Fractures and Soft Tissue Injuries

Zoya Minasyan RN, MSN-Edu

FRACTURES

• Disruption or break in continuity of the structure of bone• Fractures can be classified

– Open or closed– Complete or incomplete– Based on direction of fracture line– Displaced or nondisplaced

– Open or closed• Open—skin broken and bone and soft tissue exposed• Closed—skin intact

Open and closed fracture

FRACTURES

– Complete or incomplete• Complete—break is completely through bone• Incomplete—bone is still in one piece but break occurs

across the bone shaft

– Based on direction of fracture line• Linear• Oblique• Transverse• Longitudinal • Spiral

CLASSIFICATION ACCORDING TO LOCATION

Fig. 63-8. Types of fractures. A, Transverse fracture is a fracture in which the line of the fracture extends across the bone shaft at a right angle to the longitudinal axis. B, Spiral fracture is a fracture in which the line of the fracture extends in a spiral direction along the shaft of the bone. C, Greenstick fracture is an incomplete fracture with one side splintered and the other side bent. D, Comminuted fracture is a fracture with more than two fragments. The smaller fragments appear to be floating. E, Oblique fracture is a fracture in which the line of the fracture extends in an oblique direction. F, Pathologic fracture is a spontaneous fracture at the site of a bone disease. G, Stress fracture is a fracture that occurs in normal or abnormal bone that is subject to repeated stress, such as from jogging or running.

CLASSIFICATION

Displaced or non displaced• Displaced—two ends separated from one

another• Non displaced—bone is aligned

• Injury associated with numerous signs and symptoms– Immediate localized pain– Decreased function– Inability to bear weight on or use affected part– Patient guards and protects extremity.

CLINICAL MANIFESTATIONS FRACTURE HEALING

• Bone goes through a process of self-healing.• Fracture hematoma: initial 72 hours

– Bleeding creates a hematoma, surrounding ends of fragments.• Granulation tissue: 3 to 14 days post injury

– Active phagocytosis. Granulation tissue produces basis for new bone substance (osteoid).

• Callus formation: end of second week – Minerals and new bone matrix are deposited in osteoid. Callus is composed primarily of

cartilage, osteoblasts, calcium, and phosphorus• Ossification• Consolidation

- As callus continues to develop, distance between bone fragments diminishes and eventually closes.

• Remodeling up to a year after injury– Excess bone tissue is reabsorbed. – Union is complete.

CLINICAL MANIFESTATIONSFRACTURE HEALING

• Factors influencing healing– Age• Healing time of fractures increases with age.

– Site of fracture– Implants– Infection– Blood supply to area

CLINICAL MANIFESTATIONSFRACTURE HEALING

• Electrical stimulation and pulsed electromagnetic fields (PEMFs)– Stimulate bone healing – Electric currents modify cell mechanisms, causing bone

remodeling.– Electrodes are placed over skin or cast and are used 10 to 12

hours each day.• Overall goals of fracture treatment

– realignment of bone fragments– Immobilization to maintain realignment– Restoration of normal or near-normal function of injured parts

CLINICAL MANIFESTATIONSFRACTURE HEALING

• Closed reduction: Nonsurgical, manual realignment of bone fragments to previous anatomic position.– Traction manually applied to bone fragments to restore position, length, and

alignment• Open reduction: through surgical incision.

– Includes internal fixation with use of wires, screws, pins, plates, rods, or nails– Chief disadvantages

• Possibility of infection• Complications associated with anesthesia • Effects of preexisting medical conditions

– Early initiation of ROM of the joint– Open reduction with internal fixation (ORIF)– Continuous passive motion (CPM) to various joints.

• Helps prevent adhesions• Results in faster reconstruction of bone, rapid healing of cartilage, and decreased

complications

Amputation

• The goal of amputation surgery is to preserve extremity length and fx while removing all infected, pathologic, or ischemic tissues.

• Pre op and post op teaching• Phantom limb sensation(may feel like

amputated limb is still there after surgery)

COLLABORATIVE CARETRACTION

• Application of a pulling force to an injured or diseased part of extremity, while countertraction pulls in opposite direction

• Purpose of any traction– Prevent or ↓ muscle spasm – Immobilize joint or part of body– ↓ a fracture or dislocation– Treat a pathologic joint condition

• Provide immobilization to prevent soft tissue damage

COLLABORATIVE CARETRACTION

• Two most common types of traction

• Skin traction Skin traction– Used for short-term treatment until skeletal traction or surgery is

possible– Tape, boots, or splints applied directly to skin to maintain alignment,

assist in reduction, and help diminish muscle spasms in injured extremity – Traction weights 5 to 10 pounds

• Skeletal traction In place for longer periods– Used to align injured bones and joints or to treat joint contractures – Provides a long-term pull that keeps injured bones and joints aligned.

Physician inserts pin or wire into bone, either partially or completely, to align and immobilize injured body part.

– Skeletal traction weight range: 5 to 45 pounds

BUCK’S TRACTION

Buck’s traction. Most commonly used for fractures of the hip and femur.

COLLABORATIVE CAREFRACTURE IMMOBILIZATION

Casts• Allows patient to perform many normal activities of

daily living • Assisting with joint stabilization while fracture heals

– During drying period Cast should be kept dry and clean. Direct pressure should be avoided After cast is completely dry, it is strong and firm and

can withstand stresses.

COMMON TYPES OF CASTS

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COLLABORATIVE CARE INJURIES TO LOWER EXTREMITIES

• Elevate extremity onto pillows above heart level for first 24 hours.

• After initial phase, casted extremity should not be placed in a dependent position because of the possibility of excessive edema.

• Observe for signs of pressure.

COLLABORATIVE CAREEXTERNAL FIXATION

External fixators. A, Stabilization of hand injury. B, Stabilization of knee injury with pins in femur and tibia.

COLLABORATIVE CAREEXTERNAL FIXATION

• Infection control is critical.• Infection signaled by

• Exudate• Erythema• Tenderness• Pain

– Instruct patient and family on meticulous skin care.

COLLABORATIVE CAREINTERNAL FIXATION

• Surgically inserted at time of realignment• metal devices used– Stainless steel– Vitallium– Titanium

• Alignment evaluated by x-ray

INTERNAL FIXATION DEVICES

Views of internal fixation devices to stabilize a fractured tibia and fibula.

COLLABORATIVE CARENUTRITIONAL THERAPY

• Adequate fluid intake – 2000 to 3000 mL/day

• High-fiber diet with fruits and vegetables• For body jacket and hip spica cast

patients- 6 small meals a day• Vitamins (B, C, D)• Calcium, Phosphorus , Magnesium

NURSING MANAGEMENT: NURSING ASSESSMENT– Deformity of affected limb– Edema– Muscle spasm– Tenderness and pain– Loss of function– Numbness, tingling, loss of distal pulses– Grating (crepitus)– Open wound over injured site, exposure of bone– Ensure airway, breathing, and circulation.– Control external bleeding with direct pressure and elevation of

extremity.– Splint joints above and below fracture sites. – Check neurovascular status distal to injury before and after splinting. – Elevate injured limb if possible.– Do not attempt to straighten fractured or dislocated joint. – Apply ice packs to affected area.– Obtain x-rays of affected area.– Mark location of pulses to facilitate repeat assessment.

NURSING MANAGEMENTNURSING ASSESSMENT

• Ongoing monitoring– Vital signs, level of consciousness, oxygen

saturation, neurovascular status, and pain– Compartment syndrome• Characterized by excessive pain, pallor,

paresthesia, paralysis, and pulselessness

– Monitor for fat embolism.

NURSING MANAGEMENTNURSING ASSESSMENT

• Subjective data– Past health history

• Traumatic injury• Long-term repetitive forces (stress fracture)• Bone or systemic disease• Prolonged immobility• Osteoporosis

– Medications• Use of corticosteroids (osteoporotic fracture)• Analgesics

– Surgery or other treatments• First aid treatment of fracture• Previous musculoskeletal surgeries

NURSING MANAGEMENTNURSING ASSESSMENT

• Objective data– Skin lacerations – Pallor and cool skin or bluish and warm distal to injury– Hematoma– Edema at site of fracture – ↓ or absent pulse distal to injury– ↓ skin temperature– Delayed capillary refill– ↓ or absent sensation– Restricted or lost function of affected part– Local bony deformities– Abnormal angulation– Shortening, rotation, or crepitation of affected part – Muscle weakness

NURSING MANAGEMENTNURSING DIAGNOSES

• Impaired physical mobility• Risk for peripheral neurovascular

dysfunction • Acute pain• Ineffective self-health management

NURSING MANAGEMENTPLANNING

• Goals– Have physiologic healing with no associated

complications– Obtain satisfactory pain relief – Achieve maximal rehabilitation potential

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NURSING MANAGEMENTNURSING IMPLEMENTATION

• Health promotionTo take appropriate safety precautions. Nurses should advocate for actions to

decrease injuries. Encourage moderate exercise to keep

muscles strong and maintain balance.Calcium and vitamin D intake Acute intervention

– Patients with fractures can be treated in the emergency department or a physician’s office.

NURSING MANAGEMENT

PREOPERATIVE MANAGEMENT Nurse should Inform patients of……• Immobilization • Assistive devices that will be used • Expected activity limitations after surgeryPOSTOPERATIVE MANAGEMENT• Monitor vitals.• Apply general principles of nursing care.• Perform frequent neurovascular assessments of

affected extremity.• Minimize pain and discomfort through proper

alignment and positioning.

NURSING MANAGEMENTPOSTOPERATIVE MANAGEMENT

• Monitor limitations in movement.• Carefully observe dressings or casts for bleeding or drainage.• Significant ↑ in size of drainage area should be reported.• Measure and assess patency of system and volume of drainage. • Constipation can be prevented by

– Increased activity– High fluid intake (>2500 mL/day)– Diet high in bulk and roughage

• Warm fluids, stool softeners, laxatives, or suppositories may be necessary.

• Rapid de-conditioning of cardiopulmonary system– Result of prolonged bed rest– Results in

• Orthostatic hypotension• Decreased lung capacity

NURSING MANAGEMENT: TRACTION

• Pressure over bony prominence created by wrinkling sheets or bedclothes may cause pressure necrosis.

• skin pressure may impair blood flow and cause injury to peripheral neurovascular structures.

• External rotation of hip can occur when skin traction is used on lower extremities.

• Nurse can correct this position by placing a pillow, sandbag, or rolled-up draw sheet along greater trochanteric region of the femur.

• Observe skeletal traction pins for infection.• Pin care includes regular removal of exudate, rinsing

of pin sites, and drying of the area.

NURSING MANAGEMENTAMBULATORY AND HOME CARE

• Cast care– Do’s

• Apply ice directly over fracture site for first 24 hours• Check with health care provider before getting

fiberglass wet• Elevate extremity above level of heart for first 48

hours • Move joints above and below cast regularly• Report signs of possible problems to health care

provider• Keep appointment to have fracture and cast

checked

NURSING MANAGEMENTAMBULATORY AND HOME CARE

• Cast care– Don’ts• Get plaster cast wet• Remove any padding• Insert any objects inside cast• Bear weight on new cast for 48 hours

– Not all casts are weight bearing

• Cover cast with plastic for prolonged periods

AMBULATION

• Reinforce physical therapist’s instructions.• Use of goinometer-measurement of joint range

of motion.( p-1575)

• Nurse may need to assist patient with lower extremity dysfunction. – Usually start mobility training when able to

sit in bed, dangle feet over side

AMBULATION

• Degrees of weight-bearing ambulation– Non–weight-bearing ambulation– Touch-down/toe-touch weight-bearing

ambulation– Partial–weight-bearing ambulation– Weight bearing as tolerated – Full–weight-bearing ambulation Devices for ambulation range from a cane to a

walker or crutches.

ASSISTIVE DEVICES

• Transfer belt should be placed around patient’s waist to provide stability during learning stages.

• Discourage patient from reaching for furniture or relying on another person for support.

COMPARTMENT SYNDROME

• Elevated intracompartmental pressure within a confined myofascial compartment compromises neurovascular function of tissues within that space.

COMPARTMENT SYNDROME

• Two basic types of compartment syndrome– ↓ compartment size • Resulting from restrictive dressing, splints, casts,

excessive traction, or premature closure of fascia

– ↑ compartment size • Related to bleeding, edema, chemical response

to snakebite, or IV filtration

COMPARTMENT SYNDROMECLINICAL MANIFESTATIONS

• Six Ps are characteristic of impending compartment syndrome.– Paresthesia: numbness and tingling– Pain: distal to injury that is not relieved by opioid

analgesics and pain on passive stretch of muscle traveling through compartment

– Pressure: ↑ in compartment– Pallor: coolness and loss of normal color of

extremity– Paralysis: loss of function– Pulselessness: diminished/absent peripheral pulses

COMPARTMENT SYNDROMECOLLABORATIVE CARE

• Prompt, accurate diagnosis• Extremity should not be elevated above heart level.

– Elevation may raise venous pressure and slow arterial perfusion.• Application of cold compresses may result in

vasoconstriction and may exacerbate (make worse) compartment syndrome.

• May be necessary to remove or loosen bandage • Reduction in traction weight may ↓ external

circumferential pressures.• Surgical decompression may be necessary.(Fasciotomy-

surgical site left open for several days to ensure adequate soft tissue decompression; risk for infection and delayed wound healing is a potential problem following fasciotomy)

VENOUS THROMBOEMBOLISM

• Veins of lower extremities and pelvis are highly susceptible to thrombosis.

• Aggravated by inactivity of muscles that normally assist in pumping action of venous blood

• Instruct patient to wear compression stockings• Anticoagulants may be ordered.

• Precipitating factors– Incorrectly applied cast or traction– Local pressure on a vein– Immobility

FAT EMBOLISM (FES)• Presence of systemic fat globules from fracture that are

distributed into tissues and organs after a traumatic skeletal injury

• Contributory factor in many deaths associated with fracture• Fractures most often causing FES are those of long bones, ribs,

tibia, and pelvis.• Known to occur following total joint replacement, spinal fusion,

liposuction, crash injury, and bone marrow transplantation• Most patients manifest symptoms 24 to 48 hours after injury.

Patient may become comatose. • Tissues most often affected

– Lungs– Brain– Heart– Kidneys– Skin

FAT EMBOLISM (FES)COLLABORATIVE CARE

• Treatment– Fluid resuscitation– Correction of acidosis– Replacement of blood loss

• Encourage coughing and deep breathing. • Oxygen to treat hypoxia

Hip dislocationSoft tissue injury of the hip. A, Normal. B, Subluxation

(partial dislocation). C, Dislocation.

Carpal Tunnel Syndrome (CTS)

• Is acondition caused by compression of the median nerve, which enters the hand through the carpal tunnel.

• Clinical manifestations: WEAKNESS, BURNING PAIN, NUMBNESS, IMPAIRED SENSATION.

• Physical signs– Tinel’s sign:tapping over the median nerve in the wrist– Phalen’s sign:flex the wrists and hold for 60 sec(look for

tingling sensation)• This condition caused by pressure from– Trauma, edema, inflammation, rheumatoid arthritis

A, Wrist structures involved in carpal tunnel syndrome. B, Decompression of median nerve by incision through the

transverse carpal ligament.

• Debridment-removal of tissue, cells, etc..• Arthroplasty-replacement of joints- use of

abductor pillow• Close reduction-nonsurgical, manual realignment

of bone fragments to teir anatomical position• Open reduction-correction by surgical incision• Sprain-injury to ligaments• Strain-injury to muscles or tendon• RICE- rest, ice, compression, elevation• Patient and caregiver teaching guide (Lewis, 8th

edition; table 63-1, page 1584)

Delegation decisions

• RN– Assessment, check for compartment syndrome, monitor cast,

determine correct body alignment, instruct pt and family about correct body alignment, teach ROM, assess for complication-infection, constipation, DVT, renal caliculi, atelectasis)

• LVN– Check color, temp, capillary refill, monitor skin integrity,

drainage, skin irritation, pain management,• NA– Position cast above the heart, apply ice as directed by RN,

maintain body position, assist pt with ROM, notify RN about pt complaints of pain, tingling, or decreased sensation on the effected extremity.

Prevention of musculoskeletal problems in the older adults

• Use ramps instead of stairs• Eliminate scatter rugs in the home• Treat pain• Use a walker or cane to help prevent falls• Eat health diet to prevent weight gain• Get regular and frequent exercise and activity• Good shoes for safety and comfort• Avoid walking on uneven surfaces and wet floors