Justin Ubay

BSN212
Group 48A
FRACTURES

Diagnosis
A bone fracture can be diagnosed clinically, based on the history given and the physical
examination performed by to view the bone suspected of being fractured.
In situations where x-ray alone is insufficient, a computed tomograph (CT scan) may
be performed.

Nursing management

1. Provide emergency management when situation warrants, for a new fracture.

Assess the five “Ps”.

Determine the mechanism of injury.

Immobilize the part. Move injured parts as little as possible.

Cover any open wounds with a sterile, or clean dressing.

Reassess the five “Ps”.

Apply traction if circulatory compromise is present.

Elevate the injured limb, if possible.

Apply cold to the injured area.

Call emergency medical services.

2. Assess for circulatory impairment (cyanosis, coldness, mottling, decreased peripheral
pulses, positive blanch sign, edema not relieved by elevation, pain or cramping).

3. Assess for neurologic impairment (lack of sensation or movement, pain, or

tenderness, or numbness and tingling).

4. Administer analgesic medications.

5. Explain fracture management to the child and family. Depending on the type of break
and its location, repair (by realignment or reduction) may be made by closed or
open reduction followed by immobilization with a splint, traction or a cast.

6. Maintain skin integrity and prevent breakdown.

7. Prevent Complications

Prevent circulatory impairment by assessing pulses, color and temperature, and by

reporting changes immediately.

Prevent nerve compression syndromes by testing sensation and motor function,

including subjective symptoms of pain, muscular weakness, burning sensation,
limited ROM, and altered sensation. Correct alignment to alleviate pressure if
appropriate, and notify the health care provider.

Avoid compartment syndrome by assessing for muscle weakness and pain out of
proportion to injury. Early detection is critical to prevent tissue damage.

Causes of compartment syndrome include tight dressings or casts, hemorrhage, trauma,

burns and surgery.

Treatment entails pressure relief, which sometimes require performing a fasciotomy.

8. Prevent infection, including osteomyelitits, bys using infection control measures.

9. Prevent renal calculi by encouraging fluids, monitoring I&O, and mobilizing the child
as much as possible.

10. Prevent pulmonary emboli by carefully monitoring adolescents and children with
multiple fractures. Emboli generally occur within the first 24 hours.
Immobilization
Since bone healing is a natural process which will most often occur, fracture treatment
aims to ensure the best possible function of the injured part after healing. Bone
fractures are typically treated by restoring the fractured pieces of bone to their
natural positions and maintaining those positions while the bone heals. Often,
aligning the bone, called reduction, in good position and verifying the improved
alignment with an X-ray is all that is needed. This process is extremely painful
 without anesthesia, about as painful as breaking the bone itself. To this end, a
fractured limb is usually immobilized with a plaster or fiberglass cast or splint
which holds the bones in position and immobilizes the joints above and below the
fracture. When the initial post-fracture edema or swelling goes down, the fracture
may be placed in a removable brace or orthosis. If being treated with
surgery, surgical nails, screws, plates and wires are used to hold the fractured
bone together more directly. Alternatively, fractured bones may be treated by
the Ilizarov method which is a form of external fixator.

Occasionally smaller bones, such as phalanges of the toes and fingers, may be treated
without the cast, by buddy wrapping them, which serves a similar function to making a
cast. By allowing only limited movement, fixation helps preserve anatomical alignment
while enablingcallus formation, towards the target of achieving union.

Splinting results in the same outcome as casting in children who have a distal radius
fracture with little shifting.

Surgery

Surgical methods of treating fractures have their own risks and benefits, but usually
surgery is done only if conservative treatment has failed or is very likely to fail. With
some fractures such as hip fractures with is usually caused by
osteoporosis or osteogenesis Imperfecta , surgery is offered routinely, because the
complications of non-operative treatment include deep vein thrombosis (DVT)
and pulmonary embolism, which are more dangerous than surgery. When a joint surface
is damaged by a fracture, surgery is also commonly recommended to make an accurate
anatomical reduction and restore the smoothness of the joint. Infection is especially
dangerous in bones, due to the recrudescent nature of bone infections. Bone tissue is
predominantly extracellular matrix, rather than living cells, and the few blood
vessels needed to support this low metabolism are only able to bring a limited number
of immune cells to an injury to fight infection. For this reason, open
fractures andosteotomies call for very careful antiseptic procedures
and prophylactic antibiotics.

Occasionally bone grafting is used to treat a fracture.

Sometimes bones are reinforced with metal. These implants must be designed and
installed with care. Stress shielding occurs when plates or screws carry too large of a
portion of the bone's load, causing atrophy. This problem is reduced, but not eliminated,
by the use of low-modulus materials, including titanium and its alloys. The heat
generated by the friction of installing hardware can easily accumulate and damage bone
tissue, reducing the strength of the connections. If dissimilar metals are installed in
contact with one another, galvanic corrosion will result. The metal ions produced can
damage the bone locally and may cause systemic effects as well.

Electrical bone growth stimulation or osteostimulation has been attempted to speed or

improve bone healing. Results however do not support its effectiveness.[16]

Complications

Some fractures can lead to serious complications including a condition known

as compartment syndrome. If not treated, compartment syndrome can result in
amputation of the affected limb. Other complications may include non-union, where the
fractured bone fails to heal or mal-union, where the fractured bone heals in a deformed
manner.

How is a fracture diagnosed?

When you arrive for medical care, the doctor will take a history of the injury. Where,
when, and why did the injury occur? Did the person trip and fall, or did they pass out
before the fall? Are there other injuries that take precedence over the fracture? For
example, a person who falls and hurts their wrist because they had a stroke or heart
attack will have their fracture care delayed to allow care for the life threatening illness.
The injured area will be examined and a search will happen for potential associated
injuries. These include damage to skin, arteries and nerves.
Pain control is a main concern and many times, pain medication will be prescribed
before the diagnosis is made. If the doctor believes that an operation is likely, pain
medication will be given through an intravenous (IV) line or by an injection into the
muscle. This allows the stomach to remain empty for potential anesthesia.
A decision will be made whether x-rays are required, and which type of x-ray should be
taken to make the diagnosis and better assess the injury. There are guidelines in place
to help doctors decide if an x-ray is necessary. Some include the Ottawa ankle and knee
x-ray rules.
The body is three dimensional, and plain film x-rays are only two dimensional. Therefore,
two or three x-rays of the injured areas may be taken in different positions and planes to
give a true picture of the injury. Sometimes the fracture will not be seen in one position,
but is easily seen in another.
There are areas of the body where one bone fracture is associated with another fracture
at a more distant part. For example, the bones of the forearm make a circle and it is
difficult to break just one bone in that circle. Think of trying to break a pretzel in just one
place, it is difficult to do. Therefore broken bones at the wrist may be associated with an
elbow injury. Similarly, an ankle injury can be accompanied by a knee fracture. The
doctor may x-ray areas of the body that don't initially appear to be injured.
Occasionally, the broken bone isn't easily seen, but there may be other signs that a
fracture exists. In elbow injuries, fluid seen in the joint on x-ray is an indicator of a subtle
fracture. And in wrist injuries, fractures of the scaphoid or navicular bone may not show
up on x-ray for one to two weeks, and diagnosis is made solely on physical examination
with swelling and tenderness over the snuffbox at the base of the thumb.
In children, bones may have numerous growth plates that can cause confusion when
reading an x-ray. Sometimes, the doctor will choose to x-ray the opposite arm or leg to
determine what normal is for the child before deciding whether a fracture exists.

What is the treatment of a fracture?

Initial treatment for fractures of the arms, legs, hands and feet in the field include
splinting the extremity in the position it is found, elevation and ice. Immobilization will be
very helpful with initial pain control. For injuries of the neck and back, many times, first
responders or paramedics may choose to place the injured person on a long board and
in a neck collar to protect the spinal cord from potential injury.
Once the fracture has been diagnosed, the initial treatment for most limb fractures is a
splint. Padded pieces of plaster or fiberglass are placed over the injured limb and
wrapped with gauze and an elastic wrap to immobilize the break. The joints above and
below the injury are immobilized to prevent movement at the fracture site. This initial
splint does not go completely around the limb. After a few days, the splint is removed
and replaced by a circumferential cast. Circumferential casting does not occur initially
because fractures swell (edema). This swelling would cause a build up of pressure
under the cast, yielding increased pain and the potential for damage to the tissues under
the cast.
Surgery
Surgery on fractures are very much dependent on what bone is broken, where it is
broken, and whether the orthopedic surgeon believes that the break is at risk (for staying
where it is) once the bone fragments have been aligned. If the surgeon is concerned that
the bones will heal improperly, an operation will be needed. Sometimes bones that
appear to be aligned normally are splinted, and at a recheck appointment, are found to
be unstable and require surgery.
Surgery can include closed reduction and casting, where under anesthesia, the bones
are manipulated so that alignment is restored and a cast is placed to hold the bones in
that alignment. Sometimes, the bones are broken in such a way that they need to have
metal hardware inserted to hold them in place. Open reduction means that, in the
operating room, the skin is cut open and pins, plates, or rods are inserted into the bone
to hold it in place until healing occurs. Depending on the fracture, some of these pieces
of metal are permanent (never removed), and some are temporary until the healing of
the bone is complete and surgically removed at a later time.