w11 fractures Flashcards
what is a fracture
a disruption or break in the continuity of the structure of bone
what is an open fracture
skin is broken, exposing the bone and causing soft tissue injury
what is a closed fracture
the skin has not been ruptured and remains intact
complete fracture
if the break is completely through the bone
incomplete fracture
fracture occurs partly across a bone shaft but the bone is still in one piece (non-displaced)
-incomplete fracture is often the result of bending or crushing forces applied to a bone
displaced fracture
two ends of the broken bone are separated from one another and out of their normal position
-displaced fractures are usually comminuted (more than two fragments) or oblique
nondisplaced fracture
the periosteum is intact across the fracture and the bone is still in alignment
-usually are transverse, spiral, or greenstick
what are the clinical manifestations of a fracture?
immediate localized pain, decreased function, and inability to bear weight on or use the affected part
- pt guards and protects the extremity against movement
- moving may damage the soft tissue and convert a closed fracture to an open fracture or create further injury to adjacent neuro-vascular structures
- fracture hematoma
when a fracture occurs bleeding creates a hematoma which surrounds the ends of the fragments
- the hematoma is extravasated blood that changes from a liquid to a semisold clot
- this hematoma occurs in the initial 72 hours after injury
- granulation tissue
- active phagocytosis absorb the products of local necrosis
- the hematoma converts to granulation tissues
- granulation tissue consists of new blood vessels, fibroblasts, and osteoblasts and produces the basis for new bone structure called osteoid during 3-14 days after injury
- callus formation
- as minerals (calcium, phosphorus, and magnesium) and new bone matrix are deposited in the osteoid, an unorganized network of bone is formed that is woven about the fracture parts
- callus is composed primarily of cartilage, osteoblasts, calcium, and phosphorus
- appears by the end of the second week after injury
- evidence of callus formation can be verified by radiography.
- ossification
Ossification of the callus occurs from 3 weeks to 6 months after the fracture and continues until the fracture has healed
- callus ossification is sufficient to prevent movement at the fracture site when the bones are gently stressed
- fracture is still evident on a radiograph
- during this stage of clinical union, the patient may be allowed limited mobility or the cast may be removed
- consolidation
as callus continues to develop distance between bone fragments diminishes and eventually closes
- ossification continues during this stage
- can occur up to one year following injury
- remodelling
- excess bone tissue is reabsorbed in the final stage of bone healing and union is completed
- gradual return of the injured bone to its pre injury structural strength and shape occurs
- bone remodels in response to physical landings stress of Wolff’s law
- weight bearing is gradually introduced
- new bone is deposited in Estes subjected to stress and resorbed at areas where there is little stress
problems w/ fracture healing- delayed union
Fracture healing progresses more slowly than expected; healing eventually occurs
problems w/ fracture healing-nonunion
Fracture fails to heal properly despite treatment; no radiographic evidence of callus formation
problems w/ fracture healing- malunion
Fracture heals in expected time but in unsatisfactory position, possibly resulting in deformity or dysfunction
problems w/ fracture healing- angulation
Fracture heals in abnormal position in relation to midline of structure (type of malunion)
problems w/ fracture healing- pseudoarthrosis
Type of nonunion occurring at fracture site in which a false joint is formed with abnormal movement at site
problems w/ fracture healing- refracture
New fracture occurs at original fracture site
problems w/ fracture healing-myositis ossificans
-Deposition of calcium in muscle tissue at the site of significant blunt muscle trauma or repeated muscle injury
what are the goals of fracture treatment
1) anatomical realignment of bone fragments (reduction)
2) immobilization to maintain realignment
3) restoration of normal or near-normal function of the injured part
what is closed reduction
- non surgical manual realignment of bone fragments to their previous anatomical position
- traction and counetrtraction are manually applied to the bone to restore position, length and alignment
- perform under local or general anaesthesia
what is open reduction
- correction of bone alignment through a surgical incision
- often includes internal fixation of the fracture with the use of wires, screws, pins, plates, intramedullary rods, or nails
what is open reduction
- correction of bone alignment through a surgical incision
- often includes internal fixation of the fracture with the use of wires, screws, pins, plates, intramedullary rods, or nails
disadvantage of open reduction
-infection, complications associated w/ anaesthesia, and the effect of pre-existing medical conditions (e.g., diabetes)
what is traction
the application of a pulling force to an injured or disease part of the body/extremity
what is counetrtraction?
pulls in the opposite direction
why is traction used
- prevent/reduce pain and muscle spasms associated w/ low back pain or coeval sprain (whiplash)
- immobilize a joint or part of the body
- reduce a fracture or dislocation
- treat a pathological joint condition (e.g., tumour infection)
- provides immobilization to prevent soft tissue damage
- promote active/passive exercise
- expands a joint space during arthroscopic procedures
- expand a joint space before major joint reconstruction
skin traction
used for short term treatments (48-72r hrs) until skeletal traction or surgery is possible
Tape, boots, or splints are applied directly to the skin to maintain alignment, assist in reduction, and help diminish muscle spasms in the injured extremity
a buck traction boot
t is a type of skin traction used to immobilize a fracture, prevent hip flexion contractures, and reduce muscle spasms
skeletal traction
- used for longer periods
- used to align injured bones and joints or to treat contractures and congenital hip dysplasia
- provides a long-term pull that keeps the injured bones and joints aligned
what is the weight for skeletal traction
ranges from 2-20kg
-too much weight can result in delayed union or nonunion
what is the weight for skin traction
2.3-4.5kg
what is the priority assessment for skin traction?
skin is a priority since pressure points and skin breakdown develop quickly
-asses every 2-4 hours
what is the disadvantage of skeletal traction
risk for infection in the area of the bone where the skeletal pin has been inserted and the consequences of prolonged immobility
a cast
a temporary circumferential immobilization device
- common followed closed reduction
- allows pt to perform ALD’S while providing sufficient immobilization to ensure stability
external fixation
- is a metallic device composed of metal pens that are inserted into the bone and attached to external rods to stabilize the fracture while it heals
- assessment for pin loosening and infection is critical
- indicated in closed fractures, complex fractures with extensive soft tissue damage, correction of body defects (congenital) nonunion or malunion and limb lengthening
- attached directly to the bones by percutaneous transfixing pins or wires
why do we use external fixation
- used in attempt to salvage extremities that otherwise might require amputation
- it is long-term
assessments for external fixation
- assessment for pin loosening and infection is critical
- infection is signalled by exudate, erythema, tenderness and pain -may need to remove the device
how do we care for external pin fixation
half-strength hydrogen peroxide w/ normal saline
internal fixation
internal fixation devices (pins, plates, intramedullary rods, metal and bioabsorbale screws) are surgically inserted at the time of realignment
-are biologically inert and made from stainless steel, vitallium, or titanium
fractures can be classified as
- open or close
- complete or incomplete
- based on direction of fracture line
- displaced or nondisplaced
neuro-vascular and musculoskeletal
they have the potential to cause changes in the neuro-vasucalr status of an injured extremity
-tramua, application of a cast, constructive dressing, poor positioning, and the physiological response to the traumatic injury can cause nerve or vascular damage usually distal to the injury
assessments for neuro-vascualr
should include peripheral vascular assessment (color temp, cap refill, peripheral pulses, and edema)
- and a peripheral neurological assessment (sensation, motor function, and pain)
- combare both extremities to obtain accurate assessment
what does pallor or cool to cold extremity below the injury could indicate
arterial insufficiency
what dose a wam, cyanotic extremity indicate?
poor venous return
normal cap refill is_?
less than 3 seconds
-indicates good arterial perfusion
what dose a diminished or absent pulse distal to the injury indicate?
vascular dysfunction and insufficiency
what are the two types of traction?
skin or skeletal
what is the disadvantages to skeletal traction
disadvantages of skeletal traction are risk for infection in the area of the bone where the skeletal pin has been inserted and the consequences of prolonged immobility.
when can u start weight bearing after u got a cast
24-72 hours after
what should u not do with a cast
do not get a cast wet, remove any padding, insert any objects into the cast or weight bear for 48hrs (until dry)
-do not insert any objects or remove any paddings
what should u do with a cast
apply ice directly over fracture for the first 24 hrs
- raise the extremity above the heart for the first 48hrs
- move joints above & below cast often
reporting assessment w/ casts
increase pain, swelling w/ discolouration of toes/fingers
- pain during movement
- burning or tingling under cast
- sores or foul odours under cast
petaling a cast
- once the cast is thoroughly dry, the edges may have to bepetalledto prevent skin irritation from rough edges and to prevent plaster debris from falling into the cast and causing irritation or pressure necrosis.
- several strips (petals) of tape are placed over the rough areas to ensure a smooth cast edge
why should u never cover a a fresh plaster cast over w/ a blanket?
A fresh plaster cast should never be covered with a blanket because air cannot circulate and heat builds up in the cast.
sling
- nurse must ensure that the axillary area is well padded to prevent skin excoriation and maceration associated w/ direct skin-to-skin contact
- sling should not put pressure on the posterior neck
- movement of the fingers (unless contraindicated) should be encouraged to enhance the pumping action of vascular and soft tissue structures to decrease edema
Thomas/metal splint
for fractures of arm or leg and is used to immobilize the injured limb
-consists of a ring at one end to fit around the upper arm or leg and two metal shafts extending down the sides of the limb in a long U w/ a crosspiece at the bottom where traction is applied
peripheral vascular assessment consists of
colour, temperature, cap refill, peripheral pulses and edema
peripheral neurological assessment include
sensation, motor function and pain
-both extremities are compared to obtain an accurate assessment
what are the complications of immobility
DVT
- infection
- compartment syndrome
- pulmonary embolism
what is compartment syndrome?
condition in which swelling and increased pressure w/in a limited space (a compartment) press on and compromise in the function of blood vessels, nerves, and tendons that run through that compartment
-classified as acute, subacute, or chronic
what are the causes compartment syndrome
- decreased compartment size resulting from restrictive dressing, splints, casts, excessive traction or premature closure of fascia
- increased compartment contents r/t bleeding, edema, chemical response to snakebite or intravenous infiltration
infection
- high incidence for infections w/ open fractures and soft tissue injuries
- tetanus
- osetemoyelitis
DVT
veins of lower extremities and the pelvis are highly susceptible to thrombus formation after a fracture
manifestations of DVT
unilateral leg edema, pain, tenderness on palpation, warm skin, erythema, dilated superficial veins
fat embolism syndrome
characterized by the prescence of systemic fat globules from fractures that are distributed into tissues and organs after a traumatic skeletal injury
manifestations of fat embolism syndrome
chest pain, tachypnea, cyansosis, dyspnea, apprehension, tachycardia, and decrease Paco2
what are the 6 p’s
paresthesia
pressure (increase pressure in compartment)
paralysis: loss of function
pain: distal to injury & not relieved by opioids & pain on passive stretch of muscle travelling through compartment
pallor-coolness and loss of normal colour of extremity
pulselessnes- diminished/absent peripheral pulses
*need to be immediately reported
do we elevated a limb in compartment syndrome?
should never be elevated above the heart level
- elevation may raise venous pressure and slow arterial perfusion
- keep pt NPO and don’t put ice bc it cause vasoconstriction and worsen
cold compress and compartment syndrome?
application of cold compress may result in vasoconstriction and may exacerbate compartment syndrome
pulmonary embolisms s/s
chest pain
dyspnea
can be slow or sudden
hemoptysis (20%)
-cough, pleuritic chest, crackles, fever
-sudden change in mental status as a result of hypoxemia
-massive emboli may produce abrupt hypotension, pallor, hypoxemia
-chest pain may not be present
-ecg may indicate tachycardia and right ventricular strain
-medium size emboli often cause pleuritic chest pain, dyspnea, slight fever, productive cough w/ blood-streaked sputum
-tachycardia and pleural friction rub
nursing care for PE
bed rest, semi-fowler’s
-IV line for medication and fluid therapy
-oxygen therapy as ordered
-careful monitoring of vital signs, cardiac dysrhythmia
-abgs, Lund sounds
monitor aPTT and INR
assessing for complications of anticoagulant therapy
hypoxia, hypotensions
-coughing and deep breathing should be encouraged
-provide oxygen N/P or simple mask
why should we reposition the pt who has PE as little as possible?
The patient should be repositioned as little as possible before fracture immobilization or stabilization because of the danger of dislodging more fat droplets into the general circulation
