Bone regenerates rather than simply repaired through fibrous tissue (Porth and Gaspard, 2004). Bone healing process starts with the formation of hemtoma at the fracture site. The formation of fibrocartilage tissue occurs in 3 days to 2 weeks after fracture. Fibrous tissue has to first stabilize the fracture fragment before cartilage can form into healing process. Early bone formation is often called primary callus and progressively stabilizes the fracture site. The mechanical factors of treatment such as immobilization or internal fixation are important features to facilitate the healing process. Mary underwent surgeries to stabilize her pelvis. The orthopaedic surgeons first stabilized the fracture by using an external frame to temporarily hold the bones in proper alignment, which allowed Mary to deliver a stillborn baby in the natural way. The further surgery was ORIF (open reduction internal fixation). The fractured bones are rigidly fixed with cannulated screws and external fixator to prevent future displacement and allow for rehabilitation to begin as quickly as possible.
Bone formation takes much longer time. Callus formation (2 to 6 weeks) occurs as the maturing of the granulation tissue continues. The outcome of ossification (3 weeks to 6 months) is that the gap at the fracture site is united or bridged. The final stage is consolidation and remodeling (Altizer, 2002a). Most likely, Mary has to have several months of temporary disability.
Several factors may influence bone healing, including age, hormones, functional activity, nerve function, nutrition, drugs, and local fractured bone condition (Orthoteers, 2001). Because of delivery of baby and large surface area of fractures, nutrition is significant in the case. As Marieb (1995) stated, bone is the storehouse of calcium in body. If blood calcium level is low, bone will demineralize to compensate and may delay bone healing. Diary food is the best source of calcium. However, it is not the usual food for Chinese people. Mary eats small meals and dislikes diary product, thus she is provided ‘Ensure Plus’ which has high calcium, high protein, and multiple minerals and vitamins as her diet supplement.
It is important that Mary is guided and encouraged to move and weight bear. Researches indicates that controlled cyclical loading produces a hypertrophic response and increases bone mineral content (Sheppard, 2001), i.e. exercise and loading facilitates bone healing.
Interpretation of the diagnostic data
Radiography is the most important diagnostic data for an orthopaedic patient. Also as infection is a common complication of trauma and surgery, early recognition of a local infection is an object of nursing, as it may prevent patient from developing sepsis and, thus, decrease morbidity; further to visual observation of local swellings, redness and warmth in her wound and her pin sites, a white blood cell count (WBCs) is an important diagnostic data for potential infection. Radiography and WBC will be discussed in this section.
- Computerized Tomography (CT )scan
The only specialized diagnostic test Mary underwent was CT scan. The CT scanner produces a narrow x-ray beam that examines body sections from many different angles. CT scanning of bone provides a series of tomograms to represent cross-sectional images of various bone layers, which can be translated by a computer and displayed on a monitor. The traditional x-ray takes only a flat or frontal picture. The CT scanner is about 100 times more sensitive than the x-ray machine. Thus, it is a much more effective but costly diagnostic test. CT scanning is crucial in this case, as the pelvis consists of irregular shape bones, and fractures of the posterior elements of pelvis are not easy to be seen on the plain X-ray (Chipno, 1982).
CT scan can visualize internal structure of body; it is the most important diagnostic data for orthopaedic surgery. The findings of Mary ‘s CT accurately confirm her pelvic fracture. There is a fracture through the right sacral ala which is minimally displaced, and the fracture extends into the sacroiliac joint inferiorly. There is slight widening of the anterior aspect of the right sacroiliac joint. Comminuted minimally displaced fractures of the superior and inferior pubic rami are present on the right. On the left, there is a mildly comminuted fracture involving the anterior margin of the acetabulum. The fracture fragments are minimally displaced. No gap is present in the articular surface. These findings demonstrate the position and displacement of the fracture fragments, which help surgeons to get as much information as possible about the fracture before beginning surgery. Additional, Mary’s CT scans help to exclude some complications from the trauma: i.e. no abdominal bleeding, bladder injury, bowl injury, and spinal cord injury was detected.
As a result, interpretation of CT scans is an important complement to physical assessment. As a part of orthopaedic team, nurses need to learn how to read the radiographs. Though Mary was not keen to see her radiographs, nurses may need to explain the findings of her CT scans, so that Mary can better understand and cooperate with her treatment.
- White blood cell count (WBC)
Mary was at high risk of osteomyelitis (bone infection) due to traumatic pelvic fracture and post orthopaedic surgeries. Ostoemyelitis can be caused by bacteria or by fungus. The acute infection needs to be treated promptly and adequately to prevent the development of chronic osteomyelitis, which usually needs surgical removal of dead bone (Porth et al., 2004).
The blood test of WBC is one of the diagnostic data that may indicate osteomyelitis. There was a sequence of elevated WBC in Mary’s case, i.e. 17.28, 14.12, 10.14, 11.26, and 11.05. High WBC usually indicates an imflammatory and immune response, however, nurses need to know the diagnose of osteomylitis needs to consider acompanying signs and symptoms of infection (e.g. pain in bone, local redness, or fever) and combine with other examinations (e.g. blood culture). As there were no physical signs of infection and no other tests support infection, osteomyelitis was not diagnosed. But this still needed to be considered until WBC went back to normal. Luckily, Mary’s WBC was elevated only five days, thus it probably related to trauma and acute stress (Hendler et al., 2002).
Pharmacological interventions and implications to nursing practice
Pain control and embolism prevention are the major concerns for post orthopaedic surgery patients. This section will discuss nursing interventions for the use of Morphine and Warfarin.
Morphine is a strong analgesic, but only has action on central nervous system (CNS), i.e. alteration of the perception of and response to painful stimuli. Morphine is mostly metabolized by the liver, finally excreted via kidney, thus, Morphine should be cautiously used for patients with kidney disease and liver disease (Deglin & Vallerand, 2001). Mary is a Hepatitis B carrier, she can be prescribed Morphine as her liver function has been normal.
Morphine is a controlled drug. There is a general principles pertaining to the administration and storage and there is specific legislation for prescription (Galbraith, Bullock, and Manias, 1997). Nurses should be aware of only doctors are entitled to prescribe Morphine and complete the drug chart.
Mary felt convenient and secure to use Morphine through PCA (patient controlled analgesia). Only Mary could push PCA button, and she would not overuse Morphine since the maximize dosage has been prescribed and locked into PCA.
The nursing interventions focus on observation of Morphine’s side effects. Morphine produces generalized CNS depression. Respiratory depression is the leading side effect, thus it is very important to regularly monitor respiratory rate and oxygen valuations. Nurses should encourage Mary to practice deep breathing and cough. Also, nurses need to help Mary to realize Morphine’s other side effects, including confusion, blurred vision, hypotension, bradycardia, constipation, nausea, vomiting, urinary retention (Deglin et al., 2001), so that effective nursing interventions can be provided.
Mary is at high risk of deep vein thrombosis (DVT) due to pelvic fracture, surgeries, and prolonged immobilization. DVT refers to the formation of a thrombus (blood clot) within a deep vein, commonly in the thigh or calf. it is limb-threatening. If the thrombus breaks free and travels through the veins, it can reach the lungs, where it is called a pulmonary embolism (PE). PE is a potentially fatal condition that can kill within hours. Both DVT and PE may be asymptomatic and difficult to detect. Thus, prophylaxis is very important (Orthopaedic surgery, 2004).
Anticoagulant, Warfarin acts indirectly to prevent synthesis in the liver of vitamin K-dependent clotting factors. Warfarin is administered orally and metabolized by liver (Galbraith et al., 1997). If Mary’s liver function is diminished, Warfarin may need to be stopped or decrease its doses.
Side effects include GI tract reaction and bleeding (Deglin et al., 2001). Bleeding is a major concern as Mary has several operation wounds and pin sites, and she still has post-natal bleeding. Nurses should check for excessive bleeding from these areas regularly. Also, nurses need to educate Mary to report unusual bleeding or bruising, e.g. bleeding gum or nose, black stools, red or brown urine.
Dosage is highly individualized based on the International Normalized Ratio (INR) system, which is the best means of standardizing measurement of prothrombin time to monitor oral anticoagulant therapy. Mary needs to do daily blood test to provide INR to doctors. Nurses should check oral anticoagulant therapy chart diligently and instruct Mary to take Warfarin exactly as directed. Vitamin K is a useful antidote to Warfarin in case of hemorrhage (Galbraith et al., 1997), however, Mary needs to avoid excess Vitamin K, such as broccoli (Booth, 2000) in her food which overcome Warfarin effect.
Conclusion
Pelvic fracture is a serious injury, involving significant force, may have severe complications, and surgical fixation is usually needed. The bone healing will take months or years; it is a hard process for the patient. Orthopaedic nurses should be able to read relevant radiograph and lab test and familiar with pharmacological interventions, so that to effectively promote health care.
References
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Altizer, L. (2002b). Orthopaedic essentials: Neurovascular assessment. Orthopaedic Nursing. 21 (4), 48-51.
Booth, S., (2000).Vitamin K: Another Reason To Eat Your Greens. Agricultural Research Magazine. 2000 (11). Retrieved July 23, 2004 from
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