fracture

1. Fractures

2. Fracture
Break in the continuity of the bone
when force is applied that exceeds
the tensile strength or compressive
strength of the bone. The breaking of
a bone, cartilage, or the like, or the
resulting condition.

3. CAUSES OF FRACTURE
 Trauma
 Osteoporosis
 Overuse of long bones
 Aging

4. Fracture Types
• Open fracture (Also called compound fracture.)-
the bone exits and is visible through the skin, or
a deep wound that exposes the bone through
the skin.
• Closed fracture (Also called simple fracture.)-
the bone is broken, but the skin is intact.
Fractures have a variety of names. Below is a
listing of the common types that may occur:

5. • Simple (closed) - little or no bone displacement . The
broken bone hasn’t pierced the skin.
SIMPLE

6. • Compound- fracture ruptures the skin & bone protrudes.
or ‘open’ fracture. The broken bone penetrates through
the skin, or a wound leads to the fracture site. The risk of
infection is higher with this type of fracture.

7. • Green stick - occurs mostly in children whose bones have
not calcified or hardened . Fracture on one side of the
bone, causing a bend on the other side of the bone. The
broken bone is not completely separated.
GREENSTICK

8. • Transverse - crack perpendicular to long axis of the bone -
displacement may occur. The break is in a straight line
across the bone. The two ends tend to stay together i.e.
it's a stable fracture
TRANSVERSE

9. • Oblique - diagonal crack across the long axis of the bone
& chance of displacement
OBLIQUE

10. • Spiral - diagonal crack involving a "twisting" of the bone
about the longitudinal axis (occurs in skiing when bindings
are too tight).
SPIRAL

11. • Comminuted (blowout) - "crushing" fracture - more
common in elderly. It may cause permanent discrepancy in
leg length. This generally needs surgery using pins to hold
everything together until the bone heals.
COMMINUTED

12. • Impacted - one end of bone is driven up into the
other - may result in length discrepancy

13. • Depressed – broken bone is pressed inward
(skull fracture)

14. • Avulsion - fragment of bone is pulled away by
tendon (Hip flexors, adductors). This type of
fracture is more common in the knee and shoulder
joints.

15. • Displaced fracture- Meaning the bone ends are no
longer touching. This means they'll have to be
reduced back together before healing will occur.

16. • Hairline fracture- This is a small crack in the bone from a
repetitive action like running which is so tiny you may not
see it on X-ray, but it hurts! This has an excellent prognosis
if we give the bone a rest from repetitive injury as the
damage is mild.

17. • Stress fracture- A stress fracture is an overuse
injury, the bone fail’s to absorb the shock that is
being put upon it and become weakened. It is seen
in the lower leg, the shin bone (tibia), or foot.

18. • Pathological fracture– bones weakened by various
diseases (such as osteoporosis or cancer) tend to
break with very little force.

20. Pathophysiolgy of
Fracture

21. Bone impact
exceed tensile
strength
Break in the
continuity of
the bone
Swelling
Pain
Moderate to
severe energy
transmitted
Fat embolus
Myoglobinurea
Compartment
syndrome
Deformity
Loss of function
Impaired
sensation
Decrease
mobility
Bleeding

22. Hematoma
formation
Bone tissue dies
Decalcify fracture
bone ends
Bone tissue
revascularization
Stimulates
inflammatory
response

23. Procallus
Callus
Remodeling
New bones
Osteoblast

24. Clinical Manifestations
• Local Swelling, Oedema
• Severe pain/ local tenderness
• Loss of function or abnormal movement of affected part
• Deformities such as shortening, rotation
• Crepitation
• Muscle spasm
• Anaesthesia and flaccidity (few minute to hrs.)
- This is due to a temporary loss of nerve function at the
site associated vascular injury.
• Discoloration
• Paralysis

25. Complication
Osteomyelitis
The open area is a rich
culture medium for
infection. It retards
healing by destroying
newly formed bone
and interrupting it’s
blood supply.
S. aureus is the usual
cause.

26. Embolism
Fat & Pulmonary
Embolism.
Fractures of long bones
may release enough fat
to travel through the
veins, they attract
platelets which become
part of the
microembolus and
deplete circulating
platelets
Complications

27. Delayed union
Complications
Failure
incorrect

28. Nerve Damage
- Bone fragments
may rupture and
compress nerves
that may also be
damaged by
dislocation or direct
trauma
Complications

29. Dislocation
temporary displacement of
one or more bones in a joint
in which the opposing bone
surface loss contact entirely.
Complications
Subluxation
if the contact bone
between the opposing bone
surface is partially lost.

30. Myoglobinuria
Severe muscle trauma.
An excess myoglobin
(intracellular muscle protein)
in the urine.
Muscles damage, with
disruption of sarcolemma,
releases myoglobin which
would lead to renal failure
Complication

31. COMPARTMENT SYNDROME
- Pressure build within the compartment due to
bleeding.
- swelling reaches the point at which the fascia
permits no outward enlargement
- increasing pressure is directed inward and
compresses components in the compartments.
Complication

32. Diagnostic Tests

33. RADIOLOGIC EXAM
Radiologic exam- to determine location extent of
fracture/trauma; may reveal preexisting undiagnosed
fracture.
Bone scan, tomograms, CT, MRI scan
- Visualized fractures, bleeding and soft tissue
damage. May be prepared for diagnostic tool
because of superior ability to image some types of
injuries.
Arteriogram
- May be done when occult vascular damage is
suspected.

34. Urine creatinine clearance
- Muscle trauma increases load of Creatinine for renal
clearance.
- Creatinine level and urea nitrogen level should be
analyzed when renal function is elevated.
- NORMAL VALUE
- 0.6-1.3 mg/dL
URINE ANALYSIS

35. Blood Urea Nitrogen
- Urea normally freely filtered through renal
glomeruli, small amount reabsorbed in the
tubule and the remainder excreted in the
urine.
-NORMAL VALUE
8-25 mg/dl
URINE ANALYSIS

36. BLOOD ANALYSIS
Hemoglobin
- main component of erythrocyte & serve
as the vehicle for transportation of O2 and CO2.
- NORMAL VALUES
Male: 14-16.5 g/dL Female: 12-15 g/dL
Hematocrit
- Determinations are important in identifying
anemia.
- Fasting is not required.
- NORMAL VALUES
- Male: 42%-52% Female: 35%-47%

37. BLOOD ANALYSIS
- Immune defense system of the body.
- Cell count assess each leukocytes distribution.
- increase WBC, normal response to trauma.
NORMAL VALUE
4,500 – 11, 000 cells/L
WBC

38. Coagulation profile
activated Partial Thromboplastin Time (aPTT)
- Test screens
deficiencies & inhibitors of all factors
except factor VII & XIII.
- Screen for coagulation disorders.
- NORMAL VALUE
20-36 seconds

39. Coagulation profile
Prothrombin Time (PT)
- Measures the amount of time it takes for clot
formation
- within 2 sec (+ or - ) of the control is considered
normal.
NORMAL VALUES
- Male: 9.6 -11.8 seconds Female: 9.5 -11.3
seconds
-
PT > 30 seconds at risk for
HEMORRHAGE

40. Steps in Fracture Healing
 1.) Inflammatory Phase
 Bleeding from bone, bone periosteum, &
tissues surrounding the bone
 - formation of fracture hematoma & initiation of
inflammatory response
 - Induction (stimulus for bone regeneration) -
caused by:
 Without Oxygen bone necrosis starts (fractured
bone becomes hypoxic immediately)

41. Inflammatory response - lasts between days
2- 9 following injury:
phagocytes & lysosomes clear necrosed bone
and other debris.
A fibrin mesh forms and “walls off” the fracture
site which serves for fibroblasts and capillary
buds, capillaries grow into the hematoma in a
fracture, the new blood supply arises from
periosteum
normally 3/4 of blood flow in adult bone arises
from endosteum.

43. 2.) Fibrocartilagenous callus Formation
Lasts an average of 3 weeks
Fibroblasts and osteoblasts arrive from periosteum &
endosteum
Within 2-3 days, fibroblasts produce collagen fibers that span
the break
This tissue is called Fibro - Cartilagenous Callus and
serves to “splint” the bone
FCC is formed both in and around the fracture site
Osteoblasts in outer layer of FCC begin to lay down
new hard bone
in a non-immobilized fracture, the FCC has poor
vascularization
Steps in Fracture Healing

44. 3.) Hard Boney Callus Formation & Ossification
Weeks to months
Fracture fragments are joined by collagen, cartilage, &
then immature bone
Osteoblasts form trabecular bone along fracture periphery
(external callus)
Trabecular bone is then laid down in the fracture interior
(internal callus)
Ossification (mineralization) starts by 2-3 weeks &
continues for 3-4 months
Alkaline phosphatase is secreted by osteoblasts
blood serum levels serve as an indicator of the rate of bone
formation
Steps in Fracture Healing

45. In non-Immobilized fractures, more
“cartilage” than bone is laid down
this must later be replaced by normal
cancellous bone
results in a longer healing time and fractured area
remains weak for a longer period
fibrocartilage callus is gradually replaced by one
made of spongy bone, known as the bony callus.
Fractures should be reduced (immobilized)
within 3-5 days

46. 4.) Bone Remodeling
Months to years (mechanically stable at 40 days)
Excess material inside bone shaft is replaced by more
compact bone
Final remodeled structure is influenced by optimal
bone stress
the bony callus is remodelled in response to
mechanical stresses placed on it, so that it forms
a strong permanent (bone) patch at the fracture
site.
Steps in Fracture Healing
1.
3. 4.

47. 1. 2.
3. 4.

49. Factors Enhancing Bone Healing
Youth
Early Immobilization of fracture fragments
Maximum bone fragment contact
Adequate blood supply
Proper Nutrition
Vitamines A & D
Weight bearing exercise for long bones in the late
stages of healing
Adequate hormones:
growth hormone
thyroxine
calcitonin

50. Factors Inhibiting Bone Healing
Age
Fractured Femur Healing Time
infant: 4 weeks
teenager: 12 to 16 weeks
60 year old adult: 18 to 20 weeks
Extensive local soft tissue trauma
Bone loss due to the severity of the fracture
Inadequate immobilization (motion at the fracture
site)
Infection
Avascular Necrosis

51. Therapeutic Implications for
Treating Fractures
Active ROM exercises to joints above and below
immobilized region
Resistive ROM exercises to muscle groups that are not
immobilized
Once the cast or immobilization device has been
removed:
gentle but progressive resistance exercises of all immobilized joints
evaluate strength of joint(s) and compare to non-injured counterparts
return to vigorous activity only after strength discrepency <
15%

52. GOALS OF FRACTURE TREATMENT
• Restore the patient to optimal functional state
• Prevent fracture and soft-tissue complications
• Get the fracture to heal, and in a position which will
produce optimal functional recovery
• Rehabilitate the patient as early as possible

53. TREATMENT
Depending on the site of the fracture and the severity
of the injury, treatment options may include:
Splints – to discourage movement of the broken limb
Braces – to support the bone
Plaster cast – to provide support and immobilise the
bone
Traction – this option is less common
Surgically inserted metal rods or plates – to hold the
bone pieces together
& Pain relief.

54. MANAGEMENT OF THE INJURED
PATIENT
• Life saving measures
• Diagnose and treat life threatening injuries
• Emergency orthopaedic involvement
– Life saving
– Complication saving
– Emergency orthopaedic management (Day 1)
– Monitoring of fracture (Days to weeks)
– Rehabilitation + treatment of complications
(weeks to months)

55. LIFE SAVING MEASURES
–A Airway and cervical spine
immobilisation
–B Breathing
–C Circulation (treatment and diagnosis
of cause)
–D Disability (head injury)
–E Exposure (musculo-skeletal injury)

56. EMERGENCY ORTHOPAEDIC
MANAGEMENT
• Life saving measures
• Reducing a pelvic fracture in haemodynamically
unstable patient
• Applying pressure to reduce haemorrhage from open
fracture
– Complication saving
• Early and complete diagnosis of the extent of injuries
• Diagnosing and treating soft-tissue injuries

57. DIAGNOSING THE SOFT TISSUE
INJURY
• Skin
• Open fractures, degloving injuries and ischaemic
necrosis
– Muscles
• Crush and compartment syndromes
– Blood vessels
• Vasospasm and arterial laceration
– Nerves
• Neurapraxias, axonotmesis, neurotmesis
– Ligaments
• Joint instability and dislocation

58. TREATING THE SOFT TISSUE
INJURY
• All severe soft tissue injuries require urgent
treatment
• Open fractures , Vascular injuries, Nerve injuries,
Compartment syndromes, Fracture/dislocations
– After the treatment of the soft tissue injury the
fracture requires rigid fixation
– A severe soft-tissue injury will delay fracture
healing

59. DIAGNOSING THE BONE INJURY
– Clinical assessment
• History
• Co-morbidities
• Exposure/systematic examination
– “First-aid” reduction
– Splintage and analgesia
– Radiographs
• Two planes including joints above and below area of injury

60. INDICATIONS FOR OPERATIVE
TREATMENT
• General trend toward operative treatment last 30 yrs
• Improved implants and antibiotic prophylaxis, Use of closed and
minimally invasive methods
• Current absolute indications:-
• Polytrauma Displaced intra-articular fractures
• Open fractures with vascular injuries or compartment symptoms,
Pathological fracture, Non-unions
• Current relative indications:-
• Loss of position with closed method, Poor functional result with
non-anatomical reduction, Displaced fractures with poor blood supply,
Economic and medical indications

61. REHABILITATION
• Restoring the patient as close to pre-injury functional
level as possible
• May not be possible with:-
– Severe fractures or other injuries
– Frail, elderly patients
– Approach needs to be:-
• Pragmatic with realistic targets
• Multidisciplinary
– Physiotherapist, Occupational therapist, District nurse, Social
workers

62. Nursing Diagnosis
1. Acute pain r/t stimulation of free nerve
endings 2 to soft tissue injury.
2. Risks for peripheral neurovascular dysfunction
r/t reduction/interruption of blood flow.
3. Impaired Gas Exchange r/t altered blood
flow/fat emboli.
4. Impaired physical mobility r/t skeletal
instability 2 to physical trauma.

63. 5. Impaired Tissue integrity r/t insertion of
traction pins wires and screw/ physical
immobilization
6. Situational low Self –Esteem r/t loss of body
parts/ change in functional abilities.
7. Ineffective peripheral tissue perfusion r/t
reduced arterial venous blood flow; tissue
edema; hematoma formation.
Nursing Diagnosis