AMPUTATION

- refers to the removal of a body parts as a • Upper Extremity Amputation

result of trauma or surgical intervention
• usually necessitated by severe trauma,
it is necessitated by: malignant tumors, or congenital
malformation
• malignant tumor
Nursing Interventions
• trauma
• Provide care preoperatively
• acute arterial insufficiency
- initiation of exercises to strengthen
Types:
muscles of extremities in preparation
• Below-the-Knee Amputation (BKA) for crutch walking

• common in peripheral vascular disease - coughing and deep breathing exercises

• facilitates successful adaptation to - emotional support for anticipated

prosthesis because of retained knee alteration in body image
function
• Monitor vital signs and stump dressing
• BKA for signs of hemorrhage

• Place tourniquet at bed side for use

only if hemorrhage is life-threatening

• Elevate stump for 12 – 24 hours to

decrease edema; remove pillow after
this time to prevent contractures

• Provide stump care:

- keep bandaged to shrink and shape

stump in preparation for prosthesis

• when wound is healed, wash stump

• Above-the-Knee Amputation daily, avoiding the use of oil which may
cause maceration

• Leg Prosthesis (AKA)

• Prosthesis (BKA)

• Arm Prosthesis

• Arm Prosthesis

- apply pressure to the end of stump

with progressively firmer surfaces to
toughen the stump
 - encourage patient to move the stump
- place client with a lower extremity
amputation in a prone position twice
daily to stretch the flexor muscles and
prevent hip flexion contractures
• Teach client about phantom limb
sensation
phantom limb:
• physiologic reaction of the nerves in
the stump causing an unpleasant
feeling that the limb is still there; this
response may or may not be
precipitated by psychological overlay
• phantom limb pain
• when the unpleasant feeling become
painful or disagreeable
• characteristic of phantom limb pain:
sensations
• may be constant or intermittent, and
of varying severity
• institute care that may help relieve
phantom limb phenomenon:
 have the client look at the stump or
close eyes and put the stump through
full range of motion as if the full limb
were still there
• if the client continues to have severe
pain of long duration, medical therapy
may be instituted:
 injecting the nerve endings with
alcohol to give temporary relief
 surgical revision of the stump
Consider the special needs related to an upper
extremity amputation:
• mastery of the upper extremity
prosthesis is more complex than that
of a lower extremity prosthesis
• the client must do the bilateral
shoulder exercises to prepare for
fitting the prosthesis
• the artificial hand cannot be used
above the head or behind the back
because of the harnessing
• no artificial hand can duplicate all the
fine movements of the fingers and
thumb of the normal hand, although
the development of the electronic limb
does not negate the possibility for the
future
• there is a loss of sensory feedback;
therefore, the client must use visual
control at all times (a blind person
could not adequately use a functional
prosthesis)
• Support client through fitting,
application, and utilization of
prosthesis
• Encourage family to participate in care
• Allow the client to express emotional
reaction
FRACTURE
• is a break in the continuity of bone and
is defined according to type and extent
• it occurs when the bone is subjected to
stress greater than it can absorb
• can be caused by direct blow, crushing
force, sudden twisting motion, and
even extreme muscle contraction
• other structures also may be involved
(soft tissue trauma, ruptured tendons,
severed nerves and damaged blood
vessels)
 • CLOSED (SIMPLE) FRACTURE • EPIPHYSAL Fx

skin (mucous membrane) over fracture • GREENSTICK FRACTURE

area remains intact one of the bone is broken and the

other is bent; most commonly seen in children
• OPEN (COMPOUND)
• IMPACTED FX
the bone is exposed to air through a
break in the skin, and soft tissue and infection a fractured bone is driven inward
are common
• PATHOPHYSIOLOGY
• PATHOLOGIC Fx
Sudden direct/indirect force, fall, weakness
a fracture results from weakening of
by bone infection/bone tumors
the bone structure by pathological processes,
such as neoplasia or osteomalacia; also called 
spontaneous fracture
10-40 minutes, muscles surrounding the bone
• COMMINUTED Fx are flaccid then go to spasm

the bone is splintered or crushed, with 

three or more fragments
•
• COMPRESSION Fx
Interferes with vascular and lymphatic
a fractured bone compressed by other circulation
bone

• COMPLETE Fx/ TRANSVERSE Tissue surrounding fracture swells
the bone fractured straight across 
• INCOMPLETE Fx Healing begins
involves a portion of the cross section • Grading of Open Fracture
of the bone or may be longitudinal
• Grade I:
• DEPRESSED Fx
 with clean wound < 1 cm long
bone fragments are driven inward
• Grade II:
• SPIRAL
 with a larger wound without extensive
break partially encircles the bone soft-tissue damage
• OBLIQUE Fx • Grade III:
at an angle across the bone  the most severe; with extensive soft
• AVULSION Fx tissue damage

fragment of bone pulled off by a • OTA (Orthopaedic Trauma Association)

ligament or tendon attachment classification
 • there are five parts to the code:
 Bone
 Location
 Type
 Group
 Subgroup
• Clinical Manifestations
Pain:
• continuous type and increases in
severity until bone fragments are
immobilized
• muscular spasm in fractures helps to
minimize further movement of the
fracture fragments (natural splint)
• Localized Swelling and Discoloration
Loss of Function (Paralysis):
• cannot function properly because
normal function of the muscles
depends on the integrity of the bones
which they are attached
•
False motion:
• fractured area tends to move
unnaturally (false motion) instead of
remaining rigid as it normally would
•
Deformity:(Angulation, Shortening, Rotation)
• severely angulated fracture fragments
may be felt at the fracture site and
often push up against the soft tissue to
cause tenting effect on the angulation
• bending forces and unequal muscle
pull cause angulation
•
• shortening of the extremity occurs as
the bone fragments slide and override
each other(2.5-5 cm) because of the
pull of muscles on the long axis of the
extremity
•
• rotation occurs when fracture
fragment rotate out of their normal
longitudinal axis (produced by unequal
pull of the muscles that are attached to
the fracture fraghments)
Crepitus:
a grating sound may be heard as the bone
fragments rub against each other
•
• occurs as a result of trauma and
hemorrhage that follow a fracture
• these may not develop for several hour
or days after the injury
•
Local Shock:
• shortly after fracture occurred, nerve
function at the fracture site may be
temporarily lost
• the area may become numb, and the
surrounding muscles may become
flaccid
• Diagnostic Evaluation
• History and physical examination
• X-ray evaluation to confirm the
diagnosis and direct the treatment
 - the ease of diagnosis varies with the
location and severity of the fracture
• Emergency Interventions
• immobilize the body parts affected
(splinting)
• when moving the patient without
splint, the affected extremity must be
supported above and below the
fracture site
• accomplished by bringing the bone
fragment into apposition (ends in
contact) by manual manipulation
• the extremity is held in desired
position by cast, splint or other devices
•
• the immobilizing device maintains the
reduction and stabilizes the extremity
for bone healing

• immobilization of the long bones of the • x-rays are obtained to determine that
lower extremities may be the bone fragment is in correct
accomplished by bandaging the alignment
extremities together
• set of mechanisms for straightening
• broken bones or relieving pressure on
the skeletal system
In open fracture:
• CAST/SPLINT
• the wound is covered with a clean
(sterile) dressing to prevent •
contamination of the deeper tissue
Traction
• no attempt is made to reduce the
Skeletal Traction
fracture, even if one of the bone
fragments is protruding through the • traction is applied directly to the bone
wound by use of a metal pin or wire inserted
into or through the bone or by tongs
• Management
inserted into the skull
Principles:
• SKELETAL TRACTION
1. Fracture Reduction and Immobilization
• Overhead Bucks Traction
2. Preservation and Restoration of the
• Hip Traction
Injured Part
•
•
Skin Traction
Fracture Reduction and Immobilization:
• applies pull to an affected body
• reduction refers to restoration of the
structure by straps attached to the skin
fracture fragments into anatomic
surrounding the structure
rotation and alignment
• SKIN TRACTION
• Methods
• Thomas Traction
Closed Reduction
• Halo-Vest Traction
 • Bryant Traction
• Traction Bed
•
The purpose of traction is to:
• To regain normal length and alignment
of involved bone.
• To reduce and immobilize a fractured
bone.
• To lessen or eliminate muscle spasms.
• Nailing
• To relieve pressure on nerves,
especially spinal.
• To prevent or reduce skeletal
deformities or muscle contractures.
• and affected extremities during the
External Fixators
• Open Reduction Internal Fixation
(ORIF)
• through a surgical approach, the
fracture fragments are reduced
• internal fixation devices in the form of
metallic pins, wires, screws, plates,
nails or rods (ORIM) may be used to
hold bone fragments in position until
solid bone healing occurs
• SCREW & PLATING
• Open Reduction Intra-Medullary
•
Preservation and Restoration of the Injured
Part:
• is an ongoing process in the unaffected
period of immobilization

• is a method of immobilizing bones to • exercises designed to preserve

allow a fracture to heal.
• external fixation is accomplished by
placing pins or screws into the bone on
both sides of the fracture
function, maintain muscle strength,
and reduce joint stiffness should be
started early
•

• EXTERNAL FIXATORS • swelling is controlled by elevating the

injured extremity and applying ice as
Roger-Anderson External Fixator (RAEF) prescribed
• • frequent neurovascular monitoring is
Ilizarov External Fixator (Circular) done, and the orthopedist is notified
immediately if neurovascular
• compromise is identified
• Hoffman •
• SUZUKI • encouraging the patient to participate
in ADLs, which promote independent
• PELVIS EXTERNALFIXATOR
functioning and self-esteem
• WRIST EXTERNAL FIXATOR
• gradual resumption of activities is
• promoted within the therapeutic
prescription
 • Bone Healing
Reactive Phase:
• after fracture, the first change is the
presence of blood cells within the
tissues which are adjacent to the injury
site
• soon after fracture, the blood vessels
constrict, stopping any further
bleeding
•
• within a few hours after fracture, the
extravascular blood cells, known as a
"hematoma", form a blood clot
• FRACTURE HEMATOMA
• •
• all of the cells within the blood clot
and some of the cells outside of the
blood clot, but adjacent to the injury
site, also degenerate and die
• within this same area, the fibroblasts
survive and replicate
• they form a loose aggregate of cells,
interspersed with small blood vessels,
known as granulation tissue
• •
Reparative Phase:
- days after fracture, the cells of the
periosteum replicate and transform
• periosteal cells proximal to the
fracture gap develop into
chondroblasts and form hyaline
cartilage
• periosteal cells distal to the fracture
gap develop into osteoblasts and form
Remodelling Phase:
woven bone
•
• fibroblasts within the granulation
tissue also develop into chondroblasts
and form hyaline cartilage
• these two new tissues grow in size
until they unite with their counterparts
from other pieces of the fracture
(fracture callus)
•
• eventually, the fracture gap is bridged
by the hyaline cartilage and woven
bone, restoring some of its original
strength
• the next phase is the replacement of
the hyaline cartilage and woven bone
with lamellar bone
• the replacement process is known as
endochondral ossification with respect
to the hyaline cartilage and "bony
substitution" with respect to the
woven bone
•
• "vascular channels" with many
accompanying osteoblasts penetrate
the mineralized matrix
this new lamellar bone is in the form of
trabecular bone
• eventually, all of the woven bone and
cartilage of the original fracture callus
is replaced by trabecular bone,
restoring most of the bone's original
strength
• ENDOCHONDRAL OSSIFICATION
•
• remodeling process substitutes the
trabecular bone with compact bone
 • trabecular bone is first resorbed by • Inadequate fracture immobilization
osteoclasts, creating a shallow
• Infection
resorption pit known as a "Howship's
lacuna“ • Complications from the treatment
• • Metabolic problems
• then osteoblasts deposit compact bone
within the resorption pit

• eventually, the fracture callus is

remodelled into a new shape which
closely duplicates the bone's original
shape and strength

• BONE REMODELLING

• BONE HEALING PROCESS

• Factors Affecting Bone Healing

• weeks to months are required for most

fracture to heal

 Reduction of the displaced fracture

must be accurate and successfully
maintained to ensure healing

 Adequate blood supply

 Age of patient

 Type of fracture (flat bone fractures

heal faster)

 Weight-bearing

Factors that may interrupt fracture healing:

• Loss of fracture hematoma by

debridement

• Devitalization of the adjacent tissues

by inadequate blood supply

• Extensive space between bone ends

• Interposition of soft tissue between

bone ends