Nursing Assessment of Fractures and Inflammation

Overview

• The lecture covers fractures, inflammation/immunity, and burns.
• Students will learn about the anatomy and physiology of the immune system, how alterations in inflammation/immunity impact the body (specifically with fractures), and how to prioritize nursing assessments and clinical manifestations related to injuries.

Fractures

• A fracture is a break in the continuity of a bone.
• Treatment methods differ between children and adults.
• Fractures in infants are rare, except in cases of motor vehicle accidents or falls.
• The clavicle is the most commonly broken bone in childhood, especially in children under 10.
• Young males (15-24) and older adults (>65) have the highest incidence of fractures.
• Causes of fractures include direct blows, crushing forces, sudden twisting motions, cancer, osteoporosis, and Cushing's syndrome.

Fracture Types

• Typical Complete Fractures (Closed & Open) -Closed fractures do not break the skin, open ones do.
• Comminuted fractures: Multiple bone fragments.
• Linear fractures: Fracture line parallel to the bone's long axis.
• Oblique fractures: Fracture line at an angle to the bone's long axis.
• Spiral fractures: Encircling fracture line shaped like a spiral staircase.
• Transverse fractures: Perpendicular fracture line.
• Impacted fractures: Fracture fragments forced into each other.
• Pathological fractures: Bone weakened by disease (e.g., tumors, osteoporosis).
• Avulsion fractures: Fragment of bone connected to ligament or tendon detaches, e.g.
• Compression Fractures: Bone is squeezed together.
• Displaced fractures: Fragments out of normal alignment.
• Extracapsular fractures: Fragment close to the joint capsule but outside it.
• Intracapsular fractures: Fragment within the joint capsule.
• Incomplete Fractures (Greenstick, Torus, Bowing, Stress, Transchondral)
  • Greenstick: Fracture in one cortex of a bone.
  • Torus: Buckling of the bone cortex.
  • Bowing: Bending of the bone.
  • Stress: Microfracture
  • Transchondral: Separation of cartilage from the bone shaft.

Classification of Fractures

• Classification factors include the name of the injured bone, location of the injury (e.g., metaphysis, diaphysis, epiphysis), orientation of the fracture, and condition of overlying tissues (e.g., open vs. closed).

Clinical Manifestations of Fractures

• Common symptoms include pain, impaired sensation, loss of functional ability, discoloration, bleeding at the site of injury, unnatural alignment, swelling, muscle spasms, tenderness, and crepitus (a grating sound). Numbness can occur for up to 20 minutes after injury.

Nursing Assessment of Fractures

• Assess for apprehension, guarding of injury site, skin lacerations, pallor and cool or bluish skin, ecchymosis, hematoma, edema; pulses.
• Assess for reduced/absent pulse distal to injury, decreased skin temperature, and delayed capillary refill.
• Assess for paresthesias, decreased or absent sensation.
• Assess for restricted or lost function; abnormal angulation; shortening; rotation; crepitation; muscle weakness.
• Assess for possible findings on radiograph, bone scan, CT scan or MRI.

Compartment Syndrome

• Compartment syndrome is a serious condition due to increased pressure in a muscle compartment of the extremity.
• This often has to do with a fracture that increases pressure.
• The assessment involves using the 5 P's mnemonic of pain, pulse, pallor, paresthesia, and paralysis.

Fracture Healing

• Direct healing occurs when bone cortices contact directly (common with surgical fixation.)
• Indirect healing occurs when treatment involves a cast, (callus formation is common). Neonates heal in 2-3 weeks.

Factors Influencing Bone Healing

• Positive factors include immobilization, timely correction of displacement, application of ice, electrical stimulation; adequate growth hormone, vitamin D and calcium; absence of infections, and younger age; moderate pre-injury activity.
• Negative factors include delay in correction, open fractures (increased risk of infection), presence of foreign bodies at the fracture site, immunocompromised status, decreased circulation (diabetes), malnutrition, osteoporosis, and advanced age.

Immunity and Inflammation

• Innate immunity is the body's first line of defense against pathogens, with physical barriers and chemical defenses including inflammation.
• Adaptive immunity is a more targeted defense mechanism (slower than innate).
• Two main defense systems – innate & adaptive. The innate immune system is the first line of defense, and the adaptive immune system is the third line of defense.
• First line of defense: Natural/native immunity. Second line of defense: Biochemical and cellular mechanisms.

Innate Immunity

• Physical (first line): Skin, nasal mucosa, eye secretions, cilia, acidic secretions, vaginal flora
• Second line of defense:Inflammation – Biochemical & cellular mechanisms.

Common Bacteria Encountered

• Examples include Staphylococcus Aureus, MRSA, Streptococcus, VRE and STIs.

Inflammation (Second Line of Defense)

• Inflammation is the second line of defense. The first response to injury. It is often quick and nonspecific.
• The plasma protein system consists of Complement (3 systems), Clotting, and Kinin systems. The complement system is a key part of the immune system.
• Vasodilation (erythema, warmth), vascular permeability (edema), cellular injury, activation of complement, clotting, cellular infiltration (pus).
• There are various cell components in the second line of defense, including granulocytes (neutrophils, band cells, eosinophils, basophils), histamine, and mast cells.
• Agranulocytes such as monocytes and macrophages also participate.

Local and Systemic Signs of Acute Inflammation

• Local signs are visible at the site of inflammation, while systemic signs affect the whole body.
• Local: Swelling, pain, heat, redness; serous exudate, fibrinous exudate, purulent exudate (severe).
• Systemic: Fever, leukocytosis (increased circulating leukocytes)

Wound Healing

• Wound healing has primary and secondary intention.
• Primary: Small wounds heal with minimal scarring.
• Secondary: Large wounds, more extensive scarring.
• Stages include coagulation, inflammation, proliferation (including new tissue formation), and remodelling/maturation (scarring).
• Phases related to wound healing include the cells and products involved in each stage.
• Factors affecting wound healing include impaired blood flow, excessive bleeding, obesity, diabetes, severe infections.

Dysfunctional Wound Healing

• Dysfunctional wound healing results from issues affecting different phases.
• Factors include ischemia, excessive fibrin deposition, diabetes mellitus, wound infections, malnutrition, medications, tobacco smoke.

Infection and Wounds

• Examples of common infections and their management during wound healing.

Third Line of Defense (Adaptive Immunity)

• Adaptive immunity involves B and T lymphocytes.
• It's slower but more targeted than innate immunity, remembering previous encounters.
• This system has many benefits: specific targeting (particular targets), the process is systemic (not restricted to the site of infection) and there's memory (the response to future exposures is much quicker).

Adaptive Immunity: Humoral Immunity

• B lymphocytes, plasma cells, antibodies function in antibody production.
• Antibodies are integral in preventing re-exposure and future infections.

Adaptive Immunity: Cell-Mediated Immunity

• T lymphocytes (helper, cytotoxic, suppressor) are crucial in cell-mediated immune responses, including activating other immune cells and destroying infected cells.

Key Points to Remember

• Students can perform system assessments with knowledge of physiological landmarks, anatomy, and lab values.
• Understanding the "why" behind responses to altered immunity and the connection to other systems
• Students should identify and apply altered immunity concepts (e.g., pathophysiology, clinical manifestations, and nursing assessment related to fractures, immunity, and inflammation).

This quiz covers critical concepts related to fractures, inflammation, and the immune system in nursing assessments. Students will explore the anatomy, types of fractures, and how inflammation and immunity affect healing processes. Prioritizing nursing assessments and understanding clinical manifestations are key focuses.