FRACTURE

Jumat, 11 Juni 2010

A. Understanding
Is the dissolution of continuity of bone tissue which is generally caused by burden exceeding bone strength.(Mansjoer, Arif, et al, 2000).
Continuity of a bone fracture is caused by damage to the external pressure which comes greater than can be absorbed by the bone. (Luckman and Sorensen's Medical Surgical Nursing. Linda Juall C)
Is the dissolution of bone fracture and is determined in accordance kontuinitas type and extent, fracture occurs when bone is subjected to greater stress than can diabsorbsinya (Smelter & Bare, 2002).
Fractures are broken bones, usually caused by trauma or physical exertion (Price, 1995).
Bone fracture is a break of continuity, most of the fractures resulting from trauma, multiple fractures secondary to disease processes such as osteoporosis, which causes a pathological fracture (Barrett and Bryant, 1990).
A fracture is a break of continuity of bone characterized by pain, swelling, deformity, impaired function, shortening, and krepitasi (Doenges, 2000).

B. Etiology
1. Direct violence
Direct violence causing a fracture at the point of violence. Such fractures are so often open fracture with transverse or oblique fracture line.
2. Indirect violence
Violence is not the direct cause fracture far away from the scene of the violence. The fracture usually is the weakest part in the delivery vector path of violence.
3. Violence caused by muscle pull
Fractures caused by muscle pull is extremely rare. Strength can be twiddling, fracturing and emphasis, the combination of the three, and withdrawal. (Oswari E, 1993)

Factors that affect fracture
1. Extrinsic Factors
The existence of external pressure which reacts in the bone depends on large, time and direction of pressure that can cause a fracture.
2. Intrinsic factor
Some of the most important properties of bone that determine the emergence of resistance to fracture, such as absorption capacity of the pressure, elasticity, fatigue, and bone density or hardness. (Ignatavicius, Donna D, 1995)
Types of Fractures

Based on the fracture properties
1. Closed fracture
If fagmen broken bones are not visible from the outside, In the book Capita Selekta Medicine in 2000, disclosed that a closed fracture is a fracture in which there was no correlation between bone fragments with the outside world. Other opinions that closed fracture is a fracture of the net (because the skin is intact or not torn) without complications (Henderson, M. A, 1992).
2. Open fracture
If the broken bone fragments visible from the outside

Based on complete / incomplete fracture
1. Complete fracture: Broken bone in the midline and usually experience a shift to shift from its normal position)
2. Incomplete fracture: fracture occurs only in a portion of the center line of the bone
Based on the form of broken lines and the relationship with the mechanism trauma
Transverse fracture, transverse direction and is the result of trauma angulasi / direct
3. Oblique fractures; Direction broken lines forming an angle to the axis of the bone and is the result of direct trauma
4. Spiral fracture, spiral fracture line direction and consequences of the trauma rotation
5. Compression fractures; suffered compression fractures where the bone (occurs in the spine)
6. Fractures komunitif; fracture with the bone broken into multiple fragments
Depressed fracture
7. Fractures with fragments driven into the (often occurs in the skull and facial bones).
8. Pathological fractures, fractures that occurred in the area of diseased bone (bone cysts, tumors, bone metastases).
9. Avulsion fracture; interested in bone fragments by a ligament or tendon on juxtaposition

Based on the number of broken lines.
1. Komunitif fracture: fracture in which more than one fracture line and interconnected.
2. Segmental fracture: fracture in which the fracture line is more than one but not related.
3. Multiple fractures: fractures where the fracture line is more than one but not on the same bone.

Based on the displacement of bone fragments.
1. Fractures Undisplaced (not shifted): complete broken lines are not shifted ttetapi both fragments and intact periosteum nasih.
2. Displaced fractures (shift): the shift of bone fragments which are also referred to the location of fragments, consisting of:
a. Longitudinam cum ad Dislokai contractionum (axis shift and overlapping).
b. Ad axim dislocation (shift that makes an angle).
c. Pilate ad dislocation (shift in where the two fragments away from each other).
d. Fatigue fractures: fractures caused by repeated pressure.
e. Pathological fracture: fracture a bone due to pathologic processes.

In a closed fracture there is a separate classification is based on the circumstances surrounding soft tissue trauma, namely:
1. Level 0: normal fracture with little or no ceddera surrounding soft tissue.
2. Level 1: fracture with superficial abrasion or bruise the skin and subcutaneous tissue.
3. Level 2: more severe fractures with soft tissue contusions and swelling of the inside.
4. Level 3: severe injury with soft tissue damage to the real threat ddan kompartement syndrome.
(Henderson, MA, 1992, Black, JM, 1995, Ignatavicius, Donna D, 1995, Mansjoer, Arif, et al, 2000, Price, Sylvia A, 1995)

C. Pathophysiology


Retention of muscle contractions that push other factors not
Strong direct



Psychological

Traumatic tissue damage skin integrity

Wound contamination, the external environment

Stimulus for release
Substance bradykinin, histamine, prostaglandin
Serotin toward the thalamus

Painful

Restriction of movement

Minimal activity

Self care deficit


D. Physiology of Bone Healing
Able to regenerate bone tissue is the same as another. Fracture stimulate the body to heal the broken bone with new bone forming path between the tip of the fracture. New bone is formed by the activity of bone cells. There are five stages of healing of bone, namely:
1. Stage One-formation of hematoma
Formed blood vessels tear and hematoma around the fracture area. Blood cells to form fibrin in order to protect the damaged bone and as a place to grow new capillaries and fibroblasts. This stage lasts 24-48 hours and the bleeding stopped completely.
2. Stage Two-Cell Proliferation
At the stadium initerjadi proliferation and differentiation of cells into fibro cartilage derived from the periosteum, `endosteum, and bone marrow that have undergone trauma. Cells that are experiencing this proliferation continues into the deeper layers and there the regenerate osteoblasts and osteogenesis process occurs. In a few days forming new bone that combines the two fragments of a broken bone. This phase lasted for eight hours after fracture to complete, depending frakturnya.
3. Stage Three-Kallus Formation
Growing cells have the potential osteogenik kondrogenik and, if given the right circumstances, the cell will begin to form bone and cartilage. This cell population is affected by the activities of osteoblasts and begin to function with absorbing osteoklast bone cells that die. Thick mass of cells with immature bone and cartilage, forming kallus or bandage on endosteal and periosteal surfaces. While the immature bone (woven bone) become more dense so that the movement at the site of fracture is reduced at 4 weeks after the fracture united.
4. Four-Consolidation Stage
When the activity of osteoclast and osteoblasts continues, webbing transformed into lamellar bone. This system is now fairly rigid and allows osteoclast break through the rubble at the fracture line, and right behind osteoclast fill remaining gaps between fragments with new bone. This is a slow process and may take several months before the bones strong to carry a normal load.
5. Stage Five-remodeling
Fracture has been bridged by a dense cuff of bone. Over the next few months or years, this rough welding reshaped by the process of bone formation resorbsi and continuous. Thicker lamellae diletidakkan places emphasis on the higher, unwanted wall removed, the marrow cavity is formed, and eventually formed a structure similar to normal. (Black, JM, et al, 1993 and Apley, A. Graham, 1993)

E. Complication
1. Early Complications
a. Damage Arteries
Rupture of an artery due to trauma can be characterized by the absence of pulse, CRT decreased, cyanosis of the distal part, the width of hematoma, and cold in the extremities caused by splinting emergency action, a change in position on the sick, the act of reduction, and surgery.

b. Kompartement Syndrome
Kompartement Syndrome is a serious complication that occurs because terjebaknya muscles, bones, nerves, and blood vessels in scar tissue. This is caused by edema or hemorrhage that put pressure on muscles, nerves, and blood vessels. Moreover, because of pressure from outside, such as gypsum and embebatan are too strong.
c. Fat embolism Syndrome
Fat embolism Syndrome (FES) is a serious complication that often occurs in cases of long bone fractures. FES occurs because fat cells produce a yellow bone marrow into the bloodstream and cause low blood oxygen levels are characterized by breathing problems, tachykardi, hypertension, tachypnea, fever.
d. Infection
Immune system is damaged when there is trauma to the tissue. In orthopedic trauma infection begins in the skin (superficial) and went inside. This usually occurs in cases of open fracture, but can also be due to the use of other materials such as surgical pins and plates.
e. Avaskuler necrosis
Avaskuler necrosis (AVN) occurs because blood flow to the bone is damaged or disrupted that can cause bone necrosis and beginning with the Volkman's ischemia.
f. Shock
Shock due to blood loss and increased capillary permeability which may lead to decreased oxygenation. This usually occurs in a fracture.
2. Complications in the Old Time
a. Delayed Union
Delayed fracture of consolidating the Union is a failure in accordance with the time needed to connect the bone. This caused karenn \ supai a decrease of blood to the bone.
b. Nonunion
Nonunion fracture is a failure berkkonsolidasi and produce a complete connection, strong and stable after 6-9 months. Nonunion was marked by the excessive movement on the side of the fracture which forms a false joint or pseudoarthrosis. This is also caused by a lack of blood flow.
c. Malunion
Malunion is the healing of bone marked by increasing levels of power and change shape (deformity). Malunion done with surgery and reimobilisasi good. (Black, JM, et al, 1993)
F. Nursing
1. Assessment
Assessment is the first step and foundation in the nursing process, for it required precision and accuracy of clients' problems and can give direction to nursing actions. Nursing process is very bergantuang success at this point. This stage is divided into:
a. Complaints generally at main complaints in cases of fracture is pain. Pain can be acute or chronic depending and duration of attack. Usually used:
1) Provoking Incident: whether there are events that become a factor that precipitates the pain.
2) Quality of Pain: What kind of pain that is perceived or portrayed clients. Would like a burning, throbbing, or stabbing.
3) Region: radiation, relief: whether the pain may subside, or if the pain spreads, and where the pain occurs.
4) Severity (scale) of Pain: how much pain that is felt by the client, can be based on the pain scale or clients to explain how much pain affected ability to function.
5) Time: how long the pain lasted, when, if gets worse at night or during the day. (Ignatavicius, Donna D, 1995)
b. Now Illness History

Data collection was performed to determine the cause of the fracture, which will help in creating a plan of action against the client. This can be a chronology of the occurrence of the disease so that later can be determined forces that occur and where the affected body part. In addition, by knowing the mechanism of injury accidents can be known to other accidents (Ignatavicius, Donna D, 1995).
c. Formerly Disease History
In this study found possible causes of fracture and bone giving instructions how long it will connect. Certain diseases such as bone cancer and Paget's disease that cause pathological fractures are often difficult to connect. In addition, diabetes with a leg wound at risk sanagt occurrence of acute or chronic osteomyelitis and diabetes also inhibits bone healing process (Ignatavicius, Donna D, 1995).
d. Family Disease History
Family illnesses associated with bone disease is one factor predisposing the occurrence of fractures, such as diabetes, osteoporosis is common in several breeds, and bone cancer tend to be genetically derived (Ignatavicius, Donna D, 1995).
e. Psychosocial History
An emotional response to the client's illness and the role of clients in family and society and the response or influence in his daily life both in family and in society (Ignatavicius, Donna D, 1995)
f. Pattern Nutrition and Metabolism
In the client fractures should consume nutrients exceeds their daily needs such as calcium, iron, protein, vit. C and others to help the healing process of bones. Evaluation of clients' nutritional patterns can help determine the cause of musculoskeletal problems and anticipate complications from inadequate nutrition, especially calcium or protein and less exposure to sunlight is a predisposing factor in musculoskeletal problems, especially in the elderly. In addition, obesity also inhibits degeneration and mobility client.
g. Activity Pattern
Because the incidence of pain, limitation of motion, then all forms of activity to be reduced and the needs of clients need a lot of clients assisted by others. Another thing that needs to be studied is a form of client activity, especially the work the client. Because there are several forms of employment are at risk for fracture compared to another job (Ignatavicius, Donna D, 1995).
h. Pattern Perception and Self Concept
The effects on fracture of the client will ketidakutan disability arising due to frakturnya, anxiety, sense of inability to perform activities optimally, and the sight of him is wrong (body image disturbance) (Ignatavicius, Donna D, 1995).
i. Sensory and Cognitive Pattern
In the client fracture rabanya power reduced, especially on the distal fracture, while in other senses do not arise in the cognitive gangguan.begitu also not susceptible to interference. In addition, the resulting pain caused by fractures (Ignatavicius, Donna D, 1995).
j. Stress Response Patterns
Fractures occur at the client anxiety about the state itself, which arises ketidakutan disability on self and body functions. Coping mechanism that a client can not be done effectively (Ignatavicius, Donna D, 1995).
k. Physical examination
Divided into two general examination (generalized status) to obtain general and local examination (lokalis). This needs to be able to implement a total care because there is a trend which shows regional specialization only a narrower but deeper.
1) Overview
general situation studied in head to toe, from head to toe.
2) Local Condition
This situation must be taken into account particularly the proximal and distal neurovaskuler status. Examination of the musculoskeletal system are:
a) Look (inspection)
Consider what can be seen, among others:
(1) Cictriks (scar tissue either natural or artificial, such as the former operations).
(2) Cape au lait spots (birth marks).
(3) fistulae.
(4) Color reddish or bluish (livide) or hyperpigmentasi.
(5) The lump, swelling, or basin with things that are not normal (abnormal).
(6) Position and shape of the extremities (deformity)
(7) Position of the road (gait, when entered into the examination room)
b) Feel (palpation)
At the time of going to palpation, the patient improved first position from the neutral position (anatomical position). Basically this is an examination that provides information in both directions, both examiner and the client. To note are:
(1) Changes in temperature around the trauma (warm) and moisture.
(2) If there is any swelling, whether there is a fluctuation or edema, especially around the joints.
(3) Tender (tenderness), krepitasi, note the location of abnormalities (1 / 3 proximal, middle, or distal).
(4) Muscles: tonus on the relaxation time or konttraksi, there are lumps on the surface or attached to the bone. It also examined the status of neurovaskuler. If there are lumps, bumps need to describe the nature of the surface, consistency, association or movement towards the surface, pain or not, and size.


c) Move (pergeraka especially the range of motion)
After checking the feel and then forwarded to move the extremities, and note whether there is a complaint of pain on movement. Recording range of motion is necessary, in order to evaluate the situation before and after. Movement joints are recorded with the size of degrees, from each direction of movement from the point 0 (neutral position) or in metric sizes. This check determines whether there is disruption of motion (mobility) or not. The movement of the visits is active and passive movements. (Reksoprodjo, Soelarto, 1995)
2. Diagnostic Examination
a. Radiological examination.
As a supporter, an important examination is the "imaging" using X-ray (x-ray). To obtain three-dimensional picture of the situation and the difficult position of the bone, then needed two projections of the AP or PA and lateral. In some circumstances additional projection is needed (special) there are indications to show pathologi sought because of the superposition. Be aware that the demand for x-ray should be on the basis of indications of usability investigation and the results are read in accordance with the request. It should be read in the x-ray:
1) The image of soft tissue.
2) Thin cortical thickness as a result of reaction of the periosteum or biomechanics or rotation as well.
3) whether there is any rare Trobukulasi fraction.
4) Sela hinge joints and the form of architecture.
Apart from a plain x-ray photograph (plane x-ray) may need particular techniques such as:
1) Tomography: describes not just one structure but other enclosed structures that are difficult visualized. In this case found that the complex structural damage on a structure in which not only but also experienced it on other structures.
2) Myelografi: describe the branches of spinal nerves and blood vessels in the vertebrae bones that were damaged by trauma.
3) Arthrografi: describes the tissues damaged by Ruda binding force.
4) Computed Tomography-Scanning: describes the transversal pieces of bone which was found a damaged bone structure.
b. Laboratory Investigation
1) Serum Calcium and Serum Phosphorus increased in the stage of bone healing.
2) Alkaline Phosphates elevated in bone damage and showed activity in forming bone osteoblastik.
3) muscle enzymes such as creatinine kinase, Lactate Dehydrogenase (LDH-5), aspartate amino transferase (AST), Aldolase which increased at the stage of healing bone.
c. Examination etc.
1) The examination of microorganism culture and sensitivity test: obtained microorganism causing the infection.
2) Biopsy of bone and muscle: in essence is the same examination with the examination of the above but more dindikasikan if there is infection.
3) Elektromyografi: there is damage caused by fracture of nerve conduction.
4) Arthroscopy: connective tissue was found damaged or torn due to excessive trauma.
5) MRI: describe all the damage caused by a fracture. (Ignatavicius, Donna D, 1995)
3. Nursing Diagnosis
a. Acute pain b / d traumatic neural network
b. Anxiety b / d of the threat to the self concept / self image


G. REFERENCES
Apley, A. Graham , Buku Ajar Ortopedi dan Fraktur Sistem Apley, Widya Medika, Jakarta, 1995.

Black, J.M, et al, Luckman and Sorensen’s Medikal Nursing : A Nursing Process Approach, 4 th Edition, W.B. Saunder Company, 1995.

Carpenito, Lynda Juall, Rencana Asuhan dan Dokumentasi Keperawatan, EGC, Jakarta, 1999.

Dudley, Hugh AF, Ilmu Bedah Gawat Darurat, Edisi II, FKUGM, 1986.

Departemen Kesehatan Republik Indonesia, Sistem Kesehatan Nasional, Jakarta, 1991.

Henderson, M.A, Ilmu Bedah untuk Perawat, Yayasan Essentia Medika, Yogyakarta, 1992.

Hudak and Gallo, Keperawatan Kritis, Volume I EGC, Jakarta, 1994.

Ignatavicius, Donna D, Medical Surgical Nursing : A Nursing Process Approach, W.B. Saunder Company, 1995.

Keliat, Budi Anna, Proses Perawatan, EGC, Jakarta, 1994.

Long, Barbara C, Perawatan Medikal Bedah, Edisi 3 EGC, Jakarta, 1996.

Oswari, E, Bedah dan Perawatannya, PT Gramedia Pustaka Utama, Jakarta, 1993.

Price, Evelyn C, Anatomi dan Fisiologi Untuk Paramedis, Gramedia, Jakarta 1997.

Reksoprodjo, Soelarto, Kumpulan Kuliah Ilmu Bedah FKUI/RSCM, Binarupa Aksara, Jakarta, 1995.

Tucker, Susan Martin, Standar Perawatan Pasien, EGC, Jakarta, 1998.