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73 Cards in this Set
- Front
- Back
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What is a fracture? |
Disruption or break in the continuity of bone structure; usually R/T trauma but may be secondary to disease (osteoporosis or cancer) |
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What are the general classifications of fractures? |
- Open/compound: skin is broken, exposing bone and causing soft tissue injury - Closed/simple: skin is intact - Complete: break completely through bone - Incomplete: partly across bone shaft or bone is still in one piece - Displaced: two ends of broken bone are separated and out of normal position (comminuted or oblique) - Nondisplaced: periosteum is intact across the fracture and the bone is still in alignment (usually transverse, spiral or greenstick) |
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How are fractures classified according to the direction of the fracture line? |
- Transverse: line of the fracture across the bone at a right angle to the longitudinal axis - Spiral: fracture line spirals along the bone shaft - Greenstick: incomplete fracture; one side is splintered and the other side is bent - Comminuted: 2+ fragments; just pieces of the bone - Compression: bone is crushed; can be entire bone - Oblique: line of fracture in an oblique line - Pathologic: spontaneous fracture at the site of a bone disease - Stress: occurs in normal or abnormal bone that is subject to repeat stress (running) |
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What are S/S of a fracture? |
- Immediate localized pain - Decreased function - Inability to bear weight - Pt guards/protects extremity against movement - Obvious bone deformity may or may not be present - Edema - Muscle spasm - Ecchymosis, contusion - Loss of function - Crepitation |
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What is done if a fracture is suspected? |
Immobilize the extremity in the position in which it was found - Unnecessary movement increases soft tissue damage - May convert a closed fracture to an open one - Possible injury to adjacent neuromuscular structures |
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What is the significance of edema and swelling? |
- Disruption and penetration of bone through skin or soft tissue - Bleeding into surrounding tissues - Unchecked bleeding and edema in a closed space can occlude circulation and damage nerves - Risk of compartment syndrome |
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What is the significance of pain and tenderness? |
- Muscle spasm R/T reflex action of muscle - Direct tissue trauma - Increased pressure on nerves - Movement of fracture parts - Encourages splinting of muscle around fracture - Reduction of motion in injured area |
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What is the significance of muscle spasm? |
- Irritation of tissues - Protective response to injury and fracture - May displace nondisplaced fracture - May prevent spontaneous reduction |
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What is the significance of deformity? |
- Abnormal position of extremity/part R/T forces of injury and muscle pulling - Possible loss of normal bony contours - Deformity is a cardinal sign of freacture - If uncorrected, bony union may be disrupted - Possible problems with restored function |
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What is the significance of ecchymosis and contusions? |
- Discolored skin R/T blood in sub-q tissue - Fracture must be managed properly to ensure restored function |
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What is the significance of crepitation? |
- Grating or crunching of bony fragments - Produces palpable or audible crunching or popping - May increase risk of nonunion if bony ends are allowed to move excessively - Micromovement of bone-end fragments assists in osteogenesis (new bone growth) |
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What are the steps of fracture healing (just know general overview; don't need to know time frames)? |
1. Bleeding at bone ends; hematoma forms 2. Granulation tissue; local necrosis is phagocytized; osteoid produced 3. Callus formation: can be verified by x-ray 4. Ossification: prevents movement at fracture site if bones are gently stressed; fracture still seen on x-ray; stage of clinical union; pt may be allowed limited movement or cast may be removed 5. Consolidation: distance between break closes; ossification continues; radiologic union (x-ray shows complete bony union) 6. Remodeling: union is complete; bone remodels in response to physical loading stress (Wolf's law) |
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What factors affect fracture healing? |
- Displacement and site of fracture - Blood supply to area - Immobilization - Internal fixation devices - Can be slowed by inadequate reduction and immobilization, infection, poor nutrition and systemic disease - Healing time increases with age - Smoking increases healing time |
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What is delayed union? |
Fracture healing does not occur within the expected time but does eventually occur |
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What is nonunion? |
Fracture healing does not occur despite treatment; no x-ray evidence of callus formation |
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What is malunion? |
Fracture heals in expected time but not in a satisfactory position; possible deformity or dysfunction |
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What is angulation? |
Fracture heals in abnormal position relative to midline of structure (type of malunion) |
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What is pseudoarthrosis? |
Type of nonunion occurring at fracture site in which a false joint is formed with abnormal movement at site |
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What is refracture? |
New fracture occurs at original fracture site |
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What is myositis ossificans? |
Deposition of calcium in muscle tissue at site of significant blunt muscle trauma or repeated muscle injury |
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What are diagnostic tests for fractures? |
- X-ray - CT, MRI - H&P |
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What are overall goals of fracture treatment? |
- Anatomic realignment of bone fragments (reduction) - Immobilization to maintain realignment - Restoration of normal/near-normal function |
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What are treatments for fractures? |
- Fracture reduction: manipulation, open/closed reduction, skin/skeletal traction - Fracture immobilization: casting, splinting, traction, external/internal fixation - Open fracture: surgical debridement, tetanus and diphtheria immunizations, prophylactic antibiotics, immobilization |
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What is closed reduction? |
- Nonsurgical, manual realignment of bone fragments to previous position - Traction and countertraction applied manually - Restores position, length and alignment - Usually done with pt under local or general anesthesia - After reduction, splints or braces immobilize the injured part to maintain alignment until healing occurs |
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What is open reduction? |
- Correction of bone alignment through a surgical incision - Usually has internal fixation with wires, screws, pins, plates, rods or nails - Use depends on pt's age, disease and type/location of fracture - Disadvantages: infection risk, complications with anesthesia, effect of pre-existing medical conditions (e.g. DM) |
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What is open reduction with internal fixation (ORIF)? |
- Used for intraarticular fractures - Early initiation of joint ROM - Facilitates early ambulation - Decreases risks of prolonged immobility - Machines provide continuous passive motion (CPM) to prevent extraarticular and intraarticular adhesions; faster reconstruction of bone plate; faster cartilage healing; deceased incidence of posttraumatic arthritis |
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What is traction? |
- Application of pulling force to an injured or diseased body part or extremity - Prevents/reduces pain and muscle spasms R/T back pain or cervical strain/whiplash - Immobilizes joint or body part - Reduces a fracture or dislocation - Treats a pathologic joint condition (tumor, infection) - Provides immobilization to prevent soft tissue injury - Promotes active and passive exercise - Expands a joint space during arthroscopic procedures or major joint reconstruction |
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What is countertraction? |
A pull in the opposite direction of traction |
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What is skin traction? |
- Short-term treatment (48-72 hrs) until skeletal traction or surgery is possible - Tape, boots or splints applied directly to skin - Maintains alignment, assists in reduction, helps diminish muscle spasms - Weights are usually 5-10 lbs - Pelvic/cervical traction may require heavier weights applied intermittently - Skin assessment is a priority - Assess key pressure points q2h |
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What is Buck's traction? |
- Type of skin traction - Used to immobilize a fracture - Prevents hip contractures - Reduces muscle spasms - Often used for hip and femur fractures |
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What is skeletal traction? |
- Longer periods than skin traction - Aligns injured joints/bones - Treats joint contractures and congenital hip dysplagia - Long-term pull that keeps the bones/joints aligned - Provider inserts a pin or wire into bone, partially or completely - Weight used is 5-45 lbs; too much weight can cause delayed union or nonunion - Major complications: infection in the bone where the pin is inserted and problems R/T prolonged immobility |
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What is balanced suspension traction? |
- Force exerted on distal fragment to align it with proximal fragment - Often used for fractures of hip, femur and lower leg - Countertraction supplied by pt's body weight, elevating end of bed or weights - Maintain continuous traction - Keep weights off the floor and moving freely |
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How are casts used to treat fractures? |
- Often used after closed reduction - Allows pt to perform ADLs - Immobilizes injured area - Natural (plaster of paris), synthetic, acrylic, or hybrid materials - Usually incorporates joints above/below injury - Cover with stockinette cut longer than cast before applying the cast - Place pad over stockinette with bony prominences - Plaster cast immersed in warm water; sets in 15 minutes, but no weight bearing for 24-72 hours - Never cover a fresh plaster cast or heat can build up and cause a burn or delay the drying period - Handle a new cast gently with an open palm to avoid denting it - After thoroughly dried, petal the edges to avoid skin irritation and prevent debris; provider tapes edges - Synthetic casts are lighter, stronger and more waterproof; provides for earlier weight bearing; activated by submersion in tepid or cool water then molded |
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How are upper extremity fractures immobilized? |
- Sugar-tong splint: acute wrist injury or significant swelling; well padded forearm with plaster splints; wrapped with elastic bandage - Posterior splint - Short arm cast (for stable wrist or metacarpal fractures); can include an aluminum finger splint; allows unrestricted elbow use - Long arm cast: stable forearm or elbow fractures and unstable wrist fractures; cast includes elbow; use of sling is recommended unless a hanging arm cast is used) |
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How are slings used to treat fractures? |
- Supports extremity - Reduces effects of edema - Ensure axillary area is well-padded - Ensure undue pressure not applied to neck - Encourage movement of fingers unless contraindicated - Encourage pt to move nonimmobilized joints to prevent contractures and stiffness |
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What is a body jacket brace? |
- Used for stable spine injuries - Extends from above nipple line to pubis - Assess pt for superior mesenteric artery syndrome (cast syndrome); occurs if brace is too tight; pt complains of ab pain/pressure and N/V - Assess bowel sounds through window in the brace - Treatment is gastric decompression (NG tube and suction) - Assess resp status, bowel/bladder function and pressure over bony prominences, esp iliac crest - Brace may be adjusted or removed if complications occur |
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How are lower extremity injuries immobilized? |
- Long leg cast: unstable ankle fracture, tibia fracture, knee/soft tissue injuries; base of toes to groin/gluteal crease - Short leg cast: stable ankle/foot injuries - Cylinder cast: knee fractures/injuries; from groin to malleoli of ankle - Robert Jones dressing: bulky padding materials, splints and elastic wrap or stockinette - Splint or immobilizer - Elevate extremity on pillows above heart level for first 24 hours - Avoid placing in dependent position - Assess for compartment syndrome - Assess for increased pressure (pain or burning, esp in heel, anterior tibia, head of fibula and malleoli) - Assess for skin breakdown |
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What is a hip spica cast? |
- Used for femur fractures in children - Immobilizes affected extremity and trunk - Extends from nipple line to base of foot (single spica) - May include opposite extremity up to area above the knee (spica and a half) or both extremities (double spica) - Assess for same problems as body jacket brace |
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What is external fixation? |
- Metallic device composed of pins inserted into bone - Attached to metal rods to stabilize fracture - Can be used to apply traction or compress fracture fragments - Used in simple fractures, complex fractures with extensive soft tissue damage, correction of congenital bony defects, non/malunion and limb lengthening - Can salvage extremities that might be amputated - Long-term process - Assess for loosening and infection - Clean with half-strength hydrogen peroxide or NS |
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What is internal fixation? |
- Pins, plates, rods, screws - Surgically inserted - Realign/maintain body fragments - X-ray evaluates proper alignment |
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What is electrical bone growth stimulation? |
- Facilitates healing for certain types of fractures, esp nonunion or delayed union May... - Increase calcium uptake of bone - Activate intercellular calcium stores - Increase production of bone growth factors (bone morphogenic protein) - Noninvasive (electrodes placed over cast or skin; 10-12 hrs/day while pt sleeps) - Semi-invasive: external power supply; electrodes inserted through skin and into bone - Invasive: surgically implanted current generator with electrode implanted in bone fragments |
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What meds are used for fractures? |
1. Central/peripheralmuscle relaxers -carisoprodol, cyclobenzaprine, methocarbamol -Given for pain relief or pain R/T muscle spasms 2. Tetanus/diphtheria prevention - Tetanus and diphtheria toxoid -Tetanus immunoglobulin (if pt not previously immunized) 3. Antibiotics -cephalosporin -Penetrates bone -Used prophylactically before surgery 4. Pain management |
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What are nutrition teaching points for fracture pts? |
- Adequate protein: 1g/kg of body weight - Vitamins, esp B, C and D - Calcium, phosphorus, magnesium for soft tissue/bone healing - 3 well-balanced meals/day - Fluid intake: 2000-3000 mL/day to promote bowel/bladder function - High-fiber diet with fruits and vegetables to prevent constipation - 6 small meals/day for pts with skeletal traction or body jacket to avoid ab pressure and cramping R/T overeating |
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Why are neurovascular assessments important for fracture pts? |
- Injuries, cast, dressing, poor position can cause nerve or vascular damage (usually distal to injury) - Peripheral neuro assessment (color, temp, cap refill, pulses, edema) - Compare both extremities - Adduct/abduct fingers, supination/pronation of hand, dorsiflexion/plantar flexion of foot, stroke plantar surface of foot to check tibial nerve - Ask about paresthesias - Tell pt to report any changes in neurovascular status |
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What are goals for pts with fractures? |
- Healing with no complications - Satisfactory pain relief - Max rehab potential |
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What can cause fractures? |
- Blunt trauma: vehicle collision, fall, direct blow, forced flexion/hyperflexion, twisting forces - Penetrating trauma: gunshot, blast - Other: pathologic conditions, violent muscle contractions/seizures, crush injury |
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What are emergency interventions for fractures? |
- Treat life-threatening injuries first - Ensure ABCs - Control external bleeding with direct pressure or sterile pressure dressing; elevate extremity - Check neurovascular status distal to injury before and after splinting - Do NOT straighten fractured or dislocated joints - Do NOT manipulate protruding bone ends - Apply ice packs to affected areas - Give tetanus/diphtheria prophylaxis if there is a skin break - Mark location of pulses to facilitate repeat assessment - Splint fracture site, including joints, above and below site |
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What are teaching points for fracture prevention? |
- Use seat belts and drive within the speed limit - Avoid distracted driving - Warm up before exercise - Use protective athletic equipment (helmets, pads) - Avoid drinking and driving and illicit drugs - Exercise regularly - Reduce falls - Adequate calcium/vitamin D intake |
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What types of subjective data are collected from fracture pts? |
- Trauma, repetitive forces, bone damage, prolonged immobility, osteoporosis, osteopenia - Corticosteroid, analgesic use - Previous injury or fracture - Estrogen replacement, calcium supplements - Loss of motion, weakness, muscle spasms - Sudden, severe pain, paresthesias - Chronic pain that increases with activity (stress fracture) |
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What types of objective data are collected from fracture pts? |
- Apprehension, guarding injury - Skin lacerations, pallor, cool or warm skin distal to injury, hematoma, edema - Reduced/absent pulses distal to injury, decreased skin temp, delayed cap refill - Paresthesias, absent/reduced sensation, hypersensation - Restricted/lost function, local bony deformity, abnormal angulation, shortening, rotation or crepitation of affected part, muscle weakness - Fracture evident on x-ray, MRI, CT or bone scan |
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What are nursing interventions for fracture pts? |
- Pre-op: tell pt type of immobilization devices and expected limitations after surgery - Postop: frequent neuro assessments; pain management, monitor traction, assess for skin breakdown/bleeding - Prevent constipation - Assess for kidney stones, DVT, PE - ROM, exercise as ordered - Coughing and deep breathing - Pt education for home care - Don't elevate extremity above the heart if compartment syndrome is suspected - Pt usually supine in center of bed - Assess for depression or PTSD - Pt education about appearance of extremity after cast removal (dry, wrinkled skin; muscle atrophy) |
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How is external rotation of the hip corrected? |
Place a pillow or rolled up towels along the greater trochanter of the femur |
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What are "Do's" for cast care? |
- Apply ice directly over fracture site for first 24 hrs; keep ice in a bag and protect cast with a cloth; avoid getting cast wet - Check with provider before getting a fiberglass cast wet - Dry cast thoroughly after water exposure; blot with a towel then use a hair dryer on low setting - Elevate extremity above heart level for first 48 hrs - Move joints above/below cast regularly - Use a hair dryer on cool setting to relieve itching - Report to provider: increased pain despite ice, elevation and meds; swelling R/T pain; discoloration of toes/fingers; pain during movement; burning/tingling, sores or foul odor under cast - Keep appointment to have fracture and cast checked |
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What are "Don'ts" for cast care? |
Don't... - Get the cast wet - Remove any padding - Insert any objects into casts - Bear weight on new cast for 48 hrs (check with provider to see if cast can bear weight) - Cover cast with plastic for prolonged periods |
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What are the degrees of weight-bearing ambulation? |
1. Non-weight bearing 2. Touch-down/toe-touch (contact with floor but no weight borne) 3. Partial-weight-bearing (25-50% of weight borne) 4. Weight bearing as tolerated (based on pt's pain and tolerance) 5. Full weight-bearing; no limitations |
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What are pt education points for assistive devices? |
- Safety issues - Involved limb usually advanced at the same time or immediately after the device - Uninvolved limb advance last - Canes held in opposite hand from injury - Use a transfer belt as pt learns to use the device - Ensure pt does not place excessive weight on the axilla - Encourage upper body exercises (push-ups, pull-ups, weight lifting) |
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What are expected outcomes for fracture pts? |
- Satisfactory pain relief - Appropriate use of cast or immobilizer - No peripheral neurovascular dysfunction - Uncomplicated bone healing |
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What are direct complications of fractures? |
- Bone infection - Bone union problems - Avascular necrosis |
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What are indirect complications of fractures? |
- Associated with blood vessel/nerve damage - Compartment syndrome - DVT - Fat embolism - Rhabdomyolysis: breakdown of skeletal muscle - Hypovolemic shock |
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How are open fractures treated to avoid infection? |
- Aggressive surgical debridement - Pulsating saline lavage in OR - Wound may be closed or require further debridement, closed suction drainage or skin grafting - Reduction by external fixation or traction - Irrigation with antibiotic - Antibiotic-impregnated beads - IV antibiotics |
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What is compartment syndrome? |
Condition in which swelling and increased pressure in a limited space press on and compromise function of blood vessels, nerves and/or tendons that run through the compartment - Reduces capillary perfusion below tissue viability - Usually involves the leg, but can also occur in arm, shoulder or buttock - 38 compartments in upper/lower extremities - Can result in contractures, disability and loss of function |
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What are the 2 basic causes of compartment syndrome? |
- Decreased compartment size R/T restrictive dressings, splints, casts, excessive traction or premature closing of fascia - Increased compartment contents R/T bleeding, inflammation, edema or IV infiltration |
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What are other causes of compartment syndrome? |
- Trauma - Long bone fractures (esp legs) - Crush injury - Distal humerus and proximal tibia are most common - Knee/leg surgery - Pt trapped under a heavy object - Limb trapped under the body during drug/alcohol overdose |
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When does compartment syndrome usually occur? |
- May occur initially due to injury or delayed several days -Ischemia can occur 4-8 hrs after onset of compartment syndrome |
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What are S/S of compartment syndrome? |
6 P's: - Pain: distal to injury; not relieved by opioids; or on passive stretch of muscle that travels through the compartment - Pressure: increased in compartment - Paresthesia: numbness, tingling - Pallor: coolness, loss of normal color of extremity - Paralysis or loss of function - Pulselessness: diminished/absence of peripheral pulses |
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How is compartment syndrome treated? |
- Early recognition is key - Frequent neurovascular checks - Do not elevate extremity above the heart - Carefully assess 6 P's, esp pain - Assess urine output: dark reddish brown urine indicates kidney injury R/T myoglobin release - Do not use cold compresses - Remove/loosen bandage, split the cast or reduce traction weight if ordered - Surgical decompression - Possible amputation |
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What are risk factors for DVT with fracture pts? |
- Veins of lower extremities/pelvis highly susceptible to thrombus formation after a fracture (esp hip) - Hip/knee replacement surgery - Limited mobility |
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How is DVT risk minimized for fracture pts? |
- Prophylactic heparin, warfarin, enoxaparin - SCDs or compression stockings - Frequent ROM exercises - Move fingers and toes regularly |
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What is fat embolism syndrome (FES)? |
Systemic fat globules are distributed to tissues and organs after a traumatic skeletal injury - Increased mortality for fracture pts - Most often caused by fractures to long bones, ribs, tibia and pelvis - Also caused by total knee replacement, spinal fusion, liposuction, crush injury and bone marrow transplant |
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What are the theories about FES causes? |
- Mechanical: fat emboli originate from fat released from injured bone marrow; then enters circulation and travels to other organs or brain and produces local ischemia/inflammation - Biochemical: hormonal changes R/T trauma or sepsis stimulates systemic release of free fatty acids which form emboli |
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What are S/S of FES? |
- Usually manifest 24-48 hours after injury - Severe forms may occur hours after - S/S of acute resp distress syndrome (ARDS): chest pain, tachypnea, cyanosis, dsypnea, apprehension, tachycardia, decreased PaO2 - Mental status changes, memory loss - Restlessness - Elevated temp - Headache - Petechiae around neck, anterior chest wall, axilla, buccal membrane and conjuctiva - Feeling of impending doom - Coma |
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How is FES diagnosed? |
- No specific labs - May have fat cells in blood, urine or sputum - PaO2 < 60 - ST changes on EKG - Decreased in platelet, Hct, prolonged PT - Chest x-ray: pulmonary infiltrate or multiple areas of consolidation; "white-out effect" |
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How is FES treated? |
- Prevention is key: careful immobilization of long bone fractures - Supportive: relieve S/S - Fluid resuscitation to prevent shock - Oxygen, intubation or positive pressure ventilation - Correct acidosis - Replace blood loss - Encourage coughing and deep breathing - Don't reposition pt unless necessary before fracture immobilization - Corticosteroid use is controversial - Most pts survive |
