9.3 Scenario Practice for Musculoskeletal and Wound Disorders

Tetanus Prophylaxis: The Decision Table

Tetanus prophylaxis is one of the most reliably tested wound topics because it is a clean lookup with two inputs: wound type and immunization history. Contaminated ("dirty") wounds include those with dirt, soil, feces, or saliva, plus puncture wounds, avulsions, crush, burns, frostbite, and missile wounds. A clean minor wound is the opposite.

Key points the exam loves: TIG is never indicated for clean minor wounds; the 5-year rule applies only to dirty wounds while clean wounds use 10 years; and adults due for a booster who have never had Tdap should get Tdap (not plain Td) to also cover pertussis.

Worked example: an adult with a complete primary series whose last booster was 8 years ago presents with a clean kitchen cut. Because the wound is clean and minor, the 10-year rule governs-8 years is within 10, so no vaccine and no TIG are needed. Change one variable to a contaminated wound and the 5-year rule now applies, so the same patient would receive a Td or Tdap booster but still no TIG, since the primary series is complete.

Laceration and Wound Assessment

For any laceration the nurse documents location, length, depth, mechanism, contamination, and neurovascular/tendon function distal to the wound before closure. Wounds over joints or involving deep structures need tendon and motor testing through full range of motion.

Closure timing (golden period)

Most lacerations may be primarily closed within roughly 6-8 hours of injury; highly vascular areas like the face tolerate closure up to ~12-24 hours because infection risk is lower. Beyond the golden period-or for bite wounds, puncture wounds, and grossly contaminated wounds-the wound is typically left open to heal by secondary intention or delayed primary closure to avoid trapping bacteria. Human and cat bites carry high infection risk and usually receive prophylactic antibiotics (e.g., amoxicillin-clavulanate). Irrigation with copious normal saline under pressure is the most important infection-prevention step.

Wound depth dictates closure technique: superficial wounds may be approximated with skin adhesive (tissue glue) or adhesive strips, while deeper or high-tension wounds need sutures or staples. The nurse anticipates local anesthesia (lidocaine, with the awareness that plain lidocaine without epinephrine is used on fingers, toes, nose, ears, and penis to avoid ischemia), control of hemostasis, and discharge teaching on signs of infection and suture/staple removal timing-roughly 3-5 days for the face, 7 days for the scalp and most of the body, and 10-14 days over joints.

Dislocations and Sprains/Strains

A dislocation is complete loss of joint-surface contact; a subluxation is partial. The mandatory nursing rule: neurovascular assessment before and after reduction, because reduction can both relieve and (rarely) cause vascular or nerve injury.

• Anterior shoulder dislocation is by far the most common (~95%); assess axillary nerve (sensation over the deltoid) and radial pulse.
• Knee dislocation is the can't-miss emergency: it has a high rate of popliteal artery injury, so check distal pulses meticulously and anticipate vascular imaging even if pulses are present.
• Hip dislocation (usually posterior, dashboard mechanism) risks sciatic nerve injury and femoral-head avascular necrosis; reduce urgently.

Sprains vs strains: a sprain injures a ligament (bone-to-bone), graded I (stretch), II (partial tear), III (complete tear with instability); a strain injures muscle or tendon. Both are managed with RICE-Rest, Ice, Compression, Elevation-with ice for the first 24-48 hours to limit swelling.

Reduction Care and Post-Reduction Monitoring

When a dislocation or displaced fracture is reduced-realigned into normal position-the emergency nurse's role spans before, during, and after. Beforehand: obtain a baseline neurovascular check, ensure consent and monitoring, and prepare for procedural sedation (continuous pulse oximetry, capnography, blood pressure, and a patent airway with suction and reversal agents at hand). Many reductions, especially recurrent anterior shoulder dislocations, are achieved with minimal analgesia, but the nurse anticipates sedation for posterior, inferior, or delayed reductions.

After reduction: immediately repeat the neurovascular assessment, immobilize the joint (sling for shoulder, knee immobilizer, etc.), arrange post-reduction imaging to confirm alignment and exclude an associated fracture, and monitor recovery from sedation. A new deficit after reduction-loss of pulse, sensation, or motor function-is treated as an emergency and reported at once.

Special Wounds: Bites, Punctures, and Foreign Bodies

Several wound types carry rules the exam targets. Puncture wounds (especially through footwear) appear benign but seed deep contamination and carry tetanus and Pseudomonas osteomyelitis risk; they are usually not sutured. Bite wounds are high-infection injuries: cat bites (deep puncture from sharp teeth) and human bites (especially "fight-bite" lacerations over the knuckles) have the highest infection rates, generally receive amoxicillin-clavulanate prophylaxis, and are typically left open rather than primarily closed (selected facial dog bites may be closed cosmetically after thorough irrigation).

Always assess rabies risk for animal bites and tetanus status for all of these. Retained foreign bodies (glass, metal, organic matter) increase infection and must be identified-often radiographically-and removed; organic material like wood is especially inflammatory. Across all special wounds, the constants are copious irrigation, tetanus assessment, and a deliberate decision about closure versus leaving the wound open.