most bones are slightly curved, it works on a three point fixation, with nails
fixed with locking screws.
Wires
Used to hold small bone fragments in position.
Internal fixation should be used when;
- adequate reduction cannot be maintained by external methods (fractures
involving joints).
- When it is important to secure early movement of a limb or joint.
- Certain cases of multiple trauma, where internal fixation of one or more
fractures may make the treatment on other injuries easier.
- Pathological fractures, where union may be uncertain, and patients life
expectancy may be short.
- Where Plaster of Paris or traction are not adequate.
6. Define the following terms;
Decompression of Carpel Tunnel.
Reducing the pressure on the median nerve in the wrist, when it has become
compressed in the Fibro Osseous tunnel. This is done by incision, releasing the
pressure.
Keller's procedure.
For treatment of Hammer toe(deformity of the toes, e.g. flexion of the
proximal interphalangeal joint). Also Mallet toe(terminal interphalangeal
joint), also causes bunions.
The prominence of the head is trimmed and the base of the phalanx is excised,
allowing the toe to drop back into neutral. The gap created fills with fibrous
tissue. The toe is shortened and takes no part in weight baring anymore.
Fowler's procedure.
Similar to Kellers and involves the straightening of the toes, but they also take
off the metatarsal heads.
Pott's fracture.
When there is a combination of fracture and dislocation of the joint surfaces
in the ankle.
Colles' fracture.
A fracture of the lower end of the radius, and tip of the ulna, just above the
wrist. Involves fracture, and displacement. Commonly seen in elderly women
after a fall when they land on their hands. The bone is restored to its normal
position under anaesthetic and a plaster cast applied for about six weeks. Can
leave wrist deformed and stiff.('dinner fork' deformity).
7. List the procedures for which x-ray/image intensifier may be required in
your department.
- When injecting anaesthetic or steroids into the spine or joints, to ensure they
are injecting into the correct area.
- For removal of plates and screws which can be hard to find.
- When inserting plates and screws, e.g. Classic hip screw, neck of femur or
intramedullery nailing.
-External fixation when pinning through the skin and tissue. e.g. Radius and
Ulna. (K-wiring)
8. Identify the hazards associated with the application of Plaster of Paris.
What observations would the practitioner make, after its application.
When applying Plaster of Paris it is important that a layer of soft padding is
applied first, which leaves a soft edge where the plaster ends to prevent
rubbing.
No sharp edges must be left, which could cause the patient discomfort and
pain.
Must be put on evenly, and enough layers to ensure it is stable. This also
avoids cracking.
Backslabs used where possible.
Where not possible, it is very important that it is not applied too tightly,
restricting circulation, and risking causing nerve damage.
If applied to loosely, it will offer no support to fracture, so the break will not
heal correctly.
Observations made will be to check capillary refill at extremities of limbs.
Check the patient can move fingers/toes, and ask the patient how it feels.
9. Explain the specific infection-control measures that are used during surgery
and why they are needed.
- Double gloving.
- Ioban drapes
- Laminar flow
- All persons in theate to wear masks
- Doors to theatre to be kept shut
- anti-biotics pre- op
- sterility of equipment
- pre-op skin prep on the ward, wrapped in sterile paper.
These specific measures are required because if infection gets into a bone it is
very difficult to treat and causes major long term complications.
Risk of infection is far greater when the bone is exposed, and can spread very
quickly.
10. Choose a patient from the orthopaedic list and describe their total care
from entering the department to leaving the recovery room.
The patient that I chose to follow from entering the department to leaving the
recovery room, was a 67 year old woman. She suffers from diet controlled
diabetes, had a right total hip operation in 2001, and had come to theatre
today for a left knee replacement.
On arrival to our department.
The patient was checked in at reception. This included checking;
- the armband corresponded with her paperwork.
- date of birth, hospital number, full name, address, ward and consultant.
- when she last ate, which was 10oclock the previous night.
- checked operational site was marked.
- no jewellry
- no allergies
- suffers from back problems - pain
- dentures in situ
- blood H.B. 11.4
- ted stockings in situ
- xrays available
- no blood ready in fridge, so hospital blood bank informed to make readily
available
There was some difficulty with language when speaking to the patient, as she
was an Indian lady. But we managed to get her to understand our questions.
On arrival to the anaesthetic room.
Monitoring was placed on the patient, to include Pulse Oxymetre, E.C.G. and
Blood pressure cuff, telling the patient before each action, what was about to
be done.
The O.D.P. squeezed the arm of the patient to block venous return for the
anaesthetist to place a 16 gauge venflon into the patients left hand, as she was
right handed, after injecting some lignacaine first to numb the area, to cause
less discomfort. A vecafix was placed to keep the venflon secure.
A flexible Y set was attached to the venflon port, so that a P.C.A. could be
attached later, as well as a port for fluids. A litre of Hartmans was attached
and the tubing fixed to arm with tape to avoid the tubing being pulled on.
Consent is checked for completion, with signatures of patient and consultant
and correct date.
After this the patient was asked to sit up and arch her back, to get optimum
access for the anaesthetist to insert a spinal needle. This was the chosen
anaesthetic, to numb all feeling from the waist down, so there was no need for
a general anaesthetic.
The skin is prepared by painting with Chlorahexadine to disinfect the area. A
sterile field is made by placing sterile drapes around the patient.
After checking dates and correct drugs are being prepared, the site is
infultrated with 2ml of 1 per cent Lignocaine, as a local anaesthetic. A filter
needle is used to draw up 2.5ml of heavy marcain and 25 micrograms of
Fentanyl. Filter needle is used so no glass fragments can get into syringe, as
these drugs are stored in glass ampoules.
The Spinal needle (22 guage) is carefully positioned into the spine, between
the vertabrae, until a back flush of Cerebral Spinal Fluid first drips from the
tube, and when the syringe of anaesthetic is attached the CSF can be seen
flushing back in the liquid. At this point the anaesthetist knows he/she are in
the correct position, and infultrates the solution.
The area is then sprayed with Opsite to act as a dressing. The anaesthetist
then mixes Cefaroxine with water for injections, and adds this to the Hartmans
solution, so it infused through the I.V. line.
He also gives the patient Midazolam for sedation, which is administered
through the venflon port.
The patient is then catheterised with a size 12 catheter, first cleaning the
area with unisept skin prep.
Finally, before leaving the anaesthetic room, a torniquet is placed as high up
the left leg as possible, to give optimum access for the surgeon to operate.
Padding is wrapped round first to protect the skin.
All monitoring is removed and the bed taken through to the operating theatre.
In the operating theatre.
All staff must wear masks on entering the Orthopaedic theatre.
A pat slide is placed half under the patient, and the other half on the
operating table, and when there are plenty of the care team in place to safely
move her across, and when the anaesthetist gives the go ahead, she is
transferred to the operating table.
Arm supports are put in place immediately, to ensure safety to the patient, and
monitoring is re-applied. Leg support is placed at the side of her left thigh,
and a sand bag used to support the foot, with the knee bent.
An oxygen mask is placed, giving the patient 5 ltrs of Oxygen. Exanguinator is
rolled up as far as possible to meet the torniquet, and once in place the
torniquet is switched on to 300mmhg, and the time is recorded on the board.
A Diathermy plate is placed on the patients abdomen, as she has previous
metalwork in her right leg.
A warming blanket (Huggy Baer) is placed over her torso and taped in place.
Overhead operation lights are switched on and the left leg is held up by a
member of the non-scrubbed team, while a surgeon and scrub nurse paint with
Betadine. They apply three layers and dry with a large swab.
Drapes are placed to make a sterile field, including an Ioban drape.
Sterile light handle covers are placed.
Diathermy is switched on to 40/40 for cutting and coagulation to include
monopolar and handheld.
Suction tubing is attached and switched on.
The surgeons ask the anaesthetist if they can commence and he confirms they
can.
The operation.
The first incision is made with a 20 blade, then onto a 10 blade to cut through
tissue, to arrive at the knee joint. The operation site is then retracted.
Jigs are used to place the saw in correct position to cut the knuckle off the
Femur, and again on the Tibia. Different Jigs are used so that the bones can
be shaped and cut back, so eventually the prosthesis joint can be fixed to look
like the original knee joint.
During this time, 500ml of Gelofusine is attached to the I.V. line, when the
Hartmans has been infused.
When the Tibia and Femur have been shaped to accomodate the prothesis, a
trial femur is placed and a wedge is put in between to ensure there is a big
enough space between them and they are flat. When the surgeon is happy, the
real prothesis is opened up and Polacos cement is mixed. When mixing
commences, the clock is started, to keep a check on the time, as it hardens in
approximately 8-12 minutes.
The time is announced every minute, to keep the surgeons aware of how long
they have left before it sets.
When mixed, the cement is applied to the Femural and Tibial componants and
fixed in place. Once this is done, the area is washed with Saline several times.
A Redivac single drain is put in place, and the first layer is sutured in place
with a number two Vicryl W9378 for the muscle and fat layer, and then a
number one Vicryl W9906 for the subcutaneous layer. Skin clips are used on
the skin.
The Ioban drape is then removed, the wound is cleaned with Betadine and then
dressed with a 15cm Velband, absorbant pad and a 15cm Crepe.
The torniquet is removed and time noted.
PCA is attached to the Y connector, and the recovery staff are called for.
When they arrive, a handover is given, to let them know what operation was
performed, what sutures were used, informed of it being Spinal anaesthesia,
and what drain and dressings were used.
Monitoring is removed, and another 500ml of Gelofusine attached to IV line.
The patient is transferred back onto the bed and the oxygen is transferred to
a cylinder brought on the bed.
In recovery.
Once the patient is in recovery, the monitoring is immediately re-applied and
observation results recorded every 5 minutes on a post-operative check sheet.
Oxygen is connected to the pipeline on 4 litres, and the drain is opened.
Other checks on the post-operative checklist include;
Wound - no oozing observed.
I.V.I. - Gelofusine in progress.
Drains - 900mls
Time received
Time noted of when PCA was attached
Note made of operation and anaesthesia.
The patient is sat up and made comfortable, giving her the PCA button and
explained to how to use it.
After half an hour has passed, 1 ltr of Saline is attached to I.V., the ward are
called to collect the patient, and another hand over given before the patient
leaves the department.