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Fracture
break or disruption in the continuity of a bone
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Types of fractures
- complete - break across entire width of bone
- incomplete - break in only part of a bone
- open or compound - skin over bone is broken
- closed or simple - doesn't break skin
- pathologic - spontaneous - fractures because of trauma to bone that has weakened it - osteoporosis, paget's, rickets
- fatigue/stress - most common in athletes
- compression - loading force applied to long axis of a bone - vertebral most common
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Stages of bone healing
- 1. hematoma formation within 48-72 hrs after injury
- 2. hematoma turns into granulation tissue
- 3. callus formation
- 4. osteoblastic proliferation - bone building
- 5. bone remodeling
- 6. bone healing completed within about 6 weeks (up to 6 months in elderly)
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Acute compartment syndrome
- serious condition in which increased pressure within one or more compartments causes massive compromise of circulation to the area
- ischemia-edema cycle
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Pathophysiology of compartment syndrome
- most commonly affects lower leg/arm
- swelling/edema in the compartment and pressure builds, impairing circulation and nerves
- can occur within 6-8 hrs of injury and up 24 hrs later
- fascia is an inelastic tissue that surrounds groups of muscles, blood vessels and nerves so the swelling in the compartment is unable to expand
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Signs of acute compartment syndrome - with fracture injury
- the 6 P's
- Pain
- Pressure
- Paralysis
- Paresthesia
- Pallor
- Pulselessness
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Emergency care for compartment syndrome
- within 4-6 hrs of onset, neuromuscular damage is irreversible; limb can become useless within 24-48 hrs
- monitor compartment pressures
- fasciotomy may be performed to relieve pressure
- pack and dress wound after fasciotomy
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Possible complications/results of compartment syndrome
- infection
- motor weakness
- Volkmann's contractures - shortening of muscle fibers that affect the forearm
- myoglobinuric renal failure (rhabdomylosis)
- crush syndrome
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Crush syndrome - related to fractures
caused by crushing injury that compresses one or more compartments resulting in hemorrhage and edema
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S/S of crush syndrome
- hypovolemia
- hyperkalemia
- rhabdomylosis
- acute tubular necrosis - dark brown urine
- muscle weakness and pain
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Treatment of crush syndrome
- fluids - hypovolemia
- diuretics - hyperkalemia
- dopamine
- kayexhalate - hyperkalemia
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Other complications of fractures (not compartment or crush syndrome)
- hypovolemic shock
- fat embolism syndrome
- venous thromboembolism
- infection
- chronic complications - ischemic necrosis, delayed union
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Fat embolism syndrome
- serious complication resulting from a fracture
- fat globules are released from yellow bone marrow into blood stream
- may go the lung - appears to be a pulmonary emboli but it's fat, not blood
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When assessing site of a possible fracture:
- change in bone alignment
- alteration in extremity length
- change in shape of bone
- pain upon movement
- decreased ROM
- crepitus
- ecchymotic skin
- subQ emphysema with bubbles under the skin
- swelling
- assess neuro status
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What are some special assessment considerations for fractures of the shoulder/upper arm; distal areas of arm; lower extremities and pelvis?
- 1. sitting or standing assessment
- 2. supine
- 3. supine
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Fracture management
- reduction or realignment of bone ends for proper healing
- immobilization
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Immobilization of fractures
- casts
- - if there is drainage under the cast, mark it so the care team can keep track of changes
- - check distal areas for color, warmth, sensation, pulses and cap. refill
- - complications: infection, circulation impairment, peripheral nerve damage, complications of immobility
- traction
- - application of pulling force to the body to provide reduction, alignment and rest at the site
- - maintain correct balance between traction pull and countertraction force
- - never put the weights on the floor; never move them without a doctor's order
- - perform skin assessments
- - clean pins with chlorohexadine
- - perform frequent neuro checks
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Operative procedures to reduce fractures
- open reduction with internal fixation (ORIF)
- external fixation
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Operative procedures for nonunion of bone after a fracture
- electrical bone stimulation
- bone grafting
- bone banking
- low-intensity pulsed ultrasound
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Interventions for relieving pain r/t fracture
- reduction and immobilization of fracture
- pain assessments
- opioid and non-opioid drugs
- RICE
- massage
- baths
- distraction
- relaxation
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Interventions to prevent infection r/t fracture
- strict aseptic technique for dressing changes/wound irrigations
- assess for inflammation
- report purulent drainage immediately
- assess for pneumonia and UTI
- prophylactic antibiotics
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Interventions for impaired physical mobility r/t fracture
- crutches
- walkers
- canes
- exercises in bed
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Interventions for imbalanced nutrition r/t fracture
- diet high in protein, calories, and calcium
- supplemental vitamins B and C
- frequent, small feedings and supplements of high-protein liquids (especially elderly)
- intake of foods high in iron
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Most common wrist/hand fracture
Colles' fracture
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Treatment of choice for hip fractures
- surgical repair - so the elderly patient can get out of bed
- ORIF
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Is the femur more commonly casted or uncasted after it's fractured?
seldom casted because of muscle spasms - repaired ORIF
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What is the chief concern with fractures of the pelvis?
associated internal damage
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What are most compression fractures of the spine associated with?
osteoporosis - multiple hairline fractures result when bone mass diminishes
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Nonsurgical management of compression fractures of the spine
- bedrest
- analgesics
- physical therapy
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Surgical management of compression fractures of the spine
vertebroplasty or kyphoplasty
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Types of amputation
- surgical - planned b/c of severe infection
- traumatic - accidental
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Complications of amputation
- hemorrhage
- infection
- phantom limb pain
- neuroma
- flexion contracture
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Phantom limb pain
- complaints that the body hurts below the site of amputation; feel like the body part is positioned abnormally; occurs early after amputation and fades with time
- pain is intense, burning feeling, crushing sensation or cramping
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Management of phantom limb pain
- must be distinguished from stump pain because treatment is different
- handle the residual limb carefully
- Beta blockers, antiepileptic drugs, antispasmodics, calcitonin and/or neurontin
- opioids do not work!!
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Exercise after amputation
- ROM to prevent flexion contractures
- trapeze and overhead frame on bed to aid with movement
- firm mattress
- prone position q3-4hr to move limb differently and take pressure off bony prominences
- elevation of lower-leg residual limb
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Stump care
wrap it correctly
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Prostheses post-amputation
- devices to help shape and shrink the residual limb and help patient adapt to walk or have some use in arm
- individual fitting and special care
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Complex regional pain syndrome
- can result from a musculoskeletal injury
- poorly understood complex disorder that includes debilitating pain, atrophy, autonomic dysfunction and motor impairment
- collaborative management - pain relief, maintaining ROM, endoscopic sympathectomy (cutting the nerves) and psychotherapy
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Meniscectomy post-op care
- leg exercises begin immediately
- knee imobilizer
- elevation of leg on one or two pillows
- ice
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Torn ligaments
- when the ACL is torn, a snap is felt, the knee gives way, swelling occurs and stiffness and pain follow
- treatment can be nonsurgical or surgical
- complete healing of knee ligaments after surgery can take 6-9 months - generally knee is immobilized; client on crutches
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Tendon ruptures
- rupture of Achilles tendon is common in adults who participate in strenuous sports
- surgical repair and leg immobilization for 6-8 weeks is required for severe damage
- tendon replacement may be needed
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Dislocations/Subluxations
- pain, immobility, alteration in contour of joint, deviation in length of extremity and rotation of extremity
- closed manipulation of the joint performed to force it back into original position
- joint is immobilized until healing occurs
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Strain
- excessive stretching of muscle or tendon when it is weak or unstable
- classified according to severity
- management - RICE; antiinflammatory meds, muscle relaxants, possible surgery
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Sprain
- excessive stretching of a ligament
- first degree - RICE
- second degree - immobilization, partial weight bearing as tear heals
- third degree - immobilization for 4-6 weeks, possible surgery
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Rotator cuff injuries
- shoulder pain; cannot initiate or maintain abduction of the arm at the shoulder
- drop arm test - can't raise their arm above head
- conservative treatment - NSAIDs, PT, sling support, ice/heat
- surgical repair for complete tear
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