Interventions for clients with musculoskeletal trauma
Musculoskeletal injury is one of the primary causes of disability in the
FRACTURES
I OVERVIEW
A fracture is a break or disruption in the continuity of a bone. Fractures can occur anywhere in the body and at any age. All fractures have the same basic pathophysiologic mechanism and nursing management, regardless of fracture type or location.
1 Pathophysiology
K CLASSIFICATION OF FRACTURES
A fracture is classified by the extent of the break as follows: Complete fracture. The break is across the entire width of the bone in such a way that the bone is divided into two distinct sections.
Incomplete fracture. The fracture does not divide the bone into two portions, because the break is through only part of the bone.
A fracture is described by the extent of associated soft-tissue damage as open (or compound) or closed (or simple). The skin surface over the broken bone is disrupted in a compound fracture, which causes an external wound. These fractures are often graded to define the extent of tissue damage. Grade I is the least severe injury, and skin damage is minimal. In grade II, an open fracture is accompanied by skin and muscle contusions. The most severe injury is grade III, in which there is damage to skin, muscle, nerve tissue, and blood vessels; the wound is more than 2.4 to
Figure 52-1 illustrates common types of fractures. The nurse needs to be familiar with the differences in these types because they often dictate the specific nursing care required for the client.
In addition to being identified by type, fractures are characterized by their cause. A pathologic (spontaneous) fracture occurs after minimal trauma to a bone that has been weakened by disease. For example, a client with bone cancer or osteoporosis can easily sustain a pathologic fracture. A fatigue or stress fracture results from excessive strain and stress on the bone. Compression fractures are produced by a loading force applied to the long axis of cancellous bone. They commonly occur in the vertebrae of clients with osteoporosis.
K STAGES OF BONE HEALING
When a bone is broken, the body immediately begins the healing process to repair the injury and restore the body’s equilibrium. Within 48 to 72 hours after the injury, a hematoma forms at the site of the fracture because bone is extremely vascular. Blood supply to and within the bone usually diminishes because of the injury, which causes an area of bone necrosis. The dead cells prompt migration of fibroblasts and osteoblasts to the fracture site as part of the inflammatory process. This prompts the formation of fibrocartilage, providing the foundation for bone healing (within 3 days to 2 weeks).
As a result of vascular and cellular proliferation, the fracture site is surrounded by new vascular tissue known as a callus (within 2 to 6 weeks). Callus formation is the beginning of a nonbony union. As healing continues, the callus is transformed from a loose, fibrous tissue into bone (within 3 weeks to 6 months). Excess callus is resorbed. During the final phase of healing, consolidation, and remodeling, bone continues to be resorbed and deposited in response to stress, reshaping to meet mechanical demands. This process may start as early as 6 weeks after fracture and can continue for up to 1 year. Figure 52-2 summarizes the stages of bone healing.
In young, healthy adult bone, healing takes about 6 weeks. In the older person who has reduced bone mass, healing time is lengthened; complete healing often takes 3 to 6 months. Other factors that affect healing include the severity of the trauma, the type of bone injured, inadequate immobilization, infections at the fracture site, and avascular necrosis (AVN).
CONSIDERATIONS FOR OLDER ADULTS
CIS Healing can be affected by a number of factors in addition to the aging process. Bone formation and strength rely on adequate nutrition. Calcium, phosphorus, vitamin D, and protein are necessary for the production of new bone (see Chapter 53). For women, the loss of estrogen after menopause is detrimental to the body’s ability to form new bone tissue. Concurrent diseases can also affect the rate at which bone heals. For instance, peripheral vascular diseases, such as arteriosclerosis, reduce arterial circulation to bone; thus the bone receives less oxygen and lesser amounts of nutrients, both of
which are needed for repair.
■ COMPLICATIONS OF FRACTURES
Regardless of the type or location of the fracture, several limb and life-threatening complications can result from the injury. The nurse must be able to recognize the clinical manifestations of impending complications so that treatment can be started immediately. In some cases, careful monitoring and assessment can prevent these complications.
ACUTE COMPARTMENT SYNDROME. Compartments are sheaths of inelastic fascia that support and partition muscles, blood vessels, and nerves in the body. Acute compartment syndrome (ACS) is a serious condition in which increased pressure within one or more compartments causes massive compromise of circulation to the area. The most common sites for ACS are the compartments in the lower leg and the dorsal and volar compartments of the forearm.
The pressure to the compartment can be from an external or internal source. Tight, bulky dressings and casts are examples of external pressure. Blood or fluid accumulation is a common source of internal pressure. ACS is not limited to clients with musculoskeletal problems; clients with severe burns, extensive insect bites, or massive infiltration of intravenous (IV) fluids are also susceptible to compartment syndrome. In these situations, edema increases pressure in one or more compartments.
PATHOPHYSIOLOGIC CHANGES. The primary patho-physiologic changes of increased compartment pressure are sometimes referred to as the ischemia-edema cycle. Capillaries within the viable muscle dilate, which raises capillary pressure. Capillaries become more permeable because of the release of histamine by the ischemic muscle tissue. As a result, plasma proteins leak into the interstitial fluid space, and edema occurs. Edema causes pressure oerve endings and subsequent pain. Blood flow to the area is reduced, and further ischemia results. Sensory deficits (e.g., paresthesia) generally appear before changes in vascular or motor signs. The color of the tissue pales, and pulses begin to weaken but rarely disappear; the affected area is usually palpably tense, and pain can be elicited with passive motion of the extremity. If the condition is not treated, cyanosis, tingling, numbness, paresis, and severe pain occur. Chart 52-1 summarizes the sequence of pathophysiologic events in compartment syndrome and the associated clinical assessment findings.
ACS is not common, but it creates an emergency situation when it does occur. Within 4 to 6 hours after the onset of compartment syndrome, neuromuscular damage is irreversible. The limb can become useless in 24 to 48 hours.
In some cases, clients at especially high risk for ACS are monitored by an invasive procedure. Compartment pressures can be monitored on a one-time basis with a handheld device with a digital display, or they can be monitored continuously. Continuous monitoring requires placement of a wick or slit-tip catheter connected to a transducer and is recommended for comatose or unresponsive at-risk clients.
If ACS is verified, the surgeon may perform a fasciotomy by making an incision through the skin and subcutaneous tissues into the fascia of the affected compartment. This procedure relieves the pressure in order to restore circulation to the affected area. No consensus exists on what pressure requires fasciotomy (normal = 0 to
POSSIBLE RESULTS OF COMPARTMENT SYNDROME. Specific problems resulting from compartment syndrome include infection, persistent motor weakness in the affected extremity, contracture, and myoglobinuric renal failure. In extreme cases, amputation may be necessary.
Infection from the necrotic tissue may become severe enough that amputation of the limb is warranted. Motor weakness from injured nerves is not reversible, and the client may require braces or other orthotic devices for assistance in movement. Volkmann’s contractures, which can begin within 12 hours of the pressure increase, result from shortening of the ischemic muscle and from nerve involvement.
Myoglobinuric renal failure (rhabdomyolysis) is a potentially fatal complication of compartment syndrome. It commonly occurs when large or multiple compartments are involved. Injured muscle tissues release myoglobulin (muscle protein) into the circulation, where it can occlude the distal convoluted tubule and precipitate acute renal failure. Although the exact pathophysiologic mechanisms are unknown, it is suspected that myoglobulin has a direct toxic effect on the kidney. Damaged muscle cells also release potassium, which cannot be excreted because of the renal failure. The resulting hyperkalemia may cause cardiac dysrhythmias.
SHOCK. Bone is quite vascular; therefore there is a risk of bleeding with bone injury. In addition, trauma can sever adjacent arteries and cause hemorrhage; consequently, hypovo-lemic shock can develop rapidly. (The pathophysiology of hy-povolemic shock is described in Chapter 37.)
FAT EMBOLISM SYNDROME. Fat embolism syndrome (
The release of fat emboli is most likely with fractures of long bones or multiple fractures, although a break in any bone with sufficient bone marrow content can cause the complication. The problem can occur at any age or in either sex, but young men between ages 20 and 40 years and older adults between ages 70 and 80 years are at the greatest risk. The older client with a fractured hip has the highest risk, but
Several theories have been offered to explain how fat is released from the bone marrow. The metabolic theory proposes that the elevated concentration of catecholamines as a result of trauma causes mobilization of free fatty acids, which leads to platelet aggregation and the formation of fat globules. The mechanical theory suggests that the pressure within yellow bone marrow is greater than capillary pressure, and therefore fats are released directly from the bone. In either case, the fat globules are deposited in small blood vessels that supply the major organs of the body, most commonly the lungs.
The earliest manifestation of
Laboratory findings in
• Decreased serum calcium levels
• Decreased red blood cell and platelet counts
• Increased serum lipase level
These changes in blood values are poorly understood, but they aid in diagnosis of the condition.
Fat embolism usually occurs within 48 hours of the fracture and can result in respiratory failure or death, often from pulmonary edema. When the lungs are affected, the complication may be misdiagnosed as a pulmonary embolism from a blood clot (Chart 52-2).
THROMBOEMBOLITIC COMPLICATIONS. Deep vein thrombosis (DVT) often develops in people who are immobile because of trauma, surgery, or disability. It is the most common complication of lower extremity surgery or trauma and the most often fatal complication of musculoskeletal surgery. A person who smokes, is obese, has heart disease, or hasdure relieves the pressure in order to restore circulation to the affected area. No consensus exists on what pressure requires fasciotomy (normal = 0 to
a history of thromboembolitic complications is at an increased risk for DVT. The incidence of life-threatening em-bolic conditions is highest in older adults, particularly during the first 2 to 3 days after musculoskeletal surgery.
Certain fracture sites are more often associated with life-threatening thrombi. For example, DVT that leads to pulmonary embolism is more likely to develop in clients with fractures of the lower extremities and pelvis. Local venous stasis secondary to trauma or surgical procedures (e.g., use of tourniquets in lower extremity injuries) increases the chance of DVT in clients with musculoskeletal trauma. A further discussion of DVT is found in Chapter 36.
INFECTION. Any time there is trauma to tissues, the body’s defense system is disrupted. Wound infections are the most common type of infection resulting from orthopedic trauma; they range from superficial skin infections to deep wound abscesses. Infection can also be caused by implanted hardware used to repair a fracture surgically, such as pins, plates, or rods. Clostridial infections can result in gas gangrene or tetanus and can prevent the bone from healing properly.
Bone infection, or osteomyelitis, is most common with open fractures in which skin integrity is lost and after surgicalrepair of a fracture (see Chapter 53). For clients experiencing this type of trauma, the risk of hospital-acquired (nosocomial) infections is increased.
AVASCULAR NECROSIS. Avascular necrosis (AVN)
is sometimes referred to as aseptic or ischemic necrosis or os-teonecrosis. Blood supply to the bone is disrupted, which results in the death of bone tissue. AVN is most often a complication of hip fractures, or any fracture in which there is displacement of bone. Surgical repair of fractures also can lead to AVN because the hardware can interfere with circulation.
FRACTURE BLISTERS. Fracture blisters are associated most commonly with high-energy fractures and twisting injuries in the lower extremities. Extensive tissue edema allows fluid to move into the weakened space between the epidermis and the dermis. The increased colloidal osmotic pressure then pulls more fluid into the space. Fracture blisters can lead to wound infection and delayed fracture treatment, which may then contribute to potential nonunion. Nursing measures that can assist in preventing or minimizing fracture blisters include maintaining proper immobilization before definitive treatment, and elevation to limit edema.
DELAYED
Delayed union describes a fracture that has not healed within 6 months of injury. Some fractures never achieve union; that is, they never completely heal (nonunion); others heal incorrectly (malunion). These problems are most common in clients with tibial fractures, fractures for which a number of different treatment techniques have been used (e.g., cast, traction), and pathologic fractures.
I Etiology
The primary cause of a fracture is trauma from a motor vehicle accident or fall. The trauma experienced may be a direct blow to the bone or an indirect force from muscle contractions or pulling forces on the bone. Sports, vigorous exercise, and malnutrition are contributing factors. Bone diseases, such as osteoporosis, increase the risk of a fracture in older adults.
1 Incidence/Prevalence
The incidence of fractures depends on the location of the injury. Rib fractures are the most common type in the adult population. Femoral shaft fractures occur most often in young and middle-aged adults. The incidence of proximal femur (hip) fractures is highest in older adults. Humeral fractures are common in adults; the older the person, usually the more proximal the fracture. Wrist (Colles’) fractures are typically seen in middle and late adulthood
► COLLABORATIVE MANAGEMENT
I* Assessment
I HISTORY
The nurse collects data to determine the cause of the fracture, which helps in developing an individualized plan of care for the client.
PRECEDING EVENTS. The nurse asks the client to recall the specific events up to the time of the injury. Some type of force, such as incisional, crush, acceleration or deceleration, shearing, or friction, leads to most musculoskeletal injuries. As a result, several body systems are often affected.
Incisional (as from a knife wound) and crush injuries cause hemorrhage and disrupt blood flow to major organs. Acceleration or deceleration injuries cause direct trauma to the spleen, brain, and kidneys when these organs are moved from their fixed locations in the body. Shearing and friction damage the skin and cause a high level of wound contamination.
By asking about the events leading to the injury, the nurse can determine which forces have been experienced and therefore which body systems or parts of the body to assess. For example, a forward fall often results in Colles’ fracture of the wrist because the person tries to catch himself or herself with an outstretched hand. Knowing the mechanism of injury also helps the nurse determine whether other types of injury, such as head and spinal cord injury, may be present.
OTHER HISTORY. A medication history, including substance abuse (recreational drug use), is important regardless of age. For example, a young adult may have had an excessive amount of alcohol, which contributed to a motor vehicle accident or to a fall at the work site. Many older adults also consume alcohol and an assortment of prescribed and over-the-counter drugs, which can cause dizziness and loss of balance.
A medical history elicits possible causes of the fracture and gives clues as to how long it will take for the bone to heal. Certain diseases, such as bone cancer and Paget’s disease, cause pathologic fractures that often do not achieve union.
The nurse asks about the client’s occupation and recreational activities. Some occupations are more hazardous than others; for instance, construction work is potentially more physically dangerous than office work. Certain hobbies and recreational activities are also extremely hazardous (e.g., skiing and in-line skating). Contact sports, such as football and ice hockey, often result in musculoskeletal injuries, including fractures. Other activities do not have such an obvious potential for injury but can cause fractures nonetheless. For instance, daily jogging and frequent marching in a band can lead to fatigue fractures
Because inadequate nutrition contributes to fractures and can inhibit bone healing, the nurse takes a complete diet history. Health promotion counseling is a major focus for comprehensive health care today
PHYSICAL ASSESSMENT/CLINICAL MANIFESTATIONS
BODY SYSTEM ASSESSMENT. The client with a fracture often sustains trauma to other body systems. Consequently, the nurse assesses all major body systems first for life-threatening complications, including head, thoracic, and abdominal injuries. The assessment of these areas is described elsewhere in this text.
MUSCULOSKELETAL ASSESSMENT. When inspecting the site of a possible fracture, the nurse observes for a change in bone alignment. The bone may appear deformed, or a limb may be internally or externally rotated. Accompanying these deviations may be an alteration in the length of the extremity (usually a shortening) or a change in bone shape. The nurse asks the client to move the involved body part. If pain is elicited, the movement is stopped immediately. Range of motion (ROM) is typically decreased. When the affected part is moved, the nurse may hear crepitation, a continuous grating sound created by bone fragments.
The nurse also observes the skin for integrity. If the skin is intact (closed fracture), the area over the fracture may be ec-chymotic (bruised) from bleeding into the underlying soft tissues. Subcutaneous emphysema, the appearance of bubbles under the skin because of air trapping, is not uncommon but is seen later.
Swelling at the fracture site is rapid and can result in marked neurovascular compromise. Therefore the nurse performs a thorough neurovascular assessment and compares the injured area with its symmetric counterpart. Skin color and temperature, sensation, mobility, pain, and pulses are assessed distal to the fracture site. If the fracture involves an extremity, the nurse checks the nails for capillary refill by applying pressure to the nail and observing for the speed of blood return. If nails are brittle or thick, the skin adjacent to the nail is assessed. Chart 52-3 describes the procedure for a neurovascular assessment, which evaluates circulation, movement, and sensation.
For an open fracture, the nurse determines the degree of soft-tissue damage and the amount of overt bleeding. The area may be lightly palpated for tenderness, but a sterile glove is worn if the skin is disrupted.
Clients often complain of moderate to severe pain at the site of the fracture or in an adjacent or distal area. For example, clients with a fractured hip may have groin pain or pain referred to the back of the knee. Pain is usually due to muscle spasm and edema, which result from the fracture. In clients with one or more fractured ribs, severe pain occurs when deepbreaths are taken. The nurse assesses respiratory status, which may be severely compromised from pain or pneumothorax (air in the pleural cavity).
SPECIAL ASSESSMENT CONSIDERATIONS. For fractures of the shoulder and upper arm, the physical assessment is best done with the client in a sitting or standing position, if possible, so that shoulder drooping or other abnormal positioning can be seen. The nurse supports the affected arm and flexes the elbow to promote comfort during the assessment. For more distal areas of the arm, the assessment is done with the client in a supine position so that the extremity can be elevated to reduce swellingThe nurse places the client in a supine position for assessment of the lower extremities and pelvis. A client with an impacted hip fracture may be able to walk for a short time after injury, although this is not recommended. The client with any type of hip fracture has pain and decreased ROM in the hip.
Some fractures can cause internal organ damage, resulting in hemorrhage. When a pelvic fracture is suspected, the nurse assesses vital signs, skin color, and the level of consciousness for indications of possible hypovolemic shock. The urine is checked for blood, which indicates damage to the urinary system, often the bladder. If the client is unable to void, the nurse suspects damage to the urethra.
i PSYCHOSOCIAL ASSESSMENT
The psychosocial status of a client with a fracture depends on the extent of the injury and other complications. Hospitaliza-tion is usually not required for a single, uncomplicated fracture, and the client may return to usual daily activities within a few days. Healing is usually complete in a young adult in 4 to 6 weeks.
In contrast, a client suffering multiple trauma can be hospitalized for weeks and may undergo many surgical procedures and other treatments. For these clients, disruptions in lifestyle can create a high level of stress.
The stresses that result from a chronic condition affect relationships between the client and family members or significant others. The nurse assesses the client’s feelings about himself or herself as a person and asks about how he or she coped with previously experienced stressful events. Body image and sexuality may be altered by deformity, treatment modalities for fracture repair, and/or long-term immobilization
B LABORATORY ASSESSMENT
No special laboratory tests are available for assessment of fractures. The client’s hemoglobin level and hematocrit are often low because of bleeding caused by the injury. If extensive soft-tissue damage accompanies the fracture, the erythro-cyte sedimentation rate (ESR) may be elevated, which indicates the expected inflammatory response. If the ESR increases during fracture healing, the client may have a bone infection. During the healing stages, serum calcium and phosphorus levels are often increased as the bone releases these elements into the blood.
■ RADIOGRAPHIC ASSESSMENT
The health care provider orders standard x-ray studies and to-mograms to confirm a diagnosis of fracture. These reveal the bone disruption, malalignment, or deformity. If the x-ray film does not show a fracture but the client is symptomatic, the x-ray study is usually repeated with additional views.
The computed tomography (CT) scan is useful in detecting fractures of complex structures, such as the hip and pelvis. It also identifies compression fractures of the spine.
i OTHER DIAGNOSTIC ASSESSMENT
The health care provider may order a bone scan (with tech-netium or gallium) for help in detecting certain types of fractures, particularly pathologic fractures. It is impossible for fractures of small bones or occult fractures to be visualized by conventional x-ray studies as early as by a bone scan. In addition, the bone scan can better determine fracture complications, such as delayed bone healing, nonunion, infection, and avascular necrosis (AVN).
Magnetic resonance imaging (MRI) is useful in determining the amount of soft-tissue damage that may have occurred with the fracture. It is also helpful in visualizing vertebral and skull fractures.
!• Analysis
■ COMMON NURSING DIAGNOSES AND COLLABORATIVE PROBLEMS
The following are commoursing diagnoses for clients with fractures:
1. Risk for Peripheral Neurovascular Dysfunction related
to bone and soft-tissue trauma and immobility
2. Acute Pain related to bone disruption, soft-tissue dam
age, muscle spasm, and edema
3. Risk for Infection related to bone trauma and soft-tissue
damage
4. Impaired Physical Mobility related to pain
5. Imbalanced Nutrition: Less Than Body Requirements
related to additional metabolic need for healing of bone
and soft tissues
K ADDITIONAL NURSING DIAGNOSES AND COLLABORATIVE PROBLEMS
In addition to the commoursing diagnoses, clients with fractures may have one or more of the following:
Activity Intolerance related to pain and impaired mobility Constipation related to prolonged immobility (particularly in older adults)
• Ineffective Coping related to prolonged immobility, hos-
pitalization, and/or lifestyle changes
Compromised Family Coping related to prolonged hos-
pitalization and/or lifestyle changes
• Deficient Diversional Activity related to prolonged hos-
pitalization and rehabilitation
Anticipatory Grieving related to altered lifestyle 1 Self-Care Deficit related to pain and immobility
• Disturbed Body Image related to deformity and/or treat
ment modality
• Sexual Dysfunction related to pain and immobility
Disturbed Sleep Pattern related to chronic pain and/or
prolonged hospitalization
Fear related to possible nursing home placement and/or death (particularly in older adults)
1 Impaired Skin Integrity and Impaired Tissue Integrity related to bone injury
The following collaborative problems may be appropriate for clients with severe fractures:
Potential for Acute Compartment Syndrome
■ Potential for Hypovolemic Shock
1 Potential for Fat Embolism Syndrome Potential for Thromboembolitic Complications
• Potential for Avascular Necrosis
4 Potential for Delayed Healing, Malunion, or Nonunion
!• Planning and Implementation
K RISK FOR PERIPHERAL NEUROVASCULAR DYSFUNCTION
noo PLANNING: EXPECTED OUTCOMES. The client with a fracture is expected to have sufficient blood flow for adequate oxygen and nutrient delivery to tissues, especially distal to the fracture site, as indicated by strong distal peripheral pulses, brisk capillary refill, normal skin color, and intact muscle function.
INTERVENTIONS. A fracture can occur anywhere. The nurse provides emergency interventions until medical treatment in a hospital is available.
EMERGENCY CARE. A fracture may be accompanied by multiple injuries to vital organs. Therefore the nurse first assesses the client for respiratory distress, bleeding, and head injury. If any of these is present, the nurse provides lifesaving care before being concerned about the fracture.
The fracture injury is then assessed (Chart 52-4). If the person is clothed, the nurse or another person trained in first aid cuts away clothing from the fracture site for best visualization. Bleeding is controlled by direct pressure on the area and digital pressure over the proximal artery nearest the fracture. At the same time, to prevent shock, the nurse checks vital signs, places the client in a supine position, and keeps him or her warm with coverings. The nurse also:
Inspects the fracture site for intactness of skin, swelling, and deformity (e.g., shortening and rotation) • Palpates the area lightly to determine temperature (coolness), decreased sensation, and blanching Assesses distal pulses by comparing affected and unaffected extremities, if applicable
■ Assesses for motor function by asking the client to move an area distal to the fracture (e.g., if a femoral fracture is suspected, he or she is asked to move the ankle and foot on the affected side; the upper portion of the leg remains immobilized)
To prevent further damage, reduce pain, and increase circulation, the nurse immobilizes the area of the fracture by splinting. Any object or device that extends to the joints above and below the fracture can be used as a splint. At the scene of an accident, the nurse may need to improvise by using available materials, such as a board. If the skin is broken, the nurse loosely applies a clean (preferably sterile) cloth to prevent further contamination of the wound. Neurovascular assessment is rechecked following splinting.
In the emergency department, physician’s office, or clinic, fracture management begins with reduction and immobilization of the fracture:
• Reduction, or realignment of the bone ends for proper
healing, is accomplished by a closed method (e.g., trac
tion) or an open (surgical) procedure.
• Immobilization is achieved by the use of bandages,
casts, traction, internal fixation, or external fixation.
The health care provider selects the treatment method on the basis of the type, location, and extent of the fracture. These interventions prevent further injury and reduce discomfort. The nurse is responsible for maintaining these devices and for assessing, preventing, and intervening for complications that can result from their use.
CRITICAL THINKING CHALLENGE
vis A 30-year-old man arrives at your emergency department via ambulance. He was the driver of a motorcycle involved in a collision with a sport utility vehicle (SUV). Paramedics report that the client was hit from the side; the bike fell on him, and he was trapped underneath the SUV. Initial reports from the ambulance en route describe an individual in shock with a mangled left leg below the knee and a left wrist fracture. The client was wearing a helmet at the time of the crash.
• What information given above is helpful in predicting other
injuries this client may have sustained?
• What are the priority assessments you should perform when
he arrives at the hospital?
• What assessments of the leg injury will determine the type
and grade of the fracture?
• What initial assessments of the injured leg should you
perform?
|
For suggested answer guidelines, go to |
http://www.wbsaunders.com/SIMON/lggy/.
NEUROVASCULAR MONITORING. The nurse performs a neurovascular assessment (Chart 52-5) at frequent intervals if the client is admitted to the hospital, depending on the severity and extent of the fracture and agency policy. The nurse pays particular attention to early signs and symptoms of acute compartment syndrome (ACS) by doing a thorough pain assessment. The client with early ACS typically complains of severe, diffuse pain that is not relieved by analgesics; pain during passive motion is greater than pain during active motion. If the client presents with this complaint, the nurse notifies the health care provider immediately.
NONSURGICAL MANAGEMENT. Nonsurgical management typically involves closed reduction and immobilization with a bandage, splint, cast, or traction. For each modality, the nurse’s primary concern is assessment and prevention of neurovascular dysfunction or compromise.
CLOSED REDUCTION. Closed reduction is the most commoonsurgical method for managing a simple fracture. While applying a manual pull, or traction, on the bone, the health care provider manipulates the bone ends so that theyrealign. Anesthesia or analgesia may be used during this procedure to minimize pain. An x-ray verifies that the bone ends are approximated before the bone is immobilized.
Bandages and Splints. For certain areas of the body, such as the scapula and clavicle, an elastic bandage or commercial mobilizer may be used to immobilize the bone during healing. Because upper extremity bones do not bear weight, splints may be sufficient to keep bone fragments in place. Figure 52-3 illustrates the use of a wrist splint for fracture immobilization. Thermoplast, a durable, flexible material for splinting, allows custom fitting to the client’s body part.
The nurse’s primary responsibility is to assess the area distal to the bandage or splint for neurovascular compromise. The client usually complains of increased discomfort that is not relieved by analgesics if the splint or bandage is too tight. The nurse reinforces the need for elevation as appropriate and teaches how to assess for circulatory changes. The client is reminded to keep the device as dry and clean as possible to prevent skin breakdown and infection.
Caste. For more complex fractures or fractures of the lower extremity, the physician or orthopedic technician applies a cast to hold bone fragments in place after reduction. A cast is a rigid device that immobilizes the affected body part while allowing other body parts to move. A cast also allows early mobility and reduces pain. Although its most common use is for fractures, a cast may be applied for correction of deformities (such as clubfoot) or for prevention of deformities (such as those seen in some clients with rheumatoid arthritis).
Cast Materials. Several types of materials are used to make casts. The traditional plaster of Paris (anhydrous calcium sulfate) cast requires application of a well-fitted stockinette under the material. If the stockinette is too tight, it may impair circulation; if it is too loose, wrinkles can lead to the development of pressure ulcers and subsequent skin breakdown. Padding is applied over the stockinette, followed by wet plaster rolls wrapped around the extremity or other body part. The cast feels hot because an immediate chemical reaction occurs, but it soon becomes damp and cool. This type of cast takes 24 to 72 hours to dry, depending on the size and location of the cast. A wet cast feels cold, smells musty, and is grayish. The cast is dry when it feels hard and firm, is odorless, and has a shiny white appearance.
On occasion, the plaster cast may have rough edges, which can crumble and cause skin irritation. To resolve this problem, the nurse petals the cast if the underlying stockinette does not cover the edges of the cast. Small strips of tape are placed over the rough edges to protect the skin. If the skin under the cast was disrupted, the health care provider, orthopedic technician, or specially trained nurse cuts a window into the cast so that the wound can be observed and cared for. A window is also an access for taking pulses, removing wound drains, or relieving abdominal distention when the client is in a body or spica cast.
If the cast is too tight, it may be cut with a cast cutter to relieve pressure or allow tissue swelling. The physician may choose to bivalve the cast (cut it lengthwise into two equal pieces) if bone healing is almost complete. The nurse can remove either half of the cast for inspection or for provision of care. The two pieces are then reunited by an elastic bandage wrap.
Synthetic materials for casts include fiberglass and polyester-cotton knit (Figure 52-4). These materials are lighter than plaster and require minimal drying time. Fiberglass casts are dry in 10 to 15 minutes and can bear weight 30 minutes at ter application. Polyester-cotton knit casts take 7 minutes to dry and can withstand weight bearing in approximately 20 minutes. Some health care providers use synthetic casts for upper extremities and plaster of Paris casts for lower extremities because plaster casts can bear more weight for a longer time.
Types of Casts. Casts can be generally divided into four main groups: arm casts, leg casts, cast braces, and body or spica casts. Table 52-1 describes specific casts that are used for various parts of the body.
When a client is in bed with an arm cast, a sling is used to elevate the arm above the heart to reduce swelling. The hand should be higher than the elbow. Ice may be ordered for the first 24 to 48 hours. When the client is out of bed, the arm is supported with a sling placed around the neck to alleviate fatigue caused by the weight of the cast. The sling should distribute the weight over a large area of the shoulders and trunk, not just the neck. Some health care providers prefer that after the first few days in an arm cast, particularly a short-arm cast, the client not use a sling, to encourage normal movement of the mobile joints and enhance bone healing.
A leg cast permits mobility and requires the client to use ambulatory aids, such as crutches. A cast shoe, sandal, or boot that attaches to the foot or a rubber walking pad attached to the sole of the cast assists in ambulation (if weight bearing is allowed) and helps prevent damage to the cast. The affected leg is elevated on several pillows to reduce swelling, and ice is applied for the first 24 hours or as ordered.
A cast brace enables the client to bend unaffected joints while the fracture is healing. The fracture must show signs of healing and minimal tissue edema before application of this cast. Two cylindric casts are made and connected by a hinge to allow joint movement. As healing occurs, the casts may be removed and replaced with a soft brace. Commercial immo-bilizers, which serve the same function as a cast brace, are available and may be used in some cases.
A body cast encircles the trunk of the body; a spica cast encases a portion of the trunk and one or two extremities. A client with either of these casts presents a special challenge for nursing care. Potential complications related to severe impairment in mobility include the following:
• Skin breakdown
• Respiratory dysfunction, such as pneumonia and atelec-
tasis
Constipation
• Joint contractures
Cast syndrome (superior mesenteric artery syndrome), an uncommon but serious complication, is most often seen in orthopedic clients who have been placed in a hip spica or body cast. Partial or complete upper intestinal obstruction results in classic symptoms: abdominal distention, epigastric pain, nausea, and vomiting. The vomiting often occurs after meals, and clients may have normal bowel sounds. Partial obstruction occurs initially from compression of the third portion of the duodenum between the superior mesenteric artery and the aorta. This progresses to complete obstruction from duodenal edema caused by continued vomiting and distention. Placing a window in the abdominal portion of the cast or bivalving the cast may be sufficient to relieve pressure on the duodenum. Management of intestinal obstruction is the same as for any client with this complication (see Chapter 57).
Cast Care. Before the cast is applied, the nurse explains the purpose of the cast and the procedure for its application.
With a plaster cast, it is particularly important for the nurse to warn the client about the heat that will be felt immediately after the wet cast is applied. The new cast is not covered; this facilitates air-drying.
When a client with a wet plaster cast is moved and turned, the nurse handles the cast with the palms of the hands to prevent indentations and resultant areas of pressure on the skin. The client is turned every 1 to 2 hours to allow air to circulate and dry all parts of the cast. If the client is hospitalized, the nurse or assistive nursing personnel places a sign at the head of the bed as a reminder that the cast is wet and requires special handling. If the health care provider orders that the cast be elevated to reduce swelling, a cloth-covered pillow is used instead of one encased in plastic, which could cause the cast to retain heat and prevent drying. Elevation of the casted extremity reduces edema but may impair arterial circulation to the affected limb. Uniform support is needed while the cast is drying to prevent development of pressure points.
For preventing contamination by urine or feces, the perineal area of a dry long leg or body cast is encased in a plastic, protective covering. Fracture pans are preferred over traditional bedpans because they are smaller and more comfortable for the client. Care is taken to prevent spillage onto the cast.
The nurse checks to ensure that the cast is not too tight and frequently monitors the client’s neurovascular status, usually every hour for the first 24 hours after application (see Chart 52-3 for a description of the procedure and normal findings). The nurse should be able to insert a finger between the cast and the skin. Ice may be applied for the first 24 to 36 hours to reduce swelling and inflammation.
Once the plaster cast is dry, it is inspected at least once every 8 hours for drainage, cracking, crumbling, alignment, and fit. Areas of drainage on the cast should be measured and documented, although there is no direct relationship between the amount of cast drainage and the amount of drainage from the wound. Plaster casts act like sponges and absorb drainage, whereas synthetic casts act like a wick, pulling drainage away from the drainage site. Padding can also absorb wound drainage. Drainage on any cast should always be measured and documented in the client record; however, sources disagree on whether drainage should be circled on the cast, because it may increase anxiety. The nurse immediately reports sudden increases in the amount of drainage or a change in the integrity of the cast to the health care provider. After swelling decreases, it is not uncommon for the cast to become too loose and need replacement. If the client is not admitted to the hospital, he or she is given instructions regarding cast care, as discussed later under Community-Based Care, p. 1141.
Cast Complications. During hospitalization, the nurse assesses for other complications resulting from casting that canbe serious and life threatening, such as infection, circulation impairment, and peripheral nerve damage. If the client returns home after cast application, the client and family are taught how to monitor for these complications and when to notify the health care provider.
Infection most often results from the breakdown of skin under the cast (pressure necrosis). If pressure necrosis occurs, the client typically complains of a very painful “hot spot” under the cast, and the cast may feel warmer in the affected area. The nurse smells the area for mustiness or an unpleasant odor that would indicate infected material. If the infection progresses, a fever may develop.
Circulation impairment and peripheral nerve damage can result from constriction of the cast. The nurse performs frequent neurovascular assessments, as described in Chart 52-
The client with a cast may be immobilized for a prolonged period, depending on the extent of the fracture and the type of cast. The nurse assesses for complications of immobility, such as skin breakdown, pneumonia, atelectasis, thromboem-bolism, and constipation. Before the cast is removed, the nurse informs the client that the cast cutter will not injure the skin but that heat may be felt during the procedure.
Because of prolonged immobilization, a joint may become contracted, usually in a fixed state of flexion, or degenerative arthritis may develop from lack of weight bearing, which is necessary for cartilage viability. Muscle can also atrophy from lack of exercise during prolonged immobilization of the affected body part, usually an extremity.
