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
Types of Fractures

Fig. 61-4
Classification by Communication with
External Environment

Fig. 61-5
Classification by Fracture Location

Fig. 61-6
 Description

 Described and classified according to:

Appearance, position, and alignment of
the fragments
Classic names
Stable or unstable
 Description

 Closed (also called simple)

 Open (also called compound)
 Description

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

 Unstable fractures
Grossly displaced
Poor fixation
 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

 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 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)
Bone Healing

Fig. 61-7
 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
 Closed reduction
Nonsurgical, manual realignment
 Open reduction
Correction of bone alignment through a
surgical incision
 Collaborative 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
 Collaborative Care
Fracture Immobilization
 Casts
Temporary circumferential immobilization
device
Common following closed reduction
Casts

Fig. 61-9
 Collaborative Care
Fracture Immobilization
 External fixation
Metallic device composed of pins that are
inserted into the bone and attached to external
rods
 Collaborative Care
Fracture Immobilization
 Internal fixation
Pins, plates, intramedullary rods, and screws
Surgically inserted at the time of realignment
 Collaborative Care
Fracture Immobilization
 Traction
Application of a pulling force to an injured
part of the body while countertraction pulls
in the opposite direction
 Collaborative Care
Fracture Immobilization
 Purpose of traction:
Prevent or reduce muscle spasm
Immobilization
Reduction
Treat a pathologic condition
 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

 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 Assessment

 Neurovascular assessment
Edema
Sensation
Motor function
Pain
 Nursing Management
Nursing Diagnoses

 Risk for peripheral neurovascular dysfunction

 Acute pain
 Risk for infection
 Nursing Management
Nursing Diagnoses

 Risk for impaired skin integrity

 Impaired physical mobility
 Ineffective therapeutic regimen management
 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 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
 Casts can cause neurovascular
complications if
Too tight
Edematous
 Frequent neurovascular checks
 Ice and elevation during early phase
 Complications of Fractures
Infection
 Open fractures and soft tissue injuries have 
incidence
 Osteomyelitis can become chronic
 Complications of Fractures
Infection
 Collaborative Care
Open fractures require aggressive surgical
debridement
Post-op IV antibiotics for 3 to 7 days
(prophylactic)
 Complications of Fractures
Compartment 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 Syndrome
 Two basic etiologies create compartment
syndrome:
Decreased compartment size (dressings,
splints, casts)
Increased compartment content (bleeding,
edema)
 Complications of Fractures
Compartment Syndrome
 Clinical Manifestations
Six Ps
1. Paresthesia (unrelieved by narcotics)

2. Pain (unrelieved by narcotics)

3. Pressure
 Complications of Fractures
Compartment Syndrome
 Clinical Manifestations
Six Ps:
4. Pallor (loss of normal color, coolness)

5. Paralysis

6. Pulselessness (decreased/absent pulses)

 Complications of Fractures
Compartment Syndrome
 Clinical Manifestations
Six Ps:
Patient may present with one or all of the
six Ps
Compare extemities
 Complications of Fractures
Compartment Syndrome
 Clinical Manifestations
Absence of peripheral pulse = ominous late
sign
Myoglobinuria
Dark reddish-brown urine
 Complications of Fractures
Compartment 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 Syndrome
 Collaborative Care
Remove/loosen the bandage and bivalve the
cast
Reduce traction weight
Surgical decompression (fasciotomy)
 Complications of Fractures
Venous Thrombosis
 Veins of the lower extremities and pelvis are
highly susceptible to thrombus formation after
fracture, especially hip fracture
 Complications of Fractures
Venous 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)
 Characterized by the presence of fat globules in
tissues and organs after a traumatic skeletal
injury
 Complications of Fractures
Fat Embolism Syndrome (FES)
 Fractures that most often cause FES:
Long bones
Ribs
Tibia
Pelvis
 Complications of Fractures
Fat Embolism Syndrome (FES)
 Tissues most often affected:
Lungs
Brain
Heart
Kidneys
Skin
 Complications of Fractures
Fat Embolism Syndrome (FES)
 Clinical Manifestations
Usually occur 24-48 hours after injury
Interstitial pneumonitis
Produce symptoms of ARDS
 Complications of Fractures
Fat Embolism Syndrome (FES)
 Clinical Manifestations
Symptoms of ARDS:
Chest pain
Tachypnea
Cyanosis
 PaO2
 Complications of Fractures
Fat Embolism Syndrome (FES)
 Clinical Manifestations
Symptoms of ARDS:
Dyspnea
Apprehension
Tachycardia
 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
 Complications of Fractures
Fat 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 (FES)
 Collaborative Care (treatment)
Symptom management
Fluid resuscitation
Oxygen
Reposition as little as possible
 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 Hip

 Intracapsular fractures:
Occur within hip joint capsule
 Extrascapular fractures
Intertrochanteric: between greater and
lesser trochanter
Subtrochanteric: below lesser trochanter
 Clinical Manifestations

 External rotation of affected leg

 Muscle spasm
 Shortening of the affected extremity
 Severe pain and tenderness in region of
fracture
 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
 Risk for peripheral neurovascular
dysfunction
 Acute pain
 Risk for impaired skin integrity
 Impaired physical mobility
 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
 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 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