Fractures Study Notes

Fractures: Signs and Symptoms

• Depend on the type and location of the break.
• Some fractures have few manifestations, detectable only with x-rays.
• Signs and symptoms:
  • Swelling
  • Bruising
  • Pain
  • Tenderness
  • Numbness
  • Loss of normal function
  • Abnormal position
  • Decreased mobility
  • Crepitus
  • Hypovolemic shock

Fracture: Diagnostic Tests and Procedures

• Standard radiographs: Reveal bone disruption, deformity, or malignancy.
• Computed tomography (CT): Detects fractures of complex structures like the hip and pelvis, or compression fractures of the spine.
• MRI: Aids in assessment of soft tissue damage.
• Bone scan: Detects small bone fractures or fractures caused by stress or disease.

Classification of Fractures

• Closed or simple fracture:
  • The bone does not break through the skin.
• Open or compound fracture:
  • Fragments of the broken bone break through the skin.
  • Open fractures have three grades of severity:
    • Grade I: Least severe injury, with minimal skin damage.
    • Grade II: Moderately severe injury, with skin and muscle contusions (bruises).
    • Grade III: Most severe injury (wound larger than 6 to 8 cm), with skin, muscle, blood vessel, and nerve damage.

Classifications of Fractures (cont.)

• Complete fracture: Break extends across the entire bone, dividing it into two separate pieces.
• Incomplete fracture: Bone only breaks partway across.
• Greenstick fracture: Common in children. Bone is splintered on one side but only bent on the other side.

Classification of Fractures (cont.)

• Simple fracture: Has one fracture line.
• Comminuted fracture: Has multiple fracture lines splitting the bone into multiple pieces.
• Displaced fracture: Bone fragments are not in alignment.
• Non-displaced fracture: Bone fragments remain in alignment.

Classification of Fractures (cont.)

• Stress fracture:
  • AKA “Fatigue.”
  • Caused by either repeated or prolonged stress.
• Pathologic fracture:
  • AKA “Spontaneous.”
  • Occurs because of a pathologic condition in the bone, such as a tumor or disease process, that causes a spontaneous break.

Classification of Fractures - Common Types

• Comminuted: Bone is fragmented.
• Oblique: Fracture occurs at an oblique angle across the bone.
• Spiral: Fracture occurs from a twisting motion (common with physical abuse).
• Impacted: Fractured bone is wedged inside the opposite fractured fragment.
• Greenstick: Fracture occurs on one side (cortex) but does not extend completely through the bone (most often in children).

Cause and Risk Factors

• Commonly caused by trauma to the bone, especially as a result of automobile accidents and falls.
• Bone disease (e.g., bone cancer) can lead to a fracture.
• Hip fractures in older adults usually result from falls.
• Risk factors for hip fractures: osteoporosis, advanced age, white race, use of psychotropic drugs, and female sex.
• In adults, ribs are the most commonly fractured bones.
• Fractures of the femur are most common in young and middle-aged adults.
• Hip and wrist fractures are most common in older adults.

Fracture Healing

• A bone begins to heal as soon as an injury occurs.
• New bone tissue is formed to repair the fracture, resulting in a sturdy union between the broken ends of the bone.

Healing Stages

• Stage 1: Hematoma formation
  • Immediately after a fracture, bleeding and edema occur.
  • In 48 to 72 hours, a clot, or hematoma, forms between the two broken ends of the bone.
• Stage 2: Fibrocartilage formation
  • Hematoma that surrounds the fracture does not resorb, as it does in other parts of the body.
  • Instead, other tissue cells enter the clot, and granulation tissue replaces the clot.
  • The tissue then forms a collar around each end of the broken bone, gradually becoming firm and forming a bridge between the two ends.
• Stage 3: Callus formation
  • Within 1 to 4 weeks after injury, granulation tissue changes into a callus, which is made up of cartilage, osteoblasts, calcium, and phosphorus.
  • The callus is larger than the diameter of the bone and serves as a temporary splint.
• Stage 4: Ossification
  • Within 3 weeks to 6 months after the break, a permanent bone callus, known as woven bone, forms.
  • During this stage, the ends of the broken bone begin to knit.
• Stage 5: Consolidation and remodeling
  • Consolidation occurs when the distance between bone fragments decreases, then closes.
  • During bone remodeling, immature bone cells are gradually replaced by mature bone cells.
  • Excess bone is chiseled away by stress to the affected part from motion, exercise, and weight-bearing.
  • Bone then takes on its original shape and size.

Fracture Healing (cont.)

• Healing is affected by:
  • Location
  • Severity of the fracture
  • Type of bone
  • Other bone pathology
  • Blood supply to the area
  • Infection
  • Adequacy of immobilization
• Age, endocrine disorders, and some drugs also affect healing.
• Healing time increases with age; it may take six times as long for the same type of fracture to heal in an older adult as in an infant.

Infection

• Osteomyelitis from contamination of the open wound associated with a fracture or from contamination of indwelling hardware used to repair the broken bone.
• When infection is inadvertently brought by surgery or other treatment, it is known as iatrogenic.
• Any infection can interfere with normal healing.
• Common after an open fracture and surgical repair and may become chronic.
• In deep, grossly contaminated wounds, gas gangrene may develop.

Infection (cont.)

• Signs and symptoms:
  • Local pain, redness, purulent wound drainage, chills, and fever.
  • With gas gangrene, foul-smelling watery drainage with significant redness and swelling.
• Treatment:
  • IV antibiotics may be given for 4 to 8 weeks, followed by 4 to 8 weeks of oral drug therapy.
  • Wound care: irrigation, treatment with antibiotic beads, and surgical removal of dead bone tissue and/or hardware.

Fat Embolism

• Fat globules are released from the marrow of the broken bone into the bloodstream, then migrate to the lungs.
• Occurs 24-48 hours after injury.
• They lodge in capillaries and obstruct blood flow.
• The fat particles break down into fatty acids, which inflame the pulmonary blood vessels, leading to pulmonary edema.
• Common with fractures of the long bones, multiple fractures, and severe trauma.

Fat Embolism (cont.)

• Respiratory distress is the first sign of a fat embolism, followed by tachycardia, tachypnea, fever, confusion, and decreased level of consciousness.
• Another characteristic feature is petechiae, a measles-like rash over the neck, upper arms, chest, or abdomen.
• Treatment:
  • Bedrest
  • Gentle handling
  • Oxygen
  • Ventilatory support
  • Fluid restriction
  • Diuretics for pulmonary edema

Deep Vein Thrombosis (DVT)

• Thrombi can break off and travel to the lungs, causing a pulmonary embolism.
• DVT is increased with immobility often associated with a fracture.
• Venous stasis, vessel damage, and altered clotting mechanisms contribute to the formation of blood clots (thrombi), most commonly in deep veins of the legs.

Compartment Syndrome

• Serious complication from internal or external pressure on the affected area.
• Compartments: enclosed spaces made of muscle, bone, nerves, blood vessels, wrapped by fibrous membrane.
• Internal pressure from bleeding/edema into a compartment; external pressure from a cast or tight dressing.

Compartment Syndrome (cont.)

• When bleeding or edema occurs in a compartment, there is nowhere for drainage to go: it is trapped in the space.
• Increased fluid puts pressure on tissues, nerves, and blood vessels, so that blood flow is decreased, resulting in pain and tissue damage.
• External pressure also can decrease blood flow to the area.

Compartment Syndrome (cont.)

• The primary symptom is pain, especially with touch or movement, that can’t be relieved with opioids.
• Other signs and symptoms: edema, pallor, weak or unequal pulses, cyanosis, tingling, numbness, paresthesia, and finally, severe pain.
• The goal of treatment is to relieve pressure.
  • When internal pressure, a surgical fasciotomy, which entails making linear incisions in the fascia, may relieve pressure on the nerves and blood vessels.
  • For external pressure, cast or dressings are replaced.

Shock

• After a fracture, there is a risk of excessive blood loss.
• Trauma may rupture local blood vessels; internal organs may be punctured, resulting in internal bleeding.
• Loss of blood leads to shock, evidenced by tachycardia; anxiety; pallor; and cool, clammy skin.
• Immobilizing fractures reduces the risk of hemorrhage.
• If severe external bleeding, external pressure should be applied, and medical assistance summoned immediately.

Joint Stiffness and Contractures

• Joint fractures or dislocations may be followed by stiffness or contractures, especially in older adults, due to immobility associated with fracture.
• Prevention requires appropriate positioning and progressive exercise programs.
• Treatment may include splints, traction, casts, surgical manipulation, and aggressive physiotherapy.

Union Problems

• Malunion
  • Expected healing time is appropriate, but unsatisfactory alignment of bone results in external deformity and dysfunction.
• Delayed union
  • Failure of a fracture to heal in the expected time.
  • The bone usually heals eventually; it may just be slower.

Union Problems (cont.)

• Nonunion
  • Occurs when a fracture never heals.
  • Treatment:
    • Osteogenic method: implantation of bone grafts.
    • Osteoconductive methods: synthetic materials to provide a matrix for bone growth.
    • Osteoinduction: substances such as platelet-derived growth factor.
    • Electric stimulation
      • Internal or external; up to 10 hours a day for 3 to 6 months.
      • Time-consuming but can prevent further surgery and bone grafts.

Posttraumatic Arthritis

• Weight-bearing joints are most vulnerable to posttraumatic arthritis.
• Excessive stress and strain on the joint or fracture must be avoided to reduce the risk of this complication.
• Can be a result of nonunion of a fracture.

Avascular Necrosis

• A variety of factors can interfere with the blood supply after a bone injury.
• Once bone cells are deprived of oxygen and nutrients, they die, and their cell walls collapse.
• Signs and symptoms:
  • Pain, instability, and decreased function in the affected area.

Avascular Necrosis (cont.)

• Treatment:
  • Relief of weight-bearing and removal of part of the bone to decrease pressure.
  • If conservative measures fail, surgical procedures may be recommended.
  • Sometimes amputation is necessary.

Complex Regional Pain Syndrome Type 1 (CRPS-Type 1)

• Precipitated by a fracture or other trauma.
• Symptoms:
  • Severe pain at the injury site despite no detectable nerve damage, edema, muscle spasm, stiffness, vasospasms, increased sweating, atrophy, contractions, and loss of bone mass.
  • Symptoms persist longer than expected with the type of injury suffered.
• Treatment:
  • Nerve blocks; physical therapy; transcutaneous electrical stimulation; and analgesics, antiseizure drugs, antidepressants, and alpha-1 adrenergic agonists.
  • Non-opioid infusions, such as lidocaine and ketamine.

Closed Reduction or Manipulation

• Reduction is the process of bringing the ends of the broken bone into proper alignment.
• Nonsurgical realignment that returns bones to their previous anatomic position.
• No surgical incision is made; however, general or local anesthesia is given.
• By using traction, manual pressure, or a combination.
• After reduction of a fracture, an x-ray is taken, and a cast is usually applied.

Open Reduction

• A surgical procedure in which an incision is made at the fracture site.
• Usually for open (compound) or comminuted fractures to clean the area of fragments and debris.

Immobilization

• Accomplished in many ways, such as fixation, casts, splints, and traction.
• Prevents movement and increases union.
• Necessary for healing to occur.

Fixation

• An attempt to attach the fragments of the broken bone together when reduction alone is not feasible because of the type and extent of the break.

Internal Fixation

• Done during an open reduction surgical procedure.
• Rods, pins, nails, screws, or metal plates are used to align bone fragments and keep them in place for healing.
• Promotes early mobilization; preferred for older adults who have brittle bones that may not heal properly or who may suffer the consequences of immobility.

External Fixation

• Pins are inserted into the bone above and below the fracture.
• Pins are then attached to an external frame and adjusted to align the bone.
• If there is soft tissue damage or infection, external fixation allows access to the site and facilitates wound care.
• Pin care is extremely important to prevent the migration of organisms along the pin from the skin to the bone.
• Patients should be taught to do their own pin care and to recognize signs of infection.

Casts, Splints, and Immobilizers

• Hold the bone in alignment while allowing movement of other parts of the body.
• Types of cast materials: plaster of Paris, fiberglass, thermoplastic resins, thermolabile plastic, and polyester-cotton knit impregnated with polyurethane.
• A variety of materials are used for splints/immobilizers.
• Four main groups of casts:
  • Upper extremity
  • Lower extremity
  • Cast brace
  • Body or spica cast

Cast: Patient Teaching

• Keep plaster casts dry; follow instructions regarding wetting synthetic casts.
• Do not remove padding or insert a foreign object inside the cast.
• Do not bear weight on a plaster cast for 48 hours; with synthetics, less than 1 hour.
• Do not cover the cast with plastic for prolonged periods.
• Report to the Health Care Provider (HCP): swelling, discoloration of toes or fingers, pain during motion, and burning or tingling under the cast.

Traction

• May be applied directly to the skin (skin traction) or attached directly to a bone (skeletal traction) with a metal pin or wire.
• Prevents or corrects deformity, decreases muscle spasm, promotes rest, and maintains the position of the injured part.
• Exerts a pulling force on a fractured extremity to align bone fragments.

Traction (cont.)

• Skin traction
  • Buck traction
    • For hip and knee contractures, muscle spasms, and alignment of hip fractures.
    • Weight used during skin traction should not be more than 5 to 10 pounds to prevent injury to the skin.
• Skeletal traction
  • Provides a strong, steady, continuous pull and can be used for prolonged periods.
  • Examples of skeletal traction are Gardner-Wells, Crutchfield, and Vinke tongs and a halo vest, in which pins are inserted into the skull on either side.

Traction (cont.)

• Complications:
  • Impaired circulation
  • Inadequate fracture alignment
  • Skin breakdown
  • Soft tissue injury
  • With skeletal traction:
    • Pin track infection and osteomyelitis

Traction (cont.)

• Weights must always hang freely.
• Ensure the correct weight is used, clamps are tight, and ropes move freely over pulleys.
• Maintain body alignment so that the line of pull is correct.
• Report skin breakdown or irritation.
• Assess affected extremities for temperature, pain, sensation, motion, capillary refill time, and pulses (neurovascular check).
• With skeletal traction, assess pin sites for redness, drainage, or odor.

Electrical Stimulation and Pulsed Electromagnetic Fields (PEMFS)

• Electrical stimulation may be used to promote bone healing.
• Current is delivered through a surgically implanted device, a device applied to the skin, or a device that uses pins inserted through the skin.
• Electrical bone stimulators are about 80% effective; average healing time is 16 weeks.
• PEMFs are noninvasive and induce electrical charges around cells to promote healing and reduce pain.

Crutches

• Increase mobility and assist with ambulation.
• A physical therapist measures the patient for proper fit and instructs in crutch-walking techniques.
• The nurse reinforces the instructions and evaluates whether the crutches are being used properly.
• A properly fitted crutch should reach to three fingerbreadths below the axilla to avoid pressure on the axilla and nerves when walking.

Crutches: Gait Patterns

*Two-point gait:
* The crutch on one side and the opposite foot are advanced at the same time.
* Used with partial weight-bearing limitations and with bilateral lower extremity prostheses
*Three-point gait
* Both crutches and the foot of the affected extremity are advanced together, followed by the foot of the unaffected extremity
* This gait requires strength and balance
* Used for partial or no weight bearing on the affected leg

Crutches: Gait Patterns (cont.)

• Four-point gait:
  • The right crutch is advanced, then the left foot, then the left crutch, then the right foot.
  • Used if weight bearing is allowed and one foot can be placed in front of the other.
• Swing-to gait:
  • Both crutches are advanced together, then both legs are lifted and placed down again on a spot behind the crutches.
  • The feet and crutches form a tripod.

Crutches: Gait Patterns (cont.)

• Swing-through gait:
  • Both crutches are advanced together, then both legs are lifted through and beyond the crutches and placed down again at a point in front of the crutches.
  • Used when there is adequate muscle power and balance in the arms and legs.

Walker

• Used for support and balance, usually by older adults.
• A modified swing-to gait is used so the walker is pushed or lifted forward, and then the legs are brought up to it.
• Rather than lifting both legs forward together (crutch walking), one foot is brought forward at a time.

Canes

• Provide minimal support and balance and relieve pressure on weight-bearing joints.
• Placed on the unaffected side with the top even with the patient’s greater trochanter to where the elbow is flexed about 30 degrees.
• A two-point or four-point gait is used with a cane.

Focused Assessment

• Health history:
  • The cause, type, and extent of the injury
  • Symptoms associated with the injury
  • Other medical problems that may have been related to the cause of the fracture
  • Current medications (prescription & OTC)

Assessment (cont.)

• Physical examination:
  • Focus on signs of complications
  • Deviations in bone alignment
  • Inspect the skin over the fracture for lacerations, bruising, or swelling
  • Neurovascular checks (pulse, skin color, capillary refill time, sensation) in the areas distal to the wound to compare circulation and sensation.
  • Assess pulse rate and volume, as well as capillary refill time in the nails distal to the injury.

Interventions

• Pain
• Inadequate peripheral circulation
• Potential for infection
• Immobility
• Potential for skin breakdown
• Potential activity intolerance

Nutrition Considerations

• Calcium and calcium supplements are recommended to prevent fractures.
• Prolonged immobilization contributes to loss of calcium and protein.
• Essential nutritional elements for bone healing: protein, calcium, and vitamins B, C, and D.
• Between-meal supplemental feedings: high in calories, protein, and calcium.
• While immobilized, a daily fluid intake of 2000 to 3000 mL is recommended, unless contraindicated, to promote bowel and bladder function.

Fracture of the Hip

• The most common cause is a fall on a hard surface.
• Many fractures in older adults are the result of osteoporosis.
• Signs/Symptoms:
  • Recent fall
  • Severe pain and tenderness in the area of the fracture site
  • Evidence of soft tissue trauma
  • The affected leg is shorter than the unaffected leg
  • The affected hip is rotated externally

Fracture of the Hip (cont.)

• Medical diagnosis:
  • Confirmed with radiography.
• Medical treatment:
  • Traction and surgical repair (internal fixation, femoral head replacement, or total hip replacement [arthroplasty]).
  • Patients may begin physical therapy as early as 1 day after surgery, depending on the type of repair; begin by sitting in a chair and then progress to a walker.

Fracture of the Hip (cont.)

• Assessment:
  • Pain
  • Impaired peripheral circulation on the affected side
• Complications:
  • Immobility
  • Skin breakdown
  • Ability to carry out activities of daily living

Fracture of the Hip (cont.)

• Interventions:
  • Relieving pain, promoting mobility and independence, and preventing complications.
  • Proper body alignment is extremely important in preventing injury to the fracture area.
  • Turn patients from side to side as ordered.
  • The affected hip must not be adducted or flexed more than 90 degrees because excessive flexion/adduction can dislocate the prosthesis.

Colles Fracture

• A break in the distal radius (wrist area).
• Commonly seen in older women using a hand to break a fall.
• Signs/symptoms:
  • Pain and swelling at the area of injury.
  • Characteristic displacement of bone (dinner fork appearance).
• Medical diagnosis:
  • Radiography.
• Medical treatment:
  • Closed reduction or manipulation of the bone and immobilization in either a splint or a cast.

Colles Fracture (cont.)

• Post-operative nursing care:
  • Assessment:
    • Pain and swelling following treatment of the fracture.
  • Interventions:
    • The extremity should be supported and protected and can be elevated on a pillow during the first few days.
    • Encourage patients to move their fingers and thumb to promote circulation and reduce swelling and to move their shoulders to prevent stiffness and contracture.
    • Teach proper cast care.

Fracture of the Pelvis

• Medical treatment:
  • A less severe non–weight-bearing fracture is treated with bedrest on a firm mattress or bed board for a few days to 6 weeks.
  • A severe weight-bearing fracture may require a pelvic sling, skeletal traction, a double hip spica cast, or external fixation.
  • Monitor patients so injuries can be treated immediately.
  • Check for the presence of blood in urine and stool and watch the abdomen for signs of rigidity or swelling (ruptured bladder or other internal injury).

Fracture of the Pelvis (cont.)

• Assessment:
  • Signs of bleeding, swelling, infection, thromboembolism, and pain.
  • Assess urine output because the absence of urine may indicate a perforated bladder.

Fracture of the Pelvis (cont.)

• Interventions:
  • When handling patients, take extreme care to prevent displacement of the fracture fragments.
  • Turn the patient only on the order of a healthcare provider.
  • Provide back care when the patient is raised from the bed using the trapeze or with adequate assistance from others.
  • Ambulation may be encouraged even though painful; follow provider’s orders.