1. Care of the Orthopedic Patient
JRMC

2. Anatomy Ball & Socket joint Acetabulum Femoral head
Cup-shaped socket in the pelvic bone
Femoral head
Ball

3. Anatomy Femoral Neck Greater & Lesser trochanter
Medial & Lateral Condyle

4. Anatomy
Regions:
Trochanteric region
Subtrochanteric Regions

5. Knee
Hinge Joint

6. Knee Make up of 3 compartments Medial compartment Lateral Compartment
Medial tibia plateau & medial femoral condyle.
Lateral Compartment
Lateral tibial plateau & Lateral femoral condyle.
Patellofemoral (kneecap)
Patella & Femoral trochlear notch

7. Total Hip Arthroplasty
THA is the replacement of the acetabulum and the femoral head (bipolar arthroplasty).
Hemi-arthroplasty is the replacement of the femoral head.

8. THA Performed on patients who have:
Rheumatoid or osteoarthritis (and who have failed conservative treatment.
Fractures
Avascular necrosis (AVN)
Congenital deformities

9. THA Total hip prosthesis consists of 3 parts:
A cup that replaces your hip socket (acetabulum)
The cup is usually plastic, but ceramic or metal are now being used.
A metal or ceramic ball that replaces the femoral head

10. THA
A metal stem that is attached to the shaft of the bone to add stability to the prosthesis.
The cup can either be cemented (not used very often any more) or non-cemented.

11. THA 2 Units PRBC on hand OR takes 1-2 hours
Hospital stay is 3 – 5 days

12. Post-Operative Care Vital Signs
Vital signs and O2 Sats every 15 min x 4, every 30 min x 2, every 1 hour x2 or until stable, then every 4 hours.
Call MD if temp >101.5º F; heart rate >100 beats per minute; or systolic blood pressure <95 (signs of volume depletion)
O2 at minimum 2L per nasal cannula x 2 hrs upon return to unit, then keep O2 sat > 94%.
Ortho patients have a tendency to run temperatures.

13. Post-Operative Care CMS:
Check CMS with vitals signs unless ordered differently. Perform neurovascular checks on the per nursing order on the Worklist
Have patient dorsi & plantar flex; document
If patient is unable to do this, notify supervisor or physician.
Teach patient how to do ankle pumps

14. Post-Operative Care Incentive Spirometry: Polar Ice Cooler
All patients should have an IS and instruct how to use and frequency of use. Incentive spirometry X 10 every hour while awake.
Polar Ice Cooler
Use throughout the hospital stay
Watch skin for excessive coldness and redness.
Encourage patient to use at home after exercises

15. Post-Operative Care SCD's/Foot pumps:
They need to be on even if the patient is independent.
Remove sleeves upon AMB or pivoting. If not removed, this increases fall risk. Readjusted sleeve when the patient gets back to bed
Make sure the devices fit correctly
Remove SCD’s for 30 minutes. Good opportunity to assess incision and heels.

16. Post-Operative Care Abductor pillow:
May use to prevent a thrashing patient from dislocating the joint in the early post-op period
Prevents dislocation of the hip in hip replacement patients or bipolar replacements
Can remove to turn patient to the side; log roll to the unaffected side and use a pillow between the legs
Assist with turning; prevent adduction and internal rotation
May leave non-operative leg unstrapped if patient is oriented.
If patient refuses the abductor pillow let the MD know; don’t assume bed pillows are OK

17. Abductor Pillow

18. Post-Operative Care Urinary output:
Know patient’s Pre-OP creatine level. Many patients have been on NSAID’s which can cause renal problems. **If urinary output is less than 30ml/hr for 3 consecutive hours, call the doctor!
Toradol is ordered for pain management post-op on some patients which can increase problems CRI. Use with caution in elderly.
If patient are voiding frequently on the bedpan or incontinent; bladder scan

19. Post-Operative Care Urinary Out cont:
Even if patients are not having problems voiding initially after surgery doesn’t mean they can’t develop problems
Discontinue Foley catheter on POD 2 unless otherwise ordered

20. Post-Operative Care Mobilization and positioning:
Mobilization is very important in preventing blood clots and pneumonia.
1st POD patient needs to be in chair BID.
It’s the nurse’s responsibility that this gets done even if it take 2 people to transfer.
Patient that has orders to ambulate on evening of surgery
Do before patient sits in the chair, because sometimes the patient will state they are too tired after sitting.

21. Post-Operative Care Mobilization and positioning continued:
Normally do not position on operative side for one week
Patient should either use the commode or ambulate to the BR after starting PT This helps build up their endurance and they don’t get so stiff from inactivity.
Recommend high toilet seat or toilet riser
Avoid ‘squatting’ position

22. Post-Operative Care Mobilization and positioning continued:
Know your patient's weight bearing status. Check orders
NWB if internal fixation
WB if hip screw unless comminuted or multiple lines of fracture, then NWB
FWB hip replacement

23. Post-Operative Care Mobilization and positioning continued:
- Patient’s heels should be elevated on bath blanket or pillow to prevent skin breakdown. Place a pillow lengthwise under the calf. Never place a pillow transversely under the knees (promotes contracture and impedes circulation).

24. Post-Operative Care Pain Management:
Medicate patient 30 minutes prior to therapy or other activity

25. Post-Operative Care -Drains Hemovac drains Not sutured in
Nursing pulls the drain on post-op day one as ordered.

26. Complications

27. Infection Occurs in 1-3% of cases
Antibiotics (usually Ancef) x 2 doses post-op within 24 hours.
Good handwashing
Symptoms:
Spiking temperature
Drainage and redness around incision

28. Deep Vein Thrombosis ~ PE
The most common medical problem that develops after TJA
Absence of prophylactic treatment the incidence of DVT
May be as high as 57% after THA and 84% after TKA

29. Deep Vein Thrombosis ~ PE
Prevention
Aspirin 81 mg
SCD or Foot Pump
Make sure the patient has SCD’s on when they are in bed.
This continues until discharge

30. Deep Vein Thrombosis ~ PE
Early Mobilization
Isometric exercise
Ankle pumps 10 times every 1-2 hours

31. Symptoms of DVT Calf pain Swelling and redness in calf
Positive Homan Sign may or may not be present.
Swelling and redness in calf

32. Symptoms of PE Sudden chest pain SOB (dyspnea)
Increase respiration (tachypnea)
Increase heart rate (tachycardia)
Anxiety
Blood in sputum

33. Pneumonia
Incentive spirometry
Early mobilization

34. Peroneal Nerve injury Causes:
Decrease blood flow and oxygenation to extremities
Traction or nerve compression during surgery.
Post-surgical pressure dressing.

35. Peroneal Nerve injury Signs & symptoms
Foot Drop
Decrease sensation to the web space between the great toe and second toe.
Make sure the straps on the abductor pillow are not too right on the leg.

36. Hip dislocation Signs and Symptoms:
Pain
Extremity shorter than the other
Internal rotation of the extremity
Patients need to follow the hip precaution instructions given to them by physical therapy.
List of hip precautions in the article about total hip.

37. Loosening of the Prosthesis
Usually requires revision of the total joint

38. Pressure Sores Usually will show up on heels.
Patients may complain of burning or pain in the heel.
Elevate both heels off the bed with a pillow or bath blankets.

39. Pressure Sores
Be aware that diabetics and/or elderly may have decrease sensation in extremities and will not feel the pain or burning.
Inspect heels BID and PRN

40. Pressure Sores Immobilizers, splints or casts can cause pressure areas
Inspect the skin if possible
If patient has a cast or splint and you cannot inspect the skin elevate the extremities and take the weight off the area. If this does not help notify the physician of the problem

41. Constipation Stool softeners and/or laxatives.
Encourage fluids and activities.
Teach the patient to watch for constipation at home.

42. Renal Failure Arthritic patients use NSAIDS for pain.
Toradol ~ Watch creatine levels.

43. Fat Embolism Fatal in 20% of the cases. Treatment is supportive.
Fractures in long bones, total joint surgeries

44. Fat Embolism Signs and Symptoms: Tachypnea Tachycardia
Restlessness and irritable
Changes in mental status ~ confusion
Dyspnea and hypoxia (desaturation)
Petechiae over chest, neck, axilla, conjunctiva
Fever
Diffuse crackles (late finding)

45. Prevention
Move patient as little as possible before the fracture is stabilized or immobilized.

46. Complications ABG’s abnormal PaO2 < 60 EKG shows ST-segment changes
Decrease platelet hemacrit
Prolonged PT
Fat cells in urine, sputum and blood
CXR “snowstorm effect”
Characterized by areas of pulmonary infiltrate or areas of consolidation.

47. Compartment Syndrome
Hallmark signs of impending compartment syndrome is pain on passive stretch. See in post-op and trauma patients.
Six Ps ~ signs and symptoms
Pain- out of proportion to physical finding, pain on flexion
Pallor
Paresthesia
Pressure
Paralysis– late sign
Pulselessness – late sign

48. Action/Intervention Relieve pressure Keep extremity at heart level
Not above because arterial flow is already compromised
Hydration
Pain management
CK (lab) will indicate muscle damage
Measure compartment pressure

49. Fasciotomy The earliest signs of compartment syndrome/
Pain distal to the injury that is out of proportion to the injury sustained.
Pain on passive stretch of muscle in the affected extremity.

50. Fracture Hips and Femurs
Femoral neck fracture
Intertrochanteric fracture
Mid shaft femur fracture
Distal femur fracture

51. Treatments ORIF Plates Screws Nailing Rodding
IM – intramedallary rodding

52. Treatment Depends on several factors: Part of the hip fractured
Severity of the fracture
How much displacement
Age of the patient

53. Fractures Femoral Neck Fractures Distal Femur Fracture
Usually treated with a hemi or total hip arthroplasty due to disruption of blood flow to the femoral head.
Distal Femur Fracture
Sometimes will have CPM

54. Total Shoulder Arthroplasty (TSA)
Post-Op exercises are passive
Immobilizer continuously to prevent abduction

55. Fracture of the Humerus
A lot of bruising and edema in upper arm
Most cases are treated without surgery
Arm is in a sling

56. Pelvic Fracture
Treated Conservatively
Can have major blood loss

57. Tibia / Fibular Fracture
Pre-Op
Elevate extremity
Ice
Watch for compartment syndrome

58. Complicated Ulnar/Radius Fracture
Elevate extremity
Ice
Monitor CMS

59. Total Knee Replacement or Arthroplasty (TKA)
The replacement of the surfaces of the knee joint with metal and/or plastic components.
Distal portion of the femur
Tibial plateau
Patella

60. TKA
Is performed on patient’s when conservative treatment hasn’t worked and who have:
Osteoarthritis
Rheumatoid arthritis
Post traumatic arthritis ( a form of osteoarthritis)

61. TKA
Surgery is about 2 hours
Hospital Stay is 3 days

62. Unicompartmental knee arthroplasty
The replacement of one of the knees three parts
Patient’s may have:
Early stage arthritis confined to one part of the knee.
Knee deformity.
Avascular and aseptic necrosis
Refractory osteomalacia

63. Unicompartmental knee arthroplasty cont.
Patients must have:
An intact ACL
No significant inflammation
No damage to other compartments, calcifications of cartilage or dislocation
Not recommended for patients who:
Obese
Have significant ligament problems

64. Unicompartmental knee arthroplasty cont.
Surgery is about 90 minutes
NO CPM
Can go home the next home.

65. Autologous Chondrocyte Implantation (ACI)
Small of cartilage damage in knee
Arthroscopy
Remove Cartilage
Send cartilage to lab
To grow more cells
Arthrotomy
To replace cartilage cells & fix deformity
Extensive
Rehab very lengthy

66. Q & A Q. When do you want physical therapy to start?
A. As ordered. Anticipate post-op day 1. Most patients should be out of bed on the operative day.
Q. Do you want gait and exercises?
Yes
Q. When do want OT to start for ADLs?
A. Post-op day 1

67. Q. Do you use SCDs or TEDs?
SCDs. Will order.
Q. Do your patients routinely have a urinary catheter placed during surgery
Yes. Will order.
Do you do an x-ray post-operatively.
Do you like ice packs on total joints?
A. Yes. Will order cooler device or ice.

68. Do you want a daily hemoglobin drawn? For how many days?
Yes. Will order. Typically for 3 days.
Do you use hip abductor pillows?
A. Yes. Will order.

69. When do you have patients return to the clinic for follow up?
For staple removal 2 weeks post-op
Do your patients require outpatient physical therapy?
A. TKA receive outpatient therapy. THA do not.

70. Do you have total hip precautions? What are they?
These have been provided to Rehab for posting in the patient rooms.
Do you use PCA?
No.
Any standard meds for constipation?
A. Yes, they are included in the post-op order sets.

71. When can we change dressings?
The silver (Ag) dressings may be left in place for 72 hours. Change if saturated. Apply gauze dressing.
When can patients shower?
Post-op day 2 or 3. MUST cover the incision/dressing with saran wrap. DO NOT get the incision wet until staples have been removed. Incision can be covered at all times, especially if there is drainage.

72. The End