Fractures

Description

 A disruption or break in the continuity of

the structure of bone
 Traumatic injuries account for the majority
of fractures
 Description

 Described and classified according to:

Type
Communication or noncommunication
with external environment
Anatomic location
Types of Fractures

Fig. 61-4
Classification by Communication with
External Environment

Fig. 61-5
Classification by Fracture Location

Fig. 61-6
 Description

 Described and classified according to:

Appearance, position, and alignment of
the fragments
Classic names
Stable or unstable
 Description

 Closed (also called simple) skin remain

intact
 Open (also called compound) skin is
breeched.
 Description

 Stable fractures
Stable: With a stable fracture, the broken ends
of the bone are lined up and barely out of place.
This type of fracture doesn't require any type
of realignment.
Stable fractures can usually be treated with
bracing and rest
 Description

 Unstable fractures
Grossly displaced
Poor fixation
Unstable fractures usually require surgery
to realign the bone
 Clinical Manifestations

Immediate localized pain

 Function
Inability to bear weight or use affected
part
Guarding
May or may not see obvious bone
deformity
 Fracture Healing

 Reparative process of self-healing (union)

occurs in the following stages:
1. Fracture hematoma (d/t bleeding, edema)
2. Granulation tissue
3. Callus formation (cells deposited in osteoid)
 Fracture Healing

 Reparative process of self-healing (union)

occurs in the following stages:
 Ossification: process process of
of creating
creating bone,
bone, that
that is
is of
of transforming
transforming

cartilage
cartilage (or
(or fibrous
fibrous tissue)
tissue) into bone. (3 wks – 6 mo)
into bone

4. Consolidation (distance between fragments

decreases → closes).
5. Remodeling (union completed; remodels to
original shape, strength)
Bone Healing

Fig. 61-7
 Collaborative Care
 Overall goals of treatment:
Anatomic realignment of bone fragments
(reduction)
Immobilization to maintain alignment
(fixation)
Restoration of normal function
 Collaborative Care
Fracture Reduction
 Closed reduction
Nonsurgical, manual realignment
 Open reduction
Correction of bone alignment through a
surgical incision
 Collaborative Care
Fracture Reduction
 Traction
 application of pulling force to attain realignment
Skin traction (short-term: 48-72 hrs)
Skeletal traction (longer periods)
 Collaborative Care
Fracture Immobilization
 Casts
Temporary circumferential immobilization
device
Common following closed reduction
Casts

Fig. 61-9
 Collaborative Care
Fracture Immobilization
 External fixation
Metallic device composed of pins that are
inserted into the bone and attached to external
rods
 Collaborative Care
Fracture Immobilization
 Internal fixation
Pins, plates, intramedullary rods, and screws
Surgically inserted at the time of realignment
 Collaborative Care
Fracture Immobilization
 Traction
Application of a pulling force to an injured
part of the body while countertraction pulls
in the opposite direction
 Collaborative Care
Fracture Immobilization
 Purpose of traction:
Prevent or reduce muscle spasm
Immobilization
Reduction
Treat a pathologic condition
 Physio Management
Assessment for Fractures

 Brief history of the accident

 Mechanism of injury
 Special emphasis focused on the region distal to
the site of injury
 Management
Assessment

 Neurovascular assessment
Color and temperature
cyanotic and cool/cold: arterial insufficiency
Blue and warm: venous insufficiency
Capillary refill (want < 3 sec)
Peripheral pulses (↓ indicates vascular insufficiency)
 Management
Assessment

 Neurovascular assessment
Edema
Motor function
Pain
 Management
Implementation
 General post-op care
Assess dressings/casts for bleeding/drainage
Prevent complications of immobility
Frequent position changes/ ambulate as permitted
ROM exercised of unaffected joints
Deep breathing
Isometric exercises
Trapeze bar if permitted
 Management
Implementation
 Traction
Ensure:
No frayed ropes, loose knots
Ropes in pulley grooves
Pulley clamps fastened securely
Appropriate body alignment
Inspect skin
Around pins
 Management
Implementation: Cast care
 Casts can cause neurovascular
complications if
Too tight
Edematous
 Frequent neurovascular checks
 Ice and elevation during early phase
 Complications of Fractures
Infection
 Open fractures and soft tissue injuries have 
incidence of infection
 Osteomyelitis can become chronic
 Complications of Fractures
Infection
 Collaborative Care
Open fractures require aggressive surgical
debridement
Post-op IV antibiotics for 3 to 7 days
(prophylactic)
 Complications of Fractures
Compartment Syndrome
 Compartment syndrome is a serious condition that occurs
when there’s a large amount of pressure inside a muscle
compartment.
 Compartments are groups of muscle tissue, blood vessels,
and nerves in your arms and legs surrounded by a very
strong membrane called the fascia. Fascia does not expand,
so swelling in a compartment can result in an increase in
pressure inside the compartment. This results in injury to
the muscles, blood vessels, and nerves inside the
compartment.
 Complications of Fractures
Compartment Syndrome
 Clinical Manifestations
Six Ps
1. Paresthesia (unrelieved by narcotics)

2. Pain (unrelieved by narcotics)

3. Pressure
 Complications of Fractures
Compartment Syndrome
 Clinical Manifestations
Six Ps:
4. Pallor (loss of normal color, coolness)

5. Paralysis
6. Pulselessness (decreased/absent pulses)
 Complications of Fractures
Compartment Syndrome
 Clinical Manifestations
Six Ps:
Patient may present with one or all of the
six Ps
Compare extemities
 Complications of Fractures
Compartment Syndrome
 Clinical Manifestations
Absence of peripheral pulse = ominous late
sign
Myoglobinuria
Dark reddish-brown urine
 Complications of Fractures
Compartment Syndrome
 Collaborative Care
Prompt, accurate diagnosis is critical
Early recognition is the key
Do not apply ice or elevate above heart level
 Complications of Fractures
Compartment Syndrome
 Collaborative Care
Remove/loosen the bandage and bivalve the
cast
Surgical decompression (fasciotomy)
 Complications of Fractures
Venous Thrombosis
 Veins of the lower extremities and pelvis are
highly susceptible to thrombus formation after
fracture, especially hip fracture
 Complications of Fractures
Venous Thrombosis
 Precipitating factors:
Venous stasis caused by incorrectly applied
casts or traction
Local pressure on a vein
Immobility
 Prevent with anticoagulant medications
 Complications of Fractures
Fat Embolism Syndrome (FES)
 Characterized by the presence of fat globules in
tissues and organs after a traumatic skeletal
injury
 Complications of Fractures
Fat Embolism Syndrome (FES)
 Fractures that most often cause FES:
Long bones
Ribs
Tibia
Pelvis
 Complications of Fractures
Fat Embolism Syndrome (FES)
 Tissues most often affected:
Lungs
Brain
Heart
Kidneys
Skin
 Complications of Fractures
Fat Embolism Syndrome (FES)
 Clinical Manifestations
Usually occur 24-48 hours after injury
Interstitial pneumonitis
Produce symptoms of ARDS Acute respiratory
distress syndrome
 Complications of Fractures
Fat Embolism Syndrome (FES)
 Clinical Manifestations
Symptoms of ARDS:
Chest pain
Tachypnea
Cyanosis
 O22
 Complications of Fractures
Fat Embolism Syndrome (FES)
 Clinical Manifestations
Symptoms of ARDS:
Dyspnea
Apprehension
Tachycardia
 Complications of Fractures
Fat Embolism Syndrome (FES)
 Collaborative Care
Treatment directed at prevention
Careful immobilization of a long bone
fracture
Most important preventative factor
 Complications of Fractures
Fat Embolism Syndrome (FES)
 Collaborative Care (treatment)
Symptom management
Fluid resuscitation
Oxygen
 Fracture of the Hip
 Fracture of proximal third of femur
 Common in the elderly
 More frequent in women than men.
 Up to 35% of clients will die within the
first year
 Fracture of the Hip

 Intracapsular fractures:
Occur within hip joint capsule
 Extrascapular fractures
Intertrochanteric: between greater and
lesser trochanter
Subtrochanteric: below lesser trochanter
 Clinical Manifestations

 External rotation of affected leg

 Muscle spasm
 Shortening of the affected extremity
 Severe pain and tenderness in region of
fracture
 Collaborative Care
 Surgical repair is preferred
Allows for early mobilization and decreases
the risk of major complications.
 Buck’s traction may be utilized
preoperatively to decrease painful muscle
spasms.
 Diagnosis
 Risk for peripheral neurovascular
dysfunction
 Acute pain
 Risk for impaired skin integrity
 Impaired physical mobility
 Post-Operative Care
 General post-op care
 Neurovascular checks
 Prevent external rotation
 Preventing Dislocation of Femur
Head Prosthesis
 Do Not
Flex hip greater than 90 degrees.
Place hip in adduction
Allow hip to internally rotate
Cross legs
Put on shoes/socks without adaptive device (8
weeks)
Sit in chair without arms to aid in rising to a
standing position
 Preventing Dislocation of Femur
Head Prosthesis
 Do
Use elevated toilet seat
Use chair in shower/tub
Use pillow between legs when on “good” side
or supine (for 8 weeks post-op)
Keep hip in neutral position when sitting,
walking and lying.
Notify surgeon if severe pain, deformity, or
loss of function