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BUKOVINIAN STATE Medical university




on the methodical conference of department

of patients’ care and higher

nurse education

“ ” ________ 200_ protocol N __

Chief of department, associate professor I.A. Plesh






nursing in surgery

for 3nd year students

of medical faculty №4,

specialty "nurse business''

Methodical instruction was prepared by:

Assistant Riabyi S.I.

Chernivtsi - 2010


(General notions about mechanical injuries. The main notions of closed trauma of soft tissues: contusion, pull, rupture. The main notions of fractures: clinical signs of closed and open fractures, diagnostic, first aid, next tactics. Purpose and nurse’s task during first aid in case of mechanical injuries. Transport immobilization, main kinds, rules of applying. The main notions about dislocations, the types, diagnostic, first aid).

^ 2. Duration of the class: 2 academic hour.

3. Study aim:

3.1. The student should know:

    • The mechanism of occurrence of fractures;

    • The classification of fractures;

    • Basic (absolute) symptoms of fractures;

    • Relative symptoms;

    • Methods of the first help at fractures;

    • Processes of healing of fractures;

    • Methods of treatment of fractures.

    • Classification of dislocations.

    • Clinical symptoms of dislocation.

    • Methods of dislocation reducing (humerus, femur, lower jaw).

    • Methods and time of immobilization.

^ 3.2. The student should be able:

    • To choose from given history the items of information, which are specify for damage;

    • To make the individual circuit of diagnostic search;

    • To estimate the results of clinical and X-ray inspection;

    • To allocate the basic symptoms of fractures of bones and to prove the diagnosis;

    • To render the first medical aid;

    • To determine medical tactics and capacity of rendering assistance.

    • To diagnose the main symptoms of traumatic dislocation;

    • To choose from anamnesis data, which indicated on mechanism of trauma and on presence of dislocation;

    • To make up individual scheme of diagnostic search;

    • To find of informative objective dislocation symptoms;

    • To prove plan of treatment;

    • To learn the main methods of dislocation reducing.

^ 3.3. The student should master practical skills:

    • applying splints of Cramer;

    • applying splints of Ditherichs;

    • applying tourniquet;

·4. Advice for students:

Fractures and dislocations

Fracture. A fracture is a structural break in the normal continuity of bone. This structural break, and hence fracture, may also occur through cartilage, epiphysis and epiphysal plate.

Dislocation. A dislocation is a total disruption of a joint with no remaining contact between the articular surfaces.

Subluxation. A subluxation is a partial disruption of a joint with partial remaining, but abnormal, contact between the articulating surfaces.

The treatment of fractures and dislocations requires a knowledge of the anatomy, physiology, and biomechanics of the musculoskeletal system. While a fracture represents a disruption in the continuity of a bone, it also represents a major soft tissue injury. The fracture surgeon must be aware of the soft tissue structures adjacent to a fracture site and be alert for neurologic and vascular components of the injury. Since many fractures occur in a setting of violent trauma, full evaluation of each patient is necessary, and the surgeon must be prepared to deal with major injuries in other tissue systems.

^ Mechanism and classification of fractures

Sufficient force applied to a bone results in fracture. A single fracture line is referred to as a simple fracture. When multiple fracture lines and bone fragments exist, the fracture is said to be comminuted. Penetrating injury producing a fracture or fracture fragments protruding through the skin constitute an open fracture. When no such wound is present, the fracture is classified as closed. The distinction is important, since open fractures are likely to be contaminated with pyogenic bacteria. The treatment and prognosis of open fractures are significantly different from those of closed fractures.

The force necessary to produce a fracture may be transmitted to the skeleton in a variety of ways. The direction and rate of application of the force govern to some extent the pattern of the fracture and the associated soft tissue injury. A bending moment applied to bone usually produces a simple transverse or oblique fracture line. When a direct blow or crushing force is applied to bone, a comminuted, open fracture often results accompanied by severe soft tissue injury. Torque force applied to bone produces a spiral or oblique fracture. Compression force applied along the longitudinal axis of the bone results in an impacted fracture at the junction between the metaphysis and diaphysis where the cortex becomes thin. The diaphyseal portion of the bone is usually impacted into the metaphyseal fragment. Traction force applied to a bone may also produce fracture. Vigorous or violent muscle contraction may produce avulsion of portions of bone where major tendons attach.

Fractures in children deserve special consideration. The periosteum is extremely strong in children, and their bones are much more resilient and less brittle than those of adults. Bending moments applied to the bone of a child may result in a «greenstick» fracture, in which there is distraction of the cortex on the convex side and compression of bone on the concave side. There will be angulation at the fracture site but no other displacement. Fractures may occur through the physeal plates and result in future growth disturbance. The parents should accordingly be cautioned. When fracture occurs entirely within the physeal plate and there is no displacement of the epiphysis relative to the metaphysis, anatomic reduction produces good results with no disturbance in growth. When the fracture line extends part way through the physeal plate and then through either the adjacent metaphysis or the epiphysis, accurate anatomic reduction is mandatory in order to avoid future growth disturbance. When compression forces have produced a fracture across the physeal plate, growth disturbance is a likely result.

More subtle trauma may also produce fractures. In the elderly patient with osteoporosis or in the patient with a metabolic bone-wasting disease, the activities of daily living may be sufficient to produce fracture in diseased bone. Such injuries are referred to as pathologic fractures. The most common cause of the pathologic fracture is metastatic carcinoma, in which fracture occurs through a deposit of tumour that has eroded and weakened bone. Healthy bone may fracture with the repetitive application of minor trauma. Such fractures are called fatigue or stress fractures and may be seen in the metatarsals after a long hike or in the tibia or femur in individuals who are vigorously training for athletic activities.

^ Complications of fractures

The early complications of fractures

Local. Sequelae of immediate local complications:

a) skin necrosis and gangrene;

b) Volkmann's ischaemia;

c) gas gangrene;

d) venous thrombosis;

e) visceral complications;

f) joint infection;

g) bone infection;

h) avascular necrosis;

i) fracture blisters.


a) fat embolism;

b) pulmonary embolism;

c) pneumonia;

d) tetanus;

e) delirium tremens.

^ The late complications of fractures


a) joint stiffness;

b) secondary osteoarthritis;

c) bone malunion:

d) delayed and nonunion;

e) growth disturbance;

f) chronic infection;

g) disuse osteoporosis;

h) Sudeck's atrophy;

i) re fracture;

j) muscle myositis ossificans:

k) late tendon rupture;

I) tissue atrophy;

m) tendonitis.


a) renal calculi;

b) accident neurosis.

^ General management of the patient

Pain. All fractures are painful and it should never be forgotten that the immediate responsibility of the physician is to relieve pain. This can be done by local splintage and by analgesics.

Blood loss. All fractures are associated with some blood loss. This may be negligible, but in fractures of the major long bones, the spine and the pelvis it can be considerable. Its loss, however, may not be immediately obvious. For example a patient suffering from a fracture of the pelvis or of the shaft of the femur can lose 2 litres of blood into the surrounding tissues without any obvious swelling or bruising. Such blood loss must be replaced.

Associated injuries. Fractures are commonly associated with other injuries, for example fractures of the pelvis may be associated with injuries to the bladder, or fractures of a long bone shaft with injuries to the blood vessels or nerves in the limb. The possibility of such injuries must always be borne in mind since they may be missed unless they are deliberately sought at the time of the first examination. In the limbs a fracture at one site may disguise the presence of a fracture elsewhere unless it is looked for and excluded.

Tetanus toxoid and antibiotics. In the case of compound fractures tetanus toxoid may have to be administered if the patient is not already fully protected. A broad-spectrum antibiotic which is effective against not only Staphylococcus aureus but also other potential invaders, e.g. anaerobic organisms, should also be administered intravenously as soon as possible and continued in many cases for at least 5 days.

^ Principles of Fracture Treatment

Reduction. Fractures are displaced as a result of either aetiologic trauma or the pull of muscles crossing the fracture site or both. In order to reduce a displaced fracture, the patient must first be relieved of his pain by either local anaesthetic injection or systemic analgesics. It is then necessary to overcome the spasm of those muscles bridging the fracture site, allowing restoration oflength of the fractured member and correction of angulation and rotation. The reduction of a fracture may be accomplished in several ways.

Manipulative reduction can be accomplished by the examiner in fractures of the distal portion of the extremities, in which it is possible to manually overcome the pull of those muscles bridging the fracture site. When the fracture is more proximal (humerus, femur), the muscle spasm is too great for manipulative reduction. In this situation it is necessary to apply steady, prolonged traction. For femoral fractures, this is accomplished by inserting a transverse pin through the proximal tibia or distal femur and placing the patient in bed with continuous pull on the pin. The muscle spasm is gradually overcome, length is restored, and alignment is achieved. It is sometimes acceptable to use skin traction by applying strips of felt to the extremity with adhesive and attaching them to the appropriate amount of weight. Some fractures are not appropriately treated by either manipulative reduction or traction. Such fractures may require surgery and open reduction. When open reduction is required, it is usually accompanied by some form of internal fixation of the fracture. Fractures that are inherently stable and in acceptable alignment require no reduction.

The goal of reduction is restoration of length of the extremity, correction of angulation and rotation, and apposition of the bone ends. Once reduction has been accomplished, fracture healing requires that the bone be immobilised.

Some fractures require excision of a portion of bone rather than reduction and immobilisation. Comminuted fractures of the patella are appropriately treated by excision of the patella and repair of the patellar tendon rather than by attempts at reduction. Fractures of the radial head with severe comminution of the articular surface are best treated by excision of the radial head and replacement with a prosthesis. In both of these situations, excision is performed to avoid a painful irregular articular surface. Prosthetic replacement is also required in fractures of the neck of the femur in elderly patients. In this situation the articular surface is not comminuted. Rather, healing is prolonged in these fractures and the circulation to the femoral head is disrupted. Overall rehabilitation of the elderly patient is significantly shortened by removing the femoral head and replacing it with a prosthetic component.


Impacted fractures with inherent stability may require only a sling or soft dressing for comfort. Fractures requiring operative reduction because of instability or inability to achieve or maintain closed reduction also require internal fixation. Techniques of internal fixation are discussed in the following sections. Most fractures of the extremities can be appropriately treated by plaster immobilisation. While the many advantages of plaster are well recognized, it should be borne in mind that improperly applied plaster may create more injury than it treats. The surgeon should be familiar with proper plaster technique. The cast should be appropriately padded and smooth on its inner surface and should not be constricting.

Since a bone participates in joint motion at both ends, it is necessary to immobilize the joint above and below the fracture site. Thus, forearm fractures require long-arm plaster immobilizing both the wrist and the elbow. Plaster maintains the reduction that has been achieved, provides rigid immobility, and relieves pain. A well-reduced, rigidly immobilized fracture should not require a significant amount of analgesic. Swelling occurs at a fracture site and, since a plaster case is rigid, increasing pressure within the cast will be heralded by increasing pain in the extremity and progressive numbness and diminished circulation of the digits. All fractured patients are cautioned to watch for these signs and should be examined the following day for assessment of the cast and the neurovascular status.

Skeletal traction is used not only to achieve reduction of fractures but also to maintain relative immobilisation of the fracture. The injured part is placed at rest either on an appropriate splint or on the bed while traction is being applied. Traction is continued until the fracture is stable enough to allow cast or brace immobilisation.

^ Open fractures

An open fracture should be treated as an emergency. Surgical debridement of the wound is required. Since open fractures are usually die result of more violent trauma, other major injuries may be present. When the patient has been fully evaluated and his condition is stable,

debridement is performed in the operating room as a formal surgical procedure. All devitalised tissue is removed, with special attention given to devitalized muscle. Macerated skin edges are debrided and the wound thoroughly irrigated with saline containing antibiotics. Bone ends, which may have embedded dirt, paint, or other material, are debrided by sharp dissection with care to preserve nerves, vessels, and tendons. Repair of nerves and tendons in an open fracture wound is rarely indicated. Vessels require repair if the circulation to the extremity is in jeopardy. When debridement is completed, a decision must be made about stabilisation of the fracture. Although some unstable fractures may require internal fixation devices, their immediate use is generally not desirable in a contaminated wound. Skeletal traction with a transverse pin placed at some distance from the fracture, cast immobilisation with a window overlying the wound, or delayed internal fixation may be utilised. The wound should be dressed open. Even in minor open fractures, we find little to recommend the practice of immediate closure. The morbidity from delayed closure at 3 to 5 days following debridement is minimal compared with the consequences of infection. Intravenous antibiotics are administered during the first several days following injury. The wound should be cultured at the time of delayed closure. When extensive skin loss has occurred, split-thickness grafting or pedicle flap grafting may be required.

^ External skeletal fixation

As an alternative form of splintage to plaster of Paris. Steinmann or other pins may be passed through the bone proximal and distal to a fracture and the pins then connected to a special metal frame. The frames may be in one or two planes and the pins may be inserted from one side (unilateral) or transfix the bone (bilateral).

Elizarov's method (fixation by metal rings). This method of fixation is particularly useful if the fracture is compound so that access is required to a wound. It provides very rigid fixation, is easily adjustable and is light. The disadvantage is the necessity of using pins to transfix the bone: these expose the bone to the risk of infection and are difficult to pass in other than subcutaneous bones such as the tibia. In practice therefore the method is used mainly for compound fractures of the tibia.

^ Internal splints

Methods of internal fixation by operation. A variety of devices is available to splint fractures internally. The fracture fragments may be wired or screwed together or united by one, or rarely two, onlay plates screwed to the bone or by a nail passed down the medullary canal). Spedal devices are available for certain fractures such as the pin and plate used for fractures of the proximal femur.

If it is felt that a fracture fragment cannot survive usefully, a decision which is sometimes made, for example, in connection with the head of the femur after fractures of the femoral neck the bone may be removed and replaced with a prosthesis

It is argued that, if internal fixation is to be used at all, it should be as strong and as rigid as possible since this allows the joints of the limb to be mobilised early, free of external splints.

Strong, rigid implants have been designed for this purpose and techniques have been developed for enhancing the quality of Fixation by applying the implant in such a way as to compress the fracture site. Internal fixation is technically difficult in comminuted fractures and in fractures through cancellous bone.

Fracture Healing. Following fracture, a haematoma rapidly develops about the bone ends. As pressure from the haematoma increases, interstitial oedema develops in the adjacent soft tissues and there is some degree of venous congestion. Leukocytes invade the haematoma. producing a sterile traumatic inflammatory reaction. Primitive mesenchymal cells within the periosteum and the medullary canal on either side of the fracture line differentiate into primitive osteoblasts and proliferate. These changes are appreciated microscopically at 48 to 72 hours. By this time there is also the development of early granulation tissue about the periphery of the haematoma. This granulation tissue contains other primitive cells from adjacent fascial planes, which also differentiate into osteoblasts.

This proliferation of osteogenic cells and the early primitive bone that they produce constitute the «fracture callus». If the fracture fragments are in apposition and rigidly immobilised, bone growth progresses until the two fracture fragments are united by a network of primitive new bone. As this bone matures, constant remodeling occurs and the trabecuiae become oriented to the long axis of the bone.

If there is motion at the fracture site, the primitive mesenchymal cells may differentiate intochondroblasts. If the motion is not excessive or if the fracture site is subsequently rigidly immobilized, this cartilaginous tissue calcifies and is gradually replaced by new bone by the process of endochondral ossification. When distraction of the fracture fragments is present or when muscle is interposed between the fracture fragments, dense fibrous tissue develops between the fracture ends. Again, if rigid immobilisation is achieved this fibrous tissue may ultimately be replaced by bone. If in the latter two situations rigid immobilisation is not achieved, nonunion results. When motion is persistent at the fracture site, the differentiation of cartilage progresses. A cleft develops between the layers of cartilage covering each fracture fragment, and cells at the periphery of this cleft differentiate into synovial cells, producing a pseudoarthrosis. If distraction at the fracture site is allowed to persist, a dense fibrous scar develops between the bone ends, producing a fibrous nonunion. Compression of a fracture enhances fracture healing. This principle is used in treatment Fractures of the tibia) shaft may be treated in a walking cast, allowing the patient to bear weight across the fracture she. The compression principle may be used with internal fixation devices. Plates have been designed owing rigid internal fixation of long bone fractures, with compression exerted at the fracture site. Fracture healing is also affected by the available blood supply to bone involved. In general, cancellous bone at the metaphyseal ends of long bones has a richer blood supply than the cliaphysis. Fractures in these areas heal more rapidly than shaft fractures. Long bones with more overlying muscle have a greater blood supply. The shaft of the femur, enveloped by muscle, has a better blood supply than the distal tibia, which is subcutaneous third of its circumference. Fractures of the tibial traditionally are slower to heal.

Dislocation of the Shoulder. Dislocations most frequently occur in the shoulder joint due to anatomical peculiarities of this joint. The most vivid sign of dislocation of the shoulder is the forced position of the limb. During dislocation of the shoulder the patient holds the arm flexed in the. elbow and abducted from the body. Compared with the intact side the external appearance of the joint is sharply altered; in the region of the joint the shoulder is not round but angular, below the protruding acromion there is a hollow, and the head of the humerus bulges the soft tissue in the subclavicular region. Oedema, observed during the first days, hemorrhage and sharp pain during movement in the region of the joint may disappear, while in old dislocations only a restriction of movement remains.

First-aid in dislocations of the shoulder consists in putting the arm in a sling and delivering the patient to a hospital. The only treatment of a traumatic dislocation is reduction which is performed by a physician.

After reduction of a dislocation a bandage is applied to the extremity for a period of 7 - 10 days, massage and movements in thejoint beginning on the 6th or 7th day to quicken the resorption of the effused blood and to strengthen thejoint capsule.

Since a dislocation is best reduced immediately after it has been sustained, it is desirable that the dislocation should be reduced as soon as possible, especially since the reduction brings the patient relief by diminishing the pains.

Reduction on the second day and tales is vendeved difficult by gveat muscular tension, especially in patients with well-developed muscles, and is therefore performed under anaesthesia. Reduction of a dislocation after 15 days is rarely possible without a surgical operation. If the dislocation is reduced in good time, the functions of the joint are in the overwhelming majority of cases fully restored, whereas surgical reduction results in restricted mobility in the joint and limits the patient's ability to work.

The simplest method of reducing a dislocation of the shoulder is the Janelidze's method. The patient is given an injection of 1 ml. of a 1 %. solution of morphine, is placed on a table (on his affected side) with the shoulder joint extending beyond the end of the table, the dislocated arm hanging freely. Some 10 - 15 minutes later, when the muscles of the shoulder girdle have relaxed, it is enough to press on the internal surface of the forearm bent at a right angle in the elbow joint and held by the wrist for the head of the humerus to slip into the articular fossa. The pressure must be exerted sufficiently strongly, but not sharply.

Another method used in reducing dislocations of the shoulder is the Kocher's method. This method consists of four parts:

First Part - The patient lies on a couch or sits in a chair. The assistant holds the patient by standing behind him and placing the hands on the patient below the clavicles.

The physician takes hold of the patient's upper arm and wrist and, Hexing the arm in the elbow, presses it against the chest and downward.

Second Part - The physician abducts the flexed forearm and at this time the dislocation is usually reduced.

Third Part - If no reduction has been effected, the physician, continuing to abduct the arm, raises it by the elbow to the level of the shoulder.

Fourth Part - The forearm is rapidly abducted to the chest so that the hand comes to rest above the clavicle on the opposite side. If the reduction fails, these movements are repeated in the same sequence.

The assistant holds the patient throughout the reduction and prevents his attempts to rise.

^ 5. Study questions:

  1. Definitions of fractures. Classification of fractures. Mechanisms of occurrence.

  2. Kinds of repair of bone’s tissues.

  3. A first aid at fractures.

  4. Methods of conservative and surgical treatment of fractures.

  5. Acare of patients with fractures.

  6. Definition of dislocations.

  7. Classification of dislocations.

  8. Methods of conservative and surgical treatment of dislocations.

  9. Kinds and engineering of applying of plaster bandages.

^ 6. The literature:

6.1. Basic :

  1. Textbook of basic nursing / Caroline Bunker Rosdahl. – J. B.Lippincott Company. Philadelphia. - 6th ed. –1995.– 1518 p.

  2. Fundamentals of nursing /Taylor Mary Carol, Mary Carol, Lillis Carol– J. B.Lippincott Company. Philadelphia. - 1989.– 1356 p.

6.2. Аdditional:

  1. Gostishev V.K. "Guidance to practical employments on general surgery". M., "Medicine" - 1987.

  2. P. of Brown. Operating block. Operating brigade. – Kharkov, 1997. – with. 1-32.

Methodical instruction was prepared by

Assistant Riabyi S.I.

A review is positive, associate professor Chomko O.J.

Materials of control of base level of preparation of students: tests.

Multiple Choices.

Choose the correct answer/statement:

  1. As to localization, the following types of the fractures are identified:

    1. Epiphysial, diaphyseal, metaphyseal.

    2. Subperiosteal, epiphiseal, methaphyseal.

    3. Epiphyseolis, diaphyseal, methaphyseal.

    4. Metaphyseal, subperiosteal, epiphiseolysis.

    5. Intrajoint, diaphyseal, methaphyseal.

  2. The local reasons of delayed-union of fracture are:

    1. Interposition of the soft tissues, beriberi;

    2. Mineral violation, beriberi;

    3. Violation of blood supply of bone’s fragments, mineral violation;

    4. Correct of bone’s fragments displacement, beriberi;

    5. Interposition of the soft tissues, violation of blood supply of bone’s fragments.

  3. What kinds of embolism possible during fracture?

    1. Air embolism.

    2. Fat embolism.

    3. Clot-embolism.

    4. Embolism of amniotic fluid.

  4. Bony crepitus and abnormal mobility are absent in cases of fracture (by localization):

    1. Epiphysial;

    2. Diaphyseal;

    3. Metaphyseal;

    4. Subperiostal;

    5. Periostal.

  5. The method of transport immobilization during fracture of femur is:

    1. Applying Diterich’s splint;

    2. Applying Cramer's splint;

    3. Applying plaster bandage;

    4. Applying compression osteosynthesis;

    5. Applying distraction osteosynthesis.

Real-life situations to be solved:

  1. Patient N., 54 years old, admit to the traumatic department with diagnosis: Intra-joint fracture of humerus bone’s column. What is the fracture?

  2. Patient B., 36 years old, admits to the urgent hospital with diagnosis: Closed comminuted fracture of medial third of left humerus. Patient’s complains: numbness, swelling and blue color of skin of left hand. What complication has this patient? What kinds of treatment indicated in this case?

Answers to the Self-Assessment:

– A.

– E.

– B.

– C.

– A.

– Epiphyseal.

– Interposition of soft tissues with compression of humerus artery. Treatment – urgent operation.


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