INTRODUCTION

A fracture is a medical term used to describe a broken bone. It occurs

when a bone is subjected to more force or pressure than it can withstand,
causing it to crack or completely break. Fractures can happen due to
various reasons, including trauma, accidents, falls, sports injuries, or
underlying medical conditions that weaken the bones.
DEFINITION
Is a medical condition characterized by a break or crack in the continuity
of the bone. It occurs when external forces or trauma exceed the bone's
ability to resist or withstand them. Fractures can range from small,
hairline cracks to complete breaks that result in separate bone fragments.
CLASSIFICATIONS OF FRACTURES
Fractures can be classified in several ways based on various factors,
including the location of the fracture, the pattern of the fracture, the
involvement of the soft tissues, and the severity of the fracture. Here are
some common classifications of bone fractures:
1. Location-based classification:
- Proximal: Fracture occurring near the upper end of the bone.
- Midshaft: Fracture occurring in the middle portion of the bone.
- Distal: Fracture occurring near the lower end of the bone.
2. Pattern-based classification:
- Transverse fracture: A straight horizontal fracture line across the
bone.
- Oblique fracture: A diagonal fracture line across the bone.
 - Spiral fracture: A fracture resulting from twisting or rotational force,
characterized by a spiral-shaped fracture line.
- Comminuted fracture: A fracture where the bone breaks into multiple
fragments.
- Avulsion fracture: A fracture caused by a pulling or tearing force that
separates a piece of bone due to the attachment of a ligament or tendon.
3. Soft tissue involvement classification:
- Closed fracture: The broken bone does not pierce through the skin.
- Open fracture (or compound fracture): The broken bone protrudes
through the skin and is exposed to the external environment, increasing
the risk of infection.
4. Severity-based classification:
- Hairline fracture (or stress fracture): A small, fine crack in the bone,
often caused by repetitive stress or overuse.
- Non-displaced fracture: The broken bone remains in its normal
position and alignment.
- Displaced fracture: The broken bone fragments are out of alignment
and may require reduction or realignment.
TYPES OF FRACTURES
1. Open fracture (compound fracture): In this type of fracture, the bone
breaks and pierces through the skin, causing an open wound.
2. Closed fracture (simple fracture): In a closed fracture, the bone breaks
but does not pierce through the skin, causing an internal injury.
3. Greenstick fracture: This type of fracture is common in children,
where the bone bends and cracks but does not completely break.
4. Transverse fracture: A transverse fracture occurs when the bone
breaks in a straight line across the bone.
5. Oblique fracture: An oblique fracture is a diagonal break that occurs
at an angle to the bone.
6. Comminuted fracture: In a comminuted fracture, the bone breaks into
several pieces or fragments.
7. Spiral fracture: A spiral fracture occurs when a bone is twisted,
resulting in a spiral-shaped break.
8. Impacted fracture: In an impacted fracture, one end of the broken
bone is jammed into the other bone.
9. Compression fracture: This type of fracture is common in vertebrae
and occurs when the bone is compressed or compressed between two
other bones.
10. Stress fracture: A stress fracture happens due to repeated stress or
overuse of a bone, often seen in athletes or those with repetitive motion
activities.
SIGNS AND SYMPTOMS OF FRACTURE
1. Pain: Fractures generally cause immediate and intense pain at the site
of the injury. The pain may worsen with movement or pressure on the
affected area.
2. Swelling: Swelling at the site of the fracture may be seen immediately
or develop over time. It can be caused by inflammation or bleeding
within the tissues surrounding the fracture.
3. Deformity: Sometimes, a broken bone may cause a visible deformity
or misalignment of the affected body part. The bone may appear bent or
out of place.
4. Bruising or discoloration: Bruising or discoloration around the
fracture site may occur due to bleeding under the skin.
5. Limited mobility or inability to move: A fracture can restrict
movement in the affected area, making it difficult or impossible to move
the body part or bear weight on it.
6. Tenderness or sensitivity: The area around the fracture site may be
tender to touch or sensitive.
7. Crepitus: Crepitus refers to a grating or grinding sensation or sound
that may be felt or heard when the broken bone ends rub against each
other.
9. Visible bone or open wound: In an open fracture, where the bone
pierces the skin, the broken bone may be visible or protruding through
the wound.
10. Difficulty or inability to bear weight: Fractures in weight-bearing
bones, such as the leg or foot, can make it difficult or impossible to put
weight on the affected limb.
11. Abnormal movement: In severe fractures, there may be abnormal
movement or instability in the affected area. The bone may move
unnaturally, causing a loss of function.
PATHOPHYSIOLOGY
Bone fracture occurs when a bone is subjected to a force that exceeds its
strength, such as a direct blow, sudden impact, or excessive stress. The
force causes the bone to break or crack, this lead to disrupts of the bone's
structure at the microscopic level. Depending on the magnitude of the
force, fractures can range from small cracks to complete breaks across
the bone which initiates an inflammatory response to address tissue
damage and initiate the healing process the nearby blood vessels dilate,
allowing immune cells and chemicals to reach the injured site which
results in swelling, redness, and warmth at the fractured area, this leads
to the formation of hematoma, which is a clot composed of blood and
other cellular debris. The hematoma serves as a temporary scaffold for
subsequent healing, with subsequent Callus formation over a time, callus
are specialized cells called chondrocytes and osteoblasts begin to
migrate to the fracture site. Chondrocytes secrete cartilage, forming a
soft callus that bridges the broken bone ends. Meanwhile, osteoblasts
deposit new bone around the fractured area, creating a hard callus, this
callus serves to stabilize the fracture, the callus undergoes remodeling
Initially, excess bone material are resorbed, and the callus gradually
transforms into normal bone tissue. Osteoclasts are responsible for
breaking down excess bone, while osteoblasts continue to deposit new
bone. This remodeling process can take several weeks to months,
depending on the severity of the fracture, as remodeling progresses; the
fractured bone undergoes a maturation process and gradually regains its
pre-fracture strength. The healing bone may exhibit increased density at
the fracture site due to increased bone deposition.
INVESTIGATIONS
1. X-rays: X-rays are often the first imaging modality used to diagnose
bone fractures. They provide a detailed image of the bone's structure and
can help identify the location, type, and extent of the fracture.
2. CT scan: A computed tomography (CT) scan may be ordered for
complex or severe fractures. It provides more detailed images by
creating cross-sectional views of the bone. CT scans are useful in
evaluating complicated fractures, assessing fracture displacement, and
evaluating for associated injuries.
3. MRI: Magnetic resonance imaging (MRI) may be used when a
fracture is suspected, but not visible on X-ray or CT scan. MRI provides
detailed images of soft tissues, such as ligaments, tendons, and muscles,
and can help diagnose associated injuries or complications.
4. Bone scan: A bone scan involves injecting a small amount of
radioactive material into the bloodstream, which is absorbed by the
bones. Areas of increased metabolic activity, such as those associated
with fractures or bone healing, show up as bright spots on the scan. Bone
scans are typically used when stress fractures or certain types of
fractures are suspected.
5. Ultrasound: Ultrasound imaging uses sound waves to create real-time
images of soft tissues. It may be used to diagnose fractures in infants, as
their bones are still growing and may not be visible on X-rays.
6. Angiography: Angiography may be performed if there is suspicion of
damage to blood vessels or arterial supply to the fractured area. It
involves injecting contrast material into blood vessels and taking X-ray
images to assess blood flow.
7. Laboratory tests: Certain blood tests may be ordered to evaluate for
underlying conditions or complications related to the fracture, such as
infection or impaired healing.
NURSING MANAGEMENT
1. Assessment: Perform a thorough assessment of the patient's injury,
including pain level, neurovascular status, and any associated symptoms
or complications.
2. Pain management: Administer prescribed pain medications and assist
in pain relief techniques, such as positioning, ice packs, or heat therapy.
Regularly assess and reassess the patient's pain levels and adjust pain
management interventions accordingly.
3. Neurovascular monitoring: Assess and monitor the patient's
neurovascular status, including sensory and motor function, pulses,
capillary refill, and skin color and temperature. Report any changes or
abnormalities to the healthcare provider immediately.
4. Mobility assistance: Collaborate with the patient and other healthcare
team members to develop an appropriate mobility plan. This may
involve the use of assistive devices (crutches, walkers, wheelchairs),
training on proper use, and implementing measures to prevent
complications such as pressure ulcers or muscle atrophy.
5. Wound care: Assess and monitor any open fractures or surgical
incisions for signs of infection, such as redness, swelling, or drainage.
Instruct the patient on proper wound care techniques, including dressing
changes and hygiene practices, and provide support and education about
infection prevention.
6. Psychological support: Recognize the patient's emotional and
psychological needs related to the fracture. Provide therapeutic
communication, encouragement, and emotional support to help the
patient cope with the injury and any associated limitations or changes in
lifestyle.
7. Collaborative care: Collaborate with other healthcare professionals,
such as orthopedic surgeons, physical therapists, and occupational
therapists, to ensure coordinated and comprehensive care for the patient.
This includes facilitating referrals, implementing care plans, and
participating in interdisciplinary discussions and assessments.
8. Education and discharge planning: Educate the patient and their
family on the nature of the fracture, activities to avoid, rehabilitation
exercises, proper medication use, potential complications, and
appropriate follow-up care. Develop a discharge plan that includes
necessary equipment, referrals for outpatient therapy or follow-up
appointments, and instructions for self-care and injury prevention.
MEDICAL MANAGEMENT
1. Closed reduction: This procedure involves manipulating the bone
fragments back into their proper alignment without surgery. It is often
performed under anesthesia or conscious sedation.
2. Open reduction and internal fixation (ORIF): In cases of severe or
complex fractures, surgery may be necessary to realign the bone
fragments and stabilize them using screws, plates, or rods.
3. Immobilization: Immobilizing the fractured bone is essential for
proper healing. This can be done through the use of splints, casts, or
braces.
4. Pain management: Pain control is crucial for patient comfort and to
facilitate rehabilitation. Non-opioid and opioid pain medications may be
prescribed, along with other techniques such as ice packs, elevation, and
relaxation techniques.
5. Physical therapy: Physical therapy plays a significant role in the
rehabilitation process. It helps restore joint mobility, muscle strength,
and function. Range-of-motion exercises, stretching, and strengthening
exercises are commonly prescribed to aid in recovery.
6. Medications: Depending on the type of fracture, the healthcare
provider may prescribe medications such as antibiotics to prevent
infection, anticoagulants to prevent blood clots, or bone-stimulating
medications to enhance healing.
7. Surgical interventions: In certain cases, additional surgical procedures
may be required, such as bone grafting to facilitate bone healing or the
use of external fixation devices to stabilize fractures with soft tissue
compromise.
COMPLICATIONS
1. Delayed or non-union: A fracture that takes longer than expected to
heal is considered a delayed union. If the bone fragments fail to heal
together at all, it is called a non-union. This may require surgical
intervention to promote healing.
2. Malunion: This occurs when the bone heals in an abnormal position,
leading to deformity, joint dysfunction, or limb length discrepancy.
Additional treatment, such as corrective surgery or physical therapy,
may be necessary.
3. Infection: Fractures can introduce bacteria into the soft tissues or
bone, leading to infection. Symptoms may include increased pain,
swelling, redness, warmth, and fever. Antibiotics may be required to
treat the infection, and surgery might be necessary to drain any
abscesses.
4. Compartment syndrome: This occurs when there is increased pressure
within a closed space (such as a compartment in the arm or leg) due to
swelling or bleeding. It can lead to restricted blood flow, tissue damage,
and nerve injury. Emergency surgery may be required to relieve the
pressure.
5. Deep vein thrombosis (DVT) and pulmonary embolism (PE):
Reduced mobility and immobilization can increase the risk of blood
clots forming in the veins of the legs (DVT). If a clot dislodges and
travels to the lungs, it can cause a potentially life-threatening pulmonary
embolism (PE). Preventive measures such as early mobilization,
compression stockings, and anticoagulant medications may be used to
reduce the risk of DVT and PE.
6. Joint stiffness: Prolonged immobilization can lead to joint stiffness
and limited range of motion. Physical therapy and rehabilitation
exercises can help restore joint function.
7. Nerve or blood vessel damage: Fractures, especially those near major
blood vessels or nerves, can cause injury to these structures. This can
result in numbness, tingling, weakness, or compromised blood flow.
Surgical intervention may be required to repair the damaged structures.