1. Fractures

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

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

4. Types of Fractures
Fig. 61-4

5. Classification by Communication with External Environment
Fig. 61-5

6. Classification by Fracture Location
Fig. 61-6

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

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

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

10. Description
Unstable fractures
Grossly displaced
Poor fixation

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

12. 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)

13. 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)

14. Bone Healing
Fig. 61-7

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

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

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

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

19. Casts
Fig. 61-9

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

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

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

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

24. 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

25. 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)

26. Nursing Management Nursing Assessment
Neurovascular assessment
Edema
Sensation
Motor function
Pain

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

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

29. 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

30. 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

31. 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

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

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

34. 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

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

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

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

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

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

40. 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

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

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

43. 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

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

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

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

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

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

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

50. 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

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

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

53. 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

54. 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

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

56. 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.

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

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

59. 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

60. Preventing Dislocation of Femur Head ProsthesisDo
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