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Fractures

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