Bone Fractures

Introduction to Bone Fractures

• Review of various aspects of bone fractures.

• Definition of a bone fracture: A break or crack in a bone, exemplified by an abnormal appearance where a bone is not continuous, illustrating the distinction between normal and fractured bone.

Causes of Bone Fractures

• Trauma: Main cause of bone fractures, includes:

  • Falls

  • Accidents (e.g., car accidents)

  • Sports injuries (twisting injuries)

  • Abuse (especially in pediatric cases)

• Disease: Conditions leading to fractures include:

  • Bone cancer

  • Osteoporosis, which can lead to spontaneous fractures as individuals unexpectedly learn they have the condition.

Healing Process

• Children heal faster than adults due to:

  • Thicker and stronger periosteum (dense fibrous membrane covering the bone).

• Healing time for fractures:

  • Ranges from 3 to 12 weeks, shorter in children.

  • Varies in adults based on health status and possible complications.

Complications of Bone Fractures

• Infection: Risk of osteomyelitis due to exposure when the fracture is open.

• Compartment syndrome: Discussed in detail later; condition where pressure increases in a muscle compartment, leading to potential nerve and vessel damage.

• Fat embolism: Particularly associated with long bone fractures (e.g., femur).

• Nerve and vessel damage: Risks arising from the proximity of nerves and blood vessels within bone structures.

Types of Bone Fractures

• Understanding types is crucial for diagnosis and treatment.

• Open (Compound) Fracture: Bone breaks through the skin.

• Closed (Simple) Fracture: Bone breaks without penetrating the skin.

• Complete Fracture: Bone fractures completely into two pieces.

• Incomplete Fracture: Bone shows partial fracture, not fully separated.

• Specific Classification:

  • Greenstick Fracture: One side bent, other broken; common in pediatric patients.

  • Comminuted Fracture: Bone broken into multiple fragments (three or more).

  • Transverse Fracture: Fracture straight across the bone shaft.

  • Oblique Fracture: Fracture slanted across the bone shaft.

  • Spiral Fracture: Fracture twisting around the bone shaft, often from twisting injuries.

Signs and Symptoms of Bone Fractures

• Diagnostic Tool: X-rays used to confirm fractures and determine type and appropriate treatment.

• Helper mnemonic: "BROKEN" for understanding fractures:

  • B: Bruising with pain and swelling at the fracture site.

  • R: Reduced movement of the affected extremity.

  • O: Odd appearance of the bone.

  • K: Crackling sound (crepitus) from bone fragments rubbing together.

  • E: Edema (swelling) and erythema (redness).

  • N: Neurovascular impairment, assessed using the "six p's":

  • Pain

  • Pallor

  • Paralysis

  • Paresthesia

  • Pulselessness

  • Poikilothermia (temperature regulation issues).

Nursing Interventions for Bone Fractures

• Safety and stabilization of the patient are paramount.

• Immobilization of the fracture: Use splints above and below the fracture to prevent further damage and to enable healing.

• Control bleeding:

  • Apply pressure to stop bleeding with a clean cloth.

  • Pay attention to patients on blood thinners; monitor relevant lab values (e.g., INR, PTT).

• Wound care for open fractures: Apply sterile dressing to reduce infection risk (osteomyelitis).

• Elevation and ice application: Helps decrease swelling; essential to prevent compartment syndrome.

• NPO status: Keep the patient nothing by mouth until evaluated by a physician for potential surgical intervention.

• Pain management: Close monitoring and documentation of effectiveness of pain medications (e.g., opioids).

• Monitoring for compartment syndrome: Early signs include increasing pain and unrelieved symptoms despite medication.

Compartment Syndrome

• Defined as increased pressure within a fascia-bound compartment, often resulting from fractures.

• Understanding fascia: Tough, non-expandable tissue surrounding compartments containing muscles, nerves, and blood vessels.

• Risks for compartment syndrome include:

  • Bleeding and swelling following fractures.

• Consequences of untreated compartment syndrome:

  • Ischemia can lead to irreversible muscle and nerve loss within 6 hours.

• Signs to monitor: Pain, paresthesia (pins and needles), and other symptoms related to neurovascular status.

Examination of Extremities Following FracturesExamination Process

• Visual Comparison

  • Compare the affected extremity to the unaffected one.

  • Look for differences in color (dusky, pale).

• Blood Supply Assessment

  • Check for signs of decreased blood supply to the affected muscle.

• Motor Function Evaluation

  • Assess whether the patient can move their fingers on the affected side.

  • Lack of movement indicates the need for further investigation.

• Temperature Assessment

  • Check for poikilothermia (inability to regulate temperature).

  • Feel temperature of both hands (e.g., affected vs. unaffected hand).

  • A significantly colder hand indicates a problem.

• Pulse Check

  • Assess for pulselessness; an absolute alarming sign.

  • Feel pulses on the affected extremity, mark the point with a black marker for consistency during assessments by other healthcare providers.

  • Use a Doppler to listen to pulses; ensure normal sounds are present.

Suspected Compartment Syndrome

• Initial Actions

  • Notify the physician immediately if compartment syndrome is suspected.

  • Position the affected extremity at heart level to avoid compromising ischemia and maintain arterial pressure.

  • Loosen or remove any restrictive clothing.

  • Consider bivalving the cast under physician guidance to relieve pressure.

  • If traction is applied, consider decreasing the weight.

  • In severe cases, a fasciotomy may be performed to relieve compartmental pressure.

• Monitoring Pressure

  • Pressure in the compartment should ideally be less than 20 mmHg; elevated pressure is concerning.

Fat Embolism Considerations

• Symptoms to Monitor

  • Sudden changes in mental status; confusion or restlessness.

  • Changes in respiratory status; increased difficulty in breathing or elevated respiratory rate, especially in patients with long bone fractures.

Treatment Options Bone Reduction

• Definition

  • Bone reduction is a procedure to return the fractured bone to its original state for natural healing.

  • Healing time varies (3-12 weeks) depending on patient health.

• Types of Bone Reduction

  • Closed Reduction

  • Manually done, typically requiring general anesthesia.

  • Usually followed by the placement of a cast.

  • Monitor for the six Ps (pain, pallor, pulselessness, paresthesia, paralysis, pressure).

  • Watch for signs of infection; look for temperature, foul smell, hot spots.

  • Keep the cast elevated above heart level initially to reduce swelling; apply ice for the first 2 days.

  • Handling tips: Use palms, not fingertips, for moving the cast to prevent dents.

  • Open Reduction

  • Requires surgical intervention.

  • Involves the use of fixation devices for stabilization.

  • Types of fixation devices:

    • Internal Fixation

    • Equipment such as pins, rods, and plates placed inside the skin.

    • External Fixation

    • Devices such as metal braces and screws attached outside the skin.

    • Adjustable when necessary.

Traction

• Function

  • Provides alignment of the bone through steady pulling action.

• Best Practices in Nursing Care

  • Ensure that weights hang freely and are not on the floor; do not remove them without physician orders.

  • Encourage the use of an overhead trapeze bar for patient mobility.

  • Monitor pin sites for foul drainage while ensuring skin integrity.

  • Regularly evaluate the pressure points due to immobility from traction; focus on monitoring the six Ps again for compartment syndrome risk.