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What is a Fracture? A bone fracture is a break in a bone. Fractures are common.

Most people fracture at least one bone during their lifetime. The severity of fractures Increase with age. Children's bones are more flexible and less likely to break. Falls or other accidents that do not harm children can cause complete fractures in older adults. Older adults suffer from fractures more than children because their bones are more likely to be brittle. Symptoms of a fracture The most common symptoms are: A. swelling around the injured area B. loss of function in the injured area C. bruising around the injured area D. deformity of a limb Types of Fractures There are many types of fractures: simple, stress, comminuted, impacted, compound, complete and incomplete. Simple: the bone is broken but the skin is not lacerated Comminuted: Bone fragments into several pieces Compound: Bone protrudes through the skin. Also called an open fracture. Complete: Bone snaps completely into two or more pieces. Incomplete: Bone cracks but doesn't separate

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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 brachialartery and nerves to the fracture site.  Radius and ulna  Femur (often associated with child abuse)  Epiphyseal plates (potential for growth deformity)

Clinical Manifestations 1) Assess for pain, pulse, pallor, paresthesia, and paralysis are seen with all types of fractures. 2)Other characteristic findings include deformity, swelling, bruising, muscle spasms, tenderness, pain, impaired sensation, loss of function, abnormality, , shock or refusal to walk (in small children).

NURSING MANAGEMENT 1. Provide emergency management when situation warrants, for a new fracture.  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. 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. .3. Maintain skin integrity and prevent breakdown. Institute appropriate measures for cast and appliance care SURGICAL MANAGEMENT Setting of bone through surgery. When surgery is needed, the procedure is called an open reduction. The doctor will give you local or general anesthesia. (General anesthesia will put you to sleep.) During the surgical procedure, the doctor may insert a rod, pin, plate, or screw into the injury to hold the bone in place. Advantages of surgery include: early mobility of injured bone and some use of the injured bone within weeks rather than months. After the bone is realigned, medication and rehabilitation will help the recovery process. Medication is used to lessen the pain. Rehabilitation prevents stiffness. Rehabilitation involves light movement of the tissues surrounding the injury. It helps increase blood flow which will aid the healing process.

BONE HEALING PROCESS

Phases of fracture healing


There are three major phases of fracture healing, two of which can be further sub-divided to make a total of six phases; 1. Reactive Phase i. Fracture and inflammatory phase ii. Granulation tissue formation 2. Reparative Phase iii. Cartilage Callus formation iv. Lamellar bone deposition 3. Remodeling Phase v. Remodeling to original bone contour

REACTIVE After fracture, the first change seen by light and electron microscopy is the presence of blood cells within the tissues which are adjacent to the injury site. Soon after fracture, the blood vessels constrict, stopping any further bleeding. Within a few hours after fracture, the extravascular blood cells form a blood clot, known as a hematoma. All of the cells within the blood clot degenerate and die. Some of the cells outside of the blood clot, but adjacent to the injury site, also degenerate and die.[3] Within this same area, the fibroblasts survive and replicate. They form a loose aggregate of cells, interspersed with small blood vessels, known as granulation tissue.

REPAIRATIVE Days after fracture, the cells of the periosteum replicate and transform. The periosteal cells proximal to the fracture gap develop into chondroblasts which form hyaline cartilage. The periosteal cells distal to the fracture gap develop into osteoblasts which form woven bone. The fibroblasts within the granulation tissue develop into chondroblasts which also form hyaline cartilage. These two new tissues grow in size until they unite with their counterparts from other parts of the fracture. These processes culminate in a new mass of heterogenous tissue which is known as the fracture callus. Eventually, the fracture gap is bridged by the hyaline cartilage and woven bone, restoring some of its original strength.The next phase is the replacement of the hyaline cartilage and woven bone with lamellar bone. The replacement process is known as endochondral ossification with respect to the hyaline cartilage and bony substitution with respect to the woven bone. Substitution of the woven bone with lamellar bone precedes the substitution of the hyaline cartilage with lamellar bone. The lamellar bone begins forming soon after the collagen matrix of either tissue becomes mineralized. At this point, the mineralized matrix is penetrated by channels, each containing a microvessel and numerous osteoblasts. The osteoblasts form new lamellar bone upon the recently exposed surface of the mineralized matrix. This new lamellar bone is in the form of trabecular bone. Eventually, all of the woven bone and cartilage of the original fracture callus is replaced by trabecular bone, restoring most of the bone's original strength.

Remodeling
The remodeling process substitutes the trabecular bone with compact bone. The trabecular bone is first resorbed by osteoclasts, creating a shallow resorption pit known as a "Howship's lacuna". Then osteoblasts deposit compact bone within the resorption pit. Eventually, the fracture callus is remodelled into a new shape which closely duplicates the bone's original shape and strength. The remodeling phase takes 3 to 5 years depending on factors such as age or general condition.

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