COURSE NAME : MEDICAL SURGICAL NURSING-1

COURSE CODE : 609

TOPIC : FRACTURE

 Lecture Delivered By
 MRS.G.E.MARGAREAT THATCHER
 Associate Professor,
 Department of Medical Surgical Nursing ,
 Sree Balaji College of Nursing
 Bharath Institute of Higher Education and Research,
 Chennai.
 DEFINITION
 A fracture is any
disruptions or break in the
continuity of the structure
of bone.
ETIOLOGY & RISK FACTORS
 Mechanical overload of bone
 Metabolic bone disease
Eg: Osteoporosis
 Direct force.Eg: Moving
object strikes body
 Indirect force Eg: Muscle
contraction
 Stress
 PREDISPOSING FACTORS
 Biologic conditions- Osteopenia
 Neoplasms
 OLD AGE
 Infections
 Post menopausal estrogen loss &

protein energy malnutrition

 High risk recreation or employment
related activity
 Incidence – male are mostly affected at
the age of 15-25 and females at the age
of 65 and more
 PATHOPHYSIOLOGY
Fracture

Muscles attached to bone are disrupted

Muscle spasm- Pull fracture fragments out of position

Proximal portion of bone remains in place, distal

displaced

Fracture fragments displaced sideways or overriding

Periosteum & blood vessels of fractured bone disrupted

Soft tissue damage

Bleeding from soft tissue & damaged bone

endings

Hematoma between fracture fragments &

beneath periosteum

Bone tissue surrounding fracture site dies

Intense inflammatory response

Vasodilation, edema, pain, loss of function,

Infiltration of WBC
TYPES OF FRACTURE
 Fracture can be described and
classified according to type,
communication or non communication
with external environment and
location of the fracture
 Stable fractures – some of the
periosteum is intact across the fracture
 Unstable fracture – grossly displaced.
 TYPES OF FRACTURE
 Open fracture(compound fracture): Break
in the skin over bone injury
Grading of open fracture
 Grade I – the wound is smaller than 1cm,
contamination is minimal
 Grade II- wound is larger than 1cm,
contamination is moderate
 Grade III – wound exceeds 6-8cm, there is
extensive damage to soft tissue, nerve,
tendon and there is high degree of
contamination
 Closed facture (simple fracture)
It has intact skin over the site of injury
 TYPES OF FRACTURE
 Appearance:
1.Burst fracture
 Multiple pieces of bone, mainly in
the vertebra
2. Comminuted fracture
- More than one fracture line, more than
2 bone fragments, Fragments crushed,
the smaller fragments appear to be
floating
3.Complete fracture
 Break across entire section of bone,
dividing into distinct fragments
5. Displaced fracture
 Fragments out of normal position at fracture
site
4. Incomplete fracture
 Fracture occurs through only one cortex of
bone, usually nondisplaced
6. Nondisplaced fracture
 -Fragments aligned at fracture site
7. Linear fracture (Longitudinal
fracture)
 Fracture line is intact; Caused by
minor- moderate force
 Periosteum is not torn away from
the bone
8. Oblique fracture
 -Fracture line occurs at 45 degree
angle across longitudinal axis of bone
9. Spiral fracture
 -the line of the fracture extends in a spiral
direction along the shaft of the bone
 Fracture line results from twisting force
10. Stellate fracture
 -Fracture line radiate from one
central point
11. Transverse fracture
 -Fracture line occurs at 90 degree
angle to longitudinal axis of bone

12. Inter articular fracture

 Fracture extending to the articular
surface of the bone
General Description
1. Avulsion
- Bone fragments are torn away from
body of the bone at the site of
attachment of ligaments or tendon
2. Compression fracture
 Bone cracks as a result of loading force
applied to its longitudinal axis
3. Greenstick fracture
- Incomplete fracture in which one side of the
cortex is broken & the other side is flexed
but intact
4. Impacted fracture
It is a communited fracture in which one
fragment is driven in to other

5. pathologic fracture
It is a spontaneous fracture due to an
underlying pathologic condition
 Anatomic Location
1. Colle’s fracture
-Fracture within last inch of distal
radius
2. Pott’s fracture
A Pott's fracture is a type of ankle
fracture that is characterized by a
break in one or more bony
prominences on the sides of the ankle
known as the malleoli
 3.torus fracture – also known as
buckling fracture, they are
incomplete fractures of the shaft of
long bone which is characterized by
bulging of the cortex.

 4.Transchondral fracture –
separation of cartilaginous joint
surface from main shaft bone
 BONE HEALING
 Self healing of bone occurs in the
following stages
Stage I – hematoma or inflammatory
stage
Stage II – granulation tissue formation
or fibro cartilage formation
Stage III – callus formation
Stage IV – ossification
Stage V – consolidation
Stage VI – remodeling
STAGE I – HEMATOMA OR INFLAMMATORY STAGE
When a fracture occurs, bleeding and edema
create a hematoma, which surrounds the ends
of the fragments.
The hematoma is extravasated blood that
changes from a liquid to a semisolid clot
Time 1 to 3 days
The blood forms a clot among the fracture
fragments, providing a small amount of
stabilization
Necrosis of adjacent bone occurs in direct
relation to the loss of blood supply to the
affected region and will extend to the area
where collateral circulation begins
 Hematoma
 Liquid to semisolid clot
 Time 1 – 3 days
 Stabilize
 Necrosis due to decrease blood supply
 Collateral circulation begins
 Vascular dilation occurs
 Phagocytic cells migrate to the area
STAGE II – GRANULATION TISSUE FORMATION
OR FIBROCARTILAGE FORMATION
 During this stage, active phagocytosis absorbs
the products of local necrosis.
 The hematoma converts to granulation tissue.
 Granulation tissue (consist of new blood vessels,
fibroblasts(type of cell that synthesizes the
extracellular matrix and collagen) and
osteoblasts) produces the basis for new bone
substance called osteoid during 3 to 14 days post
injury
STAGE III - CALLUS FORMATION
 As minerals (calcium, phosphorus and
magnesium and new bone matrix) are
deposited in the osteoid, an unorganized
network of bone is formed that is woven
about the fracture parts
 Granulation tissue matrix will convert
into callus
 Callus is primarily composed of
cartilage, osteoblasts, calcium and
phosphorus
 Duration - 2 to 6 weeks
 Proper alignment is essential during this
stage by traction or cast
STAGE IV- OSSIFICATION
 Bone develops in this stage –
osteogenisis
 Ossification of callus occurs from 3
weeks to 6 months after the fracture
and continuous until the fracture has
healed.
 Callus ossification is sufficient to
prevent movement at the fracture site
when the bones are gently stressed
 Patient can be converted from skeletal
traction to cast or the cast can be
removed to allow limited mobility.
STAGE V - CONSOLIDATION
 As callus continuous to develop, the
distance between bone fragments
diminishes and eventually closes.
 This stage is called consolidation and
ossification continues
 6 to 8 months
STAGE VI – REMODELING
 Excess bone tissue is re absorbed in the final
stage of bone healing and union is completed
 Gradual return of the injured bone to its pre
injury structural strength and shape occurs
 Bone remodel in response to physical stress
 Initially stress is provided through exercise
 8 months to 1 year
FACTORS AFFECTING BONE
HEALING
Favorable factors
 Location – good blood supply at the
bone ends, flat bones
 Minimal damage to soft tissue
 Anatomic reduction possible
 Effective immobilization
 Weight – bearing on long bone
 Proper nutrition
 Hormone functioning – growth
hormone, thyroid, calcitonin and
vitamin d
Unfavorable factors
 Fragments widely separated
 Fragments distracted by traction
 Severe communited fracture
 Severe damage to soft tissue
 Bone loss from injury or surgical excision
 Motion/rotation at fracture site as a result
of inadequate fixation
 Infection
 Impaired blood supply to one or more bone
fragments
 Location – decreased blood supply, mid shaft
 Smoking and alcoholism
 Poor nutrition
 Drugs – corticosteroids inhibit the
repair
 Age – elderly persons heal more
slowly
 Intra articular fracture
 Avascular necrosis
 Metaboilic bone diseases
 Local malignancy
 CLINICAL MANIFESTATIONS
 Deformity – due to loss of bone continuity.
Deformity is the cardinal sign of fracture.
 Edema or Swelling – due to accumulation of
serous fluid at the fracture site and
extravasations of blood into the surrounding
tissue
 Bruising ( Ecchymosis) – due to subcutaneous
bleeding at the fracture site
 Muscle spasm can cause limb shortening
 Pain – continuous pain due to spasm, overriding
of fracture fragments or damage to the
adjacent structure
 Tenderness
 Loss of function – result from pain and
discontinuity. Paralysis may cause due to nerve
damage.

 Neurovascular changes – due to damage to

peripheral nerves or the associated vascular
structure. Tingling or no palpable pulsed distal
to the fracture

 Shock – frank and occult hemorrhage can lead

to shock

 Crepitation – grating sound occurs if limb is

moved gently. Testing for crepitus can produce
further tissue damage so should minimized as
much as possible
 Warmth over injured area resulting from
increased blood flow to the area
 Impairment or loss of sensation or paralysis
in affected area
 Evidence of fracture on x-ray film
 DIAGNOSIS

 History collection

 Physical examination

 x ray

 CT scan
 MANAGEMENT
Goals:
 Assessment of injury
 Emergency management
 Reduction and stabilization of fracture
 Monitoring complications
 Eventual remobilization & rehabilitation
 Pharmacological management and nutritional
supplementation
A. Thorough initial
assessment:
 Assess the cause of fracture, type of
fracture and the severity of fracture
 Assess early complication: Arterial
damage (Pain, pallor, paresthesia,
Absent pulse, Poor capillary refill,
cyanosis)
 Neurovascular assessment
Color and temperature
 cyanotic and cool/cold: arterial
insufficiency
 cyanotic and warm: venous insufficiency
Capillary refill
 Peripheral pulses (↓ indicates vascular
insufficiency)
 Check for Edema, Sensation, Motor function,
Pain
B. EMERGENCY MANAGEMENT OF
FRACTURES

• 1. Immobilize any suspected fracture.

• 2. Support the extremity above and below

when moving. Assess color, warmth,
circulation and movement.

• 3. Suggested temporary splints: hard board,

stick, rolled sheets.
• 4. Apply sling if forearm fracture is
suspected or the suspected fractured
arm maybe bandaged to the chest.

If the fractured extremity is leg bone,

the unaffected extremity can be used
as a splint by bandaging both legs
together.
• 5. Open fracture is managed by
covering it with clean/sterile gauze to
prevent contamination
 6. DO NOT attempt to straighten or realign
or reduce a fractured extremity. Move the
affected limb as little as necessary

 7.Elevate the injured part to decrease

edema

 8.Apply cold packs to reduce

hemorrhage , edema and pain
C.FRACTURE REDUCTION/ BONE
SETTING:
Reduction - It is refers to restoration of the
fracture fragments to its actual anatomic
alignment

a. Closed reduction

b. Open reduction
a.Closed Reduction
CLOSED REDUCTION
 it is a non surgical, manual realignment
of bone fragments to their previous
anatomic position
 The extremity is held in the desired
position while the physician applies a
cast, splint or other device
 Traction and counter traction are
manually applied to the bone fragments
(to restore position, length and
alignment) for immobilization and
fracture reduction.
 It is usually performed under LA or
GA.
 X-ray is obtained to verify that the
bone fragments are correctly
aligned.
b. Open Reduction- ORIF
 The surgeon makes an incision and realigns the
fracture fragments under direct visualization.
 It is treatment of choice for compound
fracture or accompanied by severe
neurovascular injury
 Open reduction is usually performed in
combination with internal fixation for femoral
and joint fractures
 Screws, plates, pins, wires, rods or nails may
be used to maintain alignment of fracture
fragments.
 Before the surgery patient will get a course of
prophylactic intravenous antibiotics
 Internal fixation devices are biologically inert
metal devices (stainless steel, vitallium or
titanium)

Variety of internal fixation devices are available

 Plates and nails
 Intramedullary rods
 Transfixation screws
 Prosthetic implants ex- femur head, hip
prosthesis etc
c. External Fixation
 PLASTER CAST
• Rigid immobilizing device made of
plaster of Paris or fiberglass
• Provides immobilization of the
fracture, to correct a deformity, to
apply uniform pressure, to support
and stabilize
Cast types:
Nursing Management
1. Long arm
2. Short arm
3. ARM cylindrical cast and leg
cylindrical cast
4. Short leg
5. Long leg
6. Hip Spica
7. Body cast
8. Sugar tong
9. Posterior sling cast
POSTERIOR SLING CAST
AND SUGAR TONG CAST
 Thermoplastics
 Comfortable, lightweight, strong,
durable.
 Easy to remove
 Water-resistant and permeable.
 Can be reheated for additional
molding.
 Don’t require padding.
 Not as comfortable as plaster or
fiberglass.
 cost is higher.
 Procedure
 Preparation for casting
 Explanation of procedure
 Skin preparation
 Apply stockinette over padding
 Casting material submerged in water
 Squeeze excess water, apply on injured part
 It is composed of unhydro calcium sulfate
embedded in gauze.
 As the cast dries a thermo chemical reaction
occurs in which the calcium sulfate recrystallizes
and hardens with in 15 min
 Finger tips should not pressed into cast
 A fresh cast should never cover with blanket
because air cannot circulate and heat builds up
in the cast
 Nursing Management
• 1. Allow the cast to air dry
(usually 24-72 hours)

• 2. Handle a wet cast with the

PALMS not the fingertips to
avoid dents.
 Nursing Management
• 3. Keep the casted extremity
ELEVATED using a pillow to
reduce swelling.

• 4. Turn the extremity for equal

drying. DO NOT USE DRYER for
plaster cast
– Encourage mobility and range of
motion exercises
 TRACTION
 Application of a pulling force to an injured
body part or extremity while a counter traction
pulls in the opposite direction
Purpose:
 Reduce, realign & promote healing of fracture
 Decrease muscle spasm
 Prevent soft tissue damage
 Prevent or treat deformity
 Rest an inflamed or painful joint
 Reduce & treat dislocation
 Prevent contracture
SLIDING TRACTION
 Exact weight required is determined
by trial.
 For the fracture of femoral shaft an
initial weight of 10% of body weight
 Foot end is elevated so that the body
slides in opposite direction.
 1 inch (2.5 cm) for each 1 lb (0.46
kg) of traction weight
TYPES OF TRACTION ON
APPLICATION

Skin traction

Skeletal Traction
SLIDING TRACTION
 When the weight of all or part of
the body, acting under the
influence of gravity, is utilized to
provide counter-traction.
SKIN TRACTION
 Traction force is applied over a
large area of skin
 Applied over limb distal to fracture
site
 Used for Short term treatment (48
to 72 hrs)
 Tapes, boots or splints are applied
directly to the skin and maintain
alignment, assist in reduction and
to help diminish muscle spasm in
the injured extremity
 Traction weight – 5-10 Ib (2.3 –
COMMON SKIN TRACTIONS
 Buck’s Traction
 Hamilton Russel Traction
 Gallow’s or Brayant’s Traction
 Modified Brayan’s Traction
 Pelvic Traction
 Dunlop Traction
 BUCK’S TRACTION
 A foam boot is applied to  Check every 4th hourly for
client’s affected limb & decreased peripheral
attached to weight that is vascular flow, peroneal nerve
suspended off the foot of the deficit, pressure necrosis and
bed. Used for fracture femur, allergic reaction towards
knee or back. adhesive material
 Can be used unilaterally or
bilaterally.
 HAMILTON RUSSEL TRACTION
 Used for fracture of hip or femur
 A broad soft sling is placed under the knee
 BRYANT’S (GALLOW’S )
TRACTION
 the treatment of fracture shaft femur
in children up to age of 2 yrs.
 Weight of child should be less than 15-
18 kg
PELVIC TRACTION

 Used for conservative

management of IVDP
 The amount by which foot end
should be elevated depends
upon patient’s weight , more
heavy the patient, more should
be elevation.
DUNLOP TRACTION
 USED IN fracture of humerus
 Useful when flexion of elbow causes
circulatory embarrassment with loss of
radial pulse
 Apply skin traction to forearm
 Abduct shoulder about 45 degree
 the elbow is flexed 45 degree.
SKELETAL TRACTION
SKELETAL TRACTION
 Using pin or wire
 7-15 pounds/ 2.3-20.4 kg
 more frequently used in lower limb
fractures
 Should be used for those cases in
which skin traction is insufficient.
 Generally used when more weight is
needed to give traction.
 To treat fractures conservatively.
SKELETAL TRACTION
 SITES
 Upper tibial
 Lower femoral
 Lower tibial
 Calcaneus
 Olecrenon
 Metacarpel
SKELETAL TRACTION
COMPLICATIONS

 Infection
 Distraction at fracture site
 Physical damage
 Nerve Injury
SPINAL TRACTIONS
 CERVICAL TRACTIONS

 SKIN TRACTION Head Halter

traction

 SKELETAL TRACTION

Crutchfield tongs
Cone or
Barton tongs
 HEAD HALTER TRACTION

 Simple type cervical

traction
 Management of neck pain
 Weight should not
exceed 3 kg initially
 Can only be used a few
hours at a time
 Head end should be
elevated to give counter
traction
 CRUTCHFIELD TONGS
 Must incise skin and drill
cortex to place
 Rotate metal traction
loop so touches skull in
midsagittal plane
 Place at the line
connecting tips of
mastoid processes on
both sides.
 Nursing Management

• 1. ALWAYS ensure that the weights hang

freely and do not touch the floor.

• 2. NEVER remove the weights without

doctors order

• 3. Maintain proper body alignment.

• 4. Ensure that the pulleys and ropes are

properly functioning and fastened by tying
• 5. Observe and prevent foot drop
– Provide foot plate

• 6. Observe for DVT, skin irritation &

breakdown.
• 7. Provide pin site care for clients in
skeletal traction- use of
chlorhexidine is the most effective,
normal saline can be used also.
8. Promote skin integrity
– Use special mattress if possible
– Provide frequent skin care
– Assess pin entrance and cleanse the
pin with chlorhexidine solution
– Turn and reposition within the limits
of traction
Care of Client in Traction
Temperature
extremity
infection
Ropes hang freely
Alignment
Circulation Checks
Type & location of Fx
Increase fluid intake
Overhead Trapeze
No weights on bed or floor
 4. Drug Therapy
 Central & peripheral muscle relaxants

Eg: Cyclobenzaprine
 Open fracture: Tetanus & Diptheria
toxoid/ Tetanus immunoglobulin
 Bone penetrating antibiotics. Eg:
Cephalosporin
5. Nutritional Therapy
 Diet:

Protein: 1g/kg body wt.

Vitamins B,C,D
Calcium,phosphorous,magnesium
Fluids, Fiber
EARLY COMPLICATIONS
1. Nerve injury
2. Infection
3. Compartment syndrome
4. Volkmann’s contracture
5. Fat embolism syndrome (FES)
6. Deep vein thrombosis and
pulmonary embolism
7. Cast syndrome
8. Traumatic or hypovolemic shock
C/m:
 6 p’s
 PARESTHESIA
 PAIN
 PRESSURE RISES
 PALLOR
 PARALYSIS
 PULSE – DIMINISHED
LONG TERM COMPLICATION
1. Joint stiffness or post traumatic
arthritis
2. Avascular necrosis (AVN)
3. Nonfunctional union
 Delayed union
 Non union
 Fibrous union
 Malunion

4. Complex regional pain syndrome

and disuse
 NURSING MANAGEMENT
NURSING DIAGNOSES
 Risk for peripheral neurovascular
dysfunction
 Acute pain
 Risk for infection
 NURSING MANAGEMENT
NURSING DIAGNOSES
 Risk for impaired skin integrity
 Impaired physical mobility
 Ineffective therapeutic regimen
management