XII.

ORTHOPEDICS
A. Fractures:
1. S/S:
a. PAIN and tenderness
b. Unnatural MOVEMENT
c. Deformity (possible)
d. Shortening of EXTREMITY
Caused by muscle spasm
e. Crepitus (bones grating together)
f. Swelling
g. Discoloration
h. Worry about COMPARTMENT
SYNDROME
2. Tx:
a. Immobilize the bone ends plus the
adjacent joints.
b. Support fracture above and below
site.
c. Move extremity as little as possible.
d. Splints help prevent FAT emboli
and MUSCLE spasm.
e. What do you do with open
fractures? COVER WITH
SOMETHING STERILE
f. Most important thing
NEUROVASCULAR checks
g. Neurovascular checks: pulses, color,
movement, sensation, capillary refill,
temp
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3. Complications:
a. Shock: (hypovolemic)
b. Fat embolism:
With what type of fractures do you
see this? LONG BONE FRACTURE,
PELVIC FRACTURE, CRUSHING
INJURIES
Symptoms depend on what?
Petechia or rash over chest,
THROMBOCYTOPENIA
Conjunctival hemorrhages
Snow storm on CXR PATCHY
INFILTRATES.
Young males
First 36 hours
c. Compartment syndrome:
Increased PRESSURE within a
limited space.
1) Pathophysiology:
FLUID accumulates in the tissue
and impairs tissue perfusion.
The muscle becomes swollen and hard
and the client complains of
severe PAIN that is not relieved with
pain meds.
Pain unpredictable
PAIN is disproportionate to the injury.
If undetected may result in NERVE
damage and
possible amputation.

Common areas? FOREARMS &

QUADS
2) Tx:
Elevate extremity.
Soft cast then rigid cast.
Loosen the cast to restore
CIRCULATION.
Be careful in picking the answer
remove cast.
Fasciotomy- CUTS DOWN INTO
THE TISSUE TO RELIEVE THE
PRESSURE.
Cast cutters to remove cast
Instruct them the cast saw does not
touch skin but it does
VIBRATES. (So be a nice nurse
and warn them)
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d. Healing Concerns:
1) Delayed union:
Healing doesnt occur at a normal
rate.
2) Non-union:
Failure of bone ends to unite; may
require bone grafting
3) Mal-union: deformity at the
fracture site.
S/S: persistent discomfort with
MOVEMENT
4. Cast Care:
a. Ice packs on the side for first 24
hours because cast is still wet.
b. No indentations
c. Use PALMS for 1st 24 hours
casting material is wet
d. Keep uncovered and allow for air
DRYING.
e. Do not rest cast on hard surface or
sharp edge.
Rest on soft pillow, no plastic
BECAUSE PLASTIC HOLD HEAT.
f. Mark breakthrough bleeding. Circle
area, date and time site.
g. Cover cast close to GROIN with
plastic (once the cast is dry).
h. Neurovascular CHECK with the 5
Ps
i. What do you do if your client
complains of pain?
NEUROVASCULAR CHECKS
Most pain is relieved by elevation,
cold packs and analgesics. (If these
things
do not relieve the pain think
complication).
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5. Traction:
a. Miscellaneous Information:

Decreases MUSCLE SPASMS ,

reduces REEL ON THE BONES,
immobilizes
Should it be intermittent or
continuous? CONTINUOUS. NEVER
RELEIVE TRACTION
Weights should hang FREELY.
Keep client pulled up in bed and
centered with a good alignment.
Exercise non-immobilized
JOINTS.
Ropes should move FREELY and
knots should be
TUCKED.
Special air filled or foam
mattresses
b. Types of Traction:
1) Skin traction:
Used short term to relieve
MUSCLE spasms and immobilize
until SURGERY.
This is when tape or some type of
material is stuck to the skin and the
weights pull against it.
Is the skin penetrated? NO
Types: Bucks (used most often
with hip and femoral fractures)
Must do good skin assessments
2) Skeletal traction:
This traction is applied directly to
the bone with PINS and
WIRES.
Used when prolonged TRACTION
is needed.
Types: Steinman pins, Crutchfield,
Gardner-Wells tongs, Halo vest
Must monitor the pin sites and do
pin care.
Sterile tech? YES
Remove crusts? YES
Is serous drainage okay? YES
*TESTING STRATEGY*
Never relieve traction (unless youve
got a
physicians order)
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B. Total Hip Replacement:
1. Prep Op Care:
Bucks traction is used frequently
pre-op.
2. Post Op Care:
a. Nursing Considerations:
Neurovascular checks
Monitor drains (Dont want fluid to
accumulate in tissue).
Firm mattress (joints need support)
Over-bed trapeze to build upper
body strength
Positioning:

NEUTRAL rotation-toes to the ceiling

Limit flexion; want FLEXION of hip
Abduction or adduction?
ABDUCTION, LEGS APART
What exercise can the client do
while still confined to bed?
ISOMETRICS EXERCISE,
SQUEEZE THE QUADS.
INCREASE VENOUS RETURN
What is the purpose of the
trochanter roll? PREVENT
EXTERNAL ROTATION
Document in nurses notes.
No weight-bearing until ordered by
physician
Avoid crossing legs, bending over.
Is it okay to sleep on operated side?
NO
Is hydrating important with this
client? YES PREVENT DVT
Stresses to new hip joint should be
minimal in the first 3-6 MONTHS.
Is it okay to give pain meds in the
operative hip? NO
*TESTING STRATEGY*
Any time youve got somebody
with an orthopedic or a joint
problem, they need a firm mattress
for support.
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b. Complications:
1) Dislocation circulatory/NERVE
damage
S/S: shortening of leg, abnormal
rotation, cant move extremity, *pain
2) Infection:
Prophylactic antibiotics (just like
with heart valve replacement)
Remove foley and drains as soon as
possible.

These will serve as a portal for

INFECTION
3) Avascular Necrosis: (death of
tissue due to poor circulation)
4) Immobility problems
c. Client Education/Rehabilitation:
Best exercise? WALKING.
ROCKING IN ROCKING CHAIRS
FOR ELDERLY.
Avoid flexion low chairs, traveling
long distances, sitting more than 30
minutes, lifting heavy objects,
excessive bending or twisting, stair
climbing
C. Total Knee Replacement
(Arthroplasty)
1. CPM: (Continuous Passive Motion)
2. Keeps knee in motion and prevents
formation of SCAR TISSUE.
3. PT will set machine to
GRADUALLY increase flexion and
extension of knee.
4. Never HYPER EXTEND or
hyperflex knee.
5. Neurovascular checks.
6. Pain relief.
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D. Amputations:
1. Miscellaneous Information:
Amputations are performed at the
most DISTAL point that will heal.
The physician tries to preserve the
KNEE and ELBOW.
2. Immediate Post Op Care:
a. Keep what at the bedside?
TOURNIQUET
b. Elevation post op is controversial,
because of hip contractures, only
elevate for a
short time to reduce swelling.

c. Do not elevate on pillow, elevate

foot of bed.
d. Prevent hip/knee contractures.
How? EXTENTION
e. Inspect the residual limb daily to be
sure that it lies completely FLAT on
the bed.
f. Phantom pain
What is the first intervention to
decrease phantom pain?
Diversional ACTIVITY
Seen more with AKAs
Usually subsides in 3 months.
3. Rehabilitation:
a. Why is limb shaping important?
PROSTESIS
b. How do you want the stump shaped
at the end? CONED SHAPE
c. What is worn under the prosthesis?
LIMB SOCK
d. Why is it important to strengthen
the upper body? YES
e. Is it okay to massage the stump?
Promotes CIRCULATION
and decreases TENDERNESS
f. How do you teach a client to
toughen the stump?
Press into a SOFT pillow
Then a FIRM pillow
Then the BED
Then a CHAIR
NCLEX Tip: Pain: use other things
first prior to pill; the definition of pain
is what the client says it
is; Always assess the clients pain by
having them rate their pain on a pain
scale (i.e. 0-10).