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Seminar
on
Fracture
Presented by:
Ms. Durga Joshi
M. Sc Nursing
Objectives
After completion of the class students will be able to
• Define fracture
• Enlist the Causes of fracture
• Describe the types of fracture
• Discuss the Pathophysiology of fracture
• Enumerate the Clinical manifestations
• Explain the medical & nursing management of the
fracture
Definition
• A fracture is a break in the continuity of bone
and is defined according to its type and extent.
• Fracture is a break in any bone in the body.
Causes of fracture
direct
blows
crushing
forces
sudden
twisting
motions
extreme
muscle
contractions
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)
• Epiphyseal: A fracture through the epiphysis
• 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
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 is the most common procedure
for immobilizing an injury.
Splinting
• To stabilize the extremity
Why Do We Splint?
• To decrease pain
• Actually treat the injury
• 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.
Possible items for Splinting
• Splinting Using a Towel
• Splinting using a towel, in which the
towel is rolled up and wrapped
around the limb, then tied in place.
Soft Splints
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.
Guidelines for Splinting
The splint should go beyond the joints above and
below the fractured or dislocated bone to prevent
these from moving
Fracture and its nursing management
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.
• 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
Treating an Open Fracture
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
Summary
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
• www.authorstream.com
• www.slideshare.com

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Fracture and its nursing management

  • 2. Objectives After completion of the class students will be able to • Define fracture • Enlist the Causes of fracture • Describe the types of fracture • Discuss the Pathophysiology of fracture • Enumerate the Clinical manifestations • Explain the medical & nursing management of the fracture
  • 3. Definition • A fracture is a break in the continuity of bone and is defined according to its type and extent. • Fracture is a break in any bone in the body.
  • 5. 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.
  • 6. 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.
  • 7. CLASSIFICATION According to the Anatomical placement
  • 8. Greenstick fracture A fracture in which one side of a bone is broken while the other is bent (like a green stick).
  • 9. Spiral Fracture A fracture, sometimes called torsion fracture, in which a bone has been twisted apart.
  • 10. Comminuted Fracture A fracture, in which bone is broken, splintered or crushed into a number of pieces.
  • 11. Transverse Fracture A fracture, in which the break is across the bone, at a right angle to the long axis of the bone.
  • 12. Compound Fracture A fracture in which the bone is sticking through the skin. Also called an open fracture.
  • 13. Compression Fracture A fracture caused by compression, the act of pressing together. Compression fractures of the vertebrae are especially common with osteoporosis.
  • 14. 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)
  • 15. • Epiphyseal: A fracture through the epiphysis • Pathologic: it occurs through an area of diseased bone (eg, osteoporosis, bone cyst, bony metastasis, tumor); can occur without trauma or a fall
  • 16. • Stress: A fracture that results from repeated loading without bone and muscle recovery
  • 17. 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
  • 18. 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
  • 19. release chemical mediators histamins,prostaglandins | Resulting in vasodilation, edema, pain, loss of function, leukocytes and infiltration of WBC
  • 20. Clinical manifestations • pain • loss of function • deformity • shortening • crepitus • swelling and discoloration
  • 23. 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.
  • 26. Difference between internal or external fixation
  • 27. 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.
  • 28. 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.
  • 29. Traction Traction is the use of weights, ropes and pulleys to apply force to tissues surrounding a broken bone.
  • 30. 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
  • 31. • Splinting is the most common procedure for immobilizing an injury. Splinting
  • 32. • To stabilize the extremity Why Do We Splint? • To decrease pain • Actually treat the injury
  • 33. • 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. Possible items for Splinting
  • 34. • Splinting Using a Towel • Splinting using a towel, in which the towel is rolled up and wrapped around the limb, then tied in place. Soft Splints
  • 35. 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. Guidelines for Splinting
  • 36. The splint should go beyond the joints above and below the fractured or dislocated bone to prevent these from moving
  • 38. 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.
  • 39. • Do not draw exposed bones back into tissue. Treating an Open Fracture
  • 40. 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 Treating an Open Fracture
  • 41. Complication of fracture Early complications • Shock • fat embolism • compartment syndrome • deep vein thrombosis • disseminated intravascular coagulopathy • infection
  • 42. Delayed complications • delayed union and nonunion • avascular necrosis of bone • reaction to internal fixation devices
  • 43. 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.
  • 44. 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
  • 45. 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
  • 46. 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).
  • 47. • 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.
  • 48. 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.
  • 49. • 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.
  • 50. 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
  • 51. • 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.
  • 53. • 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
  • 54. • 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
  • 55. 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
  • 56. Care of traction • Assessment – skin breakdown, pain, neurovascular ,constipation • Stool softner • Plenty of fluids • Provide bedpan and urinals for elimination • Encourage clients activity
  • 58. 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
  • 59. 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. •
  • 60. 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.
  • 61. 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
  • 63. 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 • www.authorstream.com • www.slideshare.com