musculoskeletal disorders fractures immobilization and osteoporosis before you dive into this content be sure you are free from distractions and can debit your full attention be sure that you have read the textbook pages that are associated with this content be prepared to actively learn I will be sharing my knowledge and understanding with you but you must do the learning participate in your learning you will be the nurse next to that patient not me you need to acquire the knowledge skills and attitudes to take care of that patient safety competently and compassionately think beyond your next classroom exam rather think about being that nurse taking care of that patient that is what you are preparing for not classroom examinations listen with curiosity asking questions seeking answers imagine being the nurse responsible for the care of this patient imagine being the patient needing this nursing care think about your prior experiences that are related to this content from both the health care provider's point of view and or the patient's point of view think about building knowledge on the foundation of what you already know be prepared to change your understanding of this content if new information is presented take advantage of this recorded source pause as needed to think about the content or write down notes or questions be curious about learning more review the content and your notes as needed to gain understanding that you seek test yourself on the content to determine if you really learned it or not this slide contains the learning objectives that you should meet upon completion of this content I recommend that you pause the recording read these carefully make sure you understand the purpose of this learning session and that you can measure that you've accomplished them at the end the first thing I want you to do is pause and reflect I want you to start by stopping the recording and thinking and writing down in these three areas I want you to think about what you already know about this topic and write down at least three to five items I want you to stop and think about any of your prior experiences related to the content I want you to write down your thoughts and feelings related to your experiences lastly I want you to think about what you don't know about this content think about you know Dax of knowledge and understanding and things that you're curious about learning write down at least three to five items then you'll be ready to dive into the content let us consider what the pathophysiology is of a fracture and it is classified as an interruption of bone Integrity either complete or incomplete and it has many different causes including trauma pathological fractures stress fractures and avulsion fractures and if you don't know what those particular fractures are those classifications then you should go and look that up uh additional ways fractures can be classified are as stable or unstable complete or incomplete simple or compound displaced or undisplaced intraocapsular or extra capsular linear impacted oblique common noted compression and spiral included on this particular slide are some images and some definitions explanations for what these different fractures are so this one might be a good study reference for you when we're talking about fractures we want to think about clinically how does this patient present to us we want to think about the manifestations the signs and symptoms that will be shown in a patient that has a fracture generally speaking their first complaint will be of pain um it also manifests in immobility muscle spasms sometimes deformity where you can actually see that things are not lined up appropriately such as a limb that's maybe turns completely contrary to its normal linear Arrangement edema around the injury in the soft tissue there may be warmth in that area of injury ecchymosis numbness and tingling sometimes occur and crepitus where we feel that grading and and grinding because those bone ends are where the fracture is those bones are grating against each other so when you think about a patient presenting like this you want to think about our priority as the nurse what's the most important assessment that we need to do I would really like you to pause the video and take a minute write down what you think would be the top three systems that the nurse would want to assess in this patient presenting to you yeah all right so we're pausing and we're thinking before I necessarily tell you my thoughts on it I want you to consider what you think would be the most important assessments which systems are you most concerned about are there any particular safety concerns because our number one concern in nursing is keeping our patients safe in whatever situation they present in our number one concern is patient safety so I would suggest that we want to assess musculoskeletal system most definitely we want to know about their ability with this current injury you probably want to check range of motion and muscle strength we want to check the skin on especially on the injured lib the color of the temperature looking for lesions feeling for pulses checking for edema I would also suggest that we want to do a really good pain assessment on this patient as I said already patients number one complaint is generally going to be pain and so we need a good pain assessment we need to know whether they hurt only when they try to walk or use that limb or if it hurts even at rest um and if the pain is getting worse and intensifying I also would suggest we want us assess the patient for their safety needs we want to look at are they able to ambulate is it safe for them to ambulate do they need assistance if they do what kind of assistance is a person standing with them with the gate belt it's going to be sufficient or maybe they need a walker or maybe they ought not to to get out of bed at all until this fracture is addressed number of different options that will happen based upon the specific patient presentation um we also want to know if um if they're going to have to be bed bound because of this injury we also need to know um how well we'll be able to work with them on keeping them turned so that we can protect their skin from breakdown and pressure injuries additionally anyone who has a fracture from maybe a trauma including a fall we want to find out are there other injuries besides this particular fracture because there could be other concerns especially if this patient took a fall or perhaps was in a motor vehicle crash and they also injured their head and we want to make sure that we assess for a head injury and in all of those kind of cases so then we would look at what do we expect the medical management of this patient to be what kinds of things do we expect that our providers will order for the care um diagnosis of the problem and the care of it so we would probably anticipate some form of Diagnostic Imaging like x-ray CT MRI and we all want to be able to visualize the injury so that we can gain information and determine the plan of care we'll probably be looking at reduction reduction would mean the bones being realigned so that there can be healing taking place and immobilization so that they'll stay lined up and be able to heal there's a number of different ways that reduction can take place and the immobilization can take place um it does help to decrease the pain and increase the healing when the bone is realigned and stabilized we're also probably looking at some form of pain management for this patient because once we've created the situation where the bones are realigned and now the body has to do the work of healing we have to manage the patient's symptoms in the meantime which would include swelling which would include pain um maybe muscle spasms those kind of things that happen because there's been damage and until that's healed that patient's going to have some concerns in those areas and it'll be our job to help manage that so you should expect the provider to order some form of pain management for this patient um there's additional management is just depending upon the fracture depending upon its location its severity um sometimes the age of the patient plays a factor in this there's different ways that it will be reduced and immobilized so it can be that it is just reduced by pushing the you know adjusting the bones like physically manually adjusting the bones um or perhaps the fracture is not really dislocated dislodged from its place and so we just need to make sure it stays that way and it can heal so sometimes there's um what's called external um reduction and then you might have open reduction with internal fixation that's termed o-r-i-f and that is can where the patient goes to surgery they do a surgical procedure that opens that area realigns the bones using um different methods for fixation they'll put plates screws Nails different wires and that will depend upon the condition of the fracture and several other things like what kind of fracture it is the age of the patient those kind of things to stabilize that and so it can heal that is open reduction with internal fixation and then we can have external fixators now this patient may still go to surgery to have internal things done but they have external fixation done where there are devices attached to that limb that immobilizes it so that they can stay in alignment while their body heals here you can see several images of different means of casting um and an injured limb to immobilize it these are all considered external fixation devices uh casts for various fractures in various configurations and it just it depends upon which bone is injured and how it needs to be immobilized so that it can heal you'll see that there are arm casts leg casts and body or spica casts they're different um configurations here you can see that there are some that are fiberglass there are some that are plaster there are some like this boot in the in the picture here that is for made for immobilizing and yet the patient can still walk on this that would be considered a walking boot or brace or even sometimes called a cast um just depending upon what the cast is made of there'll be different restrictions for your patient cluster casts cannot get wet because then they just get they're not rigid anymore they get soft and smooshy and then they're not holding the bone properly um the fiberglass cast can get wet patients can shower sometimes they can even go swimming and different things when the cast is is what they need to kind of drain it and let it air out a little bit um the one task here that is in the in the kind of in the center upper is been created with um 3D printing so it is specialized to that patient and formed to their arm and you can see how it's breathable you can see that you know you can monitor for any uh underlying skin issues that could happen or you can imagine with these uh other casts with the um fiberglass and the plaster you can't see underneath what's going on so you don't know if perhaps there's a skin issue developing underneath um so these are are pretty neat invention and I think we're going to see more and more different types of of immobilization devices coming up that that are improvements over some of the older methods although you will see a lot of the older methods are still being used I'll take this opportunity to encourage you once again to pause and think I would like you to consider what might go wrong with a casted extremity and what patient teaching should be included when a patient has this kind of medical device that is in place so stop the audio and think for a few minutes jot down a few ideas and consider what you think could go wrong and what patient teaching should be included these images show you some of the possible ways that open reduction with internal fixation is done you can see that depending upon the kind of fracture the location of the fracture what repair might be completed you can see that they're talking on this image about the femoral neck or the intra trochanter fractures and they're treated a little bit differently because there's different part of the bone that's been interrupted on the left side of the screen you can see these x-ray images of plates and screws that have been used to fixate bones and now the images were taken after surgery to make sure everything is lined up properly and to get an idea of what it all looks like in total now think about the fact that when you have an open reduction now not only are you still having all the same concerns about your patient's safety because they've had a fracture now you're also thinking about a surgical incision that is now something that nurses need to care for and monitor and keep the patients safe so we're also thinking of pre-op and post-op concerns as the nurse taking care of this patient in in the pre-op and post-op areas this slide shows you several options that are used in external fixation and traction you can see on the far left this device that has all the Rings and um rods connecting them and you see those little white foam squares those are actually covering the pins that are inserted through the patient's skin and clamped down to hold it in place to maintain that immobilization so that that leg can heal so when you think about having patients that have external fixators such as this and there are pins now we have all the regular concerns for a patient with immobilized limb but in addition now we have all these pin sites which are potential risk for infection so every pin site has to be carefully monitored they are cleaned in a sterile way so that we don't introduce infection um the process by which the pin sites are cared for will be included in your provider's orders and your facilities will have equipment that will be used to take care of them but generally it includes using sterile technique with a cotton tipped applicators and sterile water and every time you use an applicator you're gonna use it with one swipe remember how you did when you were doing your um urinary catheter and or sternal technique and you had to use each swab for one wipe it's similar here and so you're going to use as many cotton tip applicators as is necessary to do a thorough job and each site is going to be monitored for those signs and symptoms of infection which you should know by heart um remember to clean from the insertion site outward so that you don't drag contaminants into the wounds um per order you may apply some ointment of antimicrobial if it's ordered and sometimes there'll be a specific dressing and that'll be in your provider's orders as well remember that it would be important to teach your patient what signs and symptoms that infection look like so that they can be your partner in monitoring and we need to teach them not to disturb the pins and sometimes patients will complain of like itching around the instruction site we don't want them scratching at it we don't want them trying to rub it with any objects and if the pins become loose we need to contact the provider because they'll need to come and see about re-tightening them so um think about all of the aspects that would be necessary in addition to the immobilized patient when they have this external fixation in the center of this slide you see several different methods that are used for traction that help either hold um the reduction or just relieve um like the muscle spasms that can happen in particular on the right hand side where we see box traction that is what's called Skin traction it's not it external fixators um well here's on the external but it's not through pins and so therefore it doesn't pierce the skin often used in a femoral neck fractures and femoral fractures in children femoral neck fractures mostly in our older adult population that maybe Falls and has a fractured hip the Bucks traction does not reduce the broken limb it does not hold it in place and Alignment it is used before surgery and it is used to relieve the muscle spasms that occur when that hip is fractured and then the muscles don't have the support that the bone would usually Supply so the muscles often spasm and it's very very painful for patients and so the Box traction helps to relieve that um it puts tension on the muscles so that they don't spasm because they don't have the support that they're used to it is a the whenever you have a patient in traction you're going to have pulleys you're going to have weights you're going to have ropes and strings and then whatever's attaching this to the patient's limb or in some of these cases you can say it's to their head to hold tension um all the pulleys ropes the ropes have to be um held straight or you know on their on their proper angles the weights have to hang freely if the weights are not hanging then we're not being held in the proper position and so if you have to try on a patient the weight still has to hang if you have to transport a patient the weights still have to hang freely if you remove the weights or lay them in the bed instead of let let them hang then then there's a problem with alignment and um it can cause either in the case of bugs traction those muscle spasms to return or in some of these others where the attraction is actually holding alignment to help with healing then now we have um misalignment of the bones and perhaps having to start the whole healing process again here again I'd like to encourage you to pause the recording and spend some time thinking about these questions what could go wrong for a patient in traction What nursing considerations are there what safety concerns are there so what kind of Nursing Care is needed when a patient is in traction and you are responsible for their treatment and their safety all right now just a a minute or two on some potential complications that can happen from fractures I want you to consider that if a patient has a open fracture now we have a broken bone that is puncturing through the skin and giving the potential for a severe infection even into the bone um also even if it's not an open fracture if it's displaced then those broken ends of the bone can cause damage to other tissues internally uh you really need to make sure that you understand compartment syndrome which is a very real problem that can happen with fractures it is one of the most serious complications when a person has casting or splinting when there is too much pressure in those muscular spaces and those compartments and then we have compromised blood flow and nerve conduction to the tissues that are distal remember to check your neurovascular assessments so you need to remind yourself of what those neurovascular assessments are what you're actually testing for when you do them how to properly do each of those assessments and what to do with the information when you gather it um an additional possible complication of fractures is fat embolisms and this is most frequently with fractures of long bones like the femur and the tibia and with pelvic fractures um you need to make sure that you recognize what your signs and symptoms of a fat embolism look like they're very similar to PE but they do have some key differences so you need to make sure that you understand what that might look like for your patient and to um how to assess and monitor for it occasionally patients because of the length that it takes the time it takes for a bone to properly heal and this limb needs to be immobilized continuously until the healing process is done sometimes there is some deterioration of the body because of the inactivity so we want to try to encourage our patients to stay as mobile as possible if there are certain motions that they are not allowed to do then we want to be careful but anything that they can do to keep that mobility and muscle strength we want to teach and encourage them what to do now just a little bit on some specific fractures that kind of have some they're either very frequently seen or have some special considerations so that we need to know and what this patient's going to need based on the kind of fracture that they have we have um head fracture is generally what we just refer to it at but it's usually the femoral neck that breaks and remember that a patient can have a fall that causes a fracture or they could have a pathological fracture wherein the bone is compromised from osteoporosis and it can no longer bear the weight of the body and so the bone actually breaks and then the patient falls down okay it can go either way Hip fractures are very very common in the older adult population and when you see one you'll you'll recognize that the leg is likely to be shorter on the fracture side and adducted and externally rotated um usually they cannot move that leg without significant pain this is the patient that often would benefit from Buck's traction but consider the fact that generally these are older adult patients so they probably have other comorbidities going on that we also have to manage and they're also at a higher risk for um atelectasis and pneumonia dvts and pressure injuries and and they're have anxieties and stresses like everybody else um these are often fixed with open reduction and internal fixation depending upon the nature of the fracture and the quality of the patient's bone sometimes they'll have a total hip surgery like a total hip arthroplasty or a Hemi which is half of a hip so they may only replace the ball side of the bulb and socket joint um there are some specific precautions for hip patients so you need to look into that and be familiar with the hip precautions so that we can help protect this patient from any complications of that hip surgery and help them in their recovery another frequently seen kind of fracture are rib fractures and before rib fractures there's very little medical that can be done for them because it's very difficult to immobilize or fixate those ribs when they're fractured so often it's just the healing process that takes time sometimes the patient will receive like a brace or a wrap that will help to support those ribs and um kind of ease that pain somewhat um our hip I'm sorry a rib fracture patients are at risk more than others for developing atelectasis because they don't really feel like taking those deep breaths they don't want to take deep breaths and they don't want to cough because it hurts so this is a place in time where it would be helpful to teach the patient how to splint their um tender area and support it while they do their deep breathing and coughing because it's so very important that they do that unless they might develop a pneumonia and then they have additional problems on top of the fractured ribs and then the last one I have on here is the humorous fracture and when a patient has a fracture of their humerus often it's the humoral neck that is fractured but it can be the shaft as well um the um major problem with a humerus fracture is the fact that um it has to be immobilized often with a sling and a swath which holds the weight of the arm and keeps it tight to the body so the sling holds the weight of the arm and the swath goes around to help the arm stay positioned tight to the body and if you can put yourself in that position and think about what it would be like to be the patient um it really disturbs their balance and it makes walking more of a safety issue and so it's very concerning that we want to protect this patient from a fall that could cause even further problems or maybe even another fracture so those are some of the considerations for some of these special types of fractures that we often see here is another opportunity I want you to do Applause and think and this time I want you to think about the holistic and psychosocial care concerns for this patient I want you to think about the top priorities in holistic and psychosocial care for a patient with a fracture I want you to think about question is and that would be physically and uh mentally and what anxieties do you think might be present for a patient with a fracture now we'll move into discussing osteopenia and osteoporosis which seems to be a very good fit with the discussion on fractures because often osteopenia and osteoporosis are underlying causes and risk factors for a patients become fractured if from a trauma or a fall [Music] osteoporosis textbook will say that it is a degenerative disease of the bone characterized by reduced Mass deterioration of the Matrix and diminished architectural strength and you saw on the previous Slide the uh empty um that is less dense than it used to be and it structurally losing its strength because of uh more bone loss than bone growth um primarily occurs in women after menopause which is approximately 50 51 years old men often experience osteoporosis as well but it's usually at an older age than women I want you to notice on this image that I have here that part of what we see is the deterioration is that women tend to lose some of their height and their bone density as they get older and you see how the posture changes and they become more slumped and have that uh curvature change in their upper spine you should be aware that there are a number of medications and disease processes that affect bone metabolism and you should look into which ones of those meds and diseases impact the bone and what risk factors there might be besides aging and loss of certain hormones that might contribute to bone loss osteoporosis is not generally manifested clinically until either a bone scan is done and we see what's going on with the bones or often a patient will have a fracture and then it is determined that they had osteoporosis that was uh the reason why they they fractured when they maybe had a fall um considering what this image shows about the the kyphosis that can occur as the bone is deteriorating and we see that that slumping going on consider the fact that it it compromises the center of gravity so a patient's balance is going to change when they develop this slumping and it also changes their ability to um take deep breaths so often lung capacity is affected and it may cause them to have like a lesser ability to have a good effective cough and take good deep breaths um so like I said often it's not detected unless a bone scan is done we do want to check about family history because it does tend to run in families nutrition impacts our bone health and our bone quality so we want to ask patients about their nutrition calcium and vitamin D are very important all the way throughout the life and really especially in our younger years because the better bone we build younger the better quality our bones will be when we get older um weight-bearing exercises are really beneficial to help promote rebuilding of new bone you know we have this turnover that's naturally happening where bone is broken down and rebuilt and broken down and rebuilt and this is just a continual process that our body does but as we get older and we lose certain hormones we end up having more bone loss than we have bone growth so the net effect is bone loss and weakening and deterioration of the bone one of the things that can help promote regrowth of of bone and Bone formation is weight-bearing exercises so that would be stuff like just walking um not stuff like swimming or bicycling because you're not really bearing your weight on your bones when you're doing those kind of activities to ought to look into your book to make sure that you understand the medications that are used for helping regrow bone or slow down its deterioration the focus of this course is on Pharmaceuticals although we do have to consider because as every time you're taking care of patients and every time that there are medications involved we need to know what's what's going on what meds are why they're being given what the effects are supposed to be are they having adverse effects to their side effects and are they taking that appropriately in all of the um things that we check when we're talking about meds um I want to stress that when a when a patient has this deterioration in their spine like this image shows and they develop the kyphosis and mentioned that it can change their center of gravity and lead to Falls and it changes their lung capacity there are um some surgical procedures that can be done that help to strengthen the spine there is they can sometimes have an orif of the spine or they can have kyphoplasty which helps to um kind of build up and strengthen the spine so that they can get their their height back their ability to stand up and um that that improves their risk of Falls and their ability to to breathe deeply okay I have another challenge for you to pause and think I want you to think about what patient education would you provide for a teenager regarding prevention of osteoporosis and then contrasts that with what patient education would you provide an older adult that's already diagnosed with osteoporosis those are going to look quite different and it's a good exercise for you to think about comparing and contrasting these two different scenarios now it's time for you to review the content review your notes review your reading test yourself to see if you have met these learning objectives if you still have gaps then you need to dig in deeper and look for the answers to the questions so that you can say you have mastered this content and a and achieved these learning objectives