Exam 16 - Fractures, Complications of Fractures, and Interventions

Fracture Definitions and Classifications

• Fracture: A traumatic injury to a bone where its continuity breaks.
• Causes: Forceful blows (twisting, crushing), direct force, torsion, violent muscle contractions.
• Pathological Fracture: Fracture without trauma, from weakened bones, e.g., osteoporosis, cancer, tumors, Cushing's syndrome, malnutrition, long-term steroid use.
• Open (Compound) Fracture: Bone breaks through the skin, high infection risk.
• Closed (Simple) Fracture: Bone remains contained, no skin break.
• Displaced Fracture: Bone ends separated at fracture line.
• Incomplete Fracture: Bone breaks through only one cortex.
• Classification by Appearance:
  • Complete: Fracture line through bone, periosteum disrupted on both sides
  • Comminuted: Bone splintered into 3+ fragments, multiple fracture lines
  • Transverse: Break directly across the bone at a right angle
  • Oblique: Break diagonally across the bone at approximately a 45° angle
  • Spiral: Break that coils around the bone (torsion fracture)
  • Impacted (Telescope): One bone fragment forcibly wedged into another
  • Greenstick: Incomplete fracture where one side breaks and bends, common in children due to their soft, flexible bones
  • Colles': Fracture of distal radius near wrist joint, often from falling
  • Pott's: Fracture of distal fibula and medial malleolus with foot displacement
• Signs and symptoms vary based on bone location, muscle attachments, fracture type, and related injuries.

Fracture Signs and Symptoms

• Pain: Consistent symptom, increases with movement and pressure
• Loss of function: Injured part may not move voluntarily
• Deformity: Limb bends unusually or shape changes
• Crepitus: Grating sound of bone ends, do not attempt to assess this
• False motion: Abnormal movement at fracture site
• Edema: Swelling, mostly over the fracture site
• Muscle spasms: Involuntary contractions, potentially shortening the limb
• Loss of sensation/paralysis: Distal to injury
• Bruising/hematoma: From periosteum disruption, vessel injury, soft tissue damage

Bone Repair Process

• Fracture tears periosteum and blood vessels
• Inflammation and swelling due to bleeding and edema
• Blood clots in the area
• Fibrin meshwork forms between bone ends
• Osteoblasts cross the meshwork, build collagen and calcium deposits
• Callus forms (bony deposits) as osteoblasts create bone and osteoclasts remove dead bone
• Osteoblasts and osteoclasts remodel callus into trabecular bone along stress lines

Fracture Assessment

• Seven Ps: Pain, pallor, paresthesia (numbness), paralysis, polar temperature, puffiness (edema/hematoma), pulselessness
• Subjective data: Pain, loss of sensation or movement, injury cause
• Objective data: Warmth, edema, bruising, deformity, loss of function, signs of shock, circulatory, motor & sensory impairment

Fracture Diagnosis

• Radiographic examination
• Fluoroscopy

Fracture Medical Management

• Immediate Management: Splinting, body alignment preservation, elevation, cold packs (initial 24 hrs), analgesics, monitoring color, sensation, temp, shock signs
• Secondary Management:
  • Simple fractures: Closed reduction (manual manipulation), traction, ORIF (surgical alignment), immobilization (cast, splint, internal fixation devices)
  • Open (compound) fractures: Surgical debridement, tetanus toxoid, wound culture/antibiotics, observe for infection/complications, wound closure, fracture reduction, immobilization, complication treatment

Nursing Interventions/Patient Education

• Diet, fluids, exercise unaffected joints, muscle-setting exercises, skin care, elimination, prevent immobility complications
• Patient teaching: Comfort in bed, safe transfers, weight-bearing restrictions, activity limits, ambulatory device use, edema control, pain/discomfort management, exercise, pin care (asepsis), muscle toning

Hip Fractures

• Prevalence: Most common hospital-treated fracture, mostly from falls, common in older adults (decreased flexibility, strength, bone density)
• High mortality rate after 75.
• Types:
  • Intracapsular: Femur broken inside joint (head/neck), risk of avascular necrosis; often requires prosthesis
  • Extracapsular: Outside the joint, more common, intertrochanteric/subtrochanteric, adequate blood supply = healing without avascular necrosis risk
• Symptoms: Severe pain/tenderness, leg shortening/edema, external leg/foot rotation
• Diagnosis: X-ray, CBC
• Treatment: Temporary immobilization/traction until surgery; surgical repair (nails, screws, arthroplasty, bone graft, intermedullary rod)
• Post-operative care: Vital signs monitoring, wound assessment, body alignment, DVT prevention (stockings, exercises, anticoagulants), pulmonary toilet, turning, complication monitoring (pneumonia, DVT, PE, fat embolism, urinary retention/constipation, skin breakdown, infection)
• Patient education: Hip precautions, weight-bearing, ambulation aids, exercise, DVT prevention, pain management

Vertebral Fractures

• Locations: Vertebral body, lamina, articulating processes, with/without displacement
• Pressure on spinal nerves from displacement
• Severed spinal cord = paralysis
• Symptoms: Pain, partial/complete mobility & sensory loss below injury level
• Assessment: Neurological (pupils, hand grip, extremity movement, orientation, vitals, painful stimuli), fecal/urinary retention, hemorrhage signs
• Diagnosis: X-rays, myelography, CT scans, spinal tap
• Medical Management: Stable: Pain meds, muscle relaxants, anticoagulants, upright posture; Unstable: Fracture reduction, postural positioning, traction (halo, pelvic), surgical intervention (Harrington rod)
• Nursing care: Stability maintenance, log rolling, elevated HOB, traction continuity assessment, skin integrity/distal pulses
• Patient teaching: Mattress firmness, sitting posture, lifting, back exercises

Pelvic Fractures

• Etiology/Cause*: Significant trauma (high falls, car accidents, crushing injuries)
• Symptoms: Inability to bear weight, tenderness/edema, hematuria (blood in urine), hemorrhage (life-threatening)
• Assessment*:
• Subjective*: Pelvic pain, backache, anxiety, restlessness, and disorientation (signs of shock)
• Objective*: Muscle spasm, bruising over pelvic area, inability to raise legs, external foot rotation, vitals (hypotension, tachycardia, tachypnea, oliguria, diaphoresis), observe for fat embolism, bowel sounds, urine color/output, girth
• Diagnosis*: Abdominal X-rays, CT scans, IV pyelogram, labs (CBC, urine, stool)
• Medical Management*:
• Bedrest,* pelvic sling, skeletal traction, spica/body cast
• Nursing*: Shock monitoring, abdominal girth measurement, I&O (foley catheter), nursing interventions for mobility/skin/fluids/pain, patient teaching

Compartment Syndrome

• Definition*: Arterial vessel compression reduces blood supply to an extremity’s compartment.
• Causes*: Tissue pressure increases within fascia-enclosed spaces affecting arteries, veins, muscles, nerves.
• Time-critical*: 6 hours = irreversible ischemic damage; 24-48 hours = permanent disability.
• Complications*: Volkmann’s contracture (elbow, wrist, fingers flexed), infection (delayed decompression).
• Symptoms*: Intense pain (increased with movement), numbness/tingling, inability to flex digits, coolness, pale/bluish skin, slow capillary refill, absent pulse
• Diagnosis*: Clinical assessment combined with measurement of tissue pressure directly within the compartment.
• Medical Management*: Fasciotomy (incision into fascia) to relieve pressure, open wound.
• Nursing*: Analgesics, elevation, cold packs, remove constricting material.

Shock

• Causes*: Blood loss from fractured bones or vessels.
• Symptoms*: Level of consciousness changes, restlessness/anxiety, weakness/lethargy, hypotension, tachycardia, tachypnea, hyperthermia, pale/cool/moist skin, oliguria.
• Medical Management*: Restore blood volume (IV fluids, blood products), oxygen.
• Nursing Interventions*: Fluid/IV site monitoring, frequent vital signs, urinary output, bed rest, NPO, avoid sedatives that mask neurologic changes, shock trousers if needed

Fat Embolism

• Causes*: Platelets combine with fat, travel through lungs, obstruct vessels. Rare but life-threatening (pulmonary failure), associated with multiple fractures, crush injuries, long bones/pelvic fractures.
• Symptoms*: Mental disturbances, irritability, restless, disoriented, stupor, coma, chest pain, muscle weakness, spasticity, rigidity, tachypnea, dyspnea, hypoxemia, crackles, wheezes, petechiae
• Diagnosis*: Occurs within 24-48 hours, blood gases (hypoxemia), CBC (decreased H/H, fat, platelets), urine (fat), ESR (increased)
• Nursing care*: Carefully monitor ABGs, fluids, oxygen, incentive spirometry, any steroid/digoxin therapy as ordered

Gas Gangrene

• Cause*: Severe skeletal muscle infection caused by Clostridium bacteria, associated with compound fractures & lacerations, potentially fatal if untreated.
• Symptoms*: Sudden/severe pain, toxic delirium, gas bubbles/crepitus visible in the skin, skin necrosis, watery discharge with foul odor
• Medical Management*: Debridement (surgical removal), antibiotics (penicillin, cephalosporins), possibly amputation
• Nursing*: Wound care with strict medical asepsis, infection control, isolation measures

Thromboembolism

• Causes*: Blood clot (thrombus) travels and blocks a blood vessel. High risk with pelvic/hip fractures.
• Symptoms*: Affected area cold, numb, cyanotic, sudden sharp pain, dyspnea, lung embolus cough, fever, hemoptysis.
• Assessment*: Check for warmth, edema, color changes in the extremities, signs of pulmonary involvement, and bleeding if anticoagulants are being used.
• Diagnostic Tests*: Labs (PT, PTT, INR, D-dimer, CBC), Doppler ultrasonography or duplex scanning, CT scan
• Medical Management*: Anticoagulants, thromboectomy.
• Nursing care*: Bed rest, leg elevation, active exercise, compression stockings, pulmonary assessment, anticoagulant monitoring

Delayed Fracture Healing

• Definition*: Fracture takes longer than usual to heal.
• Types*: Non-union (bone ends fail to unite within 6-9 months).
• Treatment*: Electrical stimulation to stimulate bone production

External Fixation Devices

• Used to hold bone fragments in place
• Materials: Casts, skeletal/skin traction, braces, pins
• Skeletal Pin External Fixation*:
• Immobilizes fractures using pins inserted through bone, metal frame
• Used for comminuted, open fractures, infected nonunions, or unstable joints
• Requires general anesthesia
• Frequent assessment of pins for infection

Casts

• Immobilize bone during healing
• Materials: Plaster, fiberglass, plastic
• Types*: Short arm, long leg, spica (body), bivalve
• Initial Assessment*: Baseline measurements and neurovascular assessment (pulses, color, temperature, capillary refill, sensation, motion) before and after cast application/removal, skin integrity
• Nursing interventions*: Explain the procedure, precaution/care of cast, skin care, turning, toileting, weight-bearing restrictions, and cast removal procedure

Traction

• Applies tension to an extremity/bone using weights and pulleys for alignment & stabilization
• Types:
  • Skeletal: Directly on bone using pins, tongs, wires
  • Skin: On skin using weights on bandages
• Common types: Bucks, Russell's
• Nursing Care: Frequent neurovascular checks (pulses, movement, skin), weight/pulley/rope checks, ensure alignment, meticulous skin care, pain management.

Frames and Splints

• Frames used for turning, positioning, and maintaining alignment
• Types: Balkan, Bradford, Stryker, RotoRest, MicroAIR, etc.
• Splints and braces: Immobilization and ambulation assistance
• Crutch/cane/walker use safety: Proper measurements, rubber tips, adequate upper extremity strength

This quiz covers various types of fractures, their definitions, and classifications. It addresses causes, symptoms, and specific categories such as open, closed, and displaced fractures. Test your knowledge on important medical terminology related to fractures.