ORTHOPAEDIC
COMPLICATIONS
Objectives
• Identify the primary risk factors for
orthopaedic complications
• Discuss the signs/symptoms of orthopaedic
complications
• Describe common treatment for the primary
orthopaedic complications
• Develop a nursing plan of care for specific
orthopaedic complications
Potential Complications
Low Risk



Acute Confusion
Constipation
Impaired Skin
Integrity
High Risk






DVT/PE
Compartment
Syndrome
Fat Emboli Syndrome
Hemorrhage
Wound/Surgical Site
Infection
Delayed/Nonunion
Question # 1
DVT prevention requires the nurse to educate the patient
on anticoagulant therapy to be alert for :
1. Headache
2. Epistaxis
3. Nausea
4. Chest pain
Question # 1
DVT prevention requires the nurse to
educate the patient on anticoagulant
therapy to be alert for :
2. Epistaxis
Venous Thromboembolic
Conditions
Virchow’s Triad



Endothelial injury
Hypercoagulable state
Venostasis
Deep Vein Thrombosis (DVT)

Formation of fibrin leads to development
of a thrombus (fibrin clot)

Clinical symptoms appear when thrombus
is large enough to impede blood flow in a
large vessel
Pulmonary Embolism (PE)

When venous thrombosis or part of a
thrombus dislodges from its primary site, it
becomes an embolus

Embolus can enter pulmonary circulation
and perfusion distal to the embolus can be
partially or completely occluded
DVT & PE: Risk Factors
Patient related










Increasing age
Malignancy
Varicose veins
Obesity
Trauma
Prior DVT/PE
CHF/CVA
Pregnancy
Deficiencies in clotting
cascade
Oral contraceptives
DVT & PE: Risk Factors
(continued)
Procedure related





Pelvic, hip or leg
surgery/ fracture
fixation
Surgery > 30 minutes
Postop immobilization
Postop infection
Re-operations
DVT & PE: Risk Factors
(continued)
Anesthesia related

General anesthesia
DVT: Clinical Manifestations

Unilateral swelling of
thigh/lower leg

Erythema

Warmth

Tenderness

Palpable, tender
venous cord in
popliteal space

Discomfort in leg
DVT: Diagnostics

Contrast venography

Doppler ultrasonography

Magnetic Resonance Imaging (MRI)

Radionuclide venography
PE: Clinical Manifestations






Dyspnea
Chest pain
Palpitations
Apprehension
Confusion
Anxiety






Restlessness
Cough
Hemoptysis
Diaphoresis
Syncope
Distended neck veins
PE: Diagnostics

Arterial blood gas (ABG)

Chest x-ray (CXR)

Electrocardiogram (EKG)

Ventilation-perfusion scan (VQ scan)

Pulmonary angiography

CT scan
DVT & PE: Prevention

External pneumatic compression and
graduated compression stockings

Early ambulation and range of motion

Elevation of lower extremities
DVT & PE: Prevention (cont.)

Prophylactic inferior vena cava filter

Anticoagulation
 Heparin
 LMWH (low molecular weight heparin)
 Warfarin (Coumadin)
DVT & PE: Interventions

Full dose anticoagulation with heparin/warfarin
(target INR 2-3)

Oxygen therapy for PE

Thrombolytic therapy

urokinase, streptokinase

Surgical embolectomy

Inferior vena cava filter
Question # 2
The nurse uses critical thinking to assess an impending
compartment syndrome as indicated by which of the following
patient presentations?
1. Progressive pain on PROM, paresthesia and diminished
pulse
2. Progressive pain on AROM, shiny skin and pulselessness
3. Progressive pain on AROM, increased tissue pressure
and edema
4. Progressive pain on PROM and elevated ESR & WBC
Question # 2
The nurse uses critical thinking to assess
an impending compartment syndrome as
indicated by which of the following patient
presentations?
1. Progressive pain on PROM, paresthesia
and diminished pulse
Compartment Syndrome


Compromised
circulation and
function of tissues
within a specific area
due to progressive
pressure within a
confined space
Acute, chronic or
crush
Compartment Syndrome:
Pathophysiology









Tissue swelling
Compression of vessels and nerves
Histamine release
Capillary dilation
Increase in capillary permeability
Increased edema
Decreased perfusion
Increased lactic acid
Increased blood flow
Compartment Syndrome:
Risk Factors
External compression
forces




Tight cast
Tight dressing
Prolonged compression
Crush injuries
Internal factors



Bleeding
Significant swelling/edema
Exertional
Compartment Syndrome:
Risk Factors (continued)
Miscellaneous







Acute trauma
Fracture
Infection
Skin traction
Tibial nailing
Exercise
Insensate extremity
Compartment Syndrome:
Clinical Manifestations

Early signs



Increasing pain
Pain with passive
stretch of muscles
Paresthesia

Late signs




Delayed capillary
refill
Pale extremity
Loss of pulse
Paralysis
Compartment Syndrome:
5 Ps





Pain on passive
stretch
Pallor
Pulselessness
Paresthesia
Paralysis
Compartment Syndrome:
Monitoring
If compartment syndrome is not
recognized and pressure is not relieved,
muscle damage will be irreversible after
4-6 hours of ischemia, and nerve
damage will be irreversible after 12-24
hours of ischemia. (Janzing et al., 1996)
Neurovascular Assessment
Peripheral vascular
assessment
 Color
 pale/white, pink, dusky,
cyanotic, mottled
 Temperature
 cool/cold, warm, hot
 Capillary refill
 normal < 3 seconds
 Peripheral pulses
 distal to injury, bilateral
 non-palpable: doppler
 Edema
 pitting
Neurovascular Assessment
Peripheral neurologic
assessment


Sensation
Motor function

Both elements
evaluate:


Upper extremity:
radial, median and
ulnar nerves
Lower extremity:
tibial, peroneal,
femoral and sciatic
nerves
Compartment Syndrome:
Diagnostics

Muscle damage indicated by:
Myoglobin in urine
 Elevated CPK, LDH and SGOT


Intracompartmental pressure monitor

Pressures of 30-45 mmHG a concern
Compartment Syndrome:
Prevention

Early recognition is key to
preventing or minimizing
negative outcome

Astute nursing
intervention to identify
pathologic pain in the
presence of good pain
control (epidural, PCA)
Compartment Syndrome:
Interventions

Relieve pressure source


Remove constrictive dressing
Bivalve cast

Initiate pain management

Elevate extremity at heart level

Ongoing neurovascular assessments

Fasciotomy if indicated
Question # 3
Which nursing assessment finding might
suggest the presence of a fat embolism?
1.
Ecchymosis
2.
Hematoma
3.
Petechiae
4.
Edema
Question # 3
Which nursing assessment finding might
suggest the presence of a fat embolism?
3. Petechiae
Fat Emboli Syndrome (FES)

Mechanical blockage
of blood vessels by
circulating fat
particles

Occurs following long
bone fracture, pelvic
fracture and total hip
arthroplasty
FES: Pathophysiology

Mechanical theory

Injured adipose tissue
and/or disruption of
intramedullary
compartment releases
fat into the blood
stream

Biochemical theory

Fatty acids cause
endothelial damage;
fatty acids and fats
lead to platelet
aggregation and fat
globule formation
FES: Clinical Manifestations

Signs and symptoms
can appear 12-72
hours post injury



Change in mental
status
Increased respiratory
distress
Petechiae of skin &
mucosa (appear
above nipple line and
blanch)
FES: Diagnostics





No specific labs
Fat globules may be
detected in blood,
urine or sputum
PO2 drops to < 50
mmHG
CXR with diffuse
“snowstorm” effect
VQ scan to r/o PE
FES: Interventions



Early recognition to
prevent morbidity and
mortality
Minimize movement
of long bone fractures
Respiratory support



Intubation
Ventilator
management
ICU monitoring
Question 4A

Which indicators are BEST for diagnosing
hemorrhage
A) Blood in urine/stool
 B) Labs (cbc, coagulation studies)
 C) Radiographic studies

Hemorrhage/Postoperative
Bleeding

Etiology





Trauma/surgery
Slipped ligature
Anticoagulation or
coagulation disorder
Erosion of blood
vessel by foreign body
or tumor
Infection
Hemorrhage: Risk Factors

Patient-related
 Coagulation disorders
 Low platelet count
 Excessive coagulation
 Tumor growth

Injury-related
 Fracture or foreign body interrupts blood vessel

Procedure-related
Hemorrhage:
Clinical Manifestations







Dizziness
Weakness
Anxiety
Restlessness
Confusion
Tachycardia
Lowered BP





Rapid, shallow
respirations
Pallor
Cold, clammy skin
Abnormal drainage
from wounds or
drains
Decreased urine
output
Hemorrhage:
Diagnostics

CBC

Coagulation studies

Urine and stool for
blood

Radiographic studies
Hemorrhage: Interventions

Direct pressure

Surgical intervention as indicated

Use of autologous or synthetic clotting material

Vitamin K or clotting replacement factors

Volume replacement and blood transfusion as necessary

Iron supplementation
Question # 4
To prevent nosocomial wound/surgical site infection, the
most important intervention the nurse should perform is:
1. Thorough handwashing
2. Aseptic technique with dressing changes
3. Administration of antibiotic
4. Monitoring BP and glucose levels
Question # 4
To prevent nosocomial wound/surgical site
infection, the most important intervention the
nurse should perform is:
1. Thorough handwashing
Wound and Surgical Site
Infection (SSI)
Nosocomial surgical site infections
occur within 30 days after the operative
procedure (within 1 year if an implant is
in place) and can involve skin,
subcutaneous tissue, deep soft tissues,
or actual organs manipulated during the
operative procedure. (CDC)
Wound/SSI: Risk Factors
Patient characteristics








Advanced age
Obesity/malnutrition
Hypovolemia
Diabetes
Rheumatoid arthritis
Steroid use/NSAID
use/chemotherapy
Tobacco use
Substance abuse
Wound/SSI:
Intrinsic Risk Factors
Injury characteristics
Bone displacement, comminution
 Periosteal stripping
 Involvement of more than one bone
 Vascular injury
 Significant soft tissue injury
 Open fracture/foreign body/contamination

Wound/SSI:
Extrinsic Risk Factors

Preoperative



Inadequate
immobilization of
fractured bone
Preoperative shave >
1 day prior to surgery
Duration of
preoperative
hospitalization

Intraoperative







Hair removal
Positive intraop
contamination
Irrigation, drains, packing
Primary/secondary
closures
Type and length of
procedure
Surgeon expertise
Glove punctures
Wound/SSI:
Extrinsic Risk Factors

Postoperative






Cold room
(vasoconstriction)
Insufficient fluid
replacement
Hypertension
Inadequate analgesia
Compromised blood
perfusion
Low oxygenation
Wound/SSI:
Clinical Manifestations

Increased pain

Increased temperature
around incision or wound

Fever or chills

Erythema around wound
or incision

Malodor from incision or
wound

Purulent exudate, poor
wound healing

Edema

Elevated WBC, ESR, Creactive protein
Wound/SSI: Prevention

Preoperative





Control hypertension
and blood sugar
Minimize unnecessary
movement of fractures
Treat existing
infections
Replenish nutritional
deficits
Prevent
vasoconstriction

Intraoperative







Antimicrobial prophylaxis
Strict aseptic technique
Meticulous tissue
debridement
Stabilize fractures
Avoid vasoconstriction
Gently handling of soft
tissue
Wound closure without
excessive tension
Wound/SSI: Prevention

Postoperative







Provide adequate
analgesia
Avoid vasoconstriction
Control BP and BS
Provide for adequate
nutrition
Aseptic dressing changes
Microbial therapy
Thorough handwashing
Wound/SSI: Interventions





Wound care
Systemic antibiotics
Adequate perfusion
Adequate
oxygenation
Optimal nutritional
intake
Question #5
A fracture that isn’t healing is considered
to be a non union (as opposed to a
delayed union) fracture after how long?
 6-12 weeks
 8-14 weeks
 16-24 weeks
 28-36 weeks

Delayed Union/Nonunion

Delayed union is a continuation of or increase in
bone pain and tenderness beyond a reasonable
healing period; healing is slowed but not
completely stopped

Nonunion occurs when fracture healing has not
taken place 4-6 months after the fracture occurs
and spontaneous healing is unlikely (Morris,
2001)
Delayed Union/Nonunion

Pathophysiology



Infection
Inadequate fracture
immobilization
Inadequate blood
supply to fracture site

Diagnostics



Serial x-rays
CT scans
MRI
Delayed Union/Nonunion:
Interventions

Bone grafting

Internal fixation

External fixation

Electrical bone
stimulation
Question # 1
DVT prevention requires the nurse to educate the patient
on anticoagulant therapy to be alert for :
1. Headache
2. Epistaxis
3. Nausea
4. Chest pain
Question # 1
DVT prevention requires the nurse to
educate the patient on anticoagulant
therapy to be alert for :
2. Epistaxis
Question # 2
The nurse uses critical thinking to assess an impending
compartment syndrome as indicated by which of the following
patient presentations?
1. Progressive pain on PROM, paresthesia and diminished
pulse
2. Progressive pain on AROM, shiny skin and pulselessness
3. Progressive pain on AROM, increased tissue pressure
and edema
4. Progressive pain on PROM and elevated ESR & WBC
Question # 2
The nurse uses critical thinking to assess
an impending compartment syndrome as
indicated by which of the following patient
presentations?
1. Progressive pain on PROM, paresthesia
and diminished pulse
Question # 3
Which nursing assessment finding might
suggest the presence of a fat embolism?
1.
Ecchymosis
2.
Hematoma
3.
Petechiae
4.
Edema
Question # 3
Which nursing assessment finding might
suggest the presence of a fat embolism?
3. Petechiae
Question 4A

Which indicators are BEST for diagnosing
hemorrhage
A) Blood in urine/stool
 B) Labs (cbc, coagulation studies)
 C) Radiographic studies

Question # 4
To prevent nosocomial wound/surgical site infection, the
most important intervention the nurse should perform is:
1. Thorough handwashing
2. Aseptic technique with dressing changes
3. Administration of antibiotic
4. Monitoring BP and glucose levels
Question # 4
To prevent nosocomial wound/surgical site
infection, the most important intervention the
nurse should perform is:
1. Thorough handwashing
Question #5
A fracture that isn’t healing is considered
to be a non union (as opposed to a
delayed union) fracture after how long?
 6-12 weeks
 8-14 weeks
 16-24 weeks
 28-36 weeks
