Fracture Todo Na

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FRACTURE


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ETIOLOGY

1. Direct force. When a bone is subjected to more stress than

it can absorb from an impact with a solidobject. e.g., Moving object strikes the body over the bony areas

2. Twisting.

In a twisting (torsion) fracture, an indirect

force may cause a break in a bone at alocation other than the site of the twistingforce. This type of injury is common in skiing accidents.


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3. Muscle contractionAnother indirect force fracture,

resulting from powerful contraction of

a muscle, may cause the muscles totear away from the bone, oftenfracturing or avulsing part of the bone

in the process.This type of injury may occur during a

grand mal seizure.

ETIOLOGY


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ETIOLOGY

4. Pathological fracture. Bones that have become weakened from

age or disease are easily fractured, oftenfrom just a slight movement

5. Fatigue or stress fracture. This type of injury may occur when a bone

has been subjected to repeated stress. The repeated stress of sustained running or

marching may cause stress fractures of the feetor lower extremities

Common to Soldiers and sports enthusiasts


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RISK FACTORS

Osteopenia (inadequate ossification) begins between ages 30 and

40

osteoblast activity declines, while osteoclast activity

remains level Usually caused by steroid use or Cushing syndrome

Release of osteoclast leads to accelerated boneresorption

Osteogenesis imperfecta

A congenital bone disease characterized by defectivecollagen production by osteoblasts


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RISK FACTORS

Neoplasms RANKL, a cytokine released by metastatic bone tumors,

thus promoting formation and activation of osteoclast =accelerated bone resorption

Postmenopausal estrogen loss

Remember, estrogen stimulates osteoblast activity andsynthesis of bone matrix

High-risk recreation or employment-relatedactivities (e.g., skateboarding, rock climbing)


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CLINICAL MANIFESTATIONS4. Shortening of an extremity.

Occurs because of the contraction of the muscles that areattached distal and proximal to the fractured site

The fragments often overlap by as much as 2.5 to 5 cm (1-2inches)

5. Crepitus. Refers to the grating sensation or sound caused by the rubbing

together of fractured fragments

Testing for crepitus can produce further tissue damage andtherefore should be AVOIDED

6. Discoloration and Edema. Occur after a fracture as a result of trauma or bleeding into the

tissues


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CLINICAL MANIFESTATIONS

7. Neurovascular changes

Results from damage to the peripheral nervesor to the associated vascular structures

The client may complain of tingling ornumbness sensation or have no palpable pulsedistal to the fracture

8. Shock Bony fragments may lacerate blood vessels

Frank or occult hemorrhage can lead to shock


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DIAGNOSTIC EVALUATION

Comprehensive history taking

Radiograph (X-ray) the most common methodto makethe diagnosis of fracture.

CT SCAN used to determine fracture as well asinjury to soft tissue associated with fracture

Others:

CBC to check for a decreased (Hgb snd hct),

serum ELECTROLYTES if blood loss and extensivemuscle damage has occurred

EMG-NCV to detect nerve injury


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CLASSIFICATION OFFRACTURES

Bone fractures are classified by: The position of the bone ends after fracture The completeness of the break The orientation of the bone to the long axis

Whether or not the bones ends penetrate the skin

A fracture that is associated with a large amountof nerve, blood vessel, and soft tissue damage is

called a complicated fracture.

A fracture without other damage would bereferred to as an uncomplicated fracture.


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SPECIFIC TYPES OF FRACTURE(according to direction of the fracture line in relation to the bone's

longitudinal axis.)Linear

the fracture is parallel to the long axis of thebone

Transverse

the fracture is perpendicular to the long axis ofthe bone


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longitudinal axis.)

Longitudinal.

A fracture line that runs along the length of, butnot parallel to, the bone's axis.

Oblique

A fracture line that slants across the bone.


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longitudinal axis.)

Spiral

A fracture line that runs across the bone at anoblique angle and coils or spirals around the

bone.


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SPECIFIC TYPES OF FRACTURE(according to the condition of the bone)

Complete. The bone is completely brokenor split apart.

Incomplete. The bone is not completelysplit and part of the bone remains intact.


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Closed In a closed, or simple fracture, there is

no break in the skin associated with the

fracture.

Open

An open, or compound fracture is one inwhich there is an open woundassociated with the fracture site.


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GRADING OF OPEN FRACTURE(grading of the extent of tissue damage)

Grade I Clean wound less than 1 cmlong

Grade II larger than 1 cm woundwithout extensive tissue damage;contamination is moderate

Grade III Highly contaminated, hasextensive soft tissue damage and isost severe; wound exceeds 6-8 cm


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Nondisplaced

bone ends retain their normal position

Displaced

bone ends are out of normal alignment


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Depressed

A piece of bone is driven inward, as in a skullfracture.


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Comminuted

bone fragments into three or more pieces

common in the elderly


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Greenstick

incomplete fracture where one side of the bonebreaks and the other side bends

common in children


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FRACTURE REPAIR

STEP 1

Bleeding:

produces a clot (fracturehematoma)

establishes a fibrousnetwork

Bone cells in the area die


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FRACTURE REPAIR

STEP 4Osteoblasts and osteocytes

continue to remodel thefracture for up to a year.

At this point any cast orexternal support can beremoved


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6 Stages of Fracture Healing

(Bone Repair)

1. Hematoma & inflammation

2. Angiogenesis & cartilage formation

3. Cartilage calcification (Procallus)4. Cartilage removal

5. Bone formation (Callus3 to 4 months

ossification with major adult long bonefracture)

6. Bone remodeling (may take months to years)


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FACTORS INFLUENCE THEHEALING TIME OF FRACTURES

If realignment is poor, the bone ends may notmeet or there may be soft tissue interposedbetween the bone ends. Union will not occurunder such circumstances.

If the immobilization is inefficient, union may notoccur.

The age and physical condition of the patient, aswell as dietary deficiencies, will affect the healingtime.


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FACTORS INFLUENCE THE HEALINGTIME OF FRACTURES

Additional factors in healing time are the type of fracture,

its location, and

the adequacy of the blood supply to theaffected area.

Finally, the presence of infection willseverely handicap healing or prevent italtogether.


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EMERGENCY MANAGEMENT

If fracture is suspected, IMMOBILIZE thebody part immediately after the injurybefore moving the patient

Open fracture are covered with steriledressing to prevent contamination


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THE OBJECTIVES OF THETREATMENT OF FRACTURES

(1) To regain and maintain the normalalignment of the injured part.

(2) To regain normal function of the injuredpart.

(3) To achieve the above objectives for thepatient in the shortest time possible.


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PRINCIPLES OF FRACTUREMANAGEMENT

(1)Reduction. Reduction is the process ofrestoring the bone ends (and any fracturedfragments) into their normal anatomical

positions.

- This is accomplished by open or closed

manipulation of the affected area, referred toas open reduction and closed reduction.


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REDUCTION

(a) Closed reduction is accomplished by bringing thebone ends into alignment by manipulation and manualtraction.

X-rays are taken to determine the position of the bones.

A cast is normally applied to immobilize the extremity andmaintain the reduction.

(b) In open reduction, a surgical opening is made,

allowing the bones to be reduced manually under directvisualization.

Frequently, internal fixation devices will be used to maintain thebone fragments in reduction


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(2) Immobilization. Immobilization is necessary tomaintain fracture reduction until healing occurs.Immobilization may be accomplished by externalor internal fixation.

(a) Methods of external fixation include casts, splints,and continuous traction.

(b) Internal fixation devices include pins, wires,screws, rods, nails, and plates. These devices,attached to the sides of the bone or inserted throughthe bone, provide internal immobilization of the bone.


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(3) Rehabilitation. Rehabilitation is the regainingof strength and normal function in the affectedarea.

Specific rehabilitation for each patient will be basedupon the type of fracture and the methods ofreduction and immobilization used.

The physician will generally consult with the physical

therapist to develop an individualized rehabilitationplan for each patient.

This plan is normally implemented and controlled bythe physical therapy department.


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NURSING MANAGEMENT OF APATIENT WITH A FRACTURE

a. Nursing care of a patient with a fracture,whether casted or in traction, is basedupon prevention of complications while

healing.

b. By performing an accurate nursingassessment on a regular basis, the nursing

staff can manage the patient's pain andprevent complications.

h h


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When assessing a patient with afracture, check the "5 P's"

(1)Pain. Worsening pain may indicate increased edema,lack of adequate blood supply, or tissue damage.

(2) Pulse. Check the peripheral pulses, especially those

distal to the fracture site.

(3) Pallor. Observe the color and temperature of the skin,especially around the fracture site.

(4) Paresthesia. Examine the injured area for increase ordecrease in sensation.

(5) Paralysis. Check the patient's mobility.


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In addition to the five P's mentioned above, the patient'slevel of consciousness and temperature should bechecked regularly.

Mental status changes and temperature elevation could indicatethe presence of infection.

Reposition the patient as necessary to relieve pressureareas.

Check all dressings, bandages, casts, splints, andtraction equipment to ensure that nothing is causingconstriction or pressure.

Frequent and thorough checking and observation on thepart of the nursing staff will promote healing andprevent complications.


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LIFE THREATENING COMPLICATIONS

Deep venous thrombosis (DVT)

Anterior tibial or femoral veins

May be caused by immobility

Findings include calf pain, positive Homan'ssign

Immediately after operations

anticoagulant therapy antiemboli stockings (usually)

sequential compression device (possibly)


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Pulmonary embolism (PE)

Findings include chest pain (pleuritic), suddenshortness of breath, tachycardia, palpitations,or change in mental status

If PE is suspected,do not leave client. Getcharge nurse to notify health care providerimmediately

Diagnosis confirmed via ventilation/perfusionscan or pulmonary angiography

Continuous IV heparin therapy usuallyprescribed


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Fat embolism

Definition: fat cells enter pulmonarycirculation

Associated with

multiple trauma accidents

multiple organ involvement

fractures of marrow producing bones

joint replacements

insertion of intermedullary rods Usually occurs 24 to 48 hours after the

fracture


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Hemorrhage

Abnormal loss of blood from thebody

Most common in fractures ofbone marrow producing bones


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Gas Gangrene

Gas gangrene is a severe infection of skeletalmuscle caused by the bacteria Clostridium.

These bacteria are anaerobes and spore

formers normally found in soil and in theintestinal tract of man.Gas gangrene occurs most often in wounds

that have been grossly contaminated at the

time of injury, in wounds that have a smallbut deep open wound area, and in woundsthat have a compromised blood supply andtherefore a decreased oxygen supply.


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Gas Gangrene

Nursing personnel should observe for signs ofapprehension, fever, chills, increased pulse,increased respiratory rate, and frothy foul-smelling

drainage from the wound. In treating gas gangrene, the physician will open

the wound for debridement and irrigation.

Antibiotic therapy and hyperbaric oxygen therapy

will be initiated. Frequently, amputation of theaffected extremity is necessary.


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Tetanus.

Tetanus is an acute infection caused by thetetanus bacillus, another anaerobic sporeformer.

The bacteria is introduced through a woundthat has been contaminated with soil, feces,or dust.

Toxins that have an affinity for nervoustissue cause hyperirritability, restlessness,muscle rigidity, and tonic muscular spasmsof almost every muscle group.


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TETANUS

The patient may have difficulty opening themouth due to spasm of facial muscles.Tetanus is sometimes referred to as

"lockjaw" for this reason.Treatment is similar in nature to that of

gangrene, with the addition of anti-

convulsive drugs.


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CASTSA rigid, external immobilizing device

Uses:

Immobilize a reduced fracture

Correct a deformity

Apply uniform pressure to underlying softtissues

Provide support and to stabilize a weakenedjoint


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Types of cast

Short-arm cast extends from below theelbow to the palmar crease, secured aroundthe base of the thumb. If thethumb isincluded, it is known as theThumb-spicaor gauntlet cast.

Long-arm cast Extends from the axillaryfold to the proximal palmar crease. Theelbow is usually immobilized at a rightangle.


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Long-Arm and Short-Leg Cast andCommon Pressure Areas


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Types of cast

Short-leg cast

Extends from below theknee to the base of the toes. The foot isflexed at a right angle in a flexed position

Long-leg cast Extends from the junction upperand middle third of the thigh to the base of thetoes. The knees may be slightly flexed.

Walking cast A short- or long- leg castreinforced for strength.


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Types of cast

Body cast Encircles the trunk

Shoulder spica cast A body jacket that

encloses the trunk and the shoulder andelbow

Hip spica cast Encloses the trunk and alower extremity. Adouble hip spicacastincludes both legs


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Casting Materials:

Nonplaster (Fiberglass)

Water activated polyurethane material havingthe versatility of plaster cast but is lighter in

weight, stronger, water resistant and durable.

Used for non displaced fractures with minimal

swelling and for long-term wear


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Nonplaster (Fiberglass)

Characteristic of non plaster cast (Fiberglass):

Consist of an open-weave, non absorbent fabricimpregnated with cool water-activated hardeners

Bond and reach full rigid strength in minutes

Porous and therefore diminish skin problems

Do not soften when wet, which allows forhydrotherapy

When wet, they are dried with a hair dyer on a coolsetting (thorough drying is important to preventskin breakdown)


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Casting Materials:

Plaster Traditional cast Rolls of plaster bandage are wet in cool water and

applied smoothly to the body.

A crystallizing reaction occurs and heat is given off (anexothermic reaction).

The heat given off during this reaction can beuncomfortable to the client, and the nurse shouldinform the patient about the sensation of increasing

warmth Cast needs to be exposed to air (i.e., uncovered) to

allow maximum dissipation of heat; most casts coolafter about 15min


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Plaster

After the plaster sets, the cast remains wetand somewhat soft; it does not have its fullstrength until it is dry.

While the cast is DAMP, it can be dented. It must be handled by palms of the hands

Not allowed to rest on hard surfaces or sharpedges

Cast dents may press on the skin, causingirritation and skin breakdown.


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Plaster

Characteristics of plaster cast:

Plaster cast requires 24 to 72 hours to drycompletely

Awet plaster cast appears DULL andGRAY, sounds dull on percussion, feels dampand smells musty.

Adry plaster cast is WHITE and SHINY,resonant to percussion, odorless and firm.


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HEALTH TEACHINGS

Prior to cast application

Explain condition necessitating the

castExplain purpose and goals of the cast

Describe expectations during the

casting process: e.g., the heat fromhardening plaster

CARE OF THE PATIENT WITH A


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CARE OF THE PATIENT WITH ANEWLY APPLIED CAST

a. Expose a newly applied cast to aircirculation.

It should never be covered,

b. Handle a wet cast carefully.

Never use fingers as they will leave

indentations, which cause pressure areas withinthe cast.



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c. Provide plastic-covered pillows to support the castalong its entire length. Never permit the wet cast to rest directly on a flat or

firm surface

d. Review the patient's clinical record for the type ofcast and the reason the cast has been applied. Determine PT.s knowledge of the cast purpose and

whether he has had a cast before. Instruct the patient on care of the cast that is wet and

after it is dry.

CARE OF THE PATIENT WITH


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CARE OF THE PATIENT WITHA NEWLY APPLIED CAST

e. After a cast has cooled and begins toharden, elevate the casted extremity toreduce swelling which often occurs after

application of a cast. For example, hand higher than elbow, elbow

higher than shoulder.

f. Observe all edges of the cast for anyareas that cut or put pressure on the skin.



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Observe the extremity encased in plaster forcirculatory impairment by comparing fingersor toes of the casted extremity with the

uninvolved extremity.

Circulation should be checked hourly during

the first 24 to 48 hours, then every 4 hours.

Assessment of circulation on


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Assessment of circulation ona casted extremity

(1) Check the skin temperature of the injured extremity. Itshould not be colder than the unaffected limb.

(2) Check and compare the pulses. They should be equal.

(3) Check for complaints of numbness, tingling, burning,swelling, pain, pressure, or inability to move the fingersor toes.

(4) Report presence of the above signs and symptomsIMMEDIATELY to avoid possible tissue necrosis; thesefindings indicate possible ischemia.

Assessment of circulation on


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Assessment of circulation ona casted extremity

Perform the blanching (capillary refill) test.

(1) "capillary refill, less than 3 seconds

(2) Failure to blanch, or a blue tinge, - indicates

impaired venous circulation and congestionof tissues.

(3) Failure of color to return, or cold, pale fingers or

toes -suggests impaired arterial circulation.(4) In either case, report findings IMMEDIATELY. Do

not wait. Permanent damage can result fromimpaired circulation caused by cast pressure.


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FINISHING THE DRY CAST

c. Nursing implications. A cast without a smooth,unwrinkled finish is a potential source of problems.

(1) Rough, unfinished cast edges will scrape or cut theskin. Broken skin surfaces may become infected.

(2) Loose bits of plaster from an unfinished cast maybecome lodged inside the cast, causing itching andirritation.

(3) Wrinkled or "bunched-up" edging may result inpressure areas and potential skin breakdown.


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COMPLICATIONS

Compartment syndrome Occurs when there is an increased pressure within a

limited space (e.g., cast, muscle compartment) thatcompromises the circulation and function of the tissue

within the confined area. To relieve the pressure the cast must be bivalved (cut in

half longitudinally) while maintaining alignment, and theextremity must be elevated no higher than heart level toensure arterial perfusion

If pressure is not restored, a fasciotomy may benecessary to relieved the pressure within the musclecompartment.

Cross Section of Normal Muscle


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Compartments and Cross Section WithCompartment Syndrome


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CAST CUTTING

Casts may be cut for different reasons to allow for wound dressings,

to examine a painful area, or

to relieve pressure.

Nursing personnel may be required to assist

with cast cutting at the bedside as anemergency measure.

C S C G


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CAST CUTTING

a. Bivalving the Cast. Bivalving is the recommended method for

emergency cutting to relieve pressure.

In bivalving, the cast must be cut along itsentire length on two sides (medial and lateral)and the base lining or padding cut completelydown to the skin.

To cut the cast, use a knife, a hand cutter, or anelectric cast cutter.

Use bandage scissors to cut the base material. Touse a knife for emergency cast cutting, follow thesesteps.


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FAILURE OF UNION


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FAILURE OF UNION

malunion fracture healing is not stopped but slowed

prevention of malunion

reduce and immobilize properly be sure client understands limits on activity and position

delayed union

fracture does not heal

more common with multiple fracture fragments

no evidence of fracture healing four to six months afterthe fracture

GENERAL NURSINGMANAGEMENT OF THE PATIENT


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MANAGEMENT OF THE PATIENTWITH A CAST

(1) Check the edges of the cast and all skinareas where the cast edges may causepressure.

If there are signs of edema or circulatoryimpairment, notify the charge nurse orphysician immediately.

(2) Slip your fingers under the cast edges to

detect any plaster crumbs or other foreignmaterial. Move the skin back and forthgently to stimulate circulation.


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(3) Lean down and smell the cast to detect

odors indicating tissue damage.A musty or moldy odor at the surface of the

cast may be the first indication that necrosisfrom pressure has developed underneath.

(4) Check the integrity of the cast bylooking for cracks, breaks, and soft spots.

A th t d t b h ki th f ll i


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Assess the casted part by checking the following.

(1) Assess circulation by performing the blanching

test and comparing the skin temperature andblanching reaction of the affected limb to that ofthe unaffected limb.

(2) Assess the presence of sensation in the

affected limb by touching exposed areas of skinand instructing the patient to describe what hefelt.

(3) Assess the motor ability of the affected limb byhaving the patient wiggle his fingers or toes.

P ti t d ti


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Patient education(1) Avoid resting cast on hard surfaces or sharp

edges that may dent the cast and causepressure areas.

(2) Never use a coat hanger or other foreignobject to "scratch" inside the cast. This may

cause skin damage and infection.(3) Report any danger signs to the nursing staffimmediately. Danger signs include pale, cold fingers or

toes, tingling, numbness, increased pain, pressure

spots, odor, or feeling that the cast has become tootight.

(4) Report any damage to the cast such ascracks, breaks, or soft spots.

(5) Never attempt to remove or alter the cast.


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E t l Fi ti D i


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External Fixation Devices

Used to manage open fractureswith soft-tissue damage

Provide support for complicatedor comminuted fractures

Reassure patient concerned byappearance of device


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E t l Fi ti D i


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External Fixation Devices

Discomfort is usually minimal, and earlymobility may be anticipated with thesedevices

Elevate to reduce edema

Monitor for signs and symptoms of

complications, including infection

Provide pin care (chlorhexidine solution)

Patient teaching


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Patient teaching

Report any signs of infection (redness,swelling, purulent drainage, and fever)

Instruct proper pin care at home; cleantechnique can be observed at home

The nurse instructs pt. and family aboutneurovascular checks (Five Ps) and report

any change promptly

Patient teaching


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Patient teaching

Check the integrity of fixator device, reportany loose pins or clamps immediately

Emphasize the importance of adhering to

weight- bearing instructions to minimizeloosening of the pins

Refer for physical therapy re: ambulationand safe use of ambulatory aids

OPEN REDUCTION AND


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INTERNAL FIXATION

Open reduction surgical procedures wherethe fracture fragments are realigned

It is usually performed with INTERNALFIXATION where screws, plates, pins,wires or nails mat be used to maintain

alignment of the fractured fragments


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Traction


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Traction

The application of pulling force to an injuredbody part or extremity while a countertraction pulls in the opposite direction

The pulling force can be achieved throughthe use of hand (manual traction) or more

commonly the application of weights

All t ti d t b li d i t


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All traction needs to be applied in twodirections. The lines of pull are vectors of

force. The result of the pulling force isbetween the two lines of the vectors offorce.

Countertraction is supplied by


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Countertractionis supplied bythepatient's body weight and

friction against the bed.

Additional countertraction maybe achieved by elevating thehead or foot of the bed or by

application of counter tractionapparatus


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Purposes of Traction


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Purposes of Traction

Reduce muscle spasms

Reduce, realign, immobilize andpromote healing of fractured bones

Reduce deformity

Increase space between opposingforces

Used as a short-term intervention untilother modalities are possible

Principles of Effective Traction


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Whenever traction is applied, acounterforce must be applied;frequently the patients body weight andpositioning in bed supply the counterforce

Traction must be continuous to reduceand immobilize fractures

Skeletal traction is never interrupted



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Principles of Effective TractionWeights are not removed unless

intermittent traction is prescribed

Any factor that reduces pull must be

eliminated

Ropes must be unobstructed and weightsmust hang freely

Knots or the footplate must not touch thefoot of the bed

Types of Traction


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Types of Traction

Skin traction Light traction delivered to a bone bypulling on adhesive strips attached to

the skin of an extremity;

Capable of delivering a traction forceof approximately 10lb

Skin traction


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Skin traction

Used frequently for the reduction offractures in young children

Common example of skin traction:Bucks extension traction

Cervical head halter ( to treat neck

pain)Pelvic traction (sometimes used totreat back pain)

Prior to application of the skin


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Prior to application of the skintraction,

inspect the skin for rashes,abrasions, or signs of circulatory

impairmentthe skin must be healthy inorder to tolerate the traction.

Check with the physician as to whetherthe skin should be shaved

BUCKS EXTENSION TRACTION


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BUCKS EXTENSION TRACTIONThis form of skin traction to the lower limb

provides for straight pull through a single pulleyattached to a crossbar at the foot of the bed.

The limb in traction lies parallel to the bed.

The foot of the bed is routinely elevated to providecounter traction and to keep the patient frombeing pulled down to the foot of the bed.

In Buck's extension traction, the patient isusuallynot allowed to turn and must remainflat on his back.


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RUSSELL TRACTION


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RUSSELL TRACTION

In this form of skin traction, a system of suspension andtraction pull is used.

Adhesive strips are applied as in Buck's extension, and theknee is suspended in a sling. A rope is attached to the

sling's spreader bar.

This rope There is an upward pull from the sling pulley anda forward pull from the pulleys at the foot of the bed.

In Russell traction, the angle between the thigh andthe bed is approximately 20 and there is always slightflexion of both the hip and the knee.

PELVIC TRACTION GIRDLE


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PELVIC TRACTION GIRDLE

ordinarily used for treatment of low back pain andmuscle spasm.

It is fitted snugly and evenly over the iliac crests.

The traction straps, extending on the lateral sideof each thigh, are hooked to a separate rope atmid-thigh level and each rope leads to a separatebut equal weight at the foot of the bed.

The foot of the bed is usually elevated to providecounter traction.

CERVICAL TRACTION HALTER


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CERVICAL TRACTION HALTER

A canvas head halter is used for treatment ofaffections of the cervical spine. The halter fitssnugly under the chin and around the back of thehead against the occipital protuberance.

A pulley rope is attached to the spreader bar thathooks to the top of the harness. The prescribedweights at the end of the pulley rope keep the

patient's neck and cervical spine in a positionspecified by the physician.


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CERVICAL TRACTION


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CERVICAL TRACTIONCrutchfield or Vinke tongs are used for

skeletal traction in the treatment offractures of the cervical spine.

The tong points are inserted in the parietal

area of the skull (just in the outer layers ofthe bone) and the tong is then attached tothe pulling device.

The procedures may be done under localanesthesia in the operating room or on theward.


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The Thomas splint (half ring) is applied ini ith th i fitt d t i l


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various ways: with the ring fitted posteriorlyagainst the ischium or anteriorly in the groin. The

thigh rests in a canvas or bandage-strip sling withthe popliteal space left free.

The Pearson attachment is attached by clamps to

the Thomas splint at knee level. A canvas orbandage-strip sling supports the lower leg andprovides the desired degree of knee flexion.

Afootplate is attached to the distal end of thePearson attachment to support the foot in aneutral position. The heel should be left free.


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ARM TRACTION


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ARM TRACTIONThe type of traction used for the upper

extremities will depend upon the locationof the fracture, any associated injuries, andthe preference of the physician.

As with other body parts, the arm may beimmobilized in skin traction or skeletaltraction.

The position of the arm in traction may besidearm or overhead.


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Preventive Interventions


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Promptly report any alteration insensation or circulation

Provide frequent back care andskin care

Regularly shift position

Special mattresses or otherpressure-reduction devices



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Perform active foot and leg exercises everyhour

Elastic hose, pneumatic compression hose,

or anticoagulant therapy may be prescribedTrapeze to help with movement for patients

in skeletal traction

Pin care

Exercises to maintain muscle tone andstrength

Nursing ProcessAssessmentf th P ti t i T ti


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of the Patient in Traction

Assessneurovascular statusand forcomplications

Assess formobility-relatedcomplicationsof pneumonia, atelectasis,constipation, nutritional problems, urinary

stasis, and UTI

Assess forpain and discomfort

Nursing ProcessAssessmentf th P ti t i T ti


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of the Patient in Traction

Assess emotional and behavioralresponses

Assess coping ability

Assess thought processes

Assess knowledge

NURSING MANAGEMENT OF THEPATIENT IN TRACTION


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PATIENT IN TRACTION

Prevent skin breakdown, nerve pressure,and circulatory impairment

Measures to reduce anxiety Provide and reinforce information

Encourage patient participation in decisionmaking and in care

Encourage frequent visits (family andcaregivers/ nurse) to reduce isolation

Provide diversional activities

NURSING MANAGEMENT OF THEPATIENT IN TRACTION


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PATIENT IN TRACTION

Use assistive devices Arrange consultation with/referral for physical therapy

Prevention of atelectasis and pneumonia Auscultate lungs every 4 to 8 hours Encourage coughing and deep breathing exercises

High-fiber diet Encourage fluids

Identify and include food preferences and encourageproper diet

THE ORTHOPEDIC BED


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THE ORTHOPEDIC BED


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WHEELCHAIRS The folding wheelchair is the most commonly used

mobilization device for a patient who can sit upright.

If leg elevation is required, a special board or legattachment can be secured to the chair and pillow orcushion support provided.

The use of a wheelchair allows the patient to be out ofbed, mobile, and moderately independent.


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WHEELCHAIR


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CRUTCHES

Crutches are used to promote ambulation andindependence in patients with affected lowerextremities.

The use of crutches is a complicated procedurethat is routinely taught by the physical therapydepartment. There are occasions, however,

when the nursing staff will have thisresponsibility.

CRUTCHES


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The physician will prescribe the use of crutchesand the gait (crutch-walking method) to beused.

The prescribed gait depends upon the amountof weight bearing permitted on the affectedleg(s).

The crutches must be "fitted" to the patientand instructions given for the prescribed crutch-walking method.

PREPARATION


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Have the patient lie supine, arms at sides, wearing

a shoe on the unaffected foot.

Using a tape measure, measure from the axilla to

the heel of the shoe and add two inches. Adjustthe crutch shaft to this measurement. Or . . .

Place the crutch along the patient's unaffected

side with the axillary pad at the axilla and thecrutch tip 6 to 8 inches to the side of the heel.

Adjust the crutch to fit this length.

Have the patient stand at the bedside with thecrutches in place and grip the hand bars You


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crutches in place and grip the hand bars. Youshould be able to fit two fingers between the axilla

and the axillary bar when the patient is standing inthe tripod position

Adjust the hand bar so that the


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Adjust the hand bar so that thepatient's elbow is flexed approximately30 when the hand grips the hand bar

Check each crutch for proper fit andask the patient if the crutch feelscomfortable.

CRUTCH WALKING GAITS


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The 4-point gait is used when the patientcan bear some weight on both lowerextremities. Place the patient in the tripodposition and instruct him to do the

following.(1) Move the right crutch forward.

(2) Move the left foot forward.

(3) Move the left crutch forward.

(4) Move the right foot forward.

(5) Repeat this sequence of crutch-foot-crutch-foot for desired ambulation.


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The 3-point gait is used when thepatient should not bear any weight on theaffected leg. Place the patient in the tripodposition and instruct him to do the

following.(1) Move the affected (non-weight bearing) leg

and both crutches forward together.

(2) Move the unaffected (weight bearing) legforward.

(3) Repeat this sequence for desired ambulation.


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The 2-point gait is used when thepatient can bear some weight on both lowerextremities. Place the patient in the tripodposition and instruct him to do the

following.(1) Move the right leg and left crutch forward

together.

(2) Move the left leg and the right crutch forwardtogether.

(3) Repeat this sequence for desired ambulation.


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Swing-through gait is used forpatients with lower extremities that areparalyzed and/or in braces. Place thepatient in the tripod position and instruct

him to do the following:(1) Move both crutches forward together about 6

inches.

(2) Move both legs forward together about 6inches.

(3) Repeat the sequence in rhythm for desiredambulation


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WALKERS AND CANES


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Walkers and canesare generally used as mobilizationaids for patients who can bear weight on the affected leg,but require some support.

When utilizing a walker, the patient should use themuscles of the arms and upper body to help support hisweight. After placing the walker in front of the patient,instruct the patient to ambulate with a walker using thefollowing sequence of moves.

(1) Firmly grasp the hand grips.(2) Move the walker and the affected leg forward about 6 inches.

(3) Move the unaffected leg forward, parallel to the affected leg.

(4) Repeat the sequence for each step.


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WALKERS AND CANES


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When utilizing a cane, the patientshould hold a cane on the unaffected sidewith his elbow slightly flexed and the canetip about 6 inches in front of and 6 inches to

the side of his foot. (A cane is used for balance, rather than physical

support. It is held on the unaffected side to

prevent the patient from "leaning" on it forsupport.)

CANE


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Instruct the patient to ambulate with a cane using

the following sequence.(1) Move the affected leg forward, parallel to the cane.

(2) Move the unaffected leg forward so that the heel isjust beyond the cane.

(3) Move the affected leg forward so that it is even withthe unaffected leg.

(4) Move the cane forward 6 inches to the front and 6inches to the side of the patient (starting position).

(5) Repeat the sequence for desired ambulation. If lesssupport is needed, the cane and the affected leg can bemoved together.


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OtherMusculoskeletal trauma

Contusion


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Injury to the soft tissue

Causes:

Blunt force

Blow Kick or

Fall

S/Sx Ecchymosis, pain swelling

Contusion: Management


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Relieve edema and swellingElevate feet (extremity)

Cold compressmax. of 20minsApply pressure bandage

Apply warm compress

After six hours of injury to promoteabsorption

Sprain and Strain


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Sprain Injury to ligamentous structuresurrounding a joint

Usually caused by wrenching ortwisting

Strain

Injury to muscles or tendons

Caused by twists pull and/or tear


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Sprain and Strain: Management


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Teach the importance of stretching andwarming up exercise before strenuousactivity Elastic bandage may also be applied prior to

activity for additional support

Encourage to adhere to exercise program toregain muscle tone and strength

This is in collaboration with the physicaltherapist

Fracture Todo Na

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