BRIEF DESCRIPTION OF THE DISEASE

FRACTURE
Fracture is a complete or incomplete disruption in the continuity of bone structure and is
defined according to its type of extent.
Fractures occur when the bone is subjected to stress greater than it can absorb.
Types of fracture

Open fracture
- Is one in which the skin or mucous membrane wound extends to the fractured bone.
Open fractures are graded according to the following criteria:
* Grade I is a clean wound less than 1 cm long.
* Grade II is a larger wound without extensive tissue damage.
* Grade III is highly contaminated, has extensive soft tissue damage, and most severe.
Closed fracture
- Is one that does not cause a break in the skin.
Complete fracture
- Involves a break across the entire cross section of the bone and is frequently
displaced (removed from its normal position).
Incomplete fracture
- Involves a break through only part of the cross section of the bone.

Risk factors:

Bone trauma
Sport related injuries
Old age
Falls
Malnutrition and other diseases

Causes:

Direct blows
Crushing forces
Sudden twisting motion
Extreme muscle contraction.

Clinical Manifestation

Acute Pain
Loss of function
Deformity
Shortening
Crepitus
Localized edema and ecchymosis
Other manifestations:
- Soft tissue edema
- Hemorrhage into the muscles and joints

Joint dislocations and Ruptured tendon

Damaged blood vessels

Diagnostic Test

X-rays which provide clear images of bone. X-rays can show whether a bone is intact or
broken. They can also show the type of fracture and where it is located within the femur. To
make sure no other breaks are missed, your hip and ankle joints will also be x-rayed.

Computed tomography (CT) scan shows a cross-sectional image of the limb. It can provide
valuable information about the severity of the fracture. This scan can show whether the
fracture enters the joint surface and, if so, how many pieces of bone there are.

Emergency Management

Immobilize any suspected fracture.

Support the extremity above and below when moving the affected part from the vehicle.
Adequate splinting is essential, suggested temporary splints- hardboard, stick, rolled sheets.
Apply sling if forearm fracture is suspected or the suspected fractured arm maybe bandaged
to the chest.
Open fracture is managed by covering a clean or sterile gauze to prevent contamination.
Do not attempt to reduce the fracture.

Medical Management
Reduction - refers to restoration of the fracture fragments to anatomic alignment and positioning.
Either closed reduction or open reduction may be used to reduce a fracture.

Closed reduction- is accomplished by bringing the bone fragments into anatomic alignment
through manipulation and manual traction. The extremity is held in the aligned position while
the physician applies a cast, splint or other device.
Open reduction- through a surgical approach, the fracture fragments are anatomically
aligned. Internal fixation devices (metallic pins, wires, screws, plates, nails, or rods) maybe
used to hold the fragments until solid bone healing occurs.

Immobilization
After the fracture has been reduced, the bone fragments must be immobilized and maintained
in proper position and alignment until union occurs. Immobilization maybe accomplished by external
or internal fixation.
Maintaining and restoring function

Isometric and muscle-setting exercises are encouraged to promote circulation.

Participation in activities of daily living is encouraged to promote independent functioning
and self-esteem.
Gradual resumption of activities is promoted within the therapeutic prescription.

Nonsurgical Treatment

Skeletal traction traction is a pulley system of weights and counterweights that holds the
broken pieces of bone together. A pin is placed in a bone to position the leg.

Casting and bracing. Casts and braces hold the bones in place while they heal. In many cases
of distal femur fracture, however, a cast or brace cannot correctly line up the bone pieces
because shortened muscles pull the pieces out of place. Only fractures that are limited to two
parts and are stable and well aligned can be treated with a brace. Casts and braces can also be
uncomfortable.

General nursing management:

Closed fracture

Assist in reduction and immobilization.

Administer pain medications and muscle relaxants.
Teach patient in caring for the cast.
Teach patient about potential complication of fracture and to report infection and continuous
pain.

Open fracture

Prevent wound and bone infection.

Administer prescribed antibiotics and tetanus prophylaxis.
Assist in serial wound debridement.
Elevate the extremity to prevent edema formation.
Administration of traction and cast.

Factors that enhance fracture healing

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2.
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Immobilization of fracture fragments

Maximum bone fragment contact
Sufficient blood supply
Proper nutrition
Exercise: weight bearing for long bones
Hormones: growth hormone, thyroid, calcitonin, vitamin D, and anabolic steroids
Electric potential across fractures

Factors that affect healing process:

1.
2.
3.
4.
5.
6.
7.
8.
9.

The extent of damage to the bone and soft tissue.

The approximation of the ends of the bones.
The presence of secondary problem.
The involvement of systemic factors.
Bone loss
Inadequate immobilization
Corticosteroids
Age (elderly persons heal more slowly)
Infection

Early Complications of fracture:

Shock

- Hypovolemic shock resulting from haemorrhage is more frequently in trauma patients with
pelvic fractures and in patients with a displaced or open femoral fracture in which the femoral
artery is torn by bone fragments.

Fat embolism syndrome

- FES is more common in patients with multiple fractures. At the time of fracture, fat
globules may diffuse from the marrow into the vascular compartment. The fat globules may
occlude the small blood vessels that supply the lungs, brain, kidneys, and other organs.
Compartment syndrome
- Compartment syndrome in an extremity is a limb-threatening condition that occurs
when perfusion pressure falls below tissue pressure within a closed anatomic compartment.

Delayed Complications:

Delayed union, Malunion, and Non-union

- Delayed union occurs when healing does not occur within the expected time frame
for the location and type of fracture. Non-union results from failure of the ends of a fractured
bone to unite, whereas Malunion results from failure of the ends of a fractured bone to unite
in normal alignment.
Avascular Necrosis of Bone
- AVN Occurs when the bone loses its blood supply and dies. It may occur after a
fracture with disruption of the blood supply to the distal area. The patient develops pain and
experiences limited movement. X-rays reveal loss of mineralized matrix and structural
collapse.
Reaction to internal fixation devices
- Problems may include Mechanical failure; material failure; corrosion of the device;
causing local inflammation; allergic response to the metallic alloy used; and osteoporotic
remodelling adjacent to the fixation site.
Complex regional pain syndrome
- CPRS is painful sympathetic nervous system problem. This syndrome is frequently chronic,
with extension of symptoms to adjacent areas of the body.

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.
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 correct
homeostatic disturbances is essential.

Compartment syndrome is managed by controlling swelling by elevating the extremity to

heart level or by releasing restrictive devices.
Nonunion is treated with internal fixation, bone grafting, electronic bone stimulation, or a
combination of these
Reaction to internal fixation devices involves protection from osteoporosis, altered bone
structure, and trauma.
Complex regional pain syndrome involves elevation of the extremity, pain relief, range-ofmotion exercises, and helping patients with chronic pain, disuse atrophy, and osteoporosis.
Hip Fracture
Elderly people who have low density from osteoporosis and who tend to fall frequently have
a high incidence of hip fracture. Weak quadriceps muscles, generally frailty due to age, and
conditions that produce decreased cerebral arterial perfusion contribute to the incidence of falls.
**Mortality rate 1 year post- hip fracture range between 12% to 32 %. (Schoen, 2006).
Two major types of Hip fracture
1. Intracapsular fractures
- Fractures of the neck and the femur.
- Fracture of the neck of the femur may damage the vascular system that supplies blood to
the head and the neck of the femur, and the bone may become ischemic. For this reason,
AVN is common in patients with femoral neck fracture.
2. Extracapsular fractures
- Fracture of the trochanteric region (between the base of the neck and the lesser trochanter
of the femur) and the subtrochanteric region.
- Extracapsular fractures have an excellent blood supply and heal more rapidly; however,
extensive tissue damage may occur at the time of injury.
Clinical manifestations of intracapsular fractures

Leg is shortened, adducted, and externally rotated.

Pain in the hip and groin or in the medial side of the knee.
The patient cannot move the leg without a significant increase in pain.
The patient is more comfortable with the leg slightly flexed in external rotation.

Medical Management

Bucks extension traction a type of temporary skin traction, maybe applied to reduce spasm,
to immobilize the extremity, and to relieved pain.

** The goal of surgical treatment of hip fracture is to obtain a satisfactory fixation so that the
patient can be immobilized quickly and avoid secondary medical problems.
Surgical treatment consists of:

Open or closed reduction of the fracture and internal fixation.

Replacement of the femoral head with prosthesis (hemiarrthroplasty/Partial Hip
Replacement).

It is a surgical procedure where only the femoral head (the ball) of the damaged hip joint
is replaced. The acetabulum (the socket) is not replaced. By contrast, in total hip
replacement, the acetabulum is replaced with a prosthetic. Broken and fractured hips
traumatic hip injury are the primary reason for partial hip replacement.

**Austin Moore prosthesis- an artificial substitute for a missing part, used for functional reasons.

Closed reduction with percutaneous stabilization for an intracapsular fracture.

**surgical intervention is carried out as soon as possible after injury. The preoperative objective is
to ensure that the patient is in a favourable condition as possible for surgery. Displaced femoral
neck fractures are treated as emergencies with reduction and external fixation performed within 12
to 24 hours after fracture. The femoral head is often replaced with prosthesis if there is a complete
disruption of blood flow to the femoral head, which may cause AVN.
** After general or spinal anesthesia, the hip fracture is reduced under x-ray visualization. A stable
fracture is usually fixed with nails, a nail and plate combination, multiple pins, or compression
screw devices. The orthopaedic surgeon determines the specific fixation device based on the fracture
site or sites. Adequate reduction is important for fracture healing: the better the reduction, the better
the healing.
Nursing Management
The immediate post-operative care for a patient with a hip fracture is similar to that for other patients
undergoing major surgery.

Attention is given to pain management, prevention of secondary medical problems, and early
mobilization of the patient so that independent functioning can be restored.
The nurse encourages deep breathing and dorsiflexion exercises every 1 to 2 hours.
Thigh-high anti-embolism stockings or pneumatic compression devices are used.
Anticoagulants are administered as prescribed to prevent the formation of thromboemboli.
The nurse administers prescribed prophylactic IV antibiotics and monitor he patients
hydration, nutritional status and urine output.
A pillow placed between the legs is essential to maintain abduction and alignment and
provide needed support when turning the patient.
Repositioning the patient. The most comfortable and safest way to turn the patient is to turn
to the uninjured side.
Promoting exercise. The patient is encouraged to exercise as much as possible by means of
the over bed trapeze.

Health promotion

Osteoporosis screening of patients who have experienced hip fracture is important for
prevention of future fractures. With dual-energy x-ray absorptiometry (DXA) scan testing, the
risk for additional fracture can be predicted.
Specific patient education regarding dietary requirements, lifestyle changes, and weight
bearing exercise to promote health is needed.
Specific therapeutic interventions need to be initiated to slow bone loss and to build bone
mineral density.
Prevention of falls is also important and maybe achieved through exercises to improve
muscle tone and balance and through the elimination of environmental hazards.