Orthopedics Flashcards
S/S Fracture
Pain and tenderness Unnatural movement Possible deformity Crepitus Swelling Discoloration
What can muscle spasms cause in a fracture?
complication of this?
Shortening of an extremity
*Think of a bone moving inward after they were previously visible… Bacteria can follow!
What is the biggest worry about a fracture?
Compartment Syndrome
How to treat a fracture
Position?
Support?
Movement?
Immobilize the bone ends and adjacent joints
Support above and below site
Move as little as possible
How do splints help?
They prevent fat and emboli and muscle spasms
What do you do if you have an open fracture?
Cover it up! With preferably something sterile
Most IMPORTANT assessment for a fracture?
NEUROVASCULAR checks
Pulse Color Movement* Neuro Sensation* Neuro Cap refill Temperature
3 biggest complications to worry about with a fracture
- Hypovolemic Shock
- Fat emboli
- Compartment Syndrome
What kind of fractures will we most likely see fat emboli? These fractures also lead to what?
What do the S/S depend on?
Long bones (femur)
Pelvic fractures
Crushing injuries
SHOCK!
S/S depend on where the fat embolus goes
S/S of fat emboli
What will the XR show? What doe this mean?
Who most commonly gets these?
What time frame will they occur?
Petechiae over chest (Chest rash d/t embolization of skin capillaries or thrombocytopenia)
Conjunctival hemorrhage
XR shows a Snow Storm (fat emboli in the lungs)
Young males - risk takers
First 36 hours, then worry about PE
What is the patho of Compartment syndrome?
S/S?
What is the pain like?
Common areas?
What could happen if it’s undetected?
There is increased pressure within a limited space
Fluid accumulates and causes impaired tissue perfusion
Muscle becomes swollen and hard
PAIN! - unrelieved by medication and not proportionate for the fracture
Forearm and quads
Nerve damage and possible amputation
How do we treat compartment syndrome?
Relieve the pressure?
What kind of cast?
Will we manipulate the cast?
What is our last resort if untreated?
Do you have to have a fracture for this?
NCLEX**
Elevate extremity
Soft cast THEN rigid cast
We might lose it to restore circulation
Fasciotomy
Nope! - Burns and cellulitis, carpal tunnel
REMOVE CAST SHOULD NOT BE FIRST ANSWER! Only if they have like HORRIBLE NV checks like pulseless, purple arm
What to tell patient about cast removal?
Saw doesn’t touch the skin
Warn about the vibration
Plaster cast – WET!
How long is it wet for?
Where do we put ice? Why?
How do we touch it?
How do we let it dry?
24 hours
Ice packs on the SIDES to decrease edema from the trauma - not not the top because it’s still wet duh
PALMS
Rest on soft surface UNCOVERED to allow for air drying (Covered won’t let the heat escape and we don’t want to trap heat next to the skin) - So you don’t even want a plastic pillow!
Once the paster cast is DRY
What do we need to mark? - How?
What needs covered? With what?
Most important thing to a assess?
Mark breakthrough bleeding - Circle area; date and time
Cover the cast close to the groin with plastic
NeuroVASCULAR checks! 5 P’s!
(Pulseless, paralysis, paresthesia, pain, pallor)
Plaster cast —
What usually relieves pain for this patient?
How often to check after these are done?
…… And if it doesn’t work?
Elevation, cold packs, analgesics
Reassess in 30 minutes!
Risk for COMPARTMENT SYNDROME
Why are fiberglass casts more common?
What can you do earlier?
They are lightweight, waterproof, and stronger than plaster casts
Earlier weight bearing
And they have fun colors!!
What is something to remember to if a patient comes into the ED and their foot hurts??
ARE YOU DIABETIC?
*Always be thinking about other problems
Can you ever stick ANYTHING in the cast?
NO NEVER! You maybe could apply something cool like a cool blow dryer
What does traction do for the patient?
Is this continuous or intermittent?
How are weights hung?
Ropes?
Decreases muscle spasms
Reduces (realigns) bones
Immobilizes
Continuous!
Weight are hung freely - This means they should be touching the bed or the floor!
The ropes need to move freely and knots need to be SECURE
Traction positioning?
What if they are underweight and can’t stay pulled up in bed?
Mattress?
Exercise?
Patient should be pulled up in bed and centered with good alignment
Think like an old lady… Need to have someone help and hold the weights at the same time you are pulling them up
You might need to do this like every hour…. Never tie them up so they don’t fall down in bed!!! And this could hurt their armpits
Special air-filled or foam mattress
Exercise the non-immobilized joints
NCLEX: WHAT DO YOU NEED AN ORDER FOR WITH TRACTION?
What happens if you do it without an order??
NEVER RELIEVE TRACTION WITHOUT AN ORDER!!!
It can cause more muscle spasms!!
What do you do if you need to move the patient on traction?
Need to have someone else hold the weights at the same time so traction is not relieved
What are the 2 different kinds of traction?
Skeletal
Skin
What is Skin traction used for?
What kind of supplies are involved?
Used for a patient to relieve muscle spasms and immobilize the patient until surgery
Usually involves tape, boot, splint, to some type of material stuck to the skin and the weights are pulled against it
Is there skin penetration with skin traction?
What is an important thing to assess?
NO!
GOOD skin assessments
Most common type of SKIN traction?
What is this mostly used for?
Buck’s
Hip and femoral fractures
How is skeletal traction used?
When is it used?
Traction is directly applied to the bone with pins and wires
Used when prolonged traction is needed
What are common types of skeletal traction?
Steinmann pins
Crutchfield
Gardner-Wells tongs
Halo vest
Important things to remember with pin sites and pin care
Clean or sterile?
Crusts?
Drainage?
STERILE technique!
REMOVE the crusts because bacteria like the crusties and you are blocking the drainage to get out
Serous drainage is okay! This looks like clear
What do we do if a pin falls out of skeletal traction?
We need to hold the body part ourselves and call to help!!!!
This is not when we are going to do vitals and assessments ASAP…. We need to immobilize them because the pins aren’t there to do their job!!!
What is an ortho complication of having a patient immobile for a long period of time?
How can we prevent it?
Foot Drop! D/T weakness or nerve damage
May use a foot drop boot or high top tennis shoes
What is commonly used for a pot-op hip? Why?
Bucks traction: Prepare the patient for surgery and leave it on for a few days to prepare the patient nutritionally
POST-op Hip replacement
Important assessment?
Monitor what and why?
MATTREE TYPE?****
NeuroVASCULAR checks
Monitor drains if present because we don’t want fluid to accumulate in the tissues
FIRM MATTRESS! ANYTIME WE GET AN ORTHO OR JOINT PROBLEM, THEY NEED A FIRM MATTRESS FOR SUPPORT
POST-op Hip replacement
How do we build upper-body strength?
What bed exercises are good?
What do we need an order for????
Trapeze bar
Isometric exercises (squeezing quads/gluts)
NO WEIGHT BEARING UNTIL ORDER
POST-op Hip replacement–
How do we position them?
How do we roll them? To prevent what? Document?
Abduction or adduction?
NEUTRAL rotation: toes toward the ceiling! Towel or padding here
TROCHANTER roll to prevent external rotation *document this
We want ABduction, keeping the legs slightly apart to keep the hips in their socket
*Abductor pillow
THINGS TO AVOID POST-HIP
**Flexion - We want extension!
Leg crossing Low toilets / chairs Bending over Raising the bed of the bed too high Traveling long-distance Heavy lifting Excessive bending/twisting STAIRS
How to sleep post hip?
What is super important? Why?
NOT ON THE OPERATED SIDE until allowed by physician
Hydration - they are immobile! Prevents DVT/pneumonia
How long should we limit stress to the new hip joint?
3-6 months
Can we give pain meds into the operated hip?
NO
What does dislocation cause?
S/S?
Circulatory and nerve damage
Shortening of leg, abnormal rotation, can’t move extremity
PAIN**
How do we prevent infection?
How should we treat it? - What needs removed?
Prophylactic antibiotics
REMOVE DRAINS! - Foley or wound drains because bacteria love artificial stuff!!
What is is called when we have tissue death due to poor circulation?
Avascular Necrosis
Best exercise to tell a hip patient?
What about little old lady?
Walking, then swimming
Rocking chair! They’ll have to push with their legs
TOTAL KNEE what device do they get post-op?
What does this do?
How is it adjusted?
Where do we store it?
Assessment***??
CPM Continuous Passive Motion
Keeps the knee in position and prevents scar tissue formation
Gradually adjusted to increase flexion an extension of the knee
NOT on the floor!!!! Think about infection control! - Any clean surface
NEUROVASCULAR
Pain meds
Never too what to a post-op knee?
Hyperextend or hyperflex
Where are amputation preformed?
At the most distal point that will heal, and especially trying to preserve the knee and elbow
Immediate POST-op amputation
Keep what at the bedside? Why?
Elevation? What to keep in mind with this? How often?
TOURNIQUET! In case there is a massive hemorrhage
Elevation is controversial bc of hip contractors, but if there is an order, only do it for a short time to reduce swelling!
Elevate FOOT OF BED!!! NOT on a pillow!
Only a few times a day**
How do we prevent a hip/knee contracture?
What is best for BKA?
EXTENSION! Laying flat
BKA: prone position:
Worry with hip and knee!
What is the first intervention with phantom pain?
Where do we see these occurring more?
When does it usually go away?
Diversional activity
*LEAST INVASIVE FIRST - Try other things before pain meds
MUST USE 0-10 SCALE
AKA
Usually subsides in 3 months - may never go away
Why do we do limb shaping?
What shape is best?
To prepare for a prothesis
Cone/small/round so it can fit down into the prothesis
What do we wear under a prothesis?
What strength is important to build?
A limb sock - wrapped from the tip up w figure 8
Upper-body bc they will use crutches or a walker
Do we want to massage the stump? Why?
YES because it promotes circulation and decreases tenderness
How do we tell the patient do toughen up a stump?
Press into a
- Soft pillow
- Firm pillow
- Bed
- Chair
Best way to use a walker?
Walk INTO it
Crutches —
How far below the armpit? What is this preventing?
Best way to ambulate with crutches and stairs?
1-2 inches below the armpit to prevent the risk of brachial nerve damage
Up with the good leg
Down with the bad leg/crutch
What side of the body do we put the cane?
On the STRONGER side
Stroke may affect 1 side
Long bone fracture, pelvic injuries, and crushing injuries lead to what?
Fat emboli
SHOCK
Forearm and quads?
Compartment Syndrome
Petechiae and conjunctival hemorrhage mean what?
Fat emboli!
Young males / risk takers at risk for what?
Fat emboli
Prevents fat emboli and muscle spasms?
Splints
