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Fractures

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Disruption or break in the continuity of the structure of bone. Majority of fractures from traumatic injuries Some fractures secondary to disease process Cancer or osteoporosis

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Classification of Fractures

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Open or closed Complete or incomplete Based on direction of fracture line Displaced or nondisplaced

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Open or Closed Fractures

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Depends on communication or noncommunication with external environment Open—skin broken and bone and soft tissue exposed Closed—skin intact

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Complete or Incomplete Fractures

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Complete—break is completely through bone Incomplete—bone is still in one piece but break occurs across the bone shaft

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Classification of Direction of Fractures

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Linear Oblique - diagonally across the shaft of the bone. Transverse - perpendicular to the shaft of the bone. Longitudinal Spiral

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Displaced or Nondisplaced Fractures

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Displaced—two ends separated from one another Nondisplaced—bone is aligned and periosteum is intact

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Signs and symptoms of a Fracture

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Mechanism of injury associated with numerous signs and symptoms Immediate localized pain Decreased function Inability to bear weight on or use affected part Patient guards and protects extremity.

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Nursing Considerations of a Fracture

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Fracture may not be accompanied by obvious bone deformity. Immobilize extremity if fracture is suspected. Unnecessary movement Increases soft tissue damage May convert a closed fracture to open

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Stages of Fracture Healing

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Fracture hematoma Granulation tissue Callus formation Ossification Consolidation Remodeling

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Fracture Healing: Fracture Hematoma

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Initial 72 hours Bleeding creates a hematoma, surrounding ends of fragments. Hematoma is extravasated blood that changes from liquid to semisolid clot.

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Fracture Healing: Granulation Tissue

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3 to 14 days post injury Active phagocytosis absorbs products of local necrosis. Hematoma converts to granulation tissue. Granulation tissue produces basis for new bone substance (osteoid).

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Fracture Healing: Callus Formation

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End of second week Minerals and new bone matrix are deposited in osteoid. Unorganized bone network is formed and woven around fracture parts. Callus is composed primarily of cartilage, osteoblasts, calcium, and phosphorus.

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Fracture Healing: Consolidation

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As callus continues to develop, distance between bone fragments diminishes and eventually closes. Ossification continues. Can be equated with radiologic union

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Fracture Healing: Remodeling

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Up to a year after injury Excess bone tissue is reabsorbed. Union is complete. Gradual return to preinjury structural strength and shape occurs. Bone remodels in response to physical loading stress.

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Factors Influencing Fracture Healing

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Age Initial displacement Site of fracture Implants Infection Blood supply to area Hormones

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Delayed Union of Fracture Healing

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Does not occur in the expected time.

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Nounion of Fracture Healing

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The fracture doesn't heal at all.

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Electrical stimulation and pulsed electromagnetic fields (PEMFs)

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Stimulate bone healing Electric currents modify cell mechanisms, causing bone remodeling. Electrodes are placed over skin or cast and are used 10 to 12 hours each day.

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Rib Fractures Nursing Considerations

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Increased risk of Pneumothorax. Treated with Pain Medication

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Pelvic Fractures Nursing Considerations

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Digestive and reproductive organs are located within the pelvic ring. Large nerves and blood vessels that go to the legs pass through it. Pelvic fracture can be associated with substantial bleeding, nerve injury, and internal organ damage. Stable fracture will get conservative care. Unstable fracture will require surgical intervention

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Femoral Neck Fracture Nursing Considerations

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Requires much force Often very displaced due to muscle contraction Increase risk of fat embolism

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Colles' Fracture

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Fracture of distal radius. Usually occurs when attempting to break a fall.

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Fracture Treatment

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Assess NV, vital signs Elevate, apply ice Pain, medicate May need assistive devices in bed Prevent DVT/ Blood clots Cast application and care Assist with traction application and cont to assess, provide pin care Skin vs skeletal traction

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Overall Goals of Fracture Treatment

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Anatomic realignment of bone fragments Immobilization to maintain realignment Restoration of normal or near-normal function of injured parts

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Fracture Reduction: Closed Reduction

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Nonsurgical, manual realignment of bone fragments to previous anatomic position Traction and countertraction manually applied to bone fragments to restore position, length, and alignment

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Fracture Reduction: Open Reduction

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Correction of bone alignment through surgical incision Includes internal fixation with use of wires, screws, pins, plates, intramedullary rods, or nails Chief disadvantages Possibility of infection Complications associated with anesthesia Effects of preexisting medical conditions Early initiation of ROM of the joint If open reduction with internal fixation (ORIF) is used for intraarticular fractures Machines can provide continuous passive motion (CPM) to various joints. Helps prevent extraarticular and intraarticular adhesions Results in faster reconstruction of subchondral bone plate, rapid healing of articular cartilage, and decreased complications

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Fraction Care: Traction

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Application of a pulling force to an injured or diseased part of body or extremity, while countertraction pulls in opposite direction

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Purpose of Traction

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Prevent or decrease muscle spasm. Immobilize joint or part of body. Decrease a fracture or dislocation. Treat a pathologic joint condition. Provide immobilization to prevent soft tissue damage Reduce muscle spasm associated with low back pain or cervical whiplash Expand a joint space During arthroscopic procedures or Before major joint reconstruction

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Two Most Common Types of Traction

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Skin Traction Skeletal Traction

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Skin Traction

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Used for short-term treatment until skeletal traction or surgery is possible Tape, boots, or splints applied directly to skin to maintain alignment, assist in reduction, and help diminish muscle spasms in injured extremity Traction weights 5 to 10 pounds

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Skeletal Traction

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In place for longer periods Used to align injured bones and joints or to treat joint contractures and congenital hip dysplasia Provides a long-term pull that keeps injured bones and joints aligned Physician inserts pin or wire into bone, either partially or completely, to align and immobilize injured body part. Skeletal traction weight range: 5 to 45 pounds Too much weight results in delayed union or nonunion.

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Buck's Traction

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When traction is used, forces are usually exerted on distal fragment to obtain alignment with proximal fragment. This is when they use the boot. Most commonly used for fractures of the hip and femur.

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Nursing Consideration for Traction

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Assess NV status Ropes and weights should be free hanging No knots to prevent traction in pulley Weights correct Skin surface checks for breakdown or pressure Pain medication Provide for ADLS/ get a trapeze bar Prevent blood clots/pnemonia

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Consideratioins for Traction

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Fracture alignment depends on correct positioning and alignment while traction forces remain constant. Forces must be pulling in opposite direction to prevent patient from sliding to end or side of bed. Countertraction commonly supplied by patient's body weight or augmented by elevating end of bed Imperative that nurse maintains traction constantly and does not interrupt weight applied to traction

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Nursing Management of Traction

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Nurse should inspect exposed skin regularly when slings are used with traction. Pressure over bony prominence created by wrinkling sheets or bedclothes may cause pressure necrosis. Persistent skin pressure may impair blood flow and cause injury to peripheral neurovascular structures. Observe skeletal traction pins for infection. Pin care varies but usually includes regular removal of exudate, rinsing of pin sites, and drying of the area. External rotation of hip can occur when skin traction is used on lower extremities. Nurse can correct this position by placing a pillow, sandbag, or rolled-up draw sheet along greater trochanteric region of the femur.

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Direct Complications of Fractures

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Problems with bone infection Bone union Avascular necrosis

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Indirect Complications of Fractures

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Blood vessels and nerve damage Compartment syndrome Deep vein thrombosis Fat embolism Traumatic or hypovolemic shock

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Infections of Fractures

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High incidence in open fractures and soft tissue injuries Massive or blunt soft tissue injury often has more serious consequences than fracture. Devitalized and contaminated tissue is an ideal medium for pathogens. Treatment is costly in terms of Extended nursing and medical care Time for treatment Loss of patient income Osteomyelitis may become chronic.

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Compartment Syndrome

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Decreased sensation of the involved nerves. Pain increases with passively stretching the involved muscles. Tense extremity swelling. Early Symptoms: Pain - severe, constant pain out of proportion of severity of injury. Pressure - pain on palpation. Paresthesia Late Symptoms: Paresis, Pallor, Pulselessness - last to occur.

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Fat Embolism (FES)

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Presence of systemic fat globules from fracture that are distributed into tissues and organs after a traumatic skeletal injury Contributory factor in many deaths associated with fracture Fractures most often causing FES are those of long bones, ribs, tibia, and pelvis. Known to occur following total joint replacement, spinal fusion, liposuction, crash injury, and bone marrow transplantation

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Signs and Symptoms of FES

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irritability, rest-lessness, tachypnea, tachycardia, changes in mental status, diffuse crackles (a late finding), dyspnea, hypoxia, fever, and petechiae in a vest distribution.

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Nursing Intervention of FES

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HOB up High Apply O2 Chest Xray Get Arterial Blood Gas

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Clinical Manifestation of FES

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Early recognition crucial in preventing potentially lethal course Most patients manifest symptoms 24 to 48 hours after injury. Fat globules transported to lungs cause a hemorrhagic interstitial pneumonitis. Clinical course of fat embolus may be rapid and acute. Patient frequently expresses a feeling of impending disaster. In a short time skin color changes from pallor to cyanosis. Patient may become comatose. No specific laboratory examinations are available. Certain diagnostic abnormalities may be present. Fat cells in blood, urine, or sputum ↓ platelet count and hematocrit levels Prolonged prothrombin time

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