Presentation is loading. Please wait.

Presentation is loading. Please wait.

1Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Chapter 42 Fractures.

Similar presentations


Presentation on theme: "1Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Chapter 42 Fractures."— Presentation transcript:

1 1Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Chapter 42 Fractures

2 2Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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 3Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

4 4Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

5 5Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 42-1

6 6Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

7 7Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

8 8Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

9 9Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

10 10Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

11 11Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

12 12Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

13 13Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 42-2

14 14Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

15 15Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Complications

16 16Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

17 17Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Infection Signs and symptoms 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

18 18Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

19 19Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

20 20Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

21 21Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

22 22Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

23 23Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Compartment Syndrome Primary symptom is pain, especially with touch or movement, that cant 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

24 24Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

25 25Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

26 26Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Malunion Expected healing time is appropriate but unsatisfactory alignment of bone results in external deformity and dysfunction

27 27Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Delayed Union Failure of a fracture to heal in the expected time The bone usually heals eventually; it may just be slower

28 28Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

29 29Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

30 30Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

31 31Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

32 32Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Complex Regional Pain Syndrome Type 1 (CRPSType 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

33 33Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Complex Regional Pain Syndrome Type 1 (CRPSType 1) Treatment Nerve blocks, physical therapy, transcutaneous electrical stimulation, and analgesics, muscle relaxants, and antidepressants

34 34Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

35 35Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

36 36Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Medical Treatment

37 37Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Reduction The process of bringing the ends of the broken bone into proper alignment

38 38Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

39 39Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 42-3

40 40Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

41 41Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Immobilization Necessary for healing to occur Prevents movement and increases union Accomplished in many ways, such as fixation, casts, splints, and traction

42 42Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

43 43Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

44 44Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 42-4

45 45Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

46 46Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 42-5

47 47Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 42-6

48 48Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Therapeutic Measures

49 49Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

50 50Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

51 51Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Traction Skin traction Bucks 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

52 52Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 42-7

53 53Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 29-8

54 54Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Traction Complications Impaired circulation, inadequate fracture alignment, skin breakdown, and soft tissue injury Pin track infection and osteomyelitis can occur with skeletal traction

55 55Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Assistive Devices

56 56Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

57 57Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 42-8

58 58Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

59 59Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

60 60Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

61 61Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 42-9

62 62Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Walker Used for support and balance, usually by older adults

63 63Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Canes Provide minimal support and balance, and relieve pressure on weight-bearing joints Placed on the unaffected side with the top even with the patients greater trochanter

64 64Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

65 65Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

66 66Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

67 67Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Interventions Acute Pain Ineffective Tissue Perfusion Risk for Infection Impaired Physical Mobility Risk for Impaired Skin Integrity Activity Intolerance

68 68Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Management of Specific Fractures

69 69Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Fracture of the Hip Medical diagnosis Radiography Medical treatment 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

70 70Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 42-10

71 71Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

72 72Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

73 73Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

74 74Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Colles Fracture Assessment 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

75 75Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Fracture of the Pelvis Medical diagnosis Radiography

76 76Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

77 77Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

78 78Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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 physicians orders


Download ppt "1Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Chapter 42 Fractures."

Similar presentations


Ads by Google