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1-Fractures.pptFractures
Description
- A disruption or break in the continuity of the structure of bone
- Traumatic injuries account for the majority of fractures
Description
- Described and classified according to:
Type
Communication or noncommunication with external environment
Anatomic location
Types of Fractures
Fig. 61-4
Classification by Communication with
External Environment
Fig. 61-5
Classification by Fracture Location
Fig. 61-6
Description
- Described and classified according to:
Appearance, position, and alignment of the fragments
Classic names
Stable or unstable
Description
- Closed (also called simple) skin remain intact
- Open (also called compound) skin is breeched.
Description
- Stable fractures
Occur when a piece of the periosteum is intact across the fracture
External or internal fixation has rendered the fragments stationary
Description
- Unstable fractures
Grossly displaced
Poor fixation
Clinical Manifestations
Immediate localized pain
Function
Inability to bear weight or use affected part
Guarding
May or may not see obvious bone deformity
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)
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)
Bone Healing
Fig. 61-7
Collaborative Care
- Overall goals of treatment:
Anatomic realignment of bone fragments (reduction)
Immobilization to maintain alignment (fixation)
Restoration of normal function
Collaborative Care
Fracture Reduction
- Closed reduction
Nonsurgical, manual realignment
- Open reduction
Correction of bone alignment through a surgical incision
Collaborative 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
Collaborative Care
Fracture Immobilization
- Casts
Temporary circumferential immobilization device
Common following closed reduction
Casts
Fig. 61-9
Collaborative Care
Fracture Immobilization
- External fixation
Metallic device composed of pins that are inserted into the bone and attached to external rods
Collaborative Care
Fracture Immobilization
- Internal fixation
Pins, plates, intramedullary rods, and screws
Surgically inserted at the time of realignment
Collaborative Care
Fracture Immobilization
- Traction
Application of a pulling force to an injured part of the body while countertraction pulls in the opposite direction
Collaborative Care
Fracture Immobilization
- Purpose of traction:
Prevent or reduce muscle spasm
Immobilization
Reduction
Treat a pathologic condition
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
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)
Nursing Management
Nursing Assessment
- Neurovascular assessment
Edema
Sensation
Motor function
Pain
Nursing Management
Nursing Diagnoses
- Risk for peripheral neurovascular dysfunction
- Acute pain
- Risk for infection
Nursing Management
Nursing Diagnoses
- Risk for impaired skin integrity
- Impaired physical mobility
- Ineffective therapeutic regimen management
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
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
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 Fractures
Infection
- Open fractures and soft tissue injuries have incidence
- Osteomyelitis can become chronic
Complications of Fractures
Infection
- Collaborative Care
Open fractures require aggressive surgical debridement
Post-op IV antibiotics for 3 to 7 days (prophylactic)
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
Complications of Fractures
Compartment Syndrome
- Two basic etiologies create compartment syndrome:
Decreased compartment size (dressings, splints, casts)
Increased compartment content (bleeding, edema)
Complications of Fractures
Compartment Syndrome
- Clinical Manifestations
Six Ps
Paresthesia (unrelieved by narcotics)
Pain (unrelieved by narcotics)
Pressure
Complications of Fractures
Compartment Syndrome
- Clinical Manifestations
Six Ps:
Pallor (loss of normal color, coolness)
Paralysis
Pulselessness (decreased/absent pulses)
Complications of Fractures
Compartment Syndrome
- Clinical Manifestations
Six Ps:
Patient may present with one or all of the six Ps
Compare extemities
Complications of Fractures
Compartment Syndrome
- Clinical Manifestations
Absence of peripheral pulse = ominous late sign
Myoglobinuria
Dark reddish-brown urine
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
Complications of Fractures
Compartment Syndrome
- Collaborative Care
Remove/loosen the bandage and bivalve the cast
Reduce traction weight
Surgical decompression (fasciotomy)
Complications of Fractures
Venous Thrombosis
- Veins of the lower extremities and pelvis are highly susceptible to thrombus formation after fracture, especially hip fracture
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
Complications of Fractures
Fat Embolism Syndrome (FES)
- Characterized by the presence of fat globules in tissues and organs after a traumatic skeletal injury
Complications of Fractures
Fat Embolism Syndrome (FES)
- Fractures that most often cause FES:
Long bones
Ribs
Tibia
Pelvis
Complications of Fractures
Fat Embolism Syndrome (FES)
- Tissues most often affected:
Lungs
Brain
Heart
Kidneys
Skin
Complications of Fractures
Fat Embolism Syndrome (FES)
- Clinical Manifestations
Usually occur 24-48 hours after injury
Interstitial pneumonitis
Produce symptoms of ARDS
Complications of Fractures
Fat Embolism Syndrome (FES)
- Clinical Manifestations
Symptoms of ARDS:
Chest pain
Tachypnea
Cyanosis
PaO2
Complications of Fractures
Fat Embolism Syndrome (FES)
- Clinical Manifestations
Symptoms of ARDS:
Dyspnea
Apprehension
Tachycardia
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
Complications of Fractures
Fat Embolism Syndrome (FES)
- Collaborative Care
Treatment directed at prevention
Careful immobilization of a long bone fracture
Most important preventative factor
Complications of Fractures
Fat Embolism Syndrome (FES)
- Collaborative Care (treatment)
Symptom management
Fluid resuscitation
Oxygen
Reposition as little as possible
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
Fracture of the Hip
- Intracapsular fractures:
Occur within hip joint capsule
- Extrascapular fractures
Intertrochanteric: between greater and lesser trochanter
Subtrochanteric: below lesser trochanter
Clinical Manifestations
- External rotation of affected leg
- Muscle spasm
- Shortening of the affected extremity
- Severe pain and tenderness in region of fracture
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.
Nursing Diagnosis
- Risk for peripheral neurovascular dysfunction
- Acute pain
- Risk for impaired skin integrity
- Impaired physical mobility
Post-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 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
Preventing Dislocation of Femur Head Prosthesis
- Do
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
