1. Fractures Etiology/pathophysiology
A traumatic injury to a bone in which the continuity of the tissue of the bone is broken
Pathological or spontaneous fractures

2. Fractures Types of fractures: Figure 4-23, 4-24 p. 143
open, compound, closed, greenstick, complete, comminuted, impacted, transverse, oblique, spiral, Colle’s, and Pott’s
Figure 4-23, 4-24 p. 143

3. Fractures Clinical manifestations/assessment Pain
Loss of normal function
Obvious deformity
Change in the curvature or length of bone
Crepitus (grating sound with movement)
Soft tissue edema
Warmth over injured area
Ecchymosis of skin surrounding injured area
Loss of sensation distal to injury

4. Fractures Diagnostic tests Medical Management Radiographic examination
Immediate
Splinting to prevent edema
Body alignment
Elevation of body part
Application of cold packs
Observe pt. for s/sx shock
Pain Management

5. Fractures Medical Management cont. Secondary Management
For closed fracture: optimal reduction through:
Closed reduction (manual manipulation)
Traction
Open reduction with Internal Fixation
+ wound debridement and cleansing
Immobilization

6. Fractures Nursing Interventions Application of cold packs
Administration of pain medication
Neurovascular assessment
Observe for s/sx shock
Cast care
Skin care

7. Fractures Nursing Interventions cont. Exercise unaffected joints
Diet/vitamin supplementation
Elimination support
Patient Teaching:
Moving in bed
Transferring safely
Weight-bearing restrictions/activity limitations
Use ambulatory devices
Pain control
Edema control
Exercises
Cast Care

8. Types of Fractures

10. Fractures Closed (simple) TYPES OF FRACTURES Immobilization Traction
Closed reduction (physical manipulation)
Immobilization
Traction
Open reduction with internal fixation device (ORIF)

11. Fractures Open (compound) Surgical debridement and culture of wound
Administration of tetanus toxoid
Observation for signs of infection
Closure of wound
Reduction and immobilization of fracture

12. Compound Fracture

13. Fractures Fracture of the hip Clinical manifestations:
Etiology/pathophysiology
Most common type of fracture
Women at higher risk due to osteoporosis
Clinical manifestations:
Severe pain at site
Inability to move the leg voluntarily
Shortening and/or external rotation of the leg

15. See page 137 Figure 4-16
Types of Hip Fractures

17. Fracture of the Hip Diagnostic tests Medical Management
Radiographic examination
Hemoglobin/hematocrit
Medical Management
Buck’s or Russell’s traction until surgery
Surgical repair
Internal fixation
Nail and screws
Prosthetic implants

19. Fracture of the Hip The choice of fixation device depends on the:
Location of the fracture
Potential for avascular necrosis of femoral head and neck

21. Fracture of the Hip Nursing Considerations PRE-OPERATIVELY:
Focus:  preventing shock and further complications
Maintain proper alignment through traction and abduction of the hip when turning pt.
Note: know MD instructions re: turning and to which side(s)
Elevate HOB 45⁰

22. Fracture of the Hip POST-OPERATIVE Interventions
Nursing Considerations cont.
POST-OPERATIVE Interventions
Wound and drain assessment
Vital signs
Incentive spirometer and turning every 2 hours
Antiembolic stockings; anticoagulation therapy
With hip replacement:
Maintain leg abduction- Instruct: DO NOT CROSS LEGS!
Chairs and commode seats should be raised to prevent flexion of hip beyond 60 degrees

23. Fracture of the Hip PATIENT TEACHING: ORIF
Assess ability to understand
Assist to dangle at bedside
No weight on operative side
Turn every 2 hours, maintain abduction for hip replacement patients
Physical therapy will instruct as to ambulation and weight-bearing
As patient progresses, encourage continuing ambulation only with assistance

24. Total Hip Replacement Hip arthroplasty: total replacement of hip joint
Medical Animation Total Hip Arthroplasty

25. Hip arthroplasty (total hip replacement).
Figure 44-14
Hip arthroplasty (total hip replacement).

26. Total Knee Replacement
Knee Arthroplasty (total knee replacement)
Replacement of the knee joint
Restore motion of the joint, relieve pain, or correct deformity

27. Figure 44-11
A, Tibial and femoral components of total knee prosthesis. B, Total knee prosthesis in place.

28. Surgical Interventions for Total Knee or Total Hip Replacement

29. Arthroplasty Post Op Nursing interventions Empty and record HemoVac
Give oxygen 2-3 L/min
Incentive spirometer; cough and deep-breathe
Record I&O
Bed rest for hours
Change dressing as ordered
Diet as ordered
Neurovascular checks and vital signs every 4 hours

30. Arthroplasty Post op Total Hip Arthroplasty
Post Op Nursing Interventions cont.
Maintain position of operative area
Physical therapy will initiate ambulation and prescribe routine
Encourage fluid intake
Antiembolisim stockings
Post op Total Hip Arthroplasty
Avoid adduction and hyperflexion of hip
Encourage fluid intake and high-fiber foods
Use toilet riser to prevent hyperflexion of hip

31. Arthroplasty Post Op Total Knee Arthroplasty:
Activity: CPM machine (managed by PT)
Pain Control
Discharge Instructions

32. Arthroplasty Patient teaching for Total Hip Arthroplasty
Avoid hip flexion beyond 60 degrees for approximately 10 days; beyond 90 degrees for 2-3 months
Avoid adduction of the affected leg beyond midline for 2-3 months (maintain abduction)
Maintain partial weight-bearing for approximately 2-3 months
Avoid positioning on the operative side

33. Arthroplasty Patient Teaching Total Knee Arthroplasty:
Partial weight-bearing restriction
Use of ambulatory aid
Exercises: Active flexion and straight-leg raises at home
Use of resting knee extension splint
Appropriate positioning
Pain medication use
Use of ongoing cool paks
PT follow up/ CPM at home

34. Fracture of the Vertebrae
Etiology/pathophysiology
Diving accidents
Blows to the head or body
Osteoporosis
Metastatic cancer
Motorcycle and car accidents
Displaced fracture may place pressure on or sever the spinal cord nerves

35. Fracture of the Vertebrae
Clinical manifestations/assessment
Pain at site of injury
Partial or complete loss of mobility or sensation
Evidence of fracture/fracture dislocation on x-ray

36. Fracture of the Vertebrae
Diagnostic Tests
Radiographic Studies
Spinal Tap – presence of blood indicates trauma
Medical Management
Stable injuries:
treated with pain medication and muscle relaxants
Anticoagulants may be ordered prophylactically
Back support – brace, corset, cast

37. Fracture of the Vertebrae
Unstable fractures:
Traction and postural positioning to reduce the facture
Cranial skeletal traction for cervical spine fractures
Pelvic traction for lumbar fractures
Open reduction – using Harrington Rod; followed by use of body cast

38. Fracture of the Vertebrae
Nursing Interventions
Log-rolling pt. for position changes
Turning pt. in specialty bed
Elevate HOB no more than 30⁰
Using stabilization devices
Neurovascular assessments
Cast care/pin care
Patient teaching

39. Fractures of the Vertebrae
Patient Teaching:
Firm mattress
Sitting in straight firm chairs
No more than min at a time
Proper lifting technique
Follow MD lifting restrictions
Back exercises –per MD and PT

40. Fracture of the Pelvis Etiology/pathophysiology
Falls (esp. from great heights)
Automobile accidents
Crushing accidents
When trauma is severe enough to fracture the pelvis, vital abdominal organs may also be damaged.

41. Fracture of the Pelvis Diagnostic Tests
Clinical manifestations/assessment
Unable to bear weight without discomfort
Pelvic tenderness and edema
Hematuria
Signs of shock/hemorrhage
Diagnostic Tests
Abdominal radiographic studies CT
IVP to determine any kidney damage
H & H, UA, stool for occult blood

42. Fracture of the Pelvis Medical Management/Nursing Interventions
Bedrest x 3 wks, then
Ambulation with crutches x 6 weeks
NWB x 3 months
More severe fractures may require surgery and/or traction, spica or body cast

43. Fracture of the Pelvis Nursing Interventions
Monitor for s/sx progressive shock
Measure abdominal girth q 8 hrs
Foley cath prn monitor urinary output volume, color
Safety with impaired mobility
Skin care, including turning schedule
Pain management
Hydration

44. Fracture of the Pelvis Patient Teaching
Reinforce reason for immobility and NWB
Explain pain management strategy
Explain turning and moving techniques to prevent skin breakdown

45. Complications of Fractures

46. Complications of Fractures
Shock (hemorrhage)
Compartment Syndrome
Fat Embolism
Gas Gangrene
Thromboembolism

47. Complications
Hemorrhage is by far the most life-threatening complication.

48. Shock Cause Clinical manifestations Blood loss, pain, fear
Altered level of consciousness, restlessness
Hypotension, tachycardia, and tachypnea
Pale, cool, moist skin

49. Shock Medical Management Restore blood volume Shock trousers Oxygen
IV fluids: LR, D5W.9NS
Whole blood, plasma
Shock trousers
Oxygen

50. Shock Nursing Interventions IV fluid administration Frequent VS
Monitor urinary output – volume, color
Avoid Trendelenburg position – tends to push abdominal organs against the diaphragm
Keep warm
NPO
Avoid sedatives, tranquilizers, narcotics
Emotional support for pt. and family

51. Compartment Syndrome
Compartments are enclosed spaces made up of muscle, bone, nerves, blood vessels wrapped by fibrous membrane (fascia)
Causes of Compartment Syndrome:
Internal or external compression on area
Internal pressure-bleeding, edema into compartment
External pressure-cast or tight dressing

52. Compartment Syndrome
Increased pressure puts pressure on tissues, nerves, blood vessels
Blood flow decreased—resulting in pain, tissue damage
Rare, but serious  can become emergency very quickly

53. Compartment Syndrome
Within 4-6 hours after onset, irreversible muscle ischemia can occur as a result of compression of arteries, nerves, and tendons

54. Compartment Syndrome Symptoms
Pain, especially with touch or movement, not relieved with opioid analgesics
Edema, pallor, weak or unequal pulses
Cyanosis
Tingling, numbness, paresthesia
Severe pain

55. Compartment Syndrome
Medical Management-Fasciotomy-incision into the fascia if internal pressure is cause.
External pressure-remove cast
(From Beare, P.G., Myers, J.L. [1998]. Adult health nursing. [3rd ed.]. St. Louis: Mosby.)
Compartment syndrome.

56. Compartment Syndrome Nursing Interventions
Administration Analgesic(s) – careful documentation of relief obtained – OR NOT!
↑ affected limb to level of heart
Apply cold packs
Remove constricting material
Monitor for s/sx infection
Encourage pt. to express fears and emotional needs

57. Compartment Syndrome Volkmann’s Contracture
Permanent contracture that can occur as result of compartment syndrome
Clawhand, flexion of wrist and fingers
Atrophy of forearm

58. VOLKMANN’S CONTRACTURES

59. Fat Embolism
Cause: Fat globules released from marrow of broken bone into bloodstream
Once fat globules enter bloodstream, they migrate to lungs
Too large to pass through circulation, they lodge in pulmonary capillaries, obstruct blood flow
Fat particles break down into fatty acids, inflame blood vessels , cause pulmonary edema

60. Fat Embolism
Most commonly associated with fractures of long bones, multiple fractures and severe trauma
Occurs hours after injury
Most often in young men y old and older adults y old

61. Fat Embolism Signs/symptoms Respiratory distress Tachycardia Tachypnea
Fever
Confusion
Decreased level of consciousness
Petichiae-neck, upper arms, chest, abdomen, buccal and conjunctival membranes

62. Fat Embolism Diagnostic Tests Based on clinical s/sx ABG  hypoxemia
Appear within hrs of injury
ABG  hypoxemia
H &H decreased
Fat is present in blood and urine
↑ ESR
Platelets ↓

63. Fat Embolism Treatment Bed rest Gentle handling
Oxygen and/or ventilatory support
Fluid restriction/diuretics for pulmonary edema
Steroids may be used

64. Gas Gangrene
Cause : Infection of skeletal muscle by Clostridium Perfringens (gram +)
Produce exotoxins that destroy skin tissue
Anaerobic
Clinical manifestations:
Pain at site of injury
Signs of infection
Gas bubbles under the skin  crepitus
Necrotic skin at site, foul odor from wound

65. Gas Gangrene Medical Management Nursing Interventions
Establish a larger wound to admit air and promote drainage
Excision of gangrenous tissue
Antibiotic therapy
Nursing Interventions
Strict aseptic technique w/wound care
All contaminated equipment must be autoclaved
Administer antibiotics, analgesics

66. Gas Gangrene

67. Thromboembolus Cause: Blood vessel occluded by embolus
Associated with reduced skeletal muscle contractions and bed rest
Clinical Manifestations/Assessment
Area tingles, is cold, numb and cyanotic
Pulmonary embolus causes sharp chest pain, dyspnea, cough

68. Thromboembolus Diagnostic Tests Medical Management Medical hx
Physical exam
Lab: PT, INR, CBC
Doppler US, CT of lungs; ventilation/perfusion scan
Medical Management
Anticoagulants
Poss. thrombectomy

69. Thromboembolus Nursing Interventions FOB ↑
Teach active exercises – per MD paramenters
Warm moist heat
Antiembolism stockings
Assess lung sounds
Monitor lab results
CMS checks
Pain Management