Fractures

• Etiology/pathophysiology– A traumatic injury to a bone in which the

continuity of the tissue of the bone is broken

– Pathological or spontaneous fractures

Fractures

• Types of fractures: – open, compound, closed, greenstick, complete,

comminuted, impacted, transverse, oblique, spiral, Colle’s, and Pott’s

– Figure 4-23, 4-24 p. 143

Fractures

• Clinical manifestations/assessment• Pain• Loss of normal function• Obvious deformity• Change in the curvature or length of bone• Crepitus (grating sound with movement)• Soft tissue edema• Warmth over injured area• Ecchymosis of skin surrounding injured area• Loss of sensation distal to injury

Fractures

• Diagnostic tests• Radiographic examination

• Medical Management– Immediate

• Splinting to prevent edema• Body alignment• Elevation of body part• Application of cold packs• Observe pt. for s/sx shock• Pain Management

Fractures

• Medical Management cont.– Secondary Management

• For closed fracture: optimal reduction through:– Closed reduction (manual manipulation)– Traction– Open reduction with Internal Fixation

» + wound debridement and cleansing– Immobilization

Fractures

• Nursing Interventions– Application of cold packs– Administration of pain medication– Neurovascular assessment– Observe for s/sx shock– Cast care– Skin care

Fractures

• Nursing Interventions cont.– Exercise unaffected joints– Diet/vitamin supplementation– Elimination support– Patient Teaching:

• Moving in bed• Transferring safely• Weight-bearing restrictions/activity limitations• Use ambulatory devices• Pain control• Edema control• Exercises• Cast Care

Types of Fractures

Fractures

• TYPES OF FRACTURES• Closed (simple)

– Closed reduction (physical manipulation)– Immobilization– Traction– Open reduction with internal fixation device

(ORIF)

Fractures

• Open (compound)• Surgical debridement and culture of wound• Administration of tetanus toxoid• Observation for signs of infection• Closure of wound• Reduction and immobilization of fracture

Compound Fracture

Fractures

• Fracture of the hip– Etiology/pathophysiology

• Most common type of fracture• Women at higher risk due to osteoporosis

– Clinical manifestations:• Severe pain at site• Inability to move the leg voluntarily• Shortening and/or external rotation of the leg

See page 137 Figure 4-16

Types of Hip Fractures

Fracture of the Hip

– Diagnostic tests• Radiographic examination• Hemoglobin/hematocrit

– Medical Management• Buck’s or Russell’s traction until surgery• Surgical repair

– Internal fixation– Nail and screws – Prosthetic implants

Fracture of the Hip

• The choice of fixation device depends on the:– Location of the fracture– Potential for avascular necrosis of femoral head

and neck

Fracture of the Hip

• Nursing Considerations– PRE-OPERATIVELY:

• Focus: preventing shock and further complications

• Maintain proper alignment through traction and abduction of the hip when turning pt.

Note: know MD instructions re: turning and to which side(s)

• Elevate HOB 45⁰

Fracture of the Hip

• Nursing Considerations cont.

– POST-OPERATIVE Interventions• Wound and drain assessment• Vital signs• Incentive spirometer and turning every 2 hours• Antiembolic stockings; anticoagulation therapy• With hip replacement:

– Maintain leg abduction- Instruct: DO NOT CROSS LEGS!– Chairs and commode seats should be raised to prevent

flexion of hip beyond 60 degrees

Fracture of the Hip

• PATIENT TEACHING: ORIF• Assess ability to understand• Assist to dangle at bedside• No weight on operative side• Turn every 2 hours, maintain abduction for hip

replacement patients• Physical therapy will instruct as to ambulation

and weight-bearing• As patient progresses, encourage continuing

ambulation only with assistance

Total Hip Replacement

• Hip arthroplasty: total replacement of hip joint

http://www.youtube.com/watch?v=WJ1E12xcaTsMedical Animation Total Hip Arthroplasty

Figure 44-14

Hip arthroplasty (total hip replacement).

Total Knee Replacement

• Knee Arthroplasty (total knee replacement)– Replacement of the knee joint– Restore motion of the joint, relieve pain, or

correct deformity

Figure 44-11

A, Tibial and femoral components of total knee prosthesis. B, Total knee

prosthesis in place.

Surgical Interventions for Total Knee or Total Hip Replacement

Arthroplasty• Post Op Nursing interventions

• Empty and record HemoVac• Give oxygen 2-3 L/min• Incentive spirometer; cough and deep-breathe• Record I&O• Bed rest for 24-48 hours• Change dressing as ordered• Diet as ordered• Neurovascular checks and vital signs every 4

hours

Arthroplasty

• Post Op Nursing Interventions cont.• Maintain position of operative area• Physical therapy will initiate ambulation and

prescribe routine• Encourage fluid intake• Antiembolisim stockings

• Post op Total Hip Arthroplasty– Avoid adduction and hyperflexion of hip– Encourage fluid intake and high-fiber foods– Use toilet riser to prevent hyperflexion of hip

Arthroplasty

• Post Op Total Knee Arthroplasty:– Activity: CPM machine (managed by PT)– Pain Control– Discharge Instructions

Arthroplasty

• Patient teaching for Total Hip Arthroplasty–Avoid hip flexion beyond 60 degrees for

approximately 10 days; beyond 90 degrees for 2-3 months

–Avoid adduction of the affected leg beyond midline for 2-3 months (maintain abduction)

–Maintain partial weight-bearing for approximately 2-3 months

–Avoid positioning on the operative side

Arthroplasty

• Patient Teaching Total Knee Arthroplasty:– Partial weight-bearing restriction– Use of ambulatory aid– Exercises: Active flexion and straight-leg raises at

home– Use of resting knee extension splint– Appropriate positioning– Pain medication use– Use of ongoing cool paks– PT follow up/ CPM at home

Fracture of the Vertebrae

• Etiology/pathophysiology• Diving accidents• Blows to the head or body• Osteoporosis• Metastatic cancer• Motorcycle and car accidents• Displaced fracture may place pressure on or

sever the spinal cord nerves

Fracture of the Vertebrae

• Clinical manifestations/assessment– Pain at site of injury– Partial or complete loss of mobility or

sensation– Evidence of fracture/fracture dislocation on

x-ray

Fracture of the Vertebrae

• Diagnostic Tests– Radiographic Studies– Spinal Tap – presence of blood indicates trauma

• Medical Management– Stable injuries:

• treated with pain medication and muscle relaxants• Anticoagulants may be ordered prophylactically• Back support – brace, corset, cast

Fracture of the Vertebrae

– Unstable fractures:• Traction and postural positioning to

reduce the facture• Cranial skeletal traction for cervical spine

fractures• Pelvic traction for lumbar fractures• Open reduction – using Harrington Rod;

followed by use of body cast

Fracture of the Vertebrae

• Nursing Interventions– Log-rolling pt. for position changes– Turning pt. in specialty bed– Elevate HOB no more than 30⁰– Using stabilization devices– Neurovascular assessments– Cast care/pin care– Patient teaching

Fractures of the Vertebrae

• Patient Teaching:– Firm mattress– Sitting in straight firm chairs

• No more than 20-30 min at a time

– Proper lifting technique• Follow MD lifting restrictions

– Back exercises –per MD and PT

Fracture of the Pelvis

• Etiology/pathophysiology• Falls (esp. from great heights)• Automobile accidents• Crushing accidents

– When trauma is severe enough to fracture the pelvis, vital abdominal organs may also be damaged.

Fracture of the Pelvis

• Clinical manifestations/assessment• Unable to bear weight without discomfort• Pelvic tenderness and edema• Hematuria• Signs of shock/hemorrhage

• Diagnostic Tests– Abdominal radiographic studies– CT– IVP to determine any kidney damage– H & H, UA, stool for occult blood

Fracture of the Pelvis

• Medical Management/Nursing Interventions• Bedrest x 3 wks, then• Ambulation with crutches x 6 weeks• NWB x 3 months• More severe fractures may require surgery

and/or traction, spica or body cast

Fracture of the Pelvis

• Nursing Interventions– Monitor for s/sx progressive shock– Measure abdominal girth q 8 hrs– Foley cath prn monitor urinary output volume,

color– Safety with impaired mobility– Skin care, including turning schedule– Pain management– Hydration

Fracture of the Pelvis

• Patient Teaching– Reinforce reason for immobility and NWB– Explain pain management strategy– Explain turning and moving techniques to prevent

skin breakdown

Complications of Fractures

Complications of Fractures

• Shock (hemorrhage)• Compartment Syndrome• Fat Embolism• Gas Gangrene• Thromboembolism

Complications

• Hemorrhage is by far the most life-threatening complication.

Shock

• Cause– Blood loss, pain, fear

• Clinical manifestations–Altered level of consciousness,

restlessness–Hypotension, tachycardia, and

tachypnea–Pale, cool, moist skin

Shock

• Medical Management• Restore blood volume

– IV fluids: LR, D5W.9NS–Whole blood, plasma

• Shock trousers• Oxygen

Shock

• Nursing Interventions– IV fluid administration– Frequent VS– Monitor urinary output – volume, color– Avoid Trendelenburg position – tends to push

abdominal organs against the diaphragm– Keep warm– NPO– Avoid sedatives, tranquilizers, narcotics– Emotional support for pt. and family

Compartment Syndrome

• Compartments are enclosed spaces made up of muscle, bone, nerves, blood vessels wrapped by fibrous membrane (fascia)

• Causes of Compartment Syndrome:– Internal or external compression on area

• Internal pressure-bleeding, edema into compartment• External pressure-cast or tight dressing

Compartment Syndrome

• Increased pressure puts pressure on tissues, nerves, blood vessels

• Blood flow decreased—resulting in pain, tissue damage

• Rare, but serious can become emergency very quickly

Compartment Syndrome

• Within 4-6 hours after onset, irreversible muscle ischemia can occur as a result of compression of arteries, nerves, and tendons

Compartment Syndrome

• Symptoms– Pain, especially with touch or movement,

not relieved with opioid analgesics– Edema, pallor, weak or unequal pulses– Cyanosis– Tingling, numbness, paresthesia– Severe pain

Compartment Syndrome

• Medical Management-Fasciotomy-incision into the fascia if internal pressure is cause.

• External pressure-remove cast

Compartment syndrome.

(From Beare, P.G., Myers, J.L. [1998]. Adult health nursing. [3rd ed.]. St. Louis: Mosby.)

Compartment Syndrome

• Nursing Interventions– Administration Analgesic(s) – careful

documentation of relief obtained – OR NOT!– ↑ affected limb to level of heart– Apply cold packs– Remove constricting material– Monitor for s/sx infection– Encourage pt. to express fears and emotional

needs

Compartment Syndrome

• Volkmann’s Contracture– Permanent contracture that can occur as result of

compartment syndrome– Clawhand, flexion of wrist and fingers– Atrophy of forearm

VOLKMANN’S CONTRACTURES

Fat Embolism• Cause: Fat globules released from marrow of broken

bone into bloodstream

• Once fat globules enter bloodstream, they migrate to lungs

• Too large to pass through circulation, they lodge in pulmonary capillaries, obstruct blood flow

• Fat particles break down into fatty acids, inflame blood vessels , cause pulmonary edema

Fat Embolism

• Most commonly associated with fractures of long bones, multiple fractures and severe trauma

• Occurs 24-48 hours after injury• Most often in young men 20-40 y old and

older adults 70-80 y old

Fat Embolism

• Signs/symptoms– Respiratory distress– Tachycardia– Tachypnea– Fever– Confusion– Decreased level of consciousness– Petichiae-neck, upper arms, chest, abdomen,

buccal and conjunctival membranes

Fat Embolism

• Diagnostic Tests– Based on clinical s/sx

• Appear within 24-48 hrs of injury

– ABG hypoxemia– H &H decreased– Fat is present in blood and urine– ↑ ESR– Platelets ↓

Fat Embolism

• Treatment– Bed rest– Gentle handling– Oxygen and/or ventilatory support– Fluid restriction/diuretics for pulmonary

edema– Steroids may be used

Gas Gangrene

• Cause : Infection of skeletal muscle by Clostridium Perfringens (gram +)– Produce exotoxins that destroy skin tissue– Anaerobic

• Clinical manifestations:– Pain at site of injury– Signs of infection– Gas bubbles under the skin crepitus– Necrotic skin at site, foul odor from wound

Gas Gangrene

• Medical Management– Establish a larger wound to admit air and promote

drainage– Excision of gangrenous tissue– Antibiotic therapy

• Nursing Interventions– Strict aseptic technique w/wound care– All contaminated equipment must be autoclaved– Administer antibiotics, analgesics

Gas Gangrene

Thromboembolus

• Cause: Blood vessel occluded by embolus– Associated with reduced skeletal muscle

contractions and bed rest

• Clinical Manifestations/Assessment– Area tingles, is cold, numb and cyanotic– Pulmonary embolus causes sharp chest pain,

dyspnea, cough

Thromboembolus

• Diagnostic Tests– Medical hx– Physical exam– Lab: PT, INR, CBC– Doppler US, CT of lungs; ventilation/perfusion

scan• Medical Management

– Anticoagulants– Poss. thrombectomy

Thromboembolus

• Nursing Interventions– FOB ↑ – Teach active exercises – per MD paramenters– Warm moist heat– Antiembolism stockings– Assess lung sounds– Monitor lab results– CMS checks– Pain Management