Fractures

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

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

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

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

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

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

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

8. Types of Fractures

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

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

12. Compound Fracture

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

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

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

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

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

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

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

24. Total Hip Replacement • Hip arthroplasty: total replacement of hip joint http://www.youtube.com/watch?v=WJ1E12xcaTs Medical Animation Total Hip Arthroplasty

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

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

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

28. Surgical Interventions for Total Knee or Total Hip Replacement

29. Arthroplasty • Post Op Nursing interventions • Empty and record HemoVac • Give oxygen 2-3 L/min • Incentive spirometer; cough and deep-breathe • Record I&O • Bed rest for 24-48 hours • Change dressing as ordered • Diet as ordered • Neurovascular checks and vital signs every 4 hours

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

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

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

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

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

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

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

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

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

39. Fractures of the Vertebrae • Patient Teaching: • Firm mattress • Sitting in straight firm chairs • No more than 20-30 min at a time • Proper lifting technique • Follow MD lifting restrictions • Back exercises –per MD and PT

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

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

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

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

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

45. Complications of Fractures

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

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

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

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

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