Fracture – Safety of the client during transfer

Fracture Possible Complications:

– A break in the continuity of the bone. They occur when – Fat Embolus
the physical force – Compartment Syndrome
exerted on the bone is stronger than the bone itself. – Nonunion of the fracture side
Other Name of fracture: – Arterial damage during treatment
– Broken Bone – Infection
– Bone fracture – Sepsis
There are many types of fractures: – Hemorrhage leading to shock
1. Closed simple/ uncomplicated fracture 5 Nursing Diagnosis
 bone breaks but there is no puncture or open wound in 1. Pain related to fracture, soft tissue damage, muscle
the skin. spasm and surgery.
1. Open compound/ complicated fracture 2. Impaired physical mobility related to fractured hip
 Involves trauma to surrounding tissue and a break in 3. Impaired skin integrity related to surgical incision
the skin. 4. Risk for disturbed thought process related to age,
1. Comminuted fracture stress of trauma, unfamiliar
 a fracture in which the bone fragments into several surroundings and drug theraphy
pieces. 5. Risk for impaired urinary elimination related to
1. Greenstick fracture immobility
 an incomplete fracture in which the bone is bent. This
type occurs Fractures
most often in children. A. Description: A fracture is any disruption in the normal
1. Spiral ( torsion) continuity of a bone caused by trauma, twisting
 Involve a fracture of twisting around the shaft of the as a result of muscle spasm or indirect loss of leverage
bone. or bone decalcification and disease that result in
1. Transverse osteopenia.
 Occurs straight across the bone B. Specific Types of Fractures (taken from Brunner &
1. Oblique Suddarth’s)
 Occur at an angle across the bone (less than a a. Avulsion: A fracture in which a fragment of bone has
transverse) been pulled away by a ligament or tendon
1. Pathological Fracture and its attachment
 Result from weakness in bone tissue. b. Comminuted: A fracture in which bone has splintered
Causes/Etiology into several fragments
-Crushing force or direct blow c. Compound: A fracture in which damage also involves
-Torsion fracture can occur from sudden twisting the skin or mucous membranes; also
-Extremely forceful muscle contraction called an open fracture
Predisposing Risk factor d. Compression: A fracture in which bone has been
-Age- aging process compressed (seen in vertebral fractures)
- Sex e. Epiphyseal: A fracture through the epiphysis
-Pathology- Paget’s disease, Osteomyelitis, Ricket’s f. Greenstick: A fracture in which one side of a bone is
Sign and Symptoms broken and the other side is bent
- 5 P’s g. Impacted: A fracture in which a bone fragment is
1. Pain driven into another bone fragment
2. Pallor h. Oblique: A fracture occurring at an angle across the
3. Paresthesia bone (less stable than a transverse fracture)
4. Polar i. Pathologic: A fracture that occurs through an area of
5. Pulselessness diseased bone (eg. Osteoporosis, bone cyst,
- Edema Paget’s disease, bony metastasis, tumor); can occur
- Tenderness without trauma or a fall
- Abnormal movement j. Simple: A fracture that remains contained; does not
- Crepitus break the skin
- Loss of Function k. Spiral: A fracture that twists around the shaft of the
- Ecchymoses bone
- Visible deformity l. Stress: A fracture that results from repeated loading
Patophysiology: without bone and muscle recovery
Diagnostic Studies m. Transverse: A fracture that is straight across the bone
– An x-ray examination is used to determine the C. Clinical manifestations
presence of a fracture. Not all of these clinical manifestations are present in
Medical Management every fracture.
- a. Pain: The pain is continuous and increases in severity
Surgical management until the bone fragments are immobilize.
Nursing Management b. Deformity: Swelling from local hemorrhage may cause
– RICES Management deformity at the fracture site. Muscle
R- Rest spasm can cause limb shortening, a rotational deformity
I- Ice Compress or angulation. Compared with the
C- Cast uninjured side, the fracture site may also have obvious
E- Elevation deformity.
S- Safety c. Bruising (ecchymosis). Bruising develops from
– Give meds as ordered subcutaneous bleeding at the fracture site
– Prevent infection d. Musce spasm: Frequently accompanying fractures,
– Cover any breaks in the skin with clean or sterile involuntary muscle spasm actually serves as
dressings
a natural splint to decrease further motion of fracture
fragments.
e. Loss of function: Any loss of function results either
from pain caused by the fracture or from
loss of the lever-arm function in an affected extremity.
Paralysis may be caused by nerve
damage.
f. Abnormal mobility and crepitus: When the extremity is
examined with the hands, a grating
sensation, called crepitus, can be felt. It is caused by the
rubbing of the bone fragments against
each other.
g. Neurovascular changes: Neurovascular injury results
from damage to peripheral nerves or to the
associated vascular structures. The client may complain
of numbness and tingling or have no
palpable pulse distal to the fracture.
h. Shock: Bony fragments may lacerate blood vessels.
Frank or occult hemorrhage can lead to
shock.
D. Complications of fractures
I. Fat embolism
1. Description: A fat embolism originates in the bone
marrow and occurs after a
fracture when a fat globule is released in to the
bloodstream.
• Clients with long bone fractures are at the greatest risk
for the development of
a fat embolism
• Fat embolism can occur with the first48 to 72 hours
following the injury
2. Assessment: Findings often suggest pulmonary
embolism
• Restlessness, hypoxemia, or mental status changes
• Tachycardia and hypotension
• Dyspnea and tachypnea
• Petechial rash over the upper chest and neck
3. Interventions
• Notify the physician immediately while initiating
emergency care
• Treat symptoms as prescribe to prevent respiratory
failure and death
• Cortiscosteroids may be given to reduce pulmonary
injury
II. Compartment syndrome
1. Description
• Tough fascia surrounds muscle groups, forming
compartments from which
arteries, veins and nerves enter and exit opposite ends
• Compartment syndrome occurs when pressure
increases within one or more
compartments, leading to decreased blood flow, tissue
ischemia and
neurovascular impairment
• Within 4 to 6 hours after the onset of compartment
syndrome, neurovascular
damage is irreversible if not treated
2. Assessment
• Unrelieved or increased pain in the limb
• Tissue that is distal to the involved area becomes pale,
dusky or edematous
• Pain with passive movement and joint dysfunction
• Pulselessness and loss of sensation (paresthesia)
3. Interventions
• Notify the physician immediately and prepare to assist
physician
• If severe, assist the physician with fasciotomy to
relieve pressure and restore
tissue perfusion
• Loosen tight dressing or bivalve restrictive cast as
prescribed
III. Infection and osteomyelitis
1. Description: Infection and osteomyelitis can be caused
by the introduction of
organisms into bones initially leading to localized bone
infection
2. Assessment
• Tachycardia and fever (usually above 101 F)
• Erythema and pain in the area surrounding the
infection
• Leukocytosis and elevated ESR
3. Interventions
• Notify the physicians
• Prepare to initiate aggressive, long-term intravenous
antibiotic therapy
• Administer hyperbaric oxygen therapy to promote
healing
• Surgery is performed for resistant osteomyelitis with
sequestrectoy and/or
bone grafts
IV. Avascular necrosis
1. Description: Avascular necrosis occurs when a fracture
interrupts the blood supply to
a section of bone, leading to bone death
2. Assessment:
• Pain
• Decreased sensation
3. Interventions
• Notify the physician if pain or numbness occurs
• Prepare the client for removal of necrotic tissue
because it serves as a focus
for infection
V. Pulmonary embolism
1. Description: Pulmonary embolism is caused by the
movement of foreign particles
(blood clot, fat or air) into the pulmonary circulation
2. Assessment
• Restlessness and apprehension
• Sudden onset of dyspnea and chest pain
• Cough, hemoptysis, hypoxemia or crackles
3. Interventions
• Notify the physician if signs of emboli are present
• Given oxygen IV anticoagulant therapy if prescribed
E. Emergency Management of Fractures
a. Immobilize affected extremity with cast or splint.
b. If a compound (open) fracture exists, splint the
extremity and cover the wound with a sterile
dressing.
c. Assess neurovascular status of the extremity
d. Interventions for a fracture are reduction, fixation,
traction and cast.
F. Medical Management of a Fracture
a. Reduction of a fracture restores the bone to proper
alignment.
i. Closed reduction is a nonsurgical intervention
performed by manual manipulation.
• Closed reduction may be performed under local or
general anesthesia
• A cast may be applied following reduction
ii. Open reduction involves surgical intervention
• Fracture may be treated with internal fixation devices.
• The client may be placed in traction or a cast following
the procedure.
b. Fixation
i. Internal fixation follows an open reduction
• Internal fixation involves the application of screws,
plates, pins, or intramedullary
rods to hold the fragments in alignment
• Internal fixation may involve the removal of damaged
bone and replacement with
a prosthesis
• Internal fixation provides immediate bone strength.
ii. External fixation is the use of an external frame to
stabilize a fracture by attaching
skeletal pins through bone fragments to a rigid external
support
• External fixation provides more freedom of movement
than with traction
• Monitor pin stability and provide pin care to decrease
infection risks
• Risk of infection exists with both fixation methods
• External is commonly used when massive trauma is
present
c. Traction
i. Description
• Traction is the exertion of a pulling force applied in two
directions to reduce and
immobilize a fracture
• Traction provides proper bone alignment and reduces
muscle spasms
ii. Interventions
• Maintain proper body alignment
• Ensure that the weights hang freely and do not touch
the floor
• Do not remove or lift the weights without a physician’s
order
• Ensure that pulleys are not obstructed and that ropes
in the pulleys move freely
• Place knots in the ropes to prevent slipping
• Check the ropes for fraying.
d. Skeletal traction
i. Description: Traction is applied mechanically to the
bone with pins, wires and tongs
ii. Interventions
• Monitor color, motion, and sensation of the affected
extremity
• Monitor the insertion sites for redness, swelling,
drainage or increased pain
• Provide insertion site care as prescribed
e. Skin traction
i. Description: Skin traction is applied by using elastic
bandages or adhesive.
ii. Cervical skin traction relieves muscle spasms and
compression in the upper extremities
and neck.
• Cervical skin traction uses a head halter and chin pad
to attach the traction
• Use powder to protect the ears from friction rub
• Position the client with the head of the bed elevated 30
to 40 degrees, and attach
the weights to a pulley system over the head of the bed.
iii. Buck’s (extension) skin traction is used to
alleviate muscle spasms and immobilize a
lower limb by maintaining a straight pull on the limb with
the use of weights.
• A boot appliance is applied to attach to the traction
• The weights are attached to a pulley; allow the weights
to hang freely over the
edge of bed.
• Not more than 8 to 10 lb of weight should be applied
• Elevate the foot of the bed to provide the traction
iv. Russell’s skin traction:
• Used to stabilize a fractured femur before surgery
• Similar to Buck’s traction but provides a double pull
using a knee sling that pulls
at the knee and foot
v. Pelvic skin traction is used to relieve low back, hip,
or leg pain or to reduce muscle
spasm.
• Apply the traction snugly over the pelvis and iliac crest
and attach to the weights
• Use measures as prescribed to prevent the client from
slipping down in bed.
f. Balanced suspension traction
i. Description
• Balanced suspension traction is used with skin or
skeletal traction
• Used to approximate fractures of the femur, tibia or
fibula
• Balanced suspension traction is produced by a
counterforce other than client
ii. Interventions
• Position the client in a low Fowler’s position on either
the side or the back.
• Maintain a 20-degree angle from the thigh to the bed
• Protect the skin from breakdown
• Provide pin care if pins are used with the skeletal
traction
• Clean the pin sites with sterile normal saline and
hydrogen peroxide or povidoneiodine
(Betadine) as prescribed or per agency policy.
g. Dunlop’s traction
i. Description: Horizontal traction is used to align
fractures of the humerus; vertical
traction maintains the forearm in proper alignment.
ii. Interventions: Nursing care is similar to that for Buck’s
skin traction.
h. Casts
i. Description: Plaster or fiberglass casts are used to
immobilize bones and joints into
correct alignment after a fracture or injury.
ii. Interventions
• Keep the cast and extremity elevated
• Allow a wet cast 24 to 72 hours to dry (synthetic casts
dry in 20 minutes)
• Handle a wet cast with the palms of the hands until dry
• Turn the extremity every 1 to 2 hours, unless
contraindicated, to allow air
circulation and promote drying of the cast.
• A hair dryer can be used on a cool setting to dry a
plaster cast (heat cannot be
used on a plaster cast because the cast heats up and
burns the skin)
• Monitor the extremity for circulatory impairment such
as pain, swelling,
discoloration, tingling, numbness, coolness or diminished
pulse.
• Notify the physician immediately if circulatory
impairment occurs
• Petal the cast; maintain smooth edges around the cast
to prevent crumbling of the
cast material
• Monitor for signs of infection such as temperature, hot
spots on the cast, foul
odor, or changes in pain
• If an open draining area exists on the affected
extremity, the physician will make
a cutout portion of the cast or a window.
• Instruct the client not to stick objects inside the cast
• Teach the client to keep the cast clean and dry
• Instruct the client in isometric exercises to prevent
muscle atrophy
1
BASICS OF FRACTURE
What is a fracture?
A fracture is a partial or complete break in the structural
continuity of bone. When a fracture
occurs, it is classified as either open or closed:
• Open fracture (Also called compound fracture.) -
The bone exits and is visible through
the skin, or a deep wound that exposes the bone through
the skin or one of the body
cavities breached.
• Closed fracture (Also called simple fracture.) -
The bone is broken, but the skin is
intact.
Fractures have a variety of names. Below is a listing of
the common types that may occur in
children:
• Greenstick - incomplete fracture. The broken bone is
not completely separated.
• Transverse - the break is in a straight line across the
bone.
• Spiral - the break spirals around the bone; common in
a twisting injury.
• Oblique - diagonal break across the bone.
2 benign causes
• Compression - the bone is crushed, causing the
broken bone to be wider or flatter in
appearance.
• Comminuted – there are more than two bony
fragments.
Describing a Fracture:
A systematic approach is needed:
• Type of fracture
○ Transverse
○ Spiral
○ Oblique
○ Simple etc
• Anatomical location
○ Which bone is affected?
○ Which side - left or right?
○ Is the fracture proximal, middle or distal?
○ Is it intra-articular or extra-articular
• Displacement of the fracture fragments
○ Shift
○ Alignment
3 • Bones are softer in children and tend to buckle or bend
○ Shortening
○ Rotation
• Associated fractures
○ Dislocation
○ Open or closed fracture etc.
Examples of describing a fracture
• "This is a oblique fracture of the mid-shaft of the right
tibia with no displacement"
• "This is a transverse fracture of the distal radius with
dorsal angulation"
Important Definitions
• Shift - loss of alignment in the cortices of the shaft of
the bone resulting onto sideways
displacement
• Angulation - loss of normal longitudinal axial
alignment of the shaft of the bone. This
may be anterior, posterior, medial or lateral
• Shortening - the bone appears shortened as a result
of overlap of the fracture fragments
or due to impaction at the fracture site
• Rotation - this refers to the rotation of the distal
fragment (relative to the proximal
fragment) along the long axis of the bone. This may be
external or internal
• Undisplaced - the fracture fragments are almost in
anatomical location
• Impacted fracture - a fracture that occurs as a result
of compression of cancellous bone
in its long axis causing two bone ends to be forced
tightly together.
What causes a fracture?
Fractures occur when there is more force applied to the
bone than the bone can absorb. Bones are
weakest when they are twisted.
Breaks in bones can occur from falls, trauma, or as a
result of a direct blow or kick to the body.
Fractures results from:
• A single traumatic incident. Breaks in bones can occur
from falls, trauma, or as a result of
a direct blow or kick to the body.
• Repetitive stress
• Abnormal weakening of the bone (Pathological
fracture).
Pathological fractures:
4
Fractures occur in bones which have been weakened
already due to a pathological process.
Causes of pathological fractures can be classified into
generalised bone conditions or local
General bone conditions
• Osteogenesis imperfecta
• Post-menopausal osteoporosis
• Metabolic bone disease
• Paget's disease
Local benign causes
• Chronic infection of bone
• Solitary bone cysts
• Aneurysmal bone cysts
• Chondromas
Primary bone tumours such as chondrosarcomas,
osteosarcomas and Ewing's sarcoma are all
causes of pathological fractures and may metastasise to
the breast, kidney, lung, prostate and
thyroid.
A child's bone differs from adult bone in a variety
of ways:
• A child's bone heals much faster than an adult's bone.
The younger the child, the
faster the healing occurs.
rather than completely break.
• Children have open growth plates, also called
epiphysis, located at the end of the long
bones. This is an area where the bone grows. Injury to
the growth plate can lead to
limb length discrepancies or angular deformities.
What are the symptoms of a fracture?
The following are the most common symptoms of a
fracture. However, each child may
experience symptoms differently. Symptoms may
include:
• Pain and tenderness in the injured area
• swelling in the injured area
• obvious deformity in the injured area
• difficulty using or moving the injured area in a normal
manner
• warmth, bruising, or redness in the injured area
The symptoms of a broken bone may resemble other
conditions. Always consult your child's
physician for a diagnosis.
How is a fracture diagnosed?
5
The physician makes the diagnosis with physical
examination and diagnostic tests. During the
examination the physician obtains a complete medical
history of the child and asks how the
injury occurred.
Diagnostic procedures may include:
• X-rays - a diagnostic test which uses invisible
electromagnetic energy beams to
produce images of internal tissues, bones, and organs
onto film.
• Magnetic resonance imaging (MRI) - a diagnostic • Energy of the injury
procedure that uses a • Fracture site
combination of large magnets, radiofrequencies, and a ○ Adequate compression?
computer to produce detailed ○ Any movement?
images of organs and structures within the body. This • Infection
test is done to rule out any • Mode of treatment
associated abnormalities of the spinal cord and nerves. Factors influencing bone healing:
• Computed tomography scan (Also called a CT or Systemic factors Local factors
CAT scan.) - a diagnostic Age and Comorbidity
imaging procedure that uses a combination of x-rays and Degree of local trauma / soft
computer technology to tissue
produce cross-sectional images (often called slices), both Hormones Degree of bone loss
horizontally and vertically, Functional
of the body. A CT scan shows detailed images of any activity
part of the body, including the Vascular injury
bones, muscles, fat, and organs. CT scans are more Nerve function Type of bone fractured
detailed than general x-rays. Nutrition Degree of immobilisation /
Treatment of Fractures : stability
When treating a fracture, it is important to remember Drugs (NSAID) Sterility / Infection
you are treating not only the fracture but Growth Factors Local pathological condition
the patient as a whole. Cigarette Smoke Energy of Injury
Aims of Fracture Treatment Anatomic location
Before considering how to treat a fracture, it is important Fracture Treatment :
to understand what the aims of fracture Treatment can only commence once a fracture has been
treatment are: diagnosed:
• Restore optimum function of the injured limb • Clinical assessment
• Obtain and maintain reduction of the fracture • Radiological imaging
• Encourage union (restoration of normal bone structure) NB -
of the fracture • Always need radiographs in two views
• Prevent complications • In order for radiograph to be adequate, the joints
• Provide adequate pain relief above and below the injury should be
• Rehabilitation of the patient. included.
How do Fractures Heal? General Principles
6 The following points should be taken into account:
Bone healing occurs in four stages: • Average time taken for bones to unite is 8 weeks
• Stage 1 – Tissue destruction & Haematoma formation. • Lower limb fractures take approximately twice as long
○ After any fracture, bleeding occurs from the ends of to unite as the upper limb
the bone and from the fractures
surrounding tissues • Fractures in adults take an average twice as long to
○ The vessels that are torn at the time of fracture lead heal in comparison to those in
to the formation of a fracture children
haematoma. • Transverse fractures take longer to heal than oblique
• Stage 2 –Inflammation and Cellular proliferation and or spiral fractures
vascular ingrowths • Compound and comminuted fractures are particularly
○ Within 8 hours of the fracture occurring, an acute slow to unite
inflammation reaction occurs, 8
with proliferation of cells under the periosteum and • No fracture heals in less than 3 weeks.
within the breached Treatment of closed fracture :
medullary canal • Reduction
○ The bone fragment ends are surrounded by cellular 1. Closed reduction
tissues that bridge the fracture 2. Open reduction
○ The haematoma is reabsorbed and fine new capillaries
• Immobilization (hold reduction)
grow in the area.
1. Cast splintage (Plaster of Paris or synthetic plaster)
• Stage 3 - Callus formation 2. Functional bracing
○ The proliferating cells are potentially chondrogenic 3. Continuous traction (Skeletal or skin traction)
and osteogenic in nature 4. Internal fixation
○ Under the right circumstances, the cell population 5. External fixation
changes to osteoblasts and
• Rehabilitation and exercise
osteoclasts
Which treatment is appropriate?
○ The dead bone is mopped up and woven bone appears
When deciding which treatment is appropriate, the
in the fracture callus.
following point should be noted:
• Stage 4 - Consolidation and remodeling
• Does the fracture need reducing?
○ The woven bone is replaced by lamellar bone and the
fracture is solidly united • If reduction is required, how should this be carried out?
○ New bone is remodeled to resemble the original Is the fracture stable or unstable?
normal structure. ○ Open / closed?
What affects Fracture Healing? ○ Is precise reduction necessary?
7 • How to hold the fracture in reduction? It is important to
Numerous factors can affect fracture healing: prevent loss of alignment while
• Patient - do they comply with the appropriate the bone ends are uniting:
treatment? ○ No support needed
○ Traction
 Thomas' splint • Traction - the disimpaction of the fragments. It serves
○ External splints to align the proximal and distal
 Non-rigid supports - sling, bandaging etc. parts of the limb
 Plaster of Paris • Stable - position of the fragments that can be safely
○ External fixators held in position in a plaster while the
 IIazarov frame fracture is healing
○ Internal fixation • Unstable - position of the fragments that cannot be
 Plates safely held in position in a plaster
 Screws while the fracture is healing.
 intramedullary nails Fracture complications:
○ Joint replacement 10
• Treatment plan These can be of a general nature, local - involving
○ How long does the fracture need to be immobilised structures around the fracture site or those that
for? are applicable to all fractures.
○ When can they start mobilising again? General complications
NB: - • Association with internal haemorrhage
• If the articular surface is damaged, a perfect • Shock
anatomical reduction (< 2mm) is required • Metabolic responses to trauma
• It is of up most importance to start early mobilisation • External haemorrhage and infection - open fractures
to prevent joint stiffness. only
General Management of Fractures • Hypostatic pneumonia
• Pain control with analgesics • Urinary tract infections
• Assessment of blood loss • Deep vein thrombosis leading to pulmonary embolism
9
• Pressure sores
• Management of associated injuries
• Muscle wasting
• Judicious use of antibiotics if the injury is an open one.
• Demineralisation of the bone.
Treatment Options
Local complications
Taking all the factors into consideration, there are five
• Skin damage - includes stretching of the skin by the
possible methods of fracture treatment:
underlying fracture fragments,
• No treatment is necessary except possible comfort and
lacerations, fracture blisters, necrosis and skin loss
protection
• Vascular injuries - these may arise at the time of injury
• Immobilize with an external splint without the need for
e.g. disruption of the vessel by the
reduction
fracture fragments or may arise post manipulation of the
• Closed reduction with manipulation or traction followed fracture or post operatively
by immobilization with an
• Neurological injuries - damage during the fracture
external splint or further traction
mechanism to the spinal cord, brachial
• Open reduction and internal fixation (ORIF) plexus, nerve root or peripheal branch
• Excision of fracture fragment and prosthetic • Tendon injury - the tendon may become bound down,
replacement. compressed or even rupture
Aims of Immobilisation
• Visceral injuries - especially in the chest and pelvis.
• Pain relief Examples of local complications occurring as a result of
• Limit movement at the fracture site certain pathology
• Prevent angulation and / or displacement. • Fractured face - can cause airway obstruction
Indication for Operative treatment • Broken rib - perforation of the lungs, ruptured liver
• Compound fractures • Fractures and dislocations of the knee - popliteal artery
• If closed manipulation is unsuccessful in reducing the damage
fracture • 4/5th thoracic vertebra - damage to the aorta.
• If the fracture is unstable Complications applicable to all fractures
• Soft tissue management Bone healing abnormalities
• Management of complications e.g. vascular or head • Delayed union - union is delayed. There is abnormal
injuries. movement, pain on stressing the
Comparison of Conservative vs Operative fracture and tenderness over the fracture site at a time
treatment at when union is expected. Causes
• Joint stiffness include the nature of the initial injury, with compound
○ Risk lower in operative treatment and comminuted fractures more
• Infection likely to develop non-union; other causes include
○ Risk higher in operative treatment infection of the fracture haematoma,
• Speed of Healing interposition of soft tissue between the fracture
○ Quicker in conservative treatment fragments, poor blood supply to the
• Non-union fracture site, inadequate immobilisation and pathological
○ Present in both. fractures
Important Definitions • Non-union - can be atrophic or hypertrophic. The
• Reduction - placing the bone fragments into their former is when there has been deficient
original or acceptable position bone formation at the fracture site and a hypertrophic
• Manipulation - the technique of reducing a fracture. non-union is where there has been
In many situations it is the excessive callus formation
correction of residual angulation by pressing the distal • Malunion - the bone ends heal in a clinically imperfect
fragment in the correct direction position. It most commonly
while a hand is held under the fracture to provide a causes shortening with an overlap of the bone fragments
fulcrum
• Avascular necrosis - bone death most commonly
occurs with intra-articular fractures of
the hip joint, proximal scaphoid and proximal humerus.
11
Other complications
• Infection - most commonly occurs with open fractures.
Major disorders include tetanus,
gas gangrene, toxic shock syndrome, necrotizing fasciitis
(an aggressive, life threatening
fascial infection), acute osetomyelitis (bone infection).
Chronic infection of the bone can
occur
• Joint stiffness
• Secondary osteoarthritis
• Growth disturbance if the epiphyseal growth plate has
been damaged
• Tendon ruptures or tendonitis.Sudeck's atrophy (reflex
sympathetic dystrophy) - an
abnormal peripheral autonomic response to injury
characterised by severe pain, stiffness,
discolourisation and oedema
• Myositis ossificans - an extensive calcified mass in the
soft tissues proximal to the joint
that leads to a severe mechanical block to movement
• Muscular atrophy
• Fat embolism - microparticles of fat escape the
fracture site and lodge in the glomeruli of
the kidney and lung
• Tardy nerve palsy - late onset nerve palsy
• Renal calculi
• Accident neurosis - psychiatric problem.
Injuries other than fractures
In addition to bony injuries, other anatomical structures
can also be damaged in a injury:
Joints
Joints can be damaged in three ways:
1. Subluxation - this is the partial dislocation of a joint,
in which there is still partial contact
between the joint surfaces
2. Dislocation - there is no contact between the joint
surfaces
3. Fracture dislocation - there a fracture around the
joint in addtion to the joint dislocation.
Ligaments
Ligament injuries can be grouped into three different
types:
1. Sprain - this is a partial tear in the ligament or joint
capsule but the joint however is still
stable
2. Partial rupture - this is the partial rupture of the
ligament. There is some loss of joint
stability
3. Complete rupture - this is the complete rupture of
the ligament and is associated with
joint instability.
Soft tissues :
• Blood vessels
• Nerves
Likewise, nerve injury can be grouped into three
different types:
1. Neuropraxia - there is transient loss of function as a
result of the impulse being
interrupted as it passes down the nerve fiber. It occurs
as a result of a gentle blow or
12
compression. The motor system is more frequently
damaged than sensory function.
Recovery takes hours to months
2. Axonotmesis - there is loss of function as a result of
the relative loss of continuity of
the axon and its covering of myelin. It occurs as a result
of severe compression. There
is loss of both motor and sensory systems. Recovery
takes longer than neurapraxia
3. Neurotmesis - this is the most severe lesion affecting
the nerve. There is complete
loss of motor, sensory and autonomic function and
occurs as a result of severe
bruising or cuts. There is no neural continuity. There is
no recovery.
• Muscles
Muscle injuries can be classified according to the degree
of clinical impairment:
1. Mild strain/contusion (1st degree) - a small number of
muscle fibers are torn. This is
associated with minor swelling and discomfort with little
or no loss of strength or
limitation of movement
2. Moderate strain/contusion (2nd degree) - a greater
number of muscle fibers are torn
than in the 1st degree. This is associated with a clear
loss of function
3. Severe strain/contusion (3rd degree) - there is a tear
across the whole cross sectional
area of the muscle. There is a total loss of muscle
function.
• Skin - abrasion, bruise, lacerations.
FRACTURES
Describing the level of a fracture
The anatomical divisions of a long
bone include the epiphysis (E),
epiphyseal plate (EP), and diaphysis
or shaft (D). Between the latter two is
the metaphysis (M). A fracture may
be described as lying within these
divisions, or involving a distinct
anatomical part, e.g.
A = fracture of the tibial diaphysis;
B = fracture of the femoral neck;
C = fracture of the greater
trochanter;
F = supracondylar fracture of the
femur.
For descriptive purposes a bone may
be divided into thirds. In this way:
A = fracture of the mid third of the
femur;
B = fracture of the femur in the distal
third;
C = fracture of the femur at the
junction of the middle and distal
thirds.
D = fracture of the distal metaphysis
of radial bone.