Fractures, Amputations

Bones Types

Ø Structure- axial (skull, sternum, ribs, spine), Appendicular

Ø Growth plate- cartilage, vanishes at puberty, epiphyseal

Ø Short Bones

Ø Flat Bones

Ø Irregular Bones

Complete vs Incomplete break

A complete fracture breaks a bone into separate pieces

Incomplete fracture, also known as a partial fracture, is when a bone cracks but doesn't break all the way through.

Open vs Closed breaks

An open fracture creates a break in the skin surface

Closed fracture leaves the skin intact

Displaced vs Nondisplaced

A displaced fracture occurs when a bone breaks into two or more pieces that move out of alignment

Nondisplaced fracture occurs when the pieces of bone don't separate or move far enough to be out of alignment with the rest of the bone.

Direct Injury vs Pathological

When a fracture is caused by a direct injury, the break occurs at the site of the injury.

Pathological fractures are fractures caused by minimal force due to underlying disease.

In cases of osteoporosis, the weakened bones are prone to pathological fractures.

Stress fractures result from repetitive force applied to an area.

Clients with certain medical

conditions are at Greatest risk for development of fractures; these include osteomyelitis, osteomalacia (soft/weak), osteoporosis, cancer, infection.

These disorders cause softening or inflammation in the bones, which make the bones more likely fracture.

Clinical Presentation Fracture

•Pain at fracture site

•Swelling

•Tenderness

•Bruising

•Shortening of a limb

•Deformity

•Displacement

Fracture types

Transverse: Across the long axis of the bone

Oblique: At an angle on the bone

Spiral: Result of rotational injury

Comminuted: Has more than two breaks

Avulsed: Bone fragment pulling off bone with tendon

Fracture types cont

Impacted: Part of bone pushed up into the rest of the bone, resulting in a shortening of the bone

Torus: Cortex of the bone buckles; only seen in children

Greenstick: Only one side of the bone fractured; only seen in children

Falls are the

most common cause of hip fractures. Locations of hip fractures include the femoral head and neck, intertrochanteric, and subtrochanteric areas.

An aging client may be on medications such as antihypertensives, antianxiety, and opioids may make the older adult at greater risk for falling. 

The manifestations of hip fracture include

the inability to bear weight, hip and groin pain, or the affected leg is outwardly rotated and is visibly shorter than the unaffected leg.​​​​​​​

Major cause is osteoporosis

Fracture Dx

Diagnosis is done with plain x-ray to determine the type and extent of the fracture.

In the case of hip fracture, x-ray is usually an anteroposterior pelvis x-ray, as well as cross-lateral view. X-rays may include the length of the femur.

A magnetic resonance image (MRI) may be needed if the x-rays are not definitive. ​​​​​​​

Client Education

When caring for a client with a fracture, teach proper activity, immobilization, and cast or incision care.

Instruct the client to keep the affected limb elevated to reduce swelling and pain and to manage discomfort appropriately.

Advise them to contact the provider immediately if the cast feels too tight or if pain persists despite interventions.

Frequent neurovascular assessment

•Color of limb

•Swelling/deformities

•Movement

•Temperature

•Sensation and pain

Stabilization

Stabilize the client prior to immobilization with trauma

The initial treatment of the fracture is to stabilize the fracture, either by immobilization, assist with reduction, or surgery.

Reduction of fracture is outside of the scope of practice of nurses

Other Potential Complications:

•Bleeding

•Neurovascular compromise

•Complex Regional Pain Syndrome

•Compartment syndrome

•Embolism

Respiratory

Fractures in the ribs or thoracic cavity may compromise the respiratory system.

The client may be unable to take a deep breath or have a diminished cough effort.

This puts them at risk for development of atelectasis or pneumonia.

To facilitate effective coughing and deep breathing, the client should splint the chest.

Sleep and Rest

Clients with a fracture may have difficulty getting adequate rest or sleep.

This may be due to discomfort from the injury or from treatment.

The use of pillows for support, as well as use of analgesia before sleep may allow the client to rest comfortably.

Complication: Compartment Syndrome

•Increase in pressure within the fascia/muscle

•Assess the 6 P’s:

• Pain

• Paresthesia

• Paralysis (loss of function)

• Pallor

• Pulselessness

• Poikilothermia (cool)

•Prepare for cast removal and/or emergent fasciotomy

Compartment Syndrome cont.

The pressure reduces perfusion distal to the injury.

Fractures that occur in the forearm are of the Greatest risk for development of compartment syndrome.

Complication: Embolism

•Pulmonary or Fat Embolism

•Pelvic or Hip fracture—high risk for pulmonary

•Long bone fracture – high risk for fat embolus

•S/S: acute SOB, pleuritic chest pain, tachycardia, tachypnea, cough, hemoptysis (if blood clot)

Embolism Tx

Ø Support ABCs

Ø Oxygen therapy

Ø Anticoagulation (blood clot)

Ø IVC filter

Ø Embolectomy

Chest x-ray, history, electrocardiogram, and arterial blood gases will be done for pulmonary embolism

Take Action: Interventions

•Pain control- RICE

•Immobilization- Cast care, Splint care, position

•Neurovascular status

•Embolism

Cast/Splint

Clients should be taught to keep casts dry, use a plastic cover when bathing, and avoid inserting objects or trimming edges.

Splints and immobilizers stabilize the fracture while allowing mobility of other joints and can be removed for bathing and dressing.

Ensure the skin is dry before reapplying a walking boot.

Clients should elevate

the affected extremity above heart level for the first 72 hours, move uninjured digits and limbs, and apply ice (with a protective barrier over the cast) to reduce pain and swelling.

Skin traction, often called

called Buck’s traction, uses adhesive strips or a foam boot attached to a counterweight, to maintain alignment.

is generally used for short-term treatment until skeletal traction or surgery is possible.'

Tape, boots, splints are applied directly to the skin, mainly to help decrease muscle spasms in the injured extremity.

The nurse’s responsibility in caring for a client in traction include:

Ensure the traction rope and pulley device are free from kinks and wear.

•  Ensure the weight hangs freely and does not touch the floor.

•  Maintain skeletal alignment.

•  Stabilize the weight during repositioning of client.

•  Skeletal traction: assess pin sites once per shift for manifestations of infection.

•  Skeletal traction: perform pin care once per shift using soap

Skeletal traction

uses surgically placed pins and tongs to secure traction to the bones in order to maintain alignment and allow for healing.

If an infection occurs in the bone, it is known as osteomyelitis, which is difficult to cure and may impair healing of the fracture.

It provides a long-term pull that keeps the injured bones and joints aligned.

Closed (external) reduction

nonsurgical, manual realignment of a fracture or dislocation, performed at the bedside or in the OR.

The nurse supports the client and administers pain medication as needed.

External reduction with closed fixation (ERCF) may be used, where the provider realigns the fracture and stabilizes it with external hardware or a cast.

Open reduction

is done in the operating room.

The role of the nurse for open reduction is to prepare the client for surgery.

Open reduction internal fixation (ORIF)

is one of the most common treatment options for fractures in older adults to facilitate early mobilization.

In an ORIF, the fracture is repaired surgically using hardware and fixation to return the limb to proper alignment.

Rehabilitation is started as

soon as is feasible to reduce the risk of complications of immobility.

The client will be started on anticoagulation treatment to prevent DVT.

A client-controlled analgesia may be used for pain management in addition to oral analgesics.

Neurovascular assessments will be done to assess for blood flow and nerve function distal to the injury.

Hip precautions should be initiated.

After total hip replacement (THR), clients

should avoid hip adduction, flexion over 90°, internal or external rotation, crossing legs, lying on the unoperated side, twisting, and taking baths.

Pt should sleep on their back, use a shower chair and elevated toilet seat, and may use aids like reaching tools or sock aids.

Precautions should continue for at least 6 weeks post-surgery.

Amputations

•Removal of all or part of a limb

•Traumatic injury vs Surgical amputation

•Peripheral Vascular Disease most common cause

•Risk Factors: DM, PAD, Smoking

•Level of amputation determined by tissue viability

•Goal: preserve as much tissue as possible while removing infection or necrotic areas

Physiological Amputation

Phantom pain is a pain sensation in the limb that has been amputated.

This can lead to problems with prosthesis training.

Medications such as certain anti-epileptic medications and anti-depressants (fluoxetine, SSRI) can alleviate some of this pain.

Psychosocial Amputation

Amputation, whether traumatic or medical, can cause depression and lowered self-esteem.

Clients may grieve the loss like the death of a loved one and worry about mobility, work, and being a burden.

Early intervention with physical therapy, prosthetics, and support groups helps restore activity and independence.

Considerations of the Aging Adult

Aging increases the risk of conditions like diabetes and peripheral artery disease that may lead to amputation.

Providers may hesitate to refer older adults for prosthetics if they doubt adaptation, but studies show even those over 80 can successfully adjust to using a prosthetic limb.

Amputation: Clinical Presentation

• Decreased or absent perfusion to extremity

q Pale or necrotic limb

q Absent pulse

q Area may not blanche

q Foul odor if infection or gangrene

Amputation: Diagnostic Studies

q Doppler studies- lack of flow

q Invasive angiogram- with doppler

q Ankle brachial index (ABI)- the presence of arterial disease in a limb by comparing the systolic blood pressure of the ankle and the arm.

Preoperative Care Amputation

includes education about the amputation.

If possible, a meeting with another amputee can be helpful.

Smoking cessation is advised, as well as control of diseases that compromise perfusion.

Postoperative Care Amputation

In the immediate period after amputation, the client will have a pressure dressing on the amputation site.

The client should be observed for bleeding at the site.

The residual limb should be assessed regularly for circulation: color, temperature, pulse, blanching.

Circulation is compromised if the residual limb is pale, cool, and has an absence of a pulse or blanching.

Prosthesis

Once the surgical incision has healed and the edema has subsided, the client may be fitted for a prosthetic device.

This usually occurs about 7 to 10 weeks after surgery.

The initial prosthetic device is a temporary device as the residual limb will undergo changes in size and shape for about 18 months after surgery.

After this time the client will be fitted for a permanent prosthesis.

Range of Motion and Other Physical Therapies

Preventing contractures in a residual limb involves frequent repositioning, maintaining proper limb alignment, ambulating when possible, and performing range of motion exercises.

The client should also desensitize the limb through massage, tapping, vibration and work with physical therapy to gradually bear weight on the limb.

Client Teaching

Teach the client to care for the amputation site by massaging the residual limb, inspecting it daily (using a mirror to check all areas), and monitoring for rash, blisters, abrasions, swelling, drainage.

Provide instructions on proper bandaging and advise NO using oils or lotions that could affect prosthesis fitting.

Encourage the client to express feelings of frustration or anger and consider attending a support group.