1. SAFETY/ORTHOPEDICS Part 2 Developed by Betty Guy RN, MSN Ruth Rolling RN, MSN and Carlos Torres (CFE) Technical Assistant Southeastern Louisiana University College of Nursing and Health Sciences Department of Nursing, Fall 2000

2. OBJECTIVES  Review neurovascular assessment of clients with musculoskeletal injuries.  Describe basic nursing care for the client with supportive and immobilization devices.  Compare and contrast skin and skeletal traction.  Differentiate between open, closed, stable, and unstable fractures  Identify potential complications associated with skin or skeletal traction.

3. FRACTURES Definition A fracture is a break in the continuity of the structure of the bone.

4. CLASSIFICATION OF FRACTURES Fractures are described and classified according to: Type Open or Closed Location Stable or Unstable

5. TYPES OF FRACTURES

6. OPEN vs CLOSED FRACTURE

7. STABLE FRACTURES In a stable fracture normal bone alignment is maintained or slightly displaced -- usually transverse, spiral, or greenstick

8. UNSTABLE FRACTURES An unstable fracture is grossly displaced during injury and is more difficult to repair -- usually oblique and comminuted.

9. INTERNAL FIXATION Internal fixation devices are placed during surgery. Examples include pins, plates, and screws.

10. EXTERNAL FIXATORS External fixators are composed of metal pins inserted into the bone, and attached to rods.

11. IMMOBILIZATION DEVICES Several devices are depicted to illustrate support or immobilization of a joint or bone following an injury.

12. REVIEW REVIEW ASSESSMENT OF NEUROVASCULAR FUNCTION Circulation and neurological function may be affected by edema from soft tissue trauma in the presence of a fracture. Standards of Care require ongoing neurovascular assessment for patients with musculoskeletal disorders. Assessment of the five P’s is the neurovascular assessment. REVIEW REVIEW ASSESSMENT OF NEUROVASCULAR FUNCTION

13. REVIEW THE FIVE P’s THE FIVE P’S –Pallor –Pulselessness –Paresthesia –Paralysis –Pain REVIEW THE FIVE P’s

14. CATEGORIES The following categories of orthopedic devices will be depicted: Traction Casts

15. TRACTION Traction is a means to immobilize a part of the body. Involves the use of a pulling force through application of weights to a part of the body while a second force called countertraction pulls in the opposite direction. This is accomplished via pulleys, ropes, and weights attached to the client.

16. GENERAL USES FOR TRACTION Correction of deformities Correction or improvement of a joint contracture Treatment of joint dislocation Reduction, immobilization, and alignment of a fracture Prevention and management of muscle spasm Prevention of further soft tissue damage Preoperative and postoperative positioning and alignment Rest of a diseased joint (Elkin,p. 636)

17. SKIN TRACTION Applies pull to an affected body structure or part by straps attached to the skin around the body structure or part Used intermittently. Is not placed over irritated, damaged, or broken skin Traction that is too tight puts pressure on nerves and vascular structures that could result in an irreversible neurovascular deficit

18. SKELETAL TRACTION Type of traction applied by a physician under of sterile conditions for the treatment of fractures. It involves placement of pin, wire, or nail through the bone. Weights are attached to the pin, wire, or nail using ropes and pulleys.

19. GENERAL PRINCIPLES of SKELETAL TRACTION Maintain correct body alignment. Maintain the established line of pull. Maintain countertraction. Maintain continuous traction unless ordered otherwise Prevent friction on the skin. Provide pin care according to agency protocol or physician’s orders (Elkin, p. 636,645)

20. THE FOUR P’S OF TRACTION MAINTENANCE Pounds - is the correct weight in place? Pull - is the direction of pull aligned with the long axis of the bone? Pulleys - is the rope riding over the pulley and gliding smoothly? Pressure - is each clamp and connection tight?

21. EXAMPLES OF SKIN TRACTION Cervical Traction Pelvic Traction Buck’s Traction

22. CERVICAL TRACTION Used for cervical spine disorders such as “whiplash”, muscle spasms, and neck pain Should not be used for a significant fracture or subluxation

23. PELVIC TRACTION Used for patient’s with sciatic low back pain and muscle spasms in the lower back

24. BUCK’S TRACTION Used for presurgical immobilization of fractured hip or for patients with fractured femurs, pelvic injuries, sciatica, muscle spasms, degenerative arthritis of the knees, or knee injuries

25. EXAMPLES OF SKELETAL TRACTION Balanced Suspension Traction Lateral Arm Traction Overhead Arm Traction Halo Traction

26. BALANCED SUSPENSION TRACTION Used for injury or fracture of femur, acetabulum, hip, lower leg, or any combination of these

27. LATERAL ARM TRACTION Commonly used for immobilization of fractures and dislocations of the upper arm and shoulder

28. OVERHEAD ARM TRACTION Commonly used for immobilization of fractures and dislocations of the upper arm and shoulder

29. HALO TRACTION Utilized for clients with cervical fractures and infusions, scoliosis, tortilcollus, and rheumatoid arthritis

30. CAST CARE Elevate extremities above level of heart Apply ice pack during first 48 hours following injury Support cast with palms of hand during application and immediately following to prevent indentations to cast Perform neurovascular assessment Inspect for skin irritation and breakdown especially around bony prominences and cast edges Implement range of motion exercises to non affected joints and if not contraindicated, teach isometric exercises to the affected extremity Instruct client keep cast dry and refrain from inserting any object into cast Assess client for potential complications related to fractures and cast application: infection, fat emboli, and compartment syndrome

31. TYPES of CASTS

32. Comparison of Cast Materials PLASTER Bandages impregnated with powdered CaSO 4 Dries in 48 hours No weightbearing for 48- 72 hours Less costly Smooth surface SYNTHETIC Polyester and cotton, fiberglass or plastic Dries in 7-15 minutes No weightbearing for 60 minutes More expensive Less likely to indent into skin; light weight; doesn’t crumble; and is nonabsorbent

33. THE END