ORTHOPAEDIC COMPLICATIONS ORTHOPAEDIC COMPLICATIONS.

ORTHOPAEDIC ORTHOPAEDIC COMPLICATIONSCOMPLICATIONS

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 Potential Complications

Low RiskLow Risk Acute ConfusionAcute Confusion ConstipationConstipation Impaired Skin Impaired Skin

IntegrityIntegrity

High RiskHigh Risk DVT/PEDVT/PE Compartment Compartment

SyndromeSyndrome Fat Emboli SyndromeFat Emboli Syndrome HemorrhageHemorrhage Wound/Surgical Site Wound/Surgical Site

InfectionInfection Delayed/NonunionDelayed/Nonunion

Question # 1Question # 1

DVT prevention requires the nurse to educate the patient DVT prevention requires the nurse to educate the patient on anticoagulant therapy to be alert for : on anticoagulant therapy to be alert for :

1. Headache1. Headache

2. Epistaxis2. Epistaxis

3. Nausea3. Nausea

4. Chest pain4. Chest pain


DVT prevention requires the nurse to DVT prevention requires the nurse to educate the patient on anticoagulant educate the patient on anticoagulant therapy to be alert for : therapy to be alert for :


Venous Thromboembolic Venous Thromboembolic Conditions Conditions

VirchowVirchow’’s Triads Triad Endothelial injuryEndothelial injury Hypercoagulable stateHypercoagulable state VenostasisVenostasis

Deep Vein Thrombosis (DVT)Deep Vein Thrombosis (DVT)

Formation of fibrin leads to development Formation of fibrin leads to development of a thrombus (fibrin clot)of a thrombus (fibrin clot)

Clinical symptoms appear when thrombus Clinical symptoms appear when thrombus is large enough to impede blood flow in a is large enough to impede blood flow in a large vessellarge vessel

Pulmonary Embolism (PE)Pulmonary Embolism (PE)

When venous thrombosis or part of a When venous thrombosis or part of a thrombus dislodges from its primary site, it thrombus dislodges from its primary site, it becomes an embolusbecomes an embolus

Embolus can enter pulmonary circulation Embolus can enter pulmonary circulation and perfusion distal to the embolus can be and perfusion distal to the embolus can be partially or completely occludedpartially or completely occluded

DVT & PE: Risk Factors DVT & PE: Risk Factors

Patient relatedPatient related Increasing ageIncreasing age MalignancyMalignancy Varicose veinsVaricose veins ObesityObesity TraumaTrauma Prior DVT/PEPrior DVT/PE CHF/CVACHF/CVA PregnancyPregnancy Deficiencies in clotting Deficiencies in clotting

cascadecascade Oral contraceptivesOral contraceptives

DVT & PE: Risk Factors DVT & PE: Risk Factors (continued)(continued)

Procedure relatedProcedure related Pelvic, hip or leg Pelvic, hip or leg

surgery/ fracture surgery/ fracture fixationfixation

Surgery > 30 minutesSurgery > 30 minutes Postop immobilizationPostop immobilization Postop infectionPostop infection Re-operationsRe-operations

DVT & PE: Risk Factors DVT & PE: Risk Factors (continued) (continued)

Anesthesia relatedAnesthesia related General anesthesiaGeneral anesthesia

DVT: Clinical ManifestationsDVT: Clinical Manifestations

Unilateral swelling of Unilateral swelling of thigh/lower legthigh/lower leg

ErythemaErythema

WarmthWarmth

TendernessTenderness

Palpable, tender Palpable, tender venous cord in venous cord in popliteal spacepopliteal space

Discomfort in legDiscomfort in leg

DVT: DiagnosticsDVT: Diagnostics

Contrast venographyContrast venography

Doppler ultrasonographyDoppler ultrasonography

Magnetic Resonance Imaging (MRI)Magnetic Resonance Imaging (MRI)

Radionuclide venographyRadionuclide venography

PE: Clinical ManifestationsPE: Clinical Manifestations

DyspneaDyspnea Chest painChest pain PalpitationsPalpitations ApprehensionApprehension ConfusionConfusion AnxietyAnxiety

RestlessnessRestlessness CoughCough HemoptysisHemoptysis DiaphoresisDiaphoresis SyncopeSyncope Distended neck veinsDistended neck veins

PE: DiagnosticsPE: Diagnostics Arterial blood gas (ABG)Arterial blood gas (ABG)

Chest x-ray (CXR)Chest x-ray (CXR)

Electrocardiogram (EKG)Electrocardiogram (EKG)

Ventilation-perfusion scan (VQ scan)Ventilation-perfusion scan (VQ scan)

Pulmonary angiographyPulmonary angiography

CT scan CT scan

DVT & PE: PreventionDVT & PE: Prevention

External pneumatic compression and External pneumatic compression and graduated compression stockingsgraduated compression stockings

Early ambulation and range of motionEarly ambulation and range of motion

Elevation of lower extremities Elevation of lower extremities

DVT & PE: Prevention (cont.)DVT & PE: Prevention (cont.)

Prophylactic inferior vena cava filter Prophylactic inferior vena cava filter

AnticoagulationAnticoagulationHeparinHeparinLMWH (low molecular weight heparin)LMWH (low molecular weight heparin)Warfarin (Coumadin)Warfarin (Coumadin)

DVT & PE: InterventionsDVT & PE: Interventions Full dose anticoagulation with heparin/warfarin Full dose anticoagulation with heparin/warfarin

(target INR 2-3)(target INR 2-3)

Oxygen therapy for PEOxygen therapy for PE

Thrombolytic therapyThrombolytic therapy urokinase, streptokinaseurokinase, streptokinase

Surgical embolectomySurgical embolectomy

Inferior vena cava filterInferior vena cava filter

Question # 2 Question # 2

The nurse uses critical thinking to assess an impending The nurse uses critical thinking to assess an impending compartment syndrome as indicated by which of the following compartment syndrome as indicated by which of the following patient presentations? patient presentations?

1. Progressive pain on PROM, paresthesia and diminished 1. Progressive pain on PROM, paresthesia and diminished

pulse pulse

2. Progressive pain on AROM, shiny skin and pulselessness2. Progressive pain on AROM, shiny skin and pulselessness

3. Progressive pain on AROM, increased tissue pressure 3. Progressive pain on AROM, increased tissue pressure and edemaand edema

4. Progressive pain on PROM and elevated ESR & WBC4. Progressive pain on PROM and elevated ESR & WBC


The nurse uses critical thinking to assess The nurse uses critical thinking to assess an impending compartment syndrome as an impending compartment syndrome as indicated by which of the following patient indicated by which of the following patient presentations? presentations?

1. Progressive pain on PROM, paresthesia 1. Progressive pain on PROM, paresthesia

and diminished pulse and diminished pulse

Compartment SyndromeCompartment Syndrome

Compromised Compromised circulation and circulation and function of tissues function of tissues within a specific area within a specific area due to progressive due to progressive pressure within a pressure within a confined spaceconfined space

Acute, chronic or Acute, chronic or crushcrush

Compartment Syndrome: Compartment Syndrome: PathophysiologyPathophysiology

Tissue swellingTissue swelling Compression of vessels and nervesCompression of vessels and nerves Histamine releaseHistamine release Capillary dilationCapillary dilation Increase in capillary permeabilityIncrease in capillary permeability Increased edemaIncreased edema Decreased perfusionDecreased perfusion Increased lactic acidIncreased lactic acid Increased blood flowIncreased blood flow

Compartment Syndrome: Compartment Syndrome: Risk FactorsRisk Factors

External compression External compression forcesforces Tight castTight cast Tight dressing Tight dressing Prolonged compressionProlonged compression Crush injuries Crush injuries

Internal factorsInternal factors BleedingBleeding Significant swelling/edemaSignificant swelling/edema Exertional Exertional

Compartment Syndrome:Compartment Syndrome: Risk Factors (continued) Risk Factors (continued)

MiscellaneousMiscellaneous Acute traumaAcute trauma FractureFracture InfectionInfection Skin tractionSkin traction Tibial nailingTibial nailing ExerciseExercise Insensate extremityInsensate extremity

Compartment Syndrome:Compartment Syndrome:Clinical ManifestationsClinical Manifestations

Early signsEarly signs Increasing painIncreasing pain Pain with passive Pain with passive

stretch of musclesstretch of muscles ParesthesiaParesthesia

Late signsLate signs Delayed capillary Delayed capillary

refillrefill Pale extremityPale extremity Loss of pulseLoss of pulse ParalysisParalysis

Compartment Syndrome:Compartment Syndrome: 5 Ps 5 Ps

Pain on passive Pain on passive stretchstretch

Pallor Pallor PulselessnessPulselessness ParesthesiaParesthesia ParalysisParalysis

Compartment Syndrome: Compartment Syndrome: MonitoringMonitoring

If compartment syndrome is not If compartment syndrome is not recognized and pressure is not relieved, recognized and pressure is not relieved, muscle damage will be irreversible after muscle damage will be irreversible after 4-6 hours of ischemia, and nerve 4-6 hours of ischemia, and nerve damage will be irreversible after 12-24 damage will be irreversible after 12-24 hours of ischemia. (Janzing et al., 1996)hours of ischemia. (Janzing et al., 1996)

Neurovascular Assessment Neurovascular Assessment

Peripheral vascular assessmentPeripheral vascular assessment ColorColor

pale/white, pink, dusky, pale/white, pink, dusky, cyanotic, mottledcyanotic, mottled

TemperatureTemperature cool/cold, warm, hotcool/cold, warm, hot

Capillary refillCapillary refill normal < 3 secondsnormal < 3 seconds

Peripheral pulsesPeripheral pulses distal to injury, bilateraldistal to injury, bilateral non-palpable: dopplernon-palpable: doppler

Edema Edema pitting pitting

Neurovascular AssessmentNeurovascular Assessment

Peripheral neurologic Peripheral neurologic assessmentassessment SensationSensation Motor functionMotor function

Both elements Both elements evaluate:evaluate:

Upper extremity: Upper extremity: radial, median and radial, median and ulnar nervesulnar nerves

Lower extremity: Lower extremity: tibial, peroneal, tibial, peroneal, femoral and sciatic femoral and sciatic nervesnerves

Compartment Syndrome:Compartment Syndrome:DiagnosticsDiagnostics

Muscle damage indicated by:Muscle damage indicated by:Myoglobin in urineMyoglobin in urineElevated CPK, LDH and SGOTElevated CPK, LDH and SGOT

Intracompartmental pressure monitorIntracompartmental pressure monitorPressures of 30-45 mmHG a concernPressures of 30-45 mmHG a concern

Compartment Syndrome:Compartment Syndrome:PreventionPrevention

Early recognition is key to Early recognition is key to preventing or minimizing preventing or minimizing negative outcomenegative outcome

Astute nursing Astute nursing intervention to identify intervention to identify pathologic pain in the pathologic pain in the presence of good pain presence of good pain control (epidural, PCA)control (epidural, PCA)

Compartment Syndrome:Compartment Syndrome:InterventionsInterventions

Relieve pressure sourceRelieve pressure source Remove constrictive dressingRemove constrictive dressing Bivalve castBivalve cast

Initiate pain managementInitiate pain management

Elevate extremity at heart levelElevate extremity at heart level

Ongoing neurovascular assessments Ongoing neurovascular assessments Fasciotomy if indicatedFasciotomy if indicated


Which nursing assessment finding might Which nursing assessment finding might suggest the presence of a fat embolism?suggest the presence of a fat embolism?

1.1. EcchymosisEcchymosis

2.2. HematomaHematoma

3.3. PetechiaePetechiae

4.4. Edema Edema



3. Petechiae3. Petechiae

Fat Emboli Syndrome (FES)Fat Emboli Syndrome (FES)

Mechanical blockage Mechanical blockage of blood vessels by of blood vessels by circulating fat circulating fat particles particles

Occurs following long Occurs following long bone fracture, pelvic bone fracture, pelvic fracture and total hip fracture and total hip arthroplasty arthroplasty

FES: PathophysiologyFES: Pathophysiology

Mechanical theoryMechanical theory Injured adipose tissue Injured adipose tissue

and/or disruption of and/or disruption of intramedullary intramedullary compartment releases compartment releases fat into the blood fat into the blood streamstream

Biochemical theoryBiochemical theory Fatty acids cause Fatty acids cause

endothelial damage; endothelial damage; fatty acids and fats fatty acids and fats lead to platelet lead to platelet aggregation and fat aggregation and fat globule formation globule formation

FES: Clinical ManifestationsFES: Clinical Manifestations

Signs and symptoms Signs and symptoms can appear 12-72 can appear 12-72 hours post injuryhours post injury Change in mental Change in mental

statusstatus Increased respiratory Increased respiratory

distressdistress Petechiae of skin & Petechiae of skin &

mucosa (appear mucosa (appear above nipple line and above nipple line and blanch)blanch)

FES: DiagnosticsFES: Diagnostics

No specific labsNo specific labs Fat globules may be Fat globules may be

detected in blood, detected in blood, urine or sputumurine or sputum

PO2 drops to < 50 PO2 drops to < 50 mmHGmmHG

CXR with diffuse CXR with diffuse ““snowstormsnowstorm”” effect effect

VQ scan to r/o PEVQ scan to r/o PE

FES: InterventionsFES: Interventions

Early recognition to Early recognition to prevent morbidity and prevent morbidity and mortalitymortality

Minimize movement Minimize movement of long bone fracturesof long bone fractures

Respiratory supportRespiratory support IntubationIntubation Ventilator Ventilator

managementmanagement ICU monitoring ICU monitoring

Question 4AQuestion 4A

Which indicators are BEST for diagnosing Which indicators are BEST for diagnosing hemorrhagehemorrhageA) Blood in urine/stoolA) Blood in urine/stoolB) Labs (cbc, coagulation studies)B) Labs (cbc, coagulation studies)C) Radiographic studiesC) Radiographic studies

Hemorrhage/Postoperative Hemorrhage/Postoperative Bleeding Bleeding

EtiologyEtiology Trauma/surgeryTrauma/surgery Slipped ligatureSlipped ligature Anticoagulation or Anticoagulation or

coagulation disordercoagulation disorder Erosion of blood Erosion of blood

vessel by foreign body vessel by foreign body or tumoror tumor

Infection Infection

Hemorrhage: Risk FactorsHemorrhage: Risk Factors

Patient-relatedPatient-related Coagulation disordersCoagulation disorders Low platelet countLow platelet count Excessive coagulationExcessive coagulation Tumor growthTumor growth

Injury-relatedInjury-related Fracture or foreign body interrupts blood vesselFracture or foreign body interrupts blood vessel

Procedure-relatedProcedure-related

Hemorrhage: Hemorrhage: Clinical Manifestations Clinical Manifestations

DizzinessDizziness WeaknessWeakness AnxietyAnxiety RestlessnessRestlessness ConfusionConfusion TachycardiaTachycardia Lowered BPLowered BP

Rapid, shallow Rapid, shallow respirationsrespirations

PallorPallor Cold, clammy skinCold, clammy skin Abnormal drainage Abnormal drainage

from wounds or from wounds or drainsdrains

Decreased urine Decreased urine output output

Hemorrhage: Hemorrhage: DiagnosticsDiagnostics

CBCCBC

Coagulation studies Coagulation studies

Urine and stool for Urine and stool for bloodblood

Radiographic studies Radiographic studies

Hemorrhage: InterventionsHemorrhage: Interventions Direct pressureDirect pressure

Surgical intervention as indicatedSurgical intervention as indicated

Use of autologous or synthetic clotting materialUse of autologous or synthetic clotting material

Vitamin K or clotting replacement factorsVitamin K or clotting replacement factors

Volume replacement and blood transfusion as necessaryVolume replacement and blood transfusion as necessary

Iron supplementationIron 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

Wound and Surgical Site Wound and Surgical Site Infection (SSI)Infection (SSI)

Nosocomial surgical site infections Nosocomial surgical site infections occur within 30 days after the operative occur within 30 days after the operative procedure (within 1 year if an implant is procedure (within 1 year if an implant is in place) and can involve skin, in place) and can involve skin, subcutaneous tissue, deep soft tissues, subcutaneous tissue, deep soft tissues, or actual organs manipulated during the or actual organs manipulated during the operative procedure. (CDC)operative procedure. (CDC)

Wound/SSI: Risk FactorsWound/SSI: Risk Factors

Patient characteristicsPatient characteristics Advanced ageAdvanced age Obesity/malnutritionObesity/malnutrition HypovolemiaHypovolemia DiabetesDiabetes Rheumatoid arthritisRheumatoid arthritis Steroid use/NSAID Steroid use/NSAID

use/chemotherapyuse/chemotherapy Tobacco useTobacco use Substance abuse Substance abuse

Wound/SSI: Wound/SSI: Intrinsic Risk FactorsIntrinsic Risk Factors

Injury characteristicsInjury characteristicsBone displacement, comminutionBone displacement, comminutionPeriosteal strippingPeriosteal stripping Involvement of more than one boneInvolvement of more than one boneVascular injuryVascular injurySignificant soft tissue injurySignificant soft tissue injuryOpen fracture/foreign body/contamination Open fracture/foreign body/contamination

Wound/SSI:Wound/SSI:Extrinsic Risk FactorsExtrinsic Risk Factors

PreoperativePreoperative Inadequate Inadequate

immobilization of immobilization of fractured bonefractured bone

Preoperative shave > Preoperative shave > 1 day prior to surgery1 day prior to surgery

Duration of Duration of preoperative preoperative hospitalization hospitalization

IntraoperativeIntraoperative Hair removalHair removal Positive intraop Positive intraop

contaminationcontamination Irrigation, drains, packingIrrigation, drains, packing Primary/secondary Primary/secondary

closures closures Type and length of Type and length of

procedureprocedure Surgeon expertiseSurgeon expertise Glove punctures Glove punctures

Wound/SSI:Wound/SSI: Extrinsic Risk Factors Extrinsic Risk Factors

PostoperativePostoperative Cold room Cold room

(vasoconstriction)(vasoconstriction) Insufficient fluid Insufficient fluid

replacementreplacement HypertensionHypertension Inadequate analgesiaInadequate analgesia Compromised blood Compromised blood

perfusionperfusion Low oxygenation Low oxygenation

Wound/SSI: Wound/SSI: Clinical ManifestationsClinical Manifestations

Increased painIncreased pain

Fever or chillsFever or chills

Malodor from incision or Malodor from incision or wound wound

EdemaEdema

Increased temperature Increased temperature around incision or woundaround incision or wound

Erythema around wound Erythema around wound or incisionor incision

Purulent exudate, poor Purulent exudate, poor wound healingwound healing

Elevated WBC, ESR, C-Elevated WBC, ESR, C-reactive protein reactive protein

Wound/SSI: PreventionWound/SSI: Prevention

PreoperativePreoperative Control hypertension Control hypertension

and blood sugar and blood sugar Minimize unnecessary Minimize unnecessary

movement of fracturesmovement of fractures Treat existing Treat existing

infectionsinfections Replenish nutritional Replenish nutritional

deficitsdeficits Prevent Prevent

vasoconstrictionvasoconstriction

IntraoperativeIntraoperative Antimicrobial prophylaxisAntimicrobial prophylaxis Strict aseptic techniqueStrict aseptic technique Meticulous tissue Meticulous tissue

debridementdebridement Stabilize fracturesStabilize fractures Avoid vasoconstrictionAvoid vasoconstriction Gently handling of soft Gently handling of soft

tissuetissue Wound closure without Wound closure without

excessive tension excessive tension

Wound/SSI: PreventionWound/SSI: Prevention

PostoperativePostoperative Provide adequate Provide adequate

analgesiaanalgesia Avoid vasoconstrictionAvoid vasoconstriction Control BP and BSControl BP and BS Provide for adequate Provide for adequate

nutritionnutrition Aseptic dressing changesAseptic dressing changes Microbial therapy Microbial therapy Thorough handwashing Thorough handwashing

Wound/SSI: InterventionsWound/SSI: Interventions

Wound careWound care Systemic antibioticsSystemic antibiotics Adequate perfusionAdequate perfusion Adequate Adequate

oxygenationoxygenation Optimal nutritional Optimal nutritional

intake intake

Question #5Question #5

A fracture that isn’t healing is considered A fracture that isn’t healing is considered to be a non union (as opposed to a to be a non union (as opposed to a delayed union) fracture after how long?delayed union) fracture after how long?

6-12 weeks6-12 weeks8-14 weeks8-14 weeks16-24 weeks16-24 weeks28-36 weeks28-36 weeks

Delayed Union/NonunionDelayed Union/Nonunion

Delayed union is a continuation of or increase in Delayed union is a continuation of or increase in bone pain and tenderness beyond a reasonable bone pain and tenderness beyond a reasonable healing period; healing is slowed but not healing period; healing is slowed but not completely stoppedcompletely stopped

Nonunion occurs when fracture healing has not Nonunion occurs when fracture healing has not taken place 4-6 months after the fracture occurs taken place 4-6 months after the fracture occurs and spontaneous healing is unlikely (Morris, and spontaneous healing is unlikely (Morris, 2001)2001)

Delayed Union/NonunionDelayed Union/Nonunion

PathophysiologyPathophysiology InfectionInfection Inadequate fracture Inadequate fracture

immobilizationimmobilization Inadequate blood Inadequate blood

supply to fracture sitesupply to fracture site

DiagnosticsDiagnostics Serial x-raysSerial x-rays CT scansCT scans MRI MRI

Delayed Union/Nonunion:Delayed Union/Nonunion:Interventions Interventions

Bone graftingBone grafting

Internal fixation Internal fixation

External fixationExternal fixation

Electrical bone Electrical bone stimulation stimulation


DVT prevention requires the nurse to educate the patient DVT prevention requires the nurse to educate the patient on anticoagulant therapy to be alert for : on anticoagulant therapy to be alert for :

1. Headache1. Headache


3. Nausea3. Nausea

4. Chest pain4. Chest pain


DVT prevention requires the nurse to DVT prevention requires the nurse to educate the patient on anticoagulant educate the patient on anticoagulant therapy to be alert for : therapy to be alert for :


Question # 2 Question # 2

The nurse uses critical thinking to assess an impending The nurse uses critical thinking to assess an impending compartment syndrome as indicated by which of the following compartment syndrome as indicated by which of the following patient presentations? patient presentations?

1. Progressive pain on PROM, paresthesia and diminished 1. Progressive pain on PROM, paresthesia and diminished

pulse pulse

2. Progressive pain on AROM, shiny skin and pulselessness2. Progressive pain on AROM, shiny skin and pulselessness

3. Progressive pain on AROM, increased tissue pressure 3. Progressive pain on AROM, increased tissue pressure and edemaand edema

4. Progressive pain on PROM and elevated ESR & WBC4. Progressive pain on PROM and elevated ESR & WBC


The nurse uses critical thinking to assess The nurse uses critical thinking to assess an impending compartment syndrome as an impending compartment syndrome as indicated by which of the following patient indicated by which of the following patient presentations? presentations?

1. Progressive pain on PROM, paresthesia 1. Progressive pain on PROM, paresthesia

and diminished pulse and diminished pulse



1.1. EcchymosisEcchymosis

2.2. HematomaHematoma

3.3. PetechiaePetechiae

4.4. Edema Edema



3. Petechiae3. Petechiae

Question 4AQuestion 4A

Which indicators are BEST for diagnosing Which indicators are BEST for diagnosing hemorrhagehemorrhageA) Blood in urine/stoolA) Blood in urine/stoolB) Labs (cbc, coagulation studies)B) Labs (cbc, coagulation studies)C) Radiographic studiesC) Radiographic studies

Question # 4



2. Aseptic technique with dressing changes

3. Administration of antibiotic

4. Monitoring BP and glucose levels

Question #5Question #5

A fracture that isn’t healing is considered A fracture that isn’t healing is considered to be a non union (as opposed to a to be a non union (as opposed to a delayed union) fracture after how long?delayed union) fracture after how long?

6-12 weeks6-12 weeks8-14 weeks8-14 weeks16-24 weeks16-24 weeks28-36 weeks28-36 weeks

ORTHOPAEDIC COMPLICATIONS ORTHOPAEDIC COMPLICATIONS.

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