Fracture Management: Overview and Interprofessional Care

Fractures Overview

• Fractures are classified as open/closed or displaced/nondisplaced.
• Healing is affected by the fracture site, blood supply, patient age, nutrition, smoking, and infection.
• Manifestations include pain, swelling, deformity, muscle spasms, loss of function, and crepitation, and it's important to check pulses.
• Healing stages are hematoma, granulation tissue, callus formation, ossification, consolidation, and remodeling.

Interprofessional Fracture Care

• Goals involve fracture alignment (reduction), immobilization, and restoring function.
• Closed reduction: involves manual realignment using traction, casts, splints, or braces.
• Open reduction: uses surgery with internal fixation like pins, screws, or plates.

Traction for Fractures

• Traction entails using pulling force to align bones.
• Balance skeletal traction prevents patient turning due to skin breakdown risks.
• Skin traction: uses tape, boots, or splints for short-term use (5-10 pounds) to reduce muscle spasms, requiring skin assessment for breakdown prevention.
• Skeletal traction: includes aligning injured bones/joints using pins inserted into the bone (weights range 5-45 pounds), with complications of immobility.
• Balanced suspension traction: involves patient countertraction, elevating the bed end, continuous traction, and weights kept off the floor.

Casts and Splints

• Plaster or fiberglass are the common materials.
• Casts and splints allow patients to perform ADLs while immobilizing the injury.
• Application involves covering with padding, wrapping, molding (sets in 15 min), and it takes 36-72 hours before the cast can bear weight, without covering to avoid burn risk and delayed drying.

Supportive Devices for Fractures

• Upper extremity injuries: slings, sugar tong splints, posterior splints, and short and long arm casts are needed.
• Lower extremity injuries: long leg and short leg casts, cylinder casts, and Robert Jones dressings are needed.
• Slings are used to support/elevate arms but are contraindicated with proximal humerus fractures.
• Body jacket braces: immobilize/support stable thoracic and lumbar spine injuries, covering from the nipple line to the pubis.
• Superior mesenteric artery syndrome monitoring: includes bowel sound changes, abdominal pain, nausea, and vomiting.
• The treatment for superior mesenteric artery syndrome is gastric decompression with an NG tube and suction.

Extremity Injury Management

• The injured limb is elevated above the heart using pillows for 24 hours.
• Letting the limb hang down can cause edema.
• Compartment syndrome monitoring involves watching for pain or burning in the heel, shin, fibula head, or ankle.
• Splints and immobilizers can be easily removed to check swelling/skin and allow faster recovery with early movement.

External and Internal Fixation

• External fixation involves metal pins/wires attached to external rods for traction and immobilization.
• External fixation is used for severe fractures, bone deformities, non-healing fractures, and limb lengthening.
• External fixation can help save limbs that may otherwise need amputation.
• Long-term external fixation entails checking for loose pins/infections, and cleaning with chlorhexidine.
• Internal fixation uses pins, plates, rods, or screws to hold bones together.
• X-rays are used to monitor healing progress with internal fixation.

Electrical Bone Growth Stimulation and Nutrition

• Electrical bone growth stimulation increases calcium uptake.
• Electrical currents stimulate bone growth and healing via noninvasive (worn), semi-invasive (electrodes placed), or invasive (electrodes planted) methods.
• Nutrition for bone healing includes increasing protein intake (1g/kg).
• Increased intake of vitamin BCD, calcium, phosphorus, fluids, and fiber are useful for bone healing.
• Patients with body jackets/hip spica casts should eat six small meals a day to prevent bloating.

Fracture Drug Therapy

• Muscle relaxants that treat muscle spasms include carisoprodol, cyclobenzaprine, and methocarbamol.
• Caution: muscle relaxants may cause drowsiness, dizziness, or nausea.
• Tetanus and diphtheria toxoid are given for open fractures if vaccination history indicates.
• Cephalosporins are given prophylactically before surgery.

Fracture Nursing Management

• Transport to the ED should occur ASAP for treatment.
• Musculoskeletal injuries can affect blood flow and nerves, especially below the injury site.
• Compare both sides of the body for differences.
• Health data: includes history, medications, surgeries, and daily life impact.
• Objective Data: includes general appearance, skin condition, cardiovascular status, neurovascular status, musculoskeletal condition, and possible diagnostic tests.

Neurovascular Assessment Following Fractures

• Pertains to peripheral vascular circulation.
• Pale and cold skin: indicates arterial insufficiency.
• Warm and cyanotic skin: indicates poor venous return.
• Capillary refill: over 3 seconds signifies arterial insufficiency.
• Pulses: Weak/absent pulses indicates arterial insufficiency.
• Always compare both sides when assessing pulses.

Preoperative and Postoperative Fracture Care

• Preoperative preparation: Patient education about immobilization (casts, splints, braces).
• Patient education: How to use assistive devices.
• Patient education: Activity limitations & pain control options.
• Reassurance: The patient's needs will be met.
• Monitoring: Monitor vital signs.
• Post Op Frequent neurovascular checks.
• Be careful when turning or positioning the patient to avoid causing more damage.
• Monitor for bleeding/drainage after surgery and during recovery.
• Prevent complications of immobility after surgery.
• Increase fluids and fibers.
• Stay hydrated to prevent stones.
• Monitor cardiovascular and respiratory status.

Ambulatory Care and Cast Care

• Ice for the first 24 hours and elevation above the heart for 48 hours may be recommended post-surgery.
• Move joints above/below cast to prevent stiffness.
• Itchiness Relief: Use a hairdryer for itching on a cool setting.
• The patient should check with the doctor before getting the cast wet.
• Dry the cast completely if it gets wet.
• Notify the doctor to report worsening pain despite the use of ice, elevation, and pain medication.
• Notify the doctor to report swelling, discoloration, tingling, and burning under the cast.
• Notify the doctor to report any sores or unpleasant odors emanating from the cast.
• Do not elevate limb if compartment syndrome is suspected.
• Do not get the plaster cast wet.
• Do not remove padding inside or insert any object inside the cast.
• Do not bear weight for 48 hours.
• Do not cover cast in plastic for a prolonged period.
• Pain control is essential before ambulation or physical therapy.
• Psychosocial recovery should emphasize regaining independence and preventing atrophy/muscle loss.

Complications of Fractures

• Medical emergencies warrant immediate attention, especially for open fractures with severe blood loss or fractures causing damage to major organs.
• Direct complications can occur: bone infection (osteomyelitis), bone non-union/malunion, and avascular necrosis.
• Indirect complications: compartment syndrome, venous thromboembolism (VTE), fat embolism syndrome (FES), rhabdomyolysis, or hypovolemic shock.
• Infection is common in open fractures and pose a high risk due to contaminated tissue (ideal for Clostridium tetani).
• Apply pre-operative antibiotics, surgical debridement, drainage, and skin grafting as preventive measures.
• Consider antibiotic therapy, such as IV irrigation or the use of impregnated beads.

Compartment Syndrome Specifics

• Symptoms and diagnostics: Compartment syndrome occurs when pressure increases in a closed muscle space and blocks circulation/nerve function.
• Check for 6 P's: pain, pressure, paresthesia, pallor, paralysis, and pulselessness.
• Increased compartment contents can be caused by bleeding, edema, or IV infiltration.
• Decreased compartment size can be caused by tight dressings, casts, excessive traction.
• Worsening edema is a possible venous occlusion.
• Ischemia and cell death can be consequences of arterial flow blockage.
• For treatment, DO NOT elevate the limb past the heart or apply ice because it decreases the circulation.
• Surgical decompression (Fasciotomy) to cut fascia and relieve pressure.
• Amputation as a possible option if severe.

Venous Thromboembolism

• High risk: lower extremity and pelvic fractures result in venous stasis from muscle inactivity.
• Anticoagulants (10-14 days), compression stockings, and early ambulation can be helpful.

Fat Embolism Syndrome

• Causes and details: Fat droplets enter the bloodstream and block vessels, which in turn cause organ damage.
• Caused by: long bone fractures (femur, tibia, pelvis, ribs), burns, pancreatitis, bone marrow transplant, and joint replacement.
• Mechanical emboli: Fat from marrow enters circulation and results in ischemia and inflammation.
• Biochemical: Trauma and sepsis trigger fat breakdown and forms emboli.
• Critical Recognition: Early treatment is critical because symptoms start appearing within 24-48 hours after injury.
• Chest complications often develop with symptoms such as tachypnea, mental status status, dyspnea, hypoxia, tachycardia, chest pain, and petechiae.
• Signs for recognition: dyspnea, change in mental status, chest pain.
• Analysis and labs show: Fat cells in blood urine, and sputum. Decreased PaO2 is indicated by a chest X-ray that exposes pulmonary infiltrates. Low platelets, low hematocrit, increased ESR.
• Care and treatment typically involves supportive measures including O2, ECMO, IV fluids and hemodynamic support among other options.
• Muscle breakdown is likely to release myoglobin which in turn will cause kidney failure and result in dark brown urine: Rhabdomyolysis. Monitor urine and do electrolyte functions.

Fractures Overview

• Colles are wrist fractures: the care plan mandates neurovascular checks, maintain mobility, and prevents edema.
• The primary goal of a humerus fracture plan is to prevent skin breakdown.
• There will be brace, ice and analgesics needed.

Pelvic Fractures

• Monitor any hemorrhage organ damage: these have a higher likelihood of turning into sepsis, VTE, FES, and compartment syndrome.

Hip Fractures

• To care of these, one needs to fix with hemi or with nails and screws. Make sure there is mobility.

Bone Fractures in General

• Follow CMS/NV checks for shaft breaks.
• Those with a high risk of break must go under fixation with internal/external checks. Vertebral fractures are managed with fall prevention/pain.

Fractures in the Face

• The critical plan of action is to maintain airway. It's likely trach or suction are needed. Keep in mind this requires careful c-spine consideration until there is indication of injury.

Eye Rupturing

• Signs can point to vitreous rupturing: blood prolapse/irregular pupil.

Care for Mandibular Fractures

• If the face takes traumatic trauma, a surgeon does surgery that may need a airway compromise. In emergency, wire cutters/scissors must be on hand if the airway fails.

Pre/Post OP Care

• Reassure ability to speak or swallow pre intervention. A tube may be used. To get nutrition and to hydrate and clean the interior of wire placements.

Amputation

• Could be from congenital or tumoral issues. Pre-OP involves the use of pre-cidal meds. Main issues are balancing muscles due to phantom pain.