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Chapter 42 Fractures 1.

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1 Chapter 42 Fractures 1

2 Learning Objectives Identify the types of fractures.
Describe the five stages of the healing process. Discuss the major complications of fractures, their signs and symptoms, and their management. Compare the types of medical treatment for fractures, particularly reduction and fixation. Describe common therapeutic measures for fractures, including casts, traction, crutches, walkers, and canes. Discuss the nursing care of a patient with a fracture. Describe specific types of fractures, including hip fractures, Colles’ fractures, and pelvic fractures.

3 Classification of Fractures
Closed or simple fracture The bone does not break through the skin Open or compound fracture Fragments of the broken bone break through skin Open fractures have three grades of severity Grade I: least severe injury, with minimal skin damage Grade II: moderately severe injury, with skin and muscle contusions (bruises) Grade III: most severe injury (wound larger than 6 to 8 cm), with skin, muscle, blood vessel, and nerve damage How are fractures classified as open or closed? 3

4 Classification of Fractures
Stress fracture Caused by either repeated or prolonged stress Pathologic fracture Occurs because of a pathologic condition in the bone, such as a tumor or disease process, that causes a spontaneous break What commonly causes stress fractures? 4

5 Figure 42-1 5

6 Etiology and Risk Factors
Commonly caused by trauma to the bone, especially as a result of automobile accidents and falls Bone disease, e.g., bone cancer, can lead to a fracture Hip fractures in older adults usually from falls Risk factors for hip fractures: osteoporosis, advanced age, white race, use of psychotropic drugs, and female In adults, ribs most commonly fractured Fractures of the femur most common in young and middle-aged adults Hip and wrist fractures are most common in older adults The number of hip fractures in the United States has been rising, with 338,000 reported in 1999. How much is spent each year in direct and indirect costs associated with hip fractures? 6

7 Fracture Healing A bone begins to heal as soon as an injury occurs
New bone tissue formed to repair the fracture, resulting in a sturdy union between the broken ends of the bone 7

8 Healing Stages Stage 1: hematoma formation
Immediately after a fracture, bleeding and edema occur In 48 to 72 hours, a clot or hematoma forms between the two broken ends of the bone 8

9 Healing Stages Stage 2: fibrocartilage formation
Hematoma that surrounds fracture does not resorb, as it does in other parts of the body Instead, other tissue cells enter the clot, and granulation tissue replaces the clot The tissue then forms a collar around each end of the broken bone, gradually becoming firm and forming a bridge between the two ends 9

10 Healing Stages Stage 3: callus formation
Within 1 to 4 weeks after injury, granulation tissue changes into a callus, which is made up of cartilage, osteoblasts, calcium, and phosphorus. The callus is larger than the diameter of the bone and serves as a temporary splint 10

11 Healing Stages Stage 4: ossification
Within 3 weeks to 6 months after the break, a permanent bone callus, known as woven bone, forms During this stage the ends of the broken bone begin to knit 11

12 Fracture Healing Stage 5: consolidation and remodeling
Consolidation occurs when the distance between bone fragments decreases, then closes During bone remodeling, immature bone cells are gradually replaced by mature bone cells Excess bone is chiseled away by stress to the affected part from motion, exercise, and weight bearing Bone then takes on its original shape and size 12

13 Figure 42-2 13

14 Fracture Healing Healing affected by location and severity of the fracture, type of bone, other bone pathology, blood supply to the area, infection, and the adequacy of immobilization Also age, endocrine disorders, and some drugs affect healing Healing time increases with age; it may take six times as long for the same type of fracture to heal in an older adult as in an infant In the absence of bone disease, most older adults eventually heal as well as younger adults. What population is most at risk for loss of bone mass? 14

15 Complications 15

16 Infection Osteomyelitis: from contamination of the open wound associated with a fracture or from contamination of indwelling hardware used to repair the broken bone When infection is inadvertently brought by surgery or other treatment, it is known as iatrogenic Any infection can interfere with normal healing Common after an open fracture and surgical repair and may become chronic In deep, grossly contaminated wounds, gas gangrene may develop 16

17 Infection Signs and symptoms Treatment
Local pain, redness, purulent wound drainage, chills, and fever With gas gangrene, foul-smelling watery drainage with significant redness and swelling Treatment IV antibiotics may be given for 4 to 8 weeks, followed by 4 to 8 weeks of oral drug therapy Wound care: irrigation, treatment with antibiotic beads, and surgical removal of dead bone tissue and/or hardware 17

18 Fat Embolism Fat globules released from marrow of broken bone into bloodstream, then migrate to the lungs They lodge in capillaries and obstruct blood flow The fat particles break down into fatty acids, which inflame the pulmonary blood vessels, leading to pulmonary edema Common with fractures of the long bones, multiple fractures, and severe trauma Fat embolism occurs 24 to 48 hours after injury, most often in young men ages 20 to 40 years and in older adults ages 70 to 80 years. Who is at the highest risk for fat embolism? 18

19 Fat Embolism Respiratory distress is the first sign of a fat embolism, followed by tachycardia, tachypnea, fever, confusion, and decreased level of consciousness Treatment: bed rest, gentle handling, oxygen, ventilatory support, and fluid restriction and diuretics for pulmonary edema Where may petechiae appear with a fat embolism? 19

20 Deep Vein Thrombosis Venous stasis, vessel damage, and altered clotting mechanisms contribute to formation of blood clots (thrombi), most commonly in deep veins of the legs DVT increased with immobility often associated with a fracture Thrombi can break off and travel to the lungs, causing a pulmonary embolism 20

21 Compartment Syndrome Serious complication from internal or external pressure on the affected area Compartments: enclosed spaces made of muscle, bone, nerves, blood vessels wrapped by fibrous membrane Internal pressure from bleeding/edema into a compartment; external pressure from a cast or tight dressing 21

22 Compartment Syndrome When bleeding or edema into a compartment, there is nowhere for drainage to go: it is trapped in the space Increased fluid puts pressure on tissues, nerves, and blood vessels, so that blood flow is decreased, resulting in pain and tissue damage. External pressure also can decrease blood flow to the area Although compartment syndrome is relatively rare, it is a serious condition and can create an emergency situation. How soon after the onset of compartment syndrome does irreversible muscle damage occur? Paresis (partial paralysis) can result if the condition is not treated within 24 hours. In 24 to 48 hours, the limb can become useless. 22

23 Compartment Syndrome Primary symptom is pain, especially with touch or movement, that can’t be relieved with opioids Other signs and symptoms: edema, pallor, weak or unequal pulses, cyanosis, tingling, numbness, paresthesia, and finally, severe pain The goal of treatment is to relieve pressure When internal pressure, a surgical fasciotomy, which entails making linear incisions in the fascia, may relieve pressure on the nerves and blood vessels For external pressure, cast or dressings are replaced 23

24 Shock After fracture, a risk of excessive blood loss
Trauma may rupture local blood vessels; internal organs may be punctured; results in internal bleeding Loss of blood leads to shock, evidenced by tachycardia, anxiety, pallor, and cool, clammy skin Immobilizing fractures reduces risk of hemorrhage If severe external bleeding, external pressure should be applied and medical assistance summoned immediately 24

25 Joint Stiffness and Contractures
Joint fractures or dislocations may be followed by stiffness or contractures, especially in older adults, due to immobility associated with fracture Prevention requires appropriate positioning and progressive exercise programs Treatment may employ splints, traction, casts, surgical manipulation, and aggressive physiotherapy 25

26 Malunion Expected healing time is appropriate but unsatisfactory alignment of bone results in external deformity and dysfunction 26

27 Delayed Union Failure of a fracture to heal in the expected time
The bone usually heals eventually; it may just be slower 27

28 Nonunion Occurs when a fracture never heals Treatment
Osteogenic method: implantation of bone grafts Osteoconductive methods: synthetic materials to provide a matrix for bone growth Osteoinduction: substances such as platelet-derived growth factor Electric stimulation Internal or external; up to 10 hours a day for 3-6 months Time consuming but can prevent further surgery and bone grafts 28

29 Post-Traumatic Arthritis
Weight-bearing joints are most vulnerable to posttraumatic arthritis Excessive stress and strain on the joint or fracture must be avoided to reduce the risk of this complication Can be a result of nonunion of a fracture 29

30 Avascular Necrosis A variety of factors can interfere with blood supply after a bone injury Once bone cells are deprived of oxygen and nutrients, they die and their cell walls collapse Signs and symptoms Pain, instability, and decreased function in the affected area 30

31 Avascular Necrosis Treatment
Relief of weight bearing and removal of part of the bone to decrease pressure If conservative measures fail, surgical procedures may be recommended Sometimes amputation is necessary 31

32 Complex Regional Pain Syndrome Type 1 (CRPS—Type 1)
Precipitated by a fracture or other trauma Symptoms Severe pain at the injury site despite no detectable nerve damage, edema, muscle spasm, stiffness, vasospasms, increased sweating, atrophy, contractions, and loss of bone mass Symptoms persist longer than expected with the type of injury suffered 32

33 Complex Regional Pain Syndrome Type 1 (CRPS—Type 1)
Treatment Nerve blocks, physical therapy, transcutaneous electrical stimulation, and analgesics, muscle relaxants, and antidepressants 33

34 Signs and Symptoms Depend on type and location of the break
Some fractures have so few manifestations that they can be detected only with x-ray Signs and symptoms are swelling, bruising, pain, tenderness, loss of normal function, abnormal position, and decreased mobility See Box 42-1, p. 918 34

35 Diagnostic Tests and Procedures
Standard radiographs Reveal bone disruption, deformity, or malignancy Computed tomography (CT) Detect fractures of complex structures, such as the hip and pelvis, or compression fractures of the spine Bone scan Detect small bone fractures or fractures caused by stress or disease 35

36 Medical Treatment 36

37 Reduction The process of bringing the ends of the broken bone into proper alignment 37

38 Closed Reduction or Manipulation
Nonsurgical realignment that returns bones to their previous anatomic position No surgical incision is made; however, general or local anesthesia is given By using traction, manual pressure, or a combination After reduction of a fracture, x-ray taken and a cast usually applied 38

39 Figure 42-3 39

40 Open Reduction A surgical procedure in which an incision is made at the fracture site Usually for open (compound) or comminuted fractures to clean the area of fragments and debris Effective pain management of a fracture is essential for patient mobilization and healing. 40

41 Immobilization Necessary for healing to occur
Prevents movement and increases union Accomplished in many ways, such as fixation, casts, splints, and traction 41

42 Fixation An attempt to attach the fragments of the broken bone together when reduction alone is not feasible because of the type and extent of the break 42

43 Internal Fixation Done during open reduction surgical procedure
Rods, pins, nails, screws, or metal plates used to align bone fragments and keep them in place for healing Promotes early mobilization; preferred for older adults who have brittle bones that may not heal properly, or who may suffer the consequences of immobility 43

44 Figure 42-4 44

45 External Fixation Pins are inserted into the bone, above and below fracture Pins are then attached to an external frame and adjusted to align the bone If there is soft tissue damage or infection, external fixation allows access to the site and facilitates wound care Pin care is extremely important to prevent the migration of organisms along the pin from the skin to the bone Patients should be taught to do their own pin care and to recognize signs of infection External fixation allows for early ambulation and mobility while relieving pain. Approximately what percentage of patients with external fixation have a pin track infection? 45

46 Figure 42-5 46

47 Figure 42-6 47

48 Therapeutic Measures 48

49 Casts, Splints, and Immobilizers
Hold the bone in alignment while allowing movement of other parts of the body Types of cast materials: plaster of Paris, fiberglass, thermoplastic resins, thermolabile plastic, and polyester-cotton knit impregnated with polyurethane Variety of materials used for splints/immobilizers Four main groups of casts: (1) upper extremity, (2) lower extremity, (3) cast brace, and (4) body or spica cast To prevent swelling, a patient who is wearing an arm cast should keep the arm elevated above the heart when lying in bed. Lower extremity casts are used for breaks in the upper and lower leg, ankle, and foot. After an adequate amount of healing has taken place and edema has subsided, cast braces may be used for injury to the knee. Body or spica casts are used when a fracture is located somewhere in the trunk of the body. How are casts removed? 49

50 Traction Exerts a pulling force on a fractured extremity to align bone fragments Prevents or corrects deformity, decreases muscle spasm, promotes rest, and maintains the position of the injured part May be applied directly to the skin (skin traction) or attached directly to a bone (skeletal traction) with a metal pin or wire 50

51 Traction Skin traction Skeletal traction Buck’s traction
For hip and knee contractures, muscle spasms, and alignment of hip fractures Weight used during skin traction should not be more than 5 to 10 pounds to prevent injury to the skin Skeletal traction Provides a strong, steady, continuous pull and can be used for prolonged periods Examples of skeletal traction are Gardner-Wells, Crutchfield, and Vinke tongs and a halo vest, in which pins are inserted into the skull on either side Heavier weights can be used with skeletal traction, usually from 15 to 30 pounds. What complications may occur with traction? What important points should be remembered when a patient is in traction? 51

52 Figure 42-7 52

53 Figure 29-8 53

54 Traction Complications
Impaired circulation, inadequate fracture alignment, skin breakdown, and soft tissue injury Pin track infection and osteomyelitis can occur with skeletal traction 54

55 Assistive Devices 55

56 Crutches Increase mobility and assist with ambulation
Physical therapist measures patient for proper fit and instructs in crutch-walking techniques Nurse reinforces the instructions and evaluates whether the crutches are being used properly A properly fitted crutch should reach to three fingerbreadths below the axilla to avoid pressure on the axilla and nerves when walking The success in crutch walking may depend on what factors? Axillary pressure could result in temporary or permanent numbness in the hands. 56

57 Figure 42-8 57

58 Crutches: Gait Patterns
Two-point gait The crutch on one side and the opposite foot are advanced at the same time Used with partial weight-bearing limitations and with bilateral lower extremity prostheses Three-point gait Both crutches and the foot of the affected extremity are advanced together, followed by the foot of the unaffected extremity This gait requires strength and balance Used for partial or no weight bearing on affected leg The type of gait used depends on the severity of the patient’s disability and the patient’s physical condition, trunk strength, upper and lower extremity strength, and balance. All gaits begin with what position? {AU: OK that I changed “being” to “begin”?} 58

59 Crutches: Gait Patterns
Four-point gait The right crutch is advanced, then the left foot, then the left crutch, then the right foot Used if weight bearing is allowed and one foot can be placed in front of the other Swing-to gait Both crutches are advanced together, then both legs are lifted and placed down again on a spot behind the crutches The feet and crutches form a tripod 59

60 Crutches: Gait Patterns
Swing-through gait Both crutches are advanced together, then both legs are lifted through and beyond the crutches and placed down again at a point in front of the crutches Used when adequate muscle power and balance in the arms and legs How does a patient sit down after walking on crutches? For stair climbing, the unaffected leg goes up the step first while the body is supported by the crutches. To descend stairs, the affected leg and the crutches move down one step first, followed by the unaffected leg. 60

61 Figure 42-9 61

62 Walker Used for support and balance, usually by older adults
A modified swing-to gait is used with a walker so that the walker is pushed or lifted forward, and then the legs are brought up to it. How are steps taken using a walker? 62

63 Canes Provide minimal support and balance, and relieve pressure on weight-bearing joints Placed on the unaffected side with the top even with the patient’s greater trochanter What gaits are used with a cane? When walking, it is better to lift the cane rather than slide it along to prevent catching the cane tip and tripping or falling. 63

64 Electrical Stimulation
Electrical stimulation may be used to promote bone healing by promoting bone growth An electrical current is delivered through one of three methods A surgically implanted device Device with pins that are inserted through the skin to the fracture site Pack of electrical coils applied to skin around fracture Electrical bone stimulators successful in 80% of cases, with an average healing time of 16 weeks How often is electrical bone stimulation successful? 64

65 Assessment Health history The cause, type, and extent of the injury
Symptoms associated with the injury Other medical problems that may have been related to the cause of the fracture Find out about other medical problems that either may have been related to the cause of the fracture, such as a pathologic fracture, or that may affect healing. How could medications play a role in the development of a fraction or in the rehabilitation process? 65

66 Assessment Physical examination Deviations in bone alignment
Inspect the skin over the fracture for lacerations, bruising, or swelling Neurovascular checks (pulse, skin color, capillary refill time, sensation) in the areas distal to the wound to compare circulation and sensation. Assess pulse rate and volume, as well as capillary refill time in the nails distal to the injury Because fractures usually involve some type of accidental injury, be alert for signs of serious complications, such as head, thoracic, or abdominal injuries. Why would the length of the extremity change with a fracture? Skin color is a good indication of circulation to the extremity, and pallor indicates poor circulation. 66

67 Interventions Acute Pain Ineffective Tissue Perfusion
Risk for Infection Impaired Physical Mobility Risk for Impaired Skin Integrity Activity Intolerance 67

68 Management of Specific Fractures

69 Fracture of the Hip Medical diagnosis Medical treatment Radiography
Traction and surgical repair (internal fixation, femoral head replacement, or total hip replacement) Patients may begin physical therapy as early as 1 day after surgery, depending on the type of repair; begin by sitting in a chair and then progress to a walker By age 90, 17% of men and more than 30% of women sustain hip fractures. What is the most common location of hip fractures? For older patients, surgical repair of the fracture is often the treatment of choice because it allows them to move around sooner and results in fewer complications related to immobility. Following internal fixation, weight bearing on the affected side is limited initially and then is gradually increased as tolerated. 69

70 Figure 42-10 70

71 Fracture of the Hip Assessment
Pain, impaired peripheral circulation on the affected side, complications of immobility, skin breakdown, and ability to carry out activities of daily living Older patients are particularly prone to developing delirium after a broken hip; therefore note mental status and problem behaviors related to confusion. What factors contribute to developing delirium? 71

72 Fracture of the Hip Interventions
Relieving pain, promoting mobility and independence, and preventing complications Proper body alignment is extremely important in preventing injury to the fracture area Turn patients from side to side as ordered Affected hip must not be adducted or flexed more than 90 degrees because excessive flexion/adduction can dislocate the prosthesis What comfort measures may be used to enhance the effect of pain medications? 72

73 Colles’ Fracture A break in the distal radius (wrist area)
Medical diagnosis Radiography Medical treatment Closed reduction or manipulation of the bone and immobilization in either a splint or a cast Colles’ fractures often occur in older adults, particularly older women, when an outstretched hand is used to break a fall. What are the major signs and symptoms of a Colles’ fracture? The most common complication is impaired circulation in the area resulting from edema. 73

74 Colles’ Fracture Assessment Interventions
Pain and swelling following treatment of the fracture Interventions Extremity should be supported and protected and can be elevated on a pillow during the first few days Encourage patients to move their fingers and thumb to promote circulation and reduce swelling, and to move their shoulders to prevent stiffness and contracture Teach proper cast care 74

75 Fracture of the Pelvis Medical diagnosis Radiography 75

76 Fracture of the Pelvis Medical treatment
A less severe non–weight-bearing fracture treated with bed rest on a firm mattress or bed board for a few days to 6 weeks Severe weight-bearing fracture may require a pelvic sling, skeletal traction, double hip spica cast, or external fixation Monitor patient so injuries can be treated immediately Check for presence of blood in urine and stool, and watch abdomen for signs of rigidity or swelling 76

77 Fracture of the Pelvis Assessment
Signs of bleeding, swelling, infection, thromboembolism, and pain Assess urine output because the absence of urine may indicate a perforated bladder 77

78 Fracture of the Pelvis Interventions
When handling patients, take extreme care to prevent displacement of the fracture fragments Turn patient only on the order of a physician Provide back care when patient raised from the bed using the trapeze or with adequate assistance from others Ambulation may be encouraged even though painful; follow physician’s orders 78

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