Chapter 45: Fractures

Chapter 45, fractures. 1. Fracture. ● Defined as a break or disruption in the continuity of a bone. ● When a fracture occurs, surrounding soft tissue is also injured. 2. Complete fracture. ● In Which the break extends across the entire bone, dividing it into two separate pieces. 3. Incomplete fracture. ● In which the bone breaks only partway across, leaving some portion of the bone intact. 4. Greenstick fracture. ● The bone is splintered on one side but only bent on the other. ● Describes the incomplete fractures most commonly seen in children. 5. Closed fracture (simple fracture). ● Is one in which the broken bone does not break through the skin. 6. Open fracture (compound fracture). ● Fragments of the broken bone break through the skin. 7. Open factures 3 grades of severity. ● Grade 1; lease severe injury, with minimal skin damage. ● Grade 2; moderately severe injury, with skin & muscle contusions (bruises). ● Grade 3; most severe injury (wound larger than 6 to 8 cm), with skin, muscle, blood vessel, nerve damage. 8. Common types of fractures. 9. Culture considerations. ● Older Caucasian women have high incidence of osteoporosis and therefore are at risk for fractures. ● To reduce the risk, preventive measures should be taken throughout life. ● Osteoporosis is easier to prevent than to treat. 10. Fracture healing. ● A bone geins to heal as soon as an injury occurs. ● New bone tissue is formed to repair the fracture, resulting in a sturdy union between the broken ends of the bone. ● Healing occurs in 5 stages. Stage 1; ● Hematoma formation. ● Immediately after a fracture, bleeding & edema occur. ● In 48 to 72 hours, a clot or hematoma forms between the two broken ends of the bone. Stage 2. ● Fibrocartilage formation. ● The hematoma that surrounds the fracurres does not resorb as does hematoma in other parts of the body. ● Instead, other tissue cells enter the clot and granulation tissue forms, replacing the clot. ● The granulation tissue then forms a collar around each end of the broken bone, gradually coming fim and forming a bridge between the two ends. Stage 3. ● ● ● Callus formation. Within 1 to 4 weeks after injury, the granulation tissue changes into a callus formation. Callus is made up of cartilage, osteoblasts (i.e., bone cells that form new bone), calcium, & phosphorus. The callus is larger than the diameter of the bone and serves as a temporary splint. Stage 4. ● Ossification. ● Within 3 weeks to 6 months after the break, a permanent bone callus, known as woven bone, forms. ● It is during this stage that the ends of the broken bone begin to knit. Stage 5. ● Consolidation and remodeling. ● Consolidation occurs when the distance between bone fragments decreases and eventually closes. ● During bone remodeling, the immature bone cells are gradually replaced by mature bone cells. ● The excess bone is naturally chiseled away by stress to the affected part from motion, exercise, and weight bearing. ● The bone then takes on its original shape & size. 11. Complications. ● Complications of a fracture can delay or impede healing & may even be life threatening. ● Short-term complications include infection, fat embolism, deep vein thrombosis (DVT), compartment syndrome, & shock. ● Long-term complications include joint stiffness & contractures, malunion, nonunion, delayed union, posttraumatic arthritis, avascular necrosis, & complex regional pain syndrome. 12. Infections. ● Infections of the bone, called osteomyelitis, can result from contamination of the open wound associated with a fracture, from contamination of the indwelling hardware used to repair the broken bone, or through the blood from a distant infection. ● Osteomyelitis occurs most commonly after an open fracture & surgical repair and may become chronic. In deep, grossly contaminated wounds, gas gangrene may develop. ● Signs & symptoms of bone infection are local pain, redness, purulent wound drainage, chills, & fever. With gas gangrene, a foul-smelling watery drainage is seen with significant redness & swelling of affected tissue. ● Labs. CBC with diff; The leukocyte count rarely exceeds 15,000/µL acutely and is usually normal in chronic osteomyelitis. ● Osteomyelitis requires aggressive antibiotic therapy. 13. Fat embolism. ● ● ● ● ● Fat embolism is a condition in which fat globules are released from the marrow of the broken bone into the bloodstream. Once the fat droplets enter the circulation, they migrate to the lungs. Fat embolism syndrome is most commonly associated with fractures of the long bones, multiple fractures, & severe trauma. Respiratory distress is the first sign of a fat embolism, followed by tachycardia, tachypnea, fever, confustin, & decreased level of consciousness. Another characteristic feature is petechiae, a measles-like rash over the neck, upper arms, chest or abdomen. 14. Deep vein thrombosis. ● A blood clot in a deep vein, usually developing in the legs. ● Interventions; sequential compression device (SCD). 15. Compartment syndrome. ● Compartment syndrome is a serious complication that results from internal or external pressure on the affected area. ● Compartments are located in the muscle of the extremities. ● They are enclosed spaces made up of muscle, bone, nerves, & blood vessels wrapped by a fibrous membrane, or fascia. ● External pressure caused by a cast or tight dressing can decrease blood flow to the area. ● Internal pressure can be caused by edema or bleeding into the compartment. Fluid trapped in the compartment puts pressure on the tissues, nerves, & blood vessels, decreasing blood flow and resulting in pain & tissue. ● Paresis (i.e., partial paralysis) can result if the condition is not treated within 24 hours. ● The goal of treatment is to relieve pressure (fasciotomy). 16. Shock. ● After a fracture, a risk of excessive blood loss. ● Hypovolemia. ● Loss of blood leads to shock, which is evidenced by tachycardia, anxiety, pallor, & cool, clammy skin. ● Hemoglobin blood test; is used to determine if a patient needs a blood transfusion. 17. Joint stiffness & contractors. ● Treatment may include the use of splints, traction, casts, surgical manipulation, & aggressive physiotherapy. ● Always check capillary refill on distal pulse to determine circulation (good blood flow). Check cap refills every 4 hours (ATI). 18. Signs & symptoms of fractures and their causes. ● Creptius; results from broken bone ends rubbing together. Grating sensations or sounds are felt or heard if the injured part is moved. ● ● ● Hypovolemic shock; may result from blood loss or other injuries. Paralysis; may be caused by nerve damage. Impaired sensation (numbness); sensation may be impared as a result of nerve damage or nerve entrapment from edema, bleeding, or bony fragments. 19. Reduction. ● Reduction is the process of bringing the ends of the broken bones into proper alignment. ● Close reduction or manipulation is the nonsurgical realignment of the bones that returns them to their previous anatomic position. ● Open reduction is a surgical procedure in which an incision is made at the fracture site. It is usually done for open (i.e., compound) or comminuted fractures (i.e., bone is broken or crushed into small pieces) to clean the area of fragments and debris. ● 19. Fixation. ● Fixation is an attempt to attach the fragments of the broken bone together when reduction alone is not feasible because of the type & extent of the break. ● Internal fixation is done during the open reduction surgical procedure. ● Internal fixation includes the use of; rods, pins, nails, screws, or metal plates to align bone fragments & keep them in place for healing. ● External fixation is similar to internal fixation, but the pins are inserted directly into the bone, above and below the fracture. ● The pins are then attached to an external frame and adjusted to align the bone. ● 20. Cast types & common uses. ● Short arm cast; fracture of hand or wrist, postoperative immobilization after open reduction & internal fixation. ● Long arm cast; fracture of forearm, elbow, or humerus. Postoperative immobilization after open reduction and internal fixation, can be weighted to create traction. ● Body jacket cast; stable spine injuries of the thoracic or lumbar spine. ● Bilateral long leg hip spica cast; fractures of femur, acetabulum, or pelvis. Postoperative immobilization after open reduction and internal fixation. ● Long leg cast; fracture of distal femur, knee, or lower leg. Soft tissue injury to knee or knee dislocation. Postoperative immobilization after open reduction and internal fixation. ATI can cause constipation; interventions: increase patient’s fiber. ● Short leg cast; fracture of foot, ankle, or distal tibia or fibula. Severe sprain or strain. Postoperative immobilization after open reduction & internal fixation. Correction of dormity, such talipes equinovarus. ATI, too tight of a leg cast may cause problems such as pallor (pale) and must be reported to the physician. 21. Patient teaching; cast care. ● Keep plaster cast dry; follow the physician’s instructions regarding wetting synthetic casts. ● Do not remove any padding. ● Do not insert any foreign object inside the cast. ● Do not bear weight on new plaster cast for 48 hours (with synthetics, may be less than 1 hour). ● Do not cover the cast with plastic for prolonged periods. ● Report the following to health care providers: swelling, discoloration of toes or fingers, pain during motion, and burning or tingling under cast. 22. Traction. ● Exerts a pulling force on fractured extremity to provide alignment of broken bone fragment or prevent/correct deformity. ● It is used for hip and knee contractures, muscle spasm, and alignment of hip fractures. Weight used during skin traction should not be more than 5 to 10 lbs. to prevent injury to the skin. ● The following are important points to remember when patients are in traction: ● Weights must always hang freely. ● Ensure that the amount of weight used is correct as ordered, clamps are tight, & ropes move freely over pulleys. ● Use padding to prevent trauma to skin where traction is applied. Report skin breakdown or irritation to the physician. ● With skeletal traction, assess pin sites for redness, drainage, or odor, which may indicate infection. ● Bucks traction; significantly reduces muscle spasms & relieves pain. 23. Crutches. ● A properly fitted crutch should reach to about 3 to 4 fingerbreadths below the axilla to avoid pressure on the axilla and nerves when walking. ● The hand grips are adjusted so that the elbow is slightly flexed, enough so that the elbow may be fully extended when taking a step. ● Total crutch length should equal the distance from the armpit to about 6 inches in front of a shoe. 24. ATI, Treating a patient with ORIF surgery. ● Follow ABCs. ● Interventions for suction machine draining the wound; monitor bleeding and empty the suction every 4 hours. ● Empty suction and bleeding is 500 cc/500 mL report to the physician. 25. Cast, splints & immobilizers. ● ● ● ATI; When immobilizers or splints are being used, protect parts of the splint with protective dressing, soft cloth, or soft cotton to protect and prevent skin problems and disorders. Short pieces of tape are sometimes placed over the edges of the casts to prevent skin irritations by rough edges and to protect the cast from moisture & soiling. This is referred to as petaling. Cast syndrome is caused by compression of a portion of the duodenum between the superior mesenteric artery and the aorta & vertebral column. Signs & symptoms of cast syndrome include nausea and abdominal distention. 26. Gait patterns. ● Two-point gait; The crutch on one side and the opposite foot are advanced at the same time. This gait is used with partial weight-bearing limitations and with bilateral lower extremity prostheses. ● Three-point gait; both crutches and the foot of affected extremity are advanced together, followed by the foot of the unaffected extremity. This gait requires strength and balance. It is used for partial weight breaking or no weight bearing on the affected leg. ● Four-point gait; the right crutch is advanced, then the left foot, then the left crutch, and then the right foot. This fait is used if weight bearing is allowed and one foot can be placed in front of the other. ● Swing-to gait; both crutches are advanced together and then both legs are lifted and placed down again on a spot behind the crutches. The feet and crutches form a tripod. ● Swing-through gait; both crutches are advanced together and then both legs are lifted through and beyond the crutches and placed down again at the onit in front of the crutches. This gait is used when adequate muscle power and balance in the arms and legs exist. 28. The use of crutches on stairs. ● Going up and down stairs on crutches is challenging. ● For stair climbing, the unaffected legs goes up the step first while the crutches support the body. The full body weight is transferred to the unaffected leg, followed by movement of the crutches and the affected leg to the stop. ● To descend stairs, the affected leg and the crutches move down one step first and then the unaffected leg follows. ● So, when climbing stairs, the good leg goes first and when descending stairs, the bad leg goes first. ● “The good leads up and bad leads down.” 27. Canes ● Canes are used to provide minimal support & balance and to relieve pressure on weight-bearing joints. ● The cane is placed on the unaffected side with the top of the cane even with the patient's greater trochanter. ● The elbow should be flexed to approximately 30 degrees. ● ● ● A two-point or four-point gait is used with a cane. The cane should be held close to the body on the unaffected side and advanced along with the affected leg. When walkin, it is better to lift the can rather than slide it along to prevent catching the can top and tripping or falling. 28. Hip fractures ● ABCs first. ● Signs and symptoms are muscle spasm. 29. Jaw fractures. ● Monitor for aspiration. 30. Head injury assessment basal skull fracture. ● Be alert for the leakage of cerebrospinal fluid (CSF) that occurs with basilar skull fractures. ● CSF leakage is usually seen as clear, colorless fluid draining from the nose or ear. ● If blood is in the fluid, a yellow “halo” is produced around the pink (bloody) center. ● Presence of glucose on the test strip. ● Can cause spinal headache. Chapter 46, amputations. 1. Postoperative nursing care of the patient having amputation surgery; focused assessment. ● Monitor vital signs frequently in the first 48 hours to detect early signs of problems. 2. Knowledge deficit. ● Pain or phantom limb sensation is common. ● It is often described as a burning, stinging, crushing pain. ● It tends to lessen with activity, eight bearing, and exercise. 3. Postoperative nursing care of the patient having replantation surgery. ● Focused assessment; assess the limb for edema, because massive edema often accompanies replantation. ● Interventions; measures to promote circulation to the replanted limb include elevation of the limb and miccrovascular precautions. Elevation of the limb promotes venous and lymphatic drainage. Take care not to elevate the limb above the level of the heart, because this may impair arterial flow. Several soft pillows or a stockinette connected to an intravenous pole may help to achieve this. Microvascular precautions include avoiding any substance or conditions that contribute to blood vessel spasm or constriction. Encourage the patient to abstain from nicotine and caffeine containing products for 7 to 10 days postoperatively. In addition, maintain room temperature at 80°F to prevent compensatory vasoconstriction of the peripheral tissues in response to cold. Loosen tight or restrictive gowns or pajamas. Explain the importance of these measures to the patient and family.