A fracture is a break in the continuity of bone and is defined according to its type and extent.

AVULSION – a fracture in which a fragment of bone has been pulled away by a tendon and its attachment. COMMINUTED – a fracture in which bone has splintered into several fragments COMPOUND – a fracture in which damage also involves the skin or mucous membrane; also called an open fracture COMPRESSION – a fracture in which bone has been compressed (seen in vertebral fractures) DEPRESSED – a fracture in which fragments are driven inward (seen frequency in fractures of skull and facial bones) EPIPHYSEAL – a fracture through the epiphysis GREENSTICK – a fracture in which one side of a bone is broken and the other side is bent

IMPACTED – a fracture in which a bone fragment is driven into another bone fragment OBLIQUE – a fracture occurring at an angle across the bone (less stable than a transverse fracture) PATHOLOGIC – a fracture that occurs through an area of diseased bone (eg, osteoporosis, bone cyst, Paget’s disease, bony metastasis,, tumor); can occur without trauma or a fall SIMPLE – a fracture that remains contained, with no disruption of the skin integrity SPIRAL – a fracture that twists around the shaft of the bone STRESS – a fracture that results from repeated loading without bone and muscle recovery TRANSVERSE – a fracture that is straight across the bone shaft


Grade I – is a clean wound less than 1 cm long.

Grade I – is a clean wound less than 1 cm long. Grade II – is a larger wound without extensive soft tissue damage.

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.

Pain continuous and increase in severity until the bone fragments are immobilized. muscle spasms that accompany a fracture begin within 20 minutes after the injury and result in more intense pain that the patient reports at the time of injury. muscle spasms can minimize further movement of the fracture fragments or can result in further bony fragmentation or malalignment.

Loss of function the extremity cannot function properly because normal function of the muscles depends on the integrity of the bones to which they are attached. Pain contributes to the loss of function. abnormal movement (false motion) may be present.

Deformity Cause : Displacement angulation rotation of the fragments (either visible or palpable) that is detectable when the limb is compared with the uninjured extremity. Deformity also results from soft tissue swelling.

Shortening In fractures of long bones, there is actual shortening of the extremity because of the contraction of the muscles that are attached distal and proximal to the site of the fracture. The fragments often overlap by as much as 2.5 to 5 cm (1 to 2 inches).

Crepitus a grating sensation when the extremity is examined with the hands. It is caused by the rubbing of the bone fragments against each other.

Swelling and discoloration Localized edema and discoloration of the skin (ecchymosis) occur after as a result of trauma and bleeding into the tissues. These signs may not develop for several hours after the injury.

MEDIC MANAGEME AL NT Emergency Management
• Immediately after the injury, immobilize the body part before the patient is moved. If an injured patient must be moved before splints can be applied, support the extremity above and below the fracture site to prevent rotation or angular motion. • Splint the fracture, including joints adjacent to the fracture, to prevent damage to the soft tissue. • Apply temporary, well-padded splints, clothing, to immobilize the fracture. firmly bandaged over

• Assess neurovascular status distal to the injury to determine adequacy of peripheral tissue perfusion and nerve function. Be alert for paresthesia or paralysis (compartment syndrome). • Cover the wound of an open fracture with a clean (sterile) dressing to prevent contamination of deeper tissues.

The principles of fracture treatment include reduction, immobilization, and regaining of normal and strength through rehabilitation. • The fracture is reduced using a closed method (manipulation and manual traction) or an open method (surgical placement of internalfixation devices to restore the fracture fragments to anatomic alignment and rotation. The specific method depends on the nature of the fracture. • After the fracture has been reduced, immobilization holds the bone in correct position and alignment until union occurs. Immobilization is accomplished by external or internal fixation. • Function is maintained and restored by controlling swelling by elevating the injured extremity and applying ice as prescribed. Restlessness, anxiety, and discomfort are controlled using a variety of approaches. Isometric and muscle-setting exercises are done to minimize disuse atrophy and to promote circulation. With internal fixation, the surgeon determines the extremity can withstand and prescribes the level of anxiety.

Management of complications • Treatment of shock consists of restoring blood volume and circulation, relieving pain, providing adequate splinting, and protecting the patient from further injury and other complications. See Nursing Management under Hypovolevic Shock for additional information. • Prevention and management of fat embolism includes immediate immobilization of fractures and adequate support for fractured bones during turning and positioning. Prompt initiation of respiratory support with prevention of respiratory and metabolic acidosis and correction of homeostatic disturbances is essential. Corticosteroids may be given as well as vasoactive medications, fluid replacement therapy, and morphine for pain and anxiety. • Compartment syndrome is managed by controlling swelling restrictive devices (dressing or cast). A fasciotomy (surgical decompression with excision of fibrous membrane covering and separating muscles) may be needed to relive the constrictive with moist sterile saline dressings for 3 to 5 days. The limb is splinted and elevated. Range-of-motion exercises may be performed every 4 to 6 hours.

•Nonunion (failure of the ends of a fractured bone to unite) is treated with internal fixation, bone grafting (osteogenesis , osteoconduction, osteoindunction), electronic bone simulation, or a combination of these. •Management of reaction to internal fixation devices involves protection from osteoporosis, altered bone structure, and trauma. •Management of complex regional pain syndrome involves elevation of the extremity, pain relief, range-of-motion exercises, and helping patients which chronic pain, disuse atrophy, and osteoporosis. Avoid taking blood pressure or performing venipuncture in the affected extremity.

Promoting Fracture Healing • Provide pharmacologic and management. nonpharmacologic measures for pain

• Monitor for signs of infection (if grafts were done, monitor the donor and recipients sites) • Provide patient education and reinforce information, avoidance of weight bearing, wound care, signs of infiction, and follow-up care with the orthopedic surgeon. • For the patient receiving electrical stimulation for nonunion encourage compliance with the treatment regiment. Include patient education regarding daily use of the stimulator as prescribed and need for follow-up evaluation by the orthopedist, who will evaluate the progression of bone healing with periodic radiographic studies.

Managing Closed Fractures • Encourage patients with closed (simple) fractures to return to their usual activities as rapidly as possible, within the limits of the fracture immobilization. • Teach patients how to control swelling and pain associated with the fracture and soft tissue trauma • Teach exercises to maintain the health of unaffected muscles and to strengthen muscles needed for transferring and for using assistive devices (eg. Crutches, walker) • Teach patient how to use assistive devices safely. • Arranged to help patients modify their home environment as needed and to secure personal assistant if necessary. • Provide patient teaching, including self-care, medication information, monitoring for potential complications, and the needed for continuing health care supervision.

Managing Open Fractures • The objectives of management are to prevent infection of the wound, soft tissue, and bone and to promote healing of soft tissue and bone. In an open fracture, there is the risk of osteomyelitis, tetanus, and gas gangrene. • Administer tetanus prophylaxis. • Perform serial irrigation and debridement to remove anaerobic organsisms. • Administer intravenous antibiotics to prevent or treat infection. • Perform aseptic dressing changes with sterile gauze to permit swelling and wound drainage, with wound irrigation and debridement as ordered. • Provide, or teach patient and family to perform, wound care to flap or skin graft after the wound is closed in 5 to 7 days. • Elevate, and teach patient and family to elevate, the extremity to minimize edema. • Assess neurovascular status frequently. • Take the patients temperature at regular intervals, and monitor for signs temperature at regular intervals and monitoring for signs of infection. • Promote intake of adequate nutrition to promote wound healing.

Managing fractures at Specific Sites Maximum functional recovery is the goal management. Clavicle Humerus Elbow Wrist Hand and Fingers Rib Pelvis Tibia and Fibula Femur and Hip

NURSING PROCES: The Patient with a Hip Fracture Assessment Asses the elderly patient for chronic conditions that require close monitoring. Examine the legs for edema due to congestive heart failure, and assess for peripheral pulselessness from arteriosclerotic vascular disease. Nursing Diagnoses • Pain related to fracture, soft tissue damage, muscle spasm, and surgery • Impaired physical mobility related to fractured hip • Impaired skin integrity related to surgical incision • Risk for impaired urinary elimination related to immobility • Risk for disturbed thought process related to age, stress of trauma, unfamiliar surroundings, and drug therapy • Risk for ineffective coping related to injury, anticipated surgery, and dependence • Risk for impaired home maintenance related to fractured hip and impaired mobility

Collaborative Problems/Potential Complications •Hemorrhage •Pulmonary complications •Neurovascular compromise •Deep vein thrombosis •Pressure ulcers Planning and Goals Major goals may include relief of pain, achievement of a functional stable hip, wound healing, maintenance of normal urinary elimination patterns, use of effective coping mechanisms to modify stress, oriented and participating in decision making, ability to care for self at home, and absence of complications. Relieving Pain Promoting Hip Function and Stability Promoting Wound Healing Promoting Skin Integrity Promoting normal urinary elimination patterns

Promoting patient orientation and participation in decision making Promoting effective coping mechanisms Monitoring and preventing potential complications Promoting home and community-based care Evaluation •Expected patient outcomes •Reports pain relief •Engages in therapeutic positioning •Exhibits normal wound healing and intact skin •Maintains normal urinary elimination pattern •Remain oriented and participates in decision making •Demonstrates use of effective coping mechanisms •Establishes effective communication •Experiences no complications.

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