Fractures Flashcards
Complete Fractures
- Transverse-usually stay in place after reduction, but they take longer to heal
Oblique-difficult to keep in place but they heal more rapidly - Spiral-difficult to keep in place but they heal more rapidly
- Comminuted-often unstable because it consists of two or more fragments, making healing difficult
- Avulsion-occurs when a ligament pulls the portion of bone that it is attached away from the bone
- Osteochondral-occurs when fragments of articular cartilage are sheared from the joint surface often during a dislocation or sprain
Incomplete Fractures
- Compression-the bone is crushed and usually occur in cancellous bone (vertebral body)
- Greenstick-the bone is bent or partially broken, as when breaking a green twig. Usually found in children younger than 10 years of age when the bones ar more pliable
- Perforation-the result of a missile wound, such as a bullet
- Stress-cracks in bone due to overuse or repetitive actions
Common Fractures
- Colle’s:
Fracture of the wrist where a transverse fracture of the radius just proximal to the wrist allows the fragment to rotate and displace dorsally
This gives the wrist the classic “dinner fork” deformity before it is reduced
Most common fracture in older people
Usual mechanism of injury is a FOOSH
Can be difficult to reduce successfully
- Galeazzi:
Involves a break of the radial shaft and a dislocation of the inferior radioulnar joint
The mechanism of injury is usually a fall on the hand with some rotational component
- Pott’s:
Ankle fracture that affects one or both malleoli
The distal fibula breaks close to the lateral malleolus
The deltoid ligament may also rupture or avulse the medical malleoli
The mechanism of injury is usually eversion with some external rotation
- Dupuytren’s:
The fibula fractures higher up, the medial malleolus avulses and the talus is pushed superiority between the tibia and fibula
The mechanism of injury is usually eversion with some external rotation
Screws or wires are often used to reduce and stabilize the ankle
Causes of a Fracture
- A trauma or sudden force which creates more stress than the bone can absorb
With a direct force, a bone breaks at the point of impact - With an indirect force, a bone breaks at a distance from the site of the force
- Overuse or repeated wear which causes cracks in a bone
- Pathologies such as osteoporosis, tumours, local infections or bone cysts
Stages of Healing q
- First stage:
Hematoma forms around the ends of the fractured bone within 72 hours of the initial trauma
A mesh of fibrin forms around the injury site
The ends of the bone die back several millimeters
- Second stage (start the healing process)
There is an inflammatory reaction and a proliferation of osteoblasts at the periosteum
These cells create a fibrocartilaginous bridge between the fragment ends
- Third stage:
A soft callus or point is formed from the mass of proliferating osteoblasts
Osteoclasts are also present, cleaning up the dead bone and debris
As the fibrous, immature bone is gradually calcified, movement at the fracture ends gradually decreases
Union of the fracture ends occurs at about 4 weeks
Repair is incomplete because the callus is merely calcified and not yet mature bone
- Fourth stage:
Consolidation occurs as the immature woven bone is changed into mature lamellar bone
Consolidation is a complete repair because the callus is now ossified
It may be several months before the bone is capable of bearing normal loads
No tenderness at the fracture site
- Fifth stage:
Remodeling of the irregular outer surface and reshaping of the marrow space inside the bone take place through alternating osteoclastic and osteoblastic activity
This process is governed by Wolff’s Law, where a bone responds to mechanical stress by becoming stronger and thicker the more strenuous its function
Medical Treatment of Fractures
A fracture may be treated by closed or open (surgical) reduction
- In a closed reduction:
Manual traction is applied and the bone ends are realigned
The fracture is held in place until fracture repair occurs
- In an open reduction:
The bones or bone fragments are stabilized by devices such as screws, nails, wire, metal plates
Early Complications
Early Complications:
Include torn muscles and tendons, ligament damage, compartment syndromes, nerve injuries, vascular injuries, joint hemarthrosis, bone and soft tissue infections, DVT and problems caused by poorly fitting casts
- Compartment Syndrome;
Can occur in the forearm or leg following a fracture
The swelling that accompanies marked edema, hematoma or inflammation increases the pressure within the fascial compartment
- Nerve Compression:
May be indicated by paresthesia in the tissues under the cast
- Vascular damage:
Untreated vascular damage may be indicated by an increase in observable distal red, black or blue bruising
- Bone & soft tissue infection:
Can occur with external fixation or skeletal traction along the pin tract if proper wound care is not observed
- Deep Vein Thrombosis (DVT):
May occur after a lower limb fracture indicated by pain, an increase in swelling local to the calf and a slight increase in temperature
- Pressure or plaster sore:
Occurs where the cast ischemically compresses the skin over a bony prominence
Client initially feels a local burning pain under the cast
- Cast dermatitis:
May result from poor ventilation and hygiene of the skin under the cast
Allergic reactions to the chemicals present in fibreglass casts are also possible
- Loose cast syndrome:
Occurs when a cast that is to loose rubs on bony prominence, causing skin abrasions
Late Complications
Include delayed union and non-union of the fracture, malunion, myositis ossificans, nerve compression, nerve entrapment, bone necrosis, Volkmann’s ischemic contracture, joint stiffness and disuse atrophy
- Delayed union:
Occurs if the bone does not unite within the expected time frame
May be due to inadequate circulation, insufficient splinting, excessive traction or infection
- Non-union:
Failure of the bone to heal before the repair process finishes
May be caused by an overly large gap between the bone ends wither due to bone destruction, boe less, excessive tractioning, inadequate fracture reduction, bone infection or soft tissue
- Malunion:
Unacceptable joining of the bone ends so that a deformity occurs
May be due to improper alignment of the bone ends when the fracture was reduced or displacement of the bone ends while the limb was casted
- Myositis ossificans:
Bone formation within a muscle, which occurs weeks after the initial trauma
May also result from muscle injury
Heterotopic ossification is bone formation within soft tissue
- Volkmann’s ischemic contracture:
May eventually result after a compartment syndrome or injury to an artery causes ischemic contracture of the affected muscle
While over time the ischemic muscles in the compartment are replaced by inelastic fibrous tissue, the ischemic nerve may be able to recover partial function
- Disuse osteoporosis:
May occur with prolonged immobilization
It is reversible once full use of the limb is regained
Symptom Picture
Immediately after the fracture occurs and before reduction is performed, unnatural mobility and deformity are present at the fracture site
Shock, pain, bleeding, inflammation, swelling, loss of function, muscle splinting and edema are present
Soft tissue is also injured
With stress fractures, the fracture is painful upon compression
- During Immobilization:
Following closed or open reduction, the limb may be casted or otherwise immobilized
Pain in present both locally and possibly at a distance from the fracture
Tissue repair and callus formation are occurring at the fracture site
Adhesions are developing around the injury
Due to immobilization reduced circulation, edema, disuse atrophy and CT contracture occur in the tissues under the cast
HT and TPs are present in compensating structures
Short-term complications may occur
- Immobilization Removed:
Fracture site is healing and remodelling
Decreased tissue health in the tissue that has been under the cast
Adhesions have matured around the injury
With open reduction, scars will be present
HT and TPs are present in muscles crossing the fracture site and in compensating structures
Muscle weakness or disuse atrophy is likely present in muscles crossing the fracture site
Occasionally, a pocket of chronic edema may remain local to the injury
Long-term complications may occur
Health History Questions
- What is your general health?
- When did the fracture occur?
- Do you know the mechanism of injury?
- Do you know what type of fracture?
- What other healthcare practitioners are you seeing for this injury?
- What type of immobilization was used if any?
- If there was an open reduction, were implants such as pins, screws, wires or plates used>
- Are you taking any medication?
- Are you using any supports?
- What symptoms are you currently experiencing?
- Are any early complications present?
- What are your ADL’s?
Observations
- During Immobilization:
Antalgic gait if the fracture is in the lower limb
Affected limb may be casted or an external fixation device may be used
Client may have crutches, a cane or possibly a walking cast
Antalgic posture may be present
Edema is present at the fracture site and distal
Red, black or purple bruising may be visible at the fracture site or distal to it
A pained or medicated facial expression
- Immobilization Removed:
Habituated antalgic gait and posture may be observed
Chronic edema may remain at the fracture site and distal
When a cast is initially removed, the skin that was under is likely dry, scaly or flaky
Disuse atrophy may be visible
Bruising should resolve to brown, yellow and green and then disappear
If surgery was performed, scars will be present
Palpation
- During Immobilization:
Heat and edema are present at the fracture site, although not palpable due to casting
Pain is present local to the fracture site and refers into the nearby tissue
Protective muscle spasm is present in muscles crossing the fracture site
HT and TPs are present in compensating muscles
- Immobilization Removed:
Health of the tissues that were under the cast is assessed in the first few days following cast removal
Conditions may include disuse atrophy, dry or flaky skin, local paresthesia, reduced vasomotor control, signs of inflammation or signs of tissue ischemia
After one week, as tissue health returns, adhesions associated with the fracture site are palpated
HT and TPs are present in the compensating muscles
Testing
- During Immobilization:
Testing of muscles and joints directly involved in the fracture is CI’d
AF ROM of the proximal and distal joints is assessed within pain-free ranges
- Immobilization Removed:
AF ROM of the proximal and distal joints may be slowly and carefully performed to the onset of pain only
PR ROM is performed with care
Overpressure is CI’d before consolidation has occurred
AR strength testing is performed, starting submaximally and increasing gradually to the maximum possible pain-free contraction
Reduction with No casting
If a fracture has been surgically reduced either by external fixation or by pins or plates and where no casting is present, testing follows the above protocol
Contraindications
- During Immobilization:
Limb must not be tractioned before union has occurred
Hot hydrotherapy applications should not be placed distal or immediately proximal to the cast
If the fracture was at the site of a muscle attachment or if there was laceration or severance of a tendon crossing the fracture site, to avoid further soft tissue damage, AF and AR isometrics should only be performed with the physician’s approval
With open reduction, on-site work is avoided until the skin has healed
Local techniques are avoided until the skin is fully healed if the fracture was treated by open reduction and stabilized without a cast
- Immobilization Removed:
Overpressure testing of the involved joints is CI’d before union has occurred
Hydrotherapy temperature extremes are avoided on the tissues that were under the cast
Until tissue health and muscle tone are regained in the muscles that were under the cast, it is CI’d to use deep longitudinal techniques on these muscles
If metal implants such as pins or plates have been used to repair the fracture, avoid local hot hydrotherapy applications
- Treatment
During Immobilization
Do NOT interfere with the healing process
Refer the client to the physician if complications are suspected
Positioning depends on the location of the fracture and the client’s comfort
The limb is elevated and secured so no stress is placed on the fracture site
Hydrotherapy is a cold application to the limb, distal to the cast
Reduce edema proximal to the cast
Maintain local circulation proximal to the injury
Maintain ROM with mid-range pain-free PR ROM to the proximal and distal joints
Vibrations through the cast over the fracture site may help to decrease SNS
Work distal to the cast is restricted
