15. Fractures

Fractures

A fracture is a break or disruption in the continuity of a bone, usually due to trauma or weakened bone (e.g., osteoporosis, cancer).

Pathophysiology of fracture healing

1. Hematoma formation (24–72 hrs)

2. Fibrocartilaginous callus formation (2–3 weeks)

3. Bony callus formation (3–6 weeks)

4. Bone remodeling (months to years)

⚠ Poor healing may result in malunion, nonunion, or infection (especially in open fractures).

Classification of Fractures

Closed (simple)	Bone breaks but does not pierce the skin
Open (compound)	Bone breaks and pierces the skin → Increase risk of infection
Transverse	Straight horizontal break across the bone
Oblique	Slanted break across the bone
Spiral	Twisting force causes a spiral-shaped break (common in child abuse)
Comminuted	Bone is shattered into several pieces
Greenstick	Incomplete break on one side of bone (common in children)
Impacted	One part of bone is driven into another
Pathologic	Occurs in weakened bone (e.g., osteoporosis, tumors)
Stress	Small crack from repeated stress (e.g., athletes, runners)

Signs and Symptoms

• Sudden, sharp pain

• Swelling, bruising, deformity

• Inability to move limb or bear weight

• Crepitus (grating sound)

• Shortening or rotation of the affected limb

• Visible bone (in open fracture)

• Neurovascular changes (numbness, weak pulses)

Diagnostics

• X-ray – First-line to confirm fracture and classify type

• CT scan – Better for complex fractures (e.g., pelvis, spine)

• MRI – Detects soft tissue damage or stress fractures

• Bone scan – Used in occult or stress fractures when X-ray is negative

• CBC & CRP/ESR – Elevated in open fractures to detect infection

• Neurovascular checks – Capillary refill, pulse, motor & sensory function (baseline and ongoing)

Surgical Interventions

🔩ORIF (Open Reduction & Internal Fixation)

• Displaced or unstable fractures

• Surgically aligns bone, secured with plates, screws, rods

• Early mobilization, monitor for infection, NV checks, pain control

🦿External Fixation

• Open, infected, or unstable fractures

• Frame outside body stabilizes bone via pins into bone

• Pin care critical, infection prevention, NV checks

🛠Closed Reduction with Percutaneous Pinning

• Displaced fractures not requiring open surgery

• Bone is aligned manually and stabilized with pins under imaging

• Less invasive, monitor pin sites

🔧Intramedullary Nailing

• Long bone fractures (e.g., femur, tibia)

• Metal rod inserted inside bone canal

• Allows early weight bearing, monitor for embolism

🦴Bone Grafting

• Non-union or large bone loss

• Transplant bone to fill gaps and promote healing

• Often combined with ORIF

Post Operative Nursing Management

✅ Priority:

Neuro vascular Assessment

• CMS checks: Circulation (color, cap refill, pulses), Movement, Sensation

📝 Other Key Interventions:

• Pain management (PCA, analgesics)

• Elevate limb to reduce swelling

• Ice packs in first 24–48 hrs

• Monitor for infection (fever, redness, drainage)

• Promote early ambulation (as ordered)

• Pressure ulcer prevention in immobilized patients

• DVT prophylaxis: early ambulation, compression devices, anticoagulants

• Fall precautions and patient education

• Monitor for fat embolism (esp. femur fractures): S/S: dyspnea, petechiae, confusion

Pharmacologic Management

Analgesics (e.g., morphine)	Pain relief during acute phase or post-op
Antibiotics (e.g., cefazolin)	Prevent/treat infection in open fractures
Anticoagulants (e.g., enoxaparin)	Prevent DVT/PE post-operatively
Muscle relaxants (e.g., diazepam)	Decrease muscle spasms
Vitamin D & Calcium	Promote bone healing
Bisphosphonates (if underlying osteoporosis)	Prevent future fractures by inhibiting bone resorption

Complications to watch for

• Compartment syndrome: Unrelieved pain, paresthesia, pallor, pulselessness → surgical fasciotomy

• Infection: Especially in open fractures or hardware insertion

• Delayed union/nonunion: May require bone grafting

• Fat embolism syndrome (FES): Respiratory distress, altered mental status, petechiae

• DVT/PE: Leg swelling, chest pain, SOB