Fractures

A break in the continuity of the bone is referred to as a fracture in medicine. It is a crack in a bone's surface, either through the cortex or the articular surface.

• It simply means an infection of the bone or bone marrow. 
• Pain or tenderness in the infected area. 
• Lower back pain 
• Biopsy: A biopsy of the infected bone may be taken and tested for signs of an invading organism. 
• Sequestrectomy: Removal of dead, infected bone and cartilage. 
• Use strict aseptic technique when changing the dressing and irrigating wounds. 
• Look for the sudden malpositioning of the affected limb, which may indicate a fracture. 
• Although all bones are subject to infection, the lower extremity is most commonly involved.

Fractures

A fracture is a medical condition in which there is a break in the continuity of the bone. It is a break in the surface of a bone, either across its cortex or through its articular surface.

Pathophysiology

When the fractured bone and its surrounding tissues bleed, creating a fracture hematoma, the natural healing process for the fracture begins. Between the fragmented pieces, the blood congeals to create a blood clot. Blood tubes quickly develop into the matrix of the blood clot, which resembles jelly. The non-viable material is gradually removed by phagocytes drawn to the location by the new blood vessels. The blood vessels also introduce fibroblasts, which multiply and produce collagen fibers, in the vessel walls. In this way, a collagen matrix takes the place of the blood clot. Bone fragments can only move a small amount due to collagen's rubbery consistency unless a strong or persistent force is applied.

At this stage, some of the fibroblasts begin to lay down bone matrix in the form of collagen monomers. These monomers spontaneously assemble to form the bone matrix, for which bone crystals (calcium hydroxyapatite) are deposited in amongst, in the form of insoluble crystals. This mineralization of the collagen matrix stiffens it and transforms it into bone. In fact, bone is a mineralized collagen matrix; if the mineral is dissolved out of bone, it becomes rubbery. Healing bone callus is on average sufficiently mineralized to show up on X-ray within 6 weeks in adults and less in children. This initial "woven" bone does not have the strong mechanical properties of mature bone. By a process of remodeling, the woven bone is replaced by mature "lamellar" bone. The whole process can take up to 18 months, but in adults, the strength of the healing bone is usually 80% of normal by 3 months after the injury.

The mending of bones can be aided or hampered by a number of variables. For instance, the healing of bones is hampered by any form of nicotine[3] and is aided by proper nutrition, which includes calcium intake. After the bone has sufficiently healed to support the weight, applying weight-bearing stress increases bone strength. Though there are theoretical worries that NSAIDs might slow healing, there isn't enough proof to support refraining from using this kind of analgesia in simple fractures.

Sign and Symptoms

• Pain,
• Loss of function,
• Deformity,
• Shortening,
• Crepitus,
• Swelling and discoloration.

Diagnosis

• History taking,
• Physical examination,
• X – ray,
• CT – Scan.

Treatment

• Medical Therapy: Patients should receive adequate analgesics in the form of acetaminophen or opiates, if necessary.
• Cast immobilization: A plaster or cast is the most common type of fracture treatment because most broken bones can heal successfully once they have been repositioned and a cast has been applied to keep the broken ends in proper position while they are heal.
• Functional Cast or Brace: The cast or brace allow to limited or controlled movement of nearby joints. This treatment is desirable for some but not all fractures.
• Traction: Traction is usually used to align a bone or bones by a gentle, steady pulling action.
• Open Reduction and Internal Fixation: An open reduction and internal fixation (ORIF) is a type of surgery used to fix broken bones. This is a two-part surgery. First, the broken bone is reduced or put back into place. Next, an internal fixation device is placed on the bone. This can be done with screws, plates, rods, or pins that are used to hold the broken bone together.
• External Fixation: External fixation is a surgical treatment used to stabilize the bone and soft tissues at a distance from the operative or injury focus. They provide unobstructed access to the relevant skeletal and soft tissue structures for their initial assessment and also for secondary interventions needed to restore bony continuity and a functional soft tissue cover.

The parts of an external fixator include:

1. Schanz pin,
2. Connecting rod,
3. Clamps.

In this kind of reduction, holes are drilled into uninjured areas of bones around the fracture and special bolts or wires are screwed into the holes. Outside the body, a rod or a curved piece of metal with special ball-and-socket joints joins the bolts to make a rigid support. The fracture can be set in the proper anatomical configuration by adjusting the ball-and-socket joints. Since the bolts pierce the skin, proper cleaning to prevent infection at the site of surgery must be performed.

Nursing Management

• Provide emergency care if required ( hemostasis, respiratory care, prevention of shock).
• Observe signs of fat embolism (especially during first 48 hours after the fractures.)
• Monitor fluid input and output continuously, insert IV, catheter.
• Monitor client laboratory test results for abnormal values.
• Administer IV therapy, analgesic, antibiotics and other medications as prescribed.
• Prepare client and family for surgical intervention if required.
• Provide outline post-operative nursing care and teach about possible post operative complications to clients after surgical intervention.
• Provide care to the patient with the cast (observe signs of circulatory impairment – change in skin color and temperature, diminished distal pulses, pain, and swelling of the extremity, protect the cast from damage.)
• Provide care to the client with the traction (check the weights are hanging freely, observe skin for irritation and site of skeletal traction for signs of infection; use of aseptic techniques when cleaning the site of infection.)
• In a case of hip fracture and hip replacement maintain the adduction of the affected extremity.
• Provide respiratory exercise to prevent lungs complication.
• Observe for the sign of thrombophlebitis; report it immediately to senior.
• Provide skin care to prevent pressures sores.
• Encourage fluid intake and high protein, high vitamin, high calcium diets.
• Teach the clients appropriate crutch- walking techniques.
• Provide emotional support to the clients; explain all the procedures to decrease the anxiety and to obtain cooperation