Musculoskeletal Trauma

Fractures
Concepts

The priority concepts for this chapter are

Mobility Perfusion

The interrelated concepts in this chapter are

Sensory
Tissue integrity Comfort Clotting
Perception
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Fracture:
Pathophysiology
• Break/and or disruption in the continuity of the bone
• Causes
• Trauma [most common]
• Pathology
• Metastatic CA, osteoporosis, Paget’s disease
Classification: Extent of
Break
• Complete
• Break across entire bone dividing into 2
distinct parts
• Displaced
• Bone fragments are not in alignment
• More likely to damage surrounding
nerves, vessel, soft tissues
• Incomplete
• Goes through only part of the bone; not typically
displaced
Classification: Extent of
Associated Soft-tissue
Damage
• Open [compound]
• Disrupts skin integrity; open wound &
tissue injury
• Infection risk
• Graded on extend of injury
• Grade I
• Grade II
• Grade III
• Closed [simple]
• Does not disrupt skin integrity; no visible
wound
Classification of Fractures:
Cause
• Fragility
• Pathologic [spontaneous]: result of
minimal trauma to weak bone due
to disease
• Fatigue [stress]
• Excessive strain & stress on bone
• Compression
• Loading force pressing on long axis
of callus bone i.e. vertebrae of older
patient w/osteoporosis
• Very painful
Common Types of Fractures
 Buckle Fracture
(Torus)
• Unique type of fracture that most often
occurs in children
• Compression fracture on one side of a bone
that causes the bone to bend or buckle
toward the damaged side
• Characterized by bulging of the cortex
• Result from trabecular compression from
an axial loading force along the long axis
of the bone
Stages of Bone Healing

• Stage one [24-72 h]: hematoma forms @ site

• Stage two [3 days-2 weeks]: granulation
invades hematoma; replaced by fibrocartilage
tissue [callus]
• Stage three [within 3-6 weeks]: new vascular
tissue/bone matrix
• Stage four [3-8 weeks]: callus reabsorbed &
transformed to bone
• Stage five [start as early as 4-6 weeks post &
up to 1 year]: consolidation & remodeling of
bone

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 Risk Factors
• Osteoporosis
• Falls
• MVA
• Substance use
• Diseases
• Contact sports, hazardous activities
• Physical abuse
• Lactose intolerance
• Age: bone less dense
 • Teach about
• Osteoporosis screening
Health • Fall prevention
Promotion and • Home safety
• Dangers of drinking and driving
Maintenance • Use of helmets & seat belts
• Increase Ca & Vit D intake
• Exposure to sunlight
• Weight-bearing exercises
• Bisphosphonate if indicated

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Manifestation
• PAIN [severe] & tenderness
• Deformity: internal or external rotation;
dislocation; exposed bone [open]
• Extremity shortening [due to muscle spasms]
• Unnatural movement
• Edema, Swelling
• Ecchymosis, discoloration from bleeding
• Subcutaneous emphysema [bubbles under
skin from air trapping]
• Crepitus
 13

Assessment:
Noticing
• History
• Take after patient has been made comfortable.
• Determine type of injury.
• Ask about events leading to injury.
• Obtain drug use and alcohol consumption
history.
• Medical history
• Ask about occupational and recreational
activities.
Assessment: Noticing
• Physical Assessment
• Assess all body systems for life-
threatening complications
• Check urine for blood [pelvic fx]
• Assess for swelling, perfusion, skin
integrity

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 Physical Assessment
• Vertebral compression: very painful
• Hip fx: Groin pain or referred pain to back of knee or lower back
• Shoulder, upper arm
• Assess in sitting or standing position [best done]
• Support affected area & flex elbow to promote comfort
• Distal areas of arm: do assessment w/pt. supine position so extremity can be
elevated to reduce swelling
• Assessment of leg & pelvic: supine position
 ALERT
• Rib Fx
• Monitor respiratory
status
• Assess pain level, manage
pain before continuing
w/PA
 17

Diagnostic
Assessment
• Laboratory assessment
• Hemoglobin, hematocrit
• ESR, WBC
• Serum calcium, and phosphorus
• Imaging assessment
• x-rays
• CT for complex fractures (e.g., hip,
pelvis, compression fractures of
spine)
• MRI (soft tissue damage)
 Complications of
Fractures
• SHOCK: Hemorrhagic & hypovolemic
• Esp. pelvic & long bone fx & crushing injury
• FAT EMBOLUS: fat globules
• Types of fx: Long bones [________], _______,
_______injury
• High risk population: young men; older adults
• Manifestations
• Earliest: Low arterial O2 [Hypoxemia], dyspnea,
tachypnea
• Petechiae or rash: chest, neck, upper arms
• Conjunctival hemorrhages
• Labs: ABG: Low PaO2 [<60], ESR: H; Ca, RBC, PLT: L; Lipids:
H
• Imaging: CXR: “Snow” storm, CT, MRI
 Bedrest Immobilization

Nursing
Minimal O2, IVF &
manipulation/handling vasopressors,
on turning Corticosteroids,

Pain management prn Anti-anxiety meds prn

Compartment Syndrome

• Increased _________within one or more

compartments, reducing circulation to area
[Limited space]
• Most common areas: Compartment lower
leg [tibial, forearm fx]:, quadriceps, forearm
• Patho: Accumulation of fluid in tissue
thereby impairing tissue perfusion; muscles
= hard & swollen
• PAIN: GREATER THAN EXPECTED FOR
NATURE OF INJURY [DISPROPROTIONATE]
• Untreated: cyanosis, tingling, numbness,
paresis [nerve damage], motor weakness,
infection from necrosis [amputation]
Volkmann’s Contracture of Forearm
 • If casted: _________:
restore: ___________
Compartment
Syndrome: • Fasciotomy: cutdown into
Treatment tissue to relieve:
_________ & restore
__________
Nursing
• Nsg Action
• ASSESS NV STATUS FREQUENTLY
• NOTIFY PROVIDER when CS is suspected
• Provider will bivalve the cast
• Loosen constrictive dsg or cut bandage
• Instruct to report pain NOT relieved by analgesics or
increasing intensity
• Remind to report numbness, tingling or change in
color of extremity
 Venous Thromboembolism [VTE]
•DVT & PE
•Thrombus embolus lungs
•Virchow’s triad predispose to thrombus formation
•Hypercoagulability
•Stasis
•Endothelial damage
•Findings
•Asymmetric leg/calf swelling
•Pain, erythema
•Dilated superficial veins (non-varicose)
•TX/Nsg
•Medications:
•Thrombin Inhibitors Anticoagulation: Heparin, LMWH, dabigatran,
•Factor Xa inhibitors: rivaroxaban, fondaparinux,
•Vitamin K- antagonist: Warfarin
•Thrombolytics: tPA

•Encourage early ambulation

•Position changes q2h, flex & extend feet, knees, hips: prevent stasis q2-4 h
•Walking: 4-6x times per day
•Anti-embolic stockings, SCD
•Fluids
•Monitor for swollen, red calf
•Encourage ambulation
 • Circulatory compromised post-fx
• Disruption of blood flow--- decreased
Perfusion = ischemia = bone tissue
death [necrosis]
• Most common: hip fx or fx w/bone
displacement
• Risk factors
• long-term corticosteroid use,
radiation therapy, surgical repair
or fx
• rheumatoid arthritis, and sickle
cell disease.
• Replacement of damaged bone with a
bone graft or prosthetic replacement

Avascular necrosis
can be necessary
Failure Fx to Heal

• Fx that has not healed within 6 months of injury

experiencs delayed union
• Malunion: Fracture heals incorrectly
• Nonunion: Fracture that never heals
• Can cause immobilizing deformity of the bone
involved
• Non-healing of bone = chronic bone & impaired
mobility from deformity
 • Wound infection
Infection
• Implanted hardware
• Osteomyelitis [bone infection]-open fx
 Management
• Immobilization to secure injured
extremity
• Supporting fx
• Limited movement of extremity
• Splinting: prevent muscle spasms &
fat embolus
• Open: cover with sterile covering
• Neurovascular checks: pulses, color,
movement, sensation, capillary
refill, temperature
Emergency Care: Fx
• Call 911
• Manage pain: IV opioids: fentanyl,
• Assess: ABC’s, quick head to toe assessment hydromorphone, morphine sulfate
• Life-saving measures if needed • Cardiac monitoring before drug
• CPR if needed: circulation airway, breathing administration esp age > 50
• Remove clothing [cut if needed] to inspect while • Bone reduction/realignment as
supporting area above & below injury needed & determined by provider
• Remove jewelry in case of swelling
• Apply direct pressure if bleeding & pressure over proximal
artery nearest fx
• Keep warm & place in supine position to prevent shock
• Check neurovascular status of area distal to fx
• Immobilize extremity by splinting, include joints above and
below fx site. Recheck circulation post splinting
• Cover any open areas with a sterile dsg preferably
Casts
• Fiberglass Cast: preferred
• Quick drying [30 minutes]
• Waterproof, lightweight,
stronger
• Available in varied colors
• Enables early weight-bearing
Casts
• Plaster of Paris [traditional]
• Longer to dry [24-72 h]
• Feels hot on application-generates heat- keep
uncovered—allows for drying by air
• Decrease edema: ice packs on sides 1st 24 h: cast
still wet; do not place on top---indentation lead to
pressure sore under cast
• Handling: Use _____________: 1st 24-72 h
• Do not use ________: will cause _________
• Place extremity to rest on soft pillow [decrease
edema]
• Note & mark breakthrough bleeding
• Keep cast clean & dry
• NEUROVASCULAR CHECKS: 5 P’s
• Pt reports pain: 1st do what?
_____________________
• Pain medication if NV check is ok, ice pack,
elevation
• Do not put cast to rest on hard surface or sharp edge
Other types of casts
Cast Care
Use Too tight: use cast cutter to bivalve cast: relieve pressure

Elevate Casted arm: elevate arm above heart: reduce swelling

Support Support extremity with sling

Leg Leg cast: crutches or a walker; teach to elevate on several pillows; apply ice 1st 24 h or as indicated

Inspect Inspect cast q8-12h for drainage, alignment and fit

Report Report immediately any sudden increases in amt. of drainage or change in integrity of cast
Infection

Teach patient to report very Teach to smell cast for

painful “hot spot” under cast unpleasant odor, fever

Teach patient to teach for

Teach NEVER to stick anything
circulation: movement of area
inside case: hanger or pencil to
distal to extremity, numbness,
scratch an itch: skin damage
and increased pain
Traction
• Uses a pulling force to promote, _____________,
{________________]& immobilization of the injured area
• Goal: Reduce muscle spasms & pain, & realign bones &
prevent soft tissue injury/fx; correct or prevent further
deformities
• Straight or running: The counter traction is provided by
the client’s body by applying a pulling force in a straight
line. Movement of the client’s body can alter the traction
provided
• Balanced suspension: The counter traction is produced
by devices (slings or splints) to support the fractured
extremity off the bed while pulling with ropes and
weights. The client’s body can move without altering the
traction
Traction

• Need provider order to release

• Use of weights: must hang _______: Do not let touch or rest on floor
• Patient should be pulled up in bed, centered w/good alignment
• Non-immobilized joints: exercise
• Ropes: move freely
• Secure knots
• Avoid foot drop: boot or high-top sneaker
Types of Traction: Skin

Primary purpose: decrease/relieve

________spasms & immobilize before surgery
Pulling force applied by weight [5-10 ;b] attached
to rope to skin w/tape, strap, splint, boot
No penetration of skin
Most common: Buck’s traction: preop use for hip
fx: immobilization & reduce muscle spasms
[primary purpose]; also for femur fx
Perform skin assessment: ankles, Achilles
Types of Traction: Skeletal
• Screws are inserted into the bone
• Must be continuous
• Direct application to bone with _______ and _______
• Allows for prolonged traction
• Aids in bone realignment; impairs mobility of patient
• Monitor for impaired tissue integrity: use pressure reduction
measures
Types

• Halo traction [vest[

• Crutchfield
• Gardner-Wells tongs
• Steinman pin
Nursing
• Monitor for impaired tissue integrity: use pressure reduction
measures
• IMPORTANT: MONITORING PIN SITES EVERY 8 HOURS:
INFLAMMATION, DRAINAGE; SIGNS OF INFECTION-FOLLOW AGENCY
PROTOCOLPIN CARE DAILY: PREVENT INFECTION [Under sterile
technique]
• Assess neurovascular status of the affected body part every hour for
24 hr and every 4 hr after that.
• Maintain body alignment and realign if the client seems
uncomfortable or reports pain
Nursing
Notify Move Monitor

Notify the Move the Routinely

provider if client in halo monitor skin
severe pain integrity and
from muscle traction as a document
spasms unit, without
unrelieved with applying
medications or
repositioning.
pressure to
the rods.
• will
prevent
loosening
of the pins
and pain.
 External Fixation
• fracture immobilization using percutaneous pins
and wires that are attached to a rigid external
• DISADVANTAGES
frame
• USED TO TREAT ● Comminuted fracture or
• Risk of pin site infection leading
nonunion fractures with extensive soft tissue to osteomyelitis
damage ● Leg length discrepancies from congenital
defects ● Bone loss related to tumors or
osteomyelitis
• Potential overwhelming
• ADVANTAGES appearance to client
• Immediate fracture stabilization
• Minimal blood loss occurring in
• Noncompliance issues
comparison with internal fixation
• Allowing for early mobilization and
ambulation
• Maintaining alignment of closed
fractures that could not be maintained
in cast or splint
• Permitting wound care with open
fractures
Nursing
• Elevate extremity.
• Monitor neurovascular status and skin integrity.
• Assess body image.
• Perform pin care every 8 to 12 hr. Monitor site for
• drainage, color, odor, and redness. Expect weeping or
• drainage of clear fluid for the first 48 to 72 hr.
• Observe for manifestations of fat and
• pulmonary embolism.
• Provide anti-embolism stockings and sequential
• compression device to prevent deep-vein
• thrombosis (DVT).
 • Visualization of a fracture
through an incision in the
skin, and internal fixation
with plates, screws, pins,
rods, and prosthetics as
needed
• Permits early mobility
• Preop
• Teach what to expect
during & post
• General preop teaching
• General or epidural
anesthesia teaching

Surgical: OPEN REDUCTION • Medical clearances

• Pre-op labs
INTERNAL FIXATION [ORIF]
 • Routine general post-op care
• Neurovascular assessment: be aware of ACS
• Meds: IV ketorolac
• Aggressive pain mgmt.
• Nonpharmacologic mgt.
• Skin assessment, monitor for infection, complications
• Nutritional support
ORIF: POST-OP • External fixator: Pin sites for signs inflammation or
infection
• Monitor pin sites q8-12h: drainage, color, odor, severe
redness
• Teach about alterations in dressing while fixator in
place
• Encourage expression of feelings: body-image
disturbance
• Pain control is a priority outcome
 • Use aseptic technique for
dressing changes and wound
irrigation.
• Monitor vital signs. Preventing
• Notify provider immediately if
inflammation, purulent drainage Infection
46
is noted.
• Monitor vs
• Patient may need antibiotics, VAC
system.
 Increasing Mobility
Promoting mobility
Promoting
• Physical and/or occupational
therapy

Preventing complications of impaired mobility

• See Chapters 2 and 6.
• Monitor orthostatic blood pressure out of bed for the 1st
Preventing time
• ◯ Turn and reposition the client every 2 hr.
• ◯ Have the client get out of bed from the unaffected side.
• ◯ Position the client for comfort (within restrictions)

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