Ortho

Question 1

Risk factors

Answer 1

1. Age-related Changes: Loss of bone after 30; Vertebrae collapse; Muscle atrophy; Loss of cartilage; Lax ligaments
2. Medical Hx: Paget’s Disease; Bone cancer
3. Osteoporosis: 40 mil. Americans over the age of 50!; 40% of Caucasian women over the age of 50!
4. Occupation
5. Recreational activities
6. Poor nutrition

Question 2

Classification of fractures

Answer 2

1. Extent of break: Complete; Incomplete
2. Cause
   - Pathologic (spontaneous): bone cancer
   - Fatigue (stress): jogging
   - Compression: osteoporosis
3. Extent of soft-tissue damage
   - Closed (simple): no visible wound
   - Open (compound): external wound
    Grade I : skin damage is minimal
    Grade II : skin and mascle damage
    Grade III : skin, muscle, nerve tissue and blood vessels damage

Question 3

Impacted fracture

Answer 3

when force has come down on the bone : and one part of the bone smashed on the other part.

Question 4

Greenstick fracture

Answer 4

common in children or newer bone ; after new tree branch…cant snap it

Question 5

S/s :

Answer 5

	Pain
	Loss of function
	Deformity
	Shortening
	Crepitus
	Swelling / discoloration

Question 6

Diagnostics

Answer 6

• X-ray studies
- May need to be repeated with additional views
• CT scan
- Used to dx difficult-to-evaluate fractures (hip and pelvis)
• MRI
- Helps determine amount of soft-tissue damage

Question 7

TX of fractures

Answer 7

• Reduction: restoration of bone fragramnets to anatomic allignment and rotation; performed right away
- Closed: bring ends together through amnipulation or manula traction them place cast or splint in order to immobilize it ;
- Open: surgery ; internal fixation
• Immobilization: hold bone fracture in correct allignment
- External
- Internal

Question 8

Casts:

Answer 8

• Used to immobilize, correct deformity, apply uniform pressure on underlying tissue, or support weakened joints
• Location of fx dictates type used
• Plaster ( rolls, wet with water; crystallized, 24-72 hrs to dry ) or non-plaster ( fiber glass, water resistant ( can take shower) ; less skin problems)

Question 9

Casts: nursing management

Answer 9

• Education
-Controlling edema
- Controlling pain
- Exercises to maintain health of unaffected muscles
- Exercises to increase strength of supporting muscles
- Monitoring for potential complications
• Assessment of neurovascular status – 6 P’s: pain, pressure, pallor, pulselessness, paresthesia, paralysis
• Open fx – infection prevention

Question 10

Assessment of neurovascular status – 6 P’s:

Answer 10

1. pain
2. pressure
3. pallor
4. pulselessness
5. paresthesia
6. paralysis

Question 11

Traction:

Answer 11

application of a pulling force to a part of the body provide reduction, alignment and rest .
• Uses:
 Minimize spasms
 Reduce, align, and immobilize
 Reduce deformity
 Increase space between opposing surfaces
• Short-term intervention until external or internal fixation is possible
• Skin (Backs traction: Velcro boot)or skeletal ( pins, wires, tongs or screws are surgically inserted directly into bone) most common types
• Plaster, brace and circumferential

Question 12

Pin care

Answer 12

• First 48-72 hours: clear fluid drainage or weeping expected
• Monitor pin sites every 8-12 hours for inflammation or possible infection:
 Drainage (purulent)
 Color (severe redness)
 Odor
• Chlorhexidine 2 mg/mL solution ( swab around the pin every 4-8 hrs)
• Follow agency protocol for pin site care!
Crusting around pin is natural barrier ( unless infection is present)

Question 13

Traction: nursing management

Answer 13

• Never remove weights without a prescription!
• Good body alignment important
• Ropes should be unobstructed
• Weights must hang freely
• Knots in the rope must not touch the pulleys or the bed
• Assess neurovascular status every hour for first 24 hours after application, then every 4 hours

Question 14

Acute Compartment Syndrome (ACS)

Answer 14

• Anatomic compartment – 36 out of 46 in the body are in the extremities
• Within 4-6 hours, neurovascular and muscle damage irreversible
• Limb can become useless in 24-48 hours

Question 15

ACS:

Answer 15

serious condition in which increased pressure within one or more compartments reduces circulation to the area. (most common: lower leg and forearm ).
The pressure to the compartment can be from :
External source: bulky dressing and cast
Internal: blood and fluid accumulation

Question 16

ACS: S/s

Answer 16

• Pain – out of proportion with injury; increases with passive ROM
• Sensory deficits or paresthesia
• Pale color, cool to touch
• Weak pulses
• Affected area is palpably tense
• If not treated – cyanosis, tingling, numbness, paresis, and severe pain

Question 17

ACS: TX

Answer 17

• Treatment

1. Elevation
2. Bi-valve ( cut the cast longways ; cast open to relieve the pressure )
3. Fasciotomy : cut muscle into fascia to relieve the pressure ; open wound is packed and dressed daily; until secondary healing occurs; might need skin graft to promote healing )

Question 18

Crush Syndrome (CS)

Answer 18

• External crush injury that compresses one or more compartments in leg, arm or pelvis
• Potentially life threatening!
• Muscle becomes ischemic and necrotic
• Myoglobin released into circulation
 May occlude distal renal tubules and cause renal failure

Question 19

Myoglobulin

Answer 19

muscle protein that injured muscle tissue releases into circulation where it can clog the renal tubules and cause acute renal failure.

Question 20

CS: S/s

Answer 20

• ACS
• Hypovolemia
• Hyperkalemia
• Rhabdomyolosis ( release of myoglobulin into blood stream )
• Acute tubular necrosis
• Dark brown urine
• Muscle weakness and pain

Question 21

CS: management

Answer 21

• Focuses on preventing ATN and cardiac dysrhythmias from hyperkalemia
• IVF, diuretics, low-dose dopamine to increase renal perfusion
• Goal of UO=100-200 mL/hr
• Kayexalate to reduce serum K+ levels
• Dialysis if K+ remain high or kidney failure occurs

Question 22

Hypovolemic shock

Answer 22

•	Bone is very vascular!
•	Risk for bleeding with bone injury
•	Trauma to nearby arteries can cause hemorrhage – rapidly developing hypovolemic shock
•	PELVIC Fx
	Possible internal organ damage
	Assess VS, skin color, LOC

Question 23

Venous thromboembolism (VTE)

Answer 23

 DVT and PE
 Most common complication of LE (lower extremity) surgery or trauma
 Most often fatal complication of MS surgery!

Question 24

Fat embolism syndrome (FES)

Answer 24

 Fat globules released from marrow into bloodstream
 12-48 hours after injury
 Clog small blood vessels that supply major organs – lungs
 First sign is AMS (altered mental status) secondary to low arterial O2
 Petechiae is classic sign, but can be a late sign
 Can result in respiratory failure or death

Question 25

Fracture Complications – Chronic complications

Answer 25

• Ischemic necrosis (avascular necrosis) - Blood supply to bone is disrupted – death of bone tissue - Most common with hip fx or fx with displacement (long term Prednisone :corticosteroid at risk) • Delayed union  Fx that has not healed in 6 months  Some NEVER heal: nonunion  Some heal incorrectly: malunion

Question 26

Fractures of upper extremities

Answer 26

• Colles’ fracture – distal radius (deformed wrist, pain, numbness). Check sensation at the tips od the fingers, cap refil, ROM. • Humerus fractures - Neck - Shaft ( brachial vessels must be involved) Place sling on.

Question 27

Pelvic fractures

Answer 27

``` • Pelvic fractures - Stable - Unstable • High mortality rate • Signs and symptoms: ecchymosis, tenderness, local edema, numbness and tingling , cant bear weight; hypovolemic shcok (high risk) • Nursing responsibilities/assessments ```

Question 28

Stable pelvic fx

Answer 28

 Single pubic or ischial rami  Pelvic wing of the ilium  Sacrum or coccyx • Treatment

Question 29

Unstable pelvic fx

Answer 29

* Rotational instability * Vertical instability * Combination of both

Question 30

Hip fractures

Answer 30

• Most common injury in older adults • Most frequent injury in any health care setting • High mortality rate: Osteoporosis - biggest risk factor for hip fx • 2 major types  Intracapsular  Extracapsular

Question 31

Hip fracture : S/s

Answer 31

``` • Signs and symptoms - Groin pain - Pain behind knee - back pain - No pain • Treatment  ORIF (open reduction, internal fixation)  Nonsurgical options ```

Question 32

Joint surgery

Answer 32

``` • Used to correct/repair:  Unstabilized fx  Deformity  Joint disease (DJD)  Necrotic or infected tissue  Tumors • Most common procedures  ORIF  Closed reduction with internal fixation  Most common: total joint arthroplasty or total joint replacement ```

Question 33

Joint replacement contraindications

Answer 33

: infection anywhere in body, advanced osteoporosis, rapidly progressive inflammation  Uncontrolled DM or HTN: risk for major postop complications and possible death • Most common are the hip and knee, but also can replace the finger, shoulder, elbow, wrist, and ankle • Infection prevention • Ambulation promotion

Question 34

Total hip arthroplasty (THA)

Answer 34

• Indications - Pain interrupts pt’s sleep - Pain limits ADLs - Drug therapy no longer controls pain - Pt must be able to participate in PT after surgery • Primary arthroplasty - First time pt has THA • Revision arthroplasty - Performed if implant loosens • Most often performed in patients older than 60

Question 35

THA: complications

Answer 35

1. Dislocation (subluxation or total dislocation) - Leg slightly abducted - Prevent hip flexion beyond 90 degrees - Assess for pain, rotation, shortening 2. VTE (DVT and PE) - Most potentially life-threatening complication - Older, obese, hx of VTE – more at risk - Prevention – antiembolism stockings/SCDs, anticoags (LMWHs), early ambulation 3. Infection - Can occur during hospitalization, or months/years after - Monitor incision and VS - Watch for elevated temp, excessive or foul-smelling drainage - Older pt may just have confusion!

Question 36

Knee Replacement

Answer 36

``` • Indications • Nursing management • Complications - Excessive drainage - DVT - Infection ```

Question 37

Osteomyelitis

Answer 37

• Can occur in 1 of 3 ways… - Exogenous – surgery, open fx, traumatic injury - Endogenous/Hematogenous - spread from other sites of infection (most common) - Contiguous – results from skin infection of adjacent tissues • May be acute or chronic • Most are staph  Can also be Proteus, Pseudomonas, or E. Coli

Question 38

Osteomyelitis

Answer 38

* Acute infection occurs more often in children * Chronic infection more common in adults (esp. with compromised blood supply) * Men > women * Malnutrion, ETOH, DM, kidney or liver disease, immune suppressing disorders increase risk and complicate Tx

Question 39

Osteomyelitis: S/s

Answer 39

``` • Acute infection  Fever (usually above 38 degrees C)  Swelling  Erythema/heat  Tenderness  Bone pain – constant, localized and pulsating – intensifies with movement • Chronic infection  Ulceration of skin  Sinus tract formation  Localized pain  Drainage from affected area ```

Question 40

Osteomyelitis: S/s

Answer 40

• Signs and symptoms  Hematogenous – septic manifestations and local symptoms  Direct bone contamination or spread of adjacent infection – only local symptoms  Chronic – continuously draining sinus, may have recurrent pain, inflammation, and swelling • Diagnostics  X-ray, radioisotope bone scan, MRI  Blood studies, wound and blood culture

Question 41

Osteomyelitis: TX

Answer 41

```  Antimicrobial therapy  Pain control  Infection control  HBO  If not effective, may need surgical intervention (Eg. bone graft, amputation) ```

Question 42

Acute Compartment Syndrome: early signs

Answer 42

1. Pain 2. Pressure 3. Paralysis 4. Paresthesia 5. Pallor 6. Pulselessness