FRACTURES

A. Pusey-Murray (Mrs)
RN, Cert Psych Nursing & Nursing Admin, BSc (Hons),
MPH, Dip. Ed. PhD (c)
OBJECTIVES
 Define the term fracture.
 State the types of fractures.

 Outline the etiology of fractures.

 State the diagnostic tests.

 List the clinical manifestations of fracture.

OBJECTIVES CONT’D
 Differentiate between fracture reduction and fracture
immobilization.
 State the types of casts.

 Outline the functions of casts.

 Describe the sequential events involved in fracture

healing.
 Outline the pharmacological management of fracture.
OBJECTIVES CONT’D
 Discuss the nursing management for clients with
fracture.
 State the types of orthopedic surgeries.

 List the complications of fracture.

DEFINITION
A fracture is a disruption or break in the continuity of
the structure of bone.
TYPES OF FRACTURES
TYPES OF FRACTURES
TYPES OF FRACTURES
ETIOLOGY
 Fractures can result from crushing force or direct blow.
 Torsion fractures can occur from sudden twisting
motion; persons with osteoporosis are at risk.
 Extremely forceful muscle contraction also can cause
fractures.
DIAGNOSTIC TESTS
 Ankle-arm (ankle - brachial) index: The most widely
used noninvasive test for evaluating Peripheral Vascular
Disease. Blood pressure is measured at the ankle and in
the arm while patient is at rest.
 Arthrocentesis – allows analysis of synovial fluid, blood
or pus aspirated from a joint cavity.
DIAGNOSTIC TESTS CONT’D
 Angiography
confirms circulatory impairment to determine
appropriate level for amputation. This invasive study
involves radiographic image after injection of a
radiopaque substance into a blood vessel.
DIAGNOSTIC TESTS CONT’D
 Doppler ultrasound
Evaluates blood flow to the extremities. It can reliably
distinguish exercise-related effects from severe ischemia.
DIAGNOSTIC TESTS CONT’D
 Bone scan- detects skeletal trauma and disease by
determining the degree to which the matrix of the bone
“takes up ” a bone seeking radioactive isotope.
 Biopsy – (aspiration, punch, needle, or incision) studies
bone, synovium or muscle tissue.
DIAGNOSTIC TESTS CONT’D
 Computed Tomography Scans- show soft tissue, bone,
and spinal cord in three dimensional, cross-sectional
images.
 Complete blood studies- identifies anemias, hemorrhage,
infections, neoplastic conditions, and other conditions.
DIAGNOSTIC TESTS CONT’D
 Myelography – is injection of a contrast agent into the
subarachnoid space of the spine to detect herniation,
tumour or congenital or degenerative conditions of the
spinal canal.
 Electromyography – measures muscle electrical
impulses for diagnosis of muscle or nerve disease.
CLINICAL MANIFESTATIONS
 Pain
 Edema

 Tenderness

 Abnormal movement and crepitus

 Loss of function

 Ecchymoses

 Visible deformity
CLINICAL MANIFESTATIONS CONT’D
 Paresthesias and other sensory abnormalities
 Hemorrhage, possibly leading to shock.
FRACTURE REDUCTION
 Manipulation or closed reduction
Manipulation is a nonsurgical, manual realignment of
bones to their previous anatomic position. Traction and
counteraction are manually applied to the bone
fragments to restore position, length, and alignment.
Closed reduction is usually performed under local
anaesthesia.
FRACTURE REDUCTION CONT’D
After reduction or manipulation the injured part is
immobilized by casting or traction to maintain alignment
until healing occurs.
Open reduction
is the correction of bone alignment through a surgical
incision. It may include internal fixation of the fracture
with the use of wire, screws, pins, plates, intramedullary
rods or nails.
FRACTURE REDUCTION CONT’D
The type and location of the fracture, as well as the result
of attempted closed reduction by means of traction,
influence the decision to use open reduction.
If open reduction and internal fixation are used, early
initiation of range of motion of the joint and early
ambulation is indicated to decrease the risk of
complications due to prolonged immobility.
FRACTURE REDUCTION CONT’D
 Traction
This device apply a pulling force on the fractured
extremity and result in realignment. The two most
common types are the
(a)Skin traction: used for short term treatment (24-72
hours) until skeletal traction or surgery is possible.
FRACTURE REDUCTION CONT’D
 Tapes, slings are applied directly to the skin to maintain
alignment, assist in reduction and help diminish muscle
spasms in the injured part. The traction weights is
usually limited to (5 – 10 lbs).
 (b) Skeletal Traction: generally in place for longer
periods of time, is used to align injured bones and joints.
FRACTURE REDUCTION CONT’D
It provides a long term pull that keeps the injured bones
and joints aligned. To establish skeletal traction, the
physician inserts a pin, wire or a pair of tongs into the
bone, either partially or completely, to align and
immobilize the injured body part. The traction weighs
(5lbs- 45lbs)
FRACTURE IMMOBILIZATION
 External Fixation
This is achieved by a cast or an external fixator. Casting
is a common treatment after closed reduction has been
performed. It allows the patient to perform many normal
activities of daily living while providing sufficient
immobilization to ensure stability.
FRACTURE IMMOBILIZATION
 Major cast materials include fiberglass, plaster of Paris,
polyurethane and thermolabile plastic.
TYPES OF CASTS
 Short arm casts- extend from below the elbow to the
proximal palmer crease.
 Long arm casts- extend from the axillary fold to the
proximal palmer crease.
 Short leg casts- extend from below the knee to the base
of the toes.
 Long leg casts- extend from the upper third of the thigh
to the base of the toes.
TYPES OF CASTS
 Spica casts- extend from midtrunk to cover one or both
extremities.
 Body casts- encase the trunk of the body

 Splints- are bivalved casts that provide immobilization

and allow for edema.
FUNCTIONS OF CASTS
 Immobilize a body part in a specific position.
 Provide for early mobilization of unaffected body parts.

 Correct or prevent deformities.

 Exert uniform compression to soft tissues.

 Support and stabilize unstable joints.

FRACTURE HEALING
 Fracture Hematoma
When a fracture occurs, bleeding and edema precede the
development of a hematoma, which surrounds the end of
the fragments.
FRACTURE HEALING CONT’D
 Granulation Tissue
During this stage active phagocytosis absorbs products
of local necrosis. The hematoma changes into new tissue
known as granulation tissue. Granulation tissue produces
a new bone substance called osteoid.
FRACTURE HEALING CONT’D
 Callus formation
As minerals are deposited in the osteoid, it forms an
unorganized network of bone that is woven about the
fractured parts. It usually begins to appear by the end of
the first week after injury. Evidence of callus formation
can be verified by X-ray.
FRACTURE HEALING CONT’D
 Ossification – of the callus begins within 2 to 3 weeks
after the fracture and continues until the fracture has
healed. During this stage of clinical union the patient
can be converted from skeletal traction to a cast or the
cast can be removed to allow mobility.
FRACTURE HEALING CONT’D
 Consolidation – as callus develops, the distance between
bone fragments diminishes and eventually closes.
 Remodelling – excess cells are absorbed in the final
stage of bone healing, and the union is completed.
PHARMACOLOGIC MANAGEMENT
 Patients with fracture often experience varying degrees
of pain associated with muscle spasms. These spasms are
caused by involuntary reflexes that result in muscle
injury. Medications such as analgesics eg. ibuprofen,
antimicrobial drugs eg gentamycin, erythromycin,
narcotic analgesics eg morphine, codeine are used in
treating musculoskeletal disorders.
NURSING DIAGNOSIS
 Risk for Peripheral Neurovascular Dysfunction related to
interruption of capillary blood flow.
 Impaired Physical Mobility related to use of
immobilization devices evidenced by Plaster of Paris.
 Acute pain related to injury evidenced by patient
complaining of pain to the affected limb.
NURSING DIAGNOSIS
 Risk for Constipation related to decrease mobility.
NURSING MANAGEMENT CONT’D
 Monitor neurovascular status at regular intervals by
checking temperature (circulation), movement and
sensation in affected extremity.
 Teach patient proper body alignment when using
external fixation devices. This decreases risk for
contracture formation.
NURSING MANAGEMENT CONT’D
 Elevate and support affected extremity to reduce edema
and promote comfort.
 Instruct client and significant other in care of the casted
extremity and in signs of complications.
 Instruct patient in the use of crutches, walker, or other
mobility aids. Allows patient early ambulation and
decreases risk of additional injury.
NURSING MANAGEMENT CONT’D
 Encourage diet high in fibre (whole grains, nuts,
vegetables) that will facilitate bowel movement.
 Encourage client to dink adequate fluids. Helps to
promote soft stool for easier elimination.
 Monitor patients vital signs.

 Administer prescribed analgesics.

NURSING MANAGEMENT CONT’D
 Encourage active range of motion exercise of joints not
immobilized to maintain muscle strength.
 Encourage patient to participate in activities of daily
living to foster independence and decrease fatigue.
 Administer prescribed antibiotics to provide prophylaxis
treatment of diagnosed infection.
NURSING MANAGEMENT CONT’D
 Instruct client never to insert anything between
immobilization device and skin, as this would result in
skin irritations that leads to infection.
 Advise patient to notify health care provider of severe
itching, drainage on the device, burning sensation and
foul odour from opening.
NURSING MANAGEMENT CONT’D
 Advise patient re:importance of keeping all follow up
appointments.
 If prescribed teach patient and significant other how to
apply antibacterial ointments and small dressings to pin
sites.
 Teach patient to monitor pin sites for indicators of
infection, including persistent redness, swelling,
increasing pain, and increase in body temperature.
COMPLICATIONS

 Delayed union- failure of bone fragments to unite within

normally accepted time frame for that bones healing.
 Non- union- demonstrated by nonalignment and lost
function secondary to lost bone rigidity.
 Inform the patient of complications that could occur as a
result of non compliance with discharge instructions
 Inform the patient of the importance of proper nutrition
for bone healing
COMPLICATIONS

 Infection
 Compartment Syndrome – involves increase pressure
and constriction of nerves and vessels within an atomic
compartment.
 Venous thrombosis

 Fat embolism
 A. Pusey Murray(Mrs)
RN, Cert Psych Nursing & Nursing Admin,
BSc (Hons), MPH, Dip. Ed. PhD (c)
AMPUTATION
OBJECTIVES
 At the end of this session students will be able to:
 Define the term amputation.

 Outline the diagnostic tests.

 State the clinical indicators for amputation.

 Describe the nursing management for clients with

amputation.
 List the complications of amputation.
DEFINITION
 Amputation is the removal of part or all of a limb
through bone.
DIAGNOSTIC TESTS
 Angiography: confirms circulatory impairment to
determine appropriate level for amputation. This
invasive study involves radiographic imaging after
injection of a radiopaque substance into a blood vessel.
 Doppler ultrasound: Evaluates blood flow to the
extremities.
CLINICAL INDICATORS FOR
AMPUTATION
The clinical features that indicate the need for an
amputation depend on the underlying diseases or
traumas.
Common indicators include circulatory impairment
resulting from a peripheral vascular disorder,
traumatic or thermal injuries, malignant tumors,
uncontrolled or widespread infection of the
extremity and congenital disorders.
CLINICAL INDICATORS FOR AMPUTATION
CONT’D
 Severe osteomyelitis
 Severe toxicity due to gangrene, usually caused by chronic
arterial occlusion.
 Crushing wounds.
NURSING INTERVENTIONS
 If prescribed elevate affected extremity for the first 24 hr
post operatively. This decreases swelling, however
elevation is discontinued to prevent hip flexion
contractures.
 Teach client to perform prescribed exercises which may
include the following:
 Patient attempts to straighten hip from a flexed position
against resistance or perform gluteal setting exercises.
NURSING INTERVENTIONS CONT’D
 Teach client to perform prescribed exercises which may
include the following:
Above knee amputation -Patient attempts to straighten
hip from a flexed position against resistance or perform
gluteal setting exercises.
Below knee amputation- Patient attempts to straighten
knee against resistance or perform quadriceps exercises.
NURSING INTERVENTIONS CONT’D
 Administer prescribed opiods as they provide effective
treatment of incisional pain, they may be ineffective for
phantom limb sensation because they do not alter
response of afferent nerves to noxious stimuli. Higher
opiate doses are often required to treat phantom
sensation.
NURSING INTERVENTIONS CONT’D
 Keep the client active to help decrease phantom limb
pain.
 Believe the client who reports phantom pain, the pain is
real to the client.
NURSING INTERVENTIONS CONT’D
 Encourage use of prosthesis (if prescribed). If the
amputation is the result of trauma, chronic illness or
cancer, the client is likely to experience a sense of
grieving. Early use of the prosthesis offers a prompt
return to mobility and patient’s resumption of activities
of daily living.
NURSING INTERVENTIONS CONT’D
 Gently encourage patient to look at and touch residual
limb and verbalize feelings about the amputation.
 Assist patient with adapting to loss of limb while
maintaining a sense of what perceived as the normal
sense. Such as books, pamphlets, audiovisuals can be
used to demonstrate how others have adapted to
amputation.
NURSING INTERVENTIONS CONT’D
 Teach client application of a shrinkage device such as an
elastic wrap o sock. The device should not be too tight to
impede circulation.
 Teach client to monitor residual limb for skin abrasions,
blisters and hair follicle infections. These are indicators
caused by prosthesis or shrinking device.
NURSING INTERVENTIONS CONT’D
 Point out the need to avoid putting adhesive bandages or
tapes on the stump. They may irritate the skin and cause
sores and infections when pulled off.
 Discuss the importance of wearing woolen stump sock
without holes.
NURSING INTERVENTIONS CONT’D
 Discuss ways patient may alter task performance to
continue function in vocational and interpersonal roles.
 Ensure that patient demonstrates independence in the use
of prosthesis before leaving hospital.
NURSING INTERVENTIONS CONT’D
 If amputation involved a leg, place a foot board on the
end of the bed to prevent foot drop in the remaining leg.
 Provide a high protein diet with vitamin and mineral
supplement.
 Keep the client well hydrated with oral or intravenous.
NURSING INTERVENTIONS CONT’D
 Proper education prior to discharge from the hospital and
adequate supervision and support systems are important
for successful home management of client’s with
amputation. The home environment needs to be
conducive to promotion of health and compliance with
the therapeutic regimen.
NURSING INTERVENTIONS CONT’D
 Proper education prior to discharge from the hospital and
adequate supervision and support systems are important
for successful home management of client’s with
amputation. The home environment needs to be
conducive to promotion of health and compliance with
the therapeutic regimen.
TEACHING NEEDS OF THE PATIENT
WITH A CAST
 Cast care: keep dry, do not cover with plastic
 Positioning: elevation of extremity, use of slings

 Observe for pulse and polar(coldness)

 Activity and mobility

 Exercises

 Do not scratch or stick anything under the cast

TEACHING NEEDS OF THE PATIENT
WITH A CAST
 Signs and symptoms to report: persistent pain or
swelling, changes in sensation, movement, skin colour or
temperature, signs of infection or pressure areas.
 Cast Removal

 Potential Complications: compartment syndrome,

pressure ulcer, delayed union or non union of fracture(s)
RESOLVING GRIEF AND ENHANCING BODY IMAGE
 Encourage communication and expression of feelings
 Create an accepting, supportive atmosphere

 Provide support and listen

 Encourage patient to look at, feel, and care for the

residual limb
RESOLVING GRIEF AND ENHANCING BODY IMAGE
 Help patient set realistic goals
 Help patient resume self-care and independence

 Referral to counselors and support groups

COMPLICATIONS
 Infection
 Bleeding

 Skin breakdown and pain

REFERENCES
Beers, M. H.(2004) The Merrick Manual of Medical
Information 2nd Edition

Williams & Wilkins (2006) Handbook of Medical – Surgical

Nursing 4th Edition Lippincott