Fracture is any break in the continuity or structure of bone.

DEFINITION

Fracture is any break in the continuity or structure of bone.

CLASSIFICATION

a) On the basis of etiology

(i) Traumatic fracture

(ii) Pathological fracture

b) On the basis of relationship with external environment

(i) Simple/Closed

(ii) Compound/Open

Open fracture

A fracture in which there is an external wound leading to the break in the bone. In which a wound through the adjacent or overlying soft tissue communicates with the site of the break. It is called also compound

fracture.

Closed fracture

The fracture that does not produce on open wound in the skin.

CONT………c) On the basis of pattern

(i) Transverse

(ii) Oblique

(iii) Comminuted

(iv) Segmental

d) Others

(i) Barton’s fracture (distal radius with dislocation of the radiocarpal joint)

(ii) Pott’s fracture (ankle fracture)

(iii)Greenstick fracture

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• Spiral : Occurs from a rotational force that follows a helical line (slanting & circular twisting around the bone shaft

• Oblique: Occurs diagonally across the diaphysis.

• Transverse: when the fracture line is at right angles to the long axis of the bone & usually diaphyseal (cross wise).

Greenstick fractureA fracture in which the bone is partially bent & partially broken, as a green stick breaks. The bone

is bent.

Complete fractureA fracture in which the bone is completely broken, neither fragment is connected to the other. It can be spiral, oblique, transverse & epiphyseal.

Torus/Buckle Fracture

• torus is derived from Latin (tori) meaning a swelling or protuberance

Avulsion fracture

Impacted fracture

ETIOLOGY

i) Trauma

ii) Bone disease that result in

abnormally fragile bones

iii) Falls from height

CLINICAL MANIFESTATION• Inability to use the injured part (standing, walking,

moving)• Pain or tenderness• Local swelling & brushing• Deformity of the extremity• Shortening of the part• Crepitus or grating sound due to movement

between fractured bone fragments & muscular spasm may also present

• Severe muscular rigidity• Edema, Erythema, ecchymosis

DIAGNOSTIC EVALUATION• History

• Physical examination

• Radiological studies: X-ray, CT scan, MRI, bone scan, fluoroscopy.

• Blood examination: CBC, Elevation of TC, ESR, Enzymes

STAGES IN THE HEALING OF BONE FRACTURE

i)HEMATOMA FORMATION - Blood vessels are ruptured when bone breaks. As a result, a blood- filled swelling forms.

ii) THE BREAK IS SPLINTED BY A FIBROCARTILAGE-

Connective tissue cells of various types form a mass “splint” the broken bone, closing the gap.

iii) A BONY CALLUS IS FORMED –

Osteoblasts and osteoclasts migrate to the area and multiply. Thus the fibrocartilage callus is gradually replaced by one made of spongy bone known as the bony callus.

iv) LASTLY BONE REMODELLING OCCURS-

Over the next few weeks to months the bony callus is remodeled in response to mechanical stresses placed in it, so that it forms strong permanent(bone) patch at the fracture site.

Causative factors in trauma

• In the neonate-

because of injury to nerve or bones and muscles during the birth process.

• In the toddler-

caused by falling, climbing, being struck by moving object, child abuse.

• In the preschool & school children- fall from height, RTA.

Common site of fracture of children:

• Forearm fracture are most common site (50%) involving the distal third of radius & ulna.

• Femur fractures

• Tibial Fracture & ankle fracture

ASSESSMENT

❑NURSING HISTORY AND PHYSICAL EXAMINATION:

o PAIN

o PALLOR

o PULSES

o PARESTHESIA

o PARALYSIS

Management• Reduction & immobilization are generally

achieved by traction or by closed manipulation & casting until sufficient callus has formed at the fracture site.

• Closed reduction

• Traction

• Open reduction

Closed reduction• Closed reduction is accomplished by bringing

the bone fragments into a position by manipulation & manual traction.

• Anesthesia is given to relax the child’s muscles & to relieve pain. x-ray examination is performed after the fracture is reduced to determine the alignment of the bone fragments.

Traction • Traction is a pulling force applied in a

longitudinal direction to reduce a fracture. It is also used to immobilize a fractured part & to reduce or eliminate muscle spasm.

Open reduction

• The bone fragments can be replaced under direct visualization.

• Internal fixation devices in the form of metallic screws, plates or rods may be used to hold the fragments of bone in position until solid bone healing occurs.

• These devices maintain the alignment of the fracture fragments.

Specific traction used in children …

• Bryant’s traction: it is indicated in fractures of femur & congenital dislocation of hip.

• Russell's traction: it is applied to reduce the fractures of femur or hip or specific types of knee injuries or contractures.

• Buck’s extension: it is used to prevent or to correct knee & hip contractures, to rest the limb, to prevent spasm of injured muscle or joints or to immobilize the fractured limb temporarily.

Cont..• Balanced suspension- is used to stabilize fractures of femur

• 90 degree 90 degree traction

Dunlop’s traction - helps immobilize the upper arm in the treatment of

contracture or fracture of the elbow

COMPLICATIONS:

• HAEMORRHAGE

• INFECTION

• OEDEMA

• SUBDURAL HAEMORRHAGE

• CEREBRAL OEDEMA

• EMBOLISM

• DEFORMITY

Nursing management of children with cast

• Explanation to both the child and parents about what will happen during the casting procedure.

• Assembling the necessary materials & holding the child in an appropriate position so that the bone fragments are in alignment.

Cont..

• Prevention of urinary stasis & constipation.

• The wet cast is supported with the palms of the hands, not the fingertips, to prevent denting the cast & causing pressure on the underlying skin.

Cont..

• The casted lower extremity is elevated & supported on plastic covered pillows, avoiding pressure on the heel to reduce swelling that could decrease circulation to the part.

• The casted upper extremity is elevated & supported on plastic-covered pillows or in a sling suspended from an infusion pole or from around the child’s neck.

• Observe for swelling or unusual coldness, paleness cyanosis, or a mottled appearance of the toes or fingers of a casted extremity.

• Observe for absence of blanches sign (normally nail bed turns white (blanches) when pressure is applied & returns to normal color when the pressure is released). Delay in the return in color indicates poor circulation.

• Observe for peripheral pulses of casted extremity

• Neurologic signs like tingling, numbness, pain, or a burning sensation of a casted body part.

• The area of bleeding is measured on the surface of the cast.

• The tightness of the cast to be assessed by inserting fingers between the skin and the cast after it has dried.

Cont..

• Maintenance of body temperature:

The child’s temperature is taken routinely chilling can occur because of the evaporation of water from the cast, and heating can occur because of the reaction within the cast when drying.

• Maintenance of skin integrity

1) plaster that has been splashed on the exposed skin during cast application is removed.

2) rough edges of the cast are trimmed, padded as necessary.

3) the skin is assessed for pressure or sign of infection.

4) the nurse inspects beneath the cast for food particles or small objects young children may insert between the cast and the skin.

5) Protects from getting soiled with excreta.

Cont..

• The head & upper body is elevated on pillows higher than the buttocks when toileting an older child to prevent urine from flowing beneath a body or hip spica cast.

• Turned every 2 hrs to dry the cast evenly

• Weight bearing is permitted only when the leg cast is totally dried.

Cont..

Promotion of muscle activities

• Active muscle activity or passive range of motion exercises are therapeutic for unaffected part of the body.

• Ambulation is encouraged as soon as possible.

• A sling is used to support a casted arm.

• A child with a casted leg is taught to use crutches.

cont,..

Provision of comfort measure

• Uncasted areas of the child’s body are supported with pillows for comfort.

• Appropriate activities are provided for the child to relieve stress.

• Prevention of urinary stasis & constipation

• Liberal fluid intake

• Non constipating diet containing bulk.

• Diet contain liberal amount of protein and minerals.

Cont..

Education of parents

• The parents taught how to care for the child in a cast or traction.

• Teach the parents for signs & symptoms of circulating & neurosensesory impairment & infection.

• The parents assisted for daily activity done for children.