Topic 7: Fractures

• wear a seatbelt

• follow speed limits

• avoid distracted driving

• warm up before exercise

• use protective athletic and work equipment

• do not drive under the influence

• do age appropriate exercise

• adequate calcium and vitamin D intake

• safe living enviornm

• elderly:

  • Functional, non skid, hard soled shoes

  • remove throw rugs

  • ensure adequate lighting

  • maintain a clear path to the bathroom at night

  • avoid walking on uneven/wet surfaces

what are ways to prevent fractures

vision impaired, gait instability, MSK disorders, elderly

who is at risk for fractions

fracture

a disruption or break in the continuity of the structure of the bone that usually occurs from traumatic injuries, disease, or due to medications

open fracture

fracture that goes through the skin which poses a risk for bleeding and infection 

closed fracture

fracture that does not break through the skin

displaced fracture

fracture in which pieces of the bone are out of alignment and need intervention to realign

nondisplaced fracture

fracture that heals easily because the bone is still aligned

• edema/swelling

• pain and tenderness

• muscle spasms

• deformity

• contusion (bruising)

• loss of function

• crepitation

• guarding

what are S/S of a fracture

• neurovascular assessment FIRST

• immobilization to maintain alignment and prevent displacement

• closed or open reduction

• external or internal fixation

• traction

• casts

• supportive devices like a body jacket

• elevate above the heart on pillows for 24 hours

• do not place in dependent positions (increases edema)

• monitor for compartment syndrome, increased pressure, pain, and burning

• medications: muscle relaxants, tetanus, antibiotics

what does management for fractures include

• pulses

• capillary refill

• temp of skin

• color of skin

• edema

• motor function

• sensory function: paresthesia, paralysis, numbness/tingling, hypersensitization, hyperesthesia

what does a neurovascular assessment include after a MSK injury

• pallor

• capillary refill > 3 seconds

• decreased/absent pulses

what indicates arterial insufficiency after a MSK injury

warm and cyanotic

what indicates poor venous return after a MSK injury

• Apply ice for the first 24 hours to decrease edema and swelling

• do not bear weight for 48 hours after getting cast

• elevate above the heart for the first 48 hours

• exercise the joint above and below the cast

• use a hair dryer on cool setting for itching

• dry thoroughly after getting wet

• report swelling, burning, tingling, and odor from under the cast

• do not elevate if compartment syndrome is suspected (must keep at heart level)

• Do not get plaster cast wet

• do not remove the padding

• do not cover with plastic for prolonged periods

what does patient/caregiver educate for cast care include

• compartment syndrome

• VTE

• fat embolism

• rhabdomyolysis

• infection

• hypovolemic shock

• open fractures with severe blood loss

• fractures that damage vital organs like the ribs

• bone infections

• bone nonunion/malunion

• avascular necrosis

what complications from fractures are medical emergencies

compartment syndrome

swelling and increased pressure within the muscle compartment that compromises neurovascular function of the tissue within that space, that is associated with fractures with extensive tissue damage, and crush injury

• restrictive dressing, splints, casts

• extensive trauma

• premature closure of fascia

• bleeding, inflammation, edema, IV infiltration 

what are causes of compartment syndrome

edema causes pressure that obstructs circulation and venous occlusion leads to increased edema which compromises arterial blood flow → ischemia, cell death, loss of function

why do we not elevate an extremity if someone has compartment syndrome

6 P’s

• pain that is out of proportion to injury/not managed by opioids

• pressure from swelling

• paresthesia (numbness and tingling) distal to toes

• pallor due to lack of circulation (compare B/L)

• paralysis (can’t move)

• pulselessness (going to need amputation)

what are the S/S of compartment syndrome

pain and paresthesia

what are the early S/S of compartment syndrome

paralysis and pulselessness

what are the late signs of compartment syndrome

• relieve pressure (take off ACE bandage/cast)

• notify HCP

• do not elevate above the heart

• do not apply cold compress (vasoconstriction and reduced circulation)

• may need surgical decompression (fasciotomy) or amputation

what are the interventions for compartment syndrome

cyclobenzaprine (Flexeril), carisoprodol (Soma), methocarbamol (Robaxin)

what muscle relaxants can be given after a fracture

tetanus and diphtheria toxoid and tetanus immunoglobulins (TIG)

what should be given for open fractures when immunization status is unknown

• increase protein to 1 g/kg BW to promote healing

• increase vitamins B, C, D, calcium, phosphorus, magnesium, fiber, fluids (2-3 L/day)

• if they have a body jacket/hip spica cast: 6 small meals a day (may have N/V if eating a lot at one time)

what are nutritional considerations for a patient after a fracture

VTE

complication of fracture that occurs due to venous status from muscle inactivity; RF with hip fracture/replacement, knee replacement, and bed rest

• prophylactic anticoagulants for 10-14 days

• antiembolism stockings

• SCDs

what are interventions to prevent VTE after a fracture 

fat embolism

complication from fracture in which systemic fat globules enter circulation that is most common after a fracture of the long bones, ribs, tibia, and pelvis

• careful immobilization and handling of bones

• reposition as little as possible prior to immobilization and stabilization to prevent dislodging them into circulation

what does prevention of a fat embolism include

• petechia on the neck, anterior chest wall, axilla, and head

• chest pain

• tachypnea, dyspnea,

• cyanosis, hypoxia

• tachycardia

• restless, confused

• can quickly become comatose

what are the S/S of a fat embolism 

• fat cells in blood, urine, and sputum

• decreased platelets and Hct

• increased ESR

• if PaO2 < 60 it may be in the lungs

what would labs of someone with a fat embolism reveal

• O2 and mechanical ventilation/ECMO if needed

• monitor for pulmonary edema and ARDs

• if cardiac issues: IV fluids, pulmonary vasodilators, pulmonary vasoconstrictors, and inotropic drugs

what does management for a fat embolism include

rhabdomyolysis

complication of a fracture/MSK injury that is caused by a breakdown of damaged skeletal muscle that releases myoglobin into circulation, resulting in obstruction of renal tubules and acute tubular necrosis (ATN)

dark reddish brown urine, low urine output, AKI

what are the S/S of rhabdomyolysis

increase fluids to get the myoglobin out of the body without damaging the kidneys

what is the treatment for rhabdomyolysis

• maintain patent airway and ventilation, intubate if needed

• treat as though there is a cervical injury until cleared → C collar

• assess facial nerves oculomotor, trochlear, abducens

• assess eye for rupture

• if mandibular keep wire cutter close and that patient knows how to use them, use NG tube decompression ot prevent vomiting and aspiration

what is general management for a facial fracture

• brown tissue, off-centered or tear-drop shaped pupil

• immobilize and stabilize the eye

what are S/S of rupture in the eye after a facial fracture and what is treatment

preserve as much extremity length and function as possible

what is the goal of an amputation

• assess for hemorrhage and have a tourniquet available at bedside

• avoid dangling to reduce edema

• prevent flexure contraction by avoiding sitting in a chair for more than an hour with the hips flexed or with a pillow under the surgical extremity

• lie on abdomen (tummy time) for 30 minutes 3-4 times a day with hip extended to prevent hip contractures

• avoid skin flap injury, which can cause delayed tissue healing

• if any signs of infections start antibiotics and notify HCP

• do not put powders/lotions on the nub

what are post op considerations after an amputation

phantom pain

perceived pain in missing parts of the limb after amputation that usually subsides with time but can become chronic pain