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Flashcards in Ortho Deck (42):
1

Risk factors

1. Age-related Changes: Loss of bone after 30; Vertebrae collapse; Muscle atrophy; Loss of cartilage; Lax ligaments
2. Medical Hx: Paget’s Disease; Bone cancer
3. Osteoporosis: 40 mil. Americans over the age of 50!; 40% of Caucasian women over the age of 50!
4.Occupation
5. Recreational activities
6. Poor nutrition

2

Classification of fractures

1. Extent of break: Complete; Incomplete
2. Cause
- Pathologic (spontaneous): bone cancer
- Fatigue (stress): jogging
- Compression: osteoporosis
3. Extent of soft-tissue damage
- Closed (simple): no visible wound
- Open (compound): external wound
 Grade I : skin damage is minimal
 Grade II : skin and mascle damage
 Grade III : skin, muscle, nerve tissue and blood vessels damage

3

Impacted fracture

when force has come down on the bone : and one part of the bone smashed on the other part.

4

Greenstick fracture

common in children or newer bone ; after new tree branch...cant snap it

5

S/s :

 Pain
 Loss of function
 Deformity
 Shortening
 Crepitus
 Swelling / discoloration

6

Diagnostics

• X-ray studies
- May need to be repeated with additional views
• CT scan
- Used to dx difficult-to-evaluate fractures (hip and pelvis)
• MRI
- Helps determine amount of soft-tissue damage

7

TX of fractures

• Reduction: restoration of bone fragramnets to anatomic allignment and rotation; performed right away
- Closed: bring ends together through amnipulation or manula traction them place cast or splint in order to immobilize it ;
- Open: surgery ; internal fixation
• Immobilization: hold bone fracture in correct allignment
- External
- Internal

8

Casts:

• Used to immobilize, correct deformity, apply uniform pressure on underlying tissue, or support weakened joints
• Location of fx dictates type used
• Plaster ( rolls, wet with water; crystallized, 24-72 hrs to dry ) or non-plaster ( fiber glass, water resistant ( can take shower) ; less skin problems)

9

Casts: nursing management

• Education
-Controlling edema
- Controlling pain
- Exercises to maintain health of unaffected muscles
- Exercises to increase strength of supporting muscles
- Monitoring for potential complications
• Assessment of neurovascular status – 6 P’s: pain, pressure, pallor, pulselessness, paresthesia, paralysis
• Open fx – infection prevention

10

Assessment of neurovascular status – 6 P’s:

1. pain
2. pressure
3. pallor
4. pulselessness
5. paresthesia
6. paralysis

11

Traction:

application of a pulling force to a part of the body provide reduction, alignment and rest .
• Uses:
 Minimize spasms
 Reduce, align, and immobilize
 Reduce deformity
 Increase space between opposing surfaces
• Short-term intervention until external or internal fixation is possible
• Skin (Backs traction: Velcro boot)or skeletal ( pins, wires, tongs or screws are surgically inserted directly into bone) most common types
• Plaster, brace and circumferential

12

Pin care

• First 48-72 hours: clear fluid drainage or weeping expected
• Monitor pin sites every 8-12 hours for inflammation or possible infection:
 Drainage (purulent)
 Color (severe redness)
 Odor
• Chlorhexidine 2 mg/mL solution ( swab around the pin every 4-8 hrs)
• Follow agency protocol for pin site care!
Crusting around pin is natural barrier ( unless infection is present)

13

Traction: nursing management

• Never remove weights without a prescription!
• Good body alignment important
• Ropes should be unobstructed
• Weights must hang freely
• Knots in the rope must not touch the pulleys or the bed
• Assess neurovascular status every hour for first 24 hours after application, then every 4 hours

14

Acute Compartment Syndrome (ACS)

• Anatomic compartment – 36 out of 46 in the body are in the extremities
• Within 4-6 hours, neurovascular and muscle damage irreversible
• Limb can become useless in 24-48 hours

15

ACS:

serious condition in which increased pressure within one or more compartments reduces circulation to the area. (most common: lower leg and forearm ).
The pressure to the compartment can be from :
External source: bulky dressing and cast
Internal: blood and fluid accumulation

16

ACS: S/s

• Pain – out of proportion with injury; increases with passive ROM
• Sensory deficits or paresthesia
• Pale color, cool to touch
• Weak pulses
• Affected area is palpably tense
• If not treated – cyanosis, tingling, numbness, paresis, and severe pain

17

ACS: TX

• Treatment
1. Elevation
2. Bi-valve ( cut the cast longways ; cast open to relieve the pressure )
3. Fasciotomy : cut muscle into fascia to relieve the pressure ; open wound is packed and dressed daily; until secondary healing occurs; might need skin graft to promote healing )

18

Crush Syndrome (CS)

• External crush injury that compresses one or more compartments in leg, arm or pelvis
• Potentially life threatening!
• Muscle becomes ischemic and necrotic
• Myoglobin released into circulation
 May occlude distal renal tubules and cause renal failure

19

Myoglobulin

muscle protein that injured muscle tissue releases into circulation where it can clog the renal tubules and cause acute renal failure.

20

CS: S/s

• ACS
• Hypovolemia
• Hyperkalemia
• Rhabdomyolosis ( release of myoglobulin into blood stream )
• Acute tubular necrosis
• Dark brown urine
• Muscle weakness and pain

21

CS: management

• Focuses on preventing ATN and cardiac dysrhythmias from hyperkalemia
• IVF, diuretics, low-dose dopamine to increase renal perfusion
• Goal of UO=100-200 mL/hr
• Kayexalate to reduce serum K+ levels
• Dialysis if K+ remain high or kidney failure occurs

22

Hypovolemic shock

• Bone is very vascular!
• Risk for bleeding with bone injury
• Trauma to nearby arteries can cause hemorrhage – rapidly developing hypovolemic shock
• PELVIC Fx
 Possible internal organ damage
 Assess VS, skin color, LOC

23

Venous thromboembolism (VTE)

 DVT and PE
 Most common complication of LE (lower extremity) surgery or trauma
 Most often fatal complication of MS surgery!

24

Fat embolism syndrome (FES)

 Fat globules released from marrow into bloodstream
 12-48 hours after injury
 Clog small blood vessels that supply major organs – lungs
 First sign is AMS (altered mental status) secondary to low arterial O2
 Petechiae is classic sign, but can be a late sign
 Can result in respiratory failure or death

25

Fracture Complications – Chronic complications

• Ischemic necrosis (avascular necrosis)
- Blood supply to bone is disrupted – death of bone tissue
- Most common with hip fx or fx with displacement (long term Prednisone :corticosteroid at risk)
• Delayed union
 Fx that has not healed in 6 months
 Some NEVER heal: nonunion
 Some heal incorrectly: malunion

26

Fractures of upper extremities

• Colles’ fracture – distal radius (deformed wrist, pain, numbness). Check sensation at the tips od the fingers, cap refil, ROM.
• Humerus fractures
- Neck
- Shaft ( brachial vessels must be involved)
Place sling on.

27

Pelvic fractures

• Pelvic fractures
- Stable
- Unstable
• High mortality rate
• Signs and symptoms: ecchymosis, tenderness, local edema, numbness and tingling , cant bear weight; hypovolemic shcok (high risk)
• Nursing responsibilities/assessments

28

Stable pelvic fx

 Single pubic or ischial rami
 Pelvic wing of the ilium
 Sacrum or coccyx
• Treatment

29

Unstable pelvic fx

• Rotational instability
• Vertical instability
• Combination of both

30

Hip fractures

• Most common injury in older adults
• Most frequent injury in any health care setting
• High mortality rate: Osteoporosis - biggest risk factor for hip fx
• 2 major types
 Intracapsular
 Extracapsular

31

Hip fracture : S/s

• Signs and symptoms
- Groin pain
- Pain behind knee
- back pain
- No pain
• Treatment
 ORIF (open reduction, internal fixation)
 Nonsurgical options

32

Joint surgery

• Used to correct/repair:
 Unstabilized fx
 Deformity
 Joint disease (DJD)
 Necrotic or infected tissue
 Tumors
• Most common procedures
 ORIF
 Closed reduction with internal fixation
 Most common: total joint arthroplasty or total joint replacement

33

Joint replacement contraindications

: infection anywhere in body, advanced osteoporosis, rapidly progressive inflammation
 Uncontrolled DM or HTN: risk for major postop complications and possible death
• Most common are the hip and knee, but also can replace the finger, shoulder, elbow, wrist, and ankle
• Infection prevention
• Ambulation promotion

34

Total hip arthroplasty (THA)

• Indications
- Pain interrupts pt’s sleep
- Pain limits ADLs
- Drug therapy no longer controls pain
- Pt must be able to participate in PT after surgery
• Primary arthroplasty - First time pt has THA
• Revision arthroplasty - Performed if implant loosens
• Most often performed in patients older than 60

35

THA: complications

1. Dislocation (subluxation or total dislocation)
- Leg slightly abducted
- Prevent hip flexion beyond 90 degrees
- Assess for pain, rotation, shortening
2. VTE (DVT and PE)
- Most potentially life-threatening complication
- Older, obese, hx of VTE – more at risk
- Prevention – antiembolism stockings/SCDs, anticoags (LMWHs), early ambulation
3. Infection
- Can occur during hospitalization, or months/years after
- Monitor incision and VS
- Watch for elevated temp, excessive or foul-smelling drainage
- Older pt may just have confusion!

36

Knee Replacement

• Indications
• Nursing management
• Complications
- Excessive drainage
- DVT
- Infection

37

Osteomyelitis

• Can occur in 1 of 3 ways…
- Exogenous – surgery, open fx, traumatic injury
- Endogenous/Hematogenous - spread from other sites of infection (most common)
- Contiguous – results from skin infection of adjacent tissues
• May be acute or chronic
• Most are staph
 Can also be Proteus, Pseudomonas, or E. Coli

38

Osteomyelitis

• Acute infection occurs more often in children
• Chronic infection more common in adults (esp. with compromised blood supply)
• Men > women
• Malnutrion, ETOH, DM, kidney or liver disease, immune suppressing disorders increase risk and complicate Tx

39

Osteomyelitis: S/s

• Acute infection
 Fever (usually above 38 degrees C)
 Swelling
 Erythema/heat
 Tenderness
 Bone pain – constant, localized and pulsating – intensifies with movement
• Chronic infection
 Ulceration of skin
 Sinus tract formation
 Localized pain
 Drainage from affected area

40

Osteomyelitis: S/s

• Signs and symptoms
 Hematogenous – septic manifestations and local symptoms
 Direct bone contamination or spread of adjacent infection – only local symptoms
 Chronic – continuously draining sinus, may have recurrent pain, inflammation, and swelling
• Diagnostics
 X-ray, radioisotope bone scan, MRI
 Blood studies, wound and blood culture

41

Osteomyelitis: TX

 Antimicrobial therapy
 Pain control
 Infection control
 HBO
 If not effective, may need surgical intervention (Eg. bone graft, amputation)

42

Acute Compartment Syndrome: early signs

1. Pain
2. Pressure
3. Paralysis
4. Paresthesia
5. Pallor
6. Pulselessness