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
EXTERNAL FIXATORS

 A device placed outside the skin that stabilizes bone fragments with pins or wires
connected to bars
 "Relative stability "
 Healing with callus
 "External Fixator is a device uses for stabilization and immobilization of long bone open
fractures.

 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

BONE HEALING PROCESS

Typed of Bone Healing Process
a. Healing by Direct Union
 Formation of callus requires stimulus from movement
 In cases of impacted fracture in cancellous bone or a fracture immobilized by the use of
metal plate, callus will not be formed and hence the fracture will heal by direct union.
b. Bone Healing
 Primary Fracture Healing – refers to fractures treated operatively without callus
formation.
 Secondary Fracture Healing – refers to (a) fracture treated non-operatively, with
the formation of callus and no disturbance of hematoma; (b) fractures operated
without disturbance of hematoma.

Factors Affecting Bone Healing

 Age: fractures unite faster in children
 Type of bone: faster union in flat and cancellous bone
 Pattern of fracture: spiral # > oblique # > transverse # > comminuted #
 Disturbed pathoanatomy: soft tissue interposition and ischemic # prevent faster
healing

Stages of Bone Healing Process

 Formation of Hematoma
 Cellular Proliferation
 Callus Formation
 Ossification
 Remodeling

Formation of Hematoma
 When bone is fractured, blood extravasates into the area
between and around the fragments of the bone marrow.
 Clot begins 24 hours after fracture
 Clot serves as a fibrin network for subsequent cellular invasion.

Healing by Callus

Stage 1: TISSUE DESTRUCTION AND HEMATOMA FORMATION

 Lasts for 7 days
 Blood leaks out of torn vessels and forms a hematoma between and around fracture
 Periosteum and local soft tissues are stripped off
 Ischaemic necrosis – death of some osteocytes with sensitization of the remaining
precursor cells.

Cellular Proliferation
  Occurs a few days after the fracture
 The combination of periosteal elevation and granulation tissue containing blood vessels,
fibroblasts, and osteoblasts produce a substance called osteoids forming a bridge
across the fracture site.
Stage 2: INFLAMMATION AND CELLULAR PROLIFERATION / GRANULATION TISSUE
 Lasts for 2-3 weeks
 Precursors cells form cells that differentiate and organize to provide vessels, fibroblasts,
osteoblasts etc.
 Soft granulation tissue formed between fracture fragments, providing anchorage to
fracture
 Hematoma is slowly absorbed and fine new capillaries grow into the area

Callus Formation
 After following weeks, minerals are being deposited in the osteoid forming a large
mass of differentiated tissue bridging the fracture called callus.

Stage 3: CALLUS FORMATION

 Lasts for 4-12 WEEKS
 Granulation tissue differentiates and creates osteoblasts, laying down intercellular matric
impregnated with calcium salts.
 Formation of callus/ woven bone
 Provides good strength to the fracture, decreasing the movements at the fracture site
and causes union in about 4 weeks.

Ossification and Remodelling

 Ossification – final laying down of bone, it ends with fracture having knitted together.
 Remodelling – when consolidation is completed, the excess cells are absorbed.

Stage 4: REMODELLING
 Takes 1-4 years for the bone to become strong enough to carry weight.
 With continuing osteoclastic and osteoblastic activities, the woven bone gets
transformed into lamellar bone.
 Osteoblasts fill in the remaining gap between the new bone and the fragments to
strengthen the bone.

FRACTURE HEALING
 Fracture hematoma: when a fracture occurs, bleeding creates a hematoma, which
surrounds the ends of the fragments (within 72 hours)
 Granulation tissue: active phagocytosis absorbs the products of local necrosis. The
hematoma converts to granulation tissue. Granulation tissue produces the basis for new
bone substance called osteoid (days 3 to 14)
 Callus formation: as minerals and new bone matric are deposited in the osteoid, and
unorganized network of bone is formed. It usually appears by the end of the second
week after injury. Evidence of callus formation can be verified by x-ray.
 Ossification: occurs from 3 weeks to 6 months after the fracture and continues until the
fracture has healed. During this stage of clinical union, the patient may be allowed
limited mobility or the cast may be removed.
 Consolidation: as callus continues to develop, the distance between bone fragments
diminishes and eventually closes. This stage is called consolidation, and ossification
continues. It can be equated with radiologic union.
 Remodeling: excess bone tissue is reabsorbed in the final stage of bone healing, and
union is completed. Gradual return of the injured bone to its pre injury structural strength
and shape occurs. Radiologic union occurs when there is x-ray evidence of complete
bony union. This phase can occur up to a year following injury.
NURSING DIAGNOSIS
1.Pain related to fracture as manifested by pain
2.Impaired physical mobility related to bone injury and its surrounding tissue as manifested by
unable to perfrorm ADL
3.Impaired skin integrity related to injury as evidence by contusion

NURSING MANAGEMENT
1. Ensure patient comfort and relief from pain
2. Ensure proper alignment and immobilization of the fractured area
3. Infection prevention
4. Promote early mobilization and ambulation
5. Promote adequate nutrition for bone healing and support
6. Educate the patient and the family on fracture care, rehabilitation exercises, and
preventive measures