Hip Fracture-casts-trxn

HIP FRACTURE REPAIR AND/OR REPLACEMENT • • • • •

High incidence among elderly (brittle bones, falls) o Osteoporosis, Dec. in space position, Dec. Capacity of BV, Dec. NS Response Frequent morbidity (Cardiovascular, Pulmonary, Renal, Endocrine) o After 70 y/o most common cause of death Hip supports 3X body weight Weakness in joint may be reason for fall PREVENT PNEUMONIA

2 TYPES OF HIP FRACTURES •

Intracapsular Fracture: Fracture of neck of femur May damage vascular system that supplies blood to head and neck of femur Nutrient vessels within bone interrupted and bone may die Thus, Nonunion or avascular necrosis is common o MD May do Total hip arthroplasty Risk for Dislocation  Bipolar prosthesis (Replacemetn of Heat and Neck as well as the acetabelum) o MD May do ORIF – Hip Pinning Pain  Hardware to repair  All supporting structures are still intact in the hip joint o MD May do a Hemiarthroplasty Risk for Dislocation  Partial joint replacement (Replacement of Head and Neck) o o o

•

Extracapsular Fracture: o

Fracture of Trochanteric Region (Btw base of neck and lesser trochanter of femur)  Excellent blood supply, heal readily  Extensive soft tissue damage may occur at time of injury  Not common for fracture to be comminuted and unstable  High mortality rate after interrochanteric hip fracture because clients elderly and poor surgical candidates

CLINICAL MANIFESTATIONS •

Femoral Neck Fracture o o o o o

•

Impacted Femoral Neck Fracture o o o

•

Pain with movement. Leg shortened, adducted, externally rotated Ecchymosis May C/O slight pain in groin or medial side of knee  Delays blood supply to the hip joint – RF Avascular necrosis Unable to move leg without significant increase of pain Most comfortable with leg slightly flexed in external rotation Moderate discomfort (even with movement) May allow weight bearing May not demonstrate obvious shortening or rotational changes

Extracapsular Femoral Fractures o o o o

Extremity Significantly shortened Externally rotated greater degree than intracapsular fracture Exhibits muscle spasm - Resists positioning of extremity in neutral position Large hematoma or area of ecchymosis

•

Diagnosis is confirmed by X-Ray

MEDICAL MANAGEMENT •

Temporary treatment is Skin Traction (Bucks Extension) o Heel is supported off bed to prevent pressure o Weight hangs free of bed 5-5 ½ #  Reduces muscle spasms  Immobilize extremity  Relieve pain  Sand Bags / Trochanger roll used control external rotation • Goal of Surgical Treatment o Obtain satisfactory fixation so patient can be mobilized quickly, avoid secondary medical conditions o Abductor Pillow - Important  Approach Anterior or Posterior(most common)  Relieve pain and prevent inflammation  Cut away head and replace with enlarge acetabulum Total Hip or Bi Polar Hip Prosthesis • Metal Cup with artificial head/neck • Tip femur hollowed out b/c attached to metal shaft • Increased R/F dislocation – prevent with position abduction o NO ADDUCTION • No cross legs • Not flex hip > 90o o Maintain HOB at level o Wheelchair / 3-6” apart – sitting • Open reduction of fracture and internal fixation (ORIF) o Tendons / Ligament present • Replacement femoral head with prosthesis (Hemiarthroplasty) • Intervention carried out ASAP after injury • Pre Op Objective: Ensure patient favorable condition as possible • Displaced Femoral neck may be treated as emergency o Keep hip abducted to prevent dislocation • Reduction, internal fixation performed within 12-24 hours o Minimizes effects of diminished blood supply o Reduces R/F avascular necrosis

POST OPERATIVE NURSING MANAGEMENT • • • • • • • • • • • • • •

Abductor Pillow Neurovascular assessments Vital signs frequently due to blood loss Turn and assess dressing 200-500cc first 24 hours is normal >250cc the first 8 hours call MD Prevent Secondary Medical Problems Assess history of DVT – DVT are at high risk with Hip/Knee injury Early mobilization so independent functioning restored Deep Breathing, Coughing, foot flexion exercises every 1-2 hours IV Prophylactic antibiotics Monitor Hydration, Nutritional status, and Urine output Thigh-high elastic compression stocking – TED or SCD hose Pneumatic compression devices used to prevent venous stasis - Plexi Pulses Pillow placed between leg to maintain abduction, alignment; and provide needed support during turning

• • • •

Calf Pumps (Remind daily to do) Teach to prevent internal rotation Patient is at increased risk for infection Hemovac prevents hematoma formation They are incontinent of urine and feces – Increased R/F UTI’s

• •

Cast wet handle with palm of hands 24-48o to dry completely

CAST TYPES

CARE • Elevate • Monitor Drainage • Itch use “cool” blow dryer • Check pulses • Instruct not to pull padding under cast • Circulate air around promote drying

EXTERNAL FIXATORS • • • • • •

Ambulatory or Immobilized with traction bar Open fracture with soft tissue damage Comminuted fracture Clean daily every shift (without osteomylitis) ½ / ½ with 4x4, betadine, 2x2 with split Notify MD of any drainage, assess redness, edema

CPM: CONTINOUS PASSIVE MOTION • • •

Flexion and extension 0o Post op 30-35o flexion Flexion >10o with no complications Promote mobility, circulation, healing

CRUTCH WALKING • • • • •

•

Patient Teaching with nurse reinforces education Several gaits rotate strain on muscles Palm hands Check height of crutch Stand up with tripod position o 4pt gait: opposite side with crutch / leg rotation o 2pt gait: opposite side crutch / leg together o Swing gait: Feet land tip crutches o 3pt gait: Never put weight on injured extremity Down Movement: Walk forward as far as possible advance crutch lower step weaker first, then stronger leg

•

Movement Upstairs: Stronger leg 1st, with crutch to step then bring weaker of affected side first

TRACTION • • • • • •

Pulling force to part of body Reduce alignment, mobilize fracture Minimize muscle spasms to decrease pain Increase spaced between opposing surface within joint o Example: Vertebrae to prevent cervical nerve Prevent further soft tissue damage in and around area Apply more than one direction achieves life of pull desired counter traction o 2 Types  Skin: to skin transmit traction to skeletal muscle underneath  Skeletal: Pin Placement

PRINCIPELS • • • • • •

Counter traction through body weight of patient o Increase part of bed with traction Traction must be maintained for treatment Remove Buck but with assistance to support extremity Traction neck / back pain intermittent Maintain good body alignment Weights off ground, no frayed ropes

BUCKS TRACTION • Pelvic traction: Increase oppose surface of lumbar area • Cervical: relieve pain Increases extremity cervical area (intermittent tx) o Home sitting (assess airway, skin breakdown) • • • •

•

Dunlop’s: Fracture of humorous / forearm; elbow Balanced Suspension: Fracture of femur (extremity balance between weights) Russell’s: Fracture of tibial Cervical Skeletal: Relieve muscle spasm, compression o FX of C5-C6 - Crutchfield, Binky - Prevent spinal cord injury o Log roll o Pin site care Halo Vest: Immobilize neck o Pin site care

NURSING MANAGEMENT •

Maintain affective traction

• • • • •

Neuro Checks Position with body alignment Support extremity with movement Skin Traction – Remove before surgery, care: neuro check Q2o Foot drop suggest nerve damage