Download Focus on Fractures

Fractures and Soft Tissue Injuries
Zoya Minasyan RN, MSN-Edu
FRACTURES
• Disruption or break in continuity of the structure of
bone
• Fractures can be classified
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Open or closed
Complete or incomplete
Based on direction of fracture line
Displaced or nondisplaced
– Open or closed
• Open—skin broken and bone and soft tissue exposed
• Closed—skin intact
Open and closed fracture
FRACTURES
– Complete or incomplete
• Complete—break is completely through bone
• Incomplete—bone is still in one piece but break occurs
across the bone shaft
– Based on direction of fracture line
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Linear
Oblique
Transverse
Longitudinal
Spiral
CLASSIFICATION ACCORDING TO LOCATION
Fig. 63-8. Types of fractures. A, Transverse fracture is a fracture in which the line of the fracture extends across the bone
shaft at a right angle to the longitudinal axis. B, Spiral fracture is a fracture in which the line of the fracture extends in a
spiral direction along the shaft of the bone. C, Greenstick fracture is an incomplete fracture with one side splintered and the
other side bent. D, Comminuted fracture is a fracture with more than two fragments. The smaller fragments appear to be
floating. E, Oblique fracture is a fracture in which the line of the fracture extends in an oblique direction. F, Pathologic
fracture is a spontaneous fracture at the site of a bone disease. G, Stress fracture is a fracture that occurs in normal or
abnormal bone that is subject to repeated stress, such as from jogging or running.
CLASSIFICATION
Displaced or non displaced
• Displaced—two ends separated from one
another
• Non displaced—bone is aligned
• 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.
CLINICAL MANIFESTATIONS
FRACTURE HEALING
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Bone goes through a process of self-healing.
Fracture hematoma: initial 72 hours
– Bleeding creates a hematoma, surrounding ends of fragments.
Granulation tissue: 3 to 14 days post injury
– Active phagocytosis. Granulation tissue produces basis for new bone substance
(osteoid).
Callus formation: end of second week
– Minerals and new bone matrix are deposited in osteoid. Callus is composed primarily of
cartilage, osteoblasts, calcium, and phosphorus
Ossification
Consolidation
- As callus continues to develop, distance between bone fragments diminishes and
eventually closes.
Remodeling up to a year after injury
– Excess bone tissue is reabsorbed.
– Union is complete.
CLINICAL MANIFESTATIONS
FRACTURE HEALING
• Factors influencing healing
– Age
• Healing time of fractures increases with age.
– Site of fracture
– Implants
– Infection
– Blood supply to area
CLINICAL MANIFESTATIONS
FRACTURE HEALING
• Electrical stimulation and pulsed electromagnetic fields
(PEMFs)
– 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.
• Overall goals of fracture treatment
– realignment of bone fragments
– Immobilization to maintain realignment
– Restoration of normal or near-normal function of injured
parts
CLINICAL MANIFESTATIONS
FRACTURE HEALING
• Closed reduction: Nonsurgical, manual realignment of bone fragments to
previous anatomic position.
– Traction manually applied to bone fragments to restore position, length, and
alignment
• Open reduction: through surgical incision.
– Includes internal fixation with use of wires, screws, pins, plates, rods, or nails
– Chief disadvantages
• Possibility of infection
• Complications associated with anesthesia
• Effects of preexisting medical conditions
– Early initiation of ROM of the joint
– Open reduction with internal fixation (ORIF)
– Continuous passive motion (CPM) to various joints.
• Helps prevent adhesions
• Results in faster reconstruction of bone, rapid healing of cartilage, and decreased
complications
Amputation
• The goal of amputation surgery is to preserve
extremity length and fx while removing all
infected, pathologic, or ischemic tissues.
• Pre op and post op teaching
• Phantom limb sensation(may feel like
amputated limb is still there after surgery)
COLLABORATIVE CARE
TRACTION
• Application of a pulling force to an injured or
diseased part of extremity, while
countertraction pulls in opposite direction
• Purpose of any traction
– Prevent or ↓ muscle spasm
– Immobilize joint or part of body
– ↓ a fracture or dislocation
– Treat a pathologic joint condition
• Provide immobilization to prevent soft tissue damage
COLLABORATIVE CARE
TRACTION
• Two most common types of traction
• Skin traction Skin traction
– 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
• Skeletal traction In place for longer periods
– Used to align injured bones and joints or to treat joint contractures
– 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
BUCK’S TRACTION
Buck’s traction. Most commonly used for fractures of the hip and femur.
COLLABORATIVE CARE
FRACTURE IMMOBILIZATION
Casts
• Allows patient to perform many normal activities of
daily living
• Assisting with joint stabilization while fracture heals
– During drying period
 Cast should be kept dry and clean.
 Direct pressure should be avoided
 After cast is completely dry, it is strong and firm and
can withstand stresses.
COMMON TYPES OF CASTS
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COLLABORATIVE CARE
INJURIES TO LOWER EXTREMITIES
• Elevate extremity onto pillows above
heart level for first 24 hours.
• After initial phase, casted extremity
should not be placed in a dependent
position because of the possibility of
excessive edema.
• Observe for signs of pressure.
COLLABORATIVE CARE
EXTERNAL FIXATION
External fixators. A, Stabilization of hand injury. B, Stabilization of knee injury with pins
in femur and tibia.
COLLABORATIVE CARE
EXTERNAL FIXATION
• Infection control is critical.
• Infection signaled by
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Exudate
Erythema
Tenderness
Pain
– Instruct patient and family on meticulous
skin care.
COLLABORATIVE CARE
INTERNAL FIXATION
• Surgically inserted at time of realignment
• metal devices used
– Stainless steel
– Vitallium
– Titanium
• Alignment evaluated by x-ray
INTERNAL FIXATION DEVICES
Views of internal fixation devices to stabilize a fractured tibia and fibula.
COLLABORATIVE CARE
NUTRITIONAL THERAPY
• Adequate fluid intake
– 2000 to 3000 mL/day
• High-fiber diet with fruits and vegetables
• For body jacket and hip spica cast
patients- 6 small meals a day
• Vitamins (B, C, D)
• Calcium, Phosphorus , Magnesium
NURSING MANAGEMENT: NURSING ASSESSMENT
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Deformity of affected limb
Edema
Muscle spasm
Tenderness and pain
Loss of function
Numbness, tingling, loss of distal pulses
Grating (crepitus)
Open wound over injured site, exposure of bone
Ensure airway, breathing, and circulation.
Control external bleeding with direct pressure and elevation of
extremity.
Splint joints above and below fracture sites.
Check neurovascular status distal to injury before and after splinting.
Elevate injured limb if possible.
Do not attempt to straighten fractured or dislocated joint.
Apply ice packs to affected area.
Obtain x-rays of affected area.
Mark location of pulses to facilitate repeat assessment.
NURSING MANAGEMENT
NURSING ASSESSMENT
• Ongoing monitoring
– Vital signs, level of consciousness, oxygen
saturation, neurovascular status, and pain
– Compartment syndrome
• Characterized by excessive pain, pallor,
paresthesia, paralysis, and pulselessness
– Monitor for fat embolism.
NURSING MANAGEMENT
NURSING ASSESSMENT
• Subjective data
– Past health history
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Traumatic injury
Long-term repetitive forces (stress fracture)
Bone or systemic disease
Prolonged immobility
Osteoporosis
– Medications
• Use of corticosteroids (osteoporotic fracture)
• Analgesics
– Surgery or other treatments
• First aid treatment of fracture
• Previous musculoskeletal surgeries
NURSING MANAGEMENT
NURSING ASSESSMENT
• Objective data
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Skin lacerations
Pallor and cool skin or bluish and warm distal to injury
Hematoma
Edema at site of fracture
↓ or absent pulse distal to injury
↓ skin temperature
Delayed capillary refill
↓ or absent sensation
Restricted or lost function of affected part
Local bony deformities
Abnormal angulation
Shortening, rotation, or crepitation of affected part
Muscle weakness
NURSING MANAGEMENT
NURSING DIAGNOSES
• Impaired physical mobility
• Risk for peripheral neurovascular
dysfunction
• Acute pain
• Ineffective self-health management
NURSING MANAGEMENT
PLANNING
• Goals
– Have physiologic healing with no associated
complications
– Obtain satisfactory pain relief
– Achieve maximal rehabilitation potential
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NURSING MANAGEMENT
NURSING IMPLEMENTATION
• Health promotion
To take appropriate safety precautions.
Nurses should advocate for actions to
decrease injuries.
Encourage moderate exercise to keep
muscles strong and maintain balance.
Calcium and vitamin D intake
 Acute intervention
– Patients with fractures can be treated in the
emergency department or a physician’s office.
NURSING MANAGEMENT
PREOPERATIVE MANAGEMENT
Nurse should Inform patients of……
• Immobilization
• Assistive devices that will be used
• Expected activity limitations after surgery
POSTOPERATIVE MANAGEMENT
• Monitor vitals.
• Apply general principles of nursing care.
• Perform frequent neurovascular assessments of
affected extremity.
• Minimize pain and discomfort through proper
alignment and positioning.
NURSING MANAGEMENT
POSTOPERATIVE MANAGEMENT
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Monitor limitations in movement.
Carefully observe dressings or casts for bleeding or drainage.
Significant ↑ in size of drainage area should be reported.
Measure and assess patency of system and volume of drainage.
Constipation can be prevented by
– Increased activity
– High fluid intake (>2500 mL/day)
– Diet high in bulk and roughage
• Warm fluids, stool softeners, laxatives, or suppositories may be
necessary.
• Rapid de-conditioning of cardiopulmonary system
– Result of prolonged bed rest
– Results in
• Orthostatic hypotension
• Decreased lung capacity
NURSING MANAGEMENT: TRACTION
• Pressure over bony prominence created by
wrinkling sheets or bedclothes may cause
pressure necrosis.
• skin pressure may impair blood flow and cause injury
to peripheral neurovascular structures.
• 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.
• Observe skeletal traction pins for infection.
• Pin care includes regular removal of exudate, rinsing
of pin sites, and drying of the area.
NURSING MANAGEMENT
AMBULATORY AND HOME CARE
• Cast care
– Do’s
• Apply ice directly over fracture site for first 24 hours
• Check with health care provider before getting
fiberglass wet
• Elevate extremity above level of heart for first 48
hours
• Move joints above and below cast regularly
• Report signs of possible problems to health care
provider
• Keep appointment to have fracture and cast checked
NURSING MANAGEMENT
AMBULATORY AND HOME CARE
• Cast care
– Don’ts
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Get plaster cast wet
Remove any padding
Insert any objects inside cast
Bear weight on new cast for 48 hours
– Not all casts are weight bearing
• Cover cast with plastic for prolonged periods
AMBULATION
• Reinforce physical therapist’s instructions.
• Use of goinometer-measurement of joint range
of motion.( p-1575)
• Nurse may need to assist patient with
lower extremity dysfunction.
– Usually start mobility training when able to
sit in bed, dangle feet over side
AMBULATION
• Degrees of weight-bearing ambulation
– Non–weight-bearing ambulation
– Touch-down/toe-touch weight-bearing
ambulation
– Partial–weight-bearing ambulation
– Weight bearing as tolerated
– Full–weight-bearing ambulation
Devices for ambulation range from a cane to a
walker or crutches.
ASSISTIVE DEVICES
• Transfer belt should be placed around
patient’s waist to provide stability during
learning stages.
• Discourage patient from reaching for
furniture or relying on another person for
support.
COMPARTMENT SYNDROME
• Elevated intracompartmental pressure
within a confined myofascial
compartment compromises
neurovascular function of tissues within
that space.
COMPARTMENT SYNDROME
• Two basic types of compartment
syndrome
– ↓ compartment size
• Resulting from restrictive dressing, splints, casts,
excessive traction, or premature closure of fascia
– ↑ compartment size
• Related to bleeding, edema, chemical response
to snakebite, or IV filtration
COMPARTMENT SYNDROME
CLINICAL MANIFESTATIONS
• Six Ps are characteristic of impending
compartment syndrome.
– Paresthesia: numbness and tingling
– Pain: distal to injury that is not relieved by
opioid analgesics and pain on passive stretch of
muscle traveling through compartment
– Pressure: ↑ in compartment
– Pallor: coolness and loss of normal color of
extremity
– Paralysis: loss of function
– Pulselessness: diminished/absent peripheral
pulses
COMPARTMENT SYNDROME
COLLABORATIVE CARE
• Prompt, accurate diagnosis
• Extremity should not be elevated above heart level.
– Elevation may raise venous pressure and slow arterial
perfusion.
• Application of cold compresses may result in
vasoconstriction and may exacerbate (make worse)
compartment syndrome.
• May be necessary to remove or loosen bandage
• Reduction in traction weight may ↓ external circumferential
pressures.
• Surgical decompression may be necessary.(Fasciotomysurgical site left open for several days to ensure adequate
soft tissue decompression; risk for infection and delayed
wound healing is a potential problem following fasciotomy)
VENOUS THROMBOEMBOLISM
• Veins of lower extremities and pelvis are highly
susceptible to thrombosis.
• Aggravated by inactivity of muscles
that normally assist in pumping action of venous
blood
• Instruct patient to wear compression stockings
• Anticoagulants may be ordered.
• Precipitating factors
– Incorrectly applied cast or traction
– Local pressure on a vein
– Immobility
FAT EMBOLISM (FES)
• 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
• Most patients manifest symptoms 24 to 48 hours after injury.
Patient may become comatose.
• Tissues most often affected
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Lungs
Brain
Heart
Kidneys
Skin
FAT EMBOLISM (FES)
COLLABORATIVE CARE
• Treatment
– Fluid resuscitation
– Correction of acidosis
– Replacement of blood loss
• Encourage coughing and deep breathing.
• Oxygen to treat hypoxia
Hip dislocation
Soft tissue injury of the hip. A, Normal. B, Subluxation
(partial dislocation). C, Dislocation.
Carpal Tunnel Syndrome (CTS)
• Is acondition caused by compression of the
median nerve, which enters the hand through the
carpal tunnel.
• Clinical manifestations: WEAKNESS, BURNING
PAIN, NUMBNESS, IMPAIRED SENSATION.
• Physical signs
– Tinel’s sign:tapping over the median nerve in the wrist
– Phalen’s sign:flex the wrists and hold for 60 sec(look
for tingling sensation)
• This condition caused by pressure from
– Trauma, edema, inflammation, rheumatoid arthritis
A, Wrist structures involved in carpal tunnel syndrome. B,
Decompression of median nerve by incision through the
transverse carpal ligament.
• Debridment-removal of tissue, cells, etc..
• Arthroplasty-replacement of joints- use of
abductor pillow
• Close reduction-nonsurgical, manual realignment
of bone fragments to teir anatomical position
• Open reduction-correction by surgical incision
• Sprain-injury to ligaments
• Strain-injury to muscles or tendon
• RICE- rest, ice, compression, elevation
• Patient and caregiver teaching guide (Lewis, 8th
edition; table 63-1, page 1584)
Delegation decisions
• RN
– Assessment, check for compartment syndrome,
monitor cast, determine correct body alignment,
instruct pt and family about correct body alignment,
teach ROM, assess for complication-infection,
constipation, DVT, renal caliculi, atelectasis)
• LVN
– Check color, temp, capillary refill, monitor skin
integrity, drainage, skin irritation, pain management,
• NA
– Position cast above the heart, apply ice as directed by
RN, maintain body position, assist pt with ROM, notify
RN about pt complaints of pain, tingling, or decreased
sensation on the effected extremity.
Prevention of musculoskeletal
problems in the older adults
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Use ramps instead of stairs
Eliminate scatter rugs in the home
Treat pain
Use a walker or cane to help prevent falls
Eat health diet to prevent weight gain
Get regular and frequent exercise and activity
Good shoes for safety and comfort
Avoid walking on uneven surfaces and wet floors