1. Nursing of Adults with Medical & Surgical Conditions
Fractures
&
Complications of Fractures

2. Arthroplasty Knee Arthroplasty (total knee replacement)
Replacement of the knee joint
Restore motion of the joint, relieve pain, or correct deformity

3. Arthroplasty Hip Arthroplasty (total hip replacement)
Replacement of the hip joint

4. Arthroplasty Nursing Interventions Empty and record hemovac
Give oxygen 2-3 l/min
Incentive spirometer q 2hrs
Cough and deep breathe q 2hrs
Record I&O
Bed rest hrs
Change dressing as ordered
Diet as ordered
Neurovascular checks q1hr x24, q2hrs x24, then q4hrs
Vital sighs q 4hrs
Maintain position of operative area
Physical therapy will initiate ambulation and prescribe routine
Encourage fluid intake
Antiembolisim stockings
Avoid adduction and hyperflexion of hip

5. Fracture of the Hip Etiology/pathophysiology
Most common type of fracture
Women higher risk due to osteoporosis
Types of hip fractures
Intracapsular
inside the joint
Extracapsular
outside the hip joint

6. Fracture of the Hip Signs & Symptoms Severe pain at site
Inability to move the leg voluntarily
Shortening or external rotation of the leg

7. Fracture of the Hip Diagnostic Tests Radiographic examination
Hemoglobin may be decreased because of bleeding

8. Fracture of the Hip Treatment
Buck’s or Russell’s traction until surgery
Surgical repair
Internal fixation
Neufeld nail and screws
Kuntscher nail (intramedullary rod)
Prosthetic implants
Austin Moore prosthesis
Bipolar hip replacement (hemiarthroplasty)

9. Fracture of the Hip Postoperative interventions Wound assessment
Vital signs
Assessment of drains
Jackson-Pratt, Hemovac
Incentive spirometer
Turning q 2 hours
Antiembolic stockings
Anticoagulation therapy

10. Fracture of the Hip Maintain leg abduction Turn to unoperative side
abduction pillow
Turn to unoperative side
Limit weight bearing on affected side
Chairs and commode seats should be raised to prevent flexion of hip beyond 60 degrees

11. Fracture of the Hip Patient teaching for ORIF
Assess ability to understand
Assist to dangle at bedside
No weight on operative side
Turn every 2 hours, maintain abduction
Assist with ROM
PT will instruct as to ambulation and weight bearing
As pt. progresses, encourage to continue to ambulate only with assistance

12. Fracture of the Hip Patient Teaching for Hip Prosthetic Implant
Avoid hip flexion
beyond 60 degrees for approximately 10 days
beyond 90 degrees for 2 to 3 months
Avoid adduction of the affected leg beyond midline for 2 to 3 months
Maintain partial weight bearing for approx. 2 to 3 months
Avoid positioning on the operative side in bed
Maintain abduction of the hip
“DO NOT” list

13. “DO NOT” List

14. Other Fractures Etiology/Pathophysiology
A traumatic injury to a bone in which the continuity of the tissue of the bone is broken.
Pathological or spontaneous fractures
occur without trauma
osteoporosis, metastatic cancer and bone tumors

15. Types of Fractures Open (compound)
Protrusion of the bone through the skin
Require surgical repair
Prone to infection

16. Closed (simple) Bone has NOT protruded through the skin
May be realigned by external manipulation

17. Types of Fractures Greenstick fracture Incomplete fracture
Extends only partially through the bone
Common in children because bones are more flexible

18. Types of Fractures Complete fracture
Fracture line extends entirely through the bone with the periosteum disrupted on both sides of the bone

19. Types of Fractures Comminuted fracture
Bone is splintered into three or more fragments at the site of the break
More than one fracture line

20. Types of Fractures Impacted fracture
One bone fragment is forcibly wedged into another bone fragment.

21. Types of Fractures Transverse fracture
Break runs directly across the bone.

22. Types of Fractures Oblique fracture
Break runs along a slant to the length of the bone.

23. Types of Fractures Spiral fracture Break coils around the bone.
Usually caused by a twisting force.

24. Types of Fractures Colles’ Fracture
Distal portion of the radius within 1 inch of the joint of the wrist
Commonly occurs when a person attempts to break a fall by putting their hands down

25. Types of Fractures Pott’s Fracture
Occurs at the distal end of the fibula
A piece of the medial malleolus chips off.
Medial Malleolus
Posterior Left Foot

26. Fractures
Bone Repair

27. Assessment Seven P’s of Orthopedic Assessment Pain Pallor
Does it seem out of proportion to the patient’s injury?
Does it increase with active or passive motion?
Pallor
Paresthesia or numbness
Paralysis
Polar Temperature
Is it cold compared to opposite extremity?
Puffiness from edema or hematoma
Pulselessness

28. Fractures Signs & Symptoms Pain Loss of normal function
Obvious deformity
Change in the curvature or length of bone
Crepitus (grating sound with movement)
Soft tissue edema
Warmth over injured area
Ecchymosis of skin surrounding injured area
Loss of sensation distal to injury
Signs of shock (injury, blood loss, & pain)

29. Fractures
Diagnostic Tests
Radiographic examination

30. Fractures Treatment (Immediate) Splinting to prevent edema
Body alignment
Elevation of body part
Application of cold packs, first 24 hours
Administration of analgesics
Observation for change in color, sensation, or temperature
Observe for signs of shock

31. Fractures Treatment (Secondary Management) Closed (simple)
closed reduction
traction
open reduction with internal fixation device
immobilization
external fixation device
internal fixation devices; pins, screws, plates

32. Fractures Treatment (secondary management) Open (compound)
Surgical debridement of wound
remove dirt, tissue, etc.
Administration of tetanus toxoid
Culture of wound
Observation for signs of infection
Closure of wound
Reduction of fracture
Immobilization of fracture
Treatment of complications

33. Fracture of the Vertebrae
Etiology/pathophysiology
Diving accidents
Blows to the head or body
Osteoporosis
Metastatic cancer
Motorcycle and car accidents
Displaced fracture may place pressure on or sever the spinal cord nerves

34. Fracture of the Vertebrae
Signs & Symptoms
Pain at site of injury
Partial or complete loss of mobility or sensation below level of injury
Evidence of fracture/ fracture dislocation on x-ray

35. Fracture of the Vertebrae
Treatment
Stable injuries
pain medication
muscle relaxants
back support, brace or cast
Unstable fractures
Traction
Cranial skeletal traction
Halo brace
Pelvic traction
Open reduction
Harrington rod

36. Fracture of the Pelvis Etiology/pathophsiology
Trauma involving great force
falls from extreme heights
automobile accidents
crushing accidents

37. Fracture of the Pelvis Signs & Symptoms
Unable to bear weight without discomfort
Pelvic tenderness and edema
Hematuria (bladder trauma)
Signs of shock

38. Fracture of the Pelvis Treatment Bed rest for approx. 3 weeks
Ambulate with crutches for approx. 6 weeks
More severe fractures may require surgery and/or spica or body cast

39. Complications of Fractures
Compartment Syndrome
Cause
Caused by the progressive development of arterial vessel compression and reduced blood supply to an extremity.
Signs & Symptoms
Sharp pain with movement, numbness or tingling in the affected extremity, cool & pale or cyanotic, slow capillary refill

40. Complications of Fractures
Treatment
Fasciotomy (incision into the fascia)
Complication
Volkmann’s contracture (clawhand)

41. Complications of Fractures
Shock
Cause
Blood loss, pain, fear
Signs & Symptoms
Altered level of consciousness
Restlessness
Hypotension, tachycardia, & tachypnea
Pale, cool, moist, skin
Treatment
Restore blood volume
IV fluids - LR
Administer blood
Oxygen
Shock trousers

42. Complications of Fractures
Fat Embolism
Cause
Emoblization of tissue fat with platelets
Most common with multiple fractures and long bone fractures
Signs & Symptoms
Irritability, restlessness,disorientation, stupor, and coma due to hypoxemia
Chest pain and dyspnea
Treatment
IV fluids
Steroids (reduce inflammation)
Digoxin (increase cardiac output)
Oxygen

43. Complications of Fractures
Gas Gangrene
Cause
Severe infection of the skeletal muscle by Clostridium bacteria
Signs & Symptoms
Pain at site of injury
Gas bubbles under the skin
Signs of infection
Necrotic skin at site
Foul odor from wound drainage
Treatment
Excision of gangrenous tissue
Antibiotics - Penicillin G or Keflin
Strict aseptic technique

44. Complications of Fractures
Thromboembolus
Cause
Blood vessel is occluded by an embolus
Signs & Symptoms
Area may tingle and become cold, numb, and cyanotic
Embolus in the lungs cause a sharp thoracic or upper abdominal pain, dyspnea, cough, fever, and hemoptysis
Treatment
Anticoagulants
Heparin and/or coumadin

45. Complications of Fractures
Delayed Fracture Healing
Delayed Union
Fails to heal within the usual time
Healing is impaired but will eventually repair itself
Nonunion
Failure of the ends of the fractured bone to unite
Fails to unite and produce a stable union after 6-9 months
Requires bone grafting, prosthetic implant, internal fixation, external fixation, or a combination of these methods
Electrical stimulation
New method to promote healing
Stimulates bone production

46. External Fixation Devices
Skeletal Pin External Fixation
Immobilizes fractures by the use of pins inserted through the bone an attached to a rigid external metal frame
Pin Care
Assess every 8 hours for s/s of infection
Remove exudate and clean with hydrogen peroxide using aseptic technique

47. Skeletal Pin External Fixation

48. Skeletal Pin External Fixation

49. Nonsurgical Interventions
Casts
Made of layers of plaster of paris, fiberglass, or plastic roller bandages.
Stockinette applied, a sheet of wadding, and then casting material
Nursing Assessment
Neurovascular assessment q 15 to 30 min. for first few hours then q 4hours
Assess skin at the cast edges for erythema and irritation.
Assess for odor or drainage from under cast

50. Cast Removal Uses a vibrating saw Skin Care Muscle Atrophy
Does not cut
Causes fine powder
Wear mask
Skin Care
Gently remove buildup of secretions and dead skin by washing and apply lotion
May take several days
Be careful not to remove rapidly, can cause skin impairment
Muscle Atrophy
Reassure patient that the muscle will regain strength and size with proper exercise

51. Traction
The process of putting an extremity, bone, or group of muscles under tension by means of weights and pulleys to:
align and stabilize a fracture site
relieve pressure on nerves
maintain correct positioning
prevent deformities
relieve muscle spasms

52. Types of Traction Skeletal Applied directly to a bone
The pin protrudes through the skin on both sides of the extremity and weights are attached to a rope
Used for fractures of the femur, tibia, humerus, and cervical spine

53. Balanced Suspension Skeletal Traction
                                                        

54. Tibial Pin Traction with Steinmann Pin

55. Types of Traction Skin Traction
Uses weight that pulls on sponge rubber, moleskin, elastic bandage with adherent, or plastic material attached to the skin below the fracture, with the pull exerted on the limb.

56. Types of Traction Buck’s
Used as a temporary measure to provide support and comfort to a fractured extremity until a more definite treatment is initiated
Traction in in horizontal plane with affected extremity

57. Types of Traction Russell Traction
Similar to Buck’s except that a knee sling is used to provide support to the affected leg.
Used to treat hip and knee fractures

58. Types of Traction Bryant’s Traction
Both legs are suspended at a 90 degree angle to the trunk of the body and the weight of the lower body pulls the bone fragments of the fractured leg into alignment
Used for small children with fractured femurs

59. Amputation Amputation of a portion of or an entire extremity
Malignant tumors
Injuries
Impaired circulation
Congenital deformities
Infections

60. Amputation Postoperative Nursing Interventions
Raise foot of bed to elevate extremity
do not elevate on pillow, may cause contracture
Encourage movement from side to side & place in prone position at least 2 times a day to stretch muscles
Teach strengthening exercises
Elastic wraps to shape residual extremity
Assess for respiratory complications, esp in elderly
Phantom-limb pain is normal