Management of Fractures

Management of FRACTURE

By: Ms.S Peter

MANAGEMENT OF

FRACTURE

RICE Rest Ice Compression Elevation Nursing responsibilities.??

Diagnostic Studies for Fracture• X-ray examinations: - location and extent of fractures/trauma, may 

reveal pre-existing and yet undiagnosed fracture(s).• Bone scans, tomograms, computed tomography (CT)/magnetic

resonance imaging (MRI) scans: Visualizes fractures, bleeding, and soft-tissue damage; differentiates between stress/trauma fractures and bone neoplasms.

• Arteriograms: May be done when occult vascular damage is suspected.• Complete blood count (CBC): Hematocrit (Hct)  (signifying hemorrhage 

at the fracture site or at distant organs in multiple trauma). Increased white blood cell (WBC) count is a normal stress response after trauma.

• Urine creatinine (Cr) clearance: Muscle trauma increases load of Cr for renal clearance.

• Coagulation profile: Alterations may occur because of blood loss, multiple transfusions, or liver injury.

NURSING RESPONSIBILITIES ??????

Hold

Exercise

Reduce

Principle Of Treatment of #

Outline

Clos

ed F

ract

ure

Reduce

Closed Reduction

Mechanical Traction

Open Reduction

Hold

Sustained Traction

Cast Splintage

Functional Bracing

Internal Fixation

External Fixation

Exercise

Operative

Open reduction

Mechanical Traction

Non-operative

Closed reduction

Reduction

Closed reductionSuitable for–Minimally displaced fractures–Most fractures in children– Fractures that are likely to be stable after 

reduction• Most effective when the periosteum and 

muscles on one side of fracture remain intact• Under anesthesia and muscle relaxation, a 

threefold maneuver applied:

• Preparing pat/family….. Pre-post care 

Non Operative

• Sustained traction• Cast Splintage• Functional Bracing

Operative• Internal Fixation• External Fixation

Hold

HOLD To prevent

displacement

To promote soft-tissue healing

To alleviate pain by some restriction of

movement

To allow free movement of the unaffected parts

Traction • Traction is applied to limb distal to the fracture• To exert continuous pull along the long axis of the 

boneIndications • spiral fractures of long bone shafts:– Shaft of femur– Tibia– Lower humerus

• Methods– Traction by gravity– Balanced traction– Fixed traction

Mechanical Traction • Some  fractures (eg . fracture of femoral shaft)  

are difficult to reduce by manipulation  because of powerful muscle pull

• However, they can be reduced by sustained muscle mechanical traction; also serves to hold the fracture until it starts to unite

Traction by Gravity 

Thomas Splint 

Cast   Splintage

• POP• Fiber Glass• 3-D Cortex casts (Polimer)• Velcro bandage 

INTERNAL FIXATION

Indication

1. Fracture that cannot be reduced except by operation

2. Fracture that are inherently unstable and 

prone to displacement after reduction

3.Fracture that unite poorly and slowly•  fracture of the femoral neck

4.Pathological fracture• Bone disease may prevent 

healing

5.Multiple fracture• Where early fixation reduced 

the risk of general complication

6.Fracture in patient who present severe nursing

difficulty

Depending on site and type of # the fixation is used ----• Plate & screws – long bones• Locking plate – Comminuted osteoporotic #• Intramedullary nail- Long bone -- # near the  middle 

of shaft • Compression screw plate - # neck of femur, femur 

head• Trans fixation of screws – small detached fragments – • Krischner wire – bony fragments of # of small bones 

in hand /foot• Tension band wiring – patella or 

olecranon ,,,,metaphyseal 

• Metals used ---- non corrosive ---• Chromium, nickel, molybdenum , alloy of

chromium, molybdenum and nickel , Titanium 

Advantages

Precise reduction

• ORIF-open reduction and internal fixation

Immediate stability

• Hold the fracture securely

Early movement

• no ‘fracture disease‘

• like edema, stiffness, etc

Complications

Infection

Non-union

Implant failure

Re-fracture

InfectionRisk of infection depends on:1)The patient devitalized tissue, dirty wound, unfit patient2)The surgeon thorough training, surgical dexterity and adequate assistant are all essential3)The facilities aseptic routine• The infection should be rapidly controlled

by intravenous antibiotic• If infection cannot be controlled, the

implant should be replaced with some form of external fixation

NON-UNION

Factors associated with the occurrence of delayed union and nonunion • the severity of the fracture, • the location of the fracture,• the nature of the blood supply to the bone, • the extent of soft tissue damage and its

interposition, • bone loss,• air contact • contamination, whether a tumor is involved

Systemic factors for delayed or nonunion• smoking, • alcoholism, • age,• chronic illness (e.g. diabetes mellitus),• malnutrition, • use of medications (e.g. NSAIDs and steroids

Nonunion may increase due to the treatment itself involving :• inadequate reduction,• poor stabilization,• distraction, • damage to the blood supply, or • postoperative infection. 

EXTERNAL FIXATION

• Fracture with soft tissue involvement• Severe comminuted and unstable # • Fracture of pelvis• # with nerve and vascular involvement• Infected #• United #

Advantages

technically quick and easy to perform

no soft tissue stripping;

ease of removing hardware;

risk of infection at the site of the fracture is

minimal

Management of Open FracturesA break in skin and underlying soft tissues leading directly to communicating with the fracture

Treatment- Outline

Irrigation

Debridement: Skin, Fat, Muscle, Bone

Wound closure

Analgesic + Antibiotic + Antitetanus (AAA): IV, IM

Fracture stabilization

Open # : Fracture Stabilization

• A window is made in the plaster over the wound for dressing

Immobilization in a plaster

• Eg. open fracture of tibiaSkeletal traction

• Can be easily applied• Readily reduced and adjusted• Wound can be assessed for dressing• Excellent stability

External fixator

• Rarely usedInternal fixator

Aftercare

The limb is elevated & it's

circulation carefully

monitored

Antibiotic cover

If the wound has been left open, it is inspected after 2-3 days & covered

appropriately

Physiotherapy and

rehabilitation

COMPLICATION OF FRACTURE

General Complications

• Shock• Diffuse coagulopathy

• Respiratory dysfunction

• Crush syndrome• Venous thrombosis &

Pulmonary embolism• Fat embolism• Tetanus

Nurse’s responsibilities ?????

Closed Fracture First Aid --- Immediate– initial    • Airway, Breathing and Circulation• Splint the fracture • Look for other associated injuries• Check distal circulation – is distal circulation 

satisfactory? • Check neurology – are the nerve intact?•  AMPLE history- Allergies, Medications, Past 

medical history, Last meal, Events • Radiographs – 2 views, 2sides, 2 joints, 2 times. 

First aid• immobilization• Control hemorrhage • Control pain– morphine -- • Care of wounds

General Resuscitation

Manipulation (improve position of fragments)

Splintage (hold fragments together until unite)

Exercise & weight-bearing

THANK YOU ALL ….