Chapter 63 - Nursing Management: Musculoskeletal Trauma and Orthopedic Surgery

A 28-year-old woman with a fracture of the proximal left tibia in a long leg cast complains of severe pain and a prickling sensation in the left foot. The toes on the left foot are pale and cool. Which action should the nurse take? a. Notify the health care provider immediately. b. Elevate the left leg above the level of the heart. c. Administer prescribed morphine sulfate intravenously. d. Apply ice packs to the left proximal tibia over the cast.

A Clinical manifestations of compartment syndrome include (1) paresthesia, (2) pain distal to the injury that is not relieved by opioid analgesics and pain on passive stretch of muscle traveling through the compartment, (3) pressure increases in the compartment, (4) pallor, coolness, and loss of normal color of the extremity, (5) paralysis or loss of function, and (6) pulselessness or diminished/absent peripheral pulses. Pain unrelieved by drugs and out of proportion to the level of injury is one of the first indications of impending compartment syndrome. Pulselessness and paralysis (in particular) are later signs of compartment syndrome. Notify the health care provider immediately of a patient's changing condition. Because elevation of the extremity may lower venous pressure and slow arterial perfusion, the extremity should not be elevated above heart level. Similarly, the application of cold compresses may result in vasoconstriction and exacerbate compartment syndrome.

An injured soldier had an amputation of his left leg and is reporting shooting pain and heaviness in the area of his missing leg. What would be the best response by the nurse for this patient? a. Use mirror therapy. b. Give opioid analgesics. c. Rebandage the residual limb. d. Show the patient the leg is gone.

A Mirror therapy has been shown to reduce phantom limb pain in some patients. Opioid analgesics, rebandaging the residual limb, and showing the patient that the leg is gone will not decrease phantom limb pain.

A 19-year-old male patient has a plaster cast applied to the right upper extremity for a Colles' fracture after a skateboarding accident. Which action, if taken by the nurse, is the most appropriate? a. Elevate the right arm on two pillows for 24 hours. b. Apply heating pad to reduce muscle spasms and pain. c. Limit movement of the thumb and fingers on the right hand. d. Place arm in a sling to prevent movement of the right shoulder.

A The cast should be supported on pillows during the drying period to prevent denting and flattening of the cast. The casted extremity should be elevated at or above the heart level to reduce swelling or inflammation. Ice should be applied for the first 24 to 36 hours to reduce swelling or inflammation. Active movement of the thumb and fingers should be encouraged to reduce edema and increase venous return. A sling may be used to support and protect the extremity after the cast is completely dry but the patient should perform active movements of the shoulder to prevent stiffness or contracture.

The home care nurse visits a 74-year-old man diagnosed with Parkinson's disease who fell while walking this morning. What observation is of most concern to the nurse? a. 2 × 6 cm right calf abrasion with sanguineous drainage b. Left leg externally rotated and shorter than the right leg c. Stooped posture with a shuffling gait and slow movements d. Mild pain and minimal swelling of the right ankle and foot

B Clinical manifestations of a hip fracture include external rotation, muscle spasm, shortening of the affected extremity, and severe pain and tenderness in the region of the fracture site. Expected clinical manifestations of Parkinson's disease include a stooped posture, shuffling gait, and slow movements. An abrasion is a soft tissue injury. Mild pain and minimal swelling may occur with a sprain or strain.

A nurse performs discharge teaching for a 58-year-old woman after a left hip arthroplasty (posterior approach). Which statement, if made by the patient to the nurse, indicates teaching is successful? a. "I should not try to drive a motor vehicle for 2 to 3 weeks." b. "Leg-raising exercises are necessary for several months." c. "I will not have any restrictions now on hip and leg movements." d. "Blood tests will be done weekly while taking enoxaparin (Lovenox)."

B Exercises designed to restore strength and muscle tone will be done for months after surgery. The exercises include leg raises in supine and prone positions. Driving a car is not allowed for 4 to 6 weeks. In the posterior approach hip arthroplasties, extremes of internal rotation and 90-degree flexion of the hip must be avoided for 4 to 6 weeks postoperatively. The knees must be kept apart. The patient should never cross the legs or twist to reach behind. To prevent thromboembolism, enoxaparin is administered subcutaneously and can be given at home. Enoxaparin does not require monitoring of the patient's coagulation status.

A 42-year-old man has a recent amputation of the left leg below the knee as a result of a heavy farm machinery accident. Which intervention should the nurse include in the plan of care for this patient? a. Sit in a chair for 1 to 2 hours three times each day. b. Dangle the residual limb for 20 to 30 minutes every 6 hours. c. Lay prone with hip extended for 30 minutes four times per day. d. Elevate the residual limb on a pillow for 4 to 5 days after surgery.

C To prevent hip flexion contractures, patients should lie on their abdomen for 30 minutes three or four times each day and position the hip in extension while prone. Patients should avoid sitting in a chair for more than 1 hour with hips flexed or having pillows under the surgical extremity. The patient should avoid dangling the residual limb over the bedside to minimize edema.

The nurse explains to a patient with a fracture of the distal shaft of the humerus who is returning for a 4-week checkup that healing is indicated by a. formation of callus. b. complete bony union. c. hematoma at fracture site. d. presence of granulation tissue.

Correct answer: a Rationale: Bone goes through a remarkable reparative process of self-healing (i.e., union) that occurs in stages. The third stage is callus formation. As minerals (i.e., calcium, phosphorus, and magnesium) and new bone matrix are deposited in the osteoid, an unorganized network of bone is formed that is woven about the fracture parts. Callus is composed primarily of cartilage, osteoblasts, calcium, and phosphorus. It usually appears by the end of the second week after injury. Evidence of callus formation can be verified on x-rays.

During the postoperative period, the nurse instructs the patient with an above-the-knee amputation that the residual limb should not be routinely elevated because this position promotes a. hip flexion contractures. b. skin irritation and breakdown. c. clot formation at the incision site. d. increased risk of wound dehiscence.

Correct answer: a Rationale: Flexion contractures may delay the rehabilitation process after amputations. The most common and debilitating contracture is hip flexion. To prevent flexion contractures, patients should avoid sitting in a chair for more than 1 hour with hips flexed or with pillows under the surgical extremity. Unless specifically contraindicated, patients should lie on the abdomen for 30 minutes three or four times each day and position the hip in extension while prone.

A patient with a fracture of the pelvis should be monitored for a. changes in urine output. b. petechiae on the abdomen. c. a palpable lump in the buttock. d. sudden increase in blood pressure.

Correct answer: a Rationale: Pelvic fractures may cause serious intraabdominal injury, such as paralytic ileus, hemorrhage, and laceration of the urethra, bladder, or colon. Patients may survive the initial pelvic injury, only to die of sepsis, fat embolism syndrome, or thromboembolism. Because a pelvic fracture can damage other organs, the nurse should assess bowel and urinary elimination and distal neurovascular status.

An indication of a neurovascular problem noted during assessment of the patient with a fracture is a. exaggeration of strength with movement. b. increased redness and heat below the injury. c. decreased sensation distal to the fracture site. d. purulent drainage at the site of an open fracture.

Correct answer: c Rationale: Musculoskeletal injuries have the potential for causing changes in the neurovascular status of an injured extremity. In cases of musculoskeletal trauma, application of a cast or constrictive dressing, poor positioning, and the physiologic responses to the traumatic injury can cause nerve or vascular damage, usually distal to the injury. The neurovascular assessment consists of a peripheral evaluation (i.e., color, temperature, capillary refill, peripheral pulses, and edema) and a peripheral neurologic evaluation (i.e., sensation, motor function, and pain).

A patient with a comminuted fracture of the tibia is to have an open reduction with internal fixation (ORIF) of the fracture. The nurse explains that ORIF is indicated when a. the patient is unable to tolerate prolonged immobilization. b. the patient cannot tolerate the surgery of a closed reduction. c. a temporary cast would be too unstable to provide normal mobility. d. adequate alignment cannot be obtained by other nonsurgical methods.

Correct answer: d Rationale: A comminuted fracture has more than two bone fragments. Open reduction with internal fixation (ORIF) is indicated for a comminuted fracture and is used to realign and maintain bony fragments. Other nonsurgical methods can result in a failure to obtain satisfactory reduction. Internal fixation reduces the hospital stay and the complications associated with prolonged bed rest.

The nurse suspects an ankle sprain when a patient at the urgent care center relates a. being hit by another soccer player during a game. b. having ankle pain after sprinting around the track. c. dropping a 10-lb weight on his lower leg at the health club. d. twisting his ankle while running bases during a baseball game.

Correct answer: d Rationale: A sprain is an injury to the ligamentous structures surrounding a joint, and a wrenching or twisting motion usually causes it. Most sprains occur in the ankle and knee join

In teaching a patient scheduled for a total ankle replacement, it is important to tell the patient that after surgery he should avoid a. lifting heavy objects. b. sleeping on the back. c. abduction exercises of the affected ankle. d. bearing weight on the affected leg for 6 weeks.

Correct answer: d Rationale: After total ankle arthroplasty (TAA), the patient may not bear weight for 6 weeks and must elevate the extremity to reduce and prevent edema. The patient must be careful to prevent postoperative infection and should maintain immobilization as directed by the physician.

A patient with a stable, closed fracture of the humerus caused by trauma to the arm has a temporary splint with bulky padding applied with an elastic bandage. The nurse suspects compartment syndrome and notifies the physician when the patient experiences a. increasing edema of the limb. b. muscle spasms of the lower arm. c. rebounding pulse at the fracture site. d. pain when passively extending the fingers.

Correct answer: d Rationale: One or more of the following are characteristic of compartment syndrome: (1) paresthesia (i.e., numbness and tingling sensation); (2) pain distal to the injury that is not relieved by opioid analgesics and, on passive stretch of muscle, pain that travels through the compartment; (3) increased pressure in the compartment; (4) pallor, coolness, and loss of normal color of the extremity; (5) paralysis or loss of function; and (6) pulselessness, or diminished or absent peripheral pulses. The examination also includes assessment of peripheral edema, especially pitting edema, which may occur with severe injury.

The patient is brought to the emergency department after a car accident and has a femur fracture. What nursing intervention should the nurse implement to prevent a fat embolus in this patient? a. Administer enoxaparin (Lovenox). b. Provide range-of-motion exercises. c. Apply sequential compression boots. d. Immobilize the fracture preoperatively.

D To prevent fat emboli, the nurse immobilizes the long bone to reduce movement of the fractured bone ends and decrease the risk of a fat embolus from the bone before surgical reduction. Enoxaparin is used to prevent blood clots not fat emboli. Range of motion and compression boots will not prevent a fat embolus in this patient.

A patient with osteoarthritis is scheduled for a total hip arthroplasty. The nurse explains that the purpose of this procedure is to (select all that apply) a. fuse the joint. b. replace the joint. c. prevent further damage. d. improve or maintain ROM. e. decrease the amount of destruction in the joint.

b, d Rationale: Arthroplasty is the reconstruction or replacement of a joint. This surgical procedure is performed to relieve pain, improve or maintain range of motion, and correct deformity. Total hip arthroplasty (THA) provides significant relief of pain and improvement of function for a patient with osteoarthritis (OA).