353 Joint Replacement and Fractures

Who is at risk for fractures?

very young, very old, teenagers, athletes, those with poor vitamin D and calcium intake, women, those genetically predisposed, those who experienced trauma, and those with comorbidities like bone cancer, osteoporosis, HIV, and thyroid problems

Segmental Fracture

large fragments separate from main bone

Displaced Fracture

separate, not aligned, two pieces not meeting anymore

Non-Displaced Fracture

separate but aligned, pieces are right together, just separate and must be healed

Pathological Fracture

result of non-traumatic forces (frequently underlying illness), often missed, often as a result of another condition ie osteoporosis

Incomplete Bone Fracture

goes through part of the bone (ie a crack)

Complete Bone Fracture

goes through the entire bone, makes 2 separate pieces

Closed/Simple Skin Fracture

skin remains closed or intact

Open/Compound Fracture

skin is open, greater infection risk

Comminuted Fracture

multiple tiny pieces (can be displaced or nondisplaced)

Avulsed Fracture

pulled away, ie caught in machine and breaks off

Impacted Fracture

instead of being pulled away, it is pushed down into rest of bone (ie land on something)

Transverse Fracture

transverse break across the bone

Oblique Fracture

oblique break across the bone

Spiral Fracture

like an oblique break but spirals around the bone

Greenstick Fracture

special case, usually only in kids, happens when your bones are softer, incomplete break like bending a green twig and it breaks on one side

Torus/Buckle Fracture

special case, usually only in kids, happens when your bones are softer, bulge out in middle ie from being pushed down at both ends and it buckles/bulges in the middle

Diagnostic Tests for Fractures

XRAY (most common), CT Scan/MRI if xray not able to diagnose (ie small fracture), bone scane to determine fracture complications (ie if not healing properly)

General Assessment of Fractures

deformity, edema, pain, crepitus, spasms, ecchymosis, loss of function, abnormal ROM, circulatory compromise

What are the early 3 P's? CATCH EARLY

Pain (unrelieved with medication or elevation), paresthesia (numbness, tingling) and pallor (cap refill > 3 seconds, very pale, bluish fingers and toes

What are the late 3 P's?

polar (cool fingers/toes), paralysis (unable to move fingers/toes at all), pules (doppler only pulse, no pulse)

How do you treat more stable fractures?

external immobilization (casts, splints, traction)

How do you treat less stable fractures?

internal immobilixation (surgical procedures, skeletal traction, external fixator, internal fixation (ORIF), bone grafting)

Casts

rigid, external immobilizing device, usually for 6 weeks: immobilizies a reduced fracture, correct a deformity, apply uniform pressure to soft tissues, support to stabilize a joint

What is included in a cast?

the affected bone, as well as the joints proximal and distal

What are cast material options?

fiberglass: lightweight, durable, waterproof or plaster: cheaper, heavier, break apart when wet, require time to dry

Cast: Patient Assessment

check skin (intact, redness, rubbing causing an open area), neurovascular (check fingers for warmth, swelling), edema/swelling (if cast is too tight, swelling underneath, elevate to reduce swelling, expected initially but monitor for worsening)

Cast: Cast Assessment

dry, intact, low rough edges (that can rub and cause openings in the skin)

Cast Education

purpose/goals of cast, expectations during casting process, do not scratch or stick anything under cast, cushion rough edges, activity and mobility options, assistive devices

Cast Education After

control of edema and pain, exercises, safe use of assistive devices, signs and symptoms to report like persistent pain and swelling, changes in sensation, movement, skin color or temp, signs of infection, and burning or itching at pressure areas

Important Pressure Point in Leg Cast

pressure of the peroneal nerve from knee to outside of calf can cause foot drop, which leads to issues with walking and nerve damage can be permanent

What is a body cast?

encases the whole body

What is a spica cast?

encases the trunk and portions of 1 or 2 extremities

Considerations for Body and Spica Casts

requires multiple people to position patient, perineal opening must be large enough for hygiene

Watching for Cast Syndrome

mostly seen on casts that surround trunk, hard to take deep breaths, can be from compression of mesenteric nerve, claustrophobia, anxiety

What is traction (pull) immobilization?

pull of bones to keep things perfectly aligned, purpose is to: reduce muscle spasms, reduce, align, and immobilize fractures, reduce deformity, increase space between opposing forces

Skin/Manual Traction

short term intervention, increases comfort and reduces spasms, used before surgery, can be intermittent, weight limit maximums,

Skeletal Traction

long term intervention, more of a treatment, continuous (you don't take the pins out), pins are screwed through bones to maintain positions for healing

Advanced Skeletal Traction

not used often, particularly used if someone has multiple fractures, moved away from bc person is at risk for pressure ulcers, immobility

External Fixators

put pins in, attach metal cages that go around to keep things in place, external but fixated with pins, concern about infection due to wide opening where organisms can enter

Traction Nursing Responsibilities

skin: hydration, nutrition, reposition, avoid pressure ulcers, minimizing pressure on peroneal nerve, monitoring circulation, pulses and sensation, proper body alignment, inversion, eversion, preventing infection and performing pin care

Pin Care

goal is to prevent infection, initially sites are covered by sterile non-stick dressing to allow membrane to form, later use betadine, water/saline solution per policy/order to clean inner to outer around the pins, crusting may occur and it should be left

What is Open Reduction and Internal Fixation (ORIF)

surgical procedure that repairs bone using internal hardware, open skin and reduce fracture and put an internal fix ie hip replacement surgery

ORIF Nursing Responsibilities

routine post-op care, administer IV antibiotics as ordered, wound care as ordered, elevate extremity, assess neurovascular status frequently, monitor for signs of infection, assess for safety

What are all of the complications of a fracture?

compartment syndrome, FES, DVT, osteomyelitis, avascular necrosis/non-union, localized infection at pin site

Arthro-

a prefix meaning joint

Arthroscopy

the repair of joint problems through the operating arthroscope or through open joint surgery

Arthroplasty

forming a 'new joint'

Hemiarthroplasty

the replacement of one of the articular surfaces

Osteotomy

surgical cutting of the bone (bone spurs)

Prosthesis

artificial substitute for a missing part of the body or as a replacement (remove hip and put a new one in)

-plasty

to build or make

Hemi-

half

THA

Total hip arthroplasty = total hip replacement or THR

TKA

Total knee arthroplasty = total knee replacement or TKR

Component Materials

Plastic (polyethylene)

Metal: Cobalt-chrome or titanium (used for joint stem)

Ceramic: Actually a metal oxide (ball of joint)

Cement

Cementless Hip Prosthesis

(preferred method)

Have a porous coding (like english muffin) for bone to grow into to make a very stable joint over time (must be healthy bone)

Prosthesis is hammered into more precisely bored hole in the femur

Cemented Hip Prosthesis

The prosthesis is placed into a bored opening in the femur and surrounded by the bone cement

Bored opening does not have to be precise

Long term Complications of joint replacement

- Heterotopic ossification

- Avascular necrosis

- Loosening of the joint (not right away a bit down the line)

Heterotopic ossification

extensive bone growth in odd places

Avascular necrosis

lack of blood supply to an area

Respiratory toilet

(addresses cleansing)

C-DB and Incentive spirometer

Early ~ 3 Ps

Pain: Unrelieved with medication or repositioning/elevation

Paresthesia: Numbness, tingling, pins/needle sensation

Pallor: Cap refill time > 3 sec, bluish fingers, toes

Late ~ 3 Ps

Polar: Skin temperature - cool/cold fingers/toes

Paralysis: Unable to move fingers/ toes

Pulses: Palpable pulses, Doppler pulse, or no pulse

Preventing dislocation

avoid flexing hip >90 and no internal or external rotations

Compartment syndrome

Reperfusion swelling, initial injury has happened, WBCs and all things go to area of injury, all fluid and bleeding leads to→ increased pressure within muscle compartment(s) → (possible permanent damage)

- EXTREMELY PAINFUL

Compartment syndrome: Within 4-6 hours if nothing is done

Necrosis (tissue death)

Neuromuscular damage

Death (severe)

Fasciotomy

a surgical incision through the fascia to relieve tension or pressure

How does compartment syndrome present

(leg can feel "tight")

Pain

Edema (may or may not be seen bc most of the pressure is inside)

Anxiety

Compartment syndrome interventions

1. Analgesics as ordered (if they don't work worry ab something else being wrong)

2. Elevate extremity (help decrease fluid)

3. Educate/answer questions

Fat Emboli Syndrome (FES)

Long bone/hip fracture (femur fracture)

- No treatment (supportive, maintain O2 and circulation) - prevention!

FES: Clinical Presentation

(unique trio)

- Respiratory compromise (seen first, Hypoxemia may be detected hours before the onset of respiratory complaints (IMPORTANT)

Check O2 saturation)

- Cerebral dysfunction (acute confusion)

- Petechiae (pinpoint purple areas, upper torso)

FES: Diagnosis

Hypoxia, with a paO2 < 60 mmHg and

Hypocapnia withrespiratory alkalosis

DVT

Most common complication following trauma, surgery or disability

- Can still feel pulses

- Swelling → Decrease pedal pulse

Osteomyelitis

Inflammation or infection of the bone because of penetrating organisms - Staphylococcus aureus most common

- At risk: patients with diabetes, had orthopedic surgery, previous history

- Approximately 20% to 30% will experience recurrence within 2 years, even with appropriate medical and surgical treatment

Risk reduction of Osteomyelitis

Open fractures who receive antibiotics within 6 hours of injury and prompt surgical treatment

Avoid health care-associated osteomyelitis

Osteomyletis: Diagnosis

biopsy and culture

Osteomyelitis Treatment

Long term antibiotic therapy (3 months)

Surgery/ Debridement to clean out area

Nurse Prevention of Osteomyelitis

Maintain "separation" from potential infectious agents (treated for open fracture or hip replacement will be in different areas)

Non-Union

(bone edges do not heal together)

What is compartment syndrome?

reperfusion and accumulation of fluid and WBCs that increases pressure within muscle compartments and compresses nerves and blood vessels

How do you diagnose compartment syndrome?

use a device and stick into the compartment to measure the pressure

What happens in 4-6 hours of compartment syndrome if nothing is done?

tissue necrosis, neuromuscular damage, death

What are compartment syndrome human responses?

pain, edema, anxiety, leg is tight

Compartment syndrome nursing interventions

analgesics as ordered, elevate extremity, educate and answer questions

Compartment Syndrome medical treatment

control/reduce swelling, elevate, release restrictive dressings if too tight, fasciotomy and leave open to relieve pressure butt cover with moist, sterile dressing

Nursing Responsibilities for Fasciotomy

analgesics as ordered, elevate extremity, maintain moist, sterile dressing, monitor incision, labs, VS, antibiotics as ordered, diet for healing, routine post-op care

What is FES (fat emboli syndrome)?

fat gets into blood stream and causes embolus/globuli

What is the profile of someone who gets FES?

youth, cast (instead of ORIF), closed fracture, long bone, necrosis of bone marrow, trauma

FES Treatment

there is none, only prevention

FES Preventative Care

recognize profile and increased risk, maintain adequate oxygenation and ventilation, stable hemodynamics (BP), hydration and nutrition, early ambulation, monitor labs, VS, ABGs

What is the FES triad?

respiratory, cerebral, petechiae

When does FES occur?

24-72 hours after fracture/trauma

What are the manifestations of FES?

respiratory compromise: tachypnea, dyspnea, cyanosis, elevated temp, low Hct, hypoxemia, cerebral dysfunction: confusion, drowsiness, convlusions, coma, petechiae: pinpoint, purplish areas where fat blocks small blood vessels and causes bleeding, usually in upper torso but can be in neck and eye

What is the diagnosis for FES

clinical picture and risk factors, rule out alternative pathologies, blood gasses, chest xray

FES Nursing Interventions

telemetry, ventilation via face mask or mechanical ventilator, nutrition, adequate hydration, foley catheter, SCDs, air mattress, good eye care, ongoing diagnostics

DVT/VTE

blood clot that originates in a deep vein in the body ie lower extremity, can still feel pulse since clot is in vein but see swelling since you can't get blood back to the heart, MOST COMMON POST OP COMP

DVT Human Responses

pain, swelling, decreased pedal pulse

DVT Nursing Prevention

OOB, leg/ankle exercises, adequate hydration

DVT Nursing Responsibilities

analgesia, assess pulses/pain/swelling, report to PCP