Orthopaedic Surgery - Pre and Post Operative Management in Adults

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Canberra Hospital and Health Services

Clinical Procedure
Orthopaedic Surgery – Pre and Post Operative Management
in Adults
Contents
Contents......................................................................................................................................1
Purpose.......................................................................................................................................2
Scope...........................................................................................................................................2
Section 1 – Standard pre and post operative care for all orthopaedic patients........................2
Section 2 – Neurovascular observations for orthopaedic patients............................................6
Section 3– Care of Patient with Fractured Pelvis........................................................................8
Section 4 – Care of a Patient with a Hip Fracture or Fractured Femur....................................11
Section 5 – Care of patient with upper limb fracture – humerus, radius, ulna or shoulder
replacement..............................................................................................................................13
Section 6 – Care of Patient with Lower Limb Fractures............................................................14
Section 7 – Care of patient having spinal surgery (orthopaedic surgeon)...............................15
Section 8 –Total Hip Replacement............................................................................................16
Section 9 – Total Knee Replacement (TKR)...............................................................................18
Section 10 – Application and management of traction............................................................19
Section 11 – Care and management of pinsites following application of external fixation.....21
Section 12 – Use of Knee Joint Continuous Passive Motion Machine (CPM)...........................24
Implementation........................................................................................................................25
Related Policies, Procedures, Guidelines and Legislation........................................................25
References................................................................................................................................26
Definition of Terms...................................................................................................................26
Search Terms.............................................................................................................................27
Attachment 1: Guide to assess the motor & sensory function of the Upper Limb Nerves..28
Attachment 2: Guide to assess the motor & sensory function of the Lower Limb Nerves..29
Attachment 3: Guide Vascular integrity...............................................................................30
Doc Number Version Issued Review Date Area Responsible Page

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Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register
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Purpose
To provide guidelines for the pre-operative and post-operative management of a patient

undergoing surgery for:
 total hip replacement (THR),
 total shoulder replacement (TSR) and
 total knee replacement (TKR)
 upper limb fractures
 lower limb fractures
 fractures of the pelvis orthopaedic spinal surgery.
It also provides guidelines for:

 Application and management of traction
 Use of knee joint continuous passive motion machine
 Care and management of pinsites following application of external fixation.
Scope
This document pertains to adult patients admitted for orthopaedic surgery involving joint
replacements and major limb fractures at the Canberra Hospital and Health Services (CHHS).
This document applies to the following CHHS staff working within their scope of practice:
 Medical Officers (MO)
 Registered Nurses (RN) and Enrolled Nurses (EN)
 Allied Health Professionals
 Students working under direct supervision.
Section 1 – Standard pre and post operative care for all orthopaedic patients
Day of surgery/admission
 Nursing staff caring for patient are to notify:
o Ward clerk of patient’s arrival to ward to ensure patient is admitted on the ACT
Patient Administration System (ACTPAS)
o Junior medical staff of patient’s arrival to the ward to medically admit the patient
o Clinical Nurse Consultant (CNC)/Team leader (TL) of patient’s arrival
o Pharmacy to ensure medications are reviewed and ordered.
 Complete nursing admission documentation on arrival in Patient Care and Accountability
Plan (PCAP) and if applicable the clinical hip fracture pathway, highlight those patients
who have high risks on assessment and implement a management plan
 Ensure vital signs are completed 4 hourly as per CHHS Vital Signs (Adult) and Early
Warning Scores procedure
 Ensure neurovascular observations are completed hourly for 24 hours following an injury
or post operatively as per Section 2 Neurovascular observations for orthopaedic patients

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 Ensure the following have been completed:

o Blood tests including group and screen
o Electro-cardiograph (ECG) if 50 years or above and/or if required
o Intravenous (IV) fluids charted if required
o Regular medications ordered on medication chart
o Vancomycin resistant enterococci (VRE) and Multi resistant staphylococcus aureus
(MRSA) swabs are taken/results available if from a nursing home or another hospital.
 Ensure Venous Thromboembolism (VTE) prophylaxis is in place including sequential
compression device (SCD) and graduated stockings on both limbs if no other injuries
present in lower limbs
 Consider an air mattress for the patient (not suitable for patients with a pelvic fracture)
 Ensure the patient has fasted from 2400 on day prior to surgery or as per medical orders-
refer to Fasting Guidelines-Elective and Emergency Surgery Patients Clinical Guideline
 Ensure the patient has showered/washed on the morning of surgery with Microshield
Chlorhexidine 2%
 Ensure the patient takes their essential regular medications on the morning of surgery as
outlined by the Medical Officer (MO) or the pre admission clinic
 Ensure the following has been attended:
o Consent form for treatment/surgery is valid, the operation site is marked and
initialled and the goals of care planning and resuscitation plan have been completed
by the Registrar
o Complete pre-operative checklist form and ensure all current medication charts, fluid
balance charts, IV therapy fluid charts and any hardcopy x-rays go with the patient to
theatre/holding bay
o Inform relatives of patients transfer to theatre if applicable
o Escort the patient to theatre if they meet the requirement for escort as per Patient
Escort and Transport within Canberra Hospital campus procedure.
 Refer patient to members of multidisciplinary team as required e.g. social worker maybe
required preoperatively
 Educate the patient on the importance of pressure injury prevention and document skin
integrity each shift as per Pressure Injury Prevention and Management procedure.
Day 0 post operation

Note: For routine first 24 hours post operative care refer to clinical procedure Post-
Operative Handover and Observations (First 24 hours) - Adult
Ward Nursing Staff to ensure:

 Patient bed area has been cleaned ready for admission/transfer
 All emergency equipment is functioning and available at the patient bed space, including
oxygen and suction
 Patient may have an alternating mattress if high risk for developing pressure injury (not
for pelvic fractures)

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 Monitor indwelling urinary catheter (IDC) output hourly for the first 24 hours; aim for
urine output to be at least 0.5 mL/kg/hr. If measurement does not meet this then inform
the patients MO
 Administer regular medications as per patient’s medication chart
 Assess patient’s pain levels and sedation score when vital signs are completed
Administer analgesia within prescribed limit as required based on the pain assessment
and sedation level. Encourage regular use of analgesia to promote improved movement
and mobility. If the patient is on a Patient Controlled Analgesia (PCA) or Continuous
Opioid infusion (COI), ensure patient is reviewed by the Acute Pain Service (APS)
 Commence aperients to assist in prevention of constipation
 Ensure post-operative VTE prophylaxis (heparin/clexane) is to be administered 6 hours
post completion of surgery unless contraindicated. Refer to the Venous
Thromboembolism (VTE) – Adult procedure
 Ensure thrombo-embolic device stockings (TEDS) /Calf compressors in use unless
contraindicated on both limbs
 Patient may require prophylactic intravenous antibiotics post surgery, check post-
operative record and medication chart
 Reinforce wound dressing if required. Do not remove theatre dressings
 If the patient is at risk of pressure injuries put preventative measures in place according
to level of risk assessment including minimum 4 hourly change of position and pressure
areas inspected as per Pressure Injury Prevention and Management procedure.

 For pelvic and hip fracture patient’s only, blood tests for Full Blood Count (FBC) and
Electrolyte Urea and Creatinine (EUC) to be taken at 0600 in case a blood transfusion is
required
 When the first 24 hours post-operative is completed continue to attend vital signs as per
Adult vital signs and Early warning scores procedure
 Neurovascular observations 24 hours post surgery, if stable, are recorded 4 hourly as per
Section 2 Neurovascular observations for orthopaedic patients. Continue to assess
patient’s pain levels and administer analgesia as prescribed
 Attend patient hygiene daily. Bed wash or shower depending on patient’s current
condition
 Consider IDC removal as per medical orders for lower limb surgery. If a patient has not
voided for 6 hours a bladder scan should be performed and medical staff informed of the
result, as per the Urology – Catheter Insertion and Management, Bladder Irrigation,
Nephrectomy and Trans Urethral Prostatectomy (TURP) Procedure.
 Continue to monitor intravenous therapy and IVC site
 Anticoagulation therapy to be administered as ordered:
o Anticoagulation therapy e.g. Clexane, patient education is to begin Day 1 post
operatively as required and to continue every day until discharge. It is essential this is
commenced early in admission to reduce delay in discharge. If patients are unable to
administer it themselves, they are advised to nominate a family member or friend
that will be able to do it for them. This person is then taught by the nurses how to
administer a subcutaneous injection. Should a patient have a medical condition

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rendering them unable to give their own Clexane and they have no family member
available then a referral for this is to be made to Discharge Liaison Nurse (DLN) for
follow up on discharge.
 Liaise with physiotherapists in the mobilisation of suitable patients-this will occur
according to postoperative instructions. Encourage mobilisation, repositioning and deep
breathing and coughing throughout the day
 Inspect the wound dressing for exudate. If exudate is visible may require a pressure
dressing- discuss with MO-do not remove theatre dressing
 Remove drains as per surgeon’s orders, this usually occurs on day 1
 Complete Patient Care & Accountability Plan (PCAP) and the hip fracture clinical pathway
if applicable for each shift and ensure patient is aware of plans for their care
 Make referrals to, as required:
o Social worker
o Occupational Therapist for loan equipment required on discharge
o Rehabilitation referral
o Discharge Liaison Nurse (DLN) to arrange community nursing to manage the wound
and organise the removal of staples/sutures after discharge. Staples/sutures can be
removed 14 days post surgery. A written order by MO is required for this. Be aware
some patients have dissolvable sutures so suture removal will not be required but
the suture ends will need to be trimmed to skin level.
Day 2 - 4 post operation

 Continue to attend vital signs as per Adult vital signs and early warning scores’
procedure.
 Neurovascular observations as per Section 2 Neurovascular observations for orthopaedic
patients
 Continue to assess and manage post operative pain
 Ensure bowels and bladder function is returning to normal
 Inspect the wound dressing for exudate. If exudate is visible, the wound may require a
pressure dressing therefore discuss with MO. Do not remove theatre dressing. Remove
drains as per surgeon’s orders, this is usually done on day 1. A negative pressure wound
therapy (NPWT) may have been applied to the wound– in this case the dressing remains
in situ for 7 days post operative. To apply dressing, follow the manufactures guidelines or
seek advice from Tissue Viability Unit (TVU) nurses. The TVU nurses can be contacted on
Pager via the Switchboard
 Perform daily skin integrity check, increase level of observation if patient at high risk for
a pressure injury. See Pressure Injury Prevention and Management procedure
 The patient should be mobilising as per physiotherapist’s recommendations and gait aid.
They should be becoming increasingly independent as the post op days increase
 Ensure the pharmacist is aware of discharge date/time and the discharge medications
script has been organised
 Patient education for anticoagulation therapy continues with the patient being given
opportunity to practice administration of Clexane injections. If the patient is unable to
self-administer the injections a family member or carer needs to be taught to perform
the task.
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Day of Discharge
 Anticoagulation education, if required, should be complete. The patient will receive an
initial supply of injections from the hospital pharmacy but will also require a script for
the 6 weeks duration of the therapy. Provide the patient with a Clexane kit, which
includes a sharps container (which can be taken to their General Practitioner (GP) or
local ACT Health centre for disposal)
 Provide the patient with copy of their discharge summary which should include their
outpatient clinic appointment date and time
 Ensure the patient is aware of what action to take should they suspect any complications
are developing e.g. wound breakdown, Deep Vein Thrombosis (DVT) breathing
difficulties or increase in temperature
 The patient is to be discharged prior to 10.00 a.m. If the patient is ambulant, utilise the
discharge lounge for the patient to wait for medications, transport etc.
 The patient will be supplied with discharge medications from the pharmacy. The
discharge medications can be collected by the patient from the pharmacy department or
may be delivered to the ward by the pharmacist.
Back to Table of Contents

Section 2 – Neurovascular observations for orthopaedic patients
Orthopaedic neurovascular observations are prescribed post injury and following procedures
which have the potential to affect motor, sensory and circulatory function. Neurovascular
observations are attended to accurately assess the nerve and vascular supply to a limb,
thereby identifying early any signs and symptoms that may identify the potential to cause
permanent dysfunction, such as Compartment Syndrome.
Frequency
Neurovascular observation should be attended to and documented:
 Hourly for the first 24 hours post injury, surgery, application of Plaster of Paris (POP),
backslab or fibre glass cast. If within normal parameters, fourth hourly for 24 hours and if
stable and satisfactory then 8 hourly, refer to Plaster and Polyester Cast Management.
When a new cast is applied, hourly observations commence again
 Immediately after application of traction, 30 minutes after application of traction, then
hourly for 24 hours. If observations are within normal parameters then 4 hourly for 24
hours, then if within normal parameters and stable 8 hourly until traction removed.
When traction is re-bandaged, conduct a full set of Neurovascular observations and
then again 30 minutes later
 If unable to palpate either a pedal or tibial pulse, contact the MO as they may need to
use a Doppler to find the pedal or tibial pulse.
Procedure
1. Explain and ensure the patient understands the signs and symptoms that need to be
reported, including :

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 Increased or change in pain

 Pins and needles
 Numbness.
2. Attend hand hygiene before touching the patient by either hand washing or using
Alcohol Based Hand Rub (ABHR)
3. Ensure patients skin and nails are clear of all skin preparations that may obscure natural
skin colour prior to assessment
4. Maintain the patients privacy while conducting the observations
5. Carry out vascular and neurological observations of affected limb as per Attachments 1, 2
or 3, use a good light source if observing at night time
6. Assess the vascular and sensory status of the limb below the level of injury
7. Compare neurovascular observations with the unaffected limb
8. Use a gentle touch with a finger initially. Increase pressure if sensation not detected. Ask
if sensation is normal or decreased
9. Attend hand hygiene by either hand washing or using ABHR after touching the patient
10. Record all observations on the Neurovascular Observation Chart
11. Immediately report any abnormal neurovascular observations to the MO and document
in the patient’s clinical record.
ALERT 1: If the limb is in a Plaster of Paris (POP)/ fibreglass cast, splinted or otherwise
partially covered, it may be difficult to carry out a full assessment. In this case, deficits in
the other tests, which are possible, should indicate a disruption of nerve or blood supply.
ALERT 2: If movement of the joint at or immediately below the injury is prohibited check
sensation and vascular status only. Check the movement of the most distal uninvolved
joint(s).
ALERT 3: The difference of skin tones between light-skinned and dark-skinned people
should be taken into account. Any deficits in nerve or blood supply will be noted when
compared with the unaffected limb.
If Neurological Deficit Noted In Upper Limb:

1. Check if a regional block was given and how long since it was administered
2. Check for swelling or oedema
3. Check all dressings or splinting along the limb to ensure they are not too tight
4. Check position of arm if elevated to ensure shoulder is not externally rotated too far
5. Check for pressure points under the elbow and upper arm especially for radial and ulnar
deficits
6. Check position of sling knot around the neck
7. Check technique when using crutches as pressure in the axilla can produce a brachial
plexus injury
8. Report all neurological deficits to a MO for review
9. Document all findings in the patients’ clinical record.

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The source of upper limb neurological deficits may be anywhere along the nerve pathway.
The route of the brachial plexus should be checked for pressure being exerted by external
forces.
ALERT: If damage to the nerve or blood supply of any limb is not detected within 6 hours
permanent dysfunction and deformity occurs due to muscle necrosis.
If Neurological Deficit Noted In Lower Limb:

1. Check if a regional block was given and how long since it was administered
2. Check for swelling or oedema
3. Check all dressings or splinting along the limb to ensure they are not too tight
4. Check any support used at the knee, to prevent external rotation, is not causing pressure
on the knee
5. Check hip is not dislocated
6. Report all neurological deficits to a MO for review
7. Document all findings in the patients’ clinical record.
The source of lower limb neurological deficits may be anywhere along the nerve pathway.
The route of the lumbosacral plexus should be checked for pressure being exerted by
external forces.
Additional Considerations for all Limb observations:

 Take into account environmental factors when assessing skin warmth, e.g. the room
temperature, exposure of the limb and use of ice/cold packs to reduce swelling
 If capillary refill is over 3 second, check for possible peripheral vascular disease.
ALERT:
Peripheral pulses may still be present in the initial stages of Compartment Syndrome
because the pathology takes place at the micro-vascular level.

Section 3– Care of Patient with Fractured Pelvis
Refer to Section 1 for standard pre and post operative care for all orthopaedic patients.
This patient may be admitted under the trauma team and may have other injuries which
need to be taken into account and considered when providing nursing care.
On admission to ward
Receive handover of care at the bedside from Emergency Department staff
Alert 1:
Transfer the patient with a Jordan frame until written instructions are provided as to how
the patient may be moved.

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Alert 2:
Patient should be nursed on a standard mattress to keep their pelvis stabilised.
Alert 3:
Observe the patient for Haematuria and advise MO immediately if signs or symptoms are
present.
Alert 4:
Acute compartment syndrome, fat emboli syndrome, Venous thromboembolism (VTE) and
Pulmonary Embolus (PE) are high risk complications with these injuries therefore it is
imperative neurovascular observations and vital signs are recorded as per Section 2.
Day of Surgery
As per Post Operative Handover and Observations – Adult Patients (First 24 hours)
procedure, all observations should be attended in the presence of the Post anaesthetic Care
Unit (PACU) nurse to ensure any abnormalities are identified and managed as soon as
possible. If the patient does not meet the PACU Discharge Criteria (Refer to Post Anaesthetic
Observation Chart), ward staff are to request the patient be reviewed by the anaesthetic
registrar or MO and/or returned to PACU for further recovery.
If the patient meets the Medical Emergency Team (MET) criteria, activation of MET should
occur.
In addition
 Neurovascular observations are required hourly for 24 hours, as per section 2
Neurovascular observations for orthopaedic patients
 Hourly urine measures need to be conducted for 24 hours, if haematuria is noted seek
MO review
 Provide 4 hourly pressure injury prevention including heel protection with silicone heel
dressings and leg troughs but not an alternating mattress. Oral analgesia needs to be
administered 1 hour prior to pressure area care
 Depending on the surgery performed the patient may require Jordan frame lifts, or may
be able to roll onto unaffected side. Check the patient’s clinical record for the height
permitted for the head of the bed to be elevated e.g. 30 degrees
 Patients with a fractured pelvis are not permitted monkey bars
 The patient should have bowel sounds present before commencing oral fluids and a light
diet. Diet and oral fluid status should be documented by MO
 If an external fixator is fitted, pin sites should be observed for excessive exudate see
Section 12 –Care and management of pinsites following application of external fixation
for more information
 Patient will require oral aperients to encourage normal bowel motions. Regular oral
aperients should be prescribed on the medication chart.

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 Blood tests for FBC and EUC’s to be taken at 0600hrs in case a blood transfusion is
required
 Record vital signs, neurovascular observations and urine output on fluid balance chart 4
hourly, for 24 hrs
 MO or nurse to refer patient to Physiotherapy for review and possible bed and chest
exercises. Patient may require bedrest for 6 weeks post surgery
 Patient should receive a sponge in bed, noting skin integrity and receive 4 hourly
pressure injury prevention. (Surgeon may order patients to have mechanical SCD’S Calf
compressors only)
 Oral fluids and light diet should be encouraged if patient has bowel sounds present
 Pinsite care begins day 1. as per Section 12 –Care and management of pinsites following
application of external fixation
 Pinsites are cleaned daily, covered with sterile dressing if sutures/staples in place. If
exudate is excessive pinsites may require cleaning twice a day (BD)
 Postoperative check x-ray attended.

 Patient will be reviewed by medical team and blood tests may be ordered
 Vital signs as per adult vital signs, neurovascular observations if stable are reduced to 8
hourly and IDC measures 4 hourly until IDC removed.
 Once bowels open and patient able to roll onto side IDC is usually removed at 2400hrs.
Some patients will require Jordan frame lifts for some time but IDC can be removed
(discuss with medical team).
Ongoing care
 Any sutures/staples are to be removed at 14 days with medical staff instructions
 Check x-rays usually performed at 4 and 6 weeks to assess bone healing
 Pinsite care daily as per Section 12 – Care and Management of Pinsites
 Daily sponge in bed continues. At 4 weeks on medical staff instruction patients may be
allowed to transfer to shower bath as long as pin sites (if present) have no exudate from
them
 Pressure injury prevention care continues throughout hospital stay as per Pressure Injury
Prevention and Management procedure
 Patients analgesia requirements usually decline as pain subsides and is usually controlled
by a maintenance dose
 VTE prophylaxis is paramount to prevent development of DVT /PE’s
 Any external fixators will be removed as per medical staff instructions in theatre around
the 6-8 week post-operative period. Mobilisation of the patient will occur as per medical
staff instructions
 Refer the patient to social work, occupational therapy and pharmacy for discharge
planning as required
 A period of rehabilitation maybe required in which case the patient will be referred to
rehabilitation services ( if the patient has private health insurance they can be referred to
a private rehabilitation service provider)
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 Ensure the patient is aware of their limitations for movement and requirements for
attending outpatient appointments for follow up. Educate the patient on potential
complications and what action to take if any are suspected
 The patient will be discharged when deemed safe by physiotherapist and medical staff
 Provide the patient with a discharge summary, x-rays (or CD) if required and discharge
medications as required.

Section 4 – Care of a Patient with a Hip Fracture or Fractured Femur
Note:
If the patient is 65 years and over with a hip fracture, in addition to the PCAP, the Hip
Fracture Clinical Pathway is required to be followed and completed daily.
Pre operation
 Vital signs performed 4 hourly and recorded as per adult vital signs
 Neurovascular observations hourly for 24 hours as per section 2 Neurovascular
observations for orthopaedic patients
 Elevate limb to heart level to reduce swelling. Patient may benefit from application of ice
to assist with reduction of swelling. If concerned that the patient is at risk of poor
ventilation/ atelectasis / hospital acquired pneumonia, the patient may benefit from a
partial recumbent/ sitting up position with legs elevated. Consult MO if concerned.
Alert-
Acute compartment syndrome, fat emboli syndrome, Venous thromboembolism (VTE) and
Pulmonary Embolus (PE) are high risk complications with these injuries therefore it is
imperative neurovascular observations and vital signs are recorded as per Section 2

procedure, all observations should be attended in the presence of the PACU nurse to ensure
any abnormalities are identified and managed as soon as possible. If the patient does not
meet the PACU Discharge Criteria (Refer to Post Anaesthesia Observation Chart), ward staff
are to request the patient be reviewed by the anaesthetic registrar or MO and/or returned
to PACU for further recovery. If the patient meets MET criteria, activation of MET should
occur.

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In addition
 Ensure it is documented by medical team, in the patients clinical records, if and how the
patient is to mobilise and provide 4 hourly pressure injury prevention including heels
protected with silicone heel dressings and may be off loaded in leg troughs. The patient
may have an alternating mattress if risk assessment deems it necessary
 The patient is to be rolled onto non affected side for nursing care. The patient may sit up
to 90 degrees but will often find it more comfortable to be in a reclined 30-40 degrees
position except at meal times or if the patient is at high risk of aspiration
 A Charnley Pillow is required for hip fracture patients post operatively, these can be
sourced from Ward 5A Orthopaedics
 The patient can usually commence on clear fluids and a light diet unless otherwise
documented by medical staff
 The patient will require oral aperients to encourage normal bowel motions. Regular oral
aperients should be prescribed on the medication chart.

 Blood tests for FBC and EUC’s to be taken at 0600hrs in case a blood transfusion is
required
 Physiotherapy review to mobilise patient- Hip Fractures may be on ‘Hip Precautions’
 Vital signs, neurovascular observations and urine output (if stable) can be measured and
recorded 4 hourly, for next 24 hours
 Commence Clexane education as patient will require 6 weeks of clexane therapy
 The patient can be encouraged to shower with assistance by nursing staff- this is an
opportunity to inspect the skin integrity and provide pressure injury prevention
 Intravenous fluids are to be ceased at the discretion of the medical staff
 The patient is encouraged to have analgesia on a regular basis; if the patient has a PCA in
place patient will be reviewed by APS
 Patient will have postoperative check x-ray
 The patient should be referred to an occupational therapist for assessment of
requirements for equipment on discharge and other allied health professionals as
required.

 For patients with hip fractures and who are over 65 years, as per the Hip Fracture Clinical
Pathway remove IDC at 2400hrs
 Continue Clexane education with the patient
 Patient will be reviewed by medical team and blood tests may be ordered and either a
blood or iron transfusion maybe required
 Patient will be reviewed by a physiotherapist and encouraged to increase mobility
Patient should be encouraged to sit out of bed for longer periods in the morning and
evening.
Day 3 post operation and discharge

 Continue with care as above
 Surgical dressing may be changed if required
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 Referral to rehabilitation facility if patient requires it. Discuss with Medical and Allied
Health team. Document referral in clinical record
 If the patient is being discharged to their home consider a referral to the Discharge
Liaison Nurse for community nursing for wound care and/or GP for removal of sutures at
14 days post surgery. Provide suture removal device to patient and sharps container for
Clexane syringes
 Ensure the patient is aware of limitations for movement and requirements for attending
outpatient clinic appointments for follow up
 Educate the patient on potential complications and what action to take if any are
suspected
 Provide discharge summary, x-rays (CD) and discharge medications as required.

Section 5 – Care of patient with upper limb fracture – humerus, radius, ulna
or shoulder replacement
Ensure vital signs 4 hourly and neurovascular observations hourly for 24 hours as per section
2 neurovascular observations on orthopaedic patients
Equipment:
• Patient usually fitted with sling in theatre.
Procedure
to PACU for further recovery.
If the patient meets the MET criteria, activation of MET should occur.
In addition
 Elevate arm in sling or rest arm on pillow, depending on type of fracture, to reduce
swelling and risk of potential complications
 Provide careful handling using cupped palms to ensure backslab is not damaged in first
48 hours while cast is still drying
 Give medications as charted- there maybe prophylactic antibiotics for 24 hours if patient
has had an open reduction and internal fixation; there may be extended period of
antibiotic therapy required if the fracture was a compound fracture
 Patient may commence on oral fluids and diet as tolerated
 The patient usually rests in bed until the next day.

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 Depending on the patients social circumstances the patient may be able to be discharged
day 1-2 post surgery or return to residential care when medical staff deem patient
medically stable for transfer.
 Refer the patient to Occupational Therapy for assessment pre discharge.

Section 6 – Care of Patient with Lower Limb Fractures
Alert: acute compartment syndrome, fat emboli syndrome and DVT and P/E are high risk
complications with these injuries. It is imperative to conduct neurovascular observations and
vital signs and report any concerns immediately to the medical officer. Fracture blisters also
require a medical review as it may mean that theatre is delayed until the blisters have
healed.
Day of surgery

meet the PACU Discharge Criteria (Refer to Post Anaesthetic Observation Chart), ward staff
Ensure Neurovascular observations are attended hourly for 24 hours as per Section 2
Neurovascular observations on orthopaedic patients. The patient may return from theatre
with a Camboot instead of a cast. The Camboot can be opened to perform neurovascular
observations.
In addition
 Elevate affected limb to heart level to reduce swelling and risk of potential
complications. The patient my benefit from the application of ice to reduce the swelling
 Provide careful handling using cupped palms to ensure the back slab, if present, is not
damaged in first 48 hours while cast is still drying
 Give medications as charted- there will be prophylactic antibiotics for 24 hours if patient
has had an open reduction and internal fixation; there may be extended period of
antibiotic therapy required if the fracture was a compound fracture
 Commence Clexane education as patient may require 6 weeks Clexane therapy if non
weight bearing
 The patient may commence on oral fluids and diet as tolerated

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 The patient usually rests in bed until the next day.

 Continue to elevate limb when not mobilising
 Check for wound ooze if the patient has a removable boot e.g., aircast splint or Camboot.
Check skin integrity and for signs of pressure injury or fracture blisters. If there are signs
of fracture blisters a medical review is required
 Continue Clexane education
 The patient, if medically stable and deemed safe for discharge by physiotherapy may be
discharged home (or to residential care) if social circumstances permit. This may occur
on day 1 post operation but more likely on day 2
 Ensure the patient is aware of limitations for movement and requirements for attending
outpatient clinic appointments for follow up
 Educate patient on potential complications and what action to take if any are suspected
 Provide the patient with a discharge summary, x-rays (CD) and discharge medications as
required
 Dressing change may take place day 3 if patient still in hospital otherwise this will occur
at the first outpatient clinic appointment at 2 weeks post surgery.

Section 7 – Care of patient having spinal surgery (orthopaedic surgeon)
Pre operative care

 Vital signs performed 4 hourly and recorded as per adult vital signs
 Neurovascular observations performed and recorded 4 hourly until patient goes to
theatre.
Day 0 Post operation

are to request the patient be reviewed by the anaesthetic registrar or medical officer and/or
returned to PACU for further recovery.

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Continue care as per Post operative Handover and Observations - Adult Patient (First 24
hours) procedure.
 Mobilisation must occur within physiotherapy service hours (0830- 1700) or with nursing
staff during weekends and after hours
 Weight bear as tolerated (WBAT) unless documented otherwise in patient’s clinical notes
 It is not necessary to mobilise these post spinal surgery patients on frames. The patients
need to limit the duration of sitting out of bed to 10-30 minutes each time as tolerated
 Routine spinal bracing (Sacro Cinch brace) is worn for 2 weeks post- operation
 The patient should be transferred via log rolling technique
 The patient is to be given two handouts with emphasis on care of the back post-
operatively and transverses abdominus (TA) strengthening exercises (supplied by
physiotherapists). Inspect wound dressing for exudate; if drain in place follow
postoperative instructions for removal.
Day 2 post operation and ongoing

 Continue to mobilise the patient for increasing periods of time
 Vital signs are to be performed as per vital signs and early warning scores procedure,
neurovascular observations if stable are reduced in frequency as per Section 2
Neurovascular observations of orthopaedic patients
 Observe wound site once per shift and document findings
 Patient discharge is decided upon by the treating physiotherapist and multidisciplinary
team when the patient demonstrates safety with mobility, transfers and activities of
daily living (ADL’s) in the ward environment.

Section 8 –Total Hip Replacement

In addition
 Neurovascular observations as per Section 2 Neurovascular observations in an
Orthopaedic patient
 Provide a Charnley pillow to maintain limb alignment. Charnley pillows can be sourced
from Ward 5A Orthopaedics.

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 Educate the patient on hip precautions to reduce the risk of dislocation occurring
 When moving the patient roll patient onto unaffected side, ensuring affected leg is
supported and does not cross the midline

 Continue care as per Post operative handover and Observations adult patients (first 24
hours)procedure
 IV therapy is usually ceased day 1 and intravenous cannula (IVC) removed when
antibiotics completed. Most patients will be able to return to normal diet and fluids
 Ensure that the patient is aware that discharge from hospital for this procedure is
routinely day 5 post operation (providing no complications occur).Patient may stay up to
7 days if bilateral joint replacements are performed
 Ensure patient has Day 1 x-ray performed (escort if required)
 Referrals to:
o Physiotherapist
o Occupational Therapist for equipment loan required on discharge
o Social worker if required
o Rehabilitation facility if required (private if has health insurance)
and organise the removal of staples/sutures on discharge if patient not returning to
an outpatient clinic. Staples/sutures can be removed 14 days. A written order by MO
is required for this. Be aware some patients have dissolvable sutures so suture
removal will not be required.

 Continue to attend to vital signs as per Adult vital signs and early warning scores
procedure
 Neurovascular observations as per Section 2 neurovascular observations in the
orthopaedic patient
 The patient is expected to be showering with less assistance from nursing staff than the
previous day’s requirements. Promote independence as much as possible according to
the patient’s pre-admission level of functioning
 Ensure the patients bowels and bladder are returning to normal function
 Observe surgical site dressing and change on day 3
 The patient should be mobilising as per physiotherapist’s recommendations. They should
be becoming increasingly independent as the post operation days increase
 Ensure the pharmacist is aware of discharge and discharge medications organised.
Day 5 post operation (expected day of discharge)

 Routinely Day 5 is the day of discharge for elective THR patients
 Patients are to be independently mobilising and deemed safe to discharge from:
physiotherapy, occupational therapy and also social work (if applicable). Safety for
discharge should be documented in the clinical record

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 Change patient’s dressing prior to discharge, and provide patient with staple remover
(for the community nurses) if required. If NPWT dressing is in place, the dressing may
need to be changed to a standard post operative film dressing
 Complete skin integrity check prior to discharge. If pressure injury/skin tears present
ensure documentation complete and information provided if patient transferring to
another facility. If patient is going home but requires ongoing care for these wounds
refer to DLN for community nursing follow up.

Section 9 – Total Knee Replacement (TKR)

Equipment: Patient may have an alternating mattress if assessed there is a need for it.
Alert: Patients having had Total Knee Replacement do not have a pillow under their leg. If
patient is at risk of a heel pressure injury, provide a Mepilex foam heel dressing for
protection and increase change of position frequency as well as educating the patient.
In addition
 Neurovascular observations as per Section 2 Neurovascular observations for Orthopaedic
patients.

 Post operative bloods to be taken at 0600. Remember to check the blood test results and
to notify the MO of any abnormalities, as to facilitate early blood transfusion if deemed
necessary
 Continue care as per Post operative handover and Observations adult patients (first 24
hours) procedure
 When first 24 hours is completed, continue to attend vital signs as per Vital signs and
Early warning scores procedure
 Neurovascular observations after 24 hours if stable are recorded 4 hourly as per Section
2 Neurovascular observations for orthopaedic patients

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 Ensure that patient is aware that discharge from hospital for this procedure is routinely
day 5 post operatively (providing no complications occur).Patients may stay up to 7 days
stay if bilateral joint replacements are performed
 Referrals to:
o Physiotherapist
o Occupational Therapist for equipment loan required on discharge
o Social worker if required
o Rehabilitation facility if required (private if has health insurance)
and organise the removal of staples/sutures on discharge if patient not returning to
an outpatient clinic. Staples/sutures can be removed 14 days.

 Continue to attend vital signs as per Adult vital signs and early warning scores procedure
 Neurovascular observations as per Section 2 Neurovascular Observations for
Orthopaedic Patients
 The patient is expected to be showering with less assistance from nursing staff than the
previous day’s requirements. Promote independence as much as possible according to
their pre-admission level of functioning
 Encourage mobilisation. The patient should be mobilising as per physiotherapist’s
recommendations. They should be becoming increasingly independent as the post
operation days increase
 Ensure the pharmacist is aware of discharge and discharge medications organised.
Day 5 post operation (expected day of discharge)

 Routinely Day 5 is the day of discharge for elective TKR patients
 Patients are to be independently mobilising and deemed safe to discharge from: medical
team, physiotherapy, occupational therapy and also social work (if applicable). Safety for
discharge should be documented in the Clinical record
 Change patient’s dressing prior to discharge, and provide patient with staple remover
(for the community nurses) if required. If NPWT dressing is in place, the dressing may
need to be changed to a standard post operative film dressing.

Section 10 – Application and management of traction
Equipment required:
 non adhesive skin extensions (discard white bandage that comes in pack)
 tensocrepe (pink) bandage (1 or 2 depending on limb size)
 elastoplast tape for securing cord ends
 weight bag
 goose neck or end of bed H configuration.
Note: Non adhesive Bucks traction is applied where possible as per medical orders.

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This traction is usually applied for a patient with the diagnosis of a fractured acetabulum or
fractured hip/femur with patient experiencing considerable spasm, or to maintain an
alignment of the fracture.
Alert 1: Traction should never be removed from the patient without manual traction being
applied unless there is a written order by medical staff. This may occur for procedures such
as MRI or CT scan.
Procedure
1. Attend hand hygiene before touching the patient by either hand washing or using AHBR
2. Ensure the patient has privacy during the procedure
3. Ensure patient is comfortable and offer pain relief
4. Obtain patients consent to apply traction
5. Obtain the type & weight of traction ordered & documented by the medical officer in the
patients clinical record
6. Explain the traction equipment, the procedure & the rationale for use to the patient
7. Ascertain where the site of injury is
8. Check skin on injured limb for wounds, abrasions, rashes and skin integrity. Areas of skin
damage will require protective dressing and wounds dressed appropriately prior to
traction application. The Achilles tendon area is at risk of skin damage due to slippage of
bandages. Silicone foam heel will provide protection
9. Check and record baseline neurovascular observations (Refer to Section 2, Neurovascular
observations for orthopaedic patients)
10. Prepare the bed space and equipment. A second person will be required to apply manual
traction to the limb at the heel and support the limb while skin extensions are bandaged
in place
11. Assist transfer of patient to appropriate traction bed, using appropriate Manual Handling
Device(s) (Refer to Manual Handling Policy)
ALERT 2:
Adhesive skin traction is no longer used.
ALERT 3:
Any problems with skin integrity, which will affect the safety of the patient in traction,
should be reported to the Medical Officer prior to application of traction.
12. Position the patient centrally in bed to ensure the line of pull will be correctly established
13. Bandage skin extensions in place. Foam should be over malleolus and end of extensions
should be a fist away from patient’s heel to allow enough planter flexion by the patient
without interfering with the traction. Secure bandage by 3 wraps just above ankle to
commence with and then in a figure 8 to within 1cm below tibial tuberosity
14. Rest affected limb on pillow or heel trough to ensure heel is off loaded
15. Attach one cord to the weight bag and over the pulley. Secure 2nd cord to main cord with
adhesive tape (pulley can accommodate one cord only). Gently release manual traction
once weight bag is in place
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16. Apply counter traction by elevating the foot of the bed 20 to 30 degrees. Ensure weight
bag is off the floor
17. Secure knots by taping the loose end to the main body of the rope. Taping the actual
knot will make observation and adjustments difficult
18. Perform neurovascular observations (Refer to Section 2 Neurovascular Observations for
Orthopaedic Patients):
 Immediately
 Then 30 minutes later
 Then hourly for 24 hours after initial traction application.
19. Re-bandage the traction whenever slippage of the skin extension is noted, otherwise this
can lead to skin integrity damage under the bandages
20. Neurovascular observations are also performed 30 minutes after traction is re-bandaged
(Refer to Section 2, Neurovascular Observations for Orthopaedic Patients policy)
21. Teach and encourage the patient to perform exercises to maintain full range of
movement of unaffected limbs
22. Attend hand hygiene after touching the patient by either hand washing or using ABHR
23. Any wound care requirements need to be documented on the General Wound
Assessment Form and Wound Assessment and Management Plan
24. Report any concerns to the MO.
Ongoing care
 Check the patient’s skin condition daily by washing the skin and reapplying the skin
extensions. No moisturiser is applied to the skin as this will increase the slippage of the
bandages
 Perform neurovascular observations as per Section 2 to ensure no adverse effects each
shift (Refer to Section 2, Neurovascular Observations for Orthopaedic Patients)
 Each shift check the traction set-up to ensure effectiveness and safety, maintaining the
line and magnitude of the traction pull and ensuring the correct weight is maintained.
Weight bag needs to be clear of floor at all times.

Section 11 – Care and management of pinsites following application of
external fixation
Equipment required
 Alcohol based hand rub
 Basic dressing pack
 Normal saline
 Gauze swabs
 Clean gloves
 Sterile gloves
 Personal Protective Equipment (PPE) including safety goggles / shield
 Antibiotic ointment (optional)
 Split foam dressing (optional)

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 Silver dressing (and secondary dressing) if required

 Oxygen tubing (optional)
 Wound swab (optional)
 Safety pin (if clamps in place)
 Clinical waste receptacle
 General waste receptacle.
Procedure
The initial post-op dressing remains intact for 24 hours post insertion of the pins, after which
pin site dressing/s are attended daily. If pinsite exudate is excessive twice daily pinsite care is
required.
For patient comfort and early assessment of potential problems, it is recommended that the
wound be inspected within 24 hours and on a daily basis. All pin sites should be redressed
after 24 hours as there is likely to be exudates in the first week. Pinsite infections can result
in osteomyelitis and delayed fracture healing.
External fixation is prescribed and applied by the medical officer. External skeletal pins are
used for external fixation or for skeletal traction. External fixators will be used when the
fracture is comminuted (many fragments) and/or compound (open) involving a wound,
which connects directly with the fracture site.
Attending Pin Site Dressing

1. Ensure patient has been offered analgesia prior to attending pin site dressings
2. Attend hand hygiene before touching the patient by either hand washing or using ABHR
3. Explain the procedure and obtain patient consent as per consent and treatment policy
4. Ensure the patient has privacy during the procedure
5. Don clean gloves and goggles/shield
6. Remove old dressing or sponges; warmed normal saline solution may be needed if
dressing/sponges have adhered to pins (if umbilical clamps are in place from theatre
these can be removed using a safety pin)
7. Discard waste into a clinical waste receptacle
8. Remove gloves
9. Attend hand hygiene by either hand washing or using ABHR
ALERT 1:
Aseptic technique must be rigorously maintained at all times with pin site care.
Follow principles outlines in the Aseptic technique procedure
10. Assemble clean dressing equipment on cleaned dressing trolley

11. Discard packaging in general waste receptacle
12. Attend hand hygiene by either hand washing or using ABHR
13. Don Sterile gloves
14. Observe general circulation of the limb

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ALERT 2:
Alcohol and iodine based solutions should be avoided for cleaning pins due to accelerated
corrosion of the metal and skin staining. Alcohol is damaging to the capillary bed when it
drips into the wound. Hydrogen peroxide should be avoided as it is damaging to tissue.
15. Remove any crusts that may have formed around the pins using gauze and warm normal
saline
 Rationale: Gentle removal of the crusts allows visualisation of the wound and
encourages free drainage of exudate, which may harbour infection if allowed to
collect below the skin
16. Leave the wound to dry after cleaning, or dry with a clean gauze
 Rationale: Moisture encourages colonisation
17. If exudates is present a foam dressing is cut and applied around the pin. If
sutures/staples are present a film dressing is used around the pinsites until the
staples/sutures are removed at 14 days
18. Observe the wound daily for redness, inflammation, odour, excess or purulent ooze
19. Provide the patient with education to observe and report these signs
20. Discard waste in clinical waste receptacle
21. Remove gloves
22. Attend hand hygiene be either hand washing or using ABHR
23. Document the procedure and findings in the patients Clinical Care Plan, Clinical Record
and Wound Assessment Chart see Wound Management Procedure.
Important considerations and wound observations

1. Where serous ooze persists or pus is present, a wound swab is taken and the MO
notified (Refer to Wound Management Procedure)
2. Observe the pin site for over-granulation of the skin growing up the pin site or tenting of
the skin around the pin
3. Where over-granulation has occurred or exudate is present, place a trimmed split foam
dressing over the pin site
 Rationale: This applies a small amount of pressure on the surrounding tissue to
prevent further tenting
4. Where there is increased tenderness or pain, redness, inflammation, odour, excessive
exudate or pus at the pin site alert the MO
5. Observe the pin for any movement and ensure pin attachments are secure
6. Oxygen tubing is applied to the pin points extending from the main frame to protect the
linen and blankets of the patient’s bed
7. Educate the patient on the importance of good pin site care and if they can perform the
procedure teach them to do so
8. Refer to DLN prior to discharge for community nursing follow up
Note: if the pin sites are dry and there is no exudate the patient is able to shower normally.
The external fixator can be left unprotected whilst showering provided there are no other
dressings or wounds.

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9. Document the procedure and findings in the PCAP and the patient’s clinical record. If
further wound care is required document on General Wound Assessment Chart and
Wound Assessment and Management Plan and refer to the Tissue Viability Unit (TVU)
nurses if concerned or support is required.
Note: if localised signs of infection are evident, silver dressings can be utilised for 2 weeks
and then reviewed. Consult the TVU nurses for advice.

Section 12 – Use of Knee Joint Continuous Passive Motion Machine (CPM)
Physiotherapists are required to ‘Fit’ a continuous passive motion (CPM) as a component of

post-operative care to patients in the recovery or ward environment. Adult and adolescent
patient with leg length suitable for this machine are covered by this procedure. Allied Health
Assistants or Nursing staff that assist with this process must also comply with this procedure
but are not expected to ‘fit’ a CPM.
It is the responsibility of the physiotherapist applying the CPM to ensure they are following
occupational health and safety guidelines; to ensure a clean CPM is applied, two staff
members are used for application and to inform the physiotherapy assistant of the cleaning
of the machine post use. It is the responsibility of the physiotherapy assistant to clean/store/
return the CPM to level 5 physiotherapy store room.
Procedure
CPM provides regular movement to the knee using an external motorised device which
passively moves the joint through a set arc of motion.
CPM is utilised to stimulate the formation of synovial fluid which nourishes articular
cartilage. The prevention of both the intra-articular adhesions and extra-articular
contractures helps to maintain the range of movement (ROM) of the joint. In addition the
application of CPM can prevent excess post operative swelling and reduce post operative
pain. Machines and covers are stored in level 5 physiotherapy room.
Application
1. Set the straps on the machine (the physiotherapist will demonstrate)
2. Educate the patient on the role of the CPM
3. Emphasise the importance of complying with the active exercise regime as well as the
CPM
4. Position the patient correctly:
 supine or ½ sitting only so as not to restrict knee Range of Movement (ROM)
 affected leg in slight abduction
5. Measure length of the lower leg from: knee joint to bottom of heel and knee joint to
ischial tuberosity(this can be with a tape measure or eyeball and corrected on the
patient)

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6. Adjust the machine to these lengths

7. Check the machine is in full extension for application of the patient’s leg
8. Place padding over the straps and then place the leg on machine
9. Assistance may be necessary unless the patient can complete a straight leg raise(SLR)
10. Assistance should be used to lift the CPM off the trolley onto patient’s bed
11. Check the position of the leg: patients knee joint must align with hinge and avoid limb
rotation i.e. knee and toes should point to the ceiling
12. Rolled towels may need to be used to support leg in the correct position
13. Adjust settings: speed (2-3), ROM ( as tolerated or ordered)
NOTE:
3 is the maximum speed that should be used on the CPM
14. Supply the patient with the control switch

15. Start the machine and wait until maximum knee flexion has been achieved-assess pain
16. Block the machine to avoid movement in the bed e.g. against foot of the bed or wedge
bolster between machine and bed end
17. Prescription of frequency and duration is determined on an individual basis following
discussion with the medical team and senior orthopaedic physiotherapist
18. Once a CPM has been fitted for the individual patient by the physiotherapist it may be
reapplied or removed by either an AHA or Nurse
19. Routine use of the CPM is prescribed for manipulation under anaesthetic (MUA).

Implementation
 This procedure will be available on the CHHS Policy Register.

 New staff in each division will require education as part of their orientation from those
designated/responsible for orientation to their areas.
 Medical staff will orientate other medical staff to the procedure.

Related Policies, Procedures, Guidelines and Legislation
Policies
 Patient Identification and Procedure Matching Policy
 Work Health and Safety Management (WHSMS), sub section 7.7 Hazardous Manual
Tasks and Office Ergonomics
 Nursing and Midwifery Continuing Competence Policy
Procedures
 Falls and Prevention Management Procedure
 Venous Thromboembolism (VTE) Prevention Procedure
 Pressure Injury Prevention and Management Procedure
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 Clinical Handover Procedure

 Wound Management Procedure
 ACT Health Patient Identification and Procedure Matching Procedure
 Patient Identification - Pathology Specimen Labelling Procedure
 Acute Pain Management Techniques Procedure
 Vital Signs and Early Warning Scores Procedure
 Post-operative Handover and observations-Adult patients (first 24 hours) Procedure
 Healthcare Associated Infections Procedure
Legislation
 Health Records (Privacy and Access) Act 1997
 Human Rights Act 2004
 Work Health and Safety Act 2011

References
1. ACT Health (2008) The Canberra Hospital, Acute Care Practice Manual, External Skeletal
Pin: Site Care ©. The Joanna Briggs Institute.
2. Maher A., Salmond S., Pellino, T., (2002) Orthopaedic Nursing, 3rd Edition W B
3. Saunders, Philadelphia, pp 177-180.
4. Dutton, M., (2004) Orthopaedic Examination, Evaluation and Intervention, 1st
5. Edition, McGraw-Hill, Dow.
6. Joanne Briggs Institute, TCH Manual, Neurovascular Assessment, Evidence Summary,
March 2006
7. Joanna Briggs Institute, TCH Manual, Observations: Neurovascular, Evidence Summary,
February 2009

Definition of Terms
Comminuted fracture: a fracture in many fragments

MRI – Magnetic Resonance Imaging
CT – Computed Tomography scan
Search Terms
Orthopaedic, Total Hip replacement, THR, Femur, Fracture, Total shoulder, TSR, Total knee,
TKR, Limb fractures, Ankle, Tibia, Fibula, pelvis, traction, Knee Joint, Continuous Passive
Motion Machine, CPM, Pinsites, External fixation, Skeletal, Camboot, Aircast

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Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services
specifically for its own use. Use of this document and any reliance on the information contained therein by any
third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.
Policy Team ONLY to complete the following:

Date Amended Section Amended Divisional Approval Final Approval
20 Jun 18 Complete Review Daniel Wood, ED SOH CHHS Policy Committee
This document supersedes the following:

Document Number Document Name
Traction - Pin Site Care And Management Following Application Of External Fixation,
TCH11:014
Ilizarov Fixator And Skeletal Pins Used
TCH11:013 Traction - Application And Management
TCH11:010 Neurovascular Observations For Orthopaedic Patients
TCH11:009 Mobilisation Of Patients With Lower Limb Injuries Or Post Lower Limb Surgery

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Attachment 1: Guide to assess the motor & sensory function of the Upper Limb Nerves
Circumflex, Ulnar, Radial, Median

Nerve Function Motor Normal Abnormal Sensory NORMAL ABNORMAL
CIRCUMFLEX Supplies deltoid muscle Actively abduct Can Unable to Touch over the Can feel Decreased
arm at the perform perform deltoid area: touch the or lack of
shoulder: movements. movements same as sensation.
MUSCULOCUT Supplies biceps and Actively flex arm Chart as due to pain, touch radial side unaffected Chart as
ANEOUS brachioradialis muscle at the elbow: full/ numbness or of the forearm: limb. Chart decreased
limited as full/ or absent.
ULNAR Supplies ulnar side Actively abduct movement. Touch on pad of Call medical
flexor muscles and (spread) all the Check if little finger: officer
hand's intrinsic fingers. passive
muscles. movement
RADIAL Supplies extensor Actively dorsiflex causes Sensory- touch
muscles of the arm. the hand. If in severe pain. on the back of
Plaster- actively Chart as the hand
hyperextend the decreased or between the
thumb and fingers absent – Call thumb and index
medical finger (thenar
officer space)
MEDIAN Supplies the forearm Oppose (touch) Touch index
flexor muscles thumb to all finger:
especially to the fingers of the
thumb. hand

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Attachment 2: Guide to assess the motor & sensory function of the Lower Limb Nerves
Sciatic, Femoral, Peroneal, Tibial

Nerve Function Motor Normal Abnormal Sensory Normal Abnormal
SCIATIC supplies the Thigh injury - actively Can perform Unable to Buttock or thigh Can feel touch Decreased or
hamstring flex of the knee movements. perform injury - touch all the same as lack of
muscles and Chart as full/ movements due surfaces of the unaffected sensation.
their divisions Tibial injury- actively to pain or foot limb. Chart as Chart as
plantarflex the ankle. numbness. Thigh injury- full/ decreased or
Actively evert and Check if passive touch all surfaces absent. Call
dorsiflex the foot movement causes of the foot medical Officer
severe pain. Tibial injury-
Buttock or thigh Chart as touch lateral
injury - actively move decreased or aspect of the calf,
foot and toes absent. Call heel and sole of
medical Officer the foot
FEMORAL supplies Actively extends knee: Touch medial

quadriceps aspect of foot:
femori
PERONEAL supplies the Actively dorsiflex Touch in the first
peroneal and ankle. If in POP- webbed space
anterior tibial actively extend toes at between the big
muscles. metatarsal and and second toes
phalangeal joints
TIBIAL supplies Actively plantarflex Touch on the
gastrocnemius the ankles and toes. If medial and lateral
and soleus in POP - actively surface of the
muscles, and the plantar-flex toes sole of the foot:
toes' flexors

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Attachment 3: Guide Vascular integrity
CHECK NORMAL ABNORMAL

Colour Skin colour distal to injury Skin colour should be the same as Skin different colour to unaffected limb.
unaffected limb. Chart as natural (for White or pale indicates inadequate
darker skin tones) or pink. arterial supply. Blue indicates inadequate
venous return. Chart as red, white or grey
(pale) or blue. Urgent medical review
Warmth Skin warmth distal to the injury Skin warmth should be the same as Skin different temperature to unaffected
unaffected limb. Chart as warm or cool limb. Cold indicates inadequate arterial
supply. Hot indicates inadequate venous
return. Chart as hot or cold.
Urgent medical review
Capillary return Squeeze the fleshy pad of a finger or toe Colour should return in 2 to 3 seconds. Colour takes longer than 3 seconds to
for 2 to 3 seconds. Release pressure and Chart time taken for colour to return return. Chart time taken for colour to
observe time taken for colour to return return
Peripheral pulse Peripheral pulse distal to injury Pulse should be the same strength as Diminished or no pulse palpable. Pulse
pulse on unaffected limb. Chart as may still be present with Compartment
present Syndrome. Chart as diminished or absent.
Swelling Compare size of limb with unaffected Limb is the same size as unaffected limb. Limb enlarged compared with unaffected
limb: Chart as nil limb. Chart as increased, decreased or
unchanged. Where swelling is abnormal it
is a good practice point to observe
swelling on patient handover so incoming
staff are aware of the degree of swelling

CHHS18/202 1.0 10/07/2018 01/07/2021 SOH 30 of 30

Orthopaedic Surgery - Pre and Post Operative Management in Adults

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Orthopaedic Surgery - Pre and Post Operative Management in Adults

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CHHS18/202

Canberra Hospital and Health Services

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To provide guidelines for the pre-operative and post-operative management of a patient

It also provides guidelines for:

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 Ensure the following have been completed:

Day 0 post operation

Ward Nursing Staff to ensure:

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Day 1 post operation

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Day 2 - 4 post operation

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 Increased or change in pain

If Neurological Deficit Noted In Upper Limb:

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If Neurological Deficit Noted In Lower Limb:

Additional Considerations for all Limb observations:

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Doc Number Version Issued Review Date Area Responsible Page

Day 1 post operation

Day 2 post operation

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Day 0 post operation

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Day 1 post operation

Day 2 post operation

Day 3 post operation and discharge

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Day 1 post operation

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Day 0 post operation

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 The patient usually rests in bed until the next day.

Day 1 post operation

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Pre operative care

Day 0 Post operation

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Day 1 post operation

Day 2 post operation and ongoing

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Day 0 post operation

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Day 1 post operation

Day 2 - 4 post operation

Day 5 post operation (expected day of discharge)

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Day 0 post operation

Day 1 post operation

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Day 2 - 4 post operation

Day 5 post operation (expected day of discharge)

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 Silver dressing (and secondary dressing) if required