FRACTURES

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FRACTURES

• And other Orthopaedic Disorders
• Jill Cavaiuolo

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Fracture Definition

• Description A fracture is a medical condition in
  which a bone is cracked or broken. While many
  fractures are the result of high force impact or
  stress, bone fracture can also occur as a result
  of certain medical conditions that weaken the
  bones.

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CLASSIFICATION OF
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. Closed fracture (Also called
simple fracture.)  -  the bone is broken, but the
skin is intact. Complete- the bone is completely
broken in two or more pieces Incomplete-the bone
is not broken all the way through Direction of
Fracture Line Transverse Oblique Spiral Comminuted
Compression
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Categories of Fractures

• In a compound fracture, also called an open
  fracture, the bone breaks through the skin it
  may then recede back into the wound and not be
  visible through the skin.

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Categories of Fractures

• In a simple fracture, also called a closed
  fracture, the bone breaks but there is no open
  wound in the skin.

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Categories of Fractures

• Complete fractures refer to the way the bone
  breaks In a complete fracture, the bone snaps
  into two or more parts..(i.e. ulna)

• Incomplete fractures have a bone that breaks, but
  does not go all the way through.

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Fracture Categories
http//www.hughston.com/hha/b_14_2_1a.jpg
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Common Fractures

• Greenstick  -  incomplete fracture. The broken
  bone is not completely separated.

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Common Fractures

• Transverse  -  the break is in a straight line
  across the bone.

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Common Fractures

• Spiral  -  the break spirals around the bone
  common in a twisting injury.

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Common Fractures

• Oblique  -  diagonal break across the bone.

http//brighamandwomens.staywellsolutionsonline.co
m
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Common Fractures

• Compression  -  the bone is crushed, causing the
  broken bone to be wider or flatter in appearance

http//brighamandwomens.staywellsolutionsonline.co
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Other types of Fractures

• An impacted fracture is one whose ends are driven
  into each other. This is commonly seen in arm
  fractures in children and is sometimes known as a
  buckle fracture.
• Other types of fractures are pathologic fracture,
  caused by a disease that weakens the bones, and
  stress fracture, a hairline crack.

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Examples
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Xray Example

• This xray indicates a lateral view of an oblique
  fracture to the mid humerus.

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Closed Oblique Fracture

• This fracture is considered to be mildly
  displaced.

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Types of Fractures

• Mildly displaced spiral fractures of the Tibia
  and Fibula.

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Types of Fractures

• Comminuted and mildly displaced fractures of the
  distal Tibia and Fibula.

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EXAMPLE A 57 year old 350 lbs. man who puts
significant pressure on his ankle as he walks.
Diagnosis PILON FRACTUREThis is a comminuted
fracture of the distal tibia due to axial
compression of the ankle joint. It is frequently
associated with a fracture of the distal shaft of
the fibula as well.
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WARNING

• GRAPHIC TRAUMA PICTURE

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Open Fractures

• A break in the skin and underlying soft tissue
  leading into, or communicating with the fracture
  and its hematoma

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WARNING

• THE NEXT TRAUMA SLIDE IS VERY GRAPHIC

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Open Fracture
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REVISION

• Define Fracture
• Define Open and Closed
• Define Complete or Incomplete
• Give examples of classification based on the
  direction of line.
• Define the following types of fractures.

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Did you answer that it is a closed comminuted
fracture of the femur?
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Transverse complete of Fibula
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Compound(open) of Tibia and Fibula. The tibial
break looks oblique, and the fibula appears to be
comminuted.
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FracturesSigns and Symptoms

• Some clearly present (compound fracture) or
  obvious deformity
• Swelling, tenderness, altered sensation
• Inability to move limb
• Crepitus
• Grating sound heard if ends of bone fragments
  move over e/other
• Pain immediately after injury
• Can be delayed if nerve damage in area
• Diagnostic Tests
• X-rays

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Fractures- Complications

• Muscle spasm
• Due to local pain and irritation
• Pulls bone fragments further out of position
• Causes angulation (deformity) and rotation of
  bone which can cause more soft tissue damage,
  bleeding, and inflammation.
• Infections
• Tetanus, osteomyelitis
• In Compound fractures or when surgery needed
  precautions taken (antimicrobials, tetanus
  booster shot)

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Wrist Note Swelling in top and bottom picture
and deformity in the compound (open) fracture
below.
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Complications

• Ischaemia
• Develops in limb following treatment
• Occurs as oedema increases in 1st 48 hrs after
  trauma and casting.
• Can be due to cast becoming too tight.
• The affected part becomes pale, pulseless,
  painful, paralysed, paraesthetic and 'perishing
  with cold' ('the 6 Ps').
• Fixed mottling of the skin implies irreversible
  changes.
• The limb may be red when dependent, leading to a
  misdiagnosis of inflammation, e.g. gout or
  cellulitis.

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Complications Cont.

• Compartment syndrome
• Develops shortly after fracture when more
  extensive inflammation (crush fractures)
• Increased pressure of fluid w/in fascia causes
  severe pain and ischemia or necrosis of muscle
• Pressure effects can be aggravated by cast

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Compartments of Lower Leg
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Compartment Syndrome

• Pressure Release

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Compartment Syndrome

• www.residentandstaff.com/issues/articles/2007-03_0
  1.asp

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Complications Cont.

• Nerve damage
• w/ severe trauma or tearing of periosteum
• Failure to heal (nonunion) or healing of bone w/
  deformity (malunion)
• Results if bone is not stabilized with ends
  closely approximated and aligned
• Fractures at or near joint may have long-term
  effects
• Osteoarthritis or stunted growth

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Complications Cont.

• Fat emboli
• Risk when fatty marrow escapes from bone marrow
  into vein w/in 1st week after injury
• More common in fracture of pelvis or long bones,
  especially if not well immobilized after injury
• Can travel to lungs and cause obstruction,
  extensive inflammation, and respiratory distress

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Fat Embolism

• Fat Embolism Syndrome
• Globules of fat, released from fractured bone
• Fat mixes with platelets
• Emboli travel to lungs, brain, or other areas.
• Clotting cascade activated petechiae

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Fat Embolism Syndrome

• Signs and Symptoms
• Dyspnoea
• Confusion
• Pulmonary complications
• Pulmonary Oedema
• ARDS(Acute Respiratory distress syndrome)
• Petechiae-small spots on the skin

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Complications-DVT
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Closed Fracture Considerations

• The energy of the injury
• Degree of contamination
• Patient factors
• Additional injuries

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FracturesTreatment

• Management of Pain,nausea etc.
• Cleaning the wound if open-may be done in theatre
• Immediate splinting and immobilization
• Reduction of bones to restore normal position
• Closed reduction exerting pressure and traction
• Open reduction requires surgery
• Pins, rods, plates, screws

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Splinting and Immobilization

• Casting with plaster or fiberglass, and splints .

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Closed Reduction Traction
Application of force or weight pulling on limb
that is opposed by body weight Force maintains
alignment of bones, prevents muscle spasms, and
immobilizes the limb
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Open Reduction

• Internal fixation of Radius

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External Fixation

• This is a patient treated with an external
  fixator, which is used to treat fractures that
  are too unstable for a cast. You can shower and
  use your hand gently with the external fixator in
  place.

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Internal FixationFractured Pelvis
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Internal Fixation Trans articular pin fixation
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FracturesPathophysiology Factors Affecting
Healing Process

• Amount of local damage to bone and soft tissue
• Major determining factor
• Prolonged inflammation or extensive damage to bv
  or periosteum impairs healing
• Amount of realignment and approximation
• Closer the ends of the bones are, the smaller the
  gap to fill, the faster the healing process
• Secondary problem
• Foreign material or infection delays healing

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Factors Affecting the Healing Process

• Numerous systemic factors
• Delayed healing in elderly pts w/ circulatory
  problems, diabetes mellitus, anaemia, nutritional
  deficits, steroid therapy.

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Bone Healing

• As soon as a fracture occurs, the body acts to
  protect the injured area, forming a protective
  blood clot and callus or fibrous tissue.
• New "threads" of bone cells start to grow on both
  sides of the fracture line. These threads grow
  toward each other.
• The fracture closes and the callus is absorbed.

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FracturesPathophysiology of Bone Repair
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Nursing Management

• General Observations for pins, traction and
  casts include
• Skin inspection hourly
• Neurovascular observations ½ -1 hourly
• Limb alignment
• Limb exercises
• Signs of infection warmth, swelling, pain,
  odour, discharge

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Nursing Management

• Elevation
• Monitor Pt. pain and comfort
• Remind Pt. of injured limb and positioning etc.
• Check bed positioning of Pt to ensure traction is
  functioning.
• Check equipment i.e. pulleys, pins etc.
• Pts. with traction must never have weight bags
  lifted randomly.

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Plaster Management

• Maintain cast integrity
• Turn Pt. 1-2 hrly
• Use palms when handling wet plaster
• Do not cover wet cast-allow to dry
• Check cast ooze and outline
• Educate Pt. to not shove anything inside of cast
  e.g. knitting needles

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Plaster Management

• Do not use blow dryer to dry cast
• Cast will heat when drying
• Cast is heavy
• Observe skin around cast edge, skin breaks can
  lead to infection

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A Case History
A 24 year old right hand dominant man sustained a
compound fracture of his right forearm as a
teenager. He had a deep infection that required
part of the bone to be removed. His right wrist
was severely deformed and x rays showed bone
loss and a non-union of the fracture.He had
surgery that reconstructed his bone, rehab. and
he returned to work as a full time construction
worker.
http//www.theuniversityhospital.com/limblength/te
ch.htm
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A Case History
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Other Disorders
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Sprains and Strains
Sprain. A sprain is a stretching or tearing of
ligaments. Ligaments are tough bands of fibrous
tissue that connect one bone to another. Common
locations for sprains are your ankles and knees.
Strain. A strain is a stretching or tearing of
muscle or tendon. People commonly call strains
"pulled" muscles. Hamstring and back injuries are
among the most common strains www.mayoclinic.co
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Sprains and Strains

• Both easily torn when excessive force exerted on
  a joint
• Avulsion
• Ligaments or tendons completely separated
• Painful, tenderness, discoloration (due to
  haematoma formation)
• Strength and range of movement of the joint are
  limited
• Diagnosis X-ray,scans etc. to rule out fracture
  and to note extent of damage

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Sprains and Strains Healing

• Tear, then inflammation, then granulation tissue
• Collage fibers form to create links w/ existing
  tissue
• Eventually healing mass bound together w/ fibrous
  tissue
• Healing 6 weeks
• Severe damage requires surgery

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Dislocation

• Separation of 2 bones at a joint
• Loss of contact between articulating bone
  surfaces
• Usually one bone out of position, other normal
• Eg. humerus displaced from scapula
• Subluxation
• Bone only partially displaced w/ partial loss of
  contact between surfaces
• Causes considerable soft tissue damage
• Also damage to ligaments, nerves, bv as bone
  pulled away from joint
• Inflammation and bleeding
• Severe pain, swelling, tenderness

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Dislocation

• Diagnosis confirmed by X-ray
• Treatment
• Reduction to dislocated bone, immobilization,
  therapy to maintain joint mobility
• Healing is slow if ligaments and soft tissue
  extensively damaged

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History After breaking a hip, a 70 year old
woman undergoes hip replacement surgery. After 5
days she comes back with severe hip pain.
Diagnosis TOTAL HIP PROSTHESIS SUPERIOR
DISLOCATION
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References

• Fracture classification/sprains and strains
• www.mayoclinic.com
• Radiology Web Site - McGill University
  http//sprojects.mmi.mcgill.ca/icmcradiology/index
  .aspx
• Brigham and Womens Hospital Types of Fractures
• http//brighamandwomens.staywellsolutions
  online.com