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Fracture – Safety of the client during transfer

Fracture Possible Complications:


– A break in the continuity of the bone. They occur when – Fat Embolus
the physical force – Compartment Syndrome
exerted on the bone is stronger than the bone itself. – Nonunion of the fracture side
Other Name of fracture: – Arterial damage during treatment
– Broken Bone – Infection
– Bone fracture – Sepsis
There are many types of fractures: – Hemorrhage leading to shock
1. Closed simple/ uncomplicated fracture 5 Nursing Diagnosis
 bone breaks but there is no puncture or open wound in 1. Pain related to fracture, soft tissue damage, muscle
the skin. spasm and surgery.
1. Open compound/ complicated fracture 2. Impaired physical mobility related to fractured hip
 Involves trauma to surrounding tissue and a break in 3. Impaired skin integrity related to surgical incision
the skin. 4. Risk for disturbed thought process related to age,
1. Comminuted fracture stress of trauma, unfamiliar
 a fracture in which the bone fragments into several surroundings and drug theraphy
pieces. 5. Risk for impaired urinary elimination related to
1. Greenstick fracture immobility
 an incomplete fracture in which the bone is bent. This
type occurs Fractures
most often in children. A. Description: A fracture is any disruption in the normal
1. Spiral ( torsion) continuity of a bone caused by trauma, twisting
 Involve a fracture of twisting around the shaft of the as a result of muscle spasm or indirect loss of leverage
bone. or bone decalcification and disease that result in
1. Transverse osteopenia.
 Occurs straight across the bone B. Specific Types of Fractures (taken from Brunner &
1. Oblique Suddarth’s)
 Occur at an angle across the bone (less than a a. Avulsion: A fracture in which a fragment of bone has
transverse) been pulled away by a ligament or tendon
1. Pathological Fracture and its attachment
 Result from weakness in bone tissue. b. Comminuted: A fracture in which bone has splintered
Causes/Etiology into several fragments
-Crushing force or direct blow c. Compound: A fracture in which damage also involves
-Torsion fracture can occur from sudden twisting the skin or mucous membranes; also
-Extremely forceful muscle contraction called an open fracture
Predisposing Risk factor d. Compression: A fracture in which bone has been
-Age- aging process compressed (seen in vertebral fractures)
- Sex e. Epiphyseal: A fracture through the epiphysis
-Pathology- Paget’s disease, Osteomyelitis, Ricket’s f. Greenstick: A fracture in which one side of a bone is
Sign and Symptoms broken and the other side is bent
- 5 P’s g. Impacted: A fracture in which a bone fragment is
1. Pain driven into another bone fragment
2. Pallor h. Oblique: A fracture occurring at an angle across the
3. Paresthesia bone (less stable than a transverse fracture)
4. Polar i. Pathologic: A fracture that occurs through an area of
5. Pulselessness diseased bone (eg. Osteoporosis, bone cyst,
- Edema Paget’s disease, bony metastasis, tumor); can occur
- Tenderness without trauma or a fall
- Abnormal movement j. Simple: A fracture that remains contained; does not
- Crepitus break the skin
- Loss of Function k. Spiral: A fracture that twists around the shaft of the
- Ecchymoses bone
- Visible deformity l. Stress: A fracture that results from repeated loading
Patophysiology: without bone and muscle recovery
Diagnostic Studies m. Transverse: A fracture that is straight across the bone
– An x-ray examination is used to determine the C. Clinical manifestations
presence of a fracture. Not all of these clinical manifestations are present in
Medical Management every fracture.
- a. Pain: The pain is continuous and increases in severity
Surgical management until the bone fragments are immobilize.
Nursing Management b. Deformity: Swelling from local hemorrhage may cause
– RICES Management deformity at the fracture site. Muscle
R- Rest spasm can cause limb shortening, a rotational deformity
I- Ice Compress or angulation. Compared with the
C- Cast uninjured side, the fracture site may also have obvious
E- Elevation deformity.
S- Safety c. Bruising (ecchymosis). Bruising develops from
– Give meds as ordered subcutaneous bleeding at the fracture site
– Prevent infection d. Musce spasm: Frequently accompanying fractures,
– Cover any breaks in the skin with clean or sterile involuntary muscle spasm actually serves as
dressings
a natural splint to decrease further motion of fracture III. Infection and osteomyelitis
fragments. 1. Description: Infection and osteomyelitis can be caused
e. Loss of function: Any loss of function results either by the introduction of
from pain caused by the fracture or from organisms into bones initially leading to localized bone
loss of the lever-arm function in an affected extremity. infection
Paralysis may be caused by nerve 2. Assessment
damage. • Tachycardia and fever (usually above 101 F)
f. Abnormal mobility and crepitus: When the extremity is • Erythema and pain in the area surrounding the
examined with the hands, a grating infection
sensation, called crepitus, can be felt. It is caused by the • Leukocytosis and elevated ESR
rubbing of the bone fragments against 3. Interventions
each other. • Notify the physicians
g. Neurovascular changes: Neurovascular injury results • Prepare to initiate aggressive, long-term intravenous
from damage to peripheral nerves or to the antibiotic therapy
associated vascular structures. The client may complain
• Administer hyperbaric oxygen therapy to promote
of numbness and tingling or have no
healing
palpable pulse distal to the fracture.
h. Shock: Bony fragments may lacerate blood vessels. • Surgery is performed for resistant osteomyelitis with
Frank or occult hemorrhage can lead to sequestrectoy and/or
shock. bone grafts
D. Complications of fractures IV. Avascular necrosis
I. Fat embolism 1. Description: Avascular necrosis occurs when a fracture
1. Description: A fat embolism originates in the bone interrupts the blood supply to
marrow and occurs after a a section of bone, leading to bone death
fracture when a fat globule is released in to the 2. Assessment:
bloodstream. • Pain
• Clients with long bone fractures are at the greatest risk • Decreased sensation
for the development of 3. Interventions
a fat embolism • Notify the physician if pain or numbness occurs
• Fat embolism can occur with the first48 to 72 hours • Prepare the client for removal of necrotic tissue
following the injury because it serves as a focus
2. Assessment: Findings often suggest pulmonary for infection
embolism V. Pulmonary embolism
• Restlessness, hypoxemia, or mental status changes 1. Description: Pulmonary embolism is caused by the
• Tachycardia and hypotension movement of foreign particles
(blood clot, fat or air) into the pulmonary circulation
• Dyspnea and tachypnea
2. Assessment
• Petechial rash over the upper chest and neck
• Restlessness and apprehension
3. Interventions
• Sudden onset of dyspnea and chest pain
• Notify the physician immediately while initiating
emergency care • Cough, hemoptysis, hypoxemia or crackles
3. Interventions
• Treat symptoms as prescribe to prevent respiratory
failure and death • Notify the physician if signs of emboli are present
• Cortiscosteroids may be given to reduce pulmonary • Given oxygen IV anticoagulant therapy if prescribed
injury E. Emergency Management of Fractures
II. Compartment syndrome a. Immobilize affected extremity with cast or splint.
1. Description b. If a compound (open) fracture exists, splint the
extremity and cover the wound with a sterile
• Tough fascia surrounds muscle groups, forming
dressing.
compartments from which
c. Assess neurovascular status of the extremity
arteries, veins and nerves enter and exit opposite ends
d. Interventions for a fracture are reduction, fixation,
• Compartment syndrome occurs when pressure traction and cast.
increases within one or more F. Medical Management of a Fracture
compartments, leading to decreased blood flow, tissue a. Reduction of a fracture restores the bone to proper
ischemia and alignment.
neurovascular impairment i. Closed reduction is a nonsurgical intervention
• Within 4 to 6 hours after the onset of compartment performed by manual manipulation.
syndrome, neurovascular • Closed reduction may be performed under local or
damage is irreversible if not treated general anesthesia
2. Assessment
• A cast may be applied following reduction
• Unrelieved or increased pain in the limb ii. Open reduction involves surgical intervention
• Tissue that is distal to the involved area becomes pale, • Fracture may be treated with internal fixation devices.
dusky or edematous
• The client may be placed in traction or a cast following
• Pain with passive movement and joint dysfunction the procedure.
• Pulselessness and loss of sensation (paresthesia) b. Fixation
3. Interventions i. Internal fixation follows an open reduction
• Notify the physician immediately and prepare to assist • Internal fixation involves the application of screws,
physician plates, pins, or intramedullary
• If severe, assist the physician with fasciotomy to rods to hold the fragments in alignment
relieve pressure and restore • Internal fixation may involve the removal of damaged
tissue perfusion bone and replacement with
• Loosen tight dressing or bivalve restrictive cast as a prosthesis
prescribed
• Internal fixation provides immediate bone strength. • Use measures as prescribed to prevent the client from
ii. External fixation is the use of an external frame to slipping down in bed.
stabilize a fracture by attaching f. Balanced suspension traction
skeletal pins through bone fragments to a rigid external i. Description
support • Balanced suspension traction is used with skin or
• External fixation provides more freedom of movement skeletal traction
than with traction • Used to approximate fractures of the femur, tibia or
• Monitor pin stability and provide pin care to decrease fibula
infection risks • Balanced suspension traction is produced by a
• Risk of infection exists with both fixation methods counterforce other than client
• External is commonly used when massive trauma is ii. Interventions
present • Position the client in a low Fowler’s position on either
c. Traction the side or the back.
i. Description • Maintain a 20-degree angle from the thigh to the bed
• Traction is the exertion of a pulling force applied in two • Protect the skin from breakdown
directions to reduce and • Provide pin care if pins are used with the skeletal
immobilize a fracture traction
• Traction provides proper bone alignment and reduces • Clean the pin sites with sterile normal saline and
muscle spasms hydrogen peroxide or povidoneiodine
ii. Interventions (Betadine) as prescribed or per agency policy.
• Maintain proper body alignment g. Dunlop’s traction
• Ensure that the weights hang freely and do not touch i. Description: Horizontal traction is used to align
the floor fractures of the humerus; vertical
• Do not remove or lift the weights without a physician’s traction maintains the forearm in proper alignment.
order ii. Interventions: Nursing care is similar to that for Buck’s
• Ensure that pulleys are not obstructed and that ropes skin traction.
in the pulleys move freely h. Casts
• Place knots in the ropes to prevent slipping i. Description: Plaster or fiberglass casts are used to
• Check the ropes for fraying. immobilize bones and joints into
d. Skeletal traction correct alignment after a fracture or injury.
i. Description: Traction is applied mechanically to the ii. Interventions
bone with pins, wires and tongs • Keep the cast and extremity elevated
ii. Interventions • Allow a wet cast 24 to 72 hours to dry (synthetic casts
• Monitor color, motion, and sensation of the affected dry in 20 minutes)
extremity • Handle a wet cast with the palms of the hands until dry
• Monitor the insertion sites for redness, swelling, • Turn the extremity every 1 to 2 hours, unless
drainage or increased pain contraindicated, to allow air
• Provide insertion site care as prescribed circulation and promote drying of the cast.
e. Skin traction • A hair dryer can be used on a cool setting to dry a
i. Description: Skin traction is applied by using elastic plaster cast (heat cannot be
bandages or adhesive. used on a plaster cast because the cast heats up and
ii. Cervical skin traction relieves muscle spasms and burns the skin)
compression in the upper extremities • Monitor the extremity for circulatory impairment such
and neck. as pain, swelling,
• Cervical skin traction uses a head halter and chin pad discoloration, tingling, numbness, coolness or diminished
to attach the traction pulse.
• Use powder to protect the ears from friction rub • Notify the physician immediately if circulatory
• Position the client with the head of the bed elevated 30 impairment occurs
to 40 degrees, and attach • Petal the cast; maintain smooth edges around the cast
the weights to a pulley system over the head of the bed. to prevent crumbling of the
iii. Buck’s (extension) skin traction is used to cast material
alleviate muscle spasms and immobilize a • Monitor for signs of infection such as temperature, hot
lower limb by maintaining a straight pull on the limb with spots on the cast, foul
the use of weights. odor, or changes in pain
• A boot appliance is applied to attach to the traction • If an open draining area exists on the affected
• The weights are attached to a pulley; allow the weights extremity, the physician will make
to hang freely over the a cutout portion of the cast or a window.
edge of bed. • Instruct the client not to stick objects inside the cast
• Not more than 8 to 10 lb of weight should be applied • Teach the client to keep the cast clean and dry
• Elevate the foot of the bed to provide the traction • Instruct the client in isometric exercises to prevent
iv. Russell’s skin traction: muscle atrophy
• Used to stabilize a fractured femur before surgery
• Similar to Buck’s traction but provides a double pull 1
using a knee sling that pulls BASICS OF FRACTURE
at the knee and foot What is a fracture?
v. Pelvic skin traction is used to relieve low back, hip, A fracture is a partial or complete break in the structural
or leg pain or to reduce muscle continuity of bone. When a fracture
spasm. occurs, it is classified as either open or closed:
• Apply the traction snugly over the pelvis and iliac crest • Open fracture (Also called compound fracture.) -
and attach to the weights The bone exits and is visible through
the skin, or a deep wound that exposes the bone through weakest when they are twisted.
the skin or one of the body Breaks in bones can occur from falls, trauma, or as a
cavities breached. result of a direct blow or kick to the body.
• Closed fracture (Also called simple fracture.) - Fractures results from:
The bone is broken, but the skin is • A single traumatic incident. Breaks in bones can occur
intact. from falls, trauma, or as a result of
Fractures have a variety of names. Below is a listing of a direct blow or kick to the body.
the common types that may occur in • Repetitive stress
children: • Abnormal weakening of the bone (Pathological
• Greenstick - incomplete fracture. The broken bone is fracture).
not completely separated. Pathological fractures:
• Transverse - the break is in a straight line across the 4
bone. Fractures occur in bones which have been weakened
• Spiral - the break spirals around the bone; common in already due to a pathological process.
a twisting injury. Causes of pathological fractures can be classified into
• Oblique - diagonal break across the bone. generalised bone conditions or local
2 benign causes
• Compression - the bone is crushed, causing the General bone conditions
broken bone to be wider or flatter in • Osteogenesis imperfecta
appearance. • Post-menopausal osteoporosis
• Comminuted – there are more than two bony • Metabolic bone disease
fragments. • Paget's disease
Describing a Fracture: Local benign causes
A systematic approach is needed: • Chronic infection of bone
• Type of fracture • Solitary bone cysts
○ Transverse • Aneurysmal bone cysts
○ Spiral • Chondromas
○ Oblique Primary bone tumours such as chondrosarcomas,
○ Simple etc osteosarcomas and Ewing's sarcoma are all
• Anatomical location causes of pathological fractures and may metastasise to
○ Which bone is affected? the breast, kidney, lung, prostate and
○ Which side - left or right? thyroid.
○ Is the fracture proximal, middle or distal? A child's bone differs from adult bone in a variety
○ Is it intra-articular or extra-articular of ways:
• Displacement of the fracture fragments • A child's bone heals much faster than an adult's bone.
○ Shift The younger the child, the
○ Alignment faster the healing occurs.
3 • Bones are softer in children and tend to buckle or bend
○ Shortening rather than completely break.
○ Rotation • Children have open growth plates, also called
• Associated fractures epiphysis, located at the end of the long
○ Dislocation bones. This is an area where the bone grows. Injury to
○ Open or closed fracture etc. the growth plate can lead to
Examples of describing a fracture limb length discrepancies or angular deformities.
• "This is a oblique fracture of the mid-shaft of the right What are the symptoms of a fracture?
tibia with no displacement" The following are the most common symptoms of a
• "This is a transverse fracture of the distal radius with fracture. However, each child may
dorsal angulation" experience symptoms differently. Symptoms may
Important Definitions include:
• Shift - loss of alignment in the cortices of the shaft of • Pain and tenderness in the injured area
the bone resulting onto sideways • swelling in the injured area
displacement • obvious deformity in the injured area
• Angulation - loss of normal longitudinal axial • difficulty using or moving the injured area in a normal
alignment of the shaft of the bone. This manner
may be anterior, posterior, medial or lateral • warmth, bruising, or redness in the injured area
• Shortening - the bone appears shortened as a result The symptoms of a broken bone may resemble other
of overlap of the fracture fragments conditions. Always consult your child's
or due to impaction at the fracture site physician for a diagnosis.
• Rotation - this refers to the rotation of the distal How is a fracture diagnosed?
fragment (relative to the proximal 5
fragment) along the long axis of the bone. This may be The physician makes the diagnosis with physical
external or internal examination and diagnostic tests. During the
• Undisplaced - the fracture fragments are almost in examination the physician obtains a complete medical
anatomical location history of the child and asks how the
• Impacted fracture - a fracture that occurs as a result injury occurred.
of compression of cancellous bone Diagnostic procedures may include:
in its long axis causing two bone ends to be forced • X-rays - a diagnostic test which uses invisible
tightly together. electromagnetic energy beams to
What causes a fracture? produce images of internal tissues, bones, and organs
Fractures occur when there is more force applied to the onto film.
bone than the bone can absorb. Bones are
• Magnetic resonance imaging (MRI) - a diagnostic • Energy of the injury
procedure that uses a • Fracture site
combination of large magnets, radiofrequencies, and a ○ Adequate compression?
computer to produce detailed ○ Any movement?
images of organs and structures within the body. This • Infection
test is done to rule out any • Mode of treatment
associated abnormalities of the spinal cord and nerves. Factors influencing bone healing:
• Computed tomography scan (Also called a CT or Systemic factors Local factors
CAT scan.) - a diagnostic Age and Comorbidity
imaging procedure that uses a combination of x-rays and Degree of local trauma / soft
computer technology to tissue
produce cross-sectional images (often called slices), both Hormones Degree of bone loss
horizontally and vertically, Functional
of the body. A CT scan shows detailed images of any activity
part of the body, including the Vascular injury
bones, muscles, fat, and organs. CT scans are more Nerve function Type of bone fractured
detailed than general x-rays. Nutrition Degree of immobilisation /
Treatment of Fractures : stability
When treating a fracture, it is important to remember Drugs (NSAID) Sterility / Infection
you are treating not only the fracture but Growth Factors Local pathological condition
the patient as a whole. Cigarette Smoke Energy of Injury
Aims of Fracture Treatment Anatomic location
Before considering how to treat a fracture, it is important Fracture Treatment :
to understand what the aims of fracture Treatment can only commence once a fracture has been
treatment are: diagnosed:
• Restore optimum function of the injured limb • Clinical assessment
• Obtain and maintain reduction of the fracture • Radiological imaging
• Encourage union (restoration of normal bone structure) NB -
of the fracture • Always need radiographs in two views
• Prevent complications • In order for radiograph to be adequate, the joints
• Provide adequate pain relief above and below the injury should be
• Rehabilitation of the patient. included.
How do Fractures Heal? General Principles
6 The following points should be taken into account:
Bone healing occurs in four stages: • Average time taken for bones to unite is 8 weeks
• Stage 1 – Tissue destruction & Haematoma formation. • Lower limb fractures take approximately twice as long
○ After any fracture, bleeding occurs from the ends of to unite as the upper limb
the bone and from the fractures
surrounding tissues • Fractures in adults take an average twice as long to
○ The vessels that are torn at the time of fracture lead heal in comparison to those in
to the formation of a fracture children
haematoma. • Transverse fractures take longer to heal than oblique
• Stage 2 –Inflammation and Cellular proliferation and or spiral fractures
vascular ingrowths • Compound and comminuted fractures are particularly
○ Within 8 hours of the fracture occurring, an acute slow to unite
inflammation reaction occurs, 8
with proliferation of cells under the periosteum and • No fracture heals in less than 3 weeks.
within the breached Treatment of closed fracture :
medullary canal • Reduction
○ The bone fragment ends are surrounded by cellular 1. Closed reduction
tissues that bridge the fracture 2. Open reduction
○ The haematoma is reabsorbed and fine new capillaries
• Immobilization (hold reduction)
grow in the area.
1. Cast splintage (Plaster of Paris or synthetic plaster)
• Stage 3 - Callus formation 2. Functional bracing
○ The proliferating cells are potentially chondrogenic 3. Continuous traction (Skeletal or skin traction)
and osteogenic in nature 4. Internal fixation
○ Under the right circumstances, the cell population 5. External fixation
changes to osteoblasts and
• Rehabilitation and exercise
osteoclasts
Which treatment is appropriate?
○ The dead bone is mopped up and woven bone appears
When deciding which treatment is appropriate, the
in the fracture callus.
following point should be noted:
• Stage 4 - Consolidation and remodeling
• Does the fracture need reducing?
○ The woven bone is replaced by lamellar bone and the
fracture is solidly united • If reduction is required, how should this be carried out?
○ New bone is remodeled to resemble the original Is the fracture stable or unstable?
normal structure. ○ Open / closed?
What affects Fracture Healing? ○ Is precise reduction necessary?
7 • How to hold the fracture in reduction? It is important to
Numerous factors can affect fracture healing: prevent loss of alignment while
• Patient - do they comply with the appropriate the bone ends are uniting:
treatment? ○ No support needed
○ Traction
 Thomas' splint • Traction - the disimpaction of the fragments. It serves
○ External splints to align the proximal and distal
 Non-rigid supports - sling, bandaging etc. parts of the limb
 Plaster of Paris • Stable - position of the fragments that can be safely
○ External fixators held in position in a plaster while the
 IIazarov frame fracture is healing
○ Internal fixation • Unstable - position of the fragments that cannot be
 Plates safely held in position in a plaster
 Screws while the fracture is healing.
 intramedullary nails Fracture complications:
○ Joint replacement 10
• Treatment plan These can be of a general nature, local - involving
○ How long does the fracture need to be immobilised structures around the fracture site or those that
for? are applicable to all fractures.
○ When can they start mobilising again? General complications
NB: - • Association with internal haemorrhage
• If the articular surface is damaged, a perfect • Shock
anatomical reduction (< 2mm) is required • Metabolic responses to trauma
• It is of up most importance to start early mobilisation • External haemorrhage and infection - open fractures
to prevent joint stiffness. only
General Management of Fractures • Hypostatic pneumonia
• Pain control with analgesics • Urinary tract infections
• Assessment of blood loss • Deep vein thrombosis leading to pulmonary embolism
9
• Pressure sores
• Management of associated injuries
• Muscle wasting
• Judicious use of antibiotics if the injury is an open one.
• Demineralisation of the bone.
Treatment Options
Local complications
Taking all the factors into consideration, there are five
• Skin damage - includes stretching of the skin by the
possible methods of fracture treatment:
underlying fracture fragments,
• No treatment is necessary except possible comfort and
lacerations, fracture blisters, necrosis and skin loss
protection
• Vascular injuries - these may arise at the time of injury
• Immobilize with an external splint without the need for
e.g. disruption of the vessel by the
reduction
fracture fragments or may arise post manipulation of the
• Closed reduction with manipulation or traction followed fracture or post operatively
by immobilization with an
• Neurological injuries - damage during the fracture
external splint or further traction
mechanism to the spinal cord, brachial
• Open reduction and internal fixation (ORIF) plexus, nerve root or peripheal branch
• Excision of fracture fragment and prosthetic • Tendon injury - the tendon may become bound down,
replacement. compressed or even rupture
Aims of Immobilisation
• Visceral injuries - especially in the chest and pelvis.
• Pain relief Examples of local complications occurring as a result of
• Limit movement at the fracture site certain pathology
• Prevent angulation and / or displacement. • Fractured face - can cause airway obstruction
Indication for Operative treatment • Broken rib - perforation of the lungs, ruptured liver
• Compound fractures • Fractures and dislocations of the knee - popliteal artery
• If closed manipulation is unsuccessful in reducing the damage
fracture • 4/5th thoracic vertebra - damage to the aorta.
• If the fracture is unstable Complications applicable to all fractures
• Soft tissue management Bone healing abnormalities
• Management of complications e.g. vascular or head • Delayed union - union is delayed. There is abnormal
injuries. movement, pain on stressing the
Comparison of Conservative vs Operative fracture and tenderness over the fracture site at a time
treatment at when union is expected. Causes
• Joint stiffness include the nature of the initial injury, with compound
○ Risk lower in operative treatment and comminuted fractures more
• Infection likely to develop non-union; other causes include
○ Risk higher in operative treatment infection of the fracture haematoma,
• Speed of Healing interposition of soft tissue between the fracture
○ Quicker in conservative treatment fragments, poor blood supply to the
• Non-union fracture site, inadequate immobilisation and pathological
○ Present in both. fractures
Important Definitions • Non-union - can be atrophic or hypertrophic. The
• Reduction - placing the bone fragments into their former is when there has been deficient
original or acceptable position bone formation at the fracture site and a hypertrophic
• Manipulation - the technique of reducing a fracture. non-union is where there has been
In many situations it is the excessive callus formation
correction of residual angulation by pressing the distal • Malunion - the bone ends heal in a clinically imperfect
fragment in the correct direction position. It most commonly
while a hand is held under the fracture to provide a causes shortening with an overlap of the bone fragments
fulcrum
• Avascular necrosis - bone death most commonly the axon and its covering of myelin. It occurs as a result
occurs with intra-articular fractures of of severe compression. There
the hip joint, proximal scaphoid and proximal humerus. is loss of both motor and sensory systems. Recovery
11 takes longer than neurapraxia
Other complications 3. Neurotmesis - this is the most severe lesion affecting
• Infection - most commonly occurs with open fractures. the nerve. There is complete
Major disorders include tetanus, loss of motor, sensory and autonomic function and
gas gangrene, toxic shock syndrome, necrotizing fasciitis occurs as a result of severe
(an aggressive, life threatening bruising or cuts. There is no neural continuity. There is
fascial infection), acute osetomyelitis (bone infection). no recovery.
Chronic infection of the bone can • Muscles
occur Muscle injuries can be classified according to the degree
• Joint stiffness of clinical impairment:
• Secondary osteoarthritis 1. Mild strain/contusion (1st degree) - a small number of
• Growth disturbance if the epiphyseal growth plate has muscle fibers are torn. This is
been damaged associated with minor swelling and discomfort with little
or no loss of strength or
• Tendon ruptures or tendonitis.Sudeck's atrophy (reflex
limitation of movement
sympathetic dystrophy) - an
2. Moderate strain/contusion (2nd degree) - a greater
abnormal peripheral autonomic response to injury
number of muscle fibers are torn
characterised by severe pain, stiffness,
than in the 1st degree. This is associated with a clear
discolourisation and oedema
loss of function
• Myositis ossificans - an extensive calcified mass in the
3. Severe strain/contusion (3rd degree) - there is a tear
soft tissues proximal to the joint
across the whole cross sectional
that leads to a severe mechanical block to movement
area of the muscle. There is a total loss of muscle
• Muscular atrophy function.
• Fat embolism - microparticles of fat escape the • Skin - abrasion, bruise, lacerations.
fracture site and lodge in the glomeruli of
the kidney and lung FRACTURES
• Tardy nerve palsy - late onset nerve palsy Describing the level of a fracture
• Renal calculi
• Accident neurosis - psychiatric problem.
The anatomical divisions of a long
Injuries other than fractures bone include the epiphysis (E),
In addition to bony injuries, other anatomical structures
can also be damaged in a injury:
epiphyseal plate (EP), and diaphysis
Joints or shaft (D). Between the latter two is
Joints can be damaged in three ways:
1. Subluxation - this is the partial dislocation of a joint,
the metaphysis (M). A fracture may
in which there is still partial contact be described as lying within these
between the joint surfaces
2. Dislocation - there is no contact between the joint divisions, or involving a distinct
surfaces anatomical part, e.g.
3. Fracture dislocation - there a fracture around the
joint in addtion to the joint dislocation. A = fracture of the tibial diaphysis;
Ligaments B = fracture of the femoral neck;
Ligament injuries can be grouped into three different
types: C = fracture of the greater
1. Sprain - this is a partial tear in the ligament or joint trochanter;
capsule but the joint however is still
stable F = supracondylar fracture of the
2. Partial rupture - this is the partial rupture of the femur.
ligament. There is some loss of joint
stability For descriptive purposes a bone may
3. Complete rupture - this is the complete rupture of be divided into thirds. In this way:
the ligament and is associated with
joint instability. A = fracture of the mid third of the
Soft tissues : femur;
• Blood vessels
• Nerves
B = fracture of the femur in the distal
Likewise, nerve injury can be grouped into three third;
different types:
1. Neuropraxia - there is transient loss of function as a
C = fracture of the femur at the
result of the impulse being junction of the middle and distal
interrupted as it passes down the nerve fiber. It occurs
as a result of a gentle blow or
thirds.
12 D = fracture of the distal metaphysis
compression. The motor system is more frequently
damaged than sensory function.
of radial bone.
Recovery takes hours to months
2. Axonotmesis - there is loss of function as a result of
the relative loss of continuity of