Orthopaedic
Trauma
Objectives

Identify significant findings for emergent
and urgent care of orthopaedic trauma
patients

Discuss at least 4 methods of fracture
fixation

List nursing interventions typical to trauma
patients
Question A
Dan is a 26-year old who presents in the ED
with an open fracture of the left femur following
an ATV accident. What would be the initial
treatment?
a. Irrigate the wound and initiate antibiotic
therapy.
b. Administer tetanus prophylaxis.
c. Check the ABC’s and maintain c-spine
immobilization.
d. Prepare patient for transfer to the OR.
Answer # A
Dan is a 26-year old who presents in the
ED with an open fracture of the left
femur following an ATV accident. What
would be the initial treatment?
c. Check the ABC’s and maintain
c-spine immobilization.
Trauma Statistics
Every 6 minutes,
someone in America
dies from trauma:

Motor vehicles

Farm

Falls

Gunshot wounds
Trauma Statistics

5th leading cause of
death

Leading killer of
Americans < 45 yrs of
age

1 in 4 (59 Million)
Americans injured
annually

36 Million ED visits

Bimodal distribution
 High energy injuries in
16-35 y.o.
 Low energy injuries in
elderly 70 + y.o.

Following head
injuries, pelvic
fractures are most
common cause of
traumatic death
Mechanism of Injury:
Energy Exchange

Kinetic/
Mechanical

Thermal

Chemical

Electrical

Radiant

Oxygen deprivation
Mechanism of Injury
Penetrating Trauma

High velocity missiles (bullets) =
crush/stretch

Low velocity stab wounds =
shearing/stretch

High pressure injection = explosion/tearing
Mechanism of Injury
Blunt Trauma

Compression/impact= compressed/shorten

Shearing=tearing/
dissection

Torsion/twisting= dislocation/
subluxation

Tensile/traction= stretching/tearing
Mechanism of Injury

Motor vehicle accidents

Falls

Pedestrian/Bikes/Skateboards/Scooters

Non-accidental; self-inflicted

Shaken baby

Diving

Gun Shot Wounds
Subluxation
Displacement of bone from its normal joint
position to the extent that articulating
surfaces partially loose contact
Commonly due to direct blow, indirect force
or severe twisting,
Subluxation:
Interventions
Immediate closed
reduction by
trained personnel
Question # 1
The partial disruption of
articulating surfaces is known as:
c. subluxation
Dislocation
Complete separation or displacement of
articulating surfaces:
 Urgent reduction required
 Blood supply to bone
 Nerve or vessel injury
Dislocation:
Interventions

Reduction (return to normal anatomic
alignment)
 Manually
 Regional block
 General anesthesia

Open Reduction Internal Fixation
Radial Head Dislocation
Radial dislocation may be
caused by a sudden pull
on a child's arm or hand.
For first aid, immobilize
the arm and take the
child to the doctor's
office or emergency
room.
Subluxation & Dislocation:
Nursing Diagnosis

Peripheral
neurovascular
dysfunction, risk for

Injury, risk for

Tissue perfusion,
ineffective; peripheral

Physical mobility,
impaired
Question # 2
A comminuted fracture may be classified
as an injury in which:
a. bone protrudes through the skin
surface
b. tendons and ligaments are disrupted
c. the ends of bone are impacted into one
another
d. bone is fractured into two or more
fragments.
Answer # 2
A comminuted fracture may be classified
as an injury in which:
d. bone is fractured into two or more
fragments.
Fractures
A break or
disruption in
the
continuity of
a bone
Fractures:
Clinical Manifestations








Pain
Edema
Discoloration
Inability to function
Obvious deformity
Crepitus
Muscle spasm
Protruding bone
Fractures:
Diagnostics

Radiologic exams
 Plane films

X-ray a joint above and
below injury

CT scan

MRI
Fractures

Predisposing factors:
 Osteoporosis
 Risk-taking behaviors

Mechanical overload to bone

Simplest method of classification is based on
bone’s relationship to the environment:
 Open
 Closed
Fractures:
Classifications
Fractures:
Classifications







Comminuted
Displaced/Nondisplaced
Complete/
Incomplete
Avulsion
Compression
Buckle
Butterfly








Pathologic
Articular
Transverse
Oblique
Spiral
Stellate
Fatigue/Stress
Segmental
Fractures:
Classifications
Fractures:
Classifications
Fractures:
Classifications
Fractures : Classification
by Joint Involvement




Intraarticular: fracture extends into the
joint
Intracapsular: fracture within joint capsule
Extracapsular: fracture extends outside
capsule
Supracondylar: above condyle(s)
Fractures:
Grading

Grade I


Grade II


wound < 1cm; minimal contamination
wound > 1 cm; moderate contamination
Grade III

wound > 6-8 cm; extensive damage to soft tissue,
nerve, and tendon; high degree of contamination
Question # 3
Andrew has sustained an open book
fracture of the pelvis after being pinned
under his tractor. What life-threatening
situation is causing his unstable BP?
a. Compartment syndrome
b. Overinflation of MAST trousers
c. Incorrect application of external fixation
d. Retroperitoneal hemorrhage
Answer # 3
Andrew has sustained an open book
fracture of the pelvis after being
pinned under his tractor. What lifethreatening situation is causing his
unstable BP?
d. Retroperitoneal hemorrhage
Fractures: Emergency
Management

Primary assessment for potentially lifethreatening injuries

Fracture management often secondary
 Most fractures not life threatening
 Stabilize extremity
 Cover wounds, open fractures with sterile
saline dressing
Principles of Open Fracture
Management

Treat open fractures as emergencies

Culture wounds prior to cleansing

Remove particulate matter in open fracture by
copious lavage and debridement

Cover exposed fracture fragments with a sterile
dressing

Debride devitalized tissue
Principles of Open Fracture
Management (cont.)

Obtain x-rays of affected and amputated
parts

Stabilize fractures with appropriate
materials

Provide adequate soft tissue coverage

Administer antibiotic coverage and tetanus
prophylaxis
Orthopaedic Emergencies

Spine fractures

Open book pelvic
fractures

Dislocated joint
 Elbow
 Knee
Fracture Management:
Goals

Prevent complications

Return to maximal function

Achieve best possible cosmetic result

Remember ABC’s

C-spine precautions
Assessment



Radiographic
Assessment
C-spine
Chest
Pelvis
Neurovascular
Assessment
 Upper extremity




Radial
Median
Ulnar
Lower extremity


Peroneal
Tibial
Occult Injuries





Head injury- thoracic injury
Facial fractures- neck injury & airway
occlusion
Rib fracture - pleural injury
Sternal bruise-cardiac contusion,
aortic tear
Lap belt injuries- spine
and abdominal injury
Occult Injuries (cont.)

Extremity injury- compartment syndrome

Open book pelvic injury





Benign to life-threatening (hemorrhage)
Urgent external fixation
Nerve damage
Bladder rupture
Spine fracture-ileus, neuro deficit
Fracture Healing





Hematoma formation
 1 to 3 days
Granulation
 3 days to 2 weeks
Callus formation
 2 to 6 weeks
Consolidation/Ossifica
tion
 3 weeks to 6 months
Remodeling

Wolf’s Law

Bone remodels in
response to stress
Factors Affecting Fracture
Healing

Trauma severity

Type of bone

Immobilization

Infection

Local pathology

Avascular necrosis
(AVN)

Intra-articular
fracture

Systemic factors

Osteoporosis
Fracture Management

Closed Reduction


Manual manipulation to restore alignment of bone ends
Casts/Splints/Sling/Swathe

Traction

External Fixation

Open Reduction Internal Fixation (ORIF)


Surgical realignment of fragments
Internal placement of pins, wires, plates, screws, intramedullary rods,
nails,
Closed Reduction

Casting




Immobilize and support
injured, deformed, and
postoperative extremities
Protect realigned bone
Promote healing and early
weight bearing
Serial casting to prevent
or correct deformities
Closed Reduction

Complications of
Casts


Compartment syndrome
Cast syndrome (superior
mesenteric artery
syndrome)
Question #4
Nursing assessment of skin traction such
as Buck’s, Russell’s or Bryant’s traction
includes:
a. neurovascular assessment
b. pin care
c. alignment of balanced suspension
d. prevention of skin breakdown
Answer #4
Nursing assessment of skin traction
such as Buck’s, Russell’s or Bryant’s
traction includes:
a. neurovascular assessment
d. prevention of skin breakdown
Traction
Application of a pulling
force to an injured or
diseased part of the
body or an extremity
while a countertraction
pulls in the opposite
direction
Countertraction is
usually the patient’s
body
Traction: Types

Manual
Use of hands to exert pulling force

Skin
Pulling force directly to the skin

Skeletal
Traction forces directly to the bone
Traction: Purposes


Reduce, realign, and
promote healing of
fractured bones
Decrease muscle
spasm

Immobilization

Treat deformities

Rest joints

Treat dislocations and
subluxations

Reduce deformities

Prevent contractures

Expand joint space
Traction: Classifications

Skin
Cervical

Sidearm

Pelvic sling

Buck’s

Bryant (pediatrics)

Russell’s
Traction: Classifications
Skeletal
 Halo vest

Steinman pin or
Kirschner wire with
balanced suspension
(Thomas splint with
Pearson attachment) or
BB (Bohler Braun)
frame
Traction Principles

Maintain prescribed line of pull

Maintain continuous pull

Prevent friction

Identify and maintain countertraction
Traction:
Nursing Diagnosis

Activity intolerance

Hopelessness

Breathing pattern,
ineffective

Impaired physical
mobility

Constipation

Loneliness, risk for

Disuse syndrome, high
risk for

Pain (acute or chronic)

Powerlessness

Diversional activity
deficit
Traction: Nursing
Diagnosis (cont.)

Peripheral neurovascular dysfunction, high risk for

Skin integrity impairment , high risk for

Sleep pattern disturbance

Thought process alteration

Tissue perfusion alteration venous

Urinary elimination
External Fixation
A versatile method of immobilization that
employs percutaneous transfixing
pins/wires in bone attached to a rigid
external frame
Allows wide range of anatomic correction
both congenital and acquired
External Fixation

Types of fixation
 circular frame
 semicircular frame
 unilateral frame
 bilateral
 quadrilateral frame

Pin care
External Fixation:
Indications

Acute trauma to bones with/without segmental
loss

Limb length discrepancies

Infected and non-infected long bone union and non
union; osteomyelitis

Angulation and soft tissue deformities

Correction of chronic or residual deformities
External Fixation:
Complications

Pin tract infections (most common)

Loss of alignment or correction

Joint stiffness

Contractures

Delayed healing
 non-union
 mal-union
External Fixation:
Nursing Diagnosis

Body image disturbance

Disuse syndrome, risk for

Impaired adjustment

Impaired mobility

Impaired skin integrity, risk for
External Fixation:
Nursing Diagnosis (cont.)

Infection, risk for

Injury, risk for

Pain

Peripheral neurovascular dysfunction, risk
for

Sleep pattern disturbance
ORIF
ORIF: Nursing Diagnosis

Disuse syndrome, high risk for

Impaired adjustment

Impaired physical mobility

Impaired skin integrity, high risk for

Infection, high risk for
ORIF: Nursing Diagnosis
(cont.)

Pain (acute or chronic)

Preoperative position injury, risk for

Peripheral neurovascular dysfunction,
high risk for

Sleep pattern disturbance
Question # 5
Fracture management requires astute
attention to infection control practices.
Which nursing assessment is paramount in
determining if wound/bone sepsis is
developing?
a. vital signs
b. restlessness
c. meticulous wound care
d. maintenance of fracture management
Answer # 5
Fracture management requires astute
attention to infection control practices.
Which nursing assessment is paramount
in determining if wound/bone sepsis is
developing?
a. vital signs
Fracture Management:
Nursing Considerations
Skin-Tissue Perfusion






Risk for peripheral neurovascular
dysfunction
DVT
PE
SCD-LMWH
Pressure ulcers
 Heels/Sacrum/Ears
Fracture blisters
Fracture Management:
Nursing Considerations
Nutrition






Increased needs
NPO
Ulcer prophylaxis
Banana bag
Consider DT’s
Smoking decreases healing time (tibias)
Fracture Management:
Nursing Considerations
Mobility




Prevent wrist or foot
drop
Reduce edema
Prevent contractures
Prevent deformity and
disability
Fracture Management:
Nursing Considerations
Self-Concept




Body image
Limb loss
Disfigurement
Dependence
Fracture Management:
Nursing Considerations
Elimination



Ileus secondary to medications, anesthesia
Constipation
UTI
Fracture Management:
Nursing Considerations
Infection




Open fractures
Wound contamination
Osteomyelitis
Gas Gangrene
Trauma Prevention







Seat belt usage
Child restraints
Booster seats
DUI
MADD/SADD
Speed limit
adherence
Home safety
Question # 2
A comminuted fracture may be classified
as an injury in which:
a. bone protrudes through the skin
surface
b. tendons and ligaments are disrupted
c. the ends of bone are impacted into one
another
d. bone is fractured into two or more
fragments.
Answer # 2
A comminuted fracture may be classified
as an injury in which:
d. bone is fractured into two or more
fragments.
Question # 3
Andrew has sustained an open book
fracture of the pelvis after being pinned
under his tractor. What life-threatening
situation is causing his unstable BP?
a. Compartment syndrome
b. Overinflation of MAST trousers
c. Incorrect application of external fixation
d. Retroperitoneal hemorrhage
Answer # 3
Andrew has sustained an open book
fracture of the pelvis after being
pinned under his tractor. What lifethreatening situation is causing his
unstable BP?
d. Retroperitoneal hemorrhage
Question #4
Nursing assessment of skin traction such
as Buck’s, Russell’s or Bryant’s traction
includes:
a. neurovascular assessment
b. pin care
c. alignment of balanced suspension
d. prevention of skin breakdown
Answer #4
Nursing assessment of skin traction
such as Buck’s, Russell’s or Bryant’s
traction includes:
a. neurovascular assessment
d. prevention of skin breakdown
Question # 5
Fracture management requires astute
attention to infection control practices.
Which nursing assessment is paramount in
determining if wound/bone sepsis is
developing?
a. vital signs
b. restlessness
c. meticulous wound care
d. maintenance of fracture management
Answer # 5
Fracture management requires astute
attention to infection control practices.
Which nursing assessment is paramount
in determining if wound/bone sepsis is
developing?
a. vital signs
Question #7
Personal measures I take to reduce the
risk of trauma include:
a. always wear a lap shoulder restraint when driving or
riding in the front seat of a motor vehicle
b. thoroughly obeying all traffic regulations
c. driving within the posted speed limit
d. not drinking and driving; being a designated driver in a
group
e. taking a break every two hours when driving
f. getting adequate rest and not being fatigued at the wheel