NUR 425 Week 11 Fractures PDF

**[Week 11 -- Fractures ]** **[Mechanism of Injury & Red Flags ]** **Mechanism of Injury (MOI)** - "Mechanism of destiny" - MOI: how energy is transferred from the environment onto the body - Provides insight into the potential injuries the team can expect to find - Knowing the pat...

**[Week 11 -- Fractures ]** **[Mechanism of Injury & Red Flags ]** **Mechanism of Injury (MOI)** - "Mechanism of destiny" - MOI: how energy is transferred from the environment onto the body - Provides insight into the potential injuries the team can expect to find - Knowing the pattern of injury can guide the team in predicting and preparing for certain injuries **MOI Red Flags** - - MVCs: - High-speed collisions or rollover accidents - Impact at high velocities (e.g. head-on collision, rear-end, side impact) - Ejection from vehicle (unrestrained driver) - Significant intrusion into the vehicle department - Vehicle occupant death - Motorcyclist/cyclist/pedestrian struck by vehicle - Falls from heigh (\>3m, especially onto a hard surface) - Penetrating injuries (e.g. stab wounds) with unknown trajectory or depth - Gunshot wounds to the torso, head or neck **E-Scooters** - Inc prevalence and severity of injury - Injuries more common in those \< 18 - Injuries more frequent in winter months - Increased risk of long bone fractures, and paralysis compared to cyclists **[Trauma Assessment ]** - To recognize life threatening conditions, identify injuries & set priorities for care - Includes a [PRIMARY & SECONDARY] survey in a team approach - Organized and systematic ***Primary Survey*** - A -- Airway (w simultaneous c-spine protection) - B -- Breathing - C -- Circulation - D -- Disability (neuro status) - E -- Expose/environmental controls (remove clothing to inspect entire body for injuries; keep pt warm) ***Secondary Survey*** - F -- Full set of vital signs, focused adjuncts (incl cardiac monitor, urinary catheter, & G tube), family presence - G -- Give comfort measures (verbal, touch, pharmacologic & non-pharmacologic management of pain) - H -- History & Head-to-toe assessment - I -- Inspect posterior surfaces **Trauma Panel & Diagnostics** - - CBC - Lytes & BUN - Creatinine, Amylase, Lipase - PT, PTT - Blood Type and cross match - Ethanol level - Urinalysis - Urine toxicology screen - ABGs - Lactate - ECG - Imaging (e.g. X-ray, CT, US, FAST) **[Fractures]** - Disruption/break in continuity of the structure of bone - Result from mechanical overload of the bone, when more stress is placed on the bone than it can absorb - Account for high % of traumatic injuries - Some fractures are secondary to disease process (e.g. cancer or osteoporosis weaken bone structure) **Fractures: Classification** - *Open or closed* - **Open:** skin broken, and bone and soft tissue exposed (risk of infection) - **Closed:** skin intact - *Complete or incomplete* - **Complete:** break is completely through bone - **Incomplete:** bone does not completely break (may crack/bend); bone is nondisplaced (e.g. greenstick fracture -- common in kids) - Direction of fracture line (e.g. spiral, transverse, oblique) - *Displaced or nondisplaced* - **Displaced:** two ends separated from one another (two ends are far apart) - **Nondisplaced:** bone is aligned and periosteum is intact **Fractures: Pathophysiology** - When a fracture occurs muscles attached to bone ends are disrupted muscles can undergo spasm and pull the fragments out of position - The periosteum and blood vessels in the cortex and marrow of the fractured bone are disrupted - Soft tissue damage frequently occurs - Bleeding occurs from both the soft tissue and from the damaged ends of the bone - Bone tissue surrounding the fracture site dies creating an intense inflammatory response **Fractures: Clinical manifestations** - - Immediate localized pain; tenderness; muscle spasm - Decreased/loss of function - Deformity/unnatural position - Edema -- inflammatory response - Ecchymosis -- bruising - Crepitation -- bone on bone grinding - Guarding **Fractures: Bone healing** **Stages of Bone Healing** ---------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------ **Fracture hematoma** Bleeding creates a hematoma around fracture ends, forming a semisolid clot within 72 hours. **Granulation tissue** Phagocytosis absorbs necrosis, converting the hematoma to granulation tissue, forming the basis for new bone (osteoid) within 3-14 days **Callus formation** Minerals and new bone matrix form an unorganized network of bone (callus) around the fracture, appearing by the end of the second week **Ossification** Callus ossifies from 3 wks to 6 mths, stabilizing the fracture site. Limited mobility may be allowed (some weight bearing) **Consolidation** Callus development continues, closing the gap between bone fragments, which can take up to a year (depending on bone and fracture type) **Remodeling** Excess bone is reabsorbed, restoring the bone's OG strength and shape. Bone remodels 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 - Age (e.g.. newborn: 3 wks for a midshaft femur fracture; adult: 20 wks) - Smoking (increases healing time) -- causes inflammation and dec collagen synthesis - **Adequate circulation to the fracture site and adequate fragment immobilization are crucial for effective bone healing** **Fractures: Assessment & Management** *Initial nursing assessment* - Subjective (symptoms, health hx, meds, previous sx) - Objective (signs; system-based assessment -- integumentary, CV (blood flow), neuro, MSK (movement and reflexes), etc.) *Initial Nursing Management* - Treat life-threatening injuries first - Control external bleeding ASAP with direct pressure or sterile pressure dressings and elevation of extremity - Check neurovascular status distal to injury (CHECK PULSES) before and after splinting (or any other interventions) - Elevate injured limb if possible (reduce blood flow mitigating blood loss) - Do not attempt to straighten fractured or dislocated joint (can cause more injury) - Open fractures: do not manipulate protruding bone ends; administer tetanus/antibiotic prophylaxis - Closed fractures: apply ice to area to reduce swelling - Obtain imaging - Mark location of distal pulses to facilitate repeat assessment - Immobilize/splint fracture site (above and below) - Unnecessary movement inc soft tissue damage (may convert a closed fracture to open) ***Neurovascular Assessment*** - As part of initial and on-going assessment; q30mins for first 4H of casting/splinting/traction or other intervention, and then Q3-4H - Peripheral vascular assessment -- colour, temp, cap refill, peripheral pulses, edema - Peripheral neurological assessment -- sensation, motor function and pain (wiggle their toes, fingers, etc.) - Compare bilaterally ***Collaborative Management goals of 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 through surgery - Often used for compound fractures that are comminuted or accompanied by severe neurovascular injury - Includes internal fixation (and/or external fixation) with use of pins, rods, etc. - Main disadvantages -- risk of infection + complications assoc w anesthesia *Management**:*** **Closed reduction** - Nonsurgical, manual realignment of bone fragments to previous anatomical position - Traction and countertraction manually applied to bone fragments to restore position, length, and alignment *Management**:*** **Traction** - Application of a pulling force to an injured or diseased part of body or extremity, while countertraction pulls in the opposite direction - Must be maintained constantly - **Purpose of traction:** - Prevent or reduce muscle spasm - Immobilize joint or part of body - Reduce a fracture - Two most common types of traction - **Skin traction** - Used for short term tx until skeletal fraction or sx is possible - Tape, boots, or splints, applied directly to skin to maintain alignment, assist in reduction, and help diminish muscle spasms in injured extremity (ex. Buck traction) - Skin traction weight range 2.3-4.5 kg - **Skeletal traction** - In place for longer periods - Used to align injured bones and joints or to tx joint contractures and congenital hip dysplasia - Provides a long-term pull that keeps injured bones and joints aligned - Physician inserts pin or wire into bone, either partially or completely, to align and immobilize injured body part - Skeletal traction weight range: 2-20 kg *Management**:*** **Casts** +-----------------------------------+-----------------------------------+ | **Cast Care for Patients** | | +===================================+===================================+ | **Do's** | **Don'ts** | +-----------------------------------+-----------------------------------+ | - Apply ice directly over | - Get plaster cast wet | | fracture site for first 24 | | | hrs (leave time for swelling) | - Remove padding | | | | | - Elevate extremity above level | - Insert objects inside cast | | of heart for first 48 hrs | | | | - Bear weight on new cast for | | - Move joints above and below | 48 hrs (not all casts are | | cast regularly | weight bearing) | | | | | - Reports signs of possible | - Cover cast with plastic for | | problems to HCPs | prolonged periods | | | | | | - High impact activities | +-----------------------------------+-----------------------------------+ - Temporary circumferential immobilization device - Allows the pt to perform many normal ADLs - Application incorporated joints above and below fracture - Restricts tendon and ligament movement -- assisting w joint stabilization while fracture heals *Management:* **Pharmacological Therapy** - Pain management is key - Analgesics (NSAIDs to reduce inflammation) - Muscle relaxants - Open fractures: tetanus prophylaxis, and antibiotics **[Complications of Fractures ]** - Direct complications - **Problems with bone infection\*** (common in open fractures) - Bone union - Avascular necrosis - Indirect complications - **Compartment syndrome\*** - **Rhabdomyolysis (breakdown of skeletal muscle)\*** - **Venous thromboembolism\*** - **Fat embolism syndrome\*** - Hypovolemic shock ***Infection*** - High incidence in open fractures and soft tissue injuries - Massive or blunt soft tissue injury often has more serious consequences than fracture - Treatment is costly in terms of - Extended nursing and medical care - Time for tx - Loss of patient income - Osteomyelitis may become chronic - Management/prophylaxis antibiotics, wound cleaning and debridement, wound care ***Compartment Syndrome*** - Elevated intra-compartmental pressure within a confined myofascial compartment compromises neurovascular function of tissues within that space - Causes cap perfusion to be reduced below the level necessary for tissue viability - 38 compartments are located in the upper and lower extremities - Swelling compressed blood vessels decrease circulation to that part of the body - Most often occurs in the legs (specific the anterior compartment of the leg) or forearms - Two causes: - Decreased compartment size (resulting from restrictive dressing, splints, casts, etc.) - Increased compartment volume (related to bleeding, edema, etc.) - Ischemia can occur with 4-8 hours after onset - Depends on elevation and pressure - Prolonged ischemia limb no longer viable - If untreated loss of nerve and muscle function, infection, myoglobinuria and renal failure; amputation may be necessary *Compartment syndrome:* **clinical manifestations** - May occur initially or may be delayed for several days - Six Ps are characteristics of impending compartment syndrome - **Paresthesia:** numbness and tingling d/t compression on nerves - **Pain:** distal to injury that is not relieved by opioid analgesics and pain on passive stretch of muscle travelling through compartment - **Pressure:** inc in compartment -- tense skin over area of injury - **Pallor:** coolness and loss of colour of extremity - **Paralysis:** loss of function - **Pulselessness:** diminished/absent peripheral pulses - Red flags: - throbbing pain out of proportion to the initial injury - no relief of pain with opioids - decreased or absent pulse - tense skin over area of injury *Compartment Syndrome: **Management*** - quick identification - Extremity should not be elevated above heart level - Elevation may raise venous pressure and slow arterial perfusion - Application of cold compresses may result in vasoconstriction and rebound vasodilation that may exacerbate compartment syndrome - May be necessary to remove or loosen bandage or split cast - Surgical decompression may be necessary -- fasciotomy (emergency tx) - position limb at level of heart, call MD, prepare for fasciotomy - Fasciotomy: surgically go in and cut across fascia to relieve pressure off nerves, restore circulation ***Rhabdomyolysis*** - Potentially life-threatening syndrome resulting from the breakdown of skeletal muscle fibers w leakage of muscle contents into the circulation - Common cause: crush injuries - Clinical features: nonspecific, elevated CK (helpful to indicate muscle pain), dark reddish0brown urine (first sign; indicates myoglobinuria) - Early complications include severe hyperkalemia that causes cardiac arrhythmia and arrest - The most serious late complication is **acute renal failure** - Myoglobin released from damaged muscle cells precipitates as a gel-like substance which causes obstruction in renal tubules - Large amts of myoglobin acute tubular necrosis acute renal failure - Management: fluid resuscitation and/or dialysis ***Venous Thromboembolism*** - Veins of lower extremities and pelvis are highly susceptible to thrombosis - Precipitating factors - Incorrectly applied cast or traction - Local pressure on a vein - Immobility - Age - Underlying health conditions (e.g. cancer) - Meds (e.g. estrogen-containing oral contraceptives) - Instruct pt to wear compression stockings (if indicated) - Prophylactic anticoagulant drugs may be ordered (e.g. LMW heparin) - Management may include anticoagulants and thrombolytics ***Fat embolism syndrome*** - Presence of systemic fat globules from fracture that are distributed into tissues and organs after a traumatic skeletal injury - Causes: fractures of long bones, ribs, tibia, & pelvis (most common); total joint replacement, spinal fusion, liposuction, crush injury, and bone marrow transplantation - Fatal in 5-15% of patients - 2 theories related to etiology: - Mechanical theory -- fat is released from the marrow of injured bone enters systemic circulation - Biochemical theory -- hormonal changes caused by trauma/sepsis stimulate release of free fatty acids which form into emboli *Fat Embolism Syndrome:* **Clinical Manifestations** - Usually 24-48 hrs after injury - Clinical course may be rapid and acute - Hypoxemia, dyspnea, tachypnea (early findings) - Changes in LOC - Petechial (pinpoint) rash (intravascular thromboses caused by hypoxemia) - Fat globules transported to lungs cause s&s of acute respiratory distress syndrome (ARDS) - Chest pain, tachypnea, dyspnea, tachycardia, decreased PaO2 *Fat Embolism Syndrome:* **Diagnosis & Management** - Diagnosis is made clinically - Diagnostic abnormalities: fat cells in blood; decreased PaO2, dec plt count; CXR may reveal areas of lung infiltration - Treatment = prevention - Careful immobilization of a long bone fracture is most important factor in prevention - Management is mainly supportive -- fluid resuscitation, oxygenation, encouraging coughing and deep breathing **[Pelvic Fractures ]** - MOI is usually trauma (e.g. MVCs, falls, etc.); 2/3rds of all pelvic fractures occur in pedestrians struck by vehicles - Pelvic fractures co-exist in about 30% of all multiple trauma injuries - Classified as stable or unstable (disruption of ring = unstable fracture) - Clinical manifestations: bruising around flank, groin or perineum (may indicate internal bleeding); leg length discrepancy - Up to 50% mortality (hemorrhage is significant cause) - Bind an unstable pelvic fracture: pelvic binders, sheets (whatever is initially available) - Helps to control hemorrhage -- prevent disruption of vessels and mass hemorrhage *Pelvic Fractures:* **Collaborative Management** - Thorough trauma nursing assessment - High flow O2 - Frequent monitoring of vital signs - 2 large bore IV sites, fluid boluses, cross match - Splint pelvis, immobilize spine & legs - **No foley** catheter if blood at urinary meatus **[Hip Fractures ]** - Leading cause of morbidity and mortality among old adults - Numerous studies have associated low bone mass and increasing age with an increased risk of hip fracture - Lower bone density contributes to osteoporosis - More than 90% of hip fractures are caused by falling - Described based on their location (e.g. intertrochanteric, femoral neck, subtrochanteric) - Femoral neck is a common place for fractures especially in older adults - Clinical manifestations: external rotation, muscle spasm, shortening of the affected extremity; severe pain and tenderness at fracture site *Hip Fractures:* **Collaborative Management** - Initial immobilization until surgery - Assess for neurovascular complications (assess extremity for colour, temp, cap refill, distal pulses, edema, sensation, motor function and pain) - Surgery - Pain management -- analgesics, muscle relaxants, traction - Post op care: monitor VS, neurovascular status, ins and outs, respiratory interventions (e.g. deep breathing and coughing), pain management, observe the dressing and incisions for signs of bleeding and infection - Implement measures to avoid dislocation (e.g. avoid extremes in flexion, elevate toilet seats and chairs) - Provide patient education - Physiotherapy & rehabilitation **[Trauma Tips ]** - - Assessments: - Primary & secondary survey - Reassess after each intervention - Continuous HTT reassessment will provide early detection of changes - Accurate ins and outs - Interventions: - Focus on stabilizing A,B, C, D - OXYGEN - GCS \< 8 = intubate - No foley if blood at urinary meatus - No NG tube with facial trauma or suspected basal skull \$ - Tetanus prophylaxis - Antibiotics for compound fractures, CSF leak or penetrating injury (prevent secondary osteomyelitis, meningitis, peritonitis) - Blood products - Splints - Wound/burn dressings - Pain management - Other - Succinct report/documents - Transfer early (to trauma centre if indicated) - Provide family support - Provide travel directions family