Fractures

Description

A disruption or break in the continuity of the structure of boneTraumatic injuries account for the majority of fractures

Description

Described and classified according to:TypeCommunication or noncommunication with external environmentAnatomic location

Types of FracturesFig. 61-4

Classification by Communication withExternal Environment Fig. 61-5

Classification by Fracture LocationFig. 61-6

Description

Described and classified according to:Appearance, position, and alignment of the fragmentsClassic namesStable or unstable

Description

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

Description

Stable fracturesOccur when a piece of the periosteum is intact across the fractureExternal or internal fixation has rendered the fragments stationary

Description

Unstable fracturesGrossly displacedPoor fixation

Clinical ManifestationsImmediate localized pain FunctionInability to bear weight or use affected partGuardingMay or may not see obvious bone deformity

Fracture HealingReparative 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 HealingReparative 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 HealingFig. 61-7

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

Collaborative CareFracture ReductionClosed reductionNonsurgical, manual realignmentOpen reductionCorrection of bone alignment through a surgical incision

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

Collaborative Care Fracture ImmobilizationCastsTemporary circumferential immobilization deviceCommon following closed reduction

CastsFig. 61-9

Collaborative Care Fracture ImmobilizationExternal fixationMetallic device composed of pins that are inserted into the bone and attached to external rods

Collaborative Care Fracture ImmobilizationInternal fixationPins, plates, intramedullary rods, and screws Surgically inserted at the time of realignment

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

Collaborative Care Fracture ImmobilizationPurpose of traction:Prevent or reduce muscle spasmImmobilizationReductionTreat a pathologic condition

Nursing Management Nursing Assessment for FracturesBrief history of the accidentMechanism of injurySpecial emphasis focused on the region distal to the site of injury

Nursing Management Nursing AssessmentNeurovascular assessmentColor and temperaturecyanotic and cool/cold: arterial insufficiencyBlue and warm: venous insufficiencyCapillary refill (want < 3 sec)Peripheral pulses ( indicates vascular insufficiency)

Nursing Management Nursing AssessmentNeurovascular assessmentEdemaSensationMotor functionPain

Nursing Management Nursing DiagnosesRisk for peripheral neurovascular dysfunctionAcute painRisk for infection

Nursing Management Nursing DiagnosesRisk for impaired skin integrityImpaired physical mobilityIneffective therapeutic regimen management

Nursing Management Nursing ImplementationGeneral post-op careAssess dressings/casts for bleeding/drainagePrevent complications of immobilityMeasures to prevent constipationFrequent position changes/ ambulate as permittedROM exercised of unaffected jointsDeep breathingIsometric exercisesTrapeze bar if permitted

Nursing Management Nursing ImplementationTractionEnsure:No frayed ropes, loose knotsRopes in pulley groovesPulley clamps fastened securelyWeights must hang freelyAppropriate body alignmentInspect skinAround slingsAround pins

Nursing Management Nursing Implementation: Cast careCasts can cause neurovascular complications ifToo tightEdematousFrequent neurovascular checksIce and elevation during early phaseSee Table 61-10

Complications of FracturesInfectionOpen fractures and soft tissue injuries have incidenceOsteomyelitis can become chronic

Complications of FracturesInfectionCollaborative CareOpen fractures require aggressive surgical debridementPost-op IV antibiotics for 3 to 7 days (prophylactic)

Complications of FracturesCompartment SyndromeCondition in which elevated intracompartmental pressure within a confined myofascial compartment compromises the neurovascular function of tissues within that spaceCauses capillary perfusion to be reduced below a level necessary for tissue viability

Complications of FracturesCompartment SyndromeTwo basic etiologies create compartment syndrome:Decreased compartment size (dressings, splints, casts)Increased compartment content (bleeding, edema)

Complications of FracturesCompartment SyndromeClinical ManifestationsSix PsParesthesia (unrelieved by narcotics)Pain (unrelieved by narcotics)Pressure

Complications of FracturesCompartment SyndromeClinical ManifestationsSix Ps:Pallor (loss of normal color, coolness)ParalysisPulselessness (decreased/absent pulses)

Complications of FracturesCompartment SyndromeClinical ManifestationsSix Ps:Patient may present with one or all of the six PsCompare extemities

Complications of FracturesCompartment SyndromeClinical ManifestationsAbsence of peripheral pulse = ominous late signMyoglobinuriaDark reddish-brown urine

Complications of FracturesCompartment SyndromeCollaborative CarePrompt, accurate diagnosis is criticalEarly recognition is the keyDo not apply ice or elevate above heart level

Complications of FracturesCompartment SyndromeCollaborative CareRemove/loosen the bandage and bivalve the castReduce traction weightSurgical decompression (fasciotomy)

Complications of FracturesVenous ThrombosisVeins of the lower extremities and pelvis are highly susceptible to thrombus formation after fracture, especially hip fracture

Complications of FracturesVenous ThrombosisPrecipitating factors:Venous stasis caused by incorrectly applied casts or tractionLocal pressure on a veinImmobilityPrevent with anticoagulant medications

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

Complications of FracturesFat Embolism Syndrome (FES)Fractures that most often cause FES:Long bonesRibsTibiaPelvis

Complications of FracturesFat Embolism Syndrome (FES)Tissues most often affected:LungsBrainHeart Kidneys Skin

Complications of FracturesFat Embolism Syndrome (FES)Clinical ManifestationsUsually occur 24-48 hours after injuryInterstitial pneumonitis Produce symptoms of ARDS

Complications of FracturesFat Embolism Syndrome (FES)Clinical ManifestationsSymptoms of ARDS:Chest painTachypneaCyanosis PaO2

Complications of FracturesFat Embolism Syndrome (FES)Clinical ManifestationsSymptoms of ARDS:DyspneaApprehensionTachycardia

Complications of FracturesFat Embolism Syndrome (FES)Clinical ManifestationsRapid and acute courseFeeling of impending disasterPatient may become comatose in a short time

Complications of FracturesFat Embolism Syndrome (FES)Collaborative CareTreatment directed at preventionCareful immobilization of a long bone fracture Most important preventative factor

Complications of FracturesFat Embolism Syndrome (FES)Collaborative Care (treatment)Symptom managementFluid resuscitationOxygenReposition as little as possible

Fracture of the HipFracture of proximal third of femurCommon in the elderlyMore frequent in women than men.Up to 35% of clients will die within the first year

Fracture of the HipIntracapsular fractures:Occur within hip joint capsuleExtrascapular fracturesIntertrochanteric: between greater and lesser trochanterSubtrochanteric: below lesser trochanter

Clinical ManifestationsExternal rotation of affected legMuscle spasmShortening of the affected extremitySevere pain and tenderness in region of fracture

Collaborative CareSurgical repair is preferred Allows for early mobilization and decreases the risk of major complications.Bucks traction may be utilized preoperatively to decrease painful muscle spasms.

Nursing Diagnosis Risk for peripheral neurovascular dysfunctionAcute painRisk for impaired skin integrityImpaired physical mobility

Post-Operative CareGeneral post-op care (V/S, DB & C, etc.)Neurovascular checksPrevent external rotation (sandbags, pillows)

Preventing Dislocation of Femur Head ProsthesisDo NotFlex hip greater than 90 degrees.Place hip in adduction Allow hip to internally rotateCross legsPut 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 ProsthesisDoUse elevated toilet seatUse chair in shower/tubUse 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