Fractures 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 Openskin broken and bone and soft tissue exposed Closedskin intact Open and closed fracture FRACTURES Complete or incomplete Completebreak 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 5 Fig 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 nondisplaced Displacedtwo ends separated from one another Nondisplacedbone 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 MANIFESTATIONS FRACTURE HEALING Factors influencing healing Age Healing time of fractures increases with age. Site of fracture Implants Infection Blood supply to area CLINICAL MANIFESTATIONS FRACTURE 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 MANIFESTATIONS FRACTURE 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 COLLABORATIVE CARE TRACTION 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 CARE TRACTION 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 BUCKS TRACTION Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier 13 Fig Bucks traction. Most commonly used for fractures of the hip and femur. COLLABORATIVE CARE FRACTURE 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 Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 15. 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. 16 COLLABORATIVE CARE EXTERNAL FIXATION Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 17 Fig External fixators. A, Stabilization of hand injury. B, Stabilization of knee injury with pins in femur and tibia. COLLABORATIVE CARE EXTERNAL FIXATION Infection control is critical. Infection signaled by Exudate Erythema Tenderness Pain Instruct patient and family on meticulous skin care. 18 COLLABORATIVE CARE INTERNAL FIXATION Surgically inserted at time of realignment metal devices used Stainless steel Vitallium Titanium Alignment evaluated by x-ray 19 INTERNAL FIXATION DEVICES 20 Fig Views of internal fixation devices to stabilize a fractured tibia and fibula. COLLABORATIVE CARE NUTRITIONAL 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 21 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. 22 NURSING MANAGEMENT NURSING 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. 23 NURSING MANAGEMENT NURSING 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 24 NURSING MANAGEMENT NURSING 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 25 NURSING MANAGEMENT NURSING DIAGNOSES Impaired physical mobility Risk for peripheral neurovascular dysfunction Acute pain Ineffective self-health management 26 NURSING MANAGEMENT PLANNING Goals Have physiologic healing with no associated complications Obtain satisfactory pain relief Achieve maximal rehabilitation potential. 27 NURSING MANAGEMENT NURSING IMPLEMENTATION Health promotion To 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 physicians office. 28 NURSING MANAGEMENT PREOPERATIVE MANAGEMENT Nurse should Inform patients of Immobilization Assistive devices that will be used Expected activity limitations after surgery POSTOPERATIVE 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. 29 NURSING MANAGEMENT POSTOPERATIVE 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 30 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. 31 NURSING MANAGEMENT AMBULATORY AND HOME CARE Cast care Dos 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 32 NURSING MANAGEMENT AMBULATORY AND HOME CARE Cast care Donts 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 33 AMBULATION Reinforce physical therapists 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 34 AMBULATION Degrees of weight-bearing ambulation Nonweight-bearing ambulation Touch-down/toe-touch weight-bearing ambulation Partialweight-bearing ambulation Weight bearing as tolerated Fullweight-bearing ambulation Devices for ambulation range from a cane to a walker or crutches. 35 ASSISTIVE DEVICES Transfer belt should be placed around patients waist to provide stability during learning stages. Discourage patient from reaching for furniture or relying on another person for support. 36 COMPARTMENT SYNDROME Elevated intracompartmental pressure within a confined myofascial compartment compromises neurovascular function of tissues within that space. 37 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 38 COMPARTMENT SYNDROME CLINICAL 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 39 COMPARTMENT SYNDROME COLLABORATIVE 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) 40 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 41 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 42 FAT EMBOLISM (FES) COLLABORATIVE CARE Treatment Fluid resuscitation Correction of acidosis Replacement of blood loss Encourage coughing and deep breathing. Oxygen to treat hypoxia 43 Hip dislocation Soft tissue injury of the hip. A, Normal. B, Subluxation (partial dislocation). C, Dislocation. 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 Sprain-injury to ligaments Strain-injury to muscles or tendon RICE- rest, ice, compression, elevation Patient and caregiver teaching guide table 63- 1, page 1584 Amputation: Patient and caregiver teaching guide table 63-14, page 1613