Exam 16: Fractures
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| Definition of a fracture | a traumatic injury to a bone in which the continuity of the bone tissue is broken.
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| If a fracture does occur without trauma | it is called a pathological or spontaneous fracture
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| pathological or spontaneous fracture, and may result from: | Osteoporosis.
Metastatic cancer.
Tumors of the bone.
Cushing’s Syndrome.
Malnutrition
Complications of long-term steroid use.
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| Open (Compound) Fracture | the bone breaks through the skin. There is an open wound, the danger of infection is greatly increased.
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| Closed (Simple) Fracture | fracture that remains contained, does not break the skin.
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| Displaced Fracture | the bone ends are separated at the fracture line.
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| Incomplete Fracture | bone breaks through only one cortex.
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| Fractures classified by appearance | Greenstick.
Complete.
Comminuted.
Impacted (telescope fracture).
Transverse.
Oblique.
Spiral.
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| Greenstick Fracture | One side of a bone is broken and the other side is bent. These kind of fractures occur primarily in children, because their bones are softer and more flexible than adults.
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| Complete Fracture | the fracture line extends entirely through the bone (through both cortices), with the periosteum disrupted on both sides of the bone.
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| Oblique Fracture | break runs along a slant to the length of the bone, it is approximately a 45 degree angle.
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| Spiral Fracture | breaks coils around the bone (torsion fracture results from a
twisting force).
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| Impacted (Telescope) Fracture | one bone fragment is forcibly wedged into
another bone fragment.
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| Comminuted Facture | the bone is splintered into many small fragments at the fracture site with the bone ends separated and usually misaligned.
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| Colles' fracture | fractures of the distal portion of the radius within 1 inch of the joint of the wrist, that commonly occurs from the attempt to break a fall by putting the arms down
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| Pott's fracture | distal end of the fibula, chipping off a piece of the medial
malleolus with a displacement of the foot outward.
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| Signs and Symptoms of fractures | Pain.
Loss of Function.
Deformity.
Crepitus.
False motion.
Edema.
Spasms.
Loss of sensation or paralysis distal in injury.
Bruising or hematoma.
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| During fracture: Periosteum & surrounding blood vessels | are torn by bone fragments
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| During fracture: Soft tissue around the bone | becomes inflamed and swollen d/t hemorrhage and edema
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| During fracture repair: The blood in the area | clots
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| During fracture repair: forms between fractured bones | A fibrin network forms and changes into granulation tissue
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| During fracture repair: This crosses thorugh the fibrin network and does this... | Osteoblasts incorporates calcium to form true bone.
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| During fracture repair: 6-10 days after injury | Clot consolidates into a callus that cannot endure stress or strain
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| During fracture repair: These work synergistically | Osteoblasts and osteoclasts remodel the callus into trabecular bone.
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| Seven P's of orthopedic assessment | Pain.
Pallor.
Paresthesia or numbness.
Paralysis.
Polar temperature.
Puffiness from edema or hematoma.
Pulseless
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| Fracture: Objective Data | (a) Warmth, edema, ecchymosis.
(b) Obvious deformity.
(c) Loss of normal function.
(d) Signs of systemic shock.
(e) Circulatory, motor, sensory impairment.
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| Fracture Medical Management: Immediate | Splinting to prevent edema.
Preserve body alignment.
Elevation of body part to ↓ edema.
Cold packs (during the first 24 hours) to reduce hemorrhage, edema, pain.
Administer analgesics.
Observe color, sensation, or temperature.
Observe for shock.
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| Fracture Medical Management: Secondary management for a Simple Fx Optimal Reduction | Closed reduction.
Traction.
Open Reduction with Internal Fixation.
Immobilization.
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| Closed reduction | manual manipulations, moving bony fragments into position by applying traction and pressure to distal fragments.
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| Open reduction with internal fixation (ORIF) | surgical procedure allowing fracture alignment under direct visualization using various internal fixation device applied to the bone.
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| Immobilization | a) External fixation; cast or splint.
b) Traction.
c) Internal fixation devices: pins, plates, screws, and prosthesis.
d) Combination of the above.
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| Fracture Medical Management: Secondary management Compound Fracture | Surgical Debridement.
Tetanus Toxoid.
Culture wound, ABx given.
Signs of osteomyelitis, tetanus, or gangrene.
Closure of wounds when there is no infection.
Reduce & immobilize Fx.
Treat complications.
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| Mandibular Fracture: Symptoms | Pain, swelling, ecchymosis, and bleeding in the mouth.
Misalignment of the mandible.
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| A fracture of the patient's mandible is frequently treated with | wires that splint the patient's lower jaw to the upper jaw.
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| Because vomitus is easily aspirated when the patient's jaw is wired shut, the nurse should | Wire cutters should be taped to HOB.
The patient's bedside should be checked at least twice per shift and after visitors have gone to ensure the wire cutters are in the proper place.
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| Hip Fracture types | Intracapsular
Extracapular
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| Intracapular Hip Fracture | The femur is broken inside the joint, or, fractures of the femoral head or neck that are contained within the hip capsule.
May disrupt blood supply to the femur head causing avascular necrosis.
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| Extracapular Hip Fracture | Fx happening outside the hip joint capsule. Referred to as intertrochanteric or subtrochanteric. Adequate blood supply leads to healing without concern for avascular necrosis.
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| Hip Fracture Treatment includes: (depends on type and location of fracture | Temporary immobilization/traction.
Internal fixation.
Nails and screws.
Arthroplasty/joint replacement with prothesis.
Intermedullary rod placed in the center of the bone with wires around the bone for stabilization.
May be temporary or permanent.
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| Maximum elevation for HOB with Hip Fx | 45 degrees
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| Patient Teaching w/ Hip Sx | a. Total Hip Precautions
i.Patient positioning
ii.Weight bearing as tolerated
iii.Use of ambulation assists (crutches, walker)
b.DVT prevention
c.Exercise
d.S/Sx of complications
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| Vertebrae Fracture | Fx may involve the vertebral body, lamina, and articulating processes and may discplace. If the Fx has displaced the vertebral structures, pressure may be placed on spinal nerves. Bone fragments may sever spinal cord nerves, causing paralysis.
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| Vertebrae Fracture: Objective Data | Pupillary reaction to light.
Hand grips.
Ability to move extremities.
Level of orientation.
Vital signs.
Reaction to painful stimuli.
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| Make sure Pt with Hip Sx has | Abductor Pillow
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| Vertebrae Fracture: Observe for hemorrhage | Hypotension.
Tachycardia.
Tachypnea.
Decrease renal function.
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| Vertebrae Fracture: Diagnostic Tests | Radiographic studies.
Spinal tap (presence of blood indicates trauma).
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| Vertebrae Fracture: Medical Management for Stable injuries | 1) Treat with pain medications and muscle relaxants.
2) Anticoagulant therapy- prophylaxis.
3) Maintain erect posture- back support, corset brace, or a cast.
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| Vertebrae Fracture: Medical Management for Unstable Injuries | Treatment: fracture reduction.
Postural positioning.
A Stryker frame or Foster frame may be used to facilitate turning the patient
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| Medical Management for Cranial-Skeletal Fx | cervical spine fracture- halo brace- external device of plaster or plastic brace that incorporates metal struts attached to pins is inserted into bone, allows mobility of the patient.
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| Medical Management for Pelvic | Traction lumbar spinal fracture open reduction by Harrington rod (surgical procedure- then placed in a body cast).
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| Pelvic Fractures etiology | most pelvic fractures result from trauma of great force, such as falls from high heights, automobile accidents, or crushing accidents.
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| Clinical Maifestations of Pelvic Fx | (a) Unable to bear weight without discomfort.
(b) Tenderness, edema.
(c) Hematuria (blood in urine).
(d) Hemorrhage: blood loss can be extensive (1-4L);THIS IS LIFE-THREATENING!!
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| Pelvic Fractures: Objective Data | 1) Assess muscle spasm.
2) Ecchymosis over pelvic, perineum, groin, suprapubic area.
3) Inability to raise legs when supine, Inability to bear weight.
4) External foot rotation on affected side.
5) Vital signs: observe for shock.
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| Pelvic Fractures: Diagnostic Tests | (a) Abdominal radiography: supine and lateral, if possible.
(b) CT scan; evaluate bones and intraabdominal contents.
(c) IV pyelogram; to evaluate kidney damage.
(d) Lab Tests: CBC, urine, stool: look for bleeding/anemia.
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| Pelvic Fractures: Symphysis pubis fracture with same side iliac fracture | Surgery performed. Then placed in skeletal traction 6 weeks to maintain the leg's position. When traction released: ambulate without weight bearing 3 months.
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| Pelvic Fractures: Bilateral pelvic fracture | 1) Pelvic sling.
2) Skeletal traction; external fixation
3) Spica cast/body cast.
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| Why do we measure abdominal girth? | increased girth = increased abd pressure= internal hemorrhage
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| Complications of Fractures | Compartment Syndrome.
Shock.
Fat Embolism.
Gas Gangrene.
Thromboembolus.
Delayed Fracture Healing.
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| Compartment Syndrome | Pathologic condition caused by the progressive development of arterial vessel compression and subsequent reduced blood supply to an extremity. Needs to be addressed in 12-24 hours.
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| Compartment Syndrome: S&S | Marked increases in tissue pressure within a space enclosed by fascia that affects arteries, veins, muscles, and nerves. Volkmann's Contracture.
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| Volkmann’s contracture | a permanent contracture of the forearm; presents as claw-hand, flexion of wrist and fingers, and atrophy of the forearm. Results from delayed decompression
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| Compartment Syndrome: Subjective Data | Pain: pt complains of sharp pain that increases with PROM of hand or foot. Deep, unrelenting, progressive pain, unrelieved by treatment.
Numbness or tingling in the affected extremity.
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| Compartment Syndrome: Objective Data | Inability to flex fingers or toes in affected extremity.
Coolness of the extremity.
Absence of pulse.
Pale or blue skin color.
Slow capillary refill.
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| Fasciotomy | (incision into the fascia) to relieve pressure and allow return to normal blood flow in the area.
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| Shock: | occurs as a result of blood loss from a fractured bone or severed blood vessel.
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| Fat Embolism: | platelets combine with fat globule that travels through systemic circulation to the pulmonary circulation causing partial or complete obstruction.
Rare but life threatening: consider if patient has multiple fractures or long bone/pelvic fractures.
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| Fat Embolism: Subjective Data | 1) Mental disturbances.
2) Irritability, restless, disoriented, stupor, coma.
3) Chest pain on inspiration.
4) Muscle weakness, spasticity, rigidity.
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| Fat Embolism: Objective Data | 1) Assess for tachypnea, dyspnea, hypoxemia, crackles, and wheezes.
2) Apical pulse for dysrhythmias, patient on cardiac monitor.
3) Petechiae.
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| Fat Embolism: Diagnosis | (a) Occur within 24-48 hrs.
(b) Blood gases: indicate hypoxemia.
(c) CBC: H/H decreased, Fat present, platelet count decreased.
(d) Urine: Fat present.
(e) Sedimentation rate: increased.
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| Gas Gangrene: | severe infection of the skeletal muscle caused by gram positive Clostridium bacteria-C. perfringens, which occurs in the presence of compound (open) fractures/lacerated wounds.
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| Gas Gangrene: Time frame | May occur 1-14 days after injury.
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| Gas Gangrene: Subjective data | pain (sudden/severe); characteristic finding is toxic delirium.
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| Gas Gangrene: Objective data | (a) Inspect skin of gas bubbles.
(b) Crepitation.
(c) Assess infection.
(d) Skin necrosis, thin watery discharge with foul odor.
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| Gas Gangrene: Medical Management | (a) Establish a larger wound to admit air to promote drainage.
(b) Antibiotic: PCN, Keflin.
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| Gas Gangrene: Nursing Intervention | Wound care with strict medical asepsis.
All contaminated equipment, linens must be autoclaved.
Contact isolation.
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| Thromboembolus | a condition in which a blood vessel is occluded by an embolus.
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| High risk for Thromboembolus | Pelvic and hip fractures are at high risk for this complication.
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| Thromboembolus: Clinical Manifestations | Affected area becomes cold, numb and cyanotic.
An embolus in lung causes a sudden, sharp thoracic or upper abdominal pain, dyspnea, cough, fever, and hemoptysis.
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| Thromboembolus: Subjective data | Complain of pain in lower extremities (Calf of the leg).Often patient can
pinpoint the area of pain.
Sharp pain in thoracic area when an embolus in the lung.
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| Thromboembolus: Objective Data | Positive Homan’s sign, if pain in the calf of affected leg.
Dfferences in leg size (circumference) from thigh to ankle.
Blood in sputum.
Anticoagulant therapy is ordered, assess for signs of bleeding, hematuria, hematemesis and occult blood in stool.
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| Thromboembolus: Diagnostic Tests | (a) Doppler ultrasonography or duplex scanning.
(b) CT scan.
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| Thromboembolus: Medical Management | (a) Anticoagulants, such as Heparin, Lovenox, or Warfarin (Coumadin).
(b) Thromboectomy- removal of a thrombus from the blood vessel.
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| Delayed Fracture Healing: | fails to heal within the usual time for fracture healing.
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| Non-union bone healing | failure of the ends of the fractured bones to unite.
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| Delayed Fracture Healing: Treatment | Electrical stimulation a new method of treatment in promoting healing, the electrical probes stimulate bone production.
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| Skeletal External Fixation Devices | (1) Used to hold bone fragments in normal position.
(2) Casts, skeletal/skin traction, braces, and metal pins are examples.
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| Skeletal pin external fixation | Technique immobilizes fractures by the use of pins inserted through the bone and attached to rigid external metal frame.
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| Removing dried exudates from around the pins is done | 1 to 2 times daily with hydrogen peroxide or alcohol, using surgical asepsis. (pin care per orders/SOP).
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| Pins are inserted and checked | q 8 hrs with careful observation of signs of infection and loose pins.
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| Types of Casts | Short arm.
Long arm.
Short leg.
Long leg.
Walking.
Body.
Spica.
Shoulder Spica.
Hip spica.
Bivalve.
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| Short arm cast | extends from below the elbow.
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| Long arm cast | extends from the upper level of the axillary fold to the proximal palmar crease.
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| Short leg cast | extends from below the knee to the base of the toes.
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| Long leg cast | extends from the junction of the upper and middle third of the thigh to the base of the toes.
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| Walking cast | a cast reinforced for strength
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| Body cast | encircles the trunk
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| Spica cast | incorporates a portion of the trunk and one or two extremities
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| Shoulder spica cast | a body jacket with the shoulder extending outward
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| Hip spica cast | encloses the trunk and lower extremity
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| Bivalve cast | splitting the cast on 2 sides to provide support but relieve pressure.
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| Fiberglass cast dries | Immediatley
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| Plaster cast dries | 24-48 hours
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| Traction | The process of putting an extremity, bone, or group of muscles under tension by means of weights and pulleys.
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| skin traction | Non-surgical procedure that indirectly applies traction to the patient's skeletal system.
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| Skin traction weight | Only 5 to 10 lbs of force can safely be applied to the patient's skin for a period of 3 to 4 weeks.
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| Complications associated with the use of skin traction | Skin breakdown.
Nerve damage.
Impaired circulation.
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| Buck's extension | Adhesive strips are placed along the side of the patient's extremity and wrapped with an Ace bandage to keep them from slipping.A rope extends from the foot spreader over a pulley and connected weights provide the needed traction.
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| Russell's traction | Horizontal pull is exerted on the extremity by Buck's extension.
Vertical pull is applied by the use of a knee sling.
Most often used to treat the patient with fracture of the femoral shaft.
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| Skeletal traction | Applied directly to the bone
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| Steinmann | Uses pin
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| Crutchfield | Uses tongs
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| Kirschner | Uses wires
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| Balanced suspension traction | most common form of skeletal traction for treatment of patients with fractures of the femoral shaft or humerus.
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| Frames | can be used for orthopedic patients to assist with turning and positioning while maintaining proper alignment.
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| Balkan frame | wooden or steel attachment to the hospital bed. The frame has adjustable pulleys and a trapeze bar attached to an overhead bar.
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| Bradford frame | rectangular steel with two pieces of canvas stretched tightly and laced to the frame. A space is left in the buttocks area for toileting and hygiene.
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| Stryker wedge turning frame and Foster bed | similar and assist in changing the patients position from supine to prone. Patients may become apprehensive when turned on the frame for fear of falling, so thorough explanation and reassurances are helpful.
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| CircOlectric Bed | vertical turning bed that can be operated electrically by one person and can be placed in a variety of positions. Side-to-side movement can be accomplished while maintaining proper positioning if traction is ordered.
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| RotoRest Bed | can rock a patient as much as 62 degrees, 17 times an hour. The electric powered bed can promote decubitus healing, prevent venous thrombosis, and reduce kidney stone formation.
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| Splints, Crutches and Braces | used to immobilize and assist with ambulation.
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