Fractures

Clinical manifestations of fractures: Loss of fxn

After a fracture, the extremity cannot function properly because normal function of the muscles depends on the integrity of the bones to which they are attached. Pain contributes to the loss of function. In addition, abnormal movement (false motion) may be present.

bone parts

diaphysis, metaphysis, epiphysis, medullary canal, periosteal membrane

Nursing interventions for monitoring and managing potential complications of skin traction: circulatory impairment

After skin traction is applied, the nurse assesses circulation of the foot within 15 to 30 minutes and then every 1 to 2 hours. Circulatory assessment consists of: Peripheral pulses, color, capillary refill, and temperature of the fingers or toes. Manifestations of deep vein thrombosis (DVT), which include unilateral calf tenderness, warmth, redness, and swelling. The nurse also encourages the patient to perform active foot exercises every hour when awake.

Immobilization of fractures

After the fracture has been reduced, the bone fragments must be immobilized and maintained in proper position and alignment until union occurs. Immobilization may be accomplished by external or internal fixation. Methods of external fixation include bandages, casts, splints, continuous traction, and external fixators.

Factors that inhibit fracture healing

Age >40 years Avascular necrosis Bone loss Cigarette smoking Comorbidities (e.g., diabetes, rheumatoid arthritis) Corticosteroids, nonsteroidal anti-inflammatory drugs Extensive local trauma Inadequate immobilization Infection Local malignancy Malalignment of the fracture fragments Space or tissue between bone fragments Weight bearing prior to approval

Complications of shock: compartment syndrome

An anatomic compartment is an area of the body encased by bone or fascia (e.g., the fibrous membrane that covers and separates muscles) that contains muscles, nerves, and blood vessels. The human body has 46 anatomic compartments, and 36 of these are located in the extremities Compartment syndrome is characterized by the elevation of pressure within an anatomic compartment that is above normal perfusion pressure. Compartment syndrome arises from an increase in compartment volume (e.g., from edema or bleeding), a decrease in compartment size (e.g., from a restrictive cast), or aspects of both. When the pressure within an affected compartment rises above normal, perfusion to the tissues is impaired, causing cell death, which may lead to tissue necrosis and permanent dysfunction Compartment syndrome occurs more frequently in young adults, and although it may take up to 48 hours for symptoms to present, it typically develops quickly, within 6 to 8 hours after the initial injury or after fracture repair Assessment and dx findings: The patient with acute compartment syndrome reports deep, throbbing, unrelenting pain, which is unrelieved by medications, seems disproportional to the injury, and intensifies with passive ROM. Frequent assessment of neurovascular function after a fracture is essential and focuses on the "five Ps": pain, pallor, pulselessness, paresthesias, and paralysis Paresthesia (burning or tingling sensation) is an early sign of nerve involvement. With continued nerve ischemia and edema, the patient experiences diminished sensation followed by complete numbness. Motor weakness may occur as a late sign of nerve ischemia. Motion is evaluated by asking the patient to flex and extend the wrist or plantar flex and dorsiflex the foot. No movement (paralysis) indicates nerve damage Peripheral circulation is evaluated by assessing color, temperature, capillary refill time, edema, and pulses. Cyanotic nail beds suggest venous congestion. Pallor or dusky and cold digits, prolonged capillary refill time, and diminished pulses suggest impaired arterial perfusion. Edema may obscure the function of arterial pulsation, and Doppler ultrasonography may be used to verify a pulse. Pulselessness is a very late sign of compartment syndrome A patient may not exhibit all, or even more than just one of the "five Ps"; therefore, pain assessment is most crucial in early recognition of acute compartment syndrome Palpation of the muscle, if possible, reveals it to be swollen and hard with the skin taut and shiny. The orthopedic surgeon may measure tissue pressure by inserting a tissue pressure-monitoring device, such as a handheld direct injection device (e.g., Stryker Intra-Compartmental Pressure Monitor), into the muscle compartment (normal pressure is 8 mmHg or less) Nerve and muscle tissues deteriorate as compartment pressure increases. Prolonged pressure of more than 30 mmHg can result in permanent dysfunction Medical management: Prompt management of acute compartment syndrome is essential. The surgeon needs to be notified immediately if neurovascular compromise is suspected. Delay in treatment may result in permanent nerve and muscle damage, necrosis, infection, rhabdomyolysis with acute kidney injury, and amputation If conservative measures do not restore tissue perfusion and relieve pain, a fasciotomy (surgical decompression with excision of the fascia) is indicated to relieve the constrictive muscle fascia. After fasciotomy, the wound is not sutured but is left open to allow the muscle tissues to expand; it is covered with moist, sterile saline dressings or with artificial skin. Alternatively, a vacuum dressing may be used to remove fluids and hasten wound closure. The affected arm or leg is splinted in a functional position and elevated to heart level, and prescribed intermittent passive ROM exercises are usually performed. In 2 to 3 days, when the swelling has resolved and tissue perfusion has been restored, the wound is débrided and closed (possibly with skin grafts) Nursing mgmt: The nurse should frequently assess pain and neurovascular status of the affected limb and report any negative changes that may suggest compartment syndrome immediately to the primary provider. The limb should be maintained in a functional position at the level of the heart to promote optimal blood flow. Compartment syndrome is managed by maintaining the extremity at the heart level (not above heart level), and opening and bivalving the cast (see Chapter 40) or opening the splint, if one or the other is present. Pain management is essential and is accomplished with opioid analgesia, as prescribed. Careful assessment of intake and output and urinalysis could alert the nurse to the development of rhabdomyolysis Education is necessary for those patients discharged to home-based or community settings with fractures and casts and should include recognition of the unique characteristics of acute compartment syndrome (increasing, refractory pain and neurovascular manifestations) and instructions when to contact the primary provider for emergent follow-up.

periosteal membrane

A double layer that covers entire bone except joint surfaces

Fractures

A fracture is a complete or incomplete disruption in the continuity of bone structure and is defined according to its type and extent. Fractures occur when the bone is subjected to stress greater than it can absorb. Fractures may be caused by direct blows, crushing forces, sudden twisting motions, and extreme muscle contractions. When the bone is broken, adjacent structures are also affected, which may result in soft tissue edema, hemorrhage into the muscles and joints, joint dislocations, ruptured tendons, severed nerves, and damaged blood vessels. Body organs may be injured by the force that caused the fracture or by fracture fragments.

Continuing and transitional care after THA

A nurse may assess the patient's home for potential problems and monitor wound healing. The nurse, physical therapist, or occupational therapist assesses the home environment for physical barriers that may impede the patient's rehabilitation. In addition, the nurse or therapist may need to assist the patient in acquiring devices such as reachers and long-handled shoehorns or tongs to help with dressing or a toilet seat extender to elevate the toilet seat. After successful surgery and rehabilitation, the patient can expect a hip joint that is free or almost free of pain, has good motion, is stable, and permits normal or near-normal ambulation and function.

Complications of fractures: avascular necrosis

AVN occurs when the bone loses its blood supply and dies. It may occur after a fracture with disruption of the blood supply to the distal area. It is also seen with prolonged high-dose corticosteroid therapy, radiation therapy, sickle cell disease, rheumatoid arthritis, and other diseases. The patient develops pain with movement that progresses to pain at rest. Diagnostics include history and physical examination with x-rays, CT scans, and bone scans. Medical management of AVN includes administration of NSAIDs, exercises, and limiting weight bearing of the affected region; however, total joint replacement is the definitive treatment when located in the hip or knee

Hip fractures

Annually, more than 250,000 adults older than 65 years of age sustain a hip fracture requiring hospitalization. The 1-year mortality rate among these older adults is as high as 24% Weak quadriceps muscles, slowed reflexes, decreased bone tensile strength, general frailty due to age, and conditions that produce decreased cerebral arterial perfusion (transient ischemic attacks, anemia, emboli, cardiovascular disease, effects of medications) contribute to the incidence of falls, which are the major cause of hip fracture. There are three major types of hip fracture. Extracapsular fractures are fractures of the trochanteric region (between the base of the neck and the lesser trochanter of the femur) and of the subtrochanteric region. Intracapsular fractures are fractures of the neck of the femur. Fractures of the neck of the femur may damage the vascular system that supplies blood to the head and the neck of the femur, and the bone may become ischemic. For this reason, AVN is common in patients with femoral neck fractures. Periprosthetic fractures are fractures to the regions surrounding prosthetics joints Clinical manifestations: With fractures of the femoral neck, the leg is shortened, adducted, and externally rotated. The patient reports pain in the hip and groin or in the medial side of the knee. With most fractures of the femoral neck, the patient cannot move the leg without a significant increase in pain. The patient is most comfortable with the leg slightly flexed in external rotation. Impacted intracapsular femoral neck fractures cause moderate discomfort (even with movement), may allow the patient to bear weight, and may not demonstrate obvious shortening or rotational changes. With extracapsular femoral fractures of the trochanteric or subtrochanteric regions, the extremity is significantly shortened, externally rotated to a greater degree than intracapsular fractures, exhibits muscle spasm that resists positioning of the extremity in a neutral position, and has an associated area of ecchymosis. The diagnosis is confirmed by x-ray

Assessment and dx of femoral shaft fracture

Assessment includes checking the neurovascular status of the extremity, especially circulatory perfusion of the lower leg and foot (popliteal, posterior tibial, and pedal pulses and toe capillary refill time), and comparing with the unaffected leg. A Doppler ultrasound may be indicated to assess blood flow. X-rays are used to confirm the diagnosis and determine the extent of injury. Dislocation of the hip and knee may accompany these fractures. Knee effusion suggests ligament damage and possible instability of the knee joint.

Changes in lifestyle for those with casts/splint/brace

Avoid excessive use of injured extremity. Observe prescribed weight-bearing limits. Demonstrate ability to transfer (e.g., from a bed to a chair) and/or safe use of mobility aid. Demonstrate exercises to promote circulation and minimize disuse syndrome. Report pain uncontrolled by elevating the immobilized limb and by analgesic agents (may be an indicator of impaired tissue perfusion—compartment syndrome or pressure ulcer). Verbalize care for minor skin irritations (e.g., for skin irritation from edge of cast, splint, or brace, pad rough edges with tape or moleskin; to relieve itching, blow cool air from hair dryer; do not insert foreign objects inside the cast, splint, or brace). Demonstrate ability to perform ADLs independently or with assistive devices/adaptive equipment. State indicators of complications to report promptly to primary provider (e.g., uncontrolled swelling and pain; cool, pale fingers or toes; paresthesia; paralysis; purulent drainage staining cast; signs of systemic infection; cast, splint, or brace breaks).

Buck's Extension Traction

Buck's extension traction (unilateral or bilateral) is skin traction to the lower leg. The pull is exerted in one plane when partial or temporary immobilization is desired. It is used as a temporary measure to overcome muscle spasms and promote immobilization of hip fractures in adult patients waiting for more definitive treatment such as surgery. Before the traction is applied, the nurse inspects the skin for abrasions and circulatory disturbances. The skin and circulation must be in healthy condition to tolerate the traction. The extremity should be clean and dry before the foam boot or traction tape is applied. To apply Buck's traction, the extremity is elevated and supported under the patient's heel and knee while the foam boot is placed under the leg, with the patient's heel in the heel of the boot. Next, the Velcro straps are secured around the leg. Traction tape that is overwrapped with an elastic bandage in a spiral fashion may be used instead of the boot. Excessive pressure is avoided over the malleolus and proximal fibula during application to prevent pressure ulcers and nerve damage. The rope is then affixed to the spreader or footplate over a pulley fastened to the end of the bed and attaches the prescribed weight—usually 5 to 8 lb—to the rope. The weight should hang freely, not touching the bed or the floor as this compromises the efficiency of the traction system

proximal

Closer to the point of attachment

epiphysis

End of a long bone

Providing home care after THA

Considerations: Pain management Wound care Mobility Self-care (activities of daily living) Potential complications Nursing interventions: Discuss with patient the following methods to reduce pain: -Periodic rest -Distraction and relaxation techniques -Medication therapy (e.g., nonsteroidal anti-inflammatory drugs, opioid analgesic agents): actions of medications, administration, schedule, side effects -Instruct patient in the following: -Keeping incision clean and dry -Cleansing incision daily with soap and water and changing the dressing -Recognizing signs of wound infection (e.g., pain, increased redness, swelling, purulent drainage, fever) -Explain that sutures or staples will be removed 10 to 14 days after surgery. -Educate patient about the following: -Safe use of assistive devices -Weight-bearing limits -How to change positions frequently -Limitations on hip flexion and adduction (e.g., avoid acute flexion and crossing legs) -How to stand without flexing hip acutely -Avoidance of low-seated chairs Sleeping with pillow between legs to prevent adduction -Gradual increase in activities and participation in prescribed exercise regimen -Use of important medications such as warfarin (Coumadin) and aspirin -Assess home environment for physical barriers. -Instruct patient to use elevated toilet seat and to use reachers to aid in dressing. -Encourage patient to accept assistance with activities of daily living during early convalescence until mobility and strength improve. -Arrange services and accommodations to address the patient's disability or illness, as appropriate. -Assess patient for development of potential problems, and instruct patient to report signs of potential complications: -Dislocation of prosthesis (e.g., increased pain, shortening of leg, inability to move leg, popping sensation in hip, abnormal rotation) -Deep vein thrombosis (e.g., calf pain, swelling, redness) Wound infection (e.g., pain, increased redness, swelling, purulent drainage, fever) -Pulmonary emboli (e.g., shortness of breath, tachypnea, pleuritic chest pain) -Discuss with patient the need to continue regular health care (routine physical examinations) and screenings.

Delayed complications of fractures: delayed union, nonunion, and malunion

Delayed union occurs when healing does not occur within the expected time frame for the location and type of fracture. Delayed union may be associated with distraction (pulling apart) of bone fragments, systemic or local infection, poor nutrition, or comorbidity (e.g., diabetes, autoimmune disease). The healing time is prolonged, but the fracture eventually heals Nonunion results from failure of the ends of a fractured bone to unite, whereas malunion is the healing of a fractured bone in a malaligned position In both of these instances, the patient complains of persistent discomfort and abnormal movement at the fracture site. Nonunion occurs most commonly in tibial fractures, whereas malunion occurs most commonly in fractures of the hand (or fingers) Factors contributing to delayed union, nonunion, and malunion are those associated with impaired bone healing Medical mgmt: Impaired bone healing can be treated with surgical interventions and nonsurgical interventions. Nonsurgical treatment modalities include ultrasound stimulation and electrical bone stimulation and should be used every day in order to be most effective Bone stimulators can also be invasive: completely implanted or partially implanted in the form of pins to the site of impaired healing. Electrical stimulation promotes the functioning of osteoblasts. Surgical interventions include bone grafts and internal and external fixation Grafted bone undergoes a reconstructive process that results in a gradual replacement of the graft with new bone. During surgery, the bone fragments are débrided and aligned, infection (if present) is removed, and a bone graft is placed in the bony defect. The bone graft may be an autograft (tissue, frequently from the iliac crest, harvested from the patient for their own use), an allograft (tissue harvested from a donor), or a bone graft substitute The bone graft fills the bone gap and provides a lattice structure for invasion by bone cells and actively promotes bone growth. The type of bone selected for grafting depends on function—cortical bone is used for structural strength, cancellous bone for osteogenesis, and corticocancellous bone for strength and rapid incorporation. Free vascularized bone autografts are grafted with their own blood supply, allowing for primary fracture healing. After grafting, immobilization and non-weight-bearing exercises are required while the bone graft becomes incorporated and the fracture or defect heals. Depending on the type of bone grafted and the age of the patient, healing may take from 6 to 12 months or longer. Bone grafting complications include wound or graft infection, fracture of the graft, and nonunion. Specific problems associated with autografts include a limited quantity of bone available for harvest and harvest site pain that may persist for up to 2 years after harvest. Infrequent specific allograft complications include partial acceptance (lack of host and donor histocompatibility, which retards graft incorporation), graft rejection (rapid and complete resorption of the graft), and transmission of disease (rare) Nursing mgmt: The patient with a nonunion has experienced an extended time in fracture treatment and may become frustrated with prolonged therapy. The nurse provides emotional support and encouragement to the patient and encourages adherence to the treatment regimen. The orthopedic surgeon evaluates the progression of bone healing with periodic x-rays. Nursing care for the patient with a bone graft includes pain management and monitoring the patient for possible complications. The nurse needs to reinforce educational information concerning the objectives of the bone graft, immobilization, non-weight-bearing exercises, wound care, monitoring for signs of infection, and the importance of follow-up care with the orthopedic surgeon Nursing care for the patient using bone stimulation devices focuses on patient education that addresses immobilization, weight-bearing restrictions, and correct daily use of the stimulator as prescribed

Distal

Farther from the trunk of the body

Preventing dislocation of hip prosthesis after THA

For patients undergoing a posterior or posterolateral approach for THA, maintenance of the femoral head component in the acetabular cup is essential. The risk for dislocation is more common with this approach and may occur when the hip is in full flexion, adducted (legs together), and internally rotated. Therefore, correct positioning is maintained at all times. The patient should be in a supine position with their head slightly elevated and the affected leg in a neutral position. The use of an abduction splint, a wedge pillow, or two or three pillows placed between the legs prevent adduction beyond the midline of the body. A cradle boot may be used to prevent leg rotation and to support the heel off the bed, preventing development of a pressure ulcer. When the nurse turns the patient in bed to the unaffected side, it is important to keep the operative hip in abduction (movement away from the center or median line of the body). The patient should not be turned to the operative side, which could cause dislocation, unless specified by the surgeon. The patient's hip is never flexed more than 90 degrees. When using a fracture bedpan, the nurse instructs the patient to flex the unaffected hip and to use the trapeze to lift the pelvis onto the pan. The patient is also reminded not to flex the affected hip. Limited flexion is maintained during transfers and when sitting. When the patient is initially assisted out of bed, an abduction splint or pillows are kept between the legs. The nurse encourages the patient to keep the affected hip in extension, instructing the patient to pivot on the unaffected leg with assistance by the nurse, who protects the affected hip from adduction (movement toward the center or median line of the body), flexion, internal or external rotation, and excessive weight bearing. High-seat (orthopedic) chairs with arm rests, semi-reclining chairs, and raised toilet seats are used to minimize hip joint flexion. When sitting, the patient's hips should be higher than the knees. The patient's affected leg should not be elevated when sitting. The patient may flex the knee. The nurse educates the patient about protective positioning, which includes maintaining abduction and avoiding internal and external rotation, hyperextension, and acute flexion, as described previously. At no time should the patient cross their legs or bend at the waist past 90 degrees (e.g., to put on shoes and socks). Occupational therapists can provide the patient with devices to assist with dressing below the waist. Hip precautions for patients who had a posterior or posterolateral approach for THA should be enforced for 4 months or longer after surgery. A patient who has had an anterior surgical approach may not need these precautions. Several studies have reported an anterolateral approach to THA results in a lower rate of dislocation than a posterior approach owing to its ease of access, superior visualization, and a predictable healing pattern. Using a less restrictive mobility protocol in these patients can lead to earlier and better resumption of ADL, earlier return to work, a shorter length of hospital stay, and improved patient satisfaction Dislocation may occur with positioning that exceeds the limits of the prosthesis. The nurse must monitor for signs and symptoms of dislocation of the prosthesis, which include: Increased pain at the surgical site, swelling, and immobilization Acute groin pain in the affected hip or increased discomfort Shortening of the affected extremity Abnormal external or internal rotation of the affected extremity Restricted ability or inability to move the leg Reported "popping" sensation in the hip If any of these clinical manifestations occur, the nurse (or the patient, if at home) immediately notifies the surgeon, because the hip must be reduced and stabilized promptly so that the leg does not sustain circulatory and nerve damage. After closed reduction, the hip may be stabilized with Buck's traction or a brace to prevent recurrent dislocation. As the muscles and joint capsule heal, the chance of dislocation diminishes. Stresses to the new hip joint should be avoided for the first 8 to 12 weeks, when the risk of dislocation is greatest.

Wrist fractures

Fractures of the distal radius (Colles fracture) are common and are usually the result of a fall on an open, dorsiflexed hand. This fracture is frequently seen in older adults with osteoporotic bones that do not dissipate the energy of the fall. The patient presents with a deformed wrist, pain, swelling, weakness, and limited finger ROM, and possibly reports of "tingling" in the affected hand. Tingling sensation may indicate injury to the median nerve Treatment usually consists of closed reduction and immobilization with a sugar-tong splint until swelling resides. A sugar-tong splint is a U-shaped splint (like tongs used for sugar cubes) that is placed so that it extends from the palm around the elbow to the back of the hand just below the fingers. Once the edema lessens a long or short-arm cast is applied. For fractures with extensive comminution, ORIF, plating, percutaneous pinning, or external fixation is used to achieve and maintain reduction. Pain medication is given as prescribed to aid in pain control. Active motion of the fingers and shoulder should begin promptly to reduce swelling and prevent stiffness The fingers may swell due to diminished venous and lymphatic return. The nurse assesses the sensory function of the median nerve by pricking the distal aspect of the index finger. The motor function is assessed by the patient's ability to touch the thumb to the little finger. Diminished circulation and nerve function must be treated promptly (see previous discussion of compartment syndrome).

Radial and ulnar shaft fractures

Fractures of the shaft of the bones of the forearm occur more frequently in children but can occur in adults. The radius or the ulna may be fractured at any level. Frequently, displacement occurs when both bones are broken. The forearm's unique functions of pronation and supination must be preserved with proper anatomic alignment If the fragments are not displaced, the fracture is treated by closed reduction with a long-arm cast applied from the upper arm to the proximal palmar crease. Circulation, motion, and sensation of the hand are assessed before and after the cast is applied. The arm is elevated to control edema. Frequent finger flexion and extension are encouraged to reduce edema. Active motion of the involved shoulder is essential. The reduction and alignment are monitored closely by x-rays to ensure proper alignment. The fracture is immobilized for about 12 weeks; during the last 6 weeks, the arm may be in a functional forearm brace that allows exercise of the wrist and elbow. Lifting and twisting are avoided. Displaced fractures are managed by ORIF, using a compression plate with screws, intramedullary nails, or rods. The arm is usually immobilized in a plaster splint or cast. Open and displaced fractures may be managed with external fixation devices. The arm is elevated to control swelling. Neurovascular status is assessed and documented. Elbow, wrist, and hand exercises are begun when prescribed by the primary provider.

Tibia and fibula fractures

Fractures of the tibia and fibula often occur in association with each other and tend to result from a direct blow, falls with the foot in a flexed position, or a violent twisting motion. Most of these fractures tend to be more distal than proximal; distal fractures may extend into the ankle joint (i.e., distal fractures of the tibia that extend into the joint are collectively referred to as pilon fractures). The patient presents with pain, deformity, obvious hematoma, and considerable edema

Nursing mgmt of patient in cast, splint, or brace

General health Presenting s/sx Emotional status Understanding need for device Condition of body part to be immobilized Physical assessment of part to be immobilized must include a thorough assessment of the skin and neurovascular status: degree and location of swelling, bruising, and skin abrasion Promote healing: skin lacerations and abrasions may have occurred as a result of trauma that caused the fracture must be treated before the cast, brace, or splint is applied Thoroughly cleanse skin and tx as prescribed Tetanus booster if wound is dirty and booster was give 5 or more years ago Sterile dressing cover injured skin If skin wounds are extensive, external fixator may be used to immobilize. Give fam or pt info about underlying patho cond and purpose and expectations of tx regimen Promote pt active participation in and adhere to tx program Describe anticipated sights, sounds, and sensations Ask what pt and fam know about application and care of the cast to help determine opportunities for education know why body part is immobilized Main concern following application of immobilization device is assessment and prevention of neurovascular dysfxn or compromise of the affected extremity. Assessments performed at least qhr for 1st 24 hours and q1-4 hrs after to prevent neurovascular compromise r/t edema. Peripheral circ, motion, and sensation of the affect extremity, assessing the fingers or toes of the affected extremity, and comparing them w/those of the opposite extremity. Check peripheral pulses as well as cap refill (within 3 seconds), edema, and color and temp of the skin. Note weakness or paralysis of the injured body part: assess motion. Assess for paresthesia or absense of feeling in affected extremity: nerve damage. 6 P's of neurovascular compromise. Early recognition essential to prevent loss of fxn. Swelling can create excessive pressure under cast. Elevate extremity above level of the heart during first 24-48 hours postapplication to enhance arterial perfusion and ctrl edema and notifies the primary provider at once if sings of compromised neurovascular status are present Carefulldy evaluate pain associated w/muscuoloskeletal cond, ask pt to indicate exact site and describe character and intesnity fo pain using pain rating scale. Pain associated w/underlying condition frequently ctrl by immobilization Pain due to edema is associated w/trauma, surgery, or bleeding into the tissues can be ctrl by elevated and intermittent app of ice or cold packs Ice bags(1/3rd to one half full) or cold application devices placed on each side of the cast, making sure not to indent or wet the cast. Unrelieved or pain out of proportion following cast application may indicate complications. Pain r/t compartment syndrome reletnless and not ctrl by modalities like elevation, app of ice or cold, and usual dosages of analgesic agents. Severe pain over bony prominences warn of pressure ulcers: too tight elastic wraps to hold splints in place Observe pt w/cast for systemic signs of infection: unpleasant odor from cast and purulent drainage staining cast. More common from open wound, but the moist, warm envt of splint or cast can be conduit for infection. Foul-smelling casts should be removed to prevent skin and wound infections If infection progresses, fever may develop. Nurse must notify primary provider if any of these occur. Joint stiffness. Every joint not immobilized should be exercise and moved thru ROM to maintain fxn Encourage pt to move all fingers or toes hourly when awake to stim circulation

Complications of fractures: Heterotopic ossification

Heterotopic ossification refers to benign bone growth in an atypical location, such as in the soft tissue Heterotopic ossification that is categorized as traumatic myositis ossificans usually develops in response to soft tissue trauma (e.g., contusion, sprain). It is characterized by pain and joint stiffness that causes decreased ROM. It typically occurs in young males after musculoskeletal sports injuries. If significant ROM dysfunction persists, surgery may be indicated to remove the bone growth and restore function.

Exercise after treatment for wrist fracture

Hold the hand at the level of the heart. Move the fingers from full extension to flexion. Hold and release. Repeat at least 10 times every hour when awake. Use the hand in functional activities. Actively exercise the shoulder and elbow, including complete range-of-motion exercises of both joints.

Complications of fractures: Shock

Hypovolemic shock resulting from hemorrhage is more frequently noted in trauma patients with pelvic fractures and in patients with a displaced or open femoral fracture in which the femoral artery is torn by bone fragments. Treatment for shock consists of stabilizing the fracture to prevent further hemorrhage, restoring blood volume and circulation, relieving the patient's pain, providing proper immobilization, and protecting the patient from further injury and other complications

Emergency mgmt for fractures

Immediately after injury, if a fracture is suspected, the body part must be immobilized before the patient is moved. Adequate splinting is essential. Joints proximal and distal to the fracture also must be immobilized to prevent movement of fracture fragments. Immobilization of the long bones of the lower extremities may be accomplished by bandaging the legs together, with the unaffected extremity serving as a splint for the injured one. In an upper extremity injury, the arm may be bandaged to the chest, or an injured forearm may be placed in a sling. The neurovascular status distal to the injury should be assessed both before and after splinting to determine the adequacy of peripheral tissue perfusion and nerve function. With an open fracture, the wound is covered with a sterile dressing to prevent contamination of deeper tissues. No attempt is made to reduce the fracture, even if one of the bone fragments is protruding through the wound. Splints are applied for immobilization In the ED, the patient is evaluated completely. The clothes are gently removed, first from the uninjured side of the body and then from the injured side. The patient's clothing may be cut away. The fractured extremity is moved as little as possible to avoid more damage.

Nursing interventions for monitoring and managing potential complications

Immobility-related complications may include pressure ulcers, atelectasis, pneumonia, constipation, loss of appetite, urinary stasis, urinary tract infections, and VTE formation. Early identification of pre-existing or developing conditions facilitates prompt interventions to resolve them.

mandible

lower jaw

Patients with open fractures: nursing management

In an open fracture, there is a risk for osteomyelitis, tetanus, and gas gangrene. The objectives of management are to prevent infection of the wound, soft tissue, and bone, and to promote healing of bone and soft tissue. Intravenous (IV) antibiotics are given upon the patient's arrival in the hospital along with intramuscular (IM) tetanus toxoid if needed. Wound irrigation and débridement (removal of tissues and foreign material) are initiated in the operating room as soon as possible. The wound is cultured, and bone grafting may be performed to fill in areas of bone defects. The fracture is carefully reduced and stabilized by external fixation, and the wound is usually left open. If there is any damage to blood vessels, soft tissue, muscles, nerves, or tendons, appropriate treatment is implemented. With open fractures, primary wound closure is usually delayed, particularly with higher-grade fractures. Heavily contaminated wounds are left unsutured and treated with vacuum-assisted closures (VAC) to facilitate wound drainage. Wound irrigation and débridement may be repeated, removing infected and devitalized tissue and increasing vascularity in the region The extremity is elevated to minimize edema. Neurovascular status must be assessed frequently. Temperature is monitored at regular intervals, and the patient is monitored for signs of infection. Bone grafting may be necessary to bridge bone defects and to stimulate bone healing

Clinical manifestations of fractures: shortening

In fractures of long bones, there is actual shortening of the extremity because of the compression of the fractured bone. Sometimes, muscle spasms can cause the distal and proximal site of the fracture to overlap, causing the extremity to shorten

Traction complications: urinary stasis and infection

Incomplete emptying of the bladder related to positioning in bed can result in urinary stasis and infection. In addition, the patient may find the use of a bedpan uncomfortable and may limit fluids to minimize the frequency of urination. The nurse monitors the fluid intake and the character of the urine. Adequate hydration is important; therefore, the nurse instructs the patient to consume adequate amounts of fluid and to void every 3 to 4 hours. If the patient exhibits signs or symptoms of urinary tract infection (e.g., burning or pain on urination, hematuria), the nurse notifies the primary provider.

Nursing interventions for assisting with self-care for traction patients

Initially, the patient may require assistance with self-care activities. The nurse helps the patient eat, bathe, dress, and toilet. Convenient arrangement of items such as the telephone, tissues, water, and assistive devices (e.g., reachers, overbed trapeze) may facilitate self-care. With resumption of self-care activities, the patient feels less dependent and less frustrated and experiences improved self-esteem. Because some assistance is required throughout the period of immobility, the nurse and the patient can creatively develop routines that maximize the patient's independence.

Preventing infection after THA

Infection—a serious complication of THA—may necessitate removal of the prosthesis. Patients who are older, obese, poorly nourished, smoke cigarettes, or use corticosteroid medications (e.g., prednisone) and patients who have diabetes, rheumatoid arthritis, concurrent infections (e.g., urinary tract infection, dental abscess), carry MRSA, or have hematomas are at high risk for infection Over time, one in five patients with THA will undergo revision of the prosthesis, most commonly because of aseptic loosening, infection, instability, or a mechanical complication. Because these joint infections are difficult to treat, strategies for preventing infections should be implemented at various steps of the process of care. Strict hand hygiene and utilization of appropriate infection control practices can prevent transmission of infectious organisms. Proper preoperative patient skin cleansing reduces risk of bacteria entering sites caused by invasive devices or procedures. Appropriate antibiotic administration and discontinuation, as well as thorough patient education regarding subsequent antibiotic use is important. The presence of drains provides a means by which bacteria may enter the body and attach to prosthetic equipment. Using a standard recording document to note and describe wound drainage may improve physician and nurse communication and promote decreased infection rates. Moreover, caution should be exercised during the drain removal process to prevent the drain from breaking. After the drain is removed, the nurse should clean the drain tube site with an antiseptic solution and apply a small gauze dressing if there is any oozing at the site. Acute infections may occur within 3 months after surgery and are associated with progressive superficial infections or hematomas. Delayed surgical infections may appear 4 to 24 months after surgery and may cause return of discomfort in the hip. Previously, prophylactic antibiotics were prescribed if the patient needed any future surgical or invasive procedures, such as tooth extraction or cystoscopic examination. However, the routine use of antibiotic prophylaxis prior to dental procedures for patients with total joint prostheses remains controversial and is not recommended. Antibiotic prophylaxis can still be prescribed for some patients considered at higher risk of infection (e.g., patients who are immunosuppressed) Infections occurring more than 2 years after surgery are attributed to the spread of infection through the bloodstream from another site in the body. If an infection occurs, antibiotics are prescribed. Severe infections may require surgical débridement or removal of the prosthesis.

Splints

More practical and common. Preferred method of fracture immobilization in acute care setting and for initial tx of fractures that eventually require casting Simple adn stable fractures, sprains, tendon injuries faster and easier to apply noncircumferential and allow for natural swelling during inflammatory phase of injury Easily removed: inspection ease Provide initial stability for fractures that are unstable while awaiting definitive care Contoured splints of plaster or pliable thermoplastic materials may be used for cond that do not require rigid immobilization, for those in which swelling may be anticipated, and for those that require special skin care Thermoplastic splints: warmed and molded to custom-fit affected body part Splint needs to immobilize and support the body part n a fxnl pos, must be well padded to prevent pressure, skin abrasion, and skin breakdown. Splint is overwrapped with an elastic bandage applied in a spiral fashion and w/pressure uniformly distr so that cir not restricted.

Medical mgmt of tibia and leg fractures

Most closed, nondisplaced fractures that do not involve the ankle joint (i.e., extra-articular fractures) are treated with closed reduction and immobilization in a non-weight-bearing short-leg cast or brace. The leg is elevated to control edema. Weight-bearing status varies and depends on the type of fracture. Activity decreases edema and increases circulation. Fracture healing takes 6 to 10 weeks Displaced, open, or articular fractures may be treated with skeletal traction, internal fixation with intramedullary nails or plates and screws, or external fixation. External support may be used with internal fixation. Hip, foot, and knee exercises are encouraged within the limits of the immobilizing device. Partial weight bearing is begun when prescribed and is progressed as the fracture heals in 6 to 10 weeks As with any fracture, continued neurovascular evaluation is important. The development of acute compartment syndrome requires prompt recognition and communication to the primary provider. Other complications to monitor for include nonunion, delayed union, infection, and impaired wound edge healing

Radial head fractures

Radial head fractures are fractures of the proximal radius. They are common and are usually produced by a fall on an outstretched hand with the elbow extended. If blood has collected in the elbow joint, it is aspirated to relieve pain and to allow early active elbow and forearm ROM exercises Nondisplaced fractures are typically managed nonsurgically; recent studies demonstrate decreased joint stiffness with early mobilization (i.e., within 48 hours of injury), consisting of repeated extension and flexion exercises (Kodde, Kaas, Flipsen, et al., 2015; Paschos, Mitsionis, Vasiliadis, et al., 2013). If the fracture is displaced, surgery is typically indicated, with excision of or replacement of the radial head when necessary

Educating client about self-care for hip fractures

Most patients are discharged from the hospital to an inpatient rehabilitation facility. The patient and family members or caregivers are assessed for their readiness to commence activities that promote healing and mobility. The nurse collaborates with other members of the multidisciplinary physiotherapy team (e.g., physical therapist, occupational therapist) to gather baseline data on the patient's anticipated long-term care environment post discharge, whether that is home or a long-term care facility, such as a skilled nursing facility. The patient begins a rehabilitation routine geared to meet the needs of this environment. For instance, if the patient is to be discharged home, and there are stairs in the home, then a goal of rehabilitation is that the patient will be able to get up and down stairs before discharge. The patient engages in regular exercises to improve muscle tone and balance (see Chapter 10). The safe use of ambulatory aids, any specific activity restrictions (e.g., hip precautions if total hip arthroplasty was performed), and fall prevention measures (e.g., appropriate footwear, proper lighting, removal of throw rugs, getting rid of clutter) are also vitally important education topics that must be adequately addressed prior to discharge (Saccomano & Ferrara, 2015). The patient and caregiver are educated on the indications for any newly prescribed medications, wound care, and the importance of proper nutrition. Identification of any potential complications (e.g., reddened wound, fever) and when and how to contact the patient's primary provider are also important to understand.

Potential complications of casts, splints, and braces: Compartment Syndrome

Most serious complicatino of casting and splinting Incr pressure within confined space compromises blood flow and tissue perfusion Ischemia and potentially irreversible damage to the soft tissues within that space can occur within a few hours Tight or rigid cast/splint that constricts swollen limb Dx: based on clinical suspicion, 6 p's, intracompartmental pressure earliest indicator: pain that seems out of proportion to the underlying injury and pain on passive stretch of other muscles in the immobilized limb, c/o tightness of cast/brace/splint primary provider must be notified immediately late stages: pulselessness, paresthesia, and complete paralysis Loosen splint or remove it cast univalved or bivalved elevate extremity no higher than heart level emergent surgical fasciotomy frequent neurovascular responses

Gerontologic considerations for hip fractures

Older adults (particularly women) who have low bone density from osteoporosis and who tend to fall frequently have a high incidence of hip fracture. Stress and immobility related to the trauma predispose the older adult to atelectasis, pneumonia, sepsis, VTE, pressure ulcers, and reduced ability to cope with other health problems. Many older adults hospitalized with hip fractures exhibit delirium as a result of stress of the trauma, pain, unfamiliar surroundings, sleep deprivation, and medications. In addition, delirium that develops in some older adult patients may be caused by mild cerebral ischemia or mild hypoxemia. Other factors associated with delirium include responses to malnutrition, dehydration, infectious processes, mood disturbances, and blood loss. The same factors that may cause delirium may superimpose delirium on dementia in the older adult with a fractured hip, further complicating recovery. To prevent complications, the nurse must assess the older patient for chronic conditions that require close monitoring. Examination of the legs may reveal edema due to heart failure or absence of peripheral pulses from peripheral vascular disease. Similarly, chronic respiratory problems may be present and may contribute to the possible development of atelectasis or pneumonia. Coughing and deep-breathing exercises are encouraged. Frequently, older adults take cardiac, antihypertensive, or respiratory medications that need to be continued. The patient's responses to these medications should be monitored. Dehydration and poor nutrition may be present. At times, older adults who live alone cannot call for help at the time of injury. A day or two may pass before assistance is provided, and as a result, dehydration occurs. Nutritional status may have been poor prior to admission, so the nurse should monitor for complications of dehydration and poor nutrition (e.g., pressure ulcers, etc.). Nutritional supplements are effective in improving outcomes in older adults and should be incorporated into the plan of care Muscle weakness may have initially contributed to the fall and fracture. Bed rest and immobility cause an additional loss of muscle strength unless the nurse encourages the patient to move all joints except the involved hip and knee. Patients are encouraged to use their arms and the overhead trapeze to reposition themselves. This strengthens the arms and shoulders, which facilitates walking with assistive devices.

Traction complications: Constipation and anorexia

Reduced gastrointestinal motility results in constipation and anorexia. A diet high in fiber and fluids may help stimulate gastric motility. If constipation develops, therapeutic measures may include stool softeners, laxatives, suppositories, and enemas. To improve the patient's appetite, the patient's food preferences are included, as appropriate, within the prescribed therapeutic diet.

Maintaining and restoring fxn of fractures

Reduction and immobilization are maintained as prescribed to promote bone and soft tissue healing. Edema is controlled by elevating the injured extremity and applying ice as prescribed. Neurovascular status (circulation, motion, and sensation) is monitored routinely, and the primary provider is notified immediately if signs of neurovascular compromise develop. Restlessness, anxiety, and discomfort are controlled with a variety of approaches, such as reassurance, position changes, and pain-relief strategies, including the use of analgesic medications. Isometric and muscle setting exercises are encouraged to minimize atrophy and to promote circulation. Participation in activities of daily living (ADLs) is encouraged to promote independent functioning and self-esteem. Gradual resumption of activities is promoted as prescribed. With internal fixation, the surgeon determines the amount of movement and weight-bearing stress the extremity can sustain and prescribes the level of activity.

Continuing and transitional care for hip fractures

Referral for home, community-based, or transitional care is important to enable assessment of the patient's home environment and the adequacy of resources and support of caregivers. Modifications may need to be made to ensure the patient's continuing care, safety, and mobility. During follow-up home health or outpatient clinic visits, the nurse reevaluates the patient's healing process and the continued adequacy of resources and support of caregivers. Modifications may need to be made based upon these findings. For instance, an older adult spouse may require assistance or respite care. Home health agencies, local area agencies on aging (for older adult patients), and faith community nursing organizations, may be tapped into to provide assistance within the home or with transporting the patient to follow-up outpatient appointments. Osteoporosis screening of patients who have experienced hip fracture is important for prevention of future fractures. With dual-energy x-ray absorptiometry (DEXA) scan testing, the risk of additional fracture can be predicted. Specific patient education regarding dietary requirements, lifestyle changes, and weight-bearing exercise to promote bone health is needed. Vitamin D and calcium supplements are also recommended (AAOS, 2014b). Specific therapeutic interventions need to be initiated to slow bone loss and to build bone mineral density

Stable pelvic fractures

Stable fractures of the pelvis include fracture of a single pubic or ischial ramus, fracture of ipsilateral pubic and ischial rami, fracture of the pelvic wing of the ilium (Duverney's fracture), and fracture of the sacrum or coccyx. If injury results in only a slight widening of the pubic symphysis or the anterior sacroiliac joint and the pelvic ligaments are intact, the disrupted pubic symphysis is likely to heal spontaneously with conservative management. Most fractures of the pelvis heal rapidly because the pelvic bones are mostly cancellous bone, which has a rich blood supply. Stable pelvic fractures are treated with a few days of bed rest and symptom management until discomfort is controlled. Fluids, dietary fiber, ankle and leg exercises, antiembolism stockings to aid venous return, logrolling, deep breathing, and skin care reduce the risk of complications and increase the patient's comfort. The patient with a fractured sacrum is at risk for paralytic ileus; therefore, bowel sounds should be monitored. The patient with a fracture of the coccyx experiences pain when sitting and when defecating. Sitz baths may be prescribed to relieve pain, and stool softeners may be given to ease defecation. As pain resolves, activity is gradually resumed with the use of assistive mobility devices. Early mobilization reduces problems related to immobility. Rehabilitation focuses on the goal of full weight-bearing status by 3 months post injury

Self care about casts/splints/braces

Self-care deficits encourag eparticipation in personal ccare to use assistive devices safely assist in identifying areas of self-care deficit develop strategies to achieve independence in ADLs

fibula

Smaller lower leg bone

Nursing management for hip fractures

The immediate postoperative care for a patient with a hip fracture is similar to that for other patients undergoing major surgery. Attention is given to pain management, prevention of secondary medical problems, and early mobilization of the patient so that independent functioning can be restored. During the first 24 to 48 hours, relief of pain and prevention of complications are important, and continuous neurovascular assessment is essential. The nurse encourages deep breathing and dorsiflexion and plantar flexion exercises every 1 to 2 hours. Thigh-high antiembolism stockings or pneumatic compression devices are used, and anticoagulants are given as prescribed to prevent the formation of VTE. The nurse administers prescribed analgesic medications and monitors the patient's hydration, nutritional status, and urine output.

Repositioning the patient for hip fractures

The most comfortable and safest way to turn the patient is to turn to the uninjured side. The standard method involves placing a pillow between the patient's legs to keep the affected leg in an abducted position. Proper alignment and supported abduction are maintained while turning

Traction complications: atelectasis and pneumonia

The nurse auscultates the patient's lungs every 4 to 8 hours to assess respiratory status and educates the patient about performing deep breathing and coughing exercises to aid in fully expanding the lungs and clearing pulmonary secretions. If the patient history and baseline assessment indicate that the patient is at risk for development of respiratory complications, specific therapies (e.g., the use of an incentive spirometer) may be indicated. If a respiratory complication develops, prompt institution of prescribed therapy is needed.

Nursing interventions for maintaining effective skeletal traction

The nurse must immediately investigate every report of discomfort expressed by the patient in traction. Prompt recognition of a developing neurovascular problem is essential so that corrective measures can be instituted quickly. When skeletal traction is used, the nurse checks the traction apparatus to see that the ropes are in the wheel grooves of the pulleys, the ropes are not frayed, the weights hang freely, and the knots in the rope are tied securely. The nurse also evaluates the patient's position, because slipping down in bed results in ineffective traction

Assessment of tibia and fibula fractures

The peroneal nerve is assessed; if damaged, the patient cannot dorsiflex the great toe and has diminished sensation in the first web space. The tibial artery is assessed for damage by evaluating pulses, skin temperature, and color and by testing the capillary refill response. The affected leg and ankle are compared with the unaffected leg and ankle. X-rays are indicated to determine the location, type, and extent of the fracture

Pelvic fractures

The sacrum, ilium, pubis, and ischium bones form the pelvis—a fused, stable, bony ring in adults. Motor vehicle crashes, vehicle versus pedestrian, and crush injuries can cause pelvic fractures. There is a high mortality rate associated with unstable pelvic fractures, second only to head injuries among trauma-related deaths; this is primarily related to hemorrhage, although pulmonary complications, fat emboli, thromboembolic complications, and infection are also implicated. Management of severe, life-threatening pelvic fractures is coordinated with the trauma team Signs and symptoms of pelvic fracture may include ecchymosis; tenderness over the symphysis pubis, anterior iliac spines, iliac crest, sacrum, or coccyx; local edema; numbness or tingling of the pubis, genitals, and proximal thighs; inability to bear weight without discomfort; severe back pain (retroperitoneal bleed); alterations in neurovascular status of lower extremities. Computed tomography (CT) scanning of the pelvis helps determine the extent of injury by demonstrating sacroiliac joint disruption, soft tissue trauma, pelvic hematoma, and fractures. Neurovascular assessment of the lower extremities is completed to detect any injury to pelvic blood vessels and nerves. Assessment of underlying organs for injury is indicated especially in high-impact trauma. Trauma to the ureters, urethra, rectum, vagina; abdominal vascular trauma to veins (more common) and arteries; and neurologic trauma, particularly spinal column and cord injury, should be assessed as potential concomitant injuries. Hemorrhage and shock are two of the most serious consequences that may occur. Bleeding arises mainly from the laceration of veins and arteries by bone fragments and possibly from a torn iliac artery. The peripheral pulses, especially the dorsalis pedis pulses of both lower extremities, are palpated; absence of a pulse may indicate a tear in the iliac artery or one of its branches. Abdominal CT may be performed to detect intra-abdominal hemorrhage. The patient is handled gently so that bony fragments are not displaced, which may exacerbate bleeding and shock. Exploratory laparotomy may be performed to further visualize the peritoneum (NAON, 2013). Assessment of adjacent structures must be completed when pelvic injury is suspected. Numerous classification systems have been used to describe pelvic fractures in relation to anatomy, stability, and mechanism of injury. Some fractures of the pelvis do not disrupt the pelvic ring; others disrupt the ring, which may be rotationally or vertically unstable. The severity of pelvic fractures varies. Long-term complications of pelvic fractures include malunion, nonunion, DVTs, residual gait disturbances, back pain from ligament injury, and dyspareunia and erectile dysfunction.

Hand fractures

Trauma to the hand is a frequent reason patients seek care in EDs. The most common type of metacarpal fracture in adults is referred to as boxer's fracture, which occurs when a closed fist bangs against a hard surface, fracturing the neck of the fifth finger. Falls and occupational injuries (e.g., machinery injuries, crushes) are the most common cause of phalangeal injury in adults. When any of the bones of the hand are fractured, the objectives of treatment are to regain maximum function of the hand and minimize cosmetic deformities. X-rays are the diagnostic studies of choice For a nondisplaced fracture of the phalanx (finger bone), the finger is splinted for 3 to 4 weeks to relieve pain and to protect the finger from further trauma. Splinting sometimes consists of "buddy taping" a fractured finger to an adjoining nonfractured finger. Serial x-rays may be done to monitor healing. Displaced fractures and open fractures may require ORIF, using wires or pins. If the fracture is open, or if a fingernail is avulsed, antibiotics may be prescribed The neurovascular status of the injured hand is evaluated and documented. Swelling is controlled by elevation of the hand. Functional use of the uninvolved portion of the hand is encouraged. Assistive devices might be recommended to aid the patient in performing ADLs until the hand has healed and functional status

Other early complications of fractures: VTE, DVT, PE, DIC

VTE, including DVT and PE, are associated with reduced skeletal muscle contractions and bed rest. Patients with fractures of the lower extremities and pelvis are at high risk for VTE. PE may cause death several days to weeks after injury. Disseminated intravascular coagulation (DIC) is a systemic disorder that results in widespread hemorrhage and microthrombosis with ischemia. Its causes are diverse and can include massive tissue trauma. Early manifestations of DIC include unexpected bleeding after surgery and bleeding from the mucous membranes, venipuncture sites, and gastrointestinal and urinary tracts. All open fractures are considered contaminated and are treated as soon as possible with copious irrigation, débridement, and IV antibiotics Surgical internal fixation of fractures carries a risk of infection. The nurse must monitor and instruct the patient regarding signs and symptoms of infection, including tenderness, pain, redness, swelling, local warmth, elevated temperature, and purulent drainage.

Clinical manifestations of fractures: crepitus

When the extremity is gently palpated, a crumbling sensation, called crepitus, can be felt or may be heard. It is caused by the rubbing of the bone fragments against each other.

Principles of good traction

Whenever traction is applied, countertraction must be used to achieve effective results. Countertraction is the force acting in the opposite direction. Usually, the patient's body weight and bed position adjustments supply the needed countertraction. When caring for the patient in traction, the nurse should follow these additional principles: Traction must be continuous to be effective in reducing and immobilizing fractures. Skeletal traction is never interrupted. Weights are not removed unless intermittent traction is prescribed. Any factor that might reduce the effective pull or alter its resultant line of pull must be eliminated. The patient must be in good body alignment in the center of the bed when traction is applied. Ropes must be unobstructed. Weights must hang freely and not rest on the bed or floor. Knots in the rope or the footplate must not touch the pulley or the foot of the bed.

tarsals

ankle bones

Lateral

away from the midline

long bones

bones of the arms and legs

Complications of casts/splints/brace: Pressure Ulcers

can put pressure on soft tissues LE: heel, malleoli, dorsum of foot, head of fibula, and anterior surface of patella Main UE pressure sites: medial epicondyle of humerus and ulnar styloid pressure necrosis: typically report very painful "hot spot" and tightness under cast. May feel warmer, have drainage, and emit unpleasant odor. To assess: primary provider may univalve, bivalve, or cut an opening (window) in cast to allow for inspection, access, and possible treatment Dressing may be put over exposed skin: cutout portion replaced andheld in place by elastic compression dressing or tape--prevents window edema

thorax

chest

clavicle

collar bone

phalanges

fingers, toes

metatarsals

foot bones

Anterior

front

metacarpals

hand bones

calcaneus

heel bone

transverse

in a crosswise direction

radius

lateral bone of the forearm

Plaster casts

less costly; achieve better mold than fiberglass casts heavy, not water resistance can take up to 24-72 hours to dry postapplication exothermic rxn can cause burns clean, room temp water used during cast application process Minimal layers of padding Cast should not be covered while it is drying because heat generated by chem rxn time taken to dry depends on size, thickness, and location, environmental drying conditions handle fresh cast as little as possible to prevent denting or cracking. Only handle by the palms so that indentations in cast can be prevented. Pressure areas on skin expose to circulating air to dry do not place on metallic surface or one with sharp edges; cloth covered pillow Petaling: smoothing the rough edges of the cast

ulna

medial bone of the forearm

Complications of casts: disuse syndrome

muscle atrophy and loss of strength deterioration of body systems as result of prescribed or unavoidable musculoskeletal inactivity Instruct pt to tense or contract muscles (isometric) w/o moving underlying bone. "push down, make fist" Muscle setting: quadriceps and gluteal setting exercises: maintani muscles essential for walking Isometric exercises: performed hourly while pt awake

Splints and braces materials

prefabricated and fastened with Velcro straps. May be made of plastic and cloth, leather, metal, and elastic Knee immobilizers, ankle stirrups, and cock-up wrist splints: types of prefabricated splints and braces serious disadvantage: underlying injuries not well stabilized.

diaphysis

shaft of a long bone

scapula

shoulder blade

medullary canal

the center of the shaft of the long bone

Tibia

the medial and larger bone of the lower leg

femur

thigh bone

posterior

toward the back

Medial

toward the midline

humerus

upper arm bone

Braces

used to provide support, ctrl mvmt and prevent addtl injury custom-fitted to various parts of the body: indicated for longer than splints orthotist adjusts brace for fit, position, and motion so that mvmt enhanced, any deformities are corrected, and discomfort is minimized

metaphysis

where diaphysis and epiphysis meet

carpals

wrist

Acetabulum fractures

Acetabular fractures are a type of intra-articular fracture. The typical mechanism of injury is that an external force drives the femoral shaft into the hip joint, fracturing the acetabulum. This may be caused by high-speed motor vehicle crashes (e.g., knees driven into dashboard, pedals forcibly driven upward into legs) or from falls from heights Treatment depends on the pattern of fracture. Stable, nondisplaced fractures may be managed with traction and protective weight bearing so that the affected foot is placed on the floor only for balance. Displaced and unstable acetabular fractures are treated with open reduction, joint débridement, and internal fixation or arthroplasty. Internal fixation permits early non-weight-bearing ambulation and ROM exercise. Complications seen with acetabular fractures include malunion, nerve palsy, heterotopic ossification, and posttraumatic arthritis

Educating about self-care for THA

Before the patient leaves the acute care setting, the nurse provides thorough education to promote continuity of the therapeutic regimen and active participation in the rehabilitation process. The patient may be discharged to their home, a rehabilitation unit, a transitional care unit, or a long-term care facility. The nurse advises the patient of the importance of a daily exercise program in maintaining the functional motion of the hip joint and strengthening the abductor muscles of the hip, and reminds the patient that it will take time to strengthen and retrain the muscles. The patient will need physical therapy to regain mobility. Assistive devices (crutches, walker, or cane) may be used for a time. After sufficient muscle tone has developed to permit a normal gait without discomfort, these devices are not necessary. In general, by 3 months, the patient can resume routine ADLs. Stair climbing typically may resume within 3 to 6 weeks following surgery Some discomfort with activity and at night is common for several weeks. Frequent walks, swimming, and the use of a high rocking chair are excellent for hip exercises. Restrictions must be kept in mind when resuming sexual activity. Patients should be questioned about sexual concerns and counseled on physical and functional aspects of sexual activity. Sexual intercourse can be resumed based upon the surgeon's recommendation (typically 3 to 6 months postoperatively) and should be carried out with the patient in the supine position (flat on the back) to avoid excessive adduction and flexion of the new hip Attention to positioning and comfort may enhance the intimacy of the experience. At no time during the first 4 months should the patient cross the legs or flex the hip more than 90 degrees. Assistive devices should be used for dressing, such as long-handled shoehorns or dressing sticks for putting on shoes and socks. The patient should avoid low chairs and sitting for longer than 45 minutes at a time. These precautions minimize hip flexion and the risks of prosthetic dislocation, hip stiffness, and flexion contracture. Driving requires sufficient range of motion and muscle strength; most patients are given permission to drive 4 to 6 weeks postoperatively. Traveling long distances should be avoided unless frequent position changes are possible. Other activities to avoid include tub baths, jogging, lifting heavy loads, and excessive bending and twisting (e.g., lifting, shoveling snow, forceful turning). The primary provider may give the patient a card indicating that he or she has had a joint replacement; this card may be used to alert security personnel who use screening devices at airports or malls.

Medical mgmt of hip fractures

Buck's extension traction, a type of temporary skin traction, was traditionally applied because it was believed to reduce muscle spasm, to immobilize the extremity, and to relieve pain. Its efficacy had never been established in clinical trials, however, so its routine prescription is not advocated The goal of surgical treatment for hip fractures is to obtain a satisfactory fixation so that the patient can be mobilized quickly and avoid secondary medical complications. Surgical treatment consists of (1) open or closed reduction of the fracture and internal fixation, (2) replacement of the femoral head with a prosthesis (hemiarthroplasty), or (3) closed reduction with percutaneous stabilization for an intracapsular fracture. Surgical intervention is carried out as soon as possible after injury. The preoperative objective is to ensure that the patient is in as favorable a condition as possible for the surgery. Displaced femoral neck fractures are treated as emergencies, with reduction and internal fixation performed within 24 hours after fracture. The femoral head is often replaced with a prosthesis if there is complete disruption of blood flow to the femoral head, which may cause AVN After general or spinal anesthesia, the hip fracture is reduced under x-ray visualization. A stable fracture is usually fixed with nails, a nail and plate combination, multiple pins, or compression screw devices. The orthopedic surgeon determines the specific fixation device based on the fracture site or sites. Adequate reduction is important for fracture healing—the better the reduction, the better the healing.

Complications of fractures: complex regional pain syndrome

CRPS is a rare condition characterized by chronic pain in a limb, typically after an injury. Dysfunctional peripheral and central nervous system responses that mount an excessive response to the precipitating event (e.g., fracture, surgery) are thought to be the cause of the pain. Women are affected more often than men, and the average age of diagnosis is 40 years (National Institute of Neurological Disorders and Stroke [NINDS], 2015). Two forms of CRPS exist: CRPS I (formerly called reflex sympathetic dystrophy) and CRPS II, also called causalgia, which is characterized by nerve injury Clinical manifestations of CRPS include severe burning pain, local edema, hyperesthesia, stiffness, discoloration, vasomotor skin changes (i.e., fluctuating warm, red, dry and cold, sweaty, cyanotic), and trophic changes that may include glossy, shiny skin, and changes in hair and nail growth. This syndrome is frequently chronic, with extension of symptoms to adjacent areas of the body. Dysfunction of the affected limb may also be manifested in CRPS. The diagnosis is made through the history and physical examination and ruling out other organic causes Nursing mgmt: Prevention may include early mobilization following an injury or after surgery Early effective pain relief is the focus of management. Pain may be controlled with analgesic agents. NSAIDs, topical anesthetics (e.g., lidocaine patches), corticosteroids, and opioids. Anticonvulsants (e.g., gabapentin [Neurontin]) and antidepressants (e.g., amitriptyline [Elavil]) can be effective in treating neuropathic pain. Additional treatments may include sympathetic nerve blocks, neural stimulation, and delivering prescribed medications intrathecally. Novel treatments under investigation include infusions of immunoglobulin (IVIG) and ketamine and the use of hyperbaric oxygen. The nurse evaluates the effectiveness of these interventions and therapies and helps the patient cope with CRPS manifestations through therapeutic listening, initiation of relaxation techniques and behavior modification, and referral for rehabilitation therapy. Rehabilitation initiated early can improve circulation to the affected area and maximize function. Depression and anxiety are often associated with severe pain disorders; therefore, the nurse should recommend a mental health referral as necessary The nurse avoids using the affected extremity for blood pressure measurements and venipuncture in the patient with CRPS.

Femoral shaft fractures

Considerable force is required to break the shaft of a femur in adults. Most femoral fractures occur in young adults who have been involved in motor vehicle crashes or who have fallen from heights. Frequently, these patients have associated multiple traumatic injuries The patient presents with an edematous, deformed, painful thigh and cannot move the hip or the knee. The fracture may be transverse, oblique, spiral, or comminuted. Frequently, the patient develops shock, because the loss of 1 to 2.5 L of blood into the tissues is common with these fractures

Medical management for femoral shaft fractures

Continued neurovascular monitoring and documentation are important. The fracture is immobilized so that additional soft tissue damage does not occur. Generally, skeletal traction or splinting is used to immobilize fracture fragments until the patient is physiologically stable and ready for ORIF procedures. IV opioid analgesic agents (e.g., morphine) are typically given to treat pain Internal fixation usually is carried out immediately. Intramedullary locking nail devices are typically used. Internal fixation permits early mobilization, which is associated with improved outcomes and recovery To preserve muscle strength, the patient is instructed to exercise the hip and the lower leg, foot, and toes on a regular basis. Active muscle movement enhances healing by increasing blood supply and electrical potentials at the fracture site. Prescribed weight-bearing limits are based on the type and location of the fracture and treatment approach. Physical therapy includes ROM and strengthening exercises, safe use of assistive devices, and gait training Traction may be used until surgery can be performed. Skeletal traction is a temporary intervention, however, until such time as the patient is stable and may tolerate surgical intervention Open femoral fractures require immediate and extensive irrigation and débridement in the operating suite (see previous discussion of treatment for open fractures). Depending on needs for continued débridement, intramedullary nailing may be delayed A common complication after fracture of the femoral shaft is restriction of knee motion. Active and passive knee exercises begin as soon as possible, depending on the stability of the fracture and knee ligaments. Other complications in the immediate postoperative period can include hemorrhage, compartment syndrome, and neurovascular compromise. Long-term complications may include malrotation, malunion, delayed union, and nonunion

Clinical manifestations of fracturesL deformity

Displacement, angulation, or rotation of the fragments in a fracture of the arm or leg causes a deformity that is detectable when the limb is compared with the uninjured extremity.

Nursing interventions for monitoring and managing potential complications of skin traction: skin breakdown

During the initial assessment, the nurse identifies sensitive, fragile skin (common in older adults). The nurse also inspects the skin area that is in contact with tape, foam, or shearing forces, at least every 8 hours, for signs of irritation or inflammation. The nurse performs the following procedures to monitor and prevent skin breakdown: Removes the foam boots to inspect the skin, the ankle, and the Achilles tendon three times a day. A second person is needed to support the extremity during the inspection and skin care. Palpates the area of the traction tapes daily to detect underlying tenderness. Provides frequent repositioning to alleviate pressure and discomfort, because the patient who must remain in a supine position is at increased risk for development of a pressure ulcer. Uses advanced static mattresses or overlays rather than standard hospital foam or alternating-air/low-air-loss mattresses to reduce the risk of pressure ulcer formation

The client with an external fixator

External fixators are used to manage fractures with soft tissue damage. Complicated fractures of the humerus, forearm, femur, tibia, and pelvis are managed with external skeletal fixators. They are also used to correct defects, treat nonunion, and lengthen limbs. Their use has increased in recent years with advances in orthopedic trauma care. The fixator provides skeletal stability for severe comminuted (crushed or splintered) fractures while permitting active treatment of extensive soft tissue damage (see Fig. 40-3). External fixation involves the surgical insertion of pins through the skin and soft tissues into and through the bone. A metal external frame is attached to these pins and is designed to hold the fracture in proper alignment to enable healing to occur (Lethaby, Temple, & Santy-Tomlinson, 2013). Advantages of external fixation, compared to other modes of treatment, include immediate fracture stabilization, minimization of blood loss (in comparison to internal fixation), increased patient comfort, improved wound care, promotion of early mobilization and weight bearing on the affected limb, and active exercise of adjacent uninvolved joints (Lethaby et al., 2013). The disadvantages are an increased risk for pin site loosening and infection, which can lead to osteomyelitis (Jennison, McNally, & Pandit, 2014).

Complications of fractures: Fat Embolism Syndrome

Fat embolism syndrome (FES) describes the clinical manifestations that occur when fat emboli enter circulation following orthopedic trauma, especially long bone (e.g., femur) fractures. At the time of fracture, fat globules may diffuse from the marrow into the vascular compartment. The fat globules (i.e., emboli) may occlude the small blood vessels that supply the lungs, brain, kidneys, and other organs. The onset of symptoms is rapid, typically within 12 to 72 hours of injury FES occurs more frequently in males between the ages of 10 and 40 years after a traumatic injury. Although only a small percentage of patients who survive multitrauma have a diagnosis of FES by the time of hospital discharge (0.17% to 1.29%), fat emboli have been found in as many as 82% of trauma patient autopsies Clinical manifestations: The classic triad of clinical manifestations of FES include hypoxemia, neurologic compromise, and a petechial rash. The typical first manifestations are pulmonary and include hypoxia, tachypnea, and dyspnea accompanied by tachycardia, substernal chest pain, low-grade fever, crackles, and additional manifestations of respiratory failure. Chest x-ray may show evidence of acute respiratory distress syndrome (ARDS) or it may be normal. Petechial rash may develop 2 to 3 days after the onset of symptoms. This rash is secondary to dysfunction in the microcirculation and/or thrombocytopenia and is typically located in nondependent regions (e.g., chest, mucous membranes) of the body. There may be varying degrees of neurologic deficits that can include restlessness, agitation, seizures, focal deficits, and encephalopathy Diagnosis relies on clinical examination Prevention and management: Immediate immobilization of fractures, including early surgical fixation, minimal fracture manipulation, and adequate support for fractured bones during turning and positioning, and maintenance of fluid and electrolyte balance are measures that may reduce the incidence of fat emboli. There is no specific treatment for FES; the treatment is supportive. Vasopressors, mechanical ventilation, and sometimes corticosteroids are used as supportive therapy Subtle personality changes, restlessness, irritability, or confusion in a patient who has sustained a fracture are indications for immediate arterial blood gas studies.

Monitoring wound drainage after THA

Fluid and blood accumulating at the surgical site, which could contribute to discomfort and provide a source for infection, may be drained with a closed suction portable suction device. However, the efficacy of using a wound drainage system is a controversial practice that is neither supported nor refuted in the research-based literature. Therefore, its use is most often based on the preference of the surgeon. If a wound drainage system is used, drainage of 200 to 500 mL in the first 24 hours is expected; by 48 hours postoperatively, the total drainage in 8 hours usually decreases to 30 mL or less, and the suction device is then removed; drains that remain in place for longer than 24 hours are at an increased risk for contamination, and infection may occur. The nurse promptly notifies the primary provider of excessive or foul-smelling drainage. If extensive blood loss is anticipated after total joint replacement surgery, an autotransfusion drainage system (in which the drained blood is filtered and reinfused into the patient during the immediate postoperative period) may be used to decrease the need for allogeneic blood transfusions.

Clavicle fractures

Fracture of the clavicle (collar bone) is a common injury that can result from a fall or a direct blow to the shoulder. The clavicle helps maintain the shoulder in the upward, outward, and backward position from the thorax. Therefore, when the clavicle is fractured, the patient assumes a protective position, slumping the shoulders and immobilizing the arm to prevent shoulder movements. The treatment goal is to align the shoulder in its normal position by means of closed reduction and immobilization. Surgical intervention is not typical but may be indicated if the fracture is located in the distal third of the clavicle or is severely displaced, which may result in neurovascular compromise or pneumothorax Most of these fractures occur in the middle third of the clavicle and take 3 to 6 weeks to heal. A clavicular strap, also called a figure-eight bandage may be used to pull the shoulders back, reducing and immobilizing the fracture. The nurse monitors the circulation and nerve function of the affected arm and compares it with the unaffected arm to determine variations, which may indicate disturbances in neurovascular status. A sling may be used to support the arm and relieve pain. The patient may be permitted to use the arm for light activities within the range of comfort Fracture of the distal third of the clavicle, without displacement and ligament disruption, is treated with a sling and restricted motion of the arm. When a fracture in the distal third is accompanied by a disruption of the coracoclavicular ligament that connects the coracoid process of the scapula and the inferior surface of the clavicle, the bony fragments are frequently displaced. This type of injury may be treated by open reduction with internal fixation (ORIF). The nurse cautions the patient not to elevate the arm above shoulder level until the fracture has healed (about 3 to 6 weeks) but encourages the patient to exercise the elbow, wrist, and fingers as soon as possible. When prescribed, shoulder exercises are performed to obtain full shoulder motion Vigorous activity is limited for approximately 3 months. Complications of clavicular fractures include neurovascular injuries (brachial plexus, injury, subclavian vein or artery injury from a bony fragment), pneumothorax, and nonunion

Nursing interventions for monitoring and managing potential complications of skin traction: nerve damage

Skin traction can place pressure on peripheral nerves. Care must be taken to avoid pressure on the peroneal nerve at the point at which it passes around the neck of the fibula just below the knee when traction is applied to the lower extremity. Pressure at this point can cause footdrop. The nurse regularly questions the patient about sensation and asks the patient to move the toes and foot. The nurse should immediately investigate any complaint of a burning sensation under the traction bandage or boot. Dorsiflexion of the foot demonstrates function of the peroneal nerve. Weakness of dorsiflexion or foot movement and inversion of the foot might indicate pressure on the common peroneal nerve. Plantar flexion demonstrates function of the tibial nerve. In addition, the nurse should promptly report altered sensation or impaired motor function.

Fracture reduction

Fracture reduction refers to restoration of the fracture fragments to anatomic alignment and positioning. Either closed reduction or open reduction may be used to reduce a fracture. The specific method selected depends on the nature of the fracture; however, the underlying principles are the same. Usually, the physician reduces a fracture as soon as possible to prevent loss of elasticity from the tissues through infiltration by edema or hemorrhage. In most cases, fracture reduction becomes more difficult as the injury begins to heal Before fracture reduction and immobilization, the patient is prepared for the procedure; consent for the procedure is obtained, and an analgesic agent is given as prescribed. Anesthesia may be given. The injured extremity must be handled gently to avoid additional damage. Closed reduction: In most instances, closed reduction is accomplished by bringing the bone fragments into anatomic alignment through manipulation and manual traction. The extremity is held in the aligned position while a cast, splint, or other device is applied. Reduction under anesthesia with percutaneous pinning may also be used. The immobilizing device maintains the reduction and stabilizes the extremity for bone healing. X-rays are obtained after reduction to verify that the bone fragments are correctly aligned Traction (skin or skeletal) may be used until the patient is physiologically stable to undergo surgical fixation. Open reduction: Some fractures require open reduction. Through a surgical approach, the fracture fragments are anatomically aligned. Internal fixation devices (metallic pins, wires, screws, plates, nails, or rods) may be used to hold the bone fragments in position until solid bone healing occurs. These devices may be attached to the sides of bone, or they may be inserted through the bony fragments or directly into the medullary cavity of the bone. Internal fixation devices ensure firm approximation and fixation of the bony fragments

Elbow fractures

Fractures of the distal humerus result from motor vehicle crashes, falls on the elbow (in the extended or flexed position), or a direct blow. These fractures may result in injury to the median, radial, or ulnar nerves The patient is evaluated for paresthesia and signs of compromised circulation in the forearm and hand. The most serious complication of a supracondylar fracture of the humerus is Volkmann contracture (an acute compartment syndrome), which results from antecubital swelling or damage to the brachial artery and leads to a shortening (contracture) of the forearm muscles. This more commonly occurs in children than adults and will result in a "clawlike" appearance to the hand and wrist. The nurse needs to monitor the patient regularly for compromised neurovascular status and signs and symptoms of acute compartment syndrome. If Volkmann contracture develops, fasciotomy may be necessary with débridement of the muscle Other potential complications are damage to the joint articular surfaces and hemarthrosis (i.e., blood in the joint), which may be treated by needle aspiration by the primary provider to relieve the pressure and pain. The goal of therapy is prompt reduction and stabilization of the distal humeral fracture, followed by controlled active motion after swelling has subsided and healing has begun. If the fracture is not displaced, the arm is immobilized in a posterior long-arm splint for 2 to 3 weeks. At that point, ROM exercises can begin with the use of a hinged brace Usually, a displaced fracture is treated with ORIF. Excision of bone fragments may be necessary. Additional external support with a splint is then applied. Active finger exercises are encouraged. Gentle ROM exercise of the injured joint is begun early. Motion promotes healing of injured joints by producing movement of synovial fluid into the articular cartilage. Active exercise to prevent residual limitation of motion is performed as prescribed. Total elbow arthroplasty may be indicated in the presence of significant comminution (i.e., fragmentation of bone). Pain management is achieved through the use of NSAIDs or opioid medications

Humeral neck fractures

Fractures of the proximal humerus may occur through the neck of the humerus. Impacted fractures of the neck of the humerus are seen most frequently in older women after a fall on an outstretched arm. Active middle-aged patients who are injured in a fall may suffer severely displaced humeral neck fractures with associated rotator cuff damage The patient presents with the affected arm hanging limp at the side or supported by the uninjured hand. Neurovascular assessment of the extremity is essential to evaluate the full extent of injury and the possible involvement of the nerves and blood vessels of the arm. Many impacted fractures of the surgical neck of the humerus are not displaced and do not require reduction. The arm is supported and immobilized by a sling and swathe that secure the supported arm to the trunk Limitation of motion and stiffness of the shoulder occur with disuse. Therefore, pendulum exercises begin as soon as tolerated by the patient. In pendulum or circumduction exercises, the physical therapist instructs the patient to lean forward and allow the affected arm to hang in abduction and rotate. These fractures require approximately 4 to 10 weeks to heal, and the patient should avoid vigorous arm activity for an additional 4 weeks. Residual stiffness, aching, and some limitation of ROM may persist for 6 months or longer When a humeral neck fracture is displaced, treatment consists of closed reduction with splinting, ORIF, or a hemiarthroplasty. Exercises are begun after an adequate period of immobilization

Humeral shaft fractures

Fractures of the shaft of the humerus are most frequently caused by (1) direct trauma that results in a transverse, oblique, or comminuted fracture or (2) an indirect twisting force that results in a spiral fracture. The nerves and brachial blood vessels may be injured with these fractures, so neurovascular assessment is essential to monitor the status of the nerve or blood vessels. Damage to either requires immediate attention. Well-padded splints are used to initially immobilize the upper arm and to support the arm in 90 degrees of flexion at the elbow. A sling or collar and cuff support the forearm. The weight of the hanging arm and splints put traction on the fracture site. External fixators are used to treat open fractures of the humeral shaft ORIF of a fracture of the humerus is necessary with nerve palsy, blood vessel damage, comminuted fracture, or displaced fracture. Functional bracing is another form of treatment used for these fractures. A contoured thermoplastic sleeve is secured in place with interlocking fabric (Velcro) closures around the upper arm, immobilizing the reduced fracture. As swelling decreases, the sleeve is tightened, and uniform pressure and stability are applied to the fracture. The forearm is supported with a collar and cuff sling Functional bracing allows active use of muscles, shoulder and elbow motion, and good approximation of fracture fragments. Pendulum shoulder exercises are performed as prescribed to provide active movement of the shoulder, thereby preventing a "frozen shoulder." Isometric exercises may be prescribed to prevent muscle atrophy. The callus that develops is substantial, and the sleeve can be discontinued in about 8 weeks. Complications that are seen with humeral shaft fractures include delayed union and nonunion because of decreased blood supply in that area.

Skin traction

Skin traction is used less frequently than in years past; the AAOS (2014) recently reported that there was no reduction in pain or complications associated with its use compared with other standard interventions. Nonetheless, skin traction may be prescribed for short-term use to stabilize a fractured leg, control muscle spasms, and immobilize an area before surgery. The pulling force is applied by weights that are attached to the client with Velcro, tape, straps, boots, or cuffs. The amount of weight applied must not exceed the tolerance of the skin. No more than 2 to 3.5 kg (4.5 to 8 lb) of traction can be used on an extremity. Pelvic traction is usually limited to 4.5 to 9 kg (10 to 20 lb), depending on the weight of the patient. Types of skin traction used for adults include Buck's extension traction (applied to the lower leg) (described next), the chin halter strap (occasionally used to treat chronic neck pain), and the pelvic belt (sometimes used to treat lower back pain).

Thoracolumbar spine fractures

Fractures of the thoracolumbar spine may involve (1) the vertebral body, (2) the laminae and articulating processes, and (3) the spinous processes or transverse processes. The T12 to L2 area of the spine, called the thoracolumbar junction, is most vulnerable to fracture. Fractures generally result from indirect trauma caused by excessive loading, sudden muscle contraction, or excessive motion beyond physiologic limits. Osteoporosis contributes to vertebral body collapse (compression fracture). Stable spinal fractures are caused by flexion, extension, lateral bending, or vertical loading. The anterior structural column (vertebral bodies and discs) or the posterior structural column (neural arch, articular processes, ligaments) is disrupted. Unstable fractures occur with fracture dislocations and involve disruption of both anterior and posterior structural columns. The patient with a spinal fracture presents with acute tenderness, swelling, paravertebral muscle spasm, and change in the normal curves or in the gap between spinous processes. Pain is greater with moving, coughing, or weight bearing. Immobilization is essential until initial assessments have determined if there is any spinal cord injury and whether the fracture is stable or unstable. X-rays are initially indicated to confirm the fracture(s), and CT scans or MRI studies are then indicated to precisely determine the extent of injury and spinal cord involvement If spinal cord injury with neurologic deficit does occur, it usually requires immediate surgery (laminectomy with spinal fusion) to decompress the spinal cord. Stable spinal fractures are treated conservatively with limited bed rest. Analgesic medications are prescribed for pain relief. A spinal brace or plastic thoraco-lumbar-sacral orthosis (TLSO) is applied for support during progressive ambulation and resumption of activities. X-rays are taken to monitor the healing process at 6 weeks, 3 months, 6 months, and 1 year The patient with an unstable fracture is treated with bed rest, possibly with the use of a special turning device or bed to maintain spinal alignment. Within 24 hours after fracture, open reduction, decompression, and fixation with spinal fusion and instrument stabilization are usually accomplished. Neurologic status is monitored closely during the preoperative and postoperative periods. Postoperatively, the patient may be cared for on the turning device or in a bed with a firm mattress. Progressive ambulation is begun a few days after surgery, with the patient using a body brace orthosis. Patient education emphasizes good posture, good body mechanics, and, after healing is sufficient, back-strengthening exercises.

Types of fractures book info

Fractures types are classified by location (e.g., proximal, midshaft, distal) and type. Fractures are also described according to the degree of break (e.g., a greenstick fracture refers to a partial break) or the character of any fractured bone fragments (e.g., a comminuted fracture has more than two fragments). A closed fracture (simple fracture) is one that does not cause a break in the skin. An open fracture (compound, or complex, fracture) is one in which the skin or mucous membrane wound extends to the fractured bone. Open fractures are graded according to the following criteria (Halawi & Morwood, 2015): Type I is a clean wound less than 1 cm long. Type II is a larger wound without extensive soft tissue damage or avulsions. Type III (A, B, C) is highly contaminated and has extensive soft tissue damage. It may be accompanied by traumatic amputation and is the most severe. An intra-articular fracture extends into the joint surface of a bone. Because each end of a long bone is cartilaginous, if the fracture is nondisplaced, x-rays will not always reveal the fracture because cartilage is nonradiopaque. MRI or arthroscopy will identify the fracture and confirm the diagnosis. The joint is stabilized and immobilized with a splint or cast, and no weight bearing is allowed until the fracture has healed. Intra-articular fractures often lead to posttraumatic arthritis

Preventing VTE after THA

In the absence of prophylactic therapy, which includes mechanical (e.g., intermittent compression devices) and pharmacologic prophylaxis (e.g., anticoagulant medications for at least 10 days), the risk of postoperative VTE is particularly high after orthopedic surgery. Without prophylaxis, DVT formation can develop within 7 to 14 days following surgery and lead to PE, which can be fatal. Early identification of the patient's VTE risk, ensuring that the patient receives the appropriate prophylaxis, instituting preventive measures, and monitoring the patient closely for clinical signs of the development of DVT and PE are key nursing responsibilities. Physical signs of DVT include pain and tenderness at or below the area of the clot, swelling or tightness of the affected leg, possibly with pitting edema, with either warmth or cooling, and skin discoloration; PE symptoms may include acute onset of dyspnea, tachycardia, confusion, and pleuritic chest pain. Intermittent compression devices should be applied either intraoperatively or immediately postoperatively; these devices must remain on the legs at all times, even when the patient is out of bed. Patients should be instructed to dorsi- and plantar flex the ankles and the toes 10 to 20 times every half hour while awake. In addition, patients who are post-THA should be mobilized as soon as possible to assist with decreasing venous stasis; even patients with epidural catheters should stand and ambulate when they are physically able. Clinical practice guidelines support the use of anticoagulants as the primary effective DVT prophylaxis. The decisions about which medications to use are based on patient risk for PE as well as risk for bleeding, and the dosage is based on patient weight. The use of aspirin, LMWH (e.g., enoxaparin [Lovenox], dalteparin [Fragmin]), and synthetic pentasaccharides (fondaparinux [Arixtra]) are recommended as prophylaxis for VTE should continue for up to 35 days following surgery. The duration of therapy can be variable and is based on surgeon preference and patient risk level.

Clinical manifestations of fractures: localized edema and ecchymosis

Localized edema and ecchymosis occur after a fracture as a result of trauma and bleeding into the tissues. These signs may not develop for several hours after the injury or may develop within an hour, depending on the severity of the fracture.

Skeletal traction

Skeletal traction is often used when continuous traction is desired to immobilize, position, and align a fracture of the femur, tibia, and cervical spine. It is used when traction is to be maintained for a significant amount of time, when skin traction is not possible, and when greater weight (11 to 18 kg [25 to 40 lb]) is needed to achieve the therapeutic effect. Skeletal traction involves passing a metal pin or wire (e.g., Steinmann pin, Kirschner wire) through the bone (e.g., proximal tibia or distal femur) under local anesthesia, avoiding nerves, blood vessels, muscles, tendons, and joints. Traction is then applied using ropes and weights attached to the end of the pin. Alternatively, skeletal traction may involve the application of tongs to the head that are fixed to the skull to immobilize cervical fractures (see Chapter 68). The surgeon applies skeletal traction using surgical asepsis. The insertion site is prepared with a surgical scrub agent such as chlorhexidine solution. A local anesthetic agent is given at the insertion site and periosteum. The surgeon makes a small skin incision and drills the sterile pin or wire through the bone. The patient feels pressure during this procedure and possibly some pain when the periosteum is penetrated. After insertion, the pin or wire is attached to the traction bow or caliper. The ends of the pin or wire are covered with caps to prevent injury to the patient or caregivers. The weights are attached to the pin or wire bow by a rope and pulley system that exerts the appropriate amount and direction of pull for effective traction. The weights applied initially must overcome the shortening spasms of the affected muscles. As the muscles relax, the traction weight is reduced to prevent fracture dislocation and to promote healing. Often, skeletal traction is balanced traction, which supports the affected extremity, allows for some patient movement, and facilitates patient independence and nursing care while maintaining effective traction. The Thomas splint with a Pearson attachment is frequently used with skeletal traction for fractures of the femur (see Fig. 40-6). Because upward traction is required, an overbed frame is used. When skeletal traction is discontinued, the extremity is gently supported while the weights are removed. The pin is cut close to the skin and removed by the surgeon. Internal fixation, casts, or splints are then used to immobilize and support the healing bone.

Monitoring and managing potential complications of hip fractures

Neurovascular complications may occur from direct injury or edema in the area that causes compression of nerves and blood vessels. With hip fracture, bleeding into the tissues and edema are expected. Monitoring and documenting the neurovascular status of the affected leg are vital. To prevent VTE, the nurse encourages intake of fluids and ankle and foot exercises. Antiembolism stockings, pneumatic compression devices, and prophylactic anticoagulant therapy are indicated and should be prescribed During hospitalization, the patient or the patient's caregiver should be educated regarding the signs, symptoms, and risks of VTE, and how to administer anticoagulant prophylaxis as prescribed (see Chart 42-4). Intermittent assessment of the patient's legs for signs of DVT, which may include unilateral calf tenderness, warmth, redness, and swelling, is indicated. Pulmonary complications (e.g., atelectasis, pneumonia) are a threat to older patients undergoing hip surgery. Coughing and deep-breathing exercises, intermittent changes of position, and the use of an incentive spirometer may help prevent respiratory complications. Pain must be treated with analgesic agents, typically opioids; otherwise, the patient may not be able to cough, deep breathe, or engage in prescribed activities. The nurse assesses breath sounds to detect adventitious or diminished sounds. Skin breakdown is often seen in older patients with hip fracture. Blisters caused by tape are related to the tension of soft tissue edema under a nonelastic tape. An elastic hip wrap dressing or elastic tape applied in a vertical fashion may reduce the incidence of tape blisters. In addition, patients with hip fractures tend to remain in one position and may develop pressure ulcers. Proper skin care, especially on the bony prominences, helps to relieve pressure. High-density foam mattress overlays may provide protection by distributing pressure evenly. Loss of bladder control (incontinence or retention) may occur. In general, the routine use of an indwelling catheter is avoided because of the high risk of urinary tract infection. If a catheter is inserted at the time of surgery, it usually is removed on the first postoperative day followed by a trial to void Because urinary retention is common after surgery, the nurse must assess the patient's voiding patterns. To ensure proper urinary tract function, the nurse encourages liberal fluid intake if the patient has no pre-existing cardiac disease. Delayed complications of hip fractures include infection, nonunion, and AVN of the femoral head (particularly with femoral neck fractures). Infection is suspected if the patient complains of constant p

Gerontologic considerations for rib fractures

Older adults sustaining rib fractures are at an increased risk for complications. Even in the presence of isolated rib trauma, hospital admission is recommended for the older adult with multiple rib fractures or for the older adult who cannot effectively cough and mobilize sputum Careful monitoring of respiratory status and encouraging the patient to mobilize early, and, for the bedfast patient, encouraging turning, coughing, and deep breathing and use of an incentive spirometer, can prevent respiratory complications

Promoting exercise in traction

Patient exercises, within the therapeutic limits of the traction, assist in maintaining muscle strength and tone, and in promoting circulation. Active exercises include pulling up on the trapeze, flexing and extending the feet, and range-of-motion and weight-resistance exercises for noninvolved joints. Isometric exercises of the immobilized extremity (quadriceps and gluteal setting exercises) are important for maintaining strength in major ambulatory muscles. Without exercise, the patient will lose muscle mass and strength, and rehabilitation will be greatly prolonged.

Promoting ambulation after THA

Patients begin ambulation with the assistance of a walker or crutches within a day after surgery. The nurse and the physical therapist assist the patient in achieving the goal of independent ambulation. At first, the patient may be able to stand for only a brief period because of orthostatic hypotension. Specific weight-bearing limits on the prosthesis are based on the patient's condition, the procedure, and the fixation method. Usually, patients with cemented prostheses can proceed to weight bearing as tolerated. If the patient has a press-fit, cementless, ingrowth prosthesis, weight bearing immediately after surgery may be limited to minimize micromotion of the prosthesis in the bone. As the patient is able to tolerate more activity, the nurse encourages transferring to a chair several times a day for short periods and walking for progressively greater distances.

Nursing mgmt for external fixators book

Patients should be prepared psychologically for application of the external fixator, as they may be at risk for an altered body image related to the size and bulk of the apparatus. To promote acceptance of the device, patients should be given comprehensive information about the frame, reassurance that the discomfort associated with the device is minimal, and that early mobility is anticipated; however, among patients who have had significant trauma there may not be time to engage them in this type of preparation. Clothing and other materials may need to be altered or used to cover the device. After the external fixator is applied, the extremity is elevated to the level of the heart to reduce swelling, if appropriate. Any sharp points on the fixator or pins are covered with caps to prevent device-induced injuries. The nurse must be alert for potential problems caused by pressure from the device on the skin, nerves, or blood vessels and for the development of compartment syndrome The nurse monitors the neurovascular status of the extremity every 2 to 4 hours and promptly reports changes to the primary provider (Pechar & Lyons, 2016). Because the pins are inserted externally, particular attention is focused on the pin sites for signs of inflammation and infection. The end goal is to avoid osteomyelitis (infection of the bone) The nurse assesses each pin site at least every 8 to 12 hours for redness, swelling, pain around the pin sites, warmth, and purulent drainage, because these are the most common indicators of pin site infections. In the first 48 to 72 hours postinsertion, some serous drainage, skin warmth, and mild redness at the pin sites are expected; these are expected to subside after 72 hours. Currently, there is no consensus or research-based evidence to direct the best method for cleansing and dressing percutaneous pin sites to minimize infection rates and complications In the absence of such research, aseptic technique during pin insertion (Ktistakis et al., 2015) is advised, along with general strategies such as cleansing each pin site separately to avoid cross contamination with nonshedding material (e.g., gauze, cotton-tip swab) and using chlorhexidine 2 mg/mL solution once weekly. Pin sites should be cleaned and dressed as prescribed unless there is copious drainage, the dressing becomes wet, or infection is suspected, in which case cleaning and dressing may be more frequent. If signs of infection are present or if the pins or clamps seem loose, the nurse notifies the primary provider. If activity is restricted, the nurse encourages isometric exercises as tolerated to prevent complications of mobility (e.g., thrombus formation). When the swelling subsides, the nurse helps the patient become mobile within the prescribed weight-bearing limits (non-weight bearing to full weight bearing). Adherence to weight-bearing instructions minimizes the chance of loosening of the pins when stress is applied to the bone-pin interface. The external fixator may be removed once the soft tissue heals and there are no signs of infection. The fracture may require additional stabilization by a cast, molded orthosis, or internal fixation while healing. Ilizarov fixation is a specialized type of external fixator consisting of numerous wires that penetrate the limb and are attached to a circular metal frame. This device is used to correct angulation and rotational defects, to treat nonunion (failure of bone fragments to heal), and to lengthen limbs. The device gently pulls apart the cortex of the bone and stimulates new growth through daily adjustment of the telescoping rods. The nurse must educate the patient about adjusting the telescoping rods and caring for the pin sites and apparatus, because this fixator can be in place for many months. When discharge is anticipated, the nurse educates the patient or caregiver about how to perform pin site care according to the prescribed protocol (clean technique can be used at home) and to promptly report any signs of pin site infection. The nurse also instructs the patient or family to monitor neurovascular status and report any changes promptly. The patient or family members are instructed to check the integrity of the fixator frame daily and to report loose pins or clamps. A physical therapy referral is helpful in educating the patient how to transfer, use ambulatory aids safely, and adjust to weight-bearing limits and altered gait patterns. Avoid excessive use of injured extremity. Observe prescribed weight-bearing limits. Demonstrate ability to transfer (e.g., from a bed to a chair) and/or safe use of mobility aid.

Application of cast

Performed by orthopedic technologists

Fiberglass casts

Polyurethane resins that have the versatility of plaster but are lighter in weight, stronger, water resistant, and more durable than plaster. Facilitate radiographic imaging better than plaster Benefit of reaching full rigidity within 30 minutes of application More difficult to contour and mold More commonly used for simple fractures of the upper and lower extremities Consist of open-weave, nonabsorbent fabric that requires tepid water for activation Heat given off while cast is applied: exothermic Prepare client for sensation of increasing warmth Can cause thermal injury Gore-Tex: waterproof lining for fiberglass casts If the cast is wet: the patient is instructed to shake or drain water out of it; thorough drying is important to prevent skin breakdown, infection, or irritation. The best results are achieved with casts that can easily drain, such as short-arm casts. Heels and elbows encased in wet casts may become macerated from trapped water: skin breakdown

Quadriceps setting exercise

Position patient supine with leg extended. Instruct patient to push knee back onto the mattress by contracting the anterior thigh muscles. Encourage patient to hold the position for 5 to 10 seconds. Let patient relax. Have patient repeat the exercise 10 times each hour when awake.

Gluteal setting exercise

Position patient supine with legs extended, if possible. Instruct patient to contract the muscles of the buttocks. Encourage patient to hold the contraction for 5 to 10 seconds. Let the patient relax. Have patient repeat the exercise 10 times each hour when awake.

Cast

Rigid external immobilizing device that is molded to the body Must fit shape of injured limb vcorrectly to provide best support possible Immobilizes reduced fracture, to correct or prevent a deformity (clubfoot, hip displacement), apply uniform pressure to underlying soft tissue, or support and stabilize weakened joints Permit mobilization of pt while restricting mvmt of affected body part Mainstay of tx for fractures Most common casting materials: fiberglass or plaster of Paris: moldable Choice depends on condition being tx, availability, and costs Joints proximal and distal to area immobilized are included in the cast Cast and molding may allow mvmt of joint while immobilizing a fracture (3 pt fixation in patellar tendon weight-bearing cast) 3 main groups: Short-arm cast: extends from below the elbow to palmar crease, secured around the base of the thumb. If thumb is included, it is known as a thumb spica or gauntlet cast Long-arm cast: Extends from axillary fold to the proximal palmar crease. The elbow usually is immobilized at a right angle. Short-leg cast: Extends from below the knee to the base of the toes. The foot is flexed at a right angle in a neutral position Long-leg cast: Extends from the junction of the upper and middle third of the thigh to the base of the toes. The knee may be slightly flexed. Walking cast: Short- or long-leg cast reinforced for strength Body cast: Encircles trunk Shoulder spica cast: A body jacket that encloses the trunk, shoulder, and elbow Hip spica cast: Encloses the trunk and a lower extremity. A double hip spica cast include both legs

Nursing interventions for monitoring neurovascular status for skeletal traction

The nurse evaluates the body part to be placed in traction and compares its neurovascular status (e.g., color, temperature, capillary refill, edema, pulses, ability to move, and sensations) to the unaffected extremity every hour for the first 24 hours after traction is applied and every 4 hours thereafter. The nurse instructs the patient to report any changes in sensation or movement immediately so that they can be promptly evaluated. Venous thromboembolus (VTE) formation is a significant risk for the immobilized patient. The nurse encourages the patient to do active flexion-extension ankle exercises and isometric contraction of the calf muscles (calf-pumping exercises) 10 times an hour while awake to decrease venous stasis. In addition, antiembolism stockings, compression devices, and anticoagulant therapy may be prescribed to help prevent thrombus formation. The nurse must never remove weights from skeletal traction unless a life-threatening situation occurs. Removal of the weights defeats their purpose and may result in injury to the patient.

Patient education for avoiding hip dislocated after arthroplasty with posterior or posterolateral approach

The nurse instructs the patient to: Until the hip prosthesis stabilizes after hip replacement surgery, it is necessary to follow instructions for proper positioning so that the prosthesis remains in place. Dislocation of the hip is a serious complication of surgery that causes pain and loss of function and necessitates reduction under anesthesia to correct the dislocation. Desirable positions include abduction, neutral rotation, and flexion of less than 90 degrees. When you are seated, the knees should be lower than the hip. The nurse notes the following methods for avoiding displacement: Keep the knees apart at all times. Put a pillow between the legs when sleeping. Never cross the legs when seated. Avoid bending forward when seated in a chair. Avoid bending forward to pick up an object on the floor. Use a high-seated chair and a raised toilet seat. Do not flex the hip to put on clothing such as pants, stockings, socks, or shoes. Positions to avoid after total hip replacement are shown in the illustrations.

Nursing interventions for THA

The nurse must be aware of and monitor for specific potential complications associated with THA. Complications that may occur include dislocation of the hip prosthesis, excessive wound drainage, VTE, infection, and heel pressure ulcer The nurse also monitors for complications associated with immobility. Long-term complications include heterotopic ossification (formation of bone in the periprosthetic space), avascular necrosis, and loosening of the prosthesis.

Nursing management for assessing anxiety in traction

The nurse must consider the psychological and physiologic impact of the musculoskeletal problem, traction device, and immobility. Traction restricts mobility and independence. The equipment can look threatening, and its application can be frightening. Confusion, disorientation, and behavioral problems may develop in patients who are confined in a limited space for an extended time. Therefore, the nurse must assess and monitor the patient's anxiety level and psychological responses to traction.

Nursing interventions for maintaining positioning for skeletal traction

The nurse must maintain alignment of the patient's body in traction as prescribed to promote an effective line of pull (Zhang, 2015). The nurse positions the patient's foot to avoid footdrop (plantar flexion), inward rotation (inversion), and outward rotation (eversion). The patient's foot may be supported in a neutral position by orthopedic devices (e.g., foot supports). If the patient reports severe pain from muscle spasm, the weights may be too heavy or the patient may need realignment. Pain must be reported to the primary provider if body alignment fails to reduce discomfort. Opioid and nonopioid analgesics may be used to control pain. Muscle relaxants may be prescribed to relieve muscles spasms as needed.

Gerontologic considereations for THA

The older adult patient who has had THA merits special postoperative care considerations. Early THA surgery for hip fractures (within 24 to 36 hours) is recommended for most patients once a medical assessment has been made and the patient's condition has been stabilized appropriately. If there are no contraindications (e.g., history of a bleeding disorder), these patients should receive LMWH for DVT prophylaxis; mechanical devices should be used for patients in whom anticoagulants and antiplatelet agents are contraindicated. Providing an appropriate postoperative analgesic regimen for older adults can be challenging in the presence of impaired cognition, medical comorbidities, and possible drug interactions. Consulting with a pain management specialist to specifically tailor the analgesic type and dose may be helpful (see Chapter 12). All older adult patients' post-THA should be placed on a higher-specification, foam pressure-relieving mattress rather than a standard hospital mattress A major goal following surgery in this patient population is early mobilization, in an effort to prevent the complications associated with prolonged immobility and to return the patient to functional activity. Early assisted mobilization and ambulation on the day of surgery can decrease hospital length of stay, complications, and hospital costs and can prepare patients to care for themselves at home with a higher level of independent functioning. Patients who are assigned to restricted hip precautions have slower rehabilitation and return to usual ADLs

Clinical manifestations of fractures: pain

The pain is continuous and increases in severity until the bone fragments are immobilized. Immediately after a fracture, the injured area becomes numb and the surrounding muscles flaccid. The muscle spasms that accompany a fracture begin shortly thereafter, within a few to 30 minutes, and result in more intense pain than the patient reports at the time of injury. The muscle spasms can minimize further movement of the fracture fragments or can result in further bony fragmentation or malalignment

Promoting exercise for somebody with a hip fracture

The patient is encouraged to exercise as much as possible by means of the overbed trapeze. This device helps strengthen the arms and shoulders in preparation for protected ambulation (e.g., toe touch, partial weight bearing). On the first postoperative day, the patient transfers to a chair with assistance and begins assisted ambulation. The amount of weight bearing that can be permitted depends on the stability of the fracture reduction. The primary provider prescribes the degree of weight bearing. In general, hip flexion and internal rotation restrictions apply only if the patient has had a hemiarthroplasty or total arthroplasty. Physical therapists work with the patient on transfers, ambulation, and the safe use of assistive devices. The patient can anticipate discharge to home or to an extended-care facility with the use of assistive devices. Some modifications in the home may be needed, such as installation of elevated toilet seats and grab bars.

Patients with closed fractures nursing mgmt

The patient with a closed fracture has no opening in the skin at the fracture site. The fractured bones may be nondisplaced or slightly displaced, but the skin is intact. The nurse educates the patient regarding the proper methods to control edema and pain Describe approaches to control swelling (e.g., elevate extremity to heart level). Consume a healthy diet to promote bone healing. Observe prescribed weight-bearing and activity limits. Participate in prescribed exercise regimen to maintain the health of unaffected muscles and those muscles now needed for safe transfer, mobility, etc. If indicated, demonstrate safe use of mobility aid, assistive device, immobilizing device and transfer technique. It is important to educate about exercises to maintain the health of unaffected muscles and to increase the strength of muscles needed for transferring and for using assistive devices such as crutches, walkers, and special utensils. The patient is also educated to use assistive devices safely. Plans are made to help patients modify the home environment as needed and to ensure safety, such as removing floor rugs or anything that obstructs walking paths throughout the house. Patient education includes self-care, medication information, monitoring for potential complications, and the need for continuing health care supervision. Fracture healing and restoration of strength and mobility may take an average of 6 to 8 weeks, depending on the quality of the patient's bone tissue

Nursing interventions for preventing skin breakdown for skeletal traction

The patient's elbows frequently become sore, and nerve injury may occur if the patient repositions by pushing on the elbows. In addition, patients frequently push on the heel of the unaffected leg when they raise themselves. This digging of the heel into the mattress may injure the tissues. It is important to instruct patients not to use their heels or elbows to push themselves up in bed. To encourage movement without using the elbows or heel, a trapeze can be suspended overhead within easy reach of the patient. The trapeze helps the patient move about in bed and move on and off the bedpan. Transparent film, hydrocolloid dressings, or skin sealants may also be applied to bony prominences (such as elbows) or critical areas to decrease the force of shearing and friction. Specific pressure points are assessed for irritation and inflammation at least every 8 hours. Patients at high risk for skin breakdown (e.g., older adults, malnourished patients) may need to be assessed more frequently. Areas that are particularly vulnerable to pressure caused by a traction apparatus applied to the lower extremity include the ischial tuberosity, popliteal space, Achilles tendon, and heel. If the patient is not permitted to turn on one side or the other, the nurse must make a special effort to provide back care and to keep the bed dry and free of crumbs and wrinkles. The patient can assist by holding the overhead trapeze and raising the hips off the bed. If the patient cannot do this, the nurse can push down on the mattress with one hand to relieve pressure on the back and bony prominences and to provide for some shifting of weight. Advanced static mattresses or overlays should be used rather than foam or alternating-air/low-air-loss mattresses to reduce the risk of pressure ulcer formation. The patient's heel should be placed on a pillow or heel suspension device to keep the heel from the bed's surface. For change of bed linens, the patient raises the torso while caregivers on both sides of the bed roll down and replace the upper mattress sheet. Then, as the patient raises the buttocks off the mattress, the sheets are slid under the buttocks. Finally, the lower section of the bed linens is replaced while the patient rests on the back. Sheets and blankets are placed over the patient in such a way that the traction is not disrupted.

Providing pin site care for skeletal traction

The wound at the pin insertion site requires attention, and it is important to follow the facility's specific policy pertaining to skeletal pin care. The goal is to avoid infection and development of osteomyelitis. For the first 48 hours after insertion, the site is covered with a sterile absorbent nonstick dressing and a rolled gauze or Ace-type bandage. After this time, a loose cover dressing or no dressing is recommended (a bandage is necessary if the patient is exposed to airborne dust). Evidence-based recommendations for pin site care include the following: Pins located in areas with soft tissue are at greatest risk for infection. After the first 48 to 72 hours following skeletal pin placement, pin site care should be performed daily or weekly. Chlorhexidine 2 mg/mL solution is the most effective cleansing solution. If chlorhexidine is contraindicated (due to known sensitivity or skin reaction), saline solution should be used for cleansing. Strict handwashing before and after skeletal pin site care should always take place. The nurse must inspect the pin sites every 8 hours for reaction (i.e., normal changes that occur at the pin site after insertion) and infection. Signs of reaction may include redness, warmth, and serosanguineous drainage at the site, which tend to subside after 72 hours. Signs of infection may mirror those of reaction but also include the presence of purulent drainage, pin loosening, tenting of skin at pin site, odor, and fever. Prophylactic broad-spectrum IV antibiotics may be given for 24 to 48 hours postinsertion to prevent infection; however, the evidence is confounding and there is no general consensus on the advisability of this practice. Minor infections may be readily treated with antibiotics, and infections that result in systemic manifestations may additionally warrant pin removal until the infection resolves. The nurse must inspect the pin site at least every 8 hours for signs of inflammation and evidence of infection. Due to a lack of evidence-based research findings, controversy exists about skeletal pin care, showering, and the use of massage to release skin adherence to pins. Some evidence suggests that crusting at the pin site should be retained as long as the pin site remains uninfected as the retained crusts provides a natural barrier from bacterial contamination The patient and family should be taught to perform any prescribed pin site care prior to discharge from the hospital and should be provided with written follow-up instructions that include the signs and symptoms of infection.

Nursing interventions for ensuring effective skin traction

To ensure effective skin traction, it is important to avoid wrinkling and slipping of the traction bandage and to maintain countertraction. Proper positioning must be maintained to keep the leg in a neutral position. To prevent bony fragments from moving against one another, the patient should not turn from side to side; however, the patient may shift position slightly with assistance.

Total Hip Arthroplasty

Total hip arthroplasty (THA) is the replacement of a severely damaged hip with an artificial joint. Indications for this surgery include osteoarthritis, rheumatoid arthritis, femoral neck fractures (i.e., hip fracture), failure of previous reconstructive surgeries, such as a failed prosthesis with osteotomy (surgical cutting of the bone), and conditions resulting from developmental dysplasia or Legg-Calvé-Perthes disease (avascular necrosis of the hip in childhood). A variety of total hip prostheses are available. Most consist of a metal femoral component topped by a spherical ball made of metal, ceramic, or plastic that is fitted into a plastic or metal acetabular socket The surgeon selects the prosthesis that is best suited to the individual patient, considering various factors including skeletal structure and activity level. The patient has irreversibly damaged hip joints, and the potential benefits, including improved quality of life, outweigh the surgical risks. With the advent of improved prosthetic materials and operative techniques, the life of the prosthesis has been extended, and today younger patients with severely damaged and painful hip joints are undergoing total hip replacement.

Traction information from book

Traction uses a pulling force to promote and maintain alignment to an injured part of the body. The goals of traction include decreasing muscle spasms and pain, realignment of bone fractures, and correcting or preventing deformities. The type of traction, amount of weight, and whether traction can be removed for nursing care must be determined to obtain its therapeutic effects. At times, traction needs to be applied in more than one direction to achieve the desired line of pull. When this is done, one of the lines of pull counteracts the other. These lines of pull are known as the vectors of force. The actual resultant pulling force is somewhere between the two lines of pull (see Fig. 40-4). The effects of traction are evaluated with x-ray studies, and adjustments are made if necessary. Traction is used primarily as a short-term intervention until other modalities, such as external or internal fixation, are possible. These modalities reduce the risk of disuse syndrome and minimize hospital lengths of stay, often allowing the patient to be cared for in the home setting.

Rib fractures

Uncomplicated fractures of the lower ribs occur frequently in adults of all ages, typically from either motor vehicle crashes or falls, and usually result in no impairment of function. They are typically diagnosed based on clinical presentation and confirmed with x-rays or ultrasound scans (Melendez, 2015). Because these fractures cause pain with respiratory effort, the patient tends to decrease respiratory excursions and refrains from coughing. As a result, tracheobronchial secretions are not mobilized, aeration of the lung is diminished, and a predisposition to atelectasis and pneumonia results. To help the patient cough and take deep breaths and use an incentive spirometer, the nurse may splint the chest with their hands, or may educate the patient on using a pillow to temporarily splint the affected site. NSAIDs may be prescribed to provide analgesic relief. Occasionally, an anesthesia care provider administers intercostal nerve blocks or epidural analgesia to relieve pain and to improve respiratory function Chest binders to immobilize the rib fracture are not used, because decreased chest expansion may result in atelectasis and pneumonia. Incentive spirometer use may aid in prevention of these complications. The fracture heals within 6 weeks. In addition to atelectasis and pneumonia, complications may include a flail chest, pneumothorax, and hemothorax. The assessment and management of patients with these conditions are discussed in

Unstable pelvic fractures

Unstable fractures of the pelvis may result in rotational instability (e.g., the "open book" type, in which a separation occurs at the symphysis pubis with sacroiliac ligament disruption), vertical instability, or a combination of both. Lateral or anteroposterior compression of the pelvis produces rotationally unstable pelvic fractures. Vertically unstable pelvic fractures occur when force is exerted on the pelvis vertically, as may occur when the patient falls onto extended legs or is struck from above by a falling object. Vertical shear pelvic fractures involve the anterior and posterior pelvic ring with vertical displacement, usually through the sacroiliac joint. There is generally complete disruption of the posterior sacroiliac, sacrospinous, and sacrotuberous ligaments. Immediate treatment in the ED for a patient with an unstable pelvic fracture includes stabilizing the pelvic bones and compressing bleeding vessels with a pelvic girdle, which is an external binding and stabilizing device. If major vessels are lacerated, the bleeding may be stopped through embolization using interventional radiology techniques prior to surgery. More than 10% of deaths in patients with unstable pelvic fractures occur because of frank hemorrhage Therefore, these patients are at risk for hemorrhagic shock. When the patient is hemodynamically stable, treatment generally involves external fixation or ORIF. These measures promote hemostasis, hemodynamic stability, comfort, and early mobilization.

Traction complications: Venous Thromboembolism

Venous stasis that predisposes the patient to VTE occurs with immobility. The nurse educates the patient about how to perform ankle and foot exercises within the limits of the traction therapy every 1 to 2 hours when awake to prevent DVT. Involving family members in performing these exercises can increase adherence and promote the family's involvement with the patient's care. The patient is encouraged to drink fluids to prevent dehydration and associated hemoconcentration, which contribute to stasis. The nurse monitors the patient for signs of DVT, including unilateral calf tenderness, warmth, redness, and swelling (increased calf circumference). The nurse promptly reports findings to the primary provider for evaluation and therapy. During traction therapy, the nurse encourages the patient to exercise muscles and joints that are not in traction to prevent deterioration, deconditioning, and venous stasis. The physical therapist can design bed exercises that minimize loss of muscle strength. During the patient's exercise, the nurse ensures that traction forces are maintained and that the patient is properly positioned to prevent complications resulting from poor alignment.

Fractures healing and complications

Weeks to months are required for most fractures to heal. Many factors influence the time frame of the healing process. With a comminuted fracture, fragments must be properly aligned to attain the best healing possible. It is essential for the fractured bone to have blood supply to the area to facilitate the healing process. In general, fractures of flat bones (pelvis, sternum, and scapula) heal rapidly. A complex, comminuted fracture may heal slowly. Fractures at the ends of long bones, where the bone is more vascular and cancellous, heal more quickly than do fractures in areas where the bone is dense and less vascular (midshaft). Fractures typically heal more quickly in younger patients If fracture healing is disrupted, bone union may be delayed or stopped completely. Factors that can impair fracture healing include inadequate fracture immobilization, inadequate blood supply to the fracture site or adjacent tissue, multiple trauma, extensive bone loss, infection, poor adherence to prescribed restrictions, malignancy, certain medications (e.g., corticosteroids), older age, and some disease processes (e.g., rheumatoid arthritis) Complications of fractures may be either acute or chronic. Early complications include shock, fat embolism, compartment syndrome, and VTE (deep vein thrombosis [DVT], pulmonary embolism [PE]). Delayed complications include delayed union, malunion, nonunion, AVN of bone, complex regional pain syndrome (CRPS, formerly called reflex sympathetic dystrophy), and heterotopic ossification.

Cast/splints/braces continuing and transitional care

When ready for removal: prepare pt by explaining what to expect Never remove cast themselves Cast saw will be used to remove cast: oscillating blade that vibrates but does not spin: cuts outer cast but does not penetrate deeply enough to injure skin Cut along both sides of cast. Spread and opened and a special tool is used to lift it off Scissors cut thru protective padding and stockinette to ensure no skin-cutting.