1) Bones provide structure and protection for the body while allowing movement at joints. 2) Fractures can be caused by direct or indirect forces and result in complete or incomplete breaks in the bone. 3) Clinical features of a fracture include pain, deformity, loss of function, and crepitus while diagnostic measures include x-rays.

1. BY
Shaveta Sharma
Assistant Professor
Saraswati Nursing Institute, Kurali

3.  Our skeleton is tough and flexible. It
supports weight and protects our internal
organs. Bone tissue stores minerals,
such as calcium, and it is constantly
renewed, which is how our bones are
able to heal.
 Bones are cleverly designed to allow
movement at the joints and provide great
stability. The bones provide a light but
strong framework for the bodies soft
tissues.

4.  A fracture may be a complete
break in the continuity of a
bone or it may be an
incomplete break or crack.

5.  FRACTURE-DISLOCATION
 According to their etiology
 According to their patterns

6. FRACTURE-DISLOCATION

7.  Fractures caused solely by sudden injury;,
 Fatigue fractures ,
 Pathological fractures,

11.  Extrinsic Causes
 Intrinsic Causes

12. COMPRESSION FORCES
TORSIONAL FORCES
BENDING FORCES
INDIRECT VIOLENCE
SHEARING FORCES
DIRECT VIOLENCE

13. Trauma is the most common cause of
fractures and is usually due to
automobile injury or falling from a
height.
Since direct trauma is rarely delivered
in a calibrated amount to a specific
place, the resultant fracture is rarely
predictable.
The amount and direction of force will
vary from accident to accident.
Most fractures resulting from violent
direct trauma are either comminuted
or multiple.

14.  Fractures due to indirect trauma are more
predictable than those due to direct trauma.
 Generally a force is transmitted to a bone in a
specific fashion and at a "weak link" within the
bone, causing a fracture to occur.

16.  Bending fractures occur when force is applied to a
specific focal point on a bone to the extent that the
traumatic force overcomes the elastic limit of the bone
diaphysis.
 The initial effect of a bending force is a cortical break
opposite the site of the trauma. The periosteum will
remain intact on the side of the force while tearing
over the fracture on the opposite side.
 With additional force the entire bone snaps, with
attendant tearing of vascular and soft tissue
structures within or on the diaphysis.
 Bending fractures are generally oblique or transverse,
or they may have a butterfly fragment.

18.  Torsional fractures occur when a twisting force
is applied to the long axis of a bone.
 Usually this is a result of one end of a bone
being placed in a fixed position while the other
end of the bone is forced to rotate.
 The resulting fracture will be a very long spiral
with sharp points and often sharp edges. It is
possible for the sharp points or edges to
compromise soft tissues or to cut through the
skin and result in an open fracture. Torsional
forces generally result in short or long spiral
fractures.

20.  Compressive forces along the long axis of a
bone may force the smaller diaphyseal or
metaphyseal portion of a bone to impact into
the larger epiphysis: bony substance is
thereby crushed. Similarly a compressive force
directed along the axis of the spine may result
in collapse of a vertebral body. For
compressive force to result in fracture, one
end of a bone must be in a fixed position while
the other end is forced toward the fixed end.
Compressive forces result in impacted
fractures or compression fractures.

22.  A shearing fracture is caused by a force
transmitted along the axis of a bone,
which is then transferred to a portion of
the same bone that lies peripheral to the
axis or across a joint to other bones that
are not protected by the axis of the
bone.
 The fracture line in a shear fracture will
be parallel to the direction of the applied
force. Shearing forces result in the
fracture of bony prominences not placed
along the direct axis of a diaphysis.

24. 1. Twisting causes a spiral fracture;
2. Compression causes a short oblique fracture;
3. Bending results in fracture with a triangular
'butter-fly‘ fragment;
4. Tension tends to break the bone transversely;

25. Open fracture :
When the bony fragments are
exposed to external environment by
means of wound
Closed fracture :
The fracture fragments are not
exposed to outside

26. INTRINSIC
FACTORS
FRACTURES
DUE TO
MUSCULAR
ACTION
PATHOLOGIC
FRACTURES

27.  pain,
 pulselessness,
 pallor,
 paresthesia,
 paralysis

28. OTHERS:-
 DYSFUNCTION
 LOCAL TRAUMA
 ABNORMAL POSTURE OR LIMB POSITIONING
 CREPITUS
 ABNORMAL MOBILITY
 RADIOGRAPHIC SIGNS
 FEVER
 ANAEMIA
 SHOCK
 NERVE INJURY
 NECROSIS OR GANGRENE
 FAT IN SYNOVIAL FLUID

29. Late
Early
General

30.  General complications
◦ Shock
◦ ARDS
◦ Fat embolism
◦ Head, chest, abdomen and pelvic injuries
◦ Crush syndrome
◦ Tetanus
◦ Gas gangrene
◦ Infections – UTI, Chest
◦ DVT/PE
◦ Bed sores
◦ Depression

31.  Early
Visceral injury
Vascular injury
Compartment syndrome
(later Volkmann
conctracture)
Nerve injury
Haemarthrosis
Infection
Late
Delayed union
Non-union
Mal-union
Tendon rupture
Osteonecrosis
Osteoarthritis and
joint stiffness

33.  SEEK MEDICAL ATTENTION IMMEDIATELY. DO NOT
attempt to transport victim if you suspect head, back, or
neck injury.
 Immobilize and support affected bone in position found.
DO NOT try to push protruding bone back into body or let
victim move or use affected area.
 Control any bleeding through direct pressure.
 If bone is protruding, cover with clean cloth once bleeding
is controlled.
 Observe for shock . DO NOT give victim anything to eat or
drink.
 Immobilize injured area, and, if no open wound present,
apply ice pack wrapped in clean cloth.

35.  Check for sensation, warmth, and color of toes or
fingers below suspected break.
 Place padded splint under area of suspected break.
 -Use board, rolled newspaper or magazines, or
rolled blanket for splint.
-Wrap splint in cloth or towels for padding.
-Bind splint to limb using neckties, cloth, belts, or
rope. DO NOT bind directly over break.

36.  Recheck often for sensation, warmth, and
coloring. If fingers or toes turn blue or swell,
loosen binding.
 For arm or shoulder injury, place splinted arm in
sling, with hand above elbow level. Bind arm to
victim's body by wrapping towel or cloth over sling
and around upper arm and chest; tie towel or cloth
under victim's opposite arm.

38.  Prevent fracture and soft tissue complications,
 Get fracture to heal and in satisfactory position for
optimal functional recovery.
 Intra-articular fracture needs accurate reduction &
rigid fixation but non articular fracture of bone
require anatomical reduction & stable fixation.
 Rehabilitate as early as possible by active & passive
exercises.
 Restore patient to optimal functional state

39.  Don’t treat the X-rays of the fracture, but treat the
patient
 Life saving measures
◦ Diagnose and treat life threatening injuries (head
injuries, Chest & abdominal injuries)
◦ Emergency orthopaedic involvement
 Life saving
 Complication saving
 Emergency orthopaedic management (day 1)
 Monitoring of fracture (days to weeks)
 Rehabilitation and treatment of complications
(weeks to months)

40.  A= Airway and
cervical spine
immobilisation
 B = Breathing
 C = Circulation
(treatment and
diagnosis of cause)
 D = Disability
(head injury)
 E = Exposure
(musculo-skeletal
injury)

41. 1) Reduction
2) Maintain reduction ( hold until union)
3) Rehabilitate – restore function by movement of the
joint & patient itself.
4) Prevent or treat complications

42.  High risk of infection
 Can be associated with gross soft tissue damage,
severe haemorrhage or vascular injury

43.  While contacting orthopaedic team for
definitive surgical treatment
 Irrigate wound with N.S, if not available
with
tap water. Cover wound with sterile moist
dressing.
 Immobilise limb preferable with external
fixator If not possible , by cast (including
joint above & below)

44.  Remove obvious contaminants with
meticulous effort
 IV antibiotics (e.g. cefuroxime +/-
metronidazole or gentamicin)
 Tetanus prophylaxis.
 Check distal neurovascular status
 Re-assess

45.  If necessary, what reduction technique?
1) Closed reduction
◦ Need anaesthesia/sedation, analgesia, x-ray facilities,
equipment, knowledge
◦ Used for minimally displaced fractures and most
fractures of children
 Distal part of limb pulled in line of bone
 Alignment adjusted in each plane
2) Open reduction
◦ Above + theatre staff + additional equipment

46. Necessary?
1) Relieve pain
2) Prevent mal-union – nature heals the fracture, we
keep it in a good position
3) Minimise non-union – maintenance of reduction
should be continuous

47.  How?
◦ 1) External method
 POP (+ equivalents), traction, external
fixator
◦ 2) Internal method
 Wires, pins, plates, nails, screws

48.  1) POP
◦ Advantages –
cheap, easy to use,
convenient, can be
moulded
◦ Disadvantages –
susceptibility to
damage
(disintegrates when
wet), up to 48hrs to
dry

49. 2) Resin cast
 Advantages – lighter and
stronger, more resistant
to damage, sets in 5-
10mins, max strength in
30mins
 Disadvantage – cost,
more difficult to
apply/remove, more rigid
with greater risk of
complications eg.
swelling and pressure
necrosis

50. 3) Surface traction
◦ Temporary measure
when operative
fixation not available
for awhile
◦ Skin can be injured if
applied for long
periods of time
◦ Neuro-vascular status
should be checked
during surface
traction period

51.  4) Skeletal traction
◦ Requires invasive procedure for
longer term traction requiring
heavier weights
◦ Complications associated with
pin insertion eg. infection

52.  5) External fixator
 Indications
◦ Fractures associated with soft tissue
injury
◦ Fracture associated with N/V damage
◦ Severely comminuted and unstable
fracture
◦ Unstable pelvic fracture
 Complications
◦ Pin track infection
◦ Delayed union

53.  Advantages
◦ Restoration of absolute anatomical state
◦ Shorter hospital stay
◦ Enables individuals to return to function earlier

54.  Indications
◦ Fractures that need operative fixation
◦ Inherently unstable fractures prone to re-displacement
after reduction (eg. mid-shaft femoral fractures)
◦ Pathological fracture
◦ Polytrauma (minimise ARDS)
◦ Patients with nursing difficulties (paraplegics, v.
elderly, multiple trauma)

55.  By.. Nail , plate , screws, wire.
 Complications
◦ Infection
◦ Non-union
◦ Implant failure
◦ Re-fracture

56.  Wires & pins
◦ Can be used in conjunction with
other forms of internal fixation
◦ Used to treat fractures of small
bones

57.  Plates & screw
◦ Extend along the bone and
screwed in place
◦ May be left in place or
removed (in selected cases)
after healing is complete

58.  Nail or rods
◦ Held in place by screws
until the fracture is
healed
◦ May be left in the bone
after healing is
completed

59.  Active use
 Active exercises
 Continuous passive motion

62. Systemic Factors:-
 „ „ Age
 „ „ Hormones
 „ „ Functional activity
 „ „ Nerve function
 „ „ Nutrition

63. Local Factors:-
 „ „ Energy of trauma
 „ „ Degree of bone loss
 „ „ Vascular injury
 „ „ Infection
 „ „ Type of bone fractured
 „ „ Degree of immobilization
 „ „ Pathological condition

64.  ASSESSMENT:-
 "5 P's"
 Patient's general health
 signs and symptoms
 emotional status
 understanding of need for cast
 physical assessment of part to be immobilized
includes the neurovascular status of body part,
degree and location of swelling, bruising, and skin
abrasions.

65.  “Hot Spots” – area of the cast that feel
warmer than other sections.
 May indicates tissue necrosis or infection
under the cast.
 “Wet Spots” – May indicate the drainage
under the cast or a need for additional drying
.
 Stains can indicate wound drainage or
bleeding, any other stained area should be
measured carefully and doccumented.

66.  Be aware of possible pressure points on
underlying structures, such as the lateral
malleolus under a shot leg castor epicondyle
under a short arm cast.
 An older cast may develop a sour smell
because of perspiration or normal sloughing of
outer skin layers.
 Musty, offensive odors under the cast may
indicate tissue necrosis or infection.
 If odor of mildew is present, the synthetic cast
may have not been dried properly after it
become wet

67. continuous watch for the warning signs, which are the ;
 undue swelling
 impaired circulation
 severe pain within the plaster
 The period of greatest danger is between 12 to 36
hours.

68. Acute pain r/t the musculoskeletal disorder.
 Expected outcome:- pain in the patient's body part
will be relieved.
 Nursing interventions;
◦ Assess the characteristics of the pain. ( asking the
patient to indicate the exact site of the pain, its
severity, and intensity of the pain)
◦ teach the diversional therapies to the patient.

69. ◦ Elevate the affected limb.
◦ apply the ice packs as prescribed.
◦ restrict the unnecessary movements and keep the
body part immobilized.
◦ involve the patient in the active and passive ROM.
◦ administer the analgesics as prescribed.

70.  Impaired skin integrity r/t lacerations and
abrasions.
 Expected outcome:- skin integrity will be maintained.
 Nursing interventions;
 assess for the skin of patient.
 assess for the edema, redness, numbness, parasthesia
and heat.

71.  elevate the body part of the patient.
 encourage for the ROM exercises.
 teach about the care of the cast.
 report the orthopedist, if any of above
mentioned s/s appears.

72.  Knowledge deficit r/t the treatment regimen.
 Expected outcome:- patient will obtain the optimal
level of knowledge.
 Nursing interventions;
 Assess the level of knowledge and understanding
of the patient.
 provide the information to the patient about the
underlying pathologic condition and the purpose
and the expectations of the prescribed treatment
regimen.

73.  teach the patient about what is expected
from the patient during application.
 explain about the sensations regarding the
cast application i.e. heat from the
hardening reaction of the plaster.
 teach the patient that the body part will be
immobilized after the application of the
cast.
 teach the about the care of the cast,
specially children.

74. ◦ Impaired physical mobility r/t the cast.
◦ Self care deficit : bathing/hygiene, feeding ,
dressing/grooming , or toileting due to restricted
mobility.

75.  Mobility aids & safety
 Prescribed exercise
 Elevate extremity to heart level
 Keep cast dry & cushion rough edges
 Don’t scratch under cast
 Report indicators of complications
 Avoid excessive use of injured extremity
 Report broken cast

76.  Does osteoporosis screening decrease fracture risk in
postmenopausal women? Osteoporosis results in 1.3 million fractures
annually in the US. Of the approximately 25 million American women
with osteoporosis, 8 million have had a documented fracture.
 The authors reviewed articles on risk factor assessment, bone
density tests, and osteoporosis treatment with bisphosphonates.
 they found 3 clinical risk factors that consistently predicted increased
risk of fracture: advanced age, low weight or body mass index, and
nonuse of hormone replacement therapy. The presence of any of the
3 risk factors increased the risk for fracture by 70% (relative risk, 1.7).
 Thus found that the screening of high risk women helps to reduce the
number of hip and vertebral fractures.

78.  Black M.Joyce.Medical Surgical
Nursing(2008):Elsevier publishers.vol-2,ed-8th
. P-515
- 28
 Wilkins,Williams.Mannual of Nursing
Practice(2009):Wolter Kluner.ed-9.P-279-85.
 Keen Janet hicks,Swearingen Pulmelal.Critical Care
Nursing Consultant(1997):Mosby publishersvol-1st
,ed-
1st
.P-366,318,172,108.
 Adams Jhon Crawford , Hamblen David L. Outline of
Fractures including joint injuries(1999):Churchill
Livingstone publishers, ed-11th
p 1-73.
 REFERENCES:-
 http://cal.vet.upenn.edu/projects/saortho/chapter_11/11mast.htm
 http://cal.vet.upenn.edu/projects/saortho/chapter_16/
16mast.htm
../chapter_10/10mast.htm