Caring for Clients Requiring Orthopedic Treatment Notes Orthopedic Treatment

Casts and Immobilization

• Definition: A cast is a rigid mold that immobilizes an injured structure while it heals.
• Application Principles:
  • To assure bone alignment, a cast is applied from the joint above the break to the joint below it.
  • Positioning: The joint is slightly flexed rather than set straight. This is done to decrease joint stiffness.
• Types of Casts:
  • Cylinder cast.
  • Body cast.
  • Hip spica cast.
  • For additional types, see Box 61-1 in the reference material.
• Cast Composition:
  • Fiberglass.
  • Plaster of Paris.
• Nursing Care and Handling:
  • For alignment and support of the fractured area, refer to Box 61-2.
  • While a cast is drying, it must be repositioned using only the palms of the hands to prevent indentations.
• Cast Windows:
  • Created if a client reports discomfort under the cast.
  • Utilized when a wound requires regular dressing changes.
• Bivalve Casts: Used in specific scenarios including:
  • A swollen arm or limb.
  • When a client is being weaned from a cast.
  • When a sharp x-ray image is required.
  • As a splint for arthritis.
• Cast Removal:
  • Performed using a mechanical cast cutter.
  • Nursing management for removal can be found in Nursing Guidelines 61-1.

Splints and Braces

• Splints:
  • Function: Immobilize and support an injured body part in a functional position.
  • Indications: Used when a musculoskeletal condition does not require rigid immobilization, if the injury causes a large degree of swelling, or if the area requires special skin treatment.
  • Materials: Made of plaster or thermoplastic material.
• Braces:
  • Function: Provide support, control movement, and prevent additional injury for long-term use.
  • Characteristics: Custom-fit to each individual client and made of various materials.
  • Nursing Priorities: Provide comprehensive client and family education. Scrupulous skin care is vital to maintaining skin integrity.

Fracture Reduction and Traction

• Methods of Reducing Fractures:
  • Traction.
  • Closed or open reduction.
  • Internal or external fixation.
  • Cast application.
• Traction Overview:
  • Definition: The process of pulling structures of the musculoskeletal system (see Box 61-3 and Nursing Guidelines 61-1).
  • Countertraction: All traction requires countertraction, which is supplied by the client’s own weight.
• Skin Traction:
  • Definition: A device applied to the skin that indirectly affects muscles and bones.
  • Examples: Buck traction and Russell traction.
• Skeletal Traction:
  • Definition: Traction applied directly to the bone.
  • Hardware: Uses a wire (Kirschner), pin (Steinmann), or cranial tongs (Crutchfield).
  • Mechanics: Utilizes a system of ropes, pulleys, and weights.

Surgical Reduction and Fixation

• Closed Reduction:
  • Procedure: The bone is restored to its normal position by external manipulation.
  • Immobilization: The area is then secured by a bandage, cast, or traction.
  • Verification: X-rays are taken to ensure the correct alignment of the bone.
• Open Reduction:
  • Procedure: The bone is surgically exposed and realigned.
  • Internal Fixation: The surgeon secures the bone internally using metal screws, plates, rods, nails, or pins.
  • External Fixation: The surgeon inserts metal pins into the bone or bones from outside the skin surface and then attaches a compression device to the pins.
• Open Reduction Internal Fixation (ORIF):
  • Includes the use of Buck extension, nails, and intramedullary rods.
  • Utilizes various internal fixation devices.

Orthopedic Surgery and Procedures

• Corrective Procedures (Box 61-4):
  • Arthroplasty: Joint replacement.
  • Arthrodesis: Fusion of a joint.
  • Osteotomy: Cutting of bone.
  • Hemiarthroplasty: Partial joint replacement.
  • Total arthroplasty: Replacement of the entire joint.
• Joint Replacement:
  • Can be minimally invasive or conventional joint replacement.
• Complication Risks:
  • Hemorrhage.
  • Subluxation (partial dislocation).
  • Infection.
  • Thromboembolism (blood clots).
  • Avascular necrosis (death of bone tissue due to lack of blood supply).

Nursing Management for Orthopedic Surgery

• Preoperative Management (Nursing Guidelines 61-4):
  • Obtain a complete medical and physical history.
  • Assess for complications arising from previous treatments.
  • Assist in reducing pain and the risk of infection.
  • Increase mobility where possible.
  • Help the client control anxiety and ensure they understand all instructions.
• Postoperative Management:
  • Required demonstrations of tasks or exercises.
  • Management of postsurgery devices.
  • Implementing measures to reduce the risk of excessive bleeding.
  • Reviewing primary provider’s specific orders.
  • Use of Continuous Passive Motion (CPM) devices for flexion and movement.
  • Reducing pain and inflammation.
  • Preventing general postoperative complications.
• Discharge Planning (Client and Family Teaching 61-1):
  • Establish a support system after discharge.
  • Explore the specific kinds of assistance the client will need.
  • Identify modifications needed in the home environment.
  • Provide information about home care and referrals to home healthcare agencies.
  • Provide printed discharge instructions regarding activity levels, Physical Therapy (PT), and specific symptoms that must be reported.

Specific Postoperative Care and Rehabilitation

• Hip Replacement Precautions:
  • Positioning: Maintain the legs in an abducted position using pillows or an abductor cushion.
  • Extension: Legs should be kept extended.
  • Danger Zones: Avoid adduction and flexion beyond $90^\circ$ because these positions can dislocate the prosthetic femoral head from the acetabulum.
  • Sitting: The client should sit in an elevated chair or on a seat raised by pillows to ensure flexion remains less than $90^\circ$ (refer to Box 61-5).
• Knee Replacement:
  • Postoperative Flexion: Amount of flexion and frequency of use are increased daily during the hospital stay.
  • Discharge Goal: The client should have the ability to bend the knee $90^\circ$ by the time of discharge.
• Continuous Passive Motion (CPM) Machine Limits:
  • For clients with hip replacements, flexion in a CPM machine should never exceed $30^\circ$.

Amputation and Prosthetics

• Etiology and Amputation Rationale:
  • Traumatic: Resulting from injury.
  • Therapeutic: Resulting from planned medical necessity.
• Medical and Surgical Management:
  • The client is treated for any underlying disorders that may influence the healing process.
  • Surgeons must decide the precise level at which the limb will be amputated.
• Amputation Methods:
  • Open (guillotine) amputation.
  • Closed (flap) amputation.
  • Staged amputation.
• Arm Amputation Prostheses:
  • Hook.
  • Cosmetic hand.
  • Myoelectric arm.
• Leg Amputation Management:
  • Attachment of a temporary prosthesis to a plaster shell.
  • Transition to a custom-made conventional prosthesis.
• Phantom Limb and Phantom Pain:
  • This is a potential phenomenon where the client feels sensations or pain in the missing limb.
  • It is a documented physiologic response.
• Rehabilitation Success Factors:
  • Client must maintain realistic expectations.
  • Nursing management should refer to Evidence-Based Practice 61-1.

Questions & Discussion

• Question 1: Is the following statement true or false? When a limb is placed in a cast, the joint is set straight to assure bone alignment.

  • Answer: False.
  • Rationale: When a limb is placed in a cast, the cast is applied from the joint above the break to the joint below the break. The joint is slightly flexed to decrease joint stiffness.

• Question 2: Is the following statement true or false? Braces provide support, control movement, and prevent additional injury.

  • Answer: True.
  • Rationale: Braces provide support, control movement, and prevent additional injury for long-term use. They are made of various materials and are custom fit to the client. Scrupulous skin care is vital to maintain skin integrity.

• Question 3: By the time of discharge from the hospital, a client with a knee replacement should bend the knee how many degrees?

  • A) $30^\circ$
  • B) $45^\circ$
  • C) $60^\circ$
  • D) $90^\circ$
  • Answer: D) $90^\circ$.
  • Rationale: The goal is for the client to have the ability to bend the knee $90^\circ$ by discharge.