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Key questions - Orthopaedics

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Key questions for nurses working in Orthopaedics

Peter Davis, MBE, MA, BEd, CertEd, RN, DN, ONC, is associate professor; Bryan Smith, MPH, BSc, DPSN, RN, ONC, is lecturer; both at School of Nursing, University of Nottingham.

1. Patients admitted to hospital following a fracture of the neck of femur are at high risk of venous thromboembolism (VTE). What are the current NICE-recommended interventions?

• Regularly assess patients for individual risk factors for VTE using, for example, the Autar (2003) DVT risk assessment scale;
• Use mechanical prophylaxis such as thigh-length graduated compression stockings, intermittent pneumatic compression or foot impulse devices;
• Use low molecular weight heparin or fondaparinux therapy for four weeks;
• Do not allow the patient to become dehydrated;
• Encourage patients to mobilise or arrange leg exercises if immobilised as soon as possible after surgery.

2. What lifestyle advice would you give a female adolescent to help prevent fractures due to osteoporosis in later life?

The way we live our lives can have a major impact on the health of our bones. A child's whole skeleton is replaced within about two years. Some 20% of bone health is influenced by lifestyle so advice would include:
• Get physical through the following: jogging. aerobics, dancing and team games such as football and hockey;
• Healthy eating: eat plenty of calcium and other vitamins (especially vitamin D) and minerals are also important. Avoid lots of salt, caffeine and fizzy drinks;
• Smoking has a toxic effect on bone by inhibiting the construction cells from doing their work.

3. What are current thoughts on the underlying cause of rheumatoid arthritis (RA)?

The cause of RA is likely to include genetic factors, sex hormones and an unidentified initiating agent. B-cells, T-cells, and the pro-inflammatory cytokines interleukin 1, interleukin 6 and tumour necrosis factor α (TNFα) generate persistent cellular activation, autoimmunity and inflammation of the synovial joints and a number of extra-articular sites. Latest treatments include biological therapy using TNFα blockers such as infliximab, etanercept and adalimumab, although these have potentially severe side-effects and increase the risk of opportunistic infection and reactivation of latent TB.

4. How do you recognise compartment syndrome in a young motorcyclist with a closed fracture of the tibia?

Compartment syndrome is relatively rare but when identified needs immediate medical treatment. Early detection from nursing staff can save the limb or even a patient’s life. Most cases are related to the tibia (40%), with the forearm the second most common site of injury. Many texts refer to recognition using the five Ps: Pain, paraesthesia, paralysis, pulslessness and pallor, the latter two being late signs, but there are others. Increasing pain on passive stretching of muscles is one such indicator. Pain is often described as being out of proportion to the injury and a high level of suspicion is essential to early detection.

5. What should you be aware of in a patient with a new plaster of Paris for a Colles fracture?

Any bony injury incurs swelling and this can have devastating effects on a patient’s wellbeing in a plaster cast. Wherever possible, a back slab or incomplete circumferential support is used to accommodate or allow for any swelling. If swelling continues undetected, pain can become unbearable. Limbs should be elevated and patients should be encouraged to continue this through the use of slings or pillows while at home. Colour, sensation and warmth of the fingers should also be observed as trust policies dictate. A rescue plan should be in place for those who invariably have swelling that does not subside.

Further reading
• Journal of Orthopaedic Nursing
• Bulstrode, C., Swales, C. (2007) The Musculoskeletal System at a Glance. Oxford: Blackwell Publishing.

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