Orthopedics Surgery Notes (PDF)

Orthopedics Surgery Anatomy - Muscles - are tissues that cover bones and provide movement to the skeletal system. - Ligaments - are bands of connective tissue that hold bone to bone and provide joint stability. - Tendons - form at the end of muscles and transmit forces to bone or cart...

Orthopedics Surgery Anatomy - Muscles - are tissues that cover bones and provide movement to the skeletal system. - Ligaments - are bands of connective tissue that hold bone to bone and provide joint stability. - Tendons - form at the end of muscles and transmit forces to bone or cartilage. - Cartilage - is an elastic tissue layer at the end of bones that provide support and stability. - Joints - are articulations of bones that connect one to another. Bone Tissue / Blood Suppy There are two types of bone tissue: 1. Cortical bone - the hard bone that forms the outer shell and supports tissue. 2. Cancellous bone - soft and spongy tissue located at the iliac crest, tibia, sternum, and ends of long bones. It contains the red bone marrow. Long bones - consist of a shaft (diaphysis) - two ends (epiphysis) and consist of cancellous bone. - The epiphyseal plate is a line of cartilage that separates the epiphysis from the diaphysis which is present until skeletal maturity. - Periosteum (peri - covering, osteum - bone) is a layer of connective tissue that covers all bone. If a bone is being repaired for a fracture, the periosteal layer must be stripped away using instruments called periosteal elevators. - The Synovial Membrane covers all articulating surfaces of joints. Important Sequence of instruments to fixate a bone: 1. Hold the bone with the bone holder to stabilize the fracture 2. Drill the bone with the drill (to make a hole for the screw) 3. Tap the hole (create a stable canal for the screw) 4. Measure the depth with depth gauge (determines screw length) 5. Screw with screwdriver (to insert screw in bone) A Minor count is completed for all orthopedic cases. Initial (minor) → Closing (minor) → Final (minor) Bone Grafts (types and how they are harvested)  - Purpose of a bone graft is to fill cavities after removal of large amounts of bone resulting in instability, fill bony defects, and promote union of fractures at the time of open reduction. Allograft – bone obtained from a tissue bank Autografts – harvested from patient’s own bone, usually the iliac crest which contains cortical and cancellous bone. Cancellous bone is spongy and vascular and is harvested from the anterior/posterior crest of the Ilium. Cancellous bone will grow into the host bones. Osteotome and mallet Cortical bone grafts are hard dense bone which come from the iliac crest, ilium, tibia, or ribs. They generally need to be stabilized with ortho hardware (wire/screws) as these grafts will not fuse on their own. Bone currette Instruments (identification and purpose) Kerrison Rongeur - grasp and resect lamina bone Pituitary Rongeur - grasping and removing intervertebral disc Equipment (use and nursing consideration) 1. Powered Surgical Instruments (Drills) - The scrub and circulating nurse must ensure these drills are not resting on the patient/drapes. - If the safety is not on, there is a risk the drill will activate and can injure the surgical team or patient. Accidental activation of the drill can cause a ‘strike through,’ meaning a hole or break in sterile drapes or set up, resulting in contamination. - Ensure the drill has the safety lock on when not in use. - Always test before handing them up to the surgeon to use - Ensure correct cord is attached to equipment and distal end is handed to the circulating nurse - State the size when passing Operating Room Table - The Fracture Table (left) is used for a femoral neck, femoral shaft or tibial fixation procedure. - Jackson Spinal table (right) is used when the patient is prone for spinal surgery. Extra stretcher outside the room in the event of emergency. Radiography – Imaging is frequently used in orthopedic surgery. - The C-Arm (image intensifier) provides fluoroscopy throughout the procedure. - This is operated by the surgeon or an x-ray technician. - All personnel in the OR must wear X-Ray led gowns for protection before scrubbing - Procedures that uses: External Fixation, DHS, Internal Fixation, - Procedures that doesn’t use: Closed Reduction, ORIF, TKA, THA Pneumatic Tourniquets - used in procedures involving the extremities - create a bloodless surgical field - promote visualizations of the structures during the procedure. Inflation pressure are established based on the systolic blood pressure, age of the patient, and circumference of the extremity. - Best practice should not exceed 250-300mmHg for the arm and 300-350mmHg for the thigh. Cuffs should overlap between 3 – 6 inches. - Best practice is the cuff should not be inflated for longer than 60 minutes on the upper extremity and 120 minutes on the lower extremity. - After the time is reached, the surgeon may request additional time at 15-minute intervals. The inflation, deflation and total time is documented in the patient’s chart. Bone Cement (Polymethylmethacrylate) (PMMA) - A powder component (10% Barium Sulfate) is mixed with a liquid (methyl monomer) to create a cement that is radiopaque. This is done by the scrub nurse. Mixed in closed system. - The liquid is highly flammable and the OR should be properly ventilated. - The mixture of the two substances, with excessive exposure, can cause irritation of the respiratory tract and eyes. - Special hoods and mixing devices are available to minimize staff exposure to the fumes. PMMA impregnated with antibiotic has shown to reduce infection rates. Medications  - Bacitracin is mixed with sterile saline, fills the asepto syringe, and is used to irrigate the dirty or contaminated bone/tissue. Handling Prosthesis - Prosthesis shall be meticulously handled to prevent damage or contamination. - Should be placed on a lint free surface - Visually inspected for defects by the scrub nurse and the surgeon - Handled as little as possible - If applicable, rinsed with appropriate solution (i.e. Bacitracin) - Implant information (Serial Number, Lot Number, Size, Quantity, Expiry date) will be documented - Sterilization process – biological indicator must be present for an implant! Orthopedic Surgery (causes) Fracture Surgery - A fracture is a break in the continuity of the bone as a result of trauma, infection, or bone disease (i.e. osteoporosis). The most common infectious process is osteomyelitis. The most common degenerative musculoskeletal condition is osteoarthritis. - The goal of fracture surgery is to reestablish the length, shape, and alignment of fractured bones or joints and restore anatomical function. 1. Closed Reduction - Manipulation of the fragments without incising the skin. MOVED BY SURGEON - Reduction is confirmed with radiography. - Benefits include reduced risk of infection, improved union of the fractured bone and minimizes recovery period. - A splint or cast will be used to immobilize the fracture. 2. External Fixation - This provides rigid fixation and reduction with the ability to manage soft tissue wounds and is usually used for severe open fractures, arthrodesis, congenital deformities, and highly comminuted closed fractures. - An open fracture has an increased risk of infection. - External fixation does not require a cast as the fracture is stabilized at a distance from the injury which allows for additional procedures to be completed for the soft tissue injuries if necessary (i.e. skin grafts). 3. Open Reduction and Internal Fixation (ORIF) - ORIF is used when the surgeon is unable to correct or fix the fracture with the closed method. - Internal fixation is the treatment of choice for correction of fractures of long bones or the hip. It includes the application of metal plates, screws, insertion of pins, IM rods, and/or nails. Open reduction provides exposure to the fracture site (skin incision) and fixating the fracture with internal fixation devices. The advantage is the surgeon has a direct view of the fracture and can ensure anatomic alignment is achieved. Hip Fractures (types and fixation required to fix them) 1. Intertrochanteric Fractures - Intertrochanteric fractures are common in elderly women due to osteoporosis. - Fracture of the femur between the greater and the lesser trochanters. - They are extracapsular fractures that is outside the hip joint’s fibrous capsule - Blood supply is not compromised and fracture can be fixated with plates and screws. Lead Gowns – worn by all OR personnel FIXATION: Hip-Screw Instrumentation → Commonly used is a Dynamic Hip Screw (DHS) - Guide Pin is inserted in the middle of the femoral head - Drill - Measure with depth gauge for the lag screw size - Reamer over the pin to create channel for lag screw and barrel compression plate - Tap lag scre channel - Apply plate and lag screw inserted into hip  2. Femoral Neck Fractures - Reduction is required before internal fixation of the femoral neck because of the risk of nonunion and avascular necrosis of the femoral head. - Blood supply is compromised. FIXATION: 2 types depends on the severity of the fracture 1. Internal Fixation with cannulated screws - Stable - Fixation Instrumentation → Cannulated Screws (AO Technique) - Lead Gowns – worn by all OR personnel 2. Total Hip Arthroplasty (THA) - Unstable (meaning fracture is no longer in correct anatomical alignnment and blood supply is compromised. - NO NEED for LEAD GOWNS - Unipolar (only the femoral component, no inner head to reduce the friction) and Bipolar (prosthetic head and acetabulum) - If completing a Bilateral Total Hip Replacement, the modular method of allows the surgeon to build up the hip and acetabulum so that both legs symmetrical in length and aligned Procedure: - Acetabulum is prepared first, Femur is second 3. Subtrochanteric Fracture - IM Nails - Lead Gowns – worn by all OR personnel FIXATION: Intramedullary (IM) Rods, Nails, Pins are inserted in the intramedullary canal of a fractured bone (femus, humerus, tibia) with the use of fluoroscopy. - It can also be used for Sub Trochanteric Fractures. This procedure is considered closed reduction despite the small incision sites. Common names of systems are “Nancy” “Russel-Taylor” and “Gamma (use in intertroachanteric #).” - - IM Rods are considered the gold standard as the procedure causes less scarring, blood loss, and reduced risk of infection. - The nails/rods/pins distribute the weight-bearing stresses across the length of the bone. Versus a plate/screw fixation would emphasize the stress at the fracture site. Arthroscopy Surgery (procedure and describe) Knee The knee joint consists of two articulations - one between the femur and tibial plateau - Other between the patella and the femur. The two collateral ligaments reinforce the knee capsule. - medial collateral ligament (MCL) - lateral collateral ligament (LCL). The two menisci (medial and lateral) - between the condyles of the femur and tibia and are attached to the joint capsule. The two cruciate ligaments are the anterior and posterior cruciate ligaments. - They are fibrous bands that attach to the anterior and posterior intercondylar surfaces of the femur and tibia. Arthroscopy - Arthroscopies are used for diagnostic and operative purposes, commonly for the knee, shoulder, and wrist joints. This procedure is similar to MIS surgery in that the surgeon uses a scope to visualize a joint. - Normal Saline irrigation is infused via gravity for regulated distention of the knee joint  - Arthroscopic procedures are extremely common as there are many advantages including: decreased recovery and rehabilitation time, smaller incisions, less post-op inflammation, pain, and scaring. - NO LEAD GOWNS *Torn medial collateral, medial meniscus, and anterior cruciate are the most common injuries of the knee!! a) Arthroscopic Resection and Repair of Meniscal Tear - Menisci are important structures in the knee joint that distribute load across the joint and provide capsular stability. - A meniscus tear is the most common type of injury requiring a repair. Treatment includes preserving the knee structures. b) Arthroscopic Anterior Cruciate Ligament Repair - The ACL is an important stabilizing structure of the knee and is the most frequently torn ligament. The injury is a result of simultaneous anterior and rotational stresses. Usually this is for athletes or active individuals with instability that impedes their ADLs. - The repair can sometimes require a replacement of the ligament. The most common one is a patellar tendon graft. (connects knee cap to tibia)  - Total Knee Arthroplasty (TKA) - This surgical procedure is to replace the worn surfaces of the knee. Arthritis (degenerative, rheumatoid, traumatic) is the most common diagnosis for this surgery - TKA promotes improved mobility and stability of the joint. - NO NEED FOR LEAD GOWNS Total Knee Replacements (implants) should allow for the preservation of normal ligaments while maintaining soft tissue balance and stability. - The goal is to maintain the normal motion of the knee: flexion, extension, abduction, adduction, and rotation. - It is important to remember that knee prostheses are Left and Right specific. It is imperative that the correct sided implant is selected and verified with the scrub nurse and surgeon before opening. There will be two components (implants), one tibia and one femoral. Otolaryngology (ENT) Surgery Basic Anatomy - Middle ear: consist of tympanic membrane (ear drum), Estachain tube (where air flows from pharynx), ossicles - malleus, incus, stapes (amplify received sound) - Nose: sinus: frontal, ethmoid, sphenoid, maxillary - Trachea: sits in front, Esophagus: sits at the back - Thyroid: produce and release hormone, two lobes joined by isthmus, regulated by pituitary gland - Parathyroid Gland: secretes Parathyroid hormones (PTH) - antagonist to calcitonin - Regulates Calcium in blood. If too much = increase absorption in intestine, if too little = increase removal from bone storage. Nursing Process Consideration - Facial nerve monitoring - Rhinologic surgeries: Nasal cavity is packed with patties soaked with the vasoconstrictor solution to prevent bleeding - Laryngeal surgeries - lidocaine is applied topically over larynx to prevent patient from coughing, topical epinephrine to achieve vasoconstriction. - Prep: Providone-iodine is used unless patient has allergy. Chlorhexiding is avoided because it is ototoxic. - Position: Supine with a shoulder roll placed posteriorly for maximum visualization. Most head and neck surgeries require a minor count. Initial Count (minor) → Closing Count (minor) → Final Count (minor) Tympanoplasty - Repair of tympanic membrane and reconstruction of ossicles - Indication: Conductive hearing loss FESS (Functional Endoscopic Sinus Surgery) - Insertion of endoscope through nasal cavity into the sinuses to resect inflammatory and anatomic defects of sinuses - Indication: polyps, sinus blockage, severe allergy - Purpose: ensure adequate drainage of sinuses by receding tissue and creating increased aeration of the sinuses. Radical Neck Dissection - Removal of malignant head and neck tissues, such as cervical nodes, fascia, jugular vein, 11th cranial nerve, sternocleidomastoid muscle, mandible, maxilla, thyroid, or parotid. - Modified neck dissection - only cervical nodes and fascia is removed - Intra-oral Cancer: oral resection plus radical neck dissection - commando procedure - Position: Supine with shoulder roll - AIRWAY: patient needs a tracheostomy performed before the proposed neck dissection. Tracheostomy - Opening of the trachea and insertion of a cannula through the cricoid cartilage. - Required for: prolonged intubation during course of critical illness, severe neck and mouth injuries, foreign body occluding airway, inhalation burn, paralysis of muscles that affect swallowing causing a danger of aspiration, long term unconscious or coma - Test cuff for leaks with sterile water before passing to surgeon Instruments - Equipments: Ear speculum, Boies elevator and asch forceps (manipulate # back into place), Alligator forcep, Huff suction, Fraiser suction, Trach tube and obturator. - Tracheal dilator, hook, absorbable sutures to close, nylon suture to secure trach tube Neuro Surgery Layers of Dissection 1. Skin incision made & subcutaneous tissue - local infiltration, #20 blade incision. Raney clips used for hemostasis of scalp) 2. Galea (tough aponeurosis) - dense, fibrous tissue that connects muscle to skull (to close - absorbable polysorb with cutting needle) 3. Pericranium (periosteum) - loved adson used (elevator) 4. Skull - drill with perforator to create burrhole 5. Dura - #15 blade; metz scissors to open up (to close - non absorbable nylon with taper needle) Counts - Dura count, when they start closing dura All neurosurgery procedures require a minor count. Initial Count (minor) → Closing “Dura” Count (minor) → Final Count (minor) Hemostatic Agents - Raney clips and applier - scalp hemostasis - Neuro patties (radiopaque) - has strings for ID, moistened before using - Bone wax, surgicel, gelfoam, floseal - Yasargil - to clip temporary bleed Positioning Devices for the head - prevent any movement of head 1. Mayfield head fixation device 2. Sugita Pins Nursing Considerations - Special care is given to pad the patient’s pressure points well, as neurosurgery cases are often long (3-8 hours). Patients need to be well secured on the OR bed as the table will be tiled during surgery. - Neuro surgery requires tissue dissection of highly vascular areas, resulting in the need for blood transfusion. - The most common positions used in neurosurgery are: supine, lateral or prone. Instruments - Love Adson, Bayoneted instruments, Hudson brace, Clip appliers, ICP/EVD (hydrocephalus), Hemovac/JP (subdural hematoma) Plastic Surgery Dermatomes – used for removing split thickness skin grafts (STSG) from donor sites. Mineral oil should always be available. Skin Meshers – used to produce uniform slits in a skin graft to stretch the graft to cover more burn surface area Flaps (types and blood supply) Pedicle flaps: TRAM flap where the original artery and vein remain intact and supply the same tissues that have been transferred to another area. - The muscle and the pedicle are severed at the distal point of origin and pulled through a subcutaneous tunnel to the chest to form a breast and sutured medially Free flaps: original blood supply (artery and vein) are severed from their source and reanastomosed microscopically to the recipient’s area artery/vein. This is usually a two-team approach, one for harvesting and one for site preparation. - only a small portion of the rectus muscle that carries a segment of the deep inferior epigastric perforator vessel needed to move with the fat and skin to the recipient site. Burn Surgery (skin grafts) *It is imperative that for burn surgery the room is WARM as the patient is at risk for hypothermia from tissue loss and large tissue exposure for duration of the surgery For a graft to survive, the vascularity of the recipient area must be adequate, contact between the graft and recipient must be maintained and immobilized. Dressing are a critical aspect to burn surgery! Dressings - Extremely important in plastic surgery. Dressings should accomplish 5 goals: 1. Immobilize the surgical part 2. Apply even pressure on the wound 3. Collect drainage 4. Provide comfort to the patient 5. Protect the wound 1. Split Thickness Skin Graft (STSG) - Contains epidermis and a portion of the dermis from the donor site. - This graft can be meshed to cover more burn surface area if required, however aesthetically it is not the most desirable. - It has a quick vascularization time with the recipient site. - The donor site heals rapidly by regeneration of the epithelium and can be used again for additional grafts if required. - Only a dressing is placed over the donor site (not sutured). - A downfall of STSG is the patient is at risk of developing skin contractures long term. 2. Full Thickness Skin Graft (FTSG) - Contains both epidermis and dermis. - This graft causes minimal contracture, can be used in areas of flexion, and add tissue where a loss has occurred making the skin look more aesthetically acceptable. - Donor site is closed primarily with sutures with minimal defect however the site cannot be used again. Opthalmology (Eye) Cataracts - clouding of the lens of the eye, which is typically clear Cataract Surgery (Surgery on Lens) – Cataract extraction is the removal of the opaque lens from the interior of the eye and can be accomplished by several methods. Extra Capsular Cataract Extraction (ECCE) – The anterior portion of the capsule is first ruptured in a controlled manner and removed. The surgeon expresses the lens cortex and nucleus from the eye, leaving the posterior capsule behind using phacoemulsification. Intra Capsular Cataract Extraction (ICCE) - Removal of the lens within its capsule with a cryoprobe (rare procedure performed with dislocated lens). Strabismus - Repair of any ocular misalignment, as a result of poorly controlled neuromuscular eye movements. Common procedures in pediatric population, sometimes occurs in adults and/or are re-done in adulthood. Strabismus is subdivided into four categories: Esotropia - Inward turning of one or both eyes Exotopia - Outward turning of one or both eyes Hypertropia – One eye higher than the other Hypotropia – One eye lower than the other There are two methods for strabismus muscle repair: Recession (weakening procedure) – The muscle is cut and reattached at a point further back from the front of the eye. Resection (strengthening procedure) - Segment of muscle is removed and the shortened muscle is reattached to the eye. Medications Mydriatrics - dilate pupil - permit focusing Cycloplegics - dilate pupil - inhibit focusing Miotics - constrict pupil Viscoelastics - lubricate and support Viscoadherents - maintain chamber Irrigants - lubricate and provide moisture i.e. Balanced Salt Solution (BSS) Hyperosmotics - decrease intraocular pressure Laser Precautions  - Eye protection - goggles, eye pads - permanently labelles with wavelength and ocular density, have side shields, inspected prior to use, stored in individual cases, be available for donning outside. - Limited or controlled access to laser - restrict traffic to authgorized personnel, warning signs at all entrances, keep doors to the room closed, cover windows and spaces in the door frame, reduce reflective surfaces. - Fire safety - educated annually, basin and green towels, knowledge about ETT fire protocol - Documentation - laser safety checklist, documentation should be retained Ethics - can be surmised as a system of moral principles that affect how an individual makes decisions and lives their lives. - Ethics is also known as a moral philosophy and is a systematic understanding of right and wrong as it relates to rules or standards of conduct, and good character. Ethical frameworks - assist the nurse in providing a therapeutic nurse-client relationship. - Ethical conflict can occur in a variety of ways in the operating room. Whether it be patient, staff, or interdisciplinary related. - The perioperative nurse should have an understanding and ability to communicate beliefs and values to prevent ethical conflicts. - It is imperative the perioperative nurse considers decisions that are made to serve the best interest of the patient and should have a family-centered approach. Five Focal Virtues 1. Compassion (Beneficence) – An active regard or focus on the best interests of the person being cared for. 2. Discernment – Understanding brought to action that is most helpful (insight, judgement, understanding). 3. Trustworthiness – A relationship built between the care provider and the patient/family 4. Integrity – Practicing with integrity and respecting the dignity of oneself and others. 5. Conscientiousness – Ensuring the best actions are for the patient without biased opinions. All health care professionals need to be aware of the importance of: - Identifying goals and purpose of treatment and means to achieve goals (Perioperative Nursing Data System [PNDS]) - Determine and respect patient and family values - Identify conflict and resolution CNO Ethical Values (2019) These values are implemented daily in perioperative nursing care practice: - Client well-being - Client choice - Privacy and Confidentiality - Respect for Life - Maintaining Commitments - Truthfulness - Fairness Perioperative Nurse Practice Standards include: 1. Knowledge from nursing, the sciences and the humanities. 2. Effective use of the nursing process for clinical decision-making. 3. Professional responsibility and accountability. 4. Provision of safe patient care through collaboration with multidisciplinary team members.