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Surgical treatment options

Discuss about the Identify Surgical Options For A Patient Presenting With A Mid-Shaft Fractured Femur.

The surgery for mid-shaft fractured femur depends on time. Mid-shaft femur fractures are treated depending upon pattern of fracture. Femoral neck fractures, percutaneous pinning or sliding of hip screw and anthroplasty is done for the elderly patients like in the given case study of Mr.Brown. If the skin around the fracture is still not broken, then it is advisable to wait to make it stable before surgery. If the fracture is open, it might be exposed to environment and so need to be cleaned urgently to prevent infection before immediate surgery. The leg is placed in skeletal fraction or long-leg splint between the period of initial emergency care and surgery. This helps to keep the broken bones aligned and maintain length of leg. There are three surgical treatment options available for the mid-shaft fractured femur.

External fixation is a type of operation where screws or metal pins are placed in bones above and below the site of fracture. The screws and pins are attached to bar outside skin that act as stabilizing frame for the holding bones in proper position for fast healing. It is a temporary treatment where external fixators are applied which provide temporary and good stability until the femur is healed (Kulshrestha, Roy, & Audige, 2011).

Intramedullary nailing is another surgical option where and currently in use for the mid-shaft femoral fractures opted commonly by most surgeons. In this procedure, a specially designed metal rod is inserted in femur marrow canal. The rod then passes across fracture that helps to it in position. The intramedullary nail is inserted in the canal at the knee or hip in small incision. There is crewing at the bones at both ends. This keeps the bone and nail in proper position at the time of healing (Gelalis, et al., 2012).

Screws and plates are also done as a surgical operation when the bone segments are reduced or first repositioned in their normal alignment. Metal plates and special screws are attached to the bone outer surface. These screws and plates are often used during intramedulalry nailing which is not possible for the fractures that are extended to knee or hip joints (Smith, Parvizi, & Purtill, 2011).

Patients who sustain mid-line femur fracture after a traumatic accident like tractor accident of Mr. Brown, encounter complications depending upon the severity of break or fracture location. The complications include infection, bone healing problems, nerve damage, compartment syndrome or surgical complications (Kong & Sabharwal, 2014). In fractured femur, there can be bone breaking the skin and that increases the risk for infection. If there is wrong alignment of bones or infection that causes irritation, the healing process is delayed and there is requirement of further surgery. Nerve damage can also occur where there might be weakness or numbness that is a rare complication. Compartment syndrome is also a rare complication of femoral mid-shaft fractures where there is compression of blood vessels, nerves, muscles inside compartment or closed space within the body. This generally occurs within the thigh with bleeding or inflammation because of trauma that is associated with the fracture. In case of this syndrome, immediate operation is required. Surgical complications can also occur due to hardware failure that is required to stabilize bone or hardware piece that causes pain or irritation. Nerve damage is the possible surgical complication in mid-shaft femoral fracture (Park, Noh, & Kam, 2013).

External fixation

Depending on the femoral fracture, the major complications in mid shaft femoral fracture affects the knee, however, in a different way. Femur movement when it breaks, there is ligament damage in knee that demand immediate operation for repairing the damage. Heterotopic ossification, pudendal nerve injury and Acute compartment syndrome are major complications that might occur post-operation of fractured femur (Kaiser, et al., 2011).

Heterotopic ossification occurs with an incidence of 25% as a post-operative complication after femur fracture surgery. In this, there is varying severity where bone debris from endosteal canal reaming is deposited in soft tissues that surround the site of nail insertion in Intramedullary nailing surgery (Botolin, Mauffrey, Hammerberg, Hak, & Stahel, 2013). These debris are stimulate the heterotopic bone formation that decreases debris amount left in tissues after the nailing leading to heterotopic ossification. This complication occurs at the proximal end of reamed intramedullary femoral nail posing a complication after the procedure. The nursing intervention is the physical therapy where the nurse keeps the patient with involved joint at rest to maintain a functional position and perform Passive Range of Motion (PROM) where the body parts are moved within the available range without muscle activation (Martinez de Albornoz, Khanna, Longo, Forriol, & Maffulli, 2011). It is monitored by keeping into account the movement range of the patient and pain management.

Pudendal nerve injury is another main complication that is associated with the fracture surgery where there is static interlocking in the femur nailing. This neurologic injury is a combination of direct compression and localized ischaemia of perineum against post fracture countertraction. In this, there is branching of sensory terminals of pudendal nerve that appear susceptible to injury causing complications after the surgery. It is an important and common complication after intramedullary femur nailing that might result in complete sensory loss. The nursing intervention involves pain management and medical interventions. Nurses would reduce the pudendal nerve irritability through lifestyle changes. They would perform sitting modification, avoidance of physical activities that irritate nerves, bladder and bowel management help to prevent straining of nerves and its compression that might cause nerve irritation. Continuous monitoring and refereeing to a physiotherapist would help to relax the muscles and decrease nerve irritation. Acupunture and psychotherapy can also be helpful for reducing pain and irritation of nerve (Fisher & Lotze, 2011).            

Acute compartment syndrome is a rare but important complication that takes place post femur fracture. It is a highly painful condition when the muscle pressure builds to alarming levels. This can decrease flow of blood preventing oxygen and nourishment from reaching muscle and nerve cells. The pressure need to be released or else can cause permanent disability. This requires surgery when the surgeon makes incisions in the muscle coverings and skin to relieve pressure (Kalyani, Fisher, Roberts, & Giannoudis, 2011). The  nursing intervention involves pain management by medications like epidural analgesia to relieve pain. Multimodal approach that includes use of non-steroidal anti-inflammatory drug (NSAID) and paracetamol along with an opioid considered best after pressure release through surgery. Patient education is also required before discharge after pressure release surgery by nurses for predisposition to this syndrome. The monitoring involves evaluation of any medication side effects and compartment pressure that should be less than 15mmHg via single pressure readings or continuous pressure monitoring.

Intramedullary nailing

Heterotopic ossification(HO)

In HO, there might be complications related to skin and musculoskeletal system where there might be problems regarding osteomyelitis and skin pressures. Skin complications can occur due to immobility, changes in flow of blood, improper positioning, venous stasis vasomotor tone loss and hypoxia. Contractures, muscle atrophy, osteoporosis, HO and spasticity can also occur due to immobility, joint stiffness, muscle atrophy, weakness and much more.

Nursing intervention

Rationale

Treatment for spasticity

Physical, medicine and drug therapy

It is done to promote mobility, manage leg weakness, allowing the patient to stand and provide strength. It would also provide manual dexterity by improving muscle therapy and functioning.  

Passive Range of Motion (PROM)

As movement is restricted in the patient, it provides exercise options for the, in enhancing mobility. It is done to provide a range of motion exercises that aid in movement and reduction of stiffness. It improves circulation and muscle strength along with maintenance of flexibility and pain management.

Controlling of parameters

Temperature, fatigue, anxiety, decubitus ulcers also checked as the patient has minimum mobility and can be prone to spasticity.

Repositioning of the patient

It is important at every 2 hours to avoid irritation or rubbing of skin and to avoid remaining of the patient at one position for a long time.

Patient education

It is also important for patient and families by instructing them ROM exercises to watch for potential complication signs in OH and prevent pressure sores (Mavrogenis, Soucacos, & Papagelopoulos, 2011).

Monitoring

Rationale

Serum C-reactive protein levels and pain level

It is important to monitor this protein level to check for inflammation reaction that can potentially occur in OH.  

Serial bone scans 

It is done to monitor the metabolic activity of OH and fix time for surgical resection in cases of postoperative complication and resurgence.

This nerve is stretched, damaged or can cause permanent neuropathy in the patient. There can be irreversible nerve damage that can cause impaired mobility and stretch injury  and permanent damage.

Nursing intervention

Rationale

Physical therapy

Kegal exercise should be avoided as it affects pelvic floor that is already tight and this exercise makes it tighter.  Until the symptoms of pudendal nerve injury is not treated, it is important to avoid it.

This is required to avoid further nerve damage and irritation. This is also important to check as it can lead to permanent nerve damage (Montoya, Calver, Carrick, Prats, & Corton, Anatomic relationships of the pudendal nerve branches. , 2011).

Lifestyle modifications

There should be avoidance of bending, sitting, avoiding of exercises and only follow approved exercises along with bicycling that help to prevent permanent nerve damage.

This is important to prevent recurrence of nerve damage that can cause irreversible damage leading to impaired mobility (Montoya, Calver, Carrick, Prats, & Corton, 2011).

Bladder and bowel movement management

It can cause stretch injury as straining during constipation causes damage of pudendal nerve. Patient should drink prune juice, organic whole grain high fibre, black-eyed peas and psyllium husk to avid constipation.

This is a potential thing to avoid in pudendal nerve injury as it causes straining during constipation. This can further increase damage of nerve and cause irritation that might result in permanent nerve damage.  

Pain management

It is important to take care as manipulation in connective tissue and nerve can constrict nerve impairment.

This includes conservative management of pain through medications and rating of pain on the scale from 1 to 10.

Medication management

It is also important as it is considered a gold standard and first line of treatment that manages its symptoms.

Superior Hypogastric Block is used to treat pain in the pelvic region where a thin needle is inserted through fluoroscopy in skin and then advanced to L5 location of vertebra of superior hypogastric plexus to decrease the pain by 70% (Masata, Hubka, & Martan, 2012).

Monitoring

Rationale

Pain monitoring

It is important for the nurses to monitor pain through Nerve Integrity Monitoring System (NIMS, Medtronics) that helps to prevent pain impulses and risk for central sensitization and release pain syndrome. It also prevents fibroblasts prevention and risk for scar formation.

Acute compartment syndrome is surgical emergency that can cause permanent nerve damage and causes severe injury. This cam cause permanent damage of muscles and can prevent oxygen and nourishment to reach muscles and nerve causing permanent loss of nerve sensation.

Nursing

Rationale

Multimodal approach

Opoids and NSAIDS along with paracetamol are used to manage pain in the patients. Paracetamol, NSAID and IV morphine is given at 0.1-0.2mg/Kg titrated is given to the patient.

This helps to reduce pain in the patient for traumatic pain that decreases with surgery time. Pain is managed through controlled steps that help to adjust the dose of morphine use as opioids for the pain management (Waterman, Laughlin, Kilcoyne, Cameron, & Owens, 2013).

Patient education

In this, one need to know about the various symptoms of this syndrome so that they can immediately report in case of severe complications that might require surgery and failing can cause permanent nerve damage.

It is important to understand the reoccurrence and study of complications that need to be looked for after the surgery for acute compartment syndrome. It is also important to improve their health behaviour by keeping a check on their improvement and prevent reoccurrence of this complication.

Monitoring

Rationale

Side effects of medication

This multimodal approach causes many potential side effects that can affect the patient and adverse the complicated situation. Side effects are renal toxicity, gastric ulceration, platelet aggregation inhibition that can cause hemorrhagic complications. This can aggravate the complication of acute compartment syndrome.

Nurses have to monitor the potential side effects of multimodal approach to avoid high risk for further trauma injuries, increased risk for potential side effects of medication therapy that might affect the patient and deteriorate the condition.

Pressure monitoring

It is an invasive procedure that has an huge impact on the patient having acute compartment syndrome following fracture surgery. The pressure should be below 15 mmHg to avoid complications. It is done through single pressure readings, fibreoptic transducer (camino-catheter) which is simple and reliable.

Nurses have to keep monitoring the compartment pressure as it can cause complications like inflammation, swelling, and blood supply loss in muscles, muscle scarring, loss of function and contracture. Therefore, it is important to monitor the pressure levels.

Aubut, J. A., Mehta, S., Cullen, N., Teasell, R. W., & Team, G. t. (2011). A comparison of heterotopic ossification treatment within the traumatic brain and spinal cord injured population: an evidence based systematic review. NeuroRehabilitation, 151-160.

Botolin, S., Mauffrey, C., Hammerberg, E. M., Hak, D. J., & Stahel, P. F. (2013). Heterotopic ossification in the reaming tract of a percutaneous antegrade femoral nail: a case report. Journal of medical case reports, 90.

Fisher, H. W., & Lotze, P. M. (2011). Nerve injury locations during retropubic sling procedures. . International urogynecology journal, 439-441.

Gelalis, I. D., Politis, A. N., Arnaoutoglou, C. M., Korompilias, A. V., E., P. E., Vekris, M. D., & ... & Xenakis, T. A. (2012). Diagnostic and treatment modalities in nonunions of the femoral shaft. A review. Injury, 980-988.

Kaiser, M. M., Wessel, L. M., Zachert, G., Stratmann, C., Eggert, R., Gros, N., & ... & Rapp, M. (2011). Biomechanical analysis of a synthetic femur spiral fracture model: influence of different materials on the stiffness in flexible intramedullary nailing. . Clinical Biomechanics, 592-597.

Kalyani, B. S., Fisher, B. E., Roberts, C. S., & Giannoudis, P. V. (2011). Compartment syndrome of the forearm: a systematic review. The Journal of hand surgery, 535-543.

Kong, H., & Sabharwal, S. (2014). External fixation for closed pediatric femoral shaft fractures: where are we now?. Clinical Orthopaedics and Related Research, 3814-3822.

Kulshrestha, V., Roy, T., & Audige, L. (2011). Operative versus nonoperative management of displaced midshaft clavicle fractures: a prospective cohort study. Journal of orthopaedic trauma, 31-38.

Martinez de Albornoz, P., Khanna, A., Longo, U. G., Forriol, F., & Maffulli, N. (2011). The evidence of low-intensity pulsed ultrasound for in vitro, animal and human fracture healing. . British medical bulletin.

Masata, J., Hubka, P., & Martan, A. (2012). Pudendal neuralgia following transobturator inside-out tape procedure (TVT-O)—case report and anatomical study. International urogynecology journal, 505-507.

Mavrogenis, A. F., Soucacos, P. N., & Papagelopoulos, P. J. (2011). Heterotopic ossification revisited. . Orthopedics, 177-177.

Montoya, T. I., Calver, L., Carrick, K. S., Prats, J., & Corton, M. M. (2011). Anatomic relationships of the pudendal nerve branches. American journal of obstetrics and gynecology, 504-e1.

Park, S. S., Noh, H., & Kam, M. (2013). Risk factors for overgrowth after flexible intramedullary nailing for fractures of the femoral shaft in children. Bone Joint, 254-258.

Smith, E. B., Parvizi, J., & Purtill, J. J. (2011). Delayed surgery for patients with femur and hip fractures—risk of deep venous thrombosis. Journal of Trauma and Acute Care Surgery , E113-E116 .

Waterman, C. B., Laughlin, C. M., Kilcoyne, C. K., Cameron, K. L., & Owens, L. B. (2013). Surgical treatment of chronic exertional compartment syndrome of the leg: failure rates and postoperative disability in an active patient population. JBJS, 592-596.

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