Fracture Notes (2021) - The University of Jordan

The University of Jordan Faculty of Nursing Introduction to Adult Health Nursing Dr. Ahmad Aqel 2021 Definition: Complete or incomplete disruption in the continuity of bone structure ▪ occur when the bone is subjected to stress greater than it can absorb...

The University of Jordan Faculty of Nursing Introduction to Adult Health Nursing Dr. Ahmad Aqel 2021 Definition: Complete or incomplete disruption in the continuity of bone structure ▪ occur when the bone is subjected to stress greater than it can absorb. Causes: ▪ Direct blows, ▪ Crushing forces ▪ Sudden twisting motions ▪ Extreme muscle contractions. Consequences of bone fracture ▪ Edema, Hemorrhage, Joint dislocations , Rupture tendons , Nerves injury, Blood vessels damage. Dr. Ahmad Aqel 2  Types of Fractures ▪ Complete fracture ▪ break across the entire cross-section of the bone, frequently displaced. ▪ Incomplete fracture ▪ break through only part of the cross- section of the bone (eg, green- stick) ▪ Comminuted fracture ▪ fracture that produces several fragments ▪ A closed fracture: does not cause a break in the skin. Dr. Ahmad Aqel 3  Types of Fractures Open fracture: skin wound extends to the fractured bone Intra-articular fracture Extends into the joint surface of a bone. Difficult to seen on the x-ray because cartilage is non-radiopaque. MRI or arthroscopy will identify the fracture Lead to posttraumatic arthritis Management: immobilize the joint with a splint or cast, no weight bearing Dr. Ahmad Aqel 4  Fractures Avulsion Comminuted Compression Depressed fragments are driven inward A fragment of bone bone has compressed bone (seen in fractures has been pulled splintered into (Seen in vertebral of skull and facial away fragments fracture) bones) Dr. Ahmad Aqel 5  Fractures Impacted Epiphyseal Greenstick Pathologic one side of a Occurs due to A fracture bone is diseased bone bone fragment is through the broken and without trauma driven into another the other or fall bone fragment epiphysis side is bent Dr. Ahmad Aqel 6  Fractures Open fracture Oblique Transverse A fracture and damage to straight A fracture at an skin or mucous fracture across angle across the membranes (called the bone shaft bone compound fracture) Dr. Ahmad Aqel 7  Fractures Simple fracture Stress Spiral A fracture that Results from Twists around the remains contained, repeated loading of shaft of the bone with no disruption bone and muscle of the skin integrity Dr. Ahmad Aqel 8 Signs and Symptoms of Fracture 1. Acute pain: 2. Loss of function 3. Deformity 4. Shortening of the extremity 5. Crepitus 6. Localized edema and ecchymosis. Testing for crepitus can produce further tissue damage Dr. Ahmad Aqel 9  Emergency Management 1) Immobilization: ▪ Immobilize the body part before moving pt. ▪ Immobilize the Joints proximal & distal to the fracture. ▪ Immobilize the lower extremities by bandaging the legs together, with the unaffected extremity. ▪ Bandage the arm to the chest, place forearm in a sling. Dr. Ahmad Aqel 10  Emergency Management 2. Assess for peripheral pulse & nerve function distal to the injury before and after splinting. 3. Cover the open wound with a sterile dressing. 4. Do not reduce the fracture In the emergency department – Complete evaluation. – Remove the clothes gently first from the uninjured side – The fractured extremity is moved gently Dr. Ahmad Aqel 11  Medical Management Fracture reduction ▪ Refers to restoration of the fracture fragments to anatomic alignment and positioning. ▪ Types of reduction 1. closed reduction (manipulation and manual traction) 2. open reduction ( surgical approach) Reduces a fracture ASAP to prevent loss of elasticity from the tissues through infiltration by edema or hemorrhage Dr. Ahmad Aqel 12  Medical Management Closed Reduction – Bringing the bone into anatomic alignment through manual traction. – Hold the extremity in the aligned position while the physician applies a cast, splint. – Minor analgesia may be used – Obtain X-rays to verify that the bone fragments are correctly aligned Dr. Ahmad Aqel 13  Medical Management Open Reduction by surgery, the fracture fragments aligned. Internal fixation by pins, wires, screws, plates, nails Dr. Ahmad Aqel 14  Medical Management Immobilization Immobilization by internal or external fixation. Methods of external fixation include bandages, casts, splints, continuous traction, and external fixators. Dr. Ahmad Aqel 15  Nursing Management With Closed Fractures ▪ Elevate extremity and apply ice to reduce edema ▪ Monitor neurovascular status ▪ Change position, and pain relief ▪ Teach pt Isometric and muscle-setting exercises : to minimize atrophy and to promote circulation. ▪ How to use assistive devices (crutches, walkers). ▪ Patient teaching: self-care, medication, complications. ▪ Modify the home environment as needed ▪ Reassurance: alleviate restlessness and anxiety Dr. Ahmad Aqel 16 Nursing Management / Open Fractures Risk of open fracture: osteomyelitis, tetanus, gas gangrene 1. Administer IV antibiotics, T. toxoid, Wound irrigation and debridement, wound swab for C&S as ordered 2. Surgical external fixation of fractures carries a risk of infection. (caring of wires, scrows) 3. Elevate extremity to minimize edema. 4. Monitor Temperature and signs of infection (tenderness, pain, redness, swelling, local warmth, elevated temperature, and purulent drainage). Dr. Ahmad Aqel 17  Factors that enhance fracture healing ▪ Immobilization of fracture fragments ▪ Maximum bone fragment contact ▪ Sufficient blood supply & proper nutrition ▪ Exercise: weight bearing for long bones ▪ Hormones: growth hormone, thyroid, calcitonin, vitamin D ▪ Electric potential across fracture (physiotherapy) Dr. Ahmad Aqel 18  Factors that inhibit fracture healing ▪ Extensive local trauma & Bone loss ▪ Weight bearing prior to approval ▪ Mal-alignment of the fracture fragments ▪ Inadequate immobilization ▪ Space or tissue between bone fragments ▪ Infection ▪ Localized malignancy ▪ Age (elderly persons heal more slowly) ▪ Corticosteroids (inhibit the repair rate) Dr. Ahmad Aqel 19  Complications of fracture Early complications Delayed complications Shock Delayed union, Malunion, Fat embolism Nonunion Compartment syndrome Reaction to internal Deep vein thrombosis fixation devices Pulmonary embolism Complex regional pain syndrome Heterotopic ossification Dr. Ahmad Aqel 20  Complications of fracture Hypovolemic shock – resulting from severe hemorrhage – More common with pelvic fractures & displaced femoral fracture. Treatment for shock – stabilizing the fracture, proper immobilization, – restoring blood volume and circulation, Dr. Ahmad Aqel 21  Complications of fracture Fat Embolism ▪ More common in: fracture long bones or pelvic, ▪ Clinical manifestations: The first manifestations are (hypoxia and tachypnea). petechial rash, CP, crackles, wheezes, cough, thick white sputum, tachycardia. ▪ Neurological symptoms: (headache, mild agitation to delirium & coma). ▪ sudden restlessness, irritability, or confusion occurs post fracture are indications for immediate ABG studies. Dr. Ahmad Aqel 22  Prevention and Management of fat emboli ▪ Immediate immobilization of fractures – early fixation, minimal manipulation, – maintenance of fluid and electrolyte balance. ▪ Prompt initiation of respiratory support – High-flow oxygen, mechanical ventilation with PEEP – Corticosteroids & Vasopressor medications – Accurate I&O ▪ Acute pulmonary edema and ARDS are the most common causes of death from Fat embolism. Dr. Ahmad Aqel 23  Complications of fracture Compartment Syndrome ▪ A sudden decrease in blood flow to the tissues distal to injury site that results in ischemic necrosis ▪ C/O: deep, throbbing pain, increase despite opioids ▪ Hallmark sign: pain intensifies with passive ROM ▪ pain caused by tight muscle fascia , constrictive cast, edema or hemorrhage from the fracture site ▪ Most common on the lower leg, forearm is also at risk. ▪ Permanent lose occurs if the anoxic situation continues for longer than 4 hours. Dr. Ahmad Aqel 24 Nursing management of compartment syndrome Assess: ▪ Pain, pallor, paresthesia, paralysis,pulselessness. ▪ Cyanotic nail beds suggest venous congestion. ▪ Pallor and cool & prolonged capillary refill suggest diminished arterial perfusion. ▪ Use Doppler ultrasonography to verify a pulse. Dr. Ahmad Aqel 25  Safety Nursing Compartment Alert syndrome Management ▪ Maintaining the extremity at the heart level (not above heart ▪ Opening and bivalving the cast or opening the splint ▪ A fasciotomy (excision of the fascia) to relieve the constrictive muscle ▪ Moist, sterile saline dressings, A vacuum dressing may be used to remove fluids Dr. Ahmad Aqel 26 Delayed Complications of fracture Delayed union: healing not occur within the expected time Nonunion: failure of the ends of a fractured bone to unite ▪ treated with internal fixation, bone grafting, electrical bone stimulation. Malunion: the healing in a mal aligned position Factors contributing to nonunion and mal-union ▪ Infection, Interposition of tissue between the bone ends, Inadequate immobilization & manipulation, excessive space between bone fragments, impaired blood supply. Dr. Ahmad Aqel 27 Delayed Complications Delayed complication ofoffracture fracture The bone graft may be an Autograft (from the patient, frequently from the iliac crest Allograft (from a donor) Bone grafting complications include: graft infection, fracture of the graft, nonunion ❖ The electrical stimulation enhances. mineral deposition and bone formation that promotes bone growth. Bone healing stimulator applied to the arm Dr. Ahmad Aqel 28  Nursing NursingManagement. management Emotional support Encourages adherence to the treatment regimen. Patient with a bone graft: – pain management and monitor for complications. – education concerning bone graft, immobilization, non– weight-bearing exercises, wound care, signs of infection, and follow-up Patient using bone stimulation devices – education regarding immobilization, weight-bearing restrictions, and correct daily use of the stimulator Dr. Ahmad Aqel 29  Delayed Complications of fracture Complex Regional Pain Syndrome ▪ severe burning pain, local edema, hyperesthesia, stiffness, skin discoloration, ▪ Prevention: elevation, immobilization, early effective pain relief avoids using the affected extremity for BP & venipuncture Avascular Necrosis of Bone ▪ bone loses blood supply and dies. Heterotopic ossification: ▪ Abnormal formation of bone, near bones or in muscle. Dr. Ahmad Aqel 30 Which term refers to the failure of fragments of a fractured bone to heal together? a) Malunion b) Subluxation c) Dislocation d) Nonunion. Dr. Ahmad Aqel 31