Module 13: Orthopedic Care - Cast Care and Traction

Question 1

what is a fracture

Answer 1

• a break or disruption in the continuity of a bone
  
  • displaced or not displaced
  • closed
    
    • skin is not broken
  • open (compound)
    
    • fragments of bone breath through skin
    • graded according to severity

Question 2

common causes of a fracture

Answer 2

• trauma
  
  • motor vehicle collisions
  • pedestrian vs car
  • motorbike collisions
  • pedal bike injuries
  • falls
• osteoporosis

Question 3

Immediate management of a Limb Fracture

Answer 3

• immobilize/splint (prevent inner movement)
• preserve body alignment
• elevate to prevent/ reduce deem
• cold pack 1st 24hrs
  > decrease bleeding/ decrease edema/ decrease pain
• neuromuscular assessment (CTEMPS)
• observe for signs and symptoms of shock
• compare affected and unaffected limb

Question 4

Fracture Treatment: Fixation

Answer 4

• attempt to attach fragment of broken bone together
• internal fixation
  
  • surgery using rods, pins, screws, metal plates
  • may be left in body indefinitely
  • open reduction and internal fixation (ORIF)

Question 5

Fracture treatment: external fixation

Answer 5

• pins inserted above and below fracture
  
  • pins attached to external frame
  • at risk for pin site infection

Question 6

explain the purpose of a cast

Answer 6

• immobilization of a factor and surrounding tissue allowing for healing to occur
  
  • maintains limb in a position of rest and alignment
  • reduces pain, swelling, and muscle spasms
  • remains in place until bone heals

Question 7

Describe required patient assessments when caring for a patient with a cast

Answer 7

assessing neurovascular status 
- impairment caused by pressure on the nerve or vascular supply the affected extremity 
- check distal to site 
- is there adequate circulation?
- includes:
    - pulses 
    - capillary refill 
    - skin colour and temperature 
    - sensation 
    - motor function
    - pain 
    - assess q1h x 24 h then every shift or as pe agency policy and patient condition
- CWSM (circulation- includes colour, pulse, cap refill, warmth, sensation, movement)
Cast Application
Prior:
- Baseline Assessment 
    - neurovascular assessment 
    - vital signs 
- analgesics administered if required as ordered 
- clothing/rings removed from affected limb (store valuables)
- wash and dry skin

Question 8

plaster of paris

Answer 8

• made from rolls of dry muslin
  
  • takes 24 hrs to dry and harden
  • heavy
  • can sustain heavier loads
  • cannot get wet

Question 9

fiberglass

Answer 9

• made from rolls that are activated by water or light
  
  • dry in 15-30 mins
  • lighter and cooler
  • more expensive
  • outer part is waterproof

Question 10

air cast

Answer 10

• for foot fractures its commonly used

Question 11

Describe the ongoing care of a patient with a cast with regards to positioning, position changes, exercise and nutrition

Answer 11

• assess and treat pain
• inspect for sign of drainage or door - outline drainage
• neuromuscular assessment (CTEMPS)
• vital signs - signs of infection
• assess integrity and cleanliness of cast
• evaluate skin integrity under and around cast
  
  • burning or heat sensation
  • skin redness or excoriation around the edge of cast
  • itchiness
• reduce swelling - elevate casted limb
• apply ice to outside of cast

Question 12

Cast Care: Bi-Valving

Answer 12

• medial and lateral cuts through the length of the cast to observe incision or if cast is too tight
• used to alleviate pressure from limb swelling
• cast then wrapped with tensors
• new cast will be applied when condition resolves

Question 13

Cast Care: windowing

Answer 13

• assure opening is cut in the cast in order to view the incision or area of pressure to check for circulatory impairment
• swore may be replaced and taped back in place

Question 14

Explain the common complications associated with casts

Answer 14

• compartment syndrome
• fat embolism
• deep vie thrombosis
• pulmonary emboli
• infection
• joint stiffness and contractures
• shock

Question 15

Compartment Syndrome

Answer 15

• compartments are enclosed spaces inside muscles
• blood becomes trapped in this space - pressure builds up
• pressure on tissues. nerves and blood vessels
• common causes: fractures, crush injuries
• can be due to external pressure - cast too tight
• S&S: 6 p’s
  
  • pain, not relieved by opioids
  • parenthesis
  • paralysis
  • pressure
  • pallor
  • pulseslessness
  • symptoms:
    
    • severe pain, unrelieved with opioids, edema, pallor, weak or absent pulse, cyanosis of limn, numbness, tingling, foot drop in affected leg
• irreversible damage can occur within 4-6 hours
• Treatment
  
  • internal pressure - fasciotomy
  • external - loosen dressing, cut cast

Question 16

Fat Embolism

Answer 16

• fat globules are released from bone marrow into the systemic circulation
• migrate to lungs and can lead to pulmonary edema
• most common - fractures of long bones (femur) or pelvis
• symptoms occur within 12-72 hours or injury
  
  • first signs - tachypnea, tachycardia, fever (>39c)
  • later signs - confusions, restlessness, petechial rash, fat emboli syndrome
• treatment - supportive
  
  • close monitoring
  • oxygen
  • bedrest

Question 17

Outline key learning points for instructing patients and significant others on cast care

Answer 17

• mobility and exercise
• cast and skin care
• signs and symptoms to report
• pain management

Question 18

Demonstrate common cast cutting procedures while outlining their purpose

Answer 18

• physicians orders
• cast cutter (oscillating saw) used to cut along guideline down both sides of cast
• cast spreader to separate cut edges
• cast to separate cut edges
• cast scissors used to cut the underlying padding

Question 19

Describe how to care for the extremity after cast removal

Answer 19

• neuromuscular assessment
• gently wash he skin with dampened cloth and mild soap
• check skin for flaking, irritation, bruising or edema
• assess incision for healing
• assess joint stiffness, instability or pain

Question 20

Explain the purposes of traction

Answer 20

• application of pulling pr stretching force to a part of the body
• exerted along the longitudinal axis of a bone
• reduce fractures
• treat dislocations
• correct or prevent deformities
• improve or correct contractures
• decrease muscle spasms
• reduce pain or a fracture before surgery

Question 21

Describe the principles of traction

Answer 21

• requires physicians order
  
  • to initiate traction
  • amount of traction (weight) to apply
  • to discontinue traction
• maintain counter - traction
• must be continuous
• weights must hang freely
• maintain good body alignment in centre of bed
• ropes must be unobstructed
• follow the established line of pull
• knots should not be on the pulley
• avoid bumping or jarring the bed

Question 22

skin traction

Answer 22

• applied directly to the skin
• traction force over large area of skin
• indirect pull of bone
• used hips, knees
• shorter-term treatment
• 5-10lbs

Question 23

skeletal traction

Answer 23

• applied directly to the affected bone using metal pins (or wire/screws)
• direct pull on bone
• used for cervical spine extremities
• longer term
• 10-15lbs

Question 24

Pelvis traction

Answer 24

indications:

• nerve root disorder
• sciatica
• low back muscle spasms
• minor fractures of lower spine

Question 25

Nursing Care and PT teaching in regards to traction

Answer 25

• immobility - positioning
  
  • encourage active exercises for uninvolved limbs
• monitor pain
• diet - constipation
• skin care - prevent skin breakdown
  
  • provide padding to prevent trauma to skin
  • avoid friction/shearing
  • closely monitor skin condition & report any problems
  • provide skin care regularly
    Patient Teaching
• traction in relation to fracture
• the amount of movement allowed
  
  • safety with use of trapeze bar
• correct body positioning and alignment
• to report any abnormalities in sensation

Question 26

Describe skeletal traction explaining when and why it is used

Answer 26

• applied in the operating room or at the bedside by the physician
• purpose:
  
  • promote optimal bone healing
  • correct skeletal demfority
  • prevent neuromuscular complications
  • prevent further skeletal injury
• Skull traction - for cervical spine injuries

Question 27

Halo Vest

Answer 27

• used to stabilize the cervical spine after cervical spine fracture or after surgery
• ring around head attached to outer skull with pins
• vest with sheepskin padding
• bars that attach ring to vest

Question 28

Describe the principles and rationale for performing pin site care

Answer 28

• pin site are portals of entry for microorganism and debris
• can lead to infection of the subcutaneous tissue and bone (osteomyelitis)
• pin care includes the pin sites and surrounding skin
• local reactions are expected for the first 72 hours with serous drainage
• assessment for the first 24 hrs
  
  • asses dressing q4h
  • remove dressing and assess pin sites once
• after 24 hrs
  
  • once per shift prn
• After the first 24 hrs
  
  • clean q8h if drainage present
  • q 24 h when drainage decreases
• using sterile technique
  
  • cleanse pin site with normal saline
  • start at pin insertion and move outward in concentric circles using gauze (no q-tips)
  • one gauze for each stoke
  • allow to dry thoroughly
• use a dressing until drainage subsides
• if crust is present, wrap with moist gauze and remove gently
• only use antibiotic ointment if ordered by doctor
• doctor’s order required for showering
  
  • only when drainage is minimal