Fractures Part II

Fractures Part II 150 150 Tony Guo
  • Fracture heals in abnormal position in relation to midline of structure (type of malunion)
  • Pseudoarthrosis
    • Type of nonunion occurring at fracture site in which a false joint is formed with abnormal movement at site.
  • Refracture
    • New fracture occurs at original fracture site
  • Myositis ossificans
    • Deposition of calcium in muscle tissue at site of significant blunt muscle trauma or repeated muscle injury

 

Fracture reduction

  • Closed reduction
    • Nonsurgical, manual realignment of bone fragments 
    • Traction and countertraction applied
    • Under local or general anesthesia
    • Immobilization afterwards
  • Open reduction
    • Surgical incision
    • Internal fixation
    • Risk for infection
    • Early ROM of joint to prevent adhesions
    • Facilitates early ambulation

 

Traction

  • Purpose 
    • Prevent or decrease pain and muscle spasm 
    • Immobilize joint or part of body
    • Reduce fracture or dislocation
    • Treat a pathologic joint condition
  • Pulling force to attain realignment – countertraction pulls in opposite direction
  • Two most common types of traction
    • Skin traction
    • Skeletal traction
  • Skin traction
    • Short-term (48-72 hours) 
    • Tape, boots, or splints applied directly to skin 
    • Traction weights 5 to 10 pounds 
    • Skin assessment and prevention of breakdown imperative
  • Skeletal traction
    • Long-term pull to maintain alignment
    • Pin or wire inserted into bone
    • Weights 5 to 45 lbs.
    • Risk for infection
    • Complications of immobility
    • Maintain countertraction, typically the patient’s own body weight
      • Elevate end of bed
    • Maintain continuous traction
    • Keep weights off the floor

 

Fracture immobilization

  • Cast
    • Temporary 
    • Allows patient to perform many normal activities of daily living 
    • Made of various materials
    • Typically incorporates joints above and below fracture

Upper extremity immobilization

  • Sling
    • To support and elevate arm
    • Contraindicated with proximal humerus fracture
    • Ensures axillary area is well padded
    • No undue pressure on posterior neck
    • Encourage movement of fingers and non-immobilized joints

Vertebral immobilization

  • Body jacket brace
    • Immobilization and support for stable spine injuries 
    • Monitor for superior mesenteric artery syndrome (cast syndrome)
      • Assess bowel sounds (decreased bowel)
      • Treat with gastric decompression

Lower extremity immobilization

  • Elevate extremity above heart 
  • Do not place in a dependent position
  • Observe for signs of compartment syndrome and increased pressure

External fixation

  • Metal pins and rods
  • Applies traction 
  • Compresses fracture fragments 
  • Immobilizes and holds fracture fragments in place
    • Assess for pin loosening and infection 
    • Patient teaching
    • Pin site care

Internal fixation

  • Internal fixation devices (pins, plates, intramedullary rods, metal and bioabsorbable screws) are surgically inserted to realign and maintain position of bony fragments
  • These metal devices are biologically inert and made from stainless steel, vitallium, or titanium

Electric bone growth stimulation

  • Used to facilitate healing process
    • Increase calcium uptake
    • Activate intracellular calcium stores
    • Increase bone growth factor production
  • Non-invasive, semi-invasive, and invasive methods

Drug therapy

  • Central and peripheral muscle relaxants 
    • Carisoprodol (Soma)
    • Cyclobenzaprine (Flexeril)
    • Methocarbamol (Robaxin)
  • Tetanus and diphtheria toxoid
  • Bone-penetrating antibiotics

Nutritional therapy

  • Increase protein (1 g/kg of body weight)
  • Increase Vitamins (B, C, D)
  • Increase calcium, phosphorus , and magnesium 
  • Increase fluid (2000-3000 mL/day)
  • Increase fiber with fruits and vegetables prevent constipation
  • Body jacket and hip spica cast patients: six small meals a day

 

Role of Nursing Personnel

Registered Nurse (RN)

  • Perform neurovascular assessment on the affected extremity.
  • Assess for manifestations of compartment syndrome.
  • Monitor cast during drying for denting or flattening.
  • Teach patient and caregiver about cast care and complications of casting.
  • Determine correct body alignment to enhance traction.
  • Instruct patient and caregiver about traction and correct body positioning.
  • Teach patient and caregiver ROM exercises.
  • Assess for complications associated with immobility or fracture (e.g., wound infection, constipation, VTE, renal calculi, atelectasis).
  • Develop plan to minimize complications associated with immobility or fracture.

Licensed Practical/Vocational Nurse (LPN/LVN)

  • Check color, temperature, capillary refill, and pulses distal to the cast.
  • Mark circumference of any drainage on the cast.
  • Monitor skin integrity around cast and at traction pin sites.
  • Pad cast edges and traction connections to prevent skin irritation.
  • Monitor pain intensity and administer prescribed analgesics.
  • Notify RN of changes in pain or if pain persists after prescribed analgesics are administered.

Unlicensed Assistive Personnel (UAP)

  • Position casted extremity above heart level as directed by RN.
  • Apply ice to cast as directed by RN.
  • Maintain body position and integrity of traction (after being trained and evaluated in this procedure).
  • Assist patient with passive and active ROM exercises.
  • Notify RN about patient complaints of pain, tingling, or decreased sensation in the affected extremity.

 

Role of Other Team Members

Physical Therapist

  • Assess patient’s current mobility and need for assistance.
  • Teach safe ambulation with assistive device based on patient’s weight-bearing restrictions.
  • Establish exercise regimen and teach patient to perform exercises safely.
  • Coordinate physical therapy with RN so that patient can receive timely analgesia.
  • Discuss home environment with patient and identify possible modifications to facilitate recovery (e.g., stair training if allowed by patient’s weight-bearing restrictions, bed placement on first level to avoid stairs).

Occupational Therapist

  • Assess impact of patient’s condition on ability to perform ADLs.
  • Instruct patient in use of assistive devices (e.g., long-handled reacher, shoe donner) to facilitate self-care while maintaining activity restrictions.
  • Discuss home environment with patient and identify possible modifications to facilitate recovery (e.g., bed placement on first level for access to bathroom).

 

Nursing Management: Fractures

Neurovascular assessment

  • Peripheral vascular
    • Color and temperature
    • Capillary refill
    • Pulses
    • Edema 
    • Motor function
    • Sensory function
    • Paresthesia

Nursing diagnoses

  • Impaired physical mobility related to loss of integrity of bone structures, movement of bone fragments, and prescribed movement restrictions
  • Risk for peripheral neurovascular dysfunction related to vascular insufficiency and nerve compression secondary to edema and/or mechanical compression by traction, splints, or casts
  • Acute pain related to edema, movement of bone fragments, and muscle spasms
  • Readiness for enhanced self–health management

Nursing implementation

  • Health Promotion
    • Teach safety precautions 
    • Advocate  to decrease injuries 
    • Encourage moderate exercise
    • Safe environment to reduce falls 
    • Calcium and vitamin D intake
  • Traction
    • Inspect exposed skin 
    • Monitor pin sites for infection
    • Pin site care per policy
    • Proper positioning
    • Exercise as permitted
    • Psychosocial needs
  • Ambulatory care
    • Do
      • Frequent neurovascular assessments
      • Apply ice for first 24 hours
      • Elevate  above  heart for first 48 hours 
      • Exercise joints above and below
      • Use hair dryer on cool setting for itching
      • Check with health care provider before getting wet
      • Dry thoroughly after getting wet
      • Report increasing pain despite elevation, ice, and analgesia
      • Report swelling associated  with pain and discoloration OR movement
      • Report burning or tingling under cast
      • Report sores or foul odor under cast
    • Do not
      • Elevate if compartment syndrome 
      • Get plaster cast wet
      • Remove  padding
      • Insert objects inside cast
      • Bear weight for 48 hours
      • Cover cast with plastic for prolonged period

Evaluation

  • Report satisfactory pain management
  • Demonstrate appropriate care of cast or immobilizer
  • Experience no peripheral neurovascular dysfunction
  • Experience uncomplicated bone healing

 

Complications of fractures

  • Prevent complications of immobility
    • Constipation
    • Renal calculi
    • Cardiopulmonary deconditioning
    • DVT/pulmonary emboli
  • Infection
    • High incidence in open fractures and soft tissue injuries
    • Devitalized and contaminated tissue  an ideal medium for pathogens
    • Prevention is key
    • Can lead to chronic osteomyelitis
    • Antibiotics for treatment
  • Compartment Syndrome
    • Swelling and increased pressure within a confined space
    • Compromises neurovascular function of tissues within that space
    • Usually involves the leg but can occur in any muscle group
    • Two basic types of compartment syndrome
    • Decrease compartment size 
    • Increase compartment  contents
    • Arterial flow compromised → ischemia → cell death → loss of function
      • Clinical manifestations
        • Early recognition and treatment essential
        • May occur initially or may be delayed several days
        • Ischemia can occur within 4 to 8 hours after onset
        • Six Ps 
          • Pain
  • Out of proportion to the injury that is not managed by opioid analgesics and pain on passive stretch of muscle traveling through the compartment
  • Pressure
  • Increase in pressure in the compartment
  • Paresthesia
  • Numbness and tingling
  • Pallor
  • Coolness, and loss of normal color of the extremity
  • Paralysis
  • Loss of function
  • Pulselessness
  • Diminished or absent peripheral pulses
  • Interprofessional care
    • Prompt, accurate diagnosis via regular neurovascular assessments
      • Notify of pain unrelieved by drugs and out of proportion to injury
      • Paresthesia is also an early sign
    • Assess urine output  and kidney function
    • NO elevation above heart
    • NO ice
    • Surgical decompression (fasciotomy)
  • Venous thromboembolism
    • High susceptibility aggravated by inactivity of muscles 
    • Prophylactic anticoagulant drugs 
    • Antiembolism stockings
    • Sequential compression devices
    • ROM exercises
  • Fat embolism (FES)
    • Presence of systemic fat globules from fracture that are distributed into tissues and organs after a traumatic skeletal injury 
    • Contributory factor in many deaths associated with fracture
    • Most common with fracture of long bones, ribs, tibia, and pelvis
    • Interprofessional care
      • Treatment is directed at prevention
      • Careful immobilization and handling of a long bone fracture probably the most important factor in prevention
      • Management is supportive and related to symptom management
      • Coughing and deep breathing
      • Administer O2
      • Intubation/ intermittent positive pressure ventilation

 

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