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Chapter 42

Chapter 42. Fractures. Learning Objectives. Identify the types of fractures. Describe the five stages of the healing process. Discuss the major complications of fractures, their signs and symptoms, and their management. Compare the types of medical treatment for fractures,

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Chapter 42

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  1. Chapter 42 Fractures

  2. Learning Objectives • Identify the types of fractures. • Describe the five stages of the healing process. • Discuss the major complications of fractures, their signs and symptoms, and their management. • Compare the types of medical treatment for fractures, particularly reduction and fixation. • Describe common therapeutic measures for fractures, including casts, traction, crutches, walkers, and canes. • Discuss the nursing care of a patient with a fracture. • Describe specific types of fractures, including hip fractures, Colles’ fractures, and pelvic fractures.

  3. Classification of Fractures Closed or simple fracture The bone does not break through the skin Open or compound fracture Fragments of the broken bone break through skin Open fractures have three grades of severity Grade I: least severe injury, with minimal skin damage Grade II: moderately severe injury, with skin and muscle contusions (bruises) Grade III: most severe injury (wound larger than 6 to 8 cm), with skin, muscle, blood vessel, and nerve damage

  4. Classification of Fractures Stress fracture Caused by either repeated or prolonged stress Pathologic fracture Occurs because of a pathologic condition in the bone, such as a tumor or disease process, that causes a spontaneous break

  5. Figure 42-1

  6. Etiology and Risk Factors Commonly caused by trauma to the bone, especially as a result of automobile accidents and falls Bone disease, e.g., bone cancer, can lead to a fracture Hip fractures in older adults usually from falls Risk factors for hip fractures: osteoporosis, advanced age, white race, use of psychotropic drugs, and female In adults, ribs most commonly fractured Fractures of the femur most common in young and middle-aged adults Hip and wrist fractures are most common in older adults

  7. Fracture Healing A bone begins to heal as soon as an injury occurs New bone tissue formed to repair the fracture, resulting in a sturdy union between the broken ends of the bone

  8. Healing Stages Stage 1: hematoma formation Immediately after a fracture, bleeding and edema occur In 48 to 72 hours, a clot or hematoma forms between the two broken ends of the bone

  9. Healing Stages Stage 2: fibrocartilage formation Hematoma that surrounds fracture does not resorb, as it does in other parts of the body Instead, other tissue cells enter the clot, and granulation tissue replaces the clot The tissue then forms a collar around each end of the broken bone, gradually becoming firm and forming a bridge between the two ends

  10. Healing Stages Stage 3: callus formation Within 1 to 4 weeks after injury, granulation tissue changes into a callus, which is made up of cartilage, osteoblasts, calcium, and phosphorus. The callus is larger than the diameter of the bone and serves as a temporary splint

  11. Healing Stages Stage 4: ossification Within 3 weeks to 6 months after the break, a permanent bone callus, known as woven bone, forms During this stage the ends of the broken bone begin to knit

  12. Fracture Healing Stage 5: consolidation and remodeling Consolidation occurs when the distance between bone fragments decreases, then closes During bone remodeling, immature bone cells are gradually replaced by mature bone cells Excess bone is chiseled away by stress to the affected part from motion, exercise, and weight bearing Bone then takes on its original shape and size

  13. Figure 42-2

  14. Fracture Healing Healing affected by location and severity of the fracture, type of bone, other bone pathology, blood supply to the area, infection, and the adequacy of immobilization Also age, endocrine disorders, and some drugs affect healing Healing time increases with age; it may take six times as long for the same type of fracture to heal in an older adult as in an infant

  15. Complications

  16. Infection Osteomyelitis: from contamination of the open wound associated with a fracture or from contamination of indwelling hardware used to repair the broken bone When infection is inadvertently brought by surgery or other treatment, it is known as iatrogenic Any infection can interfere with normal healing Common after an open fracture and surgical repair and may become chronic In deep, grossly contaminated wounds, gas gangrene may develop

  17. Infection Signs and symptoms Local pain, redness, purulent wound drainage, chills, and fever With gas gangrene, foul-smelling watery drainage with significant redness and swelling Treatment IV antibiotics may be given for 4 to 8 weeks, followed by 4 to 8 weeks of oral drug therapy Wound care: irrigation, treatment with antibiotic beads, and surgical removal of dead bone tissue and/or hardware

  18. Fat Embolism Fat globules released from marrow of broken bone into bloodstream, then migrate to the lungs They lodge in capillaries and obstruct blood flow The fat particles break down into fatty acids, which inflame the pulmonary blood vessels, leading to pulmonary edema Common with fractures of the long bones, multiple fractures, and severe trauma

  19. Fat Embolism Respiratory distress is the first sign of a fat embolism, followed by tachycardia, tachypnea, fever, confusion, and decreased level of consciousness Treatment: bed rest, gentle handling, oxygen, ventilatory support, and fluid restriction and diuretics for pulmonary edema

  20. Deep Vein Thrombosis Venous stasis, vessel damage, and altered clotting mechanisms contribute to formation of blood clots (thrombi), most commonly in deep veins of the legs DVT increased with immobility often associated with a fracture Thrombi can break off and travel to the lungs, causing a pulmonary embolism

  21. Compartment Syndrome Serious complication from internal or external pressure on the affected area Compartments: enclosed spaces made of muscle, bone, nerves, blood vessels wrapped by fibrous membrane Internal pressure from bleeding/edema into a compartment; external pressure from a cast or tight dressing

  22. Compartment Syndrome When bleeding or edema into a compartment, there is nowhere for drainage to go: it is trapped in the space Increased fluid puts pressure on tissues, nerves, and blood vessels, so that blood flow is decreased, resulting in pain and tissue damage. External pressure also can decrease blood flow to the area

  23. Compartment Syndrome Primary symptom is pain, especially with touch or movement, that can’t be relieved with opioids Other signs and symptoms: edema, pallor, weak or unequal pulses, cyanosis, tingling, numbness, paresthesia, and finally, severe pain The goal of treatment is to relieve pressure When internal pressure, a surgical fasciotomy, which entails making linear incisions in the fascia, may relieve pressure on the nerves and blood vessels For external pressure, cast or dressings are replaced

  24. Shock After fracture, a risk of excessive blood loss Trauma may rupture local blood vessels; internal organs may be punctured; results in internal bleeding Loss of blood leads to shock, evidenced by tachycardia, anxiety, pallor, and cool, clammy skin Immobilizing fractures reduces risk of hemorrhage If severe external bleeding, external pressure should be applied and medical assistance summoned immediately

  25. Joint Stiffness and Contractures Joint fractures or dislocations may be followed by stiffness or contractures, especially in older adults, due to immobility associated with fracture Prevention requires appropriate positioning and progressive exercise programs Treatment may employ splints, traction, casts, surgical manipulation, and aggressive physiotherapy

  26. Malunion Expected healing time is appropriate but unsatisfactory alignment of bone results in external deformity and dysfunction

  27. Delayed Union Failure of a fracture to heal in the expected time The bone usually heals eventually; it may just be slower

  28. Nonunion Occurs when a fracture never heals Treatment Osteogenic method: implantation of bone grafts Osteoconductive methods: synthetic materials to provide a matrix for bone growth Osteoinduction: substances such as platelet-derived growth factor Electric stimulation Internal or external; up to 10 hours a day for 3-6 months Time consuming but can prevent further surgery and bone grafts

  29. Post-Traumatic Arthritis Weight-bearing joints are most vulnerable to posttraumatic arthritis Excessive stress and strain on the joint or fracture must be avoided to reduce the risk of this complication Can be a result of nonunion of a fracture

  30. Avascular Necrosis A variety of factors can interfere with blood supply after a bone injury Once bone cells are deprived of oxygen and nutrients, they die and their cell walls collapse Signs and symptoms Pain, instability, and decreased function in the affected area

  31. Avascular Necrosis Treatment Relief of weight bearing and removal of part of the bone to decrease pressure If conservative measures fail, surgical procedures may be recommended Sometimes amputation is necessary

  32. Complex Regional Pain Syndrome Type 1 (CRPS—Type 1) Precipitated by a fracture or other trauma Symptoms Severe pain at the injury site despite no detectable nerve damage, edema, muscle spasm, stiffness, vasospasms, increased sweating, atrophy, contractions, and loss of bone mass Symptoms persist longer than expected with the type of injury suffered

  33. Complex Regional Pain Syndrome Type 1 (CRPS—Type 1) Treatment Nerve blocks, physical therapy, transcutaneous electrical stimulation, and analgesics, muscle relaxants, and antidepressants

  34. Signs and Symptoms Depend on type and location of the break Some fractures have so few manifestations that they can be detected only with x-ray Signs and symptoms are swelling, bruising, pain, tenderness, loss of normal function, abnormal position, and decreased mobility See Box 42-1, p. 918

  35. Diagnostic Tests and Procedures Standard radiographs Reveal bone disruption, deformity, or malignancy Computed tomography (CT) Detect fractures of complex structures, such as the hip and pelvis, or compression fractures of the spine Bone scan Detect small bone fractures or fractures caused by stress or disease

  36. Medical Treatment

  37. Reduction The process of bringing the ends of the broken bone into proper alignment

  38. Closed Reduction or Manipulation Nonsurgical realignment that returns bones to their previous anatomic position No surgical incision is made; however, general or local anesthesia is given By using traction, manual pressure, or a combination After reduction of a fracture, x-ray taken and a cast usually applied

  39. Figure 42-3

  40. Open Reduction A surgical procedure in which an incision is made at the fracture site Usually for open (compound) or comminuted fractures to clean the area of fragments and debris

  41. Immobilization Necessary for healing to occur Prevents movement and increases union Accomplished in many ways, such as fixation, casts, splints, and traction

  42. Fixation An attempt to attach the fragments of the broken bone together when reduction alone is not feasible because of the type and extent of the break

  43. Internal Fixation Done during open reduction surgical procedure Rods, pins, nails, screws, or metal plates used to align bone fragments and keep them in place for healing Promotes early mobilization; preferred for older adults who have brittle bones that may not heal properly, or who may suffer the consequences of immobility

  44. Figure 42-4

  45. External Fixation Pins are inserted into the bone, above and below fracture Pins are then attached to an external frame and adjusted to align the bone If there is soft tissue damage or infection, external fixation allows access to the site and facilitates wound care Pin care is extremely important to prevent the migration of organisms along the pin from the skin to the bone Patients should be taught to do their own pin care and to recognize signs of infection

  46. Figure 42-5

  47. Figure 42-6

  48. Therapeutic Measures

  49. Casts, Splints, and Immobilizers Hold the bone in alignment while allowing movement of other parts of the body Types of cast materials: plaster of Paris, fiberglass, thermoplastic resins, thermolabile plastic, and polyester-cotton knit impregnated with polyurethane Variety of materials used for splints/immobilizers Four main groups of casts: (1) upper extremity, (2) lower extremity, (3) cast brace, and (4) body or spica cast

  50. Traction Exerts a pulling force on a fractured extremity to align bone fragments Prevents or corrects deformity, decreases muscle spasm, promotes rest, and maintains the position of the injured part May be applied directly to the skin (skin traction) or attached directly to a bone (skeletal traction) with a metal pin or wire

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