FRACTURE

ETIOLOGY
1.

Direct force. When a bone is subjected to more stress than it can absorb from an impact with a solid object.

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 a location other than the site of the twisting force.

This type of injury is common in skiing accidents.

ETIOLOGY
3. Muscle contraction
Another indirect force fracture, resulting from powerful contraction of a muscle, may cause the muscles to tear away from the bone, often fracturing or avulsing part of the bone in the process.
This type of injury may occur during a grand mal seizure.

ETIOLOGY
4.

Pathological fracture.
Bones that have become weakened from age or disease are easily fractured, often from 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 feet or lower extremities Common to Soldiers and sports enthusiasts

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 bone resorption

Osteogenesis imperfecta A congenital bone disease characterized by defective collagen production by osteoblasts

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 and synthesis of bone matrix

High-risk

recreation or employment-related activities (e.g., skateboarding, rock climbing)

CLINICAL MANIFESTATIONS
1. Pain.
It is continuous and increases in severity until the bone fragments are IMMOBILIZED 20 minutes after injury muscle spasms occur resulting to a more intense pain

2. Loss

After a fracture, the extremity cannot function properly False motion; abnormal mobility at the fracture site may be present as well.

of function.

3. Deformity

Displacement, angulations or rotation of the fragments of the fracture of the arm or leg causes a deformity It also results from soft tissue swelling, limb shortening caused by muscle spasms in comparison with the uninjured site

(visible or palpable).

CLINICAL MANIFESTATIONS
4.

Shortening of an extremity.
Occurs because of the contraction of the muscles that are attached distal and proximal to the fractured site The fragments often overlap by as much as 2.5 to 5 cm (1-2 inches)

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 and therefore should be AVOIDED

6.

Discoloration and Edema.

Occur after a fracture as a result of trauma or bleeding into the tissues

CLINICAL MANIFESTATIONS
7.

Neurovascular changes

Results from damage to the peripheral nerves or to the associated vascular structures The client may complain of tingling or numbness sensation or have no palpable pulse distal to the fracture

8.

Shock
Bony fragments may lacerate blood vessels Frank or occult hemorrhage can lead to shock

DIAGNOSTIC EVALUATION

Comprehensive history taking

Radiograph (X-ray) the most common method to make the diagnosis of fracture.

CT SCAN used to determine fracture as well as injury to soft tissue associated with fracture Others: CBC to check for a decreased (Hgb snd hct), serum ELECTROLYTES if blood loss and extensive muscle damage has occurred EMG-NCV to detect nerve injury

CLASSIFICATION OF FRACTURES
Bone

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

fractures are classified by:

fracture that is associated with a large amount of nerve, blood vessel, and soft tissue damage is called a complicated fracture. fracture without other damage would be referred to as an uncomplicated fracture.

(according to direction of the fracture line in relation to the bone's

Linear
longitudinal axis.)

SPECIFIC TYPES OF FRACTURE

the fracture is parallel to the long axis of the bone

Transverse

the fracture is perpendicular to the long axis of the bone

(according to direction of the fracture line in relation to the bone's

longitudinal axis.)

SPECIFIC TYPES OF FRACTURE

Longitudinal.

A fracture line that runs along the length of, but not parallel to, the bone's axis.
Oblique

A fracture line that slants across the bone.

(according to direction of the fracture line in relation to the bone's

longitudinal axis.)

SPECIFIC TYPES OF FRACTURE

Spiral

A fracture line that runs across the bone at an oblique angle and coils or spirals around the bone.

SPECIFIC TYPES OF FRACTURE

(according to the condition of the bone)

Complete.

The bone is completely broken or split apart.

Incomplete.

The bone is not completely split and part of the bone remains intact.

SPECIFIC TYPES OF FRACTURE

(according to the condition of the bone)

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 in which there is an open wound associated with the fracture site.

GRADING OF OPEN FRACTURE

(grading of the extent of tissue damage)
Grade

long Grade II larger than 1 cm wound without extensive tissue damage; contamination is moderate Grade III Highly contaminated, has extensive soft tissue damage and is ost severe; wound exceeds 6-8 cm

I Clean wound less than 1 cm

SPECIFIC TYPES OF FRACTURE

(according to the condition of the bone)

Nondisplaced

bone ends retain their normal position

Displaced

bone ends are out of normal alignment

SPECIFIC TYPES OF FRACTURE

(according to the condition of the bone)

Impacted or compressed
The bone ends are wedged or jammed into each other.

SPECIFIC TYPES OF FRACTURE

(according to the condition of the bone)

Depressed

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

SPECIFIC TYPES OF FRACTURE

(according to the condition of the bone)

Comminuted

bone fragments into three or more pieces common in the elderly

SPECIFIC TYPES OF FRACTURE

(according to the condition of the bone)

Greenstick

incomplete fracture where one side of the bone breaks and the other side bends common in children

FRACTURE REPAIR
STEP 1
Bleeding:

produces a clot (fracture hematoma) establishes a fibrous network

Bone

cells in the area die

FRACTURE REPAIR
STEP 2
Cells

of the endosteum and periosteum divide and migrate into fracture zone form which stabilize the break: external callus of cartilage and bone surrounds break
internal callus develops in marrow cavity

Calluses

FRACTURE REPAIR
STEP 3
osteoblasts

replace central cartilage of external callus with spongy bone of spongy bone unite broken ends bone has been removed and replaced

struts

dead

FRACTURE REPAIR
STEP 4
Osteoblasts

and osteocytes continue to remodel the fracture for up to a year. this point any cast or external support can be removed

At

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 bone fracture) 6. Bone remodeling (may take months to years)

FACTORS INFLUENCE THE HEALING TIME OF FRACTURES

If

realignment is poor, the bone ends may not meet or there may be soft tissue interposed between the bone ends. Union will not occur under such circumstances. the immobilization is inefficient, union may not occur.

If

The

age and physical condition of the patient, as well as dietary deficiencies, will affect the healing time.

FACTORS INFLUENCE THE HEALING TIME OF FRACTURES

Additional

factors in healing time are

the type of fracture, its location, and the adequacy of the blood supply to the affected area.
Finally,

the presence of infection will severely handicap healing or prevent it altogether.

EMERGENCY MANAGEMENT
If

fracture is suspected, IMMOBILIZE the body part immediately after the injury before moving the patient fracture are covered with sterile dressing to prevent contamination

Open

THE OBJECTIVES OF THE TREATMENT OF FRACTURES

(1) To regain and maintain the normal alignment of the injured part. (2) To regain normal function of the injured part.

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

PRINCIPLES OF FRACTURE MANAGEMENT

(1) Reduction.

Reduction is the process of restoring the bone ends (and any fractured fragments) into their normal anatomical positions.
This is accomplished by open or closed manipulation of the affected area, referred to as open reduction and closed reduction.

REDUCTION
(a) Closed reduction is accomplished by bringing the bone ends into alignment by manipulation and manual traction.
X-rays are taken to determine the position of the bones. A cast is normally applied to immobilize the extremity and maintain the reduction.

(b) In open reduction, a surgical opening is made, allowing the bones to be reduced manually under direct visualization.
Frequently,

internal fixation devices will be used to maintain the bone fragments in reduction

PRINCIPLES OF FRACTURE MANAGEMENT

(2) Immobilization. Immobilization is necessary to maintain fracture reduction until healing occurs. Immobilization may be accomplished by external or 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 through the bone, provide internal immobilization of the bone.

PRINCIPLES OF FRACTURE MANAGEMENT

(3)

Rehabilitation. Rehabilitation is the regaining of strength and normal function in the affected area.
Specific rehabilitation for each patient will be based upon the type of fracture and the methods of reduction and immobilization used. The physician will generally consult with the physical therapist to develop an individualized rehabilitation plan for each patient. This plan is normally implemented and controlled by the physical therapy department.

NURSING MANAGEMENT OF A PATIENT WITH A FRACTURE

a.

b.

Nursing care of a patient with a fracture, whether casted or in traction, is based upon prevention of complications while healing. By performing an accurate nursing assessment on a regular basis, the nursing staff can manage the patient's pain and prevent complications.

When assessing a patient with a fracture, 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 or decrease in sensation.
(5) Paralysis. Check the patient's mobility.

In addition to the five P's mentioned above, the patient's level of consciousness and temperature should be checked regularly.
Mental status changes and temperature elevation could indicate the presence of infection.

Reposition the patient as necessary to relieve pressure areas.

Check all dressings, bandages, casts, splints, and traction equipment to ensure that nothing is causing constriction or pressure. Frequent and thorough checking and observation on the part of the nursing staff will promote healing and prevent complications.

LIFE THREATENING COMPLICATIONS

Deep venous thrombosis (DVT)

Anterior tibial or femoral veins May be caused by immobility Findings include calf pain, positive Homan's sign Immediately after operations

anticoagulant therapy antiemboli stockings (usually) sequential compression device (possibly)

Pulmonary embolism (PE)

Blood clot from systemic circulation enters pulmonary circulation Most commonly seen after hip fractures and total hip/knee replacements Occurs in approximately ten percent of patients undergoing hip arthroplasty May be caused by femoral vein manipulation during surgery and therefore occur without signs of DVT

Pulmonary embolism (PE)

Findings include chest pain (pleuritic), sudden shortness of breath, tachycardia, palpitations, or change in mental status If PE is suspected,do not leave client. Get charge nurse to notify health care provider immediately Diagnosis confirmed via ventilation/perfusion scan or pulmonary angiography Continuous IV heparin therapy usually prescribed

Fat embolism
Definition: fat cells enter pulmonary circulation
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

Hemorrhage
Abnormal loss of blood from the body
Most common in fractures of bone marrow producing bones

Gas Gangrene
Gas

gangrene is a severe infection of skeletal muscle caused by the bacteria Clostridium. These bacteria are anaerobes and spore formers normally found in soil and in the intestinal 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 small but deep open wound area, and in wounds that have a compromised blood supply and therefore a decreased oxygen supply.

Gas Gangrene
Nursing

personnel should observe for signs of apprehension, 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 the affected extremity is necessary.

Tetanus.
Tetanus

is an acute infection caused by the tetanus bacillus, another anaerobic spore former. The bacteria is introduced through a wound that has been contaminated with soil, feces, or dust. Toxins that have an affinity for nervous tissue cause hyperirritability, restlessness, muscle rigidity, and tonic muscular spasms of almost every muscle group.

TETANUS
The

patient may have difficulty opening the mouth 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 anticonvulsive drugs.

CASTS
A

rigid, external immobilizing device Uses:

Immobilize a reduced fracture Correct a deformity Apply uniform pressure to underlying soft tissues Provide support and to stabilize a weakened joint

Types of cast
Short-arm

elbow to the palmar crease, secured around the base of the thumb. If the thumb is included, it is known as the Thumb-spica

cast extends from below the

or gauntlet cast.
Long-arm

fold to the proximal palmar crease. The elbow is usually immobilized at a right angle.

cast Extends from the axillary

Long-Arm and Short-Leg Cast and Common Pressure Areas

Types of cast
Short-leg

cast Extends from below the knee to the base of the toes. The foot is flexed at a right angle in a flexed position

Long-leg

and middle third of the thigh to the base of the toes. The knees may be slightly flexed.

cast Extends from the junction upper

Walking

reinforced for strength.

cast A short- or long- leg cast

Types of cast
Body

cast Encircles the trunk spica cast A body jacket that

Shoulder

encloses the trunk and the shoulder and elbow

Hip

spica cast Encloses the trunk and a lower extremity. A double hip spica cast
includes both legs

Casting Materials:
Nonplaster

(Fiberglass)

Water activated polyurethane material having the 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

Nonplaster (Fiberglass)

Characteristic of non plaster cast (Fiberglass): Consist of an open-weave, non absorbent fabric impregnated 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 for hydrotherapy When wet, they are dried with a hair dyer on a cool setting (thorough drying is important to prevent skin breakdown)

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 (an exothermic reaction). The heat given off during this reaction can be uncomfortable to the client, and the nurse should inform 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 cool after about 15min

Plaster
After

the plaster sets, the cast remains wet and somewhat soft; it does not have its full strength 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 sharp edges Cast dents may press on the skin, causing irritation and skin breakdown.

Plaster
Characteristics

of plaster cast:

Plaster cast requires 24 to 72 hours to dry completely A wet plaster cast appears DULL and GRAY, sounds dull on percussion, feels damp and smells musty. A dry plaster cast is WHITE and SHINY, resonant to percussion, odorless and firm.

HEALTH TEACHINGS
Prior

to cast application

Explain condition necessitating the cast Explain purpose and goals of the cast Describe expectations during the casting process: e.g., the heat from hardening plaster

CARE OF THE PATIENT WITH A NEWLY APPLIED CAST

a. Expose a newly applied cast to air circulation.
It should never be covered,

b. Handle a wet cast carefully.

Never use fingers as they will leave indentations, which cause pressure areas within the cast.

CARE OF THE PATIENT WITH A NEWLY APPLIED CAST

c. Provide plastic-covered pillows to support the cast along 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 of cast 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 A NEWLY APPLIED CAST

e. After a cast has cooled and begins to harden, elevate the casted extremity to reduce 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 any areas that cut or put pressure on the skin.

CARE OF THE PATIENT WITH A NEWLY APPLIED CAST

Observe

the extremity encased in plaster for circulatory impairment by comparing fingers or toes of the casted extremity with the uninvolved extremity. should be checked hourly during the first 24 to 48 hours, then every 4 hours.

Circulation

Assessment of circulation on a casted extremity

(1) Check the skin temperature of the injured extremity. It should 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 fingers or toes. (4) Report presence of the above signs and symptoms IMMEDIATELY to avoid possible tissue necrosis; these findings indicate possible ischemia.

Assessment of circulation on a 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 congestion

of tissues.

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 from impaired circulation caused by cast pressure.
(3)

FINISHING THE DRY CAST

Cast

edges may have been trimmed and finished with a smooth edge at the time of application or edges may be finished after the cast is dry.

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 the skin. Broken skin surfaces may become infected. (2) Loose bits of plaster from an unfinished cast may become lodged inside the cast, causing itching and irritation. (3) Wrinkled or "bunched-up" edging may result in pressure areas and potential skin breakdown.

COMPLICATIONS
Compartment

syndrome

Occurs when there is an increased pressure within a limited space (e.g., cast, muscle compartment) that compromises 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 the extremity must be elevated no higher than heart level to ensure arterial perfusion If pressure is not restored, a fasciotomy may be necessary to relieved the pressure within the muscle compartment.

Cross Section of Normal Muscle Compartments and Cross Section With Compartment Syndrome

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 an emergency measure.

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 its entire length on two sides (medial and lateral) and the base lining or padding cut completely down to the skin.
To

cut the cast, use a knife, a hand cutter, or an electric cast cutter. Use bandage scissors to cut the base material. To use a knife for emergency cast cutting, follow these steps.

b.

Windowing the Cast.

This procedure is done on specific order of the physician. It is a potentially dangerous procedure because the underlying tissue may bulge through the window opening, causing "window edema. If a window is cut, the piece of plaster removed should be saved.

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 after the fracture

 (1)

GENERAL NURSING MANAGEMENT OF THE PATIENT WITH A CAST

Check the edges of the cast and all skin areas where the cast edges may cause pressure.
If there are signs of edema or circulatory impairment, notify the charge nurse or physician immediately.

(2)

Slip your fingers under the cast edges to detect any plaster crumbs or other foreign material. Move the skin back and forth gently to stimulate circulation.

 (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 necrosis from pressure has developed underneath.

(4)

Check the integrity of the cast by looking for cracks, breaks, and soft spots.

Assess the casted part by checking the following. (1) Assess circulation by performing the blanching test and comparing the skin temperature and blanching reaction of the affected limb to that of the unaffected limb. (2) Assess the presence of sensation in the affected limb by touching exposed areas of skin and instructing the patient to describe what he felt. (3) Assess the motor ability of the affected limb by having the patient wiggle his fingers or toes.

Patient education
(1) Avoid resting cast on hard surfaces or sharp edges that may dent the cast and cause pressure areas. (2) Never use a coat hanger or other foreign object to "scratch" inside the cast. This may cause skin damage and infection. (3) Report any danger signs to the nursing staff immediately.

(4) Report any damage to the cast such as cracks, breaks, or soft spots. (5) Never attempt to remove or alter the cast.

Danger signs include pale, cold fingers or toes, tingling, numbness, increased pain, pressure spots, odor, or feeling that the cast has become too tight.

External Fixation Devices

Used to manage open fractures with soft-tissue damage Provide support for complicated or comminuted fractures

Reassure patient concerned by appearance of device

External Fixation Devices

Discomfort

is usually minimal, and early mobility may be anticipated with these devices to reduce edema

Elevate Monitor

for signs and symptoms of complications, including infection pin care (chlorhexidine solution)

Provide

Patient teaching
Report

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

Instruct proper pin care at home; clean technique can be observed at home

The

nurse instructs pt. and family about neurovascular checks (Five Ps) and report any change promptly

Patient teaching
Check

the integrity of fixator device, report any loose pins or clamps immediately
Emphasize the importance of adhering to weight- bearing instructions to minimize loosening of the pins

Refer

for physical therapy re: ambulation and safe use of ambulatory aids

OPEN REDUCTION AND INTERNAL FIXATION

Open

reduction surgical procedures where the fracture fragments are realigned

It is usually performed with INTERNAL FIXATION where screws, plates, pins, wires or nails mat be used to maintain alignment of the fractured fragments

ORIF

Internal

fixation provides essential immobilization and helps to prevent deformity is not a substitute for bone healing

It

Traction
The

application of pulling force to an injured body part or extremity while a counter traction pulls in the opposite direction

The

pulling force can be achieved through the use of hand (manual traction) or more commonly the application of weights

 All

traction needs to be applied in two directions. The lines of pull are vectors of force. The result of the pulling force is between the two lines of the vectors of force.

Countertraction

the patient's body weight and

is supplied by

friction against the bed.

Additional

countertraction may be achieved by elevating the

head or foot of the bed or by application of counter traction apparatus

Purposes of Traction
Reduce muscle spasms Reduce, realign, immobilize and promote healing of fractured bones Reduce deformity Increase space between opposing forces Used as a short-term intervention until other modalities are possible

Principles of Effective Traction

Whenever

traction is applied, a counterforce must be applied; frequently the patients body weight and positioning in bed supply the counterforce must be continuous to reduce and immobilize fractures traction is never interrupted

Traction

Skeletal

Principles of Effective Traction

Weights

are not removed unless intermittent traction is prescribed factor that reduces pull must be eliminated must be unobstructed and weights must hang freely or the footplate must not touch the foot of the bed

Any

Ropes

Knots

Types of Traction
Skin

traction

Light traction delivered to a bone by pulling on adhesive strips attached to the skin of an extremity;
Capable of delivering a traction force of approximately 10lb

Skin traction
Used frequently for the reduction of fractures in young children Common example of skin traction:
Bucks

extension traction Cervical head halter ( to treat neck pain) Pelvic traction (sometimes used to treat back pain)

Prior

to application of the skin traction,

inspect the skin for rashes, abrasions, or signs of circulatory impairment the skin must be healthy in order to tolerate the traction.
Check

with the physician as to whether the skin should be shaved

BUCKS EXTENSION TRACTION

This

form of skin traction to the lower limb provides for straight pull through a single pulley attached to a crossbar at the foot of the bed. limb in traction lies parallel to the bed.

The The

foot of the bed is routinely elevated to provide counter traction and to keep the patient from being pulled down to the foot of the bed. Buck's extension traction, the patient is usually not allowed to turn and must remain flat on his back.

In

RUSSELL TRACTION

In this form of skin traction, a system of suspension and traction pull is used. Adhesive strips are applied as in Buck's extension, and the knee 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 and a forward pull from the pulleys at the foot of the bed. In Russell traction, the angle between the thigh and the bed is approximately 20 and there is always slight flexion of both the hip and the knee.

PELVIC TRACTION GIRDLE

ordinarily

used for treatment of low back pain and muscle spasm. is fitted snugly and evenly over the iliac crests.

It

The

traction straps, extending on the lateral side of each thigh, are hooked to a separate rope at mid-thigh level and each rope leads to a separate but equal weight at the foot of the bed.
The foot of the bed is usually elevated to provide counter traction.

CERVICAL TRACTION HALTER

A canvas head halter is used for treatment of affections of the cervical spine. The halter fits snugly under the chin and around the back of the head against the occipital protuberance. A pulley rope is attached to the spreader bar that hooks to the top of the harness. The prescribed weights at the end of the pulley rope keep the patient's neck and cervical spine in a position specified by the physician.

Types of traction
Skeletal traction Heavy traction delivered to a broken bone by pulling directly on a metal pin or wire inserted into or through a bone
Capable of delivering a traction force of approximately 40lb. used most frequently in the treatment of fractures of the femur, the tibia, the humerus, and the cervical spine.

significant problem with skeletal traction is the potential for infection, which could
develop in or around the insertion site. The site must be inspected daily for drainage and odor.

The

insertion of pins, wires, or tongs is often done in the operating room under anesthesia. Frequently, the patient will arrive on the ward with most of the traction apparatus already in place.

CERVICAL TRACTION
Crutchfield

or Vinke tongs are used for skeletal traction in the treatment of fractures of the cervical spine. The tong points are inserted in the parietal area of the skull (just in the outer layers of the bone) and the tong is then attached to the pulling device. The procedures may be done under local anesthesia in the operating room or on the ward.

SKELETAL TRACTION FOR THE FEMUR

The

combination of skeletal traction and balanced suspension is widely used for the treatment of fractures of the femoral shaft. This method of treatment provides considerable freedom of body movement while maintaining efficient traction on the injured limb. The Thomas leg splint and Pearson attachment are used to achieve this balanced suspension traction.

 The

Thomas splint (half ring) is applied in various ways: with the ring fitted posteriorly against the ischium or anteriorly in the groin. The thigh rests in a canvas or bandage-strip sling with the popliteal space left free.
Pearson attachment is attached by clamps to the Thomas splint at knee level. A canvas or bandage-strip sling supports the lower leg and provides the desired degree of knee flexion.

The

footplate is attached to the distal end of the Pearson attachment to support the foot in a neutral position. The heel should be left free.

ARM TRACTION
The

type of traction used for the upper extremities will depend upon the location of the fracture, any associated injuries, and the preference of the physician. As with other body parts, the arm may be immobilized in skin traction or skeletal traction. The position of the arm in traction may be sidearm or overhead.

Preventive Interventions
Promptly

report any alteration in sensation or circulation Provide frequent back care and skin care Regularly shift position Special mattresses or other pressure-reduction devices

Preventive Interventions
Perform

hour Elastic hose, pneumatic compression hose, or anticoagulant therapy may be prescribed Trapeze to help with movement for patients in skeletal traction Pin care Exercises to maintain muscle tone and strength

active foot and leg exercises every

Nursing ProcessAssessment of the Patient in Traction

Assess

complications

neurovascular status and for

Assess

for mobility-related complications of pneumonia, atelectasis,

constipation, nutritional problems, urinary stasis, and UTI

Assess

for pain and discomfort

Nursing ProcessAssessment of the Patient in Traction

Assess

emotional and behavioral responses coping ability thought processes knowledge

Assess Assess Assess

NURSING MANAGEMENT OF THE PATIENT IN TRACTION

Prevent

skin breakdown, nerve pressure, and circulatory impairment to reduce anxiety

Measures

Provide and reinforce information Encourage patient participation in decision making and in care Encourage frequent visits (family and caregivers/ nurse) to reduce isolation Provide diversional activities

NURSING MANAGEMENT OF THE PATIENT IN TRACTION

Use

assistive devices of atelectasis and pneumonia

Arrange consultation with/referral for physical therapy

Prevention

Auscultate lungs every 4 to 8 hours Encourage coughing and deep breathing exercises
High-fiber

diet

Encourage fluids Identify and include food preferences and encourage proper diet

THE ORTHOPEDIC BED

 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 leg attachment can be secured to the chair and pillow or cushion support provided. The use of a wheelchair allows the patient to be out of bed, mobile, and moderately independent.

WHEELCHAIR

 CRUTCHES

Crutches are used to promote ambulation and independence in patients with affected lower extremities.

The use of crutches is a complicated procedure that is routinely taught by the physical therapy department. There are occasions, however, when the nursing staff will have this responsibility.

CRUTCHES
The physician will prescribe the use of crutches and the gait (crutch-walking method) to be used. The prescribed gait depends upon the amount of weight bearing permitted on the affected leg(s).

The crutches must be "fitted" to the patient and instructions given for the prescribed crutchwalking method.

PREPARATION
Have

the patient lie supine, arms at sides, wearing a shoe on the unaffected foot. a tape measure, measure from the axilla to the heel of the shoe and add two inches. Adjust the crutch shaft to this measurement. Or . . . the crutch along the patient's unaffected side with the axillary pad at the axilla and the crutch tip 6 to 8 inches to the side of the heel. Adjust the crutch to fit this length.

Using

Place

 Have

the patient stand at the bedside with the crutches in place and grip the hand bars. You should be able to fit two fingers between the axilla and the axillary bar when the patient is standing in the tripod position

Adjust

the hand bar so that the patient's elbow is flexed approximately 30 when the hand grips the hand bar each crutch for proper fit and ask the patient if the crutch feels comfortable.

Check

CRUTCH WALKING GAITS

The 4-point gait is used when the patient can bear some weight on both lower extremities. Place the patient in the tripod position 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-footcrutch-foot for desired ambulation.

CRUTCH WALKING GAITS

The

patient should not bear any weight on the affected leg. Place the patient in the tripod position 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) leg forward. (3) Repeat this sequence for desired ambulation.

3-point gait is used when the

CRUTCH WALKING GAITS

The

patient can bear some weight on both lower extremities. Place the patient in the tripod position 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 forward together. (3) Repeat this sequence for desired ambulation.

2-point gait is used when the

CRUTCH WALKING GAITS

Swing-through

patients with lower extremities that are paralyzed and/or in braces. Place the patient 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 6 inches. (3) Repeat the sequence in rhythm for desired ambulation

gait is used for

WALKERS AND CANES

Walkers and canes are generally used as mobilization
aids for patients who can bear weight on the affected leg, but require some support.

When

muscles of the arms and upper body to help support his weight. After placing the walker in front of the patient, instruct the patient to ambulate with a walker using the following sequence of moves.
(1) (2) (3) (4) Firmly grasp the hand grips. Move the walker and the affected leg forward about 6 inches. Move the unaffected leg forward, parallel to the affected leg. Repeat the sequence for each step.

utilizing a walker, the patient should use the

WALKERS AND CANES

When

should hold a cane on the unaffected side with his elbow slightly flexed and the cane tip 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 for support.)

utilizing a cane, the patient

CANE
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 is just beyond the cane. (3) Move the affected leg forward so that it is even with the unaffected leg. (4) Move the cane forward 6 inches to the front and 6 inches to the side of the patient (starting position). (5) Repeat the sequence for desired ambulation. If less support is needed, the cane and the affected leg can be moved together.

Other Musculoskeletal trauma

Contusion
Injury

to the soft tissue Causes:

Blunt force Blow Kick or Fall
S/Sx

Ecchymosis, pain swelling

Contusion: Management
Relieve

edema and swelling

Elevate feet (extremity) Cold compress max. of 20mins Apply pressure bandage Apply warm compress
After

six hours of injury to promote absorption

Sprain and Strain

Sprain

Injury to ligamentous structure surrounding a joint

Usually

twisting

caused by wrenching or

Strain

Injury to muscles or tendons

Caused

by twists pull and/or tear

Sprain and Strain: Management

R.I.C.E.

approach to recovery

R Rest affected extremity I - Ice Compress for 15-20mins at a time (for 2-3 days) C- Compression elastic support bandages or adhesive tape E-Elevation

Sprain and Strain: Management

Teach

the importance of stretching and warming up exercise before strenuous activity

Elastic bandage may also be applied prior to activity for additional support

Encourage

to adhere to exercise program to regain muscle tone and strength

This is in collaboration with the physical therapist