Fractures

Description A disruption or break in the continuity of the structure of bone Traumatic injuries account for the majority of fractures

Description Described and classified according to: Type Communication or noncommunication with external environment Anatomic location

Types of Fractures Fig. 61-4

Classification by Communication with External Environment Fig. 61-5

Classification by Fracture Location Fig. 61-6

Description Described and classified according to: Appearance, position, and alignment of the fragments Classic names Stable or unstable

Description Closed (also called simple) Open (also called compound)

Description Stable fractures Occur when a piece of the periosteum is intact across the fracture External or internal fixation has rendered the fragments stationary

Description Unstable fractures Grossly displaced Poor fixation

Clinical Manifestations Immediate localized pain  Function Inability to bear weight or use affected part Guarding May or may not see obvious bone deformity

Fracture Healing Reparative process of self-healing (union) occurs in the following stages: Fracture hematoma (d/t bleeding, edema) Granulation tissue → osteoid (3 – 14 days post injury) Callus formation (minerals deposited in osteoid)

Fracture Healing Reparative process of self-healing (union) occurs in the following stages: Ossification (3 wks – 6 mos) Consolidation (distance between fragments decreases → closes). Remodeling (union completed; remodels to original shape, strength)

Bone Healing Fig. 61-7

Collaborative Care Overall goals of treatment: Anatomic realignment of bone fragments (reduction) Immobilization to maintain alignment (fixation) Restoration of normal function

Collaborative Care Fracture Reduction Closed reduction Nonsurgical, manual realignment Open reduction Correction of bone alignment through a surgical incision

Collaborative Care Fracture Reduction Traction (with simultaneous counter-traction) Application of pulling force to attain realignment Skin traction (short-term: 48-72 hrs) Skeletal traction (longer periods) See Table 61-7

Collaborative Care Fracture Immobilization Casts Temporary circumferential immobilization device Common following closed reduction

Casts Fig. 61-9

Collaborative Care Fracture Immobilization External fixation Metallic device composed of pins that are inserted into the bone and attached to external rods

Collaborative Care Fracture Immobilization Internal fixation Pins, plates, intramedullary rods, and screws Surgically inserted at the time of realignment

Collaborative Care Fracture Immobilization Traction Application of a pulling force to an injured part of the body while countertraction pulls in the opposite direction

Collaborative Care Fracture Immobilization Purpose of traction: Prevent or reduce muscle spasm Immobilization Reduction Treat a pathologic condition

Nursing Management Nursing Assessment for Fractures Brief history of the accident Mechanism of injury Special emphasis focused on the region distal to the site of injury

Nursing Management Nursing Assessment Neurovascular assessment Color and temperature cyanotic and cool/cold: arterial insufficiency Blue and warm: venous insufficiency Capillary refill (want < 3 sec) Peripheral pulses (↓ indicates vascular insufficiency)

Nursing Management Nursing Assessment Neurovascular assessment Edema Sensation Motor function Pain

Nursing Management Nursing Diagnoses Risk for peripheral neurovascular dysfunction Acute pain Risk for infection

Nursing Management Nursing Diagnoses Risk for impaired skin integrity Impaired physical mobility Ineffective therapeutic regimen management

Nursing Management Nursing Implementation General post-op care Assess dressings/casts for bleeding/drainage Prevent complications of immobility Measures to prevent constipation Frequent position changes/ ambulate as permitted ROM exercised of unaffected joints Deep breathing Isometric exercises Trapeze bar if permitted

Nursing Management Nursing Implementation Traction Ensure: No frayed ropes, loose knots Ropes in pulley grooves Pulley clamps fastened securely Weights must hang freely Appropriate body alignment Inspect skin Around slings Around pins

Nursing Management Nursing Implementation: Cast care Casts can cause neurovascular complications if Too tight Edematous Frequent neurovascular checks Ice and elevation during early phase See Table 61-10

Complications of Fractures Infection Open fractures and soft tissue injuries have  incidence Osteomyelitis can become chronic

Complications of Fractures Infection Collaborative Care Open fractures require aggressive surgical debridement Post-op IV antibiotics for 3 to 7 days (prophylactic)

Complications of Fractures Compartment Syndrome Condition in which elevated intracompartmental pressure within a confined myofascial compartment compromises the neurovascular function of tissues within that space Causes capillary perfusion to be reduced below a level necessary for tissue viability

Complications of Fractures Compartment Syndrome Two basic etiologies create compartment syndrome: Decreased compartment size (dressings, splints, casts) Increased compartment content (bleeding, edema)

Complications of Fractures Compartment Syndrome Clinical Manifestations Six Ps Paresthesia (unrelieved by narcotics) Pain (unrelieved by narcotics) Pressure

Complications of Fractures Compartment Syndrome Clinical Manifestations Six Ps: Pallor (loss of normal color, coolness) Paralysis Pulselessness (decreased/absent pulses)

Complications of Fractures Compartment Syndrome Clinical Manifestations Six Ps: Patient may present with one or all of the six Ps Compare extemities

Complications of Fractures Compartment Syndrome Clinical Manifestations Absence of peripheral pulse = ominous late sign Myoglobinuria Dark reddish-brown urine

Complications of Fractures Compartment Syndrome Collaborative Care Prompt, accurate diagnosis is critical Early recognition is the key Do not apply ice or elevate above heart level

Complications of Fractures Compartment Syndrome Collaborative Care Remove/loosen the bandage and bivalve the cast Reduce traction weight Surgical decompression (fasciotomy)

Complications of Fractures Venous Thrombosis Veins of the lower extremities and pelvis are highly susceptible to thrombus formation after fracture, especially hip fracture

Complications of Fractures Venous Thrombosis Precipitating factors: Venous stasis caused by incorrectly applied casts or traction Local pressure on a vein Immobility Prevent with anticoagulant medications

Complications of Fractures Fat Embolism Syndrome (FES) Characterized by the presence of fat globules in tissues and organs after a traumatic skeletal injury

Complications of Fractures Fat Embolism Syndrome (FES) Fractures that most often cause FES: Long bones Ribs Tibia Pelvis

Complications of Fractures Fat Embolism Syndrome (FES) Tissues most often affected: Lungs Brain Heart Kidneys Skin

Complications of Fractures Fat Embolism Syndrome (FES) Clinical Manifestations Usually occur 24-48 hours after injury Interstitial pneumonitis Produce symptoms of ARDS

Complications of Fractures Fat Embolism Syndrome (FES) Clinical Manifestations Symptoms of ARDS: Chest pain Tachypnea Cyanosis  PaO2

Complications of Fractures Fat Embolism Syndrome (FES) Clinical Manifestations Symptoms of ARDS: Dyspnea Apprehension Tachycardia

Complications of Fractures Fat Embolism Syndrome (FES) Clinical Manifestations Rapid and acute course Feeling of impending disaster Patient may become comatose in a short time

Complications of Fractures Fat Embolism Syndrome (FES) Collaborative Care Treatment directed at prevention Careful immobilization of a long bone fracture Most important preventative factor

Complications of Fractures Fat Embolism Syndrome (FES) Collaborative Care (treatment) Symptom management Fluid resuscitation Oxygen Reposition as little as possible

Fracture of the Hip Fracture of proximal third of femur Common in the elderly More frequent in women than men. Up to 35% of clients will die within the first year

Fracture of the Hip Intracapsular fractures: Extrascapular fractures Occur within hip joint capsule Extrascapular fractures Intertrochanteric: between greater and lesser trochanter Subtrochanteric: below lesser trochanter

Clinical Manifestations External rotation of affected leg Muscle spasm Shortening of the affected extremity Severe pain and tenderness in region of fracture

Collaborative Care Surgical repair is preferred Allows for early mobilization and decreases the risk of major complications. Buck’s traction may be utilized preoperatively to decrease painful muscle spasms.

Nursing Diagnosis Risk for peripheral neurovascular dysfunction Acute pain Risk for impaired skin integrity Impaired physical mobility

Post-Operative Care General post-op care (V/S, DB & C, etc.) Neurovascular checks Prevent external rotation (sandbags, pillows)

Preventing Dislocation of Femur Head Prosthesis Do Not Flex hip greater than 90 degrees. Place hip in adduction Allow hip to internally rotate Cross legs Put on shoes/socks without adaptive device (8 weeks) Sit in chair without arms to aid in rising to a standing position

Preventing Dislocation of Femur Head Prosthesis Do Use elevated toilet seat Use chair in shower/tub Use pillow between legs when on “good” side or supine (for 8 weeks post-op) Keep hip in neutral position when sitting, walking and lying. Notify surgeon if severe pain, deformity, or loss of function Inform dentist of presence of prosthesis