FracturesFractures
DescriptionDescription
A disruption or break in the continuity of the structure of bone
Traumatic injuries account for the majority of fractures
A disruption or break in the continuity of the structure of bone
Traumatic injuries account for the majority of fractures
DescriptionDescription
Described and classified according to:
Type
Communication or noncommunication with external environment
Anatomic location
Described and classified according to:
Type
Communication or noncommunication with external environment
Anatomic location
Types of FracturesTypes of Fractures
Fig. 61-4
Classification by Communication withExternal Environment
Classification by Communication withExternal Environment
Fig. 61-5
Classification by Fracture LocationClassification by Fracture Location
Fig. 61-6
DescriptionDescription
Described and classified according to:
Appearance, position, and alignment of the fragments
Classic names
Stable or unstable
Described and classified according to:
Appearance, position, and alignment of the fragments
Classic names
Stable or unstable
DescriptionDescription
Closed (also called simple)
Open (also called compound)
Closed (also called simple)
Open (also called compound)
DescriptionDescription
Stable fractures
Occur when a piece of the periosteum is intact across the fracture
External or internal fixation has rendered the fragments stationary
Stable fractures
Occur when a piece of the periosteum is intact across the fracture
External or internal fixation has rendered the fragments stationary
DescriptionDescription
Unstable fractures
Grossly displaced
Poor fixation
Unstable fractures
Grossly displaced
Poor fixation
Clinical ManifestationsClinical Manifestations
Immediate localized pain
Function
Inability to bear weight or use affected part
Guarding
May or may not see obvious bone deformity
Immediate localized pain
Function
Inability to bear weight or use affected part
Guarding
May or may not see obvious bone deformity
Fracture HealingFracture Healing
Reparative process of self-healing (union) occurs in the following stages:
1. Fracture hematoma (d/t bleeding, edema)
2. Granulation tissue → osteoid (3 – 14 days post injury)
3. Callus formation (minerals deposited in osteoid)
Reparative process of self-healing (union) occurs in the following stages:
1. Fracture hematoma (d/t bleeding, edema)
2. Granulation tissue → osteoid (3 – 14 days post injury)
3. Callus formation (minerals deposited in osteoid)
Fracture HealingFracture Healing
Reparative process of self-healing (union) occurs in the following stages:
4. Ossification (3 wks – 6 mos)
5. Consolidation (distance between fragments decreases → closes).
6. Remodeling (union completed; remodels to original shape, strength)
Reparative process of self-healing (union) occurs in the following stages:
4. Ossification (3 wks – 6 mos)
5. Consolidation (distance between fragments decreases → closes).
6. Remodeling (union completed; remodels to original shape, strength)
Bone HealingBone Healing
Fig. 61-7
Collaborative CareCollaborative Care
Overall goals of treatment:
Anatomic realignment of bone fragments (reduction)
Immobilization to maintain alignment (fixation)
Restoration of normal function
Overall goals of treatment:
Anatomic realignment of bone fragments (reduction)
Immobilization to maintain alignment (fixation)
Restoration of normal function
Collaborative CareFracture Reduction
Collaborative CareFracture Reduction
Closed reduction
Nonsurgical, manual realignment Open reduction
Correction of bone alignment through a surgical incision
Closed reduction
Nonsurgical, manual realignment Open reduction
Correction of bone alignment through a surgical incision
Collaborative Care Fracture ReductionCollaborative Care Fracture 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
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 Care Fracture Immobilization
Casts
Temporary circumferential immobilization device
Common following closed reduction
Casts
Temporary circumferential immobilization device
Common following closed reduction
CastsCastsCastsCasts
Fig. 61-9
Collaborative Care Fracture Immobilization
Collaborative Care Fracture Immobilization
External fixation
Metallic device composed of pins that are inserted into the bone and attached to external rods
External fixation
Metallic device composed of pins that are inserted into the bone and attached to external rods
Collaborative Care Fracture Immobilization
Collaborative Care Fracture Immobilization
Internal fixation
Pins, plates, intramedullary rods, and screws
Surgically inserted at the time of realignment
Internal fixation
Pins, plates, intramedullary rods, and screws
Surgically inserted at the time of realignment
Collaborative Care Fracture Immobilization
Collaborative Care Fracture Immobilization
Traction
Application of a pulling force to an injured part of the body while countertraction pulls in the opposite direction
Traction
Application of a pulling force to an injured part of the body while countertraction pulls in the opposite direction
Collaborative Care Fracture Immobilization
Collaborative Care Fracture Immobilization
Purpose of traction:
Prevent or reduce muscle spasm
Immobilization
Reduction
Treat a pathologic condition
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
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 temperaturecyanotic and cool/cold: arterial insufficiency
Blue and warm: venous insufficiency
Capillary refill (want < 3 sec)
Peripheral pulses (↓ indicates vascular insufficiency)
Neurovascular assessment
Color and temperaturecyanotic and cool/cold: arterial insufficiency
Blue and warm: venous insufficiency
Capillary refill (want < 3 sec)
Peripheral pulses (↓ indicates vascular insufficiency)
Nursing Management Nursing Assessment
Nursing Management Nursing Assessment
Neurovascular assessment
Edema
Sensation
Motor function
Pain
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
Risk for peripheral neurovascular dysfunction Acute pain Risk for infection
Nursing Management Nursing Diagnoses
Nursing Management Nursing Diagnoses
Risk for impaired skin integrity Impaired physical mobility Ineffective therapeutic regimen management
Risk for impaired skin integrity Impaired physical mobility Ineffective therapeutic regimen management
Nursing Management Nursing ImplementationNursing Management Nursing Implementation
General post-op careAssess dressings/casts for bleeding/drainage
Prevent complications of immobilityMeasures 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 ImplementationNursing Management Nursing Implementation
TractionEnsure:
No frayed ropes, loose knots
Ropes in pulley grooves
Pulley clamps fastened securely
Weights must hang freely
Appropriate body alignment
Inspect skinAround 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 FracturesInfection
Complications of FracturesInfection
Open fractures and soft tissue injuries have incidence
Osteomyelitis can become chronic
Open fractures and soft tissue injuries have incidence
Osteomyelitis can become chronic
Complications of FracturesInfection
Complications of FracturesInfection
Collaborative Care
Open fractures require aggressive surgical debridement
Post-op IV antibiotics for 3 to 7 days (prophylactic)
Collaborative Care
Open fractures require aggressive surgical debridement
Post-op IV antibiotics for 3 to 7 days (prophylactic)
Complications of FracturesCompartment 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
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 FracturesCompartment Syndrome
Complications of FracturesCompartment Syndrome
Two basic etiologies create compartment syndrome:
Decreased compartment size (dressings, splints, casts)
Increased compartment content (bleeding, edema)
Two basic etiologies create compartment syndrome:
Decreased compartment size (dressings, splints, casts)
Increased compartment content (bleeding, edema)
Complications of FracturesCompartment Syndrome
Complications of FracturesCompartment Syndrome
Clinical Manifestations
Six Ps
1. Paresthesia (unrelieved by narcotics)
2. Pain (unrelieved by narcotics)
3. Pressure
Clinical Manifestations
Six Ps
1. Paresthesia (unrelieved by narcotics)
2. Pain (unrelieved by narcotics)
3. Pressure
Complications of FracturesCompartment Syndrome
Complications of FracturesCompartment Syndrome
Clinical Manifestations
Six Ps:
4. Pallor (loss of normal color, coolness)
5. Paralysis
6. Pulselessness (decreased/absent pulses)
Clinical Manifestations
Six Ps:
4. Pallor (loss of normal color, coolness)
5. Paralysis
6. Pulselessness (decreased/absent pulses)
Complications of FracturesCompartment Syndrome
Complications of FracturesCompartment Syndrome
Clinical Manifestations
Six Ps:
Patient may present with one or all of the six Ps
Compare extemities
Clinical Manifestations
Six Ps:
Patient may present with one or all of the six Ps
Compare extemities
Complications of FracturesCompartment Syndrome
Complications of FracturesCompartment Syndrome
Clinical Manifestations
Absence of peripheral pulse = ominous late sign
Myoglobinuria
Dark reddish-brown urine
Clinical Manifestations
Absence of peripheral pulse = ominous late sign
Myoglobinuria
Dark reddish-brown urine
Complications of FracturesCompartment Syndrome
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
Collaborative Care
Prompt, accurate diagnosis is critical
Early recognition is the key
Do not apply ice or elevate above heart level
Complications of FracturesCompartment Syndrome
Complications of FracturesCompartment Syndrome
Collaborative Care
Remove/loosen the bandage and bivalve the cast
Reduce traction weight
Surgical decompression (fasciotomy)
Collaborative Care
Remove/loosen the bandage and bivalve the cast
Reduce traction weight
Surgical decompression (fasciotomy)
Complications of FracturesVenous Thrombosis
Complications of FracturesVenous Thrombosis
Veins of the lower extremities and pelvis are highly susceptible to thrombus formation after fracture, especially hip fracture
Veins of the lower extremities and pelvis are highly susceptible to thrombus formation after fracture, especially hip fracture
Complications of FracturesVenous Thrombosis
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
Precipitating factors:
Venous stasis caused by incorrectly applied casts or traction
Local pressure on a vein
Immobility Prevent with anticoagulant medications
Complications of FracturesFat Embolism Syndrome (FES)Complications of Fractures
Fat Embolism Syndrome (FES)
Characterized by the presence of fat globules in tissues and organs after a traumatic skeletal injury
Characterized by the presence of fat globules in tissues and organs after a traumatic skeletal injury
Complications of FracturesFat Embolism Syndrome (FES)Complications of Fractures
Fat Embolism Syndrome (FES)
Fractures that most often cause FES:
Long bones
Ribs
Tibia
Pelvis
Fractures that most often cause FES:
Long bones
Ribs
Tibia
Pelvis
Complications of FracturesFat Embolism Syndrome (FES)Complications of Fractures
Fat Embolism Syndrome (FES)
Tissues most often affected:
Lungs
Brain
Heart
Kidneys
Skin
Tissues most often affected:
Lungs
Brain
Heart
Kidneys
Skin
Complications of FracturesFat Embolism Syndrome (FES)Complications of Fractures
Fat Embolism Syndrome (FES)
Clinical Manifestations
Usually occur 24-48 hours after injury
Interstitial pneumonitis
Produce symptoms of ARDS
Clinical Manifestations
Usually occur 24-48 hours after injury
Interstitial pneumonitis
Produce symptoms of ARDS
Complications of FracturesFat Embolism Syndrome (FES)Complications of Fractures
Fat Embolism Syndrome (FES)
Clinical Manifestations
Symptoms of ARDS:
Chest pain
Tachypnea
Cyanosis
PaO2
Clinical Manifestations
Symptoms of ARDS:
Chest pain
Tachypnea
Cyanosis
PaO2
Complications of FracturesFat Embolism Syndrome (FES)Complications of Fractures
Fat Embolism Syndrome (FES)
Clinical Manifestations
Symptoms of ARDS:
Dyspnea
Apprehension
Tachycardia
Clinical Manifestations
Symptoms of ARDS:
Dyspnea
Apprehension
Tachycardia
Complications of FracturesFat Embolism Syndrome (FES)Complications of Fractures
Fat Embolism Syndrome (FES)
Clinical Manifestations
Rapid and acute course
Feeling of impending disaster
Patient may become comatose in a short time
Clinical Manifestations
Rapid and acute course
Feeling of impending disaster
Patient may become comatose in a short time
Complications of FracturesFat Embolism Syndrome (FES)Complications of Fractures
Fat Embolism Syndrome (FES)
Collaborative Care
Treatment directed at prevention
Careful immobilization of a long bone fracture
Most important preventative factor
Collaborative Care
Treatment directed at prevention
Careful immobilization of a long bone fracture
Most important preventative factor
Complications of FracturesFat Embolism Syndrome (FES)Complications of Fractures
Fat Embolism Syndrome (FES)
Collaborative Care (treatment)
Symptom management
Fluid resuscitation
Oxygen
Reposition as little as possible
Collaborative Care (treatment)
Symptom management
Fluid resuscitation
Oxygen
Reposition as little as possible
Fracture of the HipFracture 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 HipFracture of the Hip
Intracapsular fractures:Occur within hip joint capsule
Extrascapular fracturesIntertrochanteric: between greater and lesser trochanter
Subtrochanteric: below lesser trochanter
Clinical ManifestationsClinical Manifestations
External rotation of affected leg Muscle spasm Shortening of the affected extremity Severe pain and tenderness in region of
fracture
Collaborative CareCollaborative 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 CarePost-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 NotFlex 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 Prosthesis
Preventing Dislocation of Femur Head Prosthesis
DoUse elevated toilet seatUse chair in shower/tubUse 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