Orthopedics for nurses

Management of patients with musculoskeletal trauma and problems

Dr. Sameer AgarwalOrthopaedics

Khoula Hospital

Topics

• Fracture• Joint dislocation• Contusion, sprains and strain• Osteomyelitis• Low back pain• Amputation

OBJECTIVES

• Causes, clinical manifestation, diagnostic tests, management and care.

• Care modalities

• Patient education program.

• Rehabilitation

ORTHOPAEDICS

• 1840, French orthopédique, from orthopédie,

• French physician Nicholas Andry (1658-1742), from

• Greek orthos "straight, correct"

• paideia "rearing of children," from pais (genitive paidos) "child" (see pedo- ).

206 bones in the human body

Basic Bone structure

Joints

Basic anatomy

Sprains• Stretching, partial or

complete tearing of ligaments

• Typically occur when joint overextended

• Ankles, knees, wrists, fingers

• Swelling, pain, bruising

• Inability to use joint

Strains• Tearing of muscle or

tendon• Occurs due to

overstretching• Causes pain, swelling

and sometimes inability to use muscle

• Can be prevented by avoiding overexertion, good body mechanics, sports safety

Care for Musculoskeletal Injuries

• Proper care vs identifying the type of injury

• Assume any injury to an extremity includes a bone fracture.

• The general care for injuries to muscle, bone and joints includes following R.I.C.E.

R.I.C.E.

• Rest: do not move or straighten the injured area.

• Ice: apply ice to the injured area for periods of 20 minutes.

• Compression: with a firmly wrapped bandage • Elevation: do not elevate the injured part if it

causes more pain.

Many fancy terms

Splinting

• A method of immobilizing an injured extremity• ONLY : to move or transport a patient to

higher center• Splinting does not cause more pain.

Types of Splints• Soft splints

• folded blankets, towels, pillows and a sling.• Rigid splints

• include boards, metal strips and folded magazines or newspapers.

• Use a triangular bandage to secure the rigid or soft splinting material in place

• Anatomic splints • an uninjured body part to immobilize an injured area. • You can use tape to secure an uninjured finger to the

injured

Head, Neck and Back Injuries

• These injuries may cause an unintentional death or life-long neurologic damage.

• If you suspect that a person has a head, neck or back injury, tell him/her to respond verbally to any questions you ask and to avoid nodding or shaking his/her head.

• Goal is to minimize movement

Care for Head/Neck/Back

• Minimize movement of the head, neck, and back – by placing your hands on both sides of the

person’s head. – Maintain an open airway. – Let the person remain in the position in which you

found him/her until advanced medical personnel arrive and take over.

• Monitor the ABC’s

Fracture• A disruption or break in the continuity of the

structure of bone

• Traumatic injuries account for the majority of fractures

Description

• Described and classified according to:– Type– Anatomic location– Communication or non communication with

external environment

Description of fractures

Compression fx• Specific to the vertebral

body collapses, anterior aspect is reduced in height.

• From trauma or demineralization of bone (old age).

Burst fx• C1 ring is broken,

fragments move outward.

• Football injuries, heavy object dropped on head.

C - 1 (atlas)

Pediatric fractures• 1. Greenstick (torus) -

incomplete fx, bones more flexible, bends & fractures only outer edge.

• 2. Epiphyseal - fractures located at the site of an epiphysis.

Classification by Fracture Location

Description

• Described and classified according to:– Appearance, position, and alignment of the

fragments– Classic names– Stable or unstable

Description

• Closed (also called simple)

• Open (also called compound)

Classification by Communication withExternal Environment

Description

• Stable fractures– Occur when a part of the periosteum is

intact across the fractureOR

– External or internal fixation has rendered the fragments stationary

Description

• Unstable fractures

-Grossly displaced

-Poor fixation

Clinical Manifestations

– Immediate localized pain– Loss of Function

– Inability to bear weight or use affected part

– Guarding– May or may not see obvious bone deformity

Fracture Healing

Collaborative Care

• Overall goals of treatment:– Anatomic realignment of bone fragments

(reduction)– Immobilization to maintain alignment

(fixation)– Restoration of normal function

• 3 ‘R’ s

Collaborative Care - Fracture Reduction

• Closed reduction– Nonsurgical, manual realignment

• Open reduction– Correction of bone alignment through a

surgical incision

Fracture Reduction (Closed)

• Traction (with simultaneous counter-traction)– Application of pulling force to attain

realignment• Skin traction (short-term: 48-72 hrs.)• Skeletal traction (longer periods)

• Manipulation under anesthesia• To control pain and overcome muscle spasm

Collaborative Care Fracture Immobilization

• TractionApplication of a pulling force to an injured part of the body while counter traction pulls in the opposite direction

• Purpose of traction:– Prevent or reduce muscle spasm– Reduction– Immobilization– Treat a pathologic condition

Collaborative Care Fracture Immobilization

• Casts– Circumferential

immobilization device– Common following

closed reduction

Collaborative Care Fracture Immobilization

• External fixation• device composed of pins that are inserted into

the bone and attached to external rods

Open fractures external fixation

Collaborative Care Fracture Immobilization

• Internal fixationPins, plates, intramedullary rods, and screwsSurgically inserted at the time of realignment

Nursing Management Nursing Assessment for Fractures

• AMPLE history

Nursing Management Nursing Assessment

• Neurovascular assessment– Color and temperature

• cyanotic and cool/cold: arterial insufficiency• Blue and warm: venous insufficiency

– Capillary refill (< 2 sec)– Peripheral pulses (↓ indicates vascular

insufficiency)

Nursing Management Nursing Diagnoses

• Risk for peripheral neurovascular dysfunction• Acute pain• Risk for infection• Assessment of fall risk• Decubitus ulcer policy• Prolonged immobilization• DVT prophylaxis

Nursing Management Nursing Diagnoses

• Ineffective therapeutic regimen management– Analgesia– Antibiotic prophylaxis(treatment)– Thromboprophylaxis– Medication for co-mobidities– Non prescription medication

Nursing Management Nursing Implementation

• General post-op care– Assess dressings/casts for bleeding/drainage

– Prevent complications of immobility• Measures to prevent constipation• Frequent position changes/ ambulate as permitted• ROM exercises of unaffected joints• Deep breathing• Isometric exercises

Nursing Management-TractionNursing Implementation

Ensure:• No frayed ropes, loose

knots• Ropes in pulley grooves• Pulley clamps fastened

securely

• Weights must hang freely• Appropriate body

alignment– Inspect skin

• Around slings• Around pins

Nursing Management Nursing Implementation: Cast care

• Casts can cause neurovascular complications if– Too tight– Edematous

• Frequent neurovascular checks• Ice and elevation during early phase

Complications of Fractures-Infection

• Open fractures and soft tissue injuries have incidence

• Osteomyelitis can become chronic– Open fractures require aggressive surgical

debridement– Post-op IV antibiotics till wound closure

(prophylactic)

Complications of FracturesCompartment Syndrome

• elevated intra-compartmental pressure • within a confined compartment • capillary perfusion to be reduced below a level

necessary for tissue viability

Complications of FracturesCompartment Syndrome

• Two basic etiologies create compartment syndrome:– Decreased compartment size (dressings,

splints, casts)– Increased compartment content (bleeding,

edema)

Complications of FracturesCompartment Syndrome

• Clinical Manifestations Six Ps1. Pain (unrelieved by narcotics)3. Pressure (Tense tight compartment)4. Pallor (loss of normal color, coolness)5. Paresthesia (unrelieved by narcotics)6. Paralysis7. Pulselessness (decreased/absent pulses)

Complications of FracturesCompartment Syndrome

• Clinical Manifestations– Six Ps:

• Patient may present with one or all of the six Ps

• Compare extremities

DO NOT WAIT FOR ALL SIX Ps TO APPEAR

Complications of FracturesCompartment Syndrome

• Clinical Manifestations Late– Absence of peripheral pulse = ominous late

sign– Myoglobinuria

• Dark reddish-brown urine

Complications of FracturesCompartment Syndrome

• Collaborative Care– Prompt, accurate diagnosis is critical– Early recognition is the key– Do not apply ice or elevate above heart

level

Complications of FracturesCompartment Syndrome

• Collaborative Care– Remove/loosen the bandage and bivalve the

cast– Reduce traction weight– Maintain vitals (avoid hypotension)– O2 inhalation– Inform the team promptly– Surgical decompression (fasciotomy)

Complications of FracturesVenous Thrombosis

• Veins of the lower extremities and pelvis are highly susceptible to thrombus formation after fracture, especially • hip fracture• Pelvis fractures• Spine fractures• Polytrauma

Complications of FracturesVenous Thrombosis

• Precipitating factors:– Venous stasis caused by incorrectly applied

casts or traction– Local pressure on a vein– Immobility

• Prevent with anticoagulant medications

Complications of FracturesFat Embolism Syndrome (FES)

• Characterized by the presence of fat globules in tissues and organs after a traumatic skeletal injury

Complications of FracturesFat Embolism Syndrome (FES)

• Fractures that most often cause FES:– Long bones– Ribs– Tibia– Pelvis

Complications of FracturesFat Embolism Syndrome (FES)

• Tissues most often affected:– Lungs– Brain– Heart – Kidneys – Skin

Complications of FracturesFat Embolism Syndrome (FES)

• Clinical Manifestations– Usually occur 24-48 hours after injury– Interstitial pneumonitis

• Produce symptoms of ARDS

Complications of FracturesFat Embolism Syndrome (FES)

• Clinical Manifestations– Symptoms of ARDS:

• Chest pain• Tachypnea• Cyanosis• PaO2

Complications of FracturesFat Embolism Syndrome (FES)

• Clinical Manifestations– Symptoms of ARDS:

• Dyspnea• Apprehension• Tachycardia

Complications of FracturesFat Embolism Syndrome (FES)

• Clinical Manifestations– Rapid and acute course– Feeling of impending disaster– Patient may become comatose in a short

time

Complications of FracturesFat Embolism Syndrome (FES)

• Collaborative Care– Treatment directed at prevention– Careful immobilization of a long bone

fracture • Most important preventative factor

Complications of FracturesFat Embolism Syndrome (FES)

• Collaborative Care (treatment)– Symptom management– Fluid resuscitation– Oxygen– Reposition as little as possible

Fracture of the Hip

• Fracture of proximal third of femur• Common in the elderly• More frequent in women than men.• Up to 35% of clients will die within the first

year

Fracture of the Hip

• Intracapsular fractures:– Occur within hip joint capsule

• Extrascapular fractures– Intertrochanteric: between greater and lesser

trochanter– Subtrochanteric: below lesser trochanter

Clinical Manifestations

• External rotation of affected leg• Muscle spasm• Shortening of the affected extremity• Severe pain and tenderness in region of

fracture

Collaborative Care

• Surgical repair is preferred – Allows for early mobilization and decreases the

risk of major complications.• traction may be utilized preoperatively to

decrease painful muscle spasms.

Nursing Diagnosis

• Risk for peripheral neurovascular dysfunction• Acute pain• Risk for impaired skin integrity• Impaired physical mobility

Post-Operative Care

• General post-op care (V/S, DB & C, etc.)• Neurovascular checks• Prevent external rotation (sandbags, pillows)

Preventing Dislocation of Femur Head Prosthesis

• Do Not– Flex hip greater than 90 degrees.– Place hip in adduction – Allow hip to internally rotate– Cross legs

Preventing Dislocation of Femur Head Prosthesis

• Do– Use elevated toilet seat– Use chair in shower/tub– Use pillow between legs when on “good” side or

supine (for 8 weeks post-op)– Keep hip in neutral position when sitting, walking

and lying.– Notify surgeon if severe pain, deformity, or loss of

function

Dislocation

• Definition: • complete and persistent displacement of joint

• Pathology

• Part of the supporting joint capsule and some of its ligaments disrupted.

Deformity of a limb• Clinical indication of dislocation

Types of dislocation

• Congenital– Developmental Dysplasia of Hips– Congenital dislocation of knee– Arthrogryposis multiplex

• Acquired1. Traumatic

2. Pathological e.g. TB hip, Septic Arthritis3. Paralytic e.g. Poliomyelitis, cerebral palsy, etc4. Inflammatory disorders, rheumatoid arthritis,etc

Dislocation

• No joint is immune from dislocation• Most commonly occur in the following joints.

• Shoulder• Hip• Elbow• Metacarpophalengeal joint • Facet joint dislocation in cervical spine.• Acromiclavicular joint dislocation.

Investigations- Xrays

Complication

1. Acute: Injury to peripheral nerve and vessels2. Chronic: Unreduced dislocation

Recurrent dislocationTraumatic osteoarthritisJoint stiffnessAvascular necrosisMyositis ossificans

Caution !

• Excessive force should not be used in close reduction.

• Forceful manipulation may lead to fracture.• Interposition of soft tissue, bony fragment or

buttonhole in capsule may make close reduction impossible.

Remember• It is an orthopedic emergency.• Reduction should be quick and prompt.• Reduction should always be under G/A or

sedation.

Fracture Dislocation

Lot of swelling Swelling is less

Some restriction of movements

Movements grossly restricted

Osteomyelitis• Infection of the

– Bone– Bone marrow– Surrounding soft tissue

• Caused by a variety of microorganisms • Most common infecting microorganism –

staph. aureus

Clinical Manifestations Acute Osteomyelitis

• Initial infection –Infection of <1 month in duration–Both systemic and local

Clinical Manifestations Acute Osteomyelitis

• Systemic- Fever– Unwell

• Local– Constant bone pain that worsens with activity– Swelling, tenderness, warmth at infection site– Restricted movement of affected part– Later signs: drainage from sinus tracts

Diagnostic Studies

• Bone or soft tissue biopsy – Definitive way to determine causative

microorganism• Patient’s blood and/or wound culture

– Frequently positive for presence of microorganism • Lab Studies

– WBC– Erythrocyte sedimentation rate (ESR)

Radiologic Studies

• Radiologic signs Usually do not appear until 10 days to weeks after

start of clinical symptoms • Radionuclide bone scans

Helpful in diagnosis and usually positive in areas of infection

• Magnetic resonance imaging (MRI) • Computed tomography (CT)

Help identify extent of infection, including soft tissue involvement

Collaborative CareAcute Osteomyelitis

• Vigorous and prolonged intravenous (IV) antibiotic therapy– Treatment of choice for acute osteomyelitis – As long bone ischemia has not occurred– Cultures or bone biopsy should be done if possible

• Delaying antibiotic treatment may require surgical debridement and decompression

Collaborative Care Chronic Osteomyelitis

• Adults with chronic osteomyelitis --6 to 8 weeks of IV antibiotics

• Oral antibiotics may be given after acute IV therapy to ensure resolution of infection

• Monitoring patient’s response

Nursing Implementation

• Ambulatory and home care

– Importance of continuing antibiotics after symptoms have subsided should be stressed

– Periodic nursing visits provide support and decrease anxiety

– Frequent dressing changes for open wounds

Septic arthritis

• Acute inflammation of joint• Caused by microorganism• May mimic acute OM• May result from acute OM• More common in extremes of age

Acute OM vs Septic arthritisOsteomyelitis Septic arthritis

• Subacute onset of limp / non-weight bearing / refusal to use limb

• Localised pain and pain on movement

• Tenderness• Soft tissue redness / swelling

may not be present & may appear late

• +/- Fever

• Acute onset of limp / non-weight bearing / refusal to use limb

• Pain on movement and at rest

• Limited range / loss of movement

• Soft tissue redness / swelling often present

• Fever

Back Pain

• 2nd most common cause for opd visit• 60-80% of population will have lower back

pain at some time in their lives• Each year, 15-20% will have back pain• Most common cause of disability for persons <

45 years• 1% of US population is disabled• Costs to society: $20-50 billion/year

Causes of Low Back Pain• Lumbar “strain” or “sprain” –

70%• Degenerative changes – 10%• Herniated disk – 4%• Osteoporosis compression

fractures – 4%• Spinal stenosis – 3%• Spondylolisthesis – 2%

• Spondylolysis, diskogenic low back pain or other instability – 2%

• Traumatic fracture - <1%• Congenital disease - <1%• Cancer – 0.7%• Inflammatory arthritis – 0.3%• Infections – 0.01%

Pathophysiology

• Elastic rod constructed of rigid units (vertebrae) and flexible units (intervertebral disks)

• Flexibility with protection

• Truncal muscles help stabilize the spine

Clinical manifestations

• Acute < 3 months• Chronic > 3 months without improvement• Radiculopathy• Neurological deficits• Paraspinal muscle spasm

Red Flags

• History of cancer• Unexplained weight

loss• Intravenous drug use• Prolonged use of

corticosteroids• Older age

• Major Trauma• Osteoporosis• Fever• Back pain at rest or at

night• Bowel or bladder

dysfunction

Medications

• Anti-inflammatory medications (NSAID’s):– Beneficial; no differences; watch side-effects

• Narcotic Pain Relievers:– No more effective than NSAID’s– Many side effects

• Muscle Relaxants (ie. Flexeril®):– Can decrease pain and improve mobility– 70% with drowsiness/dizziness

Exercise & Bed Rest

• Advice to stay active:– ‘There is no evidence that advice to stay active is

harmful for either acute low back pain or sciatica.’• One or two days of bed rest if necessary• Light activity, avoiding heavy lifting, bending

or twisting (ie. walking)• No data on any particular exercises

Other Modalities

• Back Brace/Corset/Lumbar Support:• Traction:• Injections: Inconclusive evidence• TENS:• Hot/Cold:• Ultrasound:

Role of X-rays (Radiology)

• Usually unnecessary and not helpful• Plain X-ray:

– Age>50 years– No improvement after 6 weeks– Other worrisome findings

• MRI:– After 6 weeks if have sciatica

Injections

• Epidural injections:– Insufficient and conflicting evidence

• Facet joint injections: -conflicting evidence• Local/Trigger point injections:

– Possibly some benefit

Surgery

• Discectomy improves pain in short term.

• Microdiscectomy similar to standard discectomy.

• Automated percutaneous discectomy and laser discectomy both less effective.

Prevention

• Exercise:– Aerobic, back/leg strengthening

• Back braces and education about proper lifting techniques are partially effective

• ? weight loss and smoking cessation• Improved self esteem

AMPUTATION

Amputation “Surgical removal of limb

or part of the limb through a bone or multiple bones”

Disarticulation “Surgical removal of hole

limb or part of the limb through a joint”

Epidemiology

• Age- common in 50-75 yrs of age traumatic- common in young age• Sex- aprox. 75% male 25% female• Limb- aprox. 85% - lower limb 15% -- upper limb• Etiology: Traumatic

Diabetic, ischaemic

DDD

• Dead:• Dangerous:• Damn nuisance:

Open Guillotine modified guillotine Closed amputation revised planned

TYPES OF AMPUTATION

Level of Amputation

Complications

Infection

Hematoma

Necrosis

Contractures

Neuroma

Phantom

• Prompt, uncomplicated wound healing • Control of edema • Control of Postoperative pain • Prevention of joint contractures • Rapid rehabilitation

Goals of Postoperative Management

Care of the Stump

– keep the stump clean, dry, and free from infection at all times.

– If fitted with a prosthesis, you should remove it before going to sleep.

– Inspect and wash the stump with mild soap and warm water every night, then dry thoroughly and apply talcum powder.

– do not use the prosthesis until the skin has healed. – The stump sock should be changed daily, and the

inside of the socket may be cleaned with mild soap.

Rehabilitations1. Residual Limb Shrinkage and Shaping 2. Limb Desensitization 3. Maintain joint range of motion 4. Strengthen residual limb 5. Maximize Self reliance 6. Patient education: Future goals and prosthetic options

IT IS A REPLACEMENT Or SUBSTITUTION OF A MISSING OR A DISEASED PART

PROSTHESIS

Take Home messageStrain and spains

• Proper care more important than anatomic diagnosis

• RICE– Rest– Ice– Compression– Elevation

• Analgesia

Take home message - Fractures• Fracture management

– Reduction– Retention– Rehabilitation

• AMPLE history– Allergies– Medication– Past medical history– Last meal– Events around injury

• Awareness of 5 P – Pain– Pulseless– Pallor– Paresthesia– Paralysis

• Avoid Complications– Compartment syndrome– Fat embolism– DVT– Infection

Take Home message-Backpain

• Most common orthopaedic complaint• Aware of RED flag symptoms• Acute vs chronic backpain• Majority are better in 6 weeks-3months• Lifestyle modifications are effective• Injections and surgery has definite role• Prolonged bed rest and use of braces are

counterproductive

Take Home message-Amputation

• DDD– Dead, Deadly, Damn nuisance

• Avoid immediate and late postoperative complications

• Facilitate early and rapid rehabilitation• Teach and supervise the care of stump

Any thing else?