Fractures PDF

Adult Nursing Hinkle, J. L., & Cheever, K. H. (2022). Brunner and Suddarth’s textbook of medical-surgical nursing. Wolters kluwer india Pvt Ltd. Fractures Lecturer: Dr. Mohammad Mahdi Saeed Learning outcomes: Define fracture, its types, and causes. Identify the clinical manifestations, common treatm...

Adult Nursing Hinkle, J. L., & Cheever, K. H. (2022). Brunner and Suddarth’s textbook of medical-surgical nursing. Wolters kluwer india Pvt Ltd. Fractures Lecturer: Dr. Mohammad Mahdi Saeed Learning outcomes: Define fracture, its types, and causes. Identify the clinical manifestations, common treatment modalities, complications, and rehabilitation needs of patients with common types of fractures. Describe the nursing management including the health education needs of the patient with a cast, splint, or brace, or who is in traction. Use the nursing process as a framework for care of the older adult patient with a fracture. 1 Fractures Define: A fracture is a complete or incomplete disruption in the continuity of bone structure and is defined according to its type and extent. Fractures occur when the bone is subjected to stress greater than it can absorb. Causes: Direct blows, crushing forces, sudden twisting motions, and extreme muscle contractions. Physiology: When the bone is broken, adjacent structures are also affected, which may result in soft tissue edema, hemorrhage into the muscles and joints, joint dislocations, ruptured tendons, severed nerves, and damaged blood vessels. Body organs may be injured by the force that caused the fracture or by fracture fragments. Types of Fractures Fractures types are classified by: 1. Location (e.g., proximal, midshaft, distal) and type. 2. Degree of break (e.g., a greenstick fracture refers to a partial break) 3. Character of any fractured bone fragments (e.g., a comminuted fracture has more than two fragments). A closed fracture (simple fracture) is one that does not cause a break in the skin. An open fracture (compound, or complex, fracture) is one in which the skin or mucous membrane wound extends to the fractured bone. Open fractures are graded according to the following criteria:  Type I is a clean wound less than 1 cm long.  Type II is a larger wound without extensive soft tissue damage or avulsions.  Type III (A, B, C) is highly contaminated and has extensive soft tissue damage. It may be accompanied by traumatic amputation and is the most severe 2 An intra-articular fracture extends into the joint surface of a bone. Because each end of a long bone is cartilaginous, if the fracture is nondisplaced, x-rays will not always reveal the fracture because cartilage is nonradiopaque. MRI or arthroscopy will identify the fracture and confirm the diagnosis. The joint is stabilized and immobilized with a splint or cast, and no weight bearing is allowed until the fracture has healed. Intra-articular fractures often lead to posttraumatic arthritis. Clinical Manifestations The clinical signs and symptoms of a fracture include acute pain, loss of function, deformity, shortening of the extremity, crepitus, and localized edema and ecchymosis.  Pain The pain is continuous and increases in severity until the bone fragments are immobilized. Immediately after a fracture, the injured area becomes numb and the surrounding muscles flaccid. The muscle spasms that accompany a fracture begin shortly thereafter, within a few to 30 minutes, and result in more intense pain than the patient reports at the time of injury. The muscle spasms can minimize further movement of the fracture fragments or can result in further bony fragmentation or malalignment.  Loss of Function After a fracture, the extremity cannot function properly because normal function of the muscles depends on the integrity of the bones to which they are attached. Pain contributes to the loss of function. In addition, abnormal movement (false motion) may be present.  Deformity Displacement, angulation, or rotation of the fragments in a fracture of the arm or leg causes a deformity that is detectable when the limb is compared with the uninjured extremity.  Shortening In fractures of long bones, there is actual shortening of the extremity because of the compression of the fractured bone. Sometimes, muscle spasms can cause the distal and proximal site of the fracture to overlap, causing the extremity to shorten (Porth, 2015). 3  Crepitus When the extremity is gently palpated, a crumbling sensation, called crepitus, can be felt or may be heard. It is caused by the rubbing of the bone fragments against each other.  Localized Edema and Ecchymosis Localized edema and ecchymosis occur after a fracture as a result of trauma and bleeding into the tissues. These signs may not develop for several hours after the injury or may develop within an hour, depending on the severity of the fracture. 4 5 Emergency Management Immediately after injury, if a fracture is suspected, the body part must be immobilized before the patient is moved. Adequate splinting is essential. Joints proximal and distal to the fracture also must be immobilized to prevent movement of fracture fragments. Immobilization of the long bones of the lower extremities may be accomplished by bandaging the legs together, with the unaffected extremity serving as a splint for the injured one. In an upper extremity injury, the arm may be bandaged to the chest, or an injured forearm may be placed in a sling. The neurovascular status distal to the injury should be assessed both before and after splinting to determine the adequacy of peripheral tissue perfusion and nerve function. With an open fracture, the wound is covered with a sterile dressing to prevent contamination of deeper tissues. No attempt is made to reduce the fracture, even if one of the bone fragments is protruding through the wound. Splints are applied for immobilization. In the ED, the patient is evaluated completely. The clothes are gently removed, first from the uninjured side of the body and then from the injured side. The patient’s clothing may be cut away. The fractured extremity is moved as little as possible to avoid more damage. Medical management Reduction Fracture reduction refers to restoration of the fracture fragments to anatomic alignment and positioning. Either closed reduction or open reduction may be used to reduce a fracture. The specific method selected depends on the nature of the fracture; however, the underlying principles are the same. Usually, the physician reduces a fracture as soon as possible to prevent loss of elasticity from the tissues through infiltration by edema or hemorrhage. In most cases, fracture reduction becomes more difficult as the injury begins to heal. Before fracture reduction and immobilization, the patient is prepared for the procedure; consent for the procedure is obtained, and an analgesic agent is given as prescribed. Anesthesia may be given. The injured extremity must be handled gently to avoid additional damage. 1. Closed Reduction In most instances, closed reduction is accomplished by bringing the bone fragments into anatomic alignment through manipulation and manual traction. 6 2. Open Reduction Some fractures require open reduction. Through a surgical approach, the fracture fragments are anatomically aligned. Internal fixation devices (metallic pins, wires, screws, plates, nails, or rods) may be used to hold the bone fragments in position until solid bone healing occurs. 7 8 Complications of fracture Early complications include:  Shock,  Fat embolism,  Compartment syndrome, (increase pressure in the muscle interrupt blood vessels)  VTE (deep vein thrombosis [DVT], pulmonary embolism [PE]). Delayed complications include:  Delayed union, malunion, nonunion,  Avascular necrosis AVN of bone,  Complex regional pain syndrome (CRPS, formerly called reflex sympathetic dystrophy)  Heterotopic ossification. Growing bony tissue in the soft tissue Nursing Management of a Patient in a Cast, Splint, or Brace Before the cast, splint, or brace is applied, the nurse completes an assessment of the patient’s general health, presenting signs and symptoms, emotional status, understanding of the need for the device, and condition of the body part to be immobilized. Physical assessment of the part to be immobilized must include a thorough assessment of the skin and neurovascular status (i.e., neurologic and circulatory functioning), including the degree and location of swelling, bruising, and skin abrasions. To promote healing, any skin lacerations and abrasions that may have occurred as a result of the trauma that caused the fracture must be treated before the cast, brace, or splint is applied. The nurse thoroughly cleanses the skin and treats it as prescribed. The patient may require a tetanus booster if the wound is dirty and if the last known booster was given more than 5 years ago. Sterile dressings are used to cover the injured skin. If the skin wounds are extensive, an alternative method (e.g., external fixator) may be chosen to immobilize the body part. 9 The nurse gives the patient or family information about the underlying pathologic condition and the purpose and expectations of the prescribed treatment regimen. This knowledge promotes the patient’s active participation in and adherence to the treatment program. The nurse prepares the patient for the application of the cast, splint, or brace by describing the anticipated sights, sounds, and sensations (e.g., heat from the hardening reaction of the fiberglass or plaster) that he or she may experience. Asking the patient and family what they know about the application and care of the cast can help determine opportunities for education. The patient needs to know what to expect during application and the reason the body part must be immobilized. The main concern following the application of an immobilization device is assessment and prevention of neurovascular dysfunction or compromise of the affected extremity. Assessments are performed at least every hour for the first 24 hours and every 1 to 4 hours thereafter to prevent neurovascular compromise related to edema and/or the device. Neurovascular assessment includes the assessment of peripheral circulation, motion, and sensation of the affected extremity, assessing the fingers or toes of the affected extremity, and comparing them with those of the opposite extremity. When assessing peripheral circulation, the nurse must check peripheral pulses as well as capillary refill response (within 3 seconds), edema, and the color and temperature of the skin. While assessing motion, the nurse should note any weakness or paralysis of the injured body part. While assessing sensation, the nurse monitors for paresthesia (numbness or tingling) or absence of feeling in the affected extremity, which could indicate nerve damage (Alisangco et al., 2016). Nurses must be vigilant in assessing for subtle neurovascular changes in these patients. The “6 Ps” indicative of symptoms of neurovascular compromise are pain, poikilothermia (i.e., takes on the ambient temperature), pallor, pulselessness, paresthesia, and paralysis. Early recognition of diminished circulation and nerve function is essential to prevent loss of function. Swelling is a concern and can create excessive pressure under the cast. To augment the flow of fluid, the nurse elevates the extremity so that it is above the level of the heart during the first 24 to 48 hours postapplication to enhance arterial perfusion and control edema and notifies the primary provider at once if signs of compromised neurovascular status are present. 10