CHAPTER 42. Orthopedic Care
Nancy Saufl
OBJECTIVES
At the conclusion of this chapter, the reader will be able to:
1. Describe common orthopedic surgical procedures and their associated nursing interventions.
2. Describe the assessment and management of complications associated with orthopedic procedures.
3. Describe the pathophysiology and management of arthritic disorders.
4. Identify the various types of traction and the nursing care priorities for patients in traction.
5. Describe the treatment and nursing management of the patient with a fracture.
6. Identify the educational needs of the orthopedic patient.
I. ANATOMY AND PHYSIOLOGY
A. Skeletal system
1. System of living connective tissue, high in mineral content
a. Haversian system
(1) Nourishes bone tissue
(2) Made up of blood vessels and lymphatics
(3) Architectural unit of bone
b. Types of bone
(1) Cortical (compact) bone
(a) Dense, hard outer layer of bone
(b) Found in shafts of long bones
(c) Poor blood supply
(2) Trabecular (cancellous) bone
(a) Spongy, porous bone
(b) Found at ends of long bones and in vertebrae
(c) Rich blood supply
c. Types of cells
(1) Osteoblasts: form new bone
(2) Osteocytes: mature bone cell
(3) Osteoclast: resorb bone
2. Functions of the skeleton
a. Provides framework for the body
b. Provides attachment and leverage for muscles, facilitating movement
c. Protects vital organs and soft tissue
d. Manufactures red blood cells
e. Provides storage for:
(1) Minerals
(2) Calcium
(3) Phosphate ions
(4) Lipids
(5) Marrow elements
3. Divisions of skeleton
a. Axial: framework of head and trunk
b. Appendicular: framework of arms and legs
4. Classification of bones
a. Long bones
(1) Diaphysis: shaft of bone
(2) Epiphysis
(a) Ends of bone
(b) Helps with bone development
(c) Made of cancellous bone
(3) Metaphysis:
(a) Flared portion between diaphysis and epiphysis
(b) Growing part of bone
(c) Has richest blood supply
(4) Physis or epiphyseal plate: growth plate between epiphysis and metaphysis of immature bone
(5) Periosteum: connective tissue that covers bone
b. Short bones
(1) Sesamoid or accessory bones
(a) Carpals
(b) Tarsals
(c) Patella
(2) Primarily found in hands and feet
c. Flat bones
(1) Skull
(2) Ribs
(3) Pelvic girdle
d. Irregular bones
(1) Ossicles of ear
(2) Vertebrae
B. Tissue of musculoskeletal system
1. Connective tissue
a. Development
(1) Develops from mesenchymal cells
(2) Later differentiates into specialized connective tissue cell types
b. Types (three)
(1) Collagenous tissue
(a) Derived from dense fibrous connective tissue
(b) Constructed primarily of collagen fibers
(c) Tendons
(i) Dense fibrous connective tissue strands at the ends of muscles that attach muscles to bone
(ii) Characteristics: flexibility, strength, extensibility
(d) Ligaments
(i) Dense connective tissue bands that attach bone to bone and provide stability to joints
(e) Tendons and ligaments can withstand pulling forces.
(i) Activity
(ii) Joint motion largely affects ligaments.
(iii) Muscle contraction largely affects tendons.
(f) Fascia
(i) Made of connective tissue
(ii) Has many proprioceptive endings
(iii) Covers muscles; provides network of nerves, blood, and lymph vessels
(2) Cartilage: nonvascular tissue composed of collagenous and elastic fibers
(a) Hyaline cartilage—very elastic
(i) Found in:
[a] Trachea
[b] Synovial joints
[c] Larynx
[d] Nasal septum
[e] Ribs
(ii) Tends to get calcified in old age
(b) White fibrocartilage—thick, shock absorbing
(i) Found in:
[a] Symphysis pubis
[b] Between vertebrae
[c] Wrist and knee joints
[d] Ends of clavicle
(ii) Interarticular fibrocartilage—flattened fibrocartilaginous plates between articular surfaces of joints, such as
[a] Menisci of the knee
[b] Temporomandibular
[c] Sternoclavicular
[d] Acromioclavicular
[e] Wrist
[f] Knee joints
(iii) Connecting fibrocartilage—found in joints with limited mobility, such as the intervertebral disks
(iv) Circumferential fibrocartilage—rims surrounding sockets of articular surfaces such as the glenoidal labrum of the hip and the shoulder
(v) Stratiform fibrocartilage—forms a coating on osseous groove that tendons pass through
(c) Yellow or elastic cartilage—dense, more flexible and pliant than hyaline cartilage; strong
(i) Found in outer ear, epiglottis, and eustachian tube
(d) Synovial membrane—covers and lines joints; forms synovial fluid responsible for lubricating and nourishing articular cartilage
(3) Bone
(a) Osseous connective tissue
(b) Predominantly made up of
(i) Fibrous component called collagen
(ii) An amorphous component called calcium phosphate
(c) Highly porous and vascular
2. Muscular system
a. Made up of muscle cell bundles
b. Possess rich vascular supply
c. Covered by fascia
d. Attached to bone by tendons
e. Produces bodily movement by contraction
f. Controlled by complex interaction with the central nervous system
3. Joints: articulations where bones or two bone surfaces come together
a. Diarthrosis—freely movable synovial joint
(1) Uniaxial—move in one axis and only one plane
(a) Hinge—knee, elbow, finger, toe
(b) Pivot—radial head
(2) Biaxial—moves around two perpendicular axes, in two perpendicular planes
(a) Saddle—base of the thumb
(b) Condyloid—distal radius and wrist bones
(3) Multiaxial—moves in three or more planes and around three or more axes
(a) Ball and socket—hip, shoulder
(b) Gliding—vertebral joints
b. Amphiarthrosis—limited movement
(1) Symphysis pubis, intervertebral
c. Synarthrosis—immovable
(1) Sutures—fibrous tissue between skull bones
(2) Syndesmosis—ligament connecting bones’ distal radius and ulna, distal tibia and fibula
(3) Gomphosis—fibrous membrane connects to bone, tooth, and mandible or maxilla
(4) Range of motion—degree of movement of a joint (Figure 42-1)
(a) Angular—changes the size of angles between articulating bones
(i) Flexion—shortens the angle by bending forward
(ii) Extension—lengthens the angle by bending backward
(iii) Abduction—movement away from the midline
(iv) Adduction—movement toward the midline
(v) Plantar flexion—increases the angle between the foot and the front of the leg by bending the foot and toes down and back
(vi) Dorsiflexion—decreases the angle between the foot and the back of the leg by bending the toes and foot upward
(vii) Hyperextension—stretching a part beyond its normal anatomical limits
(b) Circular—movement around an axis
(i) Rotation—moving or pivoting a bone around its axis (side to side of the head)
(ii) Circumduction—movement that resembles a cone shape; the distal part is a wider circle (winding up to throw).
(iii) Supination—palm turns upward while forearm rotates outward.
(iv) Pronation—palm turns downward while forearm rotates inward.
(c) Gliding—moving one joint surface over another with no circular or angular movement
(d) Miscellaneous movements
(i) Elevation—moving upward, lifting
(ii) Depression—moving downward, lowering
(iii) Inversion—sole of the foot turns inward.
(iv) Eversion—sole of the foot turns outward.
(v) Protraction—moving a part forward, such as the jaw or shoulder
(vi) Retraction—moving a part backward
(vii) Opposition—moving parts together (finger and thumb)
 |
| FIGURE 42-1 ▪
Joint movements.
(From Maher AB, Salmond SW, Pellino TA: Orthopaedic nursing, Philadelphia, 2002, WB Saunders.)
|
II. PATHOPHYSIOLOGY OF THE MUSCULOSKELETAL SYSTEM
A. Common congenital and developmental abnormalities
1. Joint dysplasia
a. Incomplete formation of diarthrodial joint
b. May lead to chronic subluxation or dislocation of joint
c. Developmental dysplastic hip, including congenital dislocated hip; may lead to early secondary osteoarthritis (OA)
2. Torsional problems of the long bones
a. Deformity related to abnormal development of bone
(1) Metatarsal adductus: metatarsal deviated medially
(2) Tibial torsion: tibia rotated externally or internally
(3) Femoral anteversion: leads to intoeing with internal or external rotation of leg
b. In extreme cases, may require surgical intervention
3. Clubfoot
a. Anomaly characterized by inversion of foot and forefoot, adduction, and equinus
b. Classified as fixed or rigid
4. Osteogenesis imperfecta (“brittle bone disease”)
a. Genetic disease characterized by:
(1) Defect in collagen synthesis
(2) Generalized osteopenia
(3) Metabolical abnormalities
b. Classified according to severity: types I to III
5. Legg-Calve-Perthes disease
a. Idiopathic avascular necrosis of femoral head—flattening of femoral head
b. Seen in school-aged children
c. May lead to:
(1) Residual deformity of femoral head
(2) Fracture
(3) Early secondary OA
6. Slipped capital femoral epiphysis
a. Disruption of growth plate leading to posterior displacement of femoral head on the femoral neck
b. Seen in preteen and teenage children
c. May lead to avascular necrosis of the femoral head, limb shortening, or early secondary OA
7. Scoliosis
a. Lateral curvature of spine with vertebral rotation
b. Classified according to causative factors
(1) Idiopathic
(a) Unknown origin: accounts for 90% of cases
(b) Most frequent in children 10 to 12 years of age
(c) Occurs 10 times more frequently in females
(d) Familial pattern may be present.
(2) Congenital
(a) Develops in early embryonic life (6-8 weeks)
(b) Malformation of spine occurs, resulting in hemivertebrae or failure of segmentation of vertebrae.
(3) Neuromuscular
(a) Neuropathic (paralytic): associated with spina bifida, poliomyelitis, or cerebral palsy
(b) Myopathic: associated with muscular dystrophy
(4) Additional types of scoliosis
(a) Acquired—seen in:
(i) Rheumatoid arthritis
(ii) Rickets
(iii) Spinal cord tumors
(iv) Neurofibromatosis
(b) Traumatic: resulting from vertebral fracture after radiation
B. Metabolical bone disease
1. Osteoporosis
a. Common disorder characterized by a generalized reduction in the mass and strength of bone, leading to high risk for fracture
b. Rate of bone resorption greater than rate of bone formation
c. Multiple risk factors
(1) Prevalent with Caucasian, Asian, or Hispanic/Latino people
(2) Small skeletal frame
(3) Estrogen deficiency or postmenopausal condition
(4) Inactivity or immobility
(5) High caffeine or alcohol consumption
(6) Low-calcium or high-protein diet
(7) Female
(8) Older age
(9) Family history
(10) Certain medications (i.e., steroids, some anticonvulsants)
d. Fractures common and may be induced by minor trauma
(1) Wrists
(2) Femoral head
(3) Vertebrae
(4) Pelvis
2. Paget’s disease (osteitis deformans): chronic disorder that typically results in enlarged and deformed bones
a. Excessive breakdown and formation of bone tissue causes the bone to weaken.
b. Slow, progressive disease caused by initial bone resorption, followed by period of reactive bone formation
c. New bone is:
(1) Thicker
(2) Softer
(3) Has reduced strength
(4) Highly vascular
3. Rickets
a. Abnormal calcification of bone seen in childhood, leading to soft and deformed bones
b. Related to deficiency in vitamin D caused by:
(1) Nutritional deficit
(2) Inability to absorb or use vitamin D
4. Osteomalacia
a. Demineralization of bone in the adult leading to soft, deformed bones (“adult rickets”)
b. Related to inadequate supply of calcium or phosphorus caused by:
(1) Nutritional deficit
(2) Absorptive problem
C. Neoplastic disorders
1. Primary bone or soft tissue tumors
a. Benign or malignant tumors
(1) Bone
(2) Cartilage
(3) Connective tissue
(4) Vascular tissue near bone
b. May lead to local bone destruction and weakening of the tissue
c. Relatively uncommon
2. Bone metastasis
a. Spread of malignancy from a primary site of origin to bone
b. Lytic or blastic lesions may lead to:
(1) Bone destruction
(2) Weakening
(3) Impending or actual fracture
c. Frequent sequelae of common malignancies
(1) Breast
(2) Prostate
(3) Lung
(4) Kidney
(5) Thyroid
(6) Bladder
D. Infection
1. Bone or joint tuberculosis
a. Infection of bone or joint by Mycobacterium tuberculosis, leading to cartilage or bone destruction
b. Weight-bearing joints and vertebral bodies most common sites
c. May require surgical drainage of abscesses in addition to aggressive pharmacological treatment
2. Osteomyelitis
a. Microbial invasion of bone leading to acute or chronic infection
b. Classified according to method of microbial invasion
(1) Hematological: acute or chronic infection spread to the bone through circulatory system
(a) More common in children
(b) More easily treated in children because of higher vascularity of their bones and supportive tissues
(2) Contiguous: infection of the bone by direct extension of bacteria from infected soft tissue or surgical site
(a) More common in adults older than 50 years
(b) Risk factors include orthopedic surgeries or soft tissue trauma.
(3) Traumatic: infection of the bone by direct contamination with environmental or bodily microbes
(a) More common in young males and children
(b) Risk factors include penetrating wounds, intramedullary rods, and open fractures.
3. Septic arthritis
a. Microbial invasion of the synovial membrane, commonly bacterial in origin, leading to joint infection
b. Joint infection usually accompanied by signs and symptoms of systemic infection
c. May lead to destruction of articular cartilage and early secondary OA
E. Arthritic disorders
1. OA (degenerative joint disease or osteoarthrosis)
a. Progressive noninflammatory disorder of diarthrodial joints characterized by loss of articular cartilage, marginal osteophytes (spurs), subchondral cysts, and sclerotic changes
(1) Most common form of arthritis
(2) Primarily affects weight-bearing joints: hips, knees, spine, shoulders, interphalanges
b. Classified by causative factor
(1) Primary OA
(a) Cause unknown
(b) Increased with:
(i) Obesity
(ii) History of repetitive trauma to joint
(iii) Age
(2) Secondary OA
(a) Related to preexisting factors
(b) Seen after trauma to:
(i) Joint
(ii) Dysplasia
(iii) Other pediatric or congenital disorders of the joint
(iv) Sepsis
(v) As a result of a primary disease involving the joint such as hemophilia
c. Clinical findings
(1) Asymmetric distribution
(2) Pain or stiffness in joint, especially with weight-bearing activities
(3) Crepitation of joint
(4) Deformity of joint or decrease in range of motion
(5) Possible swelling and warmth of joint
(6) Gait disturbance (limp)
d. Conservative treatment
(1) Reduction of risk factors
(a) Weight loss if needed
(b) Decrease in weight-bearing activities
(2) Gait rest devices (cane, crutch)
(3) Local application of heat or cold
(4) Pharmacological therapy (Box 42-1)
BOX 42-1
PHARMACOLOGICAL THERAPY
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
Initial drug of choice for mild to moderate pain
NSAIDs inhibit prostaglandin formation through the cyclooxygenase (Cox) enzyme.
This enzyme exists in two isoforms, Cox-1 and Cox-2:
▪ Primary therapeutic effect of NSAIDs exhibited by blocking Cox-2.
▪ Celecoxib, (Celebrex)—100 to 200 mg orally twice per day
▪ Meloxicam, (Mobic)—7.5 to 15 mg orally daily (structurally related to piroxicam; selectively inhibits Cox-2 over Cox-1)
▪ Ketorolac, (Toradol)—10 mg orally every 4 to 6 hours or 30 mg IV or IM every 6 hours; if older than 65 years, 15 mg IV or IM every 6 hours
▪ Fenoprofen, (Nalfon, Fenopron)—300 to 600 mg orally three or four times per day to a maximum of 3.2 g daily
▪ Nabumetone, (Relafen, Relifex)—1000 mg orally daily or twice per day with maximum of 2000 mg per day
▪ Piroxicam, (Feldene, Pirox)—20 mg orally daily
▪ Sulindac, (Clinoril, Novo-Sundac)—150 to 200 mg orally twice per day with maximum daily dose of 400 mg
▪ Naproxen, (Anaprox, Aleve)—250 to 500 mg orally twice per day with maximum daily dose of 1.5 g
▪ Ketoprofen, (Orudis, Actron)—75 mg three times per day or 50 mg four times per day or 200 mg as extended-release form; maximum daily dose 300 mg, or 200 mg as extended-release form
Possible side effects:
▪ Abdominal pain
▪ Heartburn
▪ Ulcers
▪ Bleeding
▪ Renal failure
▪ Decreased liver function
Opioids
Added to NSAIDs for mild to moderate pain; adult dosage guidelines:
▪ Codeine—15 to 60 mg orally every 4 to 6 hours as needed with maximum daily dose of 360 mg
▪ Hydrocodone bitartrate, Lortab, Lorcet, or Roxicet combined in varying strengths with acetaminophen, 500 to 650 mg
▪ Oxycodone hydrochloride, Percodan, or Percocet combined in varying strengths with aspirin, 325 mg, or acetaminophen, 500 to 650 mg
▪ Propoxyphene hydrochloride, Darvon—65 mg orally every 4 hours, as needed with maximum daily dose of 390 mg
For persistent pain, stronger opioid added along with antidepressants or antianxiety drugs to increase tolerance for pain:
▪ Antidepressants helpful in reducing neuropathic pain
▪ Neurontin (Gabapentin)—originally developed for treatment of epilepsy; now widely used to relieve pain, especially neuropathic pain and postoperative chronic pain
IM, Intramuscular; IV, intravenous.
e. Nutritional supplements: glucosamine and chondroitin
(1) Substances found naturally in the body and believed to play a role in:
(a) Cartilage formation
(b) Cartilage elasticity
(2) Widely used as dietary supplement in the treatment of OA
(3) Some studies have shown that some people with mild and moderate OA taking glucosamine/chondroitin have reported pain relief similar to that of nonsteroidal anti-inflammatory drugs (NSAIDs).
(4) Some research has indicated that the supplements might slow down cartilage damage in patients with OA.
f. Disease-modifying drugs
(1) Current focus of pharmacological research
(a) Pentosan
(b) Enzyme inhibitors
(i) Doxycycline
(ii) Collagenase inhibitors
(iii) Lipids
(iv) Growth hormones
g. Topical analgesics
(1) Inexpensive, safe, effective
(2) Application by massage releases endorphins.
(3) NSAIDs
(a) Salicylate
(b) Benzydamine
(c) Diclofenac
(d) Ibuprofen
(e) Indomethacin
(f) Ketoprofen
(g) Felbinac
(h) Capsaicin
h. Intra-articular injections
(1) Corticosteroids
(2) Local anesthetics
(3) Viscosupplements (hyalgan products)
i. Surgical options
(1) Arthroscopy: diagnostic, for removal of loose bodies, and for treatment
(2) Joint fusion (arthrodesis)
(3) Osteotomy: option in early arthritis accompanied by deformity
(4) Resection arthroplasty
(5) Hemiarthroplasty: replaces one half of the joint with an artificial surface and leaves the other part in its natural (preoperative) state
(a) Most commonly performed on the hip after fracture of neck of femur
(b) Partial knee replacement (hemiarthroplasty, unicompartmental) may be performed on patient whose disease is limited to a single compartment (i.e., medial or lateral).
(i) The unicompartmental knee replacement is less invasive.
(ii) The small incision does not interfere with the main muscle control of the knee.
(c) Shoulder hemiarthroplasty may be indicated in select patients with OA or posttraumatic disorders, providing pain relief and functional improvement.
(6) Total joint replacement: arthritic or damaged joint removed and replaced with a prosthesis (artificial joint)
(7) Hip resurfacing: type of hip replacement that replaces the two surfaces of the hip joint, conserving bone (head of femur preserved)
2. Rheumatoid arthritis
a. Chronic systemic inflammatory disease potentially affecting multiple organs and joints; also considered an autoimmune disorder
(1) Extra-articular manifestations
(a) Cardiovascular changes: fibrinous pericarditis, cardiac myopathy, vasculitis
(b) Pulmonary changes: pulmonary nodules, pleuritis, pulmonary fibrosis, pleural effusion
(c) Neurological: peripheral neuropathy, carpal tunnel syndrome, nerve entrapment
(d) Gastrointestinal: bowel and mesenteric vasculitis, malabsorption, enlarged spleen
(e) Ocular: scleritis, episcleritis, Sjögren’s syndrome
(f) Integument: rheumatoid nodules, vasculitic skin lesions, purpura
(g) Hematological: anemia, thrombocytopenia, granulocytopenia, increased sedimentation rate
(h) Constitutional: fatigue, malaise, fever
(2) Articular manifestations
(a) Synovial proliferation
(b) Pannus formation
(c) Destruction of articular cartilage, with cartilage erosion, bone cysts, and osteophytes
(d) Tendon and ligament scarring and shortening with ligamentous laxity, subluxation, and contracture
b. Causative factors
(1) Etiology unknown
(a) Infectious
(b) Traumatic
(c) Stress related
(2) Genetic predisposition exists.
(3) Seen in all ages, affecting females to males 3:1
c. Clinical manifestations (musculoskeletal)
(1) Polyarticular symmetric joint distribution
(a) Can affect any synovial joint
(b) Most severe changes in weight-bearing joints
(2) Joint swollen, erythematous, and warm to touch
(3) Joint pain, stiffness, and possible contracture
(4) Joint deformity, laxity, or subluxation
(a) Deformities of knees, feet, phalanges possible
(b) Subluxation of cervical vertebrae
(5) Muscle atrophy
d. Conservative treatment
(1) Joint protection techniques
(a) Weight loss if needed
(b) Decrease in weight-bearing activities
(c) Use of large, more proximal joints in more activities
(2) Gait rest devices (cane, crutch)
(3) Program of rest and exercise
(4) Application of cold and heat
(a) Use ice for first 48 to 72 hours postoperatively.
(i) Specific duration of treatment for ice is 20 minutes “on” followed by one hour “off.”
(b) Next alternate ice with heat
(c) Finally use strictly heat.
(i) Duration of treatment for heat is 15 to 20 minutes “on” followed by a minimum of one hour “off.”
(5) Splinting or bracing of joint
(6) Pharmacological therapy (see Box 42-1)
(a) Oral NSAIDs (see OA)
(b) Oral analgesics
(c) Oral corticosteroids
(d) Oral or parenteral gold therapy
(e) Oral remittive agents: chloroquine phosphate
(f) Oral immunosuppressives: methotrexate, cyclophosphamide, azathioprine
(g) Intra-articular injection of steroid or local anesthetic
e. Surgical options
(1) Fusion of cervical spine or small joints (e.g., wrist)
(2) Synovectomy
(3) Osteotomy
(4) Tendon repair or transfer
(5) Hemiarthroplasty
(6) Total joint replacement
F. Traumatic disorders
1. Strain
a. Musculotendinous injury caused by overstretching, repetitive stress, or misuse
b. Classified according to degree of injury to musculotendinous unit
(1) First degree: mild stretching or injury
(2) Second degree: moderate stretching or tearing
(3) Third degree: severe stretching, leading to rupture of the body or insertion site of the musculotendinous unit
2. Sprain
a. Ligamentous injury caused by overstretching or overuse
b. Classified according to degree of injury to ligament
(1) First degree: mild injury involving tear of few ligamentous fibers
(2) Second degree: moderate injury with tearing of up to one half of ligamentous fibers
(3) Third degree: severe injury leading to rupture of the body of the ligament or from its bony attachment
3. Dislocation or subluxation
a. Disruption of the contact of articulating surfaces of a joint caused by force to joint or development abnormality
(1) Dislocation: complete disruption of joint
(2) Subluxation: partial disruption of joint
b. Most common in shoulder joint
c. May be accompanied by soft tissue injury, including nerve palsy
d. Recurrent dislocation may necessitate surgical repair of soft tissue or reconstruction of joint.
4. Fracture (Figure 42-2)
a. Disruption of normal continuity of a bone, often accompanied by soft tissue trauma
b. Classification of fractures
(1) Severity of fracture
(a) Compound (open): bone is broken with communication of the fracture site with an external wound.
(b) Simple (closed): bone is broken with skin intact.
(c) Complete: continuous fracture line through entire section of bone
(d) Incomplete: break in continuity of one side of cortex only, as in the “greenstick” fracture
(e) Displaced: edges of fractured bone not aligned, with higher risk for neurovascular damage
(f) Nondisplaced: edges of fractured bone remain aligned.
(g) Impacted: fractured bone fragment forcibly driven into an adjacent bone (“telescoped”)
(h) Avulsion: separation of small fragment of bone at site of a ligament or tendon attachment
(2) Direction of line of fracture
(a) Longitudinal (linear): fracture line runs parallel to axis of bone.
(b) Oblique: fracture line runs at a 45 ° angle to axis of bone.
(c) Spiral: fracture line encircles bone shaft.
(d) Transverse: fracture line runs at a 90 ° angle to longitudinal axis of bone.
(e) Comminuted: multiple fracture lines divide bone into multiple fragments.
(3) Etiology of the fracture
(a) Stress (fatigue): fracture occurs as result of repetitive microtrauma or an excessive musculotendinous pull that exceeds the strength of the bone.
(b) Pathological (spontaneous): fracture through an area of disease-weakened bone, usually related to minor trauma
(c) Compression: fracture resulting from compressive force
(4) Fractures by name
(a) Pott’s fracture: fracture at distal fibula associated with severe tibiofibular disruption
(b) Colles’ fracture: fracture of distal radius within 1 inch of joint in a characteristic manner
c. Etiology of fractures: fractures occur when bone subjected to more stress than it can absorb.
d. Predisposing factors for fractures: factors that reduce bone strength or forces that exceed bone strength
(1) Age: extremes in age
(2) Nutritional deficiency: diet low in calcium, low in vitamin D, or high in protein
(3) Metabolical diseases
(4) Inactivity or immobility: bone remains strongest under stress (“Wolff’s Law”).
(5) Physical abuse or trauma
e. Fracture healing: healing maximized when bone edges approximated
(1) Hematoma forms at site of fracture (first 24 hours).
(2) Leukocytes infiltrate site, followed by macrophages.
(3) Fibrous matrix of collagen proliferates at site.
(4) Highly vascular “callus” forms.
(5) Callus converts to loosely woven bone.
(6) Callus calcifies and remodels (full fracture “union”).
f. Goals of fracture management
(1) Reduce fracture to normal anatomical alignment.
(2) Promote bone healing.
(3) Maintain extremity function.
g. Methods of fracture reduction
(1) Closed reduction: reduction achieved without surgical intervention
(a) Continuous traction: skin or skeletal
(b) Manual traction
(c) Splints or casts
(d) External fixation
(2) Open reduction and internal fixation
(a) Allows visualization of fracture site
(3) Repair with:
(a) Pins
(b) Rods
(c) Nails
(d) Wire
(e) Screws
(f) Plate and screw combinations
 |
| FIGURE 42-2 ▪
Types of fractures.
(From Ignatavicius DD, Workman ML: Medical surgical nursing, ed 4, Philadelphia, 2002, WB Saunders.)
|
III. COMMON THERAPEUTIC DEVICES
A. Casts
1. Purpose
a. Provide temporary immobilization.
b. Prevent or correct deformities.
c. Support bone and soft tissue during healing process.
d. Promote early weight bearing.
2. Types of casts
a. Short extremity cast
(1) Applied for stable fractures or tertiary sprains
(2) May be weight bearing versus non–weight bearing
b. Long extremity cast
(1) Applied for stable or unstable fractures
(2) Immobilizes joint to protect soft tissue injuries: Achilles tendon rupture
c. Cylinder cast
(1) Applied to treat stable fractures of long bones
d. Body cast
(1) Immobilizes spine (e.g., postoperative spinal fusion)
(2) Corrects deformities (e.g., scoliosis)
e. Spica cast
(1) Immobilizes complex joint: shoulder, hip, thumb
(2) Prevents dislocation of complex joint while promoting soft tissue healing
3. Materials
a. Plaster of Paris
(1) Applied by wrapping wet plaster strips
(2) Easily molded
(3) Heavier weight
b. Fiberglass—most common
(1) Applied by wrapping wet plastic roll
(2) More difficult to mold
(3) Lightweight
c. Fiberglass-free, latex-free polymer
(1) Use in latex allergy or latex-sensitive patients.
d. Hybrid
(1) Combination of plaster of Paris and fiberglass
e. Polyester and cotton knit
f. Thermoplastic
(1) Fabric tape composed of polyester polymer
4. Early postcasting care
a. Promote cast drying.
(1) Plaster of Paris: may take 24 hours or greater to dry
(a) Leave cast uncovered and open to air.
(b) Use fans to aid drying of large casts.
(c) Position casted part on pillow or smooth surface.
(d) Move cast on pillow or with palms to avoid plaster indentation.
(e) Advise patient to expect feeling of warmth as cast dries.
(2) Fiberglass: dry within 30 minutes
(a) Blot moisture from surface with paper towel.
(b) Use blow dryer on cool or warm setting to aid drying of cast and skin.
b. Potential complications
(1) Skin breakdown
(2) Neurovascular compromise
(3) Compartment syndrome
(4) Fracture misaligned
(5) Superior mesenteric artery syndrome
(a) Only seen in body spica casts
(b) A decreased blood supply to bowel
(i) Resulting from compression of mesenteric artery
(ii) Causes necrosis to gastrointestinal tract and hemorrhage
(c) Symptoms
(i) Pain, distention, pressure in abdomen
(ii) Bowel obstruction
(iii) Nausea and vomiting
(iv) Presenting symptoms may appear days or weeks after cast applied because of retroperitoneal fat loss after patient immobilized.
(d) Postcasting care
(i) Prevent complications related to ineffective breathing pattern with body or spica cast.
[a] Note rate and quality of respirations.
[b] Reposition patient in more upright position if possible.
[c] Teach relaxation techniques, deep controlled breathing.
[d] Cut a window in the cast, bivalve or remove cast.
[e] Place nasogastric tube to decompress stomach.
[f] Patient receives nothing by mouth (NPO), receiving intravenous (IV) fluids.
[g] Prone position optimal
[h] Ligament of Treitz released surgically
c. Protect skin.
(1) Remove loose particles of plaster or plastic from cast edges and skin.
(2) Cover edges of cast to prevent skin irritation, especially important in personal area.
(a) Turn edge of skin liner (stockinette) over cast edge and secure with tape.
(b) If stockinette not used, “petal” edge with Transpore tape or moleskin.
(c) Insert diaper at buttocks to prevent soiling in children with body or spica cast.
(3) Instruct patient to avoid putting any object between cast and skin.
d. Reduce postoperative or postinjury swelling.
(1) Elevate extremity on pillow above level of heart.
(2) When cast dry, apply ice to area of injury or fracture.
e. Assess neurovascular status of extremity.
(1) Perform integrated bedside assessment of extremity (Box 42-2).
BOX 42-2
INTEGRATED BEDSIDE ASSESSMENT OF EXTREMITY
Assessment of Neurovascular Status
Pain
Edema
Color
Capillary refill
Pulses
Temperature
Sensation
Motion
(2) Note amount and change in bloody drainage on cast and in dependent areas.
B. Traction
1. Definition: application of pulling force in the presence of a counterforce
2. Purpose
a. Aligns fragments of displaced bones, preventing further soft tissue injury
b. Reduces muscle spasm
c. Maintains limb length
d. Maintains alignment of limb while resting soft tissue
e. Reduces contracture and deformity
3. Types of traction
a. Skin traction
(1) Traction force applied via wraps, straps, or prefabricated boots secured to body (e.g., Russell’s or Buck’s traction)
(2) Uses
(a) Short-term immobilization of stable fractures (e.g., Buck’s traction for proximal femoral fractures)
(b) Intermittent traction (e.g., cervical neck traction)
(3) Techniques of application
(a) Traction applied at bedside by trained individual
(b) “Customized” devices applied using Webril and moleskin
(c) Prefabricated devices (e.g., boots)
(d) Traction weight generally no more than 10 lb (4.5 kg)
b. Skeletal traction
(1) Traction applied directly to bone through transcortical or pericortical wires or screws (e.g., halo traction)
(2) Uses
(a) Long-term immobilization of fractures (commonly >1 week)
(b) Short-term to long-term immobilization of unstable fractures of long bones or pelvis
(3) Techniques of application
(a) Traction applied at bedside or in operative suite
(b) Local anesthetic applied to skin and injected into periosteum
(c) Sedation and analgesia commonly used with pediatric patients
(d) Amount of weight to traction according to patient’s body weight and complexity of fracture, usually 15 to 40 lb
(e) Use of portable x-ray to confirm fracture reduction
c. Manual traction
(1) Temporary traction applied by manual pull on extremity
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