Musculoskeletal and Wound Emergencies Study Guide for the CEN

General Information

Whether internal or externally caused, emergencies involving this body system are wide and varied. Questions about assessment and treatment of this type of emergency occupy about 10.5% of the CEN questions.

Musculoskeletal

Musculoskeletal emergencies are those that affect the patient’s muscular and skeletal systems. Emergencies can be related to trauma such as a motor vehicle accident or workplace accident, a thrombus that causes an acute arterial occlusion, or a septic joint that can occur after a sudden impact or post-surgical infection.

Amputation

Amputation is the removal of any upper or lower extremity, whether accidental or intentional. Amputations can be traumatic and unexpected, or they can be planned when a limb becomes unsalvageable for reasons such as chronic infection (especially if it has reached the bone), severe peripheral arterial disease that causes impaired blood flow, or severe chronic pain.

Assessment

Examine the patient’s residual limb closely and assess for any signs of bleeding. Perform a neurovascular and neurological check appropriate to the limb and the amount of limb that is remaining (checking pulses in the correct location). Look for any redness, swelling, chronic wounds or blisters, discharge, bruising, or other signs of infection or irritation. Ask the patient about any discomfort they may be experiencing, including phantom limb pain, which is the perception of pain in the missing portion of the limb. X-rays or CT scans can reveal any damage to underlying bone or the presence of any foreign bodies.

A CBC will be drawn to check the patient’s hemoglobin and hematocrit levels, and a type and screen will verify the patient’s blood type if they need a blood transfusion. The patient should remain on constant telemetry and have blood pressure taken frequently per facility policy.

Treatment

If the amputation is a new traumatic injury, the primary treatment goal will be to control bleeding and treat the patient’s resulting hypovolemia with intravenous replacement of blood products (packed red cells, fresh frozen plasma, cryoprecipitate, and platelets). The patient may arrive with a tourniquet applied to their residual limb or a large pressure dressing in place. They will likely go to the OR emergently to control the bleeding and debride the wound.

If released suddenly, a tourniquet that has been in place for more than two hours runs the risk of releasing a sudden rush of toxins into the bloodstream, causing organ damage and potential cardiac arrhythmias. Gradually releasing the tourniquet over 10-15 minutes once the bleeding has been controlled reduces the risk of cardiac arrest, reperfusion syndrome, and pulmonary embolism.

Other Information

After their incision has healed, the patient will visit a prosthetist to be fitted for a prosthetic. Depending on the type of amputation, the patient’s lifestyle, and their insurance coverage, a wide variety of different prosthetics of varying complexities are available. The patient will also work with physical and occupational therapy to learn to use their prosthesis and to make the adaptations necessary to live with a missing limb. Patients with lower limb amputations will also need to use mobility aids such as a wheelchair, crutches, walker, or cane at first.

Compartment Syndrome

Compartment syndrome occurs when the patient experiences swelling in a closed space, such as a muscle compartment or abdominal cavity, that obstructs blood flow and nerve function. This leads to intense pain, nerve damage, and even the risk of amputation if left untreated. Causes of compartment syndrome include trauma such as a crush injury, use of a cast or splint, swelling due to inflammation or infection, and repetitive motions such as running or jumping.

Assessment

Symptoms of compartment syndrome include severe pain, swelling, numbness, tingling, weakness in the affected limb, or loss of peripheral pulses. Compartment syndrome is diagnosed through a hands-on physical exam to assess swelling and circulation. The intracompartmental pressure can be measured using a needle or transducer. An X-ray can rule out any fractures, and a CT scan and/or MRI can rule out any other underlying tissue damage.

Treatment

The primary treatment is a fasciotomy, a large incision to relieve the intracompartmental pressure. Elevating the affected limb also helps to reduce fluid in the limb and associated swelling, reducing the pain and potential for nerve damage. The patient will need to receive heavy-duty pain medication, likely in the form of IV narcotics, to manage the extreme pain associated with the fasciotomy incisions and the compartment syndrome itself.

Multiple surgeries may be needed to relieve pressure. Due to the size of the incision made during the fasciotomy and reduced blood flow, the patient’s risk of infection is extremely high. Prophylactic antibiotics are commonly administered. If the fasciotomy and other interventions are ineffective and permanent tissue damage occurs, the patient may require amputation.

Ligament and Tendon Injuries

Ligaments and tendons can be strained, sprained, partially torn, or completely ruptured. These injuries can occur due to trauma, such as a slip on ice or sudden movement while playing sports, or they can be the result of repetitive strain over time from activities such as throwing a ball or typing frequently. Any joint can be affected. Remember that tendons connect muscle to bone, and ligaments connect bone to bone. Tendinitis refers to acute inflammation of the tendon, while tendinosis is chronic degeneration that occurs over time.

Assessment

An acute soft tissue injury presents with sudden sharp pain, swelling, and difficulty bearing weight or using the limb. A chronic soft tissue injury presents with dull aching pain that slowly worsens over time, loss of range of motion, and stiffness. Diagnostic imaging will help to make the final diagnosis. An X-ray can be used to rule out a fracture. A CT scan or MRI must be performed to see soft tissue injuries in great detail. The clinician will also perform a thorough hands-on clinical exam of the affected area.

Treatment

The treatment methods vary depending on whether the injury is acute or chronic, as well as on the severity of the injury. Acute injuries, if moderate or severe, will often resolve with rest, NSAIDs, elevation, and a compression wrap/brace. Physical therapy exercises can strengthen the injured joint to reduce the risk of future injuries. Chronic injuries can be treated with activity modification to reduce the triggering action, physical therapy exercises, massage, stretching, steroid injections, and injections of platelet-rich plasma (PRP). If the patient’s tendon or ligament has completely ruptured, surgical repair will likely be necessary, along with a prolonged period (usually 6-8 weeks, depending on the patient’s healing and surgeon preference) of non-weight-bearing or using the affected extremity.

Fractures

A fracture describes any broken bone. It can be an acute injury that happens suddenly due to trauma, such as a fall or underlying pathology, such as a cancerous lesion, or a chronic stress fracture that develops after a repetitive irritating motion. Fractures can be open, meaning that bones have protruded through the skin, or closed, meaning that the skin remains intact.

Assessment

Symptoms include sudden severe pain, obvious deformity of the injured area, swelling, bruising, numbness and tingling if nerves have been affected, and limited range of motion. The area of the fracture should be closely assessed. Perform both neurovascular and neurological checks to evaluate the circulation and nerve integrity of the affected area. Check for any damage to the skin to see whether the patient has experienced a closed or open fracture.

An X-ray will be used to confirm the presence of any fractures, whether acute or chronic. Types of fractures that patients can experience include stress, greenstick, spiral, transverse, and oblique fractures. Fractures can be comminuted, meaning that the bone is broken into at least 3 separate pieces, or non-comminuted, or stable. The fracture of any large bones such as a femur greatly increases the risk of a fat embolism, so monitor the patient closely for associated symptoms, which include respiratory distress, altered mental status, and petechiae.

Treatment

If the patient has experienced an open fracture, they will need to go to the operating room urgently for irrigation and debridement to wash out the wound thoroughly and have possible surgical fixation of their fracture. This helps to prevent infection. The patient will also likely receive several doses of intravenous antibiotics to further reduce the risk of infection. If the patient’s fracture is closed, the intervention depends on the severity of the fracture.

Some fractures can be aligned through a closed reduction (for which the patient should receive sedation and pain medication) and then have a cast or splint applied to stabilize the fracture until it heals, which can take 6-8 weeks. If the fracture is extremely severe, an external fixator will need to be applied surgically to stabilize the extremity until the swelling decreases and it is possible to complete a standard surgical repair.

Dislocations

Dislocations occur when a joint pops out of place; they can be partial or complete. Dislocations usually occur after a trauma. If they become chronic or the patient has a connective tissue disorder such as Ehlers-Danlos syndrome or Marfan syndrome, then dislocations can happen spontaneously, sometimes even with the slightest movement or while the patient is sleeping. Soft tissue injuries frequently occur after dislocations as well.

Assessment

Symptoms include severe pain, obvious deformity, swelling, limited range of motion, and numbness and tingling around the affected joint. Assess the injured extremity’s neurological and neurovascular status to ensure that blood flow and nerve function are intact. Support the injured limb as needed to reduce pain and limit any extraneous movement. An X-ray should be performed to rule out any fractures. As long as no fractures are present, patients can proceed to having their dislocation treated.

Treatment

Most dislocations can be successfully reduced (putting the joint back into place) by an experienced clinician after imaging has been performed to rule out any associated fractures. Because the closed reduction is painful, the patient should receive sedation and pain medication.

The dislocated joint will need to be immobilized using a sling or brace for about 2-6 weeks; the specific duration varies depending on the severity of the fracture. If the dislocations occur repeatedly, the patient may need to undergo surgery to reconstruct injured/stretched ligaments and tendons around the joint that allow it to dislocate.

Inflammatory Conditions

Inflammatory musculoskeletal conditions cause inflammation in joints. Most are of a chronic nature and are immune-mediated disorders. Examples include rheumatoid arthritis, psoriatic arthritis, juvenile arthritis, gout, ankylosing spondylitis, scleroderma, and lupus. Any joint in the body can be affected. Gout is caused by a buildup of uric acid in the joints.

Assessment

Symptoms include generalized pain, swelling, stiffness, and limited range of motion. The patient’s symptoms may wax and wane. Assess the patient’s level of pain and triggering conditions, and ask them about any other autoimmune disorders that they have or that a family member may have.

Diagnostic tests include a serum creatinine kinase to check for muscle damage, checking for specific autoantibodies to determine which myositis the patient has, erythrocyte sedimentation rate and C-reactive protein tests to check for inflammation, and muscle biopsies to diagnose specific disorders. Other tests include EMG testing to check for abnormal nerve function and MRIs to check for inflammation (imaging location to be determined by the location of the patient’s pain). A uric acid level will be used to diagnose gout.

Treatment

Because most inflammatory conditions are immune-mediated, immunosuppressants are the first line of treatment for inflammatory disorders. Classes of immunosuppressants include disease-modifying antirheumatic drugs (DMARDs) such as methotrexate, hydroxychloroquine, and sulfasalazine; NSAIDs like ibuprofen, naproxen, and celecoxib; corticosteroids like prednisone or dexamethasone; and biologic agents such as adalimumab (Humira) and infliximab (Remicade). If the immunosuppressants are ineffective, some patients even need to undergo chemotherapy to suppress their immune system.

Non-medication interventions include physical therapy, joint replacements, or other surgical repairs, and making lifestyle changes to reduce inflammation, like avoiding sugary foods, getting enough sleep, and reducing stress when possible.

Osteomyelitis

Osteomyelitis is a chronic infection of the bone. Conditions such as peripheral vascular disease or diabetes impair the patient’s healing ability, leading to chronic wounds (most commonly on the feet) that eventually result in bone infections. Left untreated, it can be life-threatening and/or result in limb loss.

Assessment

Symptoms include pain and tenderness in the affected site, redness, swelling, warmth, difficulty bearing weight, and purulent (pus-containing) drainage if an open wound is present. If the infection is systemic, the patient may experience a fever and chills, malaise, nausea, and fatigue.

A CBC will be performed to check for an elevated white blood cell count. Wound cultures will be obtained from the infection site to determine which type of bacteria or fungus is causing the infection. Blood cultures will be drawn to verify that the infection is not systemic. An X-ray can show bone damage and swelling. A CT scan will offer a more detailed review of the affected site.

Treatment

The patient will receive strong broad-spectrum antibiotics intravenously until the results are available from the wound cultures. The patient will likely need to have a PICC line placed for long-term administration of antibiotics. An infectious disease doctor may be consulted to guide the antibiotic therapy. The patient may undergo multiple irrigation and debridements to clean out the infection.

If the osteomyelitis cannot be resolved with antibiotic treatment and minor surgical procedures, then the affected bone will need to be removed in a surgical procedure to ensure that the infection does not spread. Amputation is sometimes needed depending on the progression of the osteomyelitis. Other underlying conditions, such as diabetes and peripheral vascular disease, must be well controlled to facilitate healing.