Orthopedic Nursing

Historical Background of Orthopedic Nursing  The word ‘orthopedics’ was derived from the Greek words; orthos meaning straight or free of deformity and pais meaning child.

History of the Philippine Orthopedic Center POC starte started d in Febru February ary 9, 1945 1945 by PCAU PCAU Genera Generall Hospit Hospital. al. The US Army Army establishe established d the hospital in Mandaluyo Mandaluyong, ng, Rizal. It was then called called as Mandaluyong Mandaluyong Emergency Hospital. Its main purpose is to help take care of the civilian casualties of war. But its function was not only as emergency basis seeing not only victims of wars but also all cases.

Orthopedics also called orthopedic surgery medical specialty concerned with the preservat preservation ion and restoratio restoration n of function function of the skeletal system and its associate associated d structures, i.e., spinal and other bones, joints, and muscles. Nicolas Nicolas Andry, a professo professorr of medicine at the University University of Paris Paris published published a textbook in Orthopedics in 1741 concerning the following; 1. Mainta Maintaini ining ng a straigh straightt child child 2. Straighte Straightening ning a deform deformed ed child child 3. Finding Finding new new ways ways to straighten straighten defor deformed med child child

In May 1945, the hospital was turned over to the Phil. Government. In August 1945, the Bureau of Health took over and only fracture cases and bone joint condition remained.  The hospital kept functioning during those difficult years and it is attributed to the skill, ingenuity, dedication and foresight of the staff lead by Dr. Jose V. delos Santos.

In 1728-1793 1728-1793,, John Hunter contribute contributed d to the advancemen advancementt of understan understanding ding fractures and other musculo-skeletal injuries.

 The hospital finally transferred to its present site in Quezon Cit y.

Orthopedics began in the 18th century with the pioneering efforts of Jean André Venet, who established an institute in Switzerland for the treatment of crippled children's skeletal deformities.

Review of Structure and Function of the Musculo-skeletal Musculo-skeletal System

I The Bones A. The human human skeleton skeleton consist consist of two main divisio division: n: 1. Axial – body body uprigh uprightt structu structure re a) Skull b) vertebral column c) ribs 2. Appendicul Appendicular ar – the the body body appendag appendages es a) Arms b) hips c) legs

In 1834-1891, Hugh Owen Thomas, an Englishman specialized in the treatment of  chronic joint disease, fractures and dislocations. In 1867-1948, Agnes Hunt, referred to as the Florence of Nightingale of Orthopedic Center in Great Britain.

B. Four Four majo majorr bone bone type type 1. Long bones bones - length length exceeds exceeds breadth breadth and thickne thickness ss 2. Short bones - equal equal in main main dimensio dimensions ns 3. Flat bones bones – primary primary made made up of cancellou cancellous s bone tissue tissue 4. Irre Irregu gula larr bones bones

 The efforts of Sir Robert Jones and the massive casualties of World War I led to the founding of many orthopedic training centers in the early 20th century. century. In 1840, William Little established the Royal Orthopedic Infirmary in Great Britain. In 1857, Anthonius Methyson of Holland described the plaster bandage. In 1866, the New York Orthopedic Dispensary was formed.

C. Long Long Bon Bones es:: 1. Stru Struct ctur ure e a) Diaphysis Diaphysis – shaft provides provides strength strength resist resist bending bending b) Metaphysis – flared portion between diaphysis diaphysis and and epiphysis epiphysis c) Epip Epiphy hysi sis s – end end Primary cancellous bone Assist with bone development d) Epiphyseal plate/line – between between metaphysis metaphysis and epiphysis - Cartilage growth in length of diaphysis and metaphysis e) Periosteu Periosteum m – connective connective tissue tissue covering covering bone bone continues at the end of bone with joint capsule but does not cover articular cartilage 2. Bloo Blood d supp supply ly

A vastly vastly increased increased knowledge knowledge of muscular muscular functions functions and of the growth growth and development of bone was gained in the 19th century. Significant advances at this time were the new operation operation of tenotomy tenotomy (the cutting cutting of tendons, tendons, which made correcting correcting deformities easier), the surgical correction of clubfoot, the invention of the Thomas splint (which (which provi provided ded better better suppor supportt for fractures fractures of long long bones bones in the limbs), limbs), and the introduction of quick-setting plaster of Paris for use in orthopedic bandages. Modern Modern orthopedic orthopedics s has extended extended beyond beyond the treatment treatment of fractures fractures,, broken broken bones, strained muscles, torn ligaments and tendons, and other traumatic injuries to deal with a wide range of acquired and congenital skeletal deformities and with the effects of  degenerative diseases such as osteoarthritis. A specialty that originally depended on the use of heavy braces and splints, orthopedics now utilizes bone grafts and artificial plastic  joints for the hip and other bones damaged by disease, as well artificial limbs special footwear, footwear, and braces braces to return return mobility to disabled disabled patients. Orthopedics Orthopedics uses the techniques of physical medicine and rehabilitation and occupational therapy in addition to those of traditional medicine and surgery.

a) Nutrient Nutrient artery artery – tunnel tunnel in the diaphys diaphysis is of long bone bone b) Periostea Periosteall vessels – supply supply compmact compmact bones with with nutrients nutrients 1

c)

Metaphysea Metaphyseall and epiphysea epiphyseall vessels vessels – supply the spongy spongy bone and narrow of the epiphysis

V Joints 3 Basic Joint Types

D. Funct unctio ions ns 1. Provides Provides framework framework for the the body body 2. Serves Serves as lever lever for skeleta skeletall muscles muscles 3. Protects Protects vital vital organs organs such as the brain, brain, heart heart and lungs lungs 4. Stores calcium and release it to the blood blood stream according to the body requirement 5. Manufactu Manufactures res new blood blood cells cells in the red bone bone marrow marrow

1. Fibrous Fibrous – composed composed of fibrous tissue, tissue, tightly, tightly, connecting connecting the articular articular surfaces surfaces of  two bones 2 types a) sutures sutures – permits permits no moveme movement nt

II Cartilage

b) syndesmo syndesmosis sis – permits permits minimal minimal movement movement between between bones

1) Fibrocartilage – greatest tensile strength occurs in the intervertebral dics and in the symphysis pubis 2) Elastic cartilage – possesses firmness and elasticity occurs in the external air and in the Eustachian tube 3) Hyaline cartilage – cushions most of the joints to help soften any impact firm yet flexible occurs also in the part of the nasal system, larynx, trachea and in the bronchial ring

2. Cartil Cartilage agenou nous s joints joints connec connectt two bones with cartil cartilage age,, allowi allowing ng only only slight slight movement. 3.

a) join jointt cap capsu sule le b) synovi synovial al membra membrane ne

III Ligaments and Tendons Ligaments – strong cords of f ibrous tissue - joint capsule provides the primary connection between the bones, but ligament bind the joints more firmly

c) articu articular lar cartil cartilage age d) syno synovi vial al cavi cavity ty

  Tendons endons – firm cords of fibrous fibrous tissue that extend from the muscle muscle to the periosteum - connects muscle to each other to other tissue

FRACTURES

A. Fracture is a break in the continuity of the bone. In adults this break is usually complete in that the periosteum and the cortical tissue on both sides are completely severed.

IV Skeletal muscle a. b.

c.

Synovial joints, the most common joint joint type, have have the most most complex structure and and permit maximum mobility. mobility. These joints include the following

In pathology, pathology, a break break in a bone, bone, caused caused by stress. Certain normal normal and pathological pathological conditions may predispose bones to fracture. Children have relatively weak bones because of incomplete calcification, and older adults, especially women past menopause, develop osteopor osteoporosis, osis, a weakening weakening of bone concomitant concomitant with aging. aging. Patholog Pathological ical conditions conditions involving the skeleton, most commonly the spread of cancer to bones, may also cause weak bones. In such cases very minor stresses may produce a fracture. Other factors, such as general health, nutrition, and heredity, also have effects on the liability of bones to fracture and their ability to heal.

Muscles Muscles can be long and tapered, tapered, short short and blunt, triangula triangular, r, quadrilate quadrilateral ral or irregular. Muscle Muscle fiber arrangem arrangement ent varies varies 1. In some muscles, the the fiber runs runs parallel to the muscles long long axis 2. In others, the fibers are oblique and bipennate like the feather of a quill pin 3. Fibers Fibers curve cut cut from a narrow narrow attachmen attachmentt at the muscles muscles and to form a triangle Main Main fun funct ctio ions ns 1. Prime Prime mover – directly directly brings brings about about a desired desired motion motion 2. Antago Antagonis nistt – muscle muscles s that that direct directly ly oppose opposes s the movemen movementt under under consideration 3. Fixation Fixation – generally generally stabilizes stabilizes a joint or its part thereby thereby maintaining maintaining position while prime mover acts

An incomplete break or greenstick fracture is mere common in children. Bone broken is bent but securely hinged at one side. A complete fracture occurs when periosteum and cortical tissue completely severed on both sides of bone. 2

B. Fracture bone fragments are labeled according to relationship to the cortex of the body.

The most important phase in obtaining the union of fracture fragments. a. Cast b. Tract ractio ion n c. Brace d. Fixatio ixation n device devices s a. Intern Internal al fixati fixation on device devices s b. Extern External al fixati fixation on device devices s

1. dist distal al – awa away y from from 2. prox proxima imall – here here to to C. Causes of fracture

CARE OF PATIENT IN CAST

1. In normal normal bones, fracture fracture occurs occurs when more more stress is placed placed upon a bone that is able to absorb such as:

Plaster Cast – is temporary immobilization device, which is made of gypsum sulfate, rendered anhydrous anhydrous by calcification when mixed with water swells and forms into hard cement.

a) Direct Direct blow blow or or crushin crushing g form form b) Twisting force (torsion a severe severe twisting of a broken bone bone at a side different different from where the force was actually applied.

FUNCTIONS 1. 2. 3. 4.

c) Powerful Powerful contractio contractions ns – highly developed developed muscles muscles contract contract so violently that that muscles tear from bone sometimes pulling a small piece of bone with it.

* Cast can be applied to the extremities, to the trunk and to the extremity and trunk as in spicas. It can be applied to encase the whole area where it should be applied or it can be applied as a splint or mold.

d) Fatigue and stress stress bone breaks after after repeated stress 2.

To immob immobil iliz ize e To prevent prevent or or correct correct deform deformity ity To support, support, maintain maintain and protect protect realigned realigned bone bone To promote promote healing healing and early early weight weight bearing bearing

Bones weakened weakened by a disease or tumors tumors and subject subject to pathological pathological fractures

Classification of fractures

*Complications of cast 1. Neurovas Neurovascular cular compromi compromise se 2. Incorrect Incorrect fracture fracture alignment alignment 3. Cast syndrom syndrome, e, superior superior mesent mesenteric eric artery artery a. Occurs Occurs with with body body cast cast b. Traction on superior superior mesenteric mesenteric artery causes decrease in blood supply to bowel c. Signs Signs and symptoms symptoms,, abdominal abdominal pain, pain, nausea nausea and vomiting vomiting 4. Compartment syndrome syndrome – is a condition in which increases increases pressure pressure within limited space, compromises circulation and function of the tissue within that space.

Broad classification 1. Open Open frac fractu ture re 2. Clos Closed ed frac fractu ture re

Principles of Fracture Treatment A. Reductio Reduction n or realignm realignment ent of bone bone fragments fragments B. Maintenan Maintenance ce or realignm realignment ent by immobiliza immobilization tion C. Resto Restorat ration ion of funct function ion

Principle in application of plaster cast

1. A cast is applied applied with padding padding first first Padding materials include the following – wadding sheet, roll cotton, stockinet felt. It can be applied as a combination like stockinet and wadding sheet. 2. Apply it to the joint joint above above and joint below below the injured injured part. part. 3. Apply it in circular motion and mold it as you do do the procedure procedure by the palm. 4. Suppor Supportt it with with the palm palm

A. Reduction 1. Closed reduction reduction – is accompanied by application of plaster cast after the fracture4 have been aligned with or without the use of anesthesia, to include the joint above and below the fracture line.

2. Open reduction – immobilization is done by nails, screws, screws, pins, wires wires or rods which are inserted with or without plates. Such devices stay in the patient indefinitely unless they produce symptoms after healing takes place.

Contraindications Contraindications of plaster cast application 1. Preg Pregna nanc ncy y 2. Skin Skin dise diseas ases es

For Circular Cast Application

B. Immobilization 3

1. Check Check for for doctor doctor’s ’s order orders s 2. Inform Inform and prepare prepare the patient patient for the the procedure procedure.. Explain to the patient and his relatives the need for placing the affected part of the body cast. Show an illustration of the type of cast to be applied to help them visualize HOW IT IS and WHAT IT IS.   They are also made aware of the approximate approximate duration duration for the the body to remain in cast, the limitation and the discomfort arising from immobilization less boredom and frustrating. If possible, a good cleaning cleaning bath and shampoo shampoo be given to the patient. patient. The affected part be cleansed thoroughly with soap and water or with detergent and dried. If there is a wound dress it accordingly. 3. Ready Ready all things things needed needed for the the applicatio application. n. 4. Position Position the the extremity extremity (by the doctor) doctor) 5. Apply padding padding includin including g the joints above and below below the fracture fracture line with thicker thicker pads on the bony prominences 6. Soak the plaster plaster cast into a bucket with with water; leave it undisturb undisturbed ed until bubble bubble ceases, one after the other. 7. Grasp both ends, when bubbles cease, towards the center without squeezing it. 8. Free Free the end of of the cast and and hand hand it to operator operator.. 9. Apply cast in CIRCULAR MOTION MOTION until the the whole area area is covered covered and mold it during during the process of application by the palm. 10. Support the cast while applying. 11. Handle the cast with care.

Care of the Patient in Cast The duration of keeping the body or part of it in cast is at least 1 month. Though, it varies among patients. Factors that influence the duration are 1. Age Age of the the pat patie ient nt 2. Part Part of the the e body body affe affecte cted d 3. The degree degree of injury injury the affectio affection n of the part

*During the entire period that the patient is in cast, the nurse responsibility is focused on the following: a. Neuro Neurovas vascul cular ar check check b. Preservat Preservation ion of the the efficiency efficiency of the cast cast c. Maintenan Maintenance ce and promotio promotion n of the integrity integrity of the system system of the body body d. Maintenan Maintenance ce of the the cleanlines cleanliness s of the cast cast A. Neurovascular checks In all casted patient, COLOR, MOTION, TEMPERATURE AND SENSATION SENSATION OF TOES/FINGERS should be observed every 30minutes for several hours. After cast application, longer if  there is edema, and then regularly every 3 hours. Circulatory impairment results in symptoms of coldness, edema, cyanosis, pain and finally numbness in the toes or fingers. The blanching sign will indicate whether or not there is an adequate circulation. When the nail of the thumb or great toes is compressed and immediately released, the color should go from white to pink with the same speed/. If  not, the circulation is slow and the toes or fingers need closer observation. Patients in arm or leg casts should be able to move and feel each toe or finger, because the same nerve does not innervate each other. All toes and fingers should be checked.

Moving patients or transferring with wet cast must be avoided as much as possible. If this is necessary, care must be taken to maintain the integrity of the cast.  The excess plaster cast is trimmed by means of a trimming knife. Cast spilled on the skin is easily removed by wiping it with a damp cloth.

Nerve Function Test

 To  To hasten drying of the cast, several ways can be used 1. Exposure Exposure to open open air or electric electric fan 2. Exposu Exposure re to to heat heat lamp lamp 3. Placing Placing the patien patientt in a warm room Care should be taken in protecting the patient form rapid drying of the cast, as this will result to a dry outer layer while the inner layer remains wet. Complaints of discomfort should be investigated and appropriate measures be given to bring comfort.

Ne rv rve

Ac ti ti on on b y t he he n ur ur se se - Test for Sensory Function

Radi Radial al

Pric Prick k web web part part betw betwee een n thum thumb b and index finger

Me di di an an Pr ic ick d is ist al al su rf rf ac ac e of i nd nde x finger

O pp pp os os e t hu humb an d l it it tl tl e finger flex wrist

Prick distal end of the small finger

Abduct all fingers

Peron eronea eall

Pric Prick k late latera rall surf surfac ace e of the the grea greatt toes toes toe

Dors Dorsif ifle lex x ankl ankle e extend toes

Finishing touches on the dried cast.   Tib Tibia iall

Rough Rough edges can be covered covered with adhesive adhesive petals, especially especially if there there is no stockinet stockinet underneath the plaster and wadding sheet.

Hype Hypere rext xten end d the the thum thumb b

Ulna Patients in body cast or spica cast is turned every 4-6 hours to promote even drying of the cast.

Edges that are extremely rough should be trimmed and smoothened very slightly with a knife.

Ac ti ti on on b y t he he pa ti ti en ent - Test for Motor Function

Pric Prick k medi medial al and and late latera rall surf surfac ace e of sole of foot

Plan Planta tarr fle flex ankl ankle e and and flex toes

Psychological Psychological Implications and Going Home In Cast 4

seco second nd

To relieve patients’ apprehension and anxieties that crowd their minds with their cast on, the nurse can help the [patient make a start toward resolving some of the problems by helping them become to remain as independent as possible. Instruction regarding cast care need to be received and patient can be reminded that frequent rest periods for the entire body are necessary. Discussing plans with the patient before before discharge discharge will make make the transition transition from the hospital hospital to another another facility facility much smoother and add to her peace of mind.

c. feelin feeling g of deep deep pressu pressure re d. pare parest sthe hesi sia a e. motor motor weakne weakness ss or paralysis paralysis 3. Infections Infections,, tissue necros necrosis is due to skin breakdo breakdown wn a. draina drainage ge thro through ugh casts casts b. sudden, sudden, unexplai unexplained ned rise rise in temperatu temperature re c. hot spot spot felt on on cast cast over over the the lesion lesion d. pressure pressure on the the groins, groins, knee, knee, ankle and metatar metatarsals sals

What to observe/remarks Spica Casts 1. Signs Signs of of respira respiratory tory distress distress 2. Signs Signs of of cast cast syndr syndrome ome a. Prolon Prolonged ged nausea nausea b. Repea Repeated ted vomiti vomiting ng c. Dist Disten enti tion on d. Vague Vague abdo abdomin minal al pain pain e. Absenc Absence e of bowel bowel soun sounds ds 3. Pressur Pressure e on the jaws, ears, face, face, clavicle area, area, anterior superior superior iliac crest, crest, groin, buttocks, and above the knee. 4. Urinary Urinary and and bowel bowel disturbanc disturbances es 5. Signs Signs of of plast plaster er cast cast a. itchiness/b itchiness/burni urning ng sensation sensation b. seve severe re pain pain c. rise rise in the the body body temper temperatu ature re d. dist distur urb b slee sleep p e. night night cries cries amon among g babies babies f. rest restle less ssne ness ss 6. Signs Signs of infection infections s and tissue tissue necro necrosis sis

Cast of the upper extremities 1. Signs Signs of impaired circulat circulation/c ion/circu irculation lation of fingers fingers such as a. cyanos cyanosis is of the the skin skin b. coldne coldness ss of the the skin skin c. loss loss of func functi tion on d. n um um bn bne ss ss e. pulselessn pulselessness ess of the the extre extremity mity f. s ev ev er ere pa pai n g. mark marked ed swel swelli ling ng 2. Nerve damage damage due to pressure pressure on on the nerve as it passes passes over bony prominences a. pain increasin increasing g in in persis persistence tence b. anes anesth thes esia ia c. feelin feeling g of deep deep press pressure ure d. pare parest sthe hesi sia a e. motor weakness weakness and paralysis paralysis 3. Infections Infections,, tissue necros necrosis is due to skin breakdo breakdown wn a. musty, musty, unpleasan unpleasantt odor over over the cast cast or edges edges of the cast cast b. drainage drainage thro through ugh cast cast or or windows windows c. sudden sudden unexpla unexplained ined rise rise in temperatu temperature re d. hot spot spot felt felt on on cast cast over over lesion lesion 4. Pressure on the elbows, axilla, axilla, wrists, metacarpals and and iliac crest crest

Turning Patient In Cast

Turning casted trunk and lower extremities must be done carefully. The Patient must be lifted and not rolled or dumped. Support should be provided to the encased part and the whole body.

Remarks 1. Avoid Avoid insertion insertions s of foreign foreign bodies bodies in cast cast 2. Avoid Avoid soil soiling ing of of the cast cast 3. Report Report signs signs of cracks cracks and weaknes weakness s of the cast 4. Maintain Maintain proper proper alignmen alignmentt of casted extrem extremity ity 5. Prope Properr suppor supportt of the cast cast

The first changing of the patients’ position is dependent on the condition of the cast and the body area involved. The first turning usually is to dry the posterior surface of the cast as well as to provide comfort and protect against respiratory complications. There There should be no attempt to turn the patient patient alone alone if one estimates estimates that one is physically unable without the patient’s assistance.

Cast of the Lower Extremities 1. Observe for impaired circulation as manifested by a. Cyanosis Cyanosis or bluish bluish discolorat discoloration ion of the the skin b. coldne coldness ss of of sensa sensatio tion n c. loss of of function function of of the affecte affected d extremi extremity ty d. n um um bn bne ss ss e. abse absenc nce e of puls pulse e f. mark marked ed swel swelli ling ng 2. Nerve damage due to pressure on the nerve as it passes over bony prominences a. increasin increasing g persiste persistent nt localize localized d pain pain b. numbne numbness ss in the the extre extremit mity y

Turning Patient in Hip Spica 1 - 1 ½  A. Supine to lateral  With 2-3 members working together the patient is gently pulled toward the unaffected side. Member remains on this side to give the patient the sense of security while the other member moves to the opposite side of the bed where the affected leg is to arrange the pillow along the entire length of the casted leg and back. 5

For traction to be effective, there must be also a pull in the OPPOSITE DIRECTION (COUNTER (COUNTER TRACTION) TRACTION) by using using the body or by elevating elevating part of the bed toward the traction.

B. Supine to prone

One member places his hands on the patient shoulder and hips, while the other support the thighs and extremities. The member of the opposite side pulls the shoulder and thighs as the patient is gently teased on his front. After the patient has been turned, observe the following points: a. Toes should should not not dips against against the the mattress mattress b. Body Body sectio section n of the cast cast plaste plasterr should should not press press the back, chest chest and abdomen c. Heels should should be maintained maintained in correct correct angulation angulations s and should be allowed allowed to extend beyond the mattress

PRINCIPLES OF TRACTION 1. MAINTAIN THE ESTABLISHED LINE OF PULL Weights should hang freely, not hitting the bed or resting on the floor. The position of  the weights should be rechecked if the level of the bed is altered.

AVOID 1. Bumping Bumping against against the weights weights when when walking walking near the bed. bed. 2. Allowing Allowing the the weight weights s to sway. Both movements can cause pain for the patient in traction. It is preferred that the weights should not hang over the patient, if necessary, the nurse should tape the weights so they will not fall on the patient.

Placing Patient in Bedpan In bowel or bladder elimination, the buttocks should be lower than the head and toward the breast. This can be achieved by:

a.

Elevating Elevating the head head part slightly slightly and placing placing a small pillow under under the back of  the patient.

2. PREVENT FRICTION Traction rope should rest in the groove of the pulley and move easily. The rope should not be frayed. The nurse should TIE securely knots in the traction rope and tape the rope ends. The rope knots should not lodge against the pulley because this will interfere with the line of pull. For the same reason, the nurse should ensure that the pulley, spreader bar and footplate do not rest against the foot of the bed.

b. Placing Placing a folded cloth on the posterior posterior aspect aspect of the bedpan. bedpan. This will absorb absorb moisture and this prevents spoiling the cast. Adult patients are usually placed in their good side first. The bedpan is placed so that the buttocks are on the posterior section of the bedpan. Pillows, blankets are then arranged to support the legs and back so that there will no be back flow. If patient can support himself by lifting with the aid of the overhead trapeze, the bedpan is slipped under the buttocks. Bladde Bladderr and bowel eliminat elimination ion in childr children en with with hip spica if placed placed in headboard frame is not difficult if the bedpan is kept constantly in the spica under the buttocks.

3. MAINTAIN COUNTER TRACTION To provide traction, the nurse must ensure that counter traction is maintained. If the weight of the patient body is to provide the counter traction, HIS BODY should not interfere with the DIRECTION OF PULL. For instance, the feet of the patient in BUCK traction should not touch the foot of the bed, or if the patient is in cervical traction, his head should not touch the head of the bed. 4. MAINTAIN CORRECT BODY ALIGNMENT The patient should have correct BODY alignment while lying centered in the bed. The nurse must ensure that the patient does not angle his body or lean off the side of the bed because the line of traction pull would then be changed or interrupted.

Instrument for Cast Removal 1. Cast cutter cutter (manu (manual al electric) electric) 2 . Sp re re ad ad er er 3. Trimm rimmin ing g knife knife 4. Band Bandag age e sciss scissor ors s 5. Plas Plaste terr sear sears s

Types of Traction 1. SKIN SKIN TRA TRACT CTIO ION N Skin traction is accomplished by weights that pull on tape, sponge rubber or plastic materials attached to the skin. TRACTION on the SKIN, TRANSMITS traction to the musculoskeletal structures. Forms 1. Buck Buck Exte Extens nsio ion n A form of skin traction in which the pull is exerted in one plane when partial or temporary immobilization is desirable. In Buck’s extension, strips of adhesive, moleskin or perforated flex foam are applied smoothly to each side of the affected extremity and attached to a spreader block at the foot.  The extremity is wrapped with elastic bandage to improve adherence of the tape to the skin and prevent slipping. A traction rope is attached to the

Points to Remember 1. After After the cast is removed, removed, support support the the part with with pillow pillow maintainin maintaining g the same position that existed in the cast. 2. Move the extremit extremity y gently gently. 3. Observe Observe the skin skin for any abras abrasions ions and and plaster plaster sore. sore. 4. Wash Wash skin with mild mild soap followe followed d by application application of oil or lanolin. lanolin. TRACTION Traction is the application of a pulling force to a part of the body. It is used to align and immobilize fractured bones, to relieve muscle spasms and to correct flexion contractures, deformities and dislocations. 6

spreader block then over the pulley, thence to a weight hung over the side of the bed. 2. Russell Russell’s ’s Tracti Traction on Russell traction when properly applied in good mechanical working efficiency is a comfortable device for the patient. The equipment required is not elaborated. A single section of  common Balkan frame can be attached to the bed with overhead bar directly above the injured limb. Four pulleys are used. These pulleys are arranged so that one is on the overhead bar at a level directly above the tubercle of the tibia of the fractured leg, another is attached to the footplate and two are attached to a crossbar at the foot of the bed and are placed at about the level of the mattress. A hammock which is used from the knee sling and traction tapes form the BASIS OF TRACTION.

fractures of the femur. It may be used with skin traction and other balanced suspension apparatus. Because upward traction is required for these fractures, the patient is placed on a fracture bed. Inasmuch as fracture occurs under varying circumstances and involves individuals of  different different ages, weights weights and body builds, NO TWO FRACTURES FRACTURES ARE ALIKE ALIKE and every fractured patient require individual treatment. By same token, traction may be modified in many ways to meet a variety variety of special special requirement requirements, s, as exempli exemplified fied by so called “BALANCED SUSPENSION TRACTION” and the “RUNNING TRACTION”. 3. MANUAL TRACTION Means the application of traction to a part of the body by the hands of the operator. When assisting with the application of traction or a cast, the nurse may be asked to apply a manual traction. This calls a firm smooth grip on the extremity and the avoidance of  sudden jerking movements.

Important points in the nursing care of patient in Russell Traction

BALANCED SUSPENSION Balanced suspension traction is used primarily for femoral fractures in adults by means of the Thomas splint with a Pearson attachment. Balanced suspension provides counter traction by its own system of weights and pulleys. Therefore when the patient lifts, the splint should also lift so that traction is maintained. The Thomas splint has a sling that supports the thigh. The nurse should check for irritation from the ring to the groin, inner thigh and ischium. The Pearson attachment is connected to the splint by the knee and supports the calf in a position parallel to and above the bed. A Steimann pin or Kirschner wire is inserted through the distal end of the femur or through the proximal or distal end of the tibia. The nurse teaches the patient and family that the traction’s main purpose is to provide sling, sling, this allows the leg to rest comfortably comfortably and provides freedom freedom to move without without disrupting traction pull or alignment. By using the overhead trapeze, the patient can lift the shoulders and upper body. This movement allows for change of linen from the top to the bottom of the bed. Similarly, the nurse can apply lotion to the patient’s back because the individual is not allowed to turn for back care.

1. The knee knee sling should should be smooth smooth and its edges edges must not cause cause pressure on the soft tissue over the peroneal nerve. 2. The heel heel of the foot foot in traction traction should should just just clear the the bed. Firm pillows should support the thigh and the calf along the entire length, leaving the heel free of the bed. 3. The popliteal popliteal space space must be watched watched for ridging ridging and skin denudation denudation.. Elevat Elevation ion of the backre backrest st is permit permitted ted and few diffic difficult ulties ies are are encountered in giving nursing care because the fractured leg is not at the mercy of the gravity and will not be altered in position. 4. Encourage Encourage active active dorsiflex dorsiflexion ion and plantar plantar flexion flexion of the feet. Important features

1. A piece of felt should should be inserted inserted between between the sling sling and the patient’s patient’s skin to prevent wrinkling of the sling under the popliteal area. This will assist in eliminating pressure sores that sometimes form at this point. 2. The heel heel should should clear the bed. bed. The ideal ideal position position for the the heels of the the patient in Russell traction is that of a person standing with his heels four inches apart. Abduction is to be avoided. 3. Two pillows pillows are usually usually placed under under the limb in traction. traction. One under the thigh to maintain the desired angle and the other under the calf  down and including the Achilles tendon.

UPPER EXTREMITY TRACTION Skin/Skeletal Sidearm traction is used to immobilized fracture of the humerus and may be applied either a skin or skeletal traction. There is outward pull on the upper arm and an upward pull on the forearm. For this reason, two separate set-ups of adhesive strips and elastic bone wraps wraps are needed. needed. In addition, addition, if skeletal skeletal traction is used, a Kirschnerw Kirschnerwire ire is usually usually inserted trough the olecranon. If the traction equipment is attached to the bed frame under the mattress, elevating the head of the bed will not disrupt the traction pull. However, if the frame is attached so that it moves when the bed position changes, the nurse should keep the head of the bed flat. Placing a folded blanket under the mattress near the traction frame can provide COUNTER  TRACTION.

2. SKELETAL TRACTION Method of traction used most frequently in the treatment of fracture of the femur, humerus and the tibia. The traction is applied directly to the bones by use of a metal pin or wire (Kirschnerwire, Steimann pin), inserted into and through a bone distal to the fracture. Usually the skin is made under local anesthesia. The pin or wire is sterilized with all the aseptic precaution of an operation. Following insertion of pins, the wound is covered with a small gauze squares. If the wire or pin extends back to the caliper, a cork placed over the end of the pin prevents the tearing of lines and other more serious accidents. Skeletal traction is applied by weights and pulleys as described for skin traction. The   Thomas Thomas Splint Splint with the Pearson Pearson attachment attachment is usually usually used with skeletal skeletal traction traction in 7

position relieves pressure from the lower back by decreasing the lumbar curve. It also provides counter traction. If traction increases pain to the back or legs, the nurse should report this to the physician.

Skeletal Overhead 90-90 traction, there is an upward pull on the upper arm, which is at a 90degree to the body. The elbow is flexed at a 90degree that the forearm is suspended in a sling and rest above and across the body. Weight is attached to the sling and to the Kirschner wire that is usually inserted through the olecranon. Because the arm is elevated, the patient should have less edema. This will be the case as long as the nurse ensures the patient keeps the involved hand supported in the sling and does not allow it to hang freely.

2. Pelv Pelvic ic slin sling g It is used continuously to stabilize and immobilize fractures of the pelvis. A large canvas sling attached to weights suspends the patient’s buttocks just off  the bed. The pelvic sling may also be used to compress the entire pelvis (by applying pressure along each side), if there is a pelvic ring separation. Compression is achieved when the physician repositions the rods from the attachment edges of the sling to grooves that are closer together toward the patient’s midline. Strict immobilization is required to maintain the traction force. The nurse should give back care every 4 hours by sliding her hands between the sling and the patient’s back. However, it is difficult to reach the buttocks for skin care and bathing and the patient may generally uncomfortable. For these reasons an external fixator may be inserted into each iliac crest to stabilize unstable fractures of the pelvis. External fixation can reduce the patient’s pain, allow for his early ambulation and facilitate nursing care.

CERVICAL TRACTION Skin Cervical Halter Skin traction is frequently used for patients with sprains or strains to the cervical spine and ruptured cervical discs. It is applied to the cervical spine by a halter with straps that go under the chin and around the head of the base of the skull. After the halter is placed, the spreader spreader bar and attached attached weights weights are connected. connected. The patient patient may have small pillow pillow under his head and should rest the back against the bed. Because cervical traction is usually ordered intermittently for a specified period, the nurse should teach the patient how to remove remove and reapply reapply it. This information information is especially especially important important for the patient because there may be the need to remove the halter if vomiting or choking occurs. Any severe headache or pain in the area of the traction should be reported.

NURSING PRIORITIES FOR PATIENTS IN TRACTION 1. Frequently Frequently inspection of the fracture dressing in the first 24hours 24hours after application. application. A bandage that appears appears loose when applied may in a very few hours cause cause constriction which if not relieved may lead to gangrene of the extremity. extremity. 2. Dress Dressing ing is applied applied in such a way as to leave leave the tips of the finger fingers s and toes exposed. exposed. Any cyanosis, cyanosis, loss of temperatu temperature, re, tingling sensation sensation in these parts should warn the nurse that the dressings are too tight. If the condition is caused by a single turn of the bandage, the turn may be divided with scissors, but it is usually advisable to notify the surgeon. 3. After the first 24 hours, hours, the fracture dressing should should be inspected inspected at least 3-4 times daily. daily. Evidences of constriction should be noted and pressure points checked – heel on the bedclothes resting on toes. 4. It is also important to ask ask the patient if there are are any painful painful areas. 5. If traction traction is in used, the apparatu apparatus s should should be checked checked to see the ropes ropes are in the wheel of the groove of the pulleys that the supporting apparatus is free of the pulleys, that the weights hang freely and that the patient has not slipped down in the bed. 6. The foot must be in natural natural positio position; n; rotation rotation outward outward or inwar inward d should should be reported. FOOT DROP is to be avoided and the patient’s foot must be maintained in the neutral neutral position position supported by appropria appropriate te orthopedic orthopedic devices. The rope sometimes frays; therefore, it too must be inspected at least daily. 7. Weigh Weights ts are are necess necessary ary to provid provide e consta constant nt force and may be ordinary ordinary metal metal traction weights or bags of water, hot or cold. It is especially important that the knots on the traction rope be tied securely. Enough weight is applied at first to overcome shortening tendency of the injured limb, but is gradually lessened as the fracture becomes more fixed. Weights should never be removed from a patient with fracture unless a life-threatening situation arises. Weight and pulley is applied to secure constant corrective extension. 8. WHEN THERE THERE IS PULL IN ONE ONE DIRECTION, DIRECTION, THERE THERE MUST MUST BE AN EQUAL PULL PULL IN THE OPPOSITE DIRECTION. Counter traction is supplied by either the patient’s body and

Skeletal Cervical Tong Skeletal traction to the cervical spine is used to immobilize and reduce fractures of the cervical spine that may injure the spinal cord. This type of traction is always continuous and is applied by Gardner, Vinki or crutchfield tongs inserted into the skull. There should be little bleeding after the first 24hours should be reported. If the tongs loosened or slip out, emergency measures include immobilizing the patient’s head with sandbags and notifying the physician immediately. immediately. With the skeletal traction to the cervical spine, there is a straight line of pull and the head of the bed may be elevated elevated 6 inches inches to provide provide counter counter traction. traction. An overhead overhead trapeze must not be used with either skin or skeletal traction because it is use could strain the individual’s neck. The physician determines the degree of stability of the spine and writes specific orders for the patient to turn. If turning is allowed, the nurse should use the “LOGROLLING”. Technique Technique that is, the patient is rolled as a unit so that the spine stays aligned and is not twisted. PELVIC TRACTION Types 1. Pelvic belt is primarily for relief of lower back pain to the lumbar spine whereas the pelvic sling is used to treat a pelvic f racture. Pelvic belt traction is applied to the lumbar spine by a pelvic belt with straps attached attached to weights. weights. It is used to reduce muscle spasms spasms and in the conservative conservative management of low back pain and herniated lumbar disc. This traction may be ordered for intermittent periods. However, patient’s cooperation is crucial to success. The nurse should place the patient in William’s position, in which both the hips and knees are flexed at a 30degree angle and the head of the bed is slightly elevated. This 8

friction against the bed (fracture of the upper extremity) or by elevating the foot of  the bed (fracture of the lower extremity). 9.

When traction frames are used, a trapeze trapeze may be suspended overhead within within easy reach of the patient. This apparatus is of great help in assisting the patient to move in bed and on and off the bedpans. NURSING CARE OF PATIENT IN TRACTION Nursing principles and implications  The purposes of traction regardless how it is achieved are 1. To reduce reduce and to immobi immobilize lize a fracture fracture 2. To lessen lessen or to eliminate eliminate muscle muscle spasm spasms s 3. To prevent prevent fracture fracture deform deformity ity

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