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Fractures
Description
A disruption or break in the continuity of the structure of
boneTraumatic 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 intactOpen (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
Inability to bear weight or use affected part
Guarding
May or may not see obvious bone deformity
Fracture HealingReparative 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 HealingReparative 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 CareOverall goals of treatment:
Anatomic realignment of bone fragments (reduction)
Immobilization to maintain alignment (fixation)
Restoration of normal function
Collaborative Care
Fracture ReductionClosed reduction
Nonsurgical, manual realignmentOpen reduction
Correction of bone alignment through a surgical incision
Collaborative Care
Fracture ReductionTraction (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 ImmobilizationCasts
Temporary circumferential immobilization device
Common following closed reduction
Casts
Fig. 61-9
Collaborative Care
Fracture ImmobilizationExternal fixation
Metallic device composed of pins that are inserted into the bone
and attached to external rods
Collaborative Care
Fracture ImmobilizationInternal fixation
Pins, plates, intramedullary rods, and screws
Surgically inserted at the time of realignment
Collaborative Care
Fracture ImmobilizationTraction
Application of a pulling force to an injured part of the body
while countertraction pulls in the opposite direction
Collaborative Care
Fracture ImmobilizationPurpose of traction:
Prevent or reduce muscle spasm
Immobilization
Reduction
Treat a pathologic condition
Nursing Management
Nursing Assessment for FracturesBrief history of the
accidentMechanism of injurySpecial emphasis focused on the
region distal to the site of injury
Nursing Management
Nursing AssessmentNeurovascular 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 AssessmentNeurovascular assessment
Edema
Sensation
Motor function
Pain
Nursing Management
Nursing DiagnosesRisk for peripheral neurovascular
dysfunctionAcute painRisk for infection
Nursing Management
Nursing DiagnosesRisk for impaired skin integrityImpaired
physical mobilityIneffective therapeutic regimen management
Nursing Management
Nursing ImplementationGeneral 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 ImplementationTraction
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 careCasts can cause
neurovascular complications if
Too tight
EdematousFrequent neurovascular checksIce and elevation
during early phaseSee Table 61-10
Complications of Fractures
InfectionOpen fractures and
incidenceOsteomyelitis can become chronic
Complications of Fractures
InfectionCollaborative Care
Open fractures require aggressive surgical debridement
Post-op IV antibiotics for 3 to 7 days (prophylactic)
Complications of Fractures
Compartment SyndromeCondition in which elevated
intracompartmental pressure within a confined myofascial
compartment compromises the neurovascular function of tissues
within that spaceCauses capillary perfusion to be reduced below
a level necessary for tissue viability
Complications of Fractures
Compartment SyndromeTwo basic etiologies create
compartment syndrome:
Decreased compartment size (dressings, splints, casts)
Increased compartment content (bleeding, edema)
Complications of Fractures
Compartment SyndromeClinical Manifestations
Six Ps
Paresthesia (unrelieved by narcotics)
Pain (unrelieved by narcotics)
Pressure
Complications of Fractures
Compartment SyndromeClinical Manifestations
Six Ps:
Pallor (loss of normal color, coolness)
Paralysis
Pulselessness (decreased/absent pulses)
Complications of Fractures
Compartment SyndromeClinical Manifestations
Six Ps:
Patient may present with one or all of the six Ps
Compare extemities
Complications of Fractures
Compartment SyndromeClinical Manifestations
Absence of peripheral pulse = ominous late sign
Myoglobinuria
Dark reddish-brown urine
Complications of Fractures
Compartment SyndromeCollaborative Care
Prompt, accurate diagnosis is critical
Early recognition is the key
Do not apply ice or elevate above heart level
Complications of Fractures
Compartment SyndromeCollaborative Care
Remove/loosen the bandage and bivalve the cast
Reduce traction weight
Surgical decompression (fasciotomy)
Complications of Fractures
Venous ThrombosisVeins of the lower extremities and pelvis
are highly susceptible to thrombus formation after fracture,
especially hip fracture
Complications of Fractures
Venous ThrombosisPrecipitating factors:
Venous stasis caused by incorrectly applied casts or traction
Local pressure on a vein
ImmobilityPrevent 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
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 HipFracture of proximal third of femurCommon
in the elderlyMore frequent in women than men.Up to 35% of
clients will die within the first year
Fracture of the HipIntracapsular fractures:
Occur within hip joint capsuleExtrascapular fractures
Intertrochanteric: between greater and lesser trochanter
Subtrochanteric: below lesser trochanter
Clinical ManifestationsExternal rotation of affected legMuscle
spasmShortening of the affected extremitySevere pain and
tenderness in region of fracture
Collaborative CareSurgical 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
dysfunctionAcute painRisk for impaired skin integrityImpaired
physical mobility
Post-Operative CareGeneral post-op care (V/S, DB & C,
etc.)Neurovascular checksPrevent external rotation (sandbags,
pillows)
Preventing Dislocation of Femur Head ProsthesisDo 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 ProsthesisDo
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
FracturesDescriptionA disruption or break in t.docx

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FracturesDescriptionA disruption or break in t.docx

  • 1. Fractures Description A disruption or break in the continuity of the structure of boneTraumatic 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
  • 2. 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 intactOpen (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
  • 3. Description Unstable fractures Grossly displaced Poor fixation Clinical Manifestations Immediate localized pain Inability to bear weight or use affected part Guarding May or may not see obvious bone deformity Fracture HealingReparative 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 HealingReparative 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)
  • 4. Bone Healing Fig. 61-7 Collaborative CareOverall goals of treatment: Anatomic realignment of bone fragments (reduction) Immobilization to maintain alignment (fixation) Restoration of normal function Collaborative Care Fracture ReductionClosed reduction Nonsurgical, manual realignmentOpen reduction Correction of bone alignment through a surgical incision Collaborative Care Fracture ReductionTraction (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
  • 5. Collaborative Care Fracture ImmobilizationCasts Temporary circumferential immobilization device Common following closed reduction Casts Fig. 61-9 Collaborative Care Fracture ImmobilizationExternal fixation Metallic device composed of pins that are inserted into the bone and attached to external rods Collaborative Care Fracture ImmobilizationInternal fixation Pins, plates, intramedullary rods, and screws Surgically inserted at the time of realignment Collaborative Care Fracture ImmobilizationTraction Application of a pulling force to an injured part of the body while countertraction pulls in the opposite direction
  • 6. Collaborative Care Fracture ImmobilizationPurpose of traction: Prevent or reduce muscle spasm Immobilization Reduction Treat a pathologic condition Nursing Management Nursing Assessment for FracturesBrief history of the accidentMechanism of injurySpecial emphasis focused on the region distal to the site of injury Nursing Management Nursing AssessmentNeurovascular 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 AssessmentNeurovascular assessment Edema Sensation
  • 7. Motor function Pain Nursing Management Nursing DiagnosesRisk for peripheral neurovascular dysfunctionAcute painRisk for infection Nursing Management Nursing DiagnosesRisk for impaired skin integrityImpaired physical mobilityIneffective therapeutic regimen management Nursing Management Nursing ImplementationGeneral 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 ImplementationTraction
  • 8. 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 careCasts can cause neurovascular complications if Too tight EdematousFrequent neurovascular checksIce and elevation during early phaseSee Table 61-10 Complications of Fractures InfectionOpen fractures and incidenceOsteomyelitis can become chronic Complications of Fractures InfectionCollaborative Care Open fractures require aggressive surgical debridement Post-op IV antibiotics for 3 to 7 days (prophylactic)
  • 9. Complications of Fractures Compartment SyndromeCondition in which elevated intracompartmental pressure within a confined myofascial compartment compromises the neurovascular function of tissues within that spaceCauses capillary perfusion to be reduced below a level necessary for tissue viability Complications of Fractures Compartment SyndromeTwo basic etiologies create compartment syndrome: Decreased compartment size (dressings, splints, casts) Increased compartment content (bleeding, edema) Complications of Fractures Compartment SyndromeClinical Manifestations Six Ps Paresthesia (unrelieved by narcotics) Pain (unrelieved by narcotics) Pressure Complications of Fractures Compartment SyndromeClinical Manifestations Six Ps: Pallor (loss of normal color, coolness)
  • 10. Paralysis Pulselessness (decreased/absent pulses) Complications of Fractures Compartment SyndromeClinical Manifestations Six Ps: Patient may present with one or all of the six Ps Compare extemities Complications of Fractures Compartment SyndromeClinical Manifestations Absence of peripheral pulse = ominous late sign Myoglobinuria Dark reddish-brown urine Complications of Fractures Compartment SyndromeCollaborative Care Prompt, accurate diagnosis is critical Early recognition is the key Do not apply ice or elevate above heart level Complications of Fractures Compartment SyndromeCollaborative Care
  • 11. Remove/loosen the bandage and bivalve the cast Reduce traction weight Surgical decompression (fasciotomy) Complications of Fractures Venous ThrombosisVeins of the lower extremities and pelvis are highly susceptible to thrombus formation after fracture, especially hip fracture Complications of Fractures Venous ThrombosisPrecipitating factors: Venous stasis caused by incorrectly applied casts or traction Local pressure on a vein ImmobilityPrevent 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
  • 12. 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
  • 13. 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
  • 14. Fracture of the HipFracture of proximal third of femurCommon in the elderlyMore frequent in women than men.Up to 35% of clients will die within the first year Fracture of the HipIntracapsular fractures: Occur within hip joint capsuleExtrascapular fractures Intertrochanteric: between greater and lesser trochanter Subtrochanteric: below lesser trochanter Clinical ManifestationsExternal rotation of affected legMuscle spasmShortening of the affected extremitySevere pain and tenderness in region of fracture Collaborative CareSurgical 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 dysfunctionAcute painRisk for impaired skin integrityImpaired
  • 15. physical mobility Post-Operative CareGeneral post-op care (V/S, DB & C, etc.)Neurovascular checksPrevent external rotation (sandbags, pillows) Preventing Dislocation of Femur Head ProsthesisDo 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 ProsthesisDo 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