FRACTURE

DEFINITION:
A fracture is a traumatic injury interrupting bone continuity

CAUSES OF FRACTURE:
1. Injury
 Direct or indirect Force or a crushing form
2. Twisting force
3. Powerful muscle contraction
4. Fatigue and stress
 Occur in normal bone, subject to repeated heavy loading, typically in athletes,
dancers or military personnel.
 Drugs like steroids and methothrexate.
5. Disease or tumor (Pathologic)
 Pathological Fractures – occurs in a bone that is made weak by some disease.
 Causes: inflammatory (osteomyelitis) neoplastic (giant cell tumor, ewings sarcoma,
secondaries)

CLINICAL MANIFESTATIONS OF FRACTURE

 Pain
 Edema
 Tenderness
 Abnormal movement and crepitus
 Loss of function
 Ecchymoses
 Visible deformity
 Paresthesias and other sensory abnormalities
CLASSIFICATIONS OF FRACTURE
TYPES:
 Closed simple, uncomplicated fractures – do not cause a break in the skin.
 Open compound, complicated fractures – involve trauma to surrounding tissue and break
in the skin.
 Comminuted fractures – produce several breaks of the bone, producing splinters and
fragments.
 Greenstick fractures – break one side of a bone and bend the other.
 Spiral (torsion) fractures – involve a fracture twisting around the shaft of the bone.
 Transverse fractures – occur straight across the bone.
 Oblique fractures – occur at an angle across the bone (less than a transverse)

Diagnostics/ Laboratory tests

To determine the presence of fracture, the following diagnostic tools are used.
 X-ray examinations: Determines location and extent of fractures/trauma, may reveal
preexisting and yet undiagnosed fracture(s).
 Bone scans, tomograms, computed tomography (CT)/magnetic resonance imaging
(MRI) scans: Visualizes fractures, bleeding, and soft-tissue damage; differentiates
between stress/trauma fractures and bone neoplasms.
  Arteriograms: May be done when occult vascular damage is suspected.
 Complete blood count (CBC): Hematocrit (Hct) may be increased
(hemoconcentration) or decreased (signifying hemorrhage at the fracture site or at
distant organs in multiple trauma). Increased white blood cell (WBC) count is a
normal stress response after trauma.
 Urine creatinine (Cr) clearance: Muscle trauma increases the load of Cr for renal
clearance.
 Coagulation profile: Alterations may occur because of blood loss, multiple
transfusions, or liver injury.

Medical management
Reduction, Immobilization & Rehabilitation

 Reduction is the technique of setting a displaced fracture to proper alignment

 Immobilization is to prevent the displacement of the fracture that might interfere with
the reunion.
 Rehabilitation essentially consists of muscle reeducation exercises and gait training.
Reduction can be done in three ways: closed manipulation, continuous traction and open
reduction.
Close Manipulation
 Re-aligning a displaced fracture by feeling it through the soft tissues.

Open Reduction
 It is performed through surgical intervention
 Open reduction internal fixation (ORIF) is a surgical approach that's used for repairing
certain types of bone fractures.
 An open reduction is an invasive surgical bone realignment. Internal fixation is the
surgical insertion of hardware to stabilize and hold the bone in place as it heals.

Types of internal fixators include:

 Plate and screws

 Intramedullary nails
 Tension band wires
 Intramedullary wires
 IM nails
 Stability rods
 Kirschner or K Wires Are Surgical Bone Pins
 K-wires come in different sizes, and as they increase in size, they become less flexible.
Some K-wires are threaded

 A cast is placed after surgery. Different types of casts may be used during the healing
process.
Complications:
Infection
 All open fractures are considered contaminated.
 Surgical internal fixation of fractures carries a risk for infection.
  The nurse must monitor for and teach the patient to monitor for signs of infection,
including tenderness, pain, redness, swelling, local warmth, elevated temperature and
purulent drainage.
 Infection must be treated promptly.
 Antibiotic therapy must be appropriate and adequate for prevention and treatment of
infection.
Compartment Syndrome (Early)
 Develops when tissue perfusion in the muscles is less than that required for tissue
viability.
 The patient complains of deep, throbbing, unrelenting pain which is not controlled by
opioids.
 The forearm and leg muscle compartments are involved most frequently.
 The pressure within a muscle compartment may increase to such an extent as to decrease
microcirculation, causing nerve and muscle anoxia and necrosis.
 Permanent function can be lost if the anoxic situation continues for longer than 6 hours.
Fat Embolism Syndrome (Early)
 After fracture of long bones or pelvis, multiple fractures, or crush injuries, fat emboli
may develop.
 Most frequently in young adults (typically those 20 to 30 years if age (and elderly
adults – fractures of the proximal femur.
 At the time of fracture, fat globules may move into the blood.
 The fat globules (emboli) occlude the small blood vessels that supply the lungs, brain,
kidneys, and other organs.
 The onset of symptoms is rapid, usually occurring within 24 to 72 hours, but may
occur up to a week after injury.
Deep Vein Thrombosis (DVT), Pulmonary Embolus (PE)
 Are associated with reduced skeletal muscle contractions and bed rest.
 Patients with fractures of the lower extremities and pelvis are at high risk for
thromboembolism.
 Pulmonary emboli may cause death several days to weeks after injury.
Late complications:

Delayed union

 is a condition that occurs when a fracture takes longer than expected to heal. It is
generally defined as a failure to reach bony union by 6 months post-injury. This also
includes fractures that are taking longer than expected to heal (i.e. distal radial fractures)

Mal-union-

 a fracture has healed, but that it has healed in less than an optimal position.

 may result in a bone being shorter than normal, twisted or rotated in a bad
position, or bent

Non union-
  Nonunion is permanent failure of healing following a broken bone.

 Nonunion is a serious complication of a fracture and may occur when the

fracture moves too much, has a poor blood supply or gets infected.
 Patients who smoke have a higher incidence of nonunion.
 In some cases a pseudo-joint (pseudarthrosis) develops between the two
fragments with cartilage formation and a joint cavity.

Cross union

 a rare complication of fractures of the forearm in children

Others
 Avascular necrosis
 Shortening
 Volkmann’s ischemic contracture
 Myositis ossificans
 Joint instability and stiffness

NURSING DIAGNOSIS
1.Pain related to fracture, soft tissue damage, muscle spasm, and surgery
2.Impaired physical mobility related to fractured hip
3.Impaired skin integrity related to surgical incision

NURSING MANAGEMENT
1. Prevent infection
 Cover any breaks in the skin with clean or sterile dressing.
2. Provide care during client transfer.
 Immobilize a fractured extremity with splint in the position of the deformity before
moving the client; avoid strengthening the injured body part if a joint is involved.
 Support the affected body part above and below fracture site when moving the client.
3. Administer prescribed medications, which may include opioid or nonopioid analgesics and
prophylactic antibiotics for an open fracture.
4. Prevent and manage potential complications.

 Observe for symptoms of life-threatening fat embolus, which may include personality
change, restlessness, dyspnea, crackles, white sputum, and petechiae over the chest
and buccal membranes. Assist with respiratory support, which must be instituted
early.
 Observe for symptoms of compartment syndrome, which include deep, unrelenting
pain; hard edematous muscle; and decreased tissue perfusion with impaired
neurovascular assessment findings.
 Monitor closely for signs and symptoms of other complications.
5. Patient education regarding different factors that affect fracture healing
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, anabolic steroids
Factors that inhibit fracture healing
 Extensive local trauma
 Bone loss
 Inadequate immobilization
 Space or tissue between bone fragments
 Infection
 Local malignancy
 Metabolic bone disease (Paget’s disease)
 Irradiated bone (radiation necrosis)
 Avascular necrosis
 Intra-articular fracture (synovial fluid contains fibrolysins, which lyse the initial clot
and retard clot formation)
 Age (elderly persons heal more slowly)
 Corticosteroids (inhibit the repair rate)