Orthopedic Surgeries and Complications Flashcards
Describe the sequential events involved in fracture healing.
in hospital:
realign “reduction”
Immobilize w/ cast
Restore func
- Fracture hematoma
-0-72 hrs
-Bleeding at broken ends creates a hematoma
-Blood changes from liquid to semi-solid clot - Granulation tissue
Day 3-14 – osteoid formed, then xray to check alignment
-Active phagocytosis absorbs products of local necrosis
-Hematoma converts to granulation tissue
-new blood vessels, fibroblasts, osteoblasts-> form new bone “osteoid”
Differentiate among closed reduction, cast immobilization, open reduction, and traction regarding purpose, complications, and nursing management.
Closed red-
Nonsurgical manual realignment
-under conscious sedation.
-Keep pt breathing but not aware, no memory even tho can talk.
-Very painful.
-Follow up xray for alignment, then cast
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Open red-
-surgery when not a simple fracture, needs screws/rods/plates to maintain alignment. Goes to post-op floor after
Traction
pulling force while countertraction pulls in an opposite direction to maintain alignment
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Fracture Immobilization
-reduction, then immobilizer
Casts
Immobilizers
External fixation-Metallic device applies traction or compresses fracture fragments
Nursing management:
Drug therapy
pain and muscle spasm
tx:Analgesics & Muscle relaxers
-Diazepam is an anxiolytic benzodiazepine
Tetanus-diptheria toxoid
abx (if open)
Nutritional therapy
Proper nutrition
Adequate energy for body to repair
protein! for bones to heal
Describe the neurovascular assessment for a client with an injured extremity.
Preventing complications(!)
Neurovascular assessments are key (more than just CWMS
periph vasc: colour, warmth, pulses, cap refill, edema,
periph neuro vasc: Sens, motor, pain
+compare both extremities
Explain common complications associated with fracture injury and fracture healing.
(D) Direct complications:
-Infection
(ID) Indirect Complications:
-Fat embolism syndrome
-Compartment Syndrome
-VTE
-Rhabdomyolysis
-Hypovolemic Shock
Infection:
-Associated with open fractures and soft tissue injuries
-Massive/ blunt soft tissue trauma often has more serious consequences than the fracture itself
-Often related to high-energy trauma
Collaborative care:
Aggressive surgical debridement
Early sterile N/S lavage
-to reduce risk of osteomyelitis
Extent of soft tissue injury determines whether the wound is closed or left open (vac dressing)
IV antibiotics for 3-7 days
Fat Embolism Syndrome (ID)
-Most often from long bone fractures
-Presence of systemic fat globules from fractures distributed into tissues & organs after a traumatic skeletal injury
-Fat globules = occlusion of pulmonary vessels = pulmonary edema, severe hypoxia & cardiovascular compromise
Signs & Symptoms: anxiety, hypoxia, dyspnea, tachypnea, tachycardia, cyanosis, crackles, neuro changes
**petechiae are a distinguishing feature
Prevention is KEY through immobilization of long bone fractures
Compartment Syndrome (ID)
-pressure within the muscles builds to dangerous levels. This pressure can decrease blood flow, which prevents nourishment and oxygen from reaching nerve and muscle cells
compromises the neurovascular function of tissues within that space
Capillary perfusion below level necessary for tissue viability
causes:
Decreased compartment size
Increased compartment content
Ischemia can occur within 4 to 12 hours
S/s
Pain that doesnt make sense
6 Ps -pressure, not poikiothermia
Paresthesia: Numbness and tingling
Pain: Distal to injury that is not relieved by opioid analgesics and pain on passive stretch of muscle traveling through compartment
Pressure: ↑ in compartment
Pallor: Coolness, and loss of normal colour of extremity
Paralysis: Loss of function
Pulselessness: Diminished/absent peripheral pulses
Rhabdomyolysis
Crush injury -> compartment syndrome-> muscle damage-> cell releases myoglobins
Myoglobin released from damaged muscle cells precipitates as a gel-like substance
Causes obstruction in renal tubules =acute tubular necrosis-> AKI
Common signs of myoglobinuria:
-Dark reddish brown urine
-Clinical manifestations associated with acute renal failure (decreased urine output, eGFR, BUN/creat increase)
NURSING CARE
-DO NOT elevate, apply cold, or compress
(Elevation may decrease venous pressure and slow arterial perfusion) (Application of cold compresses may result in vasoconstriction and exacerbate compartment syndrome)
-May be necessary to remove or loosen bandage or bivalve cast
-Reduction in traction weight may ↓ external circumferential pressures
-Surgical decompression may be necessary
“Fasciotomy” -
-Bivalve- 2 cuts down cast to allow leg to swell
Long-term complications
Joint stiffness or post-traumatic arthritis
Avascular necrosis
Altered union
Malunion
Delayed union
Non union
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Ongoing assessments are key to the prevention of complications
Vital signs
Assessment of fracture site
Neurovascular assessments
Other: respiratory, cardiovascular, integument, neurological, etc.
Preventative interventions include:
Maintaining adequate tissue perfusion
Maintaining immobilization of fracture site
Performing post-operative exercises
Maintaining hydration and nutritional status
-Rhabdomyolysis - hydration is tx
Preventing infection
-early lavage
Describe the indications for and the collaborative care and nursing management of the patient with an amputation.
Specific Ortho Surgeries: Amputation
Linked to PVD, atherosclerosis and vascular changes r/t diabetes
Amputation in younger patients usually r/t trauma
Vascular studies: arteriography, Doppler studies and venography
Goal: to preserve extremity length and function while removing all infected, pathological or ischemic tissues
(Long length of stay because of conservative approach (amputate small bits at a time, doesn’t heal, ampuate more)
Tx phantom limb pain as normal pain
Want to shrink the stump as much as possible because prosthesis can’t be fitted until swelling is stopped. Try to compress with sock /bandage
compression bandages worn at all times
Describe the types of joint replacement surgery associated with arthritis and connective tissue diseases.
Identify preoperative and postoperative management of the patient having joint replacement surgery.
random
Displacement can keep happening because ligaments are stretched. Important care immediately- relocation because the duration of stretch increases reinjury, braces
Fragility- force that normally doesn’t break a bone
Open/compound – skin open (vs closed)
Complete- all the way across the bone
Incomplete- crush/bend that doesn’t break
Displaced (vs non)- separated, out of normal position
Stable- there is a stationary piece (vs unstable)
FracturesClinical Manifestations
Edema & swelling
Pain & tenderness
Bruising
Muscle spasm
Deformity (may not be obvious)
Inability to bear weight on or loss of function
Crepitation-from air getting into tissue
Muscle spasm- with hip rotation in buttock area
tx: give antispasmotics
Neurovascular changes- indicated nerve damage,swelling and compression on nerve and vessels feeding on distal limb (ischemia, lack of blood flow)
Decreased sensation
Numbness
Hypovolemic shock
femur break can lose 1-1.5 L blood
compartment syndrome
first aid
immobilize extremity in position it was found
-May create further injury to adjacent neurovascular structures
Specific Fractures: Pelvis
Don’t operate on pelvises -pain from every movement
=immobilization to heal
Associated with highest mortality
Often associated with intra-abdominal injury
Specific Fractures: Hip
70-90% caused by osteoporosis
Require the longest hospital stays
Refers to a fracture of the proximal third of the femur
Clinical manifestations:
External rotation
Muscle spasm
Shortening of the affected limb
Pain at fracture site
If femoral head prosthesis (posterior approach), measures to prevent dislocation must be used x 6 weeks:
-Avoid extreme flexion
-Avoid crossing legs/ feet
-Avoid sitting up more than 90 degrees
-Elevated toilet sets and chair alterations are helpful
-Foam abduction pillow or pillows between legs
-Avoid turning the patient on her affected side until the surgeon approves
Indications of prosthesis dislocation are:
-Sudden, severe pain
-A lump in the buttock
-Limb shortening
-External rotation of the affected limb
Treatment for dislocation involves closed reduction under conscious sedation OR open reduction
Specific Fractures: Femur
Usually associated with damage to the adjacent soft tissue structures
Displacement of fracture fragments often results in considerable blood loss (1-1.5L)
Risk of hypovolemic shock with femur fractures, considerable loss of blood
Specific Fractures: Vertebrae
Stable: The fracture is unlikely to cause spinal cord damage
Unstable: Ligamentous structures are significantly disrupted, dislocation of the vertebral structures may occur, leading to instability and injury to the spinal cord.
-usually require surgery
All spinal injuries are initially considered unstable until diagnostics confirm stability
Goal (stable #): Keep good spinal alignment until union has been accomplished)
Treatment: Pain mgmt, mobilization, and bracing
Hard collar until Cspine ensured not injured
Stable – get fitted for aspen collar
Specific Fractures: Mandibular
Surgery: involves immobilization through wiring the jaws x 4-6 weeks
Postop care priorities:
-Patent airway
-Oral hygiene
-Communication
-Pain management
-Adequate nutrition
WIRE CUTTERS SHOULD ALWAYS BE WITH THE PATIENT
No straws – risk of aspirating
If the pt vomits/ chokes, the pt should:
-Bend his head over to the side to allow the vomit to flow out of the mouth/ nose
-Allow the nurse to suction to clear the nose/ mouth
Specific Joint Surgeries: Athroplasty
the reconstruction or replacement of a joint to relieve pain, improve or maintain ROM, and correct deformity
THA: provides significant relief of pain and improvement of function for pts w OA, RA, etc
TKA: Unremitting pain and instability as a result of severe destructive deterioration of the knee joint is the main indication for TKA
Common complications: Infection r/t aerobic streptococci and VTE
