FRACTURE

Definition:

 

                    It is define as a break in the continuity of a bone either complete or incomplete is called fracture.

 

 

 

Causes of fracture:

 

     1. All fractures are caused by trauma-

a.     Direct trauma / Direct violence

b.    Indirect trauma.

2.    Pathological fracture-

a.     Generalized weakness of bone. e.g. Rickets, osteomalacia etc.

b.    Localized weakness of bone. e.g.- Local tumor, bone cyst etc.

3.    Pathological fracture-

a.     Fracture in the disease of bone. e.g.- Bone TB, osteosarcoma. etc.

 

 

 

 

 

Classification of fracture:

 

 

 

1.   Clinical:

 

a.     Closed / Simple fracture-

      Does not communicate with external air.

b.    Open / Compound fracture-

Communicate with external air. It may be from within or without:-

         

From within- Caused by broken bone & through skin and soft tissue.

  From without- Injury of the skin and soft tissue caused by trauma.

 

c.     Complicated fracture-

The fracture involving the vessels, nerves or other organs during initial injury.

 

 

 

2.   Based on the extend of fracture line:

 

a)    Incomplete fracture – It involves only one surface or cortex of the bone.

b)    Complete fracture – Here the fracture involves the entire bone. A complete fracture could be placed or displaced. Displaced fracture poses a challenge in the treatment.

 

 

 
3.   Based on fracture patterns (Orthopedic Trauma Association classification.)

 

a)    Linear fracture – These could be transverse, oblique or spiral: Any fracture which forms an angle less than 30 degree is termed oblique.

b)    Comminuted fracture – Here the fracture fragments are more than two in number. They are further sub classified in to <_ 50% comminuting or more than 50% comminuting. Butterfly-shaped fracture is also included in this group.

c)    Segmental fracture – A fracture can break in to segments and the segments could be two level, three level, a longitudinal split or comminuted.

d)    Bone loss – This could be a < 50 % bone loss or more than 50 % bone loss or a complete bone loss.

 

 

 

 

 

Other types /Atypical fracture:

 

 

a.    Greenstick fracture :-

It is seen exclusively in children. Here the bone is elastic and usually bends due to bucking or breaking of one cortex when a force is applied. This is called greenstick fracture.

 

b.    Impacted fracture:-

Here the fracture fragments are impacted in to each other and are not separated and displaced.

 

 

c.     Stress or fatigue fracture :-

It is usually an incomplete fracture commonly seen in athletes and in bones subjected to chronic and impetitive stress (e.g. third metatarsal fracture, fracture tibia, etc.). It is due to repeated minor trauma leading to repetitive stress to the bone causing fracture. It is common in second metatarsal of foot, occurs due to repeated marching and stamping. It is also called as “March fracture’ it is treated by rest, immobilization with plaster slab of the foot.

 

 

d.    Hair line or crack fracture:-

It is very fine break in the bone which is difficult to diagnose clinically. Radiology usually helps to detect this fracture.

 

e.     Torus fracture:-

This is just a bucking of the outer cortex.

 

f.      Pathological fracture:-

In weak bone due to presence of any pathological condition./ It occurs in a diseased bone and is usually spontaneous. The force required to bring about a pathological fracture is trivial.e.g Chonic osteomyelitis, bone T.B, Osteocercoma, 

 

 

 

 

Displacement of Fractures:

 

                    A complete fracture usually gets displaced due to various factors. Depending on the direction of force, mode of injury, pull of the muscles, a fracture can show any one of the following displacements or angulations-

1.    Anterior angulations or displacement.

2.    Posterior angulations displacement.

3.    Varus or medial angulations or displacement.

4.    Valgus or lateral displacement.

5.    Shorte`ning.

6.    Translational.

 

 

 

Clinical features of fracture:

 

 

 

A.    Symptoms:

 

1.    H/O trauma.

2.    Pain.

3.    Swelling.

4.    Loss of normal functions/ Inability to move.

5.    Abnormal mobility.

6.    Deformity.

 

 

B.    Signs:

 

 

1.    Inspection:

a)    Compare with healthy part.

b)    General condition of the patient.

c)    Position of the patient.

d)    Deformity.

e)    Echymosis.

f)     Anemia due to hemorrhage.

g)    Dehydration.

h)    Defuse swelling.

 

 

2.    Palpation:

a)    Rise of local temperature.

b)    Tenderness.

c)    Abnormal mobility.

d)    Crepitation.

e)    Vessels-Palpation of distal vessels from the fracture site e.g. Radial artery, arterial dorsalis pedis.

f)     Nerves – Sensory and motor function must be tested.

 

3.    Investigation:

 

a)    Plain x-ray of the affected part in AP lateral and sometimes oblique view.

 

 

4.    Radiography:

 

a)    X-ray is essential-

b)    For localization and confirmation of fracture.

c)    For determination of number of fragment.

d)    Fracture is recent or old.

e)    To decide technique of treatment.

 

 

 

 

 

Complications of Fracture:

 

 

A.   Immediate complications:

1.    Lo`cal injury to-

 

 

                              a. Skin.

                              b. Vessels.

                              c. Nerves.

                              d. Spinal cord and roots.

                              e. Muscles.

                              d. Viscera-

                                        - Abdominal.

                                        - Thoracic.

                              e. Internal organs.

 

 

                    2. General:

                              a. Multiple injuries.

                              b. Hemorrhage- shock.

                              c. Crush syndrome.

 

 

B.    Early/ Intermediate complications:

 

 

1.    Local

 

                              a. Skin necrosis and gangrene.

                              b. Gas gangrene.

                              c. Venous thrombosis.

                              d. Joint infection.  

e. Bone infection.

                              d. Fracture.

                              f. Blister.

 

 

 

2.    General:

 

                              a. Tetanus.

                              b. Fat embolism.

                              c. Pulmonary embolism.

                              d. Pneumonia.

                              e. Delirium tremens.

 

 

3.    Late complications:

 

 

                    1. Local-

                              a. Joint-

                                        i) Stiffness.

                                        ii) Osteoarthritis.

b. Bone-

                                        i) Mal-union.

                                        ii) Delayed union.

                                        iii) Non-union.

                                        iv) Growth disturbance.

                                        v) Chronic infection.

                                        vi) Re-fracture.

c. Muscles-

                                        i) Myositis orifications.

                                        ii) Late tendon rupture.

                                        iii) Tissue atrophy.

                                        iv) Tendonitis.

d. Nerve –Tardy nerve palsy.

                    2. General-

                              a. Renal calculi.

                              b. Accident neurosis.

 

 

 

 

 

 

Management & Treatment of Fracture:

 

 

 

A. Principles of treatment:

 

 

1.    Recognition: Diagnosis and assessment of fracture.

 

                    2. Reduction of fracture: Reduction of fracture fragments is mandatory if displaced. It is usually done under general anesthesia after adequate radiographic study. Reduction methods consists of-

a)    Closed reduction.

b)    Continuous reduction.

c)    Open reduction.

 

 

                    3. Retention: (Immobilization of fracture). Once the fracture fragments are reduced. It has to be retained in that position till the fracture unites, and otherwise it tends to get displaced due to the action of muscles, gravity and inherent factors. Retention methods after closed reduction are-

a)    By plaster of paris splints.

b)    By continuous traction.

c)    Use of functional braces.

 

 

4.    Rehabilitation:- It includes following physiotherapy methods-

 

a)    Active exercise for the unimmobilized joints.

b)    Isometric exercise for the joints immobilized.

c)    Care of the plaster splints for loosing, breakage, tightness, skin excoriations, soiling etc.

d)    Training to carry out the functional activity with the unaffected limb.

e)    Once the plaster is removed, mobilizations of joints are done by appropriate active and passive exercise. Resistive exercise help to strengthen the muscles.

f)     Heat therapy to alleviate pain, swelling and spasm.

g)    Massaging of the joints after application of pain relieving gel or oils help to relax the muscles and relieve pain.

h)    Counseling to keep the depression and anxiety away.

i)      Thus rehabilitation begins with a fracture and ends once the lost functions are restored back completely.

 

 

 

 

          B. General treatment of fracture:

                    1. Remove all dirty clothing’s.

2. Examine the patient thoroughly- Record TPR &       blood pressure.

3. In case of open fracture- Wash, clean, and cover the wound with clean gauze, cotton and bandage. If bleeding does not control tourniquet is to be used.

4. X-ray to confirm diagnosis.

5. Immobilize the affected part.

6. Intra venous fluid should be given.

7. Blood transfusion- in case of excessive blood loss.

8. Analgesic- Inj- Diclofenac sodium is given.

9. Antibiotic- As prescribed.

10. Inj- A.T.S-1500 IU is to be given after skin       sensitivity test or Inj-T.I.G-250 I.U i/m is to be given in all cases of compound fracture and Inj- T.T is to be given if the patient not immunized.

11. If the patient immunized only Inj- T.T is to be given.

12. Extension of the spine in all suspected cases of spine fracture.

13. Hospitalization, correction of deformity and immobilization by-

          i. Manual reduction and plaster immobilization.

          ii. Manual reduction and continuous traction.

iii. Operative reduction and internal fixation done by screw, plate and nail.

iv. Change of posture from time to time to avoid bed sore. 

 

 

 

Management and Nursing Care of Compound / Open Fracture:

 

 

1. Received the patient and place in bed with comfortable position very gently and carefully.

2. Check the air passage with gauze piece by the help of artery or finger. If respiratory distress the patient is kept in jaw forward and oxygen inhalation start.

3. Check and record vital signs- Temperature, pulse, respiration and blood pressure properly.

4. If there is hemorrhage than i/v fluid is to be given.

5. In case of excessive blood loss then blood transfusion is needed.

6. If the patient is going to shock then steroid is to be given like- Inj- Dexamethasone.

7. Surgical toileting:

 

 

i) It should be done under general anesthesia (G/A) if G/A is not available then under analgesic, sedative with local anesthesia by the help of tourniquet.

ii) Wound is to be covered with sterile gauze piece.

iii) Shave and clean the surrounding area of the wound and wash with soap water.

iv) Remove gauze pieces from the wound and wash, clean the wound with soap water, normal saline etc.

v) Remove any foreign body and dead tissue.

vi) Repair the blood vessels, tendon, nerve and soft tissue.

vii) Incase of deep wound then it should be washed with hydrogen peroxide and normal saline.

viii) Close the wound with skin suture or keep the wound open.

ix) Finally dressed with Vaseline gauze or sterile gauze piece and apply pressure bandage.

8. Immobilize the affected limb with plaster cast.

9. Analgesic is to be given to relieve pain.

10. Antibiotic is to be given to prevent infection.

11. Immunization:

 

a. If the patient is not immunized then-

i). Inj.-TIG 250 IU i/m is to be given if it is not available then Inj.-ATS 1500 IU i/m given after skin sensitivity test.

ii). Inj.-TT 1 ample i/m stat and another one after one month.

b.    If the patient is immunized- Only Inj.-TT 1 ample i/m (Buster dose) is to be given.

 

12. Remove all dirty clothing’s.

13. Reassurance to the patient and other relatives.

14. In case of retention or incontinence of urine then catheterization is to be done with aseptic precaution.

15. Posture should be changed frequently to prevent bed sore.

16. Bowel care is taken in case of constipation mild laxative is given.

17. Mouth care is to be taken.

18. Head wash and bed bath is to be given gradually normal diet is to be given.

                     

 

 

 

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