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Care of Patients with Fractures and Amputation Musculoskeletal System(see video: http://www.youtube.

com/watch?v=C2dTbJDQ3u0) Bone growth (from Brunner and Suddarth) for video see: http://www.youtube.com/watch? v=X6E5Rz9tOKE Bone Formation (Osteogenesis) Bone begins to form long before birth. Ossification is the process by which the bone matrix (collagen fibers and ground substance) is formed and hardening minerals (eg, calcium salts) are deposited on the collagen fibers. The collagen fibers give tensile strength to the bone, and the calcium provides compressional strength. There are two basic processes of ossification: endochondral and intramembranous. Most bones in the body are formed by endochondral ossification, in which a cartilage-like tissue (osteoid) is formed, resorbed, and replaced by bone. Intramembranous ossification occurs when bone develops within membrane, as in the bones of the face and skull. Bone healing (from Brunner and Suddarth) for video see: http://www.youtube.com/watch? v=qVougiCEgH8 When a bone is fractured, the bone fragments are not merely patched together with scar tissue. Instead, the bone regenerates itself. Fracture healing occurs in four areas, including: • Bone marrow, where endothelial cells rapidly undergo transformation and become osteoblastic bone-forming cells • Bone cortex, where new osteons are formed • Periosteum, where a hard callus/bone is formed through intramembranous ossification peripheral to the fracture, and where a cartilage model is formed through endochondral ossification adjacent to the fracture site • External soft tissue, where a bridging callus (fibrous tissue) stabilizes the fracture Buckwalter (2000) summarized the process of fracture healing into six stages stimulated by the release and activation of biologic regulators and signaling molecules: 1. Hematoma and inflammation: The body’s response is similar to that after injury elsewhere in the body. There is bleeding into the injured tissue and formation of a fracture hematoma. The hematoma is the source of signaling molecules, such as cytokines, transforming growth factor-beta (TGF-β), and platelet-derived growth factor (PDGF), which initiate the fracture healing processes. The fracture fragment ends become devitalized because of the interrupted blood supply. The injured area is invaded by macrophages (large white blood cells), which débride the area. Inflammation, swelling, and pain are present. The inflammatory stage lasts several days and resolves with a decrease in pain and swelling. 2.Angiogenesis and cartilage formation: Under the influence of signaling molecules, cell proliferation and differentiation occur. Blood vessels and cartilage overlie the fracture. 3. Cartilage calcification: Chondrocytes in the cartilage callus form matrix vesicles, which regulate calcification of the cartilage. Enzymes within these matrix vesicles prepare the cartilage for calcium release and deposit. 4. Cartilage removal: The calcified cartilage is invaded by blood vessels and becomes resorbed by chondroblasts and osteoclasts. It is replaced by woven bone similar to that of the growth plate. 5. Bone formation: Minerals continue to be deposited until the bone is firmly reunited. With major adult long bone fractures, ossification takes 3 to 4 months. 6. Remodeling: The final stage of fracture repair consists of remodeling the new bone into its former structural arrangement. Remodeling may take months to years, depending on the extent of bone modification needed, the function of the bone, and the functional stresses on the bone. Cancellous bone heals and remodels more rapidly than does compact

and the general health of the person influence the rate of fracture healing. texture.  Deformity also results from soft tissue swelling. Swelling and discoloration  Localized swelling and discoloration of the skin (ecchymosis) occurs after a fracture as a result of trauma and bleeding into the tissues. and fat.  Types of Fractures Complete  involves a break across the entire cross-section of the bone and is frequently displaced (removed from normal position).  reveals any widening. or signs of irregularity. and changes in bone relationships.cortical bone. tendon.  Treatment of tears. Serial x-ray films are used to monitor the progress of bone healing. erosion. Loss of function  After a fracture. These signs may not develop for several hours after the injury. It is caused by the rubbing of the bone fragments against each other. or rotation of the fragments in a fracture of the arm or leg causes a deformity (either visible or palpable) that is detectable when the limb is compared with the uninjured extremity. CT-Scan  scan shows in detail a specific plane of involved bone and can reveal tumors of the soft tissue or injuries to the ligaments or tendons.5 to 5 cm (1 to 2 inches). cartilage. The fragments often overlap by as much as 2. the adequacy of blood supply. nerve.  FRACTURES-a break in the continuity of the bone and is defined according to its type and extent. Common Diagnostic Exams X-ray  are important in evaluating patients with musculoskeletal disorders. called crepitus. because normal function of the muscles depends on the integrity of the bones to which they are attached.  Joint x-rays reveal fluid. Traumatic  are caused by a direct blow or impact . a grating sensation. the extremity cannot function properly.  It is used to identify the location and extent of fractures in areas that are difficult to evaluate Arthroscopy  is a procedure that allows direct visualization of a joint to diagnose joint disorders. and computers to demonstrate abnormalities of soft tissues such as muscle. the surface contact of the fragments. and disease processes may be performed through the arthroscope. spur formation. Deformity  Displacement.  Pain contributes to the loss of function. and changes in the joint structure. Clinical Manifestations Pain  The pain is continuous and increases in severity until the bone fragments are immobilized. Shortening  In fractures of long bones. The type of bone fractured. narrowing.  In addition. abnormal movement (false motion) may be present. there is actual shortening of the extremity because of the contraction of the muscles that are attached above and below the site of the fracture. -occur when the bone is subjected to stress greater than it can absorb. angulation. narrowing. radio waves. Adequate immobilization is essential until there is x-ray evidence of bone formation with ossification. Magnetic Resonance Imaging  is a non-invasive imaging technique that uses magnetic fields. defects. Crepitus  When the extremity is examined with the hands. The muscle spasm that accompanies fracture is a type of natural splinting designed to minimize further movement of the fracture fragments. Incomplete  the break occurs through only part of the cross-section of the bone.  determine bone density. irregularity. can be felt.

 Medical Management Reduction  Reduction of a fracture (“setting” the bone) refers to restoration of the fracture fragments to anatomic alignment and rotation. Halo Vest  skeletal type of traction that as indicated for the treatment of fractures or dislocations of cervical or high thoracic vertebrae. a foam boot is applied to the client’s affected extremity and attached to a weight that is suspended off the foot of the bed.  Treatment of a traumatic fracture depends on the location and extent of the break and whether it is displaced.a surgical procedure that stabilizes and joins the reduced fracture by the use of metal screws.  to reduce deformity. boots. Paget’s disease. Traction  is the application of a pulling force to a part of the body. Internal fixation devices (metallic pins. placing the ends in contact) through manipulation and manual traction. screws. and is the most severe. splint. nails.can be displaced or nondisplaced. plates. Casts  a rigid external immobilizing device that is molded to the contours of the body. bone cyst.  External fixation-the immobilization of the fracture fragment with the use of certain devices like bandages. Cervical Tractions  is a simple chiropractic procedure used to correct the alignment of the entire spinal column. plates. employed especially in fractures in the femur of children. and pins.  is used to minimize muscle spasms.  and to increase space between opposing surfaces. and immobilize fractures. or foam splints. has extensive soft tissue damage. Open  Through a surgical approach. the bone is broken in such a way that it has changed in position (dislocated). Open fractures are graded according to the following criteria:  • Grade I is a clean wound less than 1 cm long. can occur without trauma or a fall Close/Simple  is one that does not cause a break in the skin. For Buck’s traction. nails. Pathologic  a fracture that occurs through an area of diseased bone (eg. The extremity is held in the desired position while the physician applies a cast. Open/Compound  is one in which the skin or mucous membrane wound extends to the fractured bone. casts. the fracture fragments are reduced. or rods) may be used to hold the bone fragments in position until solid bone healing occurs. without direct supervision of a health practitioner. Closed  is accomplished by bringing the bone fragments into apposition (ie. align. or other device.  • Grade II is a larger wound without extensive soft tissue damage. osteoporosis.  Bryant’s vertically.  • Grade III is highly contaminated. bony metastasis. Skin  involves the application of a pulling force directly to the skin through the use of skin strips. used with open redeuction.  The advantage of this kind of procedure is that it can be done at home.  Buck’s  is the most commonly used form of skin traction. tumor). The purposes of a cast are to immobilize a body part in a specific position and to apply uniform pressure on encased soft tissue.  traction on the lower limb placed .  must be applied in the correct direction and magnitude to obtain its therapeutic effects.  to reduce. Internal/External Fixation  Internal fixation. wires.  If the fracture is displaced.

 Blot dry with towel  Use hair dryer on low setting until cast is thoroughly dry. pelvis. or spine. large quantities of blood may be lost as a result of . and bone and to promote healing of soft tissue and bone. Pin sites and wounds must be regularly assessed for signs of infection and pins should be checked for loosening. pain. Muscles: Strengthening exercise for upper extremities Strengthening exercise for lower extremities Preparation for crutch walking Vascular Occlusion Paralysis Paresthesia Pulselessness Pallor Pain Fixation care assesses the pain prior to administration of analgesics.  With internal fixation. thorax. Casts/tractions/fixations care Cast Care Do’s: Apply ice directly over fracture site for 1st 24 hours wet by keeping ice in plastic bag and protecting cast with cloth. Maintaining skin integrity  The objectives of management are to prevent infection of the wound. Be aware of complaints like nausea and vomiting. Complications Shock  Hypovolemic or traumatic shock resulting from hemorrhage (both visible and nonvisible blood loss) and from loss of extracellular fluid into damaged tissues may occur in fractures of the extremities.  It is important to teach exercises to maintain the health of unaffected muscles and to increase the strength of muscles needed for transferring and for using assistive devices. thorough wound irrigation and débridement in the operating room are necessary. Be alert to more specific signs of infection. Promote mobility  The nurse encourages patients with closed (simple) fractures to return to their usual activities as rapidly as possible.  Serial irrigation and débridement are used to remove anaerobic organisms.  The nurse and physical therapist teach patients how to use assistive devices safely. the surgeon determines the amount of movement and weight-bearing stress the extremity can withstand and prescribes the level of activity.  Participation in activities of daily living (ADLs) is encouraged to promote independent functioning and self-esteem. moderate to severe pain and also non-opiod analgesics to also reduce the inflammatory process thereby reducing pain.  Gradual resumption of activities is promoted within the therapeutic prescription. Dry cast thoroughly after exposure to water. Wound healing progress should be assessed. Check with health care provider before getting fibreglass cast wet.  The nurse administers tetanus prophylaxis if indicated. Prompt. Because the bone is very vascular.splints. Increased nutritional need  The client’s nutritional status greatly affects bone and wound                      healing. Any abnormal laboratory values should be assessed as possible evidence of poor nutrition. or numbness and tingling so that proper intervention can immediately be given. and carefully documented. soft tissue. Nursing Management Pain relief  Administer opioid analgesics to treat mild. continuous tractions and external fixators. It is vital to increase the food intake to aid in the reparative process and see to it that the ability of the client to eat and swallow is not impaired. or tenderness. Maintain neurologic function  Assess for any neurologic complaints like loss of sensation in certain areas and inability to move affected parts.

). usually an extremity. The fat globules (emboli) occlude the small blood vessels that supply the lungs. Compartment syndrome  is a complication that develops when tissue perfusion in the muscles is less than that required for tissue viability. Fat Embolism  After fracture of long bones or pelvis. unrelenting pain. Burgess Technique • posterior myoplastic flap • the skin and muscle from the calf are brought forward to cover the shin bones after they have been divided Kingsley Robinson Tech. transecting fasciae and muscles. Mid-thigh amputation involves circular incision over the distal femur. Cast syndrome  psychological (claustrophobic reaction) and physiologic (superior mesenteric artery syndrome) responses to confinement in body cast. Used to: to relieve symptoms to improve function to save the patient’s quality of life Types of Amputations MINOR AMPUTATION -are amputations where only a toe or part of the foot is removed. and other organs. fat globules may move into the blood because the marrow pressure is greater than the capillary pressure or because catecholamines elevated by the patient’s stress reaction mobilize fatty acids and promote the development of fat globules in the bloodstream. which is not controlled by opioids. Volkmann’s Syndrome  or Volkmann’s contracture is a limb deformity that results from unrelieved compartment syndrome. The patient complains of deep. throbbing. especially in fractures of the femur and pelvis. creating large anterior and posterior skin flaps. This pain can be caused by (1) a reduction in the size of the muscle compartment because the enclosing muscle fascia is too tight or a cast or dressing is constrictive. Reasons for Amputation Diabetic Gangrene A gangrene (a death tissue generally with loss of vascular (nutritive) supply and followed by bacterial invasion and putrefaction. fat emboli may develop. paresthesia or complaints of increasing pain. The forearm and leg muscle compartments are involved most frequently. or (2) an increase in muscle compartment contents because of edema or hemorrhage associated with a variety of problems (eg. Fat embolism syndrome occurs most frequently in young adults (typically those 20 to 30 years of age) and elderly adults who experience fractures of the proximal femur. At the time of fracture. multiple fractures. Nerve injury  Bone fragments and tissue edema associated with the injury can cause nerve damage. As prolonged pressure causes ischemia. or crush injuries. MAJOR AMPUTATION -are amputations where part of the leg is removed Above-Knee Amputation-In this operation the bone in the thigh (femur) is divided about 12-15 cms above the knee joint and the muscle and skin closed over the end of the bone. Be alert for pallor. usually . • skew flap • muscles of the calf are brought forward in the same way as in the posterior technique but the skin flaps are skewed in relation to the muscle. fractures.trauma. coolness of the client’s affected extremity changes in the client’s ability to move the digits or the extremity. crush injuries). kidneys. muscle is gradually replaced by fibrous tissue that traps tendons and nerves AMPUTATION-is the removal of a body part. brain.

s. Infection • The infection sites provide a stronghold to dangerous bacteria. Patient with upper extremity amputation should be taught how to carry ADLs with one arm. Neoplasms may be benign. anticonvulsants. hypnosis. acupressure. Tissue Trauma • Car accidents. Nursing Management Relieve Pain • Treat the pain aggressively with medications and complimentary therapies. a number of therapies may be useful. • To complement traditional therapy. The surgeon prescribes medications based on the type of pain sensation that patient experiences. leaving no other option but amputation. acupuncture. such as phenytoin (Dilantin). The patient should avoid positions of flexion such as sitting for long periods If the patient is able. Bandage is applied in such a manner that the remaining muscles required to operate the • • • • • • • • . infection can set in. severe burns and gunshot wounds are all possible causes of traumatic injury. that develops secondary to sensory peripheral neuropathy and peripheral vascular disease complications related to the diabetic disease process Tissue Necrosis • When body tissue dies. Advised to wear a cotton t-shirt to prevent contact with the skin and shoulder harness and to enhance absorption of sweat. massage. Blood vessels and other body tissue components can be ripped or shredded beyond repair by these types of injuries. using a prosthesis will not be possible because patient will not be able to walk. lying prone (on stomach) for 30 minutes four times daily helps prevent contracture The upper extremitieare exercised and strengthened. are used for knifelike pain. and distraction Helping Achieve Physical Mobility • To reduce surgical swelling. including biofeedback.involving the lower extremities. Beta. are appropriate for burning sensations. causing dangerous conditions such as gangrene. cold application may be ordered. Well-fitting shoe should be used Bandage is applied in such a manner that the remaining muscles required to operate the prosthesis are as firm as possible. and abdominal muscles Patient is taught transfer techniques because amputation of legs changes the center of gravity. which can spread to other parts of the body Neoplasm • It is an abnormal mass of tissue as a result of neoplasia • The growth of the cells exceeds. and is uncoordinated with that of the normal tissues around it • usually causes a lump or tumor. For example. imagery. premalignant (carcinoma in situ) or malignant (cancer). and gabapentin (Neurontin) or amitriptyline (Elavil) can be used for nerve pain. trunk.blocking agents. If the hip becomes contracted. such as propanolol (Inderal).

• • Promote Wound Healing • The residual limb must be handled gently.prosthesis possible. beta-blockers may relieve dull. The support from family and friends promotes the patient’s acceptance of the loss. antiseizure medications control stabbing and cramping pain. or local anesthetics may provide relief for some patients. Early intensive rehabilitation and stump desensitization with kneading massage bring relief. ultrasound. Helping patient to resolve Grieving • The nurse creates an accepting and supportive atmosphere in which the patient and family are encouraged to express and share their feelings and work through the grief process. Assess the client’s verbal and nonverbal references to the affected area. burning discomfort. The nurse helps the patient deal with immediate needs and become oriented to realistic rehabilitation goals and future independent functioning. The nurse instructs the patient and family in wrapping the residual limb with elastic dressings. Distraction techniques and activity are helpful. Ask the client to describe his or her feelings about changes in the body image and self-esteem. Do not jump to the conclusion that acceptance has occurred. Advised to wear a cotton t-shirt to prevent contact with the skin and shoulder harness and to enhance absorption of sweat. and tricyclic antidepressants are used to improve mood and coping ability. Complications Phantom Limb Sensation Infection(Osteomyelitis) Fat-embolism Syndrome Promotion of Body Image • • Use of the word stump for referring to the remaining portion of the limb (residual limb) is controversial. technique is required • aseptic Patient with upper extremity amputation should be taught how to carry ADLs with one arm. Clients have reported feeling as if they were part of the tree when the tern was used. In addition. • are as firm as dressing is changed. The patient and the nurse need to maintain positive attitudes and to minimize fatigue and frustration during the learning process. Whenever the . transcutaneous electrical nerve stimulation (TENS). supportive supervision in a relaxed environment enables the patient to learn self-care skills. • • Promoting Independent Self-care • Practicing an activity with consistent. Minimizing Altered Sensory Perception • Keeping the patient active helps decrease the occurrence of the phantom limb pain. In addition to the nursing interventions. Some clients behave euphorically and seem to have accepted the loss.