COLLABORATIVE

In the emergency situation, planning and implementation are related to the priorities of ABCs and neurological status. Unless the musculoskeletal injury is threatening the patient's circulation because of bleeding, management of musculoskeletal injuries usually occurs after the patient is stabilized. When a musculoskeletal injury interrupts a bone or joint, the trauma causes severe muscle spasms that lead to pain, angulation (abnormal formation of angles by the bones), and overriding of the ends of the bones. These complications need to be managed immediately to prevent increased soft tissue injury, decreased venous and lymphatic return, and edema. If the patient has any exposed soft tissue or bone, cover the area with a wet, sterile saline dressing. Prevent reentry of a contaminated bone into the wound if possible.

Early immobilization of the extremity at the trauma scene—which is actually the first step in trauma rehabilitation—preserves the function and prevents further injury. Immobilization limits muscle spasm, decreases angulation and injury from the overriding bone ends, and prevents closed fractures from becoming open fractures. Traction may also be applied to align bone ends in a close-to-normal position. This procedure restores circulatory, nerve, and lymphatic function and limits tissue injury and swelling. Generally, immobilization devices that are applied before the patient is admitted to the hospital are left in place until x-rays are performed.

When the fracture is confirmed by diagnostic testing, the bone is reduced by restoring displaced bone segments to their normal position. When the physician restores the bone to normal alignment, venous and lymphatic return improves, as does soft tissue swelling. The orthopedist may perform a closed reduction in which she or he manually manipulates the bones to restore alignment. When closed reduction is not possible, a surgical (open) reduction is performed. The method of reduction depends on the grade, type, and location of the fracture.

External fixation devices are now being used frequently for many fractures that would until recently have been treated with traction. External fixation, such as the Hoffmann device, is a metal system of rods designed to maintain alignment of fracture fragments. The patient requires less immobilization and therefore usually suffers fewer of the hazards of immobility. Use the device itself to position limbs, unless it is being used to stabilize a pelvic fracture. External fixation devices may also cause complications, however. Some patients react to them with local irritation, and a few develop infections. Monitor the area every 8 hours while the patient is hospitalized and clean it according to hospital protocol. The most common method is with half-strength hydrogen peroxide. Use of povidone-iodine (Betadine) or Neosporin ointment around the pins after cleansing may also be indicated to prevent infection.

Pharmacologic Highlights

Medication or Drug Class	Dosage	Description	Rationale
Narcotic analgesia	Varies with drug	Codeine, morphine sulfate, meperidine hydrochloride	Relieve pain

Other Drugs: Antibiotics, antispasmodics.

INDEPENDENT

Follow the priorities of pain management, emotional support to cope with a sudden threat to health status, and prevention of complications. Pain may be caused by ineffective use of some treatment methods for fractures. Casts, traction, and fixation devices, once applied, should not cause pain. Improperly padded casts or ones that have been damaged may cause irritation and pressure to the casted area. Skin traction that causes friction also leads to impaired skin integrity. If the patient has soft tissue wounds that require treatment, a window in the cast may be needed. Maintain the functional integrity of the cast with attention to both immobilization of the fracture and prevention of further damage to the tissues.

Pain that seems extreme when a patient is casted or in skeletal traction may signal the advent of a compartment syndrome, a condition in which an edematous extremity is constricted by the cast. The patient complains of a burning sensation or other paresthesia. Edema may be present; pulses ordinarily remain intact. Even in the presence of substantial edema, the use of ice is contraindicated because of the danger of increased neurovascular compromise. The surgeon may bivalve the cast, remove the traction, or perform a fasciotomy.

The patient and family need a great deal of support to cope with a serious injury. Allow time each day to listen to concerns, discuss the patient's progress, and explain upcoming procedures. If the patient is a young trauma patient, you may need to work out a schedule with the patient's friends so that they can see the patient but also allow the patient adequate rest. Young adults enjoy diversional activities such as television, videos, compact disks, and radios. Older patients may experience depression and loss if the injury has long-term implications about their self-care. Consult with social workers and advanced practice nurses if the patient's anxiety or fear is abnormal. If the patient is a heavy drinker or was intoxicated at the time of injury, encourage the patient to evaluate his or her drinking patterns and the link between drinking and injury. If needed, refer the patient appropriately for a full evaluation for substance abuse.

Immobilization involving the whole person, rather than one extremity, requires aggressive prevention of the hazards of immobility. Motivate and educate the patient in order to help her or him anticipate and prevent complications. Delayed healing of either wound or bone may occur as a complication of the patient's status at the time of the fracture or as a result of immobility. Encourage a balanced diet with foods that promote healing, such as those that contain protein and vitamin C. Stimulation of the affected area by isometric and isotonic exercises also helps promote healing. Instruct the patient in those techniques, which may not initially seem possible to her or him. They provide a partial substitute for the stimulation to bone remodeling that is otherwise provided by weight bearing. Remember the design adage that is also useful in orthopedics: Form follows function.