wRITE UP FOR OSTEOMYELITIS
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FRACTURE
ETIOLOGY AND RISK FACTORS Fracture is any disruption in the normal continuity of the bone. Fracture results from mechanical overload of the bone, when more stress is placed on the bone than it can absorb. The actual amount of force necessary to cause a fracture may vary greatly, depending on the characteristics of the bone itself. A client with a metabolic bone disease such as osteoporosis, for example, may experience fracture with even minor trauma because the bone is weakened by the pre-existing disorder. Fracture may result from the direct force, as when a moving object strikes the body area over the bone. Force may also be applied indirectly, as when a powerful muscle contraction pulls against the bone. In addition, stress or fatigue can lead to fracture because of the bone's decreased ability to withstand mechanical force. The two types of bone also respond differently to mechanical load. Cortical bone, the compact outer layer, is porous and can tolerate more stress along its axis (longitudinally) than across the bone. Cancellous, or spongy, bone is the dense inner bone material. It contains web like formations and spaces filled with red marrow that make it better able to absorb force than is cortical bone. Bony projections, called trabeculae, separate the spaces and are arranged along lines of stress, making cancellous bone even stronger. Predispositions to fracture results from biologic conditions such as osteopenia (caused by steroid use or Cushing's syndrome) or osteogenesis imperfecta, which alters the strength and composition of the bone. Neoplasm can also increase the risk of fracture. Post menopausal estrogen loss and protein malnutrition lead to decreased bone mass. For persons with healthy bones, fracture can result from high risk recreation or employment related activities (skateboarding, rock climbing). CLASSIFICATION OF FRACTURES A. Closed, non-displaced – fracture that does not extend through mucous membrane or skin B. Open (compound) – bone is broken and an external wound leads down to site of fracture. Trauma graded I-III depending on extent of injury. C. Comminuted (Fragmented) – a fracture causing the bone to splinter/shatter into several small pieces; usually more than one fracture line. D. Displaced – a fracture where fragments are misaligned at the fracture site. E. Oblique – fracture line runs at a 45 degree angle across the bones longitudinal axis. F. Spiral – caused by torsional force or twisting; fracture line twists around bone shaft. G. Impacted – a fracture in which one fragment is driven or telescoped into the other.
H. Greenstick – an incomplete fracture where one side of bone is broken but other side is intact, yet bent. More common in children. GRADING OF FRACTURE ACCORDING TO SEVERITY The simplest classification method is based on whether the fracture is closed or open to the environment. A closed fracture has intact skin over the site of injury, whereas the open fracture is characterized by a beak in the skin over the bone injury. Tissue damage can be extensive with open fractures, which are graded according to their severity: A. Grade I – the wound is smaller than 1 cm; contamination is minimal. B. Grade II – the wound is larger than 1 cm; contamination is moderate. C. Grade III – the wound exceeds 6 to 8 cm; there is extensive damage to soft tissue, nerve, and tendon; and there is a high degree of contamination. CLINICAL MANIFESTATIONS Fracture diagnosis is based on the clients clinical manifestation and history, physical examinations and radiographic findings. Some fractures are immediately obvious; others are detected on the X-ray. Use of the correct radiologic view is essential for adequate evaluation of the suspected fracture. Two views take at the right angle are generally considered to be the minimal number needed for the evaluation, and they should include the joints above and below the suspected fracture to identify additional dislocations or subluxations. Abnormal X-ray findings include soft tissue edema, or displacement of ai in relation to the shift of bone after the injury. Radiographs of the fractured bone show an alteration in its normal contour and a disruption in the normal joint relationship. The fracture line itself demonstrates increased radiolucency. Radiographs are commonly taken before fracture reduction , after reduction, and then periodically during bone healing. Physical assessment may reveal any of the following clinical manifestations: DEFORMITY. Swelling from the local hemorrhage may cause deformity at the fracture site. Muscle spasms can cause limb shortening, a rational deformity, or angulations. On comparison to the uninjured side, the fracture site may also have curves. SWELLING. Edema may appear quickly as a result of localization of serious fluid at the fracture site and extravasation of blood into surrounding tissues. BRUISING. Bruising result from subcutaneous bleeding at the fracture site. MUSCLE SPASM. Frequently accompanying fractures, involving muscle spasm actually serves as a natural splint to decrease further motion of the fracture fragments.
PAIN. If the client is neurologically intact, pain always accompanies fracture; the intensity and severity of pain differ from client to client. Pain is usually continuous, increasing in severity until the fracture is immobilized. It results from muscle spasm overriding of fracture fragments, or damage to adjacent structures. TENDERNESS. Tenderness over the fracture site is caused by underlying injuries. LOSS OF FUNCTION. Any loss of function results either from pain caused by the fracture or from the loss of the lever arm function in the affected extremity. Paralysis may be caused by nerve damage. ABNORMAL MOBILITY and CREPITUS. These manifestation are caused by motion in the middle of a bone or by fracture fragments rubbing together to create grating sensations or sounds. NEUROVASCULAR CHANGES. Neurovascular injury results from the damage to peripheral nerves or to the associated vascular structures. The client may complain of numbness. SHOCK. The client who experiences blood loss or other injuries may need treatment for shock. MEDICAL MANAGEMENT (Fractures) The goal of medical management include prompt and thorough assessment of the client to discover all injuries, reduction and stabilization of the fracture with immobilization, monitoring for complications, and eventual remobilization and rehabilitation.
THOROUGH INITIAL ASSESSMENT Basic principles of trauma care must be followed during emergency management of fractures. Assessment and treatment are performed simultaneously as the rescuer addresses the general condition of the injured client. During primary assessment, the rescuer focuses on airway management, bleeding, and manifestations of shock. Any potentially life-threatening injuries must be stabilized immediately and emergency assistance summoned to transport the client to medical facility for additional intervention. An injured client should not be moved unless the current location is not safe. Because most fractures do not pose a serious threat to life, their management becomes a secondary priority in trauma care. Suspected injuries to extremities should be carefully splinted and moved as little as possible because multiple fractures occur in the same limb. If the client complains of muscle spasm after a cervical spine or head injury, a fracture or dislocation is presumed to be present until radiographs can be performed and interpreted. The rescuer must stabilize the affected area and help the client remain still. An unconscious client should receive emergency management while the rescuer carefully notes any spontaneous movement as well as the client's position, head, and extremities. The rescuer performs neurologic
assessment that is based on the type of known or suspected injury. Any soft tissue damage must also be assessed because the injury may indicate a fracture site. Open fractures should be covered to prevent additional contamination until a thorough examination can occur in the nearest hospital. REDUCING FRACTURES The first step in the management of a displaced fracture is reduction: the manipulation of the fracture to restore alignment, position, and length by bringing the fragments into close approximation. Reduction, which is also called bone setting, alleviates compression or stretching of nerves and blood vessels. Because reduction is generally painful, sedation or local or general anesthesia may be needed. Not all fractures require reduction. Fragments of a displaced fracture, for example, are already in proper alignment. Splinting or casting allows the alignment to be maintained as the fracture heals. A few other fractures cannot be adequately splinted instead are treated simply by resting the affected area until healing occurs. When a fracture of an extremity divides a bone into two fragments, the fragments are referred to as proximal and distal. Because of its muscle attachment and location, the proximal fragment cannot be manipulated or moved when the fractured bone is being set. Instead, the distal fragment is moved to realign it with the proximal bone segment. Reduction methods can be used alone or in combination. Closed Reduction To perform closed reduction, a fragments and restore bone alignment. to decrease the client's risk for loss of and to minimize the possible deforming health care provider applies manual traction to move the fracture Closed reduction should be performed as soon as possible after injury function, to prevent or delay joint degeneration (traumatic arthritis), effects of the injury.
Manual reduction is accomplished through four maneuvers, beginning with a longitudinal pull on the distal end of the fracture or extremity. Because it reverses the mechanism of injury, this pull overcomes any initial muscle spasm, any effects on limb length, and the overriding of bone fragments. Second, the bone ends of the fracture must be disengaged from each other. This is sometimes accomplished by rotating the distal portion of the fracture. In the third maneuver, the fracture fragments are realigned. This is a complex step because forces from various muscle groups have held the fragments in their new positions. Finally, the distraction force is released while alignment is maintained. Because gravity, weight-bearing, and muscle contraction can again move the fragments, an immobilization device must be applied after x-ray studies have confirmed bone alignment. The immobilizer most commonly used after closed reduction is a cast, a temporary deice made of plaster of Paris (anhydrous
calcium sulfate) or synthetic materials such as fiberglass or thermoplastic polymer. Casts are used for several purposed in addition to immobilization: prevention or correction of deformity; maintenance, support, and protection of realigned bone; and promotion of healing in order to allow early weight-bearing for ambulation. Casts may be applied in a hospital emergency department, in the operating room, or at the client's bedside in the hospital. They are also commonly applied in a physician's office or clinic. Open reduction and Internal fixation To perform open reduction, the surgeon makes an incision and realigns the fracture fragments under direct visualization. Open reduction is the treatment of choice for compound fractures that are comminuted or accompanied by severe neurovascular injury; it is also required if fracture fragments are widely separated or if soft tissue is interposed between pieces of bone. Open reduction is usually performed in combination with internal fixation for femoral and joint fractures. Screws, pins, wires, or nails may be used to maintain alignment of the fracture fragments. Rods may also be placed through the fragments or fixed to the side of the bone, or they may be inserted directly into the bone's medullary cavity. Internal fixation provides essential immobilization and helps prevent deformity, but it is not a substitute for bone healing. If proper healing fails to occur, the internal fixation device may actually loosen or break as a result of stress. External fixation Depending on the client's condition and the physician's judgment, external fixation devices may be used for fracture fragment immobilization. If for example, soft tissue damage precludes the use of a cast, external fixation would be indicated for fracture immobilization. External fixation devices maintain position for instable fractures and for weakened muscles, and they support areas with tissue or bone infection. They allow the client to use contiguous joints while the affected area remains immobilized. External fixation may also be indicated for bony non-union if fracture healing has not been successful after a certain time. Common sites for external fixation includes the face and jaw, extremities, pelvis, ribs, fingers, and toes. Traction Traction has been used to treat fractures since prehistoric times, and its principles were well known to Hippocrates. Traction is the application of a pulling force to an injured body part or extremity while a countertraction pulls in the opposite direction. The pulling force can be achieved through the use of hands or, more commonly, the application of weights. With improved surgical technique and the development of femoral prostheses and intramedullary rods, traction is not as prevalent as it once was in the treatment of orthopedic injuries.
NURSING MANAGEMENT Care of the client in a cast Care of the client in external fixation Care of a client in traction
OSTEOMYELITIS
Etiology and pathophysiology Osteomyelitis is a severe pyogenic infection of the bone, bone marrow and surrounding soft tissue. It can be caused by a variety of microbial agents (most common in staphylococcus aureus) and situations, including: • An open injury to the bone, such as an open fracture with the bone ends piercing the skin. • An infection from elsewhere in the body, such as pneumonia or a urinary tract infection that has spread to the bone through the blood (bacteremia, sepsis). • A minor trauma, which can lead to a blood clot around the bone and then a secondary infection from seeding of bacteria. • Bacteria in the bloodstream bacteremia (poor dentition), which is deposited in a focal (localized) area of the bone. This bacterial site in the bone then grows, resulting in destruction of the bone. However, new bone often forms around the site. • A chronic open wound or soft tissue infection can eventually extend down to the bone surface, leading to a secondary bone infection. (Black and Hawks, 2005) The widespread use of antibiotics in conjunction with surgical treatment has significantly reduced the mortality rate and complications associated with osteomyelitis. (Lewis, 2004) Because osteomyelitis can be extraordinarily difficult to cure even with long-term antibiotics, prompt recognition is crucial. Delayed identification or inadequate treatment can result in a chronic infection accompanied by continuing pain, chronically draining sinuses, loss of function, amputation or death. (Black and Hawks, 2005) CAUSATIVE ORGANISMS OF OSTEOMYELITIS ORGANISM POSSIBLE PREDISPOSING PROBLEM Staphylococcus aureus Pressure ulcer,
penetrating wound, open fracture, orthopedic surgery abscessed tooth, vascular insufficiency disorders (e.g. Staphylococcus epidermidis Indwelling prosthetic devices (e.g. joint replacements, fractured fixation de vices) E. coli Urinary tract infections Mycobacterium tuberculosis Tuberculosis Neisseria gonorrhoeae Gonorrhea Pseudomonas wounds, intravenous dug use Salmonella cell anemia Fungi, mycobacteria Immunocompromised host The infecting microorganisms can invade by indirect or direct entry. The indirect entry (hematogenous) of microorganisms in osteomyelitis most frequently affects growing bone in boys less than 12 years old and is associated with their higher incidence of blunt trauma. The most common sites of indirect entry in children are the distal femur, proximal tibia, humerus, and radius. Adults with vascular insufficiency disorders (e.g. diabetes mellitus) and genitourinary and respiratory infections are at higher risk for a primary infection to spread via the blood to the bone. The pelvis and vertebrae, which are vascular-rich sites of bone are the most common sites of infection. (Lewis, 2004) Puncture Sickle
Males are affected more often than females, often as a result of trauma. Susceptibility to infection increases with IV drug use, diabetes, immunocompromising diseases or a history of blood- stream infections. (Black and Hawks, 2005) Direct entry osteomyelitis can occur at any age when there is an open wound (e.g. penetrating wounds, fractures) and microorganisms gain entry to the body. Osteomyelitis may also occur in the presence of a foreign body such as an implant or an orthopedic prosthetic device (e.g. plate, total joint prosthesis ). After gaining entrance to the bone by way of the blood, the microorganisms then lodge in an area of the bone in which circulation slows, usually the metaphysis. The microorganisms grow, resulting in an increase in pressure because of the nonexpanding nature of most bones. This increasing pressure eventually leads to ischemia and vascular compromise of the periosteum. Eventually the infection passes through the bone cortex and marrow cavity, ultimately resulting in cortical devascularization and necrosis. Once ischemia occurs, the bone dies. The area of devitalized bone eventually separates from the surrounding living bone forming sequestra. The part of the periosteum that continues to have blood supply forms new bone called involucrum. (Lewis, 2004) Once formed, a sequestrum continues to be a infected island of bone surrounded by pus and difficult to reach by blood-borne antibiotics or white blood cells (WBCs). Sequestrum may enlarge and serve as a site for microorganisms that spread to other sites, including the lungs and the brain. The sequestrum can move out of the bone and into the soft tissue. Once outside the bone, the sequestrum may revascularize and then undergo removal by normal immune system process. Another possibility is that the sequestrum can be surgically removed through debridement of the necrotic bone. If the necrotic sequestrum is not resolved naturally or surgically, it may develop a sinus tract, resulting n a chronic purulent cutaneous drainage.(Lewis, 2004) Chronic osteomyelitis is either a continuous persistent problem (a result of inadequate acute treatment) or process of exacerbations and remission. Over time, granulation tissue turns to scar tissue. This vascular scar tissue provides an ideal site for continued microorganism growth in impenetrable to antibiotics. (Lewis, 2004) Clinical Manifestations Clinical manifestations may slightly vary according to the site of involvement. Infection in the long bones is accompanied by acute localized pain and redness or drainage often with a history of recent trauma or newly acquired prostheses. Fever and malaise may be present. Infection in the vertebrae usually brings pain and mobility difficulties. The client with vertebral osteomyelitis often reports a history of genitourinary
infection or drug abuse. Osteomyelitis in the foot is most commonly associated with vascular insufficiency. (Black and Hawks, 2005) Acute osteomyelitis refers to the initial infection or an infection of less than 1 month duration. The clinical manifestations of acute myelitis are both systemic and local. Systemic manifestations include fever, night sweat, chills restlessness, nausea and malaise. Local manifestations include constant bone pain that is unrelieved by rest and worsens with activity; swelling, tenderness and warmth at the infection site; and restricted movement of the affected part. Later signs include drainage from sinus tracts to the skin and/or the fracture site. (Lewis, 2004) Chronic myelitis refers to a bone infection that persists for longer than 1 month or an infection that has failed to respond to the initial course of antibiotic therapy. Systemic signs may be diminished, with local signs of infection more common, including constant bone pain and swelling, tenderness and warmth at the infection site. (Lewis, 2004) Diagnostic and Laboratory Examinations Laboratory studies and X-rays or bone scans are important in the definitive diagnosis of osteomyelitis. Elevated WBC and ESR, an elevated level of C-reactive protein (a protein that circulates in the blood and dramatically increases in level when there is inflammation) usually occur. Along with clinical manifestations, usually allow initial diagnosis and early treatment while the physician waits for further evidence from blood cultures or needle aspirate analysis. To diagnose a bone infection and identify the organisms causing it, doctors may take samples of blood, pus, joint fluid, or the bone itself to test. Usually, for vertebral osteomyelitis, samples of bone tissue are removed with a needle or during surgery. Radiographic changes related to osteomyelitis are generally evident within 7 to 10 days, but in some cases the diagnosis is not confirmed on X-rays until 3 to 4 weeks after infection develops. Early acute osteomyelitis is more efficiently identified by radionuclide bone scans, which can detect lesions within 24 to 72 hours after the onset of infection. Because of its ability to distinguish between soft tissue and bone marrow, magnetic resonance imaging It is also being used increasingly for definitive diagnosis of osteomyelitis. To diagnose osteomyelitis, the doctor will first perform a history, review of systems, and a complete physical examination. In doing so, the physician will look for signs or symptoms of soft tissue and bone tenderness and possibly swelling and redness. The doctor will also ask you to describe your symptoms and will evaluate your personal and family medical history. The doctor can then order any of the following tests to assist in confirming the diagnosis:
• Blood tests: When testing the blood, measurements are taken to confirm an infection: a CBC (complete
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blood count), which will show if there is an increased white blood cell count; an ESR (erythrocyte sedimentation rate); and/or CRP (C-reactive protein) in the bloodstream, which detects and measures inflammation in the body. Blood culture: A blood culture is a test used to detect bacteria. A sample of blood is taken and then placed into an environment that will support the growth of bacteria. By allowing the bacteria to grow, the infectious agent can then be identified and tested against different antibiotics in hopes of finding the most effective treatment. Needle aspiration: During this test, a needle is used to remove a sample of fluid and cells from the vertebral space, or bony area. It is then sent to the lab to be evaluated by allowing the infectious agent to grow on media. Biopsy: A biopsy (tissue sample) of the infected bone may be taken and tested for signs of an invading organism. Bone scan: During this test, a small amount of Technetium-99 pyrophosphate, a radioactive material, is injected intravenously into the body. If the bone tissue is healthy, the material will spread in a uniform fashion. However, a tumor or infection in the bone will absorb the material and show an increased concentration of the radioactive material, which can be seen with a special camera that produces the images on a computer screen. The scan can help your doctor detect these abnormalities in their early stages, when Xray findings may only show normal findings.
OUTCOME MANAGEMENT (Osteomyelitis) Elimination of the infecting organisms, both locally from the bone and systemically from the body, is the major treatment goal for osteomyelitis. Prompt treatment also prevents further bone deformity and injury, increases client comfort, and avoids complications of impaired mobility. Surgery is initially performed on the adult client with osteomyelitis to ensure effective debridement and drainage, elimination if dead space, and adequate soft tissue coverage. Antibiotics alone rarely resolve infection in adults, but they do work more efficiently after surgical preparation of the treatment area. High doses of parenteral antibiotics are frequently administered for 4 to 8 weeks to achieve a bactericidal level in the bone tissue. Oral antibiotics are continued for another 4 to 8 weeks, with serial bone scans and ESR measurements performed to evaluate the effectiveness of drug therapy. Open drainage wounds are packed with gauze to promote drainage. If initial treatment is delayed or inadequate, the necrotic bone separates from the living bone to form sequestra, which serves as a medium for additional microorganism growth. Chronic osteomyelitis can result.(Black and Hawks, 2005)
The objective of treating osteomyelitis is to eliminate the infection and prevent the development of chronic infection. Chronic osteomyelitis can lead to permanent deformity, possible fracture, and chronic problems, so it is important to treat the disease as soon as possible. Drainage: If there is an open wound or abscess, it may be drained through a procedure called needle aspiration. In this procedure, a needle is inserted into the infected area and the fluid is withdrawn. For culturing to identify the bacteria, deep aspiration is preferred over oftenunreliable surface swabs. Most pockets of infected fluid collections (pus pocket or abscess) are drained by open surgical procedures. Medications: Prescribing antibiotics is the first step in treating osteomyelitis. Antibiotics help the body get rid of bacteria in the bloodstream that may otherwise re-infect the bone. The dosage and type of antibiotic prescribed depends on the type of bacteria present and the extent of infection. While antibiotics are often given intravenously, some are also very effective when given in an oral dosage. It is important to first identify the offending organism through blood cultures, aspiration, and biopsy so that the organism is not masked by an initial inappropriate dose of antibiotics. The preference is to first make attempts to do procedures (aspiration or bone biopsy) to identify the organisms prior to starting antibiotics. Splinting or cast immobilization: This may be necessary to immobilize the affected bone and nearby joints in order to avoid further trauma and to help the area heal adequately and as quickly as possible. Splinting and cast immobilization are frequently done in children, although motion of joints after initial control is important to prevent stiffness and atrophy. Surgery: Most well-established bone infections are managed through open surgical procedures during which the destroyed bone is scraped out. In the case of spinal abscesses, surgery is not performed unless there is compression of the spinal cord or nerve roots. Instead, patients with spinal osteomyelitis are given intravenous antibiotics. After surgery, antibiotics against the specific bacteria involved in the infection are then intensively administered during the hospital stay and for many weeks afterward. With proper treatment, the outcome is usually good for osteomyelitis, although results tend to be worse for chronic osteomyelitis, even with surgery. Some cases of chronic osteomyelitis can be so resistant to treatment that amputation may be required; however, this is rare. Also, over many years, chronic infectious draining sites can evolve into a squamous-cell type of skin cancer; this, too, is rare. Any change in the nature of the chronic drainage, or change of the nature of the chronic drainage site, should be evaluated by a physician experienced in treating chronic bone infections. Because it is important that osteomyelitis
receives prompt medical attention, people who are at a higher risk of developing osteomyelitis should call their doctors as soon as possible if any symptoms arise.
REFERENCES:
Lewis, S. et. al. Medical – Surgical Nursing: Assessment and Management of Clinical Problems. (6th edition, 2004). Mosby, Inc. USA Black, J. and Hawks, J. Medical – Surgical Nursing: Clinical Management for Positive Outcomes. (7th edition, 2005). Elsevier, Inc. , USA Brunner L.S. & Smeltzer S.C. (2004). Textbook of Medical-Surgical Nursing. J.B. Lippincott Company. USA) Deglin, J.H. & Vallerand, A.H. (2007). Davis’s drug guide for nurses. 10th ed. E.A Davis Co. Philadelphia, Pennsylvania Smeltzer, S.C. & Bare B. C. (2000) Medical- surgical nursing: 9th ed. Philadelphia, Lippincott (2007) Lippincott manual of nursing practice series: Pathophysiology. Philadelphia: Lippincott Williams & Wilkins
ETIOLOGY AND RISK FACTORS Fracture is any disruption in the normal continuity of the bone. Fracture results from mechanical overload of the bone, when more stress is placed on the bone than it can absorb. The actual amount of force necessary to cause a fracture may vary greatly, depending on the characteristics of the bone itself. A client with a metabolic bone disease such as osteoporosis, for example, may experience fracture with even minor trauma because the bone is weakened by the pre-existing disorder. Fracture may result from the direct force, as when a moving object strikes the body area over the bone. Force may also be applied indirectly, as when a powerful muscle contraction pulls against the bone. In addition, stress or fatigue can lead to fracture because of the bone's decreased ability to withstand mechanical force. The two types of bone also respond differently to mechanical load. Cortical bone, the compact outer layer, is porous and can tolerate more stress along its axis (longitudinally) than across the bone. Cancellous, or spongy, bone is the dense inner bone material. It contains web like formations and spaces filled with red marrow that make it better able to absorb force than is cortical bone. Bony projections, called trabeculae, separate the spaces and are arranged along lines of stress, making cancellous bone even stronger. Predispositions to fracture results from biologic conditions such as osteopenia (caused by steroid use or Cushing's syndrome) or osteogenesis imperfecta, which alters the strength and composition of the bone. Neoplasm can also increase the risk of fracture. Post menopausal estrogen loss and protein malnutrition lead to decreased bone mass. For persons with healthy bones, fracture can result from high risk recreation or employment related activities (skateboarding, rock climbing). CLASSIFICATION OF FRACTURES A. Closed, non-displaced – fracture that does not extend through mucous membrane or skin B. Open (compound) – bone is broken and an external wound leads down to site of fracture. Trauma graded I-III depending on extent of injury. C. Comminuted (Fragmented) – a fracture causing the bone to splinter/shatter into several small pieces; usually more than one fracture line. D. Displaced – a fracture where fragments are misaligned at the fracture site. E. Oblique – fracture line runs at a 45 degree angle across the bones longitudinal axis. F. Spiral – caused by torsional force or twisting; fracture line twists around bone shaft. G. Impacted – a fracture in which one fragment is driven or telescoped into the other.
H. Greenstick – an incomplete fracture where one side of bone is broken but other side is intact, yet bent. More common in children. GRADING OF FRACTURE ACCORDING TO SEVERITY The simplest classification method is based on whether the fracture is closed or open to the environment. A closed fracture has intact skin over the site of injury, whereas the open fracture is characterized by a beak in the skin over the bone injury. Tissue damage can be extensive with open fractures, which are graded according to their severity: A. Grade I – the wound is smaller than 1 cm; contamination is minimal. B. Grade II – the wound is larger than 1 cm; contamination is moderate. C. Grade III – the wound exceeds 6 to 8 cm; there is extensive damage to soft tissue, nerve, and tendon; and there is a high degree of contamination. CLINICAL MANIFESTATIONS Fracture diagnosis is based on the clients clinical manifestation and history, physical examinations and radiographic findings. Some fractures are immediately obvious; others are detected on the X-ray. Use of the correct radiologic view is essential for adequate evaluation of the suspected fracture. Two views take at the right angle are generally considered to be the minimal number needed for the evaluation, and they should include the joints above and below the suspected fracture to identify additional dislocations or subluxations. Abnormal X-ray findings include soft tissue edema, or displacement of ai in relation to the shift of bone after the injury. Radiographs of the fractured bone show an alteration in its normal contour and a disruption in the normal joint relationship. The fracture line itself demonstrates increased radiolucency. Radiographs are commonly taken before fracture reduction , after reduction, and then periodically during bone healing. Physical assessment may reveal any of the following clinical manifestations: DEFORMITY. Swelling from the local hemorrhage may cause deformity at the fracture site. Muscle spasms can cause limb shortening, a rational deformity, or angulations. On comparison to the uninjured side, the fracture site may also have curves. SWELLING. Edema may appear quickly as a result of localization of serious fluid at the fracture site and extravasation of blood into surrounding tissues. BRUISING. Bruising result from subcutaneous bleeding at the fracture site. MUSCLE SPASM. Frequently accompanying fractures, involving muscle spasm actually serves as a natural splint to decrease further motion of the fracture fragments.
PAIN. If the client is neurologically intact, pain always accompanies fracture; the intensity and severity of pain differ from client to client. Pain is usually continuous, increasing in severity until the fracture is immobilized. It results from muscle spasm overriding of fracture fragments, or damage to adjacent structures. TENDERNESS. Tenderness over the fracture site is caused by underlying injuries. LOSS OF FUNCTION. Any loss of function results either from pain caused by the fracture or from the loss of the lever arm function in the affected extremity. Paralysis may be caused by nerve damage. ABNORMAL MOBILITY and CREPITUS. These manifestation are caused by motion in the middle of a bone or by fracture fragments rubbing together to create grating sensations or sounds. NEUROVASCULAR CHANGES. Neurovascular injury results from the damage to peripheral nerves or to the associated vascular structures. The client may complain of numbness. SHOCK. The client who experiences blood loss or other injuries may need treatment for shock. MEDICAL MANAGEMENT (Fractures) The goal of medical management include prompt and thorough assessment of the client to discover all injuries, reduction and stabilization of the fracture with immobilization, monitoring for complications, and eventual remobilization and rehabilitation.
THOROUGH INITIAL ASSESSMENT Basic principles of trauma care must be followed during emergency management of fractures. Assessment and treatment are performed simultaneously as the rescuer addresses the general condition of the injured client. During primary assessment, the rescuer focuses on airway management, bleeding, and manifestations of shock. Any potentially life-threatening injuries must be stabilized immediately and emergency assistance summoned to transport the client to medical facility for additional intervention. An injured client should not be moved unless the current location is not safe. Because most fractures do not pose a serious threat to life, their management becomes a secondary priority in trauma care. Suspected injuries to extremities should be carefully splinted and moved as little as possible because multiple fractures occur in the same limb. If the client complains of muscle spasm after a cervical spine or head injury, a fracture or dislocation is presumed to be present until radiographs can be performed and interpreted. The rescuer must stabilize the affected area and help the client remain still. An unconscious client should receive emergency management while the rescuer carefully notes any spontaneous movement as well as the client's position, head, and extremities. The rescuer performs neurologic
assessment that is based on the type of known or suspected injury. Any soft tissue damage must also be assessed because the injury may indicate a fracture site. Open fractures should be covered to prevent additional contamination until a thorough examination can occur in the nearest hospital. REDUCING FRACTURES The first step in the management of a displaced fracture is reduction: the manipulation of the fracture to restore alignment, position, and length by bringing the fragments into close approximation. Reduction, which is also called bone setting, alleviates compression or stretching of nerves and blood vessels. Because reduction is generally painful, sedation or local or general anesthesia may be needed. Not all fractures require reduction. Fragments of a displaced fracture, for example, are already in proper alignment. Splinting or casting allows the alignment to be maintained as the fracture heals. A few other fractures cannot be adequately splinted instead are treated simply by resting the affected area until healing occurs. When a fracture of an extremity divides a bone into two fragments, the fragments are referred to as proximal and distal. Because of its muscle attachment and location, the proximal fragment cannot be manipulated or moved when the fractured bone is being set. Instead, the distal fragment is moved to realign it with the proximal bone segment. Reduction methods can be used alone or in combination. Closed Reduction To perform closed reduction, a fragments and restore bone alignment. to decrease the client's risk for loss of and to minimize the possible deforming health care provider applies manual traction to move the fracture Closed reduction should be performed as soon as possible after injury function, to prevent or delay joint degeneration (traumatic arthritis), effects of the injury.
Manual reduction is accomplished through four maneuvers, beginning with a longitudinal pull on the distal end of the fracture or extremity. Because it reverses the mechanism of injury, this pull overcomes any initial muscle spasm, any effects on limb length, and the overriding of bone fragments. Second, the bone ends of the fracture must be disengaged from each other. This is sometimes accomplished by rotating the distal portion of the fracture. In the third maneuver, the fracture fragments are realigned. This is a complex step because forces from various muscle groups have held the fragments in their new positions. Finally, the distraction force is released while alignment is maintained. Because gravity, weight-bearing, and muscle contraction can again move the fragments, an immobilization device must be applied after x-ray studies have confirmed bone alignment. The immobilizer most commonly used after closed reduction is a cast, a temporary deice made of plaster of Paris (anhydrous
calcium sulfate) or synthetic materials such as fiberglass or thermoplastic polymer. Casts are used for several purposed in addition to immobilization: prevention or correction of deformity; maintenance, support, and protection of realigned bone; and promotion of healing in order to allow early weight-bearing for ambulation. Casts may be applied in a hospital emergency department, in the operating room, or at the client's bedside in the hospital. They are also commonly applied in a physician's office or clinic. Open reduction and Internal fixation To perform open reduction, the surgeon makes an incision and realigns the fracture fragments under direct visualization. Open reduction is the treatment of choice for compound fractures that are comminuted or accompanied by severe neurovascular injury; it is also required if fracture fragments are widely separated or if soft tissue is interposed between pieces of bone. Open reduction is usually performed in combination with internal fixation for femoral and joint fractures. Screws, pins, wires, or nails may be used to maintain alignment of the fracture fragments. Rods may also be placed through the fragments or fixed to the side of the bone, or they may be inserted directly into the bone's medullary cavity. Internal fixation provides essential immobilization and helps prevent deformity, but it is not a substitute for bone healing. If proper healing fails to occur, the internal fixation device may actually loosen or break as a result of stress. External fixation Depending on the client's condition and the physician's judgment, external fixation devices may be used for fracture fragment immobilization. If for example, soft tissue damage precludes the use of a cast, external fixation would be indicated for fracture immobilization. External fixation devices maintain position for instable fractures and for weakened muscles, and they support areas with tissue or bone infection. They allow the client to use contiguous joints while the affected area remains immobilized. External fixation may also be indicated for bony non-union if fracture healing has not been successful after a certain time. Common sites for external fixation includes the face and jaw, extremities, pelvis, ribs, fingers, and toes. Traction Traction has been used to treat fractures since prehistoric times, and its principles were well known to Hippocrates. Traction is the application of a pulling force to an injured body part or extremity while a countertraction pulls in the opposite direction. The pulling force can be achieved through the use of hands or, more commonly, the application of weights. With improved surgical technique and the development of femoral prostheses and intramedullary rods, traction is not as prevalent as it once was in the treatment of orthopedic injuries.
NURSING MANAGEMENT Care of the client in a cast Care of the client in external fixation Care of a client in traction
OSTEOMYELITIS
Etiology and pathophysiology Osteomyelitis is a severe pyogenic infection of the bone, bone marrow and surrounding soft tissue. It can be caused by a variety of microbial agents (most common in staphylococcus aureus) and situations, including: • An open injury to the bone, such as an open fracture with the bone ends piercing the skin. • An infection from elsewhere in the body, such as pneumonia or a urinary tract infection that has spread to the bone through the blood (bacteremia, sepsis). • A minor trauma, which can lead to a blood clot around the bone and then a secondary infection from seeding of bacteria. • Bacteria in the bloodstream bacteremia (poor dentition), which is deposited in a focal (localized) area of the bone. This bacterial site in the bone then grows, resulting in destruction of the bone. However, new bone often forms around the site. • A chronic open wound or soft tissue infection can eventually extend down to the bone surface, leading to a secondary bone infection. (Black and Hawks, 2005) The widespread use of antibiotics in conjunction with surgical treatment has significantly reduced the mortality rate and complications associated with osteomyelitis. (Lewis, 2004) Because osteomyelitis can be extraordinarily difficult to cure even with long-term antibiotics, prompt recognition is crucial. Delayed identification or inadequate treatment can result in a chronic infection accompanied by continuing pain, chronically draining sinuses, loss of function, amputation or death. (Black and Hawks, 2005) CAUSATIVE ORGANISMS OF OSTEOMYELITIS ORGANISM POSSIBLE PREDISPOSING PROBLEM Staphylococcus aureus Pressure ulcer,
penetrating wound, open fracture, orthopedic surgery abscessed tooth, vascular insufficiency disorders (e.g. Staphylococcus epidermidis Indwelling prosthetic devices (e.g. joint replacements, fractured fixation de vices) E. coli Urinary tract infections Mycobacterium tuberculosis Tuberculosis Neisseria gonorrhoeae Gonorrhea Pseudomonas wounds, intravenous dug use Salmonella cell anemia Fungi, mycobacteria Immunocompromised host The infecting microorganisms can invade by indirect or direct entry. The indirect entry (hematogenous) of microorganisms in osteomyelitis most frequently affects growing bone in boys less than 12 years old and is associated with their higher incidence of blunt trauma. The most common sites of indirect entry in children are the distal femur, proximal tibia, humerus, and radius. Adults with vascular insufficiency disorders (e.g. diabetes mellitus) and genitourinary and respiratory infections are at higher risk for a primary infection to spread via the blood to the bone. The pelvis and vertebrae, which are vascular-rich sites of bone are the most common sites of infection. (Lewis, 2004) Puncture Sickle
Males are affected more often than females, often as a result of trauma. Susceptibility to infection increases with IV drug use, diabetes, immunocompromising diseases or a history of blood- stream infections. (Black and Hawks, 2005) Direct entry osteomyelitis can occur at any age when there is an open wound (e.g. penetrating wounds, fractures) and microorganisms gain entry to the body. Osteomyelitis may also occur in the presence of a foreign body such as an implant or an orthopedic prosthetic device (e.g. plate, total joint prosthesis ). After gaining entrance to the bone by way of the blood, the microorganisms then lodge in an area of the bone in which circulation slows, usually the metaphysis. The microorganisms grow, resulting in an increase in pressure because of the nonexpanding nature of most bones. This increasing pressure eventually leads to ischemia and vascular compromise of the periosteum. Eventually the infection passes through the bone cortex and marrow cavity, ultimately resulting in cortical devascularization and necrosis. Once ischemia occurs, the bone dies. The area of devitalized bone eventually separates from the surrounding living bone forming sequestra. The part of the periosteum that continues to have blood supply forms new bone called involucrum. (Lewis, 2004) Once formed, a sequestrum continues to be a infected island of bone surrounded by pus and difficult to reach by blood-borne antibiotics or white blood cells (WBCs). Sequestrum may enlarge and serve as a site for microorganisms that spread to other sites, including the lungs and the brain. The sequestrum can move out of the bone and into the soft tissue. Once outside the bone, the sequestrum may revascularize and then undergo removal by normal immune system process. Another possibility is that the sequestrum can be surgically removed through debridement of the necrotic bone. If the necrotic sequestrum is not resolved naturally or surgically, it may develop a sinus tract, resulting n a chronic purulent cutaneous drainage.(Lewis, 2004) Chronic osteomyelitis is either a continuous persistent problem (a result of inadequate acute treatment) or process of exacerbations and remission. Over time, granulation tissue turns to scar tissue. This vascular scar tissue provides an ideal site for continued microorganism growth in impenetrable to antibiotics. (Lewis, 2004) Clinical Manifestations Clinical manifestations may slightly vary according to the site of involvement. Infection in the long bones is accompanied by acute localized pain and redness or drainage often with a history of recent trauma or newly acquired prostheses. Fever and malaise may be present. Infection in the vertebrae usually brings pain and mobility difficulties. The client with vertebral osteomyelitis often reports a history of genitourinary
infection or drug abuse. Osteomyelitis in the foot is most commonly associated with vascular insufficiency. (Black and Hawks, 2005) Acute osteomyelitis refers to the initial infection or an infection of less than 1 month duration. The clinical manifestations of acute myelitis are both systemic and local. Systemic manifestations include fever, night sweat, chills restlessness, nausea and malaise. Local manifestations include constant bone pain that is unrelieved by rest and worsens with activity; swelling, tenderness and warmth at the infection site; and restricted movement of the affected part. Later signs include drainage from sinus tracts to the skin and/or the fracture site. (Lewis, 2004) Chronic myelitis refers to a bone infection that persists for longer than 1 month or an infection that has failed to respond to the initial course of antibiotic therapy. Systemic signs may be diminished, with local signs of infection more common, including constant bone pain and swelling, tenderness and warmth at the infection site. (Lewis, 2004) Diagnostic and Laboratory Examinations Laboratory studies and X-rays or bone scans are important in the definitive diagnosis of osteomyelitis. Elevated WBC and ESR, an elevated level of C-reactive protein (a protein that circulates in the blood and dramatically increases in level when there is inflammation) usually occur. Along with clinical manifestations, usually allow initial diagnosis and early treatment while the physician waits for further evidence from blood cultures or needle aspirate analysis. To diagnose a bone infection and identify the organisms causing it, doctors may take samples of blood, pus, joint fluid, or the bone itself to test. Usually, for vertebral osteomyelitis, samples of bone tissue are removed with a needle or during surgery. Radiographic changes related to osteomyelitis are generally evident within 7 to 10 days, but in some cases the diagnosis is not confirmed on X-rays until 3 to 4 weeks after infection develops. Early acute osteomyelitis is more efficiently identified by radionuclide bone scans, which can detect lesions within 24 to 72 hours after the onset of infection. Because of its ability to distinguish between soft tissue and bone marrow, magnetic resonance imaging It is also being used increasingly for definitive diagnosis of osteomyelitis. To diagnose osteomyelitis, the doctor will first perform a history, review of systems, and a complete physical examination. In doing so, the physician will look for signs or symptoms of soft tissue and bone tenderness and possibly swelling and redness. The doctor will also ask you to describe your symptoms and will evaluate your personal and family medical history. The doctor can then order any of the following tests to assist in confirming the diagnosis:
• Blood tests: When testing the blood, measurements are taken to confirm an infection: a CBC (complete
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blood count), which will show if there is an increased white blood cell count; an ESR (erythrocyte sedimentation rate); and/or CRP (C-reactive protein) in the bloodstream, which detects and measures inflammation in the body. Blood culture: A blood culture is a test used to detect bacteria. A sample of blood is taken and then placed into an environment that will support the growth of bacteria. By allowing the bacteria to grow, the infectious agent can then be identified and tested against different antibiotics in hopes of finding the most effective treatment. Needle aspiration: During this test, a needle is used to remove a sample of fluid and cells from the vertebral space, or bony area. It is then sent to the lab to be evaluated by allowing the infectious agent to grow on media. Biopsy: A biopsy (tissue sample) of the infected bone may be taken and tested for signs of an invading organism. Bone scan: During this test, a small amount of Technetium-99 pyrophosphate, a radioactive material, is injected intravenously into the body. If the bone tissue is healthy, the material will spread in a uniform fashion. However, a tumor or infection in the bone will absorb the material and show an increased concentration of the radioactive material, which can be seen with a special camera that produces the images on a computer screen. The scan can help your doctor detect these abnormalities in their early stages, when Xray findings may only show normal findings.
OUTCOME MANAGEMENT (Osteomyelitis) Elimination of the infecting organisms, both locally from the bone and systemically from the body, is the major treatment goal for osteomyelitis. Prompt treatment also prevents further bone deformity and injury, increases client comfort, and avoids complications of impaired mobility. Surgery is initially performed on the adult client with osteomyelitis to ensure effective debridement and drainage, elimination if dead space, and adequate soft tissue coverage. Antibiotics alone rarely resolve infection in adults, but they do work more efficiently after surgical preparation of the treatment area. High doses of parenteral antibiotics are frequently administered for 4 to 8 weeks to achieve a bactericidal level in the bone tissue. Oral antibiotics are continued for another 4 to 8 weeks, with serial bone scans and ESR measurements performed to evaluate the effectiveness of drug therapy. Open drainage wounds are packed with gauze to promote drainage. If initial treatment is delayed or inadequate, the necrotic bone separates from the living bone to form sequestra, which serves as a medium for additional microorganism growth. Chronic osteomyelitis can result.(Black and Hawks, 2005)
The objective of treating osteomyelitis is to eliminate the infection and prevent the development of chronic infection. Chronic osteomyelitis can lead to permanent deformity, possible fracture, and chronic problems, so it is important to treat the disease as soon as possible. Drainage: If there is an open wound or abscess, it may be drained through a procedure called needle aspiration. In this procedure, a needle is inserted into the infected area and the fluid is withdrawn. For culturing to identify the bacteria, deep aspiration is preferred over oftenunreliable surface swabs. Most pockets of infected fluid collections (pus pocket or abscess) are drained by open surgical procedures. Medications: Prescribing antibiotics is the first step in treating osteomyelitis. Antibiotics help the body get rid of bacteria in the bloodstream that may otherwise re-infect the bone. The dosage and type of antibiotic prescribed depends on the type of bacteria present and the extent of infection. While antibiotics are often given intravenously, some are also very effective when given in an oral dosage. It is important to first identify the offending organism through blood cultures, aspiration, and biopsy so that the organism is not masked by an initial inappropriate dose of antibiotics. The preference is to first make attempts to do procedures (aspiration or bone biopsy) to identify the organisms prior to starting antibiotics. Splinting or cast immobilization: This may be necessary to immobilize the affected bone and nearby joints in order to avoid further trauma and to help the area heal adequately and as quickly as possible. Splinting and cast immobilization are frequently done in children, although motion of joints after initial control is important to prevent stiffness and atrophy. Surgery: Most well-established bone infections are managed through open surgical procedures during which the destroyed bone is scraped out. In the case of spinal abscesses, surgery is not performed unless there is compression of the spinal cord or nerve roots. Instead, patients with spinal osteomyelitis are given intravenous antibiotics. After surgery, antibiotics against the specific bacteria involved in the infection are then intensively administered during the hospital stay and for many weeks afterward. With proper treatment, the outcome is usually good for osteomyelitis, although results tend to be worse for chronic osteomyelitis, even with surgery. Some cases of chronic osteomyelitis can be so resistant to treatment that amputation may be required; however, this is rare. Also, over many years, chronic infectious draining sites can evolve into a squamous-cell type of skin cancer; this, too, is rare. Any change in the nature of the chronic drainage, or change of the nature of the chronic drainage site, should be evaluated by a physician experienced in treating chronic bone infections. Because it is important that osteomyelitis
receives prompt medical attention, people who are at a higher risk of developing osteomyelitis should call their doctors as soon as possible if any symptoms arise.
REFERENCES:
Lewis, S. et. al. Medical – Surgical Nursing: Assessment and Management of Clinical Problems. (6th edition, 2004). Mosby, Inc. USA Black, J. and Hawks, J. Medical – Surgical Nursing: Clinical Management for Positive Outcomes. (7th edition, 2005). Elsevier, Inc. , USA Brunner L.S. & Smeltzer S.C. (2004). Textbook of Medical-Surgical Nursing. J.B. Lippincott Company. USA) Deglin, J.H. & Vallerand, A.H. (2007). Davis’s drug guide for nurses. 10th ed. E.A Davis Co. Philadelphia, Pennsylvania Smeltzer, S.C. & Bare B. C. (2000) Medical- surgical nursing: 9th ed. Philadelphia, Lippincott (2007) Lippincott manual of nursing practice series: Pathophysiology. Philadelphia: Lippincott Williams & Wilkins
