Fractures, Casts & Traction
Nursing 267
Spring 2003
Fracture – break in continuity of bone
•
Greenstick
•
Transverse
•
Oblique
•
Spiral
•
Comminuted
•
Pathological
•
Fatigue
•
Also Classified as
– Complete
– Incomplete
– Simple
– Compound (open)
Incidence
•
risk if disease affecting
locomotion
< 45 yrs more in males
> 45 yrs more in females
•
Elderly
have greatest risk
Stages of Bone Healing
•
Break
•
Hematoma -
time of Fx- fibrin network
•
Granulation – 1st week after
Fx – fibroblasts colonize & bridge
•
Callus Formation – 2nd week after Fx – fibroblasts à
osteoblasts àcement
•
Ossification
– 2-3weeks after Fx à till healed … ? 2-3 months
•
Union – callus calcified
Healing varies – ? damage, condition, area of Fx & age
of Patient
•
Humerus 10-12 weeks
•
Forearm 8-10 weeks
•
Femur 6 months
•
Lower
leg 3 months
•
Spine 6-12 months
Consolidation ½ in 6 yo than 60 yo
Signs & Symptoms of Fx
•
Pain …………………...
•
Loss
Function………….
•
Swelling/edema……….
•
Ecchymosis…………...
•
Deformity……………...
•
Crepitus
•
Hemorrhage
•
Nerve/Tissue
damage
•
Shock
•
Occurs
sprains & strains
•
Contracted
muscles à shortening
•
Physiologic
Splinting
Field Management of Fx
•
Assess
•
Turn
off equipment
•
Cover
open wounds
•
“
Splint them where they lie”
•
Handle
gently
•
Elevate
affected extremity
•
Neurovascular
Ö’s
E R Mgt of Fx
•
Assess
•
Elevate
•
Monitor
vitals
•
Pain
control
•
Tetanus
•
X-Ray
•
Treatment
Neurovascular Assessment
•
5 P’s
•
PAIN
•
PULSE
•
PALLOR
•
PARESTHESIA
•
PARALYSIS
Neurovascular Assessment
• Circulatory
–
Coldness
–
Blanching
–
Cyanosis
–
Pulse
change
• Neuro
–
Tingling
–
Numbness
–
burning
•
Document
symptoms
•
Temporary
Splints - don’t remove w/o order
•
Observe
frequently for change
–
color,
sensation, temp, pulse, etc……MD
•
VS
q15 m
– shock P & R , B/P & T ¯…………….MD
•
Head
injury r/o …pain med
•
Tetanus
toxoid
Complications of Fxs
•
Shock
& Hemorrhage
•
Fat
embolism
•
Thromboembolism
•
Infection
•
Delayed
complications
–
Delayed
union
–
Nonunion
–
Avascular
Necrosis
–
Ischemic
paralysis or contractures
–
Compartment
Syndrome
–
Osteomyelitis
Complications of Fx
•
Shock & Hemorrhage - 1st 24 hr
–
???
FATAL
–
Cold,
clammy, agitated
– P & R , B/P & T ¯
–
Treat
Promptly!!!
–
Bone...
vascular
–
Avg
blood loss Closed Fx….800-1200mL
–
Approx.
1” swelling / liter hemorrhage
Fat embolism- usually 48 hr after Fracture
•
Fat
clumps in pulmonary capillaries ®
–
leakage
& CNS dysfunction
– S & S Classic Signs
•
dyspnea, R, hypoxemia (O2 ¯,PCO2 )
•
crackles,
wheezes, Sudden Chest Pain
•
diaphoresis,
pallor & pt collapse
–
CNS manifests as :
•
impending doom -
anxiety
•
mental changes
•
Systemic Emboli -
–
CLASSIC SIGNS :
•
petechial
hemorrhage
–skin, conjunctival, buccal membrane,
hard palate, retina, chest & axillary fold
–
Be
alert, esp.
•
multiple Fx
•
Fx long bones
•
Fx Pelvis
–
Who
ya gonna call????
Treatment of Fat Embolism
•
HOB
•
Call
MD
• Adm. O2
•
Keep
pt calm
•
ABG’s
as ordered
•
ET
ready to insert
•
Someone
stay with pt !!!
Delayed Union
•
Not
healed in usual time
–
Causes:
•
Activity
•
Infection –
bone/surrounding
•
Poor
immobilization
•
Defective
metabolism PRO, vit C,B & D
–
Treatment
•
Temporary àcomplete immobilization
•
Electrical
stimulation
•
? surgery
Nonunion
•
Ends
don’t unite
•
Causes
–
Same
as for delayed union
•
Treatment
–
Same
Avascular Necrosis of bone
•
Bone loses blood supply
–
Usually HIP
–
Treatment –
•
Brace
indefinitely
•
Crutches
•
Bone Graft
Ischemic Paralysis –
Compartment Syndrome
•
Upper
Extremity
–
Volkman’s
Ischemic Contracture (claw hand)
•
Lower
Extremity
–
Anterior
Tibial Compartment Syndrome
•
Cause-
trauma/pressure à injury/spasm to artery…..not just
fx
• S & S…. 5 P’s - neurovascular Ö
• Notify MD immediately
•
Teach
pt S & S
•
Treat-
remove problem
Osteomyelitis
•
Infection
in bone- can harbor years
–
Long
bones – children
–
Vertebrae
– adults
•
Direct
entry – open fx or surg
•
Indirect
– blood-borne distant site
•
Inflammation
– pain, purulent drainage, edema
•
Strict
asepsis – hard to treat, sterile dressing
•
Treat
– rest, antibiotics, surg- bone scraping
Objectives of Fracture Treatment
•
Reduction
- realignment
•
Immobilization
– til healed
•
Rehabilitation
– Types of Reduction
•
Closed
•
Traction
•
Open
•
Closed reduction – manipulation, MD reduces fx by pulling, pieces fall in place, cast or
splint applied
•
Traction –
force applied in 2 directions
–
Regain
alignment
–
Reduce
& immobilize
–
¯ or eliminate edema
•
Skin
•
Skeletal
• Skin & Skeletal
(Balanced Suspension)
Cast Application
•
Cover
floor
•
Stockinette
over affected part
•
Sheet
wadding next
•
Submerge
1 roll cast material in water
•
When
bubbling stops, squeeze excess
•
Hand
to MD, /w edge rolled out
•
Observe
for neurovascular problems
•
Handle
/w palms only
•
AIR
DRY ONLY
•
Support
on pillows – never cover til dry
Principles of Cast Care
•
casted part as much as possible
•
Ice
bag – 1st 24 hr, check q2h
•
Remove
rough edges – petals
• Neurovascular Ö
– Color, temp, motion, sensation, etc
–
Q1h
x 3, q2h x 48h, q4h
•
Call
MD if
–
in pallor, tingling, numbness,
burning or pain
•
Check
for Odor
•
Never
disregard continued c/o pain
•
Clean
/w damp cloth & dry cleanser
Types of Traction pg 1773-5
•
Buck’s
Traction Skin traction, hip, femur, knee, back.. immobilize fx & relieve
spasm & pain
•
Pelvic
Traction Skin traction, pelvis separation, barely off bed.. Iliac crest
•
Russell’s
Skin traction, femur & hip, pressure hamstring @ popliteal
•
Bryant’s
Traction Skin traction,femur in sm children, hip joints in under 2 yo &
under 30 lbs, buttocks just clear bed
•
Balanced
suspension traction Skeletal tx, femur shaft, acetabulum, tibia or combo
•
Head
Halter Skin traction,
Casts
•
Sugar
tong
• Plaster of Paris padded allows
for swelling
• Short arm stable fx, full movement elbow
• Long arm fx forearm or unstable
wrist
•
Short
leg
•
Long
leg
Casts cont
• Body jacket stable T/L spine
injuries, obs for cast syndrome N V
P… “window”
• Spica cast is 2 casts, body &
long leg
• Single hip spica femoral fx esp
children… be careful what you give them to play with!!
•
Double
hip spica
• Other External fixators metal
pins inserted into bone & attached to ext rods…watch for exudate, also for
lenghening
Congenital
•
Club Foot
– Talipes varus bending inward
– Talipes valgus bending outward
– Talipes calcaneus dorsiflexion, toes higher than heel
– Talipes equinovarus (TEV) plantar
flexion, toes lower than heels (most
common)
– (1) correct deformity (2) maint til normal muscle balance (3) follow up
– Early treatment is best, will
require freq changes
• Metatarsus Adductus (varus)
pigeon-toed
– Abnormal intrauterine positioning
Metatarsus Adductus (Varus)
•
Most
common
•
Abnormal
intrauterine position
•
Heel
& ankle remain neutral
•
Treatment
–
Gentle
stretching
–
6
weeks
–
Orthopaedic
therapy
–
casts/
Developmental Dysplasia of Hip (DDH)
•
10
per 1000 live births
•
There
are 3 degrees
–
Acetabular
dysplasia (preluxation)
–
Sublimation (most common)
–
Dislocation
– femoral head looses contact /w acetabulum
•
S&S
–
Asymmerty
of gluteal & thigh folds
–
Ltd
hip abduction, shortening of femur
–
Ortolani
click ( under 4 wks)
–
Trendelenburg
sign
Trendelenburg sign
•
Child
stands on normal leg then shifts to affected & pelvis will tilt downward.
•
Instead
of upward which is normal
•
Nurses
are in the excellent position to detect this, why?
–
TREATMENT
•
NB
– 6mo - Pavlik Harness, ? Spica cast
•
6mo-18mo
– stand & walk, traction Þcast
•
Older
- ? Surgery, hard > 4yrs
Osteogenesis Imperfecta (OI)
•
Inherited,
connective tissue
•
Excessively
fragile bones
•
Supportive
•
Careful
handling
•
Puberty
helps ….why?
•
Skeletal
Limb Deficiency
–
Amelia
–
Meromelia
–
phocomelia
Kyphosis
•
Ý convex angle thoracic spine
–
TB,
chronic arthritis, comp. fx T spine
–
Skeletal
growth
–
Has
compensatory lordosis (concave lumbar)
–
Exercises
to strengthen
•
Weight lifting
–bench
•
Dance
•
Swimming
•
Lordosis
cervical or lumbar curve
Obesity
Pain
Treat
cause
Scoliosis
• Spinal deformity
–
Lateral
curvature
–
Spinal
rotation
–
Thoracic
hypokyphosis
• Growth spurt
• R/O causes
• Treatment
–
Depends
on severity
•
Goal – well
balanced torso
•
Adolescent body image - fragile