Ortho Flashcards
MAIN FUNCTION: (VM is BSS)
Support
Protection of vital organs
Movement
Blood cell production
Mineral storage
bones
Provide supporting framework to body and protect underlying organs and tissues
bones participate in
red and white blood cell production
Serve as a site for storage of inorganic minerals (Ca++,
PO4-) and contain organic
material (collagen)
bones are dynamic or not dynamic?
Dynamic tissue (osteoblasts, osteoclasts)
ligaments (bone gets a lig up from bone)
Connect bones to bones
More elastic than tendons
tendons
Attach muscles to bones
both ligaments and tendons have (blood won’t touch ligs and tendons)
poor blood supply which delays healing
fascia
Layers of connective tissue with intermeshed fibers
bursae (what type of tissue and fluid?)
Small sacs of connective tissue lined with connective tissue containing viscous synovial fluid
age related - loss of bone density due to
increase resorption and decreased formation leading to osteopenia (loss of bone mineral density) and osteoporosis, kyphosis
age related - loss of water from vertebral discs =
loss height
age related - falls
increase likelihood of fractures d/t to loss of bone mass
age related - Increase risk for cartilage
erosion-direct contact between bone ends-osteoarthritis
age related - Decreased muscle mass and strength…how much loss?
almost 30% lost by age 70-leads to decreased ability to release glycogen during stress and decreased BMR
inspection - start with what? (start with the general)
Always start with your initial contact with the patient
Look for symmetry, general body built
palpation
If injury is the presenting problem, proceed with caution
Palpation of soft tissue and joints allows for assessment of skin temperature, swelling, tenderness and crepitation
movement
Observe/ Evaluate ROM
5/5
Normal strength (moves against full resistance)
4/5 (4 is a moderate number)
Moderate strength (moves against some resistance)
3/5
Person can raise hand off table without any resistance applied
2/5
Eg. Person able to slide hand across table but not lift it
1/5
Flicker
0/5
paralysis
sprains and strains
Usually associated with abnormal stretching or twisting
sprain (I sprained my lig)
injury to the ligaments surrounding a joint
Sprains classified according to the amount of ligament fibers torn: 1st, 2nd and 3rd degree (sprains on 1st, 2nd and 3rd base)
First degree: tears of only few fibers
Second degree: partial disruption of the involved tissue with more swelling and tenderness
Third degree: complete tearing of the ligament
STRAIN (I’m straining my muscles)
STRAIN: stretching of a muscle and its fascial sheath
strain clinical manifestation (straining my muscle w/ pain and edema)
Clinical Manifestation include:
Pain, edema, decreased function and bruising
strains and sprains what to do - rice me (and how high to elevate?)
RICE
Rest
Ice
Compression
Elevation above heart level
Analgesia
NSAIDS=decrease prostaglandins that contribute to inflammation and pain; increase risk for GI bleeding in older adults or if in excessive quantity
Opioids if severe
dislocation - what can happen? Worst case
Dislocation:
Needs to be attended promptly
The longer the timeframe before Reduction, the greater the possibility of developing Avascular Necrosis
dislocation nursing care
NURSING CARE:
Pain management
Support/protect the injured part
fractures
Disruption or break in continuity of structure of bone
Majority of fractures from traumatic injuries
Some fractures secondary to disease process
Cancer or osteoporosis
fractures clinical manifestations
Edema and swelling
Localized pain and point tenderness
Decreased function
Muscle spasms
Inability to bear weight or use
Guarding against movement
May or may not have deformity
Ecchymosis and crepitation
Immobilize affected limb if you suspect fracture!!!!
fractures - edema and swelling result from..and can cause what?
disruption of soft tissue or bleeding into the surrounding tissue.
If it occurs in a closed space, it can occlude circulation and damage nerves - May lead to COMPARTMENT SYNDROME
fracture - Compartment Syndrome
Compartment Syndrome:
An elevation of pressure within a closed fascial compartment
Can be caused by hemorrhage and or edema within a closed space or by external compression or arterial occlusion
fracture clinical manifestation (fracture door)
- Pain and tenderness
- Deformity
- Ecchymosis
- Crepitation
fracture objective behavior
Objective Data
Apprehension
Guarding
Point tenderness
Skin lacerations, color changes
Hematoma, edema
Restricted or lost function
Deformities; abnormal angulation
Shortening, rotation, or crepitation (crackling noise)
Imaging findings
fracture neurovascular assessment - (temp, cap refill, pulse, blood)
Peripheral vascular
Color and temperature-⬇temp?
Capillary refill-?prolonged
Pulses- ↓ or absent pulse
Edema, hematoma ( pool of mostly clotted blood)
factors influencing healing (site) and which takes longest to heal?
Displacement and site of fracture (fx)
Type of fx: Open and comminuted fractures take longest
Blood supply to area
Immobilization
Internal fixation devices
Infection or poor nutrition
Age
Smoking
fracture - Closed reduction (you can reduce it yourself) and ex of what type of fractures
Closed reduction
Correction or Setting of a fractured bone without surgery
Ex: hip or shoulder
fracture - open reduction
Open reduction: ORIF (Open reduction and internal fixation)
Surgical incision
Internal fixation-plates, pins and screws, intramedullary nail
Risk for infection
fracture -External Fixation (metal can be external)
External Fixation (Ex fix)
Metal pins and rods
Applies traction
Compresses fracture fragments
Immobilizes and holds fracture fragments in place with pins
fracture cast care - ice and elevation?
Common after Closed Reduction
Frequent neurovascular assessments
Apply ice for first 24 hours
Elevate above heart for first 48 hours
Exercise joints above and below.
Use hair dryer on cool setting for itching
Patient education / CAST CARE
Do not get wet but if do, dry thoroughly after getting wet.
Report increasing pain despite elevation, ice, and analgesia.
Report swelling associated with pain and discoloration OR movement.
Report burning, tingling, sores, or foul odors under cast.
Don’t insert anything into cast or remove anything
Use hair dryer on cool if itchy
hip fracture - can see what?
Common in older adults
Can see shortening and external rotation of affected extremity
hip surgery - teaching
Maintain hip abduction with pillows
Teach patient not to cross legs, internally rotate legs, or bend over at the waist (tying shoes). Teach to keep knees spread apart.
post op fractures
Monitor vitals
General principles of postoperative nursing care
Minimize pain and discomfort.
Monitor for bleeding or drainage
Aseptic technique
Blood salvage and reinfusion (collection of the patient’s own blood during and/or after surgery for transfusion back to the patient)
post op fractures - Frequent neurovascular assessments (CSM)
Frequent neurovascular assessments
Monitor Circulation, Sensation, Movement
Monitor compartment syndrome
compartment syndrome 6 ps
THE 6 P’S
PAIN
PALLOR
PULSELESSNESS
PARESTHESIA (pair of pins and needles)
PARALYSIS
POIKILOTHERMIA (inability to maintain a constant core temperature)
complicated fractures - compartment syndrome and what percentage?
Results from increased pressure within muscle compartments (fascia)
Occurs in 9.1% of fxs
Multiple other causes
compartment syndrome - Early recognition via regular
Early recognition via regular neurovascular assessments!
Notify if pain unrelieved by drugs and out of proportion to injury
compartment syndrome treatment - ice or elevation? Surgery?
Treatment:
Bivalve or remove cast ASAP
Fasciotomy (surgical decompression)
No ICE
No Elevation
fracture complications (HHITR F fracture)
- Infection if open or surgical repair
- Delayed healing, nonunion of bones, deformity
- Venous thromboembolus (especially surgery on pelvis and lower extremity)
- Hemorrhage
- Fat embolism
- Renal Calculi
Fat embolism
Fat embolism syndrome (FES)
Presence of systemic fat globules from fracture that are distributed into tissues and organs after a traumatic skeletal injury
Caused by fat obstructing the blood vessels
Contributory factor in many deaths associated with fracture
fat emoblism - Mechanical theory (mechanical marrow)
Mechanical theory
Fat released from marrow and enters circulation where it can obstruct
fat emoblism - biochemical theory (hormones are biology)
Biochemical theory
Hormonal changes caused by trauma stimulate release of fatty acids to form fat emboli.
Fat Emboli Syndrome - Fat globules travel to lungs cause a (fat causes pneumonia)
Fat globules travel to lungs cause a hemorrhagic interstitial pneumonitis.
FES (fat embolis syndrome) collaborative care - do what first? (cough the fat out, and don’t move)
Treatment is aimed at prevention
Careful immobilization of a long bone fracture is probably the most important factor in prevention IMMEDIATELY DONE
Cough and deep breathing
FES (Fat embolism syndrome) collaborative care (Fat needs 02 and hepburn)
Management is symptom-related and supportive
Oxygen for respiratory distress (intubation may be required for severe respiratory distress)
Corticosteroids (controversial) and Heparin
FES collaborative care - Assistive devices for…
ambulation that can help reduce or eliminate weight bearing on affected limbs
joint replacement - most common, and what meds?
Most common are THR (total hip replacement) also known as THA (see previous discussion)
TKA-can replace part or all of knee joint
Major complications are infection and VTE=antibiotics and anticoagulants given postop
osteomyelitis
Severe infection of bone, bone marrow, and surrounding soft tissue
osteomyelitis - acute infection time frame
Acute: Infection of <1 month in duration
chronic osteomyelitis femur - local signs of infection are…(femur stays local)
Systemic signs diminished
Local signs of infection more common
Pain, swelling, warmth
osteomyelitis collaborative care - how long for antibiotics? (your patient in for 4-6 weeks)
Surgical removal infected bone
Extended use of antibiotics-4-6 week minimum
amputation - pre op
Pre Op Teaching/ Education:
Phantom pain
Pain management
Need for grieve/psychological support
Need for rehab and prosthesis
osteoporosis
Who are at Risk:
1 in 2 Americans over 50 years old will be at risk for fractures r/t osteoporosis
44 million Americans (55% over age 50) will either have or is at risk of Osteoporosis
80% of those with osteoporosis are female (National Osteoporosis Foundation 2010)
Prevention:
Encourage those at risk to be screened
Assess diet for calcium and vit D intake
Those with lactose intolerance should seek alternative source of calcium
Weight bearing exercise
Maintain optimal urinary function
Minimize alcohol intake and quite smoking
Home safety assessment for fall risk
compartment syndrome - monitor for…(tea goes in the compartment with creatinine)
Monitor for dark tea colored urine-muscle breakdown=
myoglobinuria-proteins precipitate in renal tubules and cause acute kidney injury
Monitor creatinine for renal compromise
why do fractures cause renal calculi?
Immobility alters urinary elimination. With upright position, urine flows d/t gravity. If flat in bed, kidneys and ureters are level, cause urinary stasis, increase risk of UTI and renal calculi – calcium stones lodge into renal pelvis or ureters. Immobilized pt usually have hypercalcemia causing them to be at risk for renal calculi
fat embolism most common with fractures of (fat L TRP)
long bones, ribs, tibia, and pelvic bones
fat emboli syndrome - when do symptoms start? (fat at 12)
Early recognition crucial
Symptoms 12-24 hrs after injury. Clinical course of fat embolus may be rapid and acute
fat emboli - In a short time skin color changes from…(Fat can change colors)
pallor to cyanosis.
Patient may become comatose
fat emboli - petchea where? (Fat petchea)
neck, chest wall, axilla, buccal membrane, conjunctiva
FES - cane - relieves what percentage of weight bearing? (cane at 40)
relieve 40% of weight bearing
Use to support affected area
FES - walker and crutches
Allow complete non-weight bearing ambulation
osteomyelitis caused by what organisms? (the big ones)
Most common microorganism is Staphylococcus aureus but can be caused by variety of organisms (MRSA, Pseudomonas, and Enterobacteriaceae
Indirect entry (hematogenous)
osteomyelitis - from what?
common among Young boys
Blunt trauma
Vascular insufficiency disorders
IVDU
GI & respiratory infections
Direct entry
Via open wound/open fractures, orthopedic surgeries
Foreign object-joint prosthesis
osteomyelitis - local manifestations (worse with what?)
Pain unrelieved by rest; worsens with activity
Swelling, tenderness, warmth
Restricted movement
osteomyelitis - systemic manifestations (the osteo system feels like kicking)
Fever
Night sweats
Chills
Restlessness
Nausea
Malaise
Drainage (late)
osteomyelitis chronic
Infection lasting longer >1 month or has failed to respond to initial course of antibiotic therapy
Continuous and persistent or process of exacerbations and remissions
chronic osteomyelitis - femur - what is the progression? (granny scars with no 02)
Granulation tissue turns to scar tissue → avascular → ideal site for microorganisms to grow → away from antibiotic penetration
osteomyelitis - antibiotics (antibotics for poly on meth)
Antibiotic-impregnated polymethyl methacrylate bead chains=antibiotic spacers inserted into infected bone
osteomyelitis - irrigation
Intermittent or constant antibiotic irrigation of bone
osteomyelitis - casts?
Casts or braces
osteomyelitis - wound care
Negative-pressure wound therapy=wound vac
Hyperbaric oxygen therapy
osteomyelitis - last resort
Removal of prosthetic devices (hardware)
Muscle flaps, skin grafting, bone grafts
Amputation
amputation post op - compression and…(can’t flex an amputation)
Use of rigid or compression dressings to minimize edema
Monitor for signs and symptoms of infection
Prevention of flexion contractures (permanent flexing)
amputation - post op education (just keep it clean)
management/Education:
Maintain aseptic technique during wound care
osteoporosis treatment - what to take with vitamins?
Treatment:
Calcium supplement w/Vit D (take on empty stomach or with orange juice)
osteoporosis treatment (BAM - osteo is gone)
Bisphosphates, Alendronate, RANKL inhibitor (monoclonal antibody)
dislocation - Avascular Necrosis (and what parts of the body are at risk?)
bone cell death as a result of inadequate blood supply
The hip and shoulder are particularly at risk for this
open reduction - early ROM to prevent what?
ROM of joint to prevent adhesions
Facilitates early ambulation
types of fractures (fracture my DOCs)
Can be open or closed
Complete or incomplete
Displaced or nondisplaced
how often for pin care w/ a fracture?
Pin site care done every shift and pin sites usually wrapped with gauge
fracture neurovascular - Peripheral
Peripheral neurologic
Sensation and motor function-Paresthesias (pins and needles), absent, ↓ or ↑ sensation, muscle weakness
hip surgery - monitor for (hip lump)
sudden severe pain, loss of function, a lump in the buttocks, leg shortening, and external rotation=prosthetic dislocation
Do not turn patient on affected side
Can have a significant blood loss → monitor CBC
where do most complicated fractures occur?
Forearm, lower leg primary areas=36% of cases result from tib-fib fxs
hip fracture can be treated with…
ORIF- with nail or plate, pins, screws
Total hip replacement=replacement of both the ball and socket (head of the femur and acetabulum)
Hemiarthroplasty-replacement of ball (head of femur) only
compartment syndrome - first symptoms (compartment starts with pp)
Pain is first symptom and includes pain with passive stretching of muscles in the affected compartment (stretching foot if lower leg)
compartment syndrome - late symptoms
Later signs=deterioration in Circulation, Sensation, movement, swelling
compartment syndrome - Permanent neurovascular damage can result as early as…
4 hours after onset
Delay more than 6 hours in dx and fasciotomy leads to permanent weakness
fat emboli syndrome - clinical behavior (fat will give me convulsions and kill me)
Petechiae
Pt frequently expresses a feeling of impending death and restlessness
Agitation, R`estlessness, Delirium, Convulsions –change in LOC
fat emboli syndrome- lungs? And esp. what? (fat in sputum)
wheezing, blood tinged sputum, copious production of white sputum, fever especially
