a) Define fracture
c) Mention the factors affecting fracture healing
d) What are the stages of fracture healing
c) Write a nursing care plan for a patient with fracture of neck of femur based on three prioritized nursing problems.
Fracture Bone
Definition
A break in the continuity of the bone
Types
Simple
Compound or open
Comminuted - breaking of the bone in more than two pieces
Green Stick - break in the bone without rupture of the periosteum - occurs in young children
Transvers
Oblique
Spiral
Avulsion - breaking of the bone due to sudden and violent pulling by the attached to the bone
Stress - fracture occurring due to repeated stress on a bone like march fracture in soldiers
Pathologic - due to some disease condition like bone metastasis, osteoporosis
Depressed fracture - a pit like depression is formed like in the skull
Impacted - fractured ends are telescoped into each other and partially immobilized
Compression - occurs in vertebrae or calcaneum
Open fractures are graded according to the following criteria:
• Grade I is a clean wound less than 1 cm long.
• Grade II is a larger wound without extensive soft tissue
damage.
• Grade III is highly contaminated, has extensive soft tissue
damage, and is the most severe.
Clinical Features
Pain
Swelling
Deformity
Warmth
Crepitus
Discoloration
Loss of proper function
Shortening of the limb
Stages of Bone Healing
Four stages
1) the formation of hematoma at the break,
2) the formation of a fibrocartilaginous callus,
3) the formation of a bony callus, and
4) remodeling and addition of compact bone.
See the picture on the right
Factors Affecting Healing of Fracture
Blood Supply.
Soft tissue injury.
Radiation.
Chemical or thermal burns
Excessive Movement. Inadequate immobilisation. Inadequate fixation or compliance.
Gap. Intact fellow bone. Interposed soft tissue.
Nutrition (Vit C required for normal collagen)
Drugs (corticosteriods inhibit osteoblast differentiation.
Emergency Management
Immobilize with splints and slings
Combat Shock
Prevent further contamination of open fractures
Pain relief
Irrigation of compound fractures with sterile solutions to minimize infection
Investigations
X-rays
CT scans
Other routine tests
Treatment
Closed reduction
Open fractures with damaged and non viable tissues debrided
Open reduction and internal fixation - plates, screws, steel wires, use of bone grafts etc
Reducion and external fixation - External fixators
Post treatment physiotherapy to restore function
Complications
Injury to the adjacent structures like muscle, nerve or blood vessel
Infection
Shock if internal bleeding occurs in a large scale like in femoral shaft fractures
Fat embolism like in fracture of the femur
Comparmental syndrome
Haemothorax, pneumothorax in rib fracture, flail chest
Delayed union
Malunion - deformity
Early setting in of osteoarthritis in joints
Osteomyelitis
Nursing Care Plan
Priorities : Pain, Spasm, gentleness in handling, analgesic administraion, timing of pain relief
Position : comfort, function, neutral position of the hip, using trochanter roll, placing pillows between legs when turning
Exercise : isometric quadriceps and gluteal muscle training
Nursing Interventions
Relieve pain or spasm causing pain
Encourage the use of trapeze
Encourage progressive safe ambulation
Teach safe use of ambulatory aids
Aseptic dressings
Assess wound appearance
Monitor intake and output
Minimize use of indwelling catheter
Arrange support services
Assess orientation status
Assess cognitive and auditory, visual deficits
Call bell made available
Collaborative Problems
Observe for shock
Monitor BP, treat hypertension
Watch for bleeding
Monitor breathing
Dehydration avoided
DVT - avoided. - thigh high elastic compression stockings and sequential compression device if availble
Capillary filling in the toes looked after - Assess popliteal, dorsalis pedis and posterior tibial pulses
Pressure sores - prevented by change of position and providing appropriate bed
Infmmation of the limb to be looked for
Avoid pressure on the popliteal vessels
Ankle stiffness - exercises
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