Type III compression injuries o Require operative treatment if ? Intraarticular damage is significant ? Radial shortening is severe o Fixation with multiple Kirschner wires or plates is often necessary, and cancellous bone grafting is frequently required to fill impacted areas. Often a combination of open and closed techniques is necessary to satisfactorily treat type III fractures. Type IV avulsion fractures o Are usually associated with radiocarpal fracture-dislocations and are therefore unstable o Often the avulsed fracture fragments are so small that they can be repaired only with suture.
o Secure reduction of the carpus to the distal radius can frequently be achieved only with Kirschner wires. Type V high-velocity fractures o Always unstable, frequently open, and difficult to treat o A combination of percutaneous pinning and external fixation is often necessary. Many of these fractures are so severely comminuted that open reduction is impossible. • CONTRAINDICATIONS Severe medical comorbidities that prevent surgery EQUIPMENT • • • Hand tray and hand table Small fragment and mini fragment set Technique-specific tray, as required ANATOMY • The distal radius and ulna may be divided into three distinct columns.
o The lateral and medial columns correspond to the scaphoid facet and lunate facets, respectively, of the distal radius. o The medial column is further divided into dorsomedial and volar medial parts. The ulnar column consists of the ulnar styloid and triangular fibrocartilage complex. ? ? Tears of the triangular fibrocartilage occur when the medial column of the distal radius, ulnar styloid, or both are intact. Distal radioulnar joint instability is associated with significant displacement of the ulnar styloid.
TECHNIQUES • • • Post-Procedure: Distraction Plate Fixation Post-Procedure: Volar Buttress Plate Fixation (Ellis) Post-Procedure: Volar Plating of Intraarticular Compression Injuries (Medoff) Post-Procedure: Distraction Plate Fixation POST-PROCEDURE CARE • • • • •
Immediately begin finger and other joint upper extremity exercises. If a splint was applied, it should be removed at 3 weeks. Percutaneous Kirschner wires should be removed at 6 weeks. Activities of daily living are allowed, but lifting should be restricted to 5 lb. Once union is achieved, remove the distraction plate and begin range-of-motion exercises. COMPLICATIONS • • • • • Median nerve injury Reflex sympathetic dystrophy Malunion, nonunion Tendon rupture Infection ANALYSIS OF RESULTS Studies have demonstrated a high percentage of good to excellent outcomes for distraction plate fixation.
OUTCOMES AND EVIDENCE Ruch et al reported good to excellent outcomes in 90% of 22 patients using this technique. Procedure: Distraction Plate Fixation Post-Procedure: Volar Buttress Plate Fixation (Ellis) POST-PROCEDURE CARE • Immobilize the wrist and forearm with a plaster sugar tong splint for 2 weeks. • • Next, use a removable ball-peen splint, permitting gentle active exercises two or three times a day for the next 2 weeks. All immobilization is removed at 4 weeks and progressive motion continued until union is solid. COMPLICATIONS • • • • •
Median nerve injury Reflex sympathetic dystrophy Malunion, nonunion Tendon rupture Infection ANALYSIS OF RESULTS The use of buttress plating for the treatment of distal radius fractures have proven to yield excellent results when surgical intervention occurs early and care is used to obtain anatomic reduction of the fracture. OUTCOMES AND EVIDENCE • • Smith et al: 100% union rate with 71% excellent, 18% good, and 11% fair results. Odumala et al: No difference in development of median nerve symptoms in patients treated with prophylactic carpal tunnel decompression compared with those without decompression.
Procedure: Volar Buttress Plate Fixation (Ellis) Post-Procedure: Volar Plating of Intraarticular Compression Injuries (Medoff) POST-PROCEDURE CARE • • • • Keep the extremity elevated at all times until postoperative swelling subsides. Beginning on the first postoperative day, remove the splint 2 to 3 times a day for rangeof- motion exercises. Allow clerical work at 2 weeks. Resistive loading is allowed when signs of radiographic union appear. COMPLICATIONS • • • • • Median nerve injury Reflex sympathetic dystrophy Malunion, nonunion Tendon rupture Infection
ANALYSIS OF RESULTS Studies have demonstrated a high percentage of good to excellent outcomes for the Medoff system. OUTCOMES AND EVIDENCE Medoff reported 20 good to excellent results in 21 patients with intraarticular comminuted distal radial fractures treated with the TriMed Wrist Fixation System (TriMed, Valencia, Calif. ). Procedure: Volar Plating of Intraarticular Compression Injuries (Medoff) PRE-OPERATIVE AND POST OPERATIVE CARE Care of Pre-operative Patient Nursing Diagnosis Knowledge deficit R/T pre-op care. Expected Outcome Patient/parent will verbalize understanding of pre- & post-op care.
Nursing Intervention 1. Implement pre- & post-op teaching program. 2. Document response. 1. Remove nail polish, make-up. 2. Bathe and shampoo the night before surgery. 3. Betadine scrub to surgical area. 4. Dress in hospital clothing after scrub. 1. NPO as ordered. 2. Sign at bedside; NPO sticker on patient. Potential aspiration R/T general No aspiration. anesthesia. 3. Re-emphasize importance of NPO to patient and parent; empty water pitcher and glass from bedside; check crib for bottles. 1. Explain procedures. 2. Provide time for patient/parent to ask questions, express fears or concerns. . Offer reassurance. Potential alteration of vital functions R/T surgery. Normal parameters for patient’s vital signs established. 1. Obtain baseline assessment of all systems ; N/V status within 8 hours pre-op. Potential infection R/T surgical procedure. Infection free post-op. Potential anxiety R/T surgery. Decreased anxiety. 2. Assess V. S. within 2 hours pre-op. Care of Post-operative Patient Nursing Diagnosis Knowledge deficit R/T post-operative care. Expected Outcome Patient and family will verbalize and demonstrate understanding of postoperative care.
Patient and family will cope effectively with surgical postoperative process. Nursing Intervention 1. Implement post-operative teaching program. 2. Document response. 1. Explain procedures. 2. Provide time for questions, expression of concerns and fears. 3. Offer reassurance. Potential anxiety R/T surgery, post-operative care. Potential respiratory Patient will not experience compromise R/T general respiratory compromise. anesthesia. 1. Assess breath sounds-HR/RR at least q shift. 2. Turn, cough and deep breathe q2 hrs. 3. Record vital signs. Patient will Alteration in comfort R/T verbalize/demonstrate relief surgery. rom pain. Potential neurovascular Patient will not experience compromise R/T surgical neurovascular compromise procedure. . 1. Assess for pain and medicate per protocol. 2. Reposition for comfort as ordered/prn. 1. Assess surgical site or affected extremity for color, capillary refill, sensation, temperature, pulses and active/passive ROM as ordered. 2. Document neurovascular status as ordered. 3. Report any neurovascular compromise to M. D. 4. Position extremity with elevation if ordered. 5. Apply ice or heat as ordered. Potential alteration in level of consciousness R/T anesthesia.
Patient will exhibit appropriate LOC. 1. Assess LOC q shift. 1. Monitor I/O q hour with IV or foley. 2. Begin ice chips or clear liquids slowly as ordered. 3. Maintain IV fluids as ordered. 4. Call M. D. for catheter order if unable to void after surgery. 5. Assess GU status q shift. Potential alteration in bowel elimination R/T Patient will have BM by postanesthesia and postoperative day #4. operative immobilization Potential alteration in skin integrity R/T immobility. Patient will not experience skin breakdown. 1. Mobilize as ordered. 2. Administer laxative of choice or suppository for no BM after 3 days. . Assess GI status q shift. 1. Assess skin q shift. 2. Provide daily nursing care. Potential alteration in fluid balance R/T surgery. Patient will have adequate fluid intake and urine output. Medical Diagnoses: Impaired Physical Mobility, Acute pain, secondary to fractured left femur, ORIF surgery, Musculosketeal impairment Assessme Nursing Client Nursing *I Evaluation nt DX/Clinical Goals/Desired Interventions/Actions/ Goals Interventio Problem Outcomes/Object Orders and Rationale ns ives Subjectiv Problem: Long Term: * Apply any ordered X Goal met.
Continue e brace before Pt was intervention Impaired Pt will be able to mobilizing the client. able to s as listed. Pt Physical ambulate around ambulate Encourage screams Mobility the nurses’ Rationale: around pt to when station 2X by “Brace support and the continue the staff discharge. stablilize a body part, nurses’ use of attempts allowing increased station by braces and to move mobility. ” (Ackley ; discharge. assistive the left Ladwig, 2008, p 552). Pt was devices lower able to after extremity *Increase complete discharge Pt demonstr ates difficulty with any movemen t of the left lower extremity . independence in ADLs Rationale: “Providing unnecessary assistance with transfers and activities may promote dependence and a loss of mobility. ” (Ackley ; Ladwig, 2008, p 552). *Obtain any assistive devices needed for activity. Rationale: “Assistive devices can help increase mobility. ” (Ackley ; Ladwig, 2008, p 552). R/T: Short Term: Objective Pt states that his pain level is a 9 on a 10 point pain rating scale. is activity until he more than feels twice. Pt comfortable did not c/o. complain Encourage of any the pt to pain or continue his discomfort independen upon ce in ADLs ambulatio and c/o n. unnecessary assistance. Pt states “I feel like I’m finally getting back to my old self. ” X Goal met. Pt able to fully complete passive range of motion exercises with assistance from the staff by the end of this shift. Pt did not complain of any pain associated with exercise session.
Continue intervention s as listed. Continue to assess pain using the 10 point pain scale q4 hrs or PRN. Continue to provide pain control and treat as needed. *Assess the pt’s pain Acute Pt will perform by using the 10 point pain, passive range of pain rating scale q4 hrs secondary motion exercises or PRN. to by the end of this fractured shift. Rationale: left femur “Single- item ratings of Pt pain intensity are valid grimaces ORIF and reliable as during surgery measures of pain any kind intensity. of motion Anxiety or “The client’s report of movemen Musculosk pain is the single most t of his eteal reliable indicator of left lower impairmen pain. ” extremity t (Ackley ; Ladwig, 2008, p. 604-605). AEB Pt’s ORIF *Before activity, treat Grimacing surgery pain. during movement Rationale: or activity “Pain limits mobility and is often Pt complaints about pain and discomfort Pt pain rating of 9 out of 10. Surgery that is 2 days postop exacerbated by movement. ” (Ackley ; Ladwig, 2008, p 552).