Topic Outline

Unit 1. Recall the Anatomy of the Skeletal System

Unit 2. Fracture
a. Definition
b. Causes of Fracture
c. Clinical manifestations of fracture
d. Classifications of Fracture
e. Diagnostic Tests
f. Complications
g. Nursing Diagnosis
h. Nursing Management
Unit 3. Bone Healing Process
a. Types of Bone Healing process
b. Factors affecting Bone Healing Process
c. Stages of Bone Healing Process
Unit 4. Management of Fracture
a. Principles
b. Different Types of the Management of Fracture
1. Traction, its types and indications
2. Casts & Molds & its indications
3. Braces & Splints & Its indications
4. Fixators and its indications
Unit 5. Applications of BST
BST Procedural Checklist Discussion

CONTENTS

Unit 1. Recall the Anatomy of the Skeletal System

Human Skeleton
Total Number of Bones-206
Divisions of the Skeletal System
1. Axial Skeleton-80 Bones
a. Skull - 29
 Cranial Bones - 8
 Facial bones – 14
 Ear Ossicles – 6
 Hyoid Bone – 1
b. Ribs and Sternum - 25
 True Ribs – 7 pairs
 False Ribs – 5 pairs (2 pairs are Floating ribs)
 -Sternum – 1
2. Appendicular skeleton- 126 bones (all bones exist in pairs)
a. Upper Limb
o Shoulder girdle
  Clavicle
 Scapula
o Arm
 Humerus
oForearm
 Radius
 Ulna
o Wrist or carpal bones
 Scaphoid
 Lunate
 Triquetrum
 Pisiform
 Trapezium
 Trapezoid
 Capitate
 Hamate
o Hand
 Metacarpals x5
 Phalanx x14
b. Lower Limb
o Pelvic girdle (hip or coxal bone)
 Ilium
 Ischium
 Pubis
o Thigh
 Femur
o Leg
 Tibia
 Fibula
o Tarsal bones
 Talas
 Calcaneus
 Cuboid
 Medial, intermediate, and lateral cuneiform
 Navicular
o Foot
o
 Metatarsals x5
 Phalanx x14

Unit 2. Fracture

DEFINITION
A fracture is a traumatic injury interrupting bone continuity.
It is a break in the continuity of bones

CAUSES OF FRACTURE
1. Injury
 Direct or indirect Force or a crushing form
 2. Twisting force
3. Powerful muscle contraction
4. Fatigue and stress

5. Disease or tumor( Pathologic)

CLINICAL MANIFESTATIONS OF FRACTURE

 Pain
 Edema
 Tenderness
 Abnormal movement and crepitus
 Loss of function
 Ecchymoses
 Visible deformity
 Paresthesias and other sensory abnormalities

CLASSIFICATIONS OF FRACTURE
TYPES:
 Closed simple, uncomplicated fractures – do not cause a break
in the skin.
 Open compound, complicated fractures – involve trauma to
surrounding tissue and break in the skin.
 Incomplete fractures– are partial cross-sectional breaks with
incomplete bone disruption.

 Complete fractures – are complete cross-sectional breaks

severing the periosteum.
 Comminuted fractures – produce several breaks of the bone,
producing splinters and fragments.
 Greenstick fractures – break one side of a bone and bend the
other.
 Spiral (torsion) fractures – involve a fracture twisting around
the shaft of the bone.
 Transverse fractures – occur straight across the bone.
 Oblique fractures – occur at an angle across the bone (less
than a transverse)


image by : physio-pedia.com

DIAGNOSTIC TESTS
To determine the presence of fracture, the following diagnostic tools are
used.

 X-ray examinations: Determines location and extent of

fractures/trauma, may reveal preexisting and yet
undiagnosed fracture(s).

 Bone scans, tomograms, computed tomography

(CT)/magnetic resonance imaging (MRI) scans: Visualizes
fractures, bleeding, and soft-tissue damage; differentiates
between stress/trauma fractures and bone neoplasms.
  Arteriograms: May be done when occult vascular damage
is suspected.
 Complete blood count (CBC): Hematocrit (Hct) may be
increased (hemoconcentration) or decreased (signifying
hemorrhage at the fracture site or at distant organs in
multiple trauma). Increased white blood cell (WBC) count
is a normal stress response after trauma.
 Urine creatinine (Cr) clearance: Muscle trauma increases
the load of Cr for renal clearance.
 Coagulation profile: Alterations may occur because of
blood loss, multiple transfusions, or liver injury.

COMPLICATIONS
NURSING DIAGNOSIS

 Pain related to fracture, soft tissue damage, muscle spasm,

and surgery
 Impaired physical mobility related to fractured hip
 Impaired skin integrity related to surgical incision
 Risk for impaired urinary elimination related to immobility
 Risk for disturbed thought process related to age, stress of
trauma, unfamiliar surroundings, and drug therapy
 Risk for ineffective coping related to injury, anticipated
surgery, and dependence
 Risk for impaired home maintenance related to fractured hip
and impaired mobility

NURSING MANAGEMENT
1.Prevent infection
 Cover any breaks in the skin with clean or sterile dressing.
2.Provide care during client transfer.
 Immobilize a fractured extremity with splint in the position
of the deformity before moving the client; avoid
strengthening the injured body part if a joint is involved.
 Support the affected body part above and below fracture
site when moving the client.
3.Provide client and family teaching.
 Explain prescribed activity restrictions and necessary
lifestyle modification because of impaired mobility.
 Teach the proper use of assistive devices, as indicated.
4.Administer prescribed medications, which may include opioid
or nonopioid analgesics and prophylactic antibiotics for an
open fracture.
5.Prevent and manage potential complications.
 Observe for symptoms of life-threatening fat embolus,
which may include personality change, restlessness,
dyspnea, crackles, white sputum, and petechaie over the
chest and buccal membranes. Assist with respiratory
support, which must be instituted early.
 Observe for symptoms of compartment syndrome, which
include deep, unrelenting pain; hard edematous muscle;
and decreased tissue perfusion with impaired
neurovascular assessment findings.
  Monitor closely for signs and symptoms of other
complications.
6.Patient education regarding different factors that affect
fracture healing
Factors that enhance fracture healing
 Immobilization of fracture fragments
 Maximum bone fragment contact
 Sufficient blood supply
 Proper nutrition
 Exercise: weight bearing for long bones
 Hormones: growth hormone, thyroid, calcitonin, vitamin D,
anabolic steroids
Factors that inhibit fracture healing
 Extensive local trauma
 Bone loss
 Inadequate immobilization
 Space or tissue between bone fragments
 Infection
 Local malignancy
 Metabolic bone disease (Paget’s disease)
 Irradiated bone (radiation necrosis)
 Avascular necrosis
 Intra-articular fracture (synovial fluid contains fibrolysins,
which lyse the initial clot and retard clot formation)
 Age (elderly persons heal more slowly)
 Corticosteroids (inhibit the repair rate)

BONE HEALING PROCESS

d. Types of Bone Healing process

e. Factors affecting Bone Healing Process

f.

Stages of Bone Healing Process

Formation of Hematoma
Cellular Proliferation
Callus Formation
Ossification
Remodeling
MANAGEMENT OF FRACTURE

Management of Fractures and its Principles

INDICATIONS
OPEN REDUCTION
- It is performed through surgical intervention.

Open reduction internal fixation (ORIF) is a surgical approach that's used for repairing
certain types of bone fractures.

An open reduction is an invasive surgical bone realignment. Internal fixation is the surgical
insertion of hardware to stabilize and hold the bone in place as it heals.

Recovery will depend on several factors:

1. severity of the injury
2. type of bone involved
3. post-operative rehabilitation
4. age
5. health condition

INDICATIONS
a. breaks in multiple places
b. moves out of position
c. sticks out through the skin

Internal fixation is an operation in orthopedics that involves the surgical implementation

of implants for the purpose of repairing a bone, a concept that dates to the mid-nineteenth
century and was made applicable for routine treatment in the mid-twentieth century. An internal
fixator may be made of stainless steel, titanium alloy, or cobalt-chrome alloy or plastics.
Types of internal fixators include:

 Plate and screws

 Kirschner wires
 Intramedullary nails
 Tension band wires
Internal fixation devices include metal plates and screws, stainless steel pins (Kirschner
wires, K-wires), and stabilizing rods that are placed into the cavity of the bone
(intramedullary nails, IM nails).

A cast is placed after surgery. Different types of casts may be used during the healing
process
Kirschner or K Wires Are Surgical Bone Pins
Kirschner Wires
K-wires come in different sizes, and as they increase in size, they become less
flexible. Some K-wires are threaded
Uses
1. to stabilize a broken bone and can be removed in the office once the fracture has
healed.
2. helps prevent movement or backing out of the wire, although that can also make
them more difficult to remove.
3. to provide a rigid anchor to the bone, and then the weight is pulled on the bone
(through the wire) to pull the broken extremity into alignment when used in traction

There are possible complications associated with the use of K-wires:

 Infection: The location of pin insertion can be a source for infection to enter the
body.If left through the skin, bacteria can travel along the pin tract and get deeper into
the body, and possibly to the bone. For this reason, patients with K-wires that are left
exposed are typically instructed on techniques for pin care to prevent infection.
 Breakage: Pins can provide stable fixation of a fracture, but most pins are relatively
thin in diameter and they can break if there is increased stress on the broken bone.
 Fracture movement: K-wires generally provide less rigid fixation of fractures than
some other techniques such as plates and screws, and metal rods. It is sometimes
possible for the fracture to shift its position when only K-wires are used for
fixation.3 Therefore, K-wires are generally used only for certain types of fractures.
 Migration: One of the most concerning complications is pin migration. For this
reason, extreme care must be used especially when using K-wires in the chest or
abdomen. Although rare, there are case reports of placing K-wires in bones around the
shoulder that were found to migrate to the chest cavity weeks or months later.

Tension Band Wiring Application

Angled Plates
SCREWS

Gliding screw
Locking Screw
EXTERNAL FIXATORS
Example:RAEF
UNiVERSAL MINI EX TERNAL FIXATOR
 Hybrid External Fixator

CAST
 A cast holds a broken bone in place as it heals. Casts also help prevent or decrease muscle
contractions, and are effective at providing immobilization, especially after surgery.

Casts immobilize the joint above and the joint below the area that is to be kept straight and
without motion. For example, a child with a forearm fracture will have a long arm cast to
immobilize the wrist and elbow joints.

The outside, or hard part of the cast, is made from two different kinds of casting materials.

 Plaster (white in color)

 Fiberglass (comes in a variety of colors, patterns, and designs)
 Stockinette
 Rolled cotton Pads
 Cast Scissor

Cast is a temporary immobilization. Its types are (a) plaster and (b) fiber glass.

Function:
1. To promote healing and early weight bearing.
2. To support, maintain and protect realigned bone.
3. To prevent or correct deformity
4. To immobilize

Nursing care

 Keep the cast clean and dry.

 Check for cracks or breaks in the cast.
 Pad rough edges to protect the skin from scratches.
 Don't scratch the skin under the cast by putting objects inside the cast.
 Use a hairdryer placed on a cool setting to blow air under the cast and cool down the hot,
itchy skin. Never blow warm or hot air into the cast.
 Don't put powders or lotion inside the cast.
 Cover the cast while your child is eating to prevent food spills and crumbs from entering the
cast.
 Prevent small toys or objects from being put inside the cast.
 Raise the cast above heart level to decrease swelling.
 Encourage your child to move his or her fingers or toes to promote circulation.
 Don't use the abduction bar on the cast to lift or carry the child.
Older children with body casts may need to use a bedpan or urinal to go to the bathroom.
Tips to keep body casts clean and dry and prevent skin irritation around the genital area
include the following:
 Use a diaper or sanitary napkin around the genital area to prevent leakage or splashing of
urine.
 Place toilet paper inside the bedpan to prevent urine from splashing onto the cast or bed.
 Keep the genital area as clean and dry as possible to prevent skin irritation.
Note for the following manifestations when patient is in cast to report to the physicians
 Fever (see Fever and children, below)
 Chills
 Increased pain
 Increased swelling above or below the cast
 Decreased ability to move toes or fingers
 Complaints of numbness or tingling
 Drainage or bad odor from the cast
 Cool or cold fingers or toes
 The cast becomes wet or dirty
 Blister, sores, or a rash develop under the cast

TYPES OF CAST, MOLDS AND INDICATIONS

1. AIRPLANE CAST – for humerus and shoulder joint with compound fracture.
2. BASKET CAST – for severe leg trauma with open wound or inflammation.
3. BODY CAST – for lower dorso-lumbar spine affectation.
4. BOOT LEG CAST – for hip and femoral fracture.
5. CAST BRACE – for fracture of femur (distal curve) with flexion and extension.
6. COLLAR CAST – for cervical affectation.
7. CYLINDRICAL LEG CAST – for fractured patella.
8. DELVIT CAST – for fracture of tibia or fibula with callus formation
9. DOUBLE HIP SPICA CAST – for fracture of hip and femur.
10. DOUBLE HIP SPICA MOLD – cervical affectation with callus formation.
11. FROG CAST – for congenital hip dislocation.
12. FUNCTIONAL CAST – for fractured humerus with abduction and adduction.
13. HANGING CAST – for fractured shaft of the humerus.
14. INTERNAL ROTATOR SPLINT – for post hip operation.
15. LONG ARM CIRCULAR CAST – for fractured radius or ulna
16. LONG ARM POSTERIOR MOLD – for fractured radius or ulna with compound affectation.
17. LONG LEG CIRCULAR CAST – for fractured tibia-fibula.
18. LONG LEG POSTERIOR MOLD – for fracture tibia-fibula with compound affectation.
19. MINERVA CAST – for upper dorsal or cervical affectation.
20. MUNSTER CAST – for fractured radius or ulna with callus formation.
21. NIGHT SPLINT – for post polio.
22. PANTALON CAST – for pelvic bone fracture
23. PATELLA TENDON BEARING CAST – for fractured tibia-fibula with callus formation.
24. QUADRILATERAL (ISCHIAL WEIGHT BEARING) CAST – for shaft of femur with callus
formation.
25. RIZZER’S JACKET – for scoliosis
26. SHORT ARM CIRCULAR CAST – for wrist and fingers.
27. SHORT ARM POSTERIOR MOLD – for wrist and fingers with compound affectation.
28. SHORT LEG CIRCULAR CAST – for ankle and foot fracture.
29. SHORT LEG POSTERIOR MOLD – for ankle and foot with compound affectation.
30. SHOULDER SPICA – for humerus and shoulder joint.
31. SINGLE HIP SPICA – for hip and 1 femur.
32. SINGLE HIP SPICA MOLD – for pelvic fracture with callus formation.
33. 1 AND ½ HIP SPICA – for hip and femur.
34. 1 AND ½ SPICA MOLD – for hip and femur with compound affectation.

CASTS

COLLAR CAST
affection of the cervical spine

BODY CAST
-affection of the dorso-lumbar spine
 MINERVA CAST
Scoliosis

RIZZER’S JACKET
-Severe scoliosis

SHORT ARM CIRCULAR CAST

-affection of the wrist and fingers
LONG ARM CIRCULAR CAST
-affection of the radius and ulna
 LONG ARM POSTERIOR MOLD
-affections on radius ulna with infection, open wound and swelling.
SHORT ARM POSTERIOR MOLD
-affections of the wrist and fingers with infections and open wounds

MUNSTER CAST
-affection of the radius ulna with callus formation allows extension and flexion of the elbow.

SHOULDER SPICA CAST

-affection of the upper portion of the humerus and shoulder joint
Airplane Cast- affection of the upper shaft of the humerus and shoulder joint with compound
fracture
FUNCTIONAL CAST
affection of the shaft with callus formation. Allow flexion and extension of the upper extremity .

SHOULDER SPICA POSTERIOR MOLD/SUGAR TONG

-affection of the upper portion of the humerus and shoulder joint with infection, open wound and swelling

HANGING CAST
-affection of the shaft of the humerus
 LONG LEG CIRCULAR CAST
-fracture tibia fibula
SHORT LEG CIRCULAR CAST
-affection of the ankle and legs

LONG LEG POSTERIOR MOLD

-affections of the tibia fibula with infection, open wounds.
SHORT LEG POSTERIOR MOLD
-affections of the ankle and toes with infections and open wounds

SINGLE HIP SPICA CAST

-Affection of the 1 hip and 1 femur
 1 ½ HIP SPICA CAST
-Affection of the hip and femur

DOUBLE HIP SPICA CAST

-bilateral affection of the hip and femur
 QUADRILATERAL CAST
-Or ischial weight bearing cast
-fx of the shaft of femur with callus formation

DELVIT CAST
–affection of the proximal tibia fibula and allow flexion and extension of the knee.

BASKET CAST
-to immobilize foot, knee and ankle while allowing wound for exposure.

BRACE CAST
-affection of the end of femur and allows gradual flexion of the knee
 FROG CAST
-Congenital hip dislocation

CYLINDER CAST
-fx of patella
CYLINDER POSTERIOR MOLD
-affection of the patella infection, open wound and swelling
 PANTALON CAST
-affection of the pelvis

PATELLAR TENDON BEARING CAST

-ex. Shaft tibia fibula with callus formation

BRACES AND SPLINTS

For scoliosis

Boston Brace- For scoliosis

Knight Taylor Brace
Chairback Brace- Lumbosacral affection
For CervicoThoracLumbar Spine affection

CERVICO THORACIC
ORTHOSIS
CDH- Congenital Dysplasia of the Hip or Congental Hip dislocation or Congenital hip dysplasia

CTEV- Congetal equine varus

LUMBOSCRAL Affection

For Pott’s Disease( Thoracic)

Spinal Orthosis Brace-Scoliosis

For Cervical spine affection

A Jewett brace is a hyperextension brace that prevents the patient from bending forward too
much. It is often used to facilitate healing of an anterior wedge compression fracture involving the
T10 to L3 vertebrae.
Corset brace
A corset brace is similar to a traditional corset. It typically has metal or plastic stays to limit
forward movement. It puts pressure over the belly to take pressure off of the spine and promote
healing.
Thoraco Lumbar Affection
 Knee affection

TRACTION

TRACTIONS is the act of pulling or drawing which is associated with countertraction.

Countertraction is the patient’s body weight.
Skeletal Traction
Skeletal traction is used for fractures of the femur (thighbone), pelvis, hip, and certain upper
arm fractures. It involves inserting a pin or wire directly into the bone, then attaching weights
through pulleys or ropes to it that control the amount of pressure applied. Skeletal traction is
used for fractures that require a high amount of force applied directly to the bone, as it allows
more weight to be added with less risk of damaging the surrounding soft tissues. If you need
skeletal traction, it will be done while an anesthetic so you don't experience too much pain.

Skin Traction
Skin traction is less invasive than skeletal traction and uses splints, bandages, and adhesive
tapes positioned on the limb near the fracture and is applied directly to the skin. Weights and
pulleys are attached, and pressure is applied. When a bone breaks, the muscles and tendons
can pull the extremity into a shortened or bent position. The traction can hold the fractured
bone or dislocated joint in place. This can cause painful movement at the fracture site and
muscle cramping. Buck's traction is a type of skin traction that is widely used for femoral,
hip, and acetabular fractures, which are fractures in the socket portion of the "ball-and-
socket" hip joint.

USES O(F TRACTION

1. To immobilize and support
2. To reduce and correct fracture
3. To maintain good alignment
4. To reduce pain and muscle spasms
5. To prevent deformities

TRACTIONS AND THEIR INDICATIONS

Head Halter- cervical spine affections
Side arm or Overhead-supracondylar fracture of the humerus

Dunlop- suracondylar fx of the humerus

90-90 degree-subtrochanteric fracture of the P3 of the femur

Halo Pelvic - Scoliosis

 Halo femoral- severe scoliosis

COTREL TRACTION, a combination of head halter and pelvic girdle traction.- Severe
Scoliosis.

Bryant –Affections of the hips and femur among children

under five years of age

Pelvic Girdle-Herniated Nucleus Pulposus, low back pain or lumbosacral pain

Hammock Suspension- Pelvic affection

Buck’s Extension-Affection of the hips and femur

Boot Cast- Affections of the ankle and foot

Russell’s Traction- Affections of the femr and hips

 Vinke Skull cALIPER

Cervical Spine affection

SUMMARY
Applications of BST
BST Procedural Checklist Discussion