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Fractures. Description. A disruption or break in the continuity of the structure of bone Traumatic injuries account for the majority of fractures. Description. Described and classified according to: Type Communication or noncommunication with external environment Anatomic location.

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description
Description
  • A disruption or break in the continuity of the structure of bone
  • Traumatic injuries account for the majority of fractures
description1
Description
  • Described and classified according to:
    • Type
    • Communication or noncommunication with external environment
    • Anatomic location
description2
Description
  • Described and classified according to:
    • Appearance, position, and alignment of the fragments
    • Classic names
    • Stable or unstable
description3
Description
  • Closed (also called simple)
  • Open (also called compound)
description4
Description
  • Stable fractures
    • Occur when a piece of the periosteum is intact across the fracture
    • External or internal fixation has rendered the fragments stationary
description5
Description
  • Unstable fractures
    • Grossly displaced
    • Poor fixation
clinical manifestations
Clinical Manifestations
  • Immediate localized pain
  •  Function
  • Inability to bear weight or use affected part
  • Guarding
  • May or may not see obvious bone deformity
fracture healing
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)
fracture healing1
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)
bone healing
Bone Healing

Fig. 61-7

collaborative care
Collaborative Care
  • Overall goals of treatment:
    • Anatomic realignment of bone fragments (reduction)
    • Immobilization to maintain alignment (fixation)
    • Restoration of normal function
collaborative care fracture reduction
Collaborative CareFracture Reduction
  • Closed reduction
    • Nonsurgical, manual realignment
  • Open reduction
    • Correction of bone alignment through a surgical incision
collaborative care fracture reduction1
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
collaborative care fracture immobilization
Collaborative CareFracture Immobilization
  • Casts
    • Temporary circumferential immobilization device
    • Common following closed reduction
casts
Casts

Fig. 61-9

collaborative care fracture immobilization1
Collaborative CareFracture Immobilization
  • External fixation
    • Metallic device composed of pins that are inserted into the bone and attached to external rods
collaborative care fracture immobilization2
Collaborative CareFracture Immobilization
  • Internal fixation
    • Pins, plates, intramedullary rods, and screws
    • Surgically inserted at the time of realignment
collaborative care fracture immobilization3
Collaborative CareFracture Immobilization
  • Traction
    • Application of a pulling force to an injured part of the body while countertraction pulls in the opposite direction
collaborative care fracture immobilization4
Collaborative CareFracture Immobilization
  • Purpose of traction:
    • Prevent or reduce muscle spasm
    • Immobilization
    • Reduction
    • Treat a pathologic condition
nursing management nursing assessment for fractures
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
nursing management nursing assessment
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)
nursing management nursing assessment1
Nursing Management Nursing Assessment
  • Neurovascular assessment
    • Edema
    • Sensation
    • Motor function
    • Pain
nursing management nursing diagnoses
Nursing Management Nursing Diagnoses
  • Risk for peripheral neurovascular dysfunction
  • Acute pain
  • Risk for infection
nursing management nursing diagnoses1
Nursing Management Nursing Diagnoses
  • Risk for impaired skin integrity
  • Impaired physical mobility
  • Ineffective therapeutic regimen management
nursing management nursing implementation
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
nursing management nursing implementation1
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
nursing management nursing implementation cast care
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
complications of fractures infection
Complications of FracturesInfection
  • Open fractures and soft tissue injuries have  incidence
  • Osteomyelitis can become chronic
complications of fractures infection1
Complications of FracturesInfection
  • Collaborative Care
    • Open fractures require aggressive surgical debridement
    • Post-op IV antibiotics for 3 to 7 days (prophylactic)
complications of fractures compartment syndrome
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
complications of fractures compartment syndrome1
Complications of FracturesCompartment Syndrome
  • Two basic etiologies create compartment syndrome:
    • Decreased compartment size (dressings, splints, casts)
    • Increased compartment content (bleeding, edema)
complications of fractures compartment syndrome2
Complications of FracturesCompartment Syndrome
  • Clinical Manifestations
    • Six Ps
      • Paresthesia (unrelieved by narcotics)
      • Pain (unrelieved by narcotics)
      • Pressure
complications of fractures compartment syndrome3
Complications of FracturesCompartment Syndrome
  • Clinical Manifestations
    • Six Ps:
      • Pallor (loss of normal color, coolness)
      • Paralysis
      • Pulselessness (decreased/absent pulses)
complications of fractures compartment syndrome4
Complications of FracturesCompartment Syndrome
  • Clinical Manifestations
    • Six Ps:
      • Patient may present with one or all of the six Ps
      • Compare extemities
complications of fractures compartment syndrome5
Complications of FracturesCompartment Syndrome
  • Clinical Manifestations
    • Absence of peripheral pulse = ominous late sign
    • Myoglobinuria
      • Dark reddish-brown urine
complications of fractures compartment syndrome6
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
complications of fractures compartment syndrome7
Complications of FracturesCompartment Syndrome
  • Collaborative Care
    • Remove/loosen the bandage and bivalve the cast
    • Reduce traction weight
    • Surgical decompression (fasciotomy)
complications of fractures venous thrombosis
Complications of FracturesVenous Thrombosis
  • Veins of the lower extremities and pelvis are highly susceptible to thrombus formation after fracture, especially hip fracture
complications of fractures venous thrombosis1
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
complications of fractures fat embolism syndrome fes
Complications of FracturesFat Embolism Syndrome (FES)
  • Characterized by the presence of fat globules in tissues and organs after a traumatic skeletal injury
complications of fractures fat embolism syndrome fes1
Complications of FracturesFat Embolism Syndrome (FES)
  • Fractures that most often cause FES:
    • Long bones
    • Ribs
    • Tibia
    • Pelvis
complications of fractures fat embolism syndrome fes2
Complications of FracturesFat Embolism Syndrome (FES)
  • Tissues most often affected:
    • Lungs
    • Brain
    • Heart
    • Kidneys
    • Skin
complications of fractures fat embolism syndrome fes3
Complications of FracturesFat Embolism Syndrome (FES)
  • Clinical Manifestations
    • Usually occur 24-48 hours after injury
    • Interstitial pneumonitis
      • Produce symptoms of ARDS
complications of fractures fat embolism syndrome fes4
Complications of FracturesFat Embolism Syndrome (FES)
  • Clinical Manifestations
    • Symptoms of ARDS:
      • Chest pain
      • Tachypnea
      • Cyanosis
      •  PaO2
complications of fractures fat embolism syndrome fes5
Complications of FracturesFat Embolism Syndrome (FES)
  • Clinical Manifestations
    • Symptoms of ARDS:
      • Dyspnea
      • Apprehension
      • Tachycardia
complications of fractures fat embolism syndrome fes6
Complications of FracturesFat Embolism Syndrome (FES)
  • Clinical Manifestations
    • Rapid and acute course
    • Feeling of impending disaster
    • Patient may become comatose in a short time
complications of fractures fat embolism syndrome fes7
Complications of FracturesFat Embolism Syndrome (FES)
  • Collaborative Care
    • Treatment directed at prevention
    • Careful immobilization of a long bone fracture
      • Most important preventative factor
complications of fractures fat embolism syndrome fes8
Complications of FracturesFat Embolism Syndrome (FES)
  • Collaborative Care (treatment)
    • Symptom management
    • Fluid resuscitation
    • Oxygen
    • Reposition as little as possible
fracture of the hip
Fracture of the Hip
  • Fracture of proximal third of femur
  • Common in the elderly
  • More frequent in women than men.
  • Up to 35% of clients will die within the first year
fracture of the hip1
Fracture of the Hip
  • Intracapsular fractures:
    • Occur within hip joint capsule
  • Extrascapular fractures
    • Intertrochanteric: between greater and lesser trochanter
    • Subtrochanteric: below lesser trochanter
clinical manifestations1
Clinical Manifestations
  • External rotation of affected leg
  • Muscle spasm
  • Shortening of the affected extremity
  • Severe pain and tenderness in region of fracture
collaborative care1
Collaborative Care
  • Surgical repair is preferred
    • Allows for early mobilization and decreases the risk of major complications.
  • Buck’s traction may be utilized preoperatively to decrease painful muscle spasms.
nursing diagnosis
Nursing Diagnosis
  • Risk for peripheral neurovascular dysfunction
  • Acute pain
  • Risk for impaired skin integrity
  • Impaired physical mobility
post operative care
Post-Operative Care
  • General post-op care (V/S, DB & C, etc.)
  • Neurovascular checks
  • Prevent external rotation (sandbags, pillows)
preventing dislocation of femur head prosthesis
Preventing Dislocation of Femur Head Prosthesis
  • Do Not
    • Flex hip greater than 90 degrees.
    • Place hip in adduction
    • Allow hip to internally rotate
    • Cross legs
    • Put on shoes/socks without adaptive device (8 weeks)
    • Sit in chair without arms to aid in rising to a standing position
preventing dislocation of femur head prosthesis1
Preventing Dislocation of Femur Head Prosthesis
  • Do
    • Use elevated toilet seat
    • Use chair in shower/tub
    • Use pillow between legs when on “good” side or supine (for 8 weeks post-op)
    • Keep hip in neutral position when sitting, walking and lying.
    • Notify surgeon if severe pain, deformity, or loss of function
    • Inform dentist of presence of prosthesis