Question

1- What are nursing interventions during bone fractures or sprains?

2- What is the difference between sprains and strains?

3- What are complications of Fractures?

Answer 1

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Answer:

1.

Injury to one part of the musculoskeletal system results in malfunction of adjacent muscles, joints, and tendons.

• A fracture is a complete or incomplete disruption in the continuity of the bone structure and is defined according to its type and extent.
• Fractures occur when the bone is subjected to stress greater than it can absorb.
• When the bone is broken, adjacent structures are affected, resulting in soft tissue edema, hemorrhage into muscles and joints, joint dislocations, ruptured tendons, severed nerves and damaged blood vessels.

Classification

There are several kinds of fracture that may occur in a bone:

• Complete fracture. A complete fracture involves a break across the entire cross-section of the bone and is frequently displaced.
• Incomplete fracture. An incomplete fracture involves a break through only part of the cross section of the bone.
• Comminuted fracture. A comminuted fracture is one that produces several bone fragments.
• Closed fracture. A closed fracture is one that does not cause a break in the skin.
• Open fracture. An open fracture is one in which the skin or mucous membrane wound extends to the fractured bone.

Causes

Fractures may be caused by the following:

• Direct blows. Being hit directly by a great force could cause fracture in the bones.
• Crushing forces. Forces that come into contact with the bones and crush them could also result in fractures.
• Sudden twisting motions. Twisting the joints in a sudden motion leads to fractures.
• Extreme muscle contractions. When the muscles have reached its limit in contraction, it could lead to serious fractures.

Clinical Manifestations

The clinical signs and symptoms of a fracture may include the following but not all are present in every fracture:

• The pain is continuous and increases in severity until the bone fragments are immobilized.
• Loss of function. After a fracture, the extremity cannot function properly because normal function of the muscles depends on the integrity of the bones to which they are attached.
• Displacement, angulation, or rotation of the fragments in a fracture of the arm or leg causes a deformity that is detectable when the limb is compared with the uninjured extremity.
• There is actual shortening of the extremity because of the compression of the fractured bone.
• When the extremity is gently palpated, a crumbling sensation, called crepitus, can be felt.
• Localized edema and ecchymosis. Localized edema and ecchymosis occur after a fracture as a result of trauma and bleeding into the tissues.

Complications

Complications of fractures may either be acute or chronic.

• Hypovolemic shock resulting from hemorrhage is more frequently noted in trauma patients with pelvic fractures and in patients with displaced or open femoral fractures.
• Fat embolism syndrome. After fracture of long bones and or pelvic bones, or crush injuries, fat emboli may develop.
• Compartment syndrome. Compartment syndrome in an extremity is a limb-threatening condition that occurs when perfusion pressure falls below tissue pressure within a closed anatomic compartment.

Assessment and Diagnostic Findings

To determine the presence of fracture, the following diagnostic tools are used.

• X-ray examinations: Determines location and extent of fractures/trauma, may reveal preexisting and yet undiagnosed fracture(s).
• Bone scans, tomograms, computed tomography (CT)/magnetic resonance imaging (MRI) scans: Visualizes fractures, bleeding, and soft-tissue damage; differentiates between stress/trauma fractures and bone neoplasms.
• Arteriograms: May be done when occult vascular damage is suspected.
• Complete blood count (CBC): Hematocrit (Hct) may be increased (hemoconcentration) or decreased (signifying hemorrhage at the fracture site or at distant organs in multiple trauma). Increased white blood cell (WBC) count is a normal stress response after trauma.
• Urine creatinine (Cr) clearance: Muscle trauma increases load of Cr for renal clearance.
• Coagulation profile: Alterations may occur because of blood loss, multiple transfusions, or liver injury.

Medical Management

Management of a patient with fracture can belong to either emergent or post-emergent.

• Immediately after injury, if a fracture is suspected, it is important to immobilize the body part before the patient is moved.
• Adequate splinting is essential to prevent movement of fracture fragments.
• In an open fracture, the wound should be covered with sterile dressing to prevent contamination of the deeper tissues.
• Fracture reduction refers to restoration of the fracture fragments to anatomic alignment and positioning and can be open or closed depending on the type of fracture.

Nursing Management

Nursing management for close and open fractures should be differentiated.

Nursing Assessment

Assessment of the fractured area includes the following:

• Close fracture. The patient with close fracture is assessed for absence of opening in the skin at the fracture site.
• Open fracture. The patient with open fracture is assessed for risk for osteomyelitis, tetanus, and gas gangrene.
• The fractured site is assessed for signs and symptoms of infection.

Diagnosis

Based on the assessment data gathered, the nursing diagnoses developed include:

• Acute pain related to fracture, soft tissue injury, and muscle spasm.
• Impaired physical mobility related to fracture.
• Risk for infection related to opening in the skin in an open fracture.

Planning & Goals

Main Article: 8 Fracture Nursing Care Plans

Planning and goals developed for a patient with fracture are:

• Relief of pain.
• Achieve a pain-free, functional, and stable body part.
• Maintain asepsis.
• Maintain vital signs within normal range.
• Exhibit no evidence of complications.

Nursing Interventions

Nursing care of a patient with fracture include:

• The nurse should instruct the patient regarding proper methods to control edema and pain.
• It is important to teach exercises to maintain the health of the unaffected muscles and to increase the strength of muscles needed for transferring and for using assistive devices.
• Plans are made to help the patients modify the home environment to promote safety such as removing any obstruction in the walking paths around the house.
• Wound management. Wound irrigation and debridement are initiated as soon as possible.
• Elevate extremity. The affected extremity is elevated to minimize edema.
• Signs of infection. The patient must be assessed for presence of signs and symptoms of infection.

Evaluation

The following should be evaluated for a successful implementation of the care plan.

• Pain was relieved.
• Achieved a pain-free, functional, and stable body part.
• Maintained asepsis.
• Maintained vital signs within normal range.
• Exhibited no evidence of complications.

Discharge and Home Care Guidelines

After completion of the home care instructions, the patient or caregiver will be able to:

• Control swelling and pain. Describe approaches to reduce swelling and pain such as elevating the extremity and taking analgesics as prescribed.
• Care of the affected area. Describe management of immobilization devices or care of the incision.
• Consume diet to promote bone healing.
• Mobility aids. Demonstrate use of mobility aids and assistive devices safely.
• Avoid excessive use of injured extremity and observe weight-bearing limits.

Documentation Guidelines

The focus of documentation should include:

• Client’s description of response to pain and acceptable level of pain.
• Prior medication use.
• Level of function.
• Ability to participate in specific or desired activities.
• Signs and symptoms of infectious process.
• Wound/ incision site.
• Plan of care.
• Teaching plan.
• Response to interventions, teaching, and actions performed.
• Attainment or progress toward desired outcomes.
• Modifications to plan of care.
• Long term needs.

For sprains,

A sprain is a stretching or tearing of ligaments — the tough bands of fibrous tissue that connect two bones together in your joints. The most common location for a sprain is in your ankle. Initial treatment includes rest, ice, compression and elevation. Mild sprains can be successfully treated at home.

Diagnosis

During a physical, your doctor will examine your ankle, foot and lower leg. The doctor will touch the skin around the injury to check for points of tenderness and move your foot to check the range of motion and to understand what positions cause discomfort or pain.

If the injury is severe, your doctor may recommend one or more of the following imaging scans to rule out a broken bone or to evaluate in more detail the extent of ligament damage:

• X-ray. During an X-ray, a small amount of radiation passes through your body to produce images of the bones of the ankle. This test is good for ruling out bone fractures.
• Magnetic resonance imaging (MRI). MRIs use radio waves and a strong magnetic field to produce detailed cross-sectional or 3-D images of soft internal structures of the ankle, including ligaments.
• CT scan. CT scans can reveal more detail about the bones of the joint. CT scans take X-rays from many different angles and combine them to make cross-sectional or 3-D images.
• Ultrasound. An ultrasound uses sound waves to produce real-time images. These images may help your doctor judge the condition of a ligament or tendon when the foot is in different positions.

Treatment

Treatment for a sprained ankle depends on the severity of your injury. The treatment goals are to reduce pain and swelling, promote healing of the ligament, and restore function of the ankle. For severe injuries, you may be referred to a specialist in musculoskeletal injuries, such as an orthopedic surgeon or a physician specializing in physical medicine and rehabilitation.

Self-care

For self-care of an ankle sprain, use the R.I.C.E. approach for the first two or three days:

• Rest. Avoid activities that cause pain, swelling or discomfort.
• Ice. Use an ice pack or ice slush bath immediately for 15 to 20 minutes and repeat every two to three hours while you're awake. If you have vascular disease, diabetes or decreased sensation, talk with your doctor before applying ice.
• Compression. To help stop swelling, compress the ankle with an elastic bandage until the swelling stops. Don't hinder circulation by wrapping too tightly. Begin wrapping at the end farthest from your heart.
• Elevation. To reduce swelling, elevate your ankle above the level of your heart, especially at night. Gravity helps reduce swelling by draining excess fluid.

Medications

In most cases, over-the-counter pain relievers — such as ibuprofen (Advil, Motrin IB, others) or naproxen sodium (Aleve, others) or acetaminophen (Tylenol, others) — are enough to manage the pain of a sprained ankle.

Devices

Because walking with a sprained ankle might be painful, you may need to use crutches until the pain subsides. Depending on the severity of the sprain, your doctor may recommend an elastic bandage, sports tape or an ankle support brace to stabilize the ankle. In the case of a severe sprain, a cast or walking boot may be necessary to immobilize the ankle while the tendon heals.

Therapy

Once the swelling and pain is lessened enough to resume movement, your doctor will ask you to begin a series of exercises to restore your ankle's range of motion, strength, flexibility and stability. Your doctor or a physical therapist will explain the appropriate method and progression of exercises.

Balance and stability training is especially important to retrain the ankle muscles to work together to support the joint and to help prevent recurrent sprains. These exercises may involve various degrees of balance challenge, such as standing on one leg.

If you sprained your ankle while exercising or participating in a sport, talk to your doctor about when you can resume your activity. Your doctor or physical therapist may want you to perform particular activity and movement tests to determine how well your ankle functions for the sports you play.

Surgery

In rare cases, surgery is performed when the injury doesn't heal or the ankle remains unstable after a long period of physical therapy and rehabilitative exercise. Surgery may be performed to:

• Repair a ligament that won't heal
• Reconstruct a ligament with tissue from a nearby ligament or tendon

• The treatment for most sprains and strains is similar. For the first 1 to 2 days, use RICE therapy to reduce your pain and swelling.
• Rest: Take it easy. Your healthcare provider will tell you what activities to avoid based on your injury.
• Ice: Apply an ice pack to the injured area for no more than 20 minutes four to eight times a day for 24 to 48 hours. Don't apply ice directly to your skin.
• Compression: Your healthcare provider may ask you to wear an elastic wrap to keep the injured area from swelling and to keep it still. Special boots or a splint may also help keep the injured area from moving too much.
• *Elevation: While sitting or lying down, place the injured area on pillows above the level of your heart.
• A nonsteroidal anti-inflammatory drug (NSAID), such as ibuprofen or naproxen, will also help stop pain and swelling.
• Once your pain and swelling ease up, your healthcare provider may recommend certain exercises or physical therapy to increase the strength and flexibility of the injured area and prevent another injury. When you're able to exercise again (wait at least 2 days after your injury), applying a warm compress to the area before exercise will help loosen your muscles.
• To treat a very severe injury, your healthcare provider may apply a cast to keep the injured area still while it heals, or perform surgery.

2. DIFFERENCE BETWEEN SPRAIN AND STRAIN

A sprain occurs when you overstretch or tear a ligament, which is a band of tissue that connects the end of one bone to another. You can sprain your ankle, knee, wrist, elbow, or neck (whiplash) by falling or twisting a part of your body, or when you receive a blow to the body. You may remember feeling a pop when you hurt yourself.

A strain occurs when you pull or stress a muscle or tendon, which is a band of tissue that connects muscle to bone. You may get a strain from lifting something heavy or while playing sports. Strains commonly affect the back and thigh.

3. COMPLICATIONS OF FRACTURE

Early complications

Life-threatening complications

• These include vascular damage such as disruption to the femoral artery or its major branches by femoral fracture, or damage to the pelvic arteries by pelvic fracture.
• Patients with multiple rib fractures may develop pneumothorax, flail chest and respiratory compromise^[1].
• Hip fractures, particularly in elderly patients, lead to loss of mobility which may result in pneumonia, thromboembolic disease or rhabdomyolysis.

Local

• Vascular injury.
• Visceral injury causing damage to structures such as the brain, lung or bladder.
• Damage to surrounding tissue, nerves or skin.
• Haemarthrosis.
• Compartment syndrome (or Volkmann's ischaemia)^[2].
• Wound Infection - more common for open fractures.
• Fracture blisters^[3].

Systemic

• Fat embolism^[4].
• Shock.
• Thromboembolism (pulmonary or venous).
• Exacerbation of underlying diseases such as diabetes or coronary artery disease (CAD).
• Pneumonia.
• Compartment syndrome
• Fat embolism
• Fracture blisters

These are a relatively uncommon complication of fractures in areas where skin adheres tightly to bone with little intervening soft tissue cushioning. Examples include the ankle, wrist, elbow and foot.

Fracture blisters form over the fracture site and alter management and repair, often necessitating early cast removal and immobilisation by bed rest with limb elevation. They are believed to result from large strains applied to the skin during the initial fracture deformation, and they resemble second-degree burns rather than friction blisters. They may be clear or haemorrhagic, and they may lead to chronic ulcers and infection, with scarring on eventual healing. Management involves delay in surgical intervention and casting. Silver sulfadiazine seemed in one review to promote re-epithelialisation.

Risk factors, other than site, include any condition which predisposes to poor skin healing, including diabetes, hypertension, smoking, alcohol excess and peripheral arterial disease.

Late complications of fractures

Local

• Delayed union (fracture takes longer than normal to heal).
• Malunion (fracture does not heal in normal alignment).
• Non-union (fracture does not heal).
• Joint stiffness.
• Contractures.
• Myositis ossificans
• Avascular necrosis.
• Algodystrophy (or Sudeck's atrophy).
• Osteomyelitis.
• Growth disturbance or deformity.

Systemic

• Gangrene, tetanus, septicaemia.
• Fear of mobilising.

Problems with bone healing (non-union, delayed union and malunion)

Delayed union is failure of a fracture to consolidate within the expected time - which varies with site and nature of the fracture and with patient factors such as age. Healing processes are still continuing, but the outcome is uncertain.

Non-union occurs when there are no signs of healing after >3-6 months (depending upon the site of fracture). Non-union is one endpoint of delayed union. The distinction between delayed union and non-union can be slightly arbitrary: whilst fractures can generally be expected to heal in 3-4 months, this will vary in the case of open fractures and those associated with vascular injury, and also in the presence of patient risk factors described below. However, non-union is generally said to occur when all healing processes have ceased and union has not occurred.

Malunion occurs when the bone fragments join in an unsatisfactory position, usually due to insufficient reduction.

Factors predisposing to delayed union

• Severe soft tissue damage.
• Inadequate blood supply.
• Infection.
• Insufficient splintage.
• Excessive traction.
• Older age.
• Severe anaemia.
• Diabetes.
• Low vitamin D level.
• Hypothyroidism.
• Medications including NSAIDs and steroids.
• Complicated/compound fracture.
• Osteoporosis.

Factors disposing to non-union
Delayed union and non-union occurs in approximately 5-10% of all fractures but is more common in open long bone fractures (17% non-union) or where there is motion at the fracture site^[7]. Risk factors are all of those above and also:

• Too large a space for bony remodelling to bridge.
• Interposition of periosteum, muscle or cartilage.
• Bony site with a limited blood supply: some sites are more vulnerable to compromise of blood supply by the fracture (eg, scaphoid, femoral head and neck, and tibia).

Presentation of non-union

• Pain at fracture site, persisting for months or years.
• Non-use of extremity.
• Tenderness and swelling.
• Joint stiffness (prolonged >3 months).
• Movement around the fracture site (pseudarthrosis).
• Palpable gap at fracture site.
• Absence of callus (remodelled bone) or lack of progressive change in the callus suggests delayed union.
• Closed medullary cavities suggest non-union.
• Radiologically, bone can look inactive, suggesting the area is avascular (known as atrophic non-union) or there can be excessive bone formation on either side of the gap (known as hypertrophic non-union).

Management of non-union
Non-surgical approaches:

• Early weight bearing and casting may be helpful for delayed union and non-union.
• Bone stimulation can sometimes be used. This delivers pulsed ultrasonic or electromagnetic waves to stimulate new bone formation. It needs to be used for up to an hour every day, and may take several weeks to be effective.
• Medical treatments such as teriparatide have also been used to promote fracture healing, particularly in patients with osteoporosis^[7].

Surgical approaches:

• Debridement to establish a healthy infection-free vascularity at the fracture site.
• Bone grafting to stimulate new callus formation. Bone may be taken from the patient or may be cadaveric.
• Bone graft substitutes/osteobiologics.
• Internal fixation to reduce and stabilise the fracture. (Bone grafting provides no stability.)
• Depending on the type of non-union, any combination of the above^[6].

Myositis ossificans

Myositis ossificans occurs when calcifications and bony masses develop within muscle and can occur as a complication of fractures, especially in supracondylar fractures of the humerus^[5]. The condition tends to present with pain, tenderness, focal swelling, and joint/muscle contractures. Avoid excessive physiotherapy; rest the joint until pain subsides; NSAIDs may be helpful; and consider excision after the lesion has stabilised (usually 6-24 months). It may be difficult to distinguish from osteogenic sarcoma.

Algodystrophy

Algodystrophy, also known as Sudeck's atrophy, is a form of reflex sympathetic dystrophy (or complex regional pain syndrome type 1), usually found in the hand or foot. More than 40% of reflex sympathetic dystrophies follow trauma, notably fractures. A continuous, burning pain develops, accompanied at first by local swelling, warmth and redness, progressing to pallor and atrophy. Movement of the afflicted limb is very restricted. Treatment is usually multi-pronged:

• Rehabilitation - physiotherapy and occupational therapy to decrease sensitivity and gradually increase exercise tolerance.
• Psychological therapy.
• Pain management - often difficult and with a disputed evidence base. Approaches used are neuropathic pain medications (eg, amitriptyline, gabapentin, opioids), steroids, calcitonin, intravenous bisphosphonates and regional blocks.

Iatrogenic complications of fracture treatment

Casts
Poor cast placement may lead to problems of malunion, either because the bones are not accurately aligned or because the fracture is not sufficiently immobilised.

Prolonged cast immobilisation, or 'cast disease', can create circulatory disturbances, inflammation, and bone disease resulting in osteoporosis, chronic oedema, soft tissue atrophy, and joint stiffness. Good physiotherapy will help avoid these problems. Casts may also cause:

• Pressure ulcers.
• Thermal burns during plaster hardening.
• Thrombophlebitis.

Patients need clear information on managing a cast - for example, on keeping it dry, on reporting increased pain or tingling/numbness. Sharp edges rubbing on the skin may need to be trimmed or filed. Poor cast management leading to wetness of the skin beneath the cast can affect skin integrity, which increases the risk of infection.

Casts lead to some loss of bone density in the affected limb, a phenomenon which is seen regardless of the type of casting or skill involved^[9].

Traction
Traction prevents patients mobilising, causing additional muscle wasting and weakness. Other complications of traction include:

• Pressure ulcers.
• Pneumonia/urinary tract infections.
• Permanent footdrop contractures.
• Peroneal nerve palsy.
• Pin tract infection.
• Thromboembolism.

External fixation
Problems caused by external fixation include:

• Pin tract infection.
• Pin loosening or breakage.
• Interference with movement of the joint.
• Neurovascular damage due to pin placement.
• Misalignment due to poor placement of the fixator.
• Psychological complications: external fixation can have a massive psychological impact on the patient. Altered body image and a sense of visible disability, deformity or mutilation can occur. Some patients have to adjust their device and assist with pin site care, and this may also be frightening. Provision of adequate information before fixation, where possible, and support and information after the procedure are an essential part of care.