Fracture and its management with nursing interventions

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 Fracture:

Fracture


  • A fracture is defined as a complete or incomplete damage in the continuity of a bone.
  • A traumatic fracture is caused by some types of accident, fall, or other kind of force.
  • A pathologic fracture is a broken bone caused by disease. For e.g. Osteoporosis, bone cyst.
Types of Fracture:




  1. Closed fracture or Simple fracture- Bone is broken under the skin . Skin over the fracture area remain intact.
  2. Open or Compound fracture- Bone is broken along with skin and sometime bone comes out of skin. Soft tissue injury and infections are common.
  3. Incomplete fracture- Bone is broken but doesn't completely break.
  4. Comminuted fracture- Bone is broken into several small parts. The bone is crushed with the formation of 3 - 4 fragments.
  5. Greenstick fracture- One side of bone surface is broken and another is only bend (most common in children)
  6. Complete fracture: Bone is broken completely into two separate parts.
  7. Spiral fracture- The break partially encircles the bone.
  8. Oblique fracture- The break extends in an oblique direction.
  9. Transverse fracture- The bone is fractured straight across.


Oblique Fracture-non-displaced, displaced & compound



Greenstick fracture




Signs and Symptoms:

  • Pain or tenderness over the involved area
  • Loss of function
  • Deformity
  • Shortening of a limb
  • Crepitus sound when fractured limb is moved
  • 5P'S (Pain, Pulselessness, Pallor, Paresthesia, Paralysis)
Diagnosis:
    Radiography - X-ray of the affected bone can reveal the fracture .

Nursing Interventions:
  • Assess for shock because there may be significant blood loss.
  • Assess for signs of fat embolism (confusion, dyspnea, hypotension, tachycardia, tachypnea).
  • Apply cold packs at fracture sites(it helps to decrease bleeding and edema).
  • Notify the healthcare provider about any sign of fat emboli, dyspnea, chest pain, decreased saturation and diaphoresis.
  • Provide diet high in protein, Vitamin C to help quick healing.
  • Diet with high calcium content is usually not indicated in prolonged bedridden patient because decalcification is already there and it can cause further calculi in renal.
  • Maintain hydration.
  • Isometric exercise.
  • Positioning frequently or every 2 hrs.
  • Teach about three points (non-weight bearing) and four point gait (weight bearing)
Stages of Bone Healing:
     
   Inflammatory phase (49 hrs after the injury); hematoma is formed.
     
       Repairing phase ( pasts for 2-3 weeks); develops new tissue and cartilage known as callus.
    
       Bone remodelling ; also called final phase, solid bone replace spongy bone.
 

Stages of bone healing 

Management: 
  
   1. Initial care of a fracture of an extremity:
      
  1.   Immobilize the affected extremity with cast or splint.
  2. If a compound (open)fracture exists, splint the extremity and cover the wound with sterile gauze to prevent contamination.
  3. Assess neurovascular status of the extremity.
  4. Do not attempt to reduce the fracture.
  2. Nurse's Intervention of Closed Fracture:
  •  Assist in reduction and immobilization.
  • Administer pain medication and muscle relaxants as prescribed.
  • Teach patient about potential complication of fracture and to report infection, poor alignment, and continuous pain.
  • Teach patient to care for the cast.
  3. Nurse's Interventions in Open fracture:
  1. Administer prescribed antibiotics and tetanus prophylaxis as prescribed.
  2. Assist in serial wound debridement.
  3. Elevate the extremity to prevent edem formation.
  4. Assist in reduction and fixation of the fracture.
  5. Administer care of traction and cast.
Splint:
  •  It is used to support and immobilize a body part in functional position.
  • It is easy to apply and does not cover the entire part so circulation is not compromised.
  • It can be easily removed so visualization of injured part can be easily done.
  • Protect the open wound with sterile dressing before splinting.
Braces:
  1. Used to support, control movement and to prevent additional injury.
  2. These are indicated for longer term of use and by using braces deformity is corrected, movement is enhanced and discomfort is minimized.
Casts:
   Immobilizing tool made up of Plaster of Paris or fiber glass.This  helps in the correct alignment of the pieces of bone after a fracture or injury .
  • Plaster of Paris - Drying takes 1-3 days . When dry shiny white, hard and water resistant.Application of plaster is an exothermic reaction. A freshly applied cast should be exposed to air and supported on a firm surface.
  • Fibre Glass - Light weight and dries in 20-30 minutes, water resistant.Application of this cast causes an exothermic reaction. So educate the patient about this expected reaction.
Types of casts:
  1. Short arm casts- Cast is extending from below the elbow to palmar crease and is secured around the thumb.
  2. Thumb spica or gauntlet cast- Cast extends from below the elbow and covers thumb 
  3. Long arm casts- Extending from axilla to palmar crease, elbow is immobilized at right angle.
  4. Short leg casts- Extending below knee to base of toe.
  5. Long leg casts- Extending from the junction of thigh to the base of toe.
  6. Walking casts - Short or long leg casts reinforced for strength.
  7. Body casts- Encircle the body .
  8. Shoulder spica casts- Body jacket like casts which cover shoulder, trunk and elbow.
  9.  Hip spica casts- Encircle body and leg. In double hip spica casts both legs and body are covered with casts.




Body casts











Key points :
  • Handle the cast with palm not with finger which cause pressure area within the cast.
  • Prevent the cast from any kind of damage until it dry.
  • Cast should not be covered until it is dry and use fan to circulate air 
  • Elevate the casted limb on pillow but not amputated limb as it creates contracture.
  • Never let the wet cast to rest on a flat surface because it cause pressure within the cast.
  • Check and compare the pulse on both sides of body; it should be equal.
  • Perform blanching ( capillary refill) test.
  • Educate the patient to notify the healthcare provider if any signs of infection is present (hyperthermia, foul smell from cast)
Reduction: Restore the bone to proper alignment.
 
   1. Closed Reduction: 
  1. Non-surgical intervention performed by manual manipulation.
  2. Performed under local or general anesthesia.
  3. Cast may be applied following reduction.
    2. Open Reduction:
  •  Surgical intervention
  • Fracture may be treated with internal fixation devices.
  • Patient may be placed on traction or a cast following the procedure.
Fixation: Internal and External

   1. Internal Fixation:
  •  Follow an open reduction 
  • Involves the application of screws, plates, or intra medullary rods to hold the fragments in alignment.
  • Involves removal of damaged bone and replacement with prosthesis.
  • Provides immediate bone strength.    

Internal Fixation 



   2. External Fixation:
      
  1. Use of an external frame to stabilize a fracture.
  2. Involves attaching skeletal pins through bone fragments to a rigid external support.
  3. Used when massive tissue trauma is present.

External Fixation of Ankle


Nurse's intervention:
      -  Monitor pin stability and provide pin care to decrease infection.

Traction:
  •  It uses pulling force to align injured body part.
  • Purpose- To eliminate muscles spasm, to relieve pressure on nerve, to prevent further deformities and to regain  normal alignment of bone.
Description of different types of traction:
  1.  Straight and running traction (for e.g. Buck's extension traction) - Traction in straight line with body part resting on the bed. Counter traction is provided by patient's weight.
    2. Balanced suspension traction: It supports the affected extremity off the bed and allows some movements.Counter traction is given by slings or splints.

    3. Skin traction: Traction is applied to the skin.Weight for traction used on 
      -Extremity - 2 to 3.5 Kg
       - Pelvis - 4.5 to 9 Kg

  For example:
  • Buck traction for lower extremity
  • Chin Halter Strap for neck pain
  • Pelvic belt for lower back pain
  • Hamilton Russell traction for femur
  • Bryant's traction for femur
  • Dunlop's traction (upper arm , recommended for not more than 20 minutes).
       4. Skeletal Traction- Weight is put on pins/wires/screw which are attached surgically to the bone. Most commonly used for femur.(Thomas Splint with Pearson attachment ).Preferred when continuous traction is needed.
            For example- Halo traction (skull traction)

Hamilton Russell's Traction 



Buck's extension 



Care after Traction:

  •    T- Temperature may be from infection or fractured extremities
  •    R- Rope of traction should be hanged freely
  •    A - Alignment should be maintained (counter traction needed)
  •    C- Circulation should check with 5p's 
  •    T- Type and location of fracture
  •    I - Increase fluid intake
  •    O- Overhead trapeze use
  •    N- Never touch the weight to bed as well as to floor.
Key points : 
  1.  In a client with traction neuro vascular assessment os the priority nursing interventions.
  2. In a client with skin traction dorsiflexion of the foot indicates functioning of peroneal nerve; plantarflexion of the foot indicates functioning of the tibial nerve.
  3. In a client with skeletal traction nurse should not remove weight from the traction unless a life threatening emergency.
Complications of Fracture:
  • Fat embolism
  • Compartment syndrome
  • Avascular necrosis
  • Infection and osteomyelitis
  • Pulmonary embolism



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