Femur - Fracture

FEMUR

There is a high incidence of hip fracture among elderly people, who have brittle bones from osteoporosis (particularly women) and who tend to fall frequently. Weak quadriceps muscles, general frailty due to age, and conditions that produce decreased cerebral arterial perfusion (transient ischemic attacks, anemia, emboli, cardiovascular disease, effects of medications) contribute to the incidence of falls. 

The patient who has sustained a hip frac-ture frequently has a comorbidity (eg, cardiovascular, pulmonary, renal, endocrine). Often, a fractured hip is a catastrophic event that will have a negative impact on the patient’s lifestyle and qual-ity of life.

There are two major types of hip fracture. Intracapsular frac-tures are fractures of the neck of the femur. Extracapsular frac-tures are fractures of the trochanteric region (between the baseof the neck and the lesser trochanter of the femur) and of the sub-trochanteric region (Fig. 69-12). Fractures of the neck of the femur may damage the vascular system that supplies blood to the head and the neck of the femur, and the bone may die. For this reason, nonunion or aseptic necrosis is common in patients with femoral neck fractures.

Extracapsular intertrochanteric fractures have an excellent blood supply and heal readily. However, extensive soft tissue damage may have occurred at the time of injury. It is not uncommon for the fracture to be comminuted and unstable. There is a fairly high mortality rate after intertrochanteric hip fractures, mainly because the patients are usually elderly (70 to 85 years of age) and are poor surgical candidates.

Clinical Manifestations

With fractures of the femoral neck, the leg is shortened, ad-ducted, and externally rotated. The patient complains of pain in the hip and groin or in the medial side of the knee. With most fractures of the femoral neck, the patient is unable to move the leg without a significant increase in pain. The patient is most comfortable with the leg slightly flexed in external rotation. Im-pacted intracapsular femoral neck fractures cause moderate dis-comfort (even with movement), may allow the patient to bear weight, and may not demonstrate obvious shortening or rota-tional changes. With extracapsular femoral fractures of the tro-chanteric or subtrochanteric regions, the extremity is significantly shortened, externally rotated to a greater degree than intra-capsular fractures, exhibits muscle spasm that resists positioning of the extremity in a neutral position, and has an associated large hematoma or area of ecchymosis. The diagnosis of fractured hip is confirmed with x-ray.

Gerontologic Considerations

Hip fractures are a frequent contributor to death after the age of 75 years. Stress and immobility related to the trauma predispose the older adult to pneumonia, sepsis, and reduced ability to cope with other health problems.

Many elderly people hospitalized with hip fracture are confused as a result of the stress of the trauma, unfamiliar surroundings, sleep deprivation, medications, and systemic illness. Preoperative predictors of postoperative delirium include age older than 70 years, alcohol abuse, impaired cognitive status, poor functional status, and markedly abnormal serum sodium, potassium, or glucose con-centrations. In addition, confusion that develops in some elderly patients may be caused by mild cerebral ischemia. Other factors associated with confusion include responses to medications and anesthesia, malnutrition, dehydration, infectious processes, mood disturbances, and blood loss.

To prevent complications, the nurse must assess the elderly patient for chronic conditions that require close monitoring. Examination of the legs may reveal edema due to heart failure or peripheral pulselessness from arteriosclerotic vascular dis-ease. Similarly, chronic respiratory problems may be present and may contribute to the possible development of inadequate pulmonary ventilation. Coughing and deep-breathing exercises are encouraged. Frequently, elderly people are taking cardiac, antihypertensive, or respiratory medications that need to be continued. The patient’s responses to these medications should be monitored.

Dehydration and poor nutrition may be present. At times, elderly people who live alone are unable to summon help at the time of injury. A day or two may pass before assistance is provided, and as a result, dehydration occurs. Dehydration contributes to hemoconcentration and predisposes to thromboembolism. There-fore, the patient needs to be encouraged to consume adequate flu-ids and a healthy diet.

Muscle weakness and wasting may have contributed to the fall and fracture in the first place. Bed rest and immobility will cause an additional loss of muscle strength unless the nurse encourages the patient to move all joints except the involved hip and knee. Patients are encouraged to use their arms and the overhead trapeze to reposition themselves. This strengthens the arms and shoulders, which facilitates walking with assistive devices.

Medical Management

Temporary skin traction, Buck’s extension, may be applied to re-duce muscle spasm, to immobilize the extremity, and to relieve pain. The findings of a recent study ( Jerre et al., 2000) suggested that there is no benefit to the routine use of preoperative skin traction for patients with hip fractures and that the use of skin traction should be based on evaluation of the individual patient.

The goal of surgical treatment of hip fractures is to obtain a sat-isfactory fixation so that the patient can be mobilized quickly and avoid secondary medical complications. Surgical treatment consists of (1) open or closed reduction of the fracture and internal fixation,replacement of the femoral head with a prosthesis (hemiarthro-plasty), or (3) closed reduction with percutaneous stabilization for an intracapsular fracture. Surgical intervention is carried out as soon as possible after injury. The preoperative objective is to ensure that the patient is in as favorable a condition as possible for the sur-gery. Displaced femoral neck fractures may be treated as emergen-cies, with reduction and internal fixation performed within 12 to 24 hours after fracture. This minimizes the effects of diminished blood supply and reduces the risk for avascular necrosis.

After general or spinal anesthesia, the hip fracture is reduced under x-ray visualization using an image intensifier. A stable fracture is usually fixed with nails, a nail-and-plate combination, multiple pins, or compression screw devices (Fig. 69-13). The orthopedic surgeon determines the specific fixation device based on the fracture site or sites. Adequate reduction is important for fracture healing (the better the reduction, the better the healing).

Hemiarthroplasty (replacement of the head of the femur with a prosthesis) is usually reserved for fractures that cannot be satis-factorily reduced or securely nailed or to avoid complications of nonunion and avascular necrosis of the head of the femur. Total hip replacement may be used in selected patients with acetabular defects.

Postoperative Nursing Management

The immediate postoperative care for a patient with a hip fracture is similar to that for other patients undergoing major surgery. Attention is given to pain management, preven-tion of secondary medical problems, and early mobilization of the patient so that independent functioning can be restored.

During the first 24 to 48 hours, relief of pain and prevention of complications are priorities. The nurse encourages deep breath-ing, coughing, and foot flexion exercises every 1 to 2 hours. Thigh-high elastic compression stockings and pneumatic compression devices are used to prevent venous stasis. The nurse administers prescribed intravenous prophylactic antibiotics and monitors the patient’s hydration, nutritional status, and urine output. A pillow is placed between the legs to maintain abduction and alignment and to provide needed support when turning the patient.

REPOSITIONING THE PATIENT

The nurse may turn the patient onto the affected or unaffected extremity as prescribed by the physician. The standard method involves placing a pillow between the patient’s legs to keep the af-fected leg in an abducted position. The patient is then turned onto the side while proper alignment and supported abduction are maintained.

PROMOTING STRENGTHENING EXERCISE

The patient is encouraged to exercise as much as possible by means of the overbed trapeze. This device helps strengthen the arms and shoulders in preparation for protected ambulation (eg, toe touch, partial weight bearing). On the first postoperative day, the patient transfers to a chair with assistance and begins assisted ambulation. The amount of weight bearing that can be permit-ted depends on the stability of the fracture reduction. The physi-cian prescribes the degree of weight bearing and the rate at which the patient can progress to full weight bearing. Physical therapists work with the patient on transfers, ambulation, and the safe use of a walker and crutches.

The patient who has experienced a fractured hip can antici-pate discharge to home or to an extended care facility with the use of an ambulatory aid. Some modifications in the home may be needed to permit safe use of walkers and crutches and for the patient’s continuing care.

MONITORING AND MANAGING POTENTIAL COMPLICATIONS

Elderly people with hip fractures are particularly prone to compli-cations that may require more vigorous treatment than the fracture. In some instances, shock proves fatal. Achievement of homeostasis after injury and after surgery is accomplished through careful mon-itoring and collaborative management, including adjustment of therapeutic interventions as indicated.

Neurovascular complications may occur from direct injury tonerves and blood vessels or from increased tissue pressure. With hip fracture, bleeding into the tissues is expected. Excessive swell-ing may be observed. Therefore, the nurse must monitor the neuro-vascular status of the affected leg.

Deep vein thrombosis is the most common complication. Toprevent DVT, the nurse encourages intake of fluids and ankle and foot exercises. Elastic compression stockings, sequential compres-sion devices, and prophylactic anticoagulant therapy may be pre-scribed. The nurse assesses the patient’s legs at least every 4 hours for signs of DVT.

Pulmonary complications are a threat to elderly patients under-going hip surgery. Deep-breathing exercises, a change of position at least every 2 hours, and the use of an incentive spirometer help to prevent respiratory complications. The nurse assesses breath sounds at least every 4 to 8 hours to detect adventitious or dimin-ished sounds.

Skin breakdown is often seen in elderly patients with hip frac-ture. Blisters caused by tape are related to the tension of soft tis-sue edema under the nonelastic tape. An elastic hip spica wrap dressing (Fig. 69-14) or elastic tape applied in a vertical fashion may reduce the incidence of tape blisters. In addition, patients with hip fractures tend to remain in one position and may develop pressure ulcers. Proper skin care, especially on the heels, back, sacrum,and shoulders, helps to relieve pressure. High-density foam, sta-tic air, or another type of special mattress may provide protection by distributing pressure more evenly.

Loss of bladder control (incontinence) may occur. In general,the routine use of an indwelling catheter is avoided because of the high risk for urinary tract infection. If a catheter is inserted at the time of surgery, it usually is removed on the morning of the first postoperative day. Because urinary retention is common after sur-gery, the nurse must assess the patient’s voiding patterns. To en-sure proper urinary tract function, the nurse encourages liberal fluid intake within the cardiovascular tolerance of the patient.

Delayed complications of hip fractures include infection, non-union, avascular necrosis of the femoral head (particularly with femoral neck fractures), and fixation device problems (eg, pro-trusion of the fixation device through the acetabulum, loosening of hardware). Infection is suspected if the patient complains of per-sistent, moderate discomfort in the hip and has a mildly elevated sedimentation rate. The nursing management of the elderly patient with a hip fracture is summarized in the Plan of Nursing Care.

HEALTH PROMOTION

Osteoporosis screening of patients who have experienced hip frac-ture is important for prevention of future fractures. With dual-energy x-ray absorptiometry (DEXA) scan screening, the actual risk for additional fracture can be determined. Specific patient education regarding dietary requirements, lifestyle changes, and exercise to promote bone health is needed. Specific therapeutic in-terventions need to be initiated to retard additional bone loss and to build bone mineral density. Studies have shown that health care providers caring for patients with hip fractures fail to diagnose or treat these patients for osteoporosis despite the high probability that hip fractures are secondary to osteoporosis (Kamel, et al., 2000). Fall prevention is also important and may be achieved through exercises to improve muscle tone and balance and through the elimination of environmental hazards. In addition, the use of hip protectors that absorb or shunt impact forces may help to pre-vent an additional hip fracture if the patient were to fall.