Fractures PDF

Fractures Dr. Rose Ekama Ilesanmi Assistant Professor ( Adult Health Nursing) RAKCON  Learning Outcomes At the end of the lecture, you will be able to: Define fracture and differentiate the types Explain the stages of bone healing process Discuss the...

Fractures Dr. Rose Ekama Ilesanmi Assistant Professor ( Adult Health Nursing) RAKCON  Learning Outcomes At the end of the lecture, you will be able to: Define fracture and differentiate the types Explain the stages of bone healing process Discuss the management principles of fracture Discuss the nursing care of patient on traction  Definition Fracture is: Disruption or break in the continuity of bone Types: Traumatic: Accident Pathologic: Diseases e.g osteoporosis  Causes of Fracture Trauma ( primary cause) ✓ Sports, vigorous exercise ✓ motor vehicle crash Malnutrition ✓ Fall, especially in older adults. Bone diseases, e.g osteoporosis, ✓ Direct blow to the bone increase the risk for a fracture in older adults ✓ Indirect force from muscle contractions or pulling forces on the bone  Classification of Fracture According to the extent of the break: ❑ Incomplete fracture. : ❑ Complete: ✓ The fracture does not divide the bone into two portions ✓ The break is across the entire width of the bone ✓ the break is through only part of the bone. ✓ the bone is divided into two distinct sections ✓ Typically nondisplaced fracture ✓ If bone alignment is altered or disrupted, the fracture is also referred to as a displaced fracture ✓ commonly damage surrounding nerves, blood vessels, and other soft tissues  Classification of Fracture cont. ❑Displaced: The two ends of the ❑Nondisplaced: the bone fragments broken bone are separated from stay in alignment. each other and out of their normal ✓ Nondisplaced fractures are usually positions transverse, spiral, or greenstick ✓ Displaced fractures are often comminuted (more than 2 fragments) or oblique  Classification cont. By the extent of associated soft-tissue ❑Closed (simple ) fracture damage ✓ Does not extend through the skin ❑Open (compound) fracture ✓ No visible wound ✓ The skin surface over the broken bone is disrupted ✓ Visible external wound. ✓ These fractures are often graded to define the extent of tissue damage According to direction of fracture ❑Linear ❑ Oblique ❑Transverse ❑Longitudinal ❑Spiral fractures  Classification according to cause ❑Pathologic or spontaneous ❑A fatigue (stress) fracture: fracture (fragility fracture) results from excessive strain and ✓ Occurs from minimal trauma to a stress on the bone weakened bone by disease ✓ Occurs in recreational and ✓ Example a patient with bone professional athletes cancer or osteoporosis ❑Compression fractures: produced by a loading force applied to the long axis of cancellous bone  Clinical manifestation of fracture ❑Immediate localized pain and ❑Deformity (classic sign of fracture) tenderness ❑Edema and swelling ❑Decreased function ❑Muscle spasm ❑ Loss of function (inability to bear weight or use the affected part ❑ Bruising: with discoloration of skin ❑Crepitations: grating or crunching bony fragments  Stages of bone healing When fracture occurs: Fractures heal in five stages that are ✓ the body immediately begins the a continuous process and not single healing process stages. Goal: to repair the injury Restore the body’s equilibrium. Stages of bone Healing  Stage 1: Fracture hematoma formation When a fracture occurs: Bleeding creates a hematoma that surrounds the ends of the bone fragments. The hematoma is composed of extravasated blood that changes from a liquid to a semisolid clot Occurs within the first 72 hours after injury  Stage 2: Granulation tissue Active phagocytosis absorbs the products of local necrosis The hematoma converts to granulation tissue. Granulation tissue (consisting of new blood vessels, fibroblasts, and osteoblasts) forms the basis for new bone substance (osteoid) Process occur during days 3 to 14 after injury.  Stage 3: Callus formation Callus: An unorganized network of bone formed and woven about the fracture parts. ✓ composed of cartilage, osteoblasts, calcium, and phosphorus As minerals (calcium, phosphorus, and magnesium) and new bone matrix are deposited in the osteoid Usually appears by the end of the second week after injury. An x-ray can show evidence of callus formation. Callus formation is the beginning of a nonbony union.  Stage 4: Ossification Callus is gradually resorbed (Ossification ) Occurs from 3 weeks to 6 months after the fracture Process continues until the fracture has healed. Callus ossification is sufficient to prevent movement at the fracture site when the bones are gently stressed. But the fracture is still evident on x-ray. During this stage of clinical union, the patient may be allowed limited mobility, or the cast may be removed.  Stage 5: Consolidation As callus continues to develop, the distance between bone fragments decreases and eventually closes. Ossification continues Radiologic union: occurs when an x-ray shows complete bony union. This phase can occur up to 1 year after injury  Stage 6: Remodeling Excess bone tissue is resorbed in the last stage of bone healing Union is complete. Gradual return of the injured bone to its preinjury structural strength and shape occurs. Bone remodels in response to physical loading stress (Wolff ’s law). Initially, stress is provided through exercise. Weight bearing is gradually introduced. New bone is deposited in sites subjected to stress and resorbed at areas of little stress.  Outcomes of Healing Delayed Union: Fracture healing may not occur in the expected time Non Union: Fracture may not occur at all Malunited Fracture: the broken bone heals but may not be completely straight  Causes of Delay in bone healing Displacement and site of the fracture Excessive movement of fracture fragments Poor blood supply Infection other local tissue injury Poor nutrition Inadequate immobilization and use of Systemic disease (e.g., diabetes) internal fixation devices (e.g. screws, pins) Age: Increases healing time (an uncomplicated Smoking increases fracture healing time. midshaft femur fracture heals in 3 weeks in an infant and in 20 weeks in an adult  Diagnostic Studies ❑History and physical examination ❑ Plain X-ray ❑ CT scan ❑ MRI  Management of Fracture: Goals ❑ Anatomic realignment of bone fragments through reduction ❑Immobilization to maintain realignment ❑Restoration of normal or near-normal function of the injured part.  Management Principles ❑Fracture Reduction ❑Fracture Immobilization Manual traction Casting or splinting Closed reduction Skeletal traction Skeletal traction External fixation Open reduction Internal fixation  Fracture Reduction Closed Reduction: A nonsurgical, ✓ Traction, casting, splints, or manual realignment of bone orthoses (braces) may be used after fragments to their anatomic reduction : to maintain alignment position and immobilize the injured part ✓ Traction and countertraction are until healing occurs. manually applied to the bone fragments to restore position, length, and alignment Closed reduction cont.  Open Reduction ❑ Open reduction: Main risks of open reduction: The surgical correction of bone alignment: ✓ Infection open reduction internal fixation (ORIF) ✓ complications associated with anesthesia Includes internal fixation of the fracture: wires, ✓ Effects of preexisting medical conditions screws, pins, plates, intramedullary rods, or nails. (e.g., diabetes) ORIF facilitates early ambulation ✓ Decrease the risk for complications related to The type and location of the fracture, patient age, and prolonged immobility. concurrent disease influence the decision to use open reduction Open reduction and internal fixation (ORIF)  Traction ❑Traction is: Application of a pulling force to an Traction Device: injured , with a counter traction pull Apply a pulling force on a fractured in the opposite direction extremity to attain realignment while countertraction pulls in the opposite direction  Uses of Traction Prevent or reduce pain and muscle ✓ Provide immobilization to prevent spasm soft tissue damage Immobilize a joint or part of the body ✓ Promote active and passive exercise Maintain skeletal length and alignment ✓ Expand a joint space during Reduce a fracture or dislocation arthroscopic procedures Treat a pathologic joint condition (e.g., ✓ Expand a joint space before major tumor, infection) joint reconstruction.  Types of Traction Two Main types: ❑Skin Traction: example Buck traction ❑Skeletal Traction  Skin Traction Tape: Adhesive or non adhesive tape ✓ Boots, or splints are applied directly to the skin Uses: to help decrease muscle spasms in the injured extremity hip, knee, or femur fracture Used intermittently or over short period Traction weights: usually 5 to 10 lb (2.3 to 4.5 kg) (1/10 of body weight)  Skin traction cont. Nursing Management: Ensure: Regular assessment of the skin is a Ropes are unobstructed priority : because pressure points and Not in contact with the bed or skin breakdown may develop quickly. equipment Assess key pressure points every 2 to 4 ropes move smoothly over the hours pulleys the weights are hanging freely and not on the floor Peroneal nerve palsy: Foot drop  Skeletal traction Traction force is applied directly to Equipment: the bone ✓ Pins (Steinman, Denham pins) ✓ To align injured bones and joints ✓ Wire (Kirschner wire ) ✓ treat joint contractures and ✓ Weights are attached to align and congenital hip dysplasia. immobilize the injured body part. ✓ It provides a long term pull that ✓ Weight ranges from 5 to 45 lb (2.3 keeps the injured bones and joints to 20.4 Too muchkg). weight can result in delayed union or aligned nonunion  Types of skeletal traction ❑Balanced suspension skeletal traction ✓ Most common type  Types of traction cont. Halo Traction Immobilize and realign fractures of the cervical spine or upper thoracic spine. used for patients who require prolonged immobilization or surgery. It involves: the insertion of pins into the skull Application of a pulling force using a halo device.  Skeletal traction cont. Fracture alignment depends on the Traction must be maintained correct positioning and alignment continuously. of the patient while the traction Keep the weights off the floor forces stay constant Weights must be moving freely Countertraction is supplied by the through the pulleys. patient’s body weight or by weights pulling in the opposite direction  Common sites for skeletal traction Olecranon Upper end of tibia Metacarpal Lower end of tibia Upper end of femur Calcaneus bone Lower end of femur  Immobilization & Nursing Management of patient with Fracture TO CONTINUED IN NEXT LECTURE CLASS  References Smeltzer, S.C., Bare, B.G. and Hinkle, J.L. (2022) Brunner and Suddarth’s Textbook of Medical-Surgical Nursing. 15th Edition, Lipincott Williams & Wilkins, Philadelphia. Lewis, S.L., Dirksen, S.R., Heitkemper, M.M. and Bucher, L. (2022). Medical- Surgical Nursing: Assessment and Management of Clinical Problems, Single Volume.11 edition. Elsevier Health Sciences. Miller, MD, Thompson, SR, Hart J. (2020). Review of Orthopaedics 8th. Ed. Elsevier Saunders Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. Mosby.