Chapter 37: Managing Musculoskeletal Trauma

Managing Musculoskeletal Trauma details the management of patients experiencing musculoskeletal trauma, starting with an essential differentiation among soft tissue injuries like contusions (bruises from blunt force), strains (musculotendinous stress injury categorized in three degrees), and sprains (ligament and joint tissue injury, graded I, II, or III). Initial acute care for these injuries is uniformly centered on the RICE method: Rest, Ice, Compression, and Elevation. The chapter extends this foundational knowledge to dislocations (complete joint separation) and subluxations (partial separation), highlighting these as orthopedic emergencies that require prompt reduction and immobilization to mitigate the devastating risk of avascular necrosis (AVN). Further exploration includes specific injuries such as rotator cuff tears, epicondylitis (tennis or golfer’s elbow), ligament ruptures (ACL, PCL, collateral), meniscal tears, and Achilles tendon rupture, often necessitating management ranging from physical therapy and NSAIDs to arthroscopic or open surgical repair using grafts. The discussion pivots to fractures—breaks in bone continuity—classifying them by type (e.g., closed, open, comminuted, spiral, pathologic). Clinical manifestations, including acute pain, deformity, crepitus, and shortening of the extremity, require immediate immobilization and comprehensive neurovascular status assessment. Definitive fracture management involves reduction (restoration of anatomic alignment through closed manipulation or open reduction internal fixation, or ORIF) followed by stabilization using casts, splints, braces, or traction (skin or skeletal). Crucial attention is given to both early and late complications of trauma and immobilization. Early complications include traumatic shock, Fat Embolism Syndrome (FES), and the life-threatening acute compartment syndrome (ACS), characterized by unrelenting pain and often requiring emergent fasciotomy. Late complications encompass delayed union, nonunion, malunion, AVN, Complex Regional Pain Syndrome (CRPS), and heterotopic ossification. Immobilization requires meticulous nursing care, particularly monitoring the "five Ps" of neurovascular compromise, proper cast/splint care, and implementing isometric exercises to prevent disuse syndrome. The chapter dedicates significant focus to fractures of specific high-risk sites, such as the clavicle, humerus, elbow (risk of Volkmann contracture), pelvis (high risk of hemorrhage), and hip (especially in older adults, requiring ORIF or replacement and intense VTE prophylaxis). Finally, the text details amputation, addressing the criteria for limb level selection, the multidisciplinary rehabilitation process, and common complications, notably phantom limb pain, which is treated through both pharmacological and specialized therapies like mirror therapy. Effective management across all aspects emphasizes prevention of VTE, diligent wound and pin site care for external fixators or traction, and profound psychological support for grief and disturbed body image.