Fracture and its nursing management

Seminar on

Fracture Presented by:

Ms. Durga Joshi M. Sc Nursing

Objectives After completion of the class students will be

able to • Define fracture• Enlist the Causes of fracture • Describe the types of fracture• Discuss the Pathophysiology of fracture • Enumerate the Clinical manifestations• Explain the medical & nursing management of

the fracture

Definition • A fracture is a break in the continuity of

bone and is defined according to its type and extent.

• Fracture is a break in any bone in the body.

Causes of fracture

direct blows

crushing

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extreme muscle

contractions

Types of fracture a. Complete fracture : a break across the

entire cross-section of the bone.

b. An incomplete fracture the break occurs through only part of the cross-section of the bone.

a. Closed fracture (simple fracture) is one that does not cause a break in the skin.

b. An open fracture (compound, or complex, fracture) is one in which the skin or mucous membrane wound extends to the fractured bone.

Open fractures are graded according to 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.

CLASSIFICATION According to the Anatomical placement

Greenstick fractureA fracture in which one side of a bone is

broken while the other is bent (like a green stick).

Spiral FractureA fracture, sometimes called torsion

fracture, in which a bone has been twisted apart.

Comminuted FractureA fracture, in which bone is broken,

splintered or crushed into a number of pieces.

Transverse FractureA fracture, in which the break is across the bone, at a right angle to the long axis of the bone.

Compound FractureA fracture in which the bone is sticking through the skin. Also called an open fracture.

Compression FractureA fracture caused by compression, the act of pressing together. Compression fractures of the vertebrae are especially common with osteoporosis.

Other fracture • Avulsion: fracture which occurs when a

fragment of bone tears away from the main mass of bone.

• Depressed: A fracture in which fragments are driven inward (seen frequently in fractures of skull and facial bones)

• Epiphyseal: A fracture through the epiphysis

• Pathologic: it occurs through an area of diseased bone (eg, osteoporosis, bone cyst, bony metastasis, tumor);

can occur without trauma or a fall

• Stress: A fracture that results from repeated loading without bone and muscle recovery

Pathophysiology Due to any etiology(crushing

movement) | Fracture occurs , muscle that were attached to

bone are disrupted and cause spasm |Proximal portion of bone remains in place, the

distal portion can become displaced in response to both causative force & spasm in the associated muscles

In addition, the periosteum and blood vessels

in the cortex and marrow are disrupted | Soft tissue damage occurs, leads to bleeding

and formation of hematoma between the fracture fragment and beneath the periosteum

|Bone tissue surroundings the fracture site

dies, creating an intense inflammatory response

release chemical mediators histamins,prostaglandins

| Resulting in vasodilation, edema, pain,

loss of function, leukocytes and infiltration of WBC

Clinical manifestations • pain• loss of function• deformity• shortening• crepitus• swelling and discoloration

Diagnosis of fracture

MANAGEMENT

FIRST AID TREATMENT

MEDICAL /SURGICAL MANAGEMENT OF FRACTURES:

1.Reduction Reduction of a fracture (“setting” the bone)

refers to restoration of the fracture fragments to anatomic alignment and rotation.

Open reduction It’s a surgical approach, the fracture fragments

are reduced. External/Internal fixation devices (metallic

pins, wires, screws, plates, nails, or rods) may be used to hold the bone fragments in

position until solid bone healing occurs.

Internal fixation

External fixation

Difference between internal or external fixation

Closed reduction • closed reduction is accomplished by bringing

the bone fragments into apposition (ie, placing the ends in contact) through manipulation and manual traction.

• Extremity is held in the desired position while the physician applies a cast, splint, or other device.

• X - rays are obtained to verify that the bone fragments are correctly aligned.

• Traction (skin or skeletal) may be used to effect fracture reduction and immobilization.

2.Immobilization • Immobilization may be accomplished by

external or internal fixation.• Methods of external fixation include

bandages, casts, splints, continuous traction, and external fixators.

• Metal implants used for internal fixation serve as internal splints to immobilize the fracture.

Traction Traction is the use of weights, ropes and

pulleys to apply force to tissues surrounding a broken bone.

Traction 1. Skin traction- • Bucks traction used for knee,hip bone

fracture• Weight usually 5-7 pounds attach to

skin 2. Skeletal traction –• Needs invasive procedure • Weight is upto 10 kg attached to bone

• Splinting is the most common procedure for immobilizing an injury.

Splinting

• To stabilize the extremity

Why Do We Splint?

• To decrease pain• Actually treat the injury

• Soft materials. Towels, blankets, or pillows, tied with bandaging materials or soft cloths.

• Rigid materials. A board, metal strip, folded magazine or newspaper, or other rigid item.

Possible items for Splinting

• Splinting Using a Towel• Splinting using a towel, in which

the towel is rolled up and wrapped around the limb, then tied in place.

Soft Splints

1. Support the injured area.2. Splint injury in the

position that you find it.3. Don’t try to realign bones.4. Check for color, warmth,

and sensation.5. Immobilize above and

below the injury.

Guidelines for Splinting

The splint should go beyond the joints above and below the fractured or dislocated bone to prevent these from moving

3. Maintaining and restoring function

• Restlessness, anxiety, and discomfort are controlled with a variety of approaches, such as reassurance, position changes, and pain relief strategies, including use of analgesics.

• 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.

• Do not draw exposed bones back into tissue.

Treating an Open Fracture

DO:• Cover wound.• Splint fracture without disturbing

wound.• Place a moist 4" x 4" dressing over bone

end to prevent drying.• Assist the surgeon in debridement of

wound

Treating an Open Fracture

Complication of fracture

Early complications • Shock• fat embolism• compartment syndrome• deep vein thrombosis• disseminated intravascular coagulopathy • infection

Delayed complications• delayed union and nonunion • avascular necrosis of bone • reaction to internal fixation devices

Compartment syndrome• develops when tissue perfusion in the

muscles is less than that required for tissue viability.

• patient complains of deep, severe pain, which is not controlled by opioids.

Compartment syndrome• Reduction in size of muscle

compartment• It increase pressure in the muscle

compartment • Reduce microcircualtion,leads to

muscle and nerve anoxia and necrosis

FAT EMBOLISM SYNDROME • occurs most frequently in young

adults• fat globules may move into the

blood because the marrow pressure is greater than the capillary pressure

• usually occurring within 24 to 72 hours

NURSING MANAGEMENT Patients with closed fractures: • Encourage patient not to mobilize

fracture site.

• exercises to maintain the health of unaffected muscles for using assistive devices (eg, crutches, walker).

• teach patients how to use assistive devices safely.

• Patient teaching includes self-care, medication information, monitoring for potential complications, and the need for continuing health care supervision.

Patients with open fractures: • administers tetanus prophylaxis if indicated. • wound irrigation and debridement in the

operating room are necessary.• Intravenous antibiotics are prescribed to

prevent or treat infection.• wound is cultured.

• fracture is carefully reduced and stabilized by external fixation or intramedullary nails.

• Any damage to blood vessels, soft tissue, muscles, nerves, and tendons is treated.

• Heavily contaminated wounds are left unsutured and dressed with sterile gauze to permit swelling and wound drainage.

Care of client with castBefore application of a cast preparation of the

client includes: • Detailed explanation of the procedure • Skin preparation involves through cleansing

of the skin • Presence of unremovable particle or dust

should be reported to the physician• Roll the cast material are individually

submerged in clean water and excess water is squeezed from the roll ,apply bandage is applied to encircle the injured the body parts

• As the water evaporates the cast will dry• plaster cast generates while drying so

instruct patient for heat sensation• Do not cover the cast• Windowing or bivalving a cast means cutting

a cast along both sides then splitting it to decrease pressure on underlying tissue.

• Window may also be cut into cast to allow the physician or nurse to visualize wounds under the cast or removes drains.

Windowing

• Neurovascular assessment: It should be performed every 30 minutes for 4 hours.

• Assess the cast extremity for color, warmth, pulse distal to the cast, capillary refill.

• Movement of the distal fingers or toes, awareness of light touch distal to the cast, change in the sensation.

• Assessment of the pain: Assess the degree of pain

• Assessment of the cast: The skin around the cast edges should be observed for damage or swelling.

“Hot spots” areas of the cast that feel warmer than other section may indicate tissue necrosis or infection under the cast.

“Wet spots” may indicate drainage under the cast

Care of external fixation • Assessment- pain, nerve

supply,infection,pin site etc.• Small bleeding from pin site is normal• Critical, If extend more than 24 hours • Administer antibiotics, analgesic

medicine

Care of traction • Assessment – skin breakdown, pain,

neurovascular ,constipation• Stool softner • Plenty of fluids • Provide bedpan and urinals for

elimination• Encourage clients activity

NURSING DIAGNOSIS

:

Acute pain related breakdown of continuity of the bone as evidenced by facial expressions and verbalization of patient.

• Goals: Patient will not feel pain • Intervention:

• Assess the onset, duration, location, severity and intensity of pain.

• Administer the analgesic according to physician order.

• Provide comfort devices like sand bags for immobilization of affected parts.

• Provide diversion therapy

Impaired physical mobility related to application of traction or cast as evidenced by assessment

• Goal: Patient will able to move unaffected area.

• Intervention: • Provide range of motion exercises to the patient.• Assist the patient in ambulation after recovery of

fracture.• Provide assistance while using walker or crutches

if required.• Prevent from complication which usually occurs

due to immobility.

•  

Self care deficit related to fracture as evidenced by poor personal hygiene.

• Goal: Patient will maintain the personal hygiene

• Intervention: • Assess the need of self care • Encourage the patient or relatives to do self care

activity• Head to foot care to be provided to the patient.• Educate about importance of maintaining personal

hygiene.

Imbalanced nutrition less than body requirement relate to increase demand of nutrient for bone healing as evidenced by observation.

• Goal: Maintain the nutritional status of the patient

• Intervention: • Assess the nutritional status by intake/output chart,

biochemical measures, body mass.• Maintain intake output chart daily.• Encourages the patient to take protein rich diet.• Plenty of fluids and frequent intake of meal is

necessary.• Try to assess the daily weight of the client

Summary

References • Joyce M. Black Jane Hokanson, medical

surgical nursing,7th edition, Elsevier publication, volume 1,page no. 619-651

• Suddarth’s & burnner, text book of medical surgical nursing, eleventh edition,Wolters publication, Page no. 2079 -2104

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