MGT for fracture:

>Avulsion – a fracture in which a fragment of bone Mnemonic: EroTiCa

has been pulled away by a tendon and its attachment 1. Emmobilization (use of splints etc.)
2. Reduction or Functional reduction – where
>Pathologic – a fracture that occurs through an area
bone is returned to its normal alignment.
of diseased bone (e.g. osteoporosis, bone cyst, 3. Closed reduction – the doctor will manually
Paget’s disease, bony metastasis, tumor); can occur realign the arm or the broken extremity or
without trauma or fall bone.
>Stress – a fracture that results from repeated loading 4. Open reduction with internal fixation (a
of bone and muscle surgical procedure)
>Transverse – a fracture that is straight across the 5. Open reduction with external fixation
6. Traction – after the bone is returned to its
bone shaft
normal alignment, it will be placed that way.
The reason why it will be placed that way
S/sx for fracture: using traction is because there will be
• Pain - especially for the first 48 hrs muscle spasm when there is fracture.
• Swelling – first 48 hrs Without traction, muscle spasm will deform
• Loss of function the bone, there will be malalignment non-
• Pallor/cyanosis union. There’s traction in which ropes or
rope-like devices and weights are used to
Complications of fracture: straighten the bone and keep its normal
• Bleeding alignment.
• Shock >skin traction
• Compartment syndrome >skeletal traction
• Fat embolism – especially if the fracture * The traction was meant to maintain the
ocurs in the femur bone to its normal alignment as well as to
prevent or treat muscle spasms due to the
>s/sx: Restlessness, Decreased LOC, Increased PR, RR, fracture. After the bone is align by traction,
Hypoxia, Chest pain the extremity will be placed in casts or the
• Osteomyelitis broken bone will be placed in casts.
• Malalignment
• Nonunion >2 types of casts:
-plaster of paris
Assessment of s/sx for fracture:
Mnemonic: misPLACED -fiberglass
- Pain (sharp and piercing)
- Loss of function 1. Immobilize
- Abnormal sensation (paresthesia) Use:
- Crepitation (do not elicit: will cause pain) -splints
- Edema (swelling), Erythema (redness), -bandages
Ecchymosis (bruising)
- Deformities -sling
-cover open fractures (sterile gauze)
A fractured limb will manifest these: >Reduction:
Mnemonic: SADdER  Close reduction
- Shortened -because the muscle spasms - the most common treatment for simple
when the person experience fracture)
fractures
- Adduction (Adu-ol) –the limb will be pulled
- the doctor manually manipulates bone
by the muscles closer to the body
ends into realignment
- External Rotation -but there could also be
- -analgesia or conscious sedation is used
internal rotation
before the procedure
RECAP for Complications of fracture: - -x-ray is used to confirm realignment
1. Bleeding – there could be bleeding
especially if long bones are broken;  Open reduction with internal fixation (ORIF):
especially the femur, there’s a large artery manual realignment
there and if it’s broken, will result bleeding.
- the management or treatment for clients
2. Shock – condition in which there is
inadequate blood flow to tissues and organs, who cannot be managed by casts or
either due to loss of volume of blood or due traction
to expansion of blood vessels. - used for: hip fractures
3. Compartment syndrome – occurs during the
rehabilitation phase; during the casting
process
*How is ORIF performed?
4. Fat embolism – especially in long bones in
- Open reduction (OR): surgical incision
adults, there is yellow marrow there and for direct visualization is done = bone
could travel in veins and get lodge in the ends are realigned (reduced)
pulmonary veins or pulmonary capillaries - Internal fixation devices are used to
and cause embolism. keep the bone in place: the use of metal
5. Osteomyelitis - bone infection plates, screws, prosthesis with a femoral
6. Malalignment component (assuming there’s a hip
fracture)
7. Non-union – a type of deformity of the bone
8. Avascular necrosis
 Open reduction with external fixation (OREF)
- for severe bone damage, such as in
*Dx tests for fractures: x-rays
crushed, splintered (comminuted
fractures)
- for patients with open fracture with soft
tissue damage
 *How is OREF performed? -lower extremities are placed 90 degrees off the bed
- Open reduction (OR): surgical incision -buttocks are elevated 1 palm/1 inch of the bed
for direct visualization is performed =
bone ends are realigned (reduced) >Buck’s extension traction (aka boot traction)
- the doctor insert pins into the bone
-used for hip and femur fracture or contracture
- the pins are held in place by external
- for children aged more than 3yo, weighing more than
metal frame (to prevent bone
movement) 40lbs
- -management: remove periodically to assess skin
status
>Traction (after the bone is reduced, placed on traction) -patient should ALWAYS BE ON EXTENSION
- defn: the application of a pulling force to a part of the POSITION of the leg
body
- main purpose: reduction of pain, swelling, and spasm *Sir igor story telling* (short ver)
2 Types of traction: “this is usually used for clients with MVA or motor
1. Skeletal vehicular accidents, but the fracture was not so
- applied directly to bone with metal pin or serious and they were adult, not children and they had
wire this on. It’s a skin traction, and they can actually take
- the weight used there is 8kg (this is a off the boot, but you have to remind of the
rounded off measurement, sir igor’s management there that the client can take off the boot
technique to make it simple)
for only maximum 1 hour per day for cleaning and
2. Skin then you have to put it back on, in order for the
- applied to skin to control muscle spasm and traction to remain effective and to avoid malformation
immobilize the fracture before surgery of the extremity
- weight used to align and keep the >Russel’s traction (Femoral)
extremities straightened is 4kg (again, - for Hip and Femur fractures
rounded off measurement) -advantage: allows/permits hip and knee flexion
Principles of effective traction:
-improvement of Buck’s (because in buck’s, the legs
1. Counteraction – weight of the patient
maintained with the use of shock block to will be straight and that’s quite uncomfortable)
raise the foot of the bed -heel of the bed 20 degrees angle / 5inches above
2. Firm mattress and good body alignment the bed
-sling is applied to prevent external rotation

>Pelvic traction (hips and lumbar spine)

Principles of effective traction: (Cont.)
- not so much used for fractures, but for: low back
3. Line of pull must be continuous
4. Weights must hung freely pain and muscle spasm
5. Ropes must remain unobstructed and -elevate foot of bed to provide countertaction
aligned (otherwise, the traction becomes
ineffective) >Dunlop traction (upper extremities)
-for: elbow fractures
Types of Skin Traction (CBR PD) -Nsg mgt: assess skin status
1. Cervical traction – for cervical fractures -Dunlop traction could be either skin or skeletal
2. Bryant’s traction – this is for less than 3yo and weight traction depending on the pins used.
less than 40lbs children: fractured femur, congenital
hip dislocation
Skeletal Tractions:
3. Buck’s traction aka “boot traction” – for
contractures/fractures of hip and knee Here are devices used for skeletal traction:
– for children more than 3yo and weight more than 1. Steinman Pin
40lbs 2. Kirschner Wire
– disadvantage: the extremity or the leg that is 3. Halo
traction with boot traction is always placed on 4. Tongs
extension 5. Pearson attachment
4. Russel’s traction – for fractured femur, hip and knee
contractures 6. Thomas splint
– permits hip and knee flexion (this is the advantage
of russel’s to Buck’s traction)
5. Pelvic traction – for low back pain and muscle spasms
6. Dunlop traction – used for elbow fractures Nsg mgt for Traction care:
Mnemonics “FRACTURE”
*More detailed discussion*
> Cervical traction – used for neck fractures “F”
- Skin traction – the device used, gardner wells tongs - firm mattress (to prevent ulcers)
(no need for predrilled holes in the skull)(uses spring - foot board (to prevent foot drop)
loaded pins) - free hanging weights (the weights are needed to be
- Skeletal traction – uses crutchfield tongs / vinke hanging, in order to exert the countertraction effect. If
tongs (they are inserted through holes made in the the weights are on the floor, then there will be no
skull with a special drill under local anesthesia) countertraction and there will be a risk for
-management of nurse: massage the occiput of the malalignment and deformity in the fractured limb)
client to the back of the head
“R”
>Bryant’s traction (aka Gallows) - regain the alignment
- used for congenital hip dysplasia, hip and femur -line of pull should be in line with the deformity
fracture -ropes must hang freely
-used for children aged 0-3 yo, weighing less than
40lbs “A”
-both extremity are in traction -assess circulation with 6Ps
 >Pain - a cast is a solid encasing used to immobilize a
>Pallor fractured extremity

2 types of Cast:
Plaster of Paris Fiber glass

Cement Synthetic Nsg mgt in cast care:

*Promote drying:

a.) Plaster of Paris

Cheap Expensive -exposure to room air is encouraged to prevent
uneven drying. If using blowdryer, placed it in warm
setting.
-warn patient of warm feeling as the cast is drying
Dries in 48-72 hours Dries in 10-15 minutes (caused by exothermic reaction of the drying process)
-hold with palms, not fingertips (to avoid indentations.
If there’s indentations, notify physician) Why? The
Absorbent Non-absorbent presence of indentations could cause ulcerations to
the skin inside the cast
-elevate the casted extremity for 48hrs (to prevent
edema) Elevate it in a pillow
No weight bearing Weight bearing allowed -tell patient to notify the nurse or doctor when the
allowed patient feels the hot spots (could be signs of
infection/bleeding)
-watch out for compartment syndrome (6Ps)
(paresthesia,pallor, pulselessness, pain, pressure,
White, smooth Rough, colorful
paralysis) this could indicate increased pressure
inside the fascia. *This is dangerous because it can
>Polar pulselessness damage the nerve, and the nerve may become
>Paresthesia paralyzed, and the blood flow there could be
>Those indicates obstructive circulation of obstructed and it could cause necrosis.
the lower extremity of extremity that is
subjected to traction. b.) Fiberglass
“C” -same management is applicable
Other mgt includes: -advantage: can be wet (but after wetting it, for
-place the patient at the center of the bed example swimming activity, you should dry this
-avoid complications of immobility thoroughly to prevent skin breakdown especially at
-care for pin site: use hydrogen peroxide half-strength the elbow area)
Complications of immobility:
-atelectasis or lung collapse (can be monitored with Types of cast application:
frequent auscultation of the client’s lungs) 1. Short-arm cast – placed below the elbow to
-wasting of bones the palm
2. Long-arm cast – placed from the level of
-function loss
axillary fold to the palm
-urinary stasis - (elbow must be at right angle: functional
-constipation position)
Assist the client in moving:
-Wheel chair (2 or more RNs)
-Logroll (3 or more RNs) 3. Short-leg cast – extends from below the knees
to the toes
4. Long-leg cast – extends from the thigh to toes
“T” (knee flexed)
-trapeze bar could be placed above the patient’s bed, 5. Body cast – encircles trunk
for them to exercise, to move, to prevent wasting, or 6. Shoulder spica cast – a body jacket which
to do ADLS (activities of daily living) encloses trunk, shoulder, and elbow
7. Hip spica cast – encloses the trunk and 1
“U” lower extremity
- prevent urinary retention 8. Double hip spica cast – encloses the trunk
-Nsg mgt: increase fluid intake and 2 lower extremities

“R” Cast care: Plaster of Paris

-watch out for respiratory complications (top priority) - Petal the edges
- Lift with palm, not with fingers (prevent
“E” indentations à prevent pressure)
-ensure that skeletal traction is never interrupted - Air dry
- Skin care PRm (don’t insert sticks or any
foreign objects inside the cast)
- To circle bleeding site (write time)
- Elevate cast
- Regular monitoring (implement: no writing on
CAST the cast) *No writing for plasre of paris, but there can
*After the fractured bone been aligned and alignment is be writing on fiber glass cast.
maintained with traction, and muscle spasm has subsided, the
bone is casted.
 - Watch out for 6PS for Compartment syndrome -Crutch + bad leg, followed by good leg
(secondary to increased pressure within the limited
space) Cane:
-Goal: cane is placed on the opposite of the affected
>mgt: relieve the pressure
1. windowing: remove part of the cast to decrese leg (reciprocal motion) *If affected leg is on the right
pressure and is also used for assessment side, the cane must be placed on the left side.
2. Bivalving: splitting of the cast to decrease Because wherever the cane is, the patient tends to
pressure and is also used for wound care/x-rays lean on that side, you don’t want the patient leaning
3. Fasciotomy: if the cast is fully removed, but still on the affected leg.
the client manifests symptoms of compartment -Cane should be placed 6 inches above the foot when
syndrome, fasciotomy is done.
walking, followed by the bad leg, and then the good
This is done to relieve muscle pressure by making an
incision in the fascia. leg

Walker
-walker is a device with a 4-point support
Other nsg mgt for fracture:
-assess complication to bone healing with x-rays -Goal: nurse must position himself/herself on the
(example: nonunion) affected leg
-assist the client for ROM exercises (range of motion) -walker is positioned 6 inches forward, followed by the
-assist client for isometric exercises (can be done with bad leg, and then the good leg
tensing certain muscles, but not moving their muscle
or shortening the angle
-stay alert for: sensation loss, swelling, hot spots
Scoliosis
(signs of bleeding/infection)
-abnormal lateral curvature of the spine
-most likely hereditary
Assistive devices:
Assessment tests for scoliosis:
*Can be employed after the client has already the cast
- Forward bending test
> Crutches – pressure in the crutch should be placed
- Anterior skyline view
in the hand pad not on armpit, to prevent crutch palsy
Assessment findings:
o Measurement to determine appropriate
- Lateral spinal curve
length of the crutch: - Shoulder are not in level
1. Client lying down: measure the - Asymmetrical waist line
distance from client’s axilla to the sole + - Prominent scapula
2 inches. (That is the advisable length of Scoliosis stages:
the crutch for the client.) 1. Mild scoliosis (<15 degress)
-mgt: stretching exercise
2. Patient’s height is acquired minus (-) 2. Moderate scolios (15-45 degrees)
-mgt: exercises and braces
16 inches.
2 types of braces:
>Milwaukee (for curvature higher than the level T8 or
Nsg Interventions: >t8 curves)
*If the pt is using crutches and is in ideal length: >Boston (for T8 and below curves)
-there must be distance between axilla and armpad
-distance: 2 finger width = 1-2inches 3. Severe (45 degrees)
-mgt: surgery (spinal fusion)
*If pt is using two crutch (crutches) with one leg, that is non- -possible complication: cardiopulmonary bypass
weight bearing, must start if possible from a tripod position Scoliosis mgt:
-Distance between feet to the base of the crutch: 6 -tell the client to wear brace 23 hrs/day (1 hr for
inches (taller-wider) hygiene)
-Distance advancing: 6 inches -pt must wear cotton undershirt (to prevent ulceration
of the skin)
4 point gait:
-put shoulder bag on the lower shoulder
-most stable but slowest gait to use with crutches
(used when both legs are weight bearing)
*The patient will be forced to raise the lower shoulder
-RC, LL, LC, RL (Right crutch, left leg, left crutch,
and help with the restoration to normal angle
right leg)
2 point gait:
-fastes “walking gait” (used when both legs can be
used for partial weight bearing)
-use reciprocal motion Osteogenesis Imperfecta
-RC+LL, LC+RL
-aka brittle bone disease
3 point gait -defn: rare hereditary congenital abnormality
-aka tripod gait characterized by:
-used when leg is non weight bearing
-Crutches + weak leg, strong leg >skeletal bone fragility (risk for bone fractures and
deformity)
Other gaits can be used:
-connective tissue involvement (particularly abnormal
-swing to
-swing through (especailly used for paraplegic eyes, ears, teeth, joints, skin)
amputee with a good upper body strength -Fragility of the bone predisposes the person to
pathological bone fractures and deformities
Going up: ex stairs
-Good leg goes up first, followed by the crutch + bad Patho of OI:
leg -a genetic problem à causes osteoblasts and
fibroblasts synthesis which synthesizes abnormal
Going down: collagen à predisposing the client to multiple fractures
(esp long bones)
 -pt may experience bone deformities (from improper -could be asymptomatic (when disorder is confined to
healing and weak callus formation/thinner shorter one bone)
bones) -pain
-pt may also have fragile and discolored teeth
Dx tests of OD:
-may have loose joints a. X-ray – pagetic bone (punched out areas
indicating increased bone resorption) / overall mass of
S/sx of OI: bone is enlarged
-fragile bones (easily broken or bent) -there will be deformities, fractures, arthritic changes
-triangular shaped face (fineas and ferb) b. Laboratory tests – increased alkaline
-potential hearing loss (probably conductive) phophatase (ALP) (increased in bone damage)
-increased urinary hyrdoxyproline (increased bone
-scoliosis (spine curvature) à may create respiratory
resorption)
problems -increased calcium levels (in both blood and urine)
-loose joints
-alterations in muscle tone or development MGT for OD:
-blue, purple, or gray sclera -medications: to relieve pain and decrease bone loss
-brittle or discolored teeth a. Calcitonin – promotes bone formation
-smooth, thin skin - take for 6 months
b. Biphosphonates (Alendronate: Fosamax) –
-decreased height (may only grow to 3ft tall)
prevents bone resorption by decreasing osteoclast
-barrel-shaped rib cage activity
- given IV for 5 days
Dx tests for OI: c. Plicamycin (mithramycin) – potent anticancer
>Clinical manifestations: frequent fractures without antibiotic
apparent cause (in infant or child) -reserved for severe hypercalcemia or neuro
involvement (secondary to fractures/electrolyte
- client may have 40-100 fractures by puberty
abnormalities)
-born with fractures or die shortly after birth -axn: decreased osteoblasts/osteoclasts within days
>Only test: skin biopsy – assess the collagen fibers -serious adverse effects: liver and kidnery failure
(takes weeks to get results; not definitive) -when liver enzymes is too high, drug is temporarily
discontinued
OI MGT:
-no cure
-treat fractures Hip Replacement
-minimize bone deformities
-splints, casts, braces (aid in healing of fractures and >Total hip replacement
maintaining structure and function) - is an elective procedure
-careful handling of the pt and understand that no >goal: to relieve severe chronic pain and improve
matter how careful you may be, fracture can still occur ability to cary out ADLs when no other treatment is
-support group: Osteogenesis Imperfecta Foundation successful
(excellent resource for family and health care team) *Total hip replacement are total necessary for people
who:
Meds -are in long term steroid therapy (SLE or asthma)
-Biphosphonates: Alendronate (fosamax): bone - have avascular necrosis (AVN): a condition in which
resorption inhibitor – can increase bone density by bone tissue dies (usually in the femoral head) as a
decreasing the activity of osteoclasts result of impaired blood supply. Cause: long term
steroid use, trauma, joint replacement complications

Osteitis Deformans Components of hip replacement: 2 pieced device

a. Acetabular cup (inserted in tto the pelvic
>aka paget’s disease acetabulum)
>defn: metabolic bone disease, characterized by b. Femoral component (inserted into the femur to
increased bone loss and a large disorganized bone replace the femoral head and neck)
deposits throughout the body
>cause: unknown >average life span of total hip replacement (THR): 10
-but thought to be hereditary years
-latent viral infection contracted in young adulthood >non cemented prostheses used in younger patients
>Risk factor: old age/ living in Europe may last longer

Patho of OD: Preop care for THR:

3 phases -crutchwalking
a. Active – prolific increase in osteoclasts causing -autologous blood donation
massive bone deformity and destruction -IV antibiotics to prevent bone infection
b. Mixed – increased in osteoclasts and -pt is often admitted to hospital morning of surgery
osteoblasts activity leading to disorganized bone -pt’s length of stay in the hospital: 3-5 days
formation (depending on pt’s age and progress)
c. Inactive – osteoblastic activity exceeds
osteoclastic activity resulting to malformed bone Prevent hip dislocation:
sclerotic and highly vascular >Abduction pillow – may be used after a total hip
replacement to prevent disclocation of the prosthesis
-most common areas affected by OD: skull, vertebrae, 1. Prevent hip adduction (accross the body’s midline)
pelvis, femur – tell client to avoid crossing of legs or sexy leg pose
-place triangle pillow between legs
S/sx of OD: -if no triangle pillow, use three regular pillows (1
proximal and 2 distal)
 2. Prevent hyperflexion (bending forward more than -If amputation is above the knee (AKA), place the
90 degrees) patient prone to prevent hip contracture
-maximum angle allowed: 90 degrees -Provide emotional support (sign of acceptance:
-client must be sitting in high chairs looking on the amputated extremity or the site of
3. When turning, it is important to turn the hip and legs extremity)
simultaneously
-prevent hyperflexion: sit at 60 degree angle in Nsg Mgt
reclining chair, position is progressd to 90 (max
allowed to prevent hyperflexion) >Intraop
4. While on bed rest:
-use fracture or slipper pan (for defecation) -the level of amputation commonly cannot be
-place pt in supine position with head slightly elevated determined until surgery, when the surgeon can
-pt may be turned to the side (even to the operative directly assess the adequacy of the circulation of the
side/ if pt is comfortable enough) residual limb

Other measures to prevent hip dislocation: >Postop

1. Position – legs should be placed in abduction -at bedside in early postop period: tourniquet is
and wedge pillow is placed in between the thighs placed, because amputation requires severing and
2. Abduction tying off major arteries and veins, hemorrhage,
*prevent hip adduction (across the body’s midline): no although unexpected, is a possible complication
crossing of legs - re-wrap the stump as often as needed
-place triangle pillow between legs -pt: rewrap the stump as often as needed
-three regular pillow if no triangle pillow available (1 (the purpose of rewrapping the stump is to shape the
proximal and 2 distal) residual limb to accept prosthesis and bear weight)
3. No hip flexion greather than 90 degrees -the compression bandaging should be worn at all
-sit on high chairs times for many weeks after surgery and should be
4. Straight Neutral alignment reapplied as needed to keep it free of wrinkles and
-when turning, it is important to trun the hip and legs snug
simultaneously -change dressing daily to allow for inspection of the
5. Tronchanter Rolls – prevent external rotation stump incision

Hip dislocation

-occurs when the femoral components becomes

dislodged from the acetabular cup
-subluxation (partial dislocation) or total dislocation
-the most common postop complication for hip
replacement

S/sx:
- Audible pop followed by pain in affected hip

Signs of hip prosthesis dislocation:

>Shortened
>Adducted
>Externally rotated

Mgt:
- Notify surgeon
- Analgesics
- Under anesthesia, surgeon manipulates the
hip back into alignment and immobilizes the leg until
healing occurs

Amputation

-Highest medical priority: save limb

- the lower the amputation, the higher the chances of
ADLs normal

Nursing care:
-assess vital signs: assess decreased BP, increased
RR and PR
-monitor for bleeding
-prevent edema
-place patient on pillow first 48 hours and elevate the
amputated extremity
-tourniquet is placed at bedside to prevent bleeding
-assess for phantom limb pain
-turn the client to avoid contractures after 48 hours
-If the amputation is below the knee (BKA), place the
patient supine to prevent knee contracture