FRACTURE B.

Etiology – cause fracture

 A break/crack in the continuity of the 1. Traumatic – fracture due to
bone. direct/indirect violence
- Fracture results from
2 Mechanism mechanical injuries.
a. Direct - kinetic is applied at or near the - Due to abnormal
site of fracture. excessive force
b. Indirect - kinetic energy is transmitted a. Direct Violence
from the point of impact to a site b. Indirect Violence
where a bone is weaker. c. Muscular Violence

CLASSIFICATION OF FRACTURE o Fall

A. Morphologically (appearance) o Assault
a) Open – fracture/compound o Accidental
fracture bone that breaks 2. Pathological – fracture for illness
through the skin. or disease.
b) Closed/Swipe Fracture – Local
does not penetrate thru skin 1. Infection
2. Tumors
1. Transverse o Benign
o Fracture in which the bone o Primary
breaks across the shaft. malignant
o Metastatic tumors
2. Stellate
o Bone cancer
o Line of fracture radiator for a
a. Inflammatory
point b. Metabolic
o Star shaped fracture c. Neoplastic
d. Congenital
3. Oblique
o Slanted across bone shaft General
 osteoporosis
4. Spiral  metabolic disease
o Twist around the shaft  Paget's disease - chronic
casually twisting injury o d/o that causes bones to
grow larger and becomes
5. Comminuted weaker
o When bone breaks into 3 or  osteogenesis infer infection
more fragment  genetic d/o that prevents the body for
building strong bones
6. Segmental
o Two fractures in 1 bone C. ON THE BASIS OF STABILITY

7. Impacted Fracture 1. Complete - fracture that involves

o Break where the ends are the entire width of the bone
driven into each other a) Impacted/Buckle Fracture
Assessment b) Iron-impacted
1. Did bone break through skin
2. Is the bone break completely broken 2. Incomplete - partial fracture
or just part of it a) Greenstick
3. Details of the fracture - most common in _____
- one side is broken

1

D. ON PRESSURE OF WOUND
1. Simple/Closed - no skin breakage
2. Compound/Open - skin integrity
is intended
E. MISCELLANEOUS
1. Multiple Fracture
2. Complicated Fracture
- when the structure
surrounding the site of
fracture is injured
- damaged veins,
arteries and nerve
MANIFESTATION "BROKEN"
B - Bruising with pain & swelling
R - Reduced Movement
O - Odd appearance
K - "Krackling" sound - crepitus
E - Edema, erythema on site
N - Neurovascular impairment
- pressure on the
nerve/vascular supply
to an extremely
 Hypovolemic Shock - due to
blood loss
 Ecchymosis - due
extravasion of blood into
subcutaneous tissue
Signs and Symptoms Neurovascular
Impairment
 6 P's
 P - pain
 P - Pallor
 P - Paralysis
 P - Paresthesia
 P - Poikilothermia
 P - Pulselessness
COMPILATION OF FRACTURE
- 3 to 12 weeks
1. Delayed Union Fracture - takes more
that used time to unite
- older person
2. Non-union - fragments and not unite
3. Malunion - bone are heated but poor
in alignment
Causes:
 Age
 Smoking
 Associated Systemic
Illness
COMPLICATION OF MUSCULOSKELETAL
TRAUMA
1. Compartment Syndrome
 P - pain - early signs
 P - Pallor - dusky/pale in color
 P - Paralysis - unable to move
 P - Paresthesia - feeling
pins/needle
 P - Poikilothermia - feeling
warm, check both extremities
 P - Pulselessness - late sign,
check the radial
NURSING INTERVENTION
1. Notify Medical Doctor
2. Keep extremities at heart level
3. Loosen/remove resistance/
clothing
- cast
4. Severe Cases - Fasciotomy
done by MD
2. FAT EMBOLISM SYNDROME
to - Long bones fracture
 Signs and Symptom changes
in mental status - confusion
 Restless - difficulty of
breathing
 Increase RR
 Petechial rash (chest, axilla,
upper arm)
- heart, lungs, kidneys,
eyes --- BRAIN
3. DVT - blood clot form in one/deep
vein usually legs
4. Infection
5. Delayed Union and non-union
6. Reflex sympathetic dystrophy
- chronic conditions
characterized by
severe burning pain
2
 (arms, legs, hands
and feet)
TREATMENT:
A. EMERGENCY CARE
A. Immobilize
- correct alignment
- alleviate pain/pressure
- accelerate healing
- stabilize the injury while
traveling/transporting
a. Splinting
- cardboard piece of wound
(first aid)
- put paddling (if available for
extra support)
 pulse - circulation and motor
ability & sensation before
applying the splint
 properly fit
 pulse
b. Dressing
 sterile gauze
 secure the bandage
 applying the pressure around
the wound not over the bone
to prevent bleeding
c. Assessment of pulse, Movement,
and sensation
B. REDUCTION (operation will be @ the
bedside)
- for alignment/align bones in
place
- perform to restore bone in
Normal position
1.CLOSED REDUCTION (pushing/pulling)
- exerting effort and fraction
- we need anesthesia
- may apply fraction and casting
after
2. OPEN REDUCTION INTERNAL FIXATION
(ORIF)
- require surgery
- internal fixation used: wires,
pins, screw, plates and nails
- infection
NURSING CARE
1. Check the Neurovascular status; the 6P's.
2. Check and assess the drainage.
- check the color and smell.
3. Check the pressure/bed sore.
- the patient if applicable
- increase fluid intake
- increase protein
- orthostatic Hypotension
C. CAST
- A rigid device applied to immobilize
the injured bones and promotes bone
healing
- apply with stable fracture
TYPES OF CAST
1. PLASTER CAST
o made for gauze and plaster
strips in water.
2. SYNTHETIC CAST
o made for filter glass/plastic
strips
o lighter than the plaster cast
o dries in few minutes, but may
take a few hours to harden
fully.
3. CAST BRACE
o made for hard plastic
o soft pads inside the brace
push against the injury
o brace is held in place by
Velcro strips that can be
removed
4. SPLINT (half cast)
o made for slabs of plaster or
fiber glass that hold injury
together
o bandage is wrapped around
injury to hold slabs in place
o often used when swelling is
present
NURSING CARE
1. Check the Neurovascular status
- 6 P's (pain- early signs,
pulselessness- late sign)
2. Check the infection.
3
 3. Skin breakdown/skin integrity
4. Keep it dry.
5. Elevate cast above heart level
- decrease swelling
6. Use palm to touch cast to
prevent indentation.
D. TRACTION
- Attain realignment
- prevent/reduce pain
- reduced
fraction/dislocation
1. MANUAL TRACTIONS
 the hand directly applies
the pulling force/force the
traction.
 done by PT/ trained nurse
BENEFITS:
a. Relieve Spasm
b. Relieve nerve
compression
c. Gently stretcher the
cervical/lumbar spine
d. Improve mobilization
e. Encourage relaxation
1. SKIN TRACTION
- exerting grabbing and pulling
force through patients skin
- usually short term (24-72°)
- less weight (usually 5-10
lbs/5-7 lbs)
- uses tape, boots/ splints
directly on skin
- use operatively
- use 1-3 days/temporary
traction
Example:
 Buck's Traction for adults
 Bryant's Traction for
pediatrics
NURSING CARE
1. Check skin breakdown (q 2-4 hrs)
2. Monitor for pressure points
3. Non-adhesive - no use of adhesive
tape
4. bandage/foams/stripes
5. Skin adhesive - use of adhesive tape
attached to weight
2. BALANCE SUSPENSION TRACTION
- involves more than one force
of pull traction
- used to treat femur/upper leg
fractures where traction is via
parallel rods using ropes,
using pulley and weight.
MATERIALS:
a. Orthopedic Bed (with firm beds
mattress)
b. Bed elevation
c. Balkan Frame/Cross Bar, Curve Bar,
Vertical, Horizontal, Diagonal Bars
d. Three Pulleys/Overhead Trapeze
e. Traction Equipment
- Thomas splints
- Pearson's attachment
- Rest Splints
- Steinman's Pin Holder Slings
Three ROPES (SUSPENSION, TRACTION &
THIGH ROPE)
 TRACTION WEIGHT - (10%
body weight)
 SUSPENSION WEIGHT -
( 1/2 of Traction weight)
 THIGH ROPE - foot pedal/rest
PRINCIPLES OF TRACTION
1. Dorsal Recumbent Position
2. There must be a counter traction
- -Patient
Traction/Weight
traction
3. There must be continued traction
4. The line of the pulley's should be in
line with the line deformity
a. 1 - in the inguinal are
b. 2 - in line with knee
c. 3 - in line with 1st and 2nd
pulley
5. Avoid friction.
- no knots along the
pulley
6. Weight should be HANGING FREELY
4
 - no lifting
- no weight on the floor
7. Observe wear and tears of the bags
and rods.
3. SKELETAL TRACTION
- Application of pulling force
through placement of pins in
the bones and weight
attached.
- long bone fracture
NURSING CARE
1. Infection
2. PIN CARE (ONE PIN: ONE SWAB at
least every shift)
3. Monitor pin loosening
IN ALL TRACTION
1. Need to ensure patient is in Current
Position for bone alignment
2. Traction forces must be remained
CONSTANT
3. Keep weight off the floor hanging
freely! Never lift the weight!
ASSESSMENT
1. Neurovascular status
 Pain:
Analgesic/NSAIDS/Narcotics
 Pulse: Assessing bilateral
 Poikilothermia
 Paralysis: "can you move
this?"
 Parythermia: "can you feel
this?"
2. Alignment
 Straight
 Supine
 Head on bed at least <30°
 Ropes- check
3. Weight - create tension
- keep it hanging freely
4. Skin
 Skin breakdown
 (straps/pins/sacrum)
 Pin site care
 Inspect (Skin infection)
 New drainage
 Redness around the pin?
 Loosening of the pin?
 Clean: one clean - one swab
PATIENT EDUCATION
1. infection - prevent infection
- avoid touching of site
- keep it clean and dry
- keep environment clean
- DIET: high protein, increased
Vit. C (fruits and vegetables)
- Increase fluid Intake and Fiber
2. Alignment.
3. Recheck the bleeding.
E. SURGERY
1. EXTERNAL FIXATION
 transfixing screw/tension wires that
pass through the bone above and
below the fracture and attached to
external frame.
INDICATION:
1. Fracture is associated with severe
soft tissue damaged (including open
fracture) or those are comminuted.
2. Fracture around the joint that are
potentially suitable for internal fixation
but soft tissue are two swollen to
allow surgery.
3. Patient with severe multiple injuries
- Bilateral Femoral Fracture;
Fracture with bleeding.
4. Ununited Fracture - which can be
excised and compressed.
5. Infection/infected fracture
COMPLICATION
1. Infection
2. Damage to soft tissue and structure
- inhibit movement
- need to know the anatomical
structures
3. Over distraction
- if there is no contact between
the fragment’s union is
unlikely.
2. INTERNAL FIXATION (ORIF)
- Using of plates, nails, screams
and wires
INDICATION:
1. Patient is compliant and reliable
5
 2. With sufficient bone quality and present - increase fluid intake and fiber
less complex fracture. - Increase protein like egg,
3. Distal radial fracture chicken and etc.

Complication: EPONYM
1. Infection - prevent it infection 1. Barton's - radius
 avoid touching of site 2. Cotton fracture - ankle
 keep it clean and dry 3. Colles Fracture - Radius - ulna
 keep environment clean 4. Malgaigne's Fracture
 DIET: high protein and Vitamin 5. Monteggia's Fracture - double fracture
C 6. Bennett's Fracture - base of the thumb
 Increase Fluid Intake and 7. Galeazzi's Fracture - 3rd distal radius
o C - close - Colles
Fiber
o S - Smith
2. Alignment
o G - 3rd distal
3. Recheck the bleeding
8. Pott's Fracture - fracture of the fibula
9. Gartland type
F. ELECTRICAL BONE STIMULATION 10. Melch Type
- stimulation of bone cells for 11. Salter - Harris type
rapid healing - epiphyseal plate
- increase signal cascades in o S - straight
order to stimulate move robust o A - above
and rapid healing o L - lower
- 2 skin electrodes are placed o E - Everything
an each side of broken bone o R - Crush
and low voltage passes a 12. Thomas-epstein type - hips
small current between
electrodes II. INFLAMMATORY/INFECTIOUS DISEASE
A. SPRAIN
INDICATION: - ligaments
 -non-healing (non-union) bone - when we role ankles inusual

How to deal inflammation/swelling?

MEDICATION:
1. Analgesic- moderate pain 1. R - rest - avoid any activity that
killer /Narcotics - through pain killers cause pain
(opioids/morphine) I - ice - 20 mins 16 pack 3x a day
 Paracetamol C - compression -ankle braces,
 Acetaminophen keep things long in place
 Ibuprofen E - elevation - decrease swelling,
2. Still Softener decrease pain 20-30 mins 1-2
- decrease constipation times a day
- increase fluid intake and fiber
2. Cross friction massage
3. Antacids
3. Exercises
4. NSAIDS
a) sealed calf stretch
- pain killer/anti-inflammatory - passive ROM
- lesser Side effects compared - 3x 20 seconds hold 2-3 x a
to opioids day
5. Antibiotics b) ankle ABC 2-3 x a day
6. Anticoagulants c) weight shift
- blood thinner - 10-30 x a day , increased
- Prevent deep vein thrombosis elevation as tolerated
7. Diet d) mini squats

6
 - 30-90 x daily b) open fracture
e) gastrocnemius stretch c) orthopedic symptoms
- 3 x 20 sec hold 3 x daily d) systemic disease (DM)
f) heal raises
- 3 sets of 10-30 reps. Initial signs and symptoms
1. Bone pain
B. SPRAIN 2. Redness
- stretching injury muscle and 3. Swelling
tendon 4. Fever
o R - rest 5. Increased WBC
o I - Ice
o C - compression Classifications:
o E- elevation 1. Acute - usually within 2 weeks
2. Subacute -for 4 weeks to several
 Prevention - stretching months
3. Chronic - after several months - years
GRADE LEVEL OF MUSCLE STRAIN
TYPES OF BONE INFECTION
 Grade 1
1. Medullary
- minimal, muscle fibers are slightly
2. Superficial
form
3. Localized defect with stable bone
- damage is minimal
4. Diffuse infection with involvement of
- 2-3 weeks to recover
bone stability.
 Grade 2
- 2-3 months to recover Medications: IV antibiotics (long term)
- 50 % of the muscle fibers form
 Grade 3 Surgery Management:
- muscle fibers are completely form 1. Debridement
- 3 months- 1 year to recovery 2. Removal of the dead bone tissue
- severe pain and swelling (sequestrectomy)
- require surgery 3. Combination of Debridement and
administration of culture specific
antibiotic
C. CONTUSION
o trauma that damages blood vessels Sx:
underneath the skin 1. Open the involucrum ( new bone)
- falling 2. Remove the sequestrum (dead bone)
- bumping 3. Saucerize the bone
- getting hit - make sure a pathologic fracture is
not created
Treatment: - Stabilize the bone if needed
o R- rest if possible (external fixator is prepared)
o I - ice - swelling and help heal mere 4. Full cavity with bone hips cement
guidelines spacer.
o C- compression bandage- decrease
blood flow; decrease swelling and Diagnostic Test
pain 1. MRI, Bone Scan, CT Scan
o E- elevation - decrease blood flow, 2. UTZ
decrease discoloration 3. Blood Test
 ESR - Electrolytes Sedimentation
D. OSTEOMYELITIS Rate
- bone infection  increase ESR - inflammation
 WBC - increase WBC -
Other risk fracture inflammation/infection
a) recent trauma

7
 1. Blood and tissue culture - to identify
specific antibodies
NURSING DIAGNOSIS AND MANAGEMENT
1. Risk for infection
- proper wound healing/cleaning
- DIET: Increase Vit. C and CHON
- Administered of antibiotics as
prescribed
2. Hypertension
- monitor vital signs q 4 hours
- TSB, increase Fluid Intake
- provide a cold environment;
provide light clothing and bedding
- Administer medication as
prescribed
3. Impaired physical mobility
- ensure safety
- Passive ROM
- No weight bearing activities to the
affected area
- maintain rest
4. Acute Pain
- DBE/guided imagery
- relaxation techniques
- immobilize/splints
- avoid manipulation of the involved
area; handle the area gently
- -pain relief as prescribed
E. POTT'S DISEASE
 TB of the spine
 Tuberculosis spondylitis
 David's Disease
 Pott's carries
 Pott's Curvature
Causative Agent: Mycobacterium tuberculosis
- common site in spine
- Percival Pott 1979 English Surgeon
PATHOPHYSIOLOGY
M.TB in the lungs spreads hematogenously to
the bone (spine)
l - due to spinal column compression
Reaches the anterior portion of the vertebral
column
I
Bacteria proliferate with in the bone
I 2.
Immune cells respond to invasion
I 4.
GRANULOMA FORMATION (reaction of
infection, inflammation, imitation or foreign
objects)
I
Formation of caseous necrosis cells death that
causes tissue to become "cheese like" in
appearance
IA IB
A. Leads to destruction of trabecular bone
with in the vertebral column bodies
Sign and symptoms
1. Loss of bone density
2. Vertebral collapse
3. Gibbus formation
B. Formation of Paravertebral abscess
1. Local tissue formation
2. Compression of neural structure
Abscess+ vertebral collapse
Signs and Symptom
1. Radiculopathy ( nerve not
compression)
2. Myelopathy (spine column
compression)
3. Paralysis (paraplegia)
S/Sx = VERTEBRA POTS
 V - Vertebral column deformity
 E - Elevated temperature fever
 R - Reduced/difficulty moving the
spine
 T - tenderness over the affected
vertebrae
 E - Edema around the spine
 B - Back pain (especially with
movement)
 R - Radical Pain (radiating)
 A - Abscess Formation
 P - Paraplegia
 O - Osteopenia (bone density loss)
 T - Tissue destruction visible in
imaging studies
 S - Soft tissue swelling/inflammation
"Paraplegia" - late sign
- paralysis (motor and sensory function)
in lower half of the bones
1. Inability to walk - legs
Incontinence/bone/bladder control
3. Sexual dysfunction
Paresthesia
Diagnostic test
8
 1. Tuberculin skin test/ Mantoux
Test/Purified Protein Derivative - M.
TB
- injected they ID tilo elicit
immune response in patient
who have been expel to TB
- 48 - 72° results
- 5-10 mm/raised/induration
(significant)
- 4mm (insignificant) - BCE
PURPOSE:
1. Indicate exposure to TB not
necessarily active TB
2. presence of antibodies against
Tubercle Bacilli
2. ESR
3. ACID-FAST BACILLI - Sputum AFB
 (+) - detects presence of M. TB
 (-) - 2months of TB treatment
DO'S
- Rinse mouth with water only
- early morning collection
- (deep breathing, cough deeply)
DON'T
- Don't use mouthwash
- Don't brush
- Don't breakfast
4. Imaging
a. X-RAY
- destruction of anterior portion of
the vertebra
- collapsed vertebral body
b. MRI/CT SCAN
- detected imaging
- gibbus formation
- detects pressure of Abscess
- spinal cord compression
Mgt. GOAL
1. Minimize Deformity - prone position
side lying (proper alignment)
2. Building pts resistance
- Rest sleep
- Diet : high CHON ; diet rich in
vitamins and minerals such as
Vitamin C, D, Calcium
Immobilizing cervical
- BRACES
- SOMI (Sternal Occipital Mandibular
immobilize)
- provide control over flexion, extension,
lateral and rotational movement of the
spine (C2 -C5) vertebrae
 Upper Thoracic - Taylor's Brace
- Maintains spine in neutral position
when sitting, standing or walking,
helps posture correction.
 Lower Thoracic - Jenette’s Brace
- Control and support thoracic and
lumbar spine, reduce pain and
present further injury
 Lumbosacral - chairback brace
(waist trimmer)
- Short brace may provide low back
pain relief and spinal stability
especially after symptoms
4. Control infxn - wound care
• TB drugs
o R-rifampicin
o I - isoniazid
o P- pyrazinamide
o E- ethambutol
o S - streptomycin
Common S/E
1. R- orange-red colored urine
(temporary reversible)
2. I - peripheral neuritis
- Inflammation nerve
- vit. B6
3. P - hepatotoxicity
4. E - optic neuritis
- inflam. optic
- Decreased VA
- Blurred vision
Surgical TX
1. Arthrodesis
- referred as joint fission
- corrects the structural deformity
- done to conservative fx. fails
- removal of interpretable
disc/cartilage
- bone graft is inserted bet. the
bone
|
bone are realigned and fixed together (fixator)
9
 |  settling fluids to a contain are of
bone growth forming a single solid bone. the lungs due to immobility

1. Joint eliminated Immobility

2. Decreased bone pain l
3. Improve stability in the affected area Decrease chest wall immobility
l
2.Radical Excision Impairs the ability to clear secretion in lungs
- 6A l
- prone Mucus secretion pool in the airway
l
How? Attracts nutria
1. vertebral resection (removal) excision ;
of structure within the body Pneumonia - HYPOSTATIC PNEUMONIA
- removal of infected vertebral body
2. Spinal reconstruction 2. Bed sore
- bone grafting - prolonged immobilization
- autograft -self
- allograft - other  Mngt:
3. Costotransversectomy and - change position q 2°
anterolateral decompression - dry skin moisturizer
- Costotransversectomy - removal - Linen dry and wrinkle free
of costotransverse joint
- Decompression - Sx removal of 3. Constipation
structure that are Reason:
compressing/putting pressure to 1. Limited mobility
the SC 2. Paraplegia
3. Loss of appetite
 correct the ribs to the transverse 4. Dehydration
process of the vertebrae
1. Incision
2. Joint removal
- access to the thoracic SC
3. Spinal decompression
- Goal: to decompress the SC

4. Laminectomy
- laminal removal
- bony arch on the back of vertebral that
covers/protect the SC
- removal creates move space with in
the spinal cord
- relieve pain in the SC

5. SURGICAL DRAINAGE
o drainage of the abscess -
decrease pressure
How:
1. Incision to expose the site of abscess
2. Abscess debridement and irrigation
3. Drain placement - catheter
- continue drainage

COMPLICATION:
1. Hypostatic Pneumonia

10