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37: Care of the Orthopedic Surgical Patient

Abstract

Orthopedic surgery treats diseases and injuries of the musculoskeletal system, primarily with manipulative and operative methods. Perianesthesia nursing care of the orthopedic patient can be challenging and rigorous. In this highly technologic age, the care needed by the orthopedic patient requires both vigilant general perianesthesia care, a sound knowledge of orthopedic surgical procedures, and correct patient positioning. Familiarity with orthopedic procedures and the anticipated patient outcomes helps the perianesthesia nurse provide high-quality postoperative care for the orthopedic patient. The perianesthesia nurse must possess astute nursing observation and assessment skills to prevent untoward events in this patient population. The psychosocial challenges are generally more evident within this group because, more commonly, the goal of the surgery is focused on restoring mobility and relieving pain and disability. The nurse must be sensitive to heightened anxieties and empathetic to individual needs.

Keywords

arm; compartment syndrome; complications; drain care; DVT; ERAS; fat embolism; femoral; forearm; hip; immobilization devices; infection; intraoperative; knee; limb; pain; PE; perianesthesia; positioning; postoperative; preoperative; range-of-motion; shock; shoulder; spine; urinary retention; wound care

Orthopedics (or orthopaedics) is a specialty of health care concerned with the prevention, diagnosis, and correction of disorders of the musculoskeletal system. Orthopedic surgery is concerned with the treatment of diseases and injuries of the musculoskeletal system, primarily with manipulative and operative methods. Perianesthesia nursing care of the orthopedic patient can be challenging and rigorous. In this highly technological age, the care needed by the orthopedic patient requires both vigilant general perianesthesia care, a sound knowledge of orthopedic surgical procedures, and positioning associated with the procedure. Familiarity with orthopedic procedures and the anticipated patient outcomes helps the perianesthesia nurse provide high-quality postoperative care for the orthopedic patient. The perianesthesia nurse must possess astute nursing observation and assessment skills to prevent untoward events in this patient population. The psychosocial challenges are generally more evident within this group because, more commonly, the goal of the surgery is focused on restoring mobility and relieving pain and disability. The nurse must be sensitive to heightened anxieties and empathetic to individual needs.

Definitions

Abduction Movement away from the midline.

Adduction Movement toward the midline.

Arthrodesis Surgical fixation or fusion of a joint.

Arthroplasty Reconstruction of joints for restoration of motion and stability.

Arthroscopy Surgical examination of the interior of a joint with the insertion of an optic device (arthroscope) capable of providing an external view of an internal joint area.

Arthrotomy Surgical exploration of a joint.

Articulation The connection of bones at the joint.

Cineplastic (Kineplastic) Amputation An amputation that includes a skin flap built into a muscle; a portion of the prosthetic mechanism is activated by the muscle.

Disarticulation Amputation at a joint.

Diskectomy (Discectomy) Removal of herniated or extruded fragments of an intervertebral disk.

External Fixators Equipment used in the management of open fractures with soft tissue damage (provides stabilization for the fracture while it permits treatment of soft tissue damage).

Extension Movement to increase the joint angle; straightening or bending backward.

Fasciotomy Surgical separation of the fascia (a fibrous membrane that covers, supports, or separates the muscles) for relief of muscle constriction or reduction of fascia contracture.

Flexion Bending or decreasing the joint angle.

Hemiarthroplasty Replacement and resurfacing of the femoral head with a prosthesis.

Internal Fixation The stabilization of a reduced fracture with the use of metal screws, plates, nails, and pins.

Joint Replacement The substitution of joint surfaces with metal or plastic materials.

Laminectomy Removal of the lamina for exposure of the neural elements in the spinal canal or relief of constriction.

Lordosis Abnormal anterior convexity of the lower part of the back.

Meniscectomy Surgical removal of the damaged knee joint fibrocartilage.

Open Reduction The reduction and alignment of a fracture through surgical dissection and exposure of the fracture.

Osteoporosis Diminished amount of calcium in the bone.

Osteotomy Surgical cutting of the bone.

Paresthesia Numbness and a tingling sensation.

Scoliosis Lateral curvature of the spine.

Sequestrectomy Surgical removal of necrotic bone.

Spinal Fusion A fusion of the cervical, thoracic, or lumbar region of the spine with an iliac or other bone graft that primarily fuses the laminae and sometimes the joints, most often through the posterior approach.

Syme Amputation Modified ankle disarticulation (below-the-ankle) amputation of the foot.

General perianesthesia care including preoperative considerations

Nursing care for the orthopedic patient may begin weeks to months before surgery. Many orthopedic surgeons may have their patients begin physical therapy sessions and exercise training weeks before the surgical procedure to build the patient’s strength and knowledge regarding postoperative exercises. Additionally, for elective orthopedic cases, often patient selection and lifestyle management is part of presurgery planning. Most patients are required to complete preadmission testing and some patients may attend classes to learn postoperative care considerations which will help produce postoperative success. This is particularly important for patients undergoing a joint arthroplasty where extensive patient education may include mobility, home care, pain management, and prevention of surgical site infections.

Another preoperative requirement may consist of clearance from other specialists such as cardiologists or pulmonologists. The type of surgery, medical history, nursing assessment, surgeon preference, and anesthesia guidelines typically dictate the screening procedures required for surgery. Patients who are on particular medications, such as blood thinners, are often instructed on medication management before surgery. Prevention of surgical site infections is particularly important with joint replacement surgeries. Most often, patients are given instructions on proper cleansing of the surgical site at home as well as general grooming guidelines. At times, patients are given antimicrobial cleaning agents to use at home and, of course, the hospital follows up with standard practices for skin and surgical site preparation. Of course, there are many orthopedic surgeries that require urgent care and preoperative preparation is not possible.

Day-of-surgery nursing care is very prescriptive as well. Preoperatively, patients are prepared for surgery with proper medication management including initiation of new medications to prepare for surgery and the postoperative period. These medications often include antibiotics and may include medications to manage pain. Nursing interventions also include following The Joint Commission’s Universal Protocol standards to prevent the wrong-site surgery. In the preoperative area, this includes the preprocedure verification process consisting of taking all steps to prevent a wrong-site surgery. Correct consent processes as well as site-marking are included.1 Orthopedic surgeries often involve laterality and other specific criteria; therefore, verification precautions are of utmost importance.

Many orthopedic surgeons use a multimodal approach to pain, which often begins preoperatively. Enhanced recovery after surgery (ERAS) pathways are continuously emerging and can provide benefits to the orthopedic and spinal surgery patient. An ERAS approach to surgery helps patients be more prepared and recover faster through regional anesthesia, multimodal pain control, education, and glycemic control. Reduced complications, decreased length of stay, decreased postoperative pain, and improved functional recovery are all benefits to some, if not all, ERAS implementation processes.² Regional anesthesia is one ERAS component and may be done in the preoperative area, based on surgeon and anesthesia preference. Pain is a very common occurrence after orthopedic surgery and therefore, peripheral nerve blocks can be beneficial to the perianesthesia nurse managing the patient’s postoperative pain. See Chapter 25 for regional anesthesia information.

In additional to preprocedural regional anesthesia, local anesthesia is also often used in some orthopedic procedures. Liposomal bupivacaine is one local anesthetic that is gaining popularity among orthopedic surgeons to improve the multimodal approach to pain management. However, Jain et al. found that a periarticular injection of liposomal bupivacaine was not superior to intra-articular or periarticular injection of bupivacaine/morphine for postoperative pain control.³

After surgery is complete and the patient is taken to the postanesthesia care unit (PACU), new concerns and assessment become the focus, as detailed in this chapter. This management includes but is not limited to positioning, neurovascular assessment, care of immobilization devices, wound care, range-of-motion exercises, and observation for complications. Pain management is another focus that is discussed at the end of this chapter.

Positioning

After the initial assessment of the patient is complete and the airway is stable, attention is turned to positioning. Proper body alignment is important for orthopedic patients and requires a sound knowledge of operative procedure and body mechanics. Individual surgeons typically have specific preferences for positioning intraoperatively and postoperatively, but general guidelines apply to all patients. The goal is optimal comfort and safety for the operated limb or area. The upper extremities are generally held close to the body, and elevation should be achieved without undue pressure on the elbow or shoulder. The lower extremities are typically placed in a neutral position with support provided for the entire limb, placing heels off the bed.

Postoperatively, elevation of operative limbs is usually indicated to increase venous return, reduce swelling, and promote comfort. In the elevation of a hand or arm, the hand must be higher than the heart with no pressure on the elbow. This position can be achieved with the use of pillows, a sling, or other related device. Shoulder immobilization can be accomplished with a sling, shoulder immobilizer, or type of splint (Fig. 37.1). Splints are often used for various degrees of abduction and may be applied for rotator cuff repairs, involved humerus fracture repairs, and postoperative shoulder or arm surgery where shoulder position and elbow flexion control are desired. If a sling is used, the patient is instructed to keep the arm close to the chest with the wrist and elbow supported. All shoulder immobilizers require special care and padding to areas where skin contacts skin.

Front view of patient wearing shoulder sling. — Fig. 37.1 Shoulder immobilizer. (From Roberts and Hedges’ Clinical Procedures in Emergency Medicine and Acute Care. Chudnofsky, Carl R.; Chudnofsky, Arielle S. Published January 1, 2019. Pages 1027–1056.e1.)

Lower extremity elevation is most effective if the toes are above the heart. If the limb is not in an immobilization device, it is typically in an extended position and elevated. This position is achieved by elevating the foot of the bed rather than with the use of pillows. The entire length of the limb should be supported if pillows are used, with heels kept off the bed. Hip surgeries may take on different positions depending on the surgical intervention, trauma related, and approach. More detailed discussion regarding positioning with certain procedures is discussed later in this chapter.

Patients who undergo spinal surgery are typically in a supine position postoperatively with a neutral body alignment.⁴ Specific postoperative orders may be given related to the patient’s ability to ambulate or raise the head of the bed. Log rolling and minimal time for a position that is not supine may be ordered.

The perianesthesia nurse should also be familiar with various types of orthopedic equipment that may be used that can affect positioning in the postoperative period. At times, although rare, patients with total knee replacement and those with more extensive knee arthrotomy are placed in a continuous passive motion (CPM) machine. The purpose of CPM is to enhance the healing process by providing CPM to the joint, thus increasing circulation and movement. However, evidence shows that the inconvenience and expense may not outweigh the benefit of CPM.⁵ See further discussion in the section Perianesthesia Care After Knee Surgery.

Traction may also be used with various patients to immobilize and align a specific area. The perianesthesia nurse is not usually involved in setting up the traction but should be aware of some basic principles for maintenance: (1) the traction must be continuous, (2) the patient is centered in bed in good alignment to maintain the line of pull in line with the long bone, (3) weights should hang freely and not rest on the floor or bed, and (4) the pulley ropes should be in alignment and free of knots. One type of traction is depicted in Fig. 37.2.

Side close-up of a patient lying supine on a bed with right leg broken and supported by ropes and pulleys. Weights are suspended on the foot side of patient. — Fig. 37.2 Balanced suspension traction. Most often used for fractures of the femur, hip, and lower leg. (From Harding MM, Kwong J, Roberts D, et al. Lewis’s Medical-Surgical Nursing: Assessment and Management of Clinical Problems. 11th ed. Elsevier; 2020. p. 1453, Fig. 62.10.)

Neurovascular Assessment

Critical to the care of the patient for orthopedic surgery is assessment of the neurovascular status, especially of the operative limb if applicable. In spinal surgeries, general neurovascular status is recommended. Nerve compression or alteration in blood flow to the extremity requires immediate intervention. In the initial postoperative phase, assessment is recommended every 15 minutes for some surgeries (spinal fusions) and hourly for others (arthroplasties). These frequent assessments are recommended for initially but become less frequent as the postoperative phase is extended. Baseline neurovascular indicators should be noted from preoperative assessment and from the admission nursing assessment to the PACU. These indicators can be used to establish any deleterious effects from the surgery and to avoid the masking of potential complications. Both the affected and unaffected limbs are assessed.4

The hallmarks of neurovascular changes from constriction and circulatory embarrassment are pain, discoloration (skin that is pale or bluish), decreased mobility, coldness, diminished or absent pulses, altered capillary refilling, decreased sensation, and swelling (Box 37.1). Pain is common with patients for orthopedic surgery, and the approach to treatment must be individualized. Pain unrelieved with conventional methods, such as elevation, repositioning, and pharmacologic management, must be assessed further. Color indicates circulatory compromise.⁴ Cyanosis suggests venous obstruction; pallor suggests arterial obstruction. Mobility is assessed by determining the range of motion of the fingers or toes and strongly indicates neural compromise. Fingers are flexed, extended, spread, and wiggled. Toes should be dorsiflexed, plantarflexed, and wiggled. An inability to move the fingers or toes, pain on extension of the hand or foot, or coldness of the extremity is indicative of ischemia. Sensation is described as normal, hypesthetic (dulled), paresthetic, or anesthetic. Alteration in sensation suggests nerve compression or circulatory compromise. Limb perfusion is further assessed with the presence of peripheral pulses and capillary refilling. Capillary refilling is assessed with compression of the nail bed, which causes blanching; when the compression is released, color briskly returns. Compromise delays the filling time. With the development of pulse oximetry, a more reliable method of perfusion assessment is available. With placement of the oximeter sensor on a finger or toe of the affected limb, the pulsation is sensed and oxygen saturation is displayed. This method is more reflective of perfusion than capillary refilling and is valuable when pulses cannot be assessed because of the presence of a cast or dressing.

Box 37.1

Integrated Bedside Assessment of Extremity

Assessment of Neurovascular Status

• Pain
• Edema
• Color
• Capillary refill
• Pulses
• Temperature
• Sensation
• Motion

From Cannon S. Orthopedics and podiatry. In: Schick L, Windle PE, eds. Perianesthesia nursing core curriculum: preprocedure, Phase I and Phase II PACU nursing. 4th ed. Elsevier: St. Louis, MO; 2021. p. 698.

Care of Immobilization Devices (Cast Care)

Immediate postoperative assessment of the patient after orthopedic surgery should include the type of immobilization device applied. The soft knee immobilizer should be checked for proper placement and closure, and the surgical dressing should be checked for drainage. For care that involves traction, refer to the previous section in this chapter on positioning.

The cast is a rigid immobilization device molded to the contours of the part to which it is applied. The cast has a dual purpose: immobilization in a specific position and provision of uniform pressure on the encased soft tissue. The cast should be inspected for visibility of fingers and toes, enabling neurovascular assessment. If the cast is bivalved, the edges should be inspected for roughness to avoid discomfort and potential skin breakdown. When the patient arrives in the PACU, the cast may still be wet, and, if so, special care must be taken to prevent indentations (such as using the palms of the hand to avoid pressure from fingertips). The cast should be supported on a pillow, and hard flat surfaces should be avoided. Improper handling and flat surfaces can cause indentations that can lead to the development of pressure sores. More frequently, a fiberglass cast is applied with quicker drying properties, but the same general principles still apply.4 In general, a full cast may not be placed on a patient where wound drainage is expected (a temporary splint or cast would be used), but any drainage noted on the cast should be circled, and the time should be noted. This documentation can provide a guide for postoperative blood and fluid loss and can alert the nurse if the drainage appears to be excessive.

Wound and Drain Care

All surgical dressings should be checked for drainage and closure. Orthopedic wounds tend to ooze and may bleed more than other surgical wounds, and documentation on the dressing is recommended to note the amount of drainage. Patients with orthopedic surgery are highly susceptible to infection; therefore, strict asepsis is required when changing dressings or handling drains. Many surgeons prefer that the dressing is not removed or changed until a specified amount of time. Specialty dressings may be used and are typically determined by surgeon preference. Drains may be placed in the wound to minimize blood accumulation and the possibility of infection. If a drain is present, it should be checked to ensure that it is activated. Drains should be checked every 1 or 2 hours to maintain a proper suction, and the output should be recorded on the intake and output records.

Orthopedic surgeries can be associated with a substantial amount of blood loss, especially spinal surgeries and joint arthroplasties. Additionally, a patient with total joint replacement may commonly have a large amount of blood loss in the immediate postoperative period. Blood loss can be significant with all major orthopedic surgeries, but with advances in technology and the implementation of minimally invasive techniques, attempts are being made to keep blood loss at a minimum. Autotransfusion may be used in the form of cell saver in the operating room (OR). Autotransfusion is accomplished with the use of self-contained disposable systems designed for easy setup and safe use. The retrieval of this blood for reinfusion (autotransfusion), in addition to new medical management, has substantially reduced the need for homologous or autologous transfusions. Antifibrinolytic agents such as tranexamic acid may be used in orthopedic cases to prevent surgical blood loss. This is given intravenously or topically and is most useful in complex cases with longer OR times. Although some contradictions exist, this therapy seems to reduce blood loss and minimize the risk of a postop blood transfusion.6 Regardless of blood-conserving techniques used, if the patient experiences excessive amounts of blood loss in the PACU, surgeon notification is recommended.

Range-of-Motion Exercises

Range-of-motion exercises can be initiated in the PACU as soon as the patient is alert and cooperative. Flexion, extension, and rotation of joints distal to the operative area assist in stimulating circulation and strengthening muscles. Quad-tightening exercises, if permitted by the physician, may also be helpful. Prevention of venous stasis decreases the incidence rate of thromboembolism, and early movement of joints promotes healing and stabilization.

Observation for Complications

Postoperative complications for the patient after orthopedic surgery include deep vein thrombosis (DVT), pulmonary embolism (PE), fat embolism syndrome, compartment syndrome, shock, and urinary retention.

Deep Vein Thrombosis

Prevention of DVT is a major concern for patients undergoing orthopedic surgery, especially total joint replacement.7 Other contributing risk factors include age, previous history of DVT or PE, malignancy, smoking, estrogen or current pregnancy, vein disease, trauma, sepsis, diabetes mellitus, obesity, and clotting disorders.⁸^,⁹ Thrombosis is the formation of a blood clot associated with three conditions outlined by Virchow in 1846: venous stasis, altered clotting mechanism, and altered vessel wall integrity.⁸ In reports of total hip arthroplasty before routine prophylaxis, venous thrombosis occurred after total hip replacement in 40% to 80% of patients, and fatal pulmonary emboli occurred in 2%.⁷ Immobilization impairs the leg muscle action needed to move the blood sufficiently, and the surgical procedure injures vessel walls that activate and alter clotting mechanisms, placing the orthopedic patient at high risk of the formation of a thrombus within the deep vein. An inflammation process begins within the vessel wall and leads to DVT, and the patient usually has pain and tenderness. Signs include swelling and sometimes localized redness. Palpation of the calf reveals firmness or tension of the muscle. DVT can be difficult to diagnose. Diagnostic tests such as venography, magnetic resonance imaging, or Doppler ultrasound may be indicated.

Prevention of DVT for postoperative orthopedic patients includes providing adequate hydration, early mobility, range-of-motion exercises, mechanical prophylaxis, and pharmacologic prophylaxis when necessary. Mechanical prophylaxis may include external compression devices such as sequential compression devices that enhance venous flow. Surgeon’s preference typically dictates the choice of postoperative anticoagulant therapy when needed, and rehabilitation and mobility beginning as soon as possible postoperatively will also help to prevent venous complications, likely the most important measure.

The ideal thromboembolic prophylaxis regimen for prevention of DVT and PE varies but is not short of recommendations. Some hospitals use a detailed DVT prophylaxis screening tool or protocol to assess each patient’s individual need for anticoagulation therapy and thromboprophylaxis. Additionally, all health care facilities accredited by The Joint Commission must comply with National Patient Safety Goal 03.05.01 to “reduce the likelihood of patient harm associated with the use of anticoagulant therapy.”¹

Pulmonary Embolism

The most serious sequela of DVT is a PE, although it is becoming more uncommon in some orthopedic cases, especially when early ambulation is possible and initiated. Symptoms may be few if the clot is small; with larger clots, however, complications may include—with increasing severity—anxiety, dyspnea, tachypnea, hemoptysis, substernal pain, stabbing pleuritic pain, tachycardia, cough, signs and symptoms of cerebral ischemia, fever, elevated sedimentation rate, shock, and sudden death. Immediate nursing care involves administration of oxygen and preparation for possible diagnostic tests (such as chest x-ray) as well as preparation for possible intubation. Medications usually include heparin-bolus doses with continuous infusion or other antithrombolytic agents. Perianesthesia nurses must be vigilant to assess all postop orthopedic patients for signs and symptoms of DVT and PE.