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)
Open (also called compound)



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:
1. Fracture hematoma (d/t bleeding, edema)
2. Granulation tissue osteoid (3 14 days
post injury)
3. Callus formation (minerals deposited in
osteoid)




Fracture Healing
Reparative process of self-healing (union)
occurs in the following stages:
4. Ossification (3 wks 6 mos)
5. Consolidation (distance between fragments
decreases closes).
6. 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
1. Paresthesia (unrelieved by narcotics)
2. Pain (unrelieved by narcotics)
3. Pressure

Complications of Fractures
Compartment Syndrome
Clinical Manifestations
Six Ps:
4. Pallor (loss of normal color, coolness)
5. Paralysis
6. 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
PaO
2

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.
Bucks 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