Chapter 42

COMMON MUSCULOSKELETAL INJURIES:

-Contusions -Strains -Sprains

Nursing Management for Fractures:

-Immediate postoperative care: Encouraging Activity. ---Patient is encouraged to exercise as much as possible by means of the overbed trapeze. ---This device helps strengthen the arms and shoulders in preparation for protected ambulation (e.g., toe touch, partial weight bearing). Common complication after fracture of femoral shaft is: -restriction of knee motion ---In general, active and passive knee exercises begin as soon as possible, depending on the management approach and the stability of the fracture and knee ligaments. ---To preserve muscle strength, the patient is instructed to exercise the noninjured hip and the lower leg, foot, and toes on a regular basis ---The surgeon prescribes the degree of weight bearing and the rate at which the patient can progress to full weight bearing On the first postoperative day, generally, the patient transfers to a chair with assistance and begins assisted ambulation The amount of weight bearing that can be permitted depends on the stability of the fracture reduction. In general, hip flexion and internal rotation restrictions apply only if the patient has had a hemiarthroplasty (replacement of the ball of the hip). PT works with the patient on: -ROM -strengthening exercises -safe use of ambulatory aids -gait training. Functional ambulation stimulates fracture healing. Patient can anticipate discharge to: home or to an extended care facility with the use of an ambulatory aid Some modifications in the home may be needed, such as installation of elevated toilet seats and grab bars Monitoring and Managing Potential Complications: -Pain management -prevention of secondary medical problems such as: ---hemorrhagic shock ---atelectasis ---pneumonia ---DVT ---heart failure ---constipation ---pressure ulcer development ---bladder control problems ---pain Early mobilization of the patient is important, so that independent functioning can be restored. Elderly people with hip fractures are particularly prone to complications that may require more vigorous treatment than the fracture. Frequently, the patient develops shock because the loss of two to three units of blood into the tissues is common with these fractures. Achievement of homeostasis after injury and after surgery is accomplished through careful monitoring of: -vital signs -wound drainage from dressings and external drains (drains are typically removed 24 to 48 hours after surgery) -laboratory results -physical assessment findings -collaborative management including adjustment of therapeutic interventions as indicated. p. 1130 p. 1131 Neurovascular complications may occur from: -direct injury to nerves and blood vessels or -increased tissue pressure With hip fracture, bleeding into the tissues is expected Excessive swelling may be observed and may further impair the neuromuscular status Patients may complain of increased pain at the site, and swelling may be noted in the thigh and buttock due to hematoma formation. Ice may be applied to decrease the swelling. The nurse marks the extent of drainage on the dressing by circling the extent and noting initials, date, and time. If excessive, the nurse should notify the provider. DVT is a common postoperative complication contributing to significant morbidity and mortality in patients undergoing hip fracture surgery. ---To prevent DVT, the nurse encourages -intake of fluids -ankle and foot exercises. RN assesses legs for DVT, which may include: -unilateral calf tenderness -warmth -redness -swelling Symptoms are related to inflammatory processes, so RN assesses for: -low-grade fever -malaise -elevated white blood cell (WBC) count and -ESR: sedimentation rate The nurse administers: -anticoagulant and mechanically based prophylaxis (e.g., elastic compression stockings, sequential compression devices, and prophylactic anticoagulant therapy) as prescribed Pulmonary complications commonly include: -atelectasis and pneumonia, are a threat to elderly patients undergoing hip surgery. -Deep-breathing exercises -change of position q 2 hours -IS: incentive spirometer help prevent respiratory complications Assess breath sounds q 4 hours to detect adventitious or diminished sounds. Oxygen saturation should be assessed; supplemental oxygen may be ordered to keep the level above 95%. Pain must be treated with analgesic agents, typically opioids; otherwise, the patient may not be able to readily cough, deep breathe, or engage in prescribed activities. Out-of-bed (OOB) activities will be beneficial for lung function as well as muscle strength Heart failure is a frequent cause of mortality in elderly hip fracture patients. The cumulative effect of trauma, major surgery, and concurrent medical history place the patient at risk for heart failure. The nurse is alert for signs and symptoms associated with: -left-sided heart failure, including shortness of breath, cough, dyspnea on exertion (DOE), crackles, orthopnea, and paroxysmal nocturnal dyspnea -Right ventricular failure presents with peripheral edema (may be pitting), jugular vein distention, and abdominal distention. Edema will be in dependent areas, so the nurse assesses the sacral area as well as extremities. -Record I&Os (noting decreased urinary output) -auscultation of heart (noting presence of S3) -lung sounds (crackles) -monitoring O2 saturation -vital signs (noting decreasing blood pressure, tachycardia, and tachypnea) RN consults the surgeon if s/s of excess fluid volume persist or worsen. The nurse expects fluid restriction and administers diuretics as ordered. Skin breakdown is often seen in elderly patients with hip fracture. Blisters caused by tape are related to the tension of soft tissue edema under the nonelastic tape. An elastic hip spica wrap dressing or elastic tape applied in a vertical fashion may reduce the incidence of tape blisters. In addition, patients with hip fractures tend to remain in one position and may develop pressure ulcers. Proper skin care, especially on the heels, back, sacrum, and shoulders, and turning and frequent repositioning helps to relieve pressure. Special mattress may provide protection by distributing pressure evenly. Reduced GI motility, immobility, and the effects of anesthesia may result in constipation. If constipation develops, therapeutic measures may include stool softeners, laxatives, suppositories, and enemas. Because urinary retention is common after surgery, the nurse must assess the patient's voiding patterns and amounts, noting bladder distention and voiding of small amounts of urine (<100 mL) frequently. To ensure proper urinary tract function, the nurse monitors intake via IV route and/or by mouth if allowed and output. If no preexisting cardiac disease (e.g., heart failure, coronary artery disease) exists, then liberal intake of fluids are encouraged. The patient is informed to notify the nurse if complaints of bladder fullness or inability to void are noted. p. 1131 p. 1132 Infection is suspected if the patient complains of persistent, moderate discomfort in the hip, experiences chills or malaise, and has an elevated WBC count and erythrocyte sedimentation rate (ESR). The nurse observes the surgical incision for erythema, warmth, tenderness, and notes color, amount, and consistency of wound drainage. In the elderly, symptoms of infection may be nonspecific (e.g., patients may be afebrile without complaints); an important marker is a decline in the patient's functional status and/or the presence of confusion. The closed-wound drainage system is observed for color and amount of drainage and functioning of the drainage device. Delayed complications of hip fractures include: -malunion -delayed union or nonunion -AVN of the femoral head (particularly with femoral neck fractures) -fixation device problems (e.g., protrusion of the fixation device through the acetabulum, loosening of hardware) Healing time is 4 to 6 months Osteoporosis Screening: Specific patient education regarding dietary requirements, lifestyle changes, and weight-bearing exercise to promote bone health is needed. Prevention of falls is also important and may be achieved through exercises to improve muscle tone and balance and through the elimination of environmental hazards such as throw rugs. Other environmental considerations are the use of hand rails on the stairs, nonskid surfaces in the bathroom, grab bars in the shower, raised toilet seats, well-fitting shoes with nonskid soles, and adequate home lighting.

Maintaining and Restoring Function:

-Teach exercises to maintain the health of unaffected muscles and increase the strength of muscles needed for transferring and for using assistive devices (e.g., crutches, walker, special utensils). -teach patients how to use assistive devices safely. -Isometric and muscle-setting exercises are encouraged to minimize disuse atrophy and to promote circulation. -Participation in activities of daily living (ADLs) is encouraged to promote independent functioning and self-esteem. -Gradual resumption of activities -With internal fixation, the surgeon determines the amount of movement and weight-bearing stress the extremity can withstand and prescribes the level of activity. -Plans are made to help patients modify their home environment as needed and to secure personal assistance if necessary.

Ongoing Management in Fractures:

-improving function by restoring motion and stability, and relieving pain and disability. The principles of fracture treatment include: -reduction -immobilization -regaining of normal function and strength through rehabilitation. Reduction: Reduction of a fracture ("setting" the bone) refers to restoration of the fracture fragments to anatomic alignment and rotation. Either closed reduction or open reduction may be used to reduce a fracture. Closed Reduction. In most instances is accomplished through manipulation and manual traction. The extremity is held in the desired position while the provider applies a cast, splint, or other device. Reduction under anesthesia with percutaneous pinning may be used. The immobilizing device maintains the reduction and stabilizes the extremity for bone healing. X-rays are obtained to verify that the bone fragments are correctly aligned. Traction (skin or skeletal) may be used to effect fracture reduction and immobilization. Open Reduction. With an open fracture, surgical intervention is needed to align the bone fragments. Internal fixation devices (metallic pins, wires, screws, plates, nails, or rods) are used to hold the bone fragments in position until bone healing occurs Internal fixation devices ensure firm approximation and fixation of the bony fragments. They are not designed to support the body's weight, and they can bend, loosen, or break if stressed. The estimated strength of the bone, the stability of the fracture, reduction and fixation, and the amount of bone healing are important considerations in determining weight-bearing limits. Although the incision may appear healed, the underlying bone requires more time to repair and regain normal strength. Some orthopedic procedures require weight-bearing restrictions. The orthopedic surgeon will prescribe the weight-bearing limits and the use of protective devices (orthoses), if necessary, after surgery. Management of an Open Fracture: For patients with open fractures, prompt, thorough wound irrigation and débridement are necessary to remove foreign bodies, obvious debris, and bacteria. This is often performed in the OR. Once the wound is cleaned, the fracture is carefully reduced and stabilized by internal and/or external fixation. All open fractures are considered contaminated and carry risks for: -osteomyelitis (bone infection) -tetanus -gas gangrene Systemic antibiotics are generally ordered and administered ideally within 3 hours of injury Prevent infection of the: -wound -soft tissue -bone -promote healing of soft tissue and bone Options include sterile dressing changes to allow drainage of wound and edema from heavily contaminated injuries; the use of wound-vacuum assisted closure device; or reexploration of the wound with débridement, as necessary to remove infected and devitalized (dead) tissue and increasing vascularity in the region. After it has been determined that infection is not present, the wound is closed by: -grafting of autogenous (patient's own tissue) skin, or a flap -healing by secondary intention (a full-thickness wound heals from the base upward, by laying down new tissue). The nurse instructs patient/family to monitor temperature at regular intervals and report signs of infection to their provider Infections must be treated promptly. In 4 to 8 weeks, bone grafting may be necessary to bridge bone defects and to stimulate bone healing.

Nursing Management with Fractures:

-relief of pain -improved physical mobility -achievement of maximum level of self-care -healing of any trauma-associated lacerations and abrasions -maintenance of adequate neuromuscular function -absence of complications Provided the patient/significant others by explaining the: sights, sounds, and sensations (e.g., heat from the hardening reaction of the plaster) associated with application of internal or external device chosen to treat the fracture. Regardless of the treatment modality chosen for the fracture, patient teaching includes: -self-care -medication information -monitoring for potential complications -need for continuing health care supervision Fracture healing and restoration of full strength and mobility may take many months. Ask patient to indicate the exact site, character, and intensity of the pain to help determine its cause. -Pain associated with the underlying condition (e.g., fracture) is frequently controlled by immobilization. -Pain due to edema that is associated with trauma, surgery, or bleeding into the tissues can frequently be controlled by elevation and, if prescribed, intermittent application of cold packs. Ice bags (one-third to one-half full) or cold application devices are placed on each side of the cast or fixator, if prescribed, making sure not to indent the cast or put undue pressure on external pins. -Analgesics are administered as prescribed. -Pain may also be indicative of complications. -Unrelenting pain that is unresponsive to usual treatment measures (narcotics, elevation, cold) is associated with compartment syndrome. -Severe pain over a bony prominence may warn of an impending pressure ulcer. Discomfort due to pressure on the skin may be relieved by elevation that controls edema or by positioning that alters pressure. However, the affected limb must be elevated no higher than heart level to ensure adequate arterial perfusion. If the fracture is casted, it may be necessary to modify the cast or to apply a new cast. -Every joint and digit that is not immobilized should be exercised and moved through its ROM to maintain function. RN encourages the patient to assist in the repositioning, if not contraindicated, by use of the trapeze or bed rail. If a patient has a spica cast (a cast that stabilizes the hips and thighs, also known as a body cast), a stabilizing abduction bar may be incorporated into the cast to maintain the legs in an abducted position. This bar should never be used as a turning device. If internal fixation is required to stabilize the fracture, the provider determines weight-bearing activity. Because deep vein thrombosis (DVT) is a significant risk for the immobilized patient, the nurse encourages the patient to do active flexion-extension foot and ankle exercises and isometric contraction of the calf muscles (calf-pumping exercises) every hour while awake to decrease venous stasis in the unaffected limb. In addition, elastic stockings, intermittent compression devices such as Venodyne boots, and anticoagulant therapy may be prescribed to help prevent thrombus formation. RN encourages the patient to move digits and joints distal to injury hourly when awake to prevent problems related to inactivity

Delayed Union, Malunion, and Nonunion:

1) Delayed union means prolonged healing. May be due to inadequate blood supply, infection, or incorrect immobilization of the fracture. It may be associated with a fracture that involved: -significant loss of bone -hematoma at the fracture site -comorbidity (e.g., diabetes mellitus, autoimmune disease). -Fracture eventually does heal. 2) Malunion means flawed union Malunion associated with: -inadequate reduction of the fracture -misalignment of the fracture at the time of immobilization -infection at the fracture site and it presents as a deformity at the site visually or on X-ray. 3) Nonunion means fibrocartilage or fibrous tissue exists between the bone fragments; no bone salts have been deposited. Nonunion associated with: -infection -inadequate circulation -malignancy -noncompliance with activity restrictions. Cigarette smoking and poor nutrition place the patient at a higher risk of delayed healing or nonunion. Nonunion most commonly occurs with fractures of: -middle third of the humerus -lower third of the tibia -at neck of the femur in elderly people Factors contributing to both nonunion and malunion include: -interposition of tissue between the bone ends or -manipulation that disrupts callus formation -excessive space between bone fragments (bone gap) -limited bone contact -bone or soft tissue loss -impaired blood supply resulting in AVN *False joint (pseudarthrosis) often develops at the site of the fracture. Steroids and older nonselective anti-cyclooxygenase (COX)-2 agents have been implicated in delayed fracture healing. If (NSAIDs) are used for analgesia with fractures, the literature suggests a preferred use of selective COX-2 inhibitors for short-term duration of 10 days. Additionally, these inhibitors should be avoided in: -smokers -diabetics, -those on corticosteroids to avoid nonunion Patient complaints of: -persistent discomfort and -abnormal movement or instability at the fracture site indicate potential delayed union, malunion, or nonunion. Nonunion is treated with: -internal fixation -bone grafting -electrical bone stimulation -Combination of these therapies. Internal fixation stabilizes the bone fragments and ensures bone contact. A bone graft may be an autograft (tissue, frequently from the iliac crest, harvested from the patient for his or her own use) or an allograft (tissue harvested from a donor for a recipient). The bone graft fills the bone gap, provides a lattice structure for invasion by bone cells, and actively promotes bone growth. p. 1122 p. 1123 After grafting, immobilization and non-weight-bearing exercises are required while the bone graft becomes incorporated and the fracture or defect heals. Depending on the type of bone grafted, healing may take from 6 to 12 months or longer. Bone grafting problems include: -wound or graft infection -fracture of the graft -persistent pain -sensory loss -nonunion

Medical and Nursing Management of Joint Dislocations:

Affected joint needs to be immobilized while the patient is transported to the hospital. The dislocation is promptly reduced (i.e., displaced parts are brought into normal position) to preserve joint function. Analgesia, muscle relaxants, and possibly anesthesia are used to facilitate closed reduction (e.g., noninvasive or nonsurgical reduction). The joint is immobilized by: -bandages -splints -casts -traction and is maintained in a stable position. Neurovascular status is monitored. After reduction, if the joint is stable, gentle, progressive, active and passive movement is begun to preserve ROM and restore strength. The joint is supported between exercise sessions.

Immobilization in Fractures:

After the fracture has been reduced, the bone fragments must be immobilized, or held in correct position and alignment, until union occurs. Internal fixation, as described above, or external fixation via bandages, casts, and splints are methods used to immobilize fractures.

Specific Musculoskeletal Injuries:

Common specific musculoskeletal injuries include: -rotator cuff tears -epicondylitis -injury to the ligaments of the knee.

Nursing Management Monitoring and Managing Potential Complications:

Compartment Syndrome There are three types of compartment syndromes: 1) acute compartment syndrome 2) chronic compartment syndrome 3) crush compartment syndrome. -Acute compartment syndrome involves sudden and severe decrease in blood flow to the tissues distal to an area of injury that results in ischemic necrosis if prompt, decisive intervention does not occur. It is a potentially limb-threatening complication that occurs when increased pressure occurs within a limited space (e.g., cast, muscle compartment) that compresses the blood vessels and nerves within the area. The pressure within the confined space becomes so high that there is massive compromise to circulation and nerve transmission in the affected extremity. Permanent damage develops within a few hours if action is not taken. -Chronic compartment syndrome is characterized by: pain, aching, and tightness in a muscle or muscle group that has been subjected to inordinate stress or exercise. In this instance, muscle volume increases by as much as 20% within a short time, resulting in stretching of the fascia and inflammation. -Crush compartment syndrome is caused by: massive external compression or crushing of a compartment; for instance, this may occur when a car jack fails and a car falls on a mechanic. This type of massive injury results in systemic effects that include rhabdomyolysis that causes acute renal failure and that may eventually lead to multiple organ dysfunction syndrome (MODS)

Complications & Management of Amputation:

Complications: -hemorrhage -infection -skin breakdown -phantom limb pain -joint contracture -Massive bleeding may occur -Risk of Infection -Risk of infection increases with contaminated wounds after traumatic amputation -Skin irritation caused by the prosthesis may result in skin breakdown -Phantom limb pain caused by the severing of peripheral nerves -Joint contracture is caused by positioning and a protective flexion withdrawal pattern associated with pain and muscle imbalance Medical and Nursing Management: Dressings vary & may include: -closed rigid cast dressing -removable rigid dressing -soft dressing Closed rigid cast dressing frequently used to: -provide uniform compression -support soft tissues -control pain -prevent joint contractors For the patient with a lower extremity amputation the plaster cast may be equipped to attach a temporary prosthetic extension (pylon) and an artificial foot. This rigid dressing technique is used as a means of creating a socket for immediate postoperative prosthetic fitting. The length of the prosthesis is tailored to the individual patient. Early minimal weight bearing on the residual limb with a rigid cast dressing and a pylon attached produces little discomfort. The cast is changed in about 10 to 14 days. Elevated body temperature, severe pain, or a loose-fitting cast may necessitate earlier replacement Removable rigid dressing may be placed over a soft dressing to: -control edema -prevent joint flexion contracture -protect the residual limb from unintentional trauma during transfer activities This rigid dressing is removed several days after surgery for wound inspection and is then replaced to control edema. The dressing facilitates residual limb shaping. -Soft dressing with or without compression may be used if: -significant wound drainage and -frequent inspection of the residual limb (stump) is desired. An immobilizing splint may be incorporated in the dressing. Stump (wound) hematomas are controlled with wound drainage devices to minimize infection.

Clinical Manifestations and Assessment of Fractures:

Diagnosis is based on: -patient's symptoms -physical signs -X-ray findings Usually, the patient reports having sustained an injury to the area. ***The clinical manifestations of a fracture include: -pain -loss of function -deformity -shortening -crepitus -swelling -discoloration These clinical manifestations do not all need to be present in every fracture.

Swelling and Discoloration in Fractures:

Edema and Ecchymosis-occurs as a result of trauma and bleeding into the tissues. It is important to immobilize the body part before the patient is moved. If an injured patient must be moved before extremity splints can be applied, support the limb distal and proximal to the fracture site to prevent rotation as well as angular motion. Movement can case additional pain, soft tissue damage, and neurovascular damage. Splinting a fracture can include bandaging the legs together, with the unaffected extremity serving as a splint for the injured one. In an upper extremity injury, the arm can be bandaged to the chest, a forearm placed in a sling, or a finger can be taped to the adjacent digit. Taping, splinting, or bandaging too tightly may cause impaired distal perfusion and thus is avoided. Observing for the five warning "P's" of neurovascular impairment: 1-pain 2-poikilothermia (cold limb) 3-pallor (paleness) 4-paresthesia (can range from numbness, "pins and needles," burning, itching, and/or tingling), and 5-pulselessness (weak pulses or delayed capillary refill; normal is <2 seconds). If cervical and thoracolumbar spinal injuries are suspected, immobilization of the spine via cervical collar, spinal backboard, and the avoidance of movement is essential. If moving is necessary, log-rolling with appropriate number of staff is used. With an open fracture, the wound is covered with a sterile dressing to prevent contamination of deeper tissues. No attempt is made to reduce the fracture, even if one of the bone fragments is protruding through the wound. The patient is transferred to the hospital for treatment. Tetanus prophylaxis will be administered in the emergency room (ER) if the last known booster was over 5 years ago. Immediate priority is maintaining hemodynamic stability. Hypovolemic shock resulting from hemorrhage (both visible and nonvisible blood loss) and from loss of intravascular volume into the interstitial space may occur in fractures of the extremities, thorax, pelvis, or spine. Because the bone is very vascular, large quantities of blood may be lost as a result of trauma, especially in fractures of the femur and pelvis. Closed fracture of the femur can have an estimated blood loss (EBL) of 1,000 to 1,500 mL, while a closed fracture of the tibia can be 500 to 1,000 mL. Closed humerus fracture can result in the loss of 250 mL, while a pelvic fracture can cause 4 liters of blood loss. An open fracture can increase the EBL by 50% The nurse is aware that bleeding is a common problem with fractures. The elderly may be at increased risk if vasoconstriction is insufficient to maintain blood pressure. When a 15% to 20% acute loss of blood volume occurs, a state of inadequate blood volume exists. This has a direct impact on perfusion; as the perfusion decreases, cardiac output falls, and multiple organ failure can occur. Treatment of shock consists of: -stabilizing the fracture to prevent further hemorrhage -restoring blood volume and circulation -relieving the patient's pain -providing adequate splinting protecting the patient from further injury and other complications.

Gerontologic Considerations with Fractures:

Elderly people (particularly women) who have brittle bones from osteoporosis and who tend to fall frequently have a high incidence of hip fracture. -Weak quadriceps muscles -general frailty due to age and -comorbidities that produce decreased cerebral arterial perfusion like-(TIAs, anemia, emboli, cardiovascular disease, and medication effects) contribute to the incidence of falls Often, a fractured hip is a catastrophic event that has a negative impact on the patient's lifestyle and quality of life. Hip fractures are frequent contributor to death after 75 years of age. Many elderly people hospitalized with hip fractures exhibit delirium as a result of the: -stress of the trauma -unfamiliar surroundings -sleep deprivation -medications Preoperative predictors of postoperative delirium include age older than 70 years -PMH of alcohol abuse -impaired cognitive status -poor functional status -markedly abnormal serum sodium, potassium, or glucose concentrations. In addition, delirium that develops in some elderly patients may be caused by: -mild cerebral ischemia or -mild hypoxemia Other factors associated with delirium include: -responses to medications and anesthesia -malnutrition -dehydration -infectious processes -mood disturbances -blood loss To prevent complications, the nurse must assess the elderly patient for: -chronic preexisting conditions as described above, including polypharmacy. -Dehydration and poor nutrition may be present, contributing to hemoconcentration, and this predisposes the patient to the development of venous thromboemboli. Therefore monitoring I&Os in the elderly and assessing for DVT are particularly important. p. 1129 p. 1130 Muscle weakness and wasting, which may have initially contributed to the fall and fracture, will be further compromised by bed rest and immobility. RN encourages the patient to move all joints except the involved hip and knee Strengthening of the arms and shoulders will facilitate walking with assistive devices

Monitoring and Managing Potential Complications with Fractures:

Fat Embolism Syndrome: -An emboli is a clot that travels. -In pelvic or long-bone fractures, or in trauma patients, the fat globules released when the bone was fractured may occlude the small blood vessels that supply the lungs, brain, kidneys, and other organs. -At the time of fracture, fat globules may diffuse into the vascular compartment -Onset of symptoms is rapid, usually within 24 to 72 hours of injury -Risk factors for fat embolism syndrome (FES) include: -trauma -fracture of long bones or pelvic bones -multiple fractures -crush injuries FES occurs most frequently in young adults and in elderly adults who experience fractures of the proximal femur (hip fracture). p. 1121 p. 1122 Presenting features of FES include: -change in behavior and disorientation combined with respiratory compromise. The nurse observes for: -hypoxia -axillary -subconjunctival -chest petechiae -tachypnea -tachycardia -pyrexia The respiratory distress response includes: -tachypnea -dyspnea -crackles -wheezes -substernal chest pain Edema and hemorrhages in the alveoli impair oxygen transport, leading to hypoxia. -Arterial blood gas values show the partial pressure of oxygen (PaO2) to be less than 60 mm Hg, with an early respiratory alkalosis (hyperventilation) and later respiratory acidosis (hypoventilation) -The chest X-ray reveals a typical "snowstorm" infiltrate. Without prompt, definitive treatment: -acute pulmonary edema -acute respiratory distress syndrome (ARDS) -heart failure may develop The cerebral disturbances (due to hypoxia and the lodging of fat emboli in the brain) manifest by mental status changes varying from: -headache and mild agitation to confusion, delirium, and coma -patient appears pale -Petechiae, possibly due to a transient thrombocytopenia, are noted in the buccal membranes and conjunctival sacs, on the hard palate, and over the chest and anterior axillary folds -patient develops a fever greater than 39.5°C (~103°F) Free fat may be found in the urine if emboli are filtered by the renal tubules. Acute tubular necrosis and renal failure may develop. Immediate immobilization of fractures (including early surgical fixation), minimal fracture manipulation, adequate support for fractured bones during turning and positioning, and maintenance of fluid and electrolyte balance are measures that may reduce the incidence of fat emboli RN monitors high-risk patients (adults between 20 and 30 years of age with: -long-bone -pelvic -multiple fractures -crush injuries -elderly patients with hip fractures to identify this complication Acute pulmonary edema and ARDS are the most common causes of death. -Oxygen therapy -mechanical ventilation -positive end-expiratory pressure (PEEP) may be used to maintain arterial oxygenation Continuous monitoring of oxygen saturation is initiated -Corticosteroids may be administered IV to treat the inflammatory lung reaction and to control cerebral edema -Vasopressor medications to support cardiovascular function are administered IV to prevent hypotension, shock, and interstitial pulmonary edema -Accurate fluid intake and output records facilitate adequate fluid replacement therapy Provide calm reassurance to allay apprehension Fat emboli are a major cause of death for patients with fractures. Therefore, RN must recognize early indications of FES and report them promptly to the provider.

Nursing Alert For total hip replacement surgery:

For total hip replacement surgery, the legs should be slightly abducted. Prevent hip flexion beyond ****90 degrees to avoid dislocation of the hip after joint replacement surgery.

Preoperative Management

Goal is to have patient in optimal health at the time of surgery. Preoperatively, evaluate/assess: -cardiovascular -respiratory -renal -hepatic functions -neurovascular status of the extremity undergoing joint replacement Must consider pre-diagnosed factors like: -age (>60) -obesity -preoperative leg edema -history of any venous thromboembolic v-aricose veins -cancer -prolonged immobility -estrogens -wide variety of hematological conditions as they are indicators of risk for postoperative DVT and PE, the most common causes of postoperative mortality in those undergoing total hip replacement, and every effort is made to prevent them Post-op assessment data is compared with pre-op assessment data to identify changes and deficits

Heterotopic Ossification:

Heterotypic Ossification: AKA myositis ossificans is the abnormal formation of bone, near bones or in muscle, in response to soft tissue trauma after blunt trauma, fracture, or total joint replacement. The muscle is painful, and normal muscular contraction and movement are limited Early mobilization may prevent its occurrence -NSAIDs (e.g., ibuprofen [Advil, Motrin]) may be used prophylactically if deep muscle contusion has occurred. Usually, the bone lesion resorbs over time, but the abnormal bone eventually may need to be excised if symptoms persist.

Nursing Alert with dressings:

If the cast or elastic dressing inadvertently comes off, the nurse must immediately wrap the residual limb with an: ---elastic compression bandage. If this is not done, excessive edema will develop in a short time, resulting in a delay in rehabilitation. The nurse notifies the surgeon if a cast dressing comes off, so that another cast can be applied promptly.

Medical Management of Fractures:

If surgery cannot be performed immediately, the fracture is immobilized, so that additional soft tissue damage does not occur. Temporarily, traction can either be applied as skin or skeletal (pins or wires inserted into bones) traction. -Skin traction can put undue pressure on skin for prolonged periods of time, is limited in the amount of weight that can be applied (5 to 7 lb or less), and as a result, has limited use -Higher weights risk damage to the skin and neurovascular status of the involved extremity -Skeletal traction is used more frequently to immobilize fracture fragments until the patient is physiologically stable and ready for surgical treatment. However, skeletal traction can increase the risk of infection since sterile pin(s) are drilled or wires are placed into the bone -The weight for skeletal traction is determined by body size and the extent of the injury. With either choice, continued neurovascular monitoring and assessment of the skin is needed -Additionally, there are several types of traction. ---Straight or running traction applies the pulling force in a straight line with the body part resting on the bed. ---Buck's extension traction is an example of skin traction that is straight traction. It may be used for patients with fractures of the hip as a temporary measure to reduce muscle spasm, immobilize the extremity, and relieve pain. -Balanced suspension traction in which the affected extremity "floats" or is suspended in the traction apparatus by the balanced weights. The line of traction on the extremity remains fairly constant despite patient movement, as long as the pull remains constant The goal of surgical treatment of hip fractures is to obtain: -satisfactory fixation, so that the patient can be mobilized quickly and avoid secondary medical complications. Surgical intervention is carried out as soon as possible after injury. Surgical treatment consists of one of the following: -Open or closed reduction -internal fixation -thigh cuff orthosis may be used for external support -Replacement of the femoral head with a prosthesis (hemiarthroplasty) This is usually reserved for fractures that cannot be satisfactorily reduced or securely nailed, or to avoid complications of nonunion and AVN of the head of the femur. It is similar to a total hip replacement, but only replaces the ball portion of the hip joint, not the socket (which is replaced in total hip replacement -Closed reduction with percutaneous stabilization for an intracapsular fracture

Muscle-Setting Exercises:

Isometric contractions of the muscle maintain muscle mass and strength and prevent atrophy. -Quadriceps-Setting Exercise -Position patient supine with leg extended. -Instruct patient to push knee back onto the mattress by contracting the anterior thigh muscles. -Encourage patient to hold the position for 5 to 10 seconds. -Let patient relax. -Have the patient repeat the exercise 10 times each hour when awake. -Gluteal-Setting Exercise -Position the patient supine with legs extended, if possible. -Instruct the patient to contract the muscles of the buttocks. -Encourage the patient to hold the contraction for 5 to 10 seconds. -Let the patient relax. -Have the patient repeat the exercise 10 times each hour when awake.

Nursing Alert of Compartment Syndrome:

Late signs of compartment syndrome are pulselessness and pallor. The presence of a pulse does not rule out compartment syndrome

Loss of Function & Deformity in Fractures:

Loss of Function: After a fracture, the extremity cannot function properly because normal function of the muscles depends on the integrity of the bones to which they are attached. Pain contributes to the loss of function. In addition, abnormal movement (false motion) may be present. Deformity: -Displacement -angulation -rotation of the fragments in a fracture or soft tissue swelling causes a visible or palpable deformity. Movement may be noted at the fracture site, whereas under normal circumstances, movement of bones only occurs at joint.

Minimizing Altered Sensory Perceptions

Minimizing Altered Sensory Perceptions: -Phantom limb pain soon after surgery or 2 to 3 months later. Occurs more frequently with AKAs. Patient describes: -pain -unusual sensations -numbness -tingling -muscle cramps -feeling that the extremity is present, crushed, cramped, or twisted in an abnormal position phantom limb phenomenon unknown Keeping patient active helps decrease occurrence of phantom limb pain Early intensive rehab and stump desensitization with kneading massage can sometimes bring relief. Phantom sensations may diminish over time -Transcutaneous electrical nerve stimulation (TENS) -ultrasound -acupuncture -local anesthetics may provide some relief for patients In addition: -beta blockers may relieve dull, burning discomfort -antiseizure medications control stabbing and cramping pain -tricyclic antidepressants are used to modify pain signals and improve mood and coping ability Newer treatment include: -virtual reality in an attempt to extinguish maladaptive memory traces of the amputated limb and extinguish the pain

Monitoring Complications & Wound Drainage:

Monitoring for Complications: Complications that may occur include: -Dislocation of the hip prosthesis -excessive wound drainage -thromboembolism -infection -heel pressure ulcer Other complications associated with immobility: -heterotypic ossification -AVN -loosening of the prosthesis Monitoring Wound Drainage: If blood re-infused, it should be administered within 6 hours of initiation due to the risk of contamination. Fluid and blood drained with a portable suction device. Drainage of 200 to 500 mL in the first 24 hours is expected; by 48 hours postoperatively, the total drainage in 8 hours usually decreases to 50 mL or less, and the suction device is then removed The nurse promptly notifies the surgeon of any drainage volumes greater than anticipated.

Elderly Considerations with Fractures:

Nursing Alert Do not rely on fever as a marker for infection in the elderly. Consider change in the level of consciousness as an indication of suspicion.

Nursing Alert Orthostatic hypotension

Orthostatic hypotension -abnormal drop in BP Approximately 500 to 700 mL of blood momentarily shifts to the lower body when changing position to standing from supine, resulting in decreased venous return and arterial pressure. -Complaints of dizziness may be noted. -A drop of systolic pressure of 20 mm hg or a drop in diastolic pressure of 10 mm hg or more is diagnostic of orthostatic hypotension. It may be related to: -hypovolemia -dehydration -drug-induced hypotension -prolonged bedrest Patients should be encouraged to rise slowly and move their legs prior to rising to facilitate venous return from the extremities.

Pain in Fractures:

Pain is: -immediate -continuous -increases in severity until the bone fragments are immobilized. The muscle spasms that accompany a fracture begin within 20 minutes after the injury and result in increasing pain intensity and further bony fragmentation or malalignment.

Levels of Amputation:

Performed at the most distal point that will heal successfully. Site of amputation determined by two factors: -circulation in the part and -functional usefulness (i.e., meets the requirements for the use of a prosthesis). Goal- conserve as much extremity length as needed to preserve function and possibly to achieve a good prosthetic fit. Preservation of knee and elbow joints is desired. Most amputations involving extremities can be eventually fitted with a prosthesis. -Amputation of toes and portions of the foot causes minor changes in gait and balance. -Syme amputation (modified ankle disarticulation amputation) is performed most frequently for extensive foot trauma and produces a painless, durable extremity end that can withstand full weight-bearing. -Below-knee amputation (BKA) is preferred to above-knee amputation (AKA) because of the importance of the knee joint and the energy requirements for walking. Knee disarticulations are most successful with young, active patients who can develop precise control of the prosthesis. When AKAs are performed: -all possible length is preserved -muscles are stabilized and shaped -hip contractures are prevented for maximum ambulatory potential Most people who have a hip disarticulation amputation must rely on a wheelchair for mobility.

Promoting Rehabilitation:

Promoting Rehabilitation: Usually, not always: -young and healthy -heal rapidly -are physically able to participate in a vigorous rehabilitation program. -Needs psychological support in accepting the sudden change in body image and in dealing with the stresses of hospitalization, long-term rehabilitation, and modification of lifestyle. Their reactions are unpredictable and can include: -anger -bitterness -hostility The multidisciplinary rehabilitation team: -patient -nurse -clinical nurse specialist -physician -social worker -physical therapist -occupational therapist -psychologist -prosthetist -vocational rehabilitation worker helps the patient achieve the highest possible level of function and participation in life activities. Prosthetic clinics and amputee support groups Vocational counseling and job retraining may be necessary to help patients return to work

Amputation:

Removal of a body part, usually an extremity. Lower extremity is often necessary because of: -progressive peripheral vascular disease (often a sequela of diabetes mellitus) -MOST COMMON -fulminating gas gangrene -trauma (crushing injuries, burns, frostbite, electrical burns) -congenital deformities -chronic osteomyelitis -malignant tumor Amputation of an upper extremity occurs less frequently than amputation of a lower extremity and is most often necessary because of either: -traumatic injury or -malignant tumor

Risk Factors for Delayed Healing

Risk Factors for Delayed Healing The nurse is aware that patients who present with the following factors are at risk for delayed healing of fractures: -Extensive local trauma -Malnutrition -Bone loss -Inadequate immobilization -Space or tissue between bone fragments -Infection -Local malignancy -Metabolic bone disease (e.g., Paget's disease) -Irradiated bone (radiation necrosis) -Avascular necrosis -Intra-articular fracture (synovial fluid contains fibrolysins, which lyse the initial clot and retard clot formation) -Age (elderly persons heal more slowly) -Corticosteroids (inhibit the repair rate)

Teaching Patient Self Care:

Self-care deficits occur when a portion of the body is immobilized. RN encourages patient to participate in personal care and use assistive devices safely. RN assists patient in identifying areas of need and developing strategies to achieve independence in ADLs.

Shortening & Crepitus in Fractures:

Shortening: In fractures of long bones, there is actual shortening of the extremity because of the contraction of the muscles that are attached distal (furthest away) and proximal (nearest) to the site of the fracture. The fragments often overlap by as much as 2.5 to 5 cm (1 to 2 inches) Crepitus: Palpation of the extremity reveals a grating sensation, called crepitus, caused by the rubbing of the bone fragments against each other.

Skin Traction:

Skin traction is used to control muscle spasms and to immobilize an area before surgery. Skin traction is accomplished by using a weight to pull on traction tape or on a foam boot attached to the skin. The amount of weight applied must not exceed the tolerance of the skin. Adhesive tape and weights greater than: 6 to 8 pounds (2.7 to 3.6 kg) are AVOIDED as they may cause avulsion (pulling/tearing away) of the superficial skin layers

Nursing Alert:

Subtle personality changes, restlessness, irritability, or confusion in a patient who has sustained a fracture are indications for immediate reassessment of the patient Get: -vitals -O2 saturation -physical exam -labs

Risk Factors:

The main risk factor for contusions, strains, or sprains is: -participation in sports and physical fitness activities. Strains and sprains occur: -after intense activity or -are associated with overuse repetitive injuries, or trauma -whereas contusions can occur in any soft tissue that suffers blunt trauma. Ankles, knees, and wrists are vulnerable to sprains Strains frequently occur in the: -neck -lower back -hamstring muscle (back of the thigh). Previous injuries are a risk factor for reinjury.

Nursing Alert !!-

The nurse must never ignore complaints of pain from the patient in a cast because of the possibility of problems such as impaired tissue perfusion or pressure ulcer formation.

Nursing Alert on Fractures:

The nurse must never remove weights from skeletal traction unless an emergency situation occurs. Removal of the weights completely defeats their purpose and may result in injury to the patient.

Nursing Alert in traction:

The nurse must promptly investigate every report of discomfort expressed by the patient in traction.

Nursing Alert on what can't do:

The nurse never adjusts the clamps on the external fixator frame. It is the physician's responsibility to do so.

Nursing Alert of residual limb:

The residual limb should not be placed on a pillow, because a flexion contracture of the hip may result

TOTAL HIP REPLACEMENT

Total hip arthroplasty (TAH) or surgical replacement of the hip joint with an artificial prosthesis, is indicated for: -idiopathic osteoarthritis -acetabular dysplasia -rheumatoid arthritis -avascular necrosis -posttraumatic injury -and other causes

Venous Thromboemboli Avascular Necrosis of Bone Disseminated Intravascular Coagulation

Venous Thromboembolic: Venous thromboemboli, including DVT and pulmonary emboli (PE), are associated with reduced skeletal muscle contractions and bedrest. Patients with fractures of the lower extremities and pelvis are at high risk for venous thromboemboli. PEs may cause death several days to weeks after injury. Depending on the size and location of the emboli, symptoms vary. A massive emboli can present as: -shock and loss of consciousness The most frequent signs are: -sudden-onset shortness of breath -restlessness -increased respiratory rate -tachycardia -chest pain -low-grade fever Pleuritic pain that increases with inspiration is seen with pulmonary infarct. Moderate hypoxemia occurs -without retention of CO2 -and a cough that is productive of blood-tinged sputum may be seen Disseminated Intravascular Coagulation: DIC is a systemic disorder that results in widespread hemorrhage and microthrombosis with ischemia. Its causes are diverse and can include: -massive tissue trauma Early manifestations of DIC include: -unexpected bleeding after surgery, -bleeding from the mucous membranes -venipuncture sites -gastrointestinal -urinary tracts Avascular Necrosis of Bone: AVN occurs when the bone loses its blood supply and dies. -It may occur after a fracture with disruption of the blood supply (especially of the femoral neck). It is also seen with: -dislocations -bone transplantation -prolonged high-dose corticosteroid therapy -excessive alcohol intake -cigarette smoking -chronic renal disease -systemic lupus erythematosus -other diseases The devitalized bone may collapse or reabsorb The patient develops: -pain and -experiences limited movement X-rays reveal: -loss of mineralized matrix and -structural collapse Treatment generally consists of attempts to revitalize the bone with: -bone grafts -prosthetic replacement -arthrodesis (joint fusion)

Nursing Alert for LOC/Delirium

When a patient presents with a change in the level of consciousness, the nurse recalls the mnemonic DOG: -Drugs are reviewed to evaluate whether a medication could be associated with the altered sensorium -Oxygen saturation level is assessed for hypoxemia via pulse oximeter -Glucose level is obtained to evaluate for hypoglycemia/hyperglycemia via a finger stick since all are associated with altered LOC

disarticulation:

amputation through a joint

open reduction:

correction and alignment of the fracture after surgical dissection and exposure of the fracture

continuous passive motion (CPM) device:

device that promotes range of motion, circulation, and healing

open reduction with internal fixation (ORIF):

open surgical procedure to repair and stabilize a fracture

fracture reduction:

restoration of fracture fragments into anatomic alignment and rotation

rotator cuff:

shoulder muscles (supraspinatus, subscapularis, infraspinatus, and teres minor) and their tendons

arthrodesis:

surgical fusion of a joint

tendon transfer:

surgical procedure in which a tendon is incised at its insertion and placed at a site distant from the original insertion site in order to restore or correct the function of a muscle

Clinical Manifestations and Assessment of Joint Dislocations:

- acute pain -change in contour of the joint -change in the length of the extremity (shortening of the affected limb) -loss of normal mobility -change in the axis of the dislocated bones. X-rays confirm the diagnosis and reveal any associated fracture.

Pelvis Fracture:

-Falls -motor vehicle crashes -crush injuries can cause pelvic fractures. Pelvic fractures are serious because at least two-thirds of affected patients have significant and multiple injuries. Management of severe, life-threatening pelvic fractures is coordinated with trauma team -Hemorrhage -thoracic -intra-abdominal and -cranial injuries have priority over treatment of fractures High mortality rate associated with pelvic fractures r/t -hemorrhage -pulmonary complications -fat emboli -thromboembolic complications -infection Signs and symptoms of pelvic fracture include: -ecchymosis -tenderness over the symphysis pubis, anterior iliac spines, iliac crest, sacrum, and coccyx -local edema -numbness or tingling of the pubis, genitals, and proximal thighs -inability to bear weight without discomfort Neurovascular assessment of the lower extremities is performed to detect injury to pelvic blood vessels and nerves Peripheral pulses of both lower extremities are palpated -absence of a pulse may indicate a tear in the iliac artery or one of its branches Two Most Common Consequences that occur: -Hemorrhage and -Shock Bleeding arises from the cancellous surfaces of the fracture fragments, from laceration of veins and arteries by bone fragments, and possibly from a torn iliac artery. -Peritoneal lavage(irrigation) or -abdominal CT may be performed to detect intra-abdominal hemorrhage Injuries to: -bladder -rectum -intestines -other abdominal organs -pelvic vessels and nerves are associated with pelvic fracture Patient's urine is examined for: -blood (hematuria) or blood at the introitus or -If male, observed for scrotal hematoma. A urinary drainage catheter should not be inserted until the status of the urethra is known Ecchymosis of the: -anterior abdominal wall -flank -sacral or -gluteal region is suggestive of significant internal bleeding -Diffuse and intense abdominal pain -Hyperactive or absent bowel sounds and -abdominal rigidity -Hyper-resonance (free air) or -dullness to percussion (blood) suggest injury to the intestines or abdominal bleeding RN knows: -loss of dullness over the liver (normally percusses a dull sound) indicates the presence of free air and -dullness over regions normally tympanic may indicate the presence of blood or fluid Numerous classification systems have been used to describe pelvic fractures in relation to pelvic anatomy, stability, and mechanism of injury Some fractures of the pelvis do not disrupt the pelvic ring others do—therefore the severity of pelvic fractures varies Long-term complications of pelvic fractures include: -malunion -nonunion -residual gait disturbances -back pain from ligament injury

Post Op Management:

-Knee dressed with compression bandage. -Ice may be applied to control edema and bleeding. RN assesses neurovascular status of leg -Important to encourage active flexion of the foot every hour Goal-Prevent complications: -thromboembolism -peroneal nerve palsy -infection -limited ROM Wound suction drain removes fluid accumulating in the joint. Drainage varies depending on operative event (cement vs. non-cement; use of drains, tourniquets) and patient comorbidities. Can expected to remove drains within 24 hours. If extensive bleeding is anticipated, an autotransfusion drainage system may be used during the immediate postoperative period. Any excessive change in characteristics of the drainage is promptly reported to the surgeon. Frequently, a continuous passive motion (CPM) device is used. The patient's leg is placed in this device, which increases circulation and ROM of the knee joint. Rate and amount of extension and flexion are prescribed. No difference in using CPM device or PT. -If satisfactory flexion is not achieved, gentle manipulation of the knee joint under general anesthesia may be necessary about 2 weeks after surgery -out of bed on the evening or the day after surgery. -Knee is usually protected with a knee immobilizer (splint, cast, or brace) and is elevated when the patient sits in a chair. Physician prescribes weight-bearing limits -Progressive ambulation -using assistive devices -prescribed weight-bearing limits, begins day after surgery After discharge from the hospital, the patient may continue to use the CPM device at home and may undergo physical therapy on an outpatient basis. Late complications that may occur include: -infection and -loosening and wear of prosthetic components Patients usually can achieve a pain-free, functional joint and participate more fully in life activities than before the surgery.

Cast Care:

-Move about normally -avoid excessive use of injured extremity -avoid walking on wet, slippery floors or sidewalks -Use sling if cast on upper extremity. To prevent pressure on the cervical spinal nerves, the sling should distribute the supported weight over a large area and not on the back of the neck. Remove the arm from the sling and elevate it frequently. -Perform prescribed exercises regularly, as prescribed -Elevate the casted extremity to heart level frequently to prevent swelling. For example: when lying down, elevate the arm, so that each joint is positioned higher than the preceding proximal joint (e.g., elbow higher than the shoulder, hand higher than the elbow). -Do not attempt to scratch the skin under the cast. This may cause a break in the skin and result in the formation of a skin ulcer. -Cool air from a hair dryer may alleviate an itch. -Do not insert objects such as coat hangers inside the cast to scratch itching skin. If itching persists, contact your provider. -Cushion rough edges of the cast with tape. -Keep the cast dry but do not cover it with plastic or rubber, because this causes condensation, which dampens the cast and skin. -Moisture softens a plaster cast (a wet fiberglass cast must be dried thoroughly with a hair dryer on a cool setting to avoid skin burns). -Report any of the following to the provider: -persistent pain -swelling that does not respond to elevation -changes in sensation -decreased ability to move exposed fingers or toes -changes in capillary refill, skin color, and temperature Note: -odors around the cast -stained areas -warm spots -pressure areas Report them to the provider. Report a broken cast to the provider; do not attempt to fix it yourself.

The acronym RICE—

-Rest -Ice -Compression -Elevation —is helpful for remembering treatment interventions for musculoskeletal injuries.

Teaching the Patient Self-Care

-daily exercise program -Assistive devices (crutches, walker, or cane) -once normal gait w/out discomfort, devices not necessary. -3 months, resume ADLs -Stair climbing is permitted as prescribed, but is kept to a minimum for 3 to 6 months -Frequent walks, swimming, and use of a high rocking chair are excellent for hip exercises -Sexual intercourse resumed based upon surgeon recommendation (typically 3 to 6 months postoperatively) and should be carried out with the patient in the dependent position (flat on the back) to avoid excessive adduction and flexion of the new hip. Sexual intercourse resumption is individualized by the surgeon based upon both the position of the hip that is most unstable and the degree of hip instability at the time of surgery. General considerations are to avoid positions of instability. -NO time in first 4 months cross the legs or flex the hip more than 90 degrees. -Assistance in putting on shoes and socks may be needed -Avoid low chairs and sitting for longer than 45 minutes at a time. -Avoid Traveling long distances unless frequent position changes are possible -Avoid tub baths, jogging, lifting heavy loads, and excessive bending and twisting (e.g., lifting, shoveling snow, forceful turning).

Stable Pelvic Fractures, Unstable Pelvic Fractures, & Acetubaler Fractures:

1) Stable Pelvic Fractures: Stable fractures of the pelvis heal rapidly because the pelvic bones are mostly cancellous bone, which has a rich blood supply. -Treated with a few days of bedrest and symptom management until pain & discomfort controlled The patient with a fractured sacrum is at risk for paralytic ileus, so monitor bowel sounds 2) Unstable Pelvic Fractures: Unstable fractures of the pelvis may result in: -rotational instability (e.g., the "open book" type, in which a separation occurs at the symphysis pubis with sacral ligament disruption) -vertical instability (e.g., the vertical shear type, with superior-inferior displacement) or -combination of both Immediate treatment in ED of patient with an unstable pelvic fracture includes: -stabilizing the pelvic bones and -tamponading or compressing bleeding vessels Simple method of stabilizing the pelvis is tying of a sheet circumferentially around the hips at the level of the greater trochanters. This is often done in the field, and this temporary measure applies pressure, closes the "open-book" pubic symphysis, and assists in controlling bleeding. If major vessels are lacerated, the bleeding may be stopped through: -emergent embolization using interventional radiology techniques prior to surgery Patients with pelvic fractures can lose up to 4 to 5 liters of blood and therefore are at risk for exsanguination. Mortality rates for patients presenting with hypotension associated with pelvic fractures is approximately 50% Once patient hemodynamically stable, treatment generally involves: -external fixation or -ORIF This promotes: -hemostasis -hemodynamic stability -comfort -early mobilization 3) Acetabular Fractures: (behind / connected to pelvis) Drivers & passengers sitting in the right front seat in motor vehicle crashes may forcibly propel their knees into the dashboard, injuring the knee-thigh-hip complex The acetabulum is particularly vulnerable to fracture with these types of injuries. Treatment depends on the pattern of fracture -Stable, nondisplaced fractures may be managed with: -traction and -protective (toe-touch) weight bearing so affected foot is only placed on the floor for balance -Displaced and unstable acetabular fractures are treated with: -open reduction -joint débridement -internal fixation or -arthroplasty (replacement of all or part of the joint surfaces) Internal fixation permits early non-weight-bearing ambulation and ROM exercise. Complications seen with acetabular fractures include: -nerve palsy -heterotopic ossification -posttraumatic arthritis

Pathophysiology:

1) contusion-soft tissue injury by blunt force Examples: blow, kick, or fall, that results in bleeding into soft tissues (ecchymosis, or bruising). A hematoma (collection of blood within tissues) develops when the bleeding is sufficient to form an appreciable solid swelling. 2) strain- "pulled muscle," -injury to a musculotendinous unit caused by: overuse, overstretching, or excessive stress. A tendon connects muscle to bone, whereas a ligament connects bone to bone. 3) sprain-injury to ligaments and supporting muscle fibers that surround a joint often caused by a trauma, wrenching, or twisting motion. The injury can range from a mild stretching of the ligament to a complete tear. While H&P are important, diagnostic studies of the affected extremity may be ordered to determine diagnosis.

Assessing the Radial, Medial, and Ulnar Nerves

1)To assess the radial nerve, ask the patient to extend the forefinger against resistance. If you suspect radial nerve damage, check the sensation at the web space between the thumb and index finger by asking the patient to describe the sensation to light touch. 1) Inability to extend finger or lack of sensation suggests radial nerve abnormality. 2) To test for median nerve integrity, ask the patient to make the "OK" sign using the thumb and forefinger to make a ring. Check the strength of the "O" by trying to open it with your fingers. Assess sensation on the distal surface of the index finger. 2) Weakness indicates a median nerve abnormality. 3) To assess the ulnar nerve ask the patient to spread his fingers as widely as possible. Also check sensation to the little finger and the ulnar half of the ring finger by asking the patient to describe the sensation as you touch the area described. 3) Difficulty spreading fingers or lack of sensation suggests ulnar neuropathy.

Disuse Syndrome:

A muscle left inactive, loses strength and size. Disuse syndrome is the RN diagnosis associated with musculoskeletal inactivity. Depending on the status of the patients and length of time since the initial trauma, strengthening exercises may be ordered. The nurse will teach the patient to tense or contract muscles (isometric muscle contraction) without moving the underlying bone. The internal or external devices stabilize the underlying bone. Isometric activity, such as teaching a patient in an arm cast to "make a fist," helps reduce muscle atrophy and maintain muscle strength. Muscle-setting exercises are important in maintaining muscles essential for walking: (e.g., quadriceps-setting and gluteal-setting exercises) Isometric exercises should be performed hourly while the patient is awake.

Acute Compartment Syndrome:

A specific type of compartment syndrome in the arm is Volkmann's contracture-Dracula hand It is frequently associated with supracondylar fractures of the humerus. Elbow The following discussion focuses on acute compartment syndrome.::::::: Fascia is tough connective tissue that surrounds muscle groups, organs, nerves, blood vessels, bones, and internal structures. It does not expand readily. Therefore, if a compartment begins to swell, the pressure in the area rises, possibly compromising circulation and nerve and motor function to the point at which the limb may need to be amputated Risk factors for this complication include: -trauma from accidents -surgery -crushing injuries in which massive edema and bleeding is expected. -Casts and tight bandages -May also be caused by any condition that increases the risk of bleeding or edema in a confined space, including patients with soft tissue injury, without fractures, who are on anticoagulants, or have bleeding dycrasias (abnormal bleeding). Clinical manifestations include: -paleness of limb -cool skin temperature -delayed capillary refill -weak pulsations -paresthesia (tingling/burning sensation in the involved muscle) -decreased sensation and mobility -tight and full muscle -pain (unrelenting pain not relieved by position changes, ice, or analgesia, or pain that is disproportional to the injury) HALLMARK SIGN: -pain that occurs or intensifies with passive ROM If the nurse is concerned about neurovascular impairment, the provider is notified immediately. If the complication is secondary to a tight bandage or cast, the nurse anticipates that the bandage would be loosened or removed and the cast bivalved (cut in half longitudinally) to release the constriction -Intracompartmental pressure monitoring may be required to diagnose compartment syndrome. ***The intracompartmental pressure of a normal muscle compartment at rest is: less than 10 mmHg High tissue pressure indicates compartment syndrome. Debate exists on the intracompartmental pressure that mandates fasciotomy, but pressures exceeding: -30 mmHg suggest the need to consider a fasciotomy (when fascia is removed to release pressure). Sterile procedure If pressure is not relieved by removing the bandage or cast, and circulation is not restored, a fasciotomy may be necessary to relieve the pressure within the muscle compartment. Fasciotomy area may be surgically repaired, or graft tissue may be used when the swelling subsides. Complications that may occur after fasciotomy include: -AVN -infection

Pressure Ulcers:

AKA: "decubitus ulcers" Breakdowns in skin due to prolonged pressure on a body part. Casts or bandages can put pressure on soft tissues, causing: -tissue anoxia and pressure ulcers Susceptible sites in the lower extremity include: -heel -malleoli -dorsum of the foot -head of the fibula -tibial tuberosity -anterior surface of the patella Upper extremity sites are located at: -medial and or lateral epicondyle of the humerus, olecranon, and the ulnar styloid If patient reports: -pain and tightness in a defined casted area. -area is inspected for drainage on the cast and any emitted odor RN palpates bandage or cast noting increasing warmth, which suggests underlying tissue erythema. Even if discomfort does not occur, there may be extensive loss of tissue with skin breakdown and tissue necrosis Any suspicious findings are reported to the provider. The cast may be bivalved or an opening cut (window) in the cast in order to assess for pressure ulcer development. Portion of the cast is replaced and held in place by an elastic compression dressing or tape. RN assesses for "window edema"—that is: -swelling of the underlying tissue through the window, which creates pressure areas around the window margins. Patients who have histories of impaired sensation due to neuropathy or neurologic injury are at high risk for ulcer development; thus, removable braces may be used for management of fractures with frequent skin assessments

Clinical Manifestations and Assessment:

Ask Questions: "What were you doing at the time of the injury?" Example: many ankle sprains occur because of inversion injury (turning ankle in while walking), while muscle strains occur because of a "pulled muscle" when exercising. Assess threes "S's," -size -shape -symmetry, of the involved area in comparison to the opposite region. It is important to note presence of edema (swelling), ecchymosis (bruising), tenderness, abnormal joint motion, and pain. Contusions, strains, and sprains can present with similar symptoms of pain, edema, and discoloration from the broken blood vessels. Increased warmth may be noted at the injury site. With contusions, the nurse notes ecchymosis and edema of the injured area. The patient may complain initially of dull pain at the site that increases as edema develops and subsequent stiffness of the area, usually by the next day. Most contusions resolve in 1 to 2 weeks. Strains are graded along a continuum based on -symptoms -loss of function. A first-degree strain reflects: -tearing of few muscle fibers and is accompanied by: -minor edema -tenderness -mild muscle spasm -without a noticeable loss of function. A second-degree strain involves tearing of more muscle fibers and is manifested by: -edema -tenderness -muscle spasm -ecchymosis -notable loss of load-bearing strength of the involved extremity. A third-degree strain involves complete disruption of at least one musculotendinous unit that involves separation of muscle from muscle, muscle from tendon, or tendon from bone. Patients present with: -significant pain -muscle spasm -ecchymosis -edema -loss of function. An X-ray should be obtained to rule out bone injury because an avulsion fracture (in which a bone fragment is pulled away from the bone by a tendon) may be associated with a third-degree strain. SPRAINS: A mild sprain, termed first-degree sprain, may cause: -minor edema -tenderness -mild muscle spasm, without a noticeable loss of function. Patients are able to bear weight with minimal pain. ---Second-degree sprain is an incomplete tear of the ligament (bone-to-bone); as blood vessels rupture, ecchymosis and edema are expected and movement of the joint becomes painful. The degree of disability and pain increases during the first 2 to 3 hours after the injury because of the associated swelling and bleeding. There is restricted motion of the affected limb, and weight bearing is painful. ---Third-degree sprain involves complete ligament tear with resultant complaints of: -significant pain -muscle spasm -ecchymosis -edema -loss of function. Patients are unable to bear weight on the affected limb. Tenderness at the distal tibia (inner ankle) or fibula (outer ankle) is associated with an inversion or eversion injury may indicate a fracture.

Avoiding Hip Dislocation After Replacement Surgery PAGE 1143

Avoiding Hip Dislocation After Replacement Surgery Dislocation of the hip is a serious complication of surgery that causes pain and loss of function and necessitates reduction under anesthesia to correct the dislocation. Desirable positions include: -ABduction -neutral rotation -flexion of less than 90 degrees When seated, knees should be lower than hip Methods for avoiding displacement include the following: -Keep the knees apart at all times. -Put a pillow between the legs when sleeping. -Never cross the legs when seated. -Avoid bending forward when seated in a chair. -Avoid bending forward to pick up an object on the floor. -Use a high-seated chair and a raised toilet seat. -Do not flex the hip to put on clothing such as pants, stockings, socks, or shoes.

Focused Assessment with Infection with and Open Fracture:

Be alert for signs and symptoms of infection: -Elevated temperature -Tachycardia -Tachypnea -Redness, warmth, tenderness, purulent drainage at wound site -Leukocytosis (elevated WBCs)

Focused Assessment with Hypovolemic Shock:

Be alert for the following signs and symptoms: -Thirst -Anxiety, restlessness, altered sensorium -Elevated heart rate -Weak pulse (thready) -Decreased blood pressure -Cool, clammy skin -Decreased urine output -Decreased pulse pressure (difference between the systolic and diastolic pressure) -Decreased blood pressure; mean arterial pressure (MAP) below 60 mm Hg -Rapid, shallow respirations -Delayed capillary refill

Intraoperative Management:

Blood conserved during surgery to minimize loss via a pneumatic tourniquet that produces a "bloodless field." Intra-operative blood salvage with rein fusion (persons own blood being re-transfused to them) is used when a large volume of blood loss is anticipated, and this has shown to substantially reduce the need for allogeneic transfusions (transfusion of blood collected from someone other than the patient) -Aseptic procedure Culture of the joint during surgery, before intraoperative antibiotic therapy is begun, may be important in identifying and treating subsequent infections. If osteomyelitis develops, it is difficult to treat. Persistent infection at the site of the prosthesis usually requires removal of the implant and joint revision, which is a complex procedure. And it's not always possible to achieve a functional joint when the reconstruction procedure has to be repeated.

Buck's Extension Traction:

Buck's extension traction (unilateral or bilateral) is skin traction to the lower leg. The pull is exerted in one plane when partial or temporary immobilization is desired. **It is used to immobilize fractures of the proximal FEMUR before surgical fixation. Before traction applied, RN inspects skin for abrasions and circulatory disturbances. The skin and circulation must be in healthy condition to tolerate the traction. The extremity should be clean and dry before the foam boot or traction tape is applied. To apply Buck's traction: -one RN elevates and supports the extremity under the patient's heel and knee -while another nurse places the foam boot under the leg, with the patient's heel in the heel of the boot. -Next, the nurse secures Velcro straps around the leg. Traction tape overwrapped with elastic bandage in a spiral fashion may be used instead of the boot. Excessive pressure is avoided over the malleolus and proximal fibula during application to prevent pressure ulcers and nerve damage. The nurse then passes the rope affixed to the spreader or footplate over a pulley fastened to the end of the bed and attaches the weight—usually: 5 pounds—to the rope Complications that may develop as result of skin traction are: -Skin breakdown -nerve pressure -circulatory impairment Older adults sensitive due to fragile skin Nerve damage can result from pressure on the peripheral nerves. Foot drop may occur if pressure is applied to the peroneal nerve at the point at which it passes around the neck of the fibula just below the knee. Circulatory impairment is manifested by: -cold skin temperature -decreased peripheral pulses -slow capillary refill time -bluish skin -DVT, a serious circulatory impairment, may be manifested by: +unilateral calf tenderness +warmth +redness +swelling

Complex Regional Pain Syndrome:

Complex Regional Pain Syndrome: CRPS formerly called reflex sympathetic dystrophy or RSD, is: a painful sympathetic nervous system problem Occurs infrequently When it does occur, it is most often: -in an upper extremity after trauma -is seen in 25% of patients with Colles' fracture -more often in women Clinical manifestations of CRPS include: -severe burning pain -swelling -hyperesthesia -limited ROM -discoloration -vasomotor skin changes (i.e., fluctuating warm, red, dry and cold, sweaty, cyanotic) -abnormal nail and skin hair changes This syndrome is frequently chronic, with extension of symptoms to adjacent areas of the body. Disuse muscle atrophy and bone deossification (osteoporosis) occur with persistence of CRPS Patients may exhibit ineffective individual coping related to the chronic pain. The best treatment is: -prevention with vitamin C supplementation -early active mobilization -imagery treatment with imagined hand movements -mirror therapy for upper extremity CRPS -pharmacological treatment Prevention may include: -elevation of the extremity after injury or surgery and selection of an immobilization device (e.g., external fixator) that allows for the greatest ROM and functional use of the rest of the extremity. Early effective pain relief is the goal Pain agents include: -anesthetic nerve blocks -tricyclic antidepressants -anticonvulsants -NSAIDs -corticosteroids -muscle relaxants and For severe pain: an opioid

Types of Fractures:

Defined according to the bone involved (e.g., humerus, femur, tibia), and can be categorized in several ways, including the direction of the fracture. -Complete fracture involves a break across the entire cross-section of the bone and is frequently displaced (removed from its normal position). -Incomplete fracture (e.g., greenstick fracture) involves a break through only part of the cross-section of the bone. -Oblique fracture runs across the bone at a diagonal angle of 45 to 60 degrees. -Comminuted fracture is one that produces several bone fragments, -Impacted fracture is one whose ends are driven into each other. -Closed fracture (simple fracture) is one that does not cause a break in the skin. -Open fracture (compound, or complex, fracture) is one in which the skin or mucous membrane wound extends to the fractured bone. Some fractures have specific names, for example: -Distal radius fracture (wrist) is termed a Colles' fracture. -Stress fractures occur with repeated bone trauma from athletic activities, most frequently involving the tibia and metatarsals. -Compression fractures are caused by compression of vertebrae and are associated frequently with osteoporosis.

Femoral Shaft Fractures:

Force is required to break the shaft of the femur in adults. Most femoral fractures are seen in: -young adults involved in motor vehicle crash or -have fallen from a high place Often, these patients have associated multiple injuries The patient presents with: -an enlarged, deformed, painful thigh and cannot move the hip or the knee. The fracture may be: -transverse -oblique -spiral -comminuted Often, the patient develops shock because the loss of 2 to 3 units of blood into the tissues is common with these fractures. Expanding diameter of the thigh may indicate continued bleeding Generally: -skeletal traction or splinting is used to immobilize fracture fragments until the patient is physiologically stable and ready for ORIF procedures. -Internal fixation usually is carried out within a few days after injury -Intramedullary locking nail devices are used for midshaft (diaphyseal) fractures -Depending on the supracondylar fracture pattern, intramedullary nailing or screw plate fixation may be used -Internal fixation permits early mobilization. A thigh cuff orthosis may be used for external support. --To preserve muscle strength, patient is instructed to perform active exercises of the upper & lower extremities on a regular basis --Active muscle movement enhances healing by increasing blood supply and electrical potentials at the fracture site --Prescribed weight-bearing limits are based on the type of fracture --PT includes: ----ROM and strengthening exercises ----safe use of ambulatory aids ----gait training Healing time - 4 to 6 months A common complication after fracture of the femoral shaft is: -restriction of knee motion -Active and passive knee exercises begin as soon as possible, depending on the management approach and the stability of the fracture and knee ligaments

Femur Fractures:

Fracture of proximal femur is termed hip fracture. Thigh bone The fracture can include: -femoral head -femoral neck -somewhere between the greater and lesser trochanter (termed a intertrochanteric fracture) -shaft of the femur below the lesser trochanter (termed a subtrochanteric fracture) Fractures of the neck of the femur may damage the vascular system that supplies blood to the head and the neck of the femur, and the bone may become ischemic. For this reason, AVN is common in patients with femoral neck fractures. The elderly are particularly vulnerable to intertrochanteric fractures and generally have a much worse prognosis than do younger patients It is important for the nurse to be aware that hip fractures are associated with a high incidence of DVT and PE

Clavicle Fracture:

Fracture of the collar bone is a common injury that results from: -a fall or -a direct blow to the shoulder Frequently are associated with: -equestrian sports and cycling, when a rider is thrown forward and lands on the unprotected shoulder. -Head or cervical spine injuries may accompany these fractures. -They are also seen in the geriatric population after a low-impact fall. When the clavicle is fractured, the patient assumes: -protective position, slumping the shoulders and immobilizing the arm to prevent shoulder movements. A deformity of the clavicle may be observed, with obvious local tenderness. The treatment goal is to align the shoulder in its normal position by means of: -closed reduction and immobilization or, if displaced, an -ORIF Depending on the site of the clavicular fracture, -a figure-eight bandage (also called a clavicular strap or broad arm sling) may be used to pull the shoulders back, reducing and immobilizing the fracture Each treatment has advantages and disadvantages. When a clavicular strap is used, the axillae are well padded to prevent : -skin breakdown or -compression injury to the brachial plexus and the axillary artery. The nurse monitors: -skin -circulation and -nerve function of both arms. An arm sling may be used to support the arm and to relieve pain. A sling may cause the elbow to stiffen, so the patient is encouraged to perform elbow ROM exercises to maintain normal function and prevent stiffness. The patient may be permitted to use the arm for light activities within the range of comfort. RN cautions patient not to elevate the arm above the shoulder level until the ends of the bone have united (about 6 weeks) but encourages the patient to exercise: -elbo -wrist -fingers ASAP Vigorous activity is limited for 3 months. Complications of clavicular fractures include: -trauma to the nerves of the brachial plexus -injury to the subclavian vein or artery from a bony fragment -malunion (faulty union of fractured bone)

Promoting Ambulation

Goal-begin ambulation with PT, generally a day post-op. RN & PT assist the patient in achieving the goal of independent ambulation. Initially Orthostatic Hypotension may affect standing. Specific weight-bearing limits on the prosthesis are determined by the surgeon and are based on the patient's condition, the procedure, and the fixation method. *Weight-bearing as tolerated: -cemented prostheses *Weight-bearing immediately after surgery may be limited to minimize micromotion of the prosthesis in the bone: -press-fit, cement-less, ingrowth prosthesis As the patient is able to tolerate more activity, the nurse encourages: -transferring to a chair several times a day for short periods and walking for progressively greater distances.

Helping the Patient to Achieve Physical Mobility

Helping the Patient to Achieve Physical Mobility: Proper positioning prevents development of hip or knee joint contracture in the patient with lower extremity amputation. -ABduction -external rotation -flexion of the lower extremity are avoided Depending on surgeon's preference, residual limb may be placed in -extended position or -elevated for a brief period after surgery Prolonged elevation (after initial 24 hours post operative) is not recommended as flexion contractions are to be avoided. PT will develop exercises RN encourages the patient to turn from side to side and to assume a prone position, if possible, to stretch the flexor muscles and to prevent flexion contracture of the hip. -discourages sitting for prolonged periods, to prevent flexion contracture -legs should remain close together to prevent an abduction deformity -assistive devices (e.g., reachers) -Post-op ROM exercises started early b/c contracture deformities develop rapidly -ROM exercises include hip and knee exercises for BKAs and hip exercises for AKAs -Upper extremities, trunk, and abdominal muscles exercised and strengthened -Extensor muscles in arm and depressor muscles in shoulder play an important part in crutch walking -Major problems that can delay prosthetic fitting during this period are: (1) flexion deformities (2) nonshrinkage of the residual limb (3) abduction deformities of the hip RN assesses for systemic indicators of infection -elevated temperature -leukocytosis [elevated WBCs] with an increase of >10% bands on the differential) and promptly reports indications of infection to the surgeon.

Humeral Shaft Fracture:

Humerus shaft fractures may injure the: -nerves and brachial blood vessels in the affected arm -So, neurovascular assessment is essential to identify when immediate attention is required. A wrist drop is indicative of radial nerve injury An ORIF of a fracture of the humerus is necessary if the patient has: -nerve palsy -blood vessel damage -comminuted fracture -pathologic fracture If the fracture is uncomplicated: -well-padded splints, overwrapped with an elastic bandage, are used to initially immobilize the upper arm and to support the arm in 90 degrees of flexion at the elbow. -sling or collar and cuff support the forearm Weight of the hanging arm & splints reduces the fracture. -Functional bracing is another form of treatment used for these fractures: -contoured thermoplastic sleeve is secured in place with interlocking fabric (Velcro) closures around the upper arm, thus immobilizing the reduced fracture. -As swelling decreases, the sleeve is tightened, and uniform pressure and bone stability is maintained. The forearm is supported with a collar and cuff sling. Functional bracing allows active use of: -muscles -shoulder and elbow motion -good approximation of fracture fragments -Pendulum shoulder exercises performed for active movement of the shoulder, and preventing adhesions to shoulder joint capsule. -Isometric exercises may be prescribed to prevent muscle atrophy. Complications that are seen with humeral shaft fractures include: -delayed union and nonunion (failure of the ends of a fractured bone to unite).

Joint Dislocations Pathophysiology:

Joint is no longer in anatomic alignment. The bones are literally "out of joint." Dislocations may be: -congenital -present at birth -spontaneous or pathologic -traumatic, resulting from injury in which the joint is disrupted by force. A subluxation is a partial dislocation of the articulating surfaces. Traumatic dislocations are orthopedic emergencies because the associated joint structures, blood supply, and nerves are distorted and severely stressed. If the dislocation is not treated promptly, avascular necrosis (AVN), tissue death due to anoxia and diminished blood supply, and nerve palsy may occur.

Cast

Many injuries that were previously treated with casts may now be treated with other immobilization devices (e.g., immobilizers). In general, casts permit mobilization of the patient while restricting movement of a body part. Casts may be made of plaster or non-plaster materials. Nonplaster casts are generally referred to as fiberglass casts. - water-activated polyurethane materials are light in weight, strong, water resistant, and durable. -They are made of nonabsorbent fabric impregnated with cool water-activated hardeners that bond and reach full rigid strength in minutes. The material does not soften when wet, which allows for hydrotherapy when appropriate. -When wet, the casts are dried with a hair dryer on a cool setting; thorough drying is important to prevent skin breakdown. Plaster casts-Traditional made of rolls of plaster bandage that are wet in cool water and applied smoothly to the body. -A crystallizing reaction occurs, and heat is given off (an exothermic reaction). -The heat given off during this reaction can be uncomfortable, and the patient needs to be informed about the sensation of increasing warmth that generally dissipates after 15 minutes. -Additionally, the nurse explains that the cast needs to be exposed to air (i.e., uncovered) to allow maximum dissipation of the heat and facilitate drying, which can take 24 to 72 hours. Because the plaster cast remains wet and somewhat soft, the cast needs to remain uncovered until it is completely dry. A wet plaster cast appears dull and gray, sounds dull on percussion, feels damp, and smells musty. A dry plaster cast is white and shiny, resonant to percussion, firm, and odorless.

Tibia & Fibula Fracture*:

Most common fractures below the knee are: -tibia and fibula fractures and these tend to result from: -direct blow -falls with the foot in a flexed position -violent twisting motion The patient presents with: -pain -deformity -obvious hematoma -considerable edema Frequently, these fractures are open and involve severe soft tissue damage because there is little subcutaneous tissue in the area. The peroneal nerve is assessed for damage that may result in foot drop (inability to lift the foot) by checking for sensation of the web between the great and second toes, and for increased sensitivity of the dorsal surfaces of the foot (top). If nerve function is impaired, the patient cannot dorsiflex the great toe and has diminished sensation in the first web space (between first metatarsal and hallux [big toe]). As with all fractures, the patient is observed for signs of neurovascular complications. The development of acute compartment syndrome requires prompt recognition and resolution to prevent permanent functional deficit. Other complications include: -delayed union -infection -impaired wound edge healing due to limited soft tissue -loosening of the internal fixation hardware (if ORIF is performed to repair fracture). Most closed tibial fractures are treated with closed reduction and initial immobilization in a long-leg walking cast or a patellar tendon-bearing cast. Reduction must be relatively accurate in relation to angulation and rotation. Comminuted fractures may be treated with: -skeletal traction -internal fixation with intramedullary nails or plates and screws -external fixation External support may be used with internal fixation

Maintaining Adequate Neuromuscular Function in Fractures:

Neurovascular is assessed at least every hour initially and then every 4 hours Always comparing the affected to the noninjured extremity. Assess for the "five P's" Early recognition of diminished circulation due to EDEMA, and nerve function therefore is essential to prevent loss of function. -no higher than heart level to control edema but not impede arterial perfusion. -If neurovascular complications occur notify surgeon ASAP RN assess sensory and motor function of major nerves in the area of injury. -release any constricting bandages. Refer to Box 42-4 for assessment of peripheral nerves of the upper extremities. p. 1120 p. 1121 Normal findings of the fractured limb include: -minimal edema and discomfort -pink color -warm to touch -capillary refill less than 2 seconds -normal sensations -ability to move fingers or toes -Numbness, tingling, and burning may be caused by nerve injury from pressure at the fracture site. -Patient should report any changes in sensation or movement immediately

Joint Replacement Surgery:

One of the most frequently performed orthopedic surgeries. -Joint disease -disability or -deformity may necessitate surgical intervention to: relieve pain, improve stability, and improve function. Conditions contributing to joint degeneration include: -osteoarthritis (degenerative joint disease) -rheumatoid arthritis -trauma -congenital deformity As noted: -some fractures (e.g., femoral neck fracture) may cause disruption of the blood supply and subsequent avascular necrosis, and a joint replacement may be elected over an ORIF. Joints frequently replaced include: -hip -knee -finger joints Less frequently, more complex joints: shoulder, elbow, wrist, ankle are replaced. Timing of these procedures is important to ensure maximum function. Surgery should be performed before surrounding muscles become -contracted and atrophied and serious structural abnormalities occur. The surgeon carefully evaluates the patient, so that the most appropriate procedure is performed. p. 1140 p. 1141 Surgical procedures include: -excision of damaged and diseased tissue -repair of damaged structures (e.g., ruptured tendon) -arthroplasty (replacement of all or part of the joint surfaces) -arthrodesis (immobilizing fusion of a joint) Most joint replacements consist of: -metal and -high-density polyethylene components -Porcelain may also be used -Finger prostheses are usually silastic. The joint implants may be cemented in the prepared bone with ***polymethyl methacrylate (PMMA), a bone-bonding agent that has properties similar to bone. Loosening of the prosthesis due to cement-bone interface failure is a common reason for prosthesis failure. Press-fit, ingrowth prostheses (porous-coated, cementless artificial joint components) that allow the patient's bone to grow into and securely fix the prosthesis in the bone are alternatives to cemented prostheses. Accurate fitting and the presence of healthy bone with adequate blood supply are important in the use of cementless components. Much progress has been made in reducing the prosthesis failure rate through improved techniques, improved materials, and use of bone grafts. With joint replacement, excellent pain relief is obtained in most patients. Return of motion and function depends on: -preoperative soft tissue condition -soft tissue reactions -general muscle strength Early failure of joint replacement is associated with: -excessive activity and -preoperative joint and bone pathology Because these are elective procedures, many patients donate their own blood during the weeks preceding their surgery (autologous donation). This blood is used to replace blood lost during surgery. Autologous blood transfusions eliminate many of the risks of transfusion therapy.

.DVT & Infection Prevention:

Preventing Deep Vein Thrombosis: Risk of venous thromboembolism is particularly great after reconstructive hip surgery. Without prophylaxis, the incidence of documented: -DVT is very high and -PEs follow The peak occurrence is 2 to 7 days after surgery Signs of DVT include: -unilateral calf pain -swelling -tenderness Patient should: -consume adequate amounts of fluids -perform ankle and foot exercises hourly -elastic stockings and sequential compression devices as prescribed -transfer out of bed and ambulate with assistance beginning on the first postoperative day. Meds prescribed to prevent post-op DVT: Low-molecular-weight heparin (e.g., enoxaparin [Lovenox] dalteparin [Fragmin]) or sometimes -unfractionated heparin Preventing Infection: Patients who are at high risk for infection: -elderly -obese -poorly nourished -diabetes -rheumatoid arthritis -concurrent infections (e.g., urinary tract infection, dental abscess) -large hematomas After basic infection prevention, prophylactic antibiotics are prescribed if the patient needs any future surgical or invasive procedures, such as: -tooth extraction or -cystoscopic examination Acute infections may occur within 3 months after surgery and are associated with: -progressive superficial infections or -hematomas Delayed surgical infections may appear 4 to 24 months after surgery and may cause return of discomfort in the hip. Infections occurring more than 2 years after surgery are attributed to the spread of infection through the bloodstream from another site in the body. If an infection occurs, antibiotics are prescribed. Severe infections may require: -surgical débridement or -removal of the prosthesis

Patient Teaching & Positioning:

Providing Initial Patient Teaching: -Casted extremity must be uncovered until completely dry -supported on pillows to the level of the heart to control swelling -ice packs should be applied as prescribed over the fracture site for 1 or 2 days. -Elevate casted arm or leg when seated to promote venous return and control swelling. -Patient needs to understand that the body part will be immobilized after casting Positioning If body cast in place, RN turns the patient as a unit toward the uninjured side every 2 hours to relieve pressure and to allow the cast to dry. Avoid twisting the patient's body within the cast. Sufficient personnel helps to prevent cracking of the cast when moving patient.

Education and Infection Prevention:

Providing Patient Education: Maintenance of the femoral head (ball) component in the acetabular cup(socket) is essential. The nurse teaches the patient about positioning the leg in ABduction, which helps prevent dislocation of the prosthesis. The patient is aware that an: -abduction splint -wedge pillow or -pillows will be placed between the knees to keep the hip in ABduction. In addition, raised toilet seats that will minimize hip joint flexion may be obtained for postoperative care. Preventing Infection: Preoperative assessment of the patient for infections (including skin, urinary tract, and pulmonary infection), is necessary because of the risk for postoperative infection. Any infection 2 to 4 weeks before planned surgery may result in postponement of surgery. Preoperative skin preparation frequently begins: 1 or 2 days before the surgery. Prophylactic antibiotics are administered as a single preoperative or short peri-operative (during surgery) course

Providing Continuing Care

RN prepares the patient for cast removal or cast changes by explaining that the cast is cut with a cast cutter, which vibrates. Cutter does not penetrate deeply enough to hurt the patient's skin. The cast padding is cut with scissors. The formerly casted body part is weak from disuse, stiff, and may appear atrophied. Therefore, support is needed when the cast is removed. The skin, which is usually dry and scaly from accumulated dead skin, is vulnerable to injury from scratching. The skin needs to be washed gently and lubricated with an EMOLLIENT lotion. The RN and PT teach the patient to resume activities gradually within the prescribed therapeutic regimen. Exercises prescribed to help the patient regain joint motion are explained and demonstrated. Because the muscles are weak from disuse, the body part that has been casted cannot withstand normal stresses immediately. RN teaches the patient with noticeable swelling of affected extremity after cast removal to continue to elevate the extremity to control swelling until normal muscle tone and use are reestablished.

Reaction to *Internal* Fixation Devices and Reaction to #External# Fixation Devices

Reaction to *Internal* Fixation Devices: *Internal* fixation devices may be removed after bony union has taken place. However, in most patients, the device is not removed unless: it produces symptoms Pain and decreased function are the prime indications that a problem has developed. Problems may include: -mechanical failure (inadequate insertion and stabilization) -material failure (faulty or damaged device) -corrosion of the device, causing local inflammation -allergic response to the metallic alloy used and -osteoporotic remodeling adjacent to the fixation device, in which stress needed for bone strength is transferred to the device, causing a disuse osteoporosis If the device is removed, the bone needs to be protected from: -refracture related to osteoporosis -altered bone structure -trauma Bone remodeling reestablishes the bone's structural strength Reaction to #External# Fixation Devices: Because the screws or pins are inserted externally infection is a complication for which nurses must be vigilant. Signs of infection include: -erythema -purulent drainage -warmth -leukocytosis -fever Pin care is performed according to hospital and provider protocol

Postoperative Management

Repositioning the Patient and Preventing Dislocation Depending on the surgical approach, the nurse may turn the patient onto the affected or unaffected extremity as prescribed by the surgeon. Dislocation is more common with the posterolateral approach and is seen when the hip is: -in full flexion -adducted (legs together) -internally rotated When the patient is initially assisted out of bed, an abduction splint or pillows are kept between the legs. The nurse encourages the patient to keep the affected hip in extension, instructing the patient to pivot on the unaffected leg with assistance by the nurse, who protects the affected hip from: -adduction (together) -flexion -internal or external rotation -excessive weight-bearing Patient reminded: -not to flex the affected hip -crossing of legs is prohibited -when sitting, hips should be higher than knees -affected leg should not be elevated when sitting -may flex the knee -limited flexion during transfers & when sitting -pillow between legs when supine, side-lying, or turning -hip NEVER flexed more than 90 degrees -Do not left bed more than 60 degrees -No sleeping on operated side unless surgeon agrees -Hip precautions 4/more months post-op Objects used to recover: -Elevated toilet seats and chairs -"reaching devices" -OTs can provide the patient with devices to assist with dressing below the waist -High-seat (orthopedic) chairs -semi-reclining wheelchairs -cradle boot -Fracture bedpan with trapeze -ABduction wedge, splint, or pillow Indicators are as follows: -Increased pain at the surgical site, swelling, and immobilization -Acute groin pain in the affected hip or increased discomfort -Shortening of the leg -Abnormal external or internal rotation -Restricted ability or inability to move the leg -Reported "popping" sensation in the hip -If a prosthesis becomes dislocated, the nurse (or the patient, if at home) immediately notifies the surgeon, because the hip must be reduced and stabilized promptly, so that the leg does not sustain circulatory and nerve damage. After closed reduction, the hip may be stabilized with : -Buck's traction or -brace to prevent recurrent dislocation. As the muscles and joint capsule heal, the chance of dislocation diminishes. Stresses to the new hip joint should be avoided for the first 3 to 6 months.

Elbow Fracture:

Result from: -motor vehicle crashes -falls on the elbow (in the extended or flexed position) -direct blow RADIAL HEAD fractures are the most common fractures involving the elbow; BUT, the distal humerus or proximal ulna are also commonly involved May result in injury to median, radial, or ulnar nerves. The patient is evaluated for: paresthesia and signs of compromised circulation in the forearm and hand. The most serious complication is: -Volkmann's contracture (an acute compartment syndrome), which results from antecubital swelling or damage to the brachial artery --Contracture of the fingers and wrist occurs as the result of obstructed arterial blood flow to the forearm and hand. --Patient is unable to: -extend the fingers -describes abnormal sensation (e.g., unrelenting pain, pain on passive stretch) -exhibits signs of diminished circulation to the hand. -Although the incidence of Volkmann's contracture is rare, its devastating complications are preventable if detected early -This serious complication warrants nursing vigilance to minimize limb loss -Monitor patient neuromuscular status regularly -Severe pain at the elbow and increasing tenseness of the forearm are worrisome signs of increasing intracompartmental pressure

Risk Factors for Osteoporosis

Risk Factors for Osteoporosis Age Female Caucasian Small bone structure Postmenopausal Sedentary lifestyle Chronic obstructive pulmonary disease Smoking Steroid Family history Calcium deficiency High-protein diet Excessive alcohol intake Excessive caffeine intake Malignancy Hyperthyroidism Rheumatoid arthritis Diabetes mellitus Cushing's disease Gastrectomy

Skeletal Traction:

The goals of skeletal traction are to maintain alignment of the injured limb and counteract the shortening of the injured limb from muscle spasm before definitive treatment can occur Skeletal traction applied directly to the bone This method of traction is used: -occasionally to treat fractures of the: femur, the tibia, and the cervical spine. Traction is applied directly to the bone by use of a metal pin or wire (e.g., Steinmann pin, or Kirschner wire), which is inserted through the bone distal to the fracture, avoiding nerves, blood vessels, muscles, tendons, and joints. Tongs applied to the head are fixed to the skull to apply traction that immobilizes cervical fractures. After local anesthesia and skin preparation by the surgeon, w/ surgical asepsis, a small skin incision is made and sterile pin(s) are drilled or wire is placed through the bone. The patient feels pressure during this procedure and possibly some pain when the periosteum is penetrated. After insertion, the pin or wire is attached to the traction bow or caliper. The ends of the pin or wire are covered with corks or tape to prevent injury to the patient or caregivers. The weights are attached to the pin or wire bow by a rope-and-pulley system that exerts the appropriate amount and direction of pull for effective traction. Skeletal traction frequently uses: 7 to 12 kg (15 to 25 lb) to achieve the therapeutic effect. The weights applied initially must overcome the spasms of the affected muscles that pull on the fractured bones and shorten the limb. Often, skeletal traction is balanced traction, which supports the affected extremity, allows for some patient movement, and facilitates patient independence and nursing care while maintaining effective traction. The Thomas splint with a Pearson attachment is frequently used with skeletal traction for fractures of the femur. Because upward traction is required, an overbed frame is used. When skeletal traction is discontinued, the extremity is gently supported while the weights are removed. The pin is cut close to the skin and removed by the physician. Internal fixation, casts, or splints are then used to immobilize and support the healing bone. External fixators are often used to maintain position of unstable fractures when the use of a cast is prohibited or the patient's condition is unstable and precludes a surgical procedure to stabilize the fracture. They can also be used to manage open fractures with soft tissue damage or severe comminuted (crushed or splintered) fractures while permitting active treatment of damaged soft tissues. Complicated fractures of the: humerus, forearm, femur, tibia, and pelvis are often managed with external skeletal fixators. The fracture is: -reduced -aligned and -immobilized by a series of pins or screws inserted directly into the bone above and below the fracture and secured with the use of a metal frame. -Pin position is maintained through attachment to a portable frame. The fixator facilitates: -patient comfort -early mobility -active exercise of adjacent uninvolved joints thus, complications due to disuse and immobility are minimized.

Arm Fracture:

The most frequently broken arm bone is the RADIUS, and the site most commonly affected is the distal radius Fractures of the distal radius that may involve the distal ulna, termed a Colles' fracture, are usually the result of: a fall on an open, dorsiflexed hand -Frequently seen in elderly women with osteoporotic bones and weak soft tissues that do not dissipate the energy of the fall or -in younger people involved in sports injuries The patient presents with: -deformed wrist -radial deviation -pain -swelling -weakness -limited finger ROM -numbness Treatment usually consists of: -closed reduction and immobilization with a short-arm cast. Fractures with extensive comminution (bone is broken into a number of pieces) or impaction: -ORIF -arthroscopic percutaneous pinning -external fixation is used to achieve and maintain reduction and allow for early functional rehabilitation Wrist and forearm are elevated for 48 hours after reduction to control swelling, and active motion of the fingers and shoulder begins promptly. RN monitors for signs of neurovascular compromise comparing findings on affected limb to other limb.

Providing Pin Site Care:

The wound at the pin insertion site requires attention. Goal is to avoid infection and development of osteomyelitis Pins located in areas with considerable soft tissue should be considered at greatest risk for infection. Sites with mechanically stable bone-pin interfaces, pin care should be done on a daily or weekly basis (after the first 48 to 72 hours, when drainage may be heavy). Chlorhexidine 2 mg/mL solution may be the most effective cleansing solution for pin site care. Patients and families should be taught pin care before discharge. They should be required to demonstrate the prescribed care and provided with written instructions that include signs and symptoms of infection. RN must inspect the pin sites daily for: -reaction (i.e., normal changes that occur at the pin site after insertion) and -infection Signs of reaction may include: -redness -warmth -serous or slightly sanguinous drainage at the site These signs are expected to subside after 72 hours Signs of infection may mirror those of reaction but also include: -presence of edema -purulent drainage -erythema -excessive warmth -tenderness -pin loosening -odor RN monitors the patient for fever. Frequency of pin care needs to be increased if mechanical looseness of pins or early signs of infection are present. Minor infections may be readily treated with antibiotics, whereas infections that result in systemic manifestations may additionally warrant pin removal until the infection resolves. When pins are mechanically stable (after 48 to 72 hours), weekly pin site care may be recommended. Crusting may occur at the pin site and uncertainties currently exist about whether scabs around the pin sites should be removed. Additional research is needed to determine best practice to prevent infection with external fixators. The nurse follows institutional protocol and teaches the patient and family to perform pin site care prior to discharge from the hospital. Written follow-up instructions that include the signs and symptoms of infection should be provided.

TOTAL KNEE REPLACEMENT:

Total knee replacement surgery considered for patients with severe pain and functional disabilities r/t: -destruction of joint surfaces by arthritis (osteoarthritis, rheumatoid arthritis, posttraumatic arthritis) or -bleeding into the joint (e.g., hemarthrosis), such as may result from hemophilia ***Metal and acrylic prostheses designed to provide the patient with a functional, painless, stable joint may be used. If the patient's ligaments have weakened -fully constrained (hinged) or -semi-constrained prosthesis may be used to provide joint stability -Non-constrained prosthesis depends on the patient's ligaments for joint stability

Hand Fracture:

Trauma to the hand often requires extensive reconstructive surgery. Goal is to regain maximum function of the hand For an undisplaced fracture of the phalanx (finger bone), the finger is splinted for 3 to 4 weeks to relieve pain and to protect the finger from further trauma Displaced fractures and open fractures may require ORIF, using wires or pins

Medical and Nursing Management:

Treatment of contusions, strains, and sprains consists of: -resting and elevating the affected part -applying cold -using a compression bandage Immobilization of the affected extremity until definite diagnosis determined Monitor neurovascular status of the injured extremity- this is termed CSM: -Circulation, by way of pulses, color, temperature, and capillary refill; -Sensation, by noting awareness of light touch; and -Movement, by range of motion (ROM) of the most distal digits. Compare the injured limb in relation to the uninjured limb. After the acute inflammatory stage (e.g., 24 to 48 hours after injury), intermittent heat application (for 15 to 30 minutes, four times a day) relieves muscle spasm and promotes vasodilation, absorption, and repair. Depending on the severity of injury, progressive passive and active exercises may begin in 2 to 5 days. Severe sprains and strains may require 1 to 3 weeks of immobilization before exercises are initiated. Excessive exercise early in the course of treatment delays recovery. Strains and sprains take weeks or months to heal because ligaments and tendons are relatively avascular. Splinting may be used to prevent reinjury.

Surgical Management In Fractures:

Unstable fractures may undergo surgery Frequent surgical procedures include: -open reduction with internal fixation (ORIF) and -closed reduction with internal fixation (the fracture is reduced prior to making a surgical incision for "internal fixation" of the fracture) for fractures; -amputation for severe extremity conditions (e.g., massive trauma); -bone graft for joint stabilization, defect filling, or stimulation of bone healing; -tendon transfer for improving motion.

Rhabdomyolysis

Variety of etiologies associated with rhabdomyolysis including: -seizures -drug reactions -extreme exercise -soft tissue infections -burns -malignant hyperthermia -extended lithotomy position and -lateral decubitus positions -use of pneumatic antishock garments and -electrical and crush injuries In trauma injuries, the nurse is alert for: rhabdomyolysis, in which the crushing injury causes the breakdown of skeletal muscle, resulting in the release of muscle cell contents including: -myoglobin (a protein released from muscle when injury occurs) -creatine phosphokinase (CPK) -potassium into the systemic circulation Myoglobin results in brown or tea-colored urine Urine dipstick for blood may be positive because of the cross-reaction with myoglobin however, microscopic examination of urine may reveal no RBCs. The myoglobin threatens renal function due to renal tubular obstruction and direct toxic effects, resulting in acute renal failure. Goals of management are to: prevent acute renal failure by countering the effects of myoglobin with the use of -aggressive fluid resuscitation -bicarbonate administration (urine that is alkalized lessens myoglobin toxicity) and -possibly the administration of mannitol (Osmitrol), an osmotic diuretic to "wash out" the myoglobin. In addition, management of: -hyperkalemia with insulin/dextrose is expected. RN assesses : -urine output hourly -monitors VS -maintains strict I&Os -assesses for fluid volume deficit (secondary to the trauma) versus fluid volume excess (secondary to overhydration)

Nursing Management Maintaining Effective Traction:

When skeletal traction used, RN checks traction apparatus at least once per shift to see that the ropes are in the wheel grooves of the pulleys, that the ropes are not frayed, that the weights hang freely, and that the knots in the rope are tied securely. The nurse also evaluates the patient's position because slipping down in bed results in ineffective traction. Maintaining Positioning: The nurse must maintain alignment of the patient's body in traction as prescribed to promote an effective line of pull. The nurse positions the patient's foot to avoid: -foot drop (plantar flexion) -inward rotation (inversion) -outward rotation (eversion) The patient's foot may be supported in a neutral position by orthopedic devices (e.g., foot supports). Preventing Skin Breakdown: The patient's elbows frequently become sore, and nerve injury may occur if the patient repositions by pushing on the elbows. Patients frequently push on the heel of the unaffected leg and elbows when they raise themselves in bed. RN should protect the elbows and heels and inspect them for pressure ulcers. Trapeze can be suspended above the patient, to encourage movement without using the elbows or heels. Areas that are particularly vulnerable to pressure caused by a traction apparatus applied to the lower extremity include the: -ischial tuberosity -popliteal space -Achilles tendon -heel If the patient is not permitted to turn on one side or the other, the nurse must make a special effort to provide back care and to keep the bed dry and free of crumbs and wrinkles. The patient can assist by holding the overhead trapeze and raising the hips off the bed. If the patient cannot do this, the nurse can push down on the mattress with one hand to relieve pressure on the back and bony prominences and to provide for some shifting of weight. A pressure-relieving air-filled or high-density foam mattress overlay may reduce the risk of pressure ulcer. p. 1139 p. 1140 For change of bed linens (top to bottom rather than side to side), the patient raises the torso while nurses on both sides of the bed roll down and replace the upper mattress sheet. Then, as the patient raises the buttocks off the mattress, the nurses slide the sheets under the buttocks. Finally, the nurses replace the lower section of the bed linens while the patient rests on the back. Sheets and blankets are placed over the patient in such a way that the traction is not disrupted.

Cast bivalving:

With a cast cutter, a longitudinal(lengthwise) cut is made to divide the cast in half The under padding is cut with scissors. The cast is spread apart with cast spreaders to relieve pressure and to inspect and treat the skin without interrupting the reduction and alignment of the bone. After the pressure is relieved, the anterior and posterior parts of the cast are secured together with an elastic compression bandage to maintain immobilization. To control swelling and promote circulation, the extremity is elevated (but no higher than heart level), to minimize the effect of gravity on perfusion of the tissues.

Clinical Manifestations and Assessment of femoral neck Fractures:

With fractures of the femoral neck, the leg is shortened and externally rotated The patient complains of pain in: -the hip and groin or knee. With most fractures of the femoral neck, the patient cannot move the leg without a significant increase in pain. Impacted *intracapsular* femoral neck fractures cause: -moderate discomfort (even with movement) -may allow the patient to bear weight -may not demonstrate obvious shortening or rotational changes With #extracapsular# femoral fractures of the: trochanteric or subtrochanteric regions, the extremity is: -significantly shortened -externally rotated to a greater degree than in intracapsular fractures -exhibits muscle spasm that resists positioning of the extremity in a neutral position and -has associated large hematoma or area of ecchymosis. The diagnosis of fractured hip is confirmed with an X-ray!!!!!!

Fractures:

break in the continuity of bone caused by: -direct blows -crushing forces -sudden twisting motions -extreme muscle contractions. When the bone is broken, adjacent structures are also affected, resulting in soft tissue edema and hemorrhage into the muscles and joints, with potential: -joint dislocations -ruptured tendons -severed nerves -damaged blood vessels. Because body organs may be injured by the force that caused the fracture or by fracture fragments, it is important for nurses to have knowledge of the organs that lie beneath the fracture. For example, the nurse is alert for liver injuries with right rib fractures 6 through 12 and splenic injuries with left rib fractures 9 through 11.

bone graft:

placement of bone tissue (autologous or homologous grafts) to promote healing, to stabilize, or to replace diseased bone

hemiarthroplasty:

replacement of one of the articular surfaces (e.g., in a hip hemiarthroplasty, the femoral head and neck are replaced with a femoral prosthesis—the acetabulum is not replaced)