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Orthopedic 2

third degree sprain
1. complete rupture of the ligamentous attachment
2. severe edema with hematoma
3. usually, severe pain
4. dramatic decrease in active range of motion
5. loss of joint integrity and function
6. management
  - casting
  - surgery to restore integrity of joint
  - see second degree treatment

Fractures: classification and diagnosis
Definition: fracture is any alteration in the continuity of a bone
Fracture dislocation
1. a fracture in which the joint is dislocated in that position, fracture will not heal completely

By completeness
1. complete (bone broken in two or more pieces)
2. incomplete (bone broken but still in one piece)
By wound
1. closed = simple; does not break skin
2. open = compound = complex
  1. bone fragments break through skin
  2. injures soft tissue and often infects tissue
  3. subdivided by degree of soft tissue injury
By fracture line (illustration)
1. longitudinal = linear fracture
2. oblique is produced by a twisting force, and requires traction to heal properly.
3. spiral also results from twisting force, may accompany damage to soft tissue, and requires traction or internal fixation.
4. transverse is caused by angulation, common in pathological fractures, and generally stable after reduction.

By type of fracture
1. avulsion fractures
  1. bone fragments and soft tissue are pulled away from the bone
  2. results from a direct force on the bone
2. comminuted fractures
  1. produced by high energy forces
  2. results in two or more bone fragments
  3. splinters the fragments
  4. injures soft tissue severely
3. compression fractures
  1. often seen in the lumbar spine
  2. may be pathological (a disease weakens bone)
4. greenstick fracture
  1. results in an incomplete fracture
  2. caused by
    - compressionforces
    - angulationforces
  3. cortexof the bone bends to one side and buckles on the other
  4. cortex stays intact on the side subject to tension forces and fractures on the opposing side
  5. requires reduction or completion of the fracture line through the cortex
5. impacted fractures (telescoped)
  1. direct force breaks bone and telescopes the fragment with the smaller diameter into the fragment with the larger diameter
  2. fracture fragments move in unison
  3. rapid union occurs
6. stress fracture
  1. incomplete fracture
  2. result of repetitive trauma to region
  3. two types:
    - fatigue - from repeated trauma
    - insufficiency - pathological fracture

Classification by location in the bone

Fractures: pathophysiology
1. Predisposing factors
  1. biologic
    1. bone density
    2. client's age
2. Extrinsic factors
  1. force - direct or indirect
  2. rate of loading (how fast the force strikes)
3. Intrinsic factors - bone capabilities
4. Pathological fractures
  1. bone is weakened by disease
  2. fractures occur in response to minimal or no applied stress
  3. classification by cause: general or local disorder
    1. general: developmental, nutritional, hormonally controlled
    2. local: neoplasm, infection, cystic lesion
5. Behavioral factors - high-risk activities (such as football, ballet)
Fractures: management
1. Closed reduction
  1. purposes: realign bone fragments for healing, minimal deformity, minimal pain.
  2. pre- and post-reduction x-rays are essential to determine successful reduction of fracture
2. Immobilization
  1. purposes
    1. relieve pain
    2. keep bone fragments from moving
  2. methods: cast - synthetic or plaster, traction - skin or skeletal, splints, braces, and external fixation
  3. types of traction
    1. manual: applied by pulling on the extremity - may be used during cast application
    2. skin: applied by pulling force through the client's skin - used to relax the muscle spasm
    3. skeletal: applied directly through pins inserted into the client's bone - used to align fracture
  4. open treatment (see orthopedic surgery that follows)
1. Stages of bone healing
  1. hematomaformation
  2. fibrocartilage/granulation tissue formation
  3. callus formation
  4. ossification
  5. consolidation/remodeling
2. Evidence of healed fracture
  1. radiographic
    1. presence of external callus or cortical bone across the fracture site
    2. fracture line may remain long after healing
  2. clinical
    1. pieces of bone no longer move at fracture site
    2. no tenderness over fracture site
  3. weight bearing is pain free
Fractures: complications
1. Immediate complications of the injury
  1. shock - higher risk with pelvic and femur
  2. fat embolism- occurs after the initial 24 hours from the injury
  3. compartment syndrome- a nursing emergency
  4. deep venous thrombosis(DVT)
  5. pulmonary embolism - a complication of DVT
2. Delayed complications
  1. joint stiffness
  2. post-traumatic arthritis (osteoarthritis, type II)
  3. reflex sympathetic dystrophy
    1. painful dysfunction and disuse syndrome
    2. characterized by abnormal pain and swelling of the extremity
  4. myositis ossificans
    1. formation of hypertrophic bone near bone and muscles
    2. forms in response to trauma
    3. hypertrophic bone is removed when bone is mature
  5. malunion
    1. fracture healing is not stopped but slowed
    2. prevention of malunion
      1. reduce and immobilize properly
      2. be sure client understands limits on activity and position
  6. delayed union
    1. fracture does not heal
    2. more common with multiple fracture fragments
    3. no evidence of fracture healing four to six months after the fracture
  7. loss of adequate reduction
  8. refracture

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