Orthopaedic nursing

By Jane Osumba
 Aim
To understand principles applied in orthopedic
nursing in order to be able to care for patients
presenting with orthopaedic conditions/
diseases
objectives
 To review A &P of the bones
 To discuss fractures and the principles of
fracture management.
 To discuss indications and care of patients done
amputation of a limb
 To describe causes and management of
orthopaedic diseases
 Identify congenital malformations related to
orthopaedics and discuss their management
 Apply knowledge of orthopaedic management in
nursing patients presenting with orthopaedic
conditions.
Contents
Anatomy and physiology of the bones
Assessment to include:- Hx, physical exam,
neurovascular assessment, and
investigations
Minor injuries:- Contusion, Lacerations,
Strains, Sprains & dislocations/subluxation
Fractures:- Definition, types/classification,
clinical features, general principles of
management
Amputation and its management(definition,
indications, management)
Contents
 orthopedic diseases
(osteomyelitis;arthritis;osteoporosis &
osteomalacia
Congenital abnormalities:- Talipes,
Congenital hip dislocation & osteogenesis
imperfecta
Tumors i.e. benign and malignant
Gout and pagets’ disease
Anatomy and physiology of the
bones
 Bones are connective tissue.
 Bones have a soft center that is full of bone
marrow, where blood cells are made.
 Bones support the body, help with movement,
and offer protection to vital organs
Types of bones
There are 5 main types
of bones
Long bones- characterized
by a long shaft, like a
femur
Short bones- roughly cubed
shaped and found in wrist
Flat bones-are thin and
curved bones with two hard
bones sandwiching a soft
tissue, the skull bones
Irregular bones- bones that
do not fit in the above
categories, like hip or spine
bones
Sesamoid bones- bones
that are embedded in
tendons, like the patella
Assessment of orthopaedic
patients
History taking
Physical examination
Radiological exams
History taking
 Health Hx:- i.e.
 Initial interview
 Onset, management approach, pt’s perceptions
& expectations related to health.
 Concurrent health conditions(e.g. chronic
illnesses) & related problems (e.g. familial
tendencies/genetics)
 HX of medication use & response to pain drugs
 Any allergies
 Substance use & abuse e.g. tobacco, alcohol
 Information on pt’s learning ability, economic
status & current occupation for rehabilitation &
discharge planning
 Any other useful data as the nurse interacts with
Assessment data
 Assess & document the following
1. Pain:-
 bone pain - dull deep pain
 Muscle pain - soreness or aching/muscle cramps
 # pain - sharp and piercing pain relieved by
immobilization
NB: Sharp pain can also be due to bone infection or
pressure on a sensory nerve
 Pain increasing with activity may indicate joint
/muscle sprain,
 Steadily increasing pain- progression of an
infectious process, malignant tumors or
neurovascular condition
 Radiating pain- pressure on a nerve.
Assessment data
2. Altered sensation
 Paresthesias -burning, tingling sensations
or numbness due to pressure on nerves, or
circulatory impairment.
Assess the neurovascular function
Physical examination
 Posture
 Gait
 Bone integrity
 Joint function
 Muscle strength and size
 Skin integrity and condition
 Neurovascular status
Radiological studies
• Imaging studies - x-ray studies, C.T
scanning, M.R.I’s, arthrography, bone
densitometry
• Nuclear studies:- bone scan, arthroscopy,
• Other studies:- arthrocentesis,
Electromyography, Biopsy
• Lab studies:- blood & urine tests

Assignment
Read on each of the above
Fractures
Objectives: to
• Define the terms fracture, dislocation and Subluxation
• Identify the general causes, signs & symptoms of fractures
• Classify the different types of fractures
• Discus the general principles of the management of fractures
• Describe the role of radiography in the management of
fractures
• Explain the process of fracture healing

• State the local and general complications of fractures

 Definition
• A break in the continuity of the structure of
bone
• It can be partial or complete
• A medical condition where the bone is either
cracked or broken
• Traumatic injuries account for the majority of
fractures
Causes
Direct force- the force is applied direct to the bone
Indirect force –the force is transmitted along other
parts of the body
Muscular violence –violent contraction of muscles
in order to avoid falling e.g. quadriceps causing
fracture patella
Muscle fatigue –deprives the bones of necessary
support
Pathological – due to
-disuse of muscles leading to atrophy
-bone demineralizing diseases
-local disease
classification
5 factors taken into account when
fractures are classified.
The name of the bone
The location on the bone
The type of fracture
The group/ shape (Like a spiral fracture)
The subgroups, which looks at factors like the
displacement or if there is shortening
 Classification can also either be orthopedics
or anatomical
Anatomical classification
Based on the body part affected.
Humerus

Radius/ulna

spine

femur

Titbia
Anatomical classification-according
to fracture specification
Comminuted # : Stellate
The bone is fracture:
broken into more Fracture lines run
than two in various
fragments. directions from
one point e .g. #
of flat bones of
the skull and the
patella
Anatomical classification-according
to fracture specification
Impacted Depressed
fracture: fracture:
This # where a This # occurs in
vertical force the skull where a
drives the distal segment of bone
fragment of the gets depressed
fracture into the into the cranium
proximal
fragment.
Anatomical classification-according
to fracture specification
Avulsion fracture:
This is one, where a chip
of bone is separated by
the sudden and
unexpected contraction
of a powerful muscle
from its point of insertion
e.g.
1. The supra spinatus
muscle avulsing the
greater tuberosity of the
humerus.
2. Avulsion fracture of
the tibial tuberosity
Orthopedic classification
Communication with external environment
Closed (simple) - fracture hematoma does not
communicate with the outside

Open ( compound) - fracture hematoma

communicates with the outside through an
open wound.
Types of fractures
 Orthopedic classification
Complete fracture –
periosteum is tone Incomplete fracture -
separating the two bone
Continuity of the
fragments
bone is not
completely
disrupted e.g.
green stick
fractures in
children
 According to the Path of the # Line

Spiral Fracture Longitudinal

A severe form of Fracture
oblique fracture in A fracture in which
which the # plane the # line runs
rotates along the long nearly parallel to the
axis of the bone. These long axis of the
#s occur secondary to bone. A longitudinal
rotational force. fracture can be
considered a long
oblique fracture.
According to the Path of the # Line

Transverse Oblique Fracture

Fracture A fracture in
 A fracture in which the # line is
which the # line is at oblique angle
perpendicular to to the long axis of
the long axis of the bone.
the bone .
According to the Path of the # Line

Displaced fracture Non displaced –

–bone ends are crack without a
pulled apart from change in the
each other. normal alignment
of the bone.
Pathological fractures
It is a fracture occurring after a trivial
violence in a bone weakened by some
pathological lesion. This lesion may be :
- Localized disorder (e.g. secondary
malignant deposit)

- Generalized disorder (e.g.

osteoporosis)
 Summary of types of
fracture
 Simple little or no bone displacement
 Compound fracture ruptures the skin & bone
protrudes
 Green stick occurs mostly in children whose
bones have not calcified or hardened
 Transverse crack perpendicular to long axis of
the bone - displacement may occur
 Oblique diagonal crack across the long axis
of the bone
 Spiral diagonal crack involving a
"twisting" of the bone about the longitudinal axis
 Comminuted "crushing" fracture - more common
in elderly
 Summary of fracture types
 Depressed broken bone is pressed
inward (skull fracture)
 Avulsion fragment of bone is pulled
away by tendon
 Simple little or no bone displacement
 Compound fracture ruptures the skin &
bone protrudes
Types of fractures
Clinical features
Local injuries
Pain due to :-
 break in the continuity of the periosteum,
with or without similar discontinuity in
endosteum, as both contain multiple
nociceptors.
 Edema of nearby soft tissues caused by
bleeding of torn periosteal blood vessels
evokes pressure pain.
 Muscle spasms trying to hold bone
fragments in place
 Damage to adjacent structures such as
Clinical features
Abnormal mobility
Deformity –caused by contraction of
surrounding muscles
Loss of function of the affected limb
Shortening of the bone
Crepitus or grunting of the fragments- caused
by bone edges rubbing against each other
Hemorrhage –either internal or external
Paralysis due nerve damage
Paraesthesia due to impaired sensation
Shock
Fracture healing
Is bone self healing process/
repair/union that has the following
processes
Inflammatory Phase.
Stage of hematoma formation- after #,
bleeding & edema precede a hematoma
surrounding the fragment
There is swelling, edema & pain
The fracture fragments become
devascularized
Injured bone is invaded by microphages
Fracture healing
Reparative Phase.
Fibrin strands form within the #
hematoma
Revascularization begins
Fibroblasts & osteoblasts produce
collagen matrix at the # site.
Cartilage and fibrous connective tissue
develops.
 Fracture healing
 A) Formation of fibro cartilaginous callus.
 The phagocytic cells absorbs the products of
local necrosis.
 The hematoma changes to into Granulation
tissue constituting of young blood vessels,
fibroblasts, osteoblasts (the bone osteoid)

 B) Formation bony callus (woven bone

become calcified)).
 Osteoid mineralization to form a network of
cartilage, osteoblasts & minerals
 Begins to appear by the 1st week of # and can
be confirmed by X-ray
Fracture healing
Ossification:- calcification of callous into
bone mass that prevent movement @ the
# site
 Begins 2-3 wks after # until # is healed
 However, the # is still evident in the x-ray
 Pt can be converted from skeletal traction
to cast or cast can be removed & the pt
mobilized
Consolidation:- distance between bone
continues to diminish & eventually closes &
x-ray can confirm # union
Fracture healing
 Remodeling Phase.
 Excess material inside bone shaft is replaced
by more compact bone
 Excess cells are absorbed & union is completed.
 Return of bone to its pre-injury structure, shape
& strength
 Bone remodeling enhanced by exercises & later
weight bearing exercises
 New bone is deposited @ site of #
Fracture healing
 Factors affecting bone
healing
Enhancing Inhibiting
Early Immobilization of Extensive local trauma
fracture fragments Bone loss due to the
Bone fragments contact
severity of the fracture
Adequate blood supply
Inadequate
Proper Nutrition
immobilization
Exercise- wt. bearing for
Infection
long bones
Adequate hormones – Avascular Necrosis
Growth hormone, Thyroxin, Local malignancy
Calcitonin dernarvation
Electric potential across the
Age
#
 Management protocol

Aims : 3s (A)- safe life (B)-save the

limb
(C)-save the function
1. Efficient First Aid: This relieves the pain
and prevents complications.
2. Safe transport: This help to minimize
complications in injures to the spine, fracture of
the lower limbs, ribs(immediate immobilization
of all # ) .
3. Assessment of condition of the patients for
shock & other injuries.
 Management protocol

4.Assessment of local condition of the injured

limb for complications like nerve, vascular&
neighboring joints injuries
5.Resuscitation - manage shock if present
6.Radiography of the part
 X-ray before plaster ( to determine site and
degree of displacement)
 Post Reduction films ( wet plaster) - insurance
of good alignment
 Follow up films - assess healing
 Before removal of plaster - confirm complete
healing
 Management protocol
7.Reduction of the fracture- correction of
displacement of fragments done by :
 closed Manipulation
open reduction
8.Immobilization of the fragments.
External fixation
-Cast (plaster)
Internal fixation
-Screws
-Plates
-intramedullary nails and rod
-wires & pins
Management protocol

9. Rehabilitation
Restoration of full muscle power and joint
movements to make the limb fit for his original
function.

. Early physiotherapy : for the preservation of

function of the limb (local complication such
as ischemia ,nerve damage ,joint
stiffness ,infection etc. may endanger the
function of the limb.
Principles of fracture treatment

Three main principles of

treatment
1. Reduction
2. Immobilization
3. Rehabilitation
 1.Reduction
Getting the bone fragments into an anatomical
rotation & alignment accomplished through ;-
Closed reduction
 Obtained by manual manipulation
 Performed under L/A to reduce pain; muscle
spasms and relax muscles pulling bone
fragments out of position.
Open reduction
 Involves surgical interventions
 Used where muscles attached to the bones are
numerous and powerful
 In open wounds after surgical toilet
 2. Immobilization
keeping fragmented ends of bones still & stable
until healing takes place.
The means by which reduction is maintained
achieved through:-
 External splintage e.g. P.O.P, traction , splints
 Internal splintage e.g. internal or external
fixation
External fixation
The fracture is reduced & aligned &
immobilized by a series of pins inserted
into bone fragments
The pins are maintained in position
through attachment to a rigid portable
frame
The device facilitates :-
 Rx of soft tissue in complex #
 Patient comfort
 Early mobility
 Active exercise of the uninvolved joint
External fixation
 Prevents complications related to disuse & immobility
 Shortens hospital stay
Pre-insertion care
 Prepare the patient psychologically –reassure about
the apparatus
Post application care
 Elevate the extremity to reduce swelling
 Drainage of serous fluid is expected
 Monitor neurovascular status of injured extremity daily
 Be alert for potential problems that may arise due to
pressure of the device on the skin, blood vessels &
nerves.
External fixation
External fixation
Cover the sharp ends of the fixator and pins to
prevent device induced injury.
Assess each the pin site for swelling , redness ,
hotness , tenderness , drainage & loosening of
the pins indicative of infection
Provide pin care as appropriate
Advice the patient to maintain fixation site clean
Encourage active exercises within the limit of
tissue damage
Never adjust clamps on the external
fixator frame
Internal fixation
Internal fixation devices e.g. pins , wires,
screws, plates, nails or rods are used to
hold the bone fragments in position until
solid bone healing occurs.
The devices can be:-
 attached to the sides of the bone
 inserted through the bony fragments
 Inserted directly into medullary cavity of
the bone
The devices ensure firm fixation of the
bony fragments
Internal fixation
 Internal fixation
Post operative care
Same as any post operative patient
 Give strong opioid analgesics for pain
 Observe site for bleeding & shock
 Observe for signs of infection
 Encourage mobility as prescribed by the
sergeon
 Psychotherapy
Internal fixation
Internal fixation devices may be removed
after the bone union
For majority of pts the device is not removed
unless there is complications such as pain
and decreased function which is indicative
of:-
 Mechanical failure
 Material failure
 Corrosion of devices
Allergic response to metallic alloys used
Osteoporotic remodeling
Traction
A pulling force applied in a specific direction to
a body part by manual or mechanical means.
Exertion of a pulling force to reduce &
immobilize a #
Purpose of traction
To overcome muscle spasms
To stretch muscles and tendons
To permit joint exercise
To hold the extremity in position
To prevent further injury
Reduce pain
Maintain bone alignment
Types of traction
Fixed traction
Traction attached to stationary point e.g.
Thomas splint
Pulp traction
Used in Rx of # figures and toes;
to correct shape of fingers
Suture passes through a pulp(bone) of the
fingers then fastened to an extension piece
in cooperated in the P.O.P applied to a
hand or foot
Balanced traction
Composed of two opposing forces that are
separated by a raised structure e.g.
elevated bed to balance the forces.
Weights hung from cords which pass over
pulleys in the edges of the bed then are
attached to pt’s limb.
The opposing force is called counter-
traction and is equal to that of traction but
pulls in the opposite direction.
Counter-traction is provided by pt’s own
body weight and raised foot of the bed so
that the weight of the body counteracts pull
on the limb.
Balanced traction
Advantages
Allows pt to move freely in bed without
interfering with fracture site thus reducing
complications of immobility
Precautions
Pulleys should run smoothly without any
interference
 Cords should be in straight line without
nodes
The weights should hang freely
Bed elevators should never be removed
even for a few seconds
Types of balanced traction
Skin traction
The traction is applied to the skin from
which the force is transmitted to the
muscles then to the bones.
Special type of strapping is used.
Skin does not tolerate large weights hence
2.7 – 3.6 kgs used
Indications
Pts with arthritis
# of lower limbs
Dislocation of the spine
Skin traction
Types of skin traction
Cervical skin traction
Relieves muscle spasms and compression
in the upper extremities and neck.
Uses a head halter and a chin pad to attach
to the traction
The head of the bed is elevated at 30- 40
degrees and weights are attached to a
pulley system over the head of the bed.
Use powder to protect the ears.
Types of skin traction
Buck’s skin traction
Longitudinal skin traction applied to one or
both limbs
Pelvic skin traction
Used to relieve low back, hip & leg pain
Traction is applied over the pelvis & illiac
crest & weights are attached.
Russell´s traction
Horizontal pulling force applied to lower leg
Used to Rx # of the tibial plateau
Supports the flex knee in a sling
N/care of patient on skin
traction
Ensure effective traction- maintain counter traction:
observe for wrinkling & slipping of traction bandage
Adhesive tapes adhere to the skin and has
potential for causing skin breakdown thus observe
the skin for redness and swelling
Inspect the limb for signs of circulatory
compromise
Assess for sensation & motion of the limb
Assess for dorsiflexation of foot-pressure on
common perianal nerve.
Planter flexion of the foot(foot drop)- pressure on
tibial nerve
N/care of patient on skin traction
Change the bed from top to bottom as the
pt lifts self with aid of trapeze
Turn pt at 45 degrees to either side to
accomplish back care or linen change.
 Buck’s skin traction released 8 hourly then
rewrapped to prevent long term pressure
over the nerves & circulatory constriction;
provides opportunity to assess the skin.
Observe pts on Buck’s skin traction for
perianal palsy due to pressure from the
elastic straps on the foot over the fibula
head leading to perianal nerve ischemia.
Skin traction –N/care cont´d
If traction boot is used, it must be removed 8
hourly for inspection of the heals.
Provide a pillow underneath calf muscles to
keep heels off the bed.
Message heals 4 hourly to increase circulation
Neuromuscular observations done hrly for the
1st 24hrs then 4 hrly if findings are within
normal
Observe the foot for edema which denotes that
elastic strap is too tight
Maintain intact neurovascular status while the
pt is on traction
Types of balanced traction
Skeletal traction
Traction applied direct to skeletal structure or
bone using pins , wires or tongs
Indications
When continuous force is needed
When heavier weights are required to
overcome traction e.g.11-18kgs
Types
Balanced skeletal traction
Overhead arm traction
Skull traction –used in spinal cord injuries
Cervical traction with tongs
 Balanced skeletal traction
 Indication
–Rx of long bone and cervical spine #
Pin placement done under G/A or L/A and
parental analgesia using aseptic technique.
Prepare patient for insertion to allay anxiety,
ensure pt.'s comfort and cooperation
A pull is exerted direct on the bones by means
of Steinman's pin, Kirchner wire or Denham’s
pin then balance suspension is applied such
that the limb is supported off the bed by ropes,
pulleys and eights.
Skeletal traction
Thomas splint with Pearson attachment
used to suspend the leg in # of femur
Traction is continuous once applied
May take 3-4 months
Advantages
Permits pt to move easily and comfortably
in bed
Enables the pt to lift self off the bed for skin
care, bedpan use without discomfort or
motion at the fracture site.
Skeletal traction
Nursing care
Ensure pt maintains correct position to prevent
pain
Ensure that effective traction is maintained
Ensure skin care to prevent skin break down
Clean the pin site with sterile normal saline
Ensure that established pull is maintained
without interruption
Traction set must be free from friction
Bed must be equipped with trapeze to aid pt in
movement
Remove wrinkles in the splint or Pearson’s
attachment to avoid pressure
Nursing care
Check and reposition the splint frequently
Observe for pressure caused by the metal part
suspending the splint
If counter-traction is insufficient the pt will lean
towards the traction and the half ring will cause
pressure on the groin hence observe the pt’s
position and report so that weight can be added.
Active movement of unaffected limb maintained
by range of motions exercises 4 hourly.
When the presence of callus is demonstrated on
x-ray then skeletal traction is discontinued.
 Cast
Is rigid external immobilizing device that is molded
to the contours of the affected limb
Casting material –plaster or non-plaster
materials(fiberglass cast)
Casts permit immobilization of the pt while
restricting movement of the casted part
Purpose
Immobilize the body part
Apply uniform pressure on the encased soft tissue
Immobilize a reduced fracture
Correct deformity
Provide support and stability for weakened joints
 Types of casts
Short arm cast –extends from below the elbow
to the proximal creases secured around the
thumb. If the thumb is included then it is called
thumb spica
Long arm cast –extends from the upper level of
axillary folds to the proximal palmer creases.
Short leg cast –extends fro the upper thigh to
the base of the toes.
Body cast –encircles the trunk
Spica cast –incorporates a portion of the trunk
and one or two of the extremities
Shoulder spica cast –body jacket that encloses
the trunk, shoulder & elbows
Plaster casts
rd
Cast care
Monitor pt for pain, swelling, discoloration,
tingling or numbness, diminished or absent
pulses, paralysis and coldness of the extremity.
Assess the casted limb for signs of circulatory
compromise
Handle moist cast with palm of the hand and it
should not rest on a hard surface or sharp edge
Elevate the affected limb using a pillow to reduce
swelling
Do not ignore complains of pain, pins and
needles from a pt with casted limb as this could
indicate circulatory complications or pressure on
the nerves
Cast care
Inspect the cast at regular interval for any
complications
Observe for signs of infection
Symptoms of pain, pallor, pulselessness,
paraesthesia, paralysis (5 Ps) or coolness denote
circulatory changes or neurological disturbances.
Report to the orthopedist immediately if noted so
that dressings may be loosened or cast bivalved to
relieve pressure
Hematoma drainage - fasciotomy may be done to
improve circulation
Observe pts with extensive casts for cast syndrome
Patient education
Avoid excessive use of the injured limb
Elevate the casted limb above the heart –
prevent swelling
Keep the cast dry
Report to the hospital if the cast breaks and
not to attempt fixing of the cast
To keep the cast clean
To immediately report any oduor from cast,
stains, warmth or pressure & decreased
ability to move the limb
To report any persistent swelling, pain, that
does not respond to elevation ; changes in
Complication
Cast syndrome
–occurs in pts immobilized with large casts
Psychological component
Pt exhibits acute anxiety reaction
characterized by behavioral changes and
autonomic responses e.g. increased
respiratory rate, heart rate, BP,
diaphoresis, dilated pupils
Observe pt for these reactions
Reassure assure
Provide an environment in which pt feels
secure
Cast syndrome
Physiological component
 Are associated with imposed immobility
 GIT motility decreases; accumulation of intestinal
gases cause increased pressure resulting in
paralytic ileus
Clinical presentation
 Abdominal discomfort & distension
 Nausea & vomiting
Rx –conservatively with
 Decompression(NGT drainage)
 IVF therapy until motility is restored
 Window cut over the abdomen in casts restricting the
abdomen
 Complete obstruction or bowel gangrene –surgical
intervention
Management of specific
fractures
Upper limb fractures
Lower limb fractures
Fracture pelvis
Fracture vertebral column
Upper limb fractures
# of humeral neck
non-displaced #
RX – support the arm with a sling
Pt to avoid vigorous exercise for 6-8 weeks

Displaced #
Closed reduction or open reduction
Replacement of humeral head with
prosthesis
Fracture of upper limb
Fracture shaft of Humerus
Causes
Direct violence
Indirect twisting force
S /S – nerves and brachial blood vessels may
be injured.
Wrist drop is indication of radial nerve injury
Rx
Oblique, spiral, displaced # resulting in
shortening of the humeral shaft - a hanging
cast
Skeletal traction
 Upper limb fractures
Fractures of radial head
Caused by a fall on outstretched hand with
elbow in extension
Rx
Undisplaced # -immobilized by a sling
Displaced # -open operation with excision
of radial head
Fracture of the shaft of radius and ulna
Displacement occurs when both bones are
broken
Rx
Non displaced #- immobilized for 12 weeks;
 Upper limb fractures
Fracture of the wrist (Colle’s # )
# of the distal radius as result of a fall on open
dorsal-flexed hand
Common in elderly pt with osteoporotic disease
Pt presents with deformed wrist with radial deviation;
pain; swelling; weakness; limited finger range motion
and numbness
Rx
Closed reduction and immobilization with the cast
 Internal fixation with Kirchner wire or external device
for severe #
Wrist & arm elevated for 48hrs after reduction by
suspending the arm from an overhead frame or IV
Fracture lower limbs
Fibula tibia #
Commonest below knee fracture
Causes
Direct blow
Falls with the foot in dorsiflexed position
Violent twisting motion
Clinical presentation
Pain
Deformity
Obvious hematoma
 Edema
Soft tissue damage
# tibia fibula
Management
 Assess the pt for perineal nerve damage indicated by
inability to dorsiflex the great toe & diminished
sensation between in the first web
 Assess capillary refill time to R/O tibial artery damage
 Observe for signs of anterior compartment syndrome
e.g. pain, paraesthesia, diminished capillary refill time
Rx
 Closed reduction and immobilization with long leg cast
initially
 Short leg cast after 3-4 weeks which allow knee motion
 Fracture healing takes 16-24 weeks
# tibia fibula
Open and comminuted #
Rx
Traction with external fixation
Pt is not allowed to bear weight for about 6
weeks
Intermedullary nails and compression
plates may used with external plaster
support.
Compression plates allows for anatomical
reduction, early foot and knee motion &
weight bearing.
Elevate the leg to control edema
 Fracture lower limbs
Hip #
Common in the elderly due to osteoporotic
bones; weak quadriceps muscles
Can be:-
 Intracapsular i.e. # neck of femur or
Extracapsular- # of trochantric region
Rx
Temporary skin traction with Buck’s extension
may be applied to immobilize the limb,
reduce muscle spasms & relieve pain
Internal fixation
The femur
Femur(thigh) bone is the longest & heaviest
bone in the body
The head is spherical and fits into
acetabulum of the hip bone to form hip
joint.
The neck form the head of the shaft of
femur
The posterior surface forms the flat
triangular area, the popleteal
Distal surface has two articulatar condyles
with tibia and patella ; forms knee joint
Function –to transmit body weight through
Fracture of femur
# clinically open with focal pain, swelling &
deformity
Can result in blood loss >1L in the thigh
# head of femur
Associated with hip dislocation caused by
high energy force
Rx -surgical fixation & hemiathroplasty
# neck of femur
Usually non displaced
Occurs as a result of stress
Common in athletics
Pt usually ambulant
Fracture of femur
Rx –young pts; non-weight bearing for 6 -12
weeks
-Old pts –surgical fixation
# femoral shaft
Usually caused by direct or indirect force
Management
Long leg splint applied while awaiting definitive
management
Immobilize with Thomas splint or Buck’s traction
 surgical Rx with medullary nailing
Open # -wound debridement with delayed
medullary nailing.
Nursing care
Priority
 Immobilization; fluid replacement; pain control
 Assess vital signs and intervene accordingly
 Control bleeding in open # with direct pressure;
cover wound with sterile dressings
 DO NOT CLEAN THE WOUN AS IT IS DONE DURING
SURGICAL TOILET TO PREVENT INFECTION.
 Measure circumference of both femur to assess
edema
 Avoid I.M injection if pt has circulatory compromise
 Assess neurovascular status
 Elevate the leg to control edema
Nursing care
Give broad-spectrum antibiotic in open #
Assess circulatory status distal to the #
Assess for perianal and tibial compromise
 Tibial nerve damage –decrease or loss of
sensation in the lateral aspect of the sole of
the foot
 Perianal nerve damage - decrease or loss of
sensitivity across the top of the foot
 Sciatic nerve damage –signs of both tibial &
perianal nerve damage
Prepare pt for theatre
The pelvis
Formed by three hip bones(innominate
bones ) – Ileum, ischium & pubis
 On the lateral side is the depression known
as acetabulum which forms the hip joint
with head of the femur
Note
The pelvis protects lower urinary tract;
blood & nerve vessels of lower extremities.
Pelvic trauma may result into life
threatening haemorrhage, urologic &
neurologic dysfunction
Up to 4L of blood can accumulate in the
Fracture pelvis
Causes
Blunt trauma
A fall > 12 feet
 colliding or crashing accidents
S/S
Perineal ecchymoses
Crepitation
Pain , local swelling & tenderness
Lower limb paresis; inability to bear weight
Haematuria
Shortening of lower limbs
Classification of pelvic #
 Open #- Open wound with direct
communication to the vagina, rectum or
perineum
Mortality high due to haemorrhage
Closed # -bleeds into peritoneum
Stable # -no further pathologic
displacement of the pelvis can occur with
physical turning or moving
Unstable # -further pathologic
displacement can occur with turning or
moving
Diagnosis
Plain abdominal x –ray
CT scan or MRI indicated when
 Acetabular # is seen or suspected
 Intra- abdominal or retroperitoneal injuries
are suspected & the pt is
haemodynamically unstable
Retrograde urethrography indicated
when :-
 urethral injuries are present or suspected
 Diastases of symphysis pubis
 Injury to pelvic structures
Management
Hx taking to determine the cause
Physical exam
Observe for blood at the scrotum or
perineal ecchymoses
Check femoral pulses
Abdominal palpation to R/O liver, spleen or
bowel injuries
Gently perform manual pelvic compression
once to determine whether the pelvis is
stable or not
Exam the urethra for blood at the penile
meatus
Medical intervention
Priority : prevention & control of
haemorrhage
Open #- pt taken directly to OR for
aggressive resuscitation, ligation and
packing to control haemorrhage
May also require exploratory laparotomy to
Rx intra-abdominal injuries
No obvious abdominal injuries
 pelvis is stabilized
Immobilization done with hip spica cast
Stable # - conservative bed rest or
internal fixation within 2-3 days after injury
Surgical intervention
Open #
Placement of internal or external fixation
devices
Closed #
 Immediate external fixation of the pelvis
done as primary method of controlling
haemorrhage
Unstable #
External pelvic clamps used to reduce and
compress posterior pelvic fragments &
internal fixation done later when the pt is
stable

Nursing interventions
Ensure pt is stated on IVF
Control pain by giving analgesia
Observe vital signs
Maintain correct position
Ensure blood is taken for GXM, CBC,
hematocrit
Give supplemental oxygen
Prepare pt for theatre
Psychotherapy to pt/family
 A &P the bony vertebrae
7 cervical vertebrae
12 thoracic
5 lumber
5 sacral (fused)
4coccyx ( fused)
The vertebrae have similar structures but:
The first cervical vertebra( Atlas) is unique –a ring
like structure that articulates with occiput and
provides for normal flexion extension of the head
2nd cervical vertebra (Axis) articulates with
odontoid process of C1 and allows rotation
movement of the head
Spinal cord
Cylindrical structure that passes through
the bony spinal column
It begins at the level of foramen magnum
to L2
The spinal cord is covered by the meninges
which protects it.

Function of the vertebral column

Protection of the spinal cord
Provide vertical stability
Spinal cord injuries
Injuries occurring to bony vertebrae that
may involve the spinal cord.
Spinal cord injuries result in neurological
deficit that affect pt, family & society :-
 Physical
 Psychological
 Social
Spinal cord injuries more in males (80%)
with majority (60%) victims are between
15-30 years of age.
Most injuries are associated with MV
accidents, falls, sports & assaults.
Classification of spinal cord
injuries
Simple # -occurs without neurologic compromise
and affects the spinous or transverse process
Compression # -occurs when vertebral body is
compressed as a result of hyperextension injuries
Burst /comminuted # -shattering of vertebral
body where the bones may be driven into spinal
cord resulting in neurological deficit
Dislocation-occurs where one vertebra overrides
the other
Subluxation –occurs where there is partial or
complete dislocation
Herniation –protrusion of the annulus causing
compression
Classification of spinal cord
injuries
Fractures & dislocation of the spine are series
injuries due to spinal cord involvement
# appear commonly in C5 –C7 and T12 –L2
due to range of mobility in these areas
Causes of fracture
Trauma
Infections
Previous laminectomy
Excessive motion beyond physiologic limit
osteoporosis
 Cervical fractures
Clinical manifestations
Severe pain radiating to the radius
Inability to move both upper & lower limbs
Loss of sensation
Respiratory compromise
Rx
Minor injury –immobilized with cervical collar for 6-8
wks
Major injuries –realignment & immobilization with
skeletal traction, series of x-ray taken at intervals to
assess bony healing
Once the bone is healed traction is removed and pt
wears cervical collar for some time
Cervical traction
 Thoracic injuries
# may involve ;-
The vertebral body
The lamina & articulating processes
The spinous processes
Clinical presentation
pain
 difficulty in breathing
Rx –immobilization of the # for 4-6wks,
followed by plaster jacket worn for 3months
then extension brace worn for 3-4 months.
Lumber injuries
Clinical presentation
Severe pain radiating to the back
 pt may present with paralytic ileus;
intestinal obstruction
Difficulty in voiding
Rx
Uncomplicated # – bed rest on firm bed for
3-4 wks
Support the fracture region with a full
length brace; support used when
ambulatory & is removed when in bed
Lumber injuries
Moderate to severe fracture
Pt put on hyperextension brace in order to
achieve hyperextension of the spine to
reduce comprehension of the affected
vertebral bodies, then bed rest for 6-8 wks
or
Plaster jacket for 2 months, followed by
extension brace for 3 months
Surgical management
Indications
Progressive neurological deficit despite
reduction & spine immobilization
When there is good chance that
neurological deficit can be improved by
removal of the compression element
Operations done
Laminectomy – removal of the vertebral
ring to allow decompression, removal of
bony fragments or disk material from spinal
cord.
Surgical management
Laminotomy – division of lamina of the
spinal cord
Spinal fusion – surgical fusion of 2-6
vertebrae elements to provide stability and
prevent motion. Accomplished through use
of bony parts or chips taken from iliac crest;
use of wires or acyclic glue
Diskectomy – removal of herniated disk
tissue and related mater
Disketomy with fusion – removal of
vertebra with bone graft
chemolysis – injection to dissolve the
 Complications of fractures
Fat embolism
May occur following # long bones, Pelvis,
multiple # or crush injuries.
Mechanism
Fat globules may move into blood at the time
of # because bone marrow pressure is > than
capillary pressure.
Injury cause stress which increase production
of catecholamine resulting in use of fatty
acids and development of fat globules in the
blood stream
The fat globules combine with platelet to form
 Complications of fractures
Onset of symptoms is rapid and usually occur
within 48hrs but can also occur a few hrs to a
wk after injury
Clinical manifestations vary according to the
site of the emboli
Mnx
Strong opioid( morphine) to control the pain
This is an emergency thus observe pt for
-respiratory compromise
-Change in mental status
Transfer to CCU for further management
 Compartment syndrome
Occurs due to diminished tissue perfusion less
than required
Causes
 Reduction of the muscle compartment size due
to tightness of enclosing muscle facia due to
too tight cast or dressing .
 An increase in muscle compartment content as
result of edema or hemorrhage
Most affected sites are forearm and the leg
muscles
 Myoneural ischemia can set in if the condition
persists for 6-8hrs causing loss of function
 Compartment syndrome
Presentation
Deep throbbing pain unresponsive to
analgesics
Swelling
Diminished capillary refill
Cyanosis
Paralysis
Management
Elevate the injured limb
Apply ice after injury
Release restrictive dressings

 Compartment syndrome
Extremity is splinted in functional position
Passive range of motion exercises done every
4-6hrs when the edema has resolved and
tissue perfusion is restored.
Other complications
Thromboembolism
Infection
Disseminated intravascular coagulation
Delayed complications
Delayed union - healing does not occur at
the expected healing time for location &
type of #
Nonunion - failure of the bone ends to
unite
Avascular necrosis
The end

questions

thank you