Nursing 110 Fractures and Traction

Fractures

Disruption or break in the continuity of the structure of bone.
Majority of fractures from traumatic injuries
Some fractures secondary to disease process
Cancer or osteoporosis

Classification of Fractures

Open or closed
Complete or incomplete
Based on direction of fracture line
Displaced or nondisplaced

Open or Closed Fractures

Depends on communication or noncommunication with external environment
Open�skin broken and bone and soft tissue exposed
Closed�skin intact

Complete or Incomplete Fractures

Complete�break is completely through bone
Incomplete�bone is still in one piece but break occurs across the bone shaft

Classification of Direction of Fractures

Linear
Oblique - diagonally across the shaft of the bone.
Transverse - perpendicular to the shaft of the bone.
Longitudinal
Spiral

Displaced or Nondisplaced Fractures

Displaced�two ends separated from one another
Nondisplaced�bone is aligned and periosteum is intact

Signs and symptoms of a Fracture

Mechanism of injury associated with numerous signs and symptoms
Immediate localized pain
Decreased function
Inability to bear weight on or use affected part
Patient guards and protects extremity.

Nursing Considerations of a Fracture

Fracture may not be accompanied by obvious bone deformity.
Immobilize extremity if fracture is suspected.
Unnecessary movement
Increases soft tissue damage
May convert a closed fracture to open

Stages of Fracture Healing

Fracture hematoma
Granulation tissue
Callus formation
Ossification
Consolidation
Remodeling

Fracture Healing: Fracture Hematoma

Initial 72 hours
Bleeding creates a hematoma, surrounding ends of fragments.
Hematoma is extravasated blood that changes from liquid to semisolid clot.

Fracture Healing: Granulation Tissue

3 to 14 days post injury
Active phagocytosis absorbs products of local necrosis.
Hematoma converts to granulation tissue.
Granulation tissue produces basis for new bone substance (osteoid).

Fracture Healing: Callus Formation

End of second week
Minerals and new bone matrix are deposited in osteoid.
Unorganized bone network is formed and woven around fracture parts.
Callus is composed primarily of cartilage, osteoblasts, calcium, and phosphorus.

Fracture Healing: Consolidation

As callus continues to develop, distance between bone fragments diminishes and eventually closes.
Ossification continues.
Can be equated with radiologic union

Fracture Healing: Remodeling

Up to a year after injury
Excess bone tissue is reabsorbed.
Union is complete.
Gradual return to preinjury structural strength and shape occurs.
Bone remodels in response to physical loading stress.

Factors Influencing Fracture Healing

Age
Initial displacement
Site of fracture
Implants
Infection
Blood supply to area
Hormones

Delayed Union of Fracture Healing

Does not occur in the expected time.

Nounion of Fracture Healing

The fracture doesn't heal at all.

Electrical stimulation and pulsed electromagnetic fields (PEMFs)

Stimulate bone healing
Electric currents modify cell mechanisms, causing bone remodeling.
Electrodes are placed over skin or cast and are used 10 to 12 hours each day.

Rib Fractures Nursing Considerations

Increased risk of Pneumothorax.
Treated with Pain Medication

Pelvic Fractures Nursing Considerations

Digestive and reproductive organs are located within the pelvic ring.
Large nerves and blood vessels that go to the legs pass through it.
Pelvic fracture can be associated with substantial bleeding, nerve injury, and internal organ damage.
Stable fracture

Femoral Neck Fracture Nursing Considerations

Requires much force
Often very displaced due to muscle contraction
Increase risk of fat embolism

Colles' Fracture

Fracture of distal radius. Usually occurs when attempting to break a fall.

Fracture Treatment

Assess NV, vital signs
Elevate, apply ice
Pain, medicate
May need assistive devices in bed
Prevent DVT/ Blood clots
Cast application and care
Assist with traction application and cont to assess, provide pin care
Skin vs skeletal traction

Overall Goals of Fracture Treatment

Anatomic realignment of bone fragments
Immobilization to maintain realignment
Restoration of normal or near-normal function of injured parts

Fracture Reduction: Closed Reduction

Nonsurgical, manual realignment of bone fragments to previous anatomic position
Traction and countertraction manually applied to bone fragments to restore position, length, and alignment

Fracture Reduction: Open Reduction

Correction of bone alignment through surgical incision
Includes internal fixation with use of wires, screws, pins, plates, intramedullary rods, or nails
Chief disadvantages
Possibility of infection
Complications associated with anesthesia
Effects of preex

Fraction Care: Traction

Application of a pulling force to an injured or diseased part of body or extremity, while countertraction pulls in opposite direction

Purpose of Traction

Prevent or decrease muscle spasm.
Immobilize joint or part of body.
Decrease a fracture or dislocation.
Treat a pathologic joint condition.
Provide immobilization to prevent soft tissue damage
Reduce muscle spasm associated with low back pain or cervical

Two Most Common Types of Traction

Skin Traction
Skeletal Traction

Skin Traction

Used for short-term treatment until skeletal traction or surgery is possible
Tape, boots, or splints applied directly to skin to maintain alignment, assist in reduction, and help diminish muscle spasms in injured extremity
Traction weights 5 to 10 pounds

Skeletal Traction

In place for longer periods
Used to align injured bones and joints or to treat joint contractures and congenital hip dysplasia
Provides a long-term pull that keeps injured bones and joints aligned
Physician inserts pin or wire into bone, either partially

Buck's Traction

When traction is used, forces are usually exerted on distal fragment to obtain alignment with proximal fragment.
This is when they use the boot.
Most commonly used for fractures of the hip and femur.

Nursing Consideration for Traction

Assess NV status
Ropes and weights should be free hanging
No knots to prevent traction in pulley
Weights correct
Skin surface checks for breakdown or pressure
Pain medication
Provide for ADLS/ get a trapeze bar
Prevent blood clots/pnemonia

Consideratioins for Traction

Fracture alignment depends on correct positioning and alignment while traction forces remain constant.
Forces must be pulling in opposite direction to prevent patient from sliding to end or side of bed.
Countertraction commonly supplied by patient's body

Nursing Management of Traction

Nurse should inspect exposed skin regularly when slings are used with traction.
Pressure over bony prominence created by wrinkling sheets or bedclothes may cause pressure necrosis.
Persistent skin pressure may impair blood flow and cause injury to periphe

Direct Complications of Fractures

Problems with bone infection
Bone union
Avascular necrosis

Indirect Complications of Fractures

Blood vessels and nerve damage
Compartment syndrome
Deep vein thrombosis
Fat embolism
Traumatic or hypovolemic shock

Infections of Fractures

High incidence in open fractures and soft tissue injuries
Massive or blunt soft tissue injury often has more serious consequences than fracture.
Devitalized and contaminated tissue is an ideal medium for pathogens.
Treatment is costly in terms of
Extended

Compartment Syndrome

Decreased sensation of the involved nerves.
Pain increases with passively stretching the involved muscles.
Tense extremity swelling.
Early Symptoms: Pain - severe, constant pain out of proportion of severity of injury. Pressure - pain on palpation. Parest

Fat Embolism (FES)

Presence of systemic fat globules from fracture that are distributed into tissues and organs after a traumatic skeletal injury
Contributory factor in many deaths associated with fracture
Fractures most often causing FES are those of long bones, ribs, tibi

Signs and Symptoms of FES

irritability, rest-lessness, tachypnea, tachycardia, changes in mental status, diffuse crackles (a late finding), dyspnea, hypoxia, fever, and petechiae in a vest distribution.

Nursing Intervention of FES

HOB up High
Apply O2
Chest Xray
Get Arterial Blood Gas

Clinical Manifestation of FES

Early recognition crucial in preventing potentially lethal course
Most patients manifest symptoms 24 to 48 hours after injury.
Fat globules transported to lungs cause a hemorrhagic interstitial pneumonitis.
Clinical course of fat embolus may be rapid and