Fractures

Question 1

what are fractures

Answer 1

 Disruption or break in continuity of structure of bone
 Majority of fractures from traumatic injuries
 Some fractures secondary to disease process (pathologic)
 Cancer or osteoporosis

Question 2

types (classifications) of fractures

Answer 2

 Communication with environment
– Open—skin broken, bone exposed
—- Usually from severe external forces
– Closed—skin intact
 Extent of break
– Complete—completely through bone
– Incomplete—partly across bone shaft
 Based on direction of fracture line: Linear, oblique, transverse, longitudinal, spiral
 Displaced or nondisplaced
– Displaced: two ends separated from one another
—- Often comminuted or oblique
– Nondisplaced: periosteum is intact and bone is aligned
—- Usually transverse, spiral, or greenstick
Spiral and greenstick = abuse

Question 3

manifestations of fractures

Answer 3

 Edema and swelling
 Pain and tenderness
 Muscle spasm
 Deformity: classic sign of fracture
 Bruising
 Loss of function
 Crepitus/Crepitation

Question 4

factors influencing fracture healing

Answer 4

 Displacement and site of fracture
 Blood supply
 Other local tissue injury
 Immobilization
 Internal fixation devices
 Infection
 Poor nutrition
 Age
 Smoking

Question 5

complications of fracture healing

Answer 5

 Delayed union
 Nonunion
 Malunion- not lined up properly
 Pseudoarthrosis (Type of nonunion occurring at fracture site in which a false joint is formed with abnormal movement at site.)
 Refracture
 Myositis ossificans (Deposition of calcium in muscle tissue at site of significant blunt muscle trauma or repeated muscle injury

Question 6

overall goal of fracture treatment

Answer 6

 Anatomic realignment (reduction)
 Immobilization to maintain alignment
 Restoration of normal or near-normal function

Question 7

diagnostic assessment of fractures

Answer 7

 History and physical assessment
 X-ray
 CT scan, MRI

Question 8

closed reduction fracture

Answer 8

 Nonsurgical, manual realignment of bone fragments
 Traction and countertraction applied
 Under local or general anesthesia
 Immobilization afterwards – Traction, cast, splint, or brace

Question 9

open reduction fracture

Answer 9

 Surgical incision
 Internal fixation
— Wires, screws, pins, plates, rods, or nails
 Risk for infection
 Facilitates early ambulation
 Reduced risks related to immobility

Question 10

Pulling force applied to injured or diseased body part or extremity

Answer 10

traction

Question 11

purpose of traction

Answer 11

 Prevent or reduce pain and muscle spasm
 Immobilize joint or part of body
 Reduce fracture or dislocation
 Treat a pathologic joint condition
 Provide immobilization to prevent soft tissue injury
 Promote active and passive exercise
 Expand a joint space during arthroscopy
 Expand a joint space before reconstructive surgery

Question 12

why do we do traction

Answer 12

Pulling force to attain realignment; countertraction pulls in opposite direction

Question 13

two most common types of traction

Answer 13

 Skin traction
 Skeletal traction

Question 14

purpose and process of skin traction

Answer 14

 Short-term (48 to 72 hours)
 Tape, boots, or splints applied directly to skin to reduce muscle spasms
— For example, Buck’s traction (Figure) for hip, knee, or femur fracture
 Traction weights 5 to 10 pounds
 Skin assessment and prevention of breakdown imperative
Can lead to skin breakdown

Question 15

skeletal traction

Answer 15

 Align injured bones and joints or treat joint contractures and congenital hip
dysplasia
 Long-term pull to maintain alignment
 Pin or wire inserted into bone
 Weights 5 to 45 pounds
 Risk for delayed union, nonunion, or infection at pin sites
 Complications of immobility

Question 16

balanced suspension skeletal traction

Answer 16

 Requires correct patient positioning and alignment with constant traction forces
 Maintain countertraction, typically the patient’s own body weight
— Elevate end of bed
— Maintain continuous traction
— Keep weights off the floor and moving freely through pulleys

Question 17

Fracture Immobilization: Cast

Answer 17

 Temporary after closed reduction
 Incorporates joints above and below fracture for stabilization during healing
 Allows patient to perform many normal ADLs while maintaining immobilization
 Two most common materials
— Plaster of Paris
— Fiberglass

Question 18

application of a cast: fracture immobilization

Answer 18

 Cover affected part with stockinette and padding
 Immerse plaster of Paris material in warm water, wrap and mold it
— Sets in 15 minutes but need 36 to 72 hours before weight bearing
— Do not cover: risk for burn and delayed drying
— No direct pressure: petal edges

Question 19

components of Synthetic casting materials

Answer 19

 Lightweight, stronger, more waterproof
 Early weight bearing
 Activated by submersion in cool or tepid water, then molded to fit body part

Question 20

Fracture Immobilization: External Fixation

Answer 20

 Metal pins and wires attached to external rods
 Applies traction, compresses fragments and immobilizes reduced fragments
 Used for complex fractures with extensive soft tissue damage, congenital bone defects, nonunion or malunion, and limb lengthening
 Attempt to save extremity that may have required amputation
 Assess for pin loosening and infection
 Patient teaching
 Pin site care
— Chlorhexidine
— One cotton swab is designated for each pin to avoid cross-contamination

Question 21

Fracture Immobilization: Internal Fixation

Answer 21

Surgical realignment of bony fragments using devices such as pins, plates, intramedullary rods, and bioabsorbable screws
 Stainless steel, vitallius, or titanium
 X-ray evaluation of alignment and healing

Question 22

drug therapy for fractures

Answer 22

 Analgesics: opioid and non-opioid
 Central and peripheral muscle relaxants
— Carisoprodol (Soma)
— Cyclobenzaprine (Flexeril)
— Methocarbamol (Robaxin)
 Tetanus and diphtheria toxoid
— Given for open fracture when immunization is unknown
 Bone-penetrating antibiotics
— Cephalosporins – prophylactically preop**

Question 23

A nurse is teaching a client how to manage an external fixation device upon discharge. Which of the following by the client indicates understanding?
a. I will clean pins more often if drainage from pin sites.
b. I will use separate cotton swab for each pin.
c. I will report loosening of the pins to my doctor.
d. I will move my leg by lifting the device in the middle.
E. I will report increased redness at the pin sites.

Answer 23

a, b, c, d, e

Question 24

nutrition therapy for optimal soft tissue and bone healing

Answer 24

 Increase protein (1 g/kg of body weight)
 Increase vitamins (B, C, D)
 Increase calcium, phosphorus , and magnesium
 Increase fluid (2000 to 3000 mL/day)
 Increase fiber
— Body jacket and hip spica cast patients: six small meals a day – avoid straining*

Question 25

nursing fracture assessments

Answer 25

 Obtain brief history of --- Traumatic episode --- Mechanism of injury --- Patient position when found  Transport to ED ASAP --- Thorough assessment --- Treatment started

Question 26

subjective data for assessment of fractures

Answer 26

 Health history  Medications  Surgery or other treatments  Functional health patterns --- Health perception–health management --- Activity–exercise --- Cognitive–perceptual

Question 27

objective data for assessment of fractures

Answer 27

 General  Cardiovascular  Musculoskeletal  Neurovascular  Skin  Possible diagnostic findings: X-ray, bone scan, CT scan, or MRI

Question 28

neurovascular assessment of fractures

Answer 28

 Musculoskeletal injuries can alter the neurovascular status of an extremity --- Especially important distal to injury  Assess and document before and after treatment --- Peripheral vascular assessment --- Peripheral neurologic assessment  Compare bilaterally

Question 29

peripheral vascular assessment

Answer 29

 Color and temperature --- Pallor and cool/cold indicates arterial insufficiency --- Warm and cyanotic indicates poor venous return  Capillary refill --- Greater than 3 sec indicates arterial insufficiency - Pulses (rate, quality; compare bilaterally) --- Decreased or absent indicates arterial insufficiency  Edema --- Pitting with severe injury

Question 30

peripheral neurologic assessment

Answer 30

 Motor function -- Upper extremities ----- Abduct fingers (ulnar nerve), oppose thumb and small finger (median nerve), flex and extend wrist (radial) -- Lower extremities ----- Dorsiflexion (peroneal nerve) , plantar flexion (tibial nerve); touch web space between great and 2nd toe; stroke plantar surface  Sensory function -- Paresthesia or paralysis ----- Numbness/tingling, hypersensation, hyperesthesia

Question 31

clinical problems from fractures

Answer 31

 Musculoskeletal problem  Risk for infection  Pain

Question 32

overall goals for fracture tx

Answer 32

 Healing with no associated complications  Satisfactory pain relief  Maximal rehabilitation potential

Question 33

acute care of those with fractures

Answer 33

 Patients with fractures can be treated in the emergency department or a physician’s office  Patients may be released home or may require hospitalization

Question 34

preoperative care for fractures

Answer 34

 Preoperative preparation  Patient teaching --- Immobilization --- Assistive devices --- Expected activity limitations --- Assure that needs will be met --- Pain medication

Question 35

postoperative care of fractures

Answer 35

 Monitor vitals  General principles of postoperative care  Frequent neurovascular assessments  Be attentive to limitations with turning, positioning, and extremity support  Minimize pain and discomfort  Monitor for bleeding or drainage --- Aseptic technique --- Blood salvage and autotransfusion

Question 36

complications of immobility

Answer 36

 Constipation  Renal calculi  Cardiopulmonary deconditioning  Monitor for VTE

Question 37

traction as treatment for fractures

Answer 37

 Inspect exposed skin  Monitor pin sites for infection --- Pin site care per policy  Proper positioning  Exercise as permitted  Psychosocial needs

Question 38

cast care of fractures

Answer 38

 Frequent neurovascular assessments  Patient and caregiver teaching --- Apply ice for 1st 24 hours --- Elevate above heart for 1st 48 hours --- Exercise joints above and below cast --- Use hair dryer on cool setting for itching  Validate understanding of cast care instructions  Follow-up phone call  Teach about cast removal and possible alterations in appearance of extremity

Question 39

dos and do nots of cast care

Answer 39

Do  Dry thoroughly after getting wet  Report increasing pain despite elevation, ice, and analgesia  Report swelling associated with pain and discoloration OR movement  Report burning or tingling under cast  Report sores or foul odor under cast Do Not  Elevate if compartment syndrome suspected  Get plaster cast wet  Remove padding  Insert objects inside cast  Bear weight for 48 hours  Cover cast with plastic for prolonged period

Question 40

ambulation for fracture care

Answer 40

 Reinforce physical therapist’s instructions  Mobility training  Instruction in use of assistive aids  Pain management prior to PT

Question 41

degrees of weight-bearing

Answer 41

 Non–weight bearing  Touch-down/toe-touch weight bearing --- Contact with floor for balance; no weight borne  Partial–weight bearing --- 25-50% of weight borne  Weight bearing as tolerated --- Based on pain  Full–weight-bearing ambulation

Question 42

assistive devices

Answer 42

 Devices: cane, walker, or crutches --- Consider stability, safety, and lifestyle --- Technique for use varies --- Use transfer belt for stability when teaching how to use assistive devices --- Discourage from reaching for support --- Upper arm strength required

Question 43

rehabilitation of fractures

Answer 43

 Short-term rehabilitation --- Transition from dependence to independence with ADLs  Long-term rehabilitation --- Prevent problems associated with MS injuries: atrophy, contractures, footdrop, pain, muscle spasms --- Also: family separation, finances, inability to work, potential disability, PTSD, and caregiver support

Question 44

complications of fractures

Answer 44

Majority heal without complication Medical emergencies needing immediate attentionrequired with  Open fractures with severe blood loss  Fractures that damage vital organs Death is usually the result of  Damage to underlying organs and vascular structures  Complications of fracture or immobility

Question 45

direct vs indirect complications of fractures

Answer 45

Direct  Bone infection  Bone nonunion or malunion  Avascular necrosis Indirect  Compartment syndrome -  VTE  Fat embolism  Rhabdomyolysis  Hypovolemic shock

Question 46

compartment syndrome and s/s

Answer 46

Increased pressure and build-up, causes tissue impairment leading to cell death! TREATMENT ∙ Place extremity at the heart level (not above heart level) ∙ Open the cast or splint Fasciotomy - Fascia is cut to relieve tension & pressure * Deep, throbbing, unrelenting pain ∙ Pain unrelieved by medications ∙ Disproportional to the injury ∙ Intensifies with passive ROM

Question 47

infection from fractures

Answer 47

 High incidence in open fractures and soft tissue injuries  Devitalized and contaminated tissue is an ideal medium for pathogens --- Clostridium tetani  Measures to prevent infection and osteomyelitis (infection of the bone) are important

Question 48

open fracture infections

Answer 48

 Aggressive surgical debridement  Wound may or may not be closed at the time of surgery  The amount of soft tissue damage determines --- Repeat debridement --- Closed suction drainage --- Skin grafting  Antibiotics: irrigation, impregnated-beads, and IV

Question 49

Avascular Necrosis (AVN)

Answer 49

 Occurs when the circulatory compromise after a fracture  Blood flow is disrupted to the fracture site and the resulting ischemia leads to tissue (bone) necrosis  Common in hip fracture or in fractures with displacement of a bone  Risk factors: long-term corticosteroid use, radiation therapy, rheumatoid arthritis, and sickle cell disease  Pain, limited movement  Treatment: bone graft, prosthetic replacement,

Question 50

compartment syndrome

Answer 50

 Swelling and increased pressure within a limited space (muscle compartment) -- Compromises neurovascular function of tissues within that space ---- 38 compartments in upper and lower extremities ---- Associated with fractures with extensive tissue damage and crush injury ---- Most common: distal humerus and proximal tibia ---- May occur after knee or leg surgery or with prolonged pressure (limb trapped under body)

Question 51

two basic causes of compartment

Answer 51

 Decreased compartment size from restrictive dressings, splints, casts, excessive traction, or premature closure of fascia  Increased compartment contents due to bleeding, inflammation, edema, or IV infiltration --- Edema causes pressure that obstructs circulation and venous occlusion leads to increased edema --- Arterial flow compromised causing ischemia and cell death, leading to loss of function

Question 52

clinical manifestations of compartment syndrome

Answer 52

 Early recognition and treatment essential to avoid irreversible damage  May occur initially with injury or may be delayed several days  Ischemia can occur within 4 to 8 hours after onset  Six Ps*** ---- Pain: out of proportion to injury; not managed by opioids; passive stretch ---- Pressure ---- Paresthesia ---- Pallor ---- Paralysis or loss of function ---- Pulselessness

Question 53

interprofessional care of compartment syndrome

Answer 53

Prompt, accurate diagnosis via regular neurovascular assessments Early signs  Notify of pain unrelieved by drugs and out of proportion to injury  Paresthesia is also an early sign  Relieving the source of pressure may prevent progression Late signs  Pulselessness  Paralysis  May require amputation

Question 54

If compartment syndrome suspected

Answer 54

Do not elevate extremity above heart Do not apply cold compresses or ice  Causes vasoconstriction and reduced circulation to already compromised extremity

Question 55

treatment of compartment syndrome

Answer 55

 Relieve pressure  Surgical decompression (fasciotomy)  Amputation

Question 56

venous thromboembolism (VTE)

Answer 56

Veins of lower extremities and pelvis highly susceptible to thrombus formation due to venous stasis from muscle inactivity: Increased risk with hip fracture, THR, or TKR  Prophylactic anticoagulant drugs for 10 to 14 days  Antiembolism stockings  Intermittent pneumatic compression devices  Exercises

Question 57

Fat Embolism Syndrome (FES)

Answer 57

 Systemic fat globules from fracture that are distributed into tissues and organs (especially lungs and brain) ---- Contributory factor in mortality  Most common with fracture of long bones, ribs, tibia, and pelvis ---- May also occur after joint replacement, burns, pancreatitis, liposuction, crush injuries, and bone marrow transplants  Mechanical theory --- Fat released from marrow and enters circulation where it can obstruct leading to local ischemia and inflammation  Biochemical theory --- Hormonal changes caused by trauma or sepsis stimulate release of fatty acids to form fat emboli

Question 58

early recognition is crucial to decrease risk of death

Answer 58

Symptoms 24 to 48 hours after injury Fat emboli in the lungs cause a hemorrhagic interstitial pneumonitis leading to ARDS  Respiratory abnormalities: chest pain, tachypnea, cyanosis, dyspnea, apprehension, tachycardia, hypoxemia  Neurological abnormalities: changes in mental status due to poor O2 exchange  Petechiae on the neck, anterior chest wall, axilla, head may help discern FES from other problems  Not all patients have petechiae  Petechiae may fade before being noticed

Question 59

clinical manifestations of FES

Answer 59

 Pallor can quickly change to cyanosis; comatose  Fat cells in blood, urine, or sputum  Decreased PaO2 to less than 60 mm Hg  Decreased platelet count, hematocrit levels  Increased ESR  ECG may show ST segment and T-wave changes  Chest x-ray may show bilateral pulmonary infiltrates

Question 60

interprofessional care FES

Answer 60

Most survive FES with few complications Management is supportive and related to symptom management  Respiratory support  O2 to treat hypoxia  ECMO or mechanical ventilation for low PaO2  Monitor for pulmonary edema and/or ARDS

Question 61

management of FES interprofessional care

Answer 61

Cardiovascular problems  IV fluids  Pulmonary vasodilators  Peripheral vasoconstrictors  Inotropic drugs No current research supporting use of steroids, heparin or dextran

Question 62

prevention of FES

Answer 62

 Careful immobilization and handling of long bone fractures  Reposition as little as possible prior to immobilization and stabilization to prevent dislodging fat droplets into circulation

Question 63

what is rhabdomylysis

Answer 63

Syndrome caused by the breakdown of damaged skeletal muscle  Releases myoglobin into circulation resulting in obstruction of renal tubules, causing Acute tubular necrosis  Assess urine output --- Dark-reddish brown urine  Assess for symptoms of AKI

Question 64

A nurse is assessing a client with a casted compound fracture of femur. which is a manifestation of fat embolus. a. AMS b. reduced bowel sounds c. swelling of the toes distal to injury d. pain with passive movement of the foot distal to injurt

Answer 64

a. AMS

Question 65

A nurse is assessing a client who had an external fixation device applied 2 hr ago for a fracture of the left tibia and fibula. Which is a manifestation of compartment syndrome. a. intense pain when client's left foot is passively moved. b. capillary refill of 3 sec on the client's left toes c. hard, swollen muscle in client left leg d. burning and tingling of the client's left foot e. client reporting of minimal pain relief following a second dose of opioid medication

Answer 65

a, c, d, e

Question 66

hip fractures and prevalence

Answer 66

Fracture of proximal (upper 1/3) of femur Common in older adults  95% due to fall >300,000 hospitalizations  37% die within a year Women  Suffer 75% of all hip fractures  Over age 65 due to osteoporosis Most caused by severe direct trauma or fall

Question 67

intracapsular hip fracture

Answer 67

occurs within hip joint capsule  Capital – head of femur  Subcapital – just below head of femur  Transcervical – femoral neck  Fragility fractures  Associated with osteoporosis and minor trauma

Question 68

extracapsular hip fractures

Answer 68

occurs outside joint capsule  Intertrochanteric – between greater and lesser trochanter  Subtrochanteric – below lesser trochanter

Question 69

clinical manifestations of hip fractures

Answer 69

 External rotation  Muscle spasm  Shortening of affected extremity  Severe pain and tenderness around fracture site  Displaced femoral neck fracture may lead to avascular necrosis of femoral head

Question 70

initial treatment of hip fractures

Answer 70

Immobilization with Buck’s traction  If medically unstable  To relieve muscle spasms (used for 24-48 hours)

Question 71

surgery for hip fracture

Answer 71

 Closed reduction with percutaneous pinning (CRPP)  Repair with internal fixation devices  Replacement of femoral head—hemiarthroplasty  THR (femur and acetabulum)

Question 72

preoperative care of total hip replacement

Answer 72

Usual preoperative nursing care  Consider co-occurring health problems (older adults) Patient teaching related to surgery  May be done in ED  Start D/C plans early due to short hospital stays Pain/muscle spasm management  Analgesics or muscle relaxants  Positioning (unless contraindicated)  Traction

Question 73

general care of total hip replacement

Answer 73

 Monitor VS, I & O  Monitor respiratory status; encourage deep breathing and coughing  Pain management  Assess dressings for bleeding  Neurovascular assessment --- Color, temperature, capillary refill, distal pulses, edema, sensation, motor function, pain  Elevate leg to reduce edema

Question 74

postoperative care of total hip replacements

Answer 74

 Maintain limb alignment with pillows when turning to nonoperative side ---- Avoid operative side unless HCP approved  Trapeze  Physical therapy (exercises, transfers, walking aids)  Ambulation (usually out of bed 1st post-op day)  Weight-bearing varies ---- Limited after ORIF until healing confirmed by x-ray (usually restricted 6 to 12 weeks)  No tub bath or driving for 4 to 6 weeks  Occupational therapist for assistive devices ---- Long-handled shoehorns, sock assists, and reachers or grabbers

Question 75

patient education dos and donts to prevent dislocations of hip

Answer 75

 Hemiarthroplasty or THR by posterior approach Do  Use elevated toilet seat and chair  Remain seated on chair in shower or tub  Keep hip in neutral, straight position when sitting, walking or lying  Notify surgeon immediately if severe pain, deformity, or loss of function occurs  Discuss risk of infection related to prosthetic joint with dentist or surgeon Do Not  Flex hip greater than 90 degrees  Adduct hip  Internally rotate hip  Cross legs at knees or ankles  Put on own shoes without adaptive device for 4 to 6 weeks  Sit on chairs without arms  Fewer precautions  Avoid hyperextension

Question 76

Complications of femoral neck fractures

Answer 76

Nonunion, avascular necrosis, dislocation, osteoarthritis, shorter leg Dislocation: sudden, severe pain, lump in buttock, limb shortening, and external rotation  Keep patient NPO in anticipation of surgery  Closed reduction with sedation  Open reduction under general anesthesia Psychosocial support Resources, community services for rehabilitation after hospital discharge

Question 77

ambulatory care for total hip replacements

Answer 77

Discharge considerations  Subacute rehabilitation or acute rehabilitation (if live alone)  Home health care with PT Home care  Pain management, monitor for infection, prevent VTE  Patient teaching: bleeding precautions with anticoagulant  Exercises with PT  Home safety to prevent falls  Calcium and vitamin D supplementation: patients with osteopenia or osteoporosis