Fracture Types, Healing, and Care

• Fractures are classified as open or closed, displaced or non-displaced.
• Healing depends on the fracture site, blood supply, age, nutrition, smoking, and infection.
• Manifestations include pain, swelling, deformity, muscle spasms, loss of function, and crepitation; check pulses.
• Stages of bone healing are hematoma formation, granulation tissue development, callus formation, ossification, consolidation, and remodeling.

Interprofessional Fracture Care

• Goals include alignment (reduction), immobilization, and restoring function.

Reduction

• Closed reduction involves manual realignment, followed by a cast, splint, or brace.
• Open reduction involves surgery with internal fixation using pins, screws, or plates.

Traction

• Traction involves a pulling force to align bones.
• Balance skeletal traction involves not turning these patients; skin breakdown is a significant concern.

Skin Traction

• Skin traction is short-term, using tape, boots, or splints applied directly to the skin to reduce muscle spasms.
• Use 5-10 pounds for skin traction.
• Skin assessment and prevention of breakdown are important.

Skeletal Traction

• Aligns injured bones or joints using a pin or wire inserted into the bone for long-term alignment maintenance.
• Use 5-45 pounds for skeletal traction weights.
• Complications include immobility.

Balanced Suspension Traction

• Maintains countertraction, typically using the patient's body weight.
• Elevate the end of the bed and maintain continuous traction.
• Keep weights off the floor, allowing them to move freely through pulleys.

Casts and Splints

• Common materials include plaster or fiberglass.
• Allow the patient to perform ADLs while immobilized.
• Stabilize joints above and below the fracture.

Application

• Cover the affected part with padding, wrap, and mold the cast.
• It sets in ~15 minutes, weight-bearing possible after 36-72 hours; do not cover to avoid burns and delayed drying.

Supportive Devices

• Upper extremity injuries often require slings, sugar tong splints, posterior splints, and short and long arm casts.
• Lower extremity injuries often require long leg and short leg casts, cylinder casts, or Robert Jones dressings.
• Use of a sling is contraindicated with a proximal humerus fracture; used to support and elevate the arm.
• Body jacket brace: immobilizes and supports stable thoracic and lumbar spine injuries, covering from the nipple line to the pubis.
• Watch for superior mesenteric artery syndrome: bowel sound changes, abdominal pain, nausea/vomiting.
• Treatment includes gastric decompression with an NG tube and suction.

Extremity Injuries Management

• Elevate the limb above the heart using pillows for 24 hours; avoid letting the limb hang down to prevent edema.
• Watch for compartment syndrome characterized by pain or burning in the heel, shin, fibula head, or ankle.

Splints and Immobilizers

• Splints and immobilizers are easy to remove for swelling, skin checks, and faster recovery; used to treat early movement.

External Fixation

• Metal pins/wires attached to external rods apply traction, hold bone fragments together, and immobilize the area.
• Used for severe fractures with soft tissue damage, bone deformities, non-healing misaligned fractures, and limb lengthening procedures.
• External fixation can save limbs that would otherwise need amputation.
• Long-term treatment involves checking for loose pins and infections; clean the pin site with chlorhexidine.

Internal Fixation

• Pins, plates, rods, or screws hold bones together.
• Healing progress is monitored with X-rays.

Electrical Bone Growth Stimulation

• Increases calcium uptake.
• Uses electrical currents to stimulate bone growth and healing.
• Noninvasive type is worn outside the body.
• Semi-invasive type: electrodes are placed under the skin.
• Invasive type: electrodes are planted in the bone.

Nutrition for Bone Healing

• Increase protein intake to 1g/kg.
• Increase intake of vitamin BCD, calcium, phosphorus, magnesium, fluids, and fiber.
• Patients with body jackets or hip spica casts should eat six small meals per day to prevent bloating.

Drug Therapy

• Muscle relaxants for muscle spasms include Carisoprodol, cyclobenzaprine, and methocarbamol, which may cause drowsiness, dizziness, or nausea.
• Tetanus and diphtheria toxoid are given for open fractures if the vaccine history is unknown.
• Cephalosporins are given prophylactically before surgery.

Nursing Management

• Transport to the ED ASAP for treatment.
• Musculoskeletal injuries impact blood flow and nerves, especially below the injury site; compare both sides of the body for differences.

Relevant Data

• Subjective: health history, medications, past surgeries or treatment, daily life impact (activity level, pain perception, health management).
• Objective: general appearance, skin condition, cardiovascular status, neurovascular status, musculoskeletal condition, possible diagnostic tests.

Neurovascular Assessment

• Peripheral vascular circulation is key

Skin Color and Temperature

• Pale and cold may indicate arterial insufficiency (poor blood supply).
• Warm and cyanotic can indicate poor venous return (pooling).

Capillary Refill

• • More than 3 seconds may indicate arterial insufficiency.

Pulses

• Weak or absent may indicate poor blood supply (arterial insufficiency).
• Always compare both sides.

Preop and Post-op Care

• Preop: teach the patient what to expect regarding immobilization with casts, splints, or braces.

How to Use Assistive Devices

• Provide activity limitations and pain control options.
• Reassure patients that their needs will be met.
• Monitor vitals.

Post-op

• Frequently check neurovascular status: circulation and nerve function.
• Be careful with movement, like turning, positioning and supporting the injured area.
• Monitor for signs of bleeding or drainage, using aseptic techniques, may require blood salvation or autotransfusion.

Prevent complications of immobility

• Constipation: increase fiber and fluids.
• Kidney stones: keep hydrated.
• Heart and lung issues: monitor cardiovascular and respiratory status.

Cast Care

• Ice for the first 24 hours.
• Elevate above the heart for 48 hours.
• Move joints above and below the cast to prevent stiffness.
• Use a hairdryer for itching on the cool setting.
• Check with the doctor before getting the cast wet.

Do

• Dry the cast completely if it gets wet.
• Report worsening pain, even with ice, elevation, and pain meds.
• Report swelling, discoloration, tingling, or burning under the cast.
• Report any sores or bad odors under the cast.

Do Not

• Do not elevate the limb if compartment syndrome is suspected
• Get the plaster cast wet.
• Remove padding from inside the cast.
• Insert objects inside the cast.
• Bear weight for 48 hours.
• Cover the cast with plastic for a prolonged period.
• Ambulation: manage pain before PT.

Psychosocial Concerns

• Short-term rehab: regaining independence in daily activity.
• Long term rehab: prevent complications like muscle loss (atrophy), stiffness (contractures, foot drop), chronic pain and muscle spasms. Challenges include being away from family, financial support, job limitations, risk of permanent disability, PTSD or emotional distress, and caregiver support.

Complications of Fractures

• Medical emergencies needing immediate attention required for: open fractures with severe blood loss, fractures that damage vital organs.

Complications

• Direct: bone infection (osteomyelitis), bone nonunion/malunion (improper healing), avascular necrosis.
• Indirect: compartment syndrome, venous thromboembolism (VTE), fat embolism syndrome (FES), rhabdomyolysis, hypovolemic shock.

Infection

• Common in open fractures.
• High risk due to contaminated tissue: ideal for clostridium tetani.

Prevention

• Pre-op antibiotics, surgical debridement, drainage, skin grafting, antibiotic therapy (IV, irrigation, impregnated beads).

Compartment Syndrome

• Swelling increases pressure inside a closed muscle space, occluding circulation and nerve function.

Symptoms

• Pain: out of proportion, unrelieved by opioids, worse with passive stretch.
• Pressure: tightness in affected limb.
• Paresthesia: tingling or numbness.
• Pallor: pale or cool skin.
• Paralysis: loss of movement.
• Pulselessness: LATE sign, indicates severe ischemia.

Causes

• Decreased compartment size: tight dressings, casts, excessive traction.
• Increased compartment contents: bleeding, edema, IV infiltration.

Complications

• Venous occlusion: worsening edema.
• Arterial flow stops: ischemia and cell death.

Treatment

• Do NOT: elevate above the heart or apply ice, which worsens circulation.
• Surgical decompression (fasciotomy): cut fascia to relieve pressure.
• Amputation possible if severe.

Venous Thromboembolism

• Lower extremity and pelvic fractures = HIGH risk due to venous stasis from muscle inactivity.
• Prevention: anticoagulants (10-14), compression stockings, pneumatic compression devices, early ambulation and exercise.

Fat Embolism Syndrome

• Fat droplets enter the bloodstream, blocking vessels and damaging organs.
• Common causes: long bone fractures (femur, tibia, pelvis, ribs), burns, pancreatitis, bone marrow transplant, joint replacement.

Mechanisms

• Mechanical: fat from marrow enters circulation, leading to ischemia and inflammation.
• Biochemical: trauma/sepsis triggers fat breakdown→ forms emboli.
• Early recognition is CRITICAL; symptoms can start 24-48 hours after injury.

Common Signs

• Lungs: hemorrhagic pneumonitis→ ARDS (acute respiratory distress syndrome).
• Signs: chest pain, tachypnea, cyanosis, dyspnea, tachycardia, hypoxia, mental status changes, petechiae (unique to FES), limited blood supply, pain, warmth.

Diagnosis

• Fat cells in blood, urine, sputum.
• Decrease PaO2 (<60), low platelets, low hematocrit, increased ESR.
• Chest x-ray: pulmonary infiltrates.

Treatment

• Supportive care, including O2, ventilation, ECMO, IV fluids, hemodynamic support, pulmonary vasodilators.

Rhabdomyolysis

• Muscle breakdown→ myoglobin release→ kidney failure.

Sign

• Dark brown urine.
• Monitor: urine output, renal functions, electrolyte balance, signs of AKI.
• Overview: types of fractures and management.

Colles (wrist)

• CMS/NV checks, elevate, prevent edema, maintain joint mobility.

Humeral Shaft

• CMS/NV, elevate HOB, prevent skin breakdown, joint mobility.

Additional Types

• Clavicular: brace, ice, analgesics, PT, possible surgery.
• Pelvic: monitor for hemorrhage, organ damage, sepsis, FES, VTE, ileus, compartment syndrome.
• Hip: CMS/NV, fix with pins screws nails, hemiarthroplasty, mobility precaution.
• Femoral shaft: trauma relates, monitor hemorrhage, nerve damage, FES, non weight bearing.
• Tibial: high trauma risk, CMS/NV checks, compartment syndrome risk, external/internal fixation.
• Stable vertebral: CMS/NV, prevent bowel/bladder dysfunction, pain control, fall prevention, bracing, possible kyphoplasty.

Facial Fractures

• Initial critical management: maintain airway, suction, tracheostomy.
• Treat all facial fractures as if a c-spine injury until cleared.

Eye Injury

• Rupture: cover the eye with a protective shield.

Signs:

• Leaking vitreous humor, brown tissue prolapse, irregular pupil.
• Treatment: stabilize, airway management, cosmetic concern.

Mandibular Fracture

• Causes: trauma to face or jaw.
• Treatment: immediate surgery if the airway is compromised.

Fixation

• Wiring jaws shut for 4-6 weeks→ ALWAYS HAVE scissors.
• If they are vomiting copious amounts cut the wire, bone grafting if needed.
• Pre-op: education, reassure breathing, swallowing, speaking ability.
• Post-op: monitor airway, HOB elevated, wire cutters with patient, emergency trach tray, suction.
• Nutrition: NG tube initially, then high calorie liquid diet.
• Oral care: mouthwash, hydration, dental wax for wire irritation.
• Communication: alternative methods (writing, whiteboard).

Amputation

• Traumatic or surgical removal of an extremity.

Causes

• Peripheral vascular disease (PVD) especially diabetes.
• Trauma in younger patients.
• Burns, tumors, infections (osteomyelitis), congenital limb disorders.
• Pre surgical: treat infections and chronic infections prior to surgery, preserve as much limb function as possible.
• Assessment and clinical problems.
• Common complications: tissues integrity issue, pain (including phantom limb), musculoskeletal imbalances, body image/self-esteem issues.
• Goals: pain management, maximize rehabilitation and mobility, adapt to body image changes, adjust lifestyle for independence.

Implementation

• Control of illness to delay or eliminate the need for amputation= prevention.
• Education: examine lower extremities daily, report changes in feet or toes, review safety precautions related to recreational activities or hazardous work.

Preoperative Care

• Explain positioning, limb care, rehab expectations.
• Prepare for phantom limb sensation, "what do you know about amputation".

Postoperative

• Monitor VS, hemorrhage risk, infection.
• Prevent flexion contractures: avoid sitting >1 hour with flexed hips; lie on stomach 30 min 3-4x/day.
• Begin ROM exercises ASAP to maintain strength and balance.
• Crutch walking should start ASAP, avoid dangling limb to prevent swelling.
• Delayed prosthetic use when infection, older age, above knee or below elbow amputation.
• Properly bandaging ensures proper prosthesis fitting, supports soft tissues, reduces edema, minimizes pain, promotes residual limb shrinkage.

Prostheses

• Not all patients are candidates and depends on the amputation location.
• Expected outcomes: accept body image changing, no skin breakdown, reduction or absence of pain, able to become mobile.

Phantom Limb Sensation

• Pain or sensation in missing limb (burning, cramping, cold).
• Often decreases over time but it can be chronic.

Treatment Options

• Mirror therapy, virtual reality therapy, no universal treatment, varies by patient.

Muscular Dystrophy

• Description: progressive muscle wasting and weakness
• No neurological involvement.
• A most common type is Duchenne MD (DMD).
• Increased life expectancy due to better heart and lung care.
• Duchenne and Becker MD: X-linked recessive disorder, usually only affects males.

Diagnostic Studies

• Genetic testing, muscle serum enzymes (increase creatine kinase), electromyography, muscle biopsy, ECG.

Treatment

• There is no cure; manage the disease, slow progression and alleviate symptoms

Medications

• Corticosteroids: deflazacort slows the disease for up to 2 years.
• Disease modifying drugs: eteplirsen.

Goals

• Maintain mobility and independence with exercise, PT, assistive devices.
• Orthotic jacket prevents spinal deformities/injuries.
• Monitor heart and lung function: heart complications such as cardiomyopathy and heart failure, respiratory (CPCP.

Possible Needs

• Tracheostomy and/or mechanical ventilation if severe

Priorities

• Patient and caregiver education.
• Avoid prolonged bed rest, incorporate ROM, provide nutrition, genetic counseling, and encourage staying active.

Acute Lower Back Pain

• Description: caused by trauma, poor posture, lifting, stress, lasts <4 weeks.
• Symptoms: pain onset can be delayed (within 24 hours), muscle aches (stabbing shooting), limited ROM, difficulty standing.

Definitive Diagnostic Abnormalities

• Straight leg test: if radicular pain occurs = positive disc herniation.
• MRI and CT: only of trauma or serious condition suspected.

Types

• Localized: specific area of pain only.
• Diffuse: Larger area involving deep tissues.
• Radicular: nerve root irritation.
• Referred pain.
• Risk factors: weak muscles, obesity, pregnancy, smoking, poor posture, stress, jobs with lifting, bending, prolonged sitting (nurses).

Neurologic Data

• Depressed or absent Achilles tendon or patellar reflex and/or positive Trendelenburg test

Acute Care

• Outpatient treatment unless severe; interventions may include NSAIDs, muscle relaxants, massage, PT, heat/cold therapy, acupuncture, and/or back manipulation.
• Severe pain: corticosteroids, opioids.
• Rest only 1-2 days because more could worsen the pain.
• Avoid aggravating activities, which is usually resolves within 2 weeks without major treatment.

Prevention and Rehab

• Exercise and stretching to prevent recurrence.
• PT for posture and core strengthening.
• “Back school”→ education on proper lifting posture, good body mechanics, proper sleep, firm mattress, ergonomic work setup.

Chronic Lower Back Pain

• Lasts > 3 months or repeated flareups; often progressive.
• Causes: arthritis, osteoporosis, disc disease, scar tissues from past injuries, obesity, pregnancy, poor posture, congenital spine problems.

Spinal Stenosis- Lumbar

• Narrowing of the spinal canal.
• Acquired conditions: osteoarthritis, RA, tumors, trauma.
• Inherited conditions: congenital stenosis, scoliosis.
• Lumbar symptoms:
• Pain radiates from the lower back to the buttock/leg that worsens with walking/standing and improves when sitting or bending forward.
• Tingling, weakness, heaviness in legs.

Treatment and Management

• Similar to acute back pain but long term.

Medications

• NSAIDs, duloxetine (for pain and sleep), gabapentin (improves nerve pain and walking)

Interventions

• Weight loss, exercise, PT, alternative therapies: acupuncture, yoga, biofeedback.
• Min. Invar options: epidural steroid injections, implanted pain management devices, surgery if severe or if there is no response to treatment.

Intervertebral Disc Disease

• The intervertebral discs separate vertebrae and absorb shock

Relevant Characteristics

• Deterioration, herniation, or other disc problems, spinal levels: Cervical (C), Thoracic(T), Lumbar (L), and/or Sacral (S)
• Most Common: L4-L5, L5-S1, C5-C6, C6-C7
• Herniated discs→ pinch nerves → radiculopathy (radiating pain, numbness, tingling, decreased strength, decreased ROM

Clinical Manifestations

• Cervical disc disease: pain radiates to arms and hands, decreases reflexes, weak handgrip, shoulder pain - rule out other problems.
• Lumbar disc disease: radicular pain (sciatic nerve involvement), positive straight leg raise test, decreased reflexes, paresthesia, muscle weakness.

Cauda Equina Syndrome

• An emergency: must get surgical decompression because of multiple nerve roots
• Symptoms: severe lower back pain, progressive weakness, bowel/bladder incontinence or retention, saddle anesthesia

Diagnostic Studies

• Xray structural defects and MRI, CT, myelogram identifies disc damage.

Evaluation

• Epidural venogram, discogram→ if inconclusive, EMG→ severity of the nerve irritation

Conservative Therapy

• Limit spinal movement.

Interventions

• Heat/ice, massage, US, traction, transcutaneous nerve stimulation.
• Medications: NSAIDs, corticosteroids, opioids, muscle relaxants, antiseizure meds, antidepressants.
• Include back strengthening exercises, good body mechanics, and avoid extreme flexion or torsion.
• Most patients recover within 6 months.

Surgical Treatment

• Indications: failed conservative treatment, worsening radiculopathy, bowel/bladder dysfunction, severe pain or neurological deficits

Min. Invasive

• IDET and Radiofrequency nucleoplasty.

Other Methods

• Laminectomy and Discectomy.

Spinal Fusion

• Stabilizes spine: bone graft from fibula/iliac crest or cadaver bone, metal fixation for stability, and bone morphogenetic protein.

Artificial Disc Replacement

• Restores movement and eliminates pain: Inserted after removing the damaged disc.

Nursing Management

• Post-spine surgery: maintain spinal alignment

Lumbar Fusion Care

• Pillows under thighs (supine), between legs (side lying), log roll technique for repositioning
• Pain management: shift to to oral meds ASAP

Precautions

• Monitor for severe headaches or clear/yellow drainage, position flat, and neuro assessment every 1-4 hrs.
• Check for bowel and bladder function, use stool softeners, monitor urinary retention.
• Observe cervical spine precautions: monitor edema and use cervical site care.

Surgical Site

• Donor site care, often more painful than fusion site. Use pressure dressing and perform frequent neurovascular checks.

Patient Education

• Body mechanics - no prolonged sitting/standing; encourage walking and weight shifting. Avoid lifting, twisting, bending, stooping + use legs (not back) to absorb shock + firm mattress/bed board recommended.

Lupus

• Description: chronic autoimmune disease that affects multiple body systems and is unpredictable; etiology and pathology is unknown.

Possible Causes

• HLA complex, hormones, infections, environmental factors, autoimmune attack, Antinucleic antibody (ANA) deposit in the kidneys. Common clinical manifestations that often occur - general fever, musculoskeletal, cardiopulmonary, and renal changes.

Diagnostic Studies

• Blood rests and urine tests are most common diagnostics
• Protein creatinine is used as well.

Treatment Types:

• Multiple types of therapeutic medicines
• Avoid triggers, sun exposure, stress, infections
• Encourage emotional support and coping strategies.

Special Consideration:

• During pregnancy: pregnancy risks include spontaneous abortion and higher risk for postpartum flares

Pre-pregnancy Counselling

• Plan pregnancy where disease is as stable and medications have been cleared 3 month before.

Risk Posed

• A risk of infertility based on the use of renal, CORD and immunosuppressants.

Fibromyalgia

• Description - central pain that stems with widespread pain in musculoskeletal body. Often has tender points presented.
• Most common characteristics: Sleep problems, muscle stiffness, bowel or bladder disturbances, anxiety + share S-E exhaustion of intolerance (SEID).

Diagnostics include

• Pain in at least 118 points for 3 month and widespread bilateral pain.
• Wide-Soread Pain Index (WPI), or Symptom Severity Index(SSI)

General Characteristics also include

• Widespread burning Pain

• Allodynia and sensitivity.

  Drug therapy and non pharm therapies may be used.

Hypovolemic Shock

• Absolute hypovolemia due to the different routes: external fluid loss, such as by vomiting, diarrhea, burns , or diabetes insipidus
• Manifestations typically include - Anxiety, fast breathing, low bp, confusion, and low volume of urine.

Inter-professional Responsibilities

• Treat according to the appropriate shock protocol
• Interprofessional care often includes volume expansion, volume, pressors, or surgery.

Anaphylactic Shock

• Pathophysiology - massive dilation + vasodilation + leaky permeability
• Clinical indications - Neuro, Cardiovascular, Respiratory + integumentary
• Immediate treatment includes epinephrine in the vasts laterais
• Supportive management may also include crystalloid and steroids vasopressors.

Levels of Trauma Centers

• Level system assists to provide direct care appropriate to the patient condition
• For example, trauma level 1 indicates comprehensive care and requires resource for planning, while lower levels assist to stabilize care to the individual.

Emergency Nursing Practices

Goal

• recognize life threats ASAP!

ESI

• the less critical the status (ESI numbers of 1 to 5 range), indicates decreased need to be addressed asap.

Primary Review

• ABCs, with particular attention relating to patients such as seizures or anaphylaxis

Cardiac arrest considerations

Goal

• implement treatments for stabilization

Key Methods

• provide nursing Interventions such as stabilizing hemodynamics using ACLS and targeted temp therapy