Musculoskeletal Injuries and Nursing Care

Hip Fractures and Osteoporosis

Hip fractures are a critical concern, particularly in the geriatric population. The primary risk factor is osteoporosis, a condition characterized by decreased bone density.

Risk Factors for Hip Fractures

• Advanced Age: Patients over 50 are at higher risk due to unsteady gait, balance issues, and diminished vision/hearing.
• Osteoporosis Drivers: Post-menopausal status (due to low estrogen), inadequate calcium and Vitamin D intake, and a lack of weight-bearing exercise.
• Other Factors: Orthostatic hypotension (often caused by blood pressure or diuretic medications), smoking, alcohol use, and excessive caffeine intake.

Postoperative Nursing Care and Hip Precautions

Following surgery for a hip fracture, the nursing priority is to prevent complications such as DVT (Deep Vein Thrombosis), atelectasis (lung collapse), and prosthesis dislocation.

Key Nursing Interventions:

• DVT Prevention: Use compression stockings and compression devices; encourage frequent movement and coughing/deep breathing.
• Neurovascular Assessment: Regularly check the "7 Ps" (Pain, Pallor, Paresthesia, Paralysis, Polar/cold, Puffiness, and Pulselessness) to ensure circulation and nerve function are intact.
• Maintaining Alignment: To prevent dislocation, nurses must maintain leg abduction using a wedge pillow.

Critical Hip Precautions:

• Avoid hip flexion beyond $90^\circ$.
• Avoid adduction (crossing the legs).
• Use assistive devices like toilet risers and shower chairs.
• Do not allow the patient to lie on the operative side.

Life-Threatening Complications: Fat Emboli

A fat embolism is a medical emergency that typically occurs within 48 hours of a long bone fracture, pelvic fracture, or hip replacement. This happens when fat tissue and platelets enter the bloodstream and occlude capillaries, often in the lungs.

Clinical Manifestations:

• Respiratory: Tachypnea (rapid breathing), shortness of breath, hypoxia (low $SpO_2$), and crackles or wheezes in the lungs.
• Neurological: Restlessness, agitation, confusion, or anxiety, which may progress to stupor.
• Dermatological: The presence of petechiae (small red/purple spots) on the chest, axillary area, or conjunctival sacs.

Nursing Priorities:

1. Keep the fracture immobilized to prevent further fat release.
2. Place the patient on a cardiac monitor.
3. Monitor blood gases closely.

Traction Management

Traction is used to immobilize fractures, reduce muscle spasms, and promote healing.

General Traction Care: Ensure weights hang freely, maintain straight alignment, and keep the Head of Bed (HOB) at less than $25^\circ$.

Gout and Pharmacological Management

Gout is a systemic condition caused by the buildup of uric acid in the joints, which can form crystals and lead to the development of tophi.

Management of Gout

• Dietary: Avoid high-purine foods.
• Medications:
  • Allopurinol: Used to manage uric acid levels.
  • Colchicine: Used to treat acute attacks.

Other Essential Musculoskeletal Medications

Nurses must be familiar with several other drug classes used to manage inflammation and bone density:

• NSAIDs (Non-Steroidal Anti-Inflammatory Drugs): Such as Ibuprofen, Naproxen, and Celecoxib; used for pain and inflammation.
• Corticosteroids: Such as Prednisone and Dexamethasone; used for potent anti-inflammatory effects.
• DMARDs (Disease-Modifying Antirheumatic Drugs): Such as Methotrexate and Hydroxychloroquine; used for chronic inflammatory conditions like Rheumatoid Arthritis.
• Bisphosphonates: Such as Alendronate and Ibandronate; used to increase bone density in patients with osteoporosis.

Exam Tip: Osteomyelitis Teaching If a patient is being treated for osteomyelitis (bone infection) following an open fracture, remember that this is a difficult infection to treat. Patients must understand that they will likely require a long course of antibiotics (sometimes up to 12 weeks) and must complete the entire course even if symptoms disappear.