Fracture (2)

Tony Suharsono

Fracture

Epidemiology

Trauma is the leading cause of death in the USA

for those between the ages of 1 37, and the

fourth leading cause of death for all age group

(American Academy of Orthopaedic Surgeon)

Fracture can create significant change in oness

quality of life by causing activity restriction,

disability, and economic loss

Definition

A fracture is a break in the continuity of bone and is

defined according to its type and extent

A fracture is a break in a bone and can occur at any age

and in any bone

Fractures occur when the bone is subjected to stress

greater than it can absorb

When the bone is broken, adjacent structures are also

affected, resulting in soft tissue edema, hemorrhage into

the muscles and joints, joint dislocations, ruptured

tendons, severed nerves, and damaged blood vessels

Types of Fracture

A complete fracture involves a break across the entire cross-section

of the bone and is frequently displaced (removed from

normal position).

Incomplete fracture (eg, greenstick fracture), the break occurs

through only part of the cross-section of the bone.

A comminuted fracture is one that produces several bone fragments.

A closed fracture (simple fracture) is one that does not cause a

break in the skin.

An open fracture (compound, or complex) is one in which the

skin or mucous membrane wound extends to the fractured

bone

Types of Fracture

Open Fracture

Open fractures are graded accordingto 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.

Clinical Manifestation

Pain

The pain is continuous and increases in severity

until the bone fragments are immobilized

Loss of function

Deformity

Shortening

Crepitus

Swelling and discoloration

Patofisiology

Hematome or inflamatory stage

Immediate formation of a hematoma at the site of fracture

Amount of bone damage, soft tissue injury, and blood vessel determining

size of the hematoma

Providing a small amoun of stabilitation

1-3 day

Fibrocartilage formation

Fibroblast, osteoblast, and condroblast migrate to the fracture site as a

result of the acute inflammation and form fibrocartilage

Periosteal elevation and granulation tissue formation create a collar

around and end of each fracture fragment

Early formation of fibrous tissue called the primary callus

3 days to 3 weeks

Pathofosiology

Callus formation

Granulation tissue matures into a provisional callus as a newly formed cartilage and bone matrix disperse through the primary callus

Proper bone alignment is essential during this stage. If it slowed or interupted, the final two stages cannot occur.

2-6 weeks

Ossification

A permanent callus of rigid bone crosses the fracture gap between the periosteum and the cortex to join the fragment

Trabecullar bone gradually replaces the callus along stress line

3 weeks-6 months

Pathofisiology

Consolidaton and remodelling

Unnecessary callus is resorbed from the healing bone

The actual amount and timing of remodelling depend on the

stresses imposed on the bone by muscle, weight bearing, and

age

6 weeks to 1 year

Diagnostic Procedure

X Ray

Menentukan lokasi/luas/jenis fraktur

Dua posisi (AP/Lat), dua sendi terlibat

Bone Scanning

Menunjukkan tingkat keparahan fraktur,

identifikasi kerusakan jar lunak

Arteriogram

Jika terdapat kerusakan vaskuler

Goal of Management Fracture

Prompt and thorough assessment of the client to

discover all injuries

Reduction and stabilization of the fracture with

immobilization

Observation for complication

Remobilization and rehabilitation

Thorough Assessment Assessment and treatment are performed simultaneusly

during emergency management of fracture

During primary assessment, the rescue focused on airway management, bleeding and manisfestation of shock

Any potential life threatening injury must be stabilized immediately

Most fracture do not pose a serious treat to life, their management becomes a secondary priority in trauma care

The only exception this rule is a cervical spine injury

Suspected injury to extremity should be carefully splinted

Extensive bleeding can occur even with close fracture

Management of Fracture

Reduction

restoration of the fracture fragments to anatomic alignment

and rotation

closed reduction or open reduction may be used to reduce a

fracture

Usually,the physician reduces a fracture as soon as possible

to prevent loss of elasticity from the tissues through

infiltration by edema or hemorrhage

Before fracture reduction and immobilization, the patient is

prepared for the procedure; permission for the procedure is

obtained, and an analgesic is administered as prescribed

Management of Fracture

Closed Reduction

bringing the bone fragments into position

through manipulation and manual traction

The immobilizing device maintains the

reduction and stabilizes the extremity for bone

healing

X-rays are obtained to verify that the bone

fragments are correctlyaligned

Management of Fracture

Open Reduction

Internal fixation devices may be used to hold

the bone fragments in position until solid bone

healing occurs

Internal fixation devices ensure firm

approximation and fixation of the bony

fragments

Internal Fixation

Management of Fracture

Immobilization

After the fracture has been reduced, the bone

fragments must be immobilized, or held in

correct position and alignment, until union

occurs

Immobilization may be accomplished by

external or internal fixation

Management of Fracture

Maintaining and restoring function

Swelling is controlled by elevating the injured extremity and

applying ice

Neurovascular status (circulation, movement, sensation) is

monitored, and the orthopedic surgeon is notified

immediately if signs of neurovascular compromise are

identified

Isometric and muscle-setting 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

Factors That Enhance Fracture Healing

Immobilization of fracture fragments

Maximum bone fragment contact

Sufficient blood supply

Proper nutrition

Exercise: weight bearing for long bones

Hormones: growth hormone, thyroid,

calcitonin, vitamin D

Factors That Inhibit Fracture Healing

Extensive local trauma

Bone loss

Inadequate immobilization

Space or tissue between bone fragments

Infection

Local malignancy

Age

Complication of Fracture

Fat Embolism Syndrome

Fat embolism is a potentially life threatening

complication of long bone trauma, blunt

trauma, and intramedularry manipulation

This syndrome manifest anywhere from 4 hours

to several days after injury or orthopedic

surgery.

Fat globules, release from bone marrow, can

embolize and occlude blood vessels in the brain,

kidnes, lungs and other tissue

Complication of Fracture

Osteomyelitis

Osteomyelitis is an infection of the bone, most commonly a result of direct contamination from open fracture, penetrating wound, or surgical procedures

it takes 10 to 14 days from the time of infection exposure before radiographs will demonstrate visible changes

The most common causative organism is staphylococcus aureus

Complication of Fracture

Compartment Syndrome

Compartment syndrome develops when the presure in a

muscle compartment exceeds the intraarterial hydrostatic

pressure, causing collapse of capilaries and venules, which

lead to iskhemia and tissue necrotic

The exact pressure at which this develops is unclear, but

intracompartment pressure greater than 30 mmHg generally

are considered greatly elevated

A grace periode of about 6 hours exists before irreversible

soft tissue demage occurs

It is important to suspect compartment syndrome early

Complication of Fracture

Bleeding

Delayed union and non union

Avascular necrosis of bone

Reaction to internal fixation devices

Assessment

Neurovascular assessment

Use five P to evaluate limb circulation,

sensation and motor function

Pain : a description of pain is helpful

Pallor

Pulses

Parasthesia

Paralysis

Assessment

Inspection, the injured area for the following:

Color

Disrupted skin integrity

Extremity position

Edema, swelling, or echhimosis

Range of motion

Symmetry, alignment, deformity

Assessment

Palpation, the injury to identify the

following :

Skin temperature

Pain

Bony crepitus, joint instability

Peripheral nerve function : sensory and

motor

Nursing Diagnose

Acute pain

Impaired physical mobility

Risk for peripheral neurovaskuler

dysfunction

Risk for imbalance fluid volume

Nursing intervention

Teach patients how to control swelling and pain

associated with the fracture and with soft tissue

trauma and

Assess neurovascular status frequently

Encourages them to be active within the limits of

the fracture immobilization

Nursing intervention

Teach exercises to maintain the health of unaffected muscles and to increase the strength of muscles needed for transferring and for using assistive devices

Teach patients how to use assistive devices safely

Patient teaching includes self-care, medicationinformation, monitoring for potential complications, and the need for continuing health care supervision