Summary
# Fracture assessment and treatment
Fracture assessment and treatment involves understanding the signs and symptoms of bone breaks, factors influencing healing, and various therapeutic interventions, including specialized approaches for vertebral and hip fractures.
## 1. Fracture assessment and treatment
### 1.1 Signs and symptoms of a fracture
Fractures typically present with several key signs and symptoms:
* **Pain:** Often sharp and localized to the fracture site, worsening with movement.
* **Swelling:** Edema around the injured area due to inflammation and bleeding.
* **Bruising (ecchymosis):** Discoloration of the skin resulting from extravasation of blood. A "Griesel's sign" or "brilhematoom" (periorbital bruising) can indicate a basilar skull fracture.
* **Deformity:** Visible or palpable abnormality in the shape of the limb or bone.
* **Loss of function:** Inability to use the affected limb or body part.
* **Crepitus:** A grating or crackling sensation or sound produced when broken bone ends rub together.
* **Tenderness:** Exquisite pain upon palpation of the fracture site.
* **Open wounds:** In cases of open (compound) fractures, the bone may be exposed through the skin.
### 1.2 Factors influencing fracture healing
Several factors can either promote or impede the natural healing process of a bone fracture:
* **Patient-related factors:**
* **Age:** Younger individuals generally heal faster.
* **Nutrition:** Adequate intake of calcium, vitamin D, and protein is crucial.
* **Systemic diseases:** Conditions like diabetes mellitus, osteogenesis imperfecta, and hormonal imbalances can affect healing.
* **Smoking:** Nicotine impairs blood supply and osteoblast activity, slowing healing.
* **Medications:** Steroids and certain chemotherapy agents can hinder healing.
* **Alcohol abuse:** Chronic alcohol consumption can negatively impact bone metabolism.
* **Fracture-related factors:**
* **Type and severity of fracture:** Comminuted or unstable fractures take longer to heal.
* **Displacement:** Significantly displaced fractures require more complex reduction and immobilization.
* **Blood supply:** Disruption of blood supply to the fracture fragments (e.g., in scaphoid fractures or subcapital hip fractures) can lead to non-union.
* **Soft tissue injury:** Extensive soft tissue damage at the fracture site can compromise healing.
* **Treatment-related factors:**
* **Immobilization:** Inadequate or premature removal of immobilization devices.
* **Infection:** Osteomyelitis significantly delays healing and can lead to non-union.
* **Surgical intervention:** The choice and technique of surgical fixation play a role.
### 1.3 Treatment of fractures
The treatment of fractures is highly individualized and depends on a multitude of factors, including:
* **Type of fracture:** Simple, comminuted, spiral, oblique, transverse, greenstick, etc.
* **Location of fracture:** Specific bone, involvement of joints.
* **Degree of displacement and angulation.**
* **Patient's age, overall health, and activity level.**
* **Presence of associated injuries (e.g., neurovascular compromise, soft tissue damage).**
* **Presence of open wounds (risk of infection).**
The primary goals of fracture treatment are:
1. **Reduction:** Restoring the alignment of the bone fragments to their anatomical position. This can be achieved through closed reduction (manipulation without surgery) or open reduction (surgical realignment).
2. **Immobilization:** Maintaining the reduced position to allow for bone healing. This is typically achieved with casts, splints, braces, or internal/external fixation devices.
3. **Rehabilitation:** Restoring function and range of motion through physical therapy.
#### 1.3.1 Surgical techniques for fracture treatment
Various surgical techniques are employed to treat fractures when conservative methods are insufficient or inappropriate:
* **Open reduction and internal fixation (ORIF):** Involves surgical exposure of the fracture, realignment of the fragments, and stabilization with implants such as plates, screws, rods (intramedullary nails), or wires.
* **Intramedullary nailing:** A rod is inserted into the medullary canal of long bones (e.g., femur, tibia) to stabilize the fracture from within.
* **External fixation:** A frame is applied to the outside of the body, with pins or wires passing through the skin and bone fragments to provide stability. This is often used for complex, open, or unstable fractures.
* **Joint arthrodesis (fusion):** In cases of severe joint damage or instability due to fracture, the bones forming the joint may be surgically fused to create a stable, immobile joint. This is indicated when joint preservation is not possible or desirable due to pain or instability.
#### 1.3.2 Pseudarthrosis
Pseudarthrosis, or non-union, refers to the failure of a fractured bone to heal within the expected timeframe. It is characterized by the formation of a false joint at the fracture site, often associated with persistent pain and instability. Causes include poor blood supply, infection, inadequate immobilization, and significant gap between bone fragments. Treatment may involve surgical intervention to promote bone healing, such as bone grafting or revision fixation.
### 1.4 Specific fracture considerations
#### 1.4.1 Vertebral fractures
Vertebral fractures can range from stable compression fractures to unstable burst fractures that can compromise the spinal cord.
* **Treatment considerations:**
* **Stable fractures:** May be managed conservatively with bracing and pain management.
* **Unstable fractures:** Require surgical intervention for stabilization and decompression if neurological deficits are present. Techniques may include vertebroplasty or kyphoplasty (minimally invasive procedures to inject bone cement), or spinal fusion with instrumentation.
* **Risk factors:** Osteoporosis, trauma, tumors.
#### 1.4.2 Hip fractures
Hip fractures, particularly subcapital fractures of the femoral head, pose significant morbidity and mortality, especially in the elderly.
* **Subcapital hip fracture surgical treatment:**
* **Internal fixation:** For minimally displaced fractures, screws or a sliding hip screw with a plate may be used to fix the fracture in place, allowing the patient to bear weight sooner.
* **Hemiarthroplasty:** If the femoral head is significantly displaced or the blood supply is compromised, the femoral head is replaced with a prosthesis.
* **Total hip arthroplasty (THA):** In cases of pre-existing osteoarthritis of the hip or severe acetabular involvement, both the femoral head and the acetabulum are replaced.
* **Factors influencing choice of treatment:** Degree of displacement, fracture pattern, patient's age and mobility, presence of pre-existing arthritis.
* **Types of hip prostheses:**
* **Unipolar vs. Bipolar hemiarthroplasty:** Differentiate based on the articulation within the acetabulum.
* **Total hip replacement:** Consists of a femoral stem, femoral head, acetabular cup, and liner.
#### 1.4.3 Scaphoid fracture
The scaphoid bone in the wrist is prone to fracture, often due to a fall on an outstretched hand. Due to its precarious blood supply, scaphoid fractures have a high risk of non-union and avascular necrosis, especially when located in the waist or proximal pole. Treatment depends on the fracture pattern and displacement, ranging from conservative casting to surgical fixation with screws or bone grafting.
#### 1.4.4 Rib fractures and flail chest
Rib fractures can cause significant pain and impair breathing.
* **Risks:** Pneumothorax, hemothorax, pulmonary contusion, and pneumonia.
* **Flail chest:** A condition where a segment of the rib cage is fractured in multiple places, leading to paradoxical chest wall movement during respiration, severe pain, and respiratory compromise. Management may involve pain control, mechanical ventilation, and sometimes surgical fixation.
#### 1.4.5 Pelvic fractures
Pelvic fractures can be associated with significant bleeding and damage to pelvic organs.
* **Risks:** Hemorrhage, bladder and bowel injuries, nerve damage, long-term pain and disability.
* **Treatment:** Ranges from conservative management for stable fractures to surgical stabilization for unstable fractures.
#### 1.4.6 Knee fracture leading to inability to extend
If a patient cannot extend their knee after a trauma, it strongly suggests a fracture involving the patella (kneecap) or the distal femur. A patellar fracture disrupts the extensor mechanism.
#### 1.4.7 Luxation (Dislocation)
A luxation, or dislocation, occurs when the bones forming a joint are forcibly separated from their normal alignment. This results in joint instability, pain, and loss of function. Treatment involves reduction of the dislocation, followed by immobilization and rehabilitation.
#### 1.4.8 Hand tendon injuries
Tendon injuries in the hand, such as extensor or flexor tendon ruptures or lacerations, require precise surgical repair to restore function. Post-operative immobilization and physiotherapy are critical for successful outcomes.
### 1.5 Other trauma-related concepts mentioned (for context but not direct fracture treatment)
While not directly fracture treatments, the following concepts from the document are relevant in a trauma assessment context:
* **Epidural vs. Subdural hematoma:**
* **Epidural hematoma:** Bleeding between the dura mater and the skull, often caused by arterial tear, characterized by a "lucid interval" where the patient may regain consciousness after initial trauma before deteriorating.
* **Subdural hematoma:** Bleeding between the dura mater and the arachnoid mater, often caused by venous tear, typically presents with a more gradual decline in consciousness.
* **Discus hernia (Herniated disc):** Protrusion of the nucleus pulposus of an intervertebral disc, which can compress spinal nerves causing pain, numbness, or weakness. Treatment can include conservative measures or surgical intervention.
* **Carpal tunnel syndrome:** Compression of the median nerve at the wrist, leading to numbness, tingling, and pain in the hand.
* **Atheromatosis (Atherosclerosis):** The buildup of plaque within arteries, leading to narrowing and reduced blood flow.
* **Treatment techniques:** Endarterectomy (surgical removal of plaque), embolectomy (removal of blood clots), and endovascular techniques (angioplasty and stenting).
* **CABG (Coronary Artery Bypass Grafting):** A surgical procedure to improve blood flow to the heart muscle by bypassing blocked coronary arteries with grafts.
* **Pneumothorax:** Air in the pleural space, causing lung collapse. Management includes observation, needle decompression, or chest tube insertion.
This summary focuses on fracture assessment and treatment as per the specified document content and pages.
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# Surgical interventions and trauma management
This section delves into surgical approaches, contrasting minimally invasive techniques with traditional open surgery, and examines trauma-related conditions including hematomas and fractures.
### 1.1 Surgical approaches
The document discusses two primary surgical approaches: minimally invasive surgery and classical surgery.
#### 1.1.1 Minimally invasive surgery
Minimally invasive surgery (MIS) offers several advantages over classical surgical interventions. These benefits often include:
* Reduced tissue trauma
* Smaller incisions
* Less postoperative pain
* Shorter hospital stays
* Faster recovery times
* Lower risk of infection
#### 1.1.2 Classical surgery
Classical surgery, also known as open surgery, involves larger incisions to directly access the surgical site. While it has been the standard for many procedures, it typically entails longer recovery periods and a higher risk of complications compared to MIS.
### 1.2 Trauma management: Fractures
Fractures are a common consequence of trauma, involving the disruption of bone continuity.
#### 1.2.1 Symptoms of a fracture
The primary symptoms of a fracture include:
* Pain at the fracture site
* Swelling
* Bruising (ecchymosis)
* Deformity of the limb or affected area
* Loss of function of the affected part
* Crepitus (a grating sensation or sound when the broken ends of the bone rub together)
* Tenderness upon palpation
#### 1.2.2 Factors affecting fracture healing
Several factors can impede or slow down the healing process of a fracture:
* **Age:** Older individuals generally heal slower.
* **Nutrition:** Poor nutritional status, especially deficiencies in calcium, vitamin D, and protein, can hinder healing.
* **Blood supply:** Compromised blood flow to the fracture site, due to the fracture itself or external factors, will slow healing.
* **Infection:** Bacterial infection at the fracture site is a significant impediment to healing.
* **Type of fracture:** Some fractures, such as those with significant displacement or comminution (bone broken into multiple pieces), heal more slowly.
* **Medications:** Certain medications, like corticosteroids, can negatively impact bone healing.
* **Underlying medical conditions:** Conditions like diabetes mellitus or peripheral vascular disease can impair healing.
* **Smoking:** Nicotine constricts blood vessels, reducing blood flow and oxygen delivery to the healing bone.
* **Immobilization:** Inadequate or excessive immobilization can affect healing.
#### 1.2.3 Factors influencing fracture treatment
The management of fractures depends on a variety of factors:
* **Patient's age and overall health:** These influence the body's ability to heal and tolerate surgical interventions.
* **Type and location of the fracture:** Different bones and fracture patterns require specific treatment approaches.
* **Severity of the fracture:** Displacement, comminution, and involvement of joints are critical considerations.
* **Presence of associated injuries:** Neurovascular compromise or soft tissue damage can dictate treatment.
* **Patient's activity level and functional demands:** Treatment aims to restore function appropriate to the patient's lifestyle.
#### 1.2.4 Surgical techniques for fracture treatment
Surgical techniques aim to stabilize the fracture, promote healing, and restore alignment and function. These include:
* **Open reduction and internal fixation (ORIF):** Involves surgically exposing the fracture, reducing the fragments into alignment, and fixing them with implants like plates, screws, or rods.
* **Intramedullary nailing:** A rod is inserted into the medullary canal of long bones to provide internal support.
* **External fixation:** Pins are inserted into the bone fragments and connected to an external frame, providing stability without internal implants.
* **Joint replacement:** For severe joint fractures, such as those involving the hip or knee, prosthetic implants may be used.
#### 1.2.5 Pseudarthrosis
Pseudarthrosis refers to the failure of a fracture to heal, resulting in a false joint. This can occur when there is insufficient stability, poor blood supply, or infection. It is characterized by persistent pain and instability at the fracture site.
#### 1.2.6 Arthrodesis
Arthrodesis, also known as joint fusion, is a surgical procedure that fuses two or more bones together to eliminate movement at a joint. This is typically performed to relieve pain and improve stability in cases of severe arthritis, instability, or when other reconstructive procedures have failed.
#### 1.2.7 Treatment of vertebral fractures
Treatment for vertebral fractures varies widely based on the type and severity of the fracture, the presence of neurological deficits, and spinal stability. Options include:
* **Conservative management:** Bracing, rest, and pain management for stable, non-displaced fractures.
* **Minimally invasive techniques:** Vertebroplasty or kyphoplasty, where bone cement is injected into the fractured vertebra to stabilize it.
* **Surgical stabilization:** For unstable fractures or those with neurological compromise, spinal fusion with instrumentation (rods and screws) may be necessary.
#### 1.2.8 Scaphoid fracture
A scaphoid fracture is a fracture of the scaphoid bone, one of the carpal bones in the wrist. These fractures can be notoriously difficult to diagnose and treat due to the scaphoid's limited blood supply, which can lead to non-union (pseudarthrosis) and avascular necrosis (bone death). Symptoms include wrist pain, swelling, and tenderness, particularly in the anatomical snuffbox. Treatment depends on the fracture location and displacement, ranging from casting to surgical fixation.
#### 1.2.9 Tibial plateau fracture
A fracture of the tibial plateau, the weight-bearing surface of the tibia at the knee joint, often results from high-energy trauma. Symptoms include knee pain, swelling, inability to bear weight, and potential deformity. Management depends on the fracture pattern and degree of displacement, often requiring surgical intervention to restore articular congruity and stability, frequently involving ORIF or arthroplasty.
#### 1.2.10 Fractures of the patella
Patellar fractures involve a break in the kneecap. They can be caused by direct impact to the knee or by forceful quadriceps contraction. Symptoms include pain, swelling, difficulty straightening the leg, and a palpable gap if the patella is significantly displaced. Treatment depends on the fracture pattern and degree of displacement, ranging from conservative management with immobilization to surgical fixation with tension bands, screws, or plate fixation, or even patellectomy in severe cases.
#### 1.2.11 Bone fractures around the knee
Fractures around the knee joint, including distal femur fractures and proximal tibia fractures (tibial plateau fractures), are significant injuries that can compromise knee function. The inability to extend the knee after trauma can indicate a fracture of the patella, distal femur, or proximal tibia, or a significant soft tissue injury like a quadriceps rupture. Surgical management is often necessary to restore joint congruity and stability.
#### 1.2.12 Hip fractures
Hip fractures are common, especially in the elderly, and can significantly impact mobility and quality of life.
##### 1.2.12.1 Subcapital hip fracture
A subcapital hip fracture occurs at the femoral neck, just below the head of the femur. Surgical treatment is almost always required.
* **Internal fixation:** For non-displaced or minimally displaced fractures, screws or a dynamic hip screw (DHS) can be used to fix the fracture.
* **Hemiarthroplasty:** If the fracture is significantly displaced or the blood supply to the femoral head is compromised, the femoral head is replaced with a prosthetic component.
* **Total hip arthroplasty:** In cases of severe comminution, pre-existing arthritis, or when both the femoral head and acetabulum are involved, a total hip replacement may be performed.
The choice of surgical intervention depends on the fracture pattern, patient's age, activity level, and bone quality.
##### 1.2.12.2 Types of hip prostheses
Hip prostheses used in total hip arthroplasty typically consist of:
* **Femoral stem:** Made of metal, it is inserted into the femoral shaft.
* **Femoral head:** Made of ceramic or metal, it articulates with the acetabular cup.
* **Acetabular cup:** A shell, often lined with polyethylene or ceramic, that replaces the socket of the hip joint.
* **Bearing surfaces:** These are the materials that come into contact, such as metal-on-polyethylene, ceramic-on-polyethylene, or ceramic-on-ceramic. Each has different wear rates and risks of complications.
#### 1.2.13 Luxation (Dislocation)
A luxation, or dislocation, is the complete displacement of the bones in a joint, where the articular surfaces no longer make contact. This is a traumatic event that often results in significant pain, deformity, and loss of function. Treatment involves reduction (putting the bones back into place), followed by immobilization and rehabilitation.
#### 1.2.14 Hand tendon injuries
Tendon injuries in the hand, whether flexor or extensor tendons, require careful management to restore function.
* **Treatment:** Generally involves surgical repair to reapproximate the torn ends of the tendon. This is often followed by a period of protected motion, using splinting or dynamic bracing, to allow healing while preventing adhesions and ensuring optimal tendon gliding.
### 1.3 Trauma management: Specific conditions
#### 1.3.1 Hematomas
Hematomas are collections of blood outside of blood vessels, typically resulting from trauma.
##### 1.3.1.1 Intracranial hematomas
Intracranial hematomas are bleeding within the skull.
* **Epidural hematoma:** A collection of blood between the dura mater and the skull. These are often associated with skull fractures, particularly temporal bone fractures, and arterial bleeding. A characteristic feature is a **lucid interval**, a period of consciousness following initial loss of consciousness, before neurological deterioration.
* **Subdural hematoma:** A collection of blood between the dura mater and the arachnoid mater. These are often associated with venous bleeding and can be acute, subacute, or chronic. They may not always be associated with a skull fracture.
##### 1.3.1.2 Periorbital hematoma ("raccoon eyes")
A periorbital hematoma, characterized by bruising around the eyes (often described as "raccoon eyes"), is a significant sign of potential head injury. Its presence typically indicates a fracture of the anterior cranial fossa or the ethmoid bone, suggesting a potential base of skull fracture.
#### 1.3.2 Rib fractures
Rib fractures are common injuries resulting from blunt chest trauma.
* **Risks:** Significant rib fractures can lead to complications such as:
* **Pneumothorax:** Air in the pleural space, causing lung collapse.
* **Hemothorax:** Blood in the pleural space.
* **Pulmonary contusion:** Bruising of the lung tissue.
* **Flail chest:** A segment of the chest wall becomes detached, moving paradoxically with respiration (inward during inspiration, outward during expiration), leading to significant respiratory compromise.
* **Treatment:** Pain management is crucial to allow for deep breathing and coughing, preventing pneumonia. Severe cases may require surgical stabilization.
#### 1.3.3 Pelvic fractures
Pelvic fractures can range from minor avulsions to severe, life-threatening injuries involving significant bleeding and organ damage.
* **Risks:** Pelvic fractures carry a high risk of:
* **Hemorrhage:** The pelvis is highly vascular, and fractures can lead to substantial internal bleeding, potentially causing hypovolemic shock.
* **Urogenital injuries:** Damage to the bladder, urethra, or reproductive organs.
* **Nerve damage:** Injury to the sacral nerves.
* **Long-term sequelae:** Chronic pain, gait abnormalities, and sexual dysfunction.
* **Treatment:** Management depends on the stability and severity of the fracture. It can range from bed rest and external fixation for stable fractures to pelvic packing, embolization of bleeding vessels, and ORIF for unstable fractures.
### 1.4 Burns management
Burns are injuries to the skin and underlying tissues caused by thermal, chemical, electrical, or radiation energy.
#### 1.4.1 Causes of burns
* **Thermal:** Flames, hot liquids, steam, hot objects, friction.
* **Chemical:** Acids, alkalis, solvents, oxidizers.
* **Electrical:** Direct contact with electrical current.
* **Radiation:** Sunburn, radiation therapy.
#### 1.4.2 Classification of burns
Burns are classified by depth:
* **First-degree:** Superficial, involving only the epidermis. Redness, pain, no blisters.
* **Second-degree (partial-thickness):** Involves epidermis and dermis. Characterized by blistering, redness, pain, and may be superficial or deep partial-thickness.
* **Third-degree (full-thickness):** Involves epidermis, dermis, and subcutaneous tissue. Appears dry, leathery, and may be painless due to nerve damage.
* **Fourth-degree:** Extends into deeper tissues, including muscle, bone, or fascia.
#### 1.4.3 Determining burn extent
The extent of a burn is crucial for treatment decisions and fluid resuscitation. Methods include:
* **Rule of Nines:** Divides the body into areas representing 9% or multiples thereof (e.g., entire arm is 9%, anterior trunk is 18%).
* **Lund-Browder chart:** A more accurate method, especially for children, that accounts for variations in body proportions.
* **Palmar method:** The patient's palm (excluding fingers) represents approximately 1% of their total body surface area.
#### 1.4.4 Importance of burn localization
The location of a burn is critical because:
* **Functional impairment:** Burns over joints, hands, feet, face, or genitalia can lead to significant functional loss and cosmetic deformity.
* **Airway compromise:** Burns to the face or neck, especially with associated inhalation injury, pose an immediate threat to the airway.
* **Pressure points:** Burns in areas susceptible to pressure can impede circulation and healing.
#### 1.4.5 Referral to a burn center
Referral to a specialized burn center is recommended for:
* Full-thickness burns.
* Partial-thickness burns greater than 10% of the total body surface area (TBSA) in children or elderly patients.
* Partial-thickness burns greater than 15-20% TBSA in other age groups.
* Burns involving the face, hands, feet, genitalia, or major joints.
* Electrical or chemical burns.
* Burns with associated inhalation injury.
* Burns in patients with significant comorbidities.
#### 1.4.6 Initial management and first aid
* **Stop the burning process:** Remove the patient from the source of injury.
* **Cool the burn:** Use cool (not cold) running water for 10-20 minutes. Avoid ice.
* **Remove constricting clothing and jewelry:** Swelling can occur rapidly.
* **Cover the burn:** Use a clean, dry dressing or cling film.
* **Assess ABCs (Airway, Breathing, Circulation):** Especially important for facial or circumferential chest burns, and in cases of suspected inhalation injury.
* **Fluid resuscitation:** Crucial for large burns to maintain hemodynamic stability.
#### 1.4.7 Survival chance in burn patients
Survival chances depend on TBSA burned, depth of burns, age, presence of inhalation injury, and comorbidities. The Parkland formula is used to estimate fluid resuscitation needs, which is critical for survival.
#### 1.4.8 Daily nursing care for burn patients
Daily care involves:
* **Wound care:** Daily dressing changes, debridement of non-viable tissue.
* **Pain management:** Aggressive analgesia.
* **Nutritional support:** High-calorie, high-protein diet to support healing.
* **Physical and occupational therapy:** To maintain range of motion and prevent contractures.
* **Psychological support:** Addressing the significant emotional and psychological impact of burns.
* **Monitoring for infection:** Vigilant assessment for signs of infection.
#### 1.4.9 Post-healing problems
After the acute burn wounds have healed, patients may experience:
* **Scarring and contractures:** Leading to functional limitations and cosmetic concerns.
* **Pruritus (itching):** Persistent and bothersome.
* **Allodynia/hyperalgesia:** Increased sensitivity to pain.
* **Psychosocial issues:** Body image concerns, anxiety, depression.
#### 1.4.10 Escharotomy
An escharotomy is a surgical incision made through the full-thickness burn eschar (dead tissue) to relieve constricting pressure. This is performed when circumferential burns impair circulation or breathing, as the inelastic eschar can act like a tourniquet.
#### 1.4.11 Burn imaging techniques
* **Laser Doppler Imaging (LDI):** Assesses blood flow in the microcirculation, helping to differentiate between superficial and deep partial-thickness burns.
* **Thermography:** Measures surface temperature to identify areas of altered blood flow and inflammation.
### 1.5 Drains and drainage systems
Drains are used in surgery and trauma to remove excess fluid, blood, or pus from a surgical site or wound, preventing hematoma formation, seroma, and infection.
#### 1.5.1 Drains requiring extra attention
Wounds with drains require specific attention because:
* **Infection risk:** Drains can serve as a conduit for bacteria to enter the wound.
* **Fluid loss:** Excessive drainage can lead to dehydration and electrolyte imbalance.
* **Pain:** Drains can cause discomfort.
* **Drain blockage:** Clots or kinking can impede drainage and lead to complications.
#### 1.5.2 Types of drains and their drainage capacity
* **Round drain (Penrose drain):** A soft, latex drain that relies on gravity and capillary action for drainage. Its capacity is limited by its diameter and surface area.
* **Multitubular drain:** Consists of multiple small tubes, increasing the surface area for drainage. This can improve drainage efficiency compared to a single round drain of similar overall diameter.
#### 1.5.3 Saratoga drain
A key nursing consideration for Saratoga drains is ensuring the **suction mechanism is maintained** to provide continuous negative pressure, promoting effective drainage.
#### 1.5.4 Redon bottle (Jackson-Pratt drain)
The Redon bottle (or Jackson-Pratt bulb) is a closed-suction system that uses negative pressure to drain fluid.
* **Recognizing vacuum:** The bulb will be compressed and appear inflated when a vacuum is present. If the bulb is fully expanded, the vacuum has been lost.
* **Breaking the vacuum:** To restore the vacuum, the bulb must be squeezed empty of air while the drain outlet is occluded. Then, when the occlusion is released, the bulb re-expands, creating negative pressure.
#### 1.5.5 Nursing adaptations for drainages
Nursing care for drains involves:
* **Monitoring output:** Volume, color, consistency, and odor of drained fluid.
* **Dressing management:** Securing the drain and changing dressings as needed to prevent skin irritation and infection.
* **Maintaining suction:** For closed-suction systems, ensuring the negative pressure is maintained.
* **Assessing the wound:** Monitoring for signs of infection or complications.
* **Patient education:** Explaining the purpose of the drain and how to manage it.
#### 1.5.6 Shortening drains
Drains are often shortened using two Kochers (hemostats) to provide gentle traction and prevent accidental removal or dislodgement, while allowing for precise manipulation during the shortening process.
#### 1.5.7 Removal of chest drains (thoracic drains)
Thoracic drains are typically removed when drainage has significantly reduced and the lung has re-expanded.
* **Nursing considerations:**
* **Patient preparation:** Educate the patient on the procedure and the need to hold their breath or exhale during removal to prevent air from entering the pleural space.
* **Materials:** Have sterile dressings, petroleum jelly gauze, and tape ready.
* **Procedure:** The drain is usually removed during exhalation, and the insertion site is immediately covered with an airtight dressing.
* **Post-removal monitoring:** Observe for signs of pneumothorax, such as shortness of breath or chest pain.
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# Conditions affecting the musculoskeletal and vascular systems
This section details various conditions impacting the musculoskeletal and vascular systems, including dislocations, tendon injuries, hernias, carpal tunnel syndrome, osteoarthritis, and atherosclerosis, along with their treatments.
### 3.1 Musculoskeletal conditions
#### 3.1.1 Dislocations
A dislocation occurs when the bones of a joint are forced out of their normal alignment.
#### 3.1.2 Tendon injuries
Tendon injuries encompass a range of damage to the tough, fibrous cords that connect muscles to bones. Treatment for tendon injuries in the hand often involves surgical repair to restore function.
#### 3.1.3 Hernias
A hernia is a condition where an organ or tissue protrudes through a weak spot in the surrounding muscle or connective tissue.
##### 3.1.3.1 Inguinal hernia
Inguinal hernias are common and occur when tissue bulges through a weak spot in the abdominal muscles in the groin area. Their occurrence, symptoms, potential risks, and recovery are important considerations.
##### 3.1.3.2 Incisional hernia
An incisional hernia, also known as a scar hernia, occurs at the site of a previous surgical incision due to a weakness in the abdominal wall.
#### 3.1.4 Carpal tunnel syndrome
Carpal tunnel syndrome is a condition characterized by compression of the median nerve as it passes through the carpal tunnel in the wrist, leading to symptoms such as pain, numbness, and tingling in the hand and fingers.
#### 3.1.5 Osteoarthritis
Osteoarthritis is a degenerative joint disease where the cartilage that cushions the ends of bones wears down over time, leading to pain, stiffness, and reduced mobility.
### 3.2 Vascular conditions
#### 3.2.1 Atherosclerosis
Atherosclerosis is a condition characterized by the buildup of plaque, a fatty deposit, within the arteries, leading to their narrowing and hardening.
##### 3.2.1.1 Symptoms and risks
The symptoms of atherosclerosis depend on the arteries affected and the severity of the plaque buildup. It significantly increases the risk of cardiovascular events such as heart attack and stroke.
##### 3.2.1.2 Treatment techniques
Various techniques are employed to treat atherosclerosis:
* **Endarterectomy**: This surgical procedure involves removing the thickened inner lining of an artery, along with the accumulated plaque, to restore blood flow.
* **Embolectomy**: This is a surgical or endovascular procedure to remove a blood clot (embolus) from an artery, typically used to restore blood flow after an embolism.
* **Endovascular techniques**: These minimally invasive procedures are performed within the blood vessels. Examples include:
* **Angioplasty**: A balloon catheter is inserted into a narrowed artery and inflated to widen it.
* **Stenting**: A small mesh tube (stent) is placed in the artery after angioplasty to keep it open.
##### 3.2.1.3 Coronary Artery Bypass Grafting (CABG)
CABG is a surgical procedure to improve blood flow to the heart in people with severe coronary artery disease. Healthy blood vessels from other parts of the body are used to bypass the blocked or narrowed coronary arteries.
#### 3.2.2 Aortic aneurysm
An abdominal aortic aneurysm (AAA) is a localized widening or bulging of the aorta in the abdomen.
### 3.3 Conditions affecting both systems
#### 3.3.1 Fractures
A fracture is a break in a bone.
##### 3.3.1.1 Symptoms of a fracture
Symptoms of a fracture can include pain, swelling, bruising, deformity, and the inability to bear weight or use the affected limb.
##### 3.3.1.2 Factors affecting fracture healing
Several factors can impede the healing of a fracture:
* **Age**: Older individuals may heal more slowly.
* **Nutrition**: Inadequate intake of essential nutrients can hinder the healing process.
* **Smoking**: Smoking impairs blood flow and delays bone healing.
* **Certain medical conditions**: Conditions like diabetes can affect healing.
* **Infection**: An infection at the fracture site can severely compromise healing.
* **Medications**: Some medications can interfere with bone healing.
##### 3.3.1.3 Treatment of fractures
The treatment of fractures depends on various factors, including:
* **Type of fracture**: Simple, compound, comminuted, etc.
* **Location of fracture**: Which bone is involved and its specific region.
* **Severity of fracture**: Displacement, angulation, and fragmentation.
* **Patient's age and overall health**: The patient's ability to tolerate surgery and recover.
##### 3.3.1.4 Surgical techniques for fracture treatment
* **Internal fixation**: Using plates, screws, rods, or wires to hold bone fragments together internally.
* **External fixation**: Using pins or screws inserted into the bone and connected to an external frame to stabilize the fracture.
* **Intramedullary nailing**: Inserting a rod into the marrow cavity of a long bone to provide internal support.
##### 3.3.1.5 Pseudarthrosis
Pseudarthrosis is a complication where a fractured bone fails to heal, resulting in a false joint.
##### 3.3.1.6 Arthrodesis
Arthrodesis, also known as joint fusion, is a surgical procedure to permanently join two or more bones in a joint, eliminating movement to relieve pain or stabilize a severely damaged joint.
##### 3.3.1.7 Specific fracture types and considerations
* **Vertebral fractures (fractures of the spine)**: Treatment varies widely depending on the location and severity, ranging from conservative management (bracing, rest) to surgical stabilization.
* **Lucid interval**: This refers to a period of consciousness following a traumatic head injury during which the patient may seem to recover before deteriorating. It is often associated with epidural hematomas.
* **"Brille" hematoma**: The presence of a "brille" hematoma (an eye-shaped bruise around the eye) following trauma strongly suggests a skull fracture, particularly at the base of the skull.
* **Epidural vs. Subdural hematoma**:
* **Epidural hematoma**: Bleeding between the dura mater and the skull, often caused by a skull fracture tearing an artery. It typically has a rapid onset and can be associated with a lucid interval.
* **Subdural hematoma**: Bleeding between the dura mater and the arachnoid mater, usually caused by tearing of veins. It can have a slower onset and is more common in older adults or those with brain atrophy.
* **Rib fractures**: Risks include pneumothorax (collapsed lung), hemothorax (blood in the chest cavity), and flail chest (a segment of the chest wall becomes unstable due to multiple rib fractures).
* **Flail chest**: A condition where a segment of the rib cage breaks in multiple places, causing that part of the chest to move paradoxically inward during inspiration and outward during expiration.
* **Scaphoid fracture**: A fracture of the scaphoid bone in the wrist. Due to its precarious blood supply, it has a high risk of non-union and avascular necrosis.
* **Pelvic fractures**: These can be associated with significant bleeding, damage to pelvic organs (bladder, urethra, intestines), and nerve injuries.
* **Subcapital hip fracture**: A fracture occurring at the neck of the femur, just below the femoral head. Surgical treatment options include:
* **Internal fixation**: Using screws or a plate and screw for stable fractures.
* **Hemiarthroplasty**: Replacing only the femoral head with a prosthesis.
* **Total hip arthroplasty**: Replacing both the femoral head and the acetabulum (hip socket) with prostheses.
The choice depends on fracture stability, patient's mobility, and bone quality.
* **Bone fracture preventing knee extension**: A fracture of the patella (kneecap) is likely if a patient cannot extend their knee after trauma.
#### 3.3.2 Luxation (Dislocation)
A luxation, or dislocation, is the complete displacement of the articulating surfaces of a joint.
#### 3.3.3 Hernia inguinalis
A hernia inguinalis is a protrusion of abdominal contents through the inguinal canal.
#### 3.3.4 Hernia scar
A hernia scar, or incisional hernia, occurs at the site of a previous surgical incision.
---
# Cardiovascular and gastrointestinal surgical considerations
This section details surgical interventions for common and critical conditions affecting the cardiovascular and gastrointestinal systems, outlining procedures, indications, and potential outcomes.
### 4.1 Cardiovascular surgical considerations
Surgical management of cardiovascular diseases addresses structural abnormalities and vascular pathologies.
#### 4.1.1 Valvular heart disease
Surgical intervention for valvular heart disease is indicated when medical management fails to control symptoms or when significant hemodynamic compromise is present. The primary goal is to restore normal valve function, either through repair or replacement.
* **Aortic valve disease:** This can include stenosis (narrowing) or regurgitation (leakage). Surgical options include aortic valve replacement (AVR) with either a mechanical or bioprosthetic valve.
* **Mitral valve disease:** Similar to the aortic valve, the mitral valve can suffer from stenosis or regurgitation. Mitral valve repair is often preferred over replacement when technically feasible, as it preserves native valve function and may lead to better long-term outcomes. Mitral valve replacement (MVR) is performed when repair is not possible.
* **Tricuspid and pulmonary valve disease:** While less common indications for surgery, these valves can also be repaired or replaced in select cases, often in conjunction with procedures on the aortic or mitral valves.
**Types of heart valve prostheses:**
* **Mechanical valves:** These are durable and designed to last a lifetime. However, they require lifelong anticoagulation therapy (e.g., warfarin) to prevent clot formation on the valve surface, which carries a bleeding risk.
* **Bioprosthetic valves (tissue valves):** These are made from animal tissue (porcine or bovine) or human allografts. They generally do not require lifelong anticoagulation, making them suitable for patients who cannot tolerate or adhere to anticoagulation therapy. However, bioprosthetic valves have a limited lifespan and will eventually degenerate, often requiring re-operation.
**Indications for valve surgery:**
* Symptomatic severe valvular stenosis or regurgitation.
* Asymptomatic severe aortic stenosis.
* Severe mitral regurgitation with evidence of left ventricular dysfunction or symptoms.
* Prophylactic repair in certain asymptomatic patients with specific valve morphology and hemodynamic findings.
#### 4.1.2 Coronary artery bypass grafting (CABG)
CABG is a surgical procedure to improve blood flow to the heart muscle in patients with severe coronary artery disease. It involves bypassing blocked or narrowed coronary arteries using healthy blood vessels (grafts) harvested from other parts of the body.
* **Graft sources:**
* **Internal mammary artery (IMA):** The left internal mammary artery is commonly used and has excellent long-term patency rates.
* **Saphenous vein:** Veins from the leg are frequently used, although their patency rates are generally lower than arterial grafts over time.
* **Radial artery:** Arteries from the arm can also be used.
* **Procedure:** The surgeon attaches one end of the graft to the aorta (the main artery carrying blood from the heart) and the other end to the coronary artery beyond the blockage, creating a new path for blood flow.
* **Off-pump vs. On-pump CABG:** CABG can be performed with the heart stopped (on-pump), requiring a heart-lung machine to circulate blood, or with the heart beating (off-pump). The choice depends on patient factors and surgeon preference.
#### 4.1.3 Aortic aneurysms
An aneurysm is a bulging or swelling in the wall of an artery. Abdominal aortic aneurysms (AAAs) are particularly dangerous due to the risk of rupture, which is often fatal.
* **Abdominal aortic aneurysm (AAA):** This is a dilation of the abdominal aorta.
* **Surgical treatment:**
* **Open surgical repair:** This involves making a large incision in the abdomen, clamping the aorta above and below the aneurysm, and replacing the diseased segment with a synthetic graft (tube graft or bifurcated graft).
* **Endovascular aneurysm repair (EVAR):** This is a less invasive procedure where a stent-graft is inserted through small incisions in the groin and guided into the aorta using catheters. The stent-graft seals off the aneurysm, preventing blood flow into the weakened wall.
**Indications for AAA repair:**
* Aneurysms exceeding a certain diameter (typically 5.0-5.5 cm in men, 4.5-5.0 cm in women).
* Rapidly expanding aneurysms.
* Symptomatic aneurysms (e.g., causing pain).
### 4.2 Gastrointestinal surgical considerations
Surgical interventions in the gastrointestinal tract address a wide range of conditions, from benign functional disorders to malignant tumors.
#### 4.2.1 Esophageal conditions
* **Esophageal tumors:** Surgical resection, often involving esophagectomy (removal of part or all of the esophagus), is a primary treatment for resectable esophageal cancer. Reconstruction typically involves using a segment of the stomach or colon.
* **Achalasia:** This is a motility disorder where the lower esophageal sphincter fails to relax properly, preventing food from passing into the stomach. Surgical treatment involves a myotomy, where the muscles of the lower esophageal sphincter are cut to relieve the obstruction. Laparoscopic Heller myotomy is the most common approach.
#### 4.2.2 Gastric and duodenal conditions
* **Peptic gastritis and esophagitis:** While primarily managed medically, severe or complicated cases may require surgical intervention. This can include procedures to reduce acid production or to repair perforations.
* **Gastric perforation:** A surgical emergency, often requiring immediate closure of the perforation and treatment of any associated contamination.
* **Gastrectomy:** Surgical removal of part or all of the stomach. Indications include cancer, severe peptic ulcer disease unresponsive to medical therapy, or complications like perforation or bleeding. Different types of gastrectomy exist, such as partial gastrectomy (e.g., Billroth I or II procedures) and total gastrectomy.
* **Obesity surgery:** Various bariatric surgical procedures are performed to aid weight loss in individuals with severe obesity. These aim to reduce stomach size or alter nutrient absorption. Common procedures include sleeve gastrectomy, Roux-en-Y gastric bypass, and adjustable gastric banding.
#### 4.2.3 Small and large intestine conditions
* **Ileus:** This refers to a cessation of normal bowel motility. Surgical intervention is considered for obstructive ileus (blockage) or if a paralytic ileus is prolonged and associated with complications.
* **Appendicitis:** Inflammation of the appendix, typically treated with appendectomy (surgical removal of the appendix). Laparoscopic appendectomy is the preferred method due to faster recovery and smaller incisions.
* **Cholecystectomy:** Surgical removal of the gallbladder. This is most commonly performed for symptomatic gallstones or inflammation of the gallbladder (cholecystitis). Laparoscopic cholecystectomy is the standard of care, offering a less invasive approach with quicker recovery compared to open surgery.
* **Colostomy:** Surgical creation of an opening in the colon to the outside of the body, allowing for the diversion of fecal matter. This is often performed as a temporary or permanent solution for conditions like bowel obstruction, trauma, or inflammatory bowel disease.
#### 4.2.4 Rectal and anal conditions
* **TURP (Transurethral Resection of the Prostate) vs. Radical Prostatectomy:** These are procedures related to prostate conditions. TURP is used to treat benign prostatic hyperplasia (BPH) by removing obstructing prostate tissue. Radical prostatectomy is the surgical removal of the entire prostate gland, typically for prostate cancer.
* **Bladder cancer:** Treatment depends on the invasiveness of the cancer. For superficial bladder cancers, transurethral resection of bladder tumors (TURBT) is common. For invasive bladder cancer, radical cystectomy (removal of the bladder) may be necessary, often with urinary diversion.
* **Gynecological conditions:**
* **Uterine cancer (endometrial carcinoma):** Surgical management often involves hysterectomy (removal of the uterus) and possibly removal of ovaries and fallopian tubes (salpingo-oophorectomy), along with lymph node dissection depending on the stage and type of cancer.
* **Uterine prolapse:** Surgical repair aims to restore the uterus to its normal position and support the pelvic organs. Procedures can involve vaginal or abdominal approaches.
#### 4.2.5 Hernias
* **Inguinal hernia:** A protrusion of abdominal contents through the inguinal canal. Surgical repair (hernioplasty or herniorrhaphy) is indicated to prevent complications such as incarceration or strangulation. It can be performed open or laparoscopically.
* **Incisional hernia (littekenbreuk):** A hernia that occurs at the site of a previous surgical incision. Repair involves reinforcing the abdominal wall, often with mesh.
> **Tip:** Understanding the difference between open and laparoscopic approaches for GI surgeries is crucial, as they have distinct recovery profiles, risks, and benefits. Laparoscopy generally offers smaller incisions, less pain, and faster return to normal activities, but is not suitable for all patients or conditions.
### 4.3 Comparative surgical approaches
#### 4.3.1 Open laparotomy vs. Laparoscopy
* **Open laparotomy:** Involves a larger incision through the abdominal wall, providing direct visualization of the abdominal cavity.
* **Advantages:** Wider access for complex procedures, easier for surgeons to manage unexpected findings, and sometimes preferred for extensive adhesions or large tumors.
* **Disadvantages:** Greater postoperative pain, longer hospital stays, slower recovery, and larger scars.
* **Laparoscopy:** Performed through small incisions using a camera (laparoscope) and specialized instruments.
* **Advantages:** Less postoperative pain, smaller scars, shorter hospital stays, and quicker return to normal activities.
* **Disadvantages:** Limited tactile feedback, potential for longer operative times in complex cases, and not suitable for all surgical scenarios (e.g., severe adhesions, unstable patients).
### 4.4 Specific surgical procedures and conditions
#### 4.4.1 Gastrectomy
Surgical removal of all or part of the stomach. Indications include gastric cancer, severe peptic ulcer disease, or complications like perforation. Reconstruction options vary depending on the extent of the gastrectomy.
#### 4.4.2 Cholecystectomy
Surgical removal of the gallbladder, typically for gallstones or inflammation. Laparoscopic cholecystectomy is the standard, offering a minimally invasive approach.
#### 4.4.3 Appendicitis
Inflammation of the appendix, managed with appendectomy. Laparoscopic appendectomy is preferred for its benefits in recovery.
#### 4.4.4 Colostomy
Creation of an opening from the colon to the abdominal wall for fecal diversion. Can be temporary or permanent.
#### 4.4.5 Rectal and bladder cancer management
* **TURP:** Transurethral resection of the prostate for benign prostatic hyperplasia.
* **Radical prostatectomy:** Complete removal of the prostate for cancer.
* **Invasive bladder cancer:** May involve radical cystectomy with urinary diversion.
#### 4.4.6 Gynecological cancer and prolapse
* **Uterine cancer:** Often managed with hysterectomy, with other organs removed based on staging.
* **Uterine prolapse:** Surgical correction to restore pelvic support.
#### 4.4.7 Hernias
* **Inguinal hernia:** Surgical repair of a protrusion in the groin.
* **Incisional hernia:** Repair of a hernia at a surgical scar site, often with mesh reinforcement.
> **Example:** A patient presents with severe, symptomatic gallstones that have not responded to medical management. The standard surgical treatment would be a laparoscopic cholecystectomy. This procedure involves making several small incisions in the abdomen, inserting a camera and surgical instruments, and removing the gallbladder. Postoperative recovery is typically rapid, with most patients returning home within a day or two.
This summary covers the essential surgical considerations for the cardiovascular and gastrointestinal systems as outlined in the provided document pages. Remember to review specific indications, contraindications, and detailed operative techniques for a complete understanding.
---
# Urological, gynecological, and endocrine surgical procedures
This section details surgical interventions for various conditions affecting the urological, gynecological, and endocrine systems.
### 5.1 Urological procedures
#### 5.1.1 Prostate cancer
Prostate cancer surgery involves removing the prostate gland, typically through radical prostatectomy.
* **Radical prostatectomy:** This procedure aims to remove the entire prostate gland and seminal vesicles. It can be performed via an open approach (abdominal incision), laparoscopically, or robotically.
* **Open radical prostatectomy:** Involves a larger incision, allowing direct visualization and manual manipulation.
* **Laparoscopic radical prostatectomy:** Utilizes small incisions and a camera to perform the surgery with specialized instruments.
* **Robotic-assisted laparoscopic radical prostatectomy:** Employs a robotic system controlled by the surgeon, offering enhanced dexterity and precision.
* **Comparison with TURP (Transurethral Resection of the Prostate):**
* **TURP:** Primarily used for benign prostatic hyperplasia (BPH), it involves removing prostate tissue through the urethra. It is less invasive than radical prostatectomy but is not curative for prostate cancer.
* **Radical prostatectomy:** Curative intent for prostate cancer, aiming for complete removal of the gland. It is a more extensive surgery with a higher risk of complications such as incontinence and erectile dysfunction compared to TURP for BPH.
#### 5.1.2 Bladder cancer
Treatment for bladder cancer depends on the stage and invasiveness of the tumor.
* **Superficial bladder cancer:**
* **Transurethral resection of bladder tumor (TURBT):** The primary diagnostic and therapeutic procedure for non-muscle-invasive bladder cancer. It involves removing the tumor through the urethra using a resectoscope.
* **Intravesical therapy:** Instillation of medications directly into the bladder following TURBT to reduce the risk of recurrence or progression. Common agents include Bacillus Calmette-Guérin (BCG) or mitomycin C.
* **Invasive bladder cancer:**
* **Radical cystectomy:** Surgical removal of the entire bladder, often along with surrounding organs (prostate and seminal vesicles in men, uterus and ovaries in women) and pelvic lymph nodes.
* **Urinary diversion:** Following cystectomy, a new way to store and eliminate urine is created. Options include:
* **Ileal conduit:** A segment of the small intestine is used to create a stoma on the abdomen through which urine drains into an external bag.
* **Neobladder:** A continent reservoir created from a segment of the intestine, connected to the urethra, allowing for voluntary voiding.
* **Continent cutaneous diversion:** A stoma is created that can be catheterized to drain urine from an internal reservoir.
* **Chemotherapy:** May be used before (neoadjuvant) or after (adjuvant) surgery to kill cancer cells.
* **Radiation therapy:** Can be used as a primary treatment or in combination with chemotherapy.
### 5.2 Gynecological procedures
#### 5.2.1 Uterine prolapse
Uterine prolapse occurs when the pelvic floor muscles and ligaments weaken, allowing the uterus to descend into or beyond the vagina.
* **Surgical interventions aim to restore pelvic organ support:**
* **Uterine suspension:** The uterus is re-suspended in its normal anatomical position using sutures attached to strong ligaments.
* **Sacrocolpopexy:** A synthetic mesh is used to suspend the vaginal vault (or cervix if the uterus is preserved) to the sacrum. This can be performed abdominally or laparoscopically/robotically.
* **Vaginal hysterectomy with repair:** The uterus is removed through the vagina, and the vaginal vault is then supported.
* **Uterosacral ligament suspension:** Suturing the cervix or vaginal vault to the uterosacral ligaments.
#### 5.2.2 Uterine cancer (endometrial carcinoma)
The primary treatment for uterine cancer is surgical.
* **Hysterectomy:** Removal of the uterus.
* **Total hysterectomy:** Removal of the entire uterus, including the cervix.
* **Radical hysterectomy:** Removal of the uterus, cervix, upper part of the vagina, and surrounding parametrial tissues.
* **Bilateral salpingo-oophorectomy:** Removal of both ovaries and fallopian tubes.
* **Pelvic lymphadenectomy:** Removal of lymph nodes in the pelvis to check for cancer spread.
* **Omentectomy:** Removal of the omentum (a fold of fatty tissue in the abdomen) if there is concern for spread.
#### 5.2.3 Breast cancer
Surgical management of breast cancer depends on the type, stage, and patient factors.
* **Breast-conserving surgery (lumpectomy/partial mastectomy):** Removal of the tumor with a margin of healthy tissue. Often followed by radiation therapy.
* **Mastectomy:** Removal of the entire breast.
* **Simple mastectomy:** Removal of the breast tissue, nipple, and areola.
* **Modified radical mastectomy:** Removal of the breast tissue, nipple, areola, and axillary (underarm) lymph nodes.
* **Radical mastectomy:** Removal of the breast, axillary lymph nodes, and chest wall muscles (rarely performed today).
* **Sentinel lymph node biopsy (SLNB):** A procedure to identify and remove the first lymph node(s) that drain the tumor site. If cancer is not found in the sentinel nodes, further lymph node dissection may be avoided.
* **Axillary lymph node dissection (ALND):** Removal of a larger number of lymph nodes from the armpit. Indicated if cancer is found in the sentinel nodes or if there is extensive lymph node involvement.
### 5.3 Endocrine surgical procedures
#### 5.3.1 Pituitary tumors
Surgical removal of pituitary tumors is often the primary treatment for symptomatic or hormonally active tumors.
* **Transsphenoidal surgery:** The most common approach. The surgeon accesses the pituitary gland through the nasal cavity and sphenoid sinus.
* **Endoscopic transsphenoidal surgery:** Uses an endoscope for visualization and instrument manipulation.
* **Microscopic transsphenoidal surgery:** Uses a surgical microscope.
* **Craniotomy:** An open surgical approach through the skull. This is reserved for larger tumors that extend into the suprasellar space or have significant bony invasion.
#### 5.3.2 Thyroid issues
Surgical intervention for thyroid conditions is common and typically involves removing part or all of the thyroid gland.
* **Thyroidectomy:** Removal of all or part of the thyroid gland.
* **Total thyroidectomy:** Removal of the entire thyroid gland. This is indicated for thyroid cancer, large multinodular goiters, or Graves' disease refractory to medical treatment.
* **Hemithyroidectomy (lobectomy):** Removal of one lobe of the thyroid gland. Often performed for benign solitary nodules or small, well-differentiated thyroid cancers.
* **Isthmusectomy:** Removal of the isthmus connecting the two lobes.
* **Risks of thyroid surgery:**
* **Damage to recurrent laryngeal nerves:** Can lead to vocal cord paralysis and hoarseness.
* **Damage to parathyroid glands:** Can cause hypoparathyroidism, leading to low calcium levels (hypocalcemia).
* **Bleeding and hematoma formation:** Can compromise the airway.
* **Infection.**
* **Thyroid storm:** A rare but life-threatening exacerbation of hyperthyroidism.
#### 5.3.3 Pheochromocytoma
Pheochromocytoma is a rare tumor of the adrenal medulla that produces excess catecholamines. Surgical removal is the definitive treatment.
* **Surgical treatment:**
* **Adrenalectomy:** Surgical removal of the affected adrenal gland. This is typically performed laparoscopically.
* **Dangers associated with pheochromocytoma and its surgical treatment:**
* **Hypertensive crises:** Sudden, severe increases in blood pressure caused by catecholamine release, which can lead to stroke, heart attack, or other cardiovascular events.
* **Arrhythmias:** Irregular heartbeats.
* **Perioperative hemodynamic instability:** Unpredictable and potentially dangerous fluctuations in blood pressure and heart rate during and immediately after surgery, due to the unpredictable release of catecholamines.
* **Metastasis:** Although rare, pheochromocytomas can metastasize.
> **Tip:** Proper preoperative medical management with alpha and beta-blockers is crucial to control blood pressure and heart rate before surgery for pheochromocytoma, significantly reducing the risk of perioperative complications.
---
# Management of burns and wound drainage
This section details the classification, assessment, and treatment of burns, alongside the critical role and nursing care of wound drainage systems.
### 6.1 Burn management
#### 6.1.1 Causes of burns
Burns can be caused by various agents, including:
* Thermal agents: Heat (flames, hot liquids, steam, hot surfaces)
* Chemical agents: Acids, alkalis, oxidizing agents
* Electrical agents: High or low voltage currents
* Radiation: UV radiation (sunburn), ionizing radiation
#### 6.1.2 Classification of burns
Burns are classified based on depth and extent, which dictate treatment and prognosis.
##### 6.1.2.1 Classification by depth
* **First-degree burns:** Involve only the epidermis. They are characterized by redness, pain, and mild swelling, with no blistering. Healing is typically quick and without scarring.
* **Second-degree burns (partial-thickness):** Involve the epidermis and part of the dermis.
* **Superficial partial-thickness:** Affect the superficial dermis. They present with blisters, redness, and significant pain. Healing occurs within 1 to 3 weeks with minimal scarring.
* **Deep partial-thickness:** Extend deeper into the dermis. Blisters may be present, but the wound can appear pale or mottled. Pain sensation may be reduced. Healing takes longer (3 to 6 weeks) and may result in scarring and contractures.
* **Third-degree burns (full-thickness):** Extend through the entire dermis into the subcutaneous tissue. The burn area appears dry, leathery, and may be white, brown, or black. Sensation is lost due to nerve destruction. These burns require grafting for healing.
* **Fourth-degree burns:** Extend through subcutaneous tissue into muscle, bone, or underlying structures. These are severe injuries requiring extensive reconstruction and potentially amputation.
##### 6.1.2.2 Classification by extent
The extent of a burn is crucial for determining the severity and guiding treatment. The "Rule of Nines" is a common method for estimating the percentage of total body surface area (TBSA) affected by burns in adults.
* Head and neck: 9%
* Each arm: 9%
* Anterior trunk: 18%
* Posterior trunk: 18%
* Each leg: 18%
* Perineum: 1%
In infants and children, the distribution differs slightly, with the legs accounting for a smaller percentage and the head for a larger one.
#### 6.1.3 Assessment of burn wounds
* **Determination of burn extent:** Using the Rule of Nines or Lund-Browder chart.
* **Assessment of burn depth:** Clinical examination to determine the degree of the burn.
* **Laser Doppler Imaging and Thermography:** These advanced techniques can help assess burn depth and viability of underlying tissues by measuring blood flow and temperature variations.
#### 6.1.4 Burn management principles
* **Initial management and first aid:**
* Stop the burning process (remove from source, extinguish flames).
* Cool the burn with cool (not cold) running water for at least 10-20 minutes to reduce tissue damage.
* Remove constricting items (clothing, jewelry) to prevent compartment syndrome as swelling occurs.
* Cover the burn with a clean, dry dressing or cling film to prevent contamination and heat loss.
* Assess for airway compromise, especially in inhalation burns.
* **Fluid resuscitation:** Essential for large burns to maintain hemodynamic stability. The Parkland formula is commonly used to calculate initial fluid requirements:
$$ \text{Total fluid} = 4 \text{ mL} \times \text{Body weight (kg)} \times \text{TBSA burned (\%)} $$
Half of the calculated fluid is administered in the first 8 hours, and the remaining half over the next 16 hours. Careful monitoring of urine output, vital signs, and hemodynamic parameters is crucial.
* **Wound care:**
* **Debridement:** Removal of dead or devitalized tissue to promote healing and prevent infection.
* **Topical antimicrobial agents:** Used to prevent or treat burn wound infections.
* **Dressings:** Various types of dressings are used depending on the burn depth and phase of healing, aiming to protect the wound, absorb exudate, and promote moist wound healing.
* **Escharotomy:** A linear incision through the full-thickness burn eschar to relieve pressure and restore circulation when circumferential burns compromise vascularity or respiration.
#### 6.1.5 Referral to a burn center
Referral to a specialized burn center is recommended for:
* Full-thickness burns greater than 10% TBSA in adults or 5% TBSA in children.
* Partial-thickness burns involving the face, hands, feet, genitalia, major joints, or circumferential burns.
* Electrical or chemical burns.
* Burns with associated inhalation injury.
* Patients with significant comorbidities.
* Burns in patients younger than 5 years or older than 55 years.
#### 6.1.6 Long-term complications of burns
Potential problems after burn healing includes:
* Scarring and contractures, limiting range of motion.
* Chronic pain and hypersensitivity.
* Psychological impact and body image issues.
* Nutritional deficiencies.
* Pruritus (itching).
### 6.2 Wound drainage systems
Wounds with drainage require extra attention due to the risk of infection, maceration, and fluid loss. Drains are inserted to remove excess fluid (blood, serum, pus) from a surgical or traumatic site, promoting healing and preventing complications like hematoma or seroma formation.
#### 6.2.1 Types of drains and their drainage capacity
* **Round drain (e.g., Penrose drain):** A soft, rubber tube that lies in a wound cavity. It drains passively by capillary action. Its drainage capacity is limited as it does not create suction and can be prone to kinking.
> **Tip:** Penrose drains are typically used for superficial wounds or to promote drainage from an abscess cavity.
* **Multitubular drain:** Consists of multiple small tubes within a larger outer sheath. This design offers a larger surface area for drainage compared to a single tube, potentially increasing its drainage capacity.
* **Saratoga drain:** A type of closed suction drain with multiple channels. It is designed to provide efficient drainage under negative pressure.
> **Tip:** A key nursing consideration with Saratoga drains is ensuring the integrity of the closed system to maintain effective suction.
* **Redon drain (Jackson-Pratt drain):** A closed suction drain connected to a portable vacuum unit (Redon bottle or bulb). It utilizes negative pressure to actively remove fluid.
* **Recognizing vacuum in a Redon bottle:** The bulb or bottle will be compressed and fully expanded, indicating that suction is being applied.
* **Breaking the vacuum in a Redon bottle:** The port cap is lifted to release the vacuum, allowing for emptying and recompression.
#### 6.2.2 Nursing care of wound drainage systems
* **Monitoring drainage:**
* **Amount:** Document the volume of drainage at regular intervals. A sudden increase or decrease can indicate a problem.
* **Color:** Observe for changes in color (e.g., serosanguinous, purulent, sanguineous).
* **Odor:** Note any foul odor, which may suggest infection.
* **Maintaining the drainage system:**
* Ensure the drain is patent and not kinked.
* Keep the drainage collection device below the level of the wound to facilitate gravity drainage.
* For closed suction drains, ensure the vacuum is maintained.
* **Wound care:**
* Clean the skin around the drain insertion site regularly.
* Apply appropriate dressings to protect the skin from maceration by wound exudate.
* **Drain removal:**
* Drains are typically removed when the drainage volume significantly decreases and the wound has begun to close.
* **Shortening drains:** Drains may be shortened daily with two Kochers clamps. This is done progressively to allow the tract to close from the bottom up, minimizing the risk of a persistent sinus tract.
* **Thorax drains removal:** This procedure requires specific nursing attention. The patient is often instructed to perform a Valsalva maneuver or exhale during removal to prevent air from entering the pleural space. A sterile occlusive dressing is immediately applied.
> **Tip:** Maintaining a sterile technique during drain manipulation and dressing changes is paramount to prevent infection.
* **Patient education:** Educate the patient about the purpose of the drain, how to care for it, and what to report to the nursing staff.
---
## Common mistakes to avoid
- Review all topics thoroughly before exams
- Pay attention to formulas and key definitions
- Practice with examples provided in each section
- Don't memorize without understanding the underlying concepts
Glossary
| Term | Definition |
|------|------------|
| Minimally invasive surgery | A surgical technique that uses small incisions and specialized instruments, often with the aid of cameras, to perform procedures, resulting in less trauma and faster recovery compared to traditional open surgery. |
| Postoperative complications | Adverse events or health issues that arise after a surgical procedure, not directly related to the surgical wound itself, such as infections, blood clots, or organ dysfunction. |
| Fracture | A break in the continuity of a bone, which can range from a hairline crack to a complete shattering of the bone. |
| Pseudoarthrosis | A condition where a fractured bone fails to heal properly, resulting in a false joint that lacks stability and causes persistent pain and inability to bear weight. |
| Arthrodesis | A surgical procedure that fuses two or more bones together to stabilize a joint that is painful or unstable, often performed to treat severe arthritis or instability. |
| Lucid interval | A period of temporary consciousness or improvement that occurs after a traumatic brain injury, before the onset of neurological deterioration due to increasing intracranial pressure. |
| Brilhematoom (Periorbital hematoma) | Bruising and swelling around the eyes, commonly known as "black eyes," which can indicate a fracture in the bones surrounding the orbit or a more serious head injury. |
| Epidural hematoma | A collection of blood that forms between the dura mater and the skull, typically resulting from arterial bleeding and often associated with a skull fracture. |
| Subdural hematoma | A collection of blood that forms between the dura mater and the arachnoid mater, usually caused by venous bleeding and can be acute, subacute, or chronic. |
| Rib fractures | Breaks in one or more of the ribs, which can be caused by direct trauma to the chest and may lead to pain, difficulty breathing, and potential injury to underlying organs. |
| Flail chest | A severe chest injury where a segment of the rib cage breaks free from the rest of the chest wall, resulting in paradoxical chest movement during respiration and significant respiratory compromise. |
| Scaphoid fracture | A fracture of the scaphoid bone, one of the small carpal bones in the wrist, which is prone to delayed healing or nonunion due to its limited blood supply. |
| Pelvic fracture | A break in the bones of the pelvis, which can range from minor fractures to severe, life-threatening injuries involving significant bleeding and damage to internal organs. |
| Subcapital hip fracture | A fracture that occurs in the neck of the femur, just below the head of the bone, often requiring surgical intervention due to the risk of avascular necrosis. |
| Hip prosthesis | An artificial joint replacement used to treat severe hip damage, typically caused by osteoarthritis or fractures, involving replacing the femoral head and acetabulum. |
| Luxation (Dislocation) | The displacement of bones at a joint so that the articulating surfaces no longer meet, resulting in loss of function and pain. |
| Tendon injury | Damage to a tendon, the fibrous cord that connects muscle to bone, which can include tears, ruptures, or inflammation, affecting movement and strength. |
| Herniated disc (Discus hernia) | A condition where the soft inner material of an intervertebral disc protrudes through the outer fibrous ring, potentially compressing nearby nerves and causing pain, numbness, or weakness. |
| Carpal tunnel syndrome | A condition caused by compression of the median nerve as it passes through the carpal tunnel in the wrist, leading to numbness, tingling, and pain in the hand and fingers. |
| Arthrosis (Osteoarthritis) | A degenerative joint disease characterized by the breakdown of cartilage in the joints, leading to pain, stiffness, and reduced mobility. |
| Atheromatosis (Atherosclerosis) | A condition characterized by the buildup of fatty deposits (plaque) within the arteries, leading to hardening and narrowing of the arteries, which can restrict blood flow. |
| Endarterectomy | A surgical procedure to remove plaque buildup from the inner lining of an artery, commonly performed to improve blood flow in cases of severe atherosclerosis. |
| Embolectomy | A surgical procedure to remove an embolus (a blood clot or other foreign material) that is blocking an artery, restoring blood flow to the affected area. |
| Endovascular techniques | Minimally invasive procedures performed within blood vessels using catheters and imaging guidance, such as angioplasty and stenting, to treat vascular diseases. |
| CABG (Coronary Artery Bypass Graft) | A surgical procedure to improve blood flow to the heart by creating new pathways around blocked coronary arteries, using a blood vessel harvested from another part of the body. |
| Heart valve disease | A condition affecting the function of the heart valves, which can lead to either stenosis (narrowing) or regurgitation (leakage), impairing the heart's ability to pump blood efficiently. |
| Heart valve prosthesis | An artificial device implanted to replace a damaged or diseased heart valve, available in mechanical or biological forms, each with its own advantages and disadvantages. |
| Abdominal aortic aneurysm (AAA) | A weakening and bulging of the wall of the abdominal aorta, the largest artery in the body, which can rupture and cause life-threatening bleeding. |
| Pneumothorax | The presence of air in the pleural space, the area between the lung and the chest wall, causing the lung to collapse partially or completely. |
| Achalasia | A rare disorder of the esophagus that affects its ability to move food into the stomach, characterized by difficulty swallowing and regurgitation of food. |
| Laparotomy | A surgical procedure involving a large incision in the abdomen to access and operate on abdominal organs, considered open surgery. |
| Laparoscopy | A minimally invasive surgical technique that uses a small incision and a laparoscope (a thin, lighted tube with a camera) to view and operate on organs within the abdomen. |
| Gastrectomy | Surgical removal of all or part of the stomach, typically performed to treat stomach cancer or severe ulcers. |
| Gastritis | Inflammation of the lining of the stomach, which can be caused by various factors, including infections, medications, and stress, leading to pain, nausea, and vomiting. |
| Esophagitis | Inflammation of the esophagus, the tube connecting the throat to the stomach, often caused by acid reflux, infections, or irritants, resulting in pain and difficulty swallowing. |
| Obesity surgery (Bariatric surgery) | Surgical procedures performed on the stomach or intestines to help individuals with obesity lose weight by restricting food intake or altering the digestive process. |
| Cholecystectomy | Surgical removal of the gallbladder, usually performed to treat gallstones or other gallbladder diseases. |
| Ileus | A condition where the normal muscular contractions of the intestines, called peristalsis, stop, leading to a blockage in the small or large intestine and preventing the passage of food and waste. |
| Appendicitis | Inflammation of the appendix, a small, finger-like pouch attached to the large intestine, which typically requires surgical removal. |
| Colostomy | A surgical procedure that creates an opening (stoma) in the abdomen to divert waste from the colon to a collection bag outside the body, usually performed after bowel surgery or in cases of severe bowel disease. |
| TURP (Transurethral Resection of the Prostate) | A surgical procedure to remove excess prostate tissue that is blocking urine flow, performed by inserting an instrument through the urethra. |
| Radical prostatectomy | Surgical removal of the entire prostate gland, typically performed to treat prostate cancer. |
| Bladder cancer | Cancer that forms in the tissues of the bladder, which can be treated with surgery, chemotherapy, or radiation therapy depending on its invasiveness. |
| Uterine prolapse | A condition where the uterus descends from its normal position into the vagina, often due to weakened pelvic floor muscles. |
| Breast cancer | Cancer that develops in the cells of the breast, which can be treated with surgery, radiation therapy, chemotherapy, or hormone therapy. |
| Hypophyseal tumor (Pituitary tumor) | A growth on the pituitary gland, a small gland located at the base of the brain that produces hormones, which can affect hormone production and cause other symptoms. |
| Pheochromocytoma | A rare tumor of the adrenal gland that produces excessive amounts of adrenaline and noradrenaline, leading to high blood pressure and other symptoms. |
| Inguinal hernia | A condition where soft tissue, such as part of the intestine, protrudes through a weak spot in the abdominal muscles in the groin area. |
| Incisional hernia (Laparotomy scar hernia) | A type of hernia that occurs at the site of a previous surgical incision when the tissues weaken and allow underlying organs to protrude. |
| Burns | Injuries to the skin or other tissues caused by heat, electricity, chemicals, friction, or radiation, classified by their depth and extent. |
| Escharotomy | A surgical procedure to incise and remove dead, hardened skin (eschar) that forms over a severe burn, to relieve pressure and improve blood circulation. |
| Laser Doppler imaging | A non-invasive technique that uses laser light to measure blood flow in the skin, often used to assess burn depth and healing potential. |
| Thermography | A medical imaging technique that records the heat patterns emitted by the body, used to detect and assess conditions like inflammation or poor circulation, including in burn injuries. |
| Burn depth assessment | The process of evaluating how deeply a burn has penetrated the skin layers, which is crucial for determining the appropriate treatment and prognosis. |
| Burn wound center referral | The recommendation to transfer a burn patient to a specialized facility equipped to handle severe burn injuries, offering advanced medical care and rehabilitation. |
| Burn patient first aid | Immediate care provided to a burn victim, including cooling the burn, protecting it from further injury, and managing pain, to minimize damage and prevent complications. |
| Burn survival rate calculation | A method used to estimate the likelihood of a burn patient surviving their injuries, often based on factors like the percentage of body surface area burned, age, and pre-existing health conditions. |
| Daily nursing care for burn patients | Routine care provided to burn patients, including wound cleaning, dressing changes, pain management, fluid and nutritional support, and monitoring for signs of infection. |
| Post-burn complications | Health issues that can arise after a burn wound has healed, such as scarring, contractures, itching, and psychological distress. |
| Drainage (medical) | The process of removing excess fluid or pus from a wound or body cavity using a tube or surgical drain to promote healing and prevent infection. |
| Penrose drain | A soft, flat, latex drain that allows fluid to drain passively by capillary action from a wound site to the surface of the skin. |
| Jackson-Pratt drain (JP drain) | A closed-system surgical drain that uses a negative pressure (suction) to draw fluid from a wound into a collection bulb, commonly used after surgery. |
| Sump drain | A type of drain that utilizes suction to remove fluid from a wound or body cavity, often used in complex wounds or infections. |
| Redon bottle (Drainage bottle) | A type of closed-suction drainage system that uses a specially designed bottle to maintain negative pressure, drawing fluid away from a surgical site. |
| Vacuum (in a drainage system) | The negative pressure created within a closed drainage system, which actively pulls fluid from the wound or surgical site into the collection device. |
| Thoracic drain (Chest tube) | A tube inserted into the pleural space to remove air, fluid, or pus, used to re-expand a collapsed lung or treat conditions like pneumothorax or pleural effusion. |