Ortho Flashcards
Risk factors
- Age-related Changes: Loss of bone after 30; Vertebrae collapse; Muscle atrophy; Loss of cartilage; Lax ligaments
- Medical Hx: Paget’s Disease; Bone cancer
- Osteoporosis: 40 mil. Americans over the age of 50!; 40% of Caucasian women over the age of 50!
- Occupation
- Recreational activities
- Poor nutrition
Classification of fractures
- Extent of break: Complete; Incomplete
- Cause
- Pathologic (spontaneous): bone cancer
- Fatigue (stress): jogging
- Compression: osteoporosis - Extent of soft-tissue damage
- Closed (simple): no visible wound
- Open (compound): external wound
Grade I : skin damage is minimal
Grade II : skin and mascle damage
Grade III : skin, muscle, nerve tissue and blood vessels damage
Impacted fracture
when force has come down on the bone : and one part of the bone smashed on the other part.
Greenstick fracture
common in children or newer bone ; after new tree branch…cant snap it
S/s :
Pain Loss of function Deformity Shortening Crepitus Swelling / discoloration
Diagnostics
• X-ray studies
- May need to be repeated with additional views
• CT scan
- Used to dx difficult-to-evaluate fractures (hip and pelvis)
• MRI
- Helps determine amount of soft-tissue damage
TX of fractures
• Reduction: restoration of bone fragramnets to anatomic allignment and rotation; performed right away
- Closed: bring ends together through amnipulation or manula traction them place cast or splint in order to immobilize it ;
- Open: surgery ; internal fixation
• Immobilization: hold bone fracture in correct allignment
- External
- Internal
Casts:
- Used to immobilize, correct deformity, apply uniform pressure on underlying tissue, or support weakened joints
- Location of fx dictates type used
- Plaster ( rolls, wet with water; crystallized, 24-72 hrs to dry ) or non-plaster ( fiber glass, water resistant ( can take shower) ; less skin problems)
Casts: nursing management
• Education
-Controlling edema
- Controlling pain
- Exercises to maintain health of unaffected muscles
- Exercises to increase strength of supporting muscles
- Monitoring for potential complications
• Assessment of neurovascular status – 6 P’s: pain, pressure, pallor, pulselessness, paresthesia, paralysis
• Open fx – infection prevention
Assessment of neurovascular status – 6 P’s:
- pain
- pressure
- pallor
- pulselessness
- paresthesia
- paralysis
Traction:
application of a pulling force to a part of the body provide reduction, alignment and rest .
• Uses:
Minimize spasms
Reduce, align, and immobilize
Reduce deformity
Increase space between opposing surfaces
• Short-term intervention until external or internal fixation is possible
• Skin (Backs traction: Velcro boot)or skeletal ( pins, wires, tongs or screws are surgically inserted directly into bone) most common types
• Plaster, brace and circumferential
Pin care
• First 48-72 hours: clear fluid drainage or weeping expected
• Monitor pin sites every 8-12 hours for inflammation or possible infection:
Drainage (purulent)
Color (severe redness)
Odor
• Chlorhexidine 2 mg/mL solution ( swab around the pin every 4-8 hrs)
• Follow agency protocol for pin site care!
Crusting around pin is natural barrier ( unless infection is present)
Traction: nursing management
- Never remove weights without a prescription!
- Good body alignment important
- Ropes should be unobstructed
- Weights must hang freely
- Knots in the rope must not touch the pulleys or the bed
- Assess neurovascular status every hour for first 24 hours after application, then every 4 hours
Acute Compartment Syndrome (ACS)
- Anatomic compartment – 36 out of 46 in the body are in the extremities
- Within 4-6 hours, neurovascular and muscle damage irreversible
- Limb can become useless in 24-48 hours
ACS:
serious condition in which increased pressure within one or more compartments reduces circulation to the area. (most common: lower leg and forearm ).
The pressure to the compartment can be from :
External source: bulky dressing and cast
Internal: blood and fluid accumulation
ACS: S/s
- Pain – out of proportion with injury; increases with passive ROM
- Sensory deficits or paresthesia
- Pale color, cool to touch
- Weak pulses
- Affected area is palpably tense
- If not treated – cyanosis, tingling, numbness, paresis, and severe pain
ACS: TX
• Treatment
- Elevation
- Bi-valve ( cut the cast longways ; cast open to relieve the pressure )
- Fasciotomy : cut muscle into fascia to relieve the pressure ; open wound is packed and dressed daily; until secondary healing occurs; might need skin graft to promote healing )
Crush Syndrome (CS)
• External crush injury that compresses one or more compartments in leg, arm or pelvis
• Potentially life threatening!
• Muscle becomes ischemic and necrotic
• Myoglobin released into circulation
May occlude distal renal tubules and cause renal failure
Myoglobulin
muscle protein that injured muscle tissue releases into circulation where it can clog the renal tubules and cause acute renal failure.
CS: S/s
- ACS
- Hypovolemia
- Hyperkalemia
- Rhabdomyolosis ( release of myoglobulin into blood stream )
- Acute tubular necrosis
- Dark brown urine
- Muscle weakness and pain
CS: management
- Focuses on preventing ATN and cardiac dysrhythmias from hyperkalemia
- IVF, diuretics, low-dose dopamine to increase renal perfusion
- Goal of UO=100-200 mL/hr
- Kayexalate to reduce serum K+ levels
- Dialysis if K+ remain high or kidney failure occurs
Hypovolemic shock
• Bone is very vascular! • Risk for bleeding with bone injury • Trauma to nearby arteries can cause hemorrhage – rapidly developing hypovolemic shock • PELVIC Fx Possible internal organ damage Assess VS, skin color, LOC
Venous thromboembolism (VTE)
DVT and PE
Most common complication of LE (lower extremity) surgery or trauma
Most often fatal complication of MS surgery!
Fat embolism syndrome (FES)
Fat globules released from marrow into bloodstream
12-48 hours after injury
Clog small blood vessels that supply major organs – lungs
First sign is AMS (altered mental status) secondary to low arterial O2
Petechiae is classic sign, but can be a late sign
Can result in respiratory failure or death
Fracture Complications – Chronic complications
• Ischemic necrosis (avascular necrosis)
- Blood supply to bone is disrupted – death of bone tissue
- Most common with hip fx or fx with displacement (long term Prednisone :corticosteroid at risk)
• Delayed union
Fx that has not healed in 6 months
Some NEVER heal: nonunion
Some heal incorrectly: malunion
Fractures of upper extremities
• Colles’ fracture – distal radius (deformed wrist, pain, numbness). Check sensation at the tips od the fingers, cap refil, ROM.
• Humerus fractures
- Neck
- Shaft ( brachial vessels must be involved)
Place sling on.
Pelvic fractures
• Pelvic fractures - Stable - Unstable • High mortality rate • Signs and symptoms: ecchymosis, tenderness, local edema, numbness and tingling , cant bear weight; hypovolemic shcok (high risk) • Nursing responsibilities/assessments
Stable pelvic fx
Single pubic or ischial rami
Pelvic wing of the ilium
Sacrum or coccyx
• Treatment
Unstable pelvic fx
- Rotational instability
- Vertical instability
- Combination of both
Hip fractures
• Most common injury in older adults
• Most frequent injury in any health care setting
• High mortality rate: Osteoporosis - biggest risk factor for hip fx
• 2 major types
Intracapsular
Extracapsular
Hip fracture : S/s
• Signs and symptoms - Groin pain - Pain behind knee - back pain - No pain • Treatment ORIF (open reduction, internal fixation) Nonsurgical options
Joint surgery
• Used to correct/repair: Unstabilized fx Deformity Joint disease (DJD) Necrotic or infected tissue Tumors • Most common procedures ORIF Closed reduction with internal fixation Most common: total joint arthroplasty or total joint replacement
Joint replacement contraindications
: infection anywhere in body, advanced osteoporosis, rapidly progressive inflammation
Uncontrolled DM or HTN: risk for major postop complications and possible death
• Most common are the hip and knee, but also can replace the finger, shoulder, elbow, wrist, and ankle
• Infection prevention
• Ambulation promotion
Total hip arthroplasty (THA)
• Indications
- Pain interrupts pt’s sleep
- Pain limits ADLs
- Drug therapy no longer controls pain
- Pt must be able to participate in PT after surgery
• Primary arthroplasty - First time pt has THA
• Revision arthroplasty - Performed if implant loosens
• Most often performed in patients older than 60
THA: complications
- Dislocation (subluxation or total dislocation)
- Leg slightly abducted
- Prevent hip flexion beyond 90 degrees
- Assess for pain, rotation, shortening - VTE (DVT and PE)
- Most potentially life-threatening complication
- Older, obese, hx of VTE – more at risk
- Prevention – antiembolism stockings/SCDs, anticoags (LMWHs), early ambulation - Infection
- Can occur during hospitalization, or months/years after
- Monitor incision and VS
- Watch for elevated temp, excessive or foul-smelling drainage
- Older pt may just have confusion!
Knee Replacement
• Indications • Nursing management • Complications - Excessive drainage - DVT - Infection
Osteomyelitis
• Can occur in 1 of 3 ways…
- Exogenous – surgery, open fx, traumatic injury
- Endogenous/Hematogenous - spread from other sites of infection (most common)
- Contiguous – results from skin infection of adjacent tissues
• May be acute or chronic
• Most are staph
Can also be Proteus, Pseudomonas, or E. Coli
Osteomyelitis
- Acute infection occurs more often in children
- Chronic infection more common in adults (esp. with compromised blood supply)
- Men > women
- Malnutrion, ETOH, DM, kidney or liver disease, immune suppressing disorders increase risk and complicate Tx
Osteomyelitis: S/s
• Acute infection Fever (usually above 38 degrees C) Swelling Erythema/heat Tenderness Bone pain – constant, localized and pulsating – intensifies with movement • Chronic infection Ulceration of skin Sinus tract formation Localized pain Drainage from affected area
Osteomyelitis: S/s
• Signs and symptoms
Hematogenous – septic manifestations and local symptoms
Direct bone contamination or spread of adjacent infection – only local symptoms
Chronic – continuously draining sinus, may have recurrent pain, inflammation, and swelling
• Diagnostics
X-ray, radioisotope bone scan, MRI
Blood studies, wound and blood culture
Osteomyelitis: TX
Antimicrobial therapy Pain control Infection control HBO If not effective, may need surgical intervention (Eg. bone graft, amputation)
Acute Compartment Syndrome: early signs
- Pain
- Pressure
- Paralysis
- Paresthesia
- Pallor
- Pulselessness
