•       Direct blows
•       sudden forces
•       sudden twisting motions or extreme muscle contractions 
•       (Not only is the bone injured but surrounding structures as well. You end up with joint bleeding, soft tissue, edema, joint dislocations, tendons can rupture, nerves can be severed. Depending on where the bony prominence is, organs can be punctured.)

Complete Fracture

[image]      A break across entire cross section of bone. If its clear across bone, it will usually be displaced or not in good alignment.

Incomplete

[image]      aka greenstick. Breaks through only part of the cross section of bone.

Open fracture

[image]      aka compound fracture. Involves the skin or mucus membrane. Whenever it is open, pt will need ATB’s to prevent infection.

Closed

No break in skin integrity

Pathologic

[image]      From some kind of bone disease process, like osteoporosis, pagents disease, or any kind of bony cancer.

Fatigue or stress

Usually athletes. Comes from excessive stress or strain

Compression

Think vertebrae or elderly people. They can just sit down hard and have a compression fracture or someone falling from a height who lands on tailbone can get a compression fracture

Hematoma formation

within 48 to 72 hr after injury. (Bruising should be iced for first 24 hours at least, but then use heat to break down the bruise and the body can absorb it. Broken bone will start forming a callous

[image]      Bone remodeling

Osteoclast reformation,

[image]      Usually most bones are healed by 6 weeks, depending on health of person.

Acute compartment Syndrome

- The fibrous membranes that cover and separate the muscles. There are 46 anatomic compartments in the body and 36 of them are in the extremities.

-This is a limb threatening condition which causes swelling, possibly blood, which puts too much pressure on nerves and vascular areas distal to the area.

-You will see a sudden, severe, decrease in blood flow to the tissue DISTAL to the area of the injury. They end up with necrosis and ischemia of the extremity.

-  Pt will complain of deep, throbbing pain, which is more than what you would expect for their type of injury, and pain cannot be reduced with analgesics.


*The hallmark sign is pain that occurs or intensifies with passive range of motion.

-Typically it is seen in the legs but can occur in the arms. This pressure becomes so intense that I t even affects microcirculation so you are getting NO blood flow at all, distal to the injury.

Emergency Care and Nursing management of compartment syndrome

[image]      Within 4 to 6 hours after the onset of acute compartment syndrome, neuromuscular damage is irreversible; the limb can become useless within 24 to 48 hours.

[image]      Focus on the 5 P’s and do frequent neuro assessments. (Pain, paralysis, parasthesia (burning or tingling), pallor, pulselessness.)

[image]      They will complain of deep, throbbing pain that increases with PROM.

[image]      Note the color of distal extremity, color, temperature, capillary refill, presence of edema, pulselessness (this is a very late sign). If you lightly palpate the muscle around the fractured area, it will be swollen and very firm if compartment syndrome is present.

[image]      Normal pressure around muscle is 8mm or less, but pressure of 30 mm or greater indicates microcirculation involvement. If a cast is on, it will have to be bi-valved.

[image]      Fasciotomy maybe. Wound left open.

[image]      Splinting and elevation of EXT.

[image]      If there is no fracture, do PROM q4-6h.

Possible complications of acute compartment syndrome

[image]      Infection

[image]      Motor weakness

[image]      Volkmans contracture

[image]      Myoglobinuric renal failure, from blocked renal tubules, known as rhabdomyolysis .

[image]      Shock from possible blood loss

[image]      Fat embolism syndrome; a serious complication resulting from a fracture; fat globules are released from yellow bone marrow released into the blood stream. This is most common in those with multiple fractures and young adults. (12-48 hours after injury this fat embolus is thrown, but can occur up to 10 days later)

Fat embolism

[image]      a serious complication resulting from a fracture; fat globules are released from yellow bone marrow released into the blood stream. This is most common in those with multiple fractures and young adults. (12-48 hours after injury this fat embolus is thrown, but can occur up to 10 days later)

Signs of fat embolus

Tachypnea, tachycardia, pyrexia(fever), anxiety, dyspnea, cough, chest pain, sudden headache, agitation, delirium, coma.

Watch for suttle personality changes and irritability or confusion that comes on suddenly. May ask Doctor if we can get a set of ABG’s.

Other complications of fractures

[image]      Infection

[image]      Ischemic necrosis

[image]      Fracture blisters (under cast)

[image]      Delayed Union (healing doesn’t occur within the expected time frame)

[image]      Nonunion (not healing) like CA patients and those with disease processes

[image]      Malunion (failure of bone ends to unite together), people who are non compliant who took splint off before they were supposed to, or never got Tx at all

Musculoskeletal assessment

[image]      Check bone alignment

[image]      Extremities same length

[image]      Changes in shape of bone

[image]      Pian in bones when moving

[image]      Crepitous

[image]      Decreased Rom

[image]      Echymosis or bruising around wound site or distal from it

[image]      Swelling at fracture site

Special Considerations with physical assessments

Q       Fractures of upper extremity need to be assessed with  the client sitting because when they lay down, it causes the arms to fall back somewhat, which can be more painful.

Q       Support the affected arm to promote comfort, maybe with a pillow.

Q       Supine position for lower ext fractures and pelvic fractures

Risk for peripheral neurovascular dysfunction

[image]      Remember to check ABC’s of circulation and other injuries,  not just focus on visible wounds.

[image]      Stay with patients who are under conscious sedation.

[image]      Nurses main priority is not watching the doctor, but watching the patient’s condition (monitor, pulse ox, etc)

Casts and cast care

[image]      When we talk about splints, they are casting material that is used but it only covers parts of the extremity, and once the swelling goes down, they apply the more permanent casting material. The permanent stuff cannot be applied immediately because more swelling is to be expected for awhile.

[image]      Different types of casting material. Typically depends on who puts it on, and who its going on.

ü  Circulation checks, and teach patient how to check for it. Show them pulse, cap refill, watch for blue skin, increases in pain or swelling, all require the need to seek med attention immediately.

Types of skin traction

      Bucks traction

      Belt with traction

Halter with cervical traction

TRACTION

o   Application of a pulling force to provide reduction of a fracture, good aligment, maintenance of alignment, and rest at the site.

o   Bucks traction is done on fractured hips, which decreases the frequent muscle spasms.

Skeletal Traction

A pin is put through the skin, into the bone and a force is applied against that. Usually a heavier weight can be used on it. Pin site care needs done so clean around the pins and sometimes ATB ointment is used.

Plaster traction:

A cast has been applied to a body part and the traction is applied to the cast

Brace

Circumferential

– a belt is put around a body (could be like pelvic traction for low back problems).

General traction care

[image]      Make sure that traction weights hang freely, not touching floor or bed.

[image]      Maintain correct balance between traction pull and countertraction force

[image]      Care of weights

[image]      Skin inspection

[image]      Pin care

[image]      Neurovascular status checks (warmth, temp of skin, pulses, sensation)

Operative procedures

[image]      Open reduction Internal Fixation (ORIF)

[image]      Internally put plates or pins or screws to realign bones. Hardware may or may not be left inside.

[image]      External fixation – Supportive device and pins/screws attached to outside of extremity

[image]      Postop Care is same for any other surgery – Listen to physicians directions, they can be EXTREMELY particular with what they want done in ortho. Watch for DVT and fat embolus; observe pin sites for drainage, etc.

Procedures for NONUNION

[image]      Electrical bone stimulation

o   Non-Invasive - magnetic coils around skin that stimulates blood supply to the area. No known risks, but anyone with a pace maker can’t have this done.

o   Invasive – Placed inside the area and Tx takes about 6 months.

[image]      Bone grafting

Bone banking – Living donors are becoming more popular. For example, someone having a hip replacement may want to donate some bone. Bone cannot be donated without written consent for that purpose

Acute Bone Pain

Interventions

[image]      Use pain scale 0-10

[image]      Drug therapy will typically be some kind of opioid narcotic, depending on age and health of patient.

[image]      Immobilization of fracture provides a lot of pain relief  many times.

Sometimes muscle relaxers will be used, like with hip fractures where people have a lot of muscle spasms

Acute Bone Pain

Interventions

Analgesics

Constipation, so give fluids.

Nausea/vomiting so give anti-emetics.

Watch for respiratory depression, especially with PCA pump.

Make sure family isn’t controlling the PCA (patient controlled analgesia).  Make sure the setting is correct on the PCS pump. It should be one of the first things you check after report is those settings. When pts first come back from OR, be especially cautious of analgesia level and respiratory status…….

Complementary and alternative medicines for Pain

§  Ice at first

§  Heat later

§  Elevation

§  Massage maybe

§  Back rubs

§  Calf rubs

§  Therapeutic touch

§  Distraction

§  Imagery

§  Music

§  Repositioning when not contraindicated

Note: Medicate prior to physical therapy, ADL’s, procedures, etc 9as well as before bed time so they are comfortable to sleep).

Nursing Dx for amputations

·         Skin integrity

·         Impaired body image

·         Risk for infection

·         Impaired mobility

·         Pain

Amputation

Interventions

·         Monitor blood sugar

·         Medicate – maybe narcotics, muscle relaxers, anti-coagulants, anti depressents,

·         Plan dsg changes around pain management plan

·         (alternatives for pain)= music therapy, TENS UNIT (muscle stimulator that helps block pain).

·         Anti seizure meds help block tremors and pain, so may see anti seizures and anti inflammatories, and vitamins and minerals.

·         Prosthetic preparation

·         To combat impaired mobility, encourage repositioning

·         For body image, always assess how they are doing by how they are participating in their own care (only when they are ready). Encourage patient to express feelings.

·         For risk for infection, assess wound for rash, redness, erythema, edema, approximated suture lines, odor. If there is infection, look at WBC.

Pt teaching is extensive and includes:

·         Sometimes diabetic care. No bare feet due to neuropathy,

Impaired Physical Mobility

Risk for pressure ulcers, constipation, risk of urinary retention, DVT, fat emboli, risk for joint contracture. Slings, immobilizers do not move the joint AT ALL. Typically if they go home with a sling (not really a fracture per se, but like just for pain), have them remove sling periodically and ROM to some joints and do NOT wear the sling to bed at night

Nutrition:

Calcium supplements, vitamins B & C or complex, frequent small feedings, high protein, food high in iron (dark green leafy food), possible constipation and change of stool color when taking iron supplement.

Albumin levels, know what they should be..[3.7-5.5]

They might have pulmonary embolus if dif breathing so call 911, teach them that.

DVT risks:

Smokers, birth control, femur and pelvic fractures, etc.

Clavicle fracture:

Some Dr’s use sling, some use clavicle strap to realign bone.

Scapula fx's

Not a common fracture. Monitor breath sounds and resp status, could have punctured lung. Might be immobilized 3-4 weeks.

Proximal Humerus fx:

many have to  have surgery.

Will wear a sling with an immobilizer.

Note vascular status in affected limb after clavicle strap or sling or anything like that.

Shaft of humerus fx:

– May or may not need surgery

Hand fx:

depending on which bone, usually some kind of casts is applied.

If a finger, cast may not be on as long, or aluminum splint.

Hip fx:

·       Treatment of choice is surgical repair to allow allow the older client to get out of bed, and preserve some mobility. Different fixes depend on the types of fracture. If they have peripheral vascular disease, they need good circulation to heal from surgery so if the blood supply is not good, they may not be as likely to have a big surgery. Check vascular and neuro status.

·        

Will be shortened and externally rotated. May or may not be allowed to bare weight on extremity, it is up to physician.

Patella fx:

may be wired. Not a common fracture.

Pelvic fractures

– Big risk for fat or blood clotting.

It depends on where it is if they are allowed to bare weight.

Be considered about the liver and spleen if they have been injured too.

CBC and other blood work ups will be done to determine internal bleeding.

Watch for hemorrhage and shock.

****Give fluids, log roll, give stool softener, pain meds, cough and deep breath. Initially monitor BP and pulse often, like qh, incase of internal bleeding. When rolling, check posterior for bruising which cold indicate pooling of an internal bleed.

Compression fractures of the spine

Not usually life threatening but focus on comfort, pain meds, stool softeners, rest, etc (multiple myeloma, osteoporosis.)

May do a vertebroplasty where bone cement is injected into the skin directly at the fracture site, to fill in the area, provide more stability, and get immediate pain relief. 

Kyphoplasty involves insertin a ballon like cushion device. Google it. Toredol or another nsaid given many times to decrease inflammation (ketoralac? <~~ never given w/ renal failure. Do Creatinine and BUN).

Amputations

– More likely to have phantom leg pain if the amputation was scheduled. ***Not as much phantom pain if the amputation was traumatic.

Phantom leg pain is caused by the severing of peripheral nerves.

Watch for development of contractures.

**If amp is right below knee, they may need to lay prone at times to avoid contractures.

If they DO have phantom pain

you medicate different than you would for nerve pain:

IV calcitonin given a week before amputation surgery will relieve some degree of phantom leg pain.

Beta blockers (Inderal) can be used for constant dull burning pain (phantom).

Anti epileptics (tegrotol, carmazipine?, gabapentin, neurontin) may help knife like sharp pains.

Pt’s may also have muscle spasms or leg pain  (give baclefan many times, oresol is trade name).

It is NON therapeutic to remind the patient that they don’t have alimb so pain is not possible.

make sure they have an overbed trapeze,

prone position q3-4h when possible,

elevation is controversial,

begin physical therapy asap,

also instruct patient to pull residual leg close to non operative leg to strengthen gluteal muscles [abduction],

also push it down into bed (over and down). 

Encourage independence when possible. Preoperative fitting of prosthesis is ideal when possible. Reapply loose bandages

If a crush injury occurs:

Watch for release of myoglobin, can affect potassium and block kidney tubules.

Hyperkalemia can result

Complex regional pain syndrome –aka reflex sympathetic dystrophy

Corticosteroids and analgesia are the Tx.

Can have a sympathomimectomy to sever sympathetic nerve.

KNEE INJURIES

know them and post op care.

ACL repair bracing exercise and weight baring are up to the doctor

Dislocations and subluxations

need put back into place asap.

Watch neurovascular status. Given conscious sedation

Muscle strains and tendon pulls

TX:

RICE (rest, ice, compression, elevation),

nsaids.

DROP ARM test

is for rotator cuff injuries.

A possible rotator cuff tear can be evaluated with the drop-arm test. This test is performed by passively abducting the patient's shoulder, then observing as the patient slowly lowers the arm to the waist. Often, the arm will drop to the side if the patient has a rotator cuff tear or supraspinatus dysfunction. The patient may be able to lower the arm slowly to 90 degrees (because this is a function mostly of the deltoid muscle) but will be unable to continue the maneuver as far as the waist.)