ch 63 fractures

8/8/2019 CH 63 Fractures

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Copyright 2007, 2004, 2000, Mosby, Inc., an affi liate of Elsevier Inc. All Rights Reserved.

Focus onFocus on

FracturesFractures(Relates to Chapter 63,(Relates to Chapter 63,

Nursing Management:Nursing Management:

Musculoskeletal Trauma and Orthopedic Surgery,Musculoskeletal Trauma and Orthopedic Surgery,in the textbook)in the textbook)


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FracturesFractures

Disruption or breakin continuity ofDisruption or breakin continuity of

the structure of bonethe structure of bone Majority of fractures fromMajority of fractures from

traumatic injuriestraumatic injuries

Some fractures secondary to diseaseSome fractures secondary to diseaseprocessprocess

Cancer or osteoporosisCancer or osteoporosis


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ClassificationClassification

Fractures are described andFractures are described and

classified according toclassified according to TypeType

Communication or noncommunicationCommunication or noncommunication

with external environmentwith external environment

Anatomic location of fracture onAnatomic location of fracture on

involved boneinvolved bone


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Types of FracturesTypes of Fractures

Fig. 63-6


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Classification According toClassification According to

External EnvironmentExternal Environment

Fig. 63-7


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Classification According toClassification According to

LocationLocation

Fig. 63-8


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Fractures also described as stable orFractures also described as stable or

unstableunstable Stable fractureStable fracture

Piece of periosteum is intact acrossPiece of periosteum is intact across

fracturefracture Either external or internal fixation hasEither external or internal fixation has

rendered fragments stationaryrendered fragments stationary


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Stable fracture (contd)Stable fracture (contd)

TransverseTransverse SpiralSpiral

GreenstickGreenstick


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Unstable fractureUnstable fracture

Grossly displaced during injuryGrossly displaced during injury Site of poor fixationSite of poor fixation

Usually comminuted or obliqueUsually comminuted or oblique


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Fractures can also be classified asFractures can also be classified as

Closed (simple)Closed (simple) OpenOpen

Compound fractureCompound fracture

Communication of fracture through skinCommunication of fracture through skin

with external environmentwith external environment


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Clinical ManifestationsClinical Manifestations

Mechanism ofinjury associated withMechanism ofinjury associated with

numerous signs and symptomsnumerous signs and symptoms Immediate localized painImmediate localized pain

Decreased functionDecreased function

Inability to bear weight on or useInability to bear weight on or useaffected partaffected part

Patient guards and protects extremityPatient guards and protects extremity


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Fracture may not be accompaniedFracture may not be accompanied

by obvious bone deformityby obvious bone deformity Immobilize extremityImmobilize extremity if fracture isif fracture is

suspectedsuspected

Unnecessary movementUnnecessary movement Increases soft tissue damageIncreases soft tissue damage

May convert a closed fracture to openMay convert a closed fracture to open


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Fracture HealingFracture HealingBone goes through a remarkableBone goes through a remarkable

reparative process of selfreparative process of self--healinghealing

1.1. Fracture hematomaFracture hematoma

2.2. Granulation tissueGranulation tissue

3.3. Callus formationCallus formation

4.4. OssificationOssification

5.5. ConsolidationConsolidation

6.6. RemodelingRemodeling


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Bone Healing StagesB

one Healing Stages

Fig. 63-9


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Fracture HealingFracture Healing

Fracture hematoma: Initial 72 hoursFracture hematoma: Initial 72 hours

Bleeding creates a hematoma,B

leeding creates a hematoma,surrounding ends of fragmentssurrounding ends of fragments

Hematoma is extravasated blood thatHematoma is extravasated blood that

changes from liquid to semisolid clotchanges from liquid to semisolid clot


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Granulation tissue: 3 to 4 daysGranulation tissue: 3 to 4 days

postinjurypostinjury

Active phagocytosis absorbs productsActive phagocytosis absorbs products

of local necrosisof local necrosis

Hematoma converts to granulationHematoma converts to granulation

tissuetissue

Granulation tissue produces basis forGranulation tissue produces basis for

new bone substance (osteoid)new bone substance (osteoid)


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Fracture HealingFracture Healing Callus formation: End of secondCallus formation: End of second

weekweek

Minerals and new bone matrix areMinerals and new bone matrix aredeposited in osteoid; an organizeddeposited in osteoid; an organizednetwork of bone is formed that isnetwork of bone is formed that is

woven around fracture partswoven around fracture parts Callus is primarily composed ofCallus is primarily composed of

cartilage, osteoblasts, calcium, andcartilage, osteoblasts, calcium, andphosphorusphosphorus


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ConsolidationConsolidation

As callus continues to develop, distanceAs callus continues to develop, distancebetween bone fragments diminishesbetween bone fragments diminishes

and eventually closesand eventually closes

This stage is known as consolidationThis stage is known as consolidation

Ossification continuesOssification continues

Can be equated with radiologic unionCan be equated with radiologic union


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Fracture HealingFracture Healing Remodeling:Up to a year afterRemodeling:Up to a year afterinjuryinjury

Excess bone tissue is reabsorbedExcess bone tissue is reabsorbed

Union is completeUnion is complete

Gradual return to preinjury structuralGradual return to preinjury structural

strength and shape occursstrength and shape occurs Bone remodels in response to physicalBone remodels in response to physical

loading stressloading stress


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Remodeling (contd)Remodeling (contd)

Weight bearing is gradually introducedWeight bearing is gradually introduced New bone is deposited in sitesNew bone is deposited in sites

subjected to stresssubjected to stress

B

oneis resorbed at areas of l

ittle stress

B

oneis resorbed at areas of l

ittle stress

Radiologic union occurs when xRadiologic union occurs when x--rayray

evidence shows complete bony unionevidence shows complete bony union


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Factors influencing healingFactors influencing healing

AgeAge Initial displacementInitial displacement

ImmobilizationImmobilization ImplantsImplants

SiteSite InfectionInfection

HormonesHormones Blood supply to areaBlood supply to area


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Fracture healing mayFracture healing may

Not occur in the expected timeNot occur in the expected time Delayed unionDelayed union

Not occur at allNot occur at all

NonunionNonunion

Healing time of fractures increasesHealing time of fractures increases

with agewith age


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Causes for delayed ossificationCauses for delayed ossification

Inadequate reduction andInadequate reduction andimmobilizationimmobilization

Excessive movementExcessive movement

InfectionInfection

Poor nutritionPoor nutrition

Systemic diseaseSystemic disease


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Electrical stimulation and pulsedElectrical stimulation and pulsed

electromagnetic fields (PEMFs)electromagnetic fields (PEMFs)

Stimulate bone healingStimulate bone healing

Electric currents modify cellElectric currents modify cell

mechanisms, causing bone remodelingmechanisms, causing bone remodeling

Electrodes placed over skin or cast andElectrodes placed over skin or cast and

are used 10 to 12 hours each dayare used 10 to 12 hours each day


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Collaborative CareCollaborative Care

Overall goals of fracture treatmentOverall goals of fracture treatment

Anatomic realignment of boneAnatomic realignment of bonefragmentsfragments

Immobilization to maintainImmobilization to maintain

realignmentrealignment

Restoration of normal or nearRestoration of normal or near--normalnormal

function ofinjured partsfunction ofinjured parts


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Fracture ReductionFracture Reduction Closed reductionClosed reduction

Nonsurgical, manual realignment ofNonsurgical, manual realignment ofbone fragments to previous anatomicbone fragments to previous anatomic

positionposition

Traction and countertraction manuallyTraction and countertraction manually

applied to bone fragments to restoreapplied to bone fragments to restore

position, length, and alignmentposition, length, and alignment


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Fracture ReductionFracture Reduction Closed reduction (contd)Closed reduction (contd)

Performed while patient is under localPerformed while patient is under localor general anesthesiaor general anesthesia


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Fracture ReductionFracture Reduction Open reductionOpen reduction

Correction of bone alignment throughCorrection of bone alignment throughsurgical incisionsurgical incision

Includes internal fixation with use ofIncludes internal fixation with use of

wires, screws, pins, plates,wires, screws, pins, plates,

intramedullary rods, or nailsintramedullary rods, or nails


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Fracture ReductionFracture Reduction Open reduction (contd)Open reduction (contd)

Chief disadvantagesChief disadvantages Possibility ofinfectionsPossibility ofinfections

Complications associated with anesthesiaComplications associated with anesthesia

Effects of premorbid medical conditionsEffects of premorbid medical conditions

Early initiation of ROM of the jointEarly initiation of ROM of the joint

If open reduction with internal fixationIf open reduction with internal fixation

(ORIF) is used for intraarticular fractures(ORIF) is used for intraarticular fractures


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Fracture ReductionFracture Reduction Open reduction (contd)Open reduction (contd)

Machines can provide continuousMachines can provide continuous

passive motion (CPM) to various jointspassive motion (CPM) to various joints Help prevent extraarticular andHelp prevent extraarticular andintraarticular adhesionsintraarticular adhesions

Results in faster reconstruction ofResults in faster reconstruction ofsubchondral bone plate, rapid healing ofsubchondral bone plate, rapid healing ofarticular cartilage,articular cartilage, decreaseddecreasedcomplicationscomplications


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TractionTraction Application of a pulling force to anApplication of a pulling force to an

injured or diseased part of body orinjured or diseased part of body or

extremity while counter tractionextremity while counter traction

pulls in opposite directionpulls in opposite direction


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TractionTraction Purpose of any tractionPurpose of any traction

Prevent orPrevent or muscle spasmmuscle spasm

Immobilize joint or part of bodyImmobilize joint or part of body

a fracture or dislocationa fracture or dislocation

Treat a pathologic joint conditionTreat a pathologic joint condition


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TractionTraction Traction also indicated toTraction also indicated to

Provide immobilization to prevent softProvide immobilization to prevent soft

tissue damagetissue damage

Reduce muscle spasm associated withReduce muscle spasm associated with

low back pain or cervical whiplashlow back pain or cervical whiplash

Expand a joint spaceExpand a joint space

During arthroscopic proceduresDuring arthroscopic procedures

Before major joint reconstructionBefore major joint reconstruction


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TractionTraction Two most common types of tractionTwo most common types of traction

Skin tractionSkin traction

Skeletal tractionSkeletal traction


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TractionTraction Skin tractionSkin traction

Used for shortUsed for short--term treatment untilterm treatment until

skeletal traction or surgery is possibleskeletal traction or surgery is possible

Tape, boots, or splints applied directlyTape, boots, or splints applied directly

to skin to maintain alignment, assist into skin to maintain alignment, assist in

reduction, and help diminish musclereduction, and help diminish muscle

spasms in injured extremityspasms in injured extremity

Traction weights 5 to 10 poundsTraction weights 5 to 10 pounds


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TractionTraction Skeletal tractionSkeletal traction

In place for longer periodsIn place for longer periods

Used to align injured bones and jointsUsed to align injured bones and joints

or to treat joint contractures andor to treat joint contractures and

congenital hip dysplasiacongenital hip dysplasia

Provides a longProvides a long--term pull that keepsterm pull that keeps

injured bones and joints alignedinjured bones and joints aligned


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TractionTraction Skeletal traction (contd)Skeletal traction (contd)

Physician inserts pin or wire into bone,Physician inserts pin or wire into bone,

either partially or completely, to aligneither partially or completely, to align

and immobilize injured body partand immobilize injured body part

Skeletal traction weight ranges: 5 to 45Skeletal traction weight ranges: 5 to 45

poundspounds

Too much weight results in delayed unionToo much weight results in delayed union

or nonunionor nonunion


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TractionTraction Skeletal traction (contd)Skeletal traction (contd)

Major disadvantagesMajor disadvantages

Infection of the area of bone whereInfection of the area of bone where

skeletal pin has been insertedskeletal pin has been inserted

Consequences of prolonged immobilityConsequences of prolonged immobility


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TractionTraction When traction is used, forces areWhen traction is used, forces are

usually exerted on distal fragment tousually exerted on distal fragment to

obtain alignment with proximalobtain alignment with proximal

fragmentfragment

Bucks tractionBucks traction


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Bucks TractionBucks Traction

Fig. 63-10


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TractionTraction Fracture alignment depends onFracture alignment depends on

correct positioning and alignmentcorrect positioning and alignment

while traction forces remainwhile traction forces remain

constantconstant

Forces must be pulling in oppositeForces must be pulling in oppositedirection to prevent patient fromdirection to prevent patient from

sliding to end or side of bedsliding to end or side of bed


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TractionTraction Countertraction commonly suppliedCountertraction commonly supplied

by patients body weight orby patients body weight or

augmented by elevating end of bedaugmented by elevating end of bed

Imperative that nurse maintainsImperative that nurse maintains

traction constantly and does nottraction constantly and does notinterrupt weight applied to tractioninterrupt weight applied to traction


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Fracture ImmobilizationFracture Immobilization CastsCasts

Temporary circumferentialTemporary circumferential

immobilization deviceimmobilization device

Allows patient to perform manyAllows patient to perform many

normal activities of daily livingnormal activities of daily living

Cast materials are natural, syntheticCast materials are natural, synthetic

acrylic, fiberglassacrylic, fiberglass--free, latexfree, latex--freefree

polymer, or a hybrid of materialspolymer, or a hybrid of materials


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Fracture ImmobilizationFracture Immobilization Casts (contd)Casts (contd)

After immersion in water, plaster ofAfter immersion in water, plaster of

Paris is wrapped and molded aroundParis is wrapped and molded around

affected part after bony prominencesaffected part after bony prominences

have been paddedhave been padded

Number of layers and techniqueNumber of layers and technique

determines strength of castdetermines strength of cast


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After cast is completely dry, it is strongAfter cast is completely dry, it is strong

and firm and can withstand stressesand firm and can withstand stresses

Plaster sets in 15 minutesPlaster sets in 15 minutes

Not strong enough for weight bearingNot strong enough for weight bearing

until 24 to 72 hoursuntil 24 to 72 hours

Fresh plaster should never be coveredFresh plaster should never be covered

with a blanketwith a blanket


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During drying period, cast should beDuring drying period, cast should be

kept dry and clean, and direct pressurekept dry and clean, and direct pressure

should be avoidedshould be avoided

Once thoroughly dry, edges may needOnce thoroughly dry, edges may need

to be petaled to avoid skin irritationto be petaled to avoid skin irritation


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Fracture ImmobilizationFracture Immobilization

Fig. 63-11


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Synthetic casting materialsSynthetic casting materials

Molded to fit torso or extremity afterMolded to fit torso or extremity after

being activated by submersion in cool orbeing activated by submersion in cool or

tepid watertepid water

Used more often because they areUsed more often because they arelightweight, relatively waterproof, providelightweight, relatively waterproof, provide

immediate immobilizationimmediate immobilization


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Fracture ImmobilizationFracture Immobilization Types of castsTypes of casts

SugarSugar--tong splinttong splint

Posterior splintPosterior splint

Short arm castShort arm cast

Long arm castLong arm cast


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Common Types of CastsCommon Types of Casts

Fig. 63-12


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Fracture ImmobilizationFracture Immobilization SugarSugar--tong splinttong splint

Acute wrist injuriesAcute wrist injuries

Injuries that result in significantInjuries that result in significant

swellingswelling

Posterior splintPosterior splint Accommodates swelling in fracturedAccommodates swelling in fractured

extremity postinjuryextremity postinjury


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Fracture ImmobilizationFracture Immobilization Short arm castShort arm cast

Treatment of stable wrist orTreatment of stable wrist or

metacarpal fracturesmetacarpal fractures

Circular cast extending from distalCircular cast extending from distal

palmar area to proximal forearmpalmar area to proximal forearm

Provides wrist immobilizationProvides wrist immobilization

Permits unrestricted elbow motionPermits unrestricted elbow motion


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Fracture ImmobilizationFracture Immobilization Long arm castLong arm cast

Treatment of stable forearm or elbowTreatment of stable forearm or elbow

fractures and unstable wristfractures and unstable wrist

Similar to short arm cast but extendsSimilar to short arm cast but extends

to proximal humerus, restrictingto proximal humerus, restricting

motion in wrist and elbowmotion in wrist and elbow


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Fracture ImmobilizationFracture Immobilization Sling (contd)Sling (contd)

Placement should not put unduePlacement should not put undue

pressure on posterior neckpressure on posterior neck

Encourage patient to move fingers andEncourage patient to move fingers and

nonimmobilized joints of the uppernonimmobilized joints of the upper

extremityextremity


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Fracture ImmobilizationFracture Immobilization Body jacket (brace)Body jacket (brace)

Immobilization and support for stableImmobilization and support for stable

spine injuries of thoracic or lumbarspine injuries of thoracic or lumbar

spinespine

After application, nurse assessesAfter application, nurse assesses

patient for cast syndromepatient for cast syndrome

Cast is applied too tightlyCast is applied too tightly


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Fracture ImmobilizationFracture Immobilization Body jacket (contd)Body jacket (contd)

Nursing assessment also includesNursing assessment also includes

Observation of respiratory statusObservation of respiratory status

Bowel and bladder functionBowel and bladder function

Areas of pressure over bony prominencesAreas of pressure over bony prominences

During time required for cast to dry,During time required for cast to dry,

nurse should reposition patient everynurse should reposition patient every

2 to 3 hours2 to 3 hours


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Fracture ImmobilizationFracture Immobilization Hip spica castHip spica cast

Femoral fracturesFemoral fractures

Immobilize affected extremity andImmobilize affected extremity and

trunk securelytrunk securely

Includes two casts joined togetherIncludes two casts joined together

Body jacket castBody jacket cast

Long leg castLong leg cast


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Fracture ImmobilizationFracture Immobilization Hip spica cast (contd)Hip spica cast (contd)

Assess patient for same problems asAssess patient for same problems as

body jacket castbody jacket cast

Nurse should instruct patient inNurse should instruct patient in

positioning activities required to get onpositioning activities required to get on

and off bedpanand off bedpan

Fracture bedpan may be usedFracture bedpan may be used


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Injuries to Lower ExtremitiesInjuries to Lower Extremities Often immobilized by aOften immobilized by a

Long leg castLong leg cast

Short leg castShort leg cast

Cylinder castCylinder cast

Jones dressingJones dressing Prefabricated splint or immobilizerPrefabricated splint or immobilizer


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Injuries to Lower ExtremitiesInjuries to Lower Extremities Elevate extremity onto pillows aboveElevate extremity onto pillows above

heart level for first 24 hoursheart level for first 24 hours

After initial phase, casted extremityAfter initial phase, casted extremity

should not be placed in a dependentshould not be placed in a dependent

position because of the possibility ofposition because of the possibility of

excessive edemaexcessive edema

Observe for signs of pressureObserve for signs of pressure


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Knee ImmobilizerKnee Immobilizer

Fig. 63-13


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ExternalFixationExternalFixation Metallic deviceMetallic device

Composed of metal pins inserted intoComposed of metal pins inserted into

bone and attached to external rodsbone and attached to external rods

Applies traction or compressesApplies traction or compresses

fracture fragmentsfracture fragments

ImmobilizeImmobilize fragments when cast orfragments when cast or

other traction is not appropriateother traction is not appropriate


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ExternalFixationExternalFixation External device holds fractureExternal device holds fracture

fragments in place similar to afragments in place similar to a

surgically implanted internal devicesurgically implanted internal device

Attached directly to bone byAttached directly to bone by

percutaneous transfixing pins orpercutaneous transfixing pins or

wireswires


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ExternalFixationExternalFixation

Fig. 63-14


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ExternalFixationExternalFixation Indicated inIndicated in

Simple fractures and complexSimple fractures and complex

fractures with extensive soft tissuefractures with extensive soft tissuedamagedamage

Correction of bony defects (congenital)Correction of bony defects (congenital)

PseudoarthrosisPseudoarthrosis Nonunion or malunionNonunion or malunion

Limb lengtheningLimb lengthening


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InternalFixationInternalFixation Surgically inserted at time ofSurgically inserted at time of

realignmentrealignment

Biologically inert metal devices usedBiologically inert metal devices used

Stainless steelStainless steel

VitalliumVitallium TitaniumTitanium

Alignment evaluated by xAlignment evaluated by x--rayray


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QuickTime and aYUV420 codec decompressor

are needed to see this picture.


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Drug TherapyDrug Therapy Patients have varying degrees ofPatients have varying degrees of

pain associated with muscle spasmspain associated with muscle spasms

Involuntary reflexes result fromInvoluntary reflexes result from

edema and nerve injury followingedema and nerve injury following

muscle injurymuscle injury

Central and peripheral muscleCentral and peripheral muscle

relaxants may be prescribedrelaxants may be prescribed


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Drug TherapyDrug Therapy Side effects of muscle relaxantsSide effects of muscle relaxants

DrowsinessDrowsiness

LassitudeLassitude

HeadacheHeadache

Weakness and fatigueWeakness and fatigue

Blurred visionBlurred vision AtaxiaAtaxia

Gastrointestinal upsetGastrointestinal upset


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NutritionalNutritional TherapyTherapy Proper nutrition is essentialProper nutrition is essential

Adequate energy source needed toAdequate energy source needed to

Promote muscle strength and tonePromote muscle strength and tone

Build enduranceBuild endurance

Provide energy for ambulation andProvide energy for ambulation andgaitgait--training skillstraining skills


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NutritionalNutritional TherapyTherapy Patients dietary requirements mustPatients dietary requirements must

includeinclude

Ample protein (1 g/kg of body weight)Ample protein (1 g/kg of body weight)

Vitamins (B, C, D)Vitamins (B, C, D)

CalciumCalcium

PhosphorusPhosphorus

MagnesiumMagnesium


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NutritionalNutritional TherapyTherapy Adequate fluid intakeAdequate fluid intake

2000 to 3000 ml/day2000 to 3000 ml/day

HighHigh--fiber diet with fruits andfiber diet with fruits and

vegetablesvegetables

For body jacket and hip spica castFor body jacket and hip spica castpatients: six small meals a daypatients: six small meals a day


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Nursing ManagementNursing Management

Nursing AssessmentNursing Assessment FindingsFindings

Deformity or unnatural position ofDeformity or unnatural position of

affected limbaffected limb

Edema and ecchymosesEdema and ecchymoses

Muscle spasmMuscle spasm

Tenderness and painTenderness and pain

Loss of functionLoss of function


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Nursing AssessmentNursing Assessment Initial treatment (contd)Initial treatment (contd)

Check neurovascular status distal toCheck neurovascular status distal to

injury before and after splintinginjury before and after splinting Elevate injured limb if possibleElevate injured limb if possible

DoDo notnotattempt to straighten fracturedattempt to straighten fractured

or dislocated jointor dislocated joint DoDo notnotmanipulate protruding bonemanipulate protruding bone

endsends


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Nursing AssessmentNursing Assessment Subjective dataSubjective data

Past health historyPast health history

Traumatic injuryTraumatic injury

LongLong--term repetitive forces (stressterm repetitive forces (stressfracture)fracture)

Bone or systemic diseasesBone or systemic diseases

Prolonged immobilityProlonged immobility

OsteopeniaOsteopenia

OsteoporosisOsteoporosis


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Nursing AssessmentNursing Assessment Subjective data (contd)Subjective data (contd)

MedicationsMedications

Use of corticosteroids (osteoporoticUse of corticosteroids (osteoporotic

fracture)fracture)

AnalgesicsAnalgesics

Surgery or other treatmentsSurgery or other treatments First aid treatment of fractureFirst aid treatment of fracture

Previous musculoskeletal surgeriesPrevious musculoskeletal surgeries


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Nursing AssessmentNursing Assessment Subjective data (contd)Subjective data (contd)

CognitiveCognitive--perceptualperceptual

Sudden and severe pain in affected areasSudden and severe pain in affected areas

Numbness, tingling, loss of sensationNumbness, tingling, loss of sensation

Chronic pain that Chronic pain that with activitywith activity


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Nursing AssessmentNursing Assessment Objective dataObjective data

Apprehension, guarding ofinjuryApprehension, guarding ofinjury

Skin lacerationsSkin lacerations

Pallor and cool skin or bluish andPallor and cool skin or bluish andwarm distal to injurywarm distal to injury

EcchymosisEcchymosis

HematomaHematoma

Edema at site of fractureEdema at site of fracture


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Nursing AssessmentNursing Assessment Objective data (contd)Objective data (contd)

Restricted or lost function of affectedRestricted or lost function of affected

partpart Local bony deformitiesLocal bony deformities

Abnormal angulationAbnormal angulation

Shortening, rotation, or crepitation ofShortening, rotation, or crepitation ofaffected partaffected part

Muscle weaknessMuscle weakness


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Nursing AssessmentNursing Assessment Objective data (contd)Objective data (contd)

Localization and extent of fractures onLocalization and extent of fractures on

XX--rayray

Bone scansBone scans

Computed tomography (CT) scanComputed tomography (CT) scan

Magnetic resonance imaging (MRI)Magnetic resonance imaging (MRI)


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Neurovascular AssessmentNeurovascular Assessment Musculoskeletal injuries can causeMusculoskeletal injuries can cause

changes in neurovascular statuschanges in neurovascular status

Causes of nerve or vascular damageCauses of nerve or vascular damage

Application of a cast or constrictiveApplication of a cast or constrictive

dressingdressing

Poor positioningPoor positioning

Physiologic responsesPhysiologic responses


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NursingDiagnosesNursingDiagnoses Impaired physical mobilityImpaired physical mobility

Risk for peripheral neurovascularRisk for peripheral neurovascular

dysfunctiondysfunction

Acute painAcute pain

Ineffective therapeutic regimenIneffective therapeutic regimenmanagementmanagement


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PlanningPlanning Overall goalsOverall goals

Have physiologic healing with noHave physiologic healing with no

associated complicationsassociated complications

Obtain satisfactory pain reliefObtain satisfactory pain relief

Achieve maximal rehabilitationAchieve maximal rehabilitation

potentialpotential


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Nursing ImplementationNursing Implementation Health promotionHealth promotion

Public should be taught to takePublic should be taught to take

appropriate safety precautionsappropriate safety precautions Nurses should advocate for personalNurses should advocate for personal

actions toactions to decrease injuriesdecrease injuries

Encourage moderate exercise to keepEncourage moderate exercise to keepmuscles strong and maintain balancemuscles strong and maintain balance

Calcium and vitamin DintakeCalcium and vitamin Dintake


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Preoperative ManagementPreoperative Management Nurse should inform patients ofNurse should inform patients of

ImmobilizationImmobilization

Assistive devices that will be usedAssistive devices that will be used

Expected activity limitations afterExpected activity limitations aftersurgerysurgery

Assure patients their needs will be metAssure patients their needs will be met Assure patients pain medication will beAssure patients pain medication will be

availableavailable


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Preoperative ManagementPreoperative Management Skin preparation is very importantSkin preparation is very important

Assist in cleansing skinAssist in cleansing skin

Remove debris and hair to reduceRemove debris and hair to reduce

infectioninfection


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Postoperative ManagementPostoperative Management Monitor vitalsMonitor vitals

Apply general principles of nursingApply general principles of nursing

carecare Frequent neurovascular assessmentsFrequent neurovascular assessments

of affected extremityof affected extremity

Minimize pain and discomfortMinimize pain and discomfortthrough proper alignment andthrough proper alignment andpositioningpositioning


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Postoperative ManagementPostoperative Management Monitor limitations in movementMonitor limitations in movement

Carefully observe dressings or castsCarefully observe dressings or casts

for bleeding or drainagefor bleeding or drainage

Significant Significant in size of drainage areain size of drainage area

should be reportedshould be reported Measure and assess patency ofMeasure and assess patency of

system and volume of drainagesystem and volume of drainage


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Other MeasuresOther Measures Constipation can be prevented byConstipation can be prevented by

Increased activityIncreased activity

High fluid intake (>2500 ml/day)High fluid intake (>2500 ml/day)

Diet high in bulk and roughageDiet high in bulk and roughage

Warm fluids, stool softeners, laxatives,Warm fluids, stool softeners, laxatives,

or suppositories may be necessaryor suppositories may be necessary


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Other MeasuresOther Measures Renal calculiRenal calculi

Can develop as a result of boneCan develop as a result of bone

demineralizationdemineralization

Fluid intake of 2500 ml/dayFluid intake of 2500 ml/day

Cranberry juice or ascorbic acidCranberry juice or ascorbic acid

ii


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Other MeasuresOther Measures Rapid deconditioning ofRapid deconditioning of

cardiopulmonary systemcardiopulmonary system

Result of prolonged bed restResult of prolonged bed rest

Results inResults in

Orthostatic hypotensionOrthostatic hypotension

Decreased lung capacityDecreased lung capacity


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N i M tN i M t


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TractionTraction Persistent skin pressure may impairPersistent skin pressure may impair

blood flow and cause injury toblood flow and cause injury to

peripheral neurovascular structuresperipheral neurovascular structures Observe skeletal traction pins forObserve skeletal traction pins forinfectioninfection

Pin care varies but usually includesPin care varies but usually includesregular removal of exudate, rinsingregular removal of exudate, rinsingpin sites, and drying areapin sites, and drying area

N i M tN i M t


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TractionTraction External rotation of hip can occurExternal rotation of hip can occur

when skin traction is used on lowerwhen skin traction is used on lower

extremitiesextremities

Nurse can correct this position byNurse can correct this position by

placing a pillow, sandbag, orplacing a pillow, sandbag, or

rolledrolled--up draw sheet along greaterup draw sheet along greater

trochanteric region of the femurtrochanteric region of the femur


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N i M tN i M t


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Ambulatory and Home CareAmbulatory and Home Care Cast careCast care

Dos (contd)Dos (contd)

Move joints above and below castMove joints above and below cast

regularlyregularly

Report signs of possible problems toReport signs of possible problems to

health care providerhealth care provider Keep appointment to have fracture andKeep appointment to have fracture and

cast checkedcast checked


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N i M tN i M t


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Ambulatory and Home CareAmbulatory and Home Care Psychosocial problemsPsychosocial problems

ShortShort--term rehabilitative goalsterm rehabilitative goals

Transition from dependence toTransition from dependence toindependence in performing simpleindependence in performing simpleactivities of daily livingactivities of daily living

Preservation or Preservation or strength and endurancestrength and endurance

LongLong--term rehabilitative goalsterm rehabilitative goals Preventing problems associated withPreventing problems associated with

musculoskeletal injurymusculoskeletal injury


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AmbulationAmbulation Degrees of weightDegrees of weight--bearingbearing

ambulationambulation

NonNon--weightweight--bearing ambulationbearing ambulation TouchTouch--down/toedown/toe--touch weighttouch weight--bearingbearing

ambulationambulation

PartialPartial--weightweight--bearing ambulationbearing ambulation WeightWeight--bearing as toleratedbearing as tolerated

FullFull--weightweight--bearing ambulationbearing ambulation


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Assistive DevicesAssistive Devices Common gait patterns with assistiveCommon gait patterns with assistive

devicesdevices

TwoTwo--point gaitpoint gait

FourFour--point gaitpoint gait

SwingSwing--to gaitto gait

SwingSwing--through gaitthrough gait


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Assistive DevicesAssistive Devices Transfer belt should be placedTransfer belt should be placed

around patients waist to providearound patients waist to provide

stability during learning stagesstability during learning stages

Discourage patient from reachingDiscourage patient from reaching

for furniture or relying on anotherfor furniture or relying on another

person for supportperson for support


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Complications of FracturesComplications of Fractures InfectionInfection

High incidence in open fractures andHigh incidence in open fractures and

soft tissue injuriessoft tissue injuries

Massive or blunt soft tissue injuryMassive or blunt soft tissue injury

often has more serious consequencesoften has more serious consequences

than fracturesthan fractures Devitalized and contaminated tissue isDevitalized and contaminated tissue is

an ideal medium for pathogensan ideal medium for pathogens


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Complications of FracturesComplications of Fractures

InfectionInfection

Treatment is costly in terms ofTreatment is costly in terms of

Extended nursing and medical careExtended nursing and medical care

Time for treatmentTime for treatment

Loss of patient incomeLoss of patient income

Osteomyelitis may become chronicOsteomyelitis may become chronic


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Compartment SyndromeCompartment Syndrome

Two basic types of compartmentTwo basic types of compartmentsyndromesyndrome

Compartment sizeCompartment size Resulting from restrictive dressing,Resulting from restrictive dressing,

splints, casts, excessive traction, orsplints, casts, excessive traction, orpremature closure of fasciapremature closure of fascia

Compartment sizeCompartment size Related to bleeding, edema, chemicalRelated to bleeding, edema, chemical

response to snakebite, or IV filtrationresponse to snakebite, or IV filtration


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Expected range ofExpected range of

intracompartmental pressureintracompartmental pressure

readings is 0 to 15 mm Hgreadings is 0 to 15 mm Hg Depends on patients age and bodyDepends on patients age and body

mass indexmass index

Readings of 30 to 50 mm Hg indicateReadings of 30 to 50 mm Hg indicatecompartment syndromecompartment syndrome


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Fig 63Fig 63--1515


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Clinical ManifestationsClinical Manifestations Six Ps are characteristic ofSix Ps are characteristic of

impending compartment syndromeimpending compartment syndrome

ParesthesiaParesthesia: Numbness and tingling: Numbness and tingling

PainPain: Distal to injury that is not: Distal to injury that is not

relieved by opioid analgesics and painrelieved by opioid analgesics and pain

on passive stretch of muscle travelingon passive stretch of muscle travelingthrough compartmentthrough compartment



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Clinical ManifestationsClinical Manifestations 6 Ps (contd)6 Ps (contd)

PressurePressure:: in compartmentin compartment

PallorPallor: Coolness, and loss of normal: Coolness, and loss of normal

color of extremitycolor of extremity

ParalysisParalysis: Loss of function: Loss of function

PulselessnessPulselessness: Diminished/absent: Diminished/absent

peripheral pulsesperipheral pulses



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Clinical ManifestationsClinical Manifestations Urine output must be assessedUrine output must be assessed

because there is a possibility ofbecause there is a possibility of

muscle damagemuscle damage

Myoglobin released from damagedMyoglobin released from damaged

muscle cells precipitates as a gelmuscle cells precipitates as a gel--likelike

substancesubstance

Causes obstruction in renal tubulesCauses obstruction in renal tubules



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Clinical ManifestationsClinical Manifestations Large amounts of myoglobinemiaLarge amounts of myoglobinemia

may result in acute tubular necrosismay result in acute tubular necrosis

Acute tubular necrosis causes acuteAcute tubular necrosis causes acuterenal failurerenal failure

Common signs of myoglobinuriaCommon signs of myoglobinuria

Dark reddish brown urineDark reddish brown urine Clinical manifestations associated withClinical manifestations associated with

acute renal failureacute renal failure


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V Th b iV Th b i


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Venous ThrombosisVenous Thrombosis

Veins of lower extremities and pelvisVeins of lower extremities and pelvis

are highly susceptible to thrombosisare highly susceptible to thrombosis

formationformation

Precipitating factorsPrecipitating factors

Incorrectly applied casts or tractionIncorrectly applied casts or traction

Local pressure on a veinLocal pressure on a vein

ImmobilityImmobility

V Th b iV Th b i


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Aggravated by inactivity of musclesAggravated by inactivity of musclesthat normally assist in pumpingthat normally assist in pumping

action of venous bloodaction of venous blood Instruct patient toInstruct patient to

Wear compression gradient stockingsWear compression gradient stockings

Move fingers or toes of affectedMove fingers or toes of affectedextremity against resistance andextremity against resistance andperform ROM exercisesperform ROM exercises

V Th b iV Th b i


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Prophylactic anticoagulant drugsProphylactic anticoagulant drugs

may be orderedmay be ordered

LowLow--molecularmolecular--weight heparinweight heparin

frequently usedfrequently used

Newer class of antithrombotic drugsNewer class of antithrombotic drugs


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F t E b li (FES)F t E b li (FES)


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Fat Embolism (FES)Fat Embolism (FES)

Two theories related to originTwo theories related to origin

Mechanical theory (contd)Mechanical theory (contd)

Fat droplets transverse capillary bed toFat droplets transverse capillary bed toenter systemic circulation, where theyenter systemic circulation, where theythen embolize to other organsthen embolize to other organs

Biochemical theoryBiochemical theory

Catecholamines released at time ofCatecholamines released at time oftrauma mobilize free fatty acids fromtrauma mobilize free fatty acids fromadipose tissueadipose tissue



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BiochemicalBiochemical theory (contd)theory (contd)

Causes loss of chylomicron emulsionCauses loss of chylomicron emulsionstabilitystability

Chylomicrons form large fat globules thatChylomicrons form large fat globules thateventually lodge in the lungseventually lodge in the lungs

Biochemical change sets up anBiochemical change sets up aninflammatory response secondary toinflammatory response secondary todestabilization of free fatty acidsdestabilization of free fatty acids



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BiochemicalBiochemical theory (contd)theory (contd)

Injury to lung parenchymaInjury to lung parenchyma Tissues most often affectedTissues most often affected

LungsLungs

BrainBrain

HeartHeart

KidneysKidneys

SkinSkin


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( )( )

Clinical ManifestationsClinical Manifestations Signs and symptoms of acuteSigns and symptoms of acute

respiratory distress syndromerespiratory distress syndrome

(ARDS)(ARDS) Chest pain, tachypnea, cyanosis,Chest pain, tachypnea, cyanosis,

dyspnea, apprehension, tachycardia,dyspnea, apprehension, tachycardia,

decreased partial pressure of arterialdecreased partial pressure of arterialoxygenoxygen



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( )( )

Clinical ManifestationsClinical Manifestations Clinical course of fat embolus mayClinical course of fat embolus may

be rapid and acutebe rapid and acute

Patient frequently expresses a feelingPatient frequently expresses a feelingofimpending disasterofimpending disaster

In a short time skin color changesIn a short time skin color changes

from pallor to cyanosisfrom pallor to cyanosis

Patient may become comatosePatient may become comatose


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( )( )

Clinical ManifestationsClinical Manifestations Chest xChest x--ray may reveal areas ofray may reveal areas of

pulmonary infiltrate or multiplepulmonary infiltrate or multiple

areas of consolidationareas of consolidation WhiteWhite--out effectout effect


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ch 63 fractures

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