Institute of Nursing Education, Mumbai

Presentation on-

Fracture

Medical Surgical Nursing

Presented by-
Mr. Vireshwar Sunil Mahajani,
M. Sc Cardiovascular and Thoracic Nursing,
Institute of Nursing Education, Mumbai
 Index

Sr.
Title Page No
No
1 Aims and Objectives 1
2 Anatomy Physiology 2
3 Fracture – Introduction 7
4 Classification 8
5 Pathophysiology 15
6 Clinical Manifestation 16
7 Stages of Fracture Healing 17
8 Medical Surgical Management 18
9 Closed Reduction 20
10 Open Reduction 22
11 External and Internal Fixation 26
12 Electrical bone growth stimulation 27
13 Drug therapy and Nutritional therapy 28
14 Complications of fracture 29
15 Nursing Management 34
16 Nursing Diagnosis 36
17 Health Education 39
18 Research 41
19 Bibliography 42
AIM

At the end of the seminar students will get in depth knowledge regarding Fracture and role of nurse in
management of faracture patient.

OBJECTIVES
At the end of the seminar students will able to :
➢ Discuss Anatomy & Physiology of skeletal system.
➢ Define fracture.
➢ Enlist the Causes of fracture.
➢ Describe the types of fracture.
➢ Discuss the Pathophysiology of fracture.
➢ Enumerate the Clinical manifestations.
➢ List down various diagnostic test to be done for fracture.
➢ Explain the medical & surgical management of the fracture.
➢ Explain role of plaster , fixator (external & internal).
➢ Discuss nursing management of patient with fracture.
➢ Develop nursing diagnosis for the patient with fracture.
➢ Discuss the rehabilitation of patient with fracture.
➢ Recent research.
ANATOMY OF SKELETAL SYSTEM

MUSKULO SKELETAL SYSTEM:-

It consists of three major components: bones, muscles, and joints. Tendons, ligaments, cartilage, and
bursae serve as connecting structures and complete the system.

Bones. Composed of osseous tissue, bones are divided into two types: compact bone, which is hard and
dense and makes up the shaft and outer layers, and spongy bone, which contains numerous spaces and
makes up the ends and centers of the bones. Osteoblasts and osteoclasts are the cells responsible for the
continuous process of creating and destroying bone. Osteoblasts form new bone tissue, and osteoclasts
break down bone tissue. Bones also contain red marrow,which produces blood cells, and yellow
marrow,which is composed mostly of fat.The outer covering of bone, called the periosteum, contains
osteoblasts and blood vessels that promote nourishment and formation of new bone tissue.

Bones vary in shape and include long bones (Fig. 20.2), such as the humerus and femur; short, flat
bones, such as the sternum and ribs; and bones with irregular shapes, such as the hips and vertebrae.
Muscles. The body is composed of skeletal, smooth, and
cardiac muscle. Made up of fasciculi (long muscle
fibers) that are arranged in bundles and joined by
connective tissue, skeletal muscles attach to bones by
way of strong, fibrous cords called tendons. Ligaments
are dense, flexible, strong bands of fibrous connective
tissue that tie bones to other bones.

Cartilage is dense connective tissue consisting of fibers

embedded in a strong, gel-like substance. Cartilage lacks
nerve innervation, blood vessels, and lymph vessels, so
it is insensitive to pain and regenerates slowly and
minimally after injury. Regeneration occurs primarily at
sites where the articular cartilage meets the synovial
membrane. Cartilage may be fibrous, hyaline, or elastic.

Fibrous cartilage forms the symphysis pubis and the intervertebral discs. Hyaline cartilage covers the
articular bone surfaces (where bones meet at a joint), connects the ribs to the sternum, and is found in
the trachea, bronchi, and nasal septum. Elastic cartilage is located in the auditory canal, the external ear,
and the epiglottis.

Joints. The joint or articulation is the place where two or more bones meet. Joints provide range of
motion (ROM) for the body parts and are classified three ways: by the degree of movement they permit,
by the connecting tissues that hold them together, and by the type of motion the structure permits. Figure
20.3 illustrates the fibrous and cartilaginous joints and Figure 20.4 the synovial joints.

A joint is the structure of human body where two or more bones are held together in order to allow
various types of movements and moldings in the rigid bony human skeleton. A joint is not exclusively
for bones, there can be three different types of joints on the basis of what structures are involved in
making it.

A joint can exist between

1. Two bones (for example the shoulder joint that exists between the scapula and the humerus).

2. A cartilage and a bone (for example the joint that exists between the ribs and the costal cartilages).

3. A cartilage and a cartilage (for example the joint between the 6th and the 7th costal cartilage.
Bursae. Bursae are small, disc-shaped synovial fluid sacs located at points of friction around joints.
They act as cushions, thereby reducing the stress to adjacent structures, and facilitate movement. Two
examples of bursae are the prepatellar bursa (in the knee) and the subacromial bursa (in the shoulder).

Function of the Bones

• There are 206 bones in the adult body. The bones of the body perform five main functions.
· Provide support for the body — The skeletal system provides structural support for the
entire body. Individual bones or groups of bones provide a framework for the attachment
of soft tissues and organs.
· Store minerals and lipids — Calcium is the most abundant mineral in the body. (Ninety-
nine percent of the body's calcium is found in the skeleton.) The calcium salts of bone
are a valuable mineral reserve that maintains normal concentrations of calcium and
phosphate ions in body fluids. The bones of the skeleton also store energy reserves as
lipids in areas filled with yellow marrow.
· Produce blood cells — Red blood cells, white blood cells, and other blood elements are
produced in the red marrow, which fills the internal cavities of many bones.
· Protect body organs — Many soft tissues and organs are surrounded by skeletal
elements. For example, the rib cage protects the heart and lungs, the skull protects the
brain, the vertebrae protect the spinal cord, and the pelvis protects the delicate
reproductive organs.
· Provide leverage and movement — Many bones function as levers that can change the
magnitude and direction of the forces generated by muscles.

Bone structure

Each bone in the skeleton contains two forms of tissue: compact (dense) bone that is relatively solid and
spongy (cancellous) bone that forms an open network of struts and plates. Compact bone is found on
the external surface of the bone. Spongy bone is located inside the bone. The proportion of compact and
spongy bone varies with the shape of the bone. Compact bone is thickest where stresses arrive from a
limited range of directions. Spongy bone is located where bones are not heavily stressed or where
stresses arrive from many directions. Spongy bone is much lighter than compact bone, which helps
reduce the weight of the skeleton and makes it easier for muscles to move the bones.

Bone development and growth

The growth of the skeleton determines the size and proportions of the body. Bones begin to form in a
mother's womb about six weeks after fertilization, and portions of the skeleton do not stop growing until
about the age of 25. Most bones originate as hyaline cartilage. The cartilage is gradually converted to
bone through a process called ossification. Bone growth begins at the center of the cartilage. As bones
enlarge, bone growth activity shifts to the ends of the bones (an area commonly called the growth plate),
which results in an increase in bone length.

Bone growth "factoids"

·Skeletal muscles — These muscles contract to pull on tendons and move the bones of the
skeleton. In addition to producing skeletal movement, muscles also maintain posture and body
position, support soft tissues, guard entrances and exits to the digestive and urinary tracts, and
maintain body temperature.

· Nerves — Nerves control the contraction of skeletal muscles, interpret sensory information,
and coordinate the activities of the body's organ systems.

· Cartilage — This is a type of connective tissue. It is a firm gel-like substance. The body
contains three major types of cartilage: hyaline cartilage, elastic cartilage, and fibrocartilage.

· Hyaline cartilage is the most common type of cartilage. This type of cartilage provides stiff
but somewhat flexible support. Examples in adults include the tips of ribs (where they meet
the sternum) and part of the nasal septum. Another example is articular cartilage, which is
cartilage that covers the ends of bones within a joint. The surfaces of articular cartilage are
slick and smooth, which reduces friction during joint movement.

· Elastic cartilage provides support but can tolerate distortion without damage and return to its
original shape. The external flap of the ear is one place where elastic cartilage can be found.

· Fibrocartilage resists compression, prevents bone-to-bone contact, and limits relative

movement. Fibrocartilage can be found within the knee joint, between the pubic bones of the
pelvis, and between the spinal vertebrae.

Cartilage heals poorly, and damaged fibrocartilage in joints such as the knee can interfere with normal
movements. The knee contains both hyaline cartilage and fibrocartilage. The hyaline cartilage covers
bony surfaces and fibrocartilage pads in the joint prevent contact between bones during movement.
Injuries to the joints can produce tears in the fibrocartilage pads, and the tears do not heal. Eventually,
joint mobility is severely reduced.
FRACTURE

Definition
A fracture is a break in the continuity of bone and is defined according to its type and extent.
Fracture is break in any bone in the body. A bone fracture (sometimes abbreviated FRX or Fx, Fx,
or #) is a medical condition in which there is a break in the continuity of the bone. A bone fracture can
be the result of high force impact or stress, or trivial injury as a result of certain medical conditions that
weaken the bones, such as osteoporosis, bone cancer, or osteogenesis imperfecta, where the fracture is
then properly termed a pathologic fracture.

Although broken bone and bone break are common colloquialisms for a bone fracture, break is not a
formal orthopedic term.

CAUSES OF FRACTURE
• Direct Blows
• Crushing Forces
• Sudden Twisting Motions
• Extreme Muscle Contractions
• Injury from a car accident or athletic event
• Intentional injury, if another person strikes or pushes you
• Child abuse
• Falls from heights or falls on ice or other unsafe surfaces
• Overuse, particularly if you run or participate in sports
• Osteoporosis, A disease that causes bones to weaken in older adults
CLASSIFICATION
➢ Based on Relationship with the Environment.
➢ Based on Displacement.
➢ Based on Fracture Pattern.
➢ Based on Etiology.

➢ CLOSED FRACTURE [simple fracture]: Is one that does not cause a break in the skin.
➢ AN OPEN FRACTURE (compound, or complex ,fracture )is one in which the skin or mucous
membrane wound extends to the fractured bone.
Open fractures are graded according to following criteria:
• Grade 1 is a clean wound less than 1 cm long.
• Grade 2 is a larger wound without extensive soft tissue damage.
• Grade 3 is highly contaminated , has extensive soft tissue damage, and is the most
severe

Classification : Based on Pattern

1. Transverse Fracture - A fracture in which the # line is perpendicular to the long axis of the
bone.
2. Oblique Fracture - A fracture in which the # line is at oblique angle (45) to the long axis of the
bone
3. Spiral - A severe form of oblique fracture in which the # plane rotates along the long axis of the
bones . These #s occur secondary to rotational force.
4. Comminuted Fracture -The bones is broken into many fragments.
5. Segmental fracture-There are two fractures in one bone , but at different angels.
Compare healthy bone with different types of fractures: (a) closed fracture, (b) open fracture, (c)
transverse fracture, (d) spiral fracture, (e) comminuted fracture, (f) impacted fracture, (g) greenstick
fracture, and (h) oblique fracture.

Classification Based on Displacement

➢ NON-DISPLACED FRACTURE - The bone cracks either part or all the way through , but
does not move and maintains proper alignment.

➢ DISPLACED FRACTURE - The bone snaps into two or more parts and moves so that the two
ends are not lined up straight.

Other considerations in fracture care are displacement (fracture gap) and angulation. If angulation or
displacement is large, reduction (manipulation) of the bone may be required and, in adults, frequently
requires surgical care. These injuries may take longer to heal than injuries without displacement or
angulation.

Classification : Based on Etiology

 1. Traumatic fracture - This is a fracture due to sustained trauma. e.g.- Fractures caused by a fall,
road traffic accident, fight etc.
2. Pathological fracture - A fracture through a bone which has been made weak by some underlying
disease is called pathological fracture. e.g.- a fracture through a bone weakened by metastasis.
Osteoporosis is the most common cause of pathological fracture.
1. Tumours
2. Bone cysts
3. Osteomyelitis
4. Osteoporosis
5. Rickets

Orthopedic

In orthopedic medicine, fractures are classified in various ways. Historically they are named after the
doctor who first described the fracture conditions. However, there are more systematic classifications in
place currently.

All fractures can be broadly described as:

• Closed (simple) fractures: are those in which the skin is intact

• Open (compound) fractures: involve wounds that communicate with the fracture, or where
fracture hematoma is exposed, and may thus expose bone to contamination. Open injuries carry
a higher risk of infection.

• Compression fractures: usually occurs in the vertebrae, for example when the front portion of
a vertebra in the spine collapses due to osteoporosis (a medical condition which causes bones to
become brittle and susceptible to fracture, with or without trauma).

Other types of fracture are:

• Complete fracture: A fracture in which bone fragments separate completely.

• Incomplete fracture: A fracture in which the bone fragments are still partially joined. In such
cases, there is a crack in the osseous tissue that does not completely traverse the width of the
bone.
• Linear fracture: A fracture that is parallel to the bone's long axis.
• Transverse fracture: A fracture that is at a right angle to the bone's long axis.
• Oblique fracture: A fracture that is diagonal to a bone's long axis.
 • Spiral fracture: A fracture where at least one part of the bone has been twisted.
• Comminuted fracture: A fracture in which the bone has broken into several pieces.
• Impacted fracture: A fracture caused when bone fragments are driven into each other.
• Avulsion fracture: A fracture where a fragment of bone is separated from the main mass.

Anatomical location

An anatomical classification may begin with specifying the involved body part, such as the head or arm,
followed with more specific localization. Fractures that have additional definition criteria than merely
localization can often be classified as subtypes of fractures that merely are, such as a Holstein-Lewis
fracture being a subtype of a humerus fracture. However, most typical examples in an orthopedic
classification given in previous section cannot appropriately be classified into any specific part of an
anatomical classification, as they may apply to multiple anatomical fracture sites.

• Skull fracture
o Basilar skull fracture
o Blowout fracture - a fracture of the walls or floor of the orbit
o Mandibular fracture
o Nasal fracture
o Le Fort fracture of skull - facial fractures involving the maxillary bone and surrounding
structures in a usually bilateral and either horizontal, pyramidal or transverse way.

• Spinal fracture
o Cervical fracture
▪ Fracture of C1, including Jefferson fracture
▪ Fracture of C2, including Hangman's fracture
▪ Flexion teardrop fracture - a fracture of the anteroinferior aspect of a cervical
vertebral
▪ Clay-shoveler fracture - fracture through the spinous process of a vertebra
occurring at any of the lower cervical or upper thoracic vertebrae
▪ Burst fracture - in which a vertebra breaks from a high-energy axial load
▪ Compression fracture - a collapse of a vertebra, often in the form of wedge
fractures due to larger compression anteriorly.
▪ Chance fracture - compression injury to the anterior portion of a vertebral body
with concomitant distraction injury to posterior elements
▪ Holdsworth fracture - an unstable fracture dislocation of the thoracolumbar
junction of the spine
• Rib fracture
• Sternal fracture
• Shoulder fracture
o Clavicle fracture
o Scapular fracture
• Arm fracture
o Humerus fracture (fracture of upper arm)
▪ Supracondylar fracture
▪ Holstein-Lewis fracture - a fracture of the distal third of the humerus resulting in
entrapment of the radial nerve.
o Forearm fracture
▪ Ulnar fracture
▪ Monteggia fracture - a fracture of the proximal third of the ulna with the
dislocation of the head of the radius
▪ Hume fracture - a fracture of the olecranon with an associated anterior
dislocation of the radial head
▪ Radius fracture
▪ Essex-Lopresti fracture - a fracture of the radial head with concomitant
dislocation of the distal radio-ulnar joint with disruption of the
interosseous membrane.[5]
▪ Distal radius fracture
▪ Galeazzi fracture - a fracture of the radius with dislocation of the
distal radioulnar joint
▪ Colles' fracture - a distal fracture of the radius with dorsal
(posterior) displacement of the wrist and hand
▪ Smith's fracture - a distal fracture of the radius with volar (ventral)
displacement of the wrist and hand
▪ Barton's fracture - an intra-articular fracture of the distal radius
with dislocation of the radiocarpal joint.

• Hand fracture
o Scaphoid fracture
o Rolando fracture - a comminuted intra-articular fracture through the base of the first
metacarpal bone
o Bennett's fracture - a fracture of the base of the first metacarpal bone which extends into
the carpometacarpal (CMC) joint.
o Boxer's fracture - a fracture at the neck of a metacarpal
• Pelvic fracture
o Fracture of the hip bone
o Duverney fracture - an isolated pelvic fracture involving only the iliac wing.

• Femoral fracture
o Hip fracture (anatomically a fracture of the femur bone and not the hip bone)

• Patella fracture

• Crus fracture
o Tibia fracture
▪ Bumper fracture - a fracture of the lateral tibial plateau caused by a forced valgus
applied to the knee
▪ Segond fracture - an avulsion fracture of the lateral tibial condyle
▪ Gosselin fracture - a fractures of the tibial plafond into anterior and posterior
fragments[7]
▪ Toddler's fracture - an undisplaced and spiral fracture of the distal third to distal
half of the tibia[8]
o Fibular fracture
▪ Maisonneuve fracture - a spiral fracture of the proximal third of the fibula
associated with a tear of the distal tibiofibular syndesmosis and the interosseous
membrane.
▪ Le Fort fracture of ankle - a vertical fracture of the antero-medial part of the distal
fibula with avulsion of the anterior tibiofibular ligament.[9]
▪ Bosworth fracture - a fracture with an associated fixed posterior dislocation of
the proximal fibular fragment which becomes trapped behind the posterior tibial
tubercle. The injury is caused by severe external rotation of the ankle.[10]
o Combined tibia and fibula fracture
▪ Trimalleolar fracture - involving the lateral malleolus, medial malleolus and the
distal posterior aspect of the tibia
▪ Bimalleolar fracture - involving the lateral malleolus and the medial malleolus.
▪ Pott's fracture

• Foot fracture
o Lisfranc fracture - in which one or all of the metatarsals are displaced from the tarsus[11]
o Jones fracture - a fracture of the proximal end of the fifth metatarsal
o March fracture - a fracture of the distal third of one of the metatarsals occurring because
of recurrent stress
o Calcaneal fracture
Pathophysiology

Due to any etiology (crushing movement)

Fracture occurs , muscle that were attached to bone

Are disrupted and cause spasm

Proximal portion of bone remains in place , the distal

Portion can become displaced in response to both
Causative force & spasm in the associated muscles

In addition , the periosteum and blood vessels in the cortex and marrow are
disrupted

Soft tissue damage occurs , leads to bleeding and formation of hematoma

between the fracture fragment and beneath the periosteum

Bone tissue surroundings the fracture site dies,

creating an intense inflammatory response

release chemical mediators histamines , prostaglandins

Resulting in vasodilatation , edema, pain loss of function , leukocytes and

infiltration of WBC
Clinical manifestations
▪ Pain
▪ Loss of function
▪ Deformity
▪ Muscle spasm
▪ Crepitus
▪ Swelling and discolouration
▪ Bruising

Diagnosis

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

▪ History collection
▪ Physical examination
▪ X-ray
▪ CT scan
▪ MRI
STAGES OF FRACTURE HEALING
➢ STAGE OF HAEMATOMA - Last up to 7 days . Deprived of blood supply some osteocytes
die, while others sensitive to form daughter cells. When a fracture occurs, bleeding creates a
hematoma that surrounds the ends of the bone fragments The hematoma is extravasated blood
that changes from a liquid to a semisolid clot. This occurs in the first 72 h after injury."
➢ STAGE OF GRANULATION TISSUE (2-3 wks) - Proliferation and differentiation of
daughter cells into vessel, fibroblast etc. fracture still mobile.During this stage, active
phagocytosis ab- sorbs the products of local necrosis. The hematoma converts to granulation
tissue. Granulation tissue (consisting of new blood vessels, fibroblasts, and osteoblasts) forms
the basis for new bone substance (osteoid) during days 3-14 after injury.
➢ STAGE OF CALLUS (4-12 WEEKS) - Mineralization of granulation tissue. First sign of union
. Fracture is no more movable .callus radiologically visible usually 3 weeks after #.As minerals
(calcium, phosphorus, and magnesium) and new bone matrix are deposited in the osteoid, an
unorganized network of bone is formed and woven about the fracture parts. Callus is primarily
composed of cartilage, osteoblasts, calcium, and phosphorus. It usually appears by the end of the
second week after injury. Evidence of callus formation can be verified by X-ray.
➢ STAGE OF CONSOLIDATION (1-2 YEAR) - Callus or woven bone is replaced by mature
bone with a typical lamellar structure. As callus continues to develop, the distance between bone
fragments decreases and eventually closes. Ossification continues and can be equated with
radiologic. union, which occurs when an X-ray shows complete bony union. This phase can
occur up to 1 year after injury.
➢ STAGE OF MODELLING (MANY YEARS) - Bone is gradually strengthened . Remodelling:
Excess bone tissue is resorbed in the final stage of bone healing, and union is complete. Gradual
return of the injured bone to its preinjury structural 'strength and shape occurs. Bone remodels
in response to physical loading stress (Wolff's law)Initially, stress is provided through exercise.
Weight bearing is gradually introduced. New bone is deposited in sites subjected to stress and
resorbed at areas of little stress.
Many factors influence the time required for complete fracture healing, including displacement and site
of the fracture, blood supply to the area, immobilization, and use of internal fixation devices (e.g.,
screws, pins). The ossification process may be slowed or even stopped by inadequate reduction and
immobilization, excessive movement of fracture fragments, infection, poor nutrition, and systemic
systemic disease (e.g., diabetes)." 11 Healing time for fractures increases with age. For example, an
uncomplicated mid-shaft femur fracture heals in 3 weeks in a newborn and in 20 weeks in an adult.
Smoking also increases fracture healing time.
MEDICAL AND SURGICAL MANAGEMENT
➢ 1. Rduction
➢ 2. Immobilization
➢ 3. Maintaining and Restoring function
Treatment of bone fractures are broadly classified as surgical or conservative, the latter basically
referring to any non-surgical procedure, such as pain management, immobilization or other non-
surgical stabilization. A similar classification is open versus closed treatment, in which open
treatment refers to any treatment in which the fracture site is surgically opened, regardless of whether
the fracture itself is an open or closed fracture.

Principles of Management

• Factors influencing choice of management include:

o Type, location, and severity of fracture.
o Soft tissue damage.
o Age and health status of patient, including type and extent of other injuries.
• Goals include:
o To regain and maintain correct position and alignment.
o To regain the function of the involved part.
o To return patient to usual activities in the shortest time and at the least expense.
• The management process is a three-step process:
o Reduction setting the bone; refers to restoration of the fracture fragments into anatomic
position and alignment
o Immobilization maintains reduction until bone healing occurs.
o Rehabilitation regaining normal function of the affected part.
• Closed reduction
o Bony fragments are brought into apposition (ends in contact) by manipulation and
manual traction restoring alignment.
o May be done under anesthesia for pain relief and muscle relaxation.
o Cast or splint applied to immobilize extremity and maintain reduction.
• Traction
o Pulling force applied to accomplish and maintain reduction and alignment
o Used for fractures of long bones.
o Techniques
▪ Skin traction force applied to the skin using foam rubber, tape.
▪ Skeletal traction force applied to the bony skeleton directly, using wires, pins,
or tongs placed into or through the bone.
• Open reduction with internal fixation (ORIF)
o Operative intervention to achieve reduction, alignment, and stabilization.
▪ Bone fragments are directly visualized.
▪ Internal fixation devices (metal pins, wires, screws, plates, nails, rods) used to
hold bone fragments in position until solid bone healing occurs (may be removed
when bone is healed).
▪ After closure of the wound, splints or casts may be used for additional
stabilization and support.
• Endoprosthetic replacement
o Replacement of a fracture fragment with an implanted metal device.
o Used when fracture disrupts nutrition of the bone or treatment of choice is bony
replacement.
• External fixation device
o Stabilization of complex and open fracture with use of a metal frame and pin system.
o Permits active treatment of injured soft tissue.
▪ Wound may be left open (delayed primary wound closure).
▪ Repair of damage to blood vessels, soft tissue, muscles, nerves, and tendons as
indicated.
▪ Reconstructive surgery may be necessary .
REDUCTION
Reduction of a fracture (“setting’’ the bone) refers to restoration of the fracture fragments to anatomic
alignment and rotation.
1. Closed Reduction - Closed reduction is accomplished by bringing the bone fragments into
apposition (i.e., placing the ends in contact )through manipulation and manual traction, with no
surgical intervention. Extremity is held in the desired position while the physician applies a
cast , splint , or other device. X- rays are obtained to verify that the bone fragments are correctly
aligned. Traction (skin or skeletal) may be used to effect fracture reduction and immobilization.

TRACTION
Traction is the application of a pulling force to an injured or diseased body part or extremity. Traction
devices apply a pulling force on a fractured extremity to attain realignment while countertraction pulls
in the opposite direction
Traction to
(1) prevent or reduce pain and muscle spasm (e.g., whiplash, unrepaired hip fracture),
(2) immobilize a joint or part of the body,
(3) reduce a fracture or dislocation, and
(4) treat a pathologic joint condition (e.g., tumor, infection)
Traction is also indicated to
(1) provide immobilization to prevent soft-tissue damage,
(2) promote active and passive exercise,
(3) expand a joint space during arthroscopic procedures, and
(4) expand a joint space before major joint reconstruction. used
TYPES
1. Skin traction – Skin traction is generally used for short-term treatment (48-72 h) until skeletal
traction or sur- gery is possible. Tape, boots, or splints are applied directly to the skin, primarily
to help diminish muscle spasms in the injured extremity. Traction weights are usually limited
to 5-10lb. (2.3-4.5 kg). A Buck's traction boot is a type of skin traction used preoperatively for
the patient with a hip, knee, or femur fracture to reduce muscle spasms (Fig. 59.9).12 Pelvic or
cervical skin traction may require heavier weights applied intermittently. In skin traction,
regular assessment of the skin is a priority be- cause pressure points and skin breakdown may
develop quickly. Assess key pressure points every 2-4 h.Bucks traction used for knee , hip
bone fracture Weight usually 5-7 pounds attach to skin
2. Skeletal traction – Skeletal traction, generally in place for longer periods than skin traction, is
used to align injured bones and joints or to treat joint contractures and congenital hip dysplasiaIt
provides a long-term pull that keeps the injured bones and joints aligned. To apply skeletal
traction, the surgeon inserts a pin or wire into the bone, and weights are attached to align and
 immobilize the injured body part. Weight for skeletal traction ranges from 5 to 45 lb. (2.3-20.4
kg). The use of too much weight can result in delayed union or nonunion. The major
complications of skeletal traction are infection at the pin insertion site and the effects of
prolonged immobility. One of the more common types of skeletal traction is bal- anced
suspension traction (Fig. 59.10). Fracture alignment de- pends on the correct positioning and
alignment of the patient. Needs invasive procedure Traction is the use of weights , ropes and
pulleys to apply force to tissue surrounding a broken bone. Weight is up to 10 kg attached to
bone
3. Splinting - Splinting is the most common procedure for immobilizing an injury.
Why do we splint ?
• To stabilizer the extremity
• To decrease pain
• Actually treat the injury
Possible items for splinting - Soft material . Towels , blankets , or pillows ,tied with bandaging
materials or soft clothes Rigid materials. A board , metal strip , folded magazine or newspaper ,
Other rigid item.
Guidelines for splinting
1. Support the injured area.
2. Splint injury in the position that you find it.
3. Don’t try to realign bones.
4. Check for colour, warmth, and sensation.
5. Immobilize above and below the injury.
6. The splint should go beyond the joints above and below the fractured or dislocated bone to
prevent these from moving
OPEN REDUCTION
Correction of bone alignment through a surgical incision.
External/Internal fixation devices (metallic pins , wires, screws, plates, nails or rods) may be used to
hold the bone fragments in position until solid bone healing occurs.
Immobilization
• Immobilization may be accomplished by external or internal fixation.
• Methods of external fixation include
• Bandages, casts, splints, continuous traction, and external fixators.
• Metal implants used for internal fixation serve as internal splints to immobilize the fracture.

CASTS

Casts. A cast is a temporary circumferential immobilization device. Casting is a common treatment

following closed reduction. It allows the patient to perform many normal activities of daily living while
providing sufficient immobilization to ensure stability. Cast materials are natural (plaster of Paris),
synthetic acrylic, fiberglass-free, latex-free polymer, or a hybrid of mate- rials. Fiberglass casting
materials are commonly used because they are lighter relatively waterproof, and longer wearing than

plaster of Paris."3 Plaster of Paris is now used primarily for con- tact casting in the treatment of diabetic
foot ulcers.14 A cast generally incorporates the joints above and below a fracture. Immobilization above
and below a joint restricts tendon and ligament movement, thus assisting with joint stabilization while
the fracture heals.

Application of cast

To apply a cast on an extremity, first cover the affected part with stockinette that is cut longer than the
extremity. Then place cotton padding over the stockinette, with extra padding for bony prominences. If
plaster of Paris casting material is used, immerse it in warm water and then wrap and mold it around the
affected part. The number of layers of plaster bandage and the technique of application determine the
strength of the cast. The plaster sets within 15 min, so the patient may move around without difficulty.
However, it is not strong enough for weight bearing until about 36-72 h after application.13 The final
decision about the patient's weight bearing is made by the surgeon. Casts made of fiberglass or other
synthetic materials (thermola- bile plastic, thermoplastic resins, polyurethane) are activated by
submersion in cool or tepid water. Then they are molded to fit the torso or extremity.

A fresh plaster cast should never be covered because air can- not circulate. Heat then builds up in the
cast and may cause a burn, and drying is delayed. Avoid direct pressure on the cast during the drying
period. Handle the cast gently with an open palm to avoid denting the cast. Once the cast is thoroughly
dry, the rough edges may be petaled to minimize skin irritation. Petaling also prevents plaster of Paris
debris from falling into the cast and causing irritation or pressure necrosis. Place several strips (petals)
of tape over the rough areas to ensure a smooth cast edge.

Upper extremity injuries

Immobilization of an acute fracture or soft-tissue injury of the upper extremity is often accom- plished
by use of a

(1) sugar-tong splint,

(2) posterior splint,

(3) short arm cast, or

(4) long arm cast

. The sugar-tong splint is typically used for acute wrist injuries or injuries that may result in significant
swelling. Splints are applied over a well-padded forearm, beginning at the phalangeal joints of the hand,
extending up the dorsal aspect of the forearm around the distal humerus and then down the volar aspect
of the forearm to the distal palmar crease. The splinting material is wrapped with either elastic bandage
or bias stockinette. The sugar-tong posterior splint accommodates early swelling in the fractured
extremity.

The short arm cast is often used for the treatment of stable wrist or metacarpal fractures. An aluminum
finger splint can be incorporated into the short arm cast for concurrent treatment of phalangeal injuries.
The short arm cast is a circular cast extend- ing from the distal palmar crease to the proximal forearm.
This cast provides wrist immobilization and permits unrestricted elbow motion.

The long arm cast is commonly used for stable forearm or elbow fractures and unstable wrist fractures.
It is similar to the short arm cast but extends to the proximal humerus, restrict- ing motion at the wrist
and elbow. Support the extremity and reduce edema by elevating the extremity with a sling. However,
when a hanging arm cast is used for a proximal humerus frac- ture, elevation or a supportive sling is
contraindicated because hanging provides traction and maintains fracture alignment.

When a sling is used, ensure the axillary area is well padded to prevent skin excoriation and maceration
associated with direct skin-to-skin contact. Placement of the sling should not put undue pressure on the
neck. Encourage movement of the fingers (unless contraindicated) to enhance the pumping action of
blood vessels to decrease edema. Also encourage the patient to actively move joints of the upper
extremity that are not im- mobilized to prevent stiffness and contractures.

Vertebral injuries.
The body jacket brace is used for immobilization and support for stable spine injuries of the thoracic or
lumbar spine. The brace goes around the chest and abdomen, extending from above the nipple line to
the pubis. After application of the brace, assess the patient for the development of superior mesenteric
artery syndrome (cast syndrome). This condition occurs if the brace is applied too tightly, compressing
the superior mesenteric artery against the duodenum. The patient generally complains of abdominal
pain, abdominal pressure, nausea, and vomiting. Assess the abdomen for decreased bowel sounds (a
window in the brace may be left over the umbilicus) .Treatment of cast syndrome includes gastric
decompression with a nasogastric (NG) tube and suction. Also assess respira- tory status, bowel and
bladder function, and areas of pressure over the bony prominences, especially the iliac crest. The brace
may have to be adjusted or removed if any complications occur.

Lower extremity injuries

. Injuries to the lower extremity are often immobilized by long leg cast, short leg cast, cylinder cast, or
prefabricated splint or immobilizer. The usual indications for a long leg cast are an unstable ankle
fracture, soft-tissue injuries, a fractured tibia, and knee injuries. The cast usually extends from the base
of the toes to the groin and gluteal crease. The short leg cast is used primarily for stable ankle and foot
injuries. A cylinder cast, which is used for knee injuries or fractures, ex- tends from the groin to the
malleoli of the ankle. A Robert Jones dressing may be used temporarily to limit mobility of a joint. It is
composed of soft padding materials (absorption dressing and cotton sheet wadding), splints, and an
elastic wrap or bias-cut stockinette.

Application

After application of a lower extremity cast or dressing, the extremity should be elevated on pillows
above heart level for first 24 h. After the initial phase, a casted extremity should not be placed in a
dependent position because of the possibility of excessive edema. After cast application, observe for
signs of compartment syndrome (discussed later in the chapter) and increased pressure, especially in the
heel, anterior tibia, head of the fibula, and malleoli. This increased pressure is manifested by pain or a
burning feeling in these areas.

Prefabricated knee and ankle splints and immobilizers are used in many settings. This type of
immobilization is easy to ap- ply and remove, which permits close observation of the affected joint for
swelling and skin breakdown Depending on the injury, removal of the splint or immobilizer facilitates
ROM of the affected joint and faster return to function.

The hip spica cast is now mainly used for femur fractures in children to immobilize the affected
extremity and trunk. It extends from above the nipple line to the base of the foot (single spica) and may
include the opposite extremity up to an area above the knee (spica and a half) or both extremities (double
spica). Assess the patient with a hip spica cast for the same problems associated with the body jacket
brace.
EXTERNAL FIXATION

Metallic device composed of pins that are inserted into the bone and attached to external rods to stabilize
the fracture while it heals. It can be used to apply traction or to compress fracture fragments and
immobilize reduced fragments when the use of a cast or other traction is not appropriate. The external
device holds fracture fragments in place similar to a surgically implanted internal device The external
fixator is attached directly to the bones by percutaneous transfixing pins or wires. External fixation is
indicated primarily for complex fractures with extensive soft-tissue damage, correction of congenital
bony defects nonunion or malunion, and limb lengthening. -

External fixation is often used in an attempt to salvage extremities that otherwise may require
amputation. Because the use of an external device is a long-term process, ongoing as- sessment for pin
loosening and infection is critical. Infection (indicated by exudate, erythema, tenderness, and pain) may
require removal of the device. Instruct the patient and care- giver about meticulous pin care. Although
each surgeon has a protocol for pin care cleaning, chlorhexidine (2 mg/mL) is often used." Hydrogen
peroxide may be cytotoxic to osteoblasts and may not be bactericidal.

CARE OF EXTERNAL FIXATION

Assessment –pain ,nerve , supply , infection, pin site etc Small bleeding from pin site is normal Critical
, if extend more than 24 hours Administer antibiotics , analgesic medicine Patients with open fractures
Administers tetanus prophylaxis if indicated. Wound irrigation and debridement in the operating room
are necessary. Intravenous antibiotics are prescribed to prevent or treat infection. Wound is cultured.
Fracture is carefully reduced and stabilized by external fixation. Any damage to blood vessels ,soft tissue
,muscles, nerves , and tendons is treated. Heavily contaminated wounds are left unsutured & dressed
with sterile dressing.

INTERNAL FIXATION.

Internal fixation devices (pins, plates, intramedullary rods, metal and bioabsorbable screws) are
surgically inserted to realign and maintain position of bony fragments. These metal devices are
biologically inert and made from stainless steel, vitallium , or titanium. Proper alignment and bone
healing are evaluated regularly by X-rays.
ELECTRICAL BONE GROWTH STIMULATION.

Electrical bone growth stimulation is used to facilitate the healing process, especially for fracture
nonunion or delayed union. The mechanism of action of electrical bone growth stimulation may include

(1) in- creasing the calcium uptake and the production of bone growth factors,

(2) increasing collagen synthesis, and

(3) promoting the growth of new blood vessels.

Noninvasive, semiinvasive, and invasive methods of electrical bone growth stimulation are used.
Noninvasive stimulators use direct current or pulsed electromagnetic fields (PEMFS) to generate a weak
electrical current. Electrodes are typically in a band applied over the patient's skin or cast and worn 10-
12h each day, usually while the patient is sleeping. Semiinvasive or percutaneous bone growth
stimulators use an external power supply and electrodes that are inserted through the skin and into the
bone. Invasive stimulators re- quire surgical implantation of a current generator in an IM or
subcutaneous space. An electrode is implanted in the bone fragments.
Drug Therapy.

Patients with fractures experience varying degrees of pain associated with muscle spasms. Central and
peripheral muscle relaxants, such as carisoprodol. cyclobenzaprine, or methocarbamol may be
prescribed for management of pain associated with muscle spasms.

The threat of tetanus from an open fracture can be reduced by administering tetanus and diphtheria
toxoid or tetanus immunoglobulin for the patient who has not been previously immunized or whose
immunization is expired (see Table 65.6). Bone-penetrating antibiotics, such as a cephalosporin (e.g.,
cefazolin), are used prophylactically before surgery

Nutritional Therapy

.Proper nutrition is an essential component of the healing process in injured tissue. An adequate energy
source is needed to promote muscle strength and tone, build endurance, and provide energy for
ambulation and gait-training skills. The patient's dietary requirements must include adequate protein
(e.g., 1 g/kg of body weight), vitamins (especially B, C, and D), calcium, phosphorus, and magnesium
to ensure optimal soft tissue and bone healing Low serum protein and vita- min C deficiencies interfere
with tissue healing. Immobility and bone healing increase calcium needs.

A well-balanced diet should be supplemented by fluid intake of 2000-3000 mL/day to promote optimal
bladder and bowel function. Adequate fluid and a high-fiber diet with fruits and vegetables prevent
constipation. If immobilized in bed with skeletal traction or in a body jacket brace, the patient should
eat six small meals to avoid overeating that can contribute to abdominal pressure and cramping.

3.Maintaining and restoring function

a. Restlessness, anxiety, and discomfort are controlled with a variety of approaches, such as
reassurance, position changes, and pain relief strategies including use of analgesics.
b. Exercises are encouraged to minimize disuse atrophy and to promote circulation.
c. Participation in activities of daily living (ADLs)is encouraged to promote independent
functioning and self –esteem.
COMPLICATIONS OF FRACTURE

Immediate - Hypovolemic Shock

Early complications

▪ Fat embolism
▪ Adult respiratory distress syndrome
▪ Compartment syndrome
▪ Crush syndrome
▪ Deep vein thrombosis
▪ infection

Fat embolism

Fat Embolism Syndrome (FES) Characterized by the presence of fat globules in tissues and organs
after a traumatic skeletal injury Fractures that most often cause FES: ◦ Long bones ◦ Ribs ◦ Tibia ◦
Pelvi

Tissues most often affected: ◦ Lungs ◦ Brain ◦ Heart ◦ Kidneys ◦ Skin Clinical Manifestations  Usually
occur 24-48 hours after injury Interstitial pneumonitis  Produce symptoms of ARDS CHEST PAIN
Tachypnea Cynosis PaO

Clinical Manifestations ◦ Symptoms of ARDS: Dyspnea ◦ Apprehension ◦ Tachycardia ◦ Rapid and

acute course ◦ Feeling of impending disaster ◦ Patient may become comatose in a short time

Collaborative Care ◦ Treatment directed at prevention ◦ Careful immobilization of a long bone fracture
◦ Most important preventative factor Collaborative Care (treatment) ◦ Symptom management ◦ Fluid
resuscitation ◦Oxygen ◦ Reposition as little as possible
Adult respiratory distress syndrome

Compartment Syndrome

Compartment syndrome occurs when excessive pressure builds up inside an enclosed muscle space in
the body.
Condition in which elevated
intercompartmental pressure within a confined
myofascial compartment compromises the
neurovascular function of tissues within that
space.
Causes capillary perfusion to be reduced below
a level necessary for tissue viability
Two basic etiologies create compartment
syndrome:
• Decreased compartment size (dressings, splints,
casts)
•Increased compartment content (bleeding,
edema)
Clinical Manifestations
Six Ps
: • Patient may present with one or all of the six Ps
• Compare extremities
• Absence of peripheral pulse = ominous late sign
• Myoglobinuria
• Dark reddish-brown urine

Collaborative Care
• Prompt, accurate diagnosis is critical
• Early recognition is the key
• Do not apply ice or elevate above heart level
• Remove/loosen the bandage and bivalve the cast
• Reduce traction weight
• Surgical decompression (fasciotomy)

Crush syndrome

Deep vein thrombosis

Veins of the lower extremities and pelvis are highly susceptible to thrombus formation after fracture,
especially hip fracture
Precipitating factors:
◦ Venous stasis caused by incorrectly applied casts or traction
◦ Local pressure on a vein
◦Immobility
Prevent with anticoagulant medications
Infection

Infection. Open fractures and soft-tissue injuries have a high incidence of infection. An open fracture
usually results from severe external forces. Massive or blunt soft-tissue injury often has more serious
consequences than the fractureDamage to the surrounding soft tissue and blood vessels impairs the abil-
ity of defense mechanisms to respond to microorganisms.Devitalized and contaminated tissue is an ideal
medium for many common pathogens, including gas-forming (anaerobic) bacilli such as Clostridium
tetani. Measures to prevent infection and osteomyelitis are important
Open fractures require aggressive surgical debridement. The wound is initially cleaned by pulsating
saline lavage in the oper- ating room. Gross contaminants are irrigated and mechanically removed.
Contused, contaminated, and devitalized tissue (mus- cle, subcutaneous fat, skin, and bone fragments)
are surgically excised (debridement). The extent of soft-tissue damage deter- mines if the wound is
closed at the time of surgery and if it re- quires repeat debridement, closed suction drainage, and/or skin
grafting. Depending on the location and extent of the fracture, reduction may be maintained by external
fixation or traction. During surgery, the open wound may be irrigated with antibi- otic solution.
Antibiotic-impregnated beads may also be placed in the surgical site. The patient may have antibiotics
adminis- tered IV for 3 days during the postoperative phase of care.18 In conjunction with aggressive
surgical management, antibiotics have greatly reduced the occurrence of infection
Collaborative Care
•Open fractures require aggressive surgical debridement • Post-op IV antibiotics for 3 to 7 days
(prophylactic)
Delayed complications
➢ Delayed union and non-union
➢ Malunion
➢ Reaction to internal fixation devices (metallic pins, wires, screws, plates nails, or rod)
NURSING MANAGEMENT

Nursing Assessment.
A brief history of the traumatic episode

Nursing Implementation
Acute Care - Patients with fractures may be treated in an emergency department or a physician's office
and released to home care, or they may require hospitalization for varying amounts of time. Specific
nursing measures depend on the set- ting and type of treatment.
Preoperative Care - If surgical intervention is required to treat a fracture, patients need preoperative
preparation. In addition to the usual preoperative nursing measures (see Chapter 14), inform patients of
the type of immobilization and assistive de- vices that will be used and the expected activity limitations
after surgery. Assure patients that nursing staff will help meet their personal needs until they can resume
self-care. Remind patients that pain medication will be available if needed
Postoperative Care - In general, postoperative nursing care and management are directed toward
monitoring vital signs and applying general principles of postoperative nursing care (see Chapter
16)Frequent neurovascular assessment of the af- fected extremity is necessary to detect early and subtle
changes.
Closely monitor any limitations related to turning, positioning, and extremity support. Minimize pain
and discomfort through proper alignment and positioning. Carefully observe dressings or casts for any
signs of bleeding or drainage. Report a signifi- cant increase in size of the drainage area. If a wound
drainage system is in place, regularly measure the volume of drainage and assess its character (e.g.,
bloody, purulent). Report increased or purulent drainage immediately to the surgeon. Also assess the
patency of the drainage system, using aseptic technique to avoid contamination.
Additional nursing responsibilities depend on the type of immobilization used. A blood salvage and
reinfusion system may be used to allow recovery and reinfusion of the patient's own blood. The blood
is retrieved from a joint space or cavity, and the patient receives this blood in the form of an
autotransfusion.
Other Measures. Patients often have reduced mobility as a result of a fracture. Plan care to decrease risk
for the many complications associated with immobility. Prevent constipation by increasing patient
activity and maintaining high fluid intake (more than 2500 mL/day unless contraindicated by the
patient's health status) and a diet high in bulk and roughage (fresh fruits and vegetables)If these measures
are not effective in maintaining the patient's normal bowel elimination pat- tern, administer stool
softeners, laxatives, or suppositories. Maintain a regular time for elimination to promote bowel
regularity.
Renal calculi can develop from bone demineralization related to reduced mobility. Hypercalcemia from
demineralization causes a rise in urine pH and stone formation from the precipitation of calcium. Unless
contraindicated, fluid intake of 2500 mL/day is recommended to decrease the risk of calculi formation.
Rapid deconditioning of the cardiopulmonary system can occur as a result of prolonged bed rest,
resulting in orthostatic hypotension and decreased lung capacity. Unless contraindi- cated, these effects
can be diminished by having the patient sit on the side of the bed, allowing the patient's lower limbs to
dangle over the bedside, and having the patient perform standing transfers. When the patient is allowed
to increase activity, assess for orthostatic hypotension.

Patient with closed fractures:

• Encourage patient not to mobilize fracture site.
• Exercises to maintain the health of unaffected muscles for using assistive devices (e.g., crutches
, walker )
• Teach patients how to use assistive devices safely.
• Patient teaching includes self –care , medication information , monitoring for potential
complications, and the need for continuing health care supervision
Patients with open fractures
• Administers tetanus prophylaxis if indicated.
• Wound irrigation and debridement in the operating room are necessary.
• Intravenous antibiotics are prescribed to prevent or treat infection.
• Wound is cultured.
• Fracture is carefully reduced and stabilized by external fixation.
• Any damage to blood vessels ,soft tissue ,muscles, nerves , and tendons is treated.
• Heavily contaminated wounds are left unsutured & dressed with sterile dressing .
Nursing Diagnosis
1. Acute pain related to tissue trauma as evidenced by guarding of affected area
➔ Intervention - Provide range of motion exercises to the patient. -perform passive or assisted
ROM exercise. -provide assistance while using walker or crutches if required. -prevent from
complication which usually occurs due to immobility.
2. Impaired physical mobility related to application of traction or cast, pain as evidenced by
assessment
➔ Intervention -
• Provide range of motion exercises to the patient.
• Perform passive or assisted ROM exercise.
•Provide assistance while using walker or crutches if required.
• Prevent from complication which usually occurs due to immobility.
3. Risk for peripheral neurovascular dysfunction related to vascular insufficiency and nerve
compression secondary to edema and application of traction, splints or casts. Goal - Experience
no peripheral neuro vascular dysfunction
➔ Intervention:
 Elevate the affected limb above the level of heart to reduce edema.
 Check for peripheral pulse, capillary refill, temperature
 Immobilize or support the affected body part to prevent pressure and injury.
NURSING DIAGNOSISOF CLIENT WITH CAST
Actual Nursing Diagnosis
1. Pain related to underlying tissue injury as evidenced by patient’s verbalization.
2. Activity intolerance related to underlying tissue injury as evidenced by patient is unable to move
his Rt leg.
3. Bathing or Hygiene Self-Care Deficit related to immobility as evidenced by patient is unable to
do the day to day activities.
4. Altered tissue perfusion related to tissue injury as evidenced by swelling on the Rt leg.
5. Altered skin integrity related to operative intervention as evidenced by suture marks present on
Rt hand near wrist.
6. Altered nutrition less than normal related to anorexia as evidenced by relative’s verbalization
7. Altered elimination pattern as related to bedridden status evidenced by patient’s verbalization
8. Altered sleep pattern related to pain as evidenced by patient’s verbalization
9. Anxiety related to outcome of the injury as evidenced by patient’s reaction
10. Knowledge deficit related to outcome of the disease condition as evidenced by patient’s related
queries.

Potential Nursing Diagnosis

1. Risk for infection related to underlying bone injury and operative intervention
2. Risk for Deficient Fluid Volume related to hemorrhage and shock
3. Risk for deformity/ malunion related to underlying bone injury
4. Risk for Peripheral Neurovascular Dysfunction
5. Risk for Injury related to thromboembolism
Health education

Patient Education and Health Maintenance

• Explain basis for fracture treatment and need for patient participation in therapeutic regimen.
• Promote adjustment of usual lifestyle and responsibilities to accommodate limitations imposed
by fracture.
• Instruct patient on exercises to strengthen upper extremity muscles if crutch walking is planned.
• Instruct patient in methods of safe ambulation walker, crutches, cane.
• Emphasize instructions concerning amount of weight bearing that will be permitted on fractured
extremity.
• Discuss prevention of recurrent fractures safety considerations, avoidance of fatigue, proper
footwear.
• Encourage follow-up medical supervision to monitor for union problems.
• Teach symptoms needing attention, such as numbness, decreased function, increased pain,
elevated temperature.
• Encourage adequate balanced diet to promote bone and soft tissue healing.

Promoting Adequate Hygiene

• Encourage participation in care.

• Arrange patient area and personal items for patient convenience and to promote independence.
• Modify activities to facilitate maximum independence within prescribed limits.
• Allow time for patient to accomplish task.
• Teach safe use of mobility and necessary aids.
• Teach family how to assist patient while promoting independence in self-care.

Promoting Physical Mobility

• Perform active and passive exercises to all nonimmobilized joints.

• Encourage patient participation in frequent position changes, maintaining support to fracture
during position changes.
• Minimize prolonged periods of physical inactivity, encouraging ambulation when prescribed.
• Administer prescribed analgesics judiciously to decrease pain associated with movement.

Monitoring for Development of Infection

• Clean, debride, and irrigate open fracture wound as prescribed as soon as possible to minimize
risk of infection.
 o All open fractures are contaminated.
o Begin prescribed antibiotic therapy promptly after wound culture obtained.
• Use sterile technique during dressing changes to minimize infection of wound, soft tissues, and
bone.
• Obtain specimens for culture and sensitivity to determine causative organism.
• Administer antibiotic therapy as prescribed.

Preventing Disuse Syndrome

• Teach and encourage isometric exercises to diminish muscle atrophy.

• Encourage use of immobilized extremity within prescribed limits.

Minimizing the Psychological Effects of Trauma

• Monitor patient for symptoms of posttraumatic stress disorder.

o Memory of event; anger, helplessness, vulnerability, mood swings, depression, cognitive
impairment, sleep disturbance, increased dependency, and social withdrawal
• Assist patient to move through phases of posttraumatic stress (outcry, denial, intrusiveness,
working through, completion).
• Establish trusting therapeutic relationship with patient.
• Encourage patient to express thoughts and feelings about traumatic event.
• Encourage patient to participate in decision making to reestablish control and overcome feelings
of helplessness.
• Teach relaxation techniques to decrease anxiety.
• Encourage development of adaptive responses and participation in support groups.
• Refer patient to psychiatric liaison nurse or refer for psychotherapy, as needed.

Community and Home Care Considerations

• Assist patient to actively exercise joints above and below the immobilized fracture at frequent
intervals.
o Isometric exercises of muscles covered by cast start exercise as soon as possible after
cast application.
o Increase isometric exercises as fracture stabilizes.
• After removal of immobilizing device (eg, cast, splint), have patient start isotonic exercises and
continue with isometric exercises.
• Assess orthostatic blood pressure when patient begins to ambulate to prevent falls.
RehabilitationRECLCARE OF CLIENT WITH Restore the patient as close to pre injury functional
level as possible.
Rest, Elevation, Mobilization (active/passive)
Physiotherapy
Work assessment and reemployment CAST
PROGNOSIS

The fracture is the bone injury which can be healed with active intervention (open or closed
reduction with or without prosthesis) and immobilization usually within 6 weeks depending upon the
type, severity of the fracture and in absence of possible complications. The prognosis of the fracture is
usually good in absence of the complications like non-union, mal-union or infection. Timely
management is required for further management for removal of prosthesis, revision, etc.
RESEARCH
Objective: This study aimed to explore the epidemiological and microbiological characteristics of
fracture-related infection (FRI), analyze the drug resistance characteristics of major pathogens, and
provide timely and relatively complete clinical and microbiological data for antimicrobial treatment of
FRI.
Methods: The clinical and microbiological data of patients with FRI from January 1, 2011, to
December 31, 2020, were collected from three tertiary hospitals in Northeast China. The automatic
microbial analysis system was used for strain identification and drug susceptibility testing, and the drug
susceptibility results were determined in accordance with the latest Clinical and Laboratory Standards
Institute (CLSI) criteria (as applicable each year).
Results: A total of 744 patients with FRI were enrolled. The incidence of FRI was about 1.5%, and
81.7% were male patients, with an average age of 48.98 ± 16.01 years. Open fractures accounted for
64.8%. Motor crush (32.8%) and falling (29.8%) were the main causes of injuries. The common sites of
infection were the tibia and fibula (47.6%), femur (11.8%), foot (11.8%), and hand (11.6%). A total of
566 pathogenic bacteria were cultured in 378 patients with positive bacterial cultures, of which 53.0%
were Gram-positive bacteria and 47.0% were Gramnegative bacteria. The most common pathogen at all
sites of infection is Staphylococcus aureus. Staphylococcus aureus had a high resistance rate to penicillin
(PEN), erythromycin (ERY), and clindamycin (CLI), exceeding 50%. Methicillin-resistant
Staphylococcus aureus (MRSA) was more than 80%resistant to CLI and ERY.
Conclusions: The incidence of FRI in Northeast China was at a low level among major medical centers
nationwide. Staphylococcus aureus was still the main pathogen causing bone infections, and the
proportion of MRSA was lower than reported abroad, but we have observed an increase in the proportion
of infections. Enterobacteriaceae have a higher resistance rate to third-generation cephalosporins and
quinolones. For Enterobacteriaceae, other sensitive treatment drugs should be selected clinically.
Keywords: Epidemiology, Microbiology, Fracture-related infection, Bacterial resistance References
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