ORTHOPAEDIC COMPLICATIONS ORTHOPAEDIC COMPLICATIONS

Objectives Identify the primary risk factors for orthopaedic complications Discuss the signs/symptoms of orthopaedic complications Describe common treatment for the primary orthopaedic complications Develop a nursing plan of care for specific orthopaedic complications

Potential Complications Low Risk Acute Confusion Acute Confusion Constipation Constipation Impaired Skin Integrity Impaired Skin Integrity High Risk DVT/PE DVT/PE Compartment Syndrome Compartment Syndrome Fat Emboli Syndrome Fat Emboli Syndrome Hemorrhage Hemorrhage Wound/Surgical Site Infection Wound/Surgical Site Infection Delayed/Nonunion Delayed/Nonunion

Question # 1 DVT prevention requires the nurse to educate the patient on anticoagulant therapy to be alert for : 1. Headache 2. Epistaxis 3. Nausea 4. Chest pain

Question # 1 DVT prevention requires the nurse to educate the patient on anticoagulant therapy to be alert for : 2. Epistaxis

Venous Thromboembolic Conditions Virchows Triad Endothelial injury Endothelial injury Hypercoagulable state Hypercoagulable state Venostasis Venostasis

Deep Vein Thrombosis (DVT) Formation of fibrin leads to development of a thrombus (fibrin clot) Formation of fibrin leads to development of a thrombus (fibrin clot) Clinical symptoms appear when thrombus is large enough to impede blood flow in a large vessel Clinical symptoms appear when thrombus is large enough to impede blood flow in a large vessel

Pulmonary Embolism (PE) When venous thrombosis or part of a thrombus dislodges from its primary site, it becomes an embolus When venous thrombosis or part of a thrombus dislodges from its primary site, it becomes an embolus Embolus can enter pulmonary circulation and perfusion distal to the embolus can be partially or completely occluded Embolus can enter pulmonary circulation and perfusion distal to the embolus can be partially or completely occluded

DVT & PE: Risk Factors Patient related Increasing age Malignancy Varicose veins Obesity Trauma Prior DVT/PE CHF/CVA Pregnancy Deficiencies in clotting cascade Oral contraceptives

DVT & PE: Risk Factors (continued) Procedure related Pelvic, hip or leg surgery/ fracture fixation Surgery > 30 minutes Postop immobilization Postop infection Re-operations

DVT & PE: Risk Factors (continued) Anesthesia related General anesthesia General anesthesia

DVT: Clinical Manifestations Unilateral swelling of thigh/lower leg Unilateral swelling of thigh/lower leg Erythema Erythema Warmth Warmth Tenderness Tenderness Palpable, tender venous cord in popliteal space Palpable, tender venous cord in popliteal space Discomfort in leg Discomfort in leg

DVT: Diagnostics Contrast venography Contrast venography Doppler ultrasonography Doppler ultrasonography Magnetic Resonance Imaging (MRI) Magnetic Resonance Imaging (MRI) Radionuclide venography Radionuclide venography

PE: Clinical Manifestations Dyspnea Dyspnea Chest pain Chest pain Palpitations Palpitations Apprehension Apprehension Confusion Confusion Anxiety Anxiety Restlessness Restlessness Cough Cough Hemoptysis Hemoptysis Diaphoresis Diaphoresis Syncope Syncope Distended neck veins Distended neck veins

PE: Diagnostics Arterial blood gas (ABG) Arterial blood gas (ABG) Chest x-ray (CXR) Chest x-ray (CXR) Electrocardiogram (EKG) Electrocardiogram (EKG) Ventilation-perfusion scan (VQ scan) Ventilation-perfusion scan (VQ scan) Pulmonary angiography Pulmonary angiography CT scan CT scan

DVT & PE: Prevention External pneumatic compression and graduated compression stockings External pneumatic compression and graduated compression stockings Early ambulation and range of motion Early ambulation and range of motion Elevation of lower extremities Elevation of lower extremities

DVT & PE: Prevention (cont.) Prophylactic inferior vena cava filter Prophylactic inferior vena cava filter Anticoagulation Anticoagulation Heparin Heparin LMWH (low molecular weight heparin) LMWH (low molecular weight heparin) Warfarin (Coumadin) Warfarin (Coumadin)

DVT & PE: Interventions Full dose anticoagulation with heparin/warfarin (target INR 2-3) Full dose anticoagulation with heparin/warfarin (target INR 2-3) Oxygen therapy for PE Oxygen therapy for PE Thrombolytic therapy Thrombolytic therapy urokinase, streptokinase urokinase, streptokinase Surgical embolectomy Surgical embolectomy Inferior vena cava filter Inferior vena cava filter

Question # 2 The nurse uses critical thinking to assess an impending compartment syndrome as indicated by which of the following patient presentations? 1. Progressive pain on PROM, paresthesia and diminished pulse pulse 2. Progressive pain on AROM, shiny skin and pulselessness 3. Progressive pain on AROM, increased tissue pressure and edema and edema 4. Progressive pain on PROM and elevated ESR & WBC

Question # 2 The nurse uses critical thinking to assess an impending compartment syndrome as indicated by which of the following patient presentations? 1. Progressive pain on PROM, paresthesia and diminished pulse and diminished pulse

Compartment Syndrome Compromised circulation and function of tissues within a specific area due to progressive pressure within a confined space Compromised circulation and function of tissues within a specific area due to progressive pressure within a confined space Acute, chronic or crush Acute, chronic or crush

Compartment Syndrome: Pathophysiology Tissue swelling Tissue swelling Compression of vessels and nerves Compression of vessels and nerves Histamine release Histamine release Capillary dilation Capillary dilation Increase in capillary permeability Increase in capillary permeability Increased edema Increased edema Decreased perfusion Decreased perfusion Increased lactic acid Increased lactic acid Increased blood flow Increased blood flow

Compartment Syndrome: Risk Factors External compression forces Tight cast Tight dressing Prolonged compression Crush injuries Internal factors Bleeding Significant swelling/edema Exertional

Compartment Syndrome: Risk Factors (continued) Miscellaneous Acute trauma Fracture Infection Skin traction Tibial nailing Exercise Insensate extremity

Compartment Syndrome: Clinical Manifestations Early signs Early signs Increasing pain Increasing pain Pain with passive stretch of muscles Pain with passive stretch of muscles Paresthesia Paresthesia Late signs Late signs Delayed capillary refill Pale extremity Loss of pulse Paralysis

Compartment Syndrome: 5 Ps Pain on passive stretch Pain on passive stretch Pallor Pallor Pulselessness Pulselessness Paresthesia Paresthesia Paralysis Paralysis

Compartment Syndrome: Monitoring If compartment syndrome is not recognized and pressure is not relieved, muscle damage will be irreversible after 4-6 hours of ischemia, and nerve damage will be irreversible after 12-24 hours of ischemia. (Janzing et al., 1996)

Neurovascular Assessment Peripheral vascular assessment Color pale/white, pink, dusky, cyanotic, mottled Temperature cool/cold, warm, hot Capillary refill normal < 3 seconds Peripheral pulses distal to injury, bilateral non-palpable: doppler Edema pitting

Neurovascular Assessment Peripheral neurologic assessment Sensation Motor function Both elements evaluate: Upper extremity: radial, median and ulnar nerves Lower extremity: tibial, peroneal, femoral and sciatic nerves

Compartment Syndrome: Diagnostics Muscle damage indicated by: Muscle damage indicated by: Myoglobin in urine Myoglobin in urine Elevated CPK, LDH and SGOT Elevated CPK, LDH and SGOT Intracompartmental pressure monitor Intracompartmental pressure monitor Pressures of 30-45 mmHG a concern Pressures of 30-45 mmHG a concern

Compartment Syndrome: Prevention Early recognition is key to preventing or minimizing negative outcome Early recognition is key to preventing or minimizing negative outcome Astute nursing intervention to identify pathologic pain in the presence of good pain control (epidural, PCA) Astute nursing intervention to identify pathologic pain in the presence of good pain control (epidural, PCA)

Compartment Syndrome: Interventions Relieve pressure source Relieve pressure source Remove constrictive dressing Remove constrictive dressing Bivalve cast Bivalve cast Initiate pain management Initiate pain management Elevate extremity at heart level Elevate extremity at heart level Ongoing neurovascular assessments Ongoing neurovascular assessments Fasciotomy if indicated Fasciotomy if indicated

Question # 3 Which nursing assessment finding might suggest the presence of a fat embolism? 1. Ecchymosis 2. Hematoma 3. Petechiae 4. Edema

Question # 3 Which nursing assessment finding might suggest the presence of a fat embolism? 3. Petechiae

Fat Emboli Syndrome (FES) Mechanical blockage of blood vessels by circulating fat particles Mechanical blockage of blood vessels by circulating fat particles Occurs following long bone fracture, pelvic fracture and total hip arthroplasty Occurs following long bone fracture, pelvic fracture and total hip arthroplasty

FES: Pathophysiology Mechanical theory Mechanical theory Injured adipose tissue and/or disruption of intramedullary compartment releases fat into the blood stream Injured adipose tissue and/or disruption of intramedullary compartment releases fat into the blood stream Biochemical theory Biochemical theory Fatty acids cause endothelial damage; fatty acids and fats lead to platelet aggregation and fat globule formation

FES: Clinical Manifestations Signs and symptoms can appear 12-72 hours post injury Signs and symptoms can appear 12-72 hours post injury Change in mental status Increased respiratory distress Petechiae of skin & mucosa (appear above nipple line and blanch)

FES: Diagnostics No specific labs No specific labs Fat globules may be detected in blood, urine or sputum Fat globules may be detected in blood, urine or sputum PO2 drops to < 50 mmHG PO2 drops to < 50 mmHG CXR with diffuse snowstorm effect CXR with diffuse snowstorm effect VQ scan to r/o PE VQ scan to r/o PE

FES: Interventions Early recognition to prevent morbidity and mortality Early recognition to prevent morbidity and mortality Minimize movement of long bone fractures Minimize movement of long bone fractures Respiratory support Respiratory support Intubation Ventilator management ICU monitoring

Question 4A Which indicators are BEST for diagnosing hemorrhage Which indicators are BEST for diagnosing hemorrhage A) Blood in urine/stool A) Blood in urine/stool B) Labs (cbc, coagulation studies) B) Labs (cbc, coagulation studies) C) Radiographic studies C) Radiographic studies

Hemorrhage/Postoperative Bleeding Etiology Etiology Trauma/surgery Slipped ligature Anticoagulation or coagulation disorder Erosion of blood vessel by foreign body or tumor Infection

Hemorrhage: Risk Factors Patient-related Patient-related Coagulation disorders Coagulation disorders Low platelet count Low platelet count Excessive coagulation Excessive coagulation Tumor growth Tumor growth Injury-related Injury-related Fracture or foreign body interrupts blood vessel Fracture or foreign body interrupts blood vessel Procedure-related Procedure-related

Hemorrhage: Clinical Manifestations Dizziness Dizziness Weakness Weakness Anxiety Anxiety Restlessness Restlessness Confusion Confusion Tachycardia Tachycardia Lowered BP Lowered BP Rapid, shallow respirations Rapid, shallow respirations Pallor Pallor Cold, clammy skin Cold, clammy skin Abnormal drainage from wounds or drains Abnormal drainage from wounds or drains Decreased urine output Decreased urine output

Hemorrhage: Diagnostics CBC CBC Coagulation studies Coagulation studies Urine and stool for blood Urine and stool for blood Radiographic studies Radiographic studies

Hemorrhage: Interventions Direct pressure Direct pressure Surgical intervention as indicated Surgical intervention as indicated Use of autologous or synthetic clotting material Use of autologous or synthetic clotting material Vitamin K or clotting replacement factors Vitamin K or clotting replacement factors Volume replacement and blood transfusion as necessary Volume replacement and blood transfusion as necessary Iron supplementation Iron supplementation

Question # 4 To prevent nosocomial wound/surgical site infection, the most important intervention the nurse should perform is: 1. Thorough handwashing 2. Aseptic technique with dressing changes 3. Administration of antibiotic 4. Monitoring BP and glucose levels

Question # 4 To prevent nosocomial wound/surgical site infection, the most important intervention the nurse should perform is: 1. Thorough handwashing

Wound and Surgical Site Infection (SSI) Nosocomial surgical site infections occur within 30 days after the operative procedure (within 1 year if an implant is in place) and can involve skin, subcutaneous tissue, deep soft tissues, or actual organs manipulated during the operative procedure. (CDC)

Wound/SSI: Risk Factors Patient characteristics Advanced age Obesity/malnutrition Hypovolemia Diabetes Rheumatoid arthritis Steroid use/NSAID use/chemotherapy Tobacco use Substance abuse

Wound/SSI: Intrinsic Risk Factors Injury characteristics Bone displacement, comminution Bone displacement, comminution Periosteal stripping Periosteal stripping Involvement of more than one bone Involvement of more than one bone Vascular injury Vascular injury Significant soft tissue injury Significant soft tissue injury Open fracture/foreign body/contamination Open fracture/foreign body/contamination

Wound/SSI: Extrinsic Risk Factors Preoperative Preoperative Inadequate immobilization of fractured bone Inadequate immobilization of fractured bone Preoperative shave > 1 day prior to surgery Preoperative shave > 1 day prior to surgery Duration of preoperative hospitalization Duration of preoperative hospitalization Intraoperative Intraoperative Hair removal Positive intraop contamination Irrigation, drains, packing Primary/secondary closures Type and length of procedure Surgeon expertise Glove punctures

Wound/SSI: Extrinsic Risk Factors Postoperative Postoperative Cold room (vasoconstriction) Insufficient fluid replacement Hypertension Inadequate analgesia Compromised blood perfusion Low oxygenation

Wound/SSI: Clinical Manifestations Increased pain Increased pain Fever or chills Fever or chills Malodor from incision or wound Malodor from incision or wound Edema Edema Increased temperature around incision or wound Increased temperature around incision or wound Erythema around wound or incision Erythema around wound or incision Purulent exudate, poor wound healing Purulent exudate, poor wound healing Elevated WBC, ESR, C- reactive protein Elevated WBC, ESR, C- reactive protein

Wound/SSI: Prevention Preoperative Preoperative Control hypertension and blood sugar Control hypertension and blood sugar Minimize unnecessary movement of fractures Minimize unnecessary movement of fractures Treat existing infections Treat existing infections Replenish nutritional deficits Replenish nutritional deficits Prevent vasoconstriction Prevent vasoconstriction Intraoperative Intraoperative Antimicrobial prophylaxis Strict aseptic technique Meticulous tissue debridement Stabilize fractures Avoid vasoconstriction Gently handling of soft tissue Wound closure without excessive tension

Wound/SSI: Prevention Postoperative Postoperative Provide adequate analgesia Avoid vasoconstriction Control BP and BS Provide for adequate nutrition Aseptic dressing changes Microbial therapy Thorough handwashing

Wound/SSI: Interventions Wound care Wound care Systemic antibiotics Systemic antibiotics Adequate perfusion Adequate perfusion Adequate oxygenation Adequate oxygenation Optimal nutritional intake Optimal nutritional intake

Question #5 A fracture that isnt healing is considered to be a non union (as opposed to a delayed union) fracture after how long? A fracture that isnt healing is considered to be a non union (as opposed to a delayed union) fracture after how long? 6-12 weeks 6-12 weeks 8-14 weeks 8-14 weeks 16-24 weeks 16-24 weeks 28-36 weeks 28-36 weeks

Delayed Union/Nonunion Delayed union is a continuation of or increase in bone pain and tenderness beyond a reasonable healing period; healing is slowed but not completely stopped Delayed union is a continuation of or increase in bone pain and tenderness beyond a reasonable healing period; healing is slowed but not completely stopped Nonunion occurs when fracture healing has not taken place 4-6 months after the fracture occurs and spontaneous healing is unlikely (Morris, 2001) Nonunion occurs when fracture healing has not taken place 4-6 months after the fracture occurs and spontaneous healing is unlikely (Morris, 2001)

Delayed Union/Nonunion Pathophysiology Pathophysiology Infection Infection Inadequate fracture immobilization Inadequate fracture immobilization Inadequate blood supply to fracture site Inadequate blood supply to fracture site Diagnostics Diagnostics Serial x-rays CT scans MRI

Delayed Union/Nonunion: Interventions Bone grafting Bone grafting Internal fixation Internal fixation External fixation External fixation Electrical bone stimulation Electrical bone stimulation