1. Nursing Considerations for Fracture Management
Orthopedics

2. The Human Skeleton 206 separate bones
Axial skeleton (80 bones), skull, vertebrae, and rib cage
Appendicular skeleton (126 bones), limbs
Upper extremities have 32 bones
Lower extremities have 31 bones
Bones are classified according to shape

4. Bone Shapes Long - humerus, radius, ulna, femur, tibia and fibula
Short – bones of the hand and foot
Flat – scapula and patella
Irregular - vertebrae

6. Long Bones Ends of long bone is epiphysis
Shaft of long bone is diaphysis
Growth plates are thin line of cartilage in the ends of long bones called epiphyseal plate.

9. Tissue
Cortex or cortical bone is the compact hard connective tissue that makes up the outer layer of bone
Cancellous bone is porous and spongy. Located in iliac crest, tibia, sternum and ends of long bones.
Marrow is the innermost layer
Periosteum is the strong fibrous membrane covering the bone.

10. Fracture Classifications
Traumatic or pathologic
Simple/Closed
Open/Compound
Displaced/Nondisplaced
How the bone is fractured
Page 665 B&K

11. How the bone is fractured..
Transverse
Spiral
Oblique
Comminuted

13. Goals in Fracture Treatment
Solid union of bone in perfect alignment
Return joints and muscles to normal position
Prevent or repair vascular trauma
Ready for early rehab
Phases for fracture treatment: reduction, immobilization, rehabilitation

14. Goals 2
Keep the patient safe while accomplishing the surgical intervention!

15. Bone Healing Hematoma formation: inflammation process
Immature bone callus formation
Remodeled by osteoblasts
Mature bone forms in calcification process
Completely calcified by 6 weeks
Callus is reabsorbed in remodleling phase
Remodeling is enhanced by stress and exercise, bone resumes preinjury strength
Remodeling can take up 6 months to 1 year

16. Bone Healing

17. Improper Healing
Non-union
Delayed union
Malunion

18. Types of fracture repair
CR vs OR
IF vs EF
CRIF/CRPP
CREF
ORIF
OREF

19. Communication: What is the plan?
Age, weight, allergies, LOC
Diagnosis and procedure, side/site, open/closed
How will you fix it?
Plates, screws, rods, pins
synthes, zimmer, stryker?
Do we have that here?
Call the rep?
Multiple fractures?
What are we fixing first, second…
This will help with room set up

20. Communication Equipment Position Radiology
Radiolucent table, power, tourniquet, radiology etc
Position
Determines what additional positioning equipment will be needed
Beachchair, fracture table, hand table
Radiology
Big c-arm, miniview, flat plates
Have previous xrays, CT, MRI available

21. Communication Meds/irrigation: pulsevac? Bone graft
Autografts: separate incision?
Allografts: what is available?
Other injuries present
Preliminary procedures
Foley, nerve blocks, A line, central line
Removal external fixation or previous hardware
Need to know what you are removing before start case

22. Room Set Up Think Meds, Beds, Equipment & Implants
Need to have everything available before getting the patient
Meds: local, antibiotic irrigation
Beds: positioning equipment
Beachchair, fracture table, hand table, etc.
Equipment: tourniquet, radiology, power
Implants: specific implant trays
Make sure they are in house and sterile!!

23. Room Set Up Location of equipment depends on laterality
Have big items already in place if possible
Surgeon preference for room set up
Big C-arm comes in from non operative side
Miniview comes in from operative side
Surgeon and tech will stand on operative side
May spin bed after patient is asleep for upper extremities
Have power boxes, bovie on non operative side if possible

24. Assessment Anxiety Pain level Open vs closed fracture
Verify procedure and consent
Multiple injuries? Need to verify each one that we are fixing & which we are not with consent
Other injuries may affect positioning
Verify surgical site marking
Skin integrity
Dirt on skin/wound
Bruising, blistering, swelling, abrasions
Clothes, cast, splint
Neurovascular status of extremity

25. Postioning Transfer to bed Surgeon directs and verifies positioning
Support fracture
Make sure there is adequate help
Be conscious of other injuries
Surgeon directs and verifies positioning
Have all positioning equipment and aids in easy to grab location while positioning

26. Common Positioning for Fractures
Hand/wrist
Supine with hand table
Elbow
Lateral
Shoulder/proximal humerus
Beachchair
Pelvis
Supine on radiolucent flat top
Prone with gel chest rolls on radiolucent flat top

27. Continued Hip Femur Knee/Proximal Tibia Ankle/Foot
Supine with leg traction
Femur
Supine or lateral with leg traction for antegrade nail
Supine on radiolucent flat top for distal femur or retrograde nail
May have skeletal traction in place
Knee/Proximal Tibia
Supine with radiolucent triangle
Ankle/Foot
Supine with gel bump under hip

28. Tourniquet Controls bleeding for visualization
Pick appropriate size: min 3 inch, max 6 inch
Padding: cotton sleeve, webril
Seal edges: tape, plastic drape
Connect tourniquet hose
Pressure setting, set alarm
Not longer than 2 hours
MD should verify tourniquet placement
Time between deflation and inflation: 5 min for every 30 minutes

29. Skin Preperation Skin integrity Hair removal Skin Prep Scrub dirt off
Careful with soft tissue
Hair removal
Skin Prep
May need extra hands

30. Intra Op Documentation
Skin integrity
Previous injuries
Implants
Reference/reorder number
Lot number/serial number
Description of implant
Size
Location
Quantity
Expiration date
Tourniquet location, pressure, duration, unit #

31. Post Op Dressings Immobilization: splint, cast, immobilizer, sling
Xeroform, adaptic
Gauze
Soft roll/webril/cotton roll
Ace wrap
Immobilization: splint, cast, immobilizer, sling
Cold pad
Support and elevate newly fixed extremity

32. Good as new!