Bone Fractures: Types and Classifications

BONE DISORDERS "FRACTURES"

• Bone fractures involve a complete or incomplete disruption in bone structure continuity.
• Fractures get defined according to extent and type.

Types of Fractures: Injured Bone and Location

• Proximal Fracture: Occurs near the end of a bone closest to the body's center.
• Midshaft Fracture: Occurs in the middle portion of a long bone.
• Distal Fracture: Occurs near the end of a bone farthest from the body's center.

Fracture Patterns

Gustilo-Anderson Classification: Open Fractures

• Open fractures have a classification system based on soft tissue injury severity/extent and size of skin wounds
• Type I Injuries: Wounds are less than 1 cm, with minimal contamination and comminution, no periosteum stripping, and adequate soft tissue coverage.
• Type II Injuries: Wounds are larger than 1 cm with moderate contamination, moderate comminution, minimal periosteum stripping, and adequate soft tissue coverage.
• Type IIIB Injuries: Includes any wound size that has severe contamination, severe comminution, periosteal stripping, inadequate soft tissue coverage, use of rotation flaps or free flaps
• Type IIIC Injuries: A wound of any size that involves severe contaminations, severe comminution, periosteal stripping, vascular injury requiring repair, requires rotation flaps or free flaps

Special Circumstances

• Fracture classification helps determine severity, treatment, and potential complications

Fractures: Bone/Skin Integrity

• Simple Fracture: Remains contained with no skin disruption.
• Open Fracture: Damage involves skin or mucous membranes, also called a compound fracture.

Other Types of Fractures

• Transverse: A fracture straight across the bone shaft.
• Spiral: A fracture that twists around the bone shaft.
• Oblique: A fracture occurring at an angle across the bone (less stable than a transverse fracture).
• Comminuted: The bone has splintered into several fragments.
• Greenstick Fracture: One side of a bone breaks, and the other side bends.
• Pathologic: Occurs through an area of diseased bone and can occur without trauma or fall.
• Compression: Bone has been compressed.
• Stress: It Results from repeated loading of bone and muscle.
• Impacted: Bone fragment driven into another bone fragment.
• Avulsion: Bone fragment pulled away by a tendon and its attachment.
• Intra-articular: Extends into a joint, damaging the cartilage and affecting joint movement.
• Extra-articular: Does not reach the joint, occurring only in the bone outside the joint area.
• Colles Fracture: Occurs when the broken end of the radius tilts upward.

Causes of Fractures: Traumatic

• Direct Blow or Impact: A strong force applied directly to the bone, common in car accidents and sports injuries.
• Falls: Major cause, especially in older adults with osteoporosis.
• Twisting or Rotational Forces: Can lead to spiral/oblique fractures.
• Crush Injuries: Heavy objects falling on a limb can cause comminuted or compression fractures.

Fracture Causes: Pathological

• Cancer (Bone Tumors or Metastases): Weakens bone structure.
• Osteoporosis: Weakens bones, making them prone to fractures even with minor trauma.

Fracture Causes: Stress/Overuse

• Repetitive Impact (Overuse Injuries): Common in athletes, leading to stress fractures.
• Improper Training or Excessive Exercise: Can cause microfractures that gradually worsen.

Fracture Assessment & Nursing Process: "BROKEN"

• Bruising, reduced movement, odd appearance, krackling sounds (crepitus), and edema/erythema can be present.
• Neurovascular impairment 5 P's: pain, pallor, paralysis, paresthesia, pulselessness (late sign).
• It is necessary to perform neurovascular assessments every 30 minutes for 4 hours.
• Assess the extremity for color, warmth, distal pulse, capillary refill, movement, awareness, and sensation change
• Pain assessment degree.
• X-rays: identify fractures, breaks, dislocations.
• CT Scan: provide detailed view
• MRI: assess soft tissue damage

Nursing Diagnosis

• Acute pain due to bone continuity breakdown due to facial grimace, unstable vital signs, and presence of ecchymosis.
• Goals: less grimacing, stable vital signa

Fracture Interventions

• Provide diversion therapy, positioning, breathing exercises, or contralateral stimulation for less severe fractures.
• Immobilize the affected area with splinting, sandbags, or towels.
• Monitor the patient's condition: severity, intensity, onset, duration, and location.
• Provide ROM exercises, assist in ambulation after recovery provide assistive devices, if required.
• Prevent pressure sores by providing frequent turning and ensuring hygiene.
• Maintain nutritional needs (protein-rich), proper hydration and daily weight monitoring.
• In caring for open fractures, never draw or push exposed bones back into tissues Cover wound.
• Splint fracture without disturbing wound..
• Place a moist 4" x 4" dressing over bone end prevent drying and encourage patient not to mobilize fracture site.
• Instruct patient on self-care, medication information, complication monitoring, and the need for continuing health care supervision.

Medical / Surgical Management: Fracture Reduction

• Restoration of fracture fragments to anatomic alignment and rotation.
• External/internal fixation devices (metallic pins, screws, plates or rods) may be necessary.

Open Reduction Technique

• A surgical technique visualizes and realigns a fracture by making an incision to expose the bone for stabilization and healing.

Open Reduction Post Op Care

• Assessment- pain, nerve supply, infection, pin Site
• Small bleeding normal; Critical, if extend more than 24 hours
• Administer antibiotics, analgesic

Closed Reduction

• Non-surgical manually realigns without incision via external manipulation/traction.

Immobilization

• Accomplished by external or internal fixation.

Methods of Immobilization: Traction

Skin Traction

• Applied to skin using adhesive strips, bandages, or boots, weighing 5-10 pounds
• Indicated for short-term fractures (e.g., femur, tibia), dislocations or muscle spasms

Skeletal Traction

• Applied directly to bone with pins, wires, or screws, weighing 15-30 pounds or more
• Indicated for severe fractures (e.g., pelvic, femoral fractures)

Traction: Nursing Implementations

• T - Temperature: maintain warmth .
• R - Ropes Hang Free
• A - Alignment: affected limb properly aligned
• C - Check circulation
• T - Type & location of fracture
• I - Increase fluid intake
• O - Overhead trapeze
• N - No weights on bed/floor

C. Cast “Care of Client with Cast” Before Application

• Explanation Skin preparation Cleanse Present of particle/dust
• Rolling Clean water squeeze Apply

Cast Aftercare

• Window: Decreases Pressure.
• Visualization Drainage Assessment: Check Edges Spot: Warm=necrosis Wet=Drainage
• Circulation Elevate Limb Assess Discomfort Swelling -Call Doctor?
• Mnemonic: Circulation Assess Swelling Temperature Elevate.

Splinting

• Process use rigid items to immobilize
• Stabilize extremity Decrease pain Treat lessen injury Towels Blankets Pillows Board Metal Folded News
• Guideline: Support Splint Check Color Warmth Immobilize
• Collect Use Materials Pad Secure Check
• Maintaining Restlessness Anxiety Discomfort Use strategies Encourage Exercise Promote circulation.
• Participation Encourage Function Self esteem