Download Module5 WoundOrtho

Certified Emergency Nurse (CEN) Exam Review
Jeff Solheim
ORTHOPEDIC AND WOUND TRAUMA
Objectives:
At the completion of this section, the learner will be able to:
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Verbalize d ischarge instructions for common wounds encountered in the emergency department
Describe the process of assessing for nerve damage in the hands and feet
State the symptoms of compart ment syndrome and rhabdomyolysis
Describe the process of preserving an amputated limb
The CEN exam contains fourteen questions on orthopedic and wound trauma which invol ve the following topics:
Orthopedic Injuries
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Amputation
Co mpart ment syndrome
Contusions
Costochondritis
Foreign bodies
Fractures/dislocations
Inflammatory conditions
Joint effusion
Low back pain
Osteomyelitis
Other orthopedic trauma (e.g. Achilles tendon
rupture, blast injuries)
Sprains/strains
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Wound Emergencies
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Abrasions
Avulsions
Foreign bodies
Infections
Lacerat ions
Missile in juries (e.g. guns, paint gun, nail
gun)
Pressure ulcers
Puncture wounds
Trau ma (e.g. including degloving injuries)
Discharge Instructi ons for wounds:
Elevate area 24 to 48 hours to  pain and swelling
Maintain dressings 48 hours (change if soaked or soiled)
Cleanse area 3 to 4 times per day after dressing removed.
Apply sun block (at least SPF 15) for six months
Discharge instructions for abrasions
Apply non-adhesive dressing
Cover area with oint ment to prevent infection and adherence
Avoid direct sunlight for six months to prevent pigment changes.
Discharge instructions for sutures
Area of body
Removal recommendati on
Eyelid, lip, or face
3 – 5 days
Eyebrow
4 – 5 days
Ear
4 to 6 days
Scalp, truck, hand, or foot
7 to 10 days
Arm or leg
10 to 14 days
Over joint
14 days
Discharge instructions for other wound closure techni ques
Tape closure – leave tape on until it falls off on its own.
Staple closure – have staples removed in 10 to 14 days
Wound glue
o Avoid applying liquid or oint ment to closed wound (increases risk for dehiscence ).
o Adhesive will slough off in 5 to 10 days.
1 |P age
Certified Emergency Nurse (CEN) Exam Review
Jeff Solheim
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Puncture wounds
o Soak puncture wounds in the ED
o Encourage patients to soak puncture wounds 2 – 3 X per day for 2 – 4 days
o Encourage patient to monitor for signs of infection.
o Special puncture wounds
 High pressure injuries (e.g. grease gun, paint gun)
 Cause massive underlying tissue trauma, carry high risk for co mplications such as compartment
syndrome and infect ion.
 Require surgical intervention
 Puncture wound to the bottom of the foot
 Carry high risk for osteomyelitis.
 Teach patient signs of infection and when to return.
 Bite wounds
 Dog bites
o Associated with underlying crush injury.
o 5 – 15% become infected.
 Cat bites
o Highest rate of infect ion because long fangs penetrate deep into tissue
o Saliva contains Pasteurella multocida which can cause cellulit is, osteomyelitis, p leurit is,
septic arthrit is and bacteremia.
 Hu man
o Hu man saliva carries 10 bacteria per milliliter. So me of the bacterial is penicillin resistant.
Saliva can also transmit Hepatitis B.
o Require copious irrigation and debridement of devitalized t issue.
o They are usually left open and a bulky dressing is applied to decrease movement.
o It is recommended that prophylactic antibiotics be given with in three hours of arrival to the
ED.
 Bite wounds to the back of the hand
o Because of pro ximity of the phalanx to the surface, high risk of joint penetration with
osteomyelitis or joint effusions.
o Requires meticu lous cleansing, immobilization and antibiotic ad ministration.
 Bite wound closure
o Cat bites are usually not closed due to risk of in fection.
o Bites older than 12 hours are usually not closed due to risk of infection.
o Consider tetanus and rabies prophylaxis.
 Foreign bodies
 Stabilize but do not remove bulky objects.
 Vegetative matter (wood, thorns, etc.) will not show up on x-ray, may require CT scan, sonography,
fluoroscopy or local wound explorat ion to find and remove.
 Do not soak wounds with vegetative matter, require urgent removal.
Pressure wounds (caused by ischemia to tissue over pressure areas that may be exacerbated by dehydration or malnutrition.)
o Stage one: surface of the skin red, but skin is unbroken and wound is superficial, the ulcer fades quickly when pressure is
relieved on the area. Treat ment involves turning the patient and alleviating pressure around the wound, protecting,
cushioning and/or covering the area.
o Stage two: skin over wound is blistered (blister may be bro ken or unbroken). Treat ment involves cover and protecting
the area with dressing designed to insulate and absorb as well as protect the area. Skin lotions and emollients should b e
used as well as padding to the area.
o Stage three: this ulcer extends through all layers of the skin and carries a high rate of infection. Treat ment is aimed at
preventing infection by covering and protecting the wound and alleviat ing pressure.
o Stage four: A stage four ulcer extends through the skin involving underlying muscle, tendons and bone. Because of the
depth of this wound and the risk for infection, surgical removal of necrotic and decayed tissue may be necessary.
2 |P age
Certified Emergency Nurse (CEN) Exam Review
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Jeff Solheim
Blast injuries (When a solid or liquid converts to a gas, it expands, causing the air around it to expand as well. This expanding
air wave can lead to a variety of injuries.)
Type of
injury
Cause
Examples
Primary
injuries
Caused by compression of gas filled organs
Secondary
injuries
Caused by flying debris leaving the blast site
Tertiary
injuries
Blunt injuries caused by displacement of the body from the blast
wave.
Quaternary
injuries
Injuries not directly related to the blast wave but secondary to the
effects of the explosion.
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Ruptured tympanic memb rane
Pneumothorax
Air emboli
Gastric/intestinal ruptures
Impaled objects
Lacerat ions
Fractures
Closed head trauma
Burns
Crush injuries
Toxic inhalations
ORTHOPEDIC EMERGENCIES
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Nerve assessment
Nerve
Motor
Sensory
Radial
Extend wrist or thumb
Feeling on dorsum of thumb
Median
Oppose thumb to base of small finger
Feeling on tip of index finger
Ulnar
Abduct (fan) fingers
Feeling on tip of small fingers
Tibial
Peroneal
Plantar flex toes ( curl down)
Dorsiflex toes (curl toes up)
Feeling to bottom of foot
Feeling in first toe of web space
Joint Injuries
o Sprains and strains
Definiti on –
Sprai n –
stretch or tear
in a ligament
Rest
Ice
Co mpression
Elevation
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Definiti on:
Strain – In jury
to a muscle or
a tendon
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Memory t ip–
Strain has a “t”
in it and tendon
starts with a “t”
Memory Tip – RICE for treat ment of
orthopedic inju ries:
R – Rest
I – Ice
C – Co mpression
E - Elevation
Avoid use of limb (splints/crutches)
Range of motion should be performed four t imes per day as early as possible.
20 minutes at a time (first 48 hours, then switch to heat.)
Wrap ice bag to prevent cold injury
Elastic bandage
Rewrap twice a day and remove at night
Raise above the level of heart for first 24 hours
Crutch walking
o Fit crutches with patient wearing a shoe on the unaffected side
o The arm p ieces should be two inches below the axilla when the crutch is at a 25 degree
angle with the tips 6 to 8 inches to the side and in front of the foot.
o Adjust crutch hand pieces so that the elbow has a 30 degree angle of flexion
o
Key points
o
Remember, when
teaching crutches on
stairs: Up with the
good, down with the
bad.
When walking on a flat surface, place crutches 12 inches forward and approximately six
inches to the side.
When ascending stairs, the uninjured legs goes up first follo wed by the injured leg and crutch, when
descending stairs, the crutches and injured leg go down first followed by the uninjured leg.
3 |P age
Certified Emergency Nurse (CEN) Exam Review
Jeff Solheim
Dislocations
Joint
Mechanism
Anterior
shoulder
Falling on outstretched
arm
Posterior
shoulder
Elbow
(nursemaid’s
elbow)
Seizure or strong blow
to front of the shoulder
Fall on outstretched
arm with elbow in
extension
Co mmon in children
who are pulled, jerked
or lifted by the arm
Hip
Front seat MVC
Patella
Blow to the knee,
falling on the knee
Elbow (radius
and ulna)
Results in unstable
knee with frequent
tibial fracture
Frequently involves leg
fractures and soft tissue
injury.
Knee
Ankle
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Treat ment
Reduction, apply sling and swath
bandage or shoulder
immob ilizer.
Loss of arm length, rapid swelling,
neurovascular compro mise
Reduction and application of
supportive splint
Refuses to use arm, limited
supination but can flex and extend
elbow. Recurs until age 5
Anterior – flexion, abduction,
external rotation.
Posterior – flexion, adduction,
internal rotation
The knee is flexed, the patella is
palpable lateral to the femoral
condyle.
Deformity of the knee
Deformity of the ankle
As per anterior shoulder
Easily reduced
Reduce in < 6 hours to prevent
femoral head necrosis
Extend leg to reduce, then apply
a compression bandage or knee
immob ilizer
Requires ad mission (frequently
involves peroneal nerve and
popliteal artery.)
Splint, prepare for open
reduction (often involves blood
vessel and nerve impingement.)
Bursitis (excessive fluid or infection in a bursal sac).
o Causes in include overuse, bacterial or fungal in fections.
o Signs and symptoms
 Pain with use
 Redness, warmth, swelling and decreased range of motion to the affected area.
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Sympto ms
Arm is abducted, patient cannot
bring elbow down to chest or touch
opposite ear with hand.
Arm held to the side and cannot be
externally rotated.
Treat ment for bursitis
 Immobilization
 RICE
 Moleskin over heel
 NSAIDs and/or analgesics
Men get gout nine
times more often
than women.
Patients with
gouty arthritis
have an increased
risk for kidney
stones.
Gouty arthritis (overproduction or decreased secretion of uric acid)
o Signs and symptoms
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Pain in affected joint (first joint usually affected is great toe, progresses to insteps, ankles, heels, knees, wrists,
fingers and elbows.
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Onset often at night
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Increased with weight on joint, movement of joint or weight bearing on joint
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Elevated uric acid levels
Treat ment
 NSAIDs
 Steroids in in fected joint spaces
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PO/IV Colch icine
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Discharge instructions
Avoid thiazide d iuretics and alcohol
Decrease purine intake (herring, mussels, yeast, salmon,
sardines, anchovies, veal, bacon and organ meats.)
Avoid aspirin (interferes with uric acid excretion)
4 |P age
Certified Emergency Nurse (CEN) Exam Review
Fractures
Bone
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Clavicle
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Notes
80% in the middle third
May affect axillary, med ian,
ulnar and radial nerve as well
as damage to subclavian artery
vein (may affect airway)
May have associated
hemothorax or pneu mothorax.
Jeff Solheim
Sympto ms
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Point tenderness
Swelling/deformity
Will not raise affected arm
Head leans toward in jury,
chin points away fro m it.
Treat ment
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Scapula
Co mplications include
pulmonary contusions and rib
fractures
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Point tenderness
Pain on shoulder movement
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Shoulder
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Hu merus
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Caused by fall on outstretched
arm or direct trau ma to
shoulder.
Older patient tends to fracture
shoulder, younger person more
likely to suffer dislocation.
Assess for radial nerve damage
with middle o r distal shaft
fractures.
Assess for chest trauma.
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Pain and deformity
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Forearm
fractures
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Wrist
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Scaphoid
Assess for brachial artery
laceration, median, radial or
ulnar nerve involvement.
Co mmon mechanis ms
including falling on
outstretched hand and direct
blows.
Co mplications include
neurovascular compro mise and
Vo lkmann’s contracture.
Smith’s fracture (angulates up)
or Co lles’ fracture (angulates
down)
Assess for median nerve
damage.
Co mpression bandage over
affected arm (nondisplaced)
Sling and swath or arm
immob ilizer for 1 to 2
weeks.
Cold packs
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Sling and swath
Velpeau
Open reduction for severe
fractures
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Pro ximal hu merus: sling
and swath
Midshaft: sugar tong
Pain and deformity
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Elbow
Sling and swath until pain
subsides
Figure of 8 for midclavicular fractures
Ice to area for 12 to 24
hours
Closed reduction (radial
head fractures): cast and
sling
Co mminuted or
intraarticu lar fractures: open
reduction and fixation
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Pain and deformity
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Pain
Point tenderness
Swelling
Deformity
Angulation
Shortening of the extremity
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Closed reduction
Cast with elbow flexed 90
Sling (prevent dependency
of the arm or drooping of
the wrist.)
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Manipulation and closed
reduction
Cast
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Pain and deformity
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Wrist pain
Pain in snuff bo x area at base
of thumb.
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Cast with thu mb in
abduction.
5 |P age
Certified Emergency Nurse (CEN) Exam Review
Pelvis
Femur
Knee
Patella
Tibia/Fibula
Ankle
o
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Mortality 8 – 10 %
Mortality 40 – 60% if fracture
open.
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Associated with major t rauma
May cause severe hypovolemia
Associated with damage to
peroneal nerve, sciatic nerve
and popliteal artery.
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MVC or M BC
Auto-pedestrian
Co mplications can include
peroneal or tibial nerve
damage, popliteal artery
involvement.
Fall on knee
Knee into dashboard
Severe muscle pull
Frequently open
Co mplications include blood
loss (up to 2 L), infection, soft
tissue damage, neurovascular
compro mise, Vo lkmann’s
contracture.
Neurovascular compro mise
common (especially peroneal
nerve)
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Jeff Solheim
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Positive “barrel hoop”
Paresis/hemiparesis
Coopernail sign
Pelvic ecchymosis
Blood in the vagina/ urinary
meatus/rectum
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Oxygen/IV
ORIF
Elevate the knees
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Traction splint (fo r midshaft
fractures or upper third tibia
fractures. Do not use with
concomitant joint injuries or
femur + tib ia/fibula
fractures)
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Pain and deformity
Shortened leg
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Pain and deformity
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Long leg splint
Surgical repair.
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Knee pain
Obvious deformity
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Long leg cylinder cast
Surgery
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Deformity
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Cast
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Pain and deformity
Closed reduction with
walking cast
ORIF
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Co mplications
 Co mpart ment syndrome
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Causes of internal co mpression include:
 Bleeding – secondary to injury, fractures or vascular trauma, hemophiliacs may bleed into
their muscle co mpart ment
 Edema – secondary to injury, pro longed overuse such as forced marches or long distance
running, venomous snake or spider bites, muscular damage due to electrical burns, flu id
leaking due to hypothermia or frostbite
 Insertion of external substances – injection of paint fro m a high pressure paint gun, grease gun
or similar mechanis ms.
 Recent surgery
 Tissue damage, edema and bleed ing secondary to crush injuries are a frequent cause of
compart ment syndrome.
Causes of external co mpression include:
 Circu mferential casts, splints, tape, elastic bandages and Military anti-shock trousers (MAST
pants)
 Circu mferential burns causing inelastic skin around the muscle compart ment
 Vascular or arterial b lood loss outside the compart ment with hemato mas putting pressure on
the compart ment.
6 |P age
Certified Emergency Nurse (CEN) Exam Review

Assessment (the five Ps)
Pain
Paresthesia
Paralysis
Pallor
Pulselessness
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o
Jeff Solheim
The earliest indicator of co mpart ment syndrome is deep aching pain that is out of proportion
to the injury around the area of co mpression. The pain tends to get progressively worse and is
exacerbated if external pressure is placed over the affected compart ment. If the extremity
distal to the area of co mpart ment syndrome is manipulated, the patient may co mplain of
severe pain. For examp le, if a patient has compart ment syndrome in the forearm, and the
hand is manipulated, the patient may cry out with pain in the swollen co mpart ment as the
hand is moved.
The next sy mptom to develop is paresthesia along the distribution of the nerve which is
compressed. The loss of sensation is most dense distally.
A late sign of co mpart ment syndrome and often a poor indicator of outcome is paralysis, the
patient may describe a sensation like the “limb is giv ing out”.
As microcircu lation is obstructed, the extremity will begin to lose its color, appearing pale
(will appear dusky if dependent). The extremity may feel cool and become warmer pro ximal
to the affected compart ment.
The last sign to develop will be loss of pulse, which probably won’t be ev ident until pressures
within the co mpart ment are close to systolic pressure, preventing arterial flow through the
compart ment.
Diagnosis – May be made by measuring interco mpart mental pressures
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< 10 mm Hg : normal
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20 – 30 mm Hg: carefu l observation
 > 40 mm Hg : likely surgical deco mpression
Treat ment
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Remove external pressure
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Place at the level of the heart
 Remove ice
Rhabdomyolysis (Breakdown of muscle tissue that results in release of substances such as myoglobin, creatinine kinase,
and intramuscular electrolytes.)
 Osmo lality of myoglobin can cause flu ids to be pulled into the intravascular bed causing extravascular
dehydration.
 Myoglobin molecu les may beco me trapped in g lo meruli renal failu re.
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Lab values
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Urine
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Increased potassium, uric acid and creatinine kinase
Decreased calciu m
Dark brown in colo r
 Appears like hematuria but contains no red blood cells.
Sympto ms
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Malaise
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Fever
 Muscle tenderness
Treat ment
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Large volu mes IV fluid
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Sodiu m bicarbonate
Hemodialysis for renal failure
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7 |P age
Certified Emergency Nurse (CEN) Exam Review

Jeff Solheim
Amputation
o
Treat ment
 Treat associated life -threatening emergencies first
 Control bleed ing
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Direct pressure/ pressure dressing
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Apply blood pressure cuff to the stump 30 mm Hg above systolic
 Clamps/tourniquets as a last resort
Cleansing the wound
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o
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Cleanse with normal saline
 Avoid bacteriostatic solution or H2 O2
Partial amputation
 Splint in anatomical position
 Minimize man ipulation of amputation
Handling the amputated part
 Use sterile gloves when handling
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Cleanse the end but avoid bacteriostatic solutions or H2 O2
Minimize man ipulation
Preservation
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Wrap in sterile gauze soaked in NS or LR (avoid water).
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Place in a p lastic bag and seal.
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Place in ice but protect tissue from frostbite/freezing
8 |P age
Certified Emergency Nurse (CEN) Exam Review
Jeff Solheim
Practice Questions
A patient who sustains a wound to the back of the hand fro m the teeth of another person after punching them in the mouth carr ies the
risk of wh ich of the fo llo wing co mplications?
a.
b.
c.
d.
Osteomyelitis
Smith’s fracture
Scaphoid fracture
Hepatitis A infect ion
A patient sustains a dislocation of the elbow with compression of the median nerve. The emergency nurse would anticipate wh ich of
the following assessment findings in the injured hand associated with this in jury?
a.
b.
c.
d.
Loss of pain perception to the little finger
Inability to adduct the fourth and fifth finger
Loss of pain perception to the tip of the index finger
Inability to extend the thumb in the “hitchhiker’s sign”
A patient presents to the ED with bursitis to the knees after spending several days kneeling while scrubbing floors. The emergency
nurse would anticipate which of the following interventions for this patient?
a.
b.
c.
d.
Initiat ion of intravenous antibiotics
Steroid injections into the affected bursa
Injection of antib iotics into the affected burs a
Application of a circu mferential cast fro m mid-thigh to the toes
The emergency nurse knows a patient understands the discharge teaching they have been given when they make the following
statement after receiv ing instructions on how to use their crutches.
a.
b.
c.
d.
“When I am going up stairs with my crutches, my crutches always lead the way.”
“When I am going up stairs with my crutches, my unin jured leg always leads the way.”
“When I am going down stairs with my crutches, my injured leg always leads the way.”
“When I am going down stairs with my crutches, my uninju red leg always leads the way.”
Answers A, C, B, B
9 |P age
Certified Emergency Nurse (CEN) Exam Review
Jeff Solheim
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Hoyt, K. S., & Selfridge-Tho mas, J. (Eds.). (2007). Emergency Nursing Core Curriculum (6 ed.). St. Lou is: Saunders Elsevier.
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