Fractures of a bone.

Because each end of a long bone is

cartilaginous,
A fracture is a complete or incomplete disruption if the fracture is nondisplaced, x-rays will not
in the always reveal
continuity of bone structure and is defined the fracture because cartilage is nonradiopaque. An
according to its MRI or
type and extent. Fractures occur when the bone is arthroscopy will identify the fracture and confirm
subjected the diagnosis.
to stress greater than it can absorb. Fractures may The joint is stabilized and immobilized with a
be caused splint or
by direct blows, crushing forces, sudden twisting cast and no weight bearing is allowed until the
motions, fracture has
and extreme muscle contractions. When the bone is healed. Intra-articular fractures often lead to
broken, posttraumatic
adjacent structures are also affected, resulting in arthritis.
soft
Clinical Manifestations
tissue edema, hemorrhage into the muscles and
joints, joint
dislocations, ruptured tendons, severed nerves, and The clinical signs and symptoms of a fracture
damaged include acute
blood vessels. Body organs may be injured by the pain, loss of function, deformity, shortening of the
force extremity,
that caused the fracture or by fracture fragments. crepitus, and localized edema and ecchymosis. Not
all of these
are present in every fracture (Whiteing, 2008).
Types of Fractures
Pain
A complete fracture involves a break across the
entire crosssection The pain is continuous and increases in severity
of the bone and is frequently displaced (removed until the
from its normal position). An incomplete fracture bone fragments are immobilized. The muscle
(eg, greenstick spasms that
fracture) involves a break through only part of the accompany a fracture begin within 20 minutes after
cross-section of the bone. A comminuted fracture is the
one that injury and result in more intense pain than the
produces several bone fragments. A closed fracture patient reports
(simple at the time of injury. The muscle spasms can
fracture) is one that does not cause a break in the minimize
skin. An further movement of the fracture fragments or can
open fracture (compound, or complex, fracture) is result in
one in further bony fragmentation or malalignment.
which the skin or mucous membrane wound
extends to the Loss of Function
fractured bone (Whiteing, 2008). Open fractures
are graded After a fracture, the extremity cannot function
according to the following criteria: properly
• Grade I is a clean wound less than 1 cm long. because normal function of the muscles depends on
• Grade II is a larger wound without extensive soft the
tissue integrity of the bones to which they are attached.
damage. Pain contributes
• Grade III is highly contaminated, has extensive to the loss of function. In addition, abnormal
soft movement
tissue damage, and is the most severe. (false motion) may be present.
Fractures may also be described according to the
anatomic Deformity
placement of fragments. Specific types of fractures
are reviewed Displacement, angulation, or rotation of the
in Figure 69-2. fragments in a
An intra-articular fracture extends into the joint fracture of the arm or leg causes a deformity that is
surface detectable
when the limb is compared with the uninjured With an open fracture, the wound is covered with a
extremity. sterile
dressing to prevent contamination of deeper tissues.
Shortening No attempt
is made to reduce the fracture, even if one of the
In fractures of long bones, there is actual bone fragments is protruding through the wound.
shortening of the Splints
extremity because of the compression of the are applied for immobilization.
fractured bone. In the emergency department, the patient is
Sometimes muscle spasms can cause the distal and evaluated
proximal completely. The clothes are gently removed, first
site of the fracture to overlap, causing the extremity from the
to uninjured side of the body and then from the
shorten. injured side.
The patient’s clothing may be cut away. The
Crepitus fractured extremity
is moved as little as possible to avoid more
When the extremity is gently palpated, a crumbling damage.
sensation,
called crepitus, can be felt. It is caused by the Medical Management
rubbing
of the bone fragments against each other. Reduction
Localized Edema and Ecchymosis
Fracture reduction refers to restoration of the
Localized edema and ecchymosis occur after a fracture fragments
fracture as a to anatomic alignment and positioning. Either
result of trauma and bleeding into the tissues. closed
These signs reduction or open reduction may be used to reduce
may not develop for several hours after the injury a fracture.
or may The specific method selected depends on the nature
develop within an hour, depending on the severity of the
of the fracture; however, the underlying principles are the
fracture. same.
Usually, the physician reduces a fracture as soon as
possible to
Emergency Management
prevent loss of elasticity from the tissues through
infiltration
Immediately after injury, if a fracture is suspected,
by edema or hemorrhage. In most cases, fracture
it is important
reduction
to immobilize the body part before the patient is
becomes more difficult as the injury begins to heal.
moved. Adequate splinting is essential. Joints
Before fracture reduction and immobilization, the
proximal and
patient
distal to the fracture must be immobilized to
is prepared for the procedure; consent for the
prevent movement
procedure is
of fracture fragments. Immobilization of the long
obtained, and an analgesic is administered as
bones of the lower extremities may be
prescribed.
accomplished by
Anesthesia may be administered. The injured
bandaging the legs together, with the unaffected
extremity
extremity serving as a splint for the injured one. In
must be handled gently to avoid additional damage.
an upper extremity
injury, the arm may be bandaged to the chest, or an
injured
forearm may be placed in a sling. The
neurovascular status
distal to the injury should be assessed both before
Closed Reduction
and after
splinting to determine the adequacy of peripheral
In most instances, closed reduction is accomplished
tissue perfusion
by
and nerve function.
bringing the bone fragments into anatomic
alignment
through manipulation and manual traction. The by elevating the injured extremity and applying ice
extremity as prescribed.
is held in the aligned position while the physician Neurovascular status (circulation, motion and
applies a sensation)
cast, splint, or other device. Reduction under is monitored routinely, and the orthopedic surgeon
anesthesia with is notified immediately if signs of neurovascular
percutaneous pinning may also be used. The compromise
immobilizing develop. Restlessness, anxiety, and discomfort are
device maintains the reduction and stabilizes the controlled
extremity with a variety of approaches, such as reassurance,
for bone healing. X-rays are obtained to verify that position
the bone changes, and pain relief strategies, including use of
fragments are correctly aligned. analgesics.
Traction (skin or skeletal) may be used until the Isometric and muscle-setting exercises are
patient encouraged to
is physiologically stable to undergo surgical minimize atrophy and to promote circulation.
fixation. Use of Participation
traction and the nursing management of a patient in in activities of daily living (ADLs) is encouraged to
traction promote
are discussed more fully in Chapter 67. independent functioning and self-esteem. Gradual
resumption
Open Reduction of activities is promoted within the therapeutic
prescription.
Some fractures require open reduction. Through a With internal fixation, the surgeon determines
surgical the amount of movement and weight-bearing stress
approach, the fracture fragments are anatomically the
aligned. extremity can sustain and prescribes the level of
Internal fixation devices (metallic pins, wires, activity. (See Nursing Process sections in Chapter
screws, 67 for more information
plates, nails, or rods) may be used to hold the bone about caring for patients who have a cast, are in
fragments traction, or are undergoing orthopedic surgery.)
in position until solid bone healing occurs. These
devices may be attached to the sides of bone, or Nursing Management
they may
be inserted through the bony fragments or directly Patients With Closed Fractures
into the
medullary cavity of the bone (Fig. 69-3). Internal The patient with a closed fracture has no opening in
fixation the
devices ensure firm approximation and fixation of skin at the fracture site. The fractured bones may be
the bony nondisplaced
fragments. or slightly displaced, but the skin is intact. The
nurse
Immobilization instructs the patient regarding the proper methods
to control
After the fracture has been reduced, the bone edema and pain (Chart 69-1). It is important to
fragments teach exercises
must be immobilized and maintained in proper to maintain the health of unaffected muscles and to
position and increase the strength of muscles needed for
alignment until union occurs. Immobilization may transferring and
be accomplished for using assistive devices such as crutches,
by external or internal fixation. Methods of external walkers, and special
fixation include bandages, casts, splints, continuous utensils. The patient is also taught how to use
traction, and external fixators. assistive
devices safely. Plans are made to help patients
Maintaining and Restoring Function
modify the
home environment as needed and to ensure safety,
Reduction and immobilization are maintained as
such as
prescribed
removing floor rugs or anything that obstructs
to promote bone and soft tissue healing. Edema is
walking
controlled
paths throughout the house. Patient teaching
includes selfcare, Fracture Healing and Complications
medication information, monitoring for potential
complications, and the need for continuing health Weeks to months are required for most fractures to
care supervision. heal.
Fracture healing and restoration of strength and Many factors influence the time frame of the
mobility may take an average maximum of 6 to 8 healing process
weeks, depending (Chart 69-2). With a comminuted fracture,
on the quality of the patient’s bone tissue. fragments must
be properly aligned to attain the best healing
Patients With Open Fractures possible. It is
essential for the fractured bone to have blood
In an open fracture, there is a risk for osteomyelitis, supply to the
tetanus, area to facilitate the healing process. In general,
and gas gangrene. The objectives of management fractures of
are to prevent flat bones (pelvis, sternum, and scapula) heal
infection of the wound, soft tissue, and bone and to rapidly. A
promote healing of bone and soft tissue. complex, comminuted fracture may heal slower.
Intravenous (IV) Fractures at
antibiotics are administered immediately upon the the ends of long bones, where the bone is more
patient’s vascular and
arrival in the hospital along with tetanus toxoid if cancellous, heal more quickly than do fractures in
needed. areas
Wound irrigation and débridement are initiated in where the bone is dense and less vascular
the (midshaft).
operating room as soon as possible. The wound is Weight bearing stimulates healing of stabilized
cultured and bone grafting may be performed to fill fractures of
in areas of bone the long bones in the lower extremities. If fracture
defects. The fracture is carefully reduced and healing is disrupted, bone union may be delayed
stabilized by or stopped completely. Factors that can impair
external fixation and the wound is usually left open fracture
for 5 to healing include inadequate fracture immobilization,
7 days for intermittent irrigation and cleansing (see inadequate
Chapter blood supply to the fracture site or adjacent tissue,
67). If there is any damage to blood vessels, soft extensive
tissue, space between bone fragments, interposition of soft
muscles, nerves, or tendons, appropriate treatment tissue between bone ends, displacement of fracture
is implemented. fragments
With open fractures, primary wound closure is or ends, infection, and metabolic problems.
usually Complications of fractures may be either acute or
delayed. Heavily contaminated wounds are left chronic.
unsutured Early complications include shock, fat embolism,
and dressed with sterile gauze to permit edema and compartment
wound syndrome, and venous thromboemboli (deep vein
drainage. Wound irrigation and débridement may thrombosis [DVT], pulmonary embolism [PE]).
be Delayed
repeated, removing infected and devitalized tissue complications include delayed union, malunion,
and nonunion,
increasing vascularity in the region. AVN of bone, reaction to internal fixation devices,
The extremity is elevated to minimize edema. It is complex
important regional pain syndrome (CRPS, formerly called
to assess neurovascular status frequently. reflex sympathetic
Temperature dystrophy [RSD]), and heterotopic ossification.
is monitored at regular intervals and the patient is
monitored Early Complications
for signs of infection. In 4 to 8 weeks, bone
grafting Shock
may be necessary to bridge bone defects and to
stimulate Hypovolemic shock resulting from hemorrhage is
bone healing. more frequently
noted in trauma patients with pelvic fractures and acidosis. The chest x-ray shows a typical
in patients with a displaced or open femoral “snowstorm”
fracture in infiltrate. Without prompt, definitive treatment,
which the femoral artery is torn by bone fragments. acute pulmonary edema, acute respiratory distress
Treatment syndrome
of shock consists of stabilizing the fracture to (ARDS), and heart failure may develop. Cerebral
prevent further disturbances
hemorrhage, restoring blood volume and (due to hypoxia and the lodging of fat emboli in the
circulation, relieving brain) are manifested by mental status changes
the patient’s pain, providing proper immobilization, varying from
and headache and mild agitation to delirium and coma.
protecting the patient from further injury and other
complications. With systemic embolization, the patient appears
(See Chapter 15 for a discussion of shock.) pale.
Petechiae, possibly due to a transient
Fat Embolism Syndrome thrombocytopenia,
are noted in the buccal membranes and
After fracture of long bones or pelvic bones, or conjunctival sacs,
crush injuries, on the hard palate, and over the chest and anterior
fat emboli may develop. Fat embolism syndrome axillary
(FES) occurs most frequently in adults younger folds. The patient develops a fever greater than
than 40 years of age and in 39.5_C
men. It is also more common in patients with (103_F). Free fat may be found in the urine if
multiple emboli are filtered
fractures (Stein, Yaekoub, Matta, et al., 2008). At by the renal tubules. Acute tubular necrosis and
the time renal
of fracture, fat globules may diffuse from the failure may develop (Harvey, 2006).
marrow into
the vascular compartment. The fat globules (ie, Prevention and Management. Immediate
emboli) may immobilization
occlude the small blood vessels that supply the of fractures including early surgical fixation,
lungs, brain, minimal fracture
kidneys, and other organs. The onset of symptoms manipulation, and adequate support for fractured
is rapid, bones
typically within 12 to 48 hours of injury (Harvey, during turning and positioning, and maintenance of
2006), but fluid
may occur up to 10 days after injury (Whiteing, and electrolyte balance are measures that may
2008). reduce the
incidence of fat emboli.
Clinical Manifestations. Presenting features Prompt initiation of respiratory support,
include hypoxia, assessment, and
tachypnea, tachycardia, and pyrexia. The monitoring is essential. The objectives of
respiratory management are to
distress response includes tachypnea, dyspnea, support the respiratory system, to prevent
crackles, respiratory failure,
wheezes, precordial chest pain, cough, large and to correct homeostatic disturbances. Acute
amounts of pulmonary
thick white sputum, and tachycardia. Occlusion of edema and ARDS are the most common causes of
a large death.
number of small vessels causes the pulmonary Respiratory support is provided with high-flow
pressure to oxygen.
rise. Edema and hemorrhages in the alveoli impair Controlled-volume ventilation with positive end-
oxygen expiratory
transport, leading to hypoxia. Arterial blood gas pressure (PEEP) may be used to prevent or treat
values pulmonary
show the partial pressure of oxygen (PaO2) to be edema. Corticosteroids may be administered IV to
less than treat the
60 mm Hg, with an early respiratory alkalosis and inflammatory lung reaction and to control cerebral
later respiratory edema
(Harvey, 2006) (see Chapter 23 for the nursing anoxia and necrosis (Konstantakos, Dalstrom,
management Nelles, et al.,
of respiratory failure and Chapter 25 for care of the 2007). Permanent function can be lost if the anoxic
patient situation
on a ventilator). Vasopressor medications to continues for longer than 6 hours (Harvey, 2006).
support cardiovascular function are administered
IV to prevent and Assessment and Diagnostic Findings. Frequent
treat hypotension, shock, and interstitial pulmonary assessment
edema. of neurovascular function after a fracture is
Accurate fluid intake and output records facilitate essential and
adequate focuses on the “five Ps”: pain, paralysis,
fluid replacement therapy. paresthesias, pallor,
and pulselessness (Whiteing, 2008). Sensory
Compartment Syndrome deficits include
deep, throbbing, escalating pain that increases with
An anatomic compartment is an area of the body passive
encased stretching. Paresthesia (burning or tingling
by bone or fascia (eg, the fibrous membrane that sensation) and
covers and numbness are early signs of nerve involvement.
separates muscles) that contains muscles, nerves, Motion is
and blood evaluated by asking the patient to flex and extend
vessels. The human body has 46 anatomic the wrist
compartments, or plantarflex and dorsiflex the foot. With
and 36 of these are located in the extremities (Fig. continued nerve
69-4). ischemia and edema, the patient experiences
Compartment syndrome in an extremity is a limb- sensations of
threatening condition that occurs when perfusion hypoesthesia (diminished sensation followed by
pressure falls below complete
tissue pressure within a closed anatomic numbness). Motor weakness may occur as a late
compartment. sign of nerve
Acute compartment syndrome involves a sudden ischemia. No movement (paralysis) indicates nerve
and damage.
severe decrease in blood flow to the tissues distal to Peripheral circulation is evaluated by assessing
an area color,
of injury that results in ischemic necrosis if prompt, temperature, capillary refill time, edema, and
decisive pulses. Cyanotic
intervention does not occur. The patient complains (ie, blue-tinged) nail beds suggest venous
of deep, congestion. Pallor
throbbing, unrelenting pain, which continues to or dusky and cold fingers or toes and prolonged
increase capillary refill
despite the administration of opioids and seems out time suggest diminished arterial perfusion. Edema
of proportion may obscure
to the injury. A hallmark sign is pain that occurs or the function of arterial pulsation, and Doppler
intensifies with passive ROM (eg, pain intensifies ultrasonography
with dorsiflexion may be used to verify a pulse. Pulselessness is a
of the wrist of the affected extremity). This pain very late sign that may signify lack of distal tissue
can be caused by (1) a reduction in the size of the perfusion,
muscle or a cast or dressing is constrictive or (2) an but it is possible to have compartment syndrome
increase in compartment with a
contents because of edema or hemorrhage from the pulse (weak) to the extremity (Konstantakos, et al.,
fracture site. The lower leg is most frequently 2007).
involved, but Palpation of the muscle, if possible, reveals it to be
the forearm is also at risk (see figure 67-2 for an swollen and hard. The orthopedic surgeon may
illustration of measure tissue
compartment syndrome of the lower leg). The pressure by inserting a tissue pressure-monitoring
pressure device,
within a muscle compartment may increase to such such as a Wick catheter, into the muscle
an extent compartment (Fig.
that microcirculation diminishes, causing nerve and 69-5). (Normal pressure is 8 mm Hg or less.) Nerve
muscle and muscle
tissues deteriorate as compartment pressure microthrombosis with ischemia. Its causes are
increases. diverse and
Prolonged pressure of more than 30 mm Hg can can include massive tissue trauma. Early
result in compromised microcirculation manifestations of
(Hessmann, Ingelfinger & DIC include unexpected bleeding after surgery, and
Rommens, 2007). bleeding
from the mucous membranes, venipuncture sites,
Medical Management. Prompt management of and gastrointestinal
acute compartment and urinary tracts. The treatment of DIC is
syndrome is essential. The surgeon needs to be discussed in Chapter 33.
notified immediately if neurovascular compromise All open fractures are considered contaminated and
is suspected. are
Delay in treatment may result in permanent nerve treated as soon as possible with IV antibiotics.
and muscle damage or even necrosis and Surgical internal
amputation. If conservative measures do not restore fixation of fractures carries a risk of infection. The
tissue perfusion and nurse must monitor and instruct the patient
relieve pain within 1 hour, a fasciotomy (surgical regarding signs
decompression and symptoms of infection, including tenderness,
with excision of the fascia) is indicated to relieve pain, redness,
the constrictive muscle fascia. After fasciotomy, swelling, local warmth, elevated temperature, and
the wound purulent drainage.
is not sutured but is left open to allow the muscle
tissues to Delayed Complications
expand; it is covered with moist, sterile saline
dressings or Delayed Union, Malunion, and Nonunion
with artificial skin. The affected arm or leg is
splinted in a Delayed union occurs when healing does not occur
functional position and elevated to heart level, and within
prescribed the expected time frame for the location and type of
passive ROM exercises are usually performed fracture.
every Delayed union may be associated with distraction
4 to 6 hours. In 3 to 5 days, when the swelling has (pulling
resolved apart) of bone fragments, systemic or local
and tissue perfusion has been restored, the wound infection, poor nutrition, or comorbidity (eg,
is diabetes mellitus, autoimmune
débrided and closed (possibly with skin grafts) disease). The healing time is prolonged; but the
(Hessmann, fracture
et al., 2007). Complications that may occur after eventually heals (Whiteing, 2008).
fasciotomy Nonunion results from failure of the ends of a
include AVN and infection. fractured
bone to unite, whereas malunion results from
Other Early Complications failure of the
ends of a fractured bone to unite in normal
Venous thromboemboli, including DVT and PE, alignment. In
are associated both of these instances, the patient complains of
with reduced skeletal muscle contractions and bed persistent
rest. discomfort and abnormal movement at the fracture
Patients with fractures of the lower extremities and site.
pelvis Factors contributing to nonunion and malunion
are at high risk for venous thromboemboli. PEs include infection
may cause at the fracture site, interposition of tissue between
death several days to weeks after injury. (See the
Chapter 31 for bone ends, inadequate immobilization or
a discussion of DVT; Chapter 30 for a discussion manipulation that
of venous disrupts callus formation, excessive space between
thromboemboli; and Chapter 23 for a discussion of bone
PE.) fragments, limited bone contact, and impaired
Disseminated intravascular coagulation (DIC) is a blood supply
systemic resulting in AVN. In nonunion, fibrocartilage or
disorder that results in widespread hemorrhage and fibrous tissue
exists between the bone fragments; no bone salts After grafting, immobilization and non–weight-
have bearing
been deposited. A false joint (pseudarthrosis) often exercises are required while the bone graft becomes
develops incorporated
at the site of the fracture (Whiteing, 2008). and the fracture or defect heals. Depending on the
type of bone grafted and the age of the patient,
Medical Management. The physician treats healing may
nonunion take from 6 to 12 months or longer. Bone grafting
with internal fixation, bone grafting, electrical bone complications
stimulation, include wound or graft infection, fracture of the
or a combination of these therapies. Internal graft, and nonunion (Boden, 2005). Specific
fixation problems associated
stabilizes the bone fragments and ensures bone with autografts include a limited quantity of bone
contact. available for harvest and harvest site pain that may
Bone grafts promote osteogenesis, persist for
osteoconduction, and up to 2 years after harvest (Boden, 2005).
osteoinduction. Osteogenesis (bone formation) Infrequent specific
occurs after allograft complications include partial acceptance
transplantation of bone because the graft contains (lack of host and donor histocompatibility, which
osteoblasts, retards
which build bony matrix. Building of this structural graft incorporation), graft rejection (rapid and
bony complete resorption
matrix promotes osteoconduction, the growth of of the graft), and transmission of disease (rare).
blood vessels
and osteoblasts within the matrix. Osteoinduction is Osteogenesis may be stimulated by electrical
the impulses;
stimulation of host stem cells to differentiate into the effectiveness is similar to that of bone grafting.
osteoblasts Use of
by several growth factors, including bone electrical impulses is not effective with large bone
morphogenetic gaps.
proteins (BMPs), particularly BMP-2, BMP-6, and The electrical stimulation modifies the tissue
BMP-9 environment,
(Boden, 2005). making it electronegative, which enhances mineral
Grafted bone undergoes a reconstructive process deposition and bone formation that promotes bone
that growth. In some situations, pins that act as cathodes
results in a gradual replacement of the graft with are
new bone. inserted percutaneously, directly into the fracture
During surgery the bone fragments are débrided site, and
and aligned, electrical impulses are directed to the fracture
infection (if present) is removed, and a bone graft is continuously.
placed in This method cannot be used when infection is
the bony defect. The bone graft may be an present.
autograft (tissue, Another method for stimulating osteogenesis is
frequently from the iliac crest, harvested from the noninvasive
patient inductive coupling. Pulsing electromagnetic fields
for his or her own use) or an allograft (tissue are delivered to the fracture for approximately 10
harvested from hours
a donor). The bone graft fills the bone gap and each day by an electromagnetic coil over the
provides a nonunion site
lattice structure for invasion by bone cells and (Fig. 69-6). During the electrical stimulation
actively promotes treatment period,
bone growth. The type of bone selected for grafting which takes 3 to 6 months or longer, rigid fracture
depends on function: cortical bone is used for fixation with adequate support is needed.
structural
strength, cancellous bone for osteogenesis, and Nursing Management. The patient with a
corticocancellous nonunion has
bone for strength and rapid incorporation. Free experienced an extended time in fracture treatment
vascularized and frequently
bone autografts are grafted with their own blood becomes frustrated with prolonged therapy. The
supply, allowing for primary fracture healing.
nurse provides emotional support and has developed. Problems may include mechanical
encouragement to failure
the patient and encourages compliance with the (inadequate insertion and stabilization); material
treatment failure
regimen. The orthopedic surgeon evaluates the (faulty or damaged device); corrosion of the device,
progression causing
of bone healing with periodic x-rays. local inflammation; allergic response to the
Nursing care for the patient with a bone graft metallic alloy
includes used; and osteoporotic remodeling adjacent to the
pain management and monitoring the patient for fixation site
possible (Bucholz, Heckman, Court-Brown, et al., 2005). If
complications. The nurse needs to reinforce the device
educational is removed, the bone needs to be protected from
information concerning the objectives of the bone refracture
graft, related to osteoporosis, altered bone structure, and
immobilization, non–weight-bearing exercises, trauma.
wound care,
monitoring for signs of infection, and the Complex Regional Pain Syndrome
importance of follow-
up care with the orthopedic surgeon. CRPS is a painful sympathetic nervous system
Nursing care for the patient with electrical bone problem. It
stimulation occurs infrequently; but when it does occur, it is
focuses on patient education that addresses most often
immobilization, in an upper extremity after trauma and is seen more
weight-bearing restrictions, and correct daily use of frequently
the stimulator as prescribed. in women. Clinical manifestations of CRPS include
severe burning pain, local edema, hyperesthesia,
Avascular Necrosis of Bone stiffness,
discoloration, vasomotor skin changes (ie,
AVN occurs when the bone loses its blood supply fluctuating warm,
and dies. red, dry and cold, sweaty, cyanotic), and trophic
It may occur after a fracture with disruption of the changes
blood that may include glossy, shiny skin and increased
supply to the distal area. It is also seen with hair and
dislocations, nail growth. This syndrome is frequently chronic,
bone transplantation, prolonged high-dose with extension
corticosteroid of symptoms to adjacent areas of the body. Disuse
therapy, chronic renal disease, sickle cell anemia, muscle atrophy and bone deossification
and other (osteoporosis) may
diseases. The devitalized bone may collapse or occur with persistent CRPS.
reabsorb.
The patient develops pain and experiences limited Nursing Management. Prevention may include
movement. elevation
X-rays reveal loss of mineralized matrix and of the extremity after injury or surgery and
structural collapse. selection of an
Treatment generally consists of attempts to immobilization device (eg, external fixator) that
revitalize allows for
the bone with bone grafts, prosthetic replacement, the greatest ROM and functional use of the rest of
or the extremity.
arthrodesis (joint fusion). Early effective pain relief is the focus of
management.
Reaction to Internal Fixation Devices Pain may need to be controlled with analgesics.
NSAIDs,
Internal fixation devices may be removed after corticosteroids, and muscle relaxants also may be
bony union used. The
has taken place. However, in most patients, the nurse helps the patient to cope with CRPS
device is manifestations
not removed unless it produces symptoms. Pain and and explores multiple ways to control pain (see
decreased Chapter 13).
function are the prime indications that a problem
Heterotopic Ossification
Heterotopic ossification (myositis ossificans) is the
abnormal
formation of bone, near bones or in muscle, in
response to soft tissue trauma or fracture after blunt
trauma or total

joint replacement. The muscle is painful, and

normal muscular
contraction and movement are limited. Early
mobilization
may prevent its occurrence. Usually the bone lesion
resorbs over time, but the abnormal bone
eventually may
need to be excised if symptoms persist.