Ch 62 Fractures
Balanced Suspension Traction When traction is used to treat fractures, the forces are usually exerted on the distal fragment to obtain alignment with the proximal fragment. One of the more common types of skeletal traction is balanced suspension traction (Fig. 62-10).
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Buck's Traction A Buck's traction boot is a type of skin traction that is used to immobilize a fracture, prevent hip flexion contractures, and reduce muscle spasms.
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Classification •Displaced or nondisplaced -Displaced: two ends separated from one another •Often comminuted or oblique -Nondisplaced: periosteum is intact and bone is aligned. •Usually transverse, spiral , or greenstick
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Compartment Syndrome Clinical Manifestations •Early recognition and treatment essential •May occur initially or may be delayed several days •Ischemia can occur within 4 to 8 hours after onset
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Evaluation •Report satisfactory pain management •Appropriate care of cast or immobilizer •No peripheral neurovascular dysfunction •Uncomplicated bone healing
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External Fixation A, Stabilization of hand injury. B, Stabilization of knee injury with pins in femur and tibia. The external fixator is attached directly to the bones by percutaneous transfixing pins or wires.
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Fasciotomy for Compartment Syndrome Volkmann's ischemic contracture of the forearm following acute compartment syndrome secondary to a supracondylar fracture of the humerus. Note the incision line of an unsuccessful fasciotomy.
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Internal Fixation Internal fixation devices (pins, plates, intramedullary rods, and metal and bioabsorbable screws) are surgically inserted to realign and maintain position of bony fragments. These metal devices are biologically inert and made from stainless steel, vitallium, or titanium. Proper alignment and bone healing are evaluated regularly by x-rays.
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Neurovascular Assessment •Peripheral neurologic -Motor function •Upper and lower extremities -Sensory function -Paresthesia
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Neurovascular Assessment •Peripheral vascular -Color and temperature -Capillary refill -Pulses -Edema
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Nursing Implementation •Acute Care -Patients with fractures can be treated in the emergency department or a physician's office -Patients are released home, or they may require hospitalization
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Stabilization of Knee Injury Pins in femur and tibia
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Types of fractures. A, Transverse fracture is a fracture in which the line of the fracture extends across the bone shaft at a right angle to the longitudinal axis. B, Spiral fracture is a fracture in which the line of the fracture extends in a spiral direction along the shaft of the bone. C, Greenstick fracture is an incomplete fracture with one side splintered and the other side bent. D, Comminuted fracture is a fracture with more than two fragments. The smaller fragments appear to be floating. E, Oblique fracture is a fracture in which the line of the fracture extends in an oblique direction. F, Pathologic fracture is a spontaneous fracture at the site of a bone disease. G, Stress fracture is a fracture that occurs in normal or abnormal bone that is subject to repeated stress, such as from jogging or running.
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Fracture Immobilization •Cast -Temporary -Allows patient to perform many normal activities of daily living -Made of various materials -Typically incorporates joints above and below fracture
A cast is a temporary circumferential immobilization device. Casting is a common treatment following closed reduction. It allows the patient to perform many normal activities of daily living while providing sufficient immobilization to ensure stability. Cast materials are natural (plaster of Paris), synthetic acrylic, fiberglass-free, latex-free polymer, or a hybrid of materials. A cast generally incorporates the joints above and below a fracture. Immobilization above and below a joint restricts tendon and ligament movement, therefore assisting with joint stabilization while the fracture heals.
Fractures •Disruption or break in continuity of structure of bone •Majority of fractures from traumatic injuries •Some fractures secondary to disease process -Cancer or osteoporosis
A fracture is a disruption or break in the continuity of the structure of bone. Although traumatic injuries account for the majority of fractures, some fractures are secondary to a disease process (pathologic fractures from cancer or osteoporosis).
Lower Extremity Immobilization •Elevate extremity above heart •Do not place in a dependent position •Observe for signs of compartment syndrome and increased pressure
After the application of a lower extremity cast or dressing, the extremity should be elevated on pillows above heart level for the first 24 hours. After the initial phase, a casted extremity should not be placed in a dependent position because of the possibility of excessive edema. After cast application, observe for signs of compartment syndrome and increased pressure, especially in the heel, anterior tibia, head of fibula, and malleoli. This increased pressure is manifested by pain or burning in these areas.
Nursing Assessment •Subjective Data - Functional Health Patterns -Estrogen replacement therapy -Calcium supplementation -Loss of motion or weakness of affected part -Muscle spasms -Pain, numbness, tingling, loss of sensation
Also obtain the following important health information related to pertinent functional health patterns: Health perception-health management: Estrogen replacement therapy, calcium supplementation Activity-exercise: Loss of motion or weakness of affected part; muscle spasms Cognitive-perceptual: Sudden and severe pain in affected area; numbness, tingling, loss of sensation distal to injury; chronic pain that increases with activity (stress fract
Nutritional Therapy •↑ Protein (1 g/kg of body weight) •↑ Vitamins (B, C, D) •↑ Calcium, phosphorus , and magnesium •↑ Fluid (2000-3000 mL/day) •↑ Fiber •Body jacket and hip spica cast patients: six small meals a day
An adequate energy source is needed to promote muscle strength and tone, build endurance, and provide energy for ambulation and gait-training skills. The patient's dietary requirements must include adequate protein (e.g., 1 g/kg of body weight), vitamins (especially B, C, and D), and calcium, phosphorus, and magnesium to ensure optimal soft tissue and bone healing. Low serum protein and vitamin C deficiencies interfere with tissue healing. Immobility and bone healing increase calcium needs. Three well-balanced meals a day usually provide the necessary nutrients. A well-balanced meal should be supplemented by a fluid intake of 2000 to 3000 mL/day to promote optimal bladder and bowel function. Adequate fluid and a high-fiber diet with fruits and vegetables will prevent constipation. If immobilized in bed with skeletal traction or in a body jacket brace, instruct the patient to eat six small meals so as not to overeating that can contribute to abdominal pressure and cramping.
External Fixation •Metal pins and rods •Applies traction •Compresses fracture fragments •Immobilizes and holds fracture fragments in place
An external fixator is a metallic device composed of metal pins that are inserted into the bone and attached to external rods to stabilize the fracture while it heals. It can be used to apply traction or to compress fracture fragments and immobilize reduced fragments when the use of a cast or other traction is not appropriate. The external device holds fracture fragments in place similar to a surgically implanted internal device.
Audience Response Question A patient has a severely sprained ankle from a sports injury. What should the nurse teach the patient prior to discharge from the urgent care center? a.Alternate cold and heat for 30 minutes each until symptoms are relieved. b.Apply cold for 20 to 30 minutes with breaks of 10 to 15 minutes during the first 2 days. c.Use continuous cold for the first 24 hours and then continuous heat until the symptoms are relieved. d.Apply continuous heat to the ankle for the first 24 hours and then continuous cold until the symptoms are relieved.
Answer: B Rationale: If an injury occurs, immediate care focuses on (1) stopping the activity and limiting movement, (2) applying ice compresses to the injured area, (3) compressing the involved extremity, (4) elevating the extremity, and (5) providing analgesia as necessary. These interventions will decrease local inflammation and pain for most musculoskeletal injuries. Cold (cryotherapy) in several forms can be used to produce hypothermia to the involved part. Physiologic changes that occur in soft tissue as a result of the use of cold include vasoconstriction and reduction in the transmission and perception of nerve pain impulses. These changes result in analgesia and anesthesia, reduction of muscle spasm without changes in muscular strength or endurance, reduction of local edema and inflammation, and reduction of local metabolic requirements. Cold is most useful when applied immediately after the injury has occurred. Ice applications should not exceed 20 to 30 minutes per application, and ice should not be applied directly to the skin. After the acute phase (usually 24 to 48 hours), warm, moist heat may be applied to the affected part to reduce swelling and provide comfort. Heat applications should not exceed 20 to 30 minutes, allowing a "cool-down" time between applications.
Audience Response Question A plaster splint is applied with an elastic bandage to the leg of a patient with a fractured tibia in preparation for open reduction and internal fixation. The patient complains of increasing pain in the affected leg and foot that is not relieved by loosening of the elastic bandage. The most appropriate action by the nurse is to a.elevate the leg on two pillows. b.apply ice over the fracture site. c.notify the health care provider. d.perform neurovascular assessment of the foot.
Answer: D Rationale: Prompt, accurate diagnosis of compartment syndrome is critical. Prevention or early recognition is the key. Regular neurovascular assessments should be performed and documented on all patients with fractures, but especially those with injury of the distal humerus or proximal tibia or soft tissue disruption in these areas. Early recognition and treatment of compartment syndrome is essential to avoid permanent damage to muscles and nerves. One or more of the following six Ps are characteristic of compartment syndrome: (1) paresthesia (numbness and tingling); (2) pain distal to the injury that is not relieved by opioid analgesics and pain on passive stretch of muscle, traveling through the compartment; (3) pressure increases in the compartment; (4) pallor, coolness, and loss of normal color of the extremity; (5) paralysis or loss of function; and (6) pulselessness or diminished/absent peripheral pulses. Carefully assess the location, quality, and intensity of the pain (see Chapter 10). Evaluate the patient's level of pain on a scale of 0 to 10. Pain unrelieved by drugs and out of proportion to the level of injury is one of the first indications of impending compartment syndrome. Pulselessness and paralysis (in particular) are later signs of compartment syndrome. After completion of the neurovascular assessment, the nurse should notify the health care provider immediately of a patient's changing condition.
Ambulatory Care Cast Care •Do -Frequent neurovascular assessments -Apply ice for first 24 hours -Elevate above heart for first 48 hours -Exercise joints above and below -Use hair dryer on cool setting for itching -Check with health care provider before getting wet
Because uncomplicated fractures are treated in an outpatient setting, the patient may require only a short hospitalization or none at all. Regardless of the type of cast material, a cast can interfere with circulation and nerve function from being applied too tightly or because of excessive edema that occurs after application. Frequent neurovascular assessment of the immobilized extremity is critical. Teach the patient to recognize and promptly report the signs of cast complications. Explain the importance of elevating the extremity above the heart level to promote venous return and applying ice to control or prevent edema are measures frequently used during the initial phase. However, if compartment syndrome is suspected, do not elevate the extremity above the heart. Instruct the patient to exercise joints above and below the cast. For itching, suggest the use of a hair dryer set on a cool setting to be directed under the cast. Check with HCP before getting fiberglass cast wet.
Bone Healing Stages A, Bleeding at fractured ends of the bone with subsequent hematoma formation. B, Organization of hematoma into fibrous network. C, Invasion of osteoblasts, lengthening of collagen strands, and deposition of calcium. D, Callus formation: new bone is built up as osteoclasts destroy dead bone. E, Remodeling is accomplished as excess callus is reabsorbed and trabecular bone is laid down.
Bone goes through a complex multistage healing process (union) that occurs in the following stages: Fracture hematoma: When a fracture occurs, bleeding creates a hematoma that surrounds the ends of the fragments. Occurs in the first 72 hours after injury. Granulation tissue. Active phagocytosis absorbs the products of local necrosis. The hematoma converts to granulation tissue (consisting of new blood vessels, fibroblasts, and osteoblasts) and forms the basis for new bone substance called osteoid during days 3 to 14 after injury. Callus formation: As minerals (calcium, phosphorus, and magnesium) and new bone matrix are deposited in the osteoid, an unorganized network of bone is formed and woven about the fracture parts. Callus is primarily composed of cartilage, osteoblasts, calcium, and phosphorus, and usually appears by the end of the second week after injury. Callus formation can be verified by x-ray. Ossification: Occurs from 3 weeks to 6 months after the fracture and continues until the fracture has healed. Callus ossification is sufficient to prevent movement at the fracture site when the bones are gently stressed. However, the fracture is still evident on x-ray. During this stage of clinical union, the patient may be allowed limited mobility or the cast may be removed. Consolidation: As callus continues to develop, the distance between bone fragments decreases and eventually closes. During this stage ossification continues and can be equated with radiologic union, which occurs when x-ray shows complete bony union. This phase can occur up to a year following injury. Remodeling: Excess bone tissue is reabsorbed in the final stage of bone healing, and union is completed. Gradual return of the injured bone to its preinjury structural strength and shape occurs. Bone remodels in response to physical loading stress (Wolf's law). Initially, stress is provided through exercise. Weight bearing is gradually introduced. New bone is deposited in sites subjected to stress and resorbed at areas of little stress.
Fracture Healing •Multistage healing process (union) 1.Fracture hematoma 2.Granulation tissue 3.Callus formation 4.Ossification 5.Consolidation 6.Remodeling
Bone goes through a complex multistage healing process (union) that occurs in the following stages: Fracture hematoma: When a fracture occurs, bleeding creates a hematoma that surrounds the ends of the fragments. Occurs in the first 72 hours after injury. Granulation tissue. Active phagocytosis absorbs the products of local necrosis. The hematoma converts to granulation tissue (consisting of new blood vessels, fibroblasts, and osteoblasts) and forms the basis for new bone substance called osteoid during days 3 to 14 after injury. Callus formation: As minerals (calcium, phosphorus, and magnesium) and new bone matrix are deposited in the osteoid, an unorganized network of bone is formed and woven about the fracture parts. Callus is primarily composed of cartilage, osteoblasts, calcium, and phosphorus, and usually appears by the end of the second week after injury. Callus formation can be verified by x-ray. Ossification: Occurs from 3 weeks to 6 months after the fracture and continues until the fracture has healed. Callus ossification is sufficient to prevent movement at the fracture site when the bones are gently stressed. However, the fracture is still evident on x-ray. During this stage of clinical union, the patient may be allowed limited mobility or the cast may be removed. Consolidation: As callus continues to develop, the distance between bone fragments decreases and eventually closes. During this stage ossification continues and can be equated with radiologic union, which occurs when x-ray shows complete bony union. This phase can occur up to a year following injury. Remodeling: Excess bone tissue is reabsorbed in the final stage of bone healing, and union is completed. Gradual return of the injured bone to its preinjury structural strength and shape occurs. Bone remodels in response to physical loading stress (Wolf's law). Initially, stress is provided through exercise. Weight bearing is gradually introduced. New bone is deposited in sites subjected to stress and resorbed at areas of little stress.
Fracture Immobilization •Cast -Synthetic casting materials •Lightweight, stronger, waterproof •Early weight bearing •Activated by submersion in cool or tepid water, then molded
Casts made of synthetic materials are being used more than plaster because they are lightweight, stronger, relatively waterproof, and provide for early weight bearing. The synthetic casting materials (thermolabile plastic, thermoplastic resins, polyurethane, and fiberglass) are activated by submersion in cool or tepid water. Then they are molded to fit the torso or extremity.
Fracture Reduction •Closed reduction -Nonsurgical, manual realignment of bone fragments -Traction and countertraction applied -Under local or general anesthesia -Immobilization afterwards
Closed reduction is a nonsurgical, manual realignment of bone fragments to their previous anatomic position. Traction and countertraction are manually applied to the bone fragments to restore position, length, and alignment. Closed reduction is usually performed while the patient is under local or general anesthesia. Traction, casting, external fixation, splints, or orthoses (braces) may be used after reduction to maintain alignment and immobilize the injured part until healing occurs.
Complications of Fracture Healing •Delayed union •Nonunion •Malunion •Angulation •Pseudoarthrosis •Refracture •Myositis ossificans
Delayed union Fracture healing progresses more slowly than expected. Healing eventually occurs. Nonunion Fracture fails to heal despite treatment. No x-ray evidence of callus formation. Malunion Fracture heals in expected time but in unsatisfactory position, possibly resulting in deformity or dysfunction. Angulation Fracture heals in abnormal position in relation to midline of structure (type of malunion). Pseudoarthrosis Type of nonunion occurring at fracture site in which a false joint is formed with abnormal movement at site. Refracture New fracture occurs at original fracture site. Myositis ossificans Deposition of calcium in muscle tissue at site of significant blunt muscle trauma or repeated muscle injury.
Assistive Devices •Devices for ambulation range from a cane to a walker or crutches •Technique for use varies •Use transfer belt for stability when teaching how to use •Discourage from reaching for support •Upper arm strength required
Devices for ambulation range from a cane (can relieve up to 40% of the weight normally borne by a lower limb) to a walker or crutches (may allow for complete non-weight-bearing ambulation). The HCP decides which device is appropriate for a patient. balancing the need for maximum stability and safety versus maneuverability required in small spaces such as bathrooms. Discuss with the patient his or her lifestyles requirements and select a device that allows each patient to feel most secure and independent. The technique for using assistive ambulation devices varies. The involved limb is usually advanced at the same time or immediately after the advance of the device. The uninvolved limb is advanced last. In almost all cases, canes are held in the hand opposite the involved extremity. Place a transfer belt (gait belt) around the patient's waist to provide stability during the learning stages of using assistive devices. Discourage the patient from reaching for furniture or relying on another person for support. If the patient has inadequate upper limb strength or poorly fitted crutches, he or she bears weight at the axilla rather than at the hands, endangering the neurovascular bundle that passes across the axilla. Patients who must ambulate without weight bearing require sufficient upper limb strength to lift their own weight at each step. Because the muscles of the shoulder girdle and upper arm may not be accustomed to this work, patients require vigorous and diligent training in preparation for this task. Push-ups, pull-ups using the overhead trapeze bar, and lifting weights develop the triceps and biceps muscles. Straight-leg raises and quadriceps-setting exercises strengthen the quadriceps muscles.
Ambulatory Care Cast Care •Do -Dry thoroughly after getting wet -Report increasing pain despite elevation, ice, and analgesia -Report swelling associated with pain and discoloration OR movement -Report burning or tingling under cast -Report sores or foul odor under cast
Dry cast thoroughly if inadvertently exposed to water. Blot dry with towel. Use hair dryer on low setting until cast is thoroughly dry. Report signs of possible problems to HCP. Increasing pain despite elevation, ice, and analgesia Swelling associated with pain and discoloration of toes or fingers Pain during movement Burning or tingling under the cast Sores or foul odor under the cast
Fat Embolism (FES) Clinical Manifestations •Early recognition of FES is crucial •Symptoms 24 to 48 hours after injury •Fat emboli in the lungs cause a hemorrhagic interstitial pneumonitis. •Respiratory and neurologic symptoms •Petechiae - neck, chest wall, axilla, buccal membrane, conjunctiva
Early recognition of FES is crucial to prevent a potentially lethal course. Most patients manifest symptoms within 24 to 48 hours after the injury. Severe forms have occurred within hours of injury. Fat emboli in the lungs cause a hemorrhagic interstitial pneumonitis with signs and symptoms of acute respiratory distress syndrome (ARDS), such as chest pain, tachypnea, cyanosis, dyspnea, apprehension, tachycardia, and decreased partial pressure of arterial O2 (PaO2). These symptoms are caused by poor oxygen exchange. Changes in mental status (a result of hypoxemia) are also part of the classic triad of signs and symptoms. Investigate memory loss, restlessness, confusion, elevated temperature, and headache so central nervous system involvement is not mistaken for alcohol withdrawal or acute head injury. Petechiae located on the neck, anterior chest wall, axilla, buccal membrane, and conjunctiva of the eye may help distinguish fat emboli from other problems. They may appear due to intravascular thromboses caused by decreased oxygenation. However, petechiae are only seen in 25% to 50% of cases of FES.
Compartment Syndrome Interprofessional Care •NO elevation above heart •NO ice •Surgical decompression (fasciotomy)
Elevation of the extremity may lower venous pressure and slow arterial perfusion. With suspected compartment syndrome, the extremity should not be elevated above the heart level. Similarly, the application of cold compresses may cause vasoconstriction and exacerbate compartment syndrome. Surgical decompression (e.g., fasciotomy) of the involved compartment may be necessary. The fasciotomy site is left open for several days to ensure adequate soft tissue decompression. Infection resulting from delayed wound closure is a potential problem after fasciotomy. In severe cases of compartment syndrome, an amputation may be required.
Fat Embolism (FES) Interprofessional Care •Coughing and deep breathing •Administer O2 •Intubation/ intermittent positive pressure ventilation
Encourage coughing and deep breathing. Administer O2 to treat hypoxia. Intubation or intermittent positive pressure ventilation may be considered if a satisfactory PaO2 cannot be obtained with supplemental oxygen alone. Some patients may develop pulmonary edema, ARDS, or both, leading to increased mortality rate. Most persons survive FES with few sequelae.
External Fixation •Assess for pin loosening and infection •Patient teaching •Pin site care
External fixation is often used in an attempt to salvage extremities that otherwise might require amputation. Because the use of an external device is a long-term process, ongoing assessment for pin loosening and infection is critical. Infection (indicated by exudate, erythema, tenderness, and pain) may require removal of the device. Instruct the patient and caregiver about meticulous pin care. Although each physician has a protocol for pin care cleaning, chlorhexidine 2mg/ml is often used.
Fat Embolism (FES) •Presence of systemic fat globules from fracture that are distributed into tissues and organs after a traumatic skeletal injury •Contributory factor in many deaths associated with fracture •Most common with fracture of long bones, ribs, tibia, and pelvis
Fat embolism syndrome (FES) is characterized by systemic fat globules from fractures that are distributed into tissues, lungs, and other organs after a traumatic skeletal injury. FES is a contributory factor in mortality associated with fractures. The fractures that most often are associated with FES include those of the long bones, ribs, tibia, and pelvis. FES can also occur after total joint replacement, spinal fusion, liposuction, crush injuries, and bone marrow transplantation.
Skeletal Traction •Maintain countertraction, typically the patient's own body weight -Elevate end of bed •Maintain continuous traction •Keep weights off the floor
Fracture alignment depends on the correct positioning and alignment of the patient while the traction forces remain constant. For extremity traction to be effective, forces must be pulling in the opposite direction (countertraction). Countertraction is commonly supplied by the patient's body weight or by weights pulling in the opposite direction and may be augmented by elevating the end of the bed. Traction must be maintained continuously. Keep the weights off the floor and moving freely through the pulleys.
Classification •Based on direction of fracture line -Linear -Oblique -Transverse -Longitudinal -Spiral
Fractures are also described and classified according to the direction of the fracture line. Types include linear, oblique, transverse, longitudinal, and spiral fractures (see next slide for Fig. 62-7).
Classification •Complete or incomplete -Complete: break is completely through bone -Incomplete: bone is still in one piece
Fractures can also be classified as complete or incomplete. A fracture is termed complete if the break is goes through the bone and incomplete if the fracture occurs partly across a bone shaft but the bone is still intact. An incomplete fracture is often the result of bending or crushing forces applied to a bone.
Preoperative Care •Patient Teaching -Immobilization -Assistive devices -Expected activity limitations -Assure that needs will be met -Pain medication
If surgical intervention is required to treat a fracture, patients will need preoperative preparation. In addition to the usual preoperative nursing measures, inform patients of the type of immobilization and assistive devices that will be used and the expected activity limitations after surgery. Assure patients that nursing staff will help meet their personal needs until they can again meet resume self-care. Remind patients that pain medication will be available if needed.
Upper Extremity Immobilization •Types of casts -Sugar-tong splint -Posterior splint -Short arm cast -Long arm cast •Sling to elevate and support arm -Contraindicated with proximal humerus fracture
Immobilization of an acute fracture or soft tissue injury of the upper extremity is often accomplished by use of (1) the sugar-tong splint, (2) the posterior splint, (3) the short arm cast, and (4) the long arm cast (Fig. 62-11). The sugar-tong splint is typically used for acute wrist injuries or injuries that may result in significant swelling. Splints are applied beginning at the phalangeal joints of the hand, extending up the dorsal aspect of the forearm around the distal humerus and then down the volar aspect of the forearm to the distal palmar crease. The splinting material is wrapped with either elastic bandage or bias stockinette, accommodating early swelling in the fractured extremity. The short arm cast is often used for the treatment of stable wrist or metacarpal fractures. An aluminum finger splint can be incorporated into the short arm cast for concurrent treatment of phalangeal injuries. This cast provides wrist immobilization and permits unrestricted elbow motion. The long arm cast is commonly used for stable forearm or elbow fractures and unstable wrist fractures. It is similar to the short arm cast but extends to the proximal humerus, restricting motion at the wrist and elbow.
Postoperative Care •Monitor vitals •General principles of nursing care •Frequent neurovascular assessments •Minimize pain and discomfort •Monitor for bleeding or drainage -Aseptic technique -Blood salvage and reinfusion
In general, postoperative nursing care and management are directed toward monitoring vital signs and applying the general principles of postoperative nursing care. Frequent neurovascular assessments of the affected extremity are necessary to detect early and subtle changes. Closely monitor any limitations of movement or activity related to turning, positioning, and extremity support. Pain and discomfort can be minimized through proper alignment and positioning. Carefully observe dressings or casts for any signs of bleeding or drainage. Report a significant increase in size of the drainage area. If a wound drainage system is in place, regularly measure the volume of drainage and assess its character (e.g., bloody, purulent). Also assess the patency of the drainage system, using aseptic technique to avoid contamination. Additional nursing responsibilities depend on the type of immobilization used. A blood salvage and reinfusion system may be used to allow recovery and reinfusion of the patient's own blood may be used. The blood is retrieved from a joint space or cavity, and the patient receives this blood in the form of an autotransfusion.
Lower Extremity Immobilization •Long leg cast •Short leg cast •Cylinder cast •Robert Jones dressing
Injuries to the lower extremity are often immobilized by long leg cast, short leg cast, cylinder cast, or prefabricated splint or immobilizer. The usual indications for applying a long leg cast are an unstable ankle fracture, soft tissue injuries, a fractured tibia, and knee injuries. The cast usually extends from the base of the toes to the groin and gluteal crease. The short leg cast is used primarily used for stable ankle and foot injuries. A cylinder cast, which is used for knee injuries or fractures, extends from the groin to the malleoli of the ankle. A Robert Jones dressing may be used temporarily to limit mobility of a joint. It is composed of soft padding materials (absorption dressing and cotton sheet wadding), splints, and an elastic wrap or bias-cut stockinette.
Ambulatory Care •Ambulation -Reinforce physical therapist's instructions -Mobility training -Instruction in use of assistive aids -Pain management
Know the overall goals of physical therapy in relation to the patient's abilities, needs, and tolerance. Mobility training and instruction in the use of assistive aids (cane, crutches, walker) constitute major areas of responsibility for physical therapist. Reinforce these instructions to the patient. The patient with lower extremity dysfunction usually starts mobility training when able to sit in bed and dangle the feet over the side. Collaborate with the physical therapist to administer analgesia before a physical therapy session.
FRACTURE HEALING •Factors influencing healing -Displacement and site of fracture -Blood supply to area -Immobilization -Internal fixation devices -Infection or poor nutrition -Age -Smoking
Many factors influence the time required for complete fracture healing including displacement and site of the fracture, blood supply to the area, immobilization, and use of internal fixation devices (e.g., screws, pins). The ossification process may be slowed or even stopped by inadequate reduction and immobilization, excessive movement of the fracture fragments, infection, poor nutrition, and systemic disease. Healing time for fractures increases with age. Smoking also increases fracture healing time. Fracture healing may not occur in the expected time (delayed union) or may not occur at all (nonunion).
Fat Embolism (FES) Clinical Manifestations •Fat cells in blood, urine, or sputum •↓ PaO2 < 60 mm Hg •ST segment and T-wave changes •↓ Platelet count, hematocrit levels •Elevated ESR •Chest x-ray →bilateral pulmonary infiltrates
No specific laboratory examinations are available to aid in the diagnosis. However, certain diagnostic abnormalities may be present. These include fat cells in the blood, urine, or sputum; a decrease of PaO2 to less than 60 mm Hg; ST segment and T-wave changes on ECG; a decrease in the platelet count and hematocrit levels; and an elevated erythrocyte sedimentation rate (ESR). A chest x-ray may show bilateral pulmonary infiltrates.
Nursing Diagnoses •Impaired physical mobility •Risk for peripheral neurovascular dysfunction •Acute pain •Readiness for enhanced health management
Nursing diagnoses for the patient with a fracture may include, but are not limited to, the following: Impaired physical mobility related to loss of integrity of bone structures, movement of bone fragments, and prescribed movement restrictions Risk for peripheral neurovascular dysfunction related to vascular insufficiency and nerve compression secondary to edema and/or mechanical compression by traction, splints, or casts Acute pain related to edema, movement of bone fragments, and muscle spasms Readiness for enhanced health management
Nursing Assessment •Subjective Data -Past medical history •Trauma •Bone or systemic diseases •Immobility •Osteopenia •Osteoporosis -Medications -Surgery or other treatments
Obtain the following health information from the client: Past health history: Traumatic injury; long-term repetitive forces (stress fracture); bone or systemic diseases, prolonged immobility, osteopenia, osteoporosis Medications: Use of corticosteroids (osteoporotic fractures); analgesics Surgery or other treatments: First aid treatment of fracture, previous musculoskeletal surgeries
Compartment Syndrome Clinical Manifestations •Six Ps -Pain -Pressure -Paresthesia -Pallor -Paralysis -Pulselessness
One or more of the following six Ps are characteristic of compartment syndrome: pain out of proportion to the injury and that is not managed by opioid analgesics, and pain on passive stretch of muscle traveling through the compartment; Increasing pressure in the compartment; paresthesia (numbness and tingling); pallor, coolness, and loss of normal color of the extremity; paralysis or loss of function; and pulselessness (diminished or absent peripheral pulses).
Infection •High incidence in open fractures and soft tissue injuries •Devitalized and contaminated tissue an ideal medium for pathogens •Prevention key •Can lead to chronic osteomyelitis
Open fractures and soft tissue injuries have a high incidence of infection. Devitalized and contaminated tissue is an ideal medium for many common pathogens, including gas-forming (anaerobic) bacilli such as Clostridrium tetani. Treatment of infection is costly in terms of extended nursing and medical care, time for treatment, and loss of patient income. Delayed or ineffective treatment can lead to the development of chronic osteomyelitis (see Chapter 63).
Infection • Aggressive surgical debridement • Wound may or may not be closed • Closed suction drainage • Skin grafting • Antibiotics - irrigation, impregnated-beads, and IV
Open fractures require aggressive surgical debridement. The wound is initially cleaned by pulsating saline lavage in the operating room. Gross contaminants are irrigated and mechanically removed. Contused, contaminated, and devitalized tissue (muscle, subcutaneous fat, skin, and bone fragments) are surgically excised (debridement). The extent of the soft tissue damage determines if the wound will be closed at the time of surgery and if requires repeat debridement, closed suction drainage, and skin grafting. Depending on the location and extent of the fracture, reduction may be maintained by external fixation or traction. During surgery the open wound may be irrigated with antibiotic solution. Antibiotic-impregnated beads may also be placed in the surgical site. The patient may have antibiotics administered IV for 3 to 7 days during the postoperative phase.
Fracture Reduction •Open reduction -Surgical incision -Internal fixation -Risk for infection -Early ROM of joint to prevent adhesions -Facilitates early ambulation
Open reduction is the correction of bone alignment through a surgical incision. It usually includes internal fixation of the fracture with the use of wires, screws, pins, plates, intramedullary rods, or nails. The main risks of this form of fracture management are infection, complications associated with anesthesia, and the effect of preexisting medical conditions (e.g., diabetes). ORIF facilitates early ambulation that decreases the risk of complications related to prolonged immobility.
Other Measures •Prevent complications of immobility -Constipation -Renal calculi -Cardiopulmonary deconditioning -DVT/pulmonary emboli
Patients often have reduced mobility as a result of a fracture. Plan care to prevent the many complications associated with immobility. Prevent constipation by increasing patient activity and maintenance of a high fluid intake (more than 2500 mL/day unless contraindicated by the patient's health status) and a diet high in bulk and roughage (fresh fruits and vegetables). If these measures are not effective in maintaining the patient's normal bowel elimination pattern, administer stool softeners, laxatives, or suppositories. Maintain a regular time for elimination to promote bowel regularity. Renal calculi can develop from bone demineralization related to reduced mobility. The hypercalcemia from demineralization causes a rise in urine pH and stone formation resulting from the precipitation of calcium. Unless contraindicated, fluid intake of 2500 mL/day is recommended. Rapid deconditioning of the cardiopulmonary system can occur as a result of prolonged bed rest, resulting in orthostatic hypotension and decreased lung capacity. Unless contraindicated, these effects can be diminished by having the patient sit on the side of the bed, allowing the patient's lower limbs to dangle over the bedside, and having the patient perform standing transfers. When the patient is allowed to increase activity, assess for orthostatic hypotension. Also assess patients for deep vein thrombosis (DVT) and pulmonary emboli.
Nursing Assessment •Objective Data -Apprehension -Guarding -Skin lacerations, color changes -Hematoma, edema -↓ or absent pulse, ↓ skin temperature -Delayed capillary refill
Perform a focused physical assessment for the following clinical manifestations: General Apprehension, guarding of injured site Integumentary Skin lacerations, pallor and cool skin or bluish and warm skin distal to injury; ecchymosis, hematoma, edema at site of fracture Cardiovascular Reduced or absent pulse distal to injury, ↓ skin temperature, delayed capillary refill
Nursing Assessment •Objective Data -Paresthesias -Absent, ↓ or ↑ sensation -Restricted or lost function -Deformities; abnormal angulation -Shortening, rotation, or crepitation -Muscle weakness -Imaging findings
Perform a focused physical assessment for the following clinical manifestations: Neurovascular Paresthesias, absent or ↓ sensation, hypersensation Musculoskeletal Restricted or lost function of affected part; local bony deformities, abnormal angulation; shortening, rotation, or crepitation of affected part; muscle weakness Possible Diagnostic Findings Identification and extent of fracture on x-ray, bone scan, CT scan, or MRI
Knee Immobilizer Prefabricated knee and ankle splints and immobilizers are used in many settings. This type of immobilization is easy to apply and remove, which permits close observation of the affected joint for signs of swelling and skin breakdown. Depending on the injury, removal of the splint or immobilizer facilitates ROM of the affected joint and faster return to function.
Prefabricated knee and ankle splints and immobilizers are used in many settings. This type of immobilization is easy to apply and remove, which permits close observation of the affected joint for signs of swelling and skin breakdown. Depending on the injury, removal of the splint or immobilizer facilitates ROM of the affected joint and faster return to function.
Compartment Syndrome Interprofessional Care •Prompt, accurate diagnosis via regular neurovascular assessments -Notify of pain unrelieved by drugs and out of proportion to injury -Paresthesia is also an early sign •Assess urine output and kidney function
Prompt, accurate diagnosis of compartment syndrome is critical. Perform and document regular neurovascular assessments on all patients with fractures, especially those with injury of the extremities or soft tissue injuries in these areas. Early recognition and effective treatment of compartment syndrome are essential to avoid permanent damage to muscles and nerves. Carefully assess the location, quality, and intensity of the pain. Evaluate the patient's level of pain on a scale of 0 to 10. Pain unrelieved by drugs and out of proportion to the level of injury is one of the first indications of impending compartment syndrome. Paresthesia is also an early sign. Notify the HCP immediately of these changes in the patient's condition. If the source of pressure is relieved (e.g., cast is cut [bivalve] or dressing loosened by order of the HCP), pain and paresthesia typically decrease and compartment syndrome is avoided. Pulselessness and paralysis are later signs. Because of the possibility of muscle damage, assess urine output. Myoglobin released from damaged muscle cells precipitates and causes obstruction in renal tubules. This condition results in acute tubular necrosis and acute kidney injury. Common signs are dark reddish brown urine and clinical manifestations associated with acute kidney injury.
Ambulatory Care •Psychosocial problems -Dependence in performing ADLs -Family separation -Finances -Inability to work -Potential disability
Short-term rehabilitative goals address the transition from dependence to independence in performing simple activities of daily living and preserving or increasing strength and endurance. During the rehabilitative phase, help the patient to adjust to any problems caused by the injury (e.g., separation from family, financial impact of medical care, loss of income from inability to work, potential for lifetime disability). Offer support and encouragement while actively listening to the patient's and caregiver's concerns.
Traction •Skeletal traction -Long-term pull to maintain alignment -Pin or wire inserted into bone -Weights 5 to 45 lbs -Risk for infection -Complications of immobility
Skeletal traction, generally in place for longer periods than skin traction, is used to align injured bones and joints or to treat joint contractures and congenital hip dysplasia. It provides a long-term pull that keeps the injured bones and joints aligned. To apply skeletal traction, the surgeon inserts a pin or wire into the bone, and weights are attached to align and immobilize the injured body part. Weight for skeletal traction ranges from 5 to 45 lbs (2.3 to 20.4 kg). The use of too much weight can result in delayed union or nonunion. The major complications of skeletal traction are infection at the pin insertion site and the effects of prolonged immobility.
Traction •Skin traction -Short-term (48-72 hours) -Tape, boots, or splints applied directly to skin -Traction weights 5 to 10 pounds -Skin assessment and prevention of breakdown imperative
Skin traction is generally used for short-term treatment (48 to 72 hours) until skeletal traction or surgery is possible. Tape, boots, or splints are applied directly to the skin to maintain alignment, primarily to help diminish muscle spasms in the injured extremity. The traction weights are usually limited to 5 to 10 lbs (2.3 to 4.5 kg). A Buck's traction boot is a type of skin traction used preoperatively for the patient with a hip fracture to reduce muscle spasms (Fig. 62-9). In skin traction, regular assessment of the skin is a priority because pressure points and skin breakdown may develop quickly. Assess key pressure points every 2 to 4 hours.
Upper Extremity Immobilization •Sling -To support and elevate arm -Contraindicated with proximal humerus fracture -Ensures axillary area is well padded -No undue pressure on posterior neck -Encourage movement of fingers and nonimmobilized joints
Support the extremity and reduce the effects of edema by maintaining elevation of the extremity with a sling. However, when a hanging arm cast is used for a proximal humerus fracture, elevation or a supportive sling is contraindicated because hanging provides traction and maintains fracture alignment. When a sling is used, ensure the axillary area is well padded to prevent skin excoriation and maceration associated with direct skin-to-skin contact. Placement of the sling should not put undue pressure on the neck. Encourage movement of the fingers (unless contraindicated) to enhance the pumping action of blood vessels to decrease edema. Also encourage the patient to actively move nonimmobilized joints of the upper extremity to prevent stiffness and contractures.
Nursing Implementation •Health Promotion -Teach safety precautions -Advocate to decrease injuries -Encourage moderate exercise -Safe environment to reduce falls -Calcium and vitamin D intake
Teach people in the community to take appropriate safety precautions to prevent injuries while at home or work, when driving, or when participating in sports. Be an advocate for personal actions known to reduce injuries, such as regularly using seat belts, driving within posted speed limits, avoiding distracted driving, warming up muscles before exercise, using protective athletic equipment (helmets and knee, wrist, and elbow pads), using safety equipment at work. Encourage individuals, especially older adults, to participate in moderate exercise to aid in the maintenance of muscle strength and balance. To reduce risk for falls, also urge them to wear nonskid, hard-soled footwear and assess their living environment for safety risks. Also stress the importance of adequate calcium and vitamin D intake for bone health.
Vertebral Immobilization •Body jacket brace -Immobilization and support for stable spine injuries -Monitor for superior mesenteric artery syndrome (cast syndrome) •Assess bowel sounds •Treat with gastric decompression
The body jacket brace is used for immobilization and support for stable spine injuries of the thoracic or lumbar spine. The brace goes around the chest and abdomen, extending from above the nipple line to the pubis. After application of the brace, assess the patient for the development of superior mesenteric artery syndrome (cast syndrome). This condition occurs if the brace is applied too tightly, which results in compression of the superior mesenteric artery against the duodenum. The patient generally complains of abdominal pain, abdominal pressure, nausea, and vomiting. Assess the abdomen for decreased bowel sounds (a window in the brace may be left over the umbilicus). Treatment includes gastric decompression with a nasogastric (NG) tube and suction. Assessment also includes monitoring respiratory status, bowel and bladder function, and areas of pressure over the bony prominences, especially the iliac crest. The brace may need to be adjusted or removed if any complications occur.
Fat Embolism (FES) Clinical Manifestations •Clinical course of fat embolus may be rapid and acute •Patient frequently expresses a feeling of impending disaster •In a short time skin color changes from pallor to cyanosis •Patient may become comatose
The clinical course of a fat embolus may be rapid and acute. Frequently the patient expresses a feeling of impending disaster. In a short time, skin color changes from pallor to cyanosis, and the patient may become comatose.
Clinical Manifestations •Localized pain •Decreased function •Inability to bear weight or use •Guard against movement •May or may not have deformity Immobilize if suspect fracture!!!!
The clinical manifestations of fracture include immediate localized pain, decreased function, and inability to bear weight on or use the affected part. The patient guards and protects the extremity against movement. Obvious bone deformity may not be present. If a fracture is suspected, the extremity is immobilized in the position in which it is found. Unnecessary movement increases soft tissue damage and may convert a closed fracture to an open fracture or create further injury to adjacent nerves and blood vessels.
Lower Extremity Immobilization •Hip spica cast -Single spica -Double spica •Assess patient for same problems as body jacket brace
The hip spica cast is now mainly used for femur fractures in children to immobilize the affected extremity and trunk. It extends from above the nipple line to the base of the foot (single spica) and may include the opposite extremity up to an area above the knee (spica and a half) or both extremities (double spica).
Nursing Planning •Overall Goals -Healing with no associated complications -Satisfactory pain relief -Maximal rehabilitation
The overall goals are that the patient with a fracture will have healing with no associated complications obtain satisfactory pain relief, and achieve maximal rehabilitation potential.
Interprofessional Care •Overall goals of fracture treatment -Anatomic realignment (reduction) -Immobilization -Restoration of normal or near-normal function
The overall goals of fracture treatment are anatomic realignment of bone fragments through reduction immobilization to maintain realignment, and restoration of normal or near-normal function of the injured part.
Fracture Immobilization •Cast -Cover affected part with stockinette and padding -Immerse plaster of paris material in warm water, wrap and mold it •Sets in 15 minutes •24-72 hours before weight bearing •Do not cover - risk for burn •No direct pressure; petal edges
To apply a cast on an extremity, the affected part is first covered with a stockinette that is cut longer than the extremity. Then place cotton padding over the stockinette with the bony prominences given extra padding. If plaster of Paris casting material is used, immerse it in warm water and then wrap and mold it around the affected part. The number of layers of plaster bandage and the technique of application determine the strength of the cast. The plaster sets within 15 minutes, so the patient may move around without difficulty. However, it is not strong enough for weight bearing until about 24 to 72 hours after application. The final decision about weight bearing is determined by the physician. A fresh plaster cast should never be covered because air cannot circulate. Heat then builds up in the cast and may cause a burn, and drying is delayed. Avoid direct pressure on the cast during the drying period. Handle the cast gently with an open palm to avoid denting the cast. Once the cast is thoroughly dry, the rough edges may need to be petaled to minimize skin irritation from rough edges and to prevent plaster of paris debris from falling into the cast and causing irritation or pressure necrosis. Several strips (petals) of tape are placed by the health care provider over the rough areas to ensure a smooth cast edge.
Traction •Pulling force to attain realignment - countertraction pulls in opposite direction •Two most common types of traction -Skin traction -Skeletal traction
Traction devices apply a pulling force on a fractured extremity to attain realignment, while countertraction pulls in the opposite direction. The two most common types of traction are skin traction and skeletal traction.
Traction •Purpose -Prevent or ↓ pain and muscle spasm -Immobilize joint or part of body -Reduce fracture or dislocation -Treat a pathologic joint condition
Traction is used to prevent or reduce pain and muscle spasm (e.g., whiplash, unrepaired hip fracture), immobilize a joint or part of the body, reduce a fracture or dislocation, and treat a pathologic joint condition (e.g., tumor, infection).
Fat Embolism (FES) Interprofessional Care •Treatment is directed at prevention •Careful immobilization and handling of a long bone fracture probably the most important factor in prevention •Management is supportive and related to symptom management
Treatment for fat embolism is directed at prevention. Careful immobilization and handling of a long bone fracture is probably the most important factor in the prevention of fat embolism. Reposition the patient as little as possible before fracture immobilization or stabilization because of the danger of dislodging fat droplets into the general circulation. Management of FES is mostly supportive and related to management of symptoms. Treatment includes fluid resuscitation to prevent hypovolemic shock, correction of acidosis, and replacement of blood loss.
Compartment Syndrome •Swelling and increased pressure within a confined space •Compromises neurovascular function of tissues within that space •Usually involves the leg but can occur in any muscle group •Two basic types of compartment syndrome -↓ Compartment size -↑ Compartment contents •Arterial flow compromised → ischemia → cell death → loss of function
Two basic causes of compartment syndrome are (1) decreased compartment size resulting from restrictive dressings, splints, casts, excessive traction, or premature closure of fascia and (2) increased compartment contents related to bleeding, inflammation, edema, or IV infiltration. Edema can create sufficient pressure to obstruct circulation and cause venous occlusion, which further increases edema. Arterial flow is eventually compromised, causing ischemia in the extremity. As ischemia continues, muscle and nerve cells are destroyed. Fibrotic tissue eventually replaces healthy tissue. Contracture, disability, and loss of function can occur. Delays in diagnosis and treatment result in irreversible muscle and nerve ischemia. The extremity may become functionally useless or severely impaired extremity. Compartment syndrome is usually associated with trauma, fractures (especially of long bones), extensive soft tissue damage, and crush injury. Fractures of the distal humerus and proximal tibia are the most common fractures associated with compartment syndrome.
Fat Embolism (FES) •Mechanical theory -Fat released from marrow and enters circulation where it can obstruct •Biochemical theory -Hormonal changes caused by trauma stimulate release of fatty acids to form fat emboli
Two theories about fat embolism exist. According to the mechanical theory, fat emboli may originate from the fat that is released from the marrow of injured bone. The fat then enters the systemic circulation where it embolizes to other organs such as the brain. As fat droplets lodge in small blood vessels, local ischemia and inflammation occur. The biochemical theory suggests hormonal changes caused by trauma or sepsis stimulate the systemic release of free fatty acids (e.g., chylomicrons) that form the fat emboli.
Ambulatory Care Cast Care •Validate understanding of cast care instructions •Follow-up phone call •Teach cast removal and possible alterations in appearance of extremity
Validate the patient's and caregiver's understanding of these instructions before discharge. A follow-up phone contact is appropriate, and home care nursing visits are warranted, especially for the patient with a body jacket brace. The cast is removed in the outpatient setting. Patients often fear being cut by the oscillating blade of the cast saw. Reassure the patient that damage to the skin is unlikely. Teach the patient about possible alterations in the appearance of the extremity (e.g., dry, wrinkled skin; atrophied muscle) that has been beneath the cast. The patient may also have anxiety related to using the injured extremity after the cast is removed.
Venous Thromboembolism •High susceptibility aggravated by inactivity of muscles •Prophylactic anticoagulant drugs •Antiembolism stockings •Sequential compression devices •ROM exercises
Veins of the lower extremities and pelvis are highly susceptible to thrombus formation after a fracture, especially a hip fracture. Venous thromboembolism (VTE) may also occur after total hip or total knee replacement surgery. In patients with limited mobility, venous stasis is aggravated by inactivity of muscles that normally assist in the pumping action of venous blood from the extremities to the heart. Because of the high risk of VTE in the orthopedic surgical patient, prophylactic anticoagulant drugs such as (1) warfarin (Coumadin), (2) low-molecular-weight heparin (LMWH) (e.g., enoxaparin [Lovenox], fondaparinux [Arixtra], or rivaroxaban [Xarelto]) may be ordered. In addition to wearing compression gradient stockings (antiembolism hose) and using sequential compression devices, the patient should dorsiflex and plantar flex the ankle of an affected lower extremity against resistance and perform ROM exercises on the unaffected leg.
Traction •Inspect exposed skin •Monitor pin sites for infection •Pin site care per policy •Proper positioning •Exercise as permitted •Psychosocial needs
When slings are used with traction, regularly inspect exposed skin areas. Persistent skin pressure may impair blood flow and cause injury to the peripheral neurovascular structures. Observe skeletal traction or external fixation pin sites for signs of infection. Pin site care may vary but often includes regularly cleansing with chlorhexidine, rinsing pin sites with sterile saline, and drying of area with sterile gauze. External rotation of the affected extremity is a classic assessment finding for a patient with unrepaired hip fracture. If skin traction is ordered preoperatively, apply traction without attempting to reposition or realign the extremity. Keep the patient in the center of the bed in a supine position to provide adequate countertraction. To offset possible problems associated with prolonged immobility, discuss specific patient activity with the HCP. If exercise is permitted, encourage participation by the patient in a simple exercise regimen based on activity restrictions. Encourage the patient to participate in frequent position changes, ROM exercises of unaffected joints, deep-breathing exercises, isometric exercises, and use of the trapeze bar (if permitted) to raise the body off the bed for linen changes and placement of the bedpan. Encourage and facilitate the hospitalized patient to stay connected with friends and family by telephone or through social media resources.
Ambulation •Degrees of weight-bearing -Non-weight-bearing -Touch-down/toe-touch weight-bearing -Partial-weight-bearing -Weight bearing as tolerated -Full-weight-bearing ambulation
When the patient begins to ambulate, know the patient's weight-bearing status and the correct technique if the patient is using an assistive device. There are different degrees of weight-bearing ambulation: non-weight-bearing (no weight on the involved extremity) touch-down/toe-touch weight-bearing ambulation (contact with floor for balance but no weight borne) partial-weight-bearing ambulation (25% to 50% of patient's weight borne) weight bearing as tolerated (based on patient's pain and tolerance) full-weight-bearing ambulation (no limitations).
