Question

Matt, age 17 years, had a crushed leg following a motorcycle accident. There was considerable soft tissue damage in addition to the fracture. Following surgery, the leg was immobilized. On the third day postoperatively, Matt complained of increased pain in the leg, and he was experiencing a high fever. Examination of the surgical sites revealed severe inflammation and swelling, as well as a purulent discharge in one incision. A sample of the discharge was sent for culture and sensitivity tests. Blood tests indicated leukocytosis. Antibacterial therapy was begun immediately. Ten days later the inflammation and infection had cleared, and Matt’s leukocyte count was almost normal, although his serum calcium levels were elevated. Matt was learning to manage crutches (non–weight-bearing) and was encouraged to exercise more by the physiotherapist, but was disappointed to find himself weak and easily tired.

Discussion Questions

1. Explain the risks for postoperative infection for Matt. (See Musculoskeletal Effects.)
2. Discuss the causes of the symptoms and lab results and how they might be treated and alleviated. (See Musculoskeletal Effects.)

Matt continues to spend much of his time in bed or lounging in a chair. He is disappointed that his leg is not healing as fast as he thought it would and asks questions about whether he will be able to ride his “hog” again. He needs several suggestions before he practices crutch walking and then settles in the TV room for a long time. Sometimes he experiences dizziness when he gets up quickly. In the last few days, he has been developing a productive cough and has shown some labored breathing. His temperature is slightly elevated, and chest auscultation indicates abnormal breath sounds. A diagnosis of hypostatic pneumonia is made, and antimicrobial therapy is started.

Discussion Questions

1. How is immobility affecting Matt’s self-image and social life? How could this be altered?
2. Explain how immobility has led to each of the following:
   1. Hypostatic pneumonia
   2. Orthostatic hypotension
3. What is the prognosis for Matt?

Answer 1

1: Risks for postoperative infection

Bone infections -- also known as osteomyelitis -- can happen when a fracture breaks the skin or after an operation.

Remove any dead tissue and often need to perform plastic surgery or reconstruction in the affected area. If left untreated, bone infections can send bacteria to other areas of the body. Cancers may develop in chronic infection areas.

Skin and soft tissue infections can quickly become bone and joint infections. Without prompt treatment, these infections can become chronic.

Immobility may lead to reduced bone mass and density, bone demineralisation and bone loss
Patients confined to bed are at increased risk of kidney stones and disuse osteoporosis
Prolonged pressure on skin over bony prominences may lead to pressure ulcers
Pressure ulcers can be prevented by position changes, skin care, risk factor assessment and observation
Bedrest alters body function and appearance, so it influences patients’ self-concept

2: Lab test

WBC (white blood cell count)
ESR (sedimentation rate)
CRP (C-reactive protein)

Prolonged bedrest, which causes both a decrease in body function and an altered appearance, can force patients to re-evaluate their self-concept

For the confirmation of infection x ray, computerized tomography (CT) scan, tagged white blood cell scan, or magnetic resonance imaging (MRI) can be done.

TREATMENT

Initially treat it with antibiotics alone, but you will likely need additional surgery to clean out the infection. During surgery, your doctor will either swab or take samples of the infected tissue to find out what type of bacteria is causing the infection. This stage of treatment may require more than one surgery. Special drains may be placed in the wound to help rid it of pus. Antibiotic delivery systems, like "antibiotic beads," may also be used to provide higher concentrations of antibiotics.

A bone infection can be hard to eliminate. It may require long-term antibiotic treatment, as well as several surgeries. Occasionally, a patient may need to take antibiotics for the rest of his or her life.

In very rare cases, amputation of the infected limb may be considered. Amputation is usually performed only as a life-saving operation for a severe infection that is out of control.

Q:How is immobility affecting Matt’s self-image and social life? How could this be altered?

• The achieving self – prolonged bedrest threatens the achievement felt from work or hobbies. Many people draw a sense of achievement from their jobs, interests and activities, which is threatened if they are unable to carry them out;
• The social self – interactions with friends and family are a vital source of self-esteem and emotional support. A breakdown in this support system can have harmful consequences for the patient’s sense of identity and security;
• The private self – bedrest creates a dependency on others; the resulting loss of independence and strain of imposing on others can diminish the private self

HYPOSTATIC PNUEMONIA IN IMMOBILITY

• Difficulty expanding lungs fully/taking a deep breath due to position.
• Weight of chest further limits lung expansion in large residents.
• Cough weakens, reducing ability to clear secretions.
• Retained secretions remain in airway, causing collapse of alveoli.
• Ability to exchange oxygen and carbon dioxide is impaired, causing under ventilation and inadequate oxygen level in blood (hypoventilation and hypoxemia).
• Difficulty taking a deep breath causes anxiety and may result in dyspnea.
• Blood redistribution and fluid shifts increase the risk for pulmonary edema and blood clots.
• Pooling of secretions increases the risk of pneumonia and lung infections.

Orthostatic hypotension

Your body becomes weak if you must stay in bed for a long period of time. You may experience orthostatic hypotension until you regain muscle strength. Sometimes prolonged sitting with your legs crossed or squatting may cause orthostatic hypotension.

What is the prognosis for Matt?

Patient will be able to do activities by self.