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Fractures

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Category: Science

Autor: anton 11 October 2010

Words: 2594 | Pages: 11

FRACTURES

Causes –

Trauma – blow to body, fall

Pathologic – if a bone is weakened, fracture may be pathologic, consisting of a collapse of the bone – osteoporosis, bone cancer

Stress – if there is usual or repetitive force on a bone because of excessive muscle usage or strain, a stress fracture may occur – seen in athletes

Prevention:

Accident prevention – hand rails, no throw rugs, obstacles on floor, education concerning automobile safety, protective sports equipment

Avoid osteoporosis – small framed, non-obese, white females most at risk; contributing factors – diet low in calcium throughout life, smoking, excessive coffee intake, high protein diet, sedentary life style

Types of fractures:

Complete – complete separation of the bone, two fragments

Incomplete – only part of the bone is broken; not broken into two fragments

Simple – skin over break is intact

Compound or open – communication between skin wound and fracture site; high risk of contamination and infection

Fracture without displacement – bone ends in good alignment

Fracture with displacement – bone segments separated at the point of fracture

Greenstick – splintering on one side of the bone (young children)

Transverse – break straight across the bone

Oblique – line of fracture angled across bone

Spiral – fracture line partially encircling the bone

Telescoped or impacted – bone ends jammed together

Comminuted – several bone fragments

Healing of Fractures –

Immobilization is necessary for healing

Bone heals during a process called callus formation, in which new blood vessels are formed, dead bone is reabsorbed, new bone matrix is laid down and becomes filled with calcium; this area of healing, the new bone is called the callus.

Process of healing:

Hematoma forms – bone is vascular; blood collects in the periosteal sheath; fastens the broken ends together

Fibrin meshwork – further clot formation

Invasion of osteoblasts – invade the fibrin, make it firm; blood vessels develop, supplying nutrients to build collagen; collagen begins to incorporate calcium deposits

Callus formation – osteoblasts continue to lay meshwork for bone growth; osteoclasts destroy the dead bone; collagen continues to be impregnated with calcium

Remodeling – excess calcium is reabsorbed

Factors interfering with healing – poor nutrition, poor circulation, inadequate reduction of fracture (bone ends not brought well into alignment), insufficient immobilization, infection at the site of injury

If callus formation does not take place, the resulting lack of repair is called non-union of fracture.

S/S of Fracture –

Pain – immediate, severe, aggravated by movement, aggravated by pressure

Loss of normal function

Obvious deformity

Crepitus or grating sound/sensation if the limb is moved (don’t try to elicit this sign)

Edema

Ecchymosis of skin in injured area (more noticeable after 1-2 days)

Loss of sensation or paralysis distal to the injury (evidence of nerve impingement)

Signs of shock due to severe tissue injury, hemorrhage with large fractures or multiple fractures

Diagnosis – evidence of fracture seen on x-ray

Medical treatment:

Reduction of fracture – bring bone ends into alignment

Immobilization of fracture – cast or hardware

Immediate care of fracture –

Splinting to prevent movement – splint joints both above and below the fracture

Preserve body alignment

Elevate part to reduce edema

Application of ice for 1st 24 hours – reduce swelling, pain, bleeding

Analgesics

Watch for changes in color, temperature, sensation, movement, pulses/capillary refill

Watch for signs of shock

Secondary management of simple fracture:

Reduction of the fracture – methods: manual manipulation (usually done with IV analgesic), traction, open reduction (surgical procedure)

Immobilization – methods: external immobilization with a cast or splint; traction; internal fixation with pins, screws, plates; insertion of prosthesis; or any combination of these methods

Surgical procedure in which the fracture is reduced and immobilized is called an Open Reduction Internal Fixation (ORIF)

Secondary management of a compound fracture:

Surgical debridement to remove dirt, debris, dead tissue, bone fragments

Administration of tetanus toxoid if the person has been immunized but with 7 years or more since the most recent booster

Administration of tetanus anti-toxin to non-immunized patient

Take cultures of wound

Prophylactic antibiotic therapy

Greatly increased risk of infection with compound fracture; many organisms; specific dangers for this type of injury – osteomyelitis (staph infection of the bone); gas gangrene (caused by the anaerobe Clostridium)

Fracture is surgically reduced and immobilized (ORIF)

Wound is closed when there is no sign of infection

Need to monitor for complications

Fractures Complications:

Ischemic paralysis – arterial blood flow to injured part is interrupted

Causes:

Trauma or pressure to arteries from the bone fragments

Tissue swelling under the cast

Compartment syndrome – rapid swelling within the fascia covering of the muscles

S/S: coldness, pallor or cyanosis, unable to move fingers or toes, severe pain unrelieved by analgesics, swelling, diminished pulse, diminished cap refill

Treatment: release of cast (split or cut)

Incising of fascia (fasciotomy)

This condition is a medical emergency – the nurse needs to identify it early and notify the orthopedist immediately – otherwise irreversible impairments can occur:

Foot drop – caused by prolonged pressure on peroneal nerve in the leg; foot slaps with walking; patient unable to dorsiflex

Volkman’s contractures – prolonged pressure on ulnar nerve; contractures deformity of lower arm and hand

Nursing: neurovascular check q 15 minutes in immediate period following ORIF, cast application, traction application; then q 1 hour for 1st 24 to 48 hours, then q 4 – 8 hours; always compare affected side to non-affected

Color – should be without pallor or cyanosis

Temperature – should be the same as the non-affected side

Movement – should be able to wiggle fingers and toes; if foot is exposed (not casted), should be able to dorsiflex foot

Sensation – should be without numbness, tingling, pain

Capillary refill – should be < 3 sec and equal B/L

Pulses – peripheral pulses on affected part (radial, pedal, posterior tibial) should be equal to the pulses on the non-affected side

Fat embolism syndrome molecules of fat enter into systemic circulation; lodge in lungs (fever, confusion or altered mental status, pallor, dyspnea, petechiae over chest); treatment is supportive and according to the symptoms

Deep Vein Thrombosis (DVT ) -- highest risk in elderly; lower extremities; highest incidence in first 2-3 days post-op. Patient usually place on prophylactic anticoagulation with heparin or Lovenox then moved to coumadin or aspirin

Osteomyelitis -- infection within the bone; s/s – redness, edema, pain, pus, fever; treatment C&S, IV antibiotics, surgical drainage and debridement; prevent by strict asepsis with all open wounds communicating with bone; condition is usually acute, but may become chronic; difficult to treat and cure; long term, high dose ABT

Non-union due to insufficient callus formation; treatment is bone grafting

Nursing Interventions for patient with a Fracture --

Pain – administer pain meds; often a combination of an oral narcotic analgesic with an oral non-narcotic analgesic is most effective in relieving pain of fracture – examples: Percocet (oxycodone + acetaminophen), Tylenol with codeine; Apply ice to affected area with MD order; reposition within limitations

High risk for altered tissue perfusion – NV checks as described previously; report abnormal findings immediately

Impaired mobility –

Positioning – avoid altering the alignment of the fracture; avoid changing the pull of the traction; take care not to damage the cast; avoid stress on internal fixation devices; generally – do not move patients with unreduced, non-immobilized fractures; patients with reduced and immobilized fractures can turn; patients in traction are somewhat limited by can turn slightly side-to-side; change position q 2 hours; overhead frame with trapeze enable patient to help adjust position

Preserve strength and mobility – encourage movement to the greatest possible extent; encourage self-care to extent possible; isometric exercises (gluteal, quadriceps); isotonic exercises (bed push-ups, pull-ups on trapeze); ROM to unaffected extremities

Maintain skin integrity – visually inspect pressure points at least q 8 hours; turn or change position q 2 hours; protective devices – low pressure bed, elbow and heel protectors; check all appliances for skin irritation (traction, casts)

Prevent respiratory, circulatory complications – cough and deep breathing; exercise as described; change position q 2; mobilize or ambulate patient as soon as possible

Constipation (due to immobility, inadequate fluid intake, narcotic analgesics) – increase fluids to 3000 cc/day; increase dietary bulk; provide privacy, comfort, regularity; stool softeners, suppositories, Fleets, laxatives prn

Risk for altered urinary function – patients who are immobilized get an increased serum calcium level because of bone loss; they may develop bladder stones from this; may also have stasis of urine due to incomplete emptying of bladder if voiding in a lying down position

For optimum bladder function – increase fluids 2000-3000 cc/day; optimal positioning for voiding; check frequently for retention; monitor I&O

Nutritional deficit – for optimum healing of fractures, need increased protein, vitamins, minerals in diet; provide a well balanced diet to meet patient’s needs; monitor food intake; provide protein supplements if needed

Patient in a Cast

Materials – plaster of paris, fiberglass, plastic

Plaster – wet before application, is heavy; need to keep dry because will soften and crumble if gotten wet; inexpensive; may be changed several times

Fiberglass and plastic – dry quickly, light weight; can be wet and still maintain their rigidity; if gotten wet, can dry with a hairdryer

Casts completely encircle the extremity or trunk; splint is the same materials but does not completely encircle the body part; like a half-cast; held in place with a bandage, often an Ace bandage

Casts are applied over clean skin; skin may be covered with cotton sheeting or stockinette; body prominences padded with cotton wadding or felt

Cast removal – electric cast saw; will not cut skin

Cast care –

Teach patient – plaster feels warm as it dries; keep the cast dry; put no sharp objects into the cast (for scratching)

Support wet plaster with the palms of the hand only; fingertips will make indentations in the cast that can produce pressure areas on underlying skin; place the wet cast on absorbent material (cotton blanket); do not cover the wet cast – allow to air dry

Circulatory – NV checks q 1 hour; ice pack to fracture site (MD order); elevate casted extremity on 1-2 pillows for 24-48 hours; any impairment of circulation – notify MD; cast will be bivalved

If the patient has had an open reduction, the cast may have a window over the site; if not – there may be drainage evident on the cast – monitor the size of the drainage spot on the cast – looking for large or increasing amounts of bright red drainage

Turn patient q 2 hours; usually any position is ok, as long as the patient is comfortable

Skin care – watch skin at the edges of the cast for irritation and pressure; apply strips of adhesive tape or moleskin over rough edges; apply plastic around perineal area to prevent soiling of cast

Monitor cast for signs of pressure areas under cast – patient may complain of a burning spot or a hot spot; make sure to notify MD and to document carefully; smell cast – an area of breakdown under the cast may cause an odor; watch for areas of drainage on the cast.

Toileting – for long leg or hip spica cast; protect cast from soiling; use fracture pan; elevate head of bed as much as possible or do a reverse Trendelenberg position

Patient in Traction

Application of force to the skin, muscles, bones to aid in relief of muscle spasms and pain, reduction of fracture, immobilization

Types:

Skin traction – applied to skin and thus indirectly to bones and muscles

Buck’s traction – used most commonly in adults; 5-8 lbs per leg; used pre-op for hip fractures; has other uses – pulling contracted muscles; relieving spasms of back and legs; patient lies in recumbent position; if no fracture, can turn any side; if fracture, turn only to unaffected side

Careful assessment of skin needed; may remove for skin assessment and neurovascular assessment q shift; usually manual traction is applied by one nurse, while the second nurse does the skin assessment, NV check, skin care, and reapplies traction

Russell traction – also skin traction; Buck’s apparatus to lower leg with pull in straight line; sling under knee holding leg suspended off bed (rope from knee sling straight up to overhead traction device); this traction may be used to treat a hip fracture in a patient who is not a candidate for ORIF

Skeletal traction – applied directly to the bones via skeletal pins inserted through the skin and bones; the pins are then attached to ropes, pulleys, weights

Balanced suspension skeletal traction – for fx of femur; pin or wire inserted through upper tibia; thigh and leg are suspended in a splint and leg attachment; can be used for any age from 3 years; can apply 20 to 35 lbs of traction; used to overcome muscle spasm associated with fx of femur; and used to realign the fx femur; patient is recumbent; can turn approximately 30 degrees to either side briefly for back care or can lift self using the trapeze; neurovascular checks are important to assess circulatory status and monitor for compartment syndrome

More on traction:

Running traction – direct pull on the part; pulls in one direction only

Suspension traction – exerts pull in a straight line on the affected part; pull in a second direction supports the extremity in a hammock or splint; result is a more even pull – and a greater net pull without increasing the weight; another advantage – the pull is maintained even when the patient moves; a suspension device can be used with either skeletal or skin traction (Russell traction – a combination of Buck’s with a suspension sling)

Balanced suspension traction – the countertraction is provided by the traction apparatus not just the patient’s body, so that the force of traction is not changed when the patient is moved.

Generally, quite a bit of time is needed for traction to overcome muscle spasms, bone overriding, with shortening of limb; patients may be in traction fro anywhere from 24 hours to 6 to 8 weeks; most patient’s are placed in traction to overcome muscle spasms and bone overriding; once these goals are achieved, the patient is usually taken to surgery to have in internal fixation, with or without application of cast.

Additional medical treatment for patient in traction:

Medications – narcotic/non-narcotic analgesics; muscle relaxants

Orthopedist does all of the application and adjustments of weights on skin and skeletal traction; may add or take off weight as treatment progresses

Bedrest

Ice packs to affected areas

Pin care twice daily for skeletal traction – danger of infection; aseptic care; cleansing of sites with antimicrobial agent; antibacterial ointments

Other external fixation devices:

Plaster or plastic braces that incorporate metal struts are attached to pins inserted into bone (halo brace)

Metal struts are attached to pins inserted into bone – extremity external fixation devices

Internal fixation devices:

Used for open reduction; indicated when there is soft tissue damage or soft tissue is caught between bone fragments; when there is nerve or vessel damage; or when cast or traction immobilization would be too extended for good patient recovery (hip fracture, femur fracture)

Devices available (nonreactive metal alloys used) –

Plates and nails – for unstable or fragmented fracture

Transfixion screws – for simple fracture

Compression screws

Intramedullary rods

Prosthetic implants – femoral head prosthesis

Bone grafts (either autograft or Homograft) may be used with the internal fixation device when excessive bone has been lost at the site

Internal fixation may also be treated with casts or traction, in addition

Care involves protecting the fixation until healing takes place; mobilization of patients who have an internal fixation is usually much earlier than for patient with an external fixation

Nursing:

Prepare patient for general anesthesia; explain the surgical procedure

Post-op – bedrest, with operative leg in neutral position

Turning to unoperated side and back q 2 hours

Check dressing; reinforce as needed (an internal fixation is very traumatic – patient often has a lot of bloody drainage and also extensive ecchymosis around surgical site)

NV checks

OOB as per MD; may be 1-2 post op day; weight bearing specifically ordered by MD

Physical therapy to help with OOB, walking; use walker

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