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Chapter: Medical Surgical Nursing: Management of Patients With Musculoskeletal Trauma

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Sports-Related Injuries

Sports-Related Injuries
Rotator Cuff Tears - Epicondylitis (Tennis Elbow) Lateral and Medial Collateral Ligament Injury - Anterior and Posterior Cruciate Ligament Injury - Meniscal Injuries - Rupture of the Achilles Tendon

Sports-Related Injuries

Many people participate in recreational sports. These recreational athletes may push themselves beyond the level of their physical conditioning and incur injuries. Injuries to the musculoskeletal system may be acute (eg, sprains, strains, dislocations, fractures), or they may be gradual, resulting from overuse (eg, chondroma-lacia patella, tendinitis, stress fractures). Professional athletes are also susceptible to injury, even though their training is supervised closely to minimize the occurrence of injury.

 

·      Contusions result from direct falls or blows. The initial dull pain becomes greater, with edema and stiffness occurring by the next day.

 

·      Sprains commonly occur in fingers, ankles, and knees. If the ligament damage is major, the joint becomes unstable, and surgical repair may be required. In addition, an avulsion frac-ture may exist.

 

·       Strains manifest with a sharp, stabbing pain caused by bleed-ing and immediate protective muscle contraction. Tennis players often suffer calf muscle strains; soccer players often experience quadriceps strains; and swimmers, weight lifters, and tennis players often suffer shoulder strains.

 

·       Tendinitis (inflammation of a tendon) is caused by overuseand is seen in tennis players (epicondylar tendinitis, or “ten-nis elbow”), in runners and gymnasts (Achilles tendinitis), and in basketball players (infrapatellar tendinitis).

 

·      Meniscal injuries of the knee occur with excessive rotational stress.

 

·      Dislocations are seen with sports that involve throwing or lifting.

 

·       Fractures occur with falls. Skaters and bikers frequently suffer Colles’ fractures of the wrist when they fall on out-stretched arms; ballet dancers and track and field athletes may experience metatarsal fractures. Stress fractures occur with repeated bone trauma from activities such as jogging, gymnastics, basketball, and aerobics. The tibias, fibulas, and metatarsals are most vulnerable.

 

Patients who have experienced a sports-related injury are of-ten highly motivated to return to their previous level of activity. Compliance with restriction of activities and gradual resumption of activities may be a significant problem for these patients. They need to be taught how to avoid further injury or new injury. With recurrence of symptoms, they need to diminish their level and in-tensity of activity to a comfortable level and to treat the symptoms with RICE. The time required to recover from a sports-related injury can be as short as a few days or longer than 6 weeks.

 

Prevention

Sports-related injuries can be prevented by the use of proper equip-ment (eg, running shoes for joggers, wrist guards for skaters) and by effectively training and conditioning of the body. Specific training needs to be tailored to the person and the sport. Warm-up routines generally include walking or slow jogging for about 5 minutes, fol-lowed by slow, gradual stretching. The athlete holds the stretch for 10 seconds before relaxing and repeating the stretch (Fig. 69-1). Preparing the body for sport activities increases the person’s flexi-bility and decreases the incidence of strains and sprains.


 

After exercise, the body needs to cool off to prevent cardiovas-cular problems such as hypotension, syncope, and dysrhythmias. Changes in activities and stresses should occur gradually. In addi-tion, the athlete needs to be taught to “tune in” to body symptoms that indicate stress and to modify activities to minimize injury and to promote healing.

ROTATOR CUFF TEARS

Rotator cuff tears may result from an acute injury or fromchronic joint stresses. Patients complain of pain, limited ROM, and some joint dysfunction, including muscle weakness. In many cases, the patient with a rotator cuff tear experiences night pain and is unable to sleep on the involved side. The patient is un-able to perform over-the-head activities. The acromioclavicu-lar joint is tender. X-rays are helpful in evaluating the joint. Arthrography and magnetic resonance imaging (MRI) are used to determine soft tissue pathology and the extent of the rotator cuff tear.

Medical Management

Initial conservative management includes use of nonsteroidal anti-inflammatory drugs (NSAIDs) including cyclooxygenase-2 (COX-2) inhibitors, rest with modification of activities, injec-tion of a corticosteroid into the shoulder joint, and progressive stretching, ROM, and strengthening exercises. Some rotator cuff tears require arthroscopic débridement (removal of devi-talized tissue) or arthroscopic or open acromioplasty with ten-don repair. Postoperatively, the shoulder is immobilized for several days to 4 weeks. Physical therapy with shoulder exercises is begun as prescribed, and the patient is instructed in how to perform the exercises at home. Full recovery is expected in 6 to 12 months.

EPICONDYLITIS (TENNIS ELBOW)

Epicondylitis is a chronic, painful condition that is caused by ex-cessive, repetitive extension, flexion, pronation, and supination activities of the forearm. These excessive, repetitious activities re-sult in inflammation (tendinitis) and minor tears in the tendons at the origin of the muscles on the medial or lateral epicondyles.Activities contributing to the development of epicondylitis in-clude tennis, racket sports, pitching, gymnastics, and repetitive use of a screwdriver. The pain characteristically radiates down the extensor (dorsal) surface of the forearm. The patient may have a weakened grasp. Most often, relief is obtained by rest and avoid-ance of the aggravating activity.

Medical Management

Application of ice after the activity and administration of NSAIDs, including COX-2 inhibitors, usually relieve the pain. In some in-stances, the arm is immobilized in a molded splint or cast. Because of its degenerative effects on tendons, local injection of a cortico-steroid is reserved for patients with severe pain who do not respond to NSAIDs and immobilization. After pain subsides, rehabilita-tion exercises include gentle and gradually increased stretching of the tendons. A tennis elbow counterforce strap to limit extension of the elbow may be prescribed when activity is resumed. Occa-sionally, surgery may be needed to release strictures or to débride the joint.

LATERAL AND MEDIAL COLLATERAL LIGAMENT INJURY

Lateral and medial collateral ligaments of the knee (Fig. 69-2) provide stability at the sides of the knee. Injury to these liga-ments occurs when the foot is firmly planted and the knee is struck—either medially, causing stretching and tearing injury to the lateral collateral ligament, or laterally, causing stretching and tearing injury to the medial collateral ligament. The patient experiences pain, joint instability, and inability to walk without assistance.


Medical Management.

Emergency management includes RICE. The joint is evaluated for fracture. Hemarthrosis (bleeding into the joint) may develop, contributing to the pain. The joint fluid is aspirated to relieve pressure.

 

The treatment depends on the severity of the sprain. Conser-vative management includes limited weight bearing and use of protective elastic bandaging or a brace. As pain subsides, ROM exercise is encouraged. The patient’s return to full activities, in-cluding sports, depends on return of motion, functional stability of the joint, and muscle strength.

 

If needed, surgical reconstruction may be performed immedi-ately or delayed. Generally, the leg is immobilized, and weight bearing is restricted for 6 to 8 weeks. A progressive rehabilitation program helps to restore the function and strength of the knee. Rehabilitation requires many months, and the patient may need to wear a derotational brace while engaging in sports.

Nursing Management

The nurse provides patient teaching about proper use of ambula-tory devices, the healing process, and activity limitation to promote healing. The nurse teaches the surgical patient about pain man-agement, medications (analgesics, antibiotics), brace use, wound care, possible complications (eg, altered neurovascular status, infec-tion, skin breakdown), and self-care.

ANTERIOR AND POSTERIOR CRUCIATE LIGAMENT INJURY

 

The anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL) of the knee stabilize forward and backward mo-tion of the femur and tibia (see Fig. 69-2). These ligaments cross in the center of the knee. Injury occurs when the foot is firmly planted, the knee is hyperextended, and the person twists the torso and femur. The patient reports a pop or tearing sensation with this twisting injury. Usually, the ACL is torn. The patient expe-riences pain, joint instability, and pain with ambulation.

Medical Management

Emergency management includes RICE. The joint is evaluated for fracture. Joint effusion and hemarthrosis require joint aspira-tion and wrapping with a compression elastic dressing.

 

Treatment depends on the severity of the injury and the effect of the injury on daily activities. Conservative treatment involves application of a brace, physical therapy, and avoidance of jump-ing activities. Surgical ACL reconstruction includes tendon repair with grafting and is performed as ambulatory arthroscopic sur-gery. After surgery, the patient is taught to control pain with oral opioid analgesics, NSAIDs, COX-2 inhibitors, and cryotherapy (a cooling pad incorporated in a dressing). The patient is taught about monitoring neurovascular status of the leg, wound care, and signs of complications that need to be reported promptly to the surgeon. Exercises (ankle pumps, quadriceps sets, and ham-string sets) are encouraged during the early postoperative period. The nurse reinforces instruction about weight-bearing limits, ex-ercise restrictions, and the use of a knee brace or immobilizer. The patient must protect the graft by complying with exercise restric-tions. The physical therapist supervises progressive ROM and weight bearing (as the patient is permitted). Continuous passive motion may be helpful in restoring full ROM. Rehabilitation after surgery typically takes 6 to 12 months.

MENISCAL INJURIES

In the knee, there are two crescent-shaped (semilunar) cartilages, called menisci, attached to the edge of the shallow articulating sur-face of the head of the tibia (see Fig. 69-2). Each meniscus moves slightly backward and forward to accommodate the condyles of the femur when the leg is flexed or extended. Normally, little twist-ing movement is permitted in the knee joint. In sports or acci-dents, twisting of the knee or repetitive squatting and impact may result in either tearing or detachment of the cartilage from its attachment to the head of the tibia.

 

These injuries leave loose cartilage in the knee joint that may slip between the femur and the tibia, preventing full extension of the leg. If this happens during walking or running, patients often describe their leg as “giving way” under them. Patients may hear or feel a click in the knee when they walk, especially when they extend the leg that is bearing weight, as in going upstairs. When the cartilage is attached to the front and back of the knee but torn loose laterally (bucket-handle tear), it may slide between the bones to lie between the condyles and prevent full flexion or extension. As a result, the knee “locks.” Meniscal injuries produce pain and disability because the patient never knows when the knee will mal-function. Also, the torn cartilage is an irritant in the joint, causing inflammation, chronic synovitis, and effusion.

Medical Management

 

Initial conservative treatment includes immobilization of the knee, use of crutches, antiinflammatory agents, analgesics, and modification of activities to avoid those causing the symptoms. If symptoms persist, the damaged cartilage is surgically removed (meniscectomy) through a procedure in which the surgeon uses an arthroscope to visualize and repair the damage. After surgery, apressure dressing is applied, and a knee-immobilizing splint may be required. The most common complication is an effusion into the knee joint, which produces marked pain. The physician may need to aspirate the joint to remove fluid and relieve the pressure. These patients are taught quadriceps-setting and ROM exercises. Additional exercises help to restore full function, stability, and strength. After arthroscopic meniscectomy, most patients resume activities in a day or two, and sports can be resumed in several weeks, as prescribed by the physician.

 

RUPTURE OF THE ACHILLES TENDON

 

Traumatic rupture of the Achilles tendon, generally within the tendon sheath, occurs during activities when there is a sudden contraction of the calf muscle with the foot fixed firmly to the floor or ground. The patient experiences sharp pain and is unable to plantar flex the foot. Immediate surgical repair of complete Achilles tendon ruptures is usually recommended to obtain satisfactory re-sults. After surgery, a cast or brace is used to immobilize the joint. In some situations, conservative management with a plantar-flexed cast for 6 to 8 weeks may be used. After immobilization, a heel lift is worn and progressive physical therapy to promote ankle ROM and strength is begun.

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