Fractures Flashcards
what are fractures
Disruption or break in continuity of structure of bone
Majority of fractures from traumatic injuries
Some fractures secondary to disease process (pathologic)
Cancer or osteoporosis
types (classifications) of fractures
Communication with environment
– Open—skin broken, bone exposed
—- Usually from severe external forces
– Closed—skin intact
Extent of break
– Complete—completely through bone
– Incomplete—partly across bone shaft
Based on direction of fracture line: Linear, oblique, transverse, longitudinal, spiral
Displaced or nondisplaced
– Displaced: two ends separated from one another
—- Often comminuted or oblique
– Nondisplaced: periosteum is intact and bone is aligned
—- Usually transverse, spiral, or greenstick
Spiral and greenstick = abuse
manifestations of fractures
Edema and swelling
Pain and tenderness
Muscle spasm
Deformity: classic sign of fracture
Bruising
Loss of function
Crepitus/Crepitation
factors influencing fracture healing
Displacement and site of fracture
Blood supply
Other local tissue injury
Immobilization
Internal fixation devices
Infection
Poor nutrition
Age
Smoking
complications of fracture healing
Delayed union
Nonunion
Malunion- not lined up properly
Pseudoarthrosis (Type of nonunion occurring at fracture site in which a false joint is formed with abnormal movement at site.)
Refracture
Myositis ossificans (Deposition of calcium in muscle tissue at site of significant blunt muscle trauma or repeated muscle injury
overall goal of fracture treatment
Anatomic realignment (reduction)
Immobilization to maintain alignment
Restoration of normal or near-normal function
diagnostic assessment of fractures
History and physical assessment
X-ray
CT scan, MRI
closed reduction fracture
Nonsurgical, manual realignment of bone fragments
Traction and countertraction applied
Under local or general anesthesia
Immobilization afterwards – Traction, cast, splint, or brace
open reduction fracture
Surgical incision
Internal fixation
— Wires, screws, pins, plates, rods, or nails
Risk for infection
Facilitates early ambulation
Reduced risks related to immobility
Pulling force applied to injured or diseased body part or extremity
traction
purpose of traction
Prevent or reduce pain and muscle spasm
Immobilize joint or part of body
Reduce fracture or dislocation
Treat a pathologic joint condition
Provide immobilization to prevent soft tissue injury
Promote active and passive exercise
Expand a joint space during arthroscopy
Expand a joint space before reconstructive surgery
why do we do traction
Pulling force to attain realignment; countertraction pulls in opposite direction
two most common types of traction
Skin traction
Skeletal traction
purpose and process of skin traction
Short-term (48 to 72 hours)
Tape, boots, or splints applied directly to skin to reduce muscle spasms
— For example, Buck’s traction (Figure) for hip, knee, or femur fracture
Traction weights 5 to 10 pounds
Skin assessment and prevention of breakdown imperative
Can lead to skin breakdown
skeletal traction
Align injured bones and joints or treat joint contractures and congenital hip
dysplasia
Long-term pull to maintain alignment
Pin or wire inserted into bone
Weights 5 to 45 pounds
Risk for delayed union, nonunion, or infection at pin sites
Complications of immobility
balanced suspension skeletal traction
Requires correct patient positioning and alignment with constant traction forces
Maintain countertraction, typically the patient’s own body weight
— Elevate end of bed
— Maintain continuous traction
— Keep weights off the floor and moving freely through pulleys
Fracture Immobilization: Cast
Temporary after closed reduction
Incorporates joints above and below fracture for stabilization during healing
Allows patient to perform many normal ADLs while maintaining immobilization
Two most common materials
— Plaster of Paris
— Fiberglass
application of a cast: fracture immobilization
Cover affected part with stockinette and padding
Immerse plaster of Paris material in warm water, wrap and mold it
— Sets in 15 minutes but need 36 to 72 hours before weight bearing
— Do not cover: risk for burn and delayed drying
— No direct pressure: petal edges
components of Synthetic casting materials
Lightweight, stronger, more waterproof
Early weight bearing
Activated by submersion in cool or tepid water, then molded to fit body part
Fracture Immobilization: External Fixation
Metal pins and wires attached to external rods
Applies traction, compresses fragments and immobilizes reduced fragments
Used for complex fractures with extensive soft tissue damage, congenital bone defects, nonunion or malunion, and limb lengthening
Attempt to save extremity that may have required amputation
Assess for pin loosening and infection
Patient teaching
Pin site care
— Chlorhexidine
— One cotton swab is designated for each pin to avoid cross-contamination
Fracture Immobilization: Internal Fixation
Surgical realignment of bony fragments using devices such as pins, plates, intramedullary rods, and bioabsorbable screws
Stainless steel, vitallius, or titanium
X-ray evaluation of alignment and healing
drug therapy for fractures
Analgesics: opioid and non-opioid
Central and peripheral muscle relaxants
— Carisoprodol (Soma)
— Cyclobenzaprine (Flexeril)
— Methocarbamol (Robaxin)
Tetanus and diphtheria toxoid
— Given for open fracture when immunization is unknown
Bone-penetrating antibiotics
— Cephalosporins – prophylactically preop**
A nurse is teaching a client how to manage an external fixation device upon discharge. Which of the following by the client indicates understanding?
a. I will clean pins more often if drainage from pin sites.
b. I will use separate cotton swab for each pin.
c. I will report loosening of the pins to my doctor.
d. I will move my leg by lifting the device in the middle.
E. I will report increased redness at the pin sites.
a, b, c, d, e
nutrition therapy for optimal soft tissue and bone healing
Increase protein (1 g/kg of body weight)
Increase vitamins (B, C, D)
Increase calcium, phosphorus , and magnesium
Increase fluid (2000 to 3000 mL/day)
Increase fiber
— Body jacket and hip spica cast patients: six small meals a day – avoid straining*
nursing fracture assessments
Obtain brief history of
— Traumatic episode
— Mechanism of injury
— Patient position when found
Transport to ED ASAP
— Thorough assessment
— Treatment started
subjective data for assessment of fractures
Health history
Medications
Surgery or other treatments
Functional health patterns
— Health perception–health management
— Activity–exercise
— Cognitive–perceptual
objective data for assessment of fractures
General
Cardiovascular
Musculoskeletal
Neurovascular
Skin
Possible diagnostic findings: X-ray, bone scan, CT scan, or MRI
neurovascular assessment of fractures
Musculoskeletal injuries can alter the neurovascular status of an extremity
— Especially important distal to injury
Assess and document before and after treatment
— Peripheral vascular assessment
— Peripheral neurologic assessment
Compare bilaterally
peripheral vascular assessment
Color and temperature
— Pallor and cool/cold indicates arterial insufficiency
— Warm and cyanotic indicates poor venous return
Capillary refill
— Greater than 3 sec indicates arterial insufficiency
- Pulses (rate, quality; compare bilaterally)
— Decreased or absent indicates arterial insufficiency
Edema
— Pitting with severe injury
peripheral neurologic assessment
Motor function
– Upper extremities
—– Abduct fingers (ulnar nerve), oppose thumb and small finger (median
nerve), flex and extend wrist (radial)
– Lower extremities
—– Dorsiflexion (peroneal nerve) , plantar flexion (tibial nerve); touch web
space between great and 2nd toe; stroke plantar surface
Sensory function
– Paresthesia or paralysis
—– Numbness/tingling, hypersensation, hyperesthesia
clinical problems from fractures
Musculoskeletal problem
Risk for infection
Pain
overall goals for fracture tx
Healing with no associated complications
Satisfactory pain relief
Maximal rehabilitation potential
acute care of those with fractures
Patients with fractures can be treated in the emergency department or a physician’s office
Patients may be released home or may require hospitalization
preoperative care for fractures
Preoperative preparation
Patient teaching
— Immobilization
— Assistive devices
— Expected activity limitations
— Assure that needs will be met
— Pain medication
postoperative care of fractures
Monitor vitals
General principles of postoperative care
Frequent neurovascular assessments
Be attentive to limitations with turning, positioning, and extremity support
Minimize pain and discomfort
Monitor for bleeding or drainage
— Aseptic technique
— Blood salvage and autotransfusion
complications of immobility
Constipation
Renal calculi
Cardiopulmonary deconditioning
Monitor for VTE
traction as treatment for fractures
Inspect exposed skin
Monitor pin sites for infection
— Pin site care per policy
Proper positioning
Exercise as permitted
Psychosocial needs
cast care of fractures
Frequent neurovascular assessments
Patient and caregiver teaching
— Apply ice for 1st 24 hours
— Elevate above heart for 1st 48 hours
— Exercise joints above and below cast
— Use hair dryer on cool setting for itching
Validate understanding of cast care instructions
Follow-up phone call
Teach about cast removal and possible alterations in appearance of extremity
dos and do nots of cast care
Do
Dry thoroughly after getting wet
Report increasing pain despite elevation, ice, and analgesia
Report swelling associated with pain and discoloration OR movement
Report burning or tingling under cast
Report sores or foul odor under cast
Do Not
Elevate if compartment syndrome suspected
Get plaster cast wet
Remove padding
Insert objects inside cast
Bear weight for 48 hours
Cover cast with plastic for prolonged period
ambulation for fracture care
Reinforce physical therapist’s instructions
Mobility training
Instruction in use of assistive aids
Pain management prior to PT
degrees of weight-bearing
Non–weight bearing
Touch-down/toe-touch weight bearing
— Contact with floor for balance; no weight borne
Partial–weight bearing
— 25-50% of weight borne
Weight bearing as tolerated
— Based on pain
Full–weight-bearing ambulation
assistive devices
Devices: cane, walker, or crutches
— Consider stability, safety, and lifestyle
— Technique for use varies
— Use transfer belt for stability when teaching how to use assistive devices
— Discourage from reaching for support
— Upper arm strength required
rehabilitation of fractures
Short-term rehabilitation
— Transition from dependence to independence with ADLs
Long-term rehabilitation
— Prevent problems associated with MS injuries: atrophy, contractures, footdrop, pain, muscle spasms
— Also: family separation, finances, inability to work, potential disability, PTSD, and caregiver support
complications of fractures
Majority heal without complication
Medical emergencies needing immediate attentionrequired with
Open fractures with severe blood loss
Fractures that damage vital organs
Death is usually the result of
Damage to underlying organs and vascular structures
Complications of fracture or immobility
direct vs indirect complications of fractures
Direct
Bone infection
Bone nonunion or malunion
Avascular necrosis
Indirect
Compartment syndrome -
VTE
Fat embolism
Rhabdomyolysis
Hypovolemic shock
compartment syndrome and s/s
Increased pressure and build-up, causes tissue impairment leading to cell death!
TREATMENT
∙ Place extremity at the heart level (not above heart level)
∙ Open the cast or splint
Fasciotomy - Fascia is cut to relieve tension & pressure
- Deep, throbbing, unrelenting pain
∙ Pain unrelieved by medications
∙ Disproportional to the injury
∙ Intensifies with passive ROM
infection from fractures
High incidence in open fractures and soft tissue injuries
Devitalized and contaminated tissue is an ideal medium for pathogens
— Clostridium tetani
Measures to prevent infection and osteomyelitis (infection of the bone) are important
open fracture infections
Aggressive surgical debridement
Wound may or may not be closed at the time of surgery
The amount of soft tissue damage determines
— Repeat debridement
— Closed suction drainage
— Skin grafting
Antibiotics: irrigation, impregnated-beads, and IV
Avascular Necrosis (AVN)
Occurs when the circulatory compromise after a fracture
Blood flow is disrupted to the fracture site and the resulting ischemia leads to tissue (bone) necrosis
Common in hip fracture or in fractures with displacement of a bone
Risk factors: long-term corticosteroid use, radiation therapy, rheumatoid arthritis, and sickle cell disease
Pain, limited movement
Treatment: bone graft, prosthetic replacement,
compartment syndrome
Swelling and increased pressure within a limited space (muscle compartment)
– Compromises neurovascular function of tissues within that space
—- 38 compartments in upper and lower extremities
—- Associated with fractures with extensive tissue damage and crush injury
—- Most common: distal humerus and proximal tibia
—- May occur after knee or leg surgery or with prolonged pressure (limb trapped under body)
two basic causes of compartment
Decreased compartment size from restrictive dressings, splints, casts,
excessive traction, or premature closure of fascia
Increased compartment contents due to bleeding, inflammation, edema, or IV infiltration
— Edema causes pressure that obstructs circulation and venous occlusion leads to increased edema
— Arterial flow compromised causing ischemia and cell death, leading to loss of function
clinical manifestations of compartment syndrome
Early recognition and treatment essential to avoid irreversible damage
May occur initially with injury or may be delayed several days
Ischemia can occur within 4 to 8 hours after onset
Six Ps***
—- Pain: out of proportion to injury; not managed by opioids; passive stretch
—- Pressure
—- Paresthesia
—- Pallor
—- Paralysis or loss of function
—- Pulselessness
interprofessional care of compartment syndrome
Prompt, accurate diagnosis via regular neurovascular assessments
Early signs
Notify of pain unrelieved by drugs and out of proportion to injury
Paresthesia is also an early sign
Relieving the source of pressure may prevent progression
Late signs
Pulselessness
Paralysis
May require amputation
If compartment syndrome suspected
Do not elevate extremity above heart
Do not apply cold compresses or ice
Causes vasoconstriction and reduced circulation to already compromised extremity
treatment of compartment syndrome
Relieve pressure
Surgical decompression (fasciotomy)
Amputation
venous thromboembolism (VTE)
Veins of lower extremities and pelvis highly susceptible to thrombus formation due to venous stasis from muscle inactivity: Increased risk with hip fracture, THR, or TKR
Prophylactic anticoagulant drugs for 10 to 14 days
Antiembolism stockings
Intermittent pneumatic compression devices
Exercises
Fat Embolism Syndrome (FES)
Systemic fat globules from fracture that are distributed into tissues and organs (especially lungs and brain)
—- Contributory factor in mortality
Most common with fracture of long bones, ribs, tibia, and pelvis
—- May also occur after joint replacement, burns, pancreatitis, liposuction, crush injuries, and bone marrow transplants
Mechanical theory
— Fat released from marrow and enters circulation where it can obstruct leading to local ischemia and inflammation
Biochemical theory
— Hormonal changes caused by trauma or sepsis stimulate release of fatty acids to form fat emboli
early recognition is crucial to decrease risk of death
Symptoms 24 to 48 hours after injury
Fat emboli in the lungs cause a hemorrhagic interstitial pneumonitis leading to ARDS
Respiratory abnormalities: chest pain, tachypnea, cyanosis, dyspnea,
apprehension, tachycardia, hypoxemia
Neurological abnormalities: changes in mental status due to poor O2 exchange
Petechiae on the neck, anterior chest wall, axilla, head may help discern FES
from other problems
Not all patients have petechiae
Petechiae may fade before being noticed
clinical manifestations of FES
Pallor can quickly change to cyanosis; comatose
Fat cells in blood, urine, or sputum
Decreased PaO2 to less than 60 mm Hg
Decreased platelet count, hematocrit levels
Increased ESR
ECG may show ST segment and T-wave changes
Chest x-ray may show bilateral pulmonary infiltrates
interprofessional care FES
Most survive FES with few complications
Management is supportive and related to symptom management
Respiratory support
O2 to treat hypoxia
ECMO or mechanical ventilation for low PaO2
Monitor for pulmonary edema and/or ARDS
management of FES interprofessional care
Cardiovascular problems
IV fluids
Pulmonary vasodilators
Peripheral vasoconstrictors
Inotropic drugs
No current research supporting use of steroids, heparin or dextran
prevention of FES
Careful immobilization and handling of long bone fractures
Reposition as little as possible prior to immobilization and stabilization to prevent dislodging fat droplets into circulation
what is rhabdomylysis
Syndrome caused by the breakdown of damaged skeletal muscle
Releases myoglobin into circulation resulting in obstruction of renal tubules, causing Acute tubular necrosis
Assess urine output
— Dark-reddish brown urine
Assess for symptoms of AKI
A nurse is assessing a client with a casted compound fracture of femur. which is a manifestation of fat embolus.
a. AMS
b. reduced bowel sounds
c. swelling of the toes distal to injury
d. pain with passive movement of the foot distal to injurt
a. AMS
A nurse is assessing a client who had an external fixation device applied 2 hr ago for a fracture of the left tibia and fibula. Which is a manifestation of compartment syndrome.
a. intense pain when client’s left foot is passively moved.
b. capillary refill of 3 sec on the client’s left toes
c. hard, swollen muscle in client left leg
d. burning and tingling of the client’s left foot
e. client reporting of minimal pain relief following a second dose of opioid medication
a, c, d, e
hip fractures and prevalence
Fracture of proximal (upper 1/3) of femur
Common in older adults
95% due to fall
>300,000 hospitalizations
37% die within a year
Women
Suffer 75% of all hip fractures
Over age 65 due to osteoporosis
Most caused by severe direct trauma or fall
intracapsular hip fracture
occurs within hip joint capsule
Capital – head of femur
Subcapital – just below head of femur
Transcervical – femoral neck
Fragility fractures
Associated with osteoporosis and minor trauma
extracapsular hip fractures
occurs outside joint capsule
Intertrochanteric – between greater and lesser trochanter
Subtrochanteric – below lesser trochanter
clinical manifestations of hip fractures
External rotation
Muscle spasm
Shortening of affected extremity
Severe pain and tenderness around fracture site
Displaced femoral neck fracture may lead to avascular necrosis of femoral head
initial treatment of hip fractures
Immobilization with Buck’s traction
If medically unstable
To relieve muscle spasms (used for 24-48 hours)
surgery for hip fracture
Closed reduction with percutaneous pinning (CRPP)
Repair with internal fixation devices
Replacement of femoral head—hemiarthroplasty
THR (femur and acetabulum)
preoperative care of total hip replacement
Usual preoperative nursing care
Consider co-occurring health problems (older adults)
Patient teaching related to surgery
May be done in ED
Start D/C plans early due to short hospital stays
Pain/muscle spasm management
Analgesics or muscle relaxants
Positioning (unless contraindicated)
Traction
general care of total hip replacement
Monitor VS, I & O
Monitor respiratory status; encourage deep breathing and coughing
Pain management
Assess dressings for bleeding
Neurovascular assessment
— Color, temperature, capillary refill, distal pulses, edema, sensation, motor
function, pain
Elevate leg to reduce edema
postoperative care of total hip replacements
Maintain limb alignment with pillows when turning to nonoperative side
—- Avoid operative side unless HCP approved
Trapeze
Physical therapy (exercises, transfers, walking aids)
Ambulation (usually out of bed 1st post-op day)
Weight-bearing varies
—- Limited after ORIF until healing confirmed by x-ray (usually restricted 6 to 12 weeks)
No tub bath or driving for 4 to 6 weeks
Occupational therapist for assistive devices
—- Long-handled shoehorns, sock assists, and reachers or grabbers
patient education dos and donts to prevent dislocations of hip
Hemiarthroplasty or THR by posterior approach
Do
Use elevated toilet seat and chair
Remain seated on chair in shower or tub
Keep hip in neutral, straight position when
sitting, walking or lying
Notify surgeon immediately if severe pain,
deformity, or loss of function occurs
Discuss risk of infection related to prosthetic
joint with dentist or surgeon
Do Not
Flex hip greater than 90 degrees
Adduct hip
Internally rotate hip
Cross legs at knees or ankles
Put on own shoes without adaptive device for 4
to 6 weeks
Sit on chairs without arms
Fewer precautions
Avoid hyperextension
Complications of femoral neck fractures
Nonunion, avascular necrosis, dislocation, osteoarthritis, shorter leg
Dislocation: sudden, severe pain, lump in buttock, limb shortening, and
external rotation
Keep patient NPO in anticipation of surgery
Closed reduction with sedation
Open reduction under general anesthesia
Psychosocial support
Resources, community services for rehabilitation after hospital discharge
ambulatory care for total hip replacements
Discharge considerations
Subacute rehabilitation or acute rehabilitation (if live alone)
Home health care with PT
Home care
Pain management, monitor for infection, prevent VTE
Patient teaching: bleeding precautions with anticoagulant
Exercises with PT
Home safety to prevent falls
Calcium and vitamin D supplementation: patients with osteopenia or
osteoporosis
