Chapter 67: Orthopedic Trauma & Surgery

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Welcome back to The Deep Dive, your shortcut to getting right up to speed on key nursing topics.

Today we're diving into a really critical area, musculoskeletal trauma and orthopedic surgery.

We're pulling out the absolute essentials from a great chapter in Lewis's medical surgical nursing, the goal, to really focus on your role, assessment, intervention, patient education in these, let's face it, often complex situations.

Exactly.

And these injuries are, well, everywhere.

Simple sprains, complex fractures, major surgeries,

accidents are a huge cause of death and disability, and the impact, pain, loss of function cost it's enormous.

Your role as a nurse is pivotal, not just in treatment, but crucially in prevention and that long road of rehabilitation.

Understanding that whole picture, that really elevates your practice.

Right.

So if you're prepping for an exam, reviewing for clinicals, or maybe you're just really curious, this deep dive is for you, we'll hit injury prevention, bone healing, those critical complications you cannot miss, and major orthopedic surgeries.

Let's make this stick.

Okay.

So when we talk musculoskeletal health, where do we even start as nurses?

It feels like it often begins before the injury, right?

With prevention.

Absolutely.

That's spot on.

Think about how many injuries come from preventable accidents.

We can make a huge difference just by empowering people with knowledge.

Your source mentions really practical stuff, seat belts, no distracted driving, simple home safety like removing throw rugs, making sure there's good lighting.

And for older adults, it's things like moderate exercise for strength and balance, plus enough calcium and vitamin D.

What's really interesting is seeing prevention not just as, you know, a public health campaign, but as a direct nursing intervention.

It saves lives.

Prevention is definitely key.

Yeah.

But okay, injuries happen.

And those common soft tissue injuries, sprains, strains, dislocations, you see those constantly.

You really do.

A sprain involves ligaments around a joint, usually from twisting.

A strain is stretching a muscle or tendon too far.

They often look similar initially.

Pain, swelling, hard to move, bruising.

And for the milder ones, the go -to immediate management is that famous acronym.

R -I -C -E.

R -I -C -E.

Rest, ice, compression, elevation.

Classic.

But what's the deeper nursing insight?

How do we apply it effectively beyond just remembering the letters?

Good question.

It's about the why and the when.

Ice, for maybe 23 minutes at a time, causes vasoconstriction.

That helps reduce inflammation and pain, but mainly those first 24 to 48 hours.

Compression, like with an elastic bandage applied distal to proximal, helps push out that edema.

Elevation above the heart does too.

Now here's where it gets interesting and maybe a bit counterintuitive for some.

After that acute phase, say 48 hours, warm moist tea can actually help reduce swelling and feel comforting.

And this is crucial, encouraging early protected movement is vital.

Not complete immobilization forever.

Protected movement helps nourish the cartilage, prevents stiffness, prevents contractures.

It actually speeds things up.

That timing nuance is a really great clinical pearl.

Okay, so beyond sprains and strains, we've got dislocations and subluxations complete or partial joint displacements.

Those sound more serious.

They generally are.

Often from significant trauma, like car crashes.

Shoulders, elbows, hips are common sites.

The most obvious sign is often a visible deformity.

Plus, intense pain, inability to use the joint.

For you, the nurse, the critical point is spotting potential complications.

Things like a vascular necrosis bone death due to lack of blood supply, especially in the hip,

or damage to nearby nerves and blood vessels.

So a prompt, thorough neurovascular assessment is absolutely non -negotiable.

Delay can mean permanent damage.

That neurovascular assessment keeps coming up.

And for good reason.

We also see repetitive strain injuries or RSIs.

What about those?

Yeah.

RSIs come from prolonged force, repetitive movements, awkward postures.

Think musicians, people on computers all day, butchers, athletes.

Prevention is huge here.

Education on ergonomics, posture, workstation setups, taking breaks,

treatment, usually supportive, rest, maybe endocides, heat or cold, and definitely physical therapy.

And probably the most common RSI you'll encounter is carpal tunnel syndrome, CTS.

Ah, carpal tunnel.

Seems like everyone knows someone with it.

It's the most common compression neuropathy up in the upper extremity.

The median nerve gets squeezed in the wrist.

Patients complain of numbness, tingling, pain, maybe weakness in the hand, often wakes them up at night.

You might check for a positive tenile sign.

Do they get tingling when you tap over the nerve?

Or a positive phalanx sign tingling after holding the wrist flexed.

Management can range from wrist splints and steroid injections all the way to surgical release.

Okay.

So across these soft tissue injuries, the core nursing seems to be rice eyes initially, pain management, immobilization when needed, and then really guiding that rehab process.

Exactly.

Tailored to the specific injury, of course, but those principles hold true.

All right.

Let's shift gears now to fractures.

A break in the bone,

could be a tiny crack, could be shattered.

How do we even start to categorize these as nurses?

Good starting point.

We classify them in a few key ways, and this helps guide your assessment and understanding.

First, is it open skin broken, bone potentially exposed or closed where the skin's intact?

That distinction is critical for infection risk.

Is it complete?

The break goes all the way through the bone or incomplete, like a green stick fracture you might see in kids where it bends and cracks partway.

We also describe the fracture lines direction transverse straight across, spiral twisting, common muted, multiple fragments.

Your text likely has good illustrations of these.

And crucially, is it displaced?

Are the bone ends out of alignment or non -displaced where the pieces are still basically lined up?

A common muted fracture, for instance, is almost always displaced.

And the signs are often pretty obvious, right?

Pain, swelling, can't bear weight.

What else might clue us in?

You might see significant bruising.

Muscle spasms can be intense as the body tries to splint itself.

You might feel or even hear crepitation, that grating sound or sensation of bone ends rubbing.

Definitely don't try to elicit that, but be aware if it happens.

And deformity is a big one.

The limb just doesn't look right.

Prompt immobilization is so important here.

Your quick action to splint the injury as it lies can prevent a close fracture from becoming open or stop further damage to nerves and vessels.

It's amazing how the body actually heals bone.

Can you walk us through that process?

What are the key stages and where can nurses really support that natural repair?

It really is a fascinating process.

Typically six stages.

First, fracture hematoma.

Bleeding at the night forms a clot, usually within 72 hours, sets the stage.

Then granulation tissue forms.

New blood vessels, fibroblasts, osteoblasts, the building blocks come in about three to 14 days.

Next is callus formation.

Minerals and new bone matrix form this sort of unorganized bridge across the break.

You can start seeing this on x -ray around week two, then ossification.

That callus hardens into actual bone.

This takes weeks to months, giving clinical union it's stable enough for gentle use, maybe cast removal.

After that, consolidation.

The gap closes completely.

Full bony union on x -ray can take up to a year.

And finally, remodeling.

The bone gradually reshapes itself back to its original strength and form, responding to the stresses placed on it.

So for nurses, the takeaway is early stages need strict immobilization and good nutrition.

Later stages need that controlled progressive stress from weight bearing and PT to remodel properly and regain full strength.

Understanding those phases really guides what we tell patients how we manage them.

What sorts of things can interfere with healing?

Oh, lots of things.

How displaced the fracture was.

Where it is, some bones have poorer blood supply.

Other tissue damage matters.

Inadequate immobilization is a big one.

Infection, obviously.

Poor nutrition, not enough protein, vitamins, calcium.

Systemic diseases like diabetes play a role.

Smoking definitely slows healing.

And naturally, healing takes longer as we age.

You also have to watch for complications like delayed union, healing slower than expected, non -union, not healing at all, or malunion, healing crooked.

Okay, so the goals are realignment, keeping it still, and getting function back.

How do we achieve that realignment, the reduction?

Two main ways.

Closed reduction is non -surgical.

The provider manually manipulates the bone ends back into place, usually with the patient sedated or under anesthesia.

Then it's immobilized with a cast, splint, maybe traction.

The other way is open reduction, that's surgery.

They open the site, realign the bones directly.

This usually involves internal fixation using pins, screws, plates, rods, right inside to hold the pieces together.

We often call this ORF, open reduction internal fixation.

ORIF sounds like it has advantages.

It does.

A big one is allowing for earlier weight bearing and movement.

That helps prevent a lot of the complications that come with being stuck in bed, like muscle wasting, blood clots, pneumonia.

And traction, we see that used too.

What are the key nursing points when caring for someone in Right.

Traction uses a pulling force.

It can reduce muscle spasms, immobilize a joint or fracture, maybe even expand a joint space before surgery.

Two main types.

Skin traction is short -term, usually 48 -72 hours.

Tape, boots, or splints are applied to the skin, and weights, usually 5 -10 pounds, provide the pull.

Bucks traction for hip fractures is a common example.

Your big priority with skin traction is skin assessment.

Check frequently for breakdown under the straps or boot, then there's skeletal traction.

Here, a pin or wire is inserted directly into the bone.

This allows for heavier weights, 5 -45 pounds, and longer -term traction.

But it carries a higher risk of infection at the pin site.

You need meticulous pin site care according to protocol.

With any traction, critical points are ensure weights hang freely, never resting on the floor or bed, make sure the ropes are in the pulley grooves, maintain counter -traction off in the patient's own body weight, and keep the patient in proper alignment.

Okay, and for immobilization, casts are super common.

What do we need to know about cast care?

Casts provide temporary immobilization.

They can be fiberglass -lighter, more water -resistant, dries faster, or the traditional plaster of Paris, which takes longer to fully harden.

For a fresh plaster cast, crucial points, leave it uncovered to allow air drying.

Handle it only with the palms of your hands, not fingertips, to avoid creating pressure points inside.

Later, you might need to pedal the edges with waterproof tape if they're rough and irritating the skin.

But the most important thing with any cast, fiberglass or plaster,

frequent, diligent neurovascular assessment of the extremity distorts the cast.

Cannot stress that enough.

You've hit on neurovascular assessment again.

Can you just quickly recap those key components for our listeners?

Why is it so vital?

Absolutely.

It bears repeating because missing changes can lead to disaster.

Neurovascular assessment has two parts, peripheral vascular and peripheral neurologic.

Vascular, check color, temperature warm, tapillary refill, brisk, sluggish, peripheral pulses, present and edema, swelling.

Neurologic, check sensation, can they feel light touch?

Motor function, can they wiggle finger stows?

And pain, especially pain that's increasing or seems out of proportion.

And always, always compare the injured side to the uninjured side.

That's your baseline.

Any deterioration, coolness, pallor, sluggish refill, decreased pulse, numbness, tingling, inability to move,

increasing pain, needs immediate reporting.

Got it.

Compare, assess systematically, report changes immediately.

Beyond the hardware, what about meds and nutrition?

Muscle relaxants like cyclobenzaprine or carosoprotein are often used for those painful spasms.

For open fractures, tetanus immunization status is checked and updated if needed.

Prophylactic antibiotics that penetrate bone like cephalosporins are given before surgery and often continued post -op.

Nutrition is huge for healing.

Patients need adequate protein, calories, and vitamins, especially C, B, D, plus minerals like calcium, phosphorus, magnesium.

Encourage plenty of fluids, two, three liters a day, and high fiber to prevent constipation, which is really common with immobility and pain meds.

Nursing care extends well beyond the hospital too.

Lots of patient education on cast care, using crutches or walkers correctly, recognizing warning signs, and addressing the psychosocial aspects.

Anxiety, maybe depression, changes in lifestyle.

It's holistic.

Okay, so manufacturers heal fine, thankfully, but we have to be sharp about spotting complications.

Some of these are true emergencies.

What are the big ones we need to have on our radar?

You're absolutely right.

Vigilance is key.

Infection is a major concern, especially with open fractures or extensive soft tissue damage.

These often require surgical debridement, cleaning out dead tissue and contaminants, thorough irrigation in the O .R., and IV antibiotics, sometimes for weeks.

Meticulous wound care, sterile dressing changes.

Preventing osteomyelitis is paramount.

And then there's the one that strikes fear into nursing students everywhere, the six Ps and compartment syndrome.

Yes, compartment syndrome.

It is an orthopedic emergency, no question.

It happens when swelling or bleeding increases pressure within a closed muscle compartment, usually in the limbs.

The fascia surrounding the muscles can only stretch so much.

As pressure builds, it squeezes blood vessels and nerves.

If it's not relieved quickly, typically within four to eight hours, it causes irreversible muscle and nerve damage, potentially leading to limb loss.

It can be caused by decreased compartment size.

Think a cast that's too tight, restrictive dressings, or increased compartment contents like bleeding, inflammation, edema after the injury.

So those infamous six Ps again, pain, pressure, paresthesia, power, paralysis,

pulselessness, which ones are the early warnings we absolutely have to catch?

This is the critical insight for you as the nurse.

Don't wait for all six.

The earliest and most reliable signs are often pain that's out of proportion to the injury, especially pain that doesn't get better with opioids, and pain on passive stretch of the muscles in that compartment.

And paresthesia, numbness, and tingling, those are your red flags.

Power, paleness, coolness, paralysis, loss of function, and pulselessness, weak or absent pulse, are late signs.

By the time you see those, significant damage may already be done.

Your source gives that scenario.

The young man with fumer tibia fractures in a cast reporting severe pain despite IV morphine.

That is compartment syndrome until proven otherwise.

That really drives home the urgency.

So if you suspect it, what's the immediate nursing action?

First, notify the healthcare provider immediately.

Don't delay and anticipate and prepare to relieve the pressure.

This might mean cutting the cask on both sides by valving it or loosening restrictive bandages.

Don't remove the cast entirely unless ordered, but relieve the constriction.

Importantly, do not elevate the limb above heart level if compartment syndrome is suspected.

Elevation can lower venous pressure and compromise arterial perfusion even more.

Also, do not apply ice or cold compresses as this causes vasoconstriction and can worsen ischemia.

Definitive treatment might require a surgical fasciotomy where they cut the fascia open to relieve the pressure.

Okay, critical points there.

Another big risk, especially with lower limb fractures and surgeries, is venous thromboembolism or VTE.

Yes, VTE meaning DVT, deep vein thrombosis, and PE, pulmonary embolism, is a major risk.

Immobility leads to venous stasis, especially in the legs.

Hip fractures, hip or knee replacements, carry a particularly high risk.

That's why prophylactic anticoagulants blood thinners like low molecular weight heparin, LMWH, example, anoxaparin, or warfarin are standard practice, often continued for several weeks post -op.

Alongside meds, you'll be encouraging ankle pumps.

Mobility as allowed may be using sequential compression devices, SCDs, or compression stockings.

Prevention is multifaceted.

And then there's fat embolism syndrome, FES.

This one sounds scary and may be a bit harder to pin down.

It is serious and can be subtle initially.

FES happens when fat globules from the marrow of injured long bones like the femur, pelvis, or ribs enter the bloodstream and travel, often lodging in the lungs.

It can also happen after joint replacement surgery.

Symptoms usually develop 24 to 48 hours after the injury.

The classic presentation involves the triad of respiratory distress, neurologic changes, and a particular rash, though not everyone gets all three.

Respiratory symptoms often mimic A.

Aard's acute respiratory distress syndrome.

Think shortness of breath, rapid breathing, low oxygen levels, maybe chest pain, apprehension.

They might become confused, restless, drowsy, due to hypoxia affecting the brain.

Now, here's a key clinical pearl that can help distinguish FES, the particular rash.

Tiny pinpoint reddish -purple spots, often on the neck, upper chest, axillae, conjunctiva.

If you see that in a patient with a long bone fracture, think FES.

Your source mentions that 24 -year -old with a femur fracture who's very restless with some axillary patica.

That's a classic FES alert.

Management is primarily supportive of oxygen, maybe mechanical ventilation, careful fluid management.

The most important thing is prevention, careful immobilization of long bone fractures to minimize movement and hopefully prevent dislodging those fat globules in the first place.

And one more quick mention,

rhabdomyolysis.

Right, rhabdo.

This is breakdown of damaged muscle tissue releasing myoglobin into the blood.

Myoglobin is toxic to the kidneys and can cause acute kidney injury.

A key sign to watch for is dark reddish -brown urine.

Also monitor kidney function tests like BUN and creatinine.

Treatment involves aggressive fluid resuscitation to flush the kidneys.

Okay, let's touch on a few specific fractures that have unique points.

The collis fracture.

That's a very common fracture of the distal radius, the bone on the thumb side of the forearm.

Often happens when someone falls onto an outstretched hand.

You might see a characteristic silver fork deformity where the wrist looks bent backward.

Nursing care focuses on good neurovascular checks of the hand, managing swelling and encouraging movement of the fingers, thumb, elbow and shoulder to prevent stiffness while the wrist is immobilized.

And the really significant one, especially in older adults, the hip fracture.

Huge issue.

Hip fractures, usually meaning a fracture of the proximal upper part of the femur, are incredibly common in older adults, often due to falls.

Osteoporosis, balanced problems, medications all contribute.

They can be intracapsular within the hip joint capsule itself, like a femoral neck fracture.

These have a higher risk of non -union or vascular necrosis because the fracture can disrupt blood supply to the femoral head.

Or they can be extracapsular outside the joint capsule, like intertrochanteric fractures.

These tend to heal better as the blood supply is richer there.

Clinically, you'll often see the legs shortened, externally rotated, foot pointing outwards, and lots of muscle spasm and pain.

The patient won't be able to bear weight.

Surgery is almost always the answer, right?

ORIF, or maybe a replacement.

Yes.

Surgery is usually done promptly to get the patient moving.

Options depend on the fracture location and the patient's condition.

It might be ORF with screws and plates.

Or if the femoral head is damaged or the fracture is intracapsular and displaced, they might do a hemiarthroplasty, replacing just the femoral head, the ball, or a total hip arthroplasty, THA, replacing both the ball and the socket.

Sometimes bucks traction might be used temporarily before surgery, mainly to reduce muscle spasms and pain.

And post -op after hip surgery, especially replacement, preventing dislocation is a massive nursing focus.

Absolutely critical.

Particularly with the traditional posterior approach surgery, where they cut muscles at the back.

You need to teach the patient and family the hip precautions religiously.

These are designed to prevent the new hip joint from popping out.

Key things to avoid.

No hip flexion beyond 90 degrees, so no bending way over, no low chairs or toilets, no adduction, crossing legs or ankles, no internal rotation, turning foot, knee inward.

This often means using an elevated toilet seat, chairs with arms, maybe an abduction pillow between the legs, especially when sleeping or turning.

Now, the anterior approach for THA is becoming more common.

It involves different muscle dissection and generally has fewer restrictions post -op, mainly avoiding hyperextension.

But you still need to know the specific precautions based on the surgical approach used.

Patient education here is just vital for a good outcome.

That's a great example of procedure -specific nursing care.

The chapter also mentions pelvic fractures, vertebral fractures.

Right.

Pelvic fractures can be very serious.

High risk for internal bleeding and organ damage because there's so much vasculature and major organs nearby.

Vertebral fractures, often compression fractures in older adults with osteoporosis, need careful handling log rolling to maintain spinal alignment.

Sometimes procedures like vertebroplasty or kyphoplasty, injecting bone cement, are done.

And facial or mandibular jaw fractures, the absolute number one priority is airway.

Always assess for airway patency and potential cervical spine injury first.

If the jaw is wired shut, you must have wire cutters or scissors taped to the head of the bed or with the patient at all times in case of emergency vomiting or choking.

Oral hygiene and liquid nutrition are also key challenges.

And finally, amputation, a truly life -altering event.

It is.

Amputations are most often due to complications of peripheral vascular disease, especially linked to diabetes, but also trauma, infection, tumors.

The goal is always to preserve as much limb length and function as possible.

Nursing care is incredibly holistic.

Physically, you're monitoring for hemorrhage, managing pain, caring for the residual limb, often using compression bandaging to shape it for a future prosthesis.

Preventing contractures is huge, especially hip or knee flexion contractures.

Encouraging prone positioning, lying on the stomach several times a day can help with hip extension for lower limb amutees.

But just as important is the psychosocial support, dealing with body image changes, grief, loss, and managing phantom limb sensation or pain.

That phantom limb sensation sounds really difficult to cope with.

It can be very distressing.

The patient feels sensations tingling, itching, pressure, even intense pain in the limb that isn't there anymore.

It's a real neurologic phenomenon.

Interestingly, things like mirror therapy, where they see the reflection of their intact limb moving where the amputated limb would be, can sometimes help trick the brain and reduce the phantom sensations.

Virtual reality is also being explored.

Rehabilitation is a long process involving physical therapy, occupational therapy, learning to use a prosthesis if appropriate.

It requires immense patient motivation and support.

Okay, to round things out, let's talk briefly about common joint surgeries, often done to relieve chronic pain from arthritis or restore function.

Exactly.

Beyond fracture repair, we see surgeries like synovectomy, removing inflamed joint lining, aphanerumatoid arthritis,

osteotomy, cutting and relining bone to correct deformity, or arthroscopic debridement, cleaning out loose debris from a joint.

But the big ones for quality of life improvement are usually the arthroplasty's joint replacements.

Like total hip arthroplasty, THA, and total knee arthroplasty, TKA.

Precisely.

THA replaces the ball and socket hip joint.

We already discussed the key nursing care around preventing dislocation after THA.

TKA replaces the knee joint surfaces.

Post -op care for TKA heavily emphasizes pain management, often using nerve blocks or multimodal analgesia, and early, often aggressive, physical therapy.

Getting that knee bending early, aiming for at least 90 degrees of flexion, is crucial for long -term function.

Continuous passive motion, CPM machines, used to be common.

But early active PT is often favored now.

We also see replacements for shoulders, elbows, fingers, ankles, each with specific rehab protocols.

And then there's arthrodesis that's different, right?

Fusing a joint.

That's right.

Arthrodesis is surgical fusion.

It's done when a joint is too severely damaged for replacement or if replacement has failed.

It relieves pain, but results in a permanently stiff, immobile joint.

Common sites include wrists, ankles, sometimes vertebrae in the spine.

And after any of these major joint surgeries, what are the main complications we're watching for?

Infection is always a major concern with implants.

Bacteria like staph or strep can cause deep joint infections, which are devastating and often require prosthesis removal.

Strict sterile technique in the OR and prophylactic antibiotics are key preventative measures.

And again, VTE blood clots remains a significant risk, especially after lower extremity joint replacement.

All those preventative measures we discussed, anticoagulants, early mobility compression devices are standard post -op care.

So wrapping up joint surgery, what's the big picture for nursing?

What's the takeaway?

It really comes down to thorough pre -op preparation, assessing risks, teaching the patient what to expect.

Then meticulous post -op care, vigilant neurovascular checks, effective pain control, preventing complications like infection and VTE,

and facilitating that early mobilization and rehabilitation according to the specific procedure.

Discharge planning starts early.

It really highlights how detail -oriented and comprehensive our care needs to be.

What stands out to you about the level of support these patients need?

We have certainly covered a lot of ground today.

From basic sprains right through to complex joint replacements, we get prevention, the amazing process of bone healing, those critical complications like compartment syndrome and FES that need immediate recognition, and the vital role of nursing assessment and intervention every step of the way, all drawn from that Lewis's chapter.

Yeah, and connecting it all.

It's clear musculoskeletal nursing.

It isn't just about bones and joints, is it?

It's fundamentally about restoring function, managing pain effectively, keeping patients safe from complications, and providing that crucial support through what can be major physical and emotional upheaval.

Your understanding, it really makes a difference to their quality of life.

Absolutely.

The breadth of knowledge you need, plus that intense focus on rehab and teaching, it really shows the impact nurses have in this specialty.

Okay, that brings us to our final provocative thought for you to ponder.

Considering the incredible advances we're seeing in orthopedic surgery,

robotics, new materials,

minimally invasive techniques, how do you think technology might further reshape patient rehab and your daily practice as a musculoskeletal nurse in the coming decade?

Could there be new roles, new responsibilities emerging for nurses in this evolving landscape?

Something to think about.

We really hope this deep dive has given you some solid insights and maybe sparked some new curiosity.

Until next time, keep learning, keep questioning, and keep making that difference.