Week 11 - Fractures & Trauma Assessment

Week 11 - Fractures: Mechanism of Injury & Red Flags

• Mechanism of Injury (MOI): describes how energy is transferred from the environment to the body, providing insight into potential injuries. Knowing the MOI helps predict and prepare for injuries.
• MOI Red Flags (MVCs): high-speed collisions or rollover accidents, impacts at high velocities (e.g., head-on, rear-end, side impact), ejection from vehicle (unrestrained driver), and significant intrusion into the vehicle.
• E-Scooters: injuries more common in those under 18 and more frequent in winter months. Increased risk of long bone fractures and paralysis compared to cyclists.
• Trauma Assessment: includes a primary and secondary survey for life-threatening conditions and injury priorities.

Primary Survey

• Airway (with simultaneous C-spine protection)
• Breathing
• Circulation
• Disability (neuro status)
• Expose/environmental controls (remove clothing for a full body assessment; keep pt warm)

Secondary Survey

• Trauma Panel & Diagnostics (e.g., CBC, Lytes & BUN, Creatinine, Amylase, Lipase, PT, PTT)

Fractures

• Disruption/break in continuity of bone, often from mechanical overload exceeding bone's ability to absorb stress. Some fractures secondary to disease (e.g., cancer, osteoporosis).
• Open Fractures: skin broken, bone/soft tissues exposed (risk of infection).
• Closed Fractures: skin intact.
• Complete Fracture: bone completely breaks through.
• Incomplete Fracture: bone does not completely break (e.g., greenstick fracture).
• Displaced Fracture: two ends separated from each other (e.g., when ends are far apart).
• Nondisplaced Fracture: bone ends aligned and periosteum intact.

Fractures: Pathophysiology

• Muscle spasm and pulling of fragments
• Disruption of periosteum and blood vessels in cortex and marrow of fractured bone.
• Bleeding from soft tissues and bone ends.
• Intense inflammatory response at fracture site from surrounding bone tissue death.

Fractures: Clinical Manifestations

• Immediate localized pain, tenderness, muscle spasm
• Deformity (unnatural position)
• Edema (inflammatory response)
• Ecchymosis (bruising)
• Decreased/loss of function

Fractures: Bone Healing - Stages

• Bleeding creates hematoma & clot within 72 hours.
• Phagocytosis absorbs necrosis and converts hematoma to granulation tissue leading to new bone formation within 3-14 days.
• Minerals and new bone matrix form an unorganized network of bone (callus) around the fracture by the end of the second week
• Callus ossifies, stabilizing the fracture site from 3 weeks to 6 months.
• Excess bone is reabsorbed; bone remodeled in response to stress with weight bearing gradually introduced.

Bone Healing: Factors Influencing Healing

• Displacement and site of the fracture
• Blood supply to the area
• Immobilization and internal fixation devices (e.g., screws, pins)
• Inadequate reduction and immobilization
• Excessive movement of fracture fragments
• Infection, poor nutrition, and systemic disease

Fractures: Assessment & Management

• Initial nursing assessment includes subjective (symptoms, hx, meds, previous sx) and objective (signs; system based assessments, e.g., integumentary, CV, neuro, MSK).
• Initial Nursing Management: treat life-threatening injuries first, then control external bleeding.

Neurovascular Assessment (as part of initial and ongoing assessments; every 3 hours first 4 hours after casting, then q.3-4 hrs)

• Peripheral vascular assessment: color, temp, cap refill, peripheral pulses, edema
• Peripheral neurological assessment: sensation, motor function, and pain (e.g., wiggle fingers, toes).
• Compare bilaterally

Collaborative Management (Goals for Fracture Treatment)

• Anatomical realignment of bone fragments
• Immobilization to maintain realignment
• Restoration of normal or near-normal function of injured parts

Management: Open Reduction

• Correction of bone alignment via surgery
• Often used for comminuted fractures with severe neurovascular injury
• Includes internal fixation (pins, rods, etc).

Management: Closed Reduction

• Nonsurgical, manual realignment of fracture to anatomical position
• Tractional forces to bone fragments to restore position, length and alignment.

Management: Traction

• Application of pulling force to injured or diseased part of body/extremity (countertraction pulls in opposite direction).
• Maintains constant pulling force to prevent/reduce muscle spasm, reduce a fracture and immobilize a joint/part of the body.
• Main traction types: skin traction and skeletal traction.

Complications of Fractures

• Direct: problems with bone infection, bone union, avascular necrosis.
• Indirect: compartment syndrome, rhabdomyolysis (breakdown of skeletal muscle), venous thromboembolism, fat embolism syndrome, and hypovolemic shock..

Cast Care for Patients (Do's and Don'ts)

• Do's: Ice directly after fracture; Elevate above heart level for 24 hrs; Move joints above and below cast.
• Don'ts: Get plaster cast wet; Insert objects inside the cast; Bear weight on new cast for 48 hrs immediately (unless otherwise specified by HCP); Don't cover cast with plastic for prolonged periods; Avoid high impact activities.

Management: Casts - Temporary circumferential immobilization device

• Allows the patient to perform many normal ADLs
• Application incorporated joints above and below fracture.

Management: Pharmacological Therapy

• Pain management is a key part; analgesic NSAID's are commonly used to reduce inflammation; muscle relaxants can also be used.
• Open fractures: tetanus prophylaxis and antibiotics.

Management for Compartment Syndrome

• Quick identification
• Elevation may exacerbate the condition (do not elevate above heart level).
• Application of cold compresses may result in vasoconstriction and rebound vasodilation that may exacerbate compartment syndrome.
• Surgical decompression (fasciotomy) may be necessary if elevation, cold compresses, or splint adjustments aren't effective.

Rhabdomyolysis

• Breakdown of skeletal muscle fibers with leakage of muscle contents into the circulation.
• Common cause: crush injuries
• Clinical features: Nonspecific, elevated CK (Creatine Kinase), dark reddish-brown urine (myoglobinuria).

Venous Thromboembolism

• Precipitating factors: incorrect cast application, local pressure on a vein, and immobility.
• Management: preventative anticoagulants as ordered by HCP (e.g., LMW heparin).

Fat Embolism Syndrome

• Presence of fat globules from fracture distributed to tissues and organs after traumatic skeletal injury.
• Causes: long bone, rib, tibia, pelvic fractures, total joint replacement, spinal fusion, liposuction, crush injury.
• Theories relate to how fat is released from the marrow into the circulatory system followed by tissue damage and oxygen deprivation.
• Clinical manifestations include: Hypoxia, dyspnea, tachypnea and changes in LOC. Petechial rash may be noted (as well as dark urine), and signs of acute respiratory distress syndrome(ARDS).

Pelvic Fractures

• Mechanism of injury (MOI) typically major trauma e.g., motor vehicle collisions, falls.
• Classified as stable or unstable based on the disruption of the ring.
• Clinical findings may include bruising around the flank, groin, or perineum (bleeding); pelvic binder (or other device) may be used.
• Management: Immediate hemorrhage control and supportive care.

Hip Fractures

• Leading cause of morbidity among older adults.
• Occur due to falls and associated low bone density.
• Clinical presentation will vary depending on the location of the fracture.
• Management: initially focuses on immobilization, neurovascular assessment, and pain management, followed by surgical interventions (as needed).

Trauma Tips

• Assess for pain management needs, including pain medication, and succinct documentation.
• Other considerations include: transfer to trauma center if indicated, and family support & travel directions.