Medical Surgical Nursing Orthopedic Nursing

FRACTURES• Fracture: break in the continuity of bone, usually accompanied by

localized tissue response and muscle spasm. Etiology: usually cause by trauma, but can also be pathologic

(osteoporosis, multiple myeloma, bone tumor) which weaken the bone structure.

Causes:1. In normal bones, fractures occurs when more stress is placed

upon a bone that is able to absorb such as:a. Direct force or crushing forceb. Twisting forcec. Powerful contractiond. Fatigue and stress

2. Pathologic Decay: bones weakened by disease or tumors and subject to pathologic fractures. e.g.: Bone cancer, osteoporosis

FRACTURES (cont…) Classification of Fractures According to: Displacement:

a. Displaced- two ends of the fractured bone are separatedb. Undisplaced-crack in the one may radiate in several direction but the

fragments do not separate Anatomical position:

a. proximal 3rd /Proximalb. middle 3rd /Midshaftc. distal 3rd /Distal

Direction of the fracture line: a. Transverse-break runs across the boneb. Oblique- break runs in slanting directionc. Spiral-break coils around the bone

Number of Fragments:a. Linear: 2 fragmentsb. Comminuted: 3 or more fragments

Condition of the skin overlying the fracturea. Closed: skin is intactb. Open: skin and tissue have been damaged

Specific Type of Fracture

• A fracture with a surface or open wound.

• Does not produce a break in the skin.

A fracture in which the bone has been compressed, seen in vertebral fractures.

A fracture, caused by repeated , prolonged or abnormal stress

A pulling away of a fragment of bone by a ligament or tendon and its attachment.

The bone bends without fracturing across completely, the cortex on the concave side usually remaining intact.

A fracture that is straight across the bone, usually caused by a force applied to the site at which fracture occurs.

A fracture with more than one fragments.

A fracture where the fragments are driven into one another.

FEMORAL FRACTURE

FRACTURES (cont…)

• Signs and Symptoms/Clinical Manifestations: Pain (especially at the time of injury) Tenderness at the site Loss of function Deformity Crepitus (grating sensation either heard or felt as bone ends

rub together.) Discoloration Bleeding from an open wound with protrusion of both ends. swelling

FRACTURES (cont…)

• Diagnostic procedures: X-ray examination reveals break in the continuity of the

skin. Therapeutic Interventions:

1. Traction/Splinting is used to maintain alignment of bone fragments and reduce the fracture until healing occurs.

2. Surgical intervention to align the bone (open reduction), often with plates and screws to hold the fracture in alignment.

3. Manipulation to reduce fracture (closed reduction)4. Application of cast to maintain alignment and immobilize limb.

( Plaster of Paris or fiberglass)5. Application of external fixation device when fractures accompany

soft tissue injury.

FRACTURES (cont…)• Stages of Bone Healinga. Formation of Hematoma: blood extravagates into the area between and

around the fragments and the bone marrow. Clot begins 24 hours after fracture occurs.

b. Cellular Proliferation: takes place at the fracture site after several days. The combination of periosteal elevation and granulation tissue containing blood vessels , fibroblast and osteoblasts produce a substance called osteoids forming a bridge across the fracture site.

c. Callus Formation: after the following weeks minerals are being deposited in the osteoids formig a large mass of differentiated tissue bridging the fracture called callus.

d. Ossification: final laying down of bone, the stage in which the fracture ends knit together.

e. Consolidation and Remodelling: when consolidation is completed, the excess cells are absorbed. The primary cancellous bone is remodelled, compact bone being formed according to stress pattern. Remodelling continues as bone is formed in relation to its function (Wolff’s Law).

FRACTURES (cont…)

• Average Period for Firm Union of Various Bones: Clavicle: 3-4 weeks Radius-Ulna 6-13 weeks Metacarpals: 4 weeks Femur: 12 weeks Fibula: 12-14 weeks OS calcis: 8-12 weeks Phalanges: 3 weeks Humerus: 6 weeks Lower 3rd Radius: 4 weeks Tibia: 8-12 weeks Tarsals: 6-8 weeks Metatarsals: 5-6 weeks

FRACTURES (cont…)

• Nursing Care of clients with Fractures: Assessment:1. Age of the patient2. Ability of the client to move extremity3. Altered appearance of the injured body part.4. Neurovascular assessment: soft tissue injury or

edema may compromise circulatory or neurologic functioning.

5. Factors precipitating injury.6. Nutritional status.

FRACTURES (cont…)

Nursing Diagnoses:1. Body image disturbance2. Constipation3. Fear4. Risk for injury5. Pain6. Impaired physical mobility7. Altered role performance8. Self-care deficit9. Risk for impaired skin integrity

FRACTURES (cont…)• Nursing Interventions:1. Enhance comfort2. Ensure adequate oxygenation of tissue3. Take measures towards restricting the function of the fractured bones.4. Maintain body mobility while keeping the injured part at rest.5. Protect against infection in the absence of an intact 1st line of defense.6. Provide adequate nutrition for healing.7. Prevent constipation.8. Promote urinary elimination.9. Prevent additional trauma to soft tissues.10. Assist in allaying anxiety.11. Assist patient to attain optimal level of independence.12. Help prevent boredom13. Anticipate underlying complications.

FRACTURES (cont…)

• Complications: Early Complications:

1. Shock (hypotension)

2. DVT (leg pain)

3. Pulmonary embolism( chest pain)

4. Fat embolism ( diaphoresis, dyspnea, pallor)

5. Compartment Syndrome.

FRACTURES (cont…)

• Compartment Syndrome: an increase in compartment pressure of the limb caused by edema resulting to compromised circulation leading to ischemia (death) to the muscles.

Five Cardinal Signs :1. Pain: unrelieved pain2. Pallor: pale skin or nailbeds, prolonged blanching3. Pulselessness: Decrease pulse4. Paresthesia: Numbness or tingling sensation5. Paralysis: inability to move fingers or toes

FRACTURES (cont…)

Late Complications:

1. Delayed Union

2. Non-Union

3. Mal-Union

4. Avascular Necrosis

5. Heterothropic Ossification/Myositis ossificans

FRACTURES (cont…)

• Evaluation/Outcomes1. Reports reduction in pain2. Maintains neurovascular functioning of the

extremities3. Maintains skin integrity4. Remains active participant in care without

compromising treatment.5. Avoids complications of mobility.6. Regains complete mobility and function after

healing.

FRACTURE EPONYMS

Musculo-Skeletal Related Injuries • Dislocation: displacement of the bone from its normal joint position to

the extent that articulating surfaces loss contact. Causes:

1. Trauma2. Diseases3. Congenital condition

Signs and Symptoms:1. Burning pain to joint2. Deformity of the joint3. Stiffness and loss of joint function4. Moderate or severe edema around joint

Nursing Care:1. To lessen swelling, elevate the affected extremity immediately. Keep it

elevated until after dislocation is reduced because manipulation increases swelling.

2. Assess the extremity for signs of neurovascular problems and compartment syndrome.

3. Administer pain medication as per doctor’s order.4. Encourage patient to perform light exercise.

Musculo-Skeletal Related Injuries

• Sprain: is an incomplete tearing of joint capsule or ligaments surrounding a joint, which does not disrupt ligament continuity or cause joint instability.

Cause: Sudden twisting of joint beyond range or motion. Signs and Symptoms:a. Pain at joint c. dislocation around jointb. Edema around joint d. decrease joint function Nursing Care:1. To reduce swelling, apply cold treatment (icebag/cold pack) for

the first 48 hours.2. After swelling is controlled, apply warm treatment (warm

compress/heat pad).3. Provide care to patient with extremity in cast or bandage.

Musculo-Skeletal Related Injuries

• Strain: injury to a tendon/muscle unit close to the joint it can be acute or chronic.

Cause: Over stretching tendons or over using muscles. Signs and Symptoms:1. Acute strain produces sudden , severe pain at the time of injury

which then subside to local tenderness. Swelling occurs rapidly.2. Chronic strain produces gradual onset stiffness, soreness and

tenderness. Nursing Care:1. For acute strain aplly ice packs for the 1st 48 hours to control

swelling.2. Then apply warm treatment3. Rest the affected part for 4-6 weeks.4. For both acute and chronic strains, permit only minimal

movemennt of the affected area.

Treatment

• Splinting: immobilization of injured limb using rigid materials.

• Purposes;

1. To avoid further soft tissue injury.

2. Lower the incidence of clincal fat embolism and shock.

3. Facilitates patients transportation and radiographic studies.

CAST• Cast: is a temporary immobilization.• Types:1. Plaster of Paris: consist of a roll of bandage stiffened

by dextrose or starch ad impregnated with hemihydrates of calcium sulfate.

2. Fiber glass Purposes:1. To promote healing and early weight bearing.2. To support , maintain and protect realigned bone3. To prevent or correct deformity4. To immobilize the injured limb

CAST• Cast Application: A cast is applied with padding first. Padding materials include the following:

a. Stockinetteb. Wadding sheet

1. Apply first the stockinette2. Apply the wadding sheet3. Fiber glass or plaster cast Instruments for Cast Removal1. Cast cutter2. Cast spreader3. Trimming knife4. Bandage scissors5. Plaster shears Contraindications

1. Pregnancy2. Skin diseases3. Swelling/edema4. Open wound5. Infection

CAST• Nursing Care;1. Handle wet cast with palms of hands not fingers2. Cast should be allowed to air dry.3. Elevate the cast with one to two pillows during drying.4. Observe hot spots and musty odor . These are signs and symptoms of

infection.5. Maintain skin integrity 6. Do neurovascular checks:a. Skin color d. mobilityb. Skin temperature e. pulsec. Sensation7. Assess for vascular occlusion8. Adhesive tape petals reduce irritation at cast edges.9. Prevent complication of immobility.a. Bedsores d. Renal calculib. Hypostatic pneumonia e. osteoporosisc. Constipation f. muscular atrophy

TYPES OF CAST, MOLDS AND INDICATIONS


• Shoulder Spica: humerus and shoulder joint


• Airplane cast: for humerus and shoulder joint with compound fracture.


• Hanging Cast: for fractured shaft of the humerus


• Functional Cast; for fractured humerus with abduction and adduction


• Short Arm Circular Cast: for wrist and fingers


• Short Arm Posterior Mold: wrist and fingers with compound affectation.

•TYPES OF CAST, MOLDS AND INDICATIONS

• Long arm Circular Cast: fractured radius or ulna


• Munster Cast/ Fuenster’s Cast: for fractured radius ulna with callus formation


• Long Arm Posterior Mold: for fractured radius or ulna with compound affectation


• Minerva Cast: for upper dorsal/ cervical spine affectation


• Rizzer’s Jacket: for scoliosis


• Body Cast: for lower dorso-lumbar spine affectation


• Double Hip Spica Cast: for Fracture of hip and femur


• . 1 And 1/2 Hip Spica: Hip and femur with compound affectation


• Basket Cast: for severe leg trauma with open wound or inflammation.


. Long Leg Posterior Mold: for fractured tibia fibula with compound affectation


• Long Leg Circular Cast: for fractured tibia fibula


• Cylindrical Leg cast; for Fractured patella


• Quadrilateral (Ischial Weight Bearing) Cast: for fractured shaft of the femur with callus formation


• Cast Brace: for fracture of the femur (distal curve) with flexion and extension.


• Short Leg Circular Cast: ankle and foot fracture


• PTB (Patellar Tendon Bearing) Cast: for fractured tibia-fibula with callus formation


• Delvet/Delbit Cast: fracture of tibia or fibula


• Short Leg Posterior Mold: ankle and foot with compound affectation


• . Boot Leg Cast: for hip and femoral fracture


• Internal Rotator Splint: for post hip operation


• Collar cast; for cervical affectation


• Pantalon Cast: for pelvic bone fracture


• Single Hip Spica: fracture of hip and femur


• Frog Cast: for congenital hip dislocation


• For hip and femur with compound affection


• Double Hip Spica Mold: cervical affectation with callus formation.


• Cocked-Up Splint for wrist drop


• Night Splint: for post polio


• Single Hip Spica Mold: pelvic fracture with callus formation

TRACTION

Traction: is the act of pulling or drawing which is associated with counter traction. Traction means that pulling force is applied to a part of the body or an extremity while a counter traction pulls in the opposite direction. In straight or running traction counter traction is supplied by the patient’s body with the bed.

Purposes: Prevent/Correct deformities Relieve pain Relieve muscle spasm Reduce/immobilize fractures

TRACTION

Principles:1. Position should be supine2. Avoid friction3. Allow the weight to hang freely4. Apply traction continuously5. There should be an adequate counter traction6. The line of pull should be in line with the deformityTypes:1. Skin Traction: applies pull to an affected body structure by

straps attached to the skin surrounding the structure.• Kinds:

a. Adhesive skin traction b. Non-adhesive skin traction

TRACTION

2. Skeletal Traction: is applied to the affected structure by a metal pin or wire inserted into the structure and attached to the traction ropes.

Often used when continuous traction is desired to immobilize, position and align a fractured bone properly during the healing process.

Nursing Care:Skin: Monitor for vascular occlusion Maintain counter traction Maintain weights hanging freely Maintain positioning Provide daily rewrapping Detection of pressure points

TRACTIONNursing Care:Skeletal: Inspection Dressing Traction apparatus Skin care Prevent complication of bed restMuscles: Strengthening exercise for upper extremities Strengthening exercise for lower extremities Preparation for crutch walkingVascular Occlusion Paralysis Paresthesia Pulselessness Pallor Pain

TYPES OF TRACTIONS AND INDICATIONS

1. BST (Balance Suspension Traction): for femoral affectation.

2. Boot Leg Cast Traction: for hip and femur affectation.

3. Braun Splint Traction: temporary traction before the BST.

4. Bryant’s Traction: for femoral fractures and hip injuries (for children below 4 yrs old)

5. Buck’s Extension: for fractured femur and hip6. Dunlop’s traction: supracondylar fracture of the

humerus.

TYPES OF TRACTIONS AND INDICATIONS

7. Halo Femoral: for severe scoliosis

8. Halo Pelvic Girdle: for scoliosis and back pain

9. Head Halter Traction: cervical spine affectation.

10. Pelvic Girdle: for lumbo-sacral affectation, HNP.

11. Russell's Traction: for fracture of femur.

12. Stove –In-Chest: for sever chest injury with multiple fracture.

13. 90-90: fracture of the femur.

TYPES OF TRACTION

KURCHNER’S WIRE HOLDER

STEINMANN PIN HOLDER

OVERHEAD

• For fracture of humerus

BOOT LEG TRACTION

• For Hip and Femoral Affection

COTREL

• Head Halter– For cervical spine

affection

• Pelvic Girdle– For lumbo-sacral

affection and Herniated Nucleus Pulposus

BRYANT’S SKIN TRACTION

• for femoral fracture, hip injuries among kids below 3 years old

HALO FEMORAL

• For severe scoliosis

HALO PELVIC

• For Scoliosis

90 DEGREE

• For fracture of femur

STOVE IN CHEST

• For severe chest injury with multiple rib fracture.

DUNLOP SKIN TRACTION

• For supracondylar fracture of the humerus

HAMMOCK SUSPENSION

KRUTCHEDFIELD TONGS

VINKE’S CALIPER

TOWERS

TYPES OF BRACES, SPLINTS AND INDICATIONS

1. Banjo Splint: for peripheral nerve injury.2. Bilateral Leg Brace: for polio3. Chair Back Brace: lumbo-sacral affectation4. Cock up splint: for wrist drop5. Dennis Brown Splint: Clubfoot or Talipes6. Finger Splint: for fractured digits7. Forester Brace; lower thoracic and upper lumbar affectation8. Jewett Brace: for scoliosis T9 and above9. Milwaukee Brace: lower thoracic and upper lumbar affectation10. Shantz Collar: cervical affectation12. Unilateral leg Brace: polio unilateral affectation13. Yamamoto Brace: severe scoliosis T9 and below.

MILWAUKEE BRACE

• For Scoliosis

FORESTER BRACE

• Cervico-Thoraco Lumbar Affection Spine

YAMAMOTO

• For Scoliosis

TAYLOR BRACE

• For upper thoracic

JEWETT BRACE

• For Lower Thoracic

CHAIRBACK BRACE

• For Lumbo-sacral fracture

CERVICAL COLLAR/ SHUNTZ COLLAR

• For cervical affection

PHILADELPHIA

• For Cervical affection

BANJO SPLINT

• For Peripheral Nerve Injury

LIVELY FINGER SPLINT

• For fracture of finger

DENIS BROWNE SPLINT

• For Clubfoot or talipes equinovarus

UNILATERAL LEG BRACE

• For Polio (one leg affection)

BILATERAL LEG BRACE

• For Polio (bilateral leg)

Roger Anderson External Fixator

MOBILITYUse of Braces and Splints: A. Purposes: Support and protect weakened muscles Prevent and correct anatomic deformities Aid ain controlling voluntary muscle movements Immobilized & protect a diseased or injured joint Provide for improvement of functionB. Nursing Care:1. Keep equipment in good repair (oil joints, replace straps when worn,

wash with saddle soap)2. Provide adequate shoes( keep in good repair, heels low and wide, high

top to hold the heel in the shoe).3. Examine the skin daily for evidence of breakdown at pressure points.4. Check alignment of braces( leg braces: joint should coincide with body

joint; back brace: upright bars in center of the back, brace should grip the pelvis and trochanter firmly, lacing should begin from the bottom).

5. Evaluate client’s response to procedure.

MOBILITY

Use of Cane:A. Purposes: improve stability of the client with lower limb disability. Maintain balance Prevent further injury Provide security while developing confidence in

ambulating. Relieve pressure on weight bearing joint Assist in increasing speed of ambulation with less fatigue Provide for greater mobility and independence

MOBILITYB. Nursing Care: 1. Ascertain that the client is able to bear weight bearing on the affected extremity2. Ensure that the client is able to use the upper extremity opposite the affected lower

extremity3. Measure to determine the length of cane required

a. Highest point should be approximately level with the greater trochanterb. Handpiece should allow 30 degrees of flexion at the elbow with the wrist held in extension.

4. Explain the proper technique in using cane.a. Hold in the hand opposite the affected extremityb. Advance the cane and the unsaffected extremity simultaneously and then the affected leg.c. Keep cane close to the bodyd. When climbing, step up with the unaffected extremity and then place the cane and the affected

lower extremity on the step; when descending, reverse the procedure.5. Observe for incorrect use of cane

a. Leaning the body over the caneb. Shortening the stride on the affected side c. Inability to develop a normal walking patternd. Persistence of the abnormal gait pattern after the cane is no longer needed.

6. Observe client’s response to procedure

MOBILITY

Crutch Walking:A. Purposes: Support body weight, assist weak muscles, and provide joint stability. Relieve pain. Prevent further injury and provide for improvement of function. Allow for greater independence.Nursing Care:1. Ensure proper fit of crutches by measuring the distance from the anterior

fold of the axilla to a point 15 cm (6 inches) out from the heel.a. Axillary bars must be 5 cm (2 inches) belaw the axillae and should be

padded.b. Hand bars should allow almost complete extension of the arm with the

elbow flexed about 30 degrees when the client places weight on the hands.

c. Rubber crutch tips should be in good condition, about 5.1 to 7.6 cm ( 3-

MOBILITY2. Assist in use of proper technique, depending on ability to bear weight and to take steps

with either one or both of the lower extremities.a. Four point alternate crutch gait Right crutch, left foot, left crutch right foot Equal but partial weight bearing on each limb Slow but stable gait; there are always three points of support on the floor The client must be able to manipulate both extremities and get one foot ahead of the

other (e.g. persons with polio, arthritis, cerebral palsy)b. Two point alternate crutch gait Right crutch and left foot simultaneously There are always two points of support on the floor This is a more rapid version of the four point gait and requires more balance and strength

(e.g., a bilateral amputee)c. Three-point gait Advance both crutches and the weaker lower extremity simultaneously, then the stronger

lower extremity Fairly rapid gait, but requires more balance and strength in the arms and good lower

extremity Used when one leg can support the whole body weight and the other cannot take full

weight bearing (e.g a client with a fractured hip)

MOBILITYd. Swing crutch gaitd.1 Swing-to-gait Place both crutches forward, lift and swing the body up to the

crutches, then place crutches in front of the body and continue There are always two points of support on the floor This technique is indicated for anyone with adequate power in

the upper arms.d.2 Swing-through-gait Place both crutches forward, lift and swing the body through the

crutches. Then place crutches in front of the body and continue. Very difficult gait, because as the client swings through the

crutches it necessitates rolling the pelvis forward and arching the back to get the center of gravity in front of the hips.

Indicated for the client who has power in the trunk and upper extremities, excellent balance, self confidence, and a dash of daring (e.g., bilateral amputee, paraplegic with braces).

MOBILITYe. Tripod crutch gaite.1 Tripod alternate gait Right crutch, left crutch, drag the body and legs forward The client constantly maintains a tripod position: both crutches are held

fairly widespread out front while both feet are held together in the back Necessary for the individual who cannot place one extremity ahead of

the other ( e.g. persons with flaccid paralysis from poliomyelitis, one with spinal cord injury.

e.2 Tripod simultaneous gait Place both crutches forward, drag the body and legs forward Because the tripod must have a large base, the client’s body must be

inclined forward sufficiently to keep the center of gravity in front of the hips.

MOBILITY

3. Observe for incorrect use of crutchesa. Using the body in poor mechanical fashionb. Hiking hips with abduction gait( common in amputees)c. Lifting crutches while still bearing down on themd. Walking on ball of foot with foot turned outward and

flexion at hip or knee levele. Hunching shoulders (crutches usually too long) or

stooping with shoulders ( crutches usually too short).f. Looking downward while ambulatingg. Bearing weight underarms; should be avoided to prevent

injury to the nerves in the brachial plexus; damage to these nerves can cause paralysis (crutch palsy).

4. Evaluate client’s response to the procedure.

MOBILITYUse of walkerA. Purposes: Maintain balance Provide additional support because of wide area of contact with the floor Allow for some ambulatory independenceNursing Care:1. Assist in selecting a walker Device should not be used unless the client will never be able to ambulate with a

cane or crutches Measure for a walker are the same as for cane The client must have a strong elbow extensor and shoulder depressor and partial

strength in the hands and wrist muscles. The client needs maximum support to ensure security and enhance confidence. Device is ordinarily limited to the home because it cannot be used on steps2. Assist in ambulating with the walker Lift the device off the floor and place forward a short distance, then advance between

the walker Two wheeled walkers: raise back legs of the device off the floor, roll walker forward,

then advance to it. Four wheeled walkers: push device forward on the floor and then walk to it.

MOBILITY

3. Observe for incorrect use of walkerKeeping arms rigid and swinging through to

counterbalance the position of the lower extremities

Tending to lean forward with abnormal flexion at the hips.

Tending to step forward with the unaffected leg and shuffle the affected leg up to the bar.

4. Evaluate client’s response.

RELATED TERMS IN ORTHOPAEDIC, DIAGNOSTIC, PROCEDURES AND

SURGERY• Ventriculography: x-ray examination of the ventricular system brain

after replacing some of the cerebrospinal fluid with air.• Angiography: x-ray of the cerebrovascular tree following the injection

of a radio-opaque medium into the spinal arachnoid space.• Craniotomy: an incision to the soft and underlying tissues and

removal of the part of the skull in order to gain access to brain to reduce a depressed fracture of the skull.

• Myelography: x-ray examination of the spinal cord after the injection of a radio-opaque medium into the spinal arachnoid.

• Cranioplasty: repair of the skull either with metal plates or a bone graft.

• Lumbar Sypathectomy: surgical removal of a portion of a symphatetic nerve ganglion.

• Open Reduction: the correction through surgical method of fracture in a dislocation by the use of nails, screws, wires, or rods with or without plates.

• Screwing: is used for fixation of bone fragment that are partially threaded.

• Wiring: internal fixation of fracture by means of wire cup.• Bone Graft:

a. Autogenous bone graft: graft taken from the patient himself, usually taken from either the tibia, fibula or ilium.b. Femogenous bone graft: graft taken from another human donor, are obtained from non-infected amputated limbs and are strored in deep freeze.

• Aspiration: removal of fluid on a joint by suction using a syringe and hallow needle under local anesthesia

• Arthrectomy: removal of loose bodies (knees), removal of a test semi lunar cartilage or removal of loose bodies which are usually osteocartilageous in nature.


SURGERY


SURGERY

RELATED TERMS IN ORTHOPAEDIC, DIAGNOSTIC, PROCEDURES AND SURGERY






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Medical Surgical Nursing Orthopedic Nursing