FRACTURE A. Description 1. A fracture is a break in the continuity of the bone. 2.

Common fracture sites:

Clavicle Humerus In subpracondylar fractures, which occur when child falls backward on hands with elbows straight, there is a high incidence of neurovascular complications due to the anatomic relationship of the brachial artery and nerves to the fracture site. Radius and ulna Femur (often associated with child abuse) Epiphyseal plates (potential for growth deformity)

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3. Types of Fracture
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Closed or simple fracture The bone is broken, but the skin is not lacerated. Open or compound fracture - The skin may be pierced by the bone or by a blow that breaks the skin at the time of the fracture. The bone may or may not be visible in the wound. Transverse fracture The fracture is at right angles to the long axis of the bone. Greenstick fracture - Fracture on one side of the bone, causing a bend on the other side of the bone. Comminuted fracture - A fracture that results in three or more bone fragments. Oblique Fracture The fracture is diagonal to a bone s long axis. Spiral Fracture At least one part of the bone has been twisted.

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4. Complications of fractures include:

problems associated with immobility (muscle atrophy, joint contracture, pressure sores) growth problems ( in children)

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infection shock venous stasis and thromboembolism pulmonary emboli and fat emboli and bone union problems

B. Etiology 1. Fractures in children usually are the result of trauma from motor vehicle accidents, falls or child abuse. 2. Because of the resilience of the soft tissue of children, fractures occur more often than soft tissue injuries. C. Pathopysiology 1. Fractures occur when the resistance of bone against the stress being exerted yields to the stress force. 2. Fractures most commonly seen in children:
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Bend Fracture is characterized by the bone bending to the breaking point and not straightening without intervention. Buckle fracture results from compression failure of the bone, with the bone telescoping on itself. Greenstick fracture is an incomplete fracture.

D. Assessment Findings 1. Clinical Manifestations

The five Ps fractures.

pain, pulse, pallor, paresthesia, and paralysis are seen with all types of

Other characteristic findings include deformity, swelling, bruising, muscle spasms, tenderness, pain, impaired sensation, loss of function, abnormality, crepitus, shock or refusal to walk (in small children).

2. Laboratory and diagnostic findings

Radiographic examination reveals initial injury and subsequent healing progress. A comparison film of an opposite, unaffected extremity is often used to look for subtle changes in the affected extremity. Blood studies reveal bleeding (decreased hemoglobin and hematocrit) and muscle damage (elevated aspartate transaminase (AST) and lactic dehygrogenase (LHD).

E. Nursing Management 1. Provide emergency management when situation warrants, for a new fracture.
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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. Institute appropriate measures for cast and appliance care. 7. Prevent Complications
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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. Prevent compartment syndrome by assessing for muscle weakness and pain out of proportion to injury. Early detection is critical to prevent tissue damage.
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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.

Etiology and Pathophysiology 1. Breaks in the continuity of bone, usually accompanied by localized tissue response and muscle spasm. 2. Cause usually trauma, but pathologic fractures may occur as a result of osteoporosis, multiple myeloma, or bone tumors, which weaken bone structure. 3. Types 1.
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Complete fracture bone completely separated into two parts, may be transverse or spiral. Incomplete fracture only part of the bone broken. Comminuted fracture bone broken into several fragments. Greenstick fracture splintering on one side of the bone, with bending of the other side; occurs only in p;iable bones, usually in children. Simple (closed) fracture bone broken but no break in the skin.

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Compound (open) fracture break in the skin at the time of fracture with or without protrusion of the bone.

1. Stages of bone healing include:

Formation of a hematoma Followed by cellular proliferation And callus formation by the osteoblasts Ossification Remodeling of the callus

Signs and Symptoms Subjective

Pain aggravated by motion Tenderness

Objective
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Loss of motion Edema Crepitus Ecchymosis

Diagnostic Procedure
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X-ray examination reveals break in continuity of bone Deformity caused by change in bone alignment; often results in shortening of the extremity.

Assessment 1. Ability of the client to move extremity. 2. Altered appearance of involved body part. 3. Neurovascular assessment, soft tissue injury or edema may compromise circulatory or neurologic functioning.

4. Factors precipitating injury. 5. Nutritional status. Nursing Diagnosis

Disturbed body image Constipation Fear Risk for injury Pain Impaired physical mobility Altered role performance Self-care deficits Risk for skin integrity

Nursing Interventions 1. Evaluate the client s general physical condition 2. Splint extremity in position found before moving the client; consider all suspected fractures until X-ray films are available. 3. Cover open wound with sterile dressing if available. 4. Observe for signs of emboli, severe chest pain, dyspnea, pallor, and diaphoresis. 5. Observe for signs of circulatory impairment such as change in skin temperature or color, numbness and tingling, unrelieved pain, decrease in pedal pulse, prolonged blanching of toes after compression or inability to move toes. 6. Protect the cast from damage until dry by elevating it on a pillow. 7. Promote drying of the cast by leaving it uncovered; a light may be used with care to promote drying. 8. Maintain bed rest until the cast is dry and ambulation is permitted. 9. Observe for swelling and notify the physician if necessary.

10. Check that weights are hanging freely and that the affected limb is not resting against anything that will impede the pull of the traction. 11. Maintain in proper alignment. 12. Observe for foot drop on clients with Russel traction or Buck s extension, since this may indicative of nerve damage. 13. Observe for signs of thrombophlebitis. 14. Encourage high protein, high vitamin diet to promote healing. 15. Encourage fluids to help prevent constipation, renal calculi, and urinary tract infection. 16. Teach isometric exercises to prevent muscle strength and tone for crutch walking. 17. Teach appropriate crutch-walking technique; non-weight bearing; weight bearing progressing to use of cane. Complications Early 1. Shock 2. Fat embolism syndrome 3. Compartment syndrome 4. Deep vein thrombosis 5. Thromboembolism 6. Pulmonary embolus Delayed 1. Delayed union and nonunion 2. Avascular Necrosis 3. Reaction to Internal Fixation devices 4. Complex Regional Pain Syndrome 5. Heterotrophic Ossification