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Fracture

Tony Suharsono

Definition
A fracture is a break in the continuity of bone and is

defined according to its type and extent A fracture is a break in a bone and can occur at any age and in any bone Fractures occur when the bone is subjected to stress greater than it can absorb When the bone is broken, adjacent structures are also affected, resulting in soft tissue edema, hemorrhage into the muscles and joints, joint dislocations, ruptured tendons, severed nerves, and damaged blood vessels

Types of Fracture
A complete fracture involves a break across the entire cross-section

of the bone and is frequently displaced (removed from normal position). Incomplete fracture (eg, greenstick fracture), the break occurs through only part of the cross-section of the bone. A comminuted fracture is one that produces several bone fragments. A closed fracture (simple fracture) is one that does not cause a break in the skin. An open fracture (compound, or complex) is one in which the skin or mucous membrane wound extends to the fractured bone

Types of Fracture
Open Fracture Open fractures are graded accordingto the

following criteria:
Grade I is a clean wound less than 1 cm long
Grade II is a larger wound without extensive soft

tissue damage Grade III is highly contaminated, has extensive soft tissue damage, and is the most severe.

Clinical Manifestation
Pain The pain is continuous and increases in severity

until the bone fragments are immobilized Loss of function Deformity Shortening Crepitus Swelling and discoloration

Patofisiology
Bone is a dynamic, changing tissue
Within 48 to 72 hours after the injury a hematoma (blood clot)

forms at the fracture site because bone has a rich blood supply Various cells that begin the healing process are attracted to the damaged bone. In about a week or so, a nonbony union called a callus develops and can be seen on x-ray examination. As healing continues, osteoclasts (bonedestroying cells) resorb any necrotic bone Osteoblasts (bone-building cells) make new bone as a replacement. This process is sometimes referred to as bone remodeling. Young, healthy adult bone completely heals in about 6 weeks

Diagnostic Procedure
X Ray Menentukan lokasi/luas/jenis fraktur Dua posisi (AP/Lat), dua sendi terlibat

Bone Scanning
Menunjukkan tingkat keparahan fraktur,

identifikasi kerusakan jar lunak Arteriogram Jika terdapat kerusakan vaskuler

General Management
Perform a primary assessment and initiate appropriate

intervention Evaluate the neurovasculer status Secure any impaled object Remove rings, other jewelry, and tight clothing from injured extremity Immobilize extremities beyond the joint above and below the site of injury Reevaluate neurovasculer status after reposition or imobilization Apply ice pack to areas of swelling

Management of Fracture
Reduction restoration of the fracture fragments to anatomic alignment

and rotation closed reduction or open reduction may be used to reduce a fracture Usually,the physician reduces a fracture as soon as possible to prevent loss of elasticity from the tissues through infiltration by edema or hemorrhage Before fracture reduction and immobilization, the patient is prepared for the procedure; permission for the procedure is obtained, and an analgesic is administered as prescribed

Management of Fracture
Closed Reduction bringing the bone fragments into position

through manipulation and manual traction The immobilizing device maintains the reduction and stabilizes the extremity for bone healing X-rays are obtained to verify that the bone fragments are correctlyaligned

Management of Fracture
Open Reduction Internal fixation devices may be used to

hold the bone fragments in position until solid bone healing occurs Internal fixation devices ensure firm approximation and fixation of the bony fragments

Internal Fixation

Management of Fracture
Immobilization After the fracture has been reduced, the bone

fragments must be immobilized, or held in correct position and alignment, until union occurs Immobilization may be accomplished by external or internal fixation

Management of Fracture
Maintaining and restoring function Swelling is controlled by elevating the injured extremity and

applying ice Neurovascular status (circulation, movement, sensation) is monitored, and the orthopedic surgeon is notified immediately if signs of neurovascular compromise are identified Isometric and muscle-setting exercises are encouraged to minimize disuse atrophy and to promote circulation Participation in activities of daily living (ADLs) is encouraged to promote independent functioning and self-esteem

Factors That Enhance Fracture Healing Immobilization of fracture fragments Maximum bone fragment contact Sufficient blood supply Proper nutrition Exercise: weight bearing for long bones Hormones: growth hormone, thyroid, calcitonin, vitamin D

Factors That Inhibit Fracture Healing Extensive local trauma Bone loss Inadequate immobilization Space or tissue between bone fragments Infection Local malignancy Age

Complication of Fracture
Fat Embolism Syndrome Fat embolism is a potentially life threatening

complication of long bone trauma, blunt trauma, and intramedularry manipulation This syndrome manifest anywhere from 4 hours to several days after injury or orthopedic surgery. Fat globules, release from bone marrow, can embolize and occlude blood vessels in the brain, kidnes, lungs and other tissue

Complication of Fracture
Osteomyelitis Osteomyelitis is an infection of the bone, most

commonly a result of direct contamination from open fracture, penetrating wound, or surgical procedures it takes 10 to 14 days from the time of infection exposure before radiographs will demonstrate visible changes The most common causative organism is staphylococcus aureus

Complication of Fracture
Compartment Syndrome Compartment syndrome develops when the presure in a

muscle compartment exceeds the intraarterial hydrostatic pressure, causing collapse of capilaries and venules, which lead to iskhemia and tissue necrotic The exact pressure at which this develops is unclear, but intracompartment pressure greater than 30 mmHg generally are considered greatly elevated A grace periode of about 6 hours exists before irreversible soft tissue demage occurs It is important to suspect compartment syndrome early

Complication of Fracture
Bleeding Delayed union and non union Avascular necrosis of bone

Reaction to internal fixation devices

Assessment
Neurovascular assessment Use five P to evaluate limb circulation,

sensation and motor function Pain : a description of pain is helpful Pallor Pulses Parasthesia Paralysis

Assessment
Inspection, the injured area for the

following: Color Disrupted skin integrity Extremity position Edema, swelling, or echhimosis Range of motion Symmetry, alignment, deformity

Assessment
Palpation, the injury to identify the

following : Skin temperature Pain Bony crepitus, joint instability Peripheral nerve function : sensory and motor

Nursing Diagnose
Acute pain Impaired physical mobility Risk for peripheral neurovaskuler

dysfunction Risk for imbalance fluid volume

Nursing intervention
Teach patients how to control swelling and pain

associated with the fracture and with soft tissue trauma and Assess neurovascular status frequently Encourages them to be active within the limits of the fracture immobilization

Nursing intervention
Teach exercises to maintain the health of

unaffected muscles and to increase the strength of muscles needed for transferring and for using assistive devices Teach patients how to use assistive devices safely Patient teaching includes self-care, medication information, monitoring for potential complications, and the need for continuing health care supervision