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Orthopaedic Trauma. Objectives. Identify significant findings for emergent and urgent care of orthopaedic trauma patients Discuss at least 4 methods of fracture fixation List nursing interventions typical to trauma patients. Question A.
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Objectives • Identify significant findings for emergent and urgent care of orthopaedic trauma patients • Discuss at least 4 methods of fracture fixation • List nursing interventions typical to trauma patients
Question A Dan is a 26-year old who presents in the ED with an open fracture of the left femur following an ATV accident. What would be the initial treatment? a. Irrigate the wound and initiate antibiotic therapy. b. Administer tetanus prophylaxis. c. Check the ABC’s and maintain c-spine immobilization. d. Prepare patient for transfer to the OR.
Answer # A Dan is a 26-year old who presents in the ED with an open fracture of the left femur following an ATV accident. What would be the initial treatment? c. Check the ABC’s and maintain c-spine immobilization.
Trauma Statistics Every 6 minutes, someone in America dies from trauma: • Motor vehicles • Farm • Falls • Gunshot wounds
5th leading cause of death Leading killer of Americans < 45 yrs of age 1 in 4 (59 Million) Americans injured annually 36 Million ED visits Bimodal distribution High energy injuries in 16-35 y.o. Low energy injuries in elderly 70 + y.o. Following head injuries, pelvic fractures are most common cause of traumatic death Trauma Statistics
Mechanism of Injury:Energy Exchange • Kinetic/ Mechanical • Thermal • Chemical • Electrical • Radiant • Oxygen deprivation
Mechanism of Injury Penetrating Trauma • High velocity missiles (bullets) = crush/stretch • Low velocity stab wounds = shearing/stretch • High pressure injection = explosion/tearing
Mechanism of Injury Blunt Trauma • Compression/impact= compressed/shorten • Shearing=tearing/ dissection • Torsion/twisting= dislocation/ subluxation • Tensile/traction= stretching/tearing
Mechanism of Injury • Motor vehicle accidents • Falls • Pedestrian/Bikes/Skateboards/Scooters • Non-accidental; self-inflicted • Shaken baby • Diving • Gun Shot Wounds
Subluxation Displacement of bone from its normal joint position to the extent that articulating surfaces partially loose contact Commonly due to direct blow, indirect force or severe twisting,
Subluxation: Interventions Immediate closed reduction by trained personnel
Question # 1 The partial disruption of articulating surfaces is known as: c. subluxation
Dislocation Complete separation or displacement of articulating surfaces: • Urgent reduction required • Blood supply to bone • Nerve or vessel injury
Dislocation: Interventions • Reduction (return to normal anatomic alignment) • Manually • Regional block • General anesthesia • Open Reduction Internal Fixation
Radial Head Dislocation Radial dislocation may be caused by a sudden pull on a child's arm or hand. For first aid, immobilize the arm and take the child to the doctor's office or emergency room.
Subluxation & Dislocation: Nursing Diagnosis • Peripheral neurovascular dysfunction, risk for • Injury, risk for • Tissue perfusion, ineffective; peripheral • Physical mobility, impaired
Question # 2 A comminuted fracture may be classified as an injury in which: a. bone protrudes through the skin surface b. tendons and ligaments are disrupted c. the ends of bone are impacted into one another d. bone is fractured into two or more fragments.
Answer # 2 A comminuted fracture may be classified as an injury in which: d. bone is fractured into two or more fragments.
Fractures A break or disruption in the continuity of a bone
Fractures: Clinical Manifestations • Pain • Edema • Discoloration • Inability to function • Obvious deformity • Crepitus • Muscle spasm • Protruding bone
Fractures: Diagnostics • Radiologic exams • Plane films • X-ray a joint above and below injury • CT scan • MRI
Fractures • Predisposing factors: • Osteoporosis • Risk-taking behaviors • Mechanical overload to bone • Simplest method of classification is based on bone’s relationship to the environment: • Open • Closed
Comminuted Displaced/Non-displaced Complete/ Incomplete Avulsion Compression Buckle Butterfly Pathologic Articular Transverse Oblique Spiral Stellate Fatigue/Stress Segmental Fractures: Classifications
Fractures : Classification by Joint Involvement • Intraarticular: fracture extends into the joint • Intracapsular: fracture within joint capsule • Extracapsular: fracture extends outside capsule • Supracondylar: above condyle(s)
Fractures: Grading • Grade I • wound < 1cm; minimal contamination • Grade II • wound > 1 cm; moderate contamination • Grade III • wound > 6-8 cm; extensive damage to soft tissue, nerve, and tendon; high degree of contamination
Question # 3 Andrew has sustained an open book fracture of the pelvis after being pinned under his tractor. What life-threatening situation is causing his unstable BP? a. Compartment syndrome b. Overinflation of MAST trousers c. Incorrect application of external fixation d. Retroperitoneal hemorrhage
Answer # 3 Andrew has sustained an open book fracture of the pelvis after being pinned under his tractor. What life-threatening situation is causing his unstable BP? d. Retroperitoneal hemorrhage
Fractures: Emergency Management • Primary assessment for potentially life-threatening injuries • Fracture management often secondary • Most fractures not life threatening • Stabilize extremity • Cover wounds, open fractures with sterile saline dressing
Principles of Open Fracture Management • Treat open fractures as emergencies • Culture wounds prior to cleansing • Remove particulate matter in open fracture by copious lavage and debridement • Cover exposed fracture fragments with a sterile dressing • Debride devitalized tissue
Principles of Open Fracture Management (cont.) • Obtain x-rays of affected and amputated parts • Stabilize fractures with appropriate materials • Provide adequate soft tissue coverage • Administer antibiotic coverage and tetanus prophylaxis
Orthopaedic Emergencies • Spine fractures • Open book pelvic fractures • Dislocated joint • Elbow • Knee
Fracture Management: Goals • Prevent complications • Return to maximal function • Achieve best possible cosmetic result • Remember ABC’s • C-spine precautions
Radiographic Assessment C-spine Chest Pelvis Neurovascular Assessment Upper extremity Radial Median Ulnar Lower extremity Peroneal Tibial Assessment
Occult Injuries • Head injury- thoracic injury • Facial fractures- neck injury & airway occlusion • Rib fracture - pleural injury • Sternal bruise-cardiac contusion, aortic tear • Lap belt injuries- spine and abdominal injury
Occult Injuries (cont.) • Extremity injury- compartment syndrome • Open book pelvic injury • Benign to life-threatening (hemorrhage) • Urgent external fixation • Nerve damage • Bladder rupture • Spine fracture-ileus, neuro deficit
Hematoma formation 1 to 3 days Granulation 3 days to 2 weeks Callus formation 2 to 6 weeks Consolidation/Ossification 3 weeks to 6 months Remodeling Wolf’s Law Bone remodels in response to stress Fracture Healing
Trauma severity Type of bone Immobilization Infection Local pathology Avascular necrosis (AVN) Intra-articular fracture Systemic factors Osteoporosis Factors Affecting Fracture Healing
Fracture Management • Closed Reduction • Manual manipulation to restore alignment of bone ends • Casts/Splints/Sling/Swathe • Traction • External Fixation • Open Reduction Internal Fixation (ORIF) • Surgical realignment of fragments • Internal placement of pins, wires, plates, screws, intramedullary rods, nails,
Closed Reduction • Casting • Immobilize and support injured, deformed, and postoperative extremities • Protect realigned bone • Promote healing and early weight bearing • Serial casting to prevent or correct deformities
Closed Reduction • Complications of Casts • Compartment syndrome • Cast syndrome (superior mesenteric artery syndrome)
Question #4 Nursing assessment of skin traction such as Buck’s, Russell’s or Bryant’s traction includes: a. neurovascular assessment b. pin care c. alignment of balanced suspension d. prevention of skin breakdown
Answer #4 Nursing assessment of skin traction such as Buck’s, Russell’s or Bryant’s traction includes: a. neurovascular assessment d. prevention of skin breakdown
Traction Application of a pulling force to an injured or diseased part of the body or an extremity while a countertraction pulls in the opposite direction Countertraction is usually the patient’s body
Traction: Types • Manual Use of hands to exert pulling force • Skin Pulling force directly to the skin • Skeletal Traction forces directly to the bone
Reduce, realign, and promote healing of fractured bones Decrease muscle spasm Immobilization Treat deformities Rest joints Treat dislocations and subluxations Reduce deformities Prevent contractures Expand joint space Traction: Purposes