Details on fracture types and its management.

1. FRACTURE

2. ANATOMY OF BONE.

3. INTRODUCTION
 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. DEFINITION:-
 A fracture may be a complete
break in the continuity of a bone
or it may be an incomplete break
or crack.

5. TYPES:-
 FRACTURE-DISLOCATION
 According to their etiology
 According to their patterns

6. • Fracture-dislocation describes joint fractures
that produce joint instability.
This classification is incomplete, since
fracture-dislocation of the shoulder indicates
dislocation of the shoulder but does not
indicate which bone, the scapula or the
humerus, is fractured.
Fracture-dislocations can be difficult to treat
because they represent intra-articular
fracture plus supporting tissue laxity.
When fracture and dislocation are found
together, the prognosis is poorer than if each
problem occurred separately.
FRACTURE-DISLOCATION

7. According to their etiology ;
 Fractures caused solely by sudden
injury;,
 Fatigue fractures ,
 Pathological fractures,

8. According to their patterns

10. CONTD…..

11. COMPRESSION FRACTURES

12. Etiology of Fractures:
 Extrinsic Causes
 Intrinsic Causes

13. EXTRINSIC FACTORS
COMPRESSION FORCES
TORSIONAL FORCES
BENDING FORCES
INDIRECT VIOLENCE
SHEARING FORCES
DIRECT VIOLENCE

14. DIRECT VIOLENCE;
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.

15. INDIRECT VIOLENCE
 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.

17. BENDING FORCES
 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.

19. TORSIONAL FORCES
 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.

21. COMPRESSION FORCES
 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.

23. SHEARING FORCES
 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.

25. How fracture happen..
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;

26. Types of Fracture…cont.
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

27. INTRINSIC
FACTORS
FRACTURES
DUE TO
MUSCULAR
ACTION
PATHOLOGIC
FRACTURES

28. Signs and Symptoms:
 pain,
 pulselessness,
 pallor,
 paresthesia,
 paralysis

29. Contd…..
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

30. COMPLICATIOS
Late
Early
General

31. Complications of fractures
 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

32. Complications of fractures
 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. MANAGEMENT

34. FIRST AID
 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.

36. Immobilizing Fractured Bone:
 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.

37. CONTD…..
 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.

39. Goals of fracture treatment
 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.

40. Management of the injured patient
 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)

41. 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)

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

43. Open (compound) fractures
 High risk of infection
 Can be associated with gross soft tissue
damage, severe haemorrhage or vascular
injury

44. Open (compound) fractures - management
 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)

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

46. Reduction
 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

47. Maintain reduction
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

48. Maintain reduction
 How?
 1) External method
 POP (+ equivalents), traction,
external fixator
 2) Internal method
 Wires, pins, plates, nails, screws

49. Maintain reduction – external method
 1) POP
 Advantages –
cheap, easy to use,
convenient, can be
moulded
 Disadvantages –
susceptibility to
damage
(disintegrates when
wet), up to 48hrs to
dry

50. Maintain reduction – external method
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

51. Maintain reduction – external method
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

52. Maintain reduction – external method
 4) Skeletal traction
 Requires invasive
procedure for longer
term traction requiring
heavier weights
 Complications associated
with pin insertion eg.
infection

53. Maintain reduction – external method
 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

54. Maintain reduction – internal method
 Advantages
 Restoration of absolute anatomical state
 Shorter hospital stay
 Enables individuals to return to function
earlier

55. Contd…..
 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)

56. Maintain reduction – internal method
 By.. Nail , plate , screws, wire.
 Complications
 Infection
 Non-union
 Implant failure
 Re-fracture

57. Maintain reduction – internal method
 Wires & pins
 Can be used in
conjunction with other
forms of internal fixation
 Used to treat fractures of
small bones

58. Maintain reduction – internal method
 Plates & screw
 Extend along the bone
and screwed in place
 May be left in place or
removed (in selected
cases) after healing is
complete

59. Maintain reduction – internal method
 Nail or rods
 Held in place by
screws until the
fracture is healed
 May be left in the
bone after healing
is completed

60. REHABLITATION:-
 Active use
 Active exercises
 Continuous passive motion

63. Factors Influencing Healing
Systemic Factors:-
 „„Age
 „„Hormones
 „„Functional activity
 „„Nerve function
 „„Nutrition

64. Factors Influencing Healing…cont.
Local Factors:-
 „„Energy of trauma
 „„Degree of bone loss
 „„Vascular injury
 „„Infection
 „„Type of bone fractured
 „„Degree of immobilization
 „„Pathological condition

65. NURSING MANAGEMENT:-
 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.

66. Cond…..
 “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.

67. Contd…..
 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

68. CONTED…..
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.

69. NURSING DIAGNOSIS:-
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.

70. CONTD…..
 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.

71. NURSING DIAGNOSIS
 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.

72. CONTD…..
 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.

73. NURSING DIAGNOSIS:-
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.

74. CONTD…..
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.

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

76. Teaching the Patient with a Cast
Home Care:-
 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

77. By-Peter F. Cronholm, MD;
Wendy Barr, MD,
 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.

79. BIBLIOGRAPHY
 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_1
1/11mast.htm
 http://cal.vet.upenn.edu/projects/saortho/chapter_1
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../chapter_10/10mast.htm