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Maureen G. Cristobal
FRACTURE
in the continuity of bones Due to stress greater than the bone can absorb
Break
Causes
Direct
blows Crushing forces Sudden twisting motions Extreme muscle contraction Pathologic conditions- osteoporosis, conditionsosteosarcoma
Pathology of fractures
Periosteum and blood vessels in the cortex, marrow, and surrounding soft tissues are disrupted Hematoma forms in the medullary canal between the fracturd ends of the bone and beneath the periosteum Bone tissue immediately adjacent to the fracture dies Tissue necrosis will stimulate inflammatory response
Fracture patterns
Closed/simpleClosed/simple- a fracture with intact skin over the fracture site Open/compound- there is a break in the Open/compoundskin over the fracture site; Grade I- clean skin puncture with Iminimal tissue damage Grade II- with skin and muscle IIcontusion, no extensive tissue damage Grade III- wound >6-8cm, with III>6extensive soft tissue damage including blood vessels and nerves
Fracture patterns
CompleteComplete-
break along the entire crosscross-section of the bone Incomplete/partial- bone continuity Incomplete/partialis not entirely disrupted; e.g. Greenstick fracture
DisplacedDisplaced-
fracture fragments are separated at the fracture site Comminuted- bone is fragmented Comminutedinto several pieces
DepressedDepressed-
fragments are driven inward e.g. skull fracture Impacted/ telescoped- one fragment telescopedis drawn into the other fragment
Compression fracture
Fracture patterns
Fracture patterns
Stellate fracture
Direction of fracture
LinearLinear-
fracture line runs parallel to the bones long axis Oblique- fracture line is at oblique Obliqueangle to the bone shaft Longitudinal- fracture line extends Longitudinallongitudinally
Direction of fracture
TransverseTransverse-
fracture line is at right angle to the bones long axis Spiral- fracture line twists around the Spiralshaft of the bone Stellate- central fracture point with Stellateseveral fissures radiating outwards
Clinical manifestations
1. Pain and tenderness continuous and increasing in intensity due to muscle spasm 2. Loss of function
4. Deformity visible or palpable due to strong muscle pull which may cause the bone fragments to override 5. Shortening of the limb due to muscle contraction above and below the site of fracture 6. Crepitus grating sensation felt as injured parts are moved against each other
7. Swelling and discoloration/bruising EcchymosisEcchymosis- due to trauma and bleeding into the tissues
EMERGENCY MANAGEMENT
Immobilize
before transport Cover open fractures Do not attempt to reduce the fracture
MEDICAL MANAGEMENT
Reduction
Setting the bone Restoring the fragments into anatomic alignment
Closed reduction Manipulation, manual traction Cast; splint Skin or skeletal traction Open reduction Surgical approach with internal fixators
External fixator
CAST
TRACTION
Internal fixators
Immobilization Bone must be immobilized and held in correct position until bone healing occurs Methods:
Bandages Cast Splints Traction External fixators Metal implants
NURSING MEASURES
Institute
Perform neurovascular assessment regularly Encourage participation in ADLs ExerciseExercise- if swelling has already subsided
BONE HEALING
Healing
timetime- depends on type of fracture, type of bone and the location of the fracture Spongy bone heals more rapidly than compact bone because of rich blood supply Bones in the arms heals more easily than those in the lower extremities
and inflammation Angiogenesis and cartilage formation (callus formation) Cartilage calcification Cartilage removal Bone formation remodeling
Bone healing
Fracture healing
Where
Bone marrow Periosteum- hard callus, soft callus Periosteum External soft tissue- bridging callus tissue-
COMPLICATIONS
Early complications Shock
Hemorrhagic (hypovolemic) and traumatic shock Due to loss of fluids into damaged tissues S/Sx: cold clammy skin; weak, thready pulse; hypotension
Occurs when marrow pressure becomes greater than capillary pressure Catecholamines also play a role by stimulating fatty acids which will form into fat globules in the bloodstream Occurs within 24-72 hours or within a 24week
S/Sx: Hypoxia Tachypnea Tachycardia Respiratory distress- chest pain, dyspnea, distresswheezes or crackles, thick white sputum, increased RR and HR, deteriorating sensorium Respiratory distress may lead to pulmonary edema and later to congestive heart failure
Compartment syndrome
Due to decreased perfusion caused by constricting casts, or edema and hemorrhage within a compartment Characterized by deep, throbbing, unrelenting pain unrelieved by opioid analgesics
Management:
Elevate extremity above heart level Release restrictive devices or bandages Fasciotomy Perform neurovascular assessment regularly
FASCIOTOMY
Deep venous thrombosis/ Pulmonary embolism Due to decreased muscle contraction and prolonged immobilization Infection Gas gangrene- caused by anaerobic gangrenebacteria Treatment involves opening the wounds widely to admit air and permit drainage
GAS GANGRENE
Volkmans Ischemic contracture Arises in the hand or forearm; due to a compartment syndrome that compromises arterial and venous circulation The end result is permanent, clawclawlike deformity of the arm and hand
Volkmanns contracture
Late complications
Delayed
union
Healing does not occur at a normal rate expected for the location and type of fracture
Delayed union
Causes:
Inaccurate
reduction Inadequate or interrupted immobilization Severe local trauma Impaired bone circulation Infection Loss of bone substance Distraction or separation of bone fragments
NonNon-union
Failure of the ends of a fractured bone to unite Characterized by persistent discomfort and abnormal movement at fracture site
NonNon-union
Causes:
Infection Interposition of tissue between bone ends Inadequate immobilization Disruption of callus formation
NonNon-union
Management:
Internal
NonNon-union
Bone grafting
Bone grafting
Malunion Healing of a fracture site with an increased degree of angulation or deformity Managed by adjustment of traction or reimmobilization
Malunion
Avascular necrosis Due to disrupted blood supply Common in femoral neck fracture
Avascular necrosis
Reaction to internal fixation device Complex regional pain syndrome Pain Edema Stiffness Discoloration Vasomotor/trophic skin changes Atrophy of muscle around the area
Heterotropic ossification Ossification of soft tissues, commonly muscles, around a fracture site after it has healed
HIP FRACTURE
Most
hip fractures occur at the femoral neck, intertrochanteric region, and subtrochanteric region in the elderly due to decreased postural stability and decresed bone mass, leading to higher incidence of falls
Common
HIP FRACTURE
Intertrochanteric fracture
comminuted and more osteoporotic This portion has a periosteum
Usually
Clinical manifestation
shortened
Medical management:
skin
Surgical management
Knowles pin- full weight-bearing is not pinweightallowed because the pin does not pull the fracture fragments together Jewett nail- stronger than Knowles pin, nailpatient can bear weight after the surgery Sliding nail/compression screwscrewcommonly used; draws fracture fragments together; also used for intertrochanteric fracture
Surgical management
Partial
IM NAILING
SCREW
PELVIC FRACTURE
Fracture involving any of the pelvic bones; this is a serious condition that requires immediate attention In the elderly, this is usually caused by falls; the worst cases, however are caused by major impacts to the body such as vehicular accidents or falls from high places Manifestations: pain on the pelvis, pain with walking, or unable to walk
Management: Unstable, weight-bearing fractureweightfractureexternal fixators through open reduction Stable, non-weight bearing fracturenonfracturetraction and bedrest
MALGAIGNE
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