The University of Jordan

Faculty of Nursing
Introduction to Adult Health Nursing

FRACTURE
Dr. AHMAD AQEL, RN, PhD
2013

Fractures
Definition:
Complete or incomplete disruption in the
continuity of bone structure.
Fractures occur when the bone is subjected to

stress greater than it can absorb.

Causes:
Direct blows, crushing forces, sudden twisting
motions, and extreme muscle contractions.

Consequences of bone fracture

Soft tissue edema

Hemorrhage into the muscles and joints
Joint dislocations
Rupture tendons
Nerves injury
Blood vessels damage.

Types of Fractures
Complete fracture

Incomplete fracture

break across the entire cross-section of the bone and is

frequently displaced.

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

(eg, green- stick fracture)

Comminuted fracture
fracture that produces several bone fragments.

Types of Fractures
A closed fracture (simple fracture)
Does not cause a break in the skin.

An open fracture (compound, or

complex)
Cause skin or mucous membrane wound extends to

the fractured bone .

Fractures
Fractures may be described according to the

anatomic placement of fragments.

An intra-articular fracture extends into the joint surface of a bone.
Because each end of a long bone is cartilaginous, if the fracture is

non-displaced, x-rays will not always reveal the fracture because

cartilage is non-radiopaque.
An MRI or arthroscopy will identify the fracture and confirm the

diagnosis.
The joint is stabilized and immobilized with a splint or cast and no

weight bearing is allowed until the fracture has healed.

Intra-articular fractures often lead to posttraumatic arthritis.

Avulsion

A fracture in which a
fragment of bone has been
pulled away by a tendon
and its attachment

Comminuted

A fracture in which bone has

splintered into several
fragments

Compression

A fracture in which bone has

been compressed (Seen in
vertebral fracture)

Depressed

A fracture in which fragments

are driven inward (seen in
fractures of skull and facial
bones)

Impacted fracture

A fracture in which
a bone fragment is
driven into another
bone fragment

Greenstick

A fracture in which one

side of a bone is broken

and the other side is bent

Epiphyseal

A fracture through

the epiphysis

Pathologic

Occurs through an area

of diseased bone without

trauma or fall

Open fracture

A fracture in which damage

also involves the skin or

mucous membranes, also
called a compound fracture

Oblique

A fracture occurring at an

angle across the bone (less

stable than a transverse
fracture)

Transverse

A fracture that is

straight across the

bone shaft

Stress

Results from
repeated loading of
bone and muscle

Spiral

Twists around
the shaft of
the bone

Simple fracture

A fracture that remains contained, with no

disruption of the skin integrity

Signs and Symptoms of Fracture

1. Acute pain
2. Loss of function
3. Deformity
4. Shortening of the extremity
5. Crepitus
6. Localized edema and ecchymosis.

Signs and Symptoms of Fracture

1. Acute Pain
The pain is continuous and increases in severity until a

fracture bones are immobilized. The muscle spasms that

accompany a fracture begin within 20 minutes after the injury

2. Loss of Function
After a fracture, the extremity cannot function properly

3. Deformity
Displacement, angulation, or rotation of the fragments in a

fracture of the arm or leg causes a deformity.

Signs and symptoms of a fracture

4. Shortening
In fractures of long bones, shortening of the extremity may

occur because of the compression of the fractured bone.

Sometimes muscle spasms can cause the distal and proximal
site of the fracture to overlap, causing the extremity to shorten.

4. Crepitus
A crumbling sensation, called crepitus, can be felt. It is caused by

the rubbing of the bone fragments against each other.

NURSING ALERT
Testing for crepitus can produce further tissue damage and

should be minimized as much as possible.

Signs and Symptoms of A fracture

5. Localized Edema and Ecchymosis
Occur as a result of trauma and bleeding into the

tissues.
These signs may not develop for several hours after the
injury or may develop within an hour, depending on the
severity of the fracture.

Emergency Management
1. Immobilize the body part before the

patient is moved.
Adequate splinting.
Immobilize the Joints proximal and distal to the fracture.
Immobilize the long bones of the lower extremities by

bandaging the legs together, with the unaffected

extremity.
The arm may be bandaged to the chest, or an injured
forearm may be placed in a sling.

Emergency Management
2. Assess the patient for peripheral tissue perfusion and nerve
function distal to the injury before and after splinting.
3. Cover the open wound with a sterile dressing.
4. Do not reduce the fracture
5. In the emergency department
Complete evaluation.
Remove the clothes gently first from the uninjured side of the body and

then from the injured side.

The fractured extremity is moved as little as possible to avoid more
damage.

Medical Management
Fracture reduction
Refers to restoration of the fracture fragments to anatomic alignment

and positioning.

Types of reduction
1. closed reduction
2. open reduction

Reduces a fracture as soon as possible to prevent loss of

elasticity from the tissues through infiltration by edema or
hemorrhage

Medical Management
Closed Reduction
Bringing the bone fragments into anatomic alignment

through manipulation and manual traction.

The extremity is held in the aligned position while the

physician applies a cast, splint, or other device.

Reduction under anesthesia with percutaneous pinning

may also be used.

X-rays are obtained to verify that the bone fragments are

correctly aligned

Medical Management
Open Reduction
Through a surgical approach,

the fracture fragments are

aligned.
Internal fixation by pins,
wires, screws, plates, nails,
to hold the bone fragments in
position until solid bone
healing occurs

Immobilization
Medical Management
After the fracture reduced, the bone fragments

must be immobilized and maintained in proper

position and alignment until union occurs.
Immobilization may be accomplished by external

or internal fixation.
Methods of external fixation include bandages,

casts, splints, continuous traction, and external

fixators.

Medical Management
Maintaining and Restoring Function
Elevate the injured extremity and apply ice to reduce

edema .
Monitor Neurovascular status
Notify the orthopedic surgeon if signs of neurovascular
compromise develop
Reassure patient to alleviate restlessness and anxiety
Change position, and pain relief
Isometric and muscle-setting exercises are encouraged
to minimize atrophy and to promote circulation.

Nursing Management With Closed

Fractures
Control edema and pain
Teach exercises to increase the strength of muscles
Teach patient how to use assistive devices (crutches,
walkers).

Modify the home environment as needed

Patient teaching includes self-care, medication,

complications.

Nursing Management With Open

Fractures
With open fracture, a risk of osteomyelitis,

tetanus, and gas gangrene.

Prevent infection of the wound,
Intravenous (IV) antibiotics are administered and

tetanus toxoid if needed.

Wound irrigation and dbridement
The wound is cultured.

Nursing Management With Open Fractures

Bone grafting may be performed to fill in areas of bone

defects.
The fracture is carefully reduced and stabilized by
external fixation
The wound is usually left open for 5 to 7 days for
intermittent irrigation and cleansing
If there is any damage to blood vessels, soft tissue,
muscles, nerves, or tendons, appropriate treatment is
implemented.
contaminated wounds are left unsutured, dressed with
sterile gauze to permit edema and wound drainage.

Nursing Management With Open Fractures

The extremity is elevated to minimize edema.
Temperature is monitored at regular intervals

and the patient is monitored for signs of infection.

In 4 to 8 weeks, bone grafting may be necessary

to bridge bone defects and to stimulate bone

healing

COMPLICATIONS
At the time of fracture, fat globules may diffuse from the

marrow into the vascular compartment.

The fat globules (ie, emboli) may occlude the small blood

vessels that supply the lungs, brain, kidneys, and other

organs.
The onset of symptoms is rapid, typically within 12 to 48
hours of injury, but may occur up to 10 days after injury

Complications of fractures
Early complications
Shock

Fat embolism
Compartment syndrome
Venous thromboemboli (deep vein thrombosis [DVT]
Pulmonary embolism [PE]

Delayed complications
Delayed union, Malunion, Nonunion
Reaction to internal fixation devices
Complex regional pain syndrome (CRPS, formerly called
reflex sympathetic dystrophy [RSD]
Heterotopic ossification

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.
Electric potential across fracture

Factors that inhibit fracture healing

Extensive local trauma
Bone loss
Weight bearing prior to approval
Mal-alignment of the fracture fragments
Inadequate immobilization
Space or tissue between bone fragments
Infection
Local malignancy
Age (elderly persons heal more slowly)
Corticosteroids (inhibit the repair rate)