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Orthopaedic Trauma

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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Orthopaedic Trauma

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  1. Orthopaedic Trauma

  2. 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

  3. 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.

  4. 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.

  5. Trauma Statistics Every 6 minutes, someone in America dies from trauma: • Motor vehicles • Farm • Falls • Gunshot wounds

  6. 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

  7. Mechanism of Injury:Energy Exchange • Kinetic/ Mechanical • Thermal • Chemical • Electrical • Radiant • Oxygen deprivation

  8. Mechanism of Injury Penetrating Trauma • High velocity missiles (bullets) = crush/stretch • Low velocity stab wounds = shearing/stretch • High pressure injection = explosion/tearing

  9. Mechanism of Injury Blunt Trauma • Compression/impact= compressed/shorten • Shearing=tearing/ dissection • Torsion/twisting= dislocation/ subluxation • Tensile/traction= stretching/tearing

  10. Mechanism of Injury • Motor vehicle accidents • Falls • Pedestrian/Bikes/Skateboards/Scooters • Non-accidental; self-inflicted • Shaken baby • Diving • Gun Shot Wounds

  11. 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,

  12. Subluxation: Interventions Immediate closed reduction by trained personnel

  13. Question # 1 The partial disruption of articulating surfaces is known as: c. subluxation

  14. Dislocation Complete separation or displacement of articulating surfaces: • Urgent reduction required • Blood supply to bone • Nerve or vessel injury

  15. Dislocation: Interventions • Reduction (return to normal anatomic alignment) • Manually • Regional block • General anesthesia • Open Reduction Internal Fixation

  16. 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.

  17. Subluxation & Dislocation: Nursing Diagnosis • Peripheral neurovascular dysfunction, risk for • Injury, risk for • Tissue perfusion, ineffective; peripheral • Physical mobility, impaired

  18. 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.

  19. Answer # 2 A comminuted fracture may be classified as an injury in which: d. bone is fractured into two or more fragments.

  20. Fractures A break or disruption in the continuity of a bone

  21. Fractures: Clinical Manifestations • Pain • Edema • Discoloration • Inability to function • Obvious deformity • Crepitus • Muscle spasm • Protruding bone

  22. Fractures: Diagnostics • Radiologic exams • Plane films • X-ray a joint above and below injury • CT scan • MRI

  23. 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

  24. Fractures: Classifications

  25. Comminuted Displaced/Non-displaced Complete/ Incomplete Avulsion Compression Buckle Butterfly Pathologic Articular Transverse Oblique Spiral Stellate Fatigue/Stress Segmental Fractures: Classifications

  26. Fractures: Classifications

  27. Fractures: Classifications

  28. Fractures: Classifications

  29. 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)

  30. 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

  31. 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

  32. 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

  33. 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

  34. 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

  35. 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

  36. Orthopaedic Emergencies • Spine fractures • Open book pelvic fractures • Dislocated joint • Elbow • Knee

  37. Fracture Management: Goals • Prevent complications • Return to maximal function • Achieve best possible cosmetic result • Remember ABC’s • C-spine precautions

  38. Radiographic Assessment C-spine Chest Pelvis Neurovascular Assessment Upper extremity Radial Median Ulnar Lower extremity Peroneal Tibial Assessment

  39. 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

  40. 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

  41. 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

  42. Trauma severity Type of bone Immobilization Infection Local pathology Avascular necrosis (AVN) Intra-articular fracture Systemic factors Osteoporosis Factors Affecting Fracture Healing

  43. 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,

  44. 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

  45. Closed Reduction • Complications of Casts • Compartment syndrome • Cast syndrome (superior mesenteric artery syndrome)

  46. 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

  47. 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

  48. 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

  49. Traction: Types • Manual Use of hands to exert pulling force • Skin Pulling force directly to the skin • Skeletal Traction forces directly to the bone

  50. 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

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