NU 350 Orthopedics Part 2
Where is pain sensed in the bone and where does the bone get the blood supply from?
The periosteum, or covering over the bone, has nerves which sense pain. Also where blood vessels.
What is a fracture? How can a fracture be caused? What would a nurse want to know about how a fracture was caused?
Disruption or break in the continuity of the structure of bone. Can be caused by trauma to the bone or a pathologic reason.
Trauma to the bone means there was a mechanical overload. Amount of force it takes to break the bone depends on the the bone and the force of the trauma
Pathologic fractures are caused by other disease processes.
Want to understand how the fracture happened? The mechanism of injury. Can have direct force, where the force is applied directly to the bone, or indirect, like falling down and fracturing your forearm from catching yourself. Can be from extensive muscle extension or flexion.
Pathologic fractures happen in osteomalacia (starting of deminerilization of bone b4 osteoporosis), syphilis, osteomyelitis (infection in the bone), spontaneous breaks with no apparent reason. Got to investigate the cause. It could be cancer.
What are the stages of healing in a fracture? Describe each.
1. Hematoma formation: Lasts about 72 hours, blood rushes to area, causing swelling. First thing to do is ice, elevate above the heart.
2. Granulation tissue formation: Starts new blood vessels, osteoblasts come in, new basis for bone formation. Takes 3-14 days. Called bubble gum state. Ends of bone aren't wiggling around. They're sticky on each end in order to bridge the gap. Once granulation tissue is solid, it changes.
3. Callus formation is when minerals come, new bone matrix is supplied. Usually, appears by end of second weeks of injury. One of the best ways to know if you're healing. Callus will show up on x-ray. Sometimes it's hard to see actual break on x-ray. Pain is gone at this point. But important to educate that the bone is still healing even thought there's no pain.
4. Ossification: Can go from 3 weeks to 6 months. Time depends on immobilization, age, quality of bone. Bone continues to heal, gotten to the point where it own't move unless a good amount of force is applied. Cast might come off at this point.
5. Consolidation: Callus continues to develop. See union, looks like the bone is healed. No fracture site anymore. Bone is wider at fracture site.
6. Remodeling: Osteoclasts remodel the bone where it is wider at the fracture site, therefore, you can't even tell the bone is wider anymore.
What are some factors affecting fracture healing?
Trauma severity - open are much worse than closed.
Type of bone
Infection slows healing
Avascular Necrosis (AVN) - The periosteum is stripped away and the blood vessels are taken away. Without blood, the bone dies. Severe fractures can do this. Common site for this is the hip due to trauma or heavy steroid use. Don't give steroid shots more than 4 times a year. Many RA pts get this bc of steroids.
Intra-articular fracture - Where the fracture is in a joint and goes up through the joint line through the cartilage, breaking the cartilage. Joint doesn't move smoothly because of uneven surface. Osteoporosis develops.
Age - Older equals slower
How do the different types of fractures occur?
Greenstick: more common in kids
Impact: Falling on the bone, squishes the bone.
Spiral: Twisting of the bone
Displaced: Means it's not in alignment. Usually going to have to realign the bone. Must have it as close to anatomical position as possible
In a humerus fracture, might have to give a cast below the break to weigh their arm down to consolidate the bone pieces together. Can't rest their arm on a pillow or raise it at all.
What are the goals of fracture treatment?
1. Reduce the fracture, put it in alignment
2. Immobilize to maintain alignment
3. Restore as near to normal as they can get. Always put people in position of function.
What is used in a closed reduction of a fracture?
Manual realignment of the bone, use local or general anesthetic. Sometimes could use traction or pulling on the bone to realign.
What is the primary function of casting for a fracture?
Immobilize, prevent or correct deformity, support, protect, maintain realigned bone, and promote healing.
What are the materials that casts can be made out of and what are their respective characteristics?
Plaster: Moldable, total contact casts, multiple cast changes. Plaster comes in rolls, put it in water which activates it, and roll it on the patient. It sets up and gets hard. Very moldable and cheap. Want to put a stocking under the cast to protect their skin. Cannot have wrinkles in the stocking. Then put padding on top of the stocking. Mainly cover bony prominences. Plaster goes over the padding. Cast padding is specific to plaster. Takes 24-48 hours to dry. Can't put any pressure on it for that long or it will have dents in it.
Fiber glass hardens to air. It is lightweigt, strong, and durable. Must have water to activate it. Has different stocking and padding. Dries quickly. Can walk on it very soon after.
How do you apply casts?
Make water temperature safe, no wrinkles in the stocking (can cause pressure, pain, and skin breakdown), put padding on over the stocking, roll from distal to proximal, overlap each roll by 1/2 width. Fiberglass must be lukewarm.
What does a nurse need to educate the patient on about cast care?
Do not get cast wet
Encourage intermittent ice for 15-20 min at a time, 3-4 times for the first 24 hrs.
Know the weight bearing status
Move any joints that are free
Don’t stick anything in the cast
Report rubbing or skin problems
Teach the 5 P’s, pain out of proportion to what it is expected, pallor, pulses, parasthesias, paralysis.
How do we remove casts?
A cast saw works by vibration. It's really noisy, could frighten some kids. Cut the cast medially and laterally (bivalve), don't ever go over midline.
Could just window, or cut out a portion of the cast to see the skin below. Doesn't compromise the integrity of the cast.
How is an open reduction for a fracture done?
Correction of the bone through surgical incision, ORIF (open reduction with internal fixation) where they put some kind of metal in the body to correct bone position. Risk is infection.
What are the types of equipment used in an ORIF?
Plates, screws, rods, compression screws, hip replacements. Immobilization is key.
What is external fixation used for? What are the concerns?
Treats open fractures, those whee the bone comes out of the skin. Usually trauma induced. They drill pins into the bone above and below the fracture. There's a rod that goes in between the pins in the bone. Once the big wound is healed, they'll take the pins and rod out and put a cast over it. Can't put a cast over a wound.
Main worry is infection where the pins are going in. S/s are redness, tenderness, exudate, and pain around the area of pins.
What should a nurse teach a patient with external fixation about how to care for it?
Pin care is key. Get q-tips and hydrogen pyroxide or betadine and clean around the pins. Want to loosen the skin around the pin and clean taht way. It will tent up around the pin. Bacteria then run up into the skin. Use new q-tip for each pin. Do the one with most drainage last.
What are key nursing concerns with fractures and fixations?
Neurovascular checks, observing for complications, and education.
What is traction regarding fractures? What are the types of traction for fractures? Describe how they work.
Traction applies a line of pull to the muscles and holds the fracture ends in alignment. Keeps them from wiggling and promotes healing.
Can be continuous or intermittent depending on fracture.
Countertraction is always the body. Key is to maintain the line of pull as it is prescribed.
Buck's traction: Short term, only 48-72 hours. Place directly on the skin. Main complication is a neurovascular compromise and skin breakdown. Only use up to 10 pounds of weight. Most of the time you have them ins this kind of traction 24/7 for a couple of days.
Skeletal traction: A bar goes through the pt's bone, most people with this have a femur fracture, usually in it for 6 weeks. Complications always include immobility and skin breakdown. They have a trapeze bar that lifts their butt off the bed if they pull on it. Weight can be up to 40 pounds on skeletal traction.
What are the tenets of nursing care for the patient on traction?
IMPAIRED PHYSICAL MOBILITY
ALTERED BOWEL OR BLADDER
POTENTIAL BREATHING PROBLEMS
What does a nurse need to know regarding neurovascular status in a patient on traction?
- Obtain baseline N/V status
- Compare to unaffected extremity
- Assess for edema, elevate if possible
- Use footboards or wrist splints for prevention
- Loosen restrictive devices
- Assess for increased pain with passive ROM
What does a nurse need to know regarding skin breakdown in a patient on traction?
- Assess for preexisting problems & notify MD
- Reposition patient and encourage position changes within limitations of traction
- Use specialty air mattress
- Pad & massage bony prominences
- Encourage intake of adequate calories & fluids
- Monitor pin sites & perform pin care
What does a nurse need to know regarding physical mobility in the patient on traction?
- Provide trapeze & instruct in its use
- Teach isometric (without weights) exercises for unaffected extremities
- Teach strengthening exercises for unaffected extremities
- Organize environment to facilitate independence
What does a nurse need to know regarding bowel and bladder in a patient on traction?
- High fiber diet, limit intake of calcium/mlk, could cause kidney stones
- Encourage 2,500 cc/day fluid
- Monitor I&O
- Report c/o flank pain, burning on urination, incomplete bladder emptying
- Use fracture bed pan, elevate HOB only within limits of countertraction
- Evaluate need for stool softeners &/or suppository regimen
What does a nurse need to know regarding the respiratory system in a patient on traction?
- Assess respirations
- Auscultate lungs every 8 hours
- Report c/o dyspnea, coughing, chest pain
- Note quality & amount of sputum
- Encourage deep breathing & coughing 10 times q 2 hrs
What does a nurse need to know regarding psychosocial status in a patient on traction?
- Assess mental status
- Provide distraction activities, lap tops, TV, crafts
- Encourage family visits
- Organize activities for maximum control for the patient
What does a nurse need to focus on when assessing for potential complications from fractures?
What are some high risk complications from fractures?
DVT & PE
FAT EMBOLISM SYNDROME
INFECTION - WOUND
What does a nurse need to know about compartment syndrome?
It is compression of the nerves and blood vessels in a muscular compartment. Mainly get it in long bones in the arms and legs.
Assess 5 P's, assist sugeons in checking compartmental pressure, assess for s/s such as pain and pressure, immobilize to quell internal forces, may have to enlarge cast due to swelling. May even do a fasciotomy to open the fascia and relieve the pressure. Obviously, infection is a complication. Must assess to prevent.
What does a nurse need to know about DVT and PE?
S/s of DVT are swelling, redness, heat. Usually in lower extremity, pain isn't uncommon. Best treatment is doppler ultrasound. Venograms are invasive and not as common.
PE is the most serious complication of a DVT. It breaks off and travels to the lungs. S/s are feeling of impending doom, apprehension, sudden anxiety, short of breath, dyspnea, chest pain, hemoptysis.
Diagnostics: Get ABGs, put on O2, do a spiral CT scan (does a 3D reconstruction of the lungs). Contraindicated in renal pts because of the contrast. Ventilation perfusion scan to see how well perfused they are. Another test is a D-dimer test. It's a blood test aht measures fibrin fragments when a clot starts degenerating. It's not specific for PE.
Treatment: DVT - anticoagulation therapy with IV heparin and warfarin (INR 2-3)
PE - O2, anticoagulation for 3-12 months, vena cava filter to catch any clots going to the lungs.
What does a nurse need to know about fat embolism syndrome.
Blockage in the vessels by fat. Mimicks a PE bc it goes to the lungs. Fat comes out of the bone, enters the bloodstream, and goes straight to the lungs. Mostly will be in long bone fractures and multi-trauma victims, pelvic fractures.
S/s are the same as PE, except for petechia. Little red dots. Petechia can get in the axillae and the oral mucosa.
Prevention: Minimal movement of the fracture, immobilize, keep hydrated.
Treatment of acute attack: O2 at 1st sign of distress, intubation and mechanical ventilation. No real treatment for fat embolus.
Most people with fat embolus die.
What does a nurse need to know about hemorrhage as a complication of fractures and surgical repair of fractures?
Prevent by immobilizing the fracture!
Early detection by checking the dressing and under the dressing, check VS, orthostatic hypotension, I&O, hct, pulses, capillary refill, skin color, extremity temperature, muscle function.
What does a nurse need to know about infection as a complication of fractures and their repair?
When you've had surgery, remember Wind, Water, Wound. 1st, the lungs or "wind" will cause infection from atelectasis. 2nd, the renal system or "water" will cause infection from UTIs. The actual wound will take the longest to develop infection.
Watch for osteomyelitis (bone infection). Bacteria lodges in the medullary canal of the bone. Comes through the blood system.
Acute is less than a month from the injury. S/s are very systemic, high fever, night sweats, chills, n/v, severe bone pain, worse w/ activity, swelling, tenderness, warmth. It will make them septic.
Chronic is an infection that has a draining sinus through the suture line. Very hard to get rid of. Usually after a month from the initial injury.
Diagnostics: C&S before antibiotics are started, Sed rate for inflammation, WBCs, X-ray, MRI.
Treatment: Antibiotics (most common side effect is yeast infection), surgical debridement, immobilization, hyperbaric oxygen for wound care to give more O2 to the area. Sometimes have to amputate the affected part.
What are two complications of fractures that have to do with union of the bone pieces?
Delayed union is when the healing doesn't occur at a normal rate. Many times the pt doesn't comply and immobilize.
Non-union is when the bone fails to unite after 3 months. They get a bone graft. They take a piece of bone out of your hip and put it in the site which consolidates the bone. Will hurt worse in the donor site (hip) than in the surgery site.