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Orthopedic Nursing: Fracture Types, Healing, and Management, Exams of Nursing

A comprehensive overview of orthopedic nursing concepts related to fractures. It covers various fracture types, including their causes, classifications, and treatment approaches. The document also delves into the healing process of fractures, discussing factors that influence healing outcomes and surgical interventions. Additionally, it explores nursing assessments and interventions for patients with traumatic limb injuries, emphasizing the importance of proper immobilization and wound care.

Typology: Exams

2024/2025

Available from 02/27/2025

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Orthopedic Nurse Certification Exam
Name 2 biological, 3 extrinsic, and 1 behavioral factor that can predispose a patient to a
fracture.✔✔Biological:
1) Age: bone structure becomes less dense/more susceptible to injury
2) Type of bone involved: some are better equipped to handle difference stresses and forces without
injury
Extrinsic:
1) Amount of force applied
2) Angle of force applied
3) Duration of force
Behavioral:
1) Participating in adrenalin-seeking activities such as skydiving, rock-climbing, motor cross
Describe nursing instructions that may be given to a patient in a cast.✔✔1) Cast should be kept dry.
2) Monitor the skin areas at the end of the cast.
3) Never stick anything into or under the cast to scratch or itch.
4) Alert medical care in case of tightness or increasing pain, numbness, color change, or temperature
change in areas of distal ends of cast.
5) Follow up if cast gets loose or cracks.
What is the basic anatomy of a long bone?✔✔Typically has two main components:
1) Diaphysis - makes up long shaft of bone. Outer portion is made of compact bone. Inner layer is made
of marrow.
2) Epiphyses - set at either end of long bone. Outer layer is compact bone and inner core is spongy bone.
Periosteum - membrane that lines both externally. - contains supply of nerve fibers, lymph, blood
vessels
Give examples of tapping fracture and penetrating fracture.✔✔1) Tapping - sustained from a small force
to a concentrated area. Bone will absorb this force - may or may not be mild soft tissue display of injury.
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Orthopedic Nurse Certification Exam

Name 2 biological, 3 extrinsic, and 1 behavioral factor that can predispose a patient to a fracture.✔✔Biological:

  1. Age: bone structure becomes less dense/more susceptible to injury
  2. Type of bone involved: some are better equipped to handle difference stresses and forces without injury Extrinsic:
  3. Amount of force applied
  4. Angle of force applied
  5. Duration of force Behavioral:
  6. Participating in adrenalin-seeking activities such as skydiving, rock-climbing, motor cross Describe nursing instructions that may be given to a patient in a cast.✔✔1) Cast should be kept dry.
  7. Monitor the skin areas at the end of the cast.
  8. Never stick anything into or under the cast to scratch or itch.
  9. Alert medical care in case of tightness or increasing pain, numbness, color change, or temperature change in areas of distal ends of cast.
  10. Follow up if cast gets loose or cracks. What is the basic anatomy of a long bone?✔✔Typically has two main components:
  11. Diaphysis - makes up long shaft of bone. Outer portion is made of compact bone. Inner layer is made of marrow.
  12. Epiphyses - set at either end of long bone. Outer layer is compact bone and inner core is spongy bone. Periosteum - membrane that lines both externally. - contains supply of nerve fibers, lymph, blood vessels Give examples of tapping fracture and penetrating fracture.✔✔1) Tapping - sustained from a small force to a concentrated area. Bone will absorb this force - may or may not be mild soft tissue display of injury.

EX: fracture of forearm when blocking a hit with a fist or bat; being kicked in lower leg

  1. Penetrating - caused by large amount of force on small area. Object of force is usually small and soft tissue involvement is minimal. EX: stab wound, gunshot wound Different from crush wound because object of force is much larger. List several factor that determine fracture-healing outcome.✔✔1) Skeletal maturity decreases healing.
  • Immature skeleton increases rate and success of healing.
  1. Single bone fracture has better prognosis than multi-bone fracture.
  2. Big displacement that affect surrounding tissues requires more healing time.
  3. Thoracic spine injury heals better than unstable lumbar/cervical spine injuries.
  4. Fracture of joint surfaces are more unstable/difficult to treat.
  5. Fracture with nearby unaffected support bone has good prognosis - acts as natural splint. Differentiate between linear, oblique, and transverse fractures.✔✔LINEAR: the fracture forms a straight line through the bone; doesn't tell if fracture line is angled or horizontal; a linear can be oblique or transverse OBLIQUE: fracture line that travels at an angle through the bone TRANSVERSE: break that travels in a horizontal line through the bone. Don't ever just say a fracture line is linear - differentiate with oblique or transverse. Describe/give examples of following bony injuries.✔✔1) CRUSH - caused by large stress on a small area; results in multiple break lines and severe soft tissue damage; EX: sledgehammer coming down on a finger or heavy suspended mass falling on foot or leg
  6. COMPRESSION - happens with large axial loading force; most often in vertebrae; EX: landing on feet or butt, fall from a moderate height
  1. SUBLUXATION: incomplete dislocation of joint from its normal position; still partial contact of joint surfaces; "partial dislocation" 3 injuries that can be sustained from a knee that hits the dashboard in a MVA.✔✔1) DASHBOARD FRACTURE: fracture of the rim of the acetabulum; caused by impact of femoral head
  2. PATELLAR FRACTURE: force of kneecap on dash
  3. POSTERIOR CRUCIATE LIGAMENT (PCL) TEAR 4 Main Components of describing and classifying a fracture✔✔1) LOCATION: distal, proximal, lateral, numbering (phalanges, tarsals, 3rd, 4th, etc.); can also describe the portion of the bone involved (diaphysis, epiphyses)
  4. DESCRIPTION OF FRACTURE LINE: comminuted, segmented, compressed, transverse
  5. DISPLACEMENT OF FRACTURE/ITS FRAGMENTS: non-displaced, angulated, distracted, simply displaced
  6. THE CONDITION OF SOFT TISSUE SURROUNDING THE BREAK: open or closed Define avulsion, comminuted, and greenstick fractures.✔✔AVULSION: break that displaces a portion of bone from its usual position COMMINUTED: describes fracture that results in greater than 2 bony fragments; usually describes crush injury GREENSTICK: result of a lesser force and doesn't cause a full-thickness break; only one side of bone is affected; not a fracture associated with displacement 4 substances that can be used surgically to enhance the healing of bone after a fracture.✔✔1) AUTOGENOUS BONE: bone graft taken from patient, usually form iliac crest; used in small bony defects, but high rate of complications
  1. ALLOGRAPHIC BONE: cadaver bone injected into a fracture site; beneficial in larger defects, but increased infection risk
  2. SYNTHETIC BONE: ceramics and sea coral; useful when injected into large fractures that have already been surgically stabilized
  3. BIOACTIVE CELLS AND PROTEIN: expensive, benefit for nonunion fractures 2 fractures only seen in the pelvic girdle✔✔1) STRADDLE FRACTURE: forcefully falling on an object in straddle position; coming down on gymnastic bar, bike seat, being bucked by a horse; it can tranversely fracture superior and inferior pubic rami and usually bilaterally
  4. DASHBOARD FRACTURE: when knee hits dashboard and the force progresses through the femur to the acetabulum Define impacted, torus, and occult fractures.✔✔1) IMPACTED: when smaller portion of bone is forced or compressed into large portion of bone; sometimes called a telescope fracture
  5. TORUS: buckle fracture, the bone appears bowed and may not even appear broken; describes a bone that buckles on the side of impact, but doesn't disrupt the other side of the bone; "incomplete fracture"
  6. OCCULT: fracture that cannot be immediately seen on x-ray; hidden or difficult to discern, usually seen via x-ray 2-4 weeks after original films/injury, after new bony formation Describe a mallet finger injury.✔✔Trauma to the end of an extended finger, caused by forceful flexion, avulses the extensor tendon from its attachment Most frequently happens with 3rd finger. Often described as a "jammed finger." TX: dorsal splint that holds DIP joint in full extension for 8 weeks Describe the Gustilo-Anderson classification system and what it's used for.✔✔Describes and rates the level of soft tissue injury in open fractures. There are 6 levels (I, II, III, IIIA, IIIB, IIIC). Type I is minimal soft tissue damage and no signs of crush mechanism. Level IIIC has high chance of amputation due to blood supply which is grossly damaged.

Describe basic nursing assessment of a traumatically injured limb.✔✔Initial assessment: visualize the limb - note the soft tissue injury, location, color of skin around it and how that compares distally Compare with the opposite and unaffected limb Note temperature, pulse, edema, neuro function (sensation and reflexes) proximal and distal to injury. Note signs of prior chronic disease - look for non-accident related ulceration, check for hair distribution, health of finger/toenails Describe devices used for internal fracture fixation.✔✔SCREWS: can be tapped or threaded, can be placed directly into bone or used with a plate (more common) PLATE: held in place by screws, used along diaphysis of bone WIRES AND PINS: good for small bone, usually stainless steels, can be pulled through skin for removal CORTICAL SCREWS: contain tight threading CANCELLOUS SCREWS: only partially threaded with wide thread MALLEOLAR SCREWS: partially threaded with narrow threading NAIL AND SLIDING SCREW-PLATE: used for hip replacements What should you tell your patient about cast care?✔✔1) Keep cast dry, especially at ends.

  1. Place plastic bag over cast for showering.
  2. Don't put things inside cast.
  3. To relieve itch, point hit dryer on low and cool into the end of it
  4. File rough edges of cast with emery board.
  5. Watch for cracks and loosening of cast.
  1. Elevate cast above heart and place ice pack on it to relieve pain and prevent swelling.
  2. Exercise body on either side of cats (wiggle fingers and toes). List diagnostic tests to evaluate a traumatic limb.✔✔1) TRANSCUTANEOUS OXYGEN PRESSURE DETERMINATION: best test for predicting outcome of amputation
  3. DOPPLER ULTRASOUND: visualizes tissue and blood flow to an extremity
  4. LASER DOPPLER FLOWMETRY: evaluates bloom flow through arteries and veins of extremities
  5. ANKLE-BRACHIAL INDEX (ABI): measures blood pressures of upper and lower extremities at rest and or after exercise
  6. ANGIOGRAM: not prognostic for amputation healing; better for artery reconstruction/repair Discuss nursing interventions for the amputee patient.✔✔Intradisciplinary approach and patient education is key. Discuss amputation vs limb salvage. Establish physical therapy. Connect patients with counselors and support groups for coping and self-image. Discuss pain management, stump care, s/s of complication, prosthetic options/devices. Want them to return to independent functioning with minimal pain. Discuss basics of stump care.✔✔Important for reduction of pain, infection, complications, and prosthetic fitting.
  • once daily washing (too much washing can dry skin and break it down)
  • Dry throughly and inspect prior to application of shrink wrap or prosthetics
  • If you can't see stump, have someone else know how to inspect.
  • Look for changes: sores, redness, warmth, changes in sensation
  • Daily massage to reduce adhesions and promote desensitization

Score of more than 7 means amputation probable. Differences between phantom limb pain, sensation, and telescoping phenomenon.✔✔PHANTOM LIMB PAIN: pain experienced by amputee in limb that has been amputated; up to 3 months after surgery; self- limiting and can be helped with medication, de-sensitization, electric stem, counseling, hypnosis, acupuncture, nerve block, etc. PHANTOM LIMB SENSATION: similar to PLP, but sensations are not painful (can be itching, tingling, temperature changes) TELESCOPING PHENOMENON: sensation of amputated limb being slowly retracted into stump; typically sensations of toes, thumbs, and index finger are last to "disappear" into stump Name and describe most common wrist fracture.✔✔Colles' fracture: break of distal radius

  • falling on outstretched hand, bracing against something on impact
  • can be seen with distal ulnar fracture, scaphoid fracture
  • can be angulated, displaced with multiple bony fragments
  • confirmed with X-ray but needs immobilization, w/wo closed reduction (sugar tong splint)
  • 1st 72 hours: ice, elevation, anti-inflam meds Tell pt to move shoulders and fingers. If swelling is down and fracture is stable, short-arm cast is applied for 4-6 weeks. Can cause carpal tunnel syndrome d/t proximity to median nerve. What is a scaphoid fracture?✔✔Most commonly broken carpal bone - at base of thumb, typically injured by falling on outstretched hand
  • tenderness in anatomical snuff box
  • needs to be immobilized with radial gutter splint or ventral splint with thumb extension
  • After immobilized, consider short cast with thumb spica
  • Can potentially tx with open reduction and screw placement
  • Slow healing fracture High risk of nonunion and avascular necrosis

Discuss 3 common amputation stump shrinkage methods and their purpose.✔✔Purpose of all is to reduce swelling post-amputation and prepare limb for prosthetic fitting. ACE BANDAGE:

  • Disadvantage: not great for shaping limb, application dependent on pt's ability and compliance SHRINKER SOCKS:
  • pre-made, easily removed, allow adequate pressure/shaping
  • Disadvantage: moderate cost, size limitations, need for frequent size changes and limb shrinks RIGID DRESSING:
  • cast placed on limb that can control edema, prosthetic shaping, protection, allow for early weight bearing, has good compliance Describe 3 common humerus fractures and their treatment.✔✔DIAPHYSEAL/SHAFT FRACTURE: common near middle of shaft, closed reduction common with cast or splint & sling in minor cases; open reduction - plate and screws usually placed ANATOMIC NECK FRACTURE: break at metaphysis of humerus; sling application and rehab program is treatment SURGICAL NECK FRACTURE: below anatomical neck or below metaphysis; severe angulation usually seen; TX: closed reduction and sling to maintain alignment What is the anatomical snuff box?✔✔Indented triangular compartment seen on dorsal lateral hand at base of thumb - distal radius makes up the base of it
  • significance: radial artery runs through here and a branch of the radial nerve; Damage to radial nerve usually happens if any part of this region is injured. Fracture most likely to occur if someone punches a wall.✔✔BOXER'S FRACTURE: fx of distal metacarpal head of 5th digit; can be seen in 4th digit
  • M1: local spread
  • M3: distant metastasis Define metastatic bone disease.✔✔Most common bone cancer seen
  • Usually later in life when primary cancers from lung, kidney, breasts, etc. spread
  • Usually seen in axial skeleton, proximal long bones
  • Anemia usually present
  • MRI, bone scan, plain films are used to diagnose
  • TX: surgical excision Define osteosarcoma.✔✔Malignant bone tumor, commonly seen in children,
  • primarily affects long bones
  • metastasis to lungs in common
  • May be palpable mass in area of pain
  • Suspected on x-ray, confirmed with biopsy, MRI, CT scan, and bone scans to rule out metastasis
  • TX: surgical removal and chemotherapy Define soft tissue sarcoma.✔✔Malignant tumors that form from connective tissue, fat, muscle fibers, and nerves.
  • Can be localized or metastasize.
  • Initial complaint is visible or palpable growing mass (diagnosis done by biopsy). What is little league elbow?✔✔Tendonitis of the elbow - forcefully pull of elbow tendons causes stress
  • Tendons can be pulled from bone w/ or w/o bony avulsion
  • C/o medial elbow pain or knot, locking, decreased ROM
  • Typically in younger athletes that forcefully/repetitively throw
  • TX: RICE, physical therapy, surgery in older athlete only What is metatarsalgia and what causes it?✔✔Pain in the ball of foot or distal metatarsals
  • Due to repetitive or high impact trauma (jumping, running on hard surfaces, poor footwear, or forcefully push-off
  • Commonly seen in endurance athletes, excessive body weight, poor shoes
  • Unchangeable risk factors: high foot arch, age, hammertoe, bunion, Morton's neuroma What is Osgood-Schlatter disease?✔✔Disorder thought to be due to repetitive minor injury to attachment site of patellar tendon on tibial tuberosity.
  • More common in males, noted at time of growth spurt
  • Will complain of pain/swelling at tibial tubercle
  • Can be common in sports with plant and pivot and directional changes Describe a posterior cruciate ligament (PCL) injury and the mechanisms of injury.✔✔- Can happen when the knee is forcefully hyperextended
  • OR when a flexed knee sustains an anterior force such as falling onto a bent knee
  • Diag. tests: posterior drawer test (when tibia displaces posteriorly), quadriceps active drawer test; MRI Describe shoulder dislocations✔✔- Most commonly dislocated joint in body
  • the humeral head is forcefully dislodged from the shoulder socket (anteriorly, posteriorly, inferiorly)
  • can injure surrounding ligaments
  • TX: relocate with closed reduction & then immobilize Different complications of orthopaedic operations.✔✔Cardio: operative ischemia, myocardial infarction (surgical)
  • opioids, oxygen, and inhalation agents can decrease stress on heart and increase oxygen available Pulmonary: aspiration is most common complication
  • TX: maintain airway, suction, give oxygen
  • Patient can avoid with preoperative fasting Hypovolemia: surgical blood loss
  • TX: locate bleeding site, control it, and give replacement as needed
  • Prevent by discontinuing pre-op aspirin intake & anti-inflame medications

What is the nursing role in three main types of anesthesia?✔✔- General: assist with intubation and its placement, help with vitals, return of mental status, reflexes, and check for anesthetic side effects

  • Regional: watch of s/s of allergic reaction by monitoring vitals and nervous system complaints or signs; assess return to function of anesthetized area
  • Conscious sedation + local: pt able to verbally respond to your monitoring of their pain & comfort; assess vitals Nursing assessment of blood less in ortho surgery✔✔- Assess pt for external signs of blood loss: checking bandages, vertigo, fatigue, anxious feelings
  • Look for s/s such as pain, weakness, tachypnea, low BP, high HR, diaphoresis
  • Order lab work
  • Stop the source of bleeding - pressure, cautery
  • Tranfuse if Hgb is less than 6 g/dL Diagnostic testing for pulmonary embolism✔✔- D-dimer (may give false positive in post-op setting)
  • V/Q (ventilation/perfusion) lung scan is gold standard
  • CT angiogram also used What are s/s of postoperative pulmonary embolism?✔✔- Sudden shortness of breath
  • Pain with inspiration
  • Chest pain
  • Cough
  • Tachycardia, decreased O2 sats _ Anxious
  • Rapid breathing Discuss acute compartment syndrome.✔✔- Considered a medical emergency
  • With an increased pressure gradient, vasculature structures within compartment collapse
  • Prevents delivery of oxygen and nutrients to muscle, nerve, bone (causing necrosis)
  • Causes: deeply bruised muscle, surgical complication
  • Injury usually happens proximal to affected compartment - cuts off circulation to all compartments distally
  • Exam: changes in skin color, sensation, temp, and pulses distal to trauma area, pain in passive range of motion of those muscles Define compartment syndrome.✔✔- Area of body accumulates increased amount of pressure in the muscle, which damages surrounding tissue
  • Compartment: anatomical site that contains muscle, arteries, veins, nerves, and bone surrounding the fascia (which is not very flexible - dangerous pressure levels)
  • Increased pressure cuts off nerve and vessel circulation to that muscle (can lead to muscle death)
  • 3 types:
  • Most common in leg How to manage acute compartment syndrome✔✔- Rapid recognition and action
  • Identify and fix cause of increased compartment pressure
  • External: remove devices that are cause; automatic BP cuffs, casts, braces, compression stockings, incorrect positioning
  • Keep limb at heart level, do NOT elevate
  • Burns victims with compartment syndrome: debridement recommended, fasciotomy may be needed if continues after external devices removed
  • Fasciotomy indicated if compartment pressure are greater than 30 mmHG and when there are clinical findings; delayed closure used after fasciotomy, last least 3 days after procedure Discuss nursing role in treatment and management of pulmonary embolism.✔✔- Ensure stability of all vitals, give oxygen if needed
  • Rest is important with frequent non-weight bearing ROM exercises in bed
  • Once stabilized, add in active weight bearing exercises
  • Maintain regular diet and hydration
  • Check frequent PTT/INR due to anticoagulant therapy
  • Educate patient on food/drug interactions of warfarin
  • Child-bearing age (need non-estrogenic contraceptive method) Discuss preoperative surgical considerations.✔✔- Get a thorough history of patient (emphasize medications, allergies - esp latex)
  • Assess current meds for anesthetic and pain med interactions (inform patient if any need to be discontinued prior to surgery)
  • TX: correct hypercalcemia like in osteoporosis What is gout and what are risk factors for it?✔✔- Over-production or under-secretion of uric acid
  • Leads to accumulation of uric acid within joint
  • S/s: pain, swelling, redness, warmth over affected joint
  • Over time, uric acid crystals can replace bone, can develop tophi and kidney disease
  • Risk factors: male gender, obesity, hyperlipidemia, excess alcohol consumption/red meat/sardines/liver consumption
  • TX: meds like diuretics, low-dose aspirin, B-complex vitamins, chemotherapy Prophylactic meds: allopurinol, colchicine, probenecid Acute attacks: indomethacin (can lead to GI inflammation - take with food What is the difference between osteomalacia and osteoporosis?✔✔Osteomalacia: decrease in mineral composition of bone, causing softening of bone; usually due to decreased vitamin D
  • Causes: dysfunctional vitamin D absorption, decreased sun exposure, meds such as seizure meds and fluoride
  • Can be reversed and treated Osteoporosis: decreased density and mass of bone, usually secondary to decreased calcium
  • Causes: age, lack of hormone & calcium, anti-inflams drugs
  • Can be stabilized but not reversed S/s of both: bone pain, muscle pain, fractures Define hypoparathyroidism.✔✔- Parathyroid gland secretes too little parathyroid hormone
  • Causes: genetic, alcoholism, injury to gland d/t surgery, GI surgeries that lead to malabsorption, liver/pancreas disease
  • Marked by hypocalcemia and how that affects the body
  • S/s: vague pain symptoms, anxiety, muscle rigidity, increased DTRs, muscle spasm/cramps, paresthesias, muscle twitching What is osteitis deformans?✔✔- Paget's disease
  • Metabolic disorder in which there is increased bone breakdown, and body compensates with rapid bone remodeling
  • Bones will appear larger but are in fact weaker; makes them high at risk for fracture and deformity
  • Areas most commonly affected: skull, spine, pelvis, legs
  • Treatment cannot reverse but can stabilize and support to reduce pain; PT/thermotherapy, stretching, meds
  • Maintenance meds: biphosphonate class, acute: anti-inflammatories and analgesics What are treatment options for osteoporosis?✔✔Goals: reduce number of fractures & pain, maintain skeletal strength and function TX:
  • regular weight bearing exercise
  • smoking cessation
  • discontinue caffeine and alcohol use
  • Increase dietary or supplemental calcium along with vitamin D
  • Meds: hormone replacement, calcitonin, biphosphanates (Fosamax, Actonel), fluoride, Evista When is maximum bone density and mass achieved?✔✔About 20 years of age How is osteoporosis diagnosed?✔✔- Incidental finding on X-ray that shows decreased bone density is usually how its first seen
  • Gold standard: DEXA scan, which measure bone mineral density (usually done near hip and spine, < 2.5 means osteoporosis)
  • Sometimes see a decrease in height and an increased thoracic kyphosis What are four important nutrients for bone health?✔✔Calcium:
  • Dairy products, dark leafy greens, vegetables Vitamin D:
  • helps with calcium absorption too
  • Foods that contain this tend to be high in fat: butter, eggs, cheese, fatty fish; SAFE EXPOSURE TO SUNLIGHT IS BEST