Fractures
Fracture
A fracture is a disruption or break in the continuity of the structure of bone, leading to impaired function and potential complications.
Traumatic injuries, such as falls, motor vehicle accidents, and sports-related injuries, are the most common causes of fractures.
Other causes include disease processes like cancer (which can weaken bone structure) or osteoporosis (pathologic fracture), infections, and stress fractures from repetitive activities.
Fractures are described as open or closed based on communication with the external environment.
Open fracture (compound fracture): The skin is broken, and bone is exposed, causing soft tissue injury and increasing the risk of infection; these require immediate medical attention.
Closed fracture (simple fracture): The skin is intact over the site; however, there may still be significant soft tissue damage beneath the skin.
Fractures are classified as complete or incomplete.
Complete fracture: The break goes entirely through the bone, dividing it into two or more fragments.
Incomplete fracture: The break is partly across a bone shaft, but the bone remains intact; often results from bending or crushing forces; examples include greenstick fractures (common in children) and hairline fractures.
Fractures are also described by the direction of the fracture line; types include linear, oblique, transverse, longitudinal, and spiral fractures.
Displaced fracture: The ends of the broken bone are separated and out of normal position; often comminuted (more than two fragments) or oblique; may require surgical intervention to restore alignment.
Nondisplaced fracture: The periosteum is intact, and the bone is still in alignment; usually transverse, spiral, or greenstick; often treated with closed reduction and immobilization.
Clinical Manifestations
Immediate localized pain that is often sharp and increases with movement or pressure.
Decreased function of the affected limb or body part.
Inability to bear weight on or use the affected part, depending on the location and severity of the fracture.
Possible visible bone deformity, such as angulation, shortening, or rotation.
Guarding of the extremity (protecting it against movement) due to pain.
Swelling, bruising, and muscle spasms around the fracture site.
Complications
The majority of fractures heal without complications; however, some fractures can lead to significant short-term and long-term problems.
Direct complications:
Bone infection (osteomyelitis): Can result from open fractures or surgical interventions; requires aggressive antibiotic treatment and possibly surgery.
Problems with bone union: Delayed union (slower than expected healing), nonunion (failure to heal), or malunion (healing in an unsatisfactory position).
Avascular necrosis (AVN): Bone cell death due to inadequate blood supply; can occur with fractures that disrupt blood vessels.
Indirect complications:
Compartment syndrome: Swelling and increased pressure within a limited space (muscle compartment) that compromises neurovascular function; requires immediate intervention (fasciotomy) to relieve pressure.
Venous thromboembolism (VTE): Includes deep vein thrombosis (DVT) and pulmonary embolism (PE); common after fractures, especially in the lower extremities; prophylactic measures include anticoagulant drugs and mechanical devices.
Fat embolism syndrome (FES): Fat globules released from the bone marrow enter the circulation and can cause respiratory distress, neurological symptoms, and petechiae; most often associated with long bone fractures.
Rhabdomyolysis: Breakdown of skeletal muscle that releases myoglobin into the circulation, leading to kidney damage; can be caused by crush injuries or prolonged immobilization.
Hypovolemic shock: Can occur due to significant blood loss from fractures, especially pelvic and long bone fractures; requires rapid fluid and blood replacement.
Most musculoskeletal injuries are not life-threatening; however, complications can be.
Death after a fracture is usually caused by damage to underlying organs and vascular structures or complications of the fracture or immobility.
Open fractures, fractures with severe blood loss, and fractures that damage vital organs (e.g., lung, heart) are medical emergencies requiring immediate attention.
Diagnostic Studies
History and physical examination, including mechanism of injury, pre-existing conditions, and thorough assessment of the injured area.
X-ray examination: Primary imaging technique to confirm the presence and type of fracture; usually includes multiple views.
CT scan: Used to detect fractures in complex areas (e.g., pelvis, spine) or to identify subtle fractures not visible on X-ray.
MRI: Provides detailed images of soft tissues and can help identify ligament or tendon injuries, stress fractures, and avascular necrosis.
Interprofessional Management
Goals of treatment include:
Anatomic realignment of bone fragments through reduction of the fracture to restore normal bone structure and function.
Immobilization to maintain realignment and prevent further injury; methods include casts, splints, traction, and external or internal fixation.
Restoration of function of the injured part through rehabilitation, including exercises to improve range of motion, strength, and mobility.
If a fracture is suspected, the extremity should be immobilized in the position in which it is found to minimize soft tissue damage and prevent a closed fracture from becoming an open fracture or further injury to adjacent nerves and blood vessels.
Fracture Reduction
Closed reduction: Nonsurgical, manual realignment of bones to their anatomic position.
Traction and countertraction are applied to bone fragments to restore position, length, and alignment; may involve manipulation and manual traction.
Usually done under local or general anesthesia to minimize pain and muscle spasm.
After reduction, the injured part is immobilized by casting, traction, external fixation, splints, or orthoses (braces) to maintain alignment until healing occurs.
Open reduction: Correction of alignment through surgery.
Usually includes internal fixation of the fracture with wires, screws, pins, plates, intramedullary rods, or nails to maintain alignment.
Main risks include infection, complications associated with anesthesia, and effects of preexisting medical conditions (e.g., diabetes).
Open reduction with internal fixation (ORIF) facilitates early ambulation, decreasing the risk of complications related to prolonged immobility.
Traction
Traction devices apply a pulling force on the fractured extremity while countertraction pulls in the opposite direction to maintain alignment and reduce muscle spasm.
Skin traction:
Generally used for short-term treatment (48–72 hours) until skeletal traction or surgery is possible.
Tape, boots, or slings are applied directly to the skin to decrease muscle spasms in the injured extremity; skin integrity must be monitored closely.
Buck’s traction is a type of skin traction device sometimes used for patients with a hip, knee, or femur fracture to reduce muscle spasms and maintain alignment before surgery.
Skeletal traction:
Used to align injured bones and joints or treat joint contractures and congenital hip dysplasia; provides a stronger, more sustained traction force than skin traction.
Requires the insertion of a pin or wire into the bone under sterile conditions.
Fracture alignment depends on correct positioning of the patient while traction forces remain constant; weights should hang freely and not be obstructed.
For extremity traction to be effective, forces must be pulling in the opposite direction (countertraction).
Countertraction:
Supplied by the patient’s body weight; may be augmented by elevating the end of the bed to provide the necessary counter-pull.
Fracture Immobilization
A cast is a temporary immobilization device allowing the patient to perform many normal activities of daily living (ADLs) while providing stability; generally incorporates the joints above and below a fracture to provide stability and support.
Synthetic casting materials (fiberglass) are light in weight, dry more quickly than plaster of Paris, and are more durable.
Immobilization of an acute fracture or soft tissue injury of the upper extremity is often accomplished by the use of a sugar-tong splint, posterior splint, short-arm cast, or long-arm cast, depending on the location and severity of the injury.
Injuries to the lower extremity can be immobilized with a long leg cast, short leg cast, cylinder cast, or prefabricated splint or immobilizer, depending on the type and location of the fracture.
An external fixator is composed of metal pins and wires inserted into the bone and attached to external rods to stabilize the fracture; it can apply traction or immobilize reduced fragments when a cast or traction is not appropriate; ongoing assessment for pin loosening and infection is needed; infection (exudate, redness, tenderness, and pain) may require removal of the device.
Internal fixation devices (pins, plates, intramedullary rods, and metal and bioabsorbable screws) are surgically inserted to realign and maintain bony fragments; metal devices are biologically inert and made from stainless steel, vitallium, or titanium; proper alignment is evaluated by X-ray studies at regular intervals.
Electrical bone growth stimulation can promote healing, especially with fracture nonunion or delayed union; uses low-level electrical currents to stimulate bone formation.
Nursing Management
Goals
The patient with a fracture will have healing with no associated complications, have acceptable pain relief, and achieve maximal rehabilitation potential to return to their pre-injury level of function.
Interventions
Patients with fractures may be treated in an emergency department or a physician’s office and released to home care or may require hospitalization; specific nursing measures depend on the type of treatment used and setting.
Preoperative Care
If surgical intervention is needed, patients must be prepared; review pain management strategies and teach patients about immobilization and assistive devices; discuss expected activity limitations after surgery.
Central and peripheral muscle relaxants, such as carisoprodol (Soma), cyclobenzaprine, or methocarbamol, may be used to manage pain associated with muscle spasms.
Give tetanus and diphtheria toxoid or tetanus immunoglobulin to the patient with an open fracture when their immunization status cannot be confirmed to prevent infection.
Bone-penetrating antibiotics, such as a cephalosporin (e.g., cefazolin), are given before surgery to prevent postoperative infection.
Postoperative Care
Perform frequent neurovascular assessments of the affected extremity, including evaluation of circulation, sensation, and motor function; monitor limitations of movement or activity related to turning, positioning, and extremity support.
Minimize pain and discomfort through proper alignment and positioning; use of ice packs and elevation can also help reduce pain and swelling.
Frequently observe dressings, casts, and wound drainage systems for bleeding or drainage; report increased or purulent drainage to the healthcare provider (HCP).
Maintain the patency of any drainage system; use aseptic technique to avoid contamination and monitor the amount and characteristics of drainage.
When slings are used with traction, inspect exposed skin areas regularly for signs of pressure or breakdown.
Observe skeletal traction pin sites for signs of infection; pin site care often includes regularly cleansing with chlorhexidine, rinsing with sterile saline, and drying the area with sterile gauze; follow established protocols for pin site care.
Proper nutrition helps ensure optimal soft tissue and bone healing; include ample protein (e.g., body weight daily), vitamins (especially B, C, and D), and calcium, phosphorus, and magnesium. Collaborate with a dietitian to ensure adequate nutritional support.
Plan care to prevent complications of immobility.
Prevent constipation by increasing activity, maintaining a high fluid intake, and providing a diet high in bulk and roughage; maintain a regular time for elimination; if these measures are not helpful, give stool softeners, laxatives, or suppositories as needed.
Renal stones can develop because of bone demineralization related to reduced mobility; unless contraindicated, maintain a fluid intake of .
Rapid deconditioning of the cardiovascular system can occur from prolonged bed rest, resulting in orthostatic hypotension and decreased lung capacity; unless contraindicated, have the patient sit on the side of the bed and perform standing transfers. Encourage deep breathing and coughing exercises to prevent respiratory complications.
When the patient is allowed to increase activity, assess for orthostatic hypotension and implement safety measures to prevent falls.
Also, assess patients for signs of VTE; they may wear compression gradient stockings (antiembolism hose) or use intermittent pneumatic compression devices; because of the high risk for VTE in the orthopedic surgical patient, prophylactic anticoagulant drugs may be given for 10–14 days; monitor for signs and symptoms of DVT and PE.
Patient and Caregiver Teaching
Teach the patient to recognize and promptly report tightness of the cast and areas of pressure or discomfort; explain the importance of elevating the extremity above heart level to promote venous return and applying ice to control or prevent edema during the initial phase.
In addition to specific instructions for cast, pin, or wound care and recognition of complications, encourage the patient to contact the HCP if questions arise. Provide written instructions and contact information for follow-up care and emergencies.