353 - fractures, joint replacement, arthritis

didnt do arthritis yet

whose at risk for fractures?

age, athletes, diet (poor vitamin D and calcium intake, excessive alcohol intake)

gender: 1 out of 2 women, 1 out of 4 men

genetics, trauma, co-morbidities such as bone cancer, osteoporosis, HIV, hyper and hypothyroidism

types of fractures

segmental, displaced, non-displaced, pathological

fragments: segmental

large fragments separate from main bone

fragments: displaced

separated, not aligned

fragments: non-displaced

separated but aligned

• aligned = much easier to heal

fragments: pathological

just sort of happens, indicates underlying illness

result of non-traumatic forces

fractures defined by: bone

incomplete vs complete

• incomplete: goes through part of bone

• complete: goes through entire bone

fractures defined by: skin

closed (simple) vs open (compound)

• close or simple: skin remained closed or intact

• open or compound: skin is open, greater infection risk

fractures: spiral

twisting of bone (not normally from a fall)

fractures: comminuted

lots of small pieces, multiple fractures

harder to heal

fractures: avulsed

piece pulled away

KIDs only: fractures

torus & greenstick

• torus: buckles in on itself (spongy)

• greenstick: think young stick that won’t break completely

fractures - diagnostic tests

x-ray: easiest way to look at bones, first choice

CT scan/MRI if occult

bone scan to determine complications: delayed healing, infection

General Assessments of Fracture

deformity, edema, pain, crepitus

spasms (may cause more pain than actual fracture)

ecchymosis, loss of function, abnormal ROM

circulatory compromise

neurovascular assessment/concerns split into

early ~ 3Ps: pain (unrelieved w meds), paresthesia (THINK nerve damage), pallor (cap refill > 3sec)

late ~ 3Ps: polar (cold fingers, toes), paralysis, pulses (doppler-only, or none)

early 3Ps are serious, late 3Ps are super severe

fracture - treatments are

determined by type/location

• more stable fracture → external immobilization

• less stable fracture → internal immobilization

more stable fracture

external immobilization

• casts, splints, traction

less stable fracture

internal immobilization

• if more conservative treatment fails OR

• immobilization risk is greater than surgical risk

• skeletal traction ~ external fixator ~ internal fixation (ORIF) ~ bone grafting

fracture repair

hardware - for life

• fix above and below fracture

immobilization - casts

rigid, external immobilizing device

uses: immobilize a reduced fracture, correct deformity, apply uniform pressure to soft tissues, support to stabilize a joint

joints proximal and distal are included

reduced fracture

pieces put back to where they should be (in its proper place)

cast materials

1. fiberglass: lightweight, durable, waterproof (colorful, for younger pt)

2. plaster: heavier, break apart when wet, require 24+ hrs to dry

cast assessments: pt

skin, neurovascular, edema/swelling

cast assessments: the cast itself

dry, intact, no rough edges

cast education - BEFORE

purpose/goals of cast, expectations during casting process (will feel heat)

do not scratch or stick under cast, cushion rough edges

activity and mobility options

cast education - AFTER

should feel better - control of edema/pain

exercises (muscle shrinks in cast - atrophy), safe use of devices

s/s to report: persistent pain, swelling, changes in sensation/movement/color/temp, signs of infection, burning or itching at pressure areas

cast - common pressure points

leg cast: monitor for peroneal nerve damage which can cause foot drop

body and spica cast encases

trunk and portions of 1 or 2 extremities

requires multiple ppl to position pt

perineal opening for hygiene

cast syndrome

in pt with body and spica cast

• claustrophobia, anxiety

  • compression of blood flow may lead to this

skeletal traction

immobility, blood clots, pneumonia?

external fixators

pins going into person’s bones, used if pt has infection in area

the frankenstein things

fractures - traction: nursing responsibilities

hydration/nutrition, back rubs, float heels, reposition, avoid shearing (skin)

minimize calf pressure (proper body alignment)

monitor pulses, sensation (circulation, infection)

position feet to avoid (peroneal nerve)

• plantar flexion, inversion, eversion

pin care

immobilization: traction’s purpose

reduce muscle spasms, deformity

reduce, align, and immobilize fractures

increase space btwn opposing forces

skin traction is a short-term intervention

skeletal traction can be used as treatment

manual (aka skin) traction

used before surgery, can be intermittent, wt limit maximums

you have a pulley and weight pulling back on boot (buck traction)

• 5-10 lbs of wt max

skeletal traction

continuous, pins are screwed through bones

treatment - pole in skeleton is pulling

INTERNAL immobilization

pin care

specific to skeletal traction/external fixators

goal: prevent infection of skin, soft tissue, bone

inspect sites q shift for infection, crusting may occur (normal)

pt education about performing this at home

pin care: initially

first 48 hrs: insertion sites may be covered by sterile non-stick dressing

pin care: later

use betadine, water/saline solution as ordered/per policy

clean inner to outer

open reduction and internal fixation (ORIF)

open body and put pieces back where they belong

• internal fixation with nails and plains

surgical procedure to help fracture w internal hardware

open reduction and internal fixation (ORIF): nursing responsibilities

routine post-op care

administer IV antibiotics, wound care as ordered

elevate extremity if possible

assess neurovascular status frequently (q4h)

monitor for signs of infection

assess for safety

complications of a fracture

compartment syndrome

fat emboli

DVT

osteomyelitis

avascular necrosis/non-union

localized infection at pin site

complication of fracture: compartment syndrome

reperfusion swelling → increase pressure within muscle compartments → compression of nerves and blood vessels

emergency situation - within 4 to 6 hrs, necrosis, neuromuscular damage, death (severe)

dx of compartment syndrome

measure pressure (intra-compartmental pressure monitor)

human response: PAIN!!!

compartment syndrome

A. normal

B. swelling of muscles, edema, possible bleeding

• arrows are where pressure is pushing out

compartment syndrome - nursing interventions

FIRST - be aware of risk profile, clinical picture

human response: pain, edema, anxiety

intervention: analgesics as ordered, elevate extremity, educate/answer qs

compartment syndrome - medical treatment

control/reduce swelling (elevate extremity)

release restrictive dressing/cast

fasciotomy: remains open (to decrease pressure), covered w moist + sterile dressing for 3-5 days

• retention sutures

interventions for fasciotomy - pain

analgesics as ordered, elevate extremity

interventions for fasciotomy - risk for infection

maintain moist, sterile dressing

monitor incision, labs (WBCs), VS (pulse, temp)

antibiotics as ordered

interventions for fasciotomy - post op status

diet for healing, routine post-op care

complication of fracture: fat emboli syndrome (FES)

pt profile: young, casted (not ORIF), closed fracture, long bone/hip fracture, necrosis of bone marrow, trauma

no treatment - supportive, prevention

fat emboli syndrome - preventative care

recognize profile, increased risk

maintain adequate oxygen, ventilation

stable hemodynamics, hydration/nutrition, early ambulation (prevents fat from escaping)

prophylaxis (prevention) of stress-related GI bleeding

monitor labs, VS, ABGs

fat emboli syndrome - clinical presentation

24-72 hrs after fracture/trauma

respiratory compromise

cerebral dysfunction, confusion

petechiae

fat emboli syndrome - respiratory comprimse

seen in 75% and will progress to failure in 10%

human response: tachypnea, dyspnea, cyanosis, elevated T, decreased hematocrit, hypoxemia may be detected hrs before onset of respiratory complaints

fat emboli syndrome - cerebral dysfunction

human response: acute confusion, drowsiness, rigidity, convulsions, coma

fat emboli syndrome - petechiae

blockages in small vessels → small pin-point hemorrhages; in upper torso but can also affect eyes

within 24-36 hrs, disappears within week

human response: nonpalpable petechial rash in chest, axilla, neck, reddened conjunctiva

FES - diagnosis

clinical pic, risk factors

rule out alt pathologies: increase ICP, PE, pneumonia

blood gases: hypoxia w paO2 < 60 mmHg AND hypocapnia (low CO2) w respiratory alkalosis

chest x-ray: fluffy white shadows

schonfeld’s criteria

score > 5 = increased probability of FES

• petechiae (5 = MOST pts), chest-xray change, diffuse alveolar infiltrates

• hypoxia, fever, tachycardia, tachypnea

FES - nurse things - supportative

telemetry (monitor heart rhythm for warnings of emboli in circulation)

ventilation via face mask or mechanical ventilator (maintain resp, function)

nutrition (via TPN or feeding tube if needed)

adequate hydration (IV fluids), foley cath (accurate I&O(

SCDs (prevent venous stasis in lower extremities)

air mattress (good skin care), good eye care (keep moist)

track progress w ongoing dxs

fracture complication - DVT

MOST common complication following trauma, surgery or disability

can progress to a pulmonary embolism so

prevention is better than treatment…

• OOB, leg/ankle exercises, adequate hydration

DVT - human response + nursing responsibilites

pain → analgesia

swelling → assess pulses, pain, swelling

decreased pedal pulse → report to PCP

fracture complication - osteomyelitis

inflammation of bone d/t penetrating organisms - Staph aureus most common

at risk: pt w diabetes mellitus, pt undergoing orthopedic surgery (placement of prostheses, management of open fractures, history of osteomyelitis)

osteomyelitis - risk reduction

open fractures receive antibiotics within 6 hrs of injury and prompt surgical treatment (get to OR)

avoid health care associated osteomyelitis, with careful attention to intravascular and urinary caths, surgical incisions, other wounds

osteomyelitis - s.s,

bone pain worse w movement

elevated WBC, temp

dx: biopsy and culture

osteomyelitis - treatment

long term antibiotic therapy (3 months), surgery, debridement, amputation

osteomyelitis - complications

abscess formation, sepsis, bone deformity, limited ROM, motor and sensory deficits

20-30% will experience recurrence within 2 yr, even w treatment

osteomyelitis - nurse things

recognize profile, increased risk

inspection of surgical site/pin site - note change in COCA, REEDA

administer antibiotics as ordered

monitor VS, labs

note complaints of worsening pain w movement

maintain separation from potential infectious agents (keep clean from dirty pts)

fracture complication - non union

poor healing, dx through clinical picture/X-ray

treatment: internal fixation (surgery), bone grafting, electrical bone stimulation

• may or may not need surgery

fracture complication - avascular necrosis

disruption of blood flow to fracture site → bone necrosis

dx: clinical pic, x-ray

treatment: repair vascular compromise, surgical joint replacement

common in hips, blood vessels need to communicate so if damaged, need to give hip replacement instead of saving

joint replacement

reconstructive normal joint with artificial or aftermarket parts

arthro -

prefix meaning joint

arthroscopy

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

• using a scope to look inside joint (can be dx or surgery)

arthroplasty

forming a new joint

• technical term for joint replacement

hemiarthroplasty

replacement of one of articular surfaces

• ex: half a hip joint

osteotomy

surgical cutting of the bone

• ex: bone has spurs (overgrowth), cut a little to restore function

prosthesis

artificial substitute of missing part of body or as replacement

most common replaceable parts (joints)

hip, knee, finger joints

less frequently: shoulder, elbow, wrist, ankles

THA - total hip arthroplasty

total hip replacement (THR)

TKA - total knee arthroplasty

total knee replacement (TKR)

who gets joint replacements

pts with osteoarthritis, rheumatoid arthritis (significant pain, decreased mobility and function)

• osteo more common in older; rheumatoid in younger

pt who sustained trauma: hip fractures (in trochanter area, cut off blood supply → joint replacement NOT joint repair w hardware)

congenital deformity: functional joint damage, worn down as they age

• hip dysplasia: not formed properly

tumors: can invade bone and cause death of bone

avascular necrosis: w/o blood supply (ex: sickle cell anemia), bone cannot supply

joint replacement: why?

increase mobility, use, joint stability

relieve pain, mobility, functionality, comfort

joint replacement: when?

after conservative therapies have failed (after PT, meds, joint injections, weight loss, activity modification - cane)

(R) hip prosthesis

hip ball - end of joint stem, fits into socket (cup)

can replace all these elements, entire native hip with artificial pieces

different pts need different size of joint stem

component materials - hip replacement

plastic (polyethylene - often in cup for ball to rotate)

cobalt-chrome or titanium metals (joint stems)

ceramic (metal oxide for ball of new hip, lasts long)

cement: old method, filling compound to hold parts in place (trend is to move away from this, for better fitting pieces)

• can dry and flake off, loosening of parts

cementless hip prosthesis

avoids cement issues (loose, jiggly), minimal prosthesis-bone bond loss

prosthesis is hammered into more precisely bored hole in femur

porous coating - healthy bone grows/sprouts, allow for stable joint

• requires good circulation

ppl do extremely well w this prosthesis

cementless hip prosthesis: disadvantages

risk of bone marrow chunks in circulation during shaft placement

potential weight-bearing restrictions in place

thigh pain (larger prosthesis)

loosening of fibers from porous coated surface

requires good circulation

cemented hip prosthesis

don’t need as much skill to place (surgical skill deviations)

prosthesis placed into bored opening in femur, surrounded by bone cement (opening doesn’t need to be precise)

early weight-bearing, smaller + lighter prosthesis

cost effective

cemented hip prosthesis: disadvantages

circulatory interruptions d/t cement

with age, cement can crack → bonding loss btwn prosthesis and bone → joint instability

knee prosthesis - before

loss of joint space

bone on bone contact → painful

bulging things → bone spurs, excessive growth

knee joint prosthesis

smooth base on bottom portion

metallic piece fit over femur to allow for smooth bending on base

complications of joint replacement

dislocation/loosening (osteolysis) of artificial joint - don’t have the normal connecting structures in native join

infection at surgical site

thromboembolism - blood clot could become lsoe and move

complications of immobility

complications of joint replacement - long term

heterotopic ossification - extensive bone growth in odd places

avascular necrosis - lack of blood supply

loosening of joint

nursing goals for joint replacement

minimize discomfort/pain

prevent infection of surgical site (leave it closed in sterile dressing for couple days, don’t peek and change often)

minimize negative consequences of immobility

prevent dislocation/loosening of prosthesis

post-op nursing responsibilites for joint replacement

vs/neurovascular checks as ordered (q1-2 hr)

control pain: meds (IV, PO, PCA, nerve block*)

monitor incision: infection, bleeding, record drainage/drain output, maintain clean, dry dressing

prevent DVT: thrombus-preventive therapy - Lovenox/Coumadin/aspirin

• AE hose, SCDs, activity and weight-bearing as allowed by surgeon, OOB w order

• active ROM

maintain body/limb alignment

respiratory toilet - C-DB, IS

assess skin integrity: investigate itching, burning (especially heels), redness of bony prominence

nutrition/hydration: balanced diet for healing, energy for PT/activity

home health/social service for rehab referrals

joint replacement: pain control

• PCA - patient controlled analgesia, moving away from this

• nerve blocks - local anesthetic, common in knee replacement, more likely to progress better

• individualize strategies: reposition

neurovascular assessment/concerns

same as fractures

early 3Ps - pain, paresthesia, pallor

late 3Ps - polar, paralysis, pulses

dislocation of hip prosthesis

dislocates more readily

human response: increased pain, swelling, immobilization, shortening of affected leg, abnormal rotation, restricted movement, popping sensation of affected hip

prevent hip prosthesis dislocation

proper positioning: maintain abduction for some replacements

• abductor pillow keeps legs apart

• posterior approach

prevent prosthesis dislocation

sometimes, hip should not bend more than 90 degrees (leaning forward is a nono) - hip should be higher than knee

affected leg should not turn inward

hip dislocation - risk

greatest during 3 months post-op

other factors: age, bone loss, RA, cognitive impairment, implant issues

important to know specific PRECAUTIONS FROM SURGEON (depends on surgical approach)

give printed literature with pictures to patient and review before discharge

dislocation of knee prosthesis

human response: pain or swelling after moving, obvious deformity of knee, numbness or no pulses in foot