Fracture

Presented by:
Mr. Ratheesh R L
 Definition
• A fracture is a break in the continuity of bone.

• Fracture is a break in any bone in the body.

Causes of fracture

direct crushing
blows forces

sudden extreme
twisting muscle
contractions
motions
 Types of fracture
a. Complete fracture : a break across the entire
cross-section of the bone.

b. An incomplete fracture the break occurs through

only part of the cross-section of the bone.
a. Closed fracture (simple fracture) is one that does
not cause a break in the skin.
b. An open fracture (compound, or complex, fracture)
is one in which the skin or mucous membrane
wound extends to the fractured bone.
Open fractures are graded according to 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.
CLASSIFICATION According to
the Anatomical placement
Greenstick fracture
A fracture in which one side of a bone is broken
while the other is bent (like a green stick).
Spiral Fracture
A fracture, sometimes called torsion fracture, in
which a bone has been twisted apart.
Comminuted Fracture
A fracture, in which bone is broken, splintered or
crushed into a number of pieces.
Transverse Fracture
A fracture, in which the break is across the bone,
at a right angle to the long axis of the bone.
Compound Fracture
A fracture in which the bone is sticking through
the skin. Also called an open fracture.
Compression Fracture
A fracture caused by compression, the act of
pressing together. Compression fractures of the
vertebrae are especially common with
osteoporosis.
 Other fracture
• Avulsion: fracture which occurs when a fragment
of bone tears away from the main mass of bone.

• Depressed: A fracture in which fragments are

driven inward (seen frequently in fractures of skull
and facial bones)
• Pathologic: it occurs through an area of diseased
bone (eg, osteoporosis, bone cyst, bony
metastasis, tumor);
can occur without trauma or a fall
• Stress: A fracture that results from repeated
loading without bone and muscle recovery
 Pathophysiology
Due to any etiology(crushing movement)
|
Fracture occurs , muscle that were attached to bone
are disrupted and cause spasm
|
Proximal portion of bone remains in place, the distal
portion can become displaced in response to both
causative force & spasm in the associated muscles
In addition, the periosteum and blood vessels in the
cortex and marrow are disrupted
|
Soft tissue damage occurs, leads to bleeding and
formation of hematoma between the fracture
fragment and beneath the periosteum
|
Bone tissue surroundings the fracture site dies,
creating an intense inflammatory response
 release chemical mediators
histamins,prostaglandins
|
Resulting in vasodilation, edema, pain, loss of
function, leukocytes and infiltration of WBC
Clinical manifestations
• pain
• loss of function
• deformity
• shortening
• crepitus
• swelling and discoloration
Diagnosis of fracture
• History collection
• Physical examination
• X ray
• CT scan
• MRI scan
MANAGEMENT
FIRST AID TREATMENT
 MEDICAL /SURGICAL
MANAGEMENT OF FRACTURES:
1. Reduction
Reduction of a fracture (“setting” the bone) refers to
restoration of the fracture fragments to anatomic
alignment and rotation.

It’s a surgical approach, the fracture fragments are

reduced.
External/Internal fixation devices (metallic pins,
wires, screws, plates, nails, or rods) may be used
to hold the bone fragments in position until solid
bone healing occurs.
Internal fixation
External
fixation
Difference between internal or
external fixation
 Closed reduction
• closed reduction is accomplished by bringing the
bone fragments into apposition (ie, placing the
ends in contact) through manipulation and manual
traction.
• Extremity is held in the desired position while the
physician applies a cast, splint, or other device.
• X - rays are obtained to verify that the bone
fragments are correctly aligned.
• Traction (skin or skeletal) may be used to effect
fracture reduction and immobilization.
 2.Immobilization
• Immobilization may be accomplished by external or
internal fixation.
• Methods of external fixation include bandages,
casts, splints, continuous traction, and external
fixators.
• Metal implants used for internal fixation serve as
internal splints to immobilize the fracture.
 Traction
Traction is the use of weights, ropes and pulleys to
apply force to tissues surrounding a broken bone.
Traction
1. Skin traction-
• Bucks traction used for knee,hip bone
fracture
• Weight usually 5-7 pounds attach to skin
2. Skeletal traction –
• Needs invasive procedure
• Weight is upto 10 kg attached to bone
 Splinting
• Splinting is the most common procedure
for immobilizing an injury.
 Why Do We Splint?
• To stabilize the extremity

• To decrease pain
• Actually treat the injury
Possible items for Splinting
• Soft materials. Towels, blankets, or pillows,
tied with bandaging materials or soft cloths.

• Rigid materials. A board, metal strip, folded

magazine or newspaper, or other rigid item.
 Soft Splints
• Splinting Using a Towel
• Splinting using a towel, in which the
towel is rolled up and wrapped
around the limb, then tied in place.
 Guidelines for Splinting
1. Support the injured area.
2. Splint injury in the position
that you find it.
3. Don’t try to realign bones.
4. Check for color, warmth, and
sensation.
5. Immobilize above and below
the injury.
The splint should go beyond the joints above and
below the fractured or dislocated bone to prevent
these from moving
 3. Maintaining and restoring
function
• Restlessness, anxiety, and discomfort are controlled
with a variety of approaches, such as reassurance,
position changes, and pain relief strategies, including
use of analgesics.

• 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.
 Treating an Open Fracture
• Do not draw exposed bones back into tissue.
Treating an Open Fracture
DO:
• Cover wound.
• Splint fracture without disturbing wound.
• Place a moist 4" x 4" dressing over bone end
to prevent drying.
• Assist the surgeon in debridement of wound
 Complication of
fracture
Early complications
• Shock
• fat embolism
• compartment syndrome
• deep vein thrombosis
• disseminated intravascular coagulopathy
• infection
Delayed complications
• delayed union and nonunion
• avascular necrosis of bone
• reaction to internal fixation devices
 Compartment syndrome
• develops when tissue perfusion in the
muscles is less than that required for tissue
viability.
• patient complains of deep, severe pain,
which is not controlled by opioids.
 Compartment syndrome
• Reduction in size of muscle compartment
• It increase pressure in the muscle
compartment
• Reduce microcircualtion,leads to muscle
and nerve anoxia and necrosis
 FAT EMBOLISM SYNDROME
• occurs most frequently in young adults
• fat globules may move into the blood
because the marrow pressure is greater
than the capillary pressure
• usually occurring within 24 to 72 hours
 NURSING MANAGEMENT
Patients with closed fractures:
• Encourage patient not to mobilize fracture
site.

• exercises to maintain the health of

unaffected muscles for using assistive
devices (eg, crutches, walker).
• 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.
 Patients with open fractures:

• administers tetanus prophylaxis if indicated.

• wound irrigation and debridement in the
operating room are necessary.
• Intravenous antibiotics are prescribed to prevent
or treat infection.
• wound is cultured.
• fracture is carefully reduced and stabilized by
external fixation or intramedullary nails.

• Any damage to blood vessels, soft tissue, muscles,

nerves, and tendons is treated.

• Heavily contaminated wounds are left unsutured

and dressed with sterile gauze to permit swelling
and wound drainage.
 Care of client with cast
Before application of a cast preparation of the
client includes:
• Detailed explanation of the procedure
• Skin preparation involves through cleansing of the
skin
• Presence of unremovable particle or dust should be
reported to the physician
• Roll the cast material are individually submerged in
clean water and excess water is squeezed from the
roll ,apply bandage is applied to encircle the
injured the body parts
• As the water evaporates the cast will dry
• plaster cast generates while drying so instruct
patient for heat sensation
• Do not cover the cast
• Windowing or bivalving a cast means cutting a
cast along both sides then splitting it to decrease
pressure on underlying tissue.
• Window may also be cut into cast to allow the
physician or nurse to visualize wounds under the
cast or removes drains.
Windowing
• Neurovascular assessment: It should be performed
every 30 minutes for 4 hours.
• Assess the cast extremity for color, warmth, pulse
distal to the cast, capillary refill.
• Movement of the distal fingers or toes, awareness of
light touch distal to the cast, change in the
sensation.
• Assessment of the pain: Assess the degree of pain
• Assessment of the cast: The skin around the
cast edges should be observed for damage or
swelling.
“Hot spots” areas of the cast that feel warmer
than other section may indicate tissue necrosis
or infection under the cast.
“Wet spots” may indicate drainage under the
cast
Care of external fixation
• Assessment- pain, nerve supply,infection,pin
site etc.
• Small bleeding from pin site is normal
• Critical, If extend more than 24 hours
• Administer antibiotics, analgesic medicine
Care of traction
• Assessment – skin breakdown, pain,
neurovascular ,constipation
• Stool softner
• Plenty of fluids
• Provide bedpan and urinals for elimination
• Encourage clients activity
 NURSING
DIAGNOSIS:
Acute pain related breakdown of continuity of the
bone as evidenced by facial expressions and
verbalization of patient.
• Goals: Patient will not feel pain
• Intervention:
• Assess the onset, duration, location, severity and intensity
of pain.
• Administer the analgesic according to physician order.
• Provide comfort devices like sand bags for immobilization
of affected parts.
• Provide diversion therapy
 Impaired physical mobility related to
application of traction or cast as evidenced by
assessment

• Goal: Patient will able to move unaffected area.

• Intervention:
• Provide range of motion exercises to the patient.
• Assist the patient in ambulation after recovery of
fracture.
• Provide assistance while using walker or crutches if
required.
• Prevent from complication which usually occurs due to
immobility.

•
Self care deficit related to fracture as evidenced by
poor personal hygiene.

• Goal: Patient will maintain the personal hygiene

• Intervention:
• Assess the need of self care
• Encourage the patient or relatives to do self care activity
• Head to foot care to be provided to the patient.
• Educate about importance of maintaining personal
hygiene.
 Imbalanced nutrition less than body requirement
relate to increase demand of nutrient for bone
healing as evidenced by observation.

• Goal: Maintain the nutritional status of the patient

• Intervention:
• Assess the nutritional status by intake/output chart,
biochemical measures, body mass.
• Maintain intake output chart daily.
• Encourages the patient to take protein rich diet.
• Plenty of fluids and frequent intake of meal is necessary.
• Try to assess the daily weight of the client
 References
• Joyce M. Black Jane Hokanson, medical
surgical nursing,7th edition, Elsevier
publication, volume 1,page no. 619-651
• Suddarth’s & burnner, text book of medical
surgical nursing, eleventh edition,Wolters
publication, Page no. 2079 -2104
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