Orthopedics

Question 1

Fractures S&S

Answer 1

Pain and tenderness
Unnatural movement
possible deformity
Shortening of extremities - caused by muscle spasms
Crepitus
Swelling
Discoloration
Worry about compartment syndrome

Question 2

Fractures Treatment

Answer 2

Immobilize the bone ends plus the adjacent joints
Support fracture above and below site
Move extremity as little as possible
(prevents further injury)
Splints help prevent fat emboli and muscle spasms
With open fractures, cover that with sterile
Muscle spasms can pull the bone back in, making it a risk for infection
Most important is neurovascular checks

You need to worry about foot drop in clients who are immobile - pick a foot drop boot or high top tennis shoes to prevent this

Question 3

Neurovascular checks

Answer 3

Pulses, color, movement, sensation, cap refill and temp

Question 4

Complications: Shock

Answer 4

Depending on type of injury - Lone bones, Pelvic fracture and crushing fractures

Question 5

Complications: Fat embolism

Answer 5

Long bones, Pelvic fractures and crushing injuries

Symptoms depend on the location of fat emboli.
Petechiae over the chest from embolization of skin capillaries or thrombocytopenia
Conjunctival hemorrhage - Bleeding into conjunctiva
Snowstorm on CXR

FIRST 36 HOUrS

Question 6

Thrombocytopenia

Answer 6

Thrombocytopenia is a condition in which you have a low blood platelet count. Platelets (thrombocytes) are colorless blood cells that help blood clot. Platelets stop bleeding by clumping and forming plugs in blood vessel injuries

Question 7

Compartment Syndrome: Patho and Treatment

Answer 7

Increased pressure within a limited space

Fluid accumulates in the tissue and impairs tissue perfusion. The muscle becomes swollen and hard and the client reports severe pain that is not relieved by pain medications

Pain is unpredictable. Pain disporportionate to the injury. If undetected, Will result in nerve damage and possible amputation.

Common Areas include the forearms and quadraceps.

Treatment:
Elevate the extremity
Soft cast (to allow for swelling) then rigid cast
Loosen the cast to restore circulation ( through bi-valving)
Be careful in picking the answer (remove cast)
Cast cutters to remove cast - Instruct the client that the cast saw does not touch the skin, but it does vibrate.
Fasciotomy - cuts down into tissue to relieve the pressure

Question 8

Cast Care: Plaster Casts

Answer 8

Ice packs on the side (to decrease edema) for the first 24 hours because cast is still wet
No indentations - use palms not fingertips
Use gloves for the 1st 24 hours - still wet
Keep uncovered and allow for air drying ( don’t trap heat next to the skin)
Do not rest cast on a hard surface or sharp edges (rest on soft pillow - no plastic because it holds heat)
Mark breakthrough bleeding
Cover cast close to groin with plastic (once the cast is dry)
Neuro checks
If client reports pain, do a neurovascular check - Most pain is relieved by elevation, cold packs and analgesics

Question 9

Cast Care: Fiberglass Cast

Answer 9

More common than plaster
Advantageous because they are lightweight waterproof and are stronger than plaster
Provide for earlier weight-bearing
DONT STICK SHIT INTO CAST

Question 10

Traction: Misc info

Answer 10

Decreases muscle spasms, reduces and immobilizes
Should be continuous
Weights should hang freely
Keep client pulled up in bed and centered with good alignment (do this with another person, one to do the weights and one to do the person)
Exercise non immobilized joints
Ropes should move freely and knots should be secure
Special air filled or foam mattress
Never release/Relieve traction ( unless you’ve got a PHC prescription)

Question 11

Skin Traction

Answer 11

Used short term to relieve muscle spasms and immobilize until surgery
This is when tape, a boot, splint or some type of material is stuck to the skin and the weights pulled against it.
The skin is not penetrated.
Common type: Buck’s ( used with hip and femoral fractures)
Good skin assessments because traction could tear off skin

Question 12

Skeletal Traction

Answer 12

This traction is applied directly to the bone with pins and wires
Used when prolonged traction is needed
Types: Steinman pins, Crutchfield, Gardner-Wells tongs, and Halo Vest

Must monitor pin sites and do pin care. Sterile technique, remove crusts and serous drainage is ok.

Question 13

Total Hip Replacement: Post op and Pre op

Answer 13

Bucks traction is used frequently pre-op

Post op care:
Neurovascular checks
Monitor drains ( don’t want fluid to accumulate in the tissues)
Firm Mattress( Joint needs support)
Over bed trapeze to build upper body strength
Positioning:
Neutral rotation - toe to the ceiling ->prevent dislocation of hip joint
Limit flexion; want extension of hip. Will make hip pop out.
Abduction (legs apart to keep hip in socket ) abductor pillow is used
Isometric exercise when confined to the bed
Trocanter roll - located on outside of legs. to prevent external rotation. Document in notes.
No weight bearing until prescribed by the PHC

Avoid crossing legs or bending over.

Is it ok to sleep on the operated side? NO

HYDRATION IS ImPORTANT because DVT and Pneumonia

Stresses to new hip joint should be minimal in the first 3-6 months

Is it ok to give pain meds in the operative hip? NO

Question 14

Hip replacement Complication: Dislocation

Answer 14

Circulatory and Nerve damage

Shortening of the leg, Abnormal rotation, can’t move extremity and pain

Question 15

Hip replacement Complication: Infection

Answer 15

Prophylactic Antibiotics (just like with heart valve replacement)

Remove indwelling cath and drains as soon as possible as they are portals for infection.

Question 16

Hip replacement Complication: Avascular Necrosis

Answer 16

Death of tissue due to poor circulation

Question 17

Hip replacement: Client Education/ Rehab

Answer 17

Best excercise is walking and swimming

Avoid Flexion - low chairs, traveling long distances, sitting more than 30 minutes, lifting heavy objects, excessive bending or twisting or stair climbing, rocking chair

Question 18

Hip replacement: Client Education/ Rehab

Answer 18

Best exercise is walking and swimming + rocking in the chair

Avoid Flexion - low chairs, traveling long distances, sitting more than 30 minutes, lifting heavy objects, excessive bending or twisting or stair climbing, rocking chair

Question 19

Total Knee Replacement (Arthoplasty)

Answer 19

Continuous Passive Movement
Keeps knee in motion and prevent formation of scar tissue
PT will set machine to gradually increase flexion and extension of knee
Never hyperextend or hyprflex knee
Neurovascular checks
Pain relief
Store CPM anywhere except the floor for infection control reasons

Question 20

Amputations

Answer 20

Amputation are performed at the most distal point that will heal
The surgeon tries to preserve the knee and the elbow

Immediate post- op care:
Keep tourniquet in case of massive hemorrhage
Elevation post op is controversial because of hip contractures. If prescribed, only for a short time to reduce swelling.
Do no elevate on pillow, Elevate foot of bed
Prevent hip and knee contracture through extension of the joint - for BKA, prone is the best to extend those joints
Inspect residual limb daily to be sure it lies completely flat on the bed

Question 21

Phantom Pain

Answer 21

What is the first intervention? Diversional activity
Seen more with AKA;s
Usually subsides in 3 months

Question 22

Rehabilitation

Answer 22

Limb shaping is important for prosthesis

You want the stump shaped as a cone
Limb stocking is worn under the prosthesis
It is important to strengthen the upper body - they will be using crutches or walker to ambulate

Massaging the stump promotes circulation and decreases tenderness

How do you teach a client to toughen the stump - Press into a soft pillow, then a firm pillow then mattress and then chair

Walkers: Walk into a walker. Advance, walk and repeat

Crutches should be 1 - 2 inches below the auxilla to prevent rusk of brachial nerve damage. When ambulating stairs with crutches, it’s up with the good leg and down with the bad reg

Cane: Used on the strong side of the body

Question 23

Crutches

Answer 23

The top of the crutches should reach to 1-1 1/2 inches below the armpit while the
client is standing up straight.

The handgrips of the crutches should be even with the top of your client’s hips. The elbows should bend a bit when using the handgrips.

Don’t let the tops of the crutches press into the client’s armpits.

When the client is going up stairs, the client should lead up with the good foot,
keeping the injured foot raised behind them. When the client is going down stairs,
hold the injured foot up in front, and hop down each stair on the good foot.

Three Point crutch walking: Client has to bear weight on the uninjured foot and
both crutches. The affected leg does not touch the ground.

Four point crutch walking: Client has to bear weight on both legs and both
crutches. Each leg is moved in sequence with the opposite crutch… the right leg with the left crutch or the left leg and the right crutch.

Question 24

Canes

Answer 24

The top of the cane should reach to the crease in the client’s wrist when the client
is standing up straight. The elbow should bend a bit when the client holds the cane.

Hold the cane in the hand opposite the side that needs support. (See “COAL”
below)

When the client walks, the cane and the injured leg swing and strike the ground at the same time.

To climb stairs, the client should grasp the handrail (if one is available) and step up
on the good leg first, with the cane in the hand opposite the injured leg. Then
step up on the injured leg.

To come DOWN stairs, put the cane on the step first, then the injured leg, and
finally the good leg, which carries the client’s body weight.

Cane
Opposite
Affected
Leg

Question 25

Walkers

Answer 25

The client should use their arms to support some of the weight. The top
of the walker should match the crease in the client’s wrist when the client
is standing up straight.

First, the client should put the walker about one step ahead of themselves, making sure the legs of the walker are level to the ground. With
both hands, grip the top of the walker for support and walk into it, stepping off on your injured leg. Touch the heel of this foot to the ground first, then flatten the foot and finally lift the toes off the ground as
the client makes a complete step with the good leg.

To sit, the client should back up until his/her legs touch the chair. The client should then reach back to feel the seat before he/she sits down.

To get up from a chair, the client should push himself/herself up and
grasp the walker’s grips. Never try to climb stairs or use an escalator with a walker.

Walk
With
Affected
Leg

Question 26

Osteomyelitis

Answer 26

is an infection in a bone. Infections can reach a bone by traveling through the bloodstream or spreading from nearby tissue. Infections can also begin in the bone itself if an injury exposes the bone to germs. In children, osteomyelitis most commonly affects the long bones of the legs and upper arms

Fever, irritability, fatigue.
Nausea.
Tenderness, redness, and warmth in the area of the infection.
Swelling around the affected bone.
Lost range of motion

Clients who are at high risk for osteomyelitis include those who are poorly nourished, elderly, or obese. Others at risk include those with impaired immune systems and chronic illnesses such as diabetes and rheumatoid arthritis. Treatment regimens restrict activity. The bone is weakened by the infective process and must be protected by immobilization devices and by avoidance of stress on the bone. IV antibiotic therapy is provided for a period of 3-6 weeks with around the clock dosing to maintain a high therapeutic blood level.

Question 27

Rheumatoid Arthritis

Answer 27

Rheumatoid arthritis is a chronic inflammatory disorder that can affect more than just your joints. In some people, the condition also can damage a wide variety of body systems, including the skin, eyes, lungs, heart and blood vessels.

Tender, warm, swollen joints
Joint stiffness that is usually worse in the mornings and after inactivity
Fatigue, fever and weight loss
These firm bumps of tissue most commonly form around pressure points, such as the elbows. However, these nodules can form anywhere in the body, including the lungs.

Question 28

Ankylosing Spondylitis

Answer 28

Ankylosing spondylitis is a type of arthritis that affects the spine. Ankylosing spondylitis symptoms include pain and stiffness from the neck down to the lower back. The spine’s bones (vertebrae) fuse together, resulting in a rigid spine. These changes may be mild or severe, and may lead to a stooped-over posture

Question 29

Marfan Syndrome

Answer 29

Marfan syndrome (MFS) is a genetic disorder of the connective tissue. The degree to which people are affected varies. People with Marfan tend to be tall, and thin, with long arms, legs, fingers, and toes. They also typically have flexible joints and scoliosis.

Question 30

What is a contraindication to elective total joint replacement surgery?

Answer 30

A recent/current infection is a contraindication to elective total joint replacement surgery. Any clinical manifestation that could indicate the presence of an infection should be reported to the HCP as soon as possible before the surgery.