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Etiology and Pathophysiology Breaks in the continuity of bone, usually accompanied by localized tissue response and muscle spasm. Cause usually trauma, but pathologic fractures may occur as a result of osteoporosis, multiple myeloma, or bone tumors, which weaken bone structure. Types

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Complete fracture bone completely separated into two parts, may be transverse or Incomplete fracture only part of the bone broken. Comminuted fracture bone broken into several fragments. Greenstick fracture splintering on one side of the bone, with bending of the other side; occurs only in p;iable bones, usually in children. Simple (closed) fracture bone broken but no break in the skin. Compound (open) fracture break in the skin at the time of fracture with or without protrusion of the bone. Stages of bone healing include:

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Formation of a hematoma Followed by cellular proliferation And callus formation by the osteoblasts Ossification Remodeling of the callus

Signs and Symptoms Subjective

Pain aggravated by motion Tenderness

Objective Loss of motion Edema Crepitus Ecchymosis

Diagnostic Procedure X-ray examination reveals break in continuity of bone Deformity caused by change in bone alignment; often results in shortening of the extremity.

Assessment 1. Ability of the client to move extremity. 2. Altered appearance of involved body part. 3. Neurovascular assessment, soft tissue injury or edema may compromise circulatory or neurologic functioning. 4. Factors precipitating injury. 5. Nutritional status. Nursing Diagnosis Disturbed body image

Constipation Fear Risk for injury Pain Impaired physical mobility Altered role performance Self-care deficits Risk for skin integrity

Nursing Interventions 1. Evaluate the clients general physical condition 2. Splint extremity in position found before moving the client; consider all suspected fractures until X-ray films are available. 3. Cover open wound with sterile dressing if available. 4. Observe for signs of emboli, severe chest pain, dyspnea, pallor, and diaphoresis. 5. Observe for signs of circulatory impairment such as change in skin temperature or color, numbness and tingling, unrelieved pain, decrease in pedal pulse, prolonged blanching of toes after compression or inability to move toes. 6. Protect the cast from damage until dry by elevating it on a pillow. 7. Promote drying of the cast by leaving it uncovered; a light may be used with care to promote drying. 8. Maintain bed rest until the cast is dry and ambulation is permitted. 9. Observe for swelling and notify the physician if necessary. 10. Check that weights are hanging freely and that the affected limb is not resting against anything that will impede the pull of the traction. 11. Maintain in proper alignment. 12. Observe for foot drop on clients with Russel traction or Bucks extension, since this may indicative of nerve damage. 13. Observe for signs of thrombophlebitis. 14. Encourage high protein, high vitamin diet to promote healing. 15. Encourage fluids to help prevent constipation, renal calculi, and urinary tract infection. 16. Teach isometric exercises to prevent muscle strength and tone for crutch walking.

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Teach appropriate crutch-walking technique; non-weight bearing; weight bearing progressing to use of cane. Complications Early 1. Shock 2. Fat embolism syndrome 3. Compartment syndrome 4. Deep vein thrombosis 5. 6. Delayed 1. 2. 3. Thromboembolism Pulmonary embolus Delayed union and nonunion Avascular Necrosis Reaction to Internal Fixation devices Complex Regional Pain Syndrome Heterotrophic Ossification

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Ortolani and Barlow Test Congenital hip dysplasia is the improper formation and function of the hip socket. Detecting developmental or congenital hip dysplasia in newborns is essential because the longer the condition goes undetected and untreated, the more difficult it is to correct. Assessment and examination in newborns is vital to detect congenital hip dysplasia. Early detection promotes timely intervention to any abnormality noted in infants. Nurses should have extensive knowledge on these assessment tests to start an early treatment just as early as the condition was suspected. Ortolani Test (steps 1-5) Ortolani test or Ortolani Maneuver is a physical examination for congenital hip dysplasia or developmental hip dysplasia. The test was named after Marino Ortolani, the person who developed it in 1937. The maneuver is performed by abducting the infants hip an assessing for a clicking sound. This test is used to detect the posterior dislocation of the hip. A positive Ortolanis sign is noted when a clicking or distinctive clunk is heard when femoral head re-enters the acetabulum. Ortolani maneuver is performed before 2-3 months of age. The maneuver is done in early infancy because after 2-3 months the development of soft tissue contracture prevents the hip from being relocated, thus, no clicking or clunking sound will be assessed in children with congenital hip dysplasia. Barlow Test (steps 6 and 7) Barlow test is a maneuver performed by bringing the thigh towards the midline of the body. Feeling of femoral head slipping out of the socket postolaterally, is considered as a positiveBarlows sign. The Ortolani test is then used to confirm that the hip is actually dislocated. Procedure

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Lay the infant in a supine position and flex the knee to 90 degrees at the hips. Proper positiong of the infant ensures accurate results. Hold the infants pelvis with one hand to stabilize it during manipulation.

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Using the other hand, the place the middle fingers over the great trochanter of the femur and the thumb on the internal side of the thigh over the lesser trochanter. Placing the fingers in this manner allows easy abduction of the hips. Slowly and gently abduct the hips while applying pressure over the greater trochanter. The femur is pulled forward while the greater trochanter is used as a fulcrum. Listen for a clicking or clunking sound while performing step number four. Normally, no sound is heard. A clicking or clunking sound is a positive Ortolanis sign and it happens when the femoral

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head is re-entering the acetabulum. With the fingers in the same position, assess the infant for Barlows sign. Hold the hips and knees at 90 degree flexion while exerting a backward pressure (down and laterally). Slowly and gently adduct (bringing the thigh towards the midline) the hip. Note any feeling of the femoral head slipping. Normally, the hip joint is stable. The feeling of the femoral head slipping out of the socket postolaterally is a positive Barlows sign.