Fracture Patients Flashcards
How can we non-surgically manage fracture patients?
Conservative
External coaptation
What are the advantages of non-surgical management?
Reduce/avoid anaesthesia
Avoid need for open surgical approach
Cheaper materials
What are some disadvantages of non-surgical management?
Fracture disease
Insufficient stability leading to delayed or non-union
Malunion
Cast sores, ischaemia
What are the aims of conservative management?
Surrounding soft tissue provides sufficient stability to keep bones aligned whilst healing
Minimise movement whilst healing - restrict exercise (cage rest, 4-6 weeks), pain relief (NSAIDs), prevent weightbearing
Which fractures are suitable for conservative management?
Selected fractures of pelvis, scapula or vertebra
Stable, minimally displaced fractures
What does an owner need to know about care for conservative management patients?
Confinement - why and how long? Assisted ambulation - hoist/belly band Non-slip rugs, ramps etc. Requirements - bed, litter tray, food, water, toys etc. Follow up/rechecks and radiographs Contact details if concerned
What are the general principles of external coaptation?
Compressive forces transmitted to bones by means of interposed soft tissues
Pressure must be evenly distributed throughout cast/splint to avoid circulatory stasis
Immobilise joint above and below fracture
This principle extends to all joints distal to fracture to avoid foot swelling
Which fractures are suitable for external coaptation?
Fractures distal to elbow/stifle
Stable fractures
50% overlap of fracture fragment on orthogonal radiographs
Fracture of one bone of a two-bone segment e.g. fractured radius with intact ulna, fractured fibula with intact tibia
2 or fewer metapodial fractures
How do we apply a cast?
First layer = stockinette Primary layer = softban Application of vetcast Cut cast + secure bivalved cast Protect sharp ends Outer protective layer Final checks - toenails and central pads visible but not protruding
What complications can occur with external coaptation?
Soft tissue injury Cast sores/pressure sores Malunion, delayed union and non-union Fracture disease Not tolerated by patient!
Describe soft tissue injury.
Ischaemic injury - mild dermatitis to avascular necrosis
Esp. sighthounds
Weekly cast changes, padding
Consider cost for owner
Describe malunion/delayed union/non-union.
Fractures treated by external coaptation may heal with rotation, angulation and/or shortening
Functional or non-functional dependent on degree/severity
What are the signs of fracture disease?
Joint stiffness
Muscle atrophy
Osteoporosis
Muscle contracture and fibrosis
How can we avoid fracture disease?
Aim for a rapid return to weightbearing
Avoid unnecessary immobilisation of joints by external coaptation
Consider other options that are less likely to cause fracture disease
What is the nurse’s role in surgical management of fracture patients?
Analgesia provision and care of patient prior to surgery
Prep for aseptic surgery
Equipment gathering and set-up for theatre
Trolley assistant for surgery
Post-op care of patient
Discharging patient to owner
What is fracture reduction?
The process of replacing the fracture segments in their original anatomical position
For what types of fractures can we use closed fracture reduction?
Recent
Stable
Lower limb - less soft tissue, easier to reduce and palpate
What methods can we use for closed fracture reduction?
Traction
Counter traction
Manipulation
Bending
How can we overcome muscle contraction during open fracture reduction?
Levers (Hohmann retractors)
Bone holders
Muscle relaxants
What is toggling in open fracture reduction?
Used on transverse fractures
Bend fracture (180 degrees)
Engage ends
Straighten limb
What implants can we use for fracture repair?
Pins Wire Screws External Skeletal Fixation (ESF) Plates and screws
Describe intramedullary pins.
Stainless steel smooth pins Rarely used alone Usually combined with a plate or ESF Kirschner wires/Steinmann pins Used alone in metapodial fractures - splinted by other bones
What complications can we see with intramedullary pins?
Length - too long/short (difficulty in retrieval/seroma - irritation)
Loosening and migration
Fracture non-union
Describe interlocking nails.
Stainless steel pin used as intramedullary pin
Locked in place using screws/bolts
Prevents rotation and axial collapse
Describe screws.
Combine with plate or interlocking nail
Used in isolation for fractures of cancellous bone
Never use in isolation for diaphyseal fractures (slower healing and greater forces through bone)
Types = locking/self-tapping/non-self-tapping etc.
What are the functions of screws?
Secure a plate to a bone to support a fracture during healing
To compress fractures together in lag fashion to enable rapid healing without callus
What two types of pins can be used in ESF?
Smooth pins
Threaded pins
What are the types of threaded pins used in ESF?
Negative profile (Ellis) Positive profile (Imex) End threaded (positive or negative) Centrally threaded (positive only) Interface pins (roughened to help stick to putty)
What two types of connecting bars can be used in ESF?
Stainless steel/carbon - reusable, rounded ends, heavy (carbon light), all clamps need to be in a straight line
Acrylic/putty - light, no limit to pin size/closeness, no protruding ends to irritate, removal more difficult?
What are the three functions of bone plates?
Compression of bone fragments - friction increases stability, primary bone healing, load sharing between bone and implants
Neutralisation of fracture forces - bone reconstructed to anatomical shape by lag screws/wire, plate applied to support bone after fracture reconstruction
Bridging the fracture - bridging fixation, plate used to shore up/support fragments, unreconstructable (comminuted) fractures, larger plate
How would we treat an articular fracture?
E.g. humeral condyle Open reduction and internal fixation (ORIF) Compression Perfect reduction Maintain joint mobility
Describe a tied-in intramedullary pin.
IM pin is left long and connected to ESF via a separate connecting bar or by bending the bar
On which bones may we find avulsion fractures?
Olecranon Greater trochanter Medial malleolus Acromion of scapula Calcaneus Tibial tuberosity
What is the principle behind using a pin and tension band on an avulsion fracture?
Active distracting forces are counteracted and converted into compressive forces
How can a nurse act as a surgical assistant?
Manage surgical table and pass instruments correctly
Assist with surgical retraction and haemostasis
Ensure that diagnostic samples are not lost and transferred appropriately to sample pots
Keep bone grafts safe and remind surgeon to use it
Keep count of surgical swabs
Run a continuous suture and cut sutures
How do we pass instruments to the surgeon?
Pass instruments in decisive manner
Tip of instrument visible and handles placed in surgeon’s waiting hand
Instrument should be slapped firmly into palm of surgeon in proper position for use
Do not reach behind member of sterile team, do pass them back-to-back
What post-op care instructions should we provide to the owner?
Young animals - warn about possibility of premature closure of growth plate Post-op X-rays Cage rest When should weightbearing occur? Suture removal Buster collar Physiotherapy? Prognosis
What complications might we see post-op?
Fracture instability, loosening, breakage, delayed or non-union
Lameness, change in limb use, change in shape, swellings, discharge, etc.
What instructions can we provide an owner with regarding cage rest?
Size What to include Bedding Relieve boredom - games, training, music Sit with dog, stroking/massage Decrease food/use food toys
What does ABC stand for when surveying emergency patients?
Airway
Breathing
Circulation
How does compensated shock present in an emergency patient?
Mild tachycardia Mild tachypnoea Injected MMs (increased CO) CRT < 1 second Normal mentation and BP (Increased CO, HR and systemic resistance to maintain BP)
How does early decompensated shock present in emergency patients?
Tachycardia Tachypnoea Pale MMs Slow CRT Weak pulse Poor mentation Hypotension Peripheral vasoconstriction, essential organ BP preserved, lactic acid accumulation
How does late decompensated shock present in emergency patients?
Bradycardia Absent CRT Severe hypotension Cheyne Stokes breathing Death
How should we initially manage RTA patients?
Assume severe injury until proven otherwise
Use minimal restraint for mobile patients
Transport recumbent animals on improvised stretcher
Restrain patients suspected of vertebral column fracture
What does A CRASH PLAN stand for?
The secondary survey
Airway, Cardiovascular, Respiratory, Abdomen, Spine, Head, Pelvis, Limbs, Arteries and veins, Nerves
What are the signs of orthopaedic injury?
Recumbency/severe lameness Limb wound(s) with pain and swelling Deformity Abnormal mobility/instability of limb Crepitation
What are the major orthopaedic injuries?
Fractures Luxations Subluxations Wounds penetrating joints Tendon lacerations/avulsions Ligament strains Muscle lacerations
Define fracture.
Disruption in the cortical continuity of a bone
Define luxation.
Complete disruption of normal relationship between articular surfaces of joint
Define subluxation.
Partial disruption of relationship between articular surfaces of joint
What first aid can we prove orthopaedic patients?
Sterile dress wounds and support dressing if possible
Cage confine patient unless only minor injuries
In the conscious patient, do not attempt to reduce luxations/fractures, or stabilise proximal limb injuries
What first aid should we provide for open fractures/luxations?
Treat as for laceration AND
Apply sterile hydrogel to exposed articular cartilage and/or bone
Clip, flush, debride, bandage
Support dress the injured limb, attempting to restore normal anatomy
What first aid should we provide for closed fractures/luxations?
May be possible to support dress the limb in reduction or near reduction
If limb is not markedly unstable, do not attempt conscious manual reduction
To support unstable fractures - use soft padding, then splinting material, then conform and outer protective layer
When we have a patient under GA for radiographs, what else can we do at the same time?
Orthogonal radiograph views
Wound care
Splint/bandage application
Reduction of dislocation?
What splinting materials are available?
Fibreglass resin
Orthoboard
Thermoplastic
Plaster of Paris
What are the functions of a bandage?
Protection (of wounds/fractures from self-trauma/contamination)
Support fracture/luxation pre-/post-op
Pressure - haemostasis, control swelling
Immobilisation - comfort, restrict movement, prevent further damage
How can we use support dressings in first aid?
Mainly useful to stabilise the distal limb only
Always apply all 4 layers
Support joint proximal and distal to injury
Splints useful - require careful application and adequate padding, good for unstable fractures
What initial management would we suggest for an upper limb fracture?
Cage rest prior to fracture repair
What are the functions of a Robert Jones bandage?
Immobilise fracture/luxation
Control swelling and oedema
Comfort
Post-op - support and control swelling
What other considerations should we have for emergency fractures?
Provide analgesia (NSAIDs and opiates) If open fracture/luxation - antibacterial therapy
What first aid can we provide for bleeding?
Apply sterile contact layer, then generous padding using absorbent layer e.g. cotton
Apply pressure - leave on for 1hr max.
