Fracture Repairs

A cracking good time

Fracture repairs is a broad category that can range from a simple, non-displaced break, to complex, open fractures. Each one needs to be treated individually and sometimes may not requrie surgical intervention instead opting for immobilising dressings, or may be so severe that it could instead require an amputate. For all of these though, pain management should be a key consideration when nursing the patient. Pain scoring can be a useful tool for these patients at all stages of their care.

BASICS

IV cannula
Clippers
ET tube (+/- Intubeaze for feline patients)
Skin scrub (I use Hibiscrub at a 50:50 dilution with warm water for initial prep, then a large ChloraPrep for final prep)
Orthopaedic kit (check what form of fixation is required e.g external fixation kit, plates, pins etc.)
Analgesia (NSAID, paracetamol - canines only, fentanyl/ketamine)
Intra-operative antibiotics (if appropriate)
IV fluidsk

EVEN BETTER WITH

Local nerve block
Constant rate infusions (CRI)
Electrocautery (if available)
Active warming (e.g. Bair Hugger)

YOU MAY WANT

Urinary catheter (if patient mobility post-op will be a concern)

The procedure and nursing considerations

Fractures can occur or a number of different reasons such as pathalogical changes such as cancer, but most commonly they are due to traumatic events such as falls or road traffic incidents. It is important to stabilise patients prior to fracture repairs as shock can be common with traumatic episodes. Ideally, we would always complete thorough assessments including x-rays, scans, and bloods to ensure that a complete overview of the patient's injuries has been performed before performing surgery in these situations.

Ensure the patient is on a heat pad with blankets and is pre-oxygenated prior to intubation. If it is a cat, make sure that they are given a full 30-90 seconds between giving Intubeaze and intubating to avoid risk of trachaeal irritation.

The location of the fracture will obviously impact on where you are clipping and prepping for surgery. It is always better to give a large clip patch, but it is important to discuss location of incisions with the surgeon prior to clipping. Clip away the fur using size 40 blade clippers and clean the surgical site with your scrub of choice. Sometimes it is useful to have a dedicated vacuum to remove fur from the surgical site prior to scrubbing. If you are needing to clean feet and between digits, I like to partially fill a glove with my scrub mix and put the foot into the glove. I can then ensure that the whole foot has been soaked and I can easily get cleaning scrub in and around toes and under nails. It can be useful to trim down any nails at this stage too, especially if the patient is not going to be using the limb fully for a while.

It can be useful to place a urinary catheter at this point too, espeically if it is due to be a long surgery and the patient is on fluids as we want to keep the patient as warm and dry as possible throughout and often they can urinate on themselves during anaesthesia. If the patient is due to be immobile for an extended amount of time after surgery, this is useful to be left in too, to prevent urine scalds.

Depending on the location of the frature repair, local nerve blocks can be performed to help reduce sensation in the limb. There are various blocks available for most areas, so this is always worth considering. I usually use bupivicaine for this (1-2mg/kg in canines, MAX 1mg/kg in felines) as it has a relativly quick onset and a long duration of effect.

Ensure that the patient has recieved analgesia prior to surgery starting, usually paracetamol (in canines only) at a higher dose is a good addition (10-20mg/kg slow IV). If you are using a CRI, it is worth getting the loading dose on board at this point so that the CRI can get started and on board before surgery begins. I like fentanyl for any orthopaedic procedures (loading dose of 2.5ug/kg slow IV followed by CRI of 2.5ug-10ug/kg/hr during anaesthesia), but be mindful that it is a respiratory depressant and can cause bradycardia, so IPPV and anticholinergics may be needed.

Move the patient to the surgical table and postion where most appropriate for the surgery. If you have use of a vacuum mat, then these can be great to keep patients warm , supported, and stable throughout the surgery. Fracture repairs can be lengthy procedures, especially the more difficult ones, so I would always recommend using active warming devices such as Bair Huggers to keep them warm. It is advised to wait until the patient is fully draped before turning on forced air warming devices. Then give another scrub and prep the area using a final cleaning stage e.g. ChloraPrep.

If there is a lot of kit, it can be useful to have a second person around to open the kit for the surgeon whilst you monitor the anaesthetic.

The surgeon can then perform the fracture repair.

I would always make sure that your patient is on IV fluids throughout the surgery (surgical maintenance rate is 5ml/kg/hr in canines and 3ml/kg/hr in felines) to help with blood pressure and have bolus rates prepared and written down in case of a bleed.

Hopefully the analgesic medications will already be on board and you should be able to have a smooth, pain free surgery. If the patient is on a CRI or has recieved high doses of analgesics, remember you may need a lower amount of anaesthetic gas to keep your patient asleep. Medications such as ketamine can have anaesthetic properties so be mindful of patient depth throughout.

If using antibiotics for the patient, check the frequency of when these should be given. Cefuroxime is commonly used in orthopaedic surgeries and is commonly given prior to incision and then at 90 minute intervals throughout until closure, but this should be confirmed with your surgeon.

Remember to lubricate the eyes during surgery and on recovery to reduce risks of corneal ulcers forming.

In recovery, it is advised to continue the pain relief and wean the patient down it before stopping - this is especially important when using CRIs and can aid in a much more gentle recovery for them too.

Disclaimer:

The information on this website is for reference and education, and any medications and doses should be prescribed by your veterinary surgeon before giving. All patients should be assessed individually and treated as such.