Fractures

FracturesFractures

DescriptionDescription

A disruption or break in the continuity of the structure of bone

Traumatic injuries account for the majority of fractures

A disruption or break in the continuity of the structure of bone

Traumatic injuries account for the majority of fractures


Described and classified according to:

Type

Communication or noncommunication with external environment

Anatomic location


Type

Communication or noncommunication with external environment

Anatomic location

Types of FracturesTypes of Fractures

Fig. 61-4

Classification by Communication withExternal Environment

Classification by Communication withExternal Environment

Fig. 61-5

Classification by Fracture LocationClassification by Fracture Location

Fig. 61-6



Appearance, position, and alignment of the fragments

Classic names

Stable or unstable


Appearance, position, and alignment of the fragments

Classic names

Stable or unstable


Closed (also called simple)

Open (also called compound)

Closed (also called simple)

Open (also called compound)


Stable fractures

Occur when a piece of the periosteum is intact across the fracture

External or internal fixation has rendered the fragments stationary

Stable fractures

Occur when a piece of the periosteum is intact across the fracture

External or internal fixation has rendered the fragments stationary


Unstable fractures

Grossly displaced

Poor fixation

Unstable fractures

Grossly displaced

Poor fixation

Clinical ManifestationsClinical Manifestations

Immediate localized pain

Function

Inability to bear weight or use affected part

Guarding

May or may not see obvious bone deformity

Immediate localized pain

Function

Inability to bear weight or use affected part

Guarding

May or may not see obvious bone deformity

Fracture HealingFracture Healing

Reparative process of self-healing (union) occurs in the following stages:

1. Fracture hematoma (d/t bleeding, edema)

2. Granulation tissue → osteoid (3 – 14 days post injury)

3. Callus formation (minerals deposited in osteoid)


1. Fracture hematoma (d/t bleeding, edema)

2. Granulation tissue → osteoid (3 – 14 days post injury)

3. Callus formation (minerals deposited in osteoid)

Fracture HealingFracture Healing


4. Ossification (3 wks – 6 mos)

5. Consolidation (distance between fragments decreases → closes).

6. Remodeling (union completed; remodels to original shape, strength)


4. Ossification (3 wks – 6 mos)

5. Consolidation (distance between fragments decreases → closes).

6. Remodeling (union completed; remodels to original shape, strength)

Bone HealingBone Healing

Fig. 61-7

Collaborative CareCollaborative Care

Overall goals of treatment:

Anatomic realignment of bone fragments (reduction)

Immobilization to maintain alignment (fixation)

Restoration of normal function

Overall goals of treatment:

Anatomic realignment of bone fragments (reduction)

Immobilization to maintain alignment (fixation)

Restoration of normal function

Collaborative CareFracture Reduction

Collaborative CareFracture Reduction

Closed reduction

Nonsurgical, manual realignment Open reduction

Correction of bone alignment through a surgical incision

Closed reduction

Nonsurgical, manual realignment Open reduction

Correction of bone alignment through a surgical incision

Collaborative Care Fracture ReductionCollaborative 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

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

Temporary circumferential immobilization device

Common following closed reduction

CastsCastsCastsCasts

Fig. 61-9



External fixation

Metallic device composed of pins that are inserted into the bone and attached to external rods

External fixation

Metallic device composed of pins that are inserted into the bone and attached to external rods



Internal fixation

Pins, plates, intramedullary rods, and screws

Surgically inserted at the time of realignment

Internal fixation

Pins, plates, intramedullary rods, and screws

Surgically inserted at the time of realignment



Traction

Application of a pulling force to an injured part of the body while countertraction pulls in the opposite direction

Traction

Application of a pulling force to an injured part of the body while countertraction pulls in the opposite direction



Purpose of traction:

Prevent or reduce muscle spasm

Immobilization

Reduction

Treat a pathologic condition

Purpose of traction:

Prevent or reduce muscle spasm

Immobilization

Reduction

Treat a pathologic condition

Nursing Management Nursing Assessment for Fractures

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

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 temperaturecyanotic and cool/cold: arterial insufficiency

Blue and warm: venous insufficiency

Capillary refill (want < 3 sec)

Peripheral pulses (↓ indicates vascular insufficiency)


Color and temperaturecyanotic and cool/cold: arterial insufficiency

Blue and warm: venous insufficiency

Capillary refill (want < 3 sec)

Peripheral pulses (↓ indicates vascular insufficiency)




Edema

Sensation

Motor function

Pain


Edema

Sensation

Motor function

Pain

Nursing Management Nursing Diagnoses


Risk for peripheral neurovascular dysfunction Acute pain Risk for infection

Risk for peripheral neurovascular dysfunction Acute pain Risk for infection



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

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

Nursing Management Nursing ImplementationNursing Management Nursing Implementation

General post-op careAssess dressings/casts for bleeding/drainage

Prevent complications of immobilityMeasures 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 ImplementationNursing Management Nursing Implementation

TractionEnsure:

No frayed ropes, loose knots

Ropes in pulley grooves

Pulley clamps fastened securely

Weights must hang freely

Appropriate body alignment

Inspect skinAround slings

Around pins

Nursing Management Nursing Implementation: Cast care

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 FracturesInfection


Open fractures and soft tissue injuries have incidence

Osteomyelitis can become chronic

Open fractures and soft tissue injuries have incidence

Osteomyelitis can become chronic



Collaborative Care

Open fractures require aggressive surgical debridement

Post-op IV antibiotics for 3 to 7 days (prophylactic)

Collaborative Care

Open fractures require aggressive surgical debridement

Post-op IV antibiotics for 3 to 7 days (prophylactic)

Complications of FracturesCompartment 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

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



Two basic etiologies create compartment syndrome:

Decreased compartment size (dressings, splints, casts)

Increased compartment content (bleeding, edema)

Two basic etiologies create compartment syndrome:

Decreased compartment size (dressings, splints, casts)

Increased compartment content (bleeding, edema)



Clinical Manifestations

Six Ps

1. Paresthesia (unrelieved by narcotics)

2. Pain (unrelieved by narcotics)

3. Pressure


Six Ps

1. Paresthesia (unrelieved by narcotics)

2. Pain (unrelieved by narcotics)

3. Pressure




Six Ps:

4. Pallor (loss of normal color, coolness)

5. Paralysis

6. Pulselessness (decreased/absent pulses)


Six Ps:

4. Pallor (loss of normal color, coolness)

5. Paralysis

6. Pulselessness (decreased/absent pulses)




Six Ps:

Patient may present with one or all of the six Ps

Compare extemities


Six Ps:

Patient may present with one or all of the six Ps

Compare extemities




Absence of peripheral pulse = ominous late sign

Myoglobinuria

Dark reddish-brown urine


Absence of peripheral pulse = ominous late sign

Myoglobinuria

Dark reddish-brown urine



Collaborative Care

Prompt, accurate diagnosis is critical

Early recognition is the key

Do not apply ice or elevate above heart level

Collaborative Care

Prompt, accurate diagnosis is critical

Early recognition is the key

Do not apply ice or elevate above heart level



Collaborative Care

Remove/loosen the bandage and bivalve the cast

Reduce traction weight

Surgical decompression (fasciotomy)

Collaborative Care

Remove/loosen the bandage and bivalve the cast

Reduce traction weight

Surgical decompression (fasciotomy)

Complications of FracturesVenous Thrombosis


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

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



Precipitating factors:

Venous stasis caused by incorrectly applied casts or traction

Local pressure on a vein

Immobility Prevent with anticoagulant medications

Precipitating factors:

Venous stasis caused by incorrectly applied casts or traction

Local pressure on a vein

Immobility Prevent with anticoagulant medications

Complications of FracturesFat Embolism Syndrome (FES)Complications of Fractures

Fat Embolism Syndrome (FES)

Characterized by the presence of fat globules in tissues and organs after a traumatic skeletal injury

Characterized by the presence of fat globules in tissues and organs after a traumatic skeletal injury



Fractures that most often cause FES:

Long bones

Ribs

Tibia

Pelvis

Fractures that most often cause FES:

Long bones

Ribs

Tibia

Pelvis



Tissues most often affected:

Lungs

Brain

Heart

Kidneys

Skin

Tissues most often affected:

Lungs

Brain

Heart

Kidneys

Skin




Usually occur 24-48 hours after injury

Interstitial pneumonitis

Produce symptoms of ARDS


Usually occur 24-48 hours after injury

Interstitial pneumonitis

Produce symptoms of ARDS




Symptoms of ARDS:

Chest pain

Tachypnea

Cyanosis

PaO2


Symptoms of ARDS:

Chest pain

Tachypnea

Cyanosis

PaO2




Symptoms of ARDS:

Dyspnea

Apprehension

Tachycardia


Symptoms of ARDS:

Dyspnea

Apprehension

Tachycardia




Rapid and acute course

Feeling of impending disaster

Patient may become comatose in a short time


Rapid and acute course

Feeling of impending disaster

Patient may become comatose in a short time



Collaborative Care

Treatment directed at prevention

Careful immobilization of a long bone fracture

Most important preventative factor

Collaborative Care

Treatment directed at prevention

Careful immobilization of a long bone fracture

Most important preventative factor



Collaborative Care (treatment)

Symptom management

Fluid resuscitation

Oxygen

Reposition as little as possible

Collaborative Care (treatment)

Symptom management

Fluid resuscitation

Oxygen

Reposition as little as possible

Fracture of the HipFracture 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 HipFracture of the Hip

Intracapsular fractures:Occur within hip joint capsule

Extrascapular fracturesIntertrochanteric: between greater and lesser trochanter

Subtrochanteric: below lesser trochanter

Clinical ManifestationsClinical Manifestations

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

fracture

Collaborative CareCollaborative 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 Nursing Diagnosis Risk for peripheral neurovascular

dysfunction Acute pain Risk for impaired skin integrity Impaired physical mobility

Post-Operative CarePost-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 NotFlex 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



DoUse 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

Fractures

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