AVULSION – a fracture in which a fragment of bone has been pulled away by a

tendon and its attachment.

COMMINUTED – a fracture in which bone has splintered into several

fragments

COMPOUND – a fracture in which damage also involves the skin or mucous

membrane; also called an open fracture

COMPRESSION – a fracture in which bone has been compressed (seen in

vertebral fractures)

DEPRESSED – a fracture in which fragments are driven inward (seen frequency

in fractures of skull and facial bones)

EPIPHYSEAL – a fracture through the epiphysis

GREENSTICK – a fracture in which one side of a bone is broken and the other
side is bent
IMPACTED – a fracture in which a bone fragment is driven into another bone
fragment

OBLIQUE – a fracture occurring at an angle across the bone (less stable than a
transverse fracture)

PATHOLOGIC – a fracture that occurs through an area of diseased bone (eg,

osteoporosis, bone cyst, Paget’s disease, bony metastasis,, tumor);
can occur without trauma or a fall

SIMPLE – a fracture that remains contained, with no disruption of the skin

integrity

SPIRAL – a fracture that twists around the shaft of the bone

STRESS – a fracture that results from repeated loading without bone and
muscle recovery

TRANSVERSE – a fracture that is straight across the bone shaft

continuous and increase in severity until the bone
fragments are immobilized.

muscle spasms that accompany a fracture begin

within 20 minutes after the injury and result in more
intense pain that the patient reports at the time of
injury.

muscle spasms can minimize further movement of

the fracture fragments or can result in further bony
fragmentation or malalignment.
the extremity cannot function properly because normal
function of the muscles depends on the integrity of the
bones to which they are attached.

Pain contributes to the loss of function.

abnormal movement (false motion) may be present.

Cause :
Displacement

angulation

rotation of the fragments (either visible or palpable)

that is detectable when the limb is compared with the
uninjured extremity. Deformity also results from soft
tissue swelling.
In fractures of long bones, there is actual shortening of
the extremity because of the contraction of the muscles
that are attached distal and proximal to the site of the
fracture.

The fragments often overlap by as much as 2.5 to 5 cm

(1 to 2 inches).
a grating sensation when the extremity is examined
with the hands.

It is caused by the rubbing of the bone fragments

against each other.
Localized edema and discoloration of the skin
(ecchymosis)

occur after as a result of trauma and bleeding into the

tissues.

These signs may not develop for several hours after the
injury.
Emergency Management

• Immediately after the injury, immobilize the body part before the patient is moved. If
an injured patient must be moved before splints can be applied, support the
extremity above and below the fracture site to prevent rotation or angular motion.

• Splint the fracture, including joints adjacent to the fracture, to prevent damage to
the soft tissue.

• Apply temporary, well-padded splints, firmly bandaged over clothing, to immobilize

the fracture.

• Assess neurovascular status distal to the injury to determine adequacy of peripheral

tissue perfusion and nerve function. Be alert for paresthesia or paralysis
(compartment syndrome).

• Cover the wound of an open fracture with a clean (sterile) dressing to prevent
contamination of deeper tissues.
Reduction of fractures
The principles of fracture treatment include reduction, immobilization, and regaining
of normal and strength through rehabilitation.

• The fracture is reduced using a closed method (manipulation and manual traction) or
an open method (surgical placement of internal-fixation devices to restore the
fracture fragments to anatomic alignment and rotation. The specific method
depends on the nature of the fracture.

• After the fracture has been reduced, immobilization holds the bone in correct
position and alignment until union occurs. Immobilization is accomplished by
external or internal fixation.

• Function is maintained and restored by controlling swelling by elevating the injured

extremity and applying ice as prescribed. Restlessness, anxiety, and discomfort are
controlled using a variety of approaches. Isometric and muscle-setting exercises are
done to minimize disuse atrophy and to promote circulation. With internal fixation,
the surgeon determines the extremity can withstand and prescribes the level of
anxiety.
Management of complications

•Treatment of shock consists of restoring blood volume and circulation,

relieving pain, providing adequate splinting, and protecting the patient from
further injury and other complications. See Nursing Management under
Hypovolevic Shock for additional information.

•Prevention and management of fat embolism includes immediate

immobilization of fractures and adequate support for fractured bones during
turning and positioning. Prompt initiation of respiratory support with prevention
of respiratory and metabolic acidosis and correction of homeostatic
disturbances is essential. Corticosteroids may be given as well as vasoactive
medications, fluid replacement therapy, and morphine for pain and anxiety.

•Compartment syndrome is managed by controlling swelling restrictive devices

(dressing or cast). A fasciotomy (surgical decompression with excision of
fibrous membrane covering and separating muscles) may be needed to relive
the constrictive with moist sterile saline dressings for 3 to 5 days. The limb is
splinted and elevated. Range-of-motion exercises may be performed every 4
to 6 hours.
•Nonunion (failure of the ends of a fractured bone to unite) is treated with
internal fixation, bone grafting (osteogenesis , osteoconduction,
osteoindunction), electronic bone simulation, or a combination of these.

•Management of reaction to internal fixation devices involves protection from

osteoporosis, altered bone structure, and trauma.

•Management of complex regional pain syndrome involves elevation of the

extremity, pain relief, range-of-motion exercises, and helping patients which
chronic pain, disuse atrophy, and osteoporosis. Avoid taking blood pressure or
performing venipuncture in the affected extremity.
Promoting Fracture Healing
•Provide pharmacologic and nonpharmacologic measures for pain
management.

•Monitor for signs of infection (if grafts were done, monitor the donor and
recipients sites)

•Provide patient education and reinforce information, avoidance of weight

bearing, wound care, signs of infiction, and follow-up care with the orthopedic
surgeon.

•For the patient receiving electrical stimulation for nonunion encourage

compliance with the treatment regiment. Include patient education regarding
daily use of the stimulator as prescribed and need for follow-up evaluation by
the orthopedist, who will evaluate the progression of bone healing with
periodic radiographic studies.
Managing Closed Fractures

•Encourage patients with closed (simple) fractures to return to their usual

activities as rapidly as possible, within the limits of the fracture
immobilization.

•Teach patients how to control swelling and pain associated with the fracture
and soft tissue trauma

•Teach exercises to maintain the health of unaffected muscles and to

strengthen muscles needed for transferring and for using assistive devices
(eg. Crutches, walker)

•Teach patient how to use assistive devices safely.

•Arranged to help patients modify their home environment as needed and to

secure personal assistant if necessary.

•Provide patient teaching, including self-care, medication information,

monitoring for potential complications, and the needed for continuing health
care supervision.
Managing Open Fractures
• The objectives of management are to prevent infection of the wound, soft tissue, and
bone and to promote healing of soft tissue and bone. In an open fracture, there is the
risk of osteomyelitis, tetanus, and gas gangrene.

• Administer tetanus prophylaxis.

• Perform serial irrigation and debridement to remove anaerobic organsisms.

• Administer intravenous antibiotics to prevent or treat infection.

• Perform aseptic dressing changes with sterile gauze to permit swelling and wound
drainage, with wound irrigation and debridement as ordered.

• Provide, or teach patient and family to perform, wound care to flap or skin graft after the
wound is closed in 5 to 7 days.

• Elevate, and teach patient and family to elevate, the extremity to minimize edema.

• Assess neurovascular status frequently.

• Take the patients temperature at regular intervals, and monitor for signs temperature at
regular intervals and monitoring for signs of infection.

• Promote intake of adequate nutrition to promote wound healing.

Managing fractures at Specific Sites
Maximum functional recovery is the goal management.

Clavicle

Humerus

Elbow

Wrist

Hand and Fingers

Rib

Pelvis

Tibia and Fibula

Femur and Hip

Assessment
Asses the elderly patient for chronic conditions that require close monitoring. Examine
the legs for edema due to congestive heart failure, and assess for peripheral
pulselessness from arteriosclerotic vascular disease.

Nursing Diagnoses
•Pain related to fracture, soft tissue damage, muscle spasm, and surgery
•Impaired physical mobility related to fractured hip
•Impaired skin integrity related to surgical incision
•Risk for impaired urinary elimination related to immobility
•Risk for disturbed thought process related to age, stress of trauma, unfamiliar
surroundings, and drug therapy
•Risk for ineffective coping related to injury, anticipated surgery, and dependence
•Risk for impaired home maintenance related to fractured hip and impaired mobility
Collaborative Problems/Potential Complications
•Hemorrhage
•Pulmonary complications
•Neurovascular compromise
•Deep vein thrombosis
•Pressure ulcers

Planning and Goals

Major goals may include relief of pain, achievement of a functional stable hip, wound
healing, maintenance of normal urinary elimination patterns, use of effective coping
mechanisms to modify stress, oriented and participating in decision making, ability to
care for self at home, and absence of complications.

Relieving Pain

Promoting Hip Function and Stability

Promoting Wound Healing

Promoting Skin Integrity

Promoting normal urinary elimination patterns

Promoting patient orientation and participation in decision making

Promoting effective coping mechanisms

Monitoring and preventing potential complications

Promoting home and community-based care

Evaluation
•Expected patient outcomes
•Reports pain relief
•Engages in therapeutic positioning
•Exhibits normal wound healing and intact skin
•Maintains normal urinary elimination pattern
•Remain oriented and participates in decision making
•Demonstrates use of effective coping mechanisms
•Establishes effective communication
•Experiences no complications.
 BIBLIOGRAPHY
Black, J.M. & Jacobs, E.M. (1997). Medical-surgical nursing clinical
management for continuity of care. 5th ed. Philadephia: W.B. Saunders
Company.

Johnson, J.Y. (2008). Handbook for Brunner & Suddarth’s textbook of medical-
surgical nursing. 11th ed. Philadelphia: Lippincott Williams & Wilkins.

Mosby. (2002). Mosby’s pocket dictionary of medicine, nursing, and allied

health. 4th ed. Singapore: Elsevier Science Pte Ltd

Porth, C.M. (1998). Pathophysiology concepts of altered health states. 5th ed.
Philadelphia: Lippincott.

Seely, R.R., et al (2007). Essentials of anatomy and physiology. 6th ed. New
York, USA: McGraw-Hill Companies, Inc.

Smeltzer, S. C. & Bare, B. G. (2008). Brunner & Suddarth’s textbook of medical-

surgical nursing. (11th ed). Philadelphia: Lippincott Williams & Wilkins.