Orthopedics Nursing

Fractures

• Signs and Symptoms:

  • Continuous pain
  • Unnatural movement
  • Deformity (e.g., foot pointed backwards)
  • Shortening of the extremity: Due to muscle spasm.
  • Crepitus: Bone ends grating together.
  • Swelling and discoloration: Major concern is compartment syndrome.
    • Compartment syndrome can lead to loss of the extremity.

• Treatment:

  • Immobilize bone ends and adjacent joints.
  • Support the fracture above and below the site.
  • Minimize extremity movement to prevent further injury.
  • Splints: Help prevent fat emboli and muscle spasm.

• Open Fractures:

  • Cover the area with a sterile covering, if available.
  • Muscle spasms may pull bones back into the wound, increasing the risk of infection.

• Neurovascular Checks: Critical for orthopedic injuries.

  • Components: Pulses, color, movement, sensation, capillary refill, temperature.
  • Neuro components: Movement and sensation (sensation can have circulatory components as well).

Complications of Fractures

• Shock: Due to bleeding, depending on the extent of the injury.

• Fat Embolus:

  • Associated Fractures: Long bones (femur), pelvic fractures, crushing injuries.
  • Symptoms depend on where the embolus goes.
  • Weird Symptoms:
    • Petechiae (rash) over the chest.
    • Conjunctival hemorrhages.
    • Snowstorm on chest x-ray (patchy infiltrates).
  • Pulmonary Symptoms: Fat emboli often travel to the lungs.
  • Typical Patient: Young males (risk-takers). Injuries are usually greater.
  • Timing: Usually occurs within the first 36 hours after the injury.
  • Late Complication: Pulmonary embolus (DVT) can occur later (weeks after the injury).

• Compartment Syndrome:

  • Cause: Fluid accumulation in the tissue impairs tissue perfusion.
  • Symptoms: Severe pain not relieved by pain medication.
    • Pain is unpredictable and disproportionate to the injury.
  • Location: Common in the forearm or quadriceps.
  • Consequences: Nerve damage, possible amputation.
  • Etiology: Can occur without a fracture (e.g., insect bite, burns); studied with fractures.

Compartment Syndrome: Treatment

• Initial Actions:

  • Loosen the cast to restore circulation.

• Fasciotomy:

  • Invasive procedure to cut into the tissue and relieve pressure, restoring circulation.

• Cast Removal:

  • Only in cases of extremely poor neurovascular checks and lack of time to consult a doctor.
    • Example: Purple hand, numbness, absent pulse under a forearm cast.

• Cast Cutters: Used to loosen the cast; vibrates and does not touch the skin.

Other Fracture Complications

• Delayed Union: Healing doesn't occur at a normal rate.
• Nonunion: Failure of bone ends to unite, possibly requiring bone grafting.
  • Signs and Symptoms: Persistent discomfort and movement.

Cast Care

• Ice Packs: Apply to the sides of the cast, not the top, for the first 24 hours to prevent indentations.
• Handling: Use palms, not fingertips, for the first 24 hours while the cast is still wet, to avoid indentations.
• Drying: Leave uncovered and dry to allow heat to escape.
  • Wet casting material generates heat.
  • Caution for diabetics with foot injuries; increased risk of problems.
• Positioning:
  • Do not rest cast on hard surfaces or sharp edges.
  • Cover cast near the groin with plastic to keep clean.
  • Elevate the cast.
• Neurovascular Checks:
  • First action for patient complaints of pain.
  • Administer pain medicine if neurovascular check is okay.
  • Reassess within 30 minutes to ensure pain relief. If pain persists, suspect compartment syndrome.
• Do Not Insert Objects Into Cast:
  • Even soft objects like Q-tips are prohibited.
• Itching Relief:
  • Offer a cool blow dryer to change the sensation.

Traction

• Purposes:
  • Decreases muscle spasms.
  • Reduces (realigns) the bones.
  • Immobilizes.
• Manual Reduction: Orthopedic doctors use hands to pop bones back into place.
• Type: Continuous traction is essential.
• Rule: Never relieve traction without a doctor's order.
  • Releasing traction can cause muscle spasms and further injury.

Weights and Patient Positioning in Traction

• Weights: Should hang freely, not touching the bed or floor.

• Patient Positioning:

  • Keep the patient pulled up in bed and centered with good alignment.
  • Buck's traction attached to the leg constantly pulls on the patient.
  • For patients with normal body weight, their weight keeps them pulled up in bed.

• Addressing Patient Sliding:

  • Incorrect Action: Lifting weights to reposition the patient breaks the NCLEX rule.
    • This relieves traction and causes muscle spasms.
  • Correct Action: Get assistance to lift the patient while someone else lifts the weights to maintain traction.

• Preventing Brachial Nerve Damage:

  • Avoid pressure under the axilla.
  • Crutches should fit one to two inches below the axilla.

• Exercise: Exercise non-immobilized joints.

• Traction Equipment:

  • Rope should move freely and the knot should be secure.
  • Egg crates and footboards are okay if they don't interfere with the traction.
  • Footboards cannot be used with Buck's traction because Buck's traction fits on the foot of the bed.
  • High-top tennis shoes can be used to prevent foot drop.

Types of Traction

• Skin Traction:
  • Tape or material is stuck to the skin, and weights pull against it.

Skin is NOT penetrated.

• Examples: Buck's and Russell's Traction.

  • Priority Assessments: Good skin assessments to monitor for skin breakdown.

• Skeletal Traction:

  • Traction is applied directly to the bone with pins or wires.
  • Used when prolonged traction is needed.
    • Prolonged Traction needed.
  • Examples: Steinmann pins, Crutchfield or Gardner-Wells tongs, halo vest.
  • Must monitor pin sites and perform pin care.
  • Technique
    • Use a sterile technique.
    • Do not want an infection down into your bone because now you've got osteomyelitis.
  • Remove Crust:
    • Yes, remove the crust that forms at the pin insertion site because bacteria likes to live in crust.
      • The drainage that's coming out forming the crust is the drainage that's bringing the infection away from the bone.
      • You don't want to leave the crust in place because then drainage can't get out and you're actually trapping infection inside the wound. You want it to come out.
    • Serious drainage is okay. (Clear fluid.)

Management of a Loose Pin in Skeletal Traction

• Immediate Actions:

  • Do not reinsert the pin.
  • Stabilize the extremity.
  • Use the call light to get someone to call the doctor.

• Rationale:

  • Reinsertion can cause infection and further injury.
  • The purpose of the pin is stabilization. When it falls out, you lose stabilization.
  • Address the problem directly by fixing the current problem instead of covering the hole or checking the VS.

Total Hip Replacement

• Pre-Op:

  • Buck's traction is used frequently to immobilize.
    • May be used for two weeks prior to surgery.
    • Sometimes used for malnourished patients.

• Post-Op:

  • Neurovascular checks.
  • Firm mattress to support the joints.
  • Monitor drains (if present) for proper function to prevent compartment syndrome.
  • Over-bed trapeze to build upper body strength for ambulation with assistive devices.
    • Need upper body strength with assistive devices (crutches, cane, walker).

Post-Op Positioning

• Neutral Rotation:

  • Toes pointed to the ceiling.
  • Avoid inward or outward rotation, which can dislocate the hip.

• Flexion:

  • Limit flexion.
  • Is bad because it will make the hip pop out.

• Extension:

  • Is the good thing.
  • We want extension.

• Abduction:

  • Legs apart.
  • Use abductor pillows to keep legs apart and maintain the hip joint in the socket.

• Isometrics:

  • Exercises while confined to bed (squeezing quads, squeezing glutes) to maintain muscle tone.
    • Squeezing muscles increases venous return and prevents DVT.

• Trochanter Roll:

  • Purpose: To prevent external rotation, preventing the foot from flipping outwardly.
  • Document the presence of the trochanter roll in your nurse's notes.

Post-Op Ambulation and Activity

• Weight-Bearing:

  • No weight-bearing until ordered by the doctor.
  • Some doctors order touchdown exercises, which means they want you to sit on the side of the bed and touchdown with your feet.

• Avoidance:

  • Avoid crossing legs and bending over.

• Sleeping Position:

  • Avoid sleeping on the operative side until the doctor says so.

• Hydration:

  • Important to prevent DVT and pneumonia due to immobility.

• Stresses:

  • Stresses to the new hip joint should be minimal in the first three to six months.

Post-Op Medications

• Analgesics:
  • Avoid giving pain meds in the operative hip because they have enough trauma over there.

Complications of Hip Replacement:

• Dislocation:

  • Can lead to circulatory and nerve damage.
    • Signs and Symptoms: Shortening of the leg, abnormal rotation, can't move the extremity, and pain.

• Infection:

  • Doctor always puts them on prophylactic antibiotics.
  • Get rid of the Foley catheter and suction and drains to reduce the amount of bacteria.
  • Bacteria wants to go to foreign bodies, such as this hip.
  • This can cause so much damage that the surgery has to be completely redone again.
  • If the patient has a foreign body in their body, they always take prophylactic antibiotics before any invasive procedure.

• Avascular Necrosis: Area is dying because there is no blood supply.

• Immobility Problems

Post-Op Exercises

• Walking:
  Good exercise for the patient.

• Swimming
  Second best exercise.

• Rocking Chair:

  • For patients who are unable to walk or swim because it encourages movement.
  • They will have to press off the floor with their feet, so it's better than nothing.

• Avoid Flexion

  • Can make the hip pop out.

• CPM (Continuous Passive Motion): Used mainly with knee replacements.

  • Check the angle of flexion setting because if they flex them too much, it can ruin their surgery, whether it's a knee or a hip or whatever.
  • Administer pain medication with the use of this CPM because this is painful.

Amputations

• Surgical Goal: Performed at the most distal point that will heal preserving the knee and elbow if possible.
  * Preserving the knee and elbow allows better use of the prosthesis.

Post-Op Management

• Tourniquet: Keep at the bedside in case of massive hemorrhage.

  • Stop the bleeding over preserving the tissue; enclave is about keeping people alive.

• Elevation:

  • Elevate on a pillow for the first 24 hours and then elevate the foot of the bed.
  • The residual limb should not stay on a pillow the whole time because it can promote a hip contracture.

• Contractures: Prevent hip and knee contractures with extension.

• Below-the-Knee Amputation:

  • Worry about a contracture forming in two places: the knee and the hip. Because we have two joints left in that extremity.
    • Encourage the patient to get into positions that would force their hip and their knee to extend (prone).

• Phantom Pain:

  • Phantom pain is real to the patient. Even though it's called phantom pain, it's real to the patient.
    • Never be judgmental of people's pain.

• Interventions:

  • First intervention to decrease phantom pain is diversional activity because we want to try the least invasive things first, like diversional activity.
  • Administer pain medicine to this patient, but we want to stay away from medicines as long as we can.

• Phantom Pain Prevalence: Seen more with above the knee amputations and usually subsides in three months.

  • Some people always have the feeling that they have kept that digit that was amputated or that extremity, whatever it was.
  • Show the NCLEX people that you're going to at least try some diversional activity.

Limb Shaping and Prosthesis

• Limb Shaping: Important for the prosthesis because you want the stump to be shaped like a cone.

  • Rounded and smaller at the end so that it will fit down into the prosthesis better.
  • Limb sock is worn under the prosthesis.

• Compression Bandage Post-Op: Post-Op purpose for the tight compression bandage on the residual limb is to control bleeding and decrease edema.

• Limb Sock: 2 Weeks Post-Op: Two weeks purpose of tight stretchy thing is shaping of the stump.

Strengthening Exercises

• Strengthen Upper Body: To help with ambulation with assistive devices.

• Weight-Bearing: Is not okay to bear weight on a new stump or prosthesis until it's well-healed.

• Massage Stump: Is good because it promotes circulation and decreases tenderness.

Patient Education

• Toughen the Stump: Teach to make it tough for the prosthesis.
• How to Toughen the Stump: Press into a soft pillow, then a firm pillow, then the bed, and then the chair.

Assistive Devices

Walkers

• How to Walk: The patient's supposed to pick the walker up, put it in front of them a little bit, and then walk into the walker.

• Walker Issues:

  • Galloping walker coming down hall, or pick it up and carry it somewhere.
  • Slider: Take the rubber caps off and put tennis balls on end so it will slide easily.

Crutches

• Fitting: Have to be measured; you are not supposed to borrow your friends crutches if you have an injury.
  * We do not want brachial nerve damage.

• Walking Up and Down Stairs: Up with the good and down with the bad (good leg and bad leg).

Canes

• Side: Used on the side that they're strongest.
• Example: If I've had a right-sided stroke, the left side of my body is going to be weaker, so I'm gonna hold the cane with my right hand.