FRACTURES

Maureen G. Cristobal

FRACTURE
in the continuity of bones  Due to stress greater than the bone can absorb
 Break

Causes
 Direct

blows  Crushing forces  Sudden twisting motions  Extreme muscle contraction  Pathologic conditions- osteoporosis, conditionsosteosarcoma

Pathology of fractures
Periosteum and blood vessels in the cortex, marrow, and surrounding soft tissues are disrupted  Hematoma forms in the medullary canal between the fracturd ends of the bone and beneath the periosteum  Bone tissue immediately adjacent to the fracture dies  Tissue necrosis will stimulate inflammatory response


Fracture patterns

Closed/simpleClosed/simple- a fracture with intact skin over the fracture site  Open/compound- there is a break in the Open/compoundskin over the fracture site;  Grade I- clean skin puncture with Iminimal tissue damage  Grade II- with skin and muscle IIcontusion, no extensive tissue damage  Grade III- wound >6-8cm, with III>6extensive soft tissue damage including blood vessels and nerves

Fracture patterns
 CompleteComplete-

break along the entire crosscross-section of the bone  Incomplete/partial- bone continuity Incomplete/partialis not entirely disrupted; e.g. Greenstick fracture

 DisplacedDisplaced-

fracture fragments are separated at the fracture site  Comminuted- bone is fragmented Comminutedinto several pieces

 DepressedDepressed-

fragments are driven inward e.g. skull fracture  Impacted/ telescoped- one fragment telescopedis drawn into the other fragment

Compression fracture

Fracture patterns

Fracture patterns

Stellate fracture

Direction of fracture
 LinearLinear-

fracture line runs parallel to the bones long axis  Oblique- fracture line is at oblique Obliqueangle to the bone shaft  Longitudinal- fracture line extends Longitudinallongitudinally

Direction of fracture
 TransverseTransverse-

fracture line is at right angle to the bones long axis  Spiral- fracture line twists around the Spiralshaft of the bone  Stellate- central fracture point with Stellateseveral fissures radiating outwards

Clinical manifestations


1. Pain and tenderness continuous and increasing in intensity due to muscle spasm 2. Loss of function

3. Preternatural mobility abnormal or exaggerated mobility due to instability of the fracture

4. Deformity  visible or palpable  due to strong muscle pull which may cause the bone fragments to override 5. Shortening of the limb  due to muscle contraction above and below the site of fracture 6. Crepitus  grating sensation felt as injured parts are moved against each other

7. Swelling and discoloration/bruising EcchymosisEcchymosis- due to trauma and bleeding into the tissues

EMERGENCY MANAGEMENT
 Immobilize

before transport  Cover open fractures  Do not attempt to reduce the fracture

MEDICAL MANAGEMENT


Reduction
Setting the bone Restoring the fragments into anatomic alignment

Closed reduction  Manipulation, manual traction  Cast; splint  Skin or skeletal traction  Open reduction  Surgical approach with internal fixators


External fixator

CAST

TRACTION

Internal fixators

Immobilization  Bone must be immobilized and held in correct position until bone healing occurs  Methods:
Bandages Cast Splints Traction External fixators Metal implants

NURSING MEASURES
 Institute

measures to reduce swelling

Protect Rest; immobilize Ice Compress Elevate

Perform neurovascular assessment regularly Encourage participation in ADLs ExerciseExercise- if swelling has already subsided

BONE HEALING
 Healing

timetime- depends on type of fracture, type of bone and the location of the fracture  Spongy bone heals more rapidly than compact bone because of rich blood supply  Bones in the arms heals more easily than those in the lower extremities

STAGES OF BONE HEALING

 Hematoma

and inflammation  Angiogenesis and cartilage formation (callus formation)  Cartilage calcification  Cartilage removal  Bone formation  remodeling

Bone healing

Fracture healing

 Where

does healing occur?

Bone marrow Periosteum- hard callus, soft callus Periosteum External soft tissue- bridging callus tissue-

COMPLICATIONS
Early complications  Shock
Hemorrhagic (hypovolemic) and traumatic shock Due to loss of fluids into damaged tissues S/Sx: cold clammy skin; weak, thready pulse; hypotension

Fat embolism syndrome



Occurs when marrow pressure becomes greater than capillary pressure Catecholamines also play a role by stimulating fatty acids which will form into fat globules in the bloodstream Occurs within 24-72 hours or within a 24week

S/Sx:  Hypoxia  Tachypnea  Tachycardia  Respiratory distress- chest pain, dyspnea, distresswheezes or crackles, thick white sputum, increased RR and HR, deteriorating sensorium  Respiratory distress may lead to pulmonary edema and later to congestive heart failure

Prevention and management:

Immediate immobilization of the fracture Minimal manipulation

-Religious monitoring for signs and symptoms

Compartment syndrome


Due to decreased perfusion caused by constricting casts, or edema and hemorrhage within a compartment Characterized by deep, throbbing, unrelenting pain unrelieved by opioid analgesics

Management:
Elevate extremity above heart level Release restrictive devices or bandages Fasciotomy Perform neurovascular assessment regularly

FASCIOTOMY

Deep venous thrombosis/ Pulmonary embolism  Due to decreased muscle contraction and prolonged immobilization Infection  Gas gangrene- caused by anaerobic gangrenebacteria  Treatment involves opening the wounds widely to admit air and permit drainage

GAS GANGRENE

Volkmans Ischemic contracture  Arises in the hand or forearm; due to a compartment syndrome that compromises arterial and venous circulation  The end result is permanent, clawclawlike deformity of the arm and hand

Volkmanns contracture

Late complications

 Delayed

union

Healing does not occur at a normal rate expected for the location and type of fracture

Delayed union
 Causes:
 Inaccurate

reduction  Inadequate or interrupted immobilization  Severe local trauma  Impaired bone circulation  Infection  Loss of bone substance  Distraction or separation of bone fragments

NonNon-union


Failure of the ends of a fractured bone to unite Characterized by persistent discomfort and abnormal movement at fracture site

NonNon-union
 Causes:

Infection Interposition of tissue between bone ends Inadequate immobilization Disruption of callus formation

NonNon-union
Management:
 Internal

fixation  Bone grafting

NonNon-union

Bone grafting

Bone grafting

Malunion Healing of a fracture site with an increased degree of angulation or deformity Managed by adjustment of traction or reimmobilization

Malunion

Avascular necrosis  Due to disrupted blood supply  Common in femoral neck fracture

Avascular necrosis

Reaction to internal fixation device Complex regional pain syndrome  Pain  Edema  Stiffness  Discoloration  Vasomotor/trophic skin changes  Atrophy of muscle around the area

Heterotropic ossification  Ossification of soft tissues, commonly muscles, around a fracture site after it has healed

HIP FRACTURE
 Most

hip fractures occur at the femoral neck, intertrochanteric region, and subtrochanteric region in the elderly due to decreased postural stability and decresed bone mass, leading to higher incidence of falls

 Common

HIP FRACTURE

2 types  1. intracapsular  2. extracapsular

Femoral neck fracture

Femoral neck fractures are difficult to consolidate because it lies entirely within the joint capsule and therefore has no periosteum  Arterial blood supply to the femoral head is usually disrupted by fracture fragments  Predisposed to non-union and avascular nonnecrosis


Intertrochanteric fracture
comminuted and more osteoporotic  This portion has a periosteum
 Usually

Clinical manifestation
 shortened

and externally rotated hip, ecchymosis

Medical management:
 skin

traction  blood transfusion as necessary

Surgical management
Knowles pin- full weight-bearing is not pinweightallowed because the pin does not pull the fracture fragments together  Jewett nail- stronger than Knowles pin, nailpatient can bear weight after the surgery  Sliding nail/compression screwscrewcommonly used; draws fracture fragments together; also used for intertrochanteric fracture


Surgical management
 Partial

hip replacement  total hip replacement

IM NAILING

Nailing with plating

SCREW

Femoral shaft fracture  Management:  Immobilize  ORIF  Skeletal traction

PELVIC FRACTURE
Fracture involving any of the pelvic bones; this is a serious condition that requires immediate attention In the elderly, this is usually caused by falls; the worst cases, however are caused by major impacts to the body such as vehicular accidents or falls from high places Manifestations: pain on the pelvis, pain with walking, or unable to walk

Management:  Unstable, weight-bearing fractureweightfractureexternal fixators through open reduction  Stable, non-weight bearing fracturenonfracturetraction and bedrest

MALGAIGNE

THANK YOU!