MANAGEMENT OF FRACTURES

CASTS
A cast is used to immobilize and hold bone fragments during reduction. It is made up of layers of plaster or fiberglass (water-activated polyurethane resin) bandages molded to the body part that it encases.

Indications * To apply uniform compression of soft tissues * To permit early mobilization * To correct and prevent deformities * To support and stabilize weak joints

Types of Casts 1 Short and long -arm cast for the upper limbs. : Extends from below the elbow to the proximal palmar crease. 2 Gauntlet Cast (thumb spica): from below the elbow to the proximal palmar crease. 3 Short and Long-leg Cast for the lower limbs. 4 Body Cast: Encircles the trunk stabilizing the spine. 5 Spica Cast: Incorporates the trunk and extremity. 6 Shoulder spica: encloses trunk, shoulder, and elbow. 7 Hip spica: encloses trunk and a lower extremity and can be single or double. Single extends from nipple line to include pelvis and one thigh while double includes both thighs and lower legs. 8 Cast-brace: External support about a fracture that is constructed with hinges to permit early motion of joints, early mobilization, and independence. 9 Cylinder Cast: Can be used for upper or lower extremity e.g. fracture or dislocation of knee or elbow dislocation.

Complications of Casts * Pressure of cast may cause necrosis, pressure sores, and nerve palsies. * Compartment syndrome * Cast syndrome associated especially of body cast, resulting to nausea, vomiting, and abdominal distention; superior mesenteric artery syndrome, resulting in diminished blood flow to the bowel and intestinal obstruction; Acute anxiety reaction symptoms associated with confinement in a space. * Thrombophlebitis * Psychological reaction (e.g., depression) associated with immobility, dependence, and loss of control.
Nursing Assessment * Assess neurovascular status of the extremity with a cast for signs of compromise to include Pain, Swelling, Discoloration, Paresthesia, Slow capillary refill; diminished or absent pulse and Paralysis. * Assess skin integrity of casted extremity for severe initial pain over bony prominences; this is a warning symptom of an impending pressure sore. Pain increases when ulceration occurs, there may be odor and drainage on cast. * Assess cardiovascular, respiratory, and GI systems for possible complications of immobility. * Assess psychological reaction to illness, cast, and immobility.
Nursing Diagnoses * Ineffective Tissue Perfusion (extremity) related to swelling and constrictive bandage or cast * Impaired Physical Mobility related to condition and casting * Risk for Injury related to potential complications
Nursing Interventions 1. Maintaining Adequate Tissue Perfusion * Elevate the extremity on cloth-covered pillow above the level of the heart. Keep the heel off the mattress. * Avoid resting cast on hard surfaces or sharp edges that can cause denting or flattening of the cast and consequent pressure sores. * Handle moist cast with palms of hands and turn patient every 2 hours while cast dries. * Assess neurovascular status hourly during the first 24 hours, then less frequently as condition warrants and swelling resolves. * If symptoms of neurovascular compromise occur, notify the doctor immediately. prepare and assist with relieve constriction. * If symptoms of pressure area occur, a window or hole cut is cut so that the skin at the pain point can be examined and treated. The window must be replaced so the tissue does not swell and cause additional pressure problems at window edge. 2. Minimizing the Effects of Immobility * Encourage the patient to move about as normally as possible. * Encourage compliance with prescribed exercises to avoid muscle atrophy and loss of strength; Active ROM for every joint that is not immobilized at regular and frequent intervals and Isometric exercises for the muscles of the casted extremity. Instruct patient to alternately contract and relax muscles without moving affected part. * Reposition and turn patient frequently. * Avoid pressure behind knees, which reduces venous return and predisposes to thromboembolism. * Use antiembolism stockings as prescribed. * Administer prophylactic anticoagulants as prescribed. * Encourage deep-breathing exercises and coughing at regular intervals to prevent atelectasis and pneumonia. * Observe for symptoms of cast syndrome characterized with nausea, vomiting, abdominal distention, abdominal pain, and decreased bowel sounds. * Encourage patient to drink plenty of fluids to avoid urinary infection and calculi secondary to immobility.
NB:
People at high risk for pulmonary emboli include older adults and persons with previous thromboembolism, obesity, heart failure, or multiple trauma.These patients require prophylaxis against thromboembolism.

Cast syndrome (superior mesenteric artery syndrome) is a rare sequela of body cast application, yet it is a potentially fatal complication. It is important to teach patients about this syndrome because this can develop as late as several weeks after cast application.
Preventing Complications * Encourage balanced nutritional intake. * Facilitate patient participation in care planning and activities. Encourage verbalization of feelings and concerns regarding casting. * Provide and encourage diversional activities. * Encourage the patient to maintain physiologic position.
Specific Care for Patient in Spica or Body Cast involves positioning e.g. Placing a bedboard under the mattress for uniform support of the body and supporting the curves of the cast with cloth-covered flexible pillows to prevents cracking and flat spots while cast is drying.

3. Turning * Move the patient to the side of the bed using a steady, even pulling motion. * Instruct the patient to place arms at side or above head. * Turn the patient as a unit. Avoid twisting the patient in the cast. * Turn the patient toward the leg not encased in plaster or toward the unoperated side if both legs are in plaster. 4. Hygienic Care * Provide hygienic care of the patient. * Protect cast from soiling. 5. Skin Care * Inspect skin for signs of irritation around cast edge. * Reach up under cast, and massage accessible skin. * Protect the toes from the pressure of the bedding. 6. Patient Education and Health Maintenance * Instruct patient to check neurovascular status and to control swelling. * Instruct patient to alternate ambulation with periods of elevation to the cast when seated. Encourage the patient to lie down several times daily with cast elevated. * Advise patient to prevent skin irritation at cast edge * Instruct patient to actively exercise every joint that is not immobilized to maintain muscle strength and to prevent atrophy. * Advise to avoid getting the cast wet. Instruct to avoid weight bearing or stress on plaster cast for 24 hours. * Instruct to report if the cast cracks or breaks and to avoid trying to fix it. * Teaching Safety Measures to prevent accidents like falls. * After cast removal instruct to clean skin with mild soap and water, blot dry, and apply emollient lotion to dry skin. Warn against scratching the skin. * Advise to continue prescribed exercises. Gradually resume activities, and elevate extremity to control swelling.
Evaluation: Expected Outcomes * No pain, discoloration, or sensory or motor impairment of affected extremity; warm, with good capillary refill * Ambulates with assistance; performing active ROM and isometric exercises every 1 to 2 hours * No signs of complications

TRACTION
Traction is force applied in a specific direction. To apply the force needed to overcome the natural force or pull of muscle groups, a system of ropes, pulleys, and weights is used.

Purposes of Traction * To reduce and immobilize fracture. * To regain normal length and alignment of an injured extremity. * To lessen or eliminate muscle spasm. * To prevent deformity. * To reduce pain.
Types of Traction i. Running Traction: A form of traction in which the pull is exerted in one pane. May use either skin or skeletal traction. Buck's extension traction is an example of running skin traction. | | ii. Balanced Suspension Traction: Uses additional weights to counterbalance the traction force and floats the extremity in the traction apparatus.The line of pull on the extremity remains fairly constant despite changes in the patient's position.
Application of Traction
Traction may be applied to the skin or to the skeletal system. * Skin Traction: Accomplished by applying a light force that pulls on tape, sponge rubber, or special device that is in contact with the skin.The pulling force is transmitted to the musculoskeletal structures. Skin traction is used as a temporary measure in adults to control muscle spasm and pain. It is used before surgery in the treatment of hip fracture (Buck's extension) and femoral shaft fractures (Russell's traction).It may be used definitively to treat fractures in children. * Skeletal Traction: Traction applied by the orthopedic surgeon under aseptic conditions using wires, pins, or tongs placed through bones.Skeletal traction is used most frequently in treating fractures of the femur, humerus (supracondylar fractures), tibia, and cervical spine.

Complications * Infection of pin tracts in skeletal traction. * Skin breakdown and dermatitis under skin traction. * Complications of immobility: Stasis pneumonia, Thrombophlebitis, Pressure ulcers, Urinary infection and calculi and Constipation
Nursing Assessment * Assess for pain, deformity, swelling, motor and sensory function, and circulatory status of the affected extremity. * Assess skin condition of the affected extremity, under skin traction and around skeletal traction, as well as over body prominences throughout the body. * Assess for signs and symptoms of complications. * Assess traction equipment for safety and effectiveness. The patient is placed on a firm mattress. The ropes and the pulleys should be in alignment. The pull should be in line with the long axis of the bone. Any factor that might reduce the pull or alter its direction must be eliminated. This means that he weights should hang freely, ropes should be unobstructed and not in contact with the bed or equipment.The amount of weight applied in skin traction must not exceed the tolerance of the skin. The condition of the skin must be inspected frequently. * Assess emotional reaction to condition and traction. * Assess patient’s understanding of the treatment plan.
NB: Traction is not accomplished if the knot in the rope or the footplate is touching the pulley or the foot of the bed or if the weights are resting on the floor. Never remove the weights when repositioning the patient who is in skeletal traction because this will interrupt the line of pull and cause the patient considerable pain.

Nursing Diagnoses * Impaired Physical Mobility related to traction therapy and underlying pathology * Risk for Impaired Skin Integrity related to pressure on soft tissues * Risk for Infection related to bacterial invasion at skeletal traction site * Ineffective Tissue Perfusion: Peripheral related to injury or traction therapy
Nursing Interventions * Minimizing the Effects of Immobility: Encourage active exercise and deep breathing exercises. * Every complaint of the patient in traction should be investigated immediately to prevent injury. * Maintaining Skin Integrity: Examine bony prominences frequently for evidence of pressure or friction irritation. Observe for skin irritation around the traction bandage. * Avoiding Infection at Pin Site: Monitor vital signs for fever or tachycardia. Assess for other signs of infection: heat, redness, fever. If directed, clean the pin tract with sterile applicators and prescribed solution. * Promoting Tissue Perfusion * Assess motor and sensory function of specific nerves that might be compromised. * Determine adequacy of circulation (e.g., color, temperature, motion, capillary refill of peripheral fingers or toes). * Patient Education and Health Maintenance
Evaluation: Expected Outcomes * Exercises as instructed; deep breathes hourly; fluid intake 2,000 to 2,500 mL/24 hours * No signs of skin breakdown under traction bandage or over bony prominences * No drainage, redness, or odor at pin site * No motor or sensory impairment; good capillary refill, color, and warmth of extremity

EXTERNAL FIXATION
External fixation is a technique of fracture immobilization in which a series of transfixing pins is inserted through bone and attached to a rigid external metal frame. The method is used mainly in the management of open fractures with severe soft tissue damage.

Advantages * Permits rigid support of severely comminuted open fractures, infected nonunions, and infected unstable joints. * Facilitates wound care (frequent debridements, irrigations, dressing changes) and soft tissue reconstruction (delayed wound closure, muscle flaps, skin grafts). * Allows early function of muscles and joints. * Allows early patient comfort. * Circular Fixators may be used for limb lengthening, correction of angulation and rotation defects, and in treatment of nonunion

Management * Adjustments are made daily at about 1 mm/day, stimulating callus and bone formation. * Patient compliance is essential. * Weight bearing is encouraged. * When the desired length or correction is achieved, the fixator is left in place without further adjustment until bone healing occurs.
Application of External Fixator * This is done under general anesthesia, the skin is cleaned and transfixing pins are inserted into the bone through small incisions above and below the fracture. * After reduction of the fracture, the appliance is stabilized by adjusting and tightening the bars connecting the sets of pins. * The sharp pinheads should be covered with plastic, cork, or rubber covers to protect the other extremity and caregivers.
Nursing Assessment * Determine the patient's understanding of procedure and fixation device. * Evaluate neurovascular status of involved body part. * Inspect each pin site for redness, drainage, tenderness, pain, and loosening of the pin. * Inspect open wounds for healing, infection, or devitalized tissue. * Assess functioning of other body systems affected by injury or immobilization.
Nursing Diagnoses * Anxiety related to appearance of external fixation device and wound * Risk for Peripheral Neurovascular Dysfunction related to swelling, fixator, and underlying condition * Risk for Infection related to open injury and skeletal pin insertion * Impaired Physical Mobility related to presence of fixator and condition
Nursing Interventions 1. Relieving Anxiety: Emphasize the positive aspects of this device in treating complex musculoskeletal problems. Encourage the patient to verbalize reaction to the device. Involve the patient in care and in the management of external fixator. 2. Maintaining Intact Neurovascular Status 3. Provide site and fixator care. 4. Wound care: The open wounds at the fracture site are usually treated by daily dressing changes using sterile technique.Monitor for local and systemic indicators of infection. 5. Encouraging Mobility. 6. Patient Education and Health Maintenance: Instruct to inspect around each pin site daily for signs of infection and loosening of pins. Watch for pain, soft-tissue swelling, and drainage. Teach how to clean around each pin daily, using aseptic technique and not to touch wound with hands.Encourage the patient to follow rehabilitation regimen.
Evaluation: Expected Outcomes * Verbalizes understanding of and comfort with fixator device * Swelling relieved; neurovascular status intact * No drainage or signs of infection at pin sites; pin tracts remain intact, no loosening of pins * Ambulating with crutches as directed
ORTHOPEDIC SURGERY

Types of Surgery * Open reduction: reduction and alignment of the fracture through surgical incision. * Internal fixation: stabilization of the reduced fracture with use of metal screw, plates, nails, or pins. * Bone graft: placement of autologous or homologous bone tissue to replace, promote healing of, or stabilize diseased bone. * Arthroplasty: repair of a joint; may be done through arthroscopy or open joint repair. * Joint replacement: a type of arthroplasty that involves replacement of joint surfaces with metal or plastic materials. Total joint replacement is the replacement of both articular surfaces within a joint. * Meniscectomy: excision of damaged meniscus (fibrocartilage) of the knee. * Tendon transfer: movement of tendon insertion point to improve function. * Fasciotomy: cutting muscle fascia to relieve constriction or contracture. * Amputation: removal of a body part.
Preoperative Management and Nursing Care * Hydration, protein, and caloric intake are assessed to maximize healing and reduce risk of complications. Correction is done by providing I.V. fluids, vitamins, and nutritional supplements as indicated. * If person has had previous corticosteroid therapy, it could contribute to current orthopedic condition (aseptic necrosis of the femoral head, osteoporosis) as well as affect the patient's response to anesthesia and the stress of surgery; may need corticotropin postoperatively. * Evaluate for infection (cold, dental, skin, UTI), which could contribute to development of osteomyelitis after surgery. It is important to determine whether preoperative antibiotics will be necessary. * Coughing and deep breathing, frequent vital sign and wound checks. * The patient should practice voiding in bedpan or urinal in recumbent position before surgery. This helps reduce the need for postoperative catheterization. * The patient is acquainted with traction apparatus and the need for splint or cast, as indicated by type of surgery.
NB: Many elderly patients are at risk for poor healing due to undernutrition.

Postoperative Management and Nursing Care * Neurovascular status is monitored, and swelling caused by edema and bleeding into tissues needs to be controlled. * The affected area is immobilized and activity limited to protect the operative site and stabilize musculoskeletal structures. * Hemorrhage and shock, which may result from significant bleeding and poor hemostasis of muscles that occur with orthopedic surgery, are monitored. * Complications of immobility are prevented through aggressive and vigilant postoperative care.
Complications
* Compartment syndrome * Shock * Atelectasis and pneumonia * Osteomyelitis, wound infections * Thromboembolism * Fat embolus * Anemia
Nursing Diagnoses * Risk for Deficient Fluid Volume related to hemorrhage * Ineffective Breathing Pattern related to effects of anesthesia, analgesics, and immobility * Risk for Peripheral Neurovascular Dysfunction related to swelling * Acute Pain related to surgical intervention * Risk for Infection related to surgical intervention * Impaired Physical Mobility related to immobilization therapy and pain * Imbalanced Nutrition: Less Than Body Requirements related to blood loss and the demands of healing
Nursing Interventions 1. Monitoring for Shock and Hemorrhage: Evaluate the blood pressure and pulse rates frequently to rule out shock. Monitor for hemorrhage as orthopedic wounds have a tendency to ooze more than other surgical wounds. Measure suction drainage if used. 2. Promoting Effective Breathing Pattern: Give respiratory depressant drugs cautiously. Opioid analgesic effects may be cumulative. Monitor respiration depth and rate frequently. Change position every 2 hours to mobilize secretions and helps prevent bronchial obstruction. 3. Monitoring Peripheral Neurovascular Status: Watch circulation distal to the part where cast, bandage, or splint has been applied. Prevent constriction leading to interference with blood or nerve supply. Elevate affected extremity to reduce swelling and bleeding into tissues. Check pulses of affected extremity and compare with unaffected extremity. 4. Relieving Pain: Institute pain relief measures as prescribed as well as nursing measures as indicated: backrubs, soft light, soft tranquil music. Be aware that muscle spasms may contribute to pain experience. 5. Preventing Infection: Monitor vital signs for fever, tachycardia, or increased respiratory rate, which may indicate infection. Examine incision for redness, increased temperature, swelling, and induration. Note character of drainage. Administer antibiotic therapy as prescribed. Maintain aseptic technique for dressing changes and wound care. 6. Minimizing the Effects of Immobility: Encourage patient to exercise by self with a planned program of exercise as soon as possible after surgery. * Providing Adequate Nutrition: Watch for signs and symptoms of anemia, especially after fracture of long bones, Monitor hemoglobin and hematocrit levels. Encourage high-iron diet, and administer blood products and iron supplements as directed.Provide a balanced diet, and increase fluids and fiber to reduce incidence of constipation associated with immobility. Avoid giving large amounts of milk to orthopedic patients on bed as it adds to calcium pool in the body and demands more calcium excretion by the kidneys, predisposing to the formation of urinary calculi. 7. Patient Education and Health Maintenance * Teach patient activities that will minimize the development of complications (eg, turning, ankle pumps, coughing, and deep breathing). * Instruct patient in dietary considerations to facilitate healing and minimize development of constipation and renal calculi. * Inform patient of techniques that facilitate moving while minimizing associated discomforts (eg, supporting injured area and practicing smooth, gentle position changes). * Encourage long-term follow-up and physical therapy (PT) exercises as prescribed to regain maximum functional potential.
Evaluation: Expected Outcomes * Blood pressure stable; drainage from wound less than 30 mL * Respirations, deep; performing effective deep breathing and coughing every 2 hours * Extremity beyond operative site neurovascularly intact * Verbalizes decreased pain * Afebrile; incision without drainage * Ambulating as directed * Eats a balanced diet high in iron; hemoglobin within normal range
ARTHROPLASTY AND TOTAL JOINT REPLACEMENT

Arthroplasty is reconstructive surgery to restore joint motion and function and to relieve pain. It generally involves replacement of bony joint structure by prosthesis.

Total joint arthroplasty is the replacement of both articular surfaces with metal or plastic components. The most common types of joint replacement

Total hip replacement (total joint arthroplasty) is the replacement of a severely damaged hip with an artificial joint. Although a large number of implants are available, most consist of a metal femoral component topped by a spherical ball fitted into a plastic acetabular socket.

Total knee arthroplasty is an implant procedure in which tibial, femoral, and patellar joint surfaces are replaced because of destroyed knee joint.

Clinical Indications * For patients with unremitting pain and irreversibly damaged joints: Primary OA Rheumatoid arthritis (RA). * Selected fractures (e.g., femoral neck fracture). * Failure of previous reconstructive surgery (osteotomy, cup arthroplasty, femoral neck fracture complications like nonunion and avascular necrosis). * Congenital hip disease. * Pathologic fractures from metastatic cancer. * Joint instability.
Considerations
* The prostheses are of various designs and may be fixed to the remaining bone by cement, press fit, or bone in growth. * Selection of the prosthesis and fixation technique depends on patient's bone structure, joint stability, and other individual characteristics, including age, weight, and activity level. * Arthroplasty is an exacting and meticulous procedure. To reduce the risk of an infected prosthesis, special precautions are carried out in the operating room
Preoperative Management and Nursing Care * Infections are ruled out as potential foci of infection can cause prosthesis infection. * Preoperative patient teaching is provided. * Antiembolism stockings are applied to minimize development of thrombophlebitis. * Skin preparation includes antimicrobial solution to reduce skin microorganisms, a potential source of infection. * Antibiotics are administered as prescribed to ensure therapeutic blood level during and immediately after surgery. Antimicrobials usually are given immediately preoperatively, intraoperatively, and postoperatively to reduce incidence of infection. * Cardiovascular, respiratory, renal, and hepatic function are assessed, and measures are taken to maximize general health condition.
Postoperative Management * Use of Appropriate Positioning to prevent dislocation of prosthesis and facilitate healing. Numerous modifications are required in positioning these patients postoperatively. * After hip arthroplasty: The patient is usually positioned supine in bed. The affected extremity is held in slight abduction by either an abduction splint or pillow or Buck's extension traction to prevent dislocation of the prosthesis. Avoid acute flexion of the hip. * After knee arthroplasty: The knee may be immobilized in extension with a firm compression dressing and an adjustable soft extension splint or long-leg plaster cast. Leg is elevated on pillows to control swelling. Alternatively, continuous passive motion may be started to facilitate joint healing and restoration of joint ROM.
NB: The patient must not adduct or flex the operated as this may lead to subluxation or dislocation of the hip. Signs of joint dislocation include shortened extremity, increasing discomfort, and inability to move joints.

* Preventing Complications: Provide aggressive care and continuous assessment. Prevent thromboembolism by continuous use of elastic hose and sequential compression devices (SCD) while patient is in bed. Discontinue SCD when patient is ambulatory.
Promoting Early Ambulation: Within 2 days after surgery, short periods of standing may be ordered. Monitor for orthostatic hypotension. Weight bearing may be limited with ingrowth prosthesis to prevent disruption of bone growth. Transfers to the chair or ambulation with aids, such as walkers, are encouraged as tolerated and based on patient's condition and type of prosthesis.

Nursing Diagnoses * Impaired Physical Mobility related to prosthetic joint
Nursing Interventions 1. Promoting Mobility: After hip arthroplasty, use an abduction splint or pillows while assisting patient to get out of bed. Keep the hip at maximum extension. Instruct patient to pivot on unoperated extremity. Assess patient for orthostatic hypotension. When patient is ready to ambulate, teach him or her to advance the walker and then advance the operated extremity to the walker, permitting weight bearing as prescribed. With increased stability, assist patient to use crutches or cane as prescribed. Encourage practice of PT exercises to strengthen muscles and prevent contractures.

After knee arthroplasty: Assist patient with transfer out of bed into wheelchair with extension splint in place. Ensure that no weight bearing is permitted until prescribed by the orthopedic surgeon. Apply continuous passive motion equipment or carry out passive ROM exercises as prescribed. 2. Community and Home Care Considerations: Encourage patient to continue to wear elastic stockings after discharge until full activities are resumed. Ensure that patient avoids excessive hip adduction, flexion, and rotation for 6 weeks after hip arthroplasty (hip precautions). Avoid sitting in low chair/toilet seat to avoid flexing hip more than 90 degrees. Keep knees apart; do not cross legs. 3. Encourage quadriceps ROM exercises as directed: Have a daily program of stretching, exercise, and rest throughout lifetime. Do not participate in any activity placing undue or sudden stress on joint (jogging, jumping, lifting heavy loads, becoming obese, excessive bending and twisting).Use a cane when taking fairly long walks. 4. Suggest self-help and energy-saving devices: Handrails by toilet. Raised toilet seat if there is some residual hip flexion problem. 5. Advise patient to sleep with two pillows between legs to prevent turning over in sleep. Patient should get out of bed with nonoperative leg. 6. Tell patient to lie prone when able twice daily for 30 minutes to promote full extension of hip. 7. Monitor for late complications like deep infection, increased pain or decreased function associated with loosening of prosthetic components, implant wear, dislocation, fracture of components, avascular necrosis or dead bone caused by loss of blood supply; heterotrophic ossification (formation of bone in periprosthetic space). 8. Assess home for safety to prevent falls 9. Patient Education and Health Maintenance: Teach patient use of supportive equipment (crutches, canes, raised toilet seat) as prescribed. Advise patient to notify all health care providers about prosthetic joint because prophylactic antibiotic will be needed if undergoing any procedure known to cause bacteremia (tooth extraction, manipulation of genitourinary tract). Avoid MRI studies because of implanted metal component. Advise patient that metal component in hip or knee may set off metal detectors (airports, some buildings). The patient should carry an ID card to explain. New hip or knee is designed for low-impact exercise, such as walking, golf, dancing. High-impact exercises, such as jogging, may cause the prosthesis to loosen.

Evaluation: Expected Outcomes
Maintaining proper positioning without evidence of complications

AMPUTATION
Amputation is the total or partial surgical removal of an extremity. Amputation is considered a surgical reconstructive procedure.

Indications * Inadequate tissue perfusion, such as results with diabetes mellitus or other peripheral vascular diseases * Severe trauma * Malignant tumor * Congenital deformity
Types of Amputation

i. Open (Guillotine): Used with infection and for patients who are poor surgical risks. Wound heals by granulation or secondary closure in about a week. ii. Closed (Myoplastic or Flap): Residual limb is covered by a flap of skin. Flap of skin is sutured posteriorly. Most common technique used for vascular disease.

Surgical Considerations * The surgeon considers possible limb salvage techniques: Revascularization, Hyperbaric oxygenation and Tumor resection with bone grafting * Determines level for amputation based on level of maximal viable tissue for wound healing. * Develops a functional, nontender, pressure-tolerant residual limb.
Types of Dressings

Soft Dressing * Secured with elastic bandage. * Permits wound inspection. * Used with patients who should avoid early weight bearing (eg, those with peripheral vascular disease).
Closed, Rigid Plaster Dressing * Applied immediately after surgery. * Controls edema. * Supports circulation, promoting healing. * Minimizes pain on movement. * Shapes residual limb. * Permits attachment of prosthetic extension (pylon) and early ambulation.
Preoperative Management * Hemodynamic evaluation is performed through testing, such as angiography, arterial blood flow, to determine optimal amputation level. * Culture and sensitivity tests of draining wounds are done to assist in control of infection preoperatively. * Evaluation of sound (contralateral) extremity is performed to determine functional potential postoperatively. * Evaluation of cardiovascular, respiratory, renal, and other body systems is necessary to determine preoperative condition of patient and reduce the risks of surgery by optimizing function. * Nutritional status is evaluated and optimized with adequate protein to enhance wound healing. * Exercises are taught to strengthen muscles for use of ambulatory aids (lower limb amputee).Use of ambulatory aids is taught. * Phantom sensation is explained and the patient is informed that he/she will continue to feel the amputated body part for some time. * Emotional support is given. Support concept of amputation as a surgical reconstructive procedure. Explore patient's perception of procedure and effect on lifestyle. Avoid unrealistic and misleading reassurance.
NB: Management of prosthesis can be slow and painful.
Postoperative Management * The extremity should be in full extension and may be elevated (if possible). * Complications are monitored e.g. hemorrhage, infection, unrelieved phantom pain, nonhealing wound. * Rehabilitation is initiated through Physiotherapy and prosthetic fitting (if indicated). * Therapy is provided for diabetes mellitus, heart disease, infection, stroke, chronic obstructive pulmonary disease, peripheral vascular disease, and age-related deterioration, which are factors limiting rehabilitation. * If wound breakdown, infection, delay in healing of residual limb occur, therapy is provided to prevent delay in rehabilitation. * Acceptance of body image change is promoted.
Nursing Diagnoses * Risk for Deficient Fluid Volume related to hemorrhage from disrupted surgical homeostasis * Ineffective Tissue Perfusion related to edema and tissue responses to surgery and prosthesis * Ineffective Coping related to change in body image * Acute or Chronic Pain related to surgical procedure and phantom sensations * Impaired Physical Mobility related to amputation, muscle weakness, alteration in body weight distribution
Nursing Interventions 1. Monitor patient for systemic symptoms of excessive blood loss, hypotension, widening pulse pressure, tachycardia, diaphoresis, decreased level of consciousness.Watch for excessive wound drainage. Monitor intake and output for fluid balance. 2. Maintaining Adequate Tissue Perfusion; Control edema and maintain pressure dressing. 3. Supporting Effective Coping: Accept patient responses to loss of body part (ie, depression, withdrawal, denial, frustration). Encourage expression of fears and concerns. Encourage participation in rehabilitation planning and self-care. Assist patient to adapt to changes in self-care activities. 4. Controlling Pain: Surgical pain: Administer prescribed medications as needed to control postoperative pain. Use nonpharmaceutical pain management techniques, such as progressive muscle relaxation and imagery. Recognize that increasing discomfort may indicate presence of hematoma, infection, or necrosis. Phantom sensations (pain): Use physical modalities (e.g., wrapping, temperature changes) and transcutaneous electrical nerve stimulation (TENS), if prescribed, in relieving discomfort. 5. Promoting Physical Activity: Encourage frequent repositioning in bed by teaching patient to avoid long periods in one position. 6. Prevent deformities: Encourage active ROM and muscle-strengthening exercises when prescribed to: Minimize muscle atrophy. Increase muscle strength and Prepare residual limb for prosthesis. 7. Promote reestablishment of balance (amputation alters distribution of body weight). Supervise ambulation, use of wheelchair, and self-care activities. 8. Patient Education and Health Maintenance: Teach patient and family how to wrap residual limb with elastic bandage to control edema and to form a firm conical shape for prosthesis fitting. Teach patient residual limb conditioning. Push the residual limb against a soft pillow. Gradually push residual limb against harder surfaces. Massage healed residual limb to soften scar, decrease tenderness, and improve vascularity. Fitting of prosthesis; Note residual limb contour and assess for residual limb contraction. Continuing care of residual limb and prosthesis. Teach patient to protect the remaining extremity from injury and to secure prompt treatment of problems.
Evaluation: Expected Outcomes * Vital signs stable; dressing reinforced once in 4 hours * Pressure dressing intact; stump elevated without edema * Participates in care plan; expresses concerns about independence * Verbalizes relief of incisional pain; dull phantom sensation tolerable * Performs ROM actively; transfers to wheelchair with assistance, participates in PT/OT activities
MUSCULOSKELETAL TRAUMA

CONTUSIONS, STRAINS, AND SPRAINS
A contusion is an injury to the soft tissue produced by a blunt force (blow, kick, or fall).
A sprain is an injury to ligamentous structures surrounding a joint; it is usually caused by a wrench or twist resulting in a decrease in joint stability. A strain is a microscopic tearing of the muscle caused by excessive force, stretching, or overuse.

Clinical Manifestations
Contusion
* Hemorrhage into injured part (ecchymosis) from rupture of small blood vessels; also associated with fractures. * Pain, swelling, and ecchymosis. * Hyperkalemia may be present with extensive contusions, resulting in destruction of body tissue and loss of blood.
STANDARDS OF CARE GUIDELINES

Caring for a Patient with Musculoskeletal Trauma, Surgery, Casting, or Immobilization
When caring for a patient with musculoskeletal trauma, surgery, casting, or immobilization, provide the following care as indicated: * Check neurovascular status of involved extremities. * Palpate for intact and equal pulses bilaterally. * Palpate for proper warmth of the skin. * Check for brisk capillary refill. * Test sensation to light touch and pain. * Observe for unusual or increased swelling. * Ensure that patient can move affected parts * Ensure proper positioning for comfort and alignment. * Determine pressure points and take precautions to prevent pressure sores. * Medicate to control pain, particularly before movement, procedures, and physical therapy. * Provide diversional activities and emotional support during long immobilizations. * Always document assessments and interventions meticulously, realizing that patient may be involved in Workers' Compensation claim or litigation due to accident and records will be essential to patient's future well-being.
NB: This information should serve as a general guideline only. Each patient situation presents a unique set of clinical factors and requires nursing judgment to guide care, which may include additional or alterative measures and approaches.

Strain * Hemorrhage into the muscle. * Swelling. * Tenderness. * Pain with isometric contraction. * May be associated spasm.
Sprain
* Rapid swelling due to extravasation of blood within tissues. * Pain on passive movement of joint. * Increasing pain during first few hours due to continued swelling.
Management
* X-ray may be done to rule out fracture. * Immobilize in splint, elastic wrap, or compression dressing to support weakened structures and control swelling. * Apply ice for first 24 hours. * Analgesics usually include nonsteroidal anti-inflammatory drugs (NSAIDs) or cyclooxygenase (COX-2) inhibitors. * Severe sprains may require surgical repair or cast immobilization.

Nursing Interventions and Patient Education * Elevate the affected part. Maintain splint or immobilization as prescribed. * Apply cold compresses for the first 24 hours (20 to 30 minutes at a time) to produce vasoconstriction, decrease edema, and reduce discomfort. * Apply heat to affected area after 24 hours (20 to 30 minutes at a time) four times per day to promote circulation and absorption. * Assess neurovascular status of contused extremity every hour to every 4 hours as patient's condition indicates. * Instruct patient on use of pain medication as prescribed. * Ensure correct use of crutches or other mobility aid with or without weight bearing, as prescribed. * Educate on need to rest injured part for about a month to allow for healing. * Teach patient to resume activities gradually. * Teach patient to avoid excessive exercise of injured part. * Teach patient to avoid reinjury by warming before exercise. * Complementary methods, such as acupuncture, biofeedback, and imagery, may contribute to healing by reducing anxiety and pain.
TENDINITIS

Tendinitis is an inflammation of a tendon caused by a lack of sufficient lubrication of the tendon sheath. May be caused by acute stress on tendon structure or by chronic overuse.

Clinical Manifestations * Onset of pain may occur immediately after activity or delayed up to a day later. ROM and resistance testing is painful. * Mild swelling occurs, and the tendon sheath is tender to the touch. * Sudden onset of sharp pain in calf and hearing/feeling a snap with associated with tendon rupture, as in Achilles tendinitis due to running injuries or stop-start activities such as basketball.
Management
* X-rays not usually diagnostic. * Thompson's test helps with diagnosis of Achilles rupture. Patient kneels on chair or lies prone. Examiner squeezes calf of affected leg. Normal response: foot moves downward, denoting intact tendon. If foot does not move, tendon is assumed to be ruptured. * Initial treatment includes rest, ice, compression, elevation (RICE). * Splinting or casting for up to 6 weeks in functional position usually necessary. * Surgical intervention may be necessary if rupture is complete. * PT to regain strength and function.
Nursing Interventions and Patient Education * Ensure understanding of need for proper immobilization for full time period even though fracture is not present. * Encourage the use of warm compresses after 24 hours to relieve pain and inflammation. * Advice patient not to return to full activity until strength is equal to unaffected extremity. * Teach proper warm-up before exercise/sports activities (stretching of all major tendons).
BURSITIS
Bursitis is a painful inflammation of the bursae, fluid-filled sacs lined with synovium similar to the lining of the joint spaces. Bursae reduce friction between tendons and bones or tendons and ligaments. They are found over joints with bony prominences, such as the trochanter, patella, and olecranon. Friction between skin and musculoskeletal tissues may result in bursitis.
Clinical Manifestations * Pain around a joint commonly the knee, elbow, shoulder, and hip. * Varying degrees of redness, warmth, and swelling may be visible. * There is point tenderness and limited ROM on examination.
Management and Nursing Interventions * Rest and immobilization of affected joint * Ice for the first 48 hours; moist heat every 4 hours thereafter * Nonopioid analgesics such as NSAIDs * ROM exercises * Intra-articular corticosteroid injection * Surgery indicated when calcified deposits or adhesions have diminished function
PLANTAR FASCIITIS

Plantar fasciitis is inflammation of the fascia that runs along the bottom of the foot from heel to toes. As the fascia is stretched, microscopic tears develop at the point where fascia attaches to the calcaneus.

Clinical Manifestations * Pain along sole of foot, usually unilateral, but may be bilateral. * Worse upon arising, long period of standing, and walking. * Tenderness of heel area.
Management and Nursing Interventions * Rest: decrease walking, running, exercise, standing. * NSAIDs for pain and inflammation. * Good supportive footwear. * Orthotic devices may be beneficial;Heel cup to cushion the heel (over the counter).Arch support orthotics for pes planus (flat foot).Cushioning of arches for pes cavus (high arch). * Stretching exercises several times per day. * Massage of bottom of foot. * Steroid injection into painful area. * Surgery for release of fascia as last resort.
TRAUMATIC JOINT DISLOCATION

Dislocation of a joint occurs when the surfaces of the bones forming the joint are no longer in anatomic contact. This is a medical emergency because of associated disruption of surrounding blood and nerve supplies. * Shoulder, fingers, elbow are most common joints to dislocate. * Mechanism of injury can be anterior, posterior, lateral, or medial force. Posterior dislocation is the most common.
Clinical Manifestations * Pain * Deformity * Change in the length of the extremity * Loss of normal movement * X-ray confirmation of dislocation without associated fracture
Management
* Immobilize part while patient is transported to emergency department, X-ray department, or clinical unit. * Secure reduction of dislocation (bring displaced parts into normal position) as soon as possible to prevent circulatory or nerve impairments; usually performed under anesthesia. * Stabilize reduction until joint structures are healed to prevent permanently unstable joint or aseptic necrosis of bone.
Nursing Interventions and Patient Education * Assess neurovascular status of extremity before and after reduction of dislocation. * Administer or teach self-administration of pain medications such as NSAIDs. * Ensure proper use of immobilization device after reduction. * Review instructions for activity restrictions and need for PT and follow-up.
KNEE INJURIES
The knee ligaments provide stability to the knee joint. These ligaments promote rotational stability (anterior cruciate ligament [ACL] and posterior cruciate ligament) and prevent varus and valgus instability (medial and lateral collateral ligaments). Pieces of cartilage that stabilize the knee internally are known as the medial and lateral menisci. Anterior cruciate ligament injuries and medial meniscus tears are common due to sports injuries.
Clinical Manifestations * Severe stresses are applied to the knee during many sports activities (e.g., soccer, skiing, running). * Injury to knee structures occurs during rapid position changes involving flexing and twisting of the joint.
P.1076

* Torn cartilage (meniscus) causes pain, tenderness, joint effusion, clicking sensations, and decreased ROM. * Knee ligaments may be torn, resulting in pain on ambulation, swelling, and joint instability. The patellar tendon may rupture.
Management
* Special assessment techniques are done to detect anterior cruciate ligament injury (see Table 32-1). * MRI shows injury to soft tissue involved. * Some injuries may be immobilized (splint, brace, or cast) and treated with PT. * ACL reconstruction frequently indicated, Postoperative continuous passive motion used. Postoperative ACL rehabilitation program includes progressive ROM, bracing (not done with synthetic ligaments).Long-term bracing during sports controversial. * Meniscal injury damaged cartilage removed through Arthroscopic or open meniscectomy. * Rehabilitation includes progressive ROM and quadriceps strengthening.
Nursing Interventions and Patient Education * After arthroscopic surgery, ensure proper use of crutches as indicated and encourage pain control through medications as prescribed and RICE. * For open joint surgery, see care of patient undergoing orthopedic surgery, page 1066. * Teach patient strengthening exercises for affected extremity. * Teach patient to prevent fatigue through rest periods, conservation of energy. * Advise on prevention of injuries using proper equipment and footwear for sports.
BE CAREFUL HOW YOU LIFT * Move your body close to an object before picking it up. * Bend at the knees, not the back, to pick up an object that is low. * Hold the object close to your abdomen and chest. * Bend at the knees again to put down an object. * Avoid reaching, twisting, or turning your back as you lift or carry an object.
PROTECT YOUR BACK WHILE SITTING AND Standing * Avoid sitting in soft, cushioned chairs too long. * If you sit for long periods at work, make sure your knees are level with your hips. Use a step stool if necessary. * If you stand for long periods, try to put one foot up on a stool, then the other. Walk around and change position periodically. * Adjust your car seat so there is a bend in your knees. Do not stretch. * Put a firm pillow behind your lower back if it does not feel supported while you are sitting. | Back exercises to strengthen abdominal and postural muscles, to stretch contracted back muscles, and to maintain flexibility. |
STAY ACTIVE AND IN GOOD HEALTH * Take a walk every day wearing comfortable, low-heeled shoes. * Eat a balanced, low-fat diet with plenty of fruits and vegetables to avoid constipation. * Get plenty of sleep on a firm mattress. * See your health care provider promptly for worsening pain or new injury.
Evaluation: Expected Outcomes * Verbalizes relief of pain with rest and medication * Performs back exercises correctly