NURS 308 - Fractures & Orthopedic Surgery

traumatic fracture

type of fracture that occurs when the patient suffers an injury that results in a broken bone - most common

pathologic fracture

type of fracture that is caused by diseased or weakened bone - due to osteomyelitis, osteoporosis, or bone tumors

open fracture (compound fracture)

type of fracture in which the bone is exposed to the external environment

closed fracture

type of fracture in which the bone is not exposed to the external environment

complete fracture

type of fracture in which the break goes through the entire bone

incomplete fracture

type of fracture in which the break partially travels through the bone - the bone is still in one piece

displaced fracture

type of fracture in which the two broken ends of the bone are not in anatomical alignment

non-displaced fracture

type of fracture in which the break does not separate the bone - the bone is still anatomically aligned

pain

swelling

muscle spasms

deformity

bruising

loss of function

crepitation

clinical manifestations of fractures:

- reduction: anatomic realignment of bone fragments

- immobilization: to maintain alignment or realignment

- restoration: to restore as much normal function as possible

what are the overall goals of medical treatment for fractures?

compartment syndrome

complication of fractures: occurs when swelling and edema from around or within the fracture puts a lot of pressure on the nerves and blood vessels in that area - increased pressure comprises the function of blood vessels, nerves, and tendons

- decreased compartment size (restriction, compression)

- increased compartment contents (edema, bleeding)

what are the two factors that predispose a patient to compartment syndrome?

- pain distal to the injury

- pulselessness

- paralysis

- pallor, cool to the touch

- paresthesias

- pressure

- myoglobinuria (rhabdo)

*the 6 P's & an M

clinical manifestations of compartment syndrome:

myoglobinuria

occurs due to damage of the muscle tissue - causes dark, reddish-brown urine

- reduce traction weights

- remove/loosen bandage or ace wrap

- bivalve cast

- fasciotomy (surgical decompression)

*prompt, accurate diagnosis is critical: notify the provider immediately !!!!!

*do NOT apply ice or elevate extremity above heart level

treatment of compartment syndrome:

do NOT apply ice or elevate extremity above heart level

what should you NOT do for a patient with compartment syndrome?

bivalve cast

a cast that is cut in half to detect or relieve pressure underneath, especially when a patient has decreased or no sensation in the portion of the body surrounded by the cast

fasciotomy

a surgical incision through the fascia to relieve tension or pressure

- hip or knee surgery, or any surgery that requires prolonged immobilization

- venous stasis caused by incorrectly applied casts or traction

- bedrest

- local pressure on a vein

precipitating factors of venous thromboembolism:

- SCDs, TED hose

- ROM on unaffected extremities

- adequate hydration

- dorsiflexion and plantar flexion of the fingers and toes of unaffected extremities against resistance

- medications: enoxaparin, heparin, oral anticoagulants

prevention of venous thromboembolism:

fat embolism

*all we can do is provide supportive treatment and hope for the best, so the main goal is prevention of fat embolism

the scariest and most life-threatening complication of a fracture because there is no treatment for it, and there is nothing we can do if it happens - contributes to mortality associated with fractures

fat embolism

complication of fractures: fat globules become emboli and enter the circulation, blocking the arterioles, and travel to the lungs causing a pulmonary embolism

long bone

the highest risk for fat embolism is with _____ fractures

24-48 hours

how long after injury does fat embolism typically occur?

- hemorrhagic interstitial pneumonitis (coughing up blood)

- adult respiratory distress syndrome (chest pain, tachypnea, cyanosis, dyspnea, apprehension, tachycardia, decreased PaO2)

- changes in LOC

- petechiae on the neck, anterior chest wall, conjunctiva

- a feeling of impending doom

- comatose (unconsciousness)

clinical manifestations of fat embolism:

- careful immobilization of long bone fracture

- reposition as little as possible before stabilization and immobilization of fracture

*do not move the patient unless necessary

prevention of fat embolism:

symptom management

fluid resuscitation

oxygen

treatment of fat embolism:

rhabdomyolysis

complication of fractures: breakdown of the surrounding muscle tissue as a result of inflammation and damage of a fracture

dark, tea-colored urine

bad headache

muscle pain

clinical manifestations of rhabdomyolysis:

fluid repletion

dialysis

treatment of rhabdomyolysis:

reduction

anatomic realignment of bone fragments to repair a fracture

protein

calcium

vitamin D

phosphorus

magnesium

*avoid large meals, eat several small meals - it takes a lot of metabolic energy to heal a fractured bone, so we don’t want our patients using all of their energy to digest large meals

a patient with a fracture should eat a well-balanced diet, including which nutrients?

closed reduction

bone fragments are moved back into place without surgically exposing the bone

open reduction

bone fragments are moved back into place surgically

fixation (casting, splinting, skin traction, skeletal traction, hardware)

immobilization of the bone to maintain realignment while the bone heals

open reduction and internal fixation (ORIF)

patient is taken to surgery for bone realignment, then hardware is implanted internally to keep the bones in place

tetanus and diphtheria immunization

what immunizations should be completed for all fractures, open or closed, if not completed within the past 5 years?

skin traction (buck's traction)

used short-term to stabilize the bone while awaiting surgery for internal fixation

skin condition

*high risk for skin breakdown with skin traction

what should the nurse ensure to assess with skin traction (buck's traction)?

skin condition and s&s of infection at pin insertion sites

what should the nurse ensure to assess with skeletal traction?

skin traction (buck's traction)

involves applying splints, bandages, or adhesive tapes to the skin directly below the fracture - once the material has been applied, weights are fastened to it - the affected body part is then pulled into the right position using a pulley system attached to the hospital bed

skeletal traction

involves placing a pin, wire, or screw in the fractured bone - after one of these devices has been inserted, weights are attached to it so the bone can be pulled into the correct position

external fixation

metallic device with pins that are inserted into the bone and attached to external rods

internal fixation

a fracture treatment in which a plate or pins are placed directly into the bone to hold the broken pieces in place

color - temperature - capillary refill - peripheral pulses - edema

*assess neurovascular condition distal to the site of the fracture

a peripheral vascular assessment on an extremity with a fracture should include:

sensation - monitor function - pain

*assess neurovascular condition distal to the site of the fracture

a peripheral neurological assessment on an extremity with a fracture should include:

increase fluid intake to 2500 mL/day

patients are at high risk for developing kidney stones after a fracture due to bone demineralization. how can kidney stones be prevented?

bone demineralization: the calcium from the bone moves into the blood, then is filtered out in the urine, which can cause renal stones

why can renal stones occur as the result of a fracture?

- apply ice directly over the fracture site for the first 24 hr (avoid getting cast wet by keeping ice in a plastic bag and protecting cast with cloth)

- check with HCP before getting fiberglass cast wet

- dry cast thoroughly if inadvertently exposed to water

- elevate extremity above heart level for the first 48 hr

- regularly move joints above and below cast

- use a hair dryer on a cool setting for itching inside the cast

- report signs of possible problems to HCP: increasing pain despite elevation, ice, analgesia; swelling with pain and discoloration of toes or fingers; pain during movement; burning or tingling under cast; sores or foul odor under cast

- keep appointment to have fracture and cast checked

- Do NOT: get cast wet; remove any padding; insert any objects inside the cast; bear weight on new cast for 48 hr (not all casts are made for weight bearing; check with HCP when unsure); cover cast with plastic fo

patient teaching on cast care:

hip fracture

type of fracture common in older adults - 95% results from falling

intracapsular fracture

a fracture inside the joint capsule - associated with osteoporosis and minor trauma

extracapsular fracture

a fracture outside the joint capsule

- external rotation of the affected leg

- muscle spasm

- severe pain and tenderness

- shortening of affected extremity

clinical manifestations of a hip fracture:

displaced femoral neck fracture

can cause serious disruption of the blood supply to the femoral head - disruption of blood flow can result in avascular necrosis of the femoral head

- temporary immobilization until surgery: buck’s traction for only 24 to 48 hours

- repair with internal fixation devices (intramedullary rods, screws)

- replacement of femoral head with a prosthesis (partial hip replacement or hemiarthroplasty)

- total hip replacement (THR)

- pain control with analgesics and/or muscle relaxants

- comfortable positioning if possible

*after a hip fracture occurs, immediately immobilize the hip and leg

treatment of hip fractures:

immediately immobilize the hip and leg

what should be done immediately after a hip fracture occurs?

arthritis, avascular necrosis

non-fracture indications for hip replacements:

arthritis

a common cause of chronic hip pain and disability

avascular necrosis

trauma that limits blood flow - can be a result of chronic alcoholism

- hip pain limits everyday activities (e.g., walking, bending)

- hip pain continues while resting, day or night

- hip stiffness limits the ability to move or lift the leg

- inadequate pain relief from conservative measures

total hip replacement (THR) surgery is recommended if:

- movement limitations: turning, maintain alignment - use the log rolling technique: turn the entire body as one unit, use a draw sheet

- avoid hip flexion > 90 degrees

- avoid positioning on affected side

- prevent external rotation: extremity support - use pillows to support the extremity in anatomical alignment

how to prevent dislocation with a hip fracture:

- complete weight bearing after adequate healing

- no tub baths for 4-6 weeks

- no driving for 4-6 weeks

- avoid flexing the hip > 90 degrees

- no stooping or squatting

- no crossing the legs at the knees or the ankles

patient education for a hip fracture:

- use an elevated toilet seat and cushions to raise sitting height

- sit in a chair that positions them with their knees a little lower than their hips

how can a patient with a hip fracture avoid flexing the hip > 90 degrees?

osteoarthritis and rheumatoid arthritis at the knee

the most common cause for knee replacement

- cortisone infections: relieves inflammation in the joint

- analgesics

- weight reduction

non-surgical treatments for knee pain:

elevated on pillows: elevate the limb to prevent or reduce swelling

how should you position the extremity after a knee replacement surgery?