1elsevier items and derived items © 2007 by saunders, an imprint of elsevier, inc. chapter 42...

1Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Chapter 42

Fractures


Learning Objectives

• Identify the types of fractures.• Describe the five stages of the healing process.• Discuss the major complications of fractures, their signs

and symptoms, and their management.• Compare the types of medical treatment for fractures,

particularly reduction and fixation.• Describe common therapeutic measures for fractures,

including casts, traction, crutches, walkers, and canes.• Discuss the nursing care of a patient with a fracture.• Describe specific types of fractures, including hip fractures,

Colles’ fractures, and pelvic fractures.


Classification of Fractures

• Closed or simple fracture • The bone does not break through the skin

• Open or compound fracture• Fragments of the broken bone break through skin • Open fractures have three grades of severity

• Grade I: least severe injury, with minimal skin damage

• Grade II: moderately severe injury, with skin and muscle contusions (bruises)

• Grade III: most severe injury (wound larger than 6 to 8 cm), with skin, muscle, blood vessel, and nerve damage


Classification of Fractures

• Stress fracture • Caused by either repeated or prolonged stress

• Pathologic fracture • Occurs because of a pathologic condition in the

bone, such as a tumor or disease process, that causes a spontaneous break


Figure 42-1


Etiology and Risk Factors

• Commonly caused by trauma to the bone, especially as a result of automobile accidents and falls

• Bone disease, e.g., bone cancer, can lead to a fracture • Hip fractures in older adults usually from falls • Risk factors for hip fractures: osteoporosis, advanced age, white

race, use of psychotropic drugs, and female • In adults, ribs most commonly fractured • Fractures of the femur most common in young and middle-aged

adults• Hip and wrist fractures are most common in older adults


Fracture Healing

• A bone begins to heal as soon as an injury occurs

• New bone tissue formed to repair the fracture, resulting in a sturdy union between the broken ends of the bone


Healing Stages

• Stage 1: hematoma formation • Immediately after a fracture, bleeding and edema

occur • In 48 to 72 hours, a clot or hematoma forms

between the two broken ends of the bone


Healing Stages

• Stage 2: fibrocartilage formation • Hematoma that surrounds fracture does not resorb,

as it does in other parts of the body • Instead, other tissue cells enter the clot, and

granulation tissue replaces the clot • The tissue then forms a collar around each end of

the broken bone, gradually becoming firm and forming a bridge between the two ends


Healing Stages

• Stage 3: callus formation • Within 1 to 4 weeks after injury, granulation tissue

changes into a callus, which is made up of cartilage, osteoblasts, calcium, and phosphorus. The callus is larger than the diameter of the bone and serves as a temporary splint


Healing Stages

• Stage 4: ossification • Within 3 weeks to 6 months after the break, a

permanent bone callus, known as woven bone, forms

• During this stage the ends of the broken bone begin to knit


Fracture Healing

• Stage 5: consolidation and remodeling • Consolidation occurs when the distance between

bone fragments decreases, then closes • During bone remodeling, immature bone cells are

gradually replaced by mature bone cells • Excess bone is chiseled away by stress to the

affected part from motion, exercise, and weight bearing

• Bone then takes on its original shape and size


Figure 42-2


Fracture Healing

• Healing affected by location and severity of the fracture, type of bone, other bone pathology, blood supply to the area, infection, and the adequacy of immobilization

• Also age, endocrine disorders, and some drugs affect healing

• Healing time increases with age; it may take six times as long for the same type of fracture to heal in an older adult as in an infant


Complications


Infection

• Osteomyelitis: from contamination of the open wound associated with a fracture or from contamination of indwelling hardware used to repair the broken bone

• When infection is inadvertently brought by surgery or other treatment, it is known as iatrogenic

• Any infection can interfere with normal healing • Common after an open fracture and surgical repair and

may become chronic • In deep, grossly contaminated wounds, gas gangrene

may develop


Infection

• Signs and symptoms• Local pain, redness, purulent wound drainage, chills, and fever • With gas gangrene, foul-smelling watery drainage with

significant redness and swelling

• Treatment• IV antibiotics may be given for 4 to 8 weeks, followed by 4 to 8 weeks of oral drug therapy • Wound care: irrigation, treatment with antibiotic beads, and

surgical removal of dead bone tissue and/or hardware


Fat Embolism

• Fat globules released from marrow of broken bone into bloodstream, then migrate to the lungs

• They lodge in capillaries and obstruct blood flow • The fat particles break down into fatty acids, which

inflame the pulmonary blood vessels, leading to pulmonary edema

• Common with fractures of the long bones, multiple fractures, and severe trauma


Fat Embolism

• Respiratory distress is the first sign of a fat embolism, followed by tachycardia, tachypnea, fever, confusion, and decreased level of consciousness

• Treatment: bed rest, gentle handling, oxygen, ventilatory support, and fluid restriction and diuretics for pulmonary edema


Deep Vein Thrombosis

• Venous stasis, vessel damage, and altered clotting mechanisms contribute to formation of blood clots (thrombi), most commonly in deep veins of the legs

• DVT increased with immobility often associated with a fracture

• Thrombi can break off and travel to the lungs, causing a pulmonary embolism


Compartment Syndrome

• Serious complication from internal or external pressure on the affected area

• Compartments: enclosed spaces made of muscle, bone, nerves, blood vessels wrapped by fibrous membrane

• Internal pressure from bleeding/edema into a compartment; external pressure from a cast or tight dressing



• When bleeding or edema into a compartment, there is nowhere for drainage to go: it is trapped in the space

• Increased fluid puts pressure on tissues, nerves, and blood vessels, so that blood flow is decreased, resulting in pain and tissue damage. External pressure also can decrease blood flow to the area



• Primary symptom is pain, especially with touch or movement, that can’t be relieved with opioids

• Other signs and symptoms: edema, pallor, weak or unequal pulses, cyanosis, tingling, numbness, paresthesia, and finally, severe pain

• The goal of treatment is to relieve pressure • When internal pressure, a surgical fasciotomy, which entails

making linear incisions in the fascia, may relieve pressure on the nerves and blood vessels

• For external pressure, cast or dressings are replaced


Shock

• After fracture, a risk of excessive blood loss • Trauma may rupture local blood vessels; internal

organs may be punctured; results in internal bleeding • Loss of blood leads to shock, evidenced by

tachycardia, anxiety, pallor, and cool, clammy skin • Immobilizing fractures reduces risk of hemorrhage • If severe external bleeding, external pressure should

be applied and medical assistance summoned immediately


Joint Stiffness and Contractures

• Joint fractures or dislocations may be followed by stiffness or contractures, especially in older adults, due to immobility associated with fracture

• Prevention requires appropriate positioning and progressive exercise programs

• Treatment may employ splints, traction, casts, surgical manipulation, and aggressive physiotherapy


Malunion

• Expected healing time is appropriate but unsatisfactory alignment of bone results in external deformity and dysfunction


Delayed Union

• Failure of a fracture to heal in the expected time

• The bone usually heals eventually; it may just be slower


Nonunion

• Occurs when a fracture never heals • Treatment

• Osteogenic method: implantation of bone grafts • Osteoconductive methods: synthetic materials to provide a

matrix for bone growth • Osteoinduction: substances such as platelet-derived growth

factor• Electric stimulation

• Internal or external; up to 10 hours a day for 3-6 months • Time consuming but can prevent further surgery and bone grafts


Post-Traumatic Arthritis

• Weight-bearing joints are most vulnerable to posttraumatic arthritis

• Excessive stress and strain on the joint or fracture must be avoided to reduce the risk of this complication

• Can be a result of nonunion of a fracture


Avascular Necrosis

• A variety of factors can interfere with blood supply after a bone injury

• Once bone cells are deprived of oxygen and nutrients, they die and their cell walls collapse

• Signs and symptoms • Pain, instability, and decreased function in the

affected area


Avascular Necrosis

• Treatment• Relief of weight bearing and removal of part of the

bone to decrease pressure • If conservative measures fail, surgical procedures

may be recommended • Sometimes amputation is necessary


Complex Regional Pain Syndrome Type 1 (CRPS—Type 1)

• Precipitated by a fracture or other trauma • Symptoms

• Severe pain at the injury site despite no detectable nerve damage, edema, muscle spasm, stiffness, vasospasms, increased sweating, atrophy, contractions, and loss of bone mass

• Symptoms persist longer than expected with the type of injury suffered


Complex Regional Pain Syndrome Type 1 (CRPS—Type 1)

• Treatment• Nerve blocks, physical therapy, transcutaneous

electrical stimulation, and analgesics, muscle relaxants, and antidepressants


Signs and Symptoms

• Depend on type and location of the break • Some fractures have so few manifestations

that they can be detected only with x-ray • Signs and symptoms are swelling, bruising,

pain, tenderness, loss of normal function, abnormal position, and decreased mobility

• See Box 42-1, p. 918


Diagnostic Tests and Procedures

• Standard radiographs• Reveal bone disruption, deformity, or malignancy

• Computed tomography (CT)• Detect fractures of complex structures, such as the hip and

pelvis, or compression fractures of the spine

• Bone scan • Detect small bone fractures or fractures caused by stress or

disease


Medical Treatment


Reduction

• The process of bringing the ends of the broken bone into proper alignment


Closed Reduction or Manipulation

• Nonsurgical realignment that returns bones to their previous anatomic position

• No surgical incision is made; however, general or local anesthesia is given

• By using traction, manual pressure, or a combination

• After reduction of a fracture, x-ray taken and a cast usually applied


Figure 42-3


Open Reduction

• A surgical procedure in which an incision is made at the fracture site

• Usually for open (compound) or comminuted fractures to clean the area of fragments and debris


Immobilization

• Necessary for healing to occur• Prevents movement and increases union • Accomplished in many ways, such as fixation,

casts, splints, and traction


Fixation

• An attempt to attach the fragments of the broken bone together when reduction alone is not feasible because of the type and extent of the break


Internal Fixation

• Done during open reduction surgical procedure • Rods, pins, nails, screws, or metal plates used

to align bone fragments and keep them in place for healing

• Promotes early mobilization; preferred for older adults who have brittle bones that may not heal properly, or who may suffer the consequences of immobility


Figure 42-4


External Fixation

• Pins are inserted into the bone, above and below fracture • Pins are then attached to an external frame and adjusted to align

the bone • If there is soft tissue damage or infection, external fixation allows

access to the site and facilitates wound care • Pin care is extremely important to prevent the migration of

organisms along the pin from the skin to the bone • Patients should be taught to do their own pin care and to

recognize signs of infection


Figure 42-5


Figure 42-6


Therapeutic Measures


Casts, Splints, and Immobilizers

• Hold the bone in alignment while allowing movement of other parts of the body

• Types of cast materials: plaster of Paris, fiberglass, thermoplastic resins, thermolabile plastic, and polyester-cotton knit impregnated with polyurethane

• Variety of materials used for splints/immobilizers• Four main groups of casts: (1) upper extremity, (2)

lower extremity, (3) cast brace, and (4) body or spica cast


Traction

• Exerts a pulling force on a fractured extremity to align bone fragments

• Prevents or corrects deformity, decreases muscle spasm, promotes rest, and maintains the position of the injured part

• May be applied directly to the skin (skin traction) or attached directly to a bone (skeletal traction) with a metal pin or wire


Traction

• Skin traction • Buck’s traction

• For hip and knee contractures, muscle spasms, and alignment of hip fractures

• Weight used during skin traction should not be more than 5 to 10 pounds to prevent injury to the skin

• Skeletal traction • Provides a strong, steady, continuous pull and can be used for

prolonged periods • Examples of skeletal traction are Gardner-Wells, Crutchfield,

and Vinke tongs and a halo vest, in which pins are inserted into the skull on either side


Figure 42-7


Figure 29-8


Traction

• Complications • Impaired circulation, inadequate fracture alignment,

skin breakdown, and soft tissue injury • Pin track infection and osteomyelitis can occur with

skeletal traction


Assistive Devices


Crutches

• Increase mobility and assist with ambulation• Physical therapist measures patient for proper fit and

instructs in crutch-walking techniques • Nurse reinforces the instructions and evaluates

whether the crutches are being used properly • A properly fitted crutch should reach to three

fingerbreadths below the axilla to avoid pressure on the axilla and nerves when walking


Figure 42-8


Crutches: Gait Patterns

• Two-point gait• The crutch on one side and the opposite foot are advanced at

the same time • Used with partial weight-bearing limitations and with bilateral

lower extremity prostheses

• Three-point gait• Both crutches and the foot of the affected extremity are

advanced together, followed by the foot of the unaffected extremity

• This gait requires strength and balance • Used for partial or no weight bearing on affected leg



• Four-point gait• The right crutch is advanced, then the left foot, then

the left crutch, then the right foot • 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, 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, then both

legs are lifted through and beyond the crutches and placed down again at a point in front of the crutches

• Used when adequate muscle power and balance in the arms and legs


Figure 42-9


Walker

• Used for support and balance, usually by older adults


Canes

• Provide minimal support and balance, and relieve pressure on weight-bearing joints

• Placed on the unaffected side with the top even with the patient’s greater trochanter


Electrical Stimulation

• Electrical stimulation may be used to promote bone healing by promoting bone growth

• An electrical current is delivered through one of three methods• A surgically implanted device• Device with pins that are inserted through the skin to the

fracture site• Pack of electrical coils applied to skin around fracture

• Electrical bone stimulators successful in 80% of cases, with an average healing time of 16 weeks


Assessment

• Health history • The cause, type, and extent of the injury • Symptoms associated with the injury• Other medical problems that may have been related

to the cause of the fracture


Assessment

• Physical examination• Deviations in bone alignment• Inspect the skin over the fracture for lacerations,

bruising, or swelling• Neurovascular checks (pulse, skin color, capillary

refill time, sensation) in the areas distal to the wound to compare circulation and sensation. Assess pulse rate and volume, as well as capillary refill time in the nails distal to the injury


Interventions

• Acute Pain• Ineffective Tissue Perfusion • Risk for Infection • Impaired Physical Mobility • Risk for Impaired Skin Integrity • Activity Intolerance


Management of Specific Fractures


Fracture of the Hip

• Medical diagnosis • Radiography

• Medical treatment • Traction and surgical repair (internal fixation,

femoral head replacement, or total hip replacement)

• Patients may begin physical therapy as early as 1 day after surgery, depending on the type of repair; begin by sitting in a chair and then progress to a walker


Figure 42-10


Fracture of the Hip

• Assessment• Pain, impaired peripheral circulation on the affected

side, complications of immobility, skin breakdown, and ability to carry out activities of daily living


Fracture of the Hip

• Interventions• Relieving pain, promoting mobility and

independence, and preventing complications • Proper body alignment is extremely important in

preventing injury to the fracture area • Turn patients from side to side as ordered • Affected hip must not be adducted or flexed more

than 90 degrees because excessive flexion/adduction can dislocate the prosthesis


Colles’ Fracture

• A break in the distal radius (wrist area)• Medical diagnosis

• Radiography

• Medical treatment • Closed reduction or manipulation of the bone and

immobilization in either a splint or a cast


Colles’ Fracture

• Assessment• Pain and swelling following treatment of the fracture

• Interventions• Extremity should be supported and protected and can be

elevated on a pillow during the first few days • Encourage patients to move their fingers and thumb to

promote circulation and reduce swelling, and to move their shoulders to prevent stiffness and contracture

• Teach proper cast care


Fracture of the Pelvis

• Medical diagnosis • Radiography



• Medical treatment • A less severe non–weight-bearing fracture treated with bed

rest on a firm mattress or bed board for a few days to 6 weeks • Severe weight-bearing fracture may require a pelvic sling,

skeletal traction, double hip spica cast, or external fixation • Monitor patient so injuries can be treated immediately • Check for presence of blood in urine and stool, and watch

abdomen for signs of rigidity or swelling



• Assessment• Signs of bleeding, swelling, infection,

thromboembolism, and pain • Assess urine output because the absence of urine

may indicate a perforated bladder



• Interventions• When handling patients, take extreme care to

prevent displacement of the fracture fragments • Turn patient only on the order of a physician • Provide back care when patient raised from the bed

using the trapeze or with adequate assistance from others

• Ambulation may be encouraged even though painful; follow physician’s orders

1elsevier items and derived items © 2007 by saunders, an imprint of elsevier, inc. chapter 42...

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bone fragments

bone remodeling

bone disease

type of bone