Dr. Ahmad Aqel

2021

The University of JordanFaculty of Nursing

Introduction to Adult Health Nursing

Definition: Complete or incomplete disruption in the

continuity of bone structure

▪ occur when the bone is subjected to stress greater than it

can absorb.

Causes:

Consequences of bone fracture

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▪ Direct blows, ▪ Crushing forces

▪ Sudden twisting motions ▪ Extreme muscle contractions.

▪ Edema, Hemorrhage, Joint dislocations , Rupture

tendons , Nerves injury, Blood vessels damage.

Types of Fractures

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▪ Complete fracture

▪ break across the entire cross-section

of the bone, frequently displaced.

▪ Incomplete fracture

▪ break through only part of the cross-

section of the bone (eg, green- stick)

▪ Comminuted fracture

▪ fracture that produces several fragments

▪ A closed fracture: does not cause a

break in the skin.

Types of Fractures

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Open fracture: skin wound extends to the

fractured bone

Intra-articular fracture

• Extends into the joint surface of a bone.

• Difficult to seen on the x-ray because cartilage

is non-radiopaque. MRI or arthroscopy will

identify the fracture

• Lead to posttraumatic arthritis

Management: immobilize the joint with a splint or

cast, no weight bearing

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A fragment of bone has been pulled away

bone has splintered into fragments

compressed bone (Seen in vertebral fracture)

Avulsion Comminuted Compression

Fractures

Depressed

fragments are driven inward (seen in fractures of skull and facial bones)

Impacted

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bone fragment is driven into another bone fragment

Greenstick

• one side of a bone is broken and the other side is bent

Fractures

• Occurs due to diseased bone without trauma or fall

Pathologic Epiphyseal

• A fracture through the epiphysis

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• A fracture and damage to skin or mucous membranes (called compound fracture)

Oblique

• A fracture at an angle across the bone

Transverse

• straight fracture across the bone shaft

Open fracture

Fractures

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Simple fracture Stress Spiral

A fracture that remains contained, with no disruption of the skin integrity

Results from repeated loading of bone and muscle

Twists around the shaft of the bone

Fractures

Signs and Symptoms of Fracture

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1. Acute pain:

2. Loss of function

3. Deformity

4. Shortening of the extremity

5. Crepitus

6. Localized edema and ecchymosis.

Testing for crepitus can produce further tissue damage

Emergency Management

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▪ Immobilize the body part before moving pt.

▪ Immobilize the Joints proximal & distal to the fracture.

▪ Immobilize the lower extremities by

bandaging the legs together, with the

unaffected extremity.

▪ Bandage the arm to the chest,

place forearm in a sling.

1) Immobilization:

Emergency Management

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2. Assess for peripheral pulse & nerve function distal to the

injury before and after splinting.

3. Cover the open wound with a sterile dressing.

4. Do not reduce the fracture

In the emergency department

– Complete evaluation.

– Remove the clothes gently first from the uninjured side

– The fractured extremity is moved gently

Medical Management

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Fracture reduction

▪ Refers to restoration of the fracture fragments to anatomic alignment and positioning.

▪ Types of reduction

1. closed reduction (manipulation and manual traction)

2. open reduction ( surgical approach)

Reduces a fracture ASAP to prevent loss of elasticity from

the tissues through infiltration by edema or hemorrhage

Medical Management

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Closed Reduction

– Bringing the bone into anatomic alignment

through manual traction.

– Hold the extremity in the aligned position while

the physician applies a cast, splint.

– Minor analgesia may be used

– Obtain X-rays to verify that the bone fragments

are correctly aligned

Medical Management

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Open Reduction

by surgery, the

fracture fragments

aligned.

• Internal fixation

by pins, wires,

screws, plates,

nails

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• Immobilization by internal or external fixation.

• Methods of external fixation include bandages, casts,

splints, continuous traction, and external fixators.

Medical Management

Immobilization

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▪ Elevate extremity and apply ice to reduce edema

▪ Monitor neurovascular status

▪ Change position, and pain relief

▪ Teach pt Isometric and muscle-setting exercises : to

minimize atrophy and to promote circulation.

▪ How to use assistive devices (crutches, walkers).

▪ Patient teaching: self-care, medication, complications.

▪ Modify the home environment as needed

▪ Reassurance: alleviate restlessness and anxiety

Nursing Management With Closed Fractures

Nursing Management / Open Fractures

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Risk of open fracture: osteomyelitis, tetanus, gas gangrene

1. Administer IV antibiotics, T. toxoid, Wound irrigation and

debridement, wound swab for C&S as ordered

2. Surgical external fixation of fractures carries a risk of

infection. (caring of wires, scrows)

3. Elevate extremity to minimize edema.

4. Monitor Temperature and signs of infection (tenderness,

pain, redness, swelling, local warmth, elevated

temperature, and purulent drainage).

Factors that enhance fracture healing

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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

▪ Electric potential across fracture (physiotherapy)

Factors that inhibit fracture healing

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▪ Extensive local trauma & Bone loss

▪ Weight bearing prior to approval

▪ Mal-alignment of the fracture fragments

▪ Inadequate immobilization

▪ Space or tissue between bone fragments

▪ Infection

▪ Localized malignancy

▪ Age (elderly persons heal more slowly)

▪ Corticosteroids (inhibit the repair rate)

Early complications Delayed complications

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• Shock

• Fat embolism

• Compartment syndrome

• Deep vein thrombosis

• Pulmonary embolism

• Delayed union, Malunion,

Nonunion

• Reaction to internal

fixation devices

• Complex regional pain

syndrome

• Heterotopic ossification

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Complications of fracture

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• Hypovolemic shock

– resulting from severe hemorrhage

– More common with pelvic fractures & displaced

femoral fracture.

Treatment for shock

– stabilizing the fracture, proper immobilization,

– restoring blood volume and circulation,

Complications of fracture

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Fat Embolism

▪ More common in: fracture long bones or pelvic,

▪ Clinical manifestations: The first manifestations are

(hypoxia and tachypnea). petechial rash, CP, crackles,

wheezes, cough, thick white sputum, tachycardia.

▪ Neurological symptoms: (headache, mild agitation to

delirium & coma).

▪ sudden restlessness, irritability, or confusion occurs post

fracture are indications for immediate ABG studies.

Complications of fracture

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▪ Immediate immobilization of fractures

– early fixation, minimal manipulation,

– maintenance of fluid and electrolyte balance.

▪ Prompt initiation of respiratory support

– High-flow oxygen, mechanical ventilation with PEEP

– Corticosteroids & Vasopressor medications

– Accurate I&O

▪ Acute pulmonary edema and ARDS are the most

common causes of death from Fat embolism.

Prevention and Management of fat emboli

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Compartment Syndrome

▪ A sudden decrease in blood flow to the tissues distal to injury site that results in ischemic necrosis

▪ C/O: deep, throbbing pain, increase despite opioids

▪ Hallmark sign: pain intensifies with passive ROM

▪ pain caused by tight muscle fascia , constrictive cast, edema or hemorrhage from the fracture site

▪ Most common on the lower leg, forearm is also at risk.

▪ Permanent lose occurs if the anoxic situation continues for longer than 4 hours.

Complications of fracture

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Assess:

▪ Pain, pallor, paresthesia, paralysis,pulselessness.

▪ Cyanotic nail beds suggest venous congestion.

▪ Pallor and cool & prolonged capillary refill suggest

diminished arterial perfusion.

▪ Use Doppler ultrasonography to verify a pulse .

Nursing management of compartment syndrome

Safety Nursing Alert

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Management

▪ Maintaining the extremity at the

heart level (not above heart

▪ Opening and bivalving the cast or

opening the splint

▪ A fasciotomy (excision of the fascia)

to relieve the constrictive muscle

▪ Moist, sterile saline dressings, A

vacuum dressing may be used to

remove fluids

Compartment syndrome

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Delayed union: healing not occur within the expected time

Nonunion: failure of the ends of a fractured bone to unite

▪ treated with internal fixation, bone grafting, electrical

bone stimulation.

Malunion: the healing in a mal aligned position

Factors contributing to nonunion and mal-union

▪ Infection, Interposition of tissue between the bone ends,

Inadequate immobilization & manipulation, excessive

space between bone fragments, impaired blood supply.

Delayed Complications of fracture

Delayed complication of fracture

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.

The bone graft may be an

Autograft (from the patient, frequently from the iliac crest

Allograft (from a donor)

Bone grafting complications include:

graft infection, fracture of the graft, nonunion

Delayed Complications of fracture

❖ The electrical stimulation enhances

mineral deposition and bone formation

that promotes bone growth. Bone healing stimulator applied to the arm

Nursing Management.

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• Emotional support

• Encourages adherence to the treatment regimen.

• Patient with a bone graft:

– pain management and monitor for complications.

– education concerning bone graft, immobilization, non–

weight-bearing exercises, wound care, signs of infection,

and follow-up

• Patient using bone stimulation devices

– education regarding immobilization, weight-bearing

restrictions, and correct daily use of the stimulator

Nursing management

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Complex Regional Pain Syndrome

▪ severe burning pain, local edema, hyperesthesia, stiffness,

skin discoloration,

▪ Prevention: elevation, immobilization, early effective pain relief

avoids using the affected extremity for BP & venipuncture

Avascular Necrosis of Bone

▪ bone loses blood supply and dies.

Heterotopic ossification:

▪ Abnormal formation of bone, near bones or in muscle.

Delayed Complications of fracture

Which term refers to the failure of fragments of a fractured bone to heal together?

a) Malunion

b) Subluxation

c) Dislocation

d) Nonunion.

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