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
break across the entire cross-section of the bone and is
frequently displaced.

Incomplete fracture
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 Comminuted

A fracture in which a A fracture in which bone has

fragment of bone has been splintered into several
pulled away by a tendon fragments
and its attachment
Compression Depressed

A fracture in which bone has A fracture in which fragments

been compressed (Seen in are driven inward (seen in
vertebral fracture) fractures of skull and facial
bones)
 Impacted fracture Greenstick

A fracture in which A fracture in which one

a bone fragment is side of a bone is broken
driven into another and the other side is bent
bone fragment
Epiphyseal Pathologic

A fracture through Occurs through an area

the epiphysis of diseased bone without
trauma or fall
 Open fracture Oblique

A fracture in which damage A fracture occurring at an

also involves the skin or angle across the bone (less
mucous membranes, also stable than a transverse
called a compound fracture fracture)
 Transverse Stress Spiral

A fracture that is Results from Twists around

straight across the repeated loading of the shaft of
bone shaft bone and muscle 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)