Fractures

Shejila C.H
PhD Scholar
MCON Manipal
 Definition of Fracture

Fracture: A fracture is a break in

the continuity of the bone that occurs
when more stress is placed on a
bone than it is able to absorb.
 Incidence:
More common in between the age of 6
to 16 yrs and above 40yrs
 Etiology
 Motor Vehicle Accident
 Fall
 Direct blow to the bone or an indirect
force from muscle contraction
 Sports
 Vigorous Exercise
 Malnutrition
 Bone Diseases like Osteoporosis
Risk Factors
 Age-above 50  Malnutrition
 Sex-Females  Alcohol
 Low body weight  Biological conditions
 Muscle weakness  Neoplasm
 Impaired vision
 Neurological
 Employment related
impairment activities
 Physical inactivity
 Smoking
Types of fracture
 CLASSIFICATION ACCORDING TO THE
COMMUNICATION WITH THE
ENVIRONMENT

 1. OPEN FRACTURE
 2. CLOSED FRACTURE
 Closed Fracture
There is no broken
skin. The bones
which are broken
do not penetrate
the skin and does
not communicate
with the outside
Open Fracture
 a break in skin
present over fracture
site. The wound
communicates with
the skin externally
and to the fractured
bone internally.
Classification according to the
direction of fracture:

1. Oblique fracture
2. Linear fracture
3. Longitudinal fracture
[Link] fracture
5. Spiral fracture
6. Stellate fracture
 Oblique Fractures

 Fractureline is at
an oblique angle,
is about 45`angle
to the shaft of
bone.
Linear Fracture
 fracture line runs
parallel to the bone’s
long axis
Longitudinal fracture
 fracture line extends
longitudinally.
Transverse fracture

 fracture line is straight

across the bone, i.e.
right angle to the
bone’s axis
Spiral fracture
 fracture line forms
spiral encircling
around the bone.
Stellate fracture
 central fracture point
with several fissures
radiating outward.
CLASSIFICATION BY TYPE
OF FRACTURE
1. Avulsion fracture
2. Compression fracture
3. Comminuted fracture
4. Greenstick fracture
5. Impacted fracture
6. Pathologic fracture
Avulsion fracture

 avulsion fracture is
one in which bone
fragments are torn
away from the body of
the bone.
 Compression Fracture
A fracture in
which bone
has been
compressed.
Comminuted fracture

 The bone is broken

into than two
fragments
 Greenstick Fracture
The fracture in
which one side of
the bone is broken
and the other side
is bent.
Impacted fracture

 a vertical force drives

the distal fragment of
the fracture into the
proximal fragment.
Pathologic fracture

 It occurs when bone

is weakened as a
result of an underlying
bone disorder , such
as osteoporosis or
tumor
 Compound Bone Fracture
The skin is broken, leading
directly into fracture
 Grade I : Minimal soft
tissue injury
 Grade II : Laceration
greater then 1cm without
extensive soft tissue flaps.
 Grade III : Extensive soft
tissue injury, including
skin, muscles, neuro
vascular structures, with
crushing.
Classification by eponym:
Named by the physician who first described them

 Colle’s fracture: It is
common fracture in
which the distal radius
is fractured with 1
inch of the articular
surface
Classification by eponym:
 Pott’s Fracture:-It
occurs at the medial
malleous of the tibia
and fibula and often is
associated with rupture
of internal lateral
ligament, chipping off
of a piece of the medial
malleolus or both .
 Pathophysiology
Etiological factors

Fracture of bone

The periostium and the blood vessels in the

cortex ,marrow and surrounded the soft tissue
are disrupted

Bleeding from the damaged ends of

bone and from nearby soft tissues

Hematoma formation in the medullary canal,

between the fractured ends of the bone and
beneath the periostium

Death of the bone tissue adjacent to fracture.

Stimulation of inflammatory response characterized

by vasodilatation, exudation of plasma and
leucocytes and infiltration of other WBC

Initiation of bone healing process

Bone healing
 Fracture healing is considered as a series of phases which occur in
sequence as follows
(I) Inflammatory Phase.
(A) Stage of hematoma formation.
(B) Stage of granulation tissue. (more fibrin to the hematoma and
increase blood flow
(II) Reparative Phase.
 (A) Stage of fibro cartilaginous callus.
 (B) Stage of bony callus (woven bone become calcified)).  
 (III) Remodeling Phase.
 Excess material inside bone shaft is
 replaced by more compact bone
Bone healing
Factors Affecting Bone Healing
Enhancing Inhibiting

Youth Age (e.g. Average # Femur Healing Time)

Early Immobilization of fracture Infant: 4 weeks
fragments Teenager: 12 to 16 weeks
Bone fragments contact Extensive local soft tissue trauma
Adequate blood supply Bone loss due to the severity of the
Proper Nutrition fracture
Adequate hormones Inadequate immobilization (motion at the

 Growth hormone fracture site)

 Thyroxin Infection

 Calcitonin Avascular Necrosis

 Sign and Symptoms of Fracture
 5 P’s : Pain and point tenderness.
Pallor
Pulse loss
Paresthesia
Paralysis
 Deformity
 Swelling
 Discoloration
 Crepitus (grating, crackling or popping sounds )
 Loss of limb function
 Numbness
 Cool skin at the end of
 extremity
 Hypovolemic shock
 Diagnostic Evaluation
 X-ray
 MRI, CT-scan
 Blood studies
 Arthroscopy
 Angiography
 Nerve conduction /
electromyogram
studies
 Management of Fracture
 Assessment
a. Type, location and
severity of fracture
b. Soft tissue damage
c. Age and health
status of patient
d. Extend of other
parts of organs
 Goals of management
 To regain and maintain correct
position and alignment.
 To regain the function of involved
part.
 To return the patient to usual
activities in the shortest time and at
the least expenses.
Principles of Management
 Efficient first aid
 Safe transport
 Assessment of general condition
 Assessment of local condition
 Resuscitation
 Radiography
 Reduction
 Immobilization
 Early physiotherapy
 Rehabilitation
 Approaches to Management

Management

Closed Open

Bandages Splints Casts Traction Internal F External F

 Closed reduction
Is the most common non
surgical method for
managing a simple
fracture.
 Bandages : are elastic or
muslin bandage used to
immobilize the bone
during healing.
 Splints : as upper
extremity bones do not
bear weight, splints may
be sufficient to keep bone
fragments in place.
 Casts : A cast is an
immobilizing device
made up of layers of
plaster or fiber
glass. A cast also
allows early mobility
and reduces pain.
 Types of cast :
Arm cast
Leg cast
Cast braces
Body or spica cast
 Traction : it’s the
application of a
pulling force to a
part of the body. It
uses a system of
ropes, pulleys, and
weights to provide
reduction,
alignment and
rest.
 Open reduction
 Internal fixation : Open
reduction with internal
fixation permits early
mobilization. Internal
fixation uses pins, screws,
rods, plates and / or
protheses to immobilize a
fracture during healing.
After the bone achives
union, the hardware may be
removed, depending on the
location and type of
fracture.
 External fixation :
Open reduction with
external fixation. The
physican makes small
percutaneous incisions so
that pins may be
implanted into the bone.
The pins are held in place
by a large external metal
frame to help in bone
healing.
Complications of Fracture
 Acute compartment syndrome.
 Thrombo embolic complication.
 Fat embolism syndrome.
 Infection.
 Avascular necrosis.
 Shock.
 Delayed union, non union and
mal union.
Compartment Syndrome
 Condition in which elevated
intracompartmental pressure
within a confined myofascial
compartment compromises
the neurovascular function of
tissues within that space
 Causes capillary perfusion to
be reduced below a level
necessary for tissue viability
Compartment Syndrome
Remove/loosen the bandage and
bivalve the cast
Reduce traction weight
Surgical decompression (fasciotomy)
Venous Thrombosis
 Veins of the lower extremities and pelvis
are highly susceptible to thrombus
formation after fracture, especially hip
fracture
 Immobility
 Venous stasis
 Prevent with anticoagulant medications
Fat embolism syndrome
 Characterized by the presence of fat globules in tissues
and organs after a traumatic skeletal injury
 Usually occur 24-48 hours after injury
 Interstitial pneumonitis
 Produce symptoms of ARDS
 Dyspnea, Apprehension, Tachycardia,Chest pain

 Tachypnea, Cyanosis, PaO

2
Fat embolism syndrome
Treatment directed at prevention
Careful immobilization of a long bone
fracture
Symptom management
Fluid resuscitation
Oxygen
Reposition as little as possible
Infection
 Open fractures and soft tissue injuries
have  incidence
 Osteomyelitis can become chronic
 Open fractures require aggressive surgical
debridement
 Post-op IV antibiotics for 3 to 7 days
(prophylactic)
Avascular necrosis & Shock.
   Avascular necrosis -is a condition that
occurs when there is loss of blood supply to
the bone
 Conservative measures include limited weight bearing
with crutches and pain medications, Immobilization
 Shock- Hypovolemic
Large quantities of blood can be lost
Stabilize fracture and restore blood volume
Delayed union, non union and
mal union
 Delayed union-prolonged
healing of bones beyond usual
time period
 Non union -cessation of all
reparative processes of healing
without bony union
 Mal union- healing of the bones
in an abnormal position 
Nursing Management
Nursing Assessment for
Fractures
 Brief history of the accident
 Mechanism of injury
 Special emphasis focused on the region
distal to the site of injury
Nursing Management
Nursing Assessment
 Neurovascular assessment
Color and temperature
 cyanoticand cool/cold: arterial insufficiency
 Blue and warm: venous insufficiency

Capillaryrefill (want < 3 sec)

Peripheral pulses (↓ indicates vascular
insufficiency)
Nursing Management
Nursing Assessment
 Neurovascular assessment
Edema
Sensation
Motor function
Pain
Nursing Management
Nursing Diagnoses
 Acute pain
 Risk for peripheral neurovascular dysfunction
 Risk for infection
 Impaired physical mobility
 Risk for disturbed sensory perception
 Risk for ineffective tissue perfusion
Nursing Management
Nursing Implementation
 General post-op care
 Assess dressings/casts for bleeding/drainage
 Prevent complications of immobility
 Measures to prevent constipation
 Frequent position changes/ ambulate as permitted

 ROM exercise of unaffected joints

 Deep breathing

 Isometric exercises

 Trapeze bar if permitted

Nursing Management
Nursing Implementation
 Traction
 Ensure:
 No frayed ropes, loose knots
 Ropes in pulley grooves
 Pulley clamps fastened securely
 Weights must hang freely
 Appropriate body alignment
 Inspect skin
 Around slings
 Around pins
Nursing Management
Nursing Implementation
 Casts can cause neurovascular
complications if
 Tootight
 Edematous
 Frequent neurovascular checks
 Ice and elevation during early phase
 REFERENCES
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Wilkins
 Black,J.M. & Hawks, J.H.(2009) Medical –Surgical Nursing :Clincal
Management for Positive Outcomes(8th Ed.) [Link]: Saunders-Elsevier
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