome.
– If a fracture is on the arms and legs, check
distal pulses and discoloration frequently.
– If there is numbness, tingling sensation
loosen the splint.
 Specific fractures

Fracture of the scapula (shoulder blade)

• It is generally the direct result of the impact of a
fall or an automobile collision.
• Dislocations of the shoulder joint, sprains and
contusions are common in this area.
• First aid consists of applying a sling and
bandaging the victim’s upper arm to his chest wall.
Figure: Applying arm sling for fracture
of the scapula
 Fracture of the upper arm (Humorous)

• Can be due to a fall or direct injury

• First aid measures include
Place a pad in the victim’s arm pit, apply a splint
in place above and below the break area
Support the forearm with a sling that does not
produce upward pressure at the fracture site.
Bind the victim’s upper arm to his chest wall
Applying splint for fracture of the upper
arm
 Fracture of the arm and wrist

• The two bones of the forearm ( radius and ulna)

may be fractured individually or together
• First aid measures is the same as fracture of the
humorous.
• Immobilize the broken bone ends at the wrist
and the elbow by well padded splints on each
side
• Bend the elbow and apply a sling with a slight
elevation keeping the thumb pointing upward
Applying splint for fracture of the arm and
wrist
 Fracture of the spine
• The back bone, or spinal column is composed of 26
bones called vertebrae. It encloses the spinal cord
which passes through circular openings in the
separate vertebras.
• Fracture of the neck or back are extremely dangerous
because the slightest movement may cause further
damage to the spinal cord and result in paralysis.
 First aid for fracture of the back (Thoracic and lumbar vertebrae)

 Handle as gently as possible (avoid

unnecessary movement).
 Log rolling is a primary technique used to
move a patient onto a long backboards.
 Send for an ambulance.
 Trauma Logroll
• Log rolling is a primary technique used to move a
patient onto a long backboards.
 One person = Cervical spine
 Two people = Roll main body
 One person = ready backboard
First aid measures for fracture of the neck
(Cervical Vertebrae)
 Do not allow the victim’s head to be bent foreword or
backward or to move from side to side.
 If the victim is lying on his back, a small pad or towel may
be placed in the space under his neck (do not put a pillow
under his head).
 Place rolled up clothing, blankets or sand bags around to
prevent movement.
 Seek medical advice and send for ambulance with trained
personnel.
Cont…
 Fracture of the upper leg (femur )
• It usually result from falls or traffic injuries. The victim is in
sever pain and shock and markedly disabled.
• The injured part/ foot is turned out ward and the limb
shortened.
First aid measures
• Apply well- padded splints & the bandages will be tied on the
following areas: just below the arm pit, at the abdomen, at the
hip, above and below the fracture site, at the lower leg and
ankle.
• Don’t try to cleanse open wound (if present).
• Send a victim to hospital for subsequent management
Applying splint for fracture of the upper leg (femur )
 Fracture of tibia and fibula

 The bones of the lower leg are the tibia

(shinbone),
 It supports the weight of the body and

 The fibula, which forms the outside wall of

the ankle and is on the outer side of the leg.
 Fracture of tibia and fibula
 Apply well- padded splints on both sides of the leg and
foot from the top of the patient’s thigh to his foot.
 The splint will be secured with a bandage
 In an emergency, insert blankets or towels between the
legs and tie them to gather.
 Remember to keep the victim’s foot pointing up ward
and
 Check for poor circulation, prevent movement of the
broken bone ends, knees and ankle.
• Send the victim to hospital for subsequent management
Applying splint for fracture of the tibia and
fibula
 Fracture of knee-cap (patella)
A broken knee-cap may be the result of
direct force or muscular action( e.g.
playing football)
Splint the leg from ankle to thigh
Place soft padding under the victim’s
ankle to raise his heel off the splint
Raise his leg slightly to prevent swelling
Refer for subsequent management
 Fracture of ankle and foot

• Fractures in this area occur most commonly in

active sports, in falls and in motor vehicle
accident.
First aid measures
 Loosen or remove the victim’s shoes, and socks
and
 Keep him lying down with his leg elevated.
 For an open wound apply large bulky dressings.
 Splint with a pillow or blanket firmly applied
with out attempting to correct the deformity.
 Refer for subsequent management
Figure Splinting ankle and foot
 Subsequent management
1. REDUCTION
• Reduction refers to restoration of the fracture
fragments to anatomic alignment.
I. Closed Reduction: closed reduction is
accomplished by bringing the bone fragments
into apposition (ie, placing the ends in contact)
through manipulation and manual traction.
II. Open Reduction: Through a surgical approach,
the fragments are reduced.
• Internal fixation devices (metallic pins,
wires, screws, plates, nails, or rods) may be
used to hold the bone fragments in position.
 Subsequent management…
2. Traction

 The application of a pulling force along the

long axis of the bone distal to the fracture.
 For this force to be effective, a force in the
opposite direction (counter traction) is
required
 Provided by elevating the foot of the bed
 Traction is used:
To minimize muscle spasm.
 To reduce fracture fragments
 To immobilize fractures
 Types of traction
A. Skin traction:-achieved by applying a wide
band of adhesive directly to the skin and
attaching weights.
 The pull of weight is indirectly transmitted to
the involved bone.
 The maximum weight applied is 2 to 4 kg.
 More weight can cause skin damage
E.g. Buck’s extension traction
• Traction
Skin traction
 Types of traction…

B. Skeletal traction
 Applied directly to the bone with local or general
anesthesia.
 A pin is inserted through the bone distal to fracture.
 It protrudes through the skin on both sides of the
extremity
 The ends of the pin should be covered with cork or
metal protectors
 A U shaped metal or a bow is attached to the pin,
which is tied to a rope on which the traction weight
hung.
 Skeletal traction is used for fracture of tibia, femur,
humerus and cervical spine.
Skeletal Traction
 Subsequent management…

II Open Reduction
 the correction of bone alignment through a
surgical incision.
 It is indicated for
 Unstable or open fracture
 Those with significant soft tissue injuries
 Failed closed reduction
 Intra articular fractures
 Open reduction may include internal fixation of
the fracture.
 Subsequent management…
III. Immobilization
After the fracture has been reduced, the bone
fragments must be immobilized, or held in correct
position and alignment, until union occurs.
Immobilization can be accomplished by:
A. External fixation devices
 Cast, splint, Brace
 Traction
 External fixators
B. Internal fixation devices.
 Cast
The most common external fixation device
Materials used for casts plaster of paris( POP)
 less expensive, fiber glass and Plastic.
 All of the materials are available in rolled
bandages, and are applied over the body part to
be immobilized
A cast may enclose – all or part of an extremity
- The trunk
- Trunk with all or a portion of
one or both extremities
 Types of Casts
• Short arm cast: Extends from below the elbow
to the palmar crease and is secured around
the base of the thumb.
• Long arm cast: Extends from the upper level
of the axillary fold to the proximal palmar
crease. The elbow is usually immobilized at a
right angle.
 Types of Casts (cont’d…)
• Short leg cast: Extends from below the knee to
the base of the toes.

• Long leg cast: Extends from the junction of the

upper and middle third of the thigh to the
base of the toes.

• Others
– Body cast, Shoulder Spica cast, Hip spica cast
Types of Casts (cont’d…)
Cast are applied after the skin is cleansed and
examined for any potential areas of infection
or breakdown.
The part then enclosed in circular stockinette
for skin protection and extra padding is made
over bony prominences.
External Fixator
Internal fixation
 Care of a patient with cast

A cast permits mobilization of the patient

while restricting movement of a body part
After application of a plaster cast
 Handle it with palm of the hand
 Support it on firm and smooth surface
 Do not rest cast on hard surface or on sharp
edge
 Promote drying of cast by leaving cast
uncovered and exposed to circulating air
 Cont…
Depending up on the thickness and environmental
condition a cast may take 24-72 hours to
completely dry.
A wet plaster cast appears dull and gray, sounds
dull on percussion, feels dump and smell musty.
A dry plaster cast is white and shiny, resonant,
odorless and firm.
Assess and manage pain by:-
 Elevating the part
 Administration of analgesics
 Cold application if prescribed
 Cont…
Pain may be indicative of complications
(compartment syndrome or impending pressure
ulcer).
 In these conditions it may be necessary to modify
or apply a new cast
Improve mobility – every joint that is not
immobilized should be exercised and moved
through its range of motion to maintain function.
Promote healing of skin abrasions – perform
wound cleaning and dressing and monitor systemic
signs of infection, odors from the cast, a discharge
that stains the cast.
 Cont…
Maintain adequate neurovascular function –
monitor circulation, sensation, temperature,
color, ability to exercise fingers or toes of the
affected extremity.
Progressive unrelieved pain, pain on passive
stretch, paresthesia, motor loss, sensory loss,
coolness, paleness, slow capillary refill,
sensation of tightness indicate potential
compartment syndrome.
 Monitor and manage potential complications
 Compartment syndrome – occurs when there is
increased tissue pressure within limited space that
compromise circulation and function of the tissue with
in confined area.
 To relieve pressure elevate the extremity no higher than
the heart level
 Pressure ulcers – caused by pressure of the cast on soft
tissue.
 A patient with pressure ulcer reports pain and tightness in
the area, a warm area on the cast suggests underlying
tissue erythema or drainage may stain the cast and emit
odor
Compartment syndrome
 Monitor and manage potential complications

 Disuse syndrome
 Immobilization in a cast can cause muscle
atrophy and loss of strength
 While in a cast patient is taught to tense/
contract muscles. i.e muscle setting exercise
 This helps to reduce muscles atrophy and
maintain muscle strength.
 Monitor and manage potential
complications
 Skin breakdown – monitor reaction of the skin
 Provide back care
 Nerve pressure – assess sensation, motion
(movement of toes and foot) and burning
sensation under the traction bandage.
 Circulatory impairment - assess peripheral
pulses, color, capillary refill and temperature.
 Assess indicators of DVT- calf tenderness,
swelling.
 Monitor and manage potential complications

 Pneumonia- prevented by deep breathing and

coughing exercise
 Constipation and anorexia – encourage high
fiber diet and fluid
 Urinary stasis and infection – encourage
adequate amount of fluid.
 Venous stasis and DVT
 Factors that impend bone healing
 Poor approximation of fragments
 Inadequate immobilization
 Compromised blood supply
 Excessive edema at the fracture site
 Infection at the fracture site
 Soft tissue injury
 Metabolic disorders (cancer, diabetes,
malnutrition)
 Medication (steroids, anticoagulants)
 Complications of Fracture
1. Early complications include:
 Shock,
 Fat embolism,
 Compartment syndrome,
 Deep vein thrombosis,
 Infection.
Complications of Fracture(cont’d…)
2. Delayed complications include:
 Delayed union and nonunion,
 Avascular necrosis of bone,
 Reaction to internal fixation devices,
 Complications of Fractures(cont’d…)
Fat Embolism Syndrome (FES)
Clinical Manifestations
– Usually occur 24-48 hours after injury

• Altered mental status

• Low arterial oxygen level and then pt

experiences tachycardia
• Symptoms of ARDS
 Complications of Fractures(cont’d…)
Fat Embolism Syndrome (FES)

• Symptoms of ARDS:
• Chest pain
• Tachypnea
• Cyanosis
– Rapid and acute course
– Feeling of impending disaster
– Patient may become comatose in a short
time
 Complications of Fractures(cont’d…)
Fat Embolism Syndrome (FES)

• Collaborative Care
– Treatment directed at prevention
– Careful immobilization of a long bone fracture
• Most important preventative factor
– Symptom management
– Fluid resuscitation and oxygen administration
– Steroids to treat the inflammatory lung reaction and
to control cerebral edema.
– Morphine for pain and anxiety
– Reposition as little as possible
 Amputation
• An amputation is removal or excision of part or
whole of a limb, usually an extremity.
Indications
 Progressive peripheral vascular disease . E.g.DM
 Trauma / accident- (crushing injuries, burns,
frostbite, explosions, ballistic injuries)
 Malignant tumors
 Congenital deformity
 Infection (fulminating gas gangrene, chronic
osteomyelitis, osteoarthritis. )
Thank You