Care of Patients with Fractures and Amputation

Musculoskeletal System(see video: http://www.youtube.com/watch?v=C2dTbJDQ3u0)

Bone growth (from Brunner and Suddarth) for video see: http://www.youtube.com/watch?
v=X6E5Rz9tOKE

Bone Formation (Osteogenesis)

Bone begins to form long before birth. Ossification is the process by which the bone matrix
(collagen fibers and ground substance) is formed and hardening minerals (eg, calcium salts) are
deposited on the collagen fibers. The collagen fibers give tensile strength to
the bone, and the calcium provides compressional strength. There are two basic processes of
ossification: endochondral and intramembranous. Most bones in the body are formed by
endochondral ossification, in which a cartilage-like tissue (osteoid) is formed, resorbed, and
replaced by bone. Intramembranous ossification occurs when bone develops within membrane, as
in the
bones of the face and skull.

Bone healing (from Brunner and Suddarth) for video see: http://www.youtube.com/watch?
v=qVougiCEgH8

When a bone is fractured, the bone
fragments are not merely patched together
with
scar tissue. Instead, the bone regenerates
itself.
Fracture healing occurs in four areas,
including:
• Bone marrow, where endothelial cells
rapidly undergo transformation
and become osteoblastic bone-forming cells
• Bone cortex, where new osteons are
formed
• Periosteum, where a hard callus/bone is
formed through intramembranous
ossification peripheral to the fracture, and
where a cartilage model is formed through
endochondral
ossification adjacent to the fracture site
• External soft tissue, where a bridging
callus (fibrous tissue)
stabilizes the fracture
Buckwalter (2000) summarized the process
of fracture healing
into six stages stimulated by the release and
activation of biologic
regulators and signaling molecules:
1. Hematoma and inflammation: The body’s
response is similar
to that after injury elsewhere in the body.
There is bleeding
into the injured tissue and formation of a
fracture hematoma.
The hematoma is the source of signaling
molecules, such as
cytokines, transforming growth factor-beta
(TGF-β), and
platelet-derived growth factor (PDGF), which
initiate the
fracture healing processes. The fracture
fragment ends become
devitalized because of the interrupted blood
supply.
The injured area is invaded by macrophages
(large white
blood cells), which débride the area.
Inflammation, swelling,
and pain are present. The inflammatory stage
lasts several
days and resolves with a decrease in pain
and swelling.
2.Angiogenesis and cartilage formation:
Under the influence of
signaling molecules, cell proliferation and
differentiation
occur. Blood vessels and cartilage overlie the
fracture.
3. Cartilage calcification: Chondrocytes in the
cartilage callus
form matrix vesicles, which regulate
calcification of the cartilage.
Enzymes within these matrix vesicles prepare
the
cartilage for calcium release and deposit.
4. Cartilage removal: The calcified cartilage is
invaded by
blood vessels and becomes resorbed by
chondroblasts and
osteoclasts. It is replaced by woven bone
similar to that of
the growth plate.
5. Bone formation: Minerals continue to be
deposited until
the bone is firmly reunited. With major adult
long bone
fractures, ossification takes 3 to 4 months.
6. Remodeling: The final stage of fracture
repair consists of remodeling
the new bone into its former structural
arrangement.
Remodeling may take months to years,
depending
on the extent of bone modification needed,
the function of
the bone, and the functional stresses on the
bone. Cancellous
bone heals and remodels more rapidly than
does compact
cortical bone.  The muscle spasm that
Serial x-ray films are used to monitor the accompanies fracture is a type of
progress of bone natural splinting designed to
healing. The type of bone fractured, the minimize further movement of
adequacy of blood supply, the fracture fragments.
the surface contact of the fragments, and the Loss of function
general health  After a fracture, the extremity
of the person influence the rate of fracture cannot function properly,
healing. Adequate because normal function of the
immobilization is essential until there is x-ray muscles depends on the integrity
evidence of bone of the bones to which they are
formation with ossification. attached.
 Pain contributes to the loss of
Common Diagnostic Exams function.
X-ray  In addition, abnormal movement
 are important in evaluating (false motion) may be present.
patients with musculoskeletal Deformity
disorders.  Displacement, angulation, or
 determine bone density, texture, rotation of the fragments in a
erosion, and changes in bone fracture of the arm or leg causes
relationships. a deformity (either visible or
 reveals any widening, narrowing, palpable) that is detectable when
or signs of irregularity. the limb is compared with the
 Joint x-rays reveal fluid, uninjured extremity.
irregularity; spur formation,  Deformity also results from soft
narrowing, and changes in the tissue swelling.
joint structure. Shortening
Magnetic Resonance Imaging  In fractures of long bones, there
 is a non-invasive imaging is actual shortening of the
technique that uses magnetic extremity because of the
fields, radio waves, and contraction of the muscles that
computers to demonstrate are attached above and below
abnormalities of soft tissues such the site of the fracture. The
as muscle, tendon, cartilage, fragments often overlap by as
nerve, and fat. much as 2.5 to 5 cm (1 to 2
CT-Scan inches).
 scan shows in detail a specific Crepitus
plane of involved bone and can  When the extremity is examined
reveal tumors of the soft tissue with the hands, a grating
or injuries to the ligaments or sensation, called crepitus, can be
tendons. felt. It is caused by the rubbing
 It is used to identify the location of the bone fragments against
and extent of fractures in areas each other.
that are difficult to evaluate Swelling and discoloration
Arthroscopy
 is a procedure that allows direct
 Localized swelling and
discoloration of the skin
visualization of a joint to
(ecchymosis) occurs after a
diagnose joint disorders.
fracture as a result of trauma
 Treatment of tears, defects, and and bleeding into the tissues.
disease processes may be These signs may not develop for
performed through the several hours after the injury.
arthroscope.
 Types of Fractures
FRACTURES-a break in the continuity of Complete
the bone and is defined
 involves a break across the
according to its type and extent.
entire cross-section of the bone
-occur when the bone is
and is frequently displaced
subjected to stress greater than
(removed from normal position).
it can absorb.
Incomplete
 the break occurs through only
Clinical Manifestations
part of the cross-section of the
Pain
bone.
 The pain is continuous and
Traumatic
increases in severity until the
 are caused by a direct blow or
bone fragments are immobilized.
impact
  can be displaced or purposes of a cast are to
nondisplaced. immobilize a body part in a
 If the fracture is displaced, the specific position and to apply
bone is broken in such a way that uniform pressure on encased soft
it has changed in position tissue.
(dislocated). Traction
 Treatment of a traumatic  is the application of a pulling
fracture depends on the location force to a part of the body.
and extent of the break and  is used to minimize muscle
whether it is displaced. spasms;
Pathologic  to reduce, align, and immobilize
 a fracture that occurs through an fractures;
area of diseased bone (eg,  to reduce deformity;
osteoporosis, bone cyst, Paget’s  and to increase space between
disease, bony metastasis, opposing surfaces.
tumor); can occur without  must be applied in the correct
trauma or a fall direction and magnitude to
Close/Simple obtain its therapeutic effects.
 is one that does not cause a Cervical Tractions
break in the skin.  is a simple chiropractic
Open/Compound procedure used to correct the
 is one in which the skin or alignment of the entire spinal
mucous membrane wound column.
extends to the fractured bone.  The advantage of this kind of
Open fractures are graded procedure is that it can be done
according to the following at home, without direct
criteria: supervision of a health
 • Grade I is a clean wound less practitioner.
than 1 cm long. Halo Vest
 • Grade II is a larger wound  skeletal type of traction that as
without extensive soft tissue indicated for the treatment of
damage. fractures or dislocations of
 • Grade III is highly cervical or high thoracic
contaminated, has extensive vertebrae.
soft tissue damage, and is the Skin
most severe.
 involves the application of a
pulling force directly to the skin
Medical Management
through the use of skin strips,
Reduction
boots, or foam splints.
 Reduction of a fracture
(“setting” the bone) refers to  Bryant’s
restoration of the fracture  traction on the lower limb placed
fragments to anatomic alignment vertically, employed especially in
and rotation. fractures in the femur of
Open children.
 Through a surgical approach, the  Buck’s
fracture fragments are reduced.  is the most commonly used form
Internal fixation devices (metallic of skin traction. For Buck’s
pins, wires, screws, plates, nails, traction, a foam boot is applied
or rods) may be used to hold the to the client’s affected extremity
bone fragments in position until and attached to a weight that is
solid bone healing occurs. suspended off the foot of the
Closed bed.
 is accomplished by bringing the Internal/External Fixation
bone fragments into apposition
(ie, placing the ends in contact)
 Internal fixation- a surgical
procedure that stabilizes and
through manipulation and
joins the reduced fracture by the
manual traction. The extremity is
use of metal screws, plates,
held in the desired position while
nails, and pins, used with open
the physician applies a cast,
redeuction.
splint, or other device.
 External fixation-the
Casts
immobilization of the fracture
 a rigid external immobilizing
fragment with the use of certain
device that is molded to the
devices like bandages, casts,
contours of the body. The
 splints, continuous tractions and healing. It is vital to increase the
external fixators. food intake to aid in the
reparative process and see to it
Nursing Management that the ability of the client to
Pain relief eat and swallow is not impaired.
 Administer opioid analgesics to Be aware of complaints like
treat mild, moderate to severe nausea and vomiting. Any
pain and also non-opiod abnormal laboratory values
analgesics to also reduce the should be assessed as possible
inflammatory process thereby evidence of poor nutrition.
reducing pain.  Casts/tractions/fixations care
Promote mobility  Cast Care
 The nurse encourages patients  Do’s:
with closed (simple) fractures to  Apply ice directly over fracture
return to their usual activities as site for 1st 24 hours wet by
rapidly as possible. keeping ice in plastic bag and
 Participation in activities of daily protecting cast with cloth.
living (ADLs) is encouraged to  Check with health care provider
promote independent functioning before getting fibreglass cast
and self-esteem. wet.
 Gradual resumption of activities  Dry cast thoroughly after
is promoted within the exposure to water.
therapeutic prescription.  Blot dry with towel
 With internal fixation, the  Use hair dryer on low
surgeon determines the amount setting until cast is
of movement and weight-bearing thoroughly dry.
stress the extremity can  Muscles:
withstand and prescribes the  Strengthening exercise for upper
level of activity. extremities
 It is important to teach exercises  Strengthening exercise for lower
to maintain the health of extremities
unaffected muscles and to
 Preparation for crutch walking
increase the strength of muscles
needed for transferring and for  Vascular Occlusion
using assistive devices.  Paralysis
 The nurse and physical therapist  Paresthesia
teach patients how to use  Pulselessness
assistive devices safely.  Pallor
Maintaining skin integrity  Pain
 The objectives of management  Fixation care
are to prevent infection of the  assesses the pain prior to
wound, soft tissue, and bone and administration of analgesics.
to promote healing of soft tissue  Pin sites and wounds must be
and bone. regularly assessed for signs of
 The nurse administers tetanus infection and pins should be
prophylaxis if indicated. checked for loosening.
 Serial irrigation and débridement  Wound healing progress should
are used to remove anaerobic be assessed, and carefully
organisms. Prompt, thorough documented.
wound irrigation and  Be alert to more specific signs of
débridement in the operating infection.
room are necessary.
Maintain neurologic function Complications
 Assess for any neurologic Shock
complaints like loss of sensation  Hypovolemic or traumatic shock
in certain areas and inability to resulting from hemorrhage (both
move affected parts, pain, or visible and nonvisible blood loss)
tenderness, or numbness and and from loss of extracellular
tingling so that proper fluid into damaged tissues may
intervention can immediately be occur in fractures of the
given. extremities, thorax, pelvis, or
Increased nutritional need spine. Because the bone is very
 The client’s nutritional status vascular, large quantities of
greatly affects bone and wound blood may be lost as a result of
 trauma, especially in fractures of  or Volkmann’s contracture is a
the femur and pelvis. limb deformity that results from
Compartment syndrome unrelieved compartment
 is a complication that develops syndrome. As prolonged pressure
when tissue perfusion in the causes ischemia, muscle is
muscles is less than that gradually replaced by fibrous
required for tissue viability. The tissue that traps tendons and
patient complains of deep, nerves
throbbing, unrelenting pain,
which is not controlled by AMPUTATION-is the removal of a body part,
opioids. This pain can be caused usually an extremity.
by (1) a reduction in the size of Used to:
the muscle compartment to relieve symptoms
because the enclosing muscle to improve function
fascia is too tight or a cast or to save the patient’s quality of life
dressing is constrictive, or (2) an
increase in muscle compartment Types of Amputations
contents because of edema or MINOR AMPUTATION
hemorrhage associated with a -are amputations where only a toe or
variety of problems (eg, part of the foot is removed.
fractures, crush injuries). The
forearm and leg muscle MAJOR AMPUTATION
compartments are involved most -are amputations where part of the leg
frequently. is removed
Fat Embolism
 After fracture of long bones or Above-Knee Amputation-In this
pelvis, multiple fractures, or operation the bone in the thigh
crush injuries, fat emboli may (femur) is divided about 12-15 cms
develop. Fat embolism syndrome above the knee joint and the
occurs most frequently in young
muscle and skin closed over the
adults (typically those 20 to 30
years of age) and elderly adults end of the bone.
who experience fractures of the
proximal femur. At the time of Mid-thigh amputation
fracture, fat globules may move involves circular incision over the
into the blood because the distal femur, creating large
marrow pressure is greater than anterior and posterior skin flaps,
the capillary pressure or because transecting fasciae and muscles.
catecholamines elevated by the
patient’s stress reaction mobilize Burgess Technique
fatty acids and promote the
development of fat globules in • posterior myoplastic flap
the bloodstream. The fat • the skin and muscle from the calf are
globules (emboli) occlude the brought forward to cover the shin
small blood vessels that supply bones after they have been divided
the lungs, brain, kidneys, and
other organs. Kingsley Robinson Tech.
Cast syndrome
 psychological (claustrophobic • skew flap
reaction) and physiologic
(superior mesenteric artery • muscles of the calf are brought
syndrome) responses to forward in the same way as in the
confinement in body cast. posterior technique but the skin
Nerve injury
flaps are skewed in relation to the
 Bone fragments and tissue muscle.
edema associated with the injury
can cause nerve damage. Be
Reasons for Amputation
alert for pallor, coolness of the
client’s affected extremity
changes in the client’s ability to Diabetic Gangrene
move the digits or the extremity,
paresthesia or complaints of A gangrene (a death tissue generally
increasing pain. with loss of vascular (nutritive)
Volkmann’s Syndrome supply and followed by bacterial
invasion and putrefaction.), usually
 involving the lower extremities, that burning sensations, and
develops secondary to sensory gabapentin (Neurontin) or
peripheral neuropathy and peripheral amitriptyline (Elavil) can be used
vascular disease complications for nerve pain.
related to the diabetic disease
process • To complement traditional
therapy, a number of therapies
Tissue Necrosis may be useful, including
biofeedback, massage, imagery,
• When body tissue dies, infection hypnosis, acupuncture,
can set in, causing dangerous acupressure, and distraction
conditions such as gangrene.
Helping Achieve Physical Mobility
Infection
• To reduce surgical swelling, cold
• The infection sites provide a application may be ordered.
stronghold to dangerous bacteria,
which can spread to other parts of • If the hip becomes contracted,
the body using a prosthesis will not be
possible because patient will not
Neoplasm be able to walk.

• It is an abnormal mass of tissue • The patient should avoid

as a result of neoplasia positions of flexion such as
sitting for long periods
• The growth of the cells exceeds,
and is uncoordinated with that of the • If the patient is able, lying prone
normal tissues around it (on stomach) for 30 minutes four
times daily helps prevent
• usually causes a lump or tumor. contracture
Neoplasms may be benign, pre-
malignant (carcinoma in situ) or • The upper extremitieare
malignant (cancer). exercised and strengthened.s,
trunk, and abdominal muscles
Tissue Trauma
• Patient is taught transfer
• Car accidents, severe burns techniques because amputation
and gunshot wounds are all possible of legs changes the center of
causes of traumatic injury. Blood gravity. Well-fitting shoe should
vessels and other body tissue be used
components can be ripped or
shredded beyond repair by these • Bandage is applied in such a
types of injuries, leaving no other manner that the remaining
option but amputation. muscles required to operate the
prosthesis are as firm as
Nursing Management possible.
Relieve Pain • Patient with upper extremity
amputation should be taught
• Treat the pain aggressively with
how to carry ADLs with one arm.
medications and complimentary
Advised to wear a cotton t-shirt
therapies. The surgeon
to prevent contact with the skin
prescribes medications based on
and shoulder harness and to
the type of pain sensation that
enhance absorption of sweat.
patient experiences. For
example, anticonvulsants, such • Bandage is applied in such a
as phenytoin (Dilantin), are used manner that the remaining
for knifelike pain. Beta- blocking muscles required to operate the
agents, such as propanolol
(Inderal), are appropriate for
 prosthesis are as firm as dressing is changed, aseptic
possible. technique is required

• Patient with upper extremity • The nurse instructs the patient

amputation should be taught and family in wrapping the
how to carry ADLs with one arm. residual limb with elastic
Advised to wear a cotton t-shirt dressings.
to prevent contact with the skin
and shoulder harness and to Helping patient to resolve Grieving
enhance absorption of sweat.
• The nurse creates an accepting
Minimizing Altered Sensory Perception and supportive atmosphere in
which the patient and family are
• Keeping the patient active helps encouraged to express and share
decrease the occurrence of the their feelings and work through
phantom limb pain. Early the grief process.
intensive rehabilitation and
stump desensitization with • The support from family and
kneading massage bring relief. friends promotes the patient’s
Distraction techniques and acceptance of the loss.
activity are helpful. In addition to
the nursing interventions, • The nurse helps the patient deal
transcutaneous electrical nerve with immediate needs and
stimulation (TENS), ultrasound, become oriented to realistic
or local anesthetics may provide rehabilitation goals and future
relief for some patients. In independent functioning.
addition, beta-blockers may
Promoting Independent Self-care
relieve dull, burning discomfort;
antiseizure medications control • Practicing an activity with
stabbing and cramping pain; and consistent, supportive
tricyclic antidepressants are supervision in a relaxed
used to improve mood and environment enables the patient
coping ability. to learn self-care skills.
Promotion of Body Image • The patient and the nurse need
to maintain positive attitudes
• Use of the word stump for and to minimize fatigue and
referring to the remaining frustration during the learning
portion of the limb (residual process.
limb) is controversial. Clients
have reported feeling as if they • Complications
were part of the tree when the
tern was used. Phantom Limb Sensation

• Assess the client’s verbal and Infection(Osteomyelitis)

nonverbal references to the
affected area. Some clients Fat-embolism Syndrome
behave euphorically and seem to
have accepted the loss. Do not
jump to the conclusion that
acceptance has occurred. Ask the
client to describe his or her
feelings about changes in the
body image and self-esteem.

Promote Wound Healing

• The residual limb must be

handled gently. Whenever the