Fracture Management

• Musculoskeletal problems covered in Chapters 67 and 68.
• Focus on diagnostic criteria, assessment findings, nursing care, and medical treatment.

Topics Covered

• Fractures, sprains, and strains: management and complications.
• Compartment syndrome.
• Traction.
• Amputation.
• Diagnostic studies: X-ray, CT, MRI, ESR, RF, CRP, Duplex venous Doppler.

Soft Tissue Injuries: Strains & Sprains

• Sprain involves injury to ligamentous structures surrounding a joint.
• Sprains result from turning or wrenching motions, primarily affecting ankles, wrists, and knees. Ligament injuries lead to joint instability.
• Strain involves excessive stretching of a muscle, particularly in the fascial sheath or a tendon, commonly affecting large muscle groups like the lower back, calf, and hamstrings and result from overuse or over stretching of the muscles.
• Nursing management focuses on sprains and strains.
• Immediate actions include:
  • Managing acute injury.
  • CMS checks of capillary refill, pulses, color, numbness/tingling.
  • RICE (rest, ice, compression, and elevation).
  • Pain medication and X-rays to manage swelling, inflammation, and identify bone damage.
  • Ambulatory and home care: elevate and apply ice, not longer than 20 minutes, and not directly to the skin for 24-48 hours, then apply moist heat.

Fractures

• Fractures involve a disruption or break in the continuity of bone structure.
• Most fractures result from traumatic injuries.
• Some fractures are secondary to disease processes like cancer or osteoporosis, which break down bone density and make bones more brittle.
• Classification:
  • Open fractures penetrate the skin; closed fractures do not.
  • Non-displaced fractures have aligned bones; displaced fractures have separated bones.
  • Fracture types include transverse, spiral, greenstick, comminuted, oblique, pathologic, and stress fractures.

Clinical Manifestations of Fractures

• Edema and swelling are typical signs.
• Pain and tenderness are common symptoms.
• Decreased or loss of function.
• Loss of function prevents bearing weight or use.
• Guarding may occur around the injury site.
• Muscle spasms and inflammation around the fracture.
• Deformity may or may not be present.
• Immobilization is essential when a fracture is suspected.

Goals of Fracture Treatment

• Anatomic realignment (reduction).
  • Strategies for fracture reduction include closed reduction, open reduction, and traction.
• Immobilization to maintain alignment.
• Restoration of normal or near-normal function.

Fracture Reduction: Closed

• Involves closed reduction, a nonsurgical, manual realignment of bone fragments.
• Includes traction and countertraction.
• Performed under local or general anesthesia.
• Immobilization is necessary afterwards using traction, a cast, splint, or brace.

Fracture Reduction: Open

• Open reduction involves surgical correction of alignment, which often includes internal fixation (ORIF).
• ORIF uses wires, screws, pins, plates, rods, or nails to align the fracture.
• Surgical incision required.
• Biggest concern: risk for infection.
• Internal fixation used, followed by early ROM of the joint to prevent adhesions.
• CPM (continuous passive motion) machines may be used.
• Facilitating early ambulation prevents long-term fracture problems.

External Fixation

• External fixation is often used for crushed injuries.
• Metal pins and wires attach to external rods.
• It applies traction, compresses fragments, and immobilizes the area.
• It immobilizes and holds fracture fragments in place.
• Nursing management includes assessing for pin loosening and signs of pin site infection.

Fracture Reduction: Traction

• Traction involves applying a pulling force to an injured or diseased part of the body to attain realignment.
• Countertraction pulls in the opposite direction.
• Purpose:
  • Prevent or reduce pain and muscle spasm.
  • Immobilize the joint or body part.
  • Reduce the fracture or dislocation.
  • Treat pathologic joint conditions, such as tumors or infections.
• The two most common types are skin and skeletal traction.

Fracture Reduction: Skin Traction

• Short-term use (48-72 hours) until surgery is possible.
• It is noninvasive and allows for pain relief.
• Skin traction uses tape, boots, or splints applied directly to the skin to maintain alignment and reduce muscle spasms.
• Traction weights are typically 5 to 10 pounds.
• Skin assessments should be done every 2-4 hours to prevent skin breakdown.
• Applied in children and adults.

Fracture Reduction: Skeletal Traction

• Used for long-term alignment of injured bones and joints.
• Treats joint contractures and congenital hip dysplasia.
• A pin or wire is inserted into the bone to align and immobilize the injured body part.
• Weights from 5 to 45 lbs. ordered by the provider.
• Risk for infection.
• Complications of immobility.
• Adults only.

Traction Implementation

• Balanced suspension traction requires correct patient position and alignment with constant traction forces.
• Maintain countertraction.
• Weights used should hang freely and not touch the floor to ensure effective traction.
• Elevate the end of the bed.
• Maintain continuous traction.

Fracture Immobilization

• Purpose is to provide a temporary, circumferential immobilization device.
• Allows patients to perform many normal ADLs while providing sufficient immobilization for stability.
• Made of various materials.
• Typically incorporates joints above and below the fracture site.

Application of a Cast

• Affected area is covered with stockinette and padding.
• Plaster of Paris material is immersed in warm water, wrapped, and molded.
• Sets in 15 minutes.
• Takes needs 24-72 hours to dry before weight bearing.
• Should not be covered, because air needs to circulate to prevent burns, and drying is delayed.
• Avoid direct pressure on cast during drying period

Neurovascular Assessment, aka CMS Assessment

• Peripheral Vascular
  • Focus on color and temperature.
  • Capillary refill.
  • Pulses.
  • Edema.
• Peripheral Neurologic
  • Sensation and motor function.
  • Pain: increased pain can be indicate impaired circulation.

Cast Care Instructions for Patients and Caregivers

• Frequent neurovascular assessments are essential.
• Should apply ice for the first 24 hours.
• Elevate above the heart for the first 48 hours.
• Exercise joints above and below the cast.
• Should use hair dryer on cool setting for itching.
• Check with your health care provider before getting the cast wet.
• Actions to take:
  • Dry the cast thoroughly after getting it wet.
  • Report increasing pain despite elevation, ice, and analgesia.
  • Report swelling associated with pain and discoloration OR movement, which release the case.
  • Report burning or tingling under the cast.
  • Report sores or foul odor under the cast.
• Actions to avoid:
  • No ice or elevation if compartment syndrome suspected.
  • Do not get plaster cast wet.
  • Avoid removing padding.
  • Do not insert objects inside the cast.
  • No weight-bearing for 48 hours.
  • Avoid covering the cast with plastic for a prolonged period.

Lower Extremity Immobilization

• Elevate the extremity above the heart for 24 hours.
• Do not place in a dependent position due to the risk of increased edema.
• Observe for signs of compartment syndrome.
• 6 P's are related to resulting from too much swelling:
• Pain.
• Increased pressure.
• Paresthesia (numbness and tingling to the distal area).
• Pallor.
• Paralysis (not being able to move).
• Pulselessness- No blood circulating to the distal area or feeling pulses.

Compartment Syndrome

• Compartment syndrome involves swelling and increased pressure within a limited space, like a muscle compartment.
• Compartment Syndrome Swelling compromises the neurovascular function of tissues within that space.
• Upper and lower extremities have 38 compartments---swelling can lead to tissue problems.
• Two basic causes:
  • Decreased compartment size results from restrictive dressings, splints, casts, excessive traction, or premature closure of fascia.
  • Increased compartment contents result from bleeding, inflammation, edema, or IV infiltration. Edema obstructs circulation.
• Arterial flow can be compromised, leading to ischemia, cell death, and loss of function.
• Early recognition critical: intervention must be instituted quickly to get the swelling reduced.
  • Clinical manifestation: May occur initially with injury or may be delayed by several day
• Ischemia can occur within 4 to 8 hours after onset.
• Prompt and accurate diagnoses that include neurovascular assessments.
• Early Signs:
  • Notify if pain is unrelieved by drugs and out of proportion to injury.
• Notify is paresthesia occurs -Relieving the source of pressure may prevent progression
• Late Signs:
  • Cardiac arrest-Tissue Death
  • Pulselessness
  • Paralysis
  • May require amputation
• If suspect compartment syndrome:
  • Do not elevate extremity above heart.
  • Avoid applying cold compresses or ice.
• Treatment:
  • Relieve pressure.
  • Perform surgical decompression (fasciotomy).
  • Possible amputation.

Fracture of the Hip

• More common in older adults.
• Signs and symptoms include severe pain and tenderness, shortening of the affected extremity, muscle spasm, and external rotation.
• Nursing management focus includes pre-op, intra-op, and post-op, including neurovascular assessments.
• Medical management may involve Buck's traction if medically unstable; surgery if stable using internal fixation devices.
• Hip fracture treatment and management depends on how safe the patient is to undergo general anesthetic.
• Postoperative care includes elevating the leg to reduce the risk of edema.
• Maintain limb alignment always.

Hip Fracture Nursing Implementation

• For a hemiarthroplasty or total hip replacement (THR) through a posterior approach: is the main goal is preventing dislocation.
• Must Do:
  • Use elevated toilet seat
  • Remain seated on chair in shower or tub
  • Keep hip in neutral, straight position when sitting, walking or lying
  • Notify surgeon immediately if severe pain, deformity, or loss of function occurs
  • Discuss risk of infection related to prosthetic joint with dentist or surgeon
• Posterior THR approach -Must avoid:
  • Flexing hip past 90 degrees
  • Adducting (abduction wedge)
  • Internally rotating and/or crossing arms
  • Putting on shoes 4-6 weeks and/or sitting in chairs w/out arms

Nursing Implementation of Hip Fracture w/Anterior Approach

• Fewer precautions must be taken.
• Hyperextension must be avoided.
• Weightbearing: ORIF (restricted for 6-12 weeks).
• No bathing in tub/driving for 4-6 weeks + mobile.
• Occupational and physical therapists should see the patient for assistive devices/exercise & ambulation before d/c.

Gerontologic Considerations for hip fracture:

• Focus on preventive safety measures that prevent falls:
  • Home safety:
  • Eliminate Tripping hazards:
  • Use grab bars:
  • Install railings on both sides of the stairs:
  • Good lighting in all rooms:
  • External hip protectors:
  • Calcium & Vitamin D use:
• Bisphosphonate use:

Spinal Fractures

• Stable Spinal Fractures are when the fractured bone or fragments will not cause damage to the spinal cord.
• Can be serious and must consider all spinal fracturs to unstable
• Maintain spinal alignment and sensory status

Spinal Fractures

• Stable spinal fractures are the fractures of where the bone is unlikely to cause spinal cord damage.
• Could result in a serious spinal injury, so...
  • Consider all spinal fractures to be unstable:
  • Maintain spinal alignment and neurologic function:

Spinal Surgery Post-Op care:

• Must maintain and assist in proper Log-Rolling and alignment.
• Adequate support and staffing is necessary.
• Assess CMS w/hourly checks
• Monitor CSF leakage and check drainage from incision.
  • Severe Headaches and clear/yellow fluid
• Assess for numbness, tingling, and loss of bowel/bladder control.

Amputation

• Clinical indication relies on underlying cause of the needing amputation.
• Should check WBC and get baseline numbers before procedures.
• Arteriography, Venography, and ultrasound can be done to assess blood flow to and from the limbs.
• Should Preserve the extremity and quality of life as well as assess risks of infection/tissue damage.
• Treat any and all infection before going through procedure.