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Management of Fractures
- 1. Management of FRACTURE By: Ms.S Peter
- 4. Diagnostic Studies for Fracture • X-ray examinations: - location and extent of fractures/trauma, may reveal pre-existing 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) (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 load of Cr for renal clearance. • Coagulation profile: Alterations may occur because of blood loss, multiple transfusions, or liver injury. NURSING RESPONSIBILITIES ??????
- 6. Outline ClosedFracture Reduce Closed Reduction Mechanical Traction Open Reduction Hold Sustained Traction Cast Splintage Functional Bracing Internal Fixation External Fixation Exercise
- 7. Operative Open reduction Mechanical Traction Non-operative Closed reduction Reduction
- 8. Closed reduction Suitable for – Minimally displaced fractures – Most fractures in children – Fractures that are likely to be stable after reduction • Most effective when the periosteum and muscles on one side of fracture remain intact • Under anesthesia and muscle relaxation, a threefold maneuver applied: • Preparing pat/family….. Pre-post care
- 10. Non Operative • Sustained traction • Cast Splintage • Functional Bracing Operative • Internal Fixation • External Fixation Hold
- 11. HOLD To prevent displacement To promote soft-tissue healing To alleviate pain by some restriction of movement To allow free movement of the unaffected parts
- 12. Traction • Traction is applied to limb distal to the fracture • To exert continuous pull along the long axis of the bone Indications • spiral fractures of long bone shafts: – Shaft of femur – Tibia – Lower humerus • Methods – Traction by gravity – Balanced traction – Fixed traction
- 13. Mechanical Traction • Some fractures (eg . fracture of femoral shaft) are difficult to reduce by manipulation because of powerful muscle pull • However, they can be reduced by sustained muscle mechanical traction; also serves to hold the fracture until it starts to unite
- 14. Traction by Gravity Thomas Splint
- 15. Cast Splintage • POP • Fiber Glass • 3-D Cortex casts (Polimer) • Velcro bandage
- 17. Indication 1. Fracture that cannot be reduced except by operation 2. Fracture that are inherently unstable and prone to displacement after reduction 3.Fracture that unite poorly and slowly • fracture of the femoral neck 4.Pathological fracture • Bone disease may prevent healing 5.Multiple fracture • Where early fixation reduced the risk of general complication 6.Fracture in patient who present severe nursing difficulty
- 18. Depending on site and type of # the fixation is used ---- • Plate & screws – long bones • Locking plate – Comminuted osteoporotic # • Intramedullary nail- Long bone -- # near the middle of shaft • Compression screw plate - # neck of femur, femur head • Trans fixation of screws – small detached fragments – • Krischner wire – bony fragments of # of small bones in hand /foot • Tension band wiring – patella or olecranon ,,,,metaphyseal
- 19. • Metals used ---- non corrosive --- • Chromium, nickel, molybdenum , alloy of chromium, molybdenum and nickel , Titanium
- 20. Advantages Precise reduction • ORIF-open reduction and internal fixation Immediate stability • Hold the fracture securely Early movement • no ‘fracture disease‘ • like edema, stiffness, etc
- 22. Infection Risk of infection depends on: 1)The patient devitalized tissue, dirty wound, unfit patient 2)The surgeon thorough training, surgical dexterity and adequate assistant are all essential 3)The facilities aseptic routine • The infection should be rapidly controlled by intravenous antibiotic • If infection cannot be controlled, the implant should be replaced with some form of external fixation
- 23. NON-UNION Factors associated with the occurrence of delayed union and nonunion • the severity of the fracture, • the location of the fracture, • the nature of the blood supply to the bone, • the extent of soft tissue damage and its interposition, • bone loss, • air contact • contamination, whether a tumor is involved
- 24. Systemic factors for delayed or nonunion • smoking, • alcoholism, • age, • chronic illness (e.g. diabetes mellitus), • malnutrition, • use of medications (e.g. NSAIDs and steroids Nonunion may increase due to the treatment itself involving : • inadequate reduction, • poor stabilization, • distraction, • damage to the blood supply, or • postoperative infection.
- 25. EXTERNAL FIXATION • Fracture with soft tissue involvement • Severe comminuted and unstable # • Fracture of pelvis • # with nerve and vascular involvement • Infected # • United #
- 26. Advantages technically quick and easy to perform no soft tissue stripping; ease of removing hardware; risk of infection at the site of the fracture is minimal
- 27. Management of Open Fractures A break in skin and underlying soft tissues leading directly to communicating with the fracture
- 28. Treatment- Outline Irrigation Debridement: Skin, Fat, Muscle, Bone Wound closure Analgesic + Antibiotic + Antitetanus (AAA): IV, IM Fracture stabilization
- 29. Open # : Fracture Stabilization • A window is made in the plaster over the wound for dressing Immobilization in a plaster •Eg. open fracture of tibiaSkeletal traction •Can be easily applied •Readily reduced and adjusted •Wound can be assessed for dressing •Excellent stability External fixator • Rarely usedInternal fixator
- 30. Aftercare The limb is elevated & it's circulation carefully monitored Antibiotic cover If the wound has been left open, it is inspected after 2-3 days & covered appropriately Physiotherapy and rehabilitation
- 32. General Complications • Shock • Diffuse coagulopathy • Respiratory dysfunction • Crush syndrome • Venous thrombosis & Pulmonary embolism • Fat embolism • Tetanus Nurse’s responsibilities ?????
- 33. Closed Fracture First Aid --- Immediate– initial • Airway, Breathing and Circulation • Splint the fracture • Look for other associated injuries • Check distal circulation – is distal circulation satisfactory? • Check neurology – are the nerve intact? • AMPLE history- Allergies, Medications, Past medical history, Last meal, Events • Radiographs – 2 views, 2sides, 2 joints, 2 times.
- 34. First aid • immobilization • Control hemorrhage • Control pain– morphine -- • Care of wounds
- 35. General Resuscitation Manipulation (improve position of fragments) Splintage (hold fragments together until unite) Exercise & weight-bearing