Fractures

1. Fractures

2. Description • A disruption or break in the continuity of the structure of bone • Traumatic injuries account for the majority of fractures

3. Description • Described and classified according to: • Type • Communication or noncommunication with external environment • Anatomic location

4. Types of Fractures Fig. 61-4

5. Classification by Communication withExternal Environment Fig. 61-5

6. Classification by Fracture Location Fig. 61-6

7. Description • Described and classified according to: • Appearance, position, and alignment of the fragments • Classic names • Stable or unstable

8. Description • Closed (also called simple) • Open (also called compound)

9. Description • Stable fractures • Occur when a piece of the periosteum is intact across the fracture • External or internal fixation has rendered the fragments stationary

10. Description • Unstable fractures • Grossly displaced • Poor fixation

11. Clinical Manifestations • Immediate localized pain •  Function • Inability to bear weight or use affected part • Guarding • May or may not see obvious bone deformity

12. Fracture Healing • Reparative process of self-healing (union) occurs in the following stages: • Fracture hematoma (d/t bleeding, edema) • Granulation tissue → osteoid (3 – 14 days post injury) • Callus formation (minerals deposited in osteoid)

13. Fracture Healing • Reparative process of self-healing (union) occurs in the following stages: • Ossification (3 wks – 6 mos) • Consolidation (distance between fragments decreases → closes). • Remodeling (union completed; remodels to original shape, strength)

14. Bone Healing Fig. 61-7

15. Collaborative Care • Overall goals of treatment: • Anatomic realignment of bone fragments (reduction) • Immobilization to maintain alignment (fixation) • Restoration of normal function

16. Collaborative CareFracture Reduction • Closed reduction • Nonsurgical, manual realignment • Open reduction • Correction of bone alignment through a surgical incision

17. Collaborative CareFracture Reduction • Traction (with simultaneous counter-traction) • Application of pulling force to attain realignment • Skin traction (short-term: 48-72 hrs) • Skeletal traction (longer periods) • See Table 61-7

18. Collaborative CareFracture Immobilization • Casts • Temporary circumferential immobilization device • Common following closed reduction

19. Casts Fig. 61-9

20. Collaborative CareFracture Immobilization • External fixation • Metallic device composed of pins that are inserted into the bone and attached to external rods

21. Collaborative CareFracture Immobilization • Internal fixation • Pins, plates, intramedullary rods, and screws • Surgically inserted at the time of realignment

22. Collaborative CareFracture Immobilization • Traction • Application of a pulling force to an injured part of the body while countertraction pulls in the opposite direction

23. Collaborative CareFracture Immobilization • Purpose of traction: • Prevent or reduce muscle spasm • Immobilization • Reduction • Treat a pathologic condition

24. Nursing Management Nursing Assessment for Fractures • Brief history of the accident • Mechanism of injury • Special emphasis focused on the region distal to the site of injury

25. Nursing Management Nursing Assessment • Neurovascular assessment • Color and temperature • cyanotic and cool/cold: arterial insufficiency • Blue and warm: venous insufficiency • Capillary refill (want < 3 sec) • Peripheral pulses (↓ indicates vascular insufficiency)

26. Nursing Management Nursing Assessment • Neurovascular assessment • Edema • Sensation • Motor function • Pain

27. Nursing Management Nursing Diagnoses • Risk for peripheral neurovascular dysfunction • Acute pain • Risk for infection

28. Nursing Management Nursing Diagnoses • Risk for impaired skin integrity • Impaired physical mobility • Ineffective therapeutic regimen management

29. Nursing Management Nursing Implementation • General post-op care • Assess dressings/casts for bleeding/drainage • Prevent complications of immobility • Measures to prevent constipation • Frequent position changes/ ambulate as permitted • ROM exercised of unaffected joints • Deep breathing • Isometric exercises • Trapeze bar if permitted

30. Nursing Management Nursing Implementation • Traction • Ensure: • No frayed ropes, loose knots • Ropes in pulley grooves • Pulley clamps fastened securely • Weights must hang freely • Appropriate body alignment • Inspect skin • Around slings • Around pins

31. Nursing Management Nursing Implementation: Cast care • Casts can cause neurovascular complications if • Too tight • Edematous • Frequent neurovascular checks • Ice and elevation during early phase • See Table 61-10

32. Complications of FracturesInfection • Open fractures and soft tissue injuries have  incidence • Osteomyelitis can become chronic

33. Complications of FracturesInfection • Collaborative Care • Open fractures require aggressive surgical debridement • Post-op IV antibiotics for 3 to 7 days (prophylactic)

34. Complications of FracturesCompartment Syndrome • Condition in which elevated intracompartmental pressure within a confined myofascial compartment compromises the neurovascular function of tissues within that space • Causes capillary perfusion to be reduced below a level necessary for tissue viability

35. Complications of FracturesCompartment Syndrome • Two basic etiologies create compartment syndrome: • Decreased compartment size (dressings, splints, casts) • Increased compartment content (bleeding, edema)

36. Complications of FracturesCompartment Syndrome • Clinical Manifestations • Six Ps • Paresthesia (unrelieved by narcotics) • Pain (unrelieved by narcotics) • Pressure

37. Complications of FracturesCompartment Syndrome • Clinical Manifestations • Six Ps: • Pallor (loss of normal color, coolness) • Paralysis • Pulselessness (decreased/absent pulses)

38. Complications of FracturesCompartment Syndrome • Clinical Manifestations • Six Ps: • Patient may present with one or all of the six Ps • Compare extemities

39. Complications of FracturesCompartment Syndrome • Clinical Manifestations • Absence of peripheral pulse = ominous late sign • Myoglobinuria • Dark reddish-brown urine

40. Complications of FracturesCompartment Syndrome • Collaborative Care • Prompt, accurate diagnosis is critical • Early recognition is the key • Do not apply ice or elevate above heart level

41. Complications of FracturesCompartment Syndrome • Collaborative Care • Remove/loosen the bandage and bivalve the cast • Reduce traction weight • Surgical decompression (fasciotomy)

42. Complications of FracturesVenous Thrombosis • Veins of the lower extremities and pelvis are highly susceptible to thrombus formation after fracture, especially hip fracture

43. Complications of FracturesVenous Thrombosis • Precipitating factors: • Venous stasis caused by incorrectly applied casts or traction • Local pressure on a vein • Immobility • Prevent with anticoagulant medications

44. Complications of FracturesFat Embolism Syndrome (FES) • Characterized by the presence of fat globules in tissues and organs after a traumatic skeletal injury

45. Complications of FracturesFat Embolism Syndrome (FES) • Fractures that most often cause FES: • Long bones • Ribs • Tibia • Pelvis

46. Complications of FracturesFat Embolism Syndrome (FES) • Tissues most often affected: • Lungs • Brain • Heart • Kidneys • Skin

47. Complications of FracturesFat Embolism Syndrome (FES) • Clinical Manifestations • Usually occur 24-48 hours after injury • Interstitial pneumonitis • Produce symptoms of ARDS

48. Complications of FracturesFat Embolism Syndrome (FES) • Clinical Manifestations • Symptoms of ARDS: • Chest pain • Tachypnea • Cyanosis •  PaO2

49. Complications of FracturesFat Embolism Syndrome (FES) • Clinical Manifestations • Symptoms of ARDS: • Dyspnea • Apprehension • Tachycardia

50. Complications of FracturesFat Embolism Syndrome (FES) • Clinical Manifestations • Rapid and acute course • Feeling of impending disaster • Patient may become comatose in a short time