FRACTURE CLASSIFICATION AND MANAGEMENT..

Bone
Bone is a living tissue
that supports soft tissues,
provides a frame for the
connection of ligaments
and tendons, and enables
locomotion.

Definition
 A fracture is disruption of the continuity
or integrity of bone

Although bones are strong, they are susceptible to breaks
(fractures) all throughout life.
The most common times in life for fractures to occur are
during youth (due to excessive activity, sports, and bad
judgement) and in the elderly (due to bone thinning and
weakening, often due to osteoporosis).

Classification
On the basis of relationship with external environment
 Closed :A fracture not communicating with the
external environment.
 Open :A fracture with break in the overlying skin and
soft tissue, leading to the fracture communicating
with the external environment.

On the basis of aetiology
 Traumatic
 Pathological
On the basis of displacement
 Undisplaced
 Displaced

On the basis of pattern;
 Transverse: The fracture line is perpendicular to
the long axis of the bone. Caused by bending
force.
 Oblique: The fracture line is oblique. Caused by
a bending force which in addition has a
component along long axis.
 Spiral: The fracture line runs spirally in more than
one plane . Caused by primarily twisting force.

 Comminuted: Fracture with multiple
fragments. It is caused by a crushing or
compression force along the long axis of
the bone.
 Segmental: There are two fractures in one
bone at different levels.

Types of Bone
 Lamellar Bone
 Collagen fibers arranged in parallel layers
 Normal adult bone
 Woven Bone (non-lamellar)
 Randomly oriented collagen fibers
 In adults, seen at sites of fracture healing,
tendon or ligament attachment and in
pathological conditions

Six most common types of
fractures:
1) Comminuted
2) Compression
3) Depressed
4) Impacted
5) Spiral
6) Greenstick

Comminuted fractures: bone breaks in many
fragments.

Compression fractures: bone is crushed.

Depressed fractures: bone is pressed inward.

Impacted fractures: broken bone ends are forced into each other.

Spiral fractures: ragged break occurs during twisting.

Greenstick fractures: bone breaks incompletely (like a young twig).

Stages of Fracture Healing
 Stage of haematoma
 Stage of granulation tissue
 Stage of callus
 Stage of remodelling
 Stage of modelling.

How fractures heal – in nature
 1) Reactive phase
 Fracture and
inflammatory phase
 Granulation tissue
formation
 2) Reparative phase
 Callus formation
 Lamellar bone
deposition
 3) Remodelling phase
 Remodelling to
original bone contour

1.) Inflammatory Phase
Bleeding from bone, bone periosteum, & tissues surrounding the
bone
formation of fracture hematoma & initiation of
inflammatory response
Induction (stimulus for bone regeneration) - caused
by:
decreased oxygen and bone necrosis (fractured bone
becomes hypoxic immediately)
disruption of & creation of new bioelectrical potentials

Inflammatory response - lasts between 2- 9 days
following injury:
phagocytes & lysosomes clear necrosed bone and other
debris
a fibrin mesh forms and “walls off” the fracture site
serves as “scaffold” for fibroblasts and capillary buds
capillaries grow into the hematoma
in a fracture, the new blood supply arises from
periosteum
normally 3/4 of blood flow in adult bone arises
from endosteum
in children, normal blood flow already comes
from periosteum.

2.) Fibrocartilagenous callus Formation
Lasts an average of 3 weeks
Fibroblasts and osteoblasts arrive from periosteum &
endosteum
Within 2-3 days, fibroblasts produce collagen fibers that
span the break

This tissue is called Fibro - Cartilagenous Callus and
serves to “splint” the bone
FCC is formed both in and around the fracture site
Osteoblasts in outer layer of FCC begin to lay down new
hard bone
in a non-immobilized fracture, the FCC has poor
vascularization

3.) Hard Bony Callus Formation & Ossification
Weeks to months
Fracture fragments are joined by collagen, cartilage, & then
immature bone
Osteoblasts form trabelcular bone along fracture periphery
(external callus)
Trabecular bone is then laid down in the fracture interior
(internal callus)

Ossification (mineralization) starts by 2-3 weeks &
continues for 3-4 months
Alkaline phosphatase is secreted by osteoblasts
blood serum levels serve as an indicator of the rate
of bone formation
In non-Immobilized fractures, more “cartilage” than
bone is laid down
this must later be replaced by normal cancellous
bone
results in a longer healing time and fractured area
remains weak for a longer period
Fractures should be reduced (immobilized) within 3-5
days

4.) Bone Remodeling
Months to years (mechanically stable at 40 days)
Excess material inside bone shaft is replaced by
more compact bone
Final remodeled structure is influenced by optimal
bone stress

 Woven bone is gradually converted to lamellar bone
 Medullary cavity is reconstituted
 Bone is restructured in response to stress and strain
(Wolff’s Law)

FRACTURE CLASSIFICATION AND MANAGEMENT..

Healing in Bone:
1D - Hematoma
3D - Inflammation
1W - Soft callus
3-6W - Callus
8+W - Re-modeling

Stages of wound healing
Time after injury
Hemostasis
Inflammation
Proliferation
Resolution/ Remodeling
PMNs, Macrophages, Lymphocytes
Reepithelialization, Angiogenesis, Fibrogenesis,
Vessel regression, Collagen remodeling
Fibrin clot, platelet
deposition
1D 3D 1wk 6wk 8wk

FACTORS INFLUENCING # HEALING
 AGE
 TYPE OF BONE
 TYPE OF FRACTURE
 GENERAL STATUS OF THE PATIENT-VITAMIN
DEF,DM,SYPHILIS,IMMUNOCOMPRAMISED.
 IMPROPER REDUCTION
 INADEQUATE BLOOD SUPPLY
 INADEQUATE IMMOLISATION
 INFECTION
 SOFT TISSUE INTERPOSITION

Factors Enhancing Bone Healing
Youth
Early Immobilization of fracture fragments
Maximum bone fragment contact
Adequate blood supply
Proper Nutrition
Vitamines A&D

Weight bearing exercise for long bones in the
late stages of healing
Adequate hormones:
growth hormone
thyroxine
calcitonin

Age
Fractured Femur Healing Time
infant: 4 weeks
teenager: 12 to 16 weeks
60 year old adult: 18 to 20 weeks
Extensive local soft tissue trauma
Factors Inhibiting Bone Healing

Bone loss due to the severity of the
fracture
Infection
Inadequate immobilization (motion at the
fracture site)
Avascular Necrosis

Acute Compartment Syndrome
 Serious condition in which increased
pressure within one or more compartments
causes massive compromise of circulation to
the area
 Prevention of pressure buildup of blood or
fluid accumulation
 Pathophysiologic changes sometimes
referred to as ischemia-edema cycle

Emergency Care - Acute
Compartment Syndrome
 Within 4 to 6 hr after the onset of acute compartment
syndrome, neuromuscular damage is irreversible; the
limb can become useless within 24 to 48 hr.
 Monitor compartment pressures.
 Fasciotomy may be performed to relieve pressure.
 Pack and dress the wound after fasciotomy.

Possible Results of Acute
Compartment Syndrome
 Infection
 Motor weakness
 Volkmann’s contractures
 Myoglobinuric renal failure, known as
rhabdomyolysis

Other Complications of Fractures
 Shock
 Fat embolism syndrome: serious complication resulting
from a fracture; fat globules are released from yellow
bone marrow into bloodstream
 Venous thromboembolism
 Infection
 Ischemic necrosis
 Fracture blisters, delayed union, nonunion, and
malunion

 Muscle Atrophy, loss of muscle strength range of
motion, pressure ulcers, and other problems
associated with immobility
 Embolism/Pneumonia/ARDS
 TREATMENT – hydration, albumin, corticosteroids
 Constipation/Anorexia
 UTI
 DVT

Musculoskeletal Assessment -
Fracture
 Change in bone alignment
 Alteration in length of extremity
 Change in shape of bone
 Pain upon movement
 Decreased ROM
 Crepitation
 Ecchymotic skin

Musculoskeletal Assessment –
Fracture (Continued)
 Subcutaneous emphysema with bubbles
under the skin
 Swelling at the fracture site

Special Assessment
Considerations
 For fractures of the shoulder and upper arm,
assess client in sitting or standing position.
 Support the affected arm to promote comfort.
 For distal areas of the arm, assess client in a
supine position.
 For fracture of lower extremities and pelvis,
client is in supine position.

Risk for Peripheral
Neurovascular Dysfunction
 Interventions include:
 Emergency care: assess for respiratory
distress, bleeding and head injury
 Nonsurgical management: closed reduction
and immobilization with a bandage, splint,
cast, or traction

Casts
 Rigid device that immobilizes the affected
body part while allowing other body parts
to move
 Cast materials: plaster, fiberglass,
polyester-cotton
 Types of casts for various parts of the
body: arm, leg, brace, body
(Continued)

Casts (Continued)
 Cast care and client education
 Cast complications: infection, circulation
impairment, peripheral nerve damage,
complications of immobility

Managing Care of the Patient in a Cast
 Casting Materials
 Relieving Pain
 Improving Mobility
 Promoting Healing
 Neurovascular Function
 Potential Complications

Cast, Splint, Braces, and Traction
Management Considerations
 Arm Casts
 Leg Casts
 Body or Spica Casts
 Splints and Braces
 External Fixator
 Traction

Musculoskeletal
Nursing Care - Casts
 Cast (Leg, arm, body)
 Different materials-
fiberglass, plastic,
plaster, stockinette
 Neurovascular
 Check color/capillary
refill
 Temperature
 Pulse
 Movement
 Sensation
 Traction
 Buck’s
 Russell’s
 Skeletal
 Traction Nursing Care
 Weighs hang free
 Pin Site care
 Skin and neurovascular
check

Cast Care (continued)
 Elevate Extremity
 Exercises – to unaffected side; isometric exercises to affected
extremity
 Keep heel off mattress
 Handle with palms of hands if cast wet
 Turn every two hours till dry
 Notify MD at once of wound drainage
 Do not place items under cast.

Traction
 Application of a pulling force to the body
to provide reduction, alignment, and rest
at that site
 Types of traction: skin, skeletal, plaster,
brace, circumferential
(Continued)

Traction (Continued)
 Traction care:
 Maintain correct balance between traction pull
and countertraction force
 Care of weights
 Skin inspection
 Pin care
 Assessment of neurovascular status

Musculoskeletal – Fractures
Treatment
 Primary Goal – reduce fracture-
 Realign and immobilize
 Medications
 Analgesics, antibiotics, tetanus toxoid
 Closed Reduction – Manual and Cast; External
Fixation Device
 Traction; Splints; Braces
 Surgery
 Open reduction with internal fixation
 Reconstructive surgery
 Endoprosthetic replacement

Nursing Management
Positioning
Strengthening Exercises
Potential Complications

Musculoskeletal
Nursing Care
 Other External Immobilizations
 Halo Vest
 External Fixation with lag screws at tibia, pelvic,
ankle/foot

Musculoskeletal
Nursing Care -2
 Promote comfort
 Assess infection
 Promote mobility
 Teach safety
 Vital Signs
 Flotation, sheep skin
 Nutrition
 Vital Signs
 Monitor elimination
 Elevate extremity to
decrease swelling/ ice
pack
 Teach skin care, cast
care, diet,
complications

Operative Procedures
 External fixation
 Postoperative care: similar to that for any
surgery; certain complications specific to
fractures and musculoskeletal surgery
include fat embolism and venous
thromboembolism

Acute Pain - Orthopedic Surgery
 Reduction and immobilization of fracture
 Assessment of pain
 Drug therapy: opioid and nonopioid drugs
(Continued)

Acute Pain (Continued)
Orthopedic Surgery
 Complementary and alternative therapies: ice,
heat, elevation of body part, massage, baths,
back rub, therapeutic touch, distraction,
imagery, music therapy, relaxation techniques

Risk for Infection
 Apply strict aseptic technique for dressing
changes and wound irrigations.
 Assess for local inflammation
 Report purulent drainage immediately to
health care provider.
(Continued)

Risk for Infection (Continued)
 Assess for pneumonia and urinary tract
infection.
 Administer broad-spectrum antibiotics
prophylactically.

Impaired Physical Mobility
 Use of crutches to promote mobility
 Use of walkers and canes to promote mobility

Imbalanced Nutrition: Less Than
Body Requirements
 Diet high in protein, calories, and calcium,
supplemental vitamins B and C
 Frequent small feedings and supplements of
high-protein liquids
 Intake of foods high in iron

Upper Extremity Fractures
 Fractures include those of the:
 Clavicle
 Scapula
 Humerus
 Olecranon
 Radius and ulna
 Wrist and hand

Lower Extremity Fractures
 Fractures include those of the:
 Femur
 Patella
 Tibia and fibula
 Ankle and foot

Fractures of the Hip
 Intracapsular or extracapsular
 Treatment of choice: surgical repair, when
possible, to allow the older client to get
out of bed
 Intramedullary rod, pins, a prosthesis, or a
fixed sliding plate
 Prosthetic device

Fractures of the Pelvis
 Associated internal damage the chief
concern in fracture management of pelvic
fractures
 Non–weight-bearing fracture of the pelvis
 Weight-bearing fracture of the pelvis

Compression Fractures of the
Spine
 Most are associated with osteoporosis
rather than acute spinal injury.
 Multiple hairline fractures result when
bone mass diminishes.
(Continued)

Compression Fractures of the
Spine (Continued)
 Nonsurgical management includes
bedrest, analgesics, and physical therapy.
 Minimally invasive surgeries are
vertebroplasty and kyphoplasty, in which
bone cement is injected.
(Continued)

FRACTURE CLASSIFICATION AND MANAGEMENT..

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FRACTURE CLASSIFICATION AND MANAGEMENT..

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