FRACTURES
A fracture is a break in the continuity of bone. A fracture occurs when the stress placed on a bone
is greater than the bone can absorb. Muscles, blood vessels, nerves, tendons, joints, and other
organs may be injured when fracture occurs.
Types of Fractures
Complete: involves entire cross section of bone, usually displaced (abnormal position).
Incomplete: involves a portion of the cross section of the bone or may be longitudinal.
Closed (simple): skin not broken.
Open (compound)—skin broken, leading directly to fracture.
o Grade I: minimal soft tissue injury.
o Grade II: laceration greater than 1 cm without extensive soft tissue flaps.
o Grade III: extensive soft tissue injury, including skin, muscle, neurovascular
structure, with crushing.
Pathologic: through an area of diseased bone (osteoporosis, bone cyst, bone tumor).
Patterns of Fracture
Greenstick—one side of the bone is broken and the other side is bent.
Transverse—straight across the bone.
Oblique—at an angle across the bone.
Spiral—twists around the shaft of the bone.
Comminuted—bone splintered into more than three fragments.
Depressed—fragments are driven inward (seen in fractures of the skull and facial bones).
Compression—bone collapses in on itself (seen in vertebral fractures).
Avulsion—fragment of bone pulled off by ligament or tendon attachment.
Impacted—fragment of bone wedged into other bone fragment.
Fracture-dislocation—fracture complicated by the bone being out of the joint.
Other—according to anatomic location: epiphyseal (end of large bones containing growth
plate), supracondylar (above the articular prominence of a bone), midshaft, intra-articular.
Clinical Manifestations
Physical Findings
Pain at site of injury Swelling
False motion and crepitus (grating sensation) Tenderness
Loss of function Deformity
Ecchymosis Paresthesia
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Altered Neurovascular Status
Injured muscle, blood vessels, nerves.
Compression of structures resulting in ischemia.
Findings:
Progressive uncontrollable pain. Pain on passive movement.
Altered sensations (paresthesia). Loss of active motion.
Diminished capillary refill & distal pulse. Pallor.
Shock
Overt hemorrhage through open wound.
Bone is very vascular. May be fatal if not detected.
Covert hemorrhage into soft tissues (in femoral fracture or with pelvic fracture).
Diagnostic Evaluation
X-ray and other imaging studies to determine integrity of bone.
Blood studies (complete blood count [CBC], electrolytes) with blood loss and extensive
muscle damage—may show decreased hemoglobin level and hematocrit.
Arthroscopy to detect joint involvement.
Angiography if associated with blood vessel injury.
Nerve conduction and electromyogram studies to detect nerve injury.
Management
Factors influencing choice of management include:
Type, location, and severity of fracture. Soft tissue damage.
Age and health status of patient, including type and extent of other injuries.
Goals include:
To regain and maintain correct position and alignment.
To regain the function of the involved part.
To return patient to usual activities in the shortest time and at the least expense.
The management process is a three-step process:
Reduction: restoration of fracture fragments into anatomic position and alignment.
Immobilization: maintains reduction until bone healing occurs.
Rehabilitation: regaining normal function of the affected part.
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Approaches to Management
Vary by specific site of fracture
Closed reduction
Bony fragments are brought into apposition (ends in contact) by manipulation and
manual traction restoring alignment.
May be done under anesthesia for pain relief and muscle relaxation.
Cast or splint applied to immobilize extremity and maintain reduction.
Traction
Pulling force applied to accomplish and maintain reduction and alignment.
Used for fractures of long bones.
Techniques
Skin traction—force applied to the skin using foam rubber, tape.
Skeletal traction—force applied to the bony skeleton directly, using wires, pins, or
tongs placed into or through the bone.
Open reduction with internal fixation (ORIF)
Operative intervention to achieve reduction, alignment, and stabilization.
Bone fragments are directly visualized.
Internal fixation devices (metal pins, wires, screws, plates, nails, rods).
After wound closure, splints or casts may be used for stabilization & support.
Endoprosthetic replacement
Replacement of a fracture fragment with an implanted metal device.
Used when fracture disrupts bone nutrition or treatment of choice is bony replacement
External fixation device
Stabilization of complex and open fracture with use of a metal frame and pin system.
Permits active treatment of injured soft tissue.
Wound may be left open (delayed primary wound closure).
Repair damage to blood vessels, soft tissue, muscles, nerves & tendons as indicated
Reconstructive surgery may be necessary (External Fixation).
Complications
Muscle atrophy, loss of muscle strength and endurance.
Loss of ROM due to joint contracture.
Pressure sores at bony prominences from immobilizing device pressing on skin.
Diminished respiratory, cardiovascular, GI function, resulting in possible pooling of
respiratory secretions, orthostatic hypotension, ileus, anorexia, and constipation.
Psychosocial compromise resulting in feelings of isolation and depression.
Other Acute Complications
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Venous stasis & thromboembolism—particularly with hip & lower extremities fractures.
Infection especially with open fractures. Neurovascular compromise.
Shock due to significant hemorrhage. Pulmonary emboli.
Fat Emboli Syndrome
Associated with embolization of marrow or tissue fat or platelets and free fatty acids to
the pulmonary capillaries, producing rapid onset of symptoms.
Clinical manifestations
Respiratory distress—tachypnea, hypoxemia, crackles, wheezes, acute pulmonary
edema, interstitial pneumonitis
Mental disturbances—irritability, restlessness, confusion, disorientation, stupor, coma
due to systemic embolization, and severe hypoxia
Fever
Petechiae in buccal membranes, hard palate, conjunctival sacs, chest, anterior axillary
folds, due to occlusion of capillaries
NURSING ALERT: Restlessness, confusion, irritability, and disorientation may be the first signs
of fat embolism syndrome. Confirm hypoxia with arterial blood gas (ABG) analysis. Young adults
(ages 20 to 30) and older adults (ages 60 to 70) with multiple fractures or fractures of long
bones or pelvis are particularly susceptible to development of fat emboli.
Bone Union Problems
Delayed union (takes longer to heal than average for type of fracture)
Nonunion (fractured bone fails to unite)
Malunion (union occurs but is faulty—misaligned)
NURSING PROCESS
Nursing Assessment
Ask patient how the fracture occurred to determine possible associated injuries.
Ask to describe location, character, & intensity of pain to determine discomfort source
Ask to describe sensations in injured extremity to evaluate neurovascular status.
Observe patient's ability to change position to assess functional mobility.
Note patient's emotional status & behavior indicators of ability to cope with injury stress
Assess patient's support system; identify current and potential sources of support,
assistance, and caregiving.
Review findings on past and present health status to aid in formulating care plan.
Conduct physical examination.
Examine skin for lacerations, abrasions, ecchymosis, edema, and temperature.
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Auscultate lungs to establish baseline assessment of respiratory function.
Assess pulses and BP; assess peripheral tissue perfusion, especially in injured
extremity, to establish circulatory status baseline.
Determine neurologic status (sensations and movement) of extremity distal to injury.
Note length, alignment, and immobilization of injured extremity.
Evaluate behavior and cognitive functioning of patient to determine ability to
participate in care planning and patient education activities.
NURSING ALERT: Change in behavior or cerebral functioning may be an early indicator of
cerebral anoxia from shock or pulmonary or fat emboli.
Nursing Diagnoses
Risk for Deficient Fluid Volume related to hemorrhage and shock
Impaired Gas Exchange related to immobility & potential pulmonary emboli or fat emboli
Risk for Peripheral Neurovascular Dysfunction
Risk for Injury related to thromboembolism
Acute or Chronic Pain related to injury
Risk for Infection related to open fracture or surgical intervention
Bathing or Hygiene Self-Care Deficit related to immobility
Impaired Physical Mobility related to injury/treatment modality
Risk for Disuse Syndrome related to injury and immobilization
Risk for Posttrauma Syndrome related to cause of injury
Nursing Interventions
Evaluating for Hemorrhage and Shock
Monitor vital signs frequently as clinical condition indicates, observing for hypotension,
elevated pulse, widening pulse pressure, cold clammy skin, restlessness, pallor.
Watch for evidence of hemorrhage on dressings or in drainage containers.
Review laboratory data; report abnormal values.
Administer prescribed fluids/blood to maintain circulating volume.
Monitor intake and output.
Monitoring for Impaired Gas Exchange
Evaluate changes in mental status and restlessness that may indicate hypoxia.
Review diagnostic evaluation data—especially ABG values and chest X-ray.
Position to enhance respiratory effort. Report any sudden or progressive changes in
respiratory status.
Encourage coughing and deep breathing to promote lung expansion and diminish pooling
of pulmonary secretions.
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Monitor pulse oximetry. Administer oxygen as prescribed.
Maintain cervical spine precautions if spinal injury is suspected.
Preventing Neurovascular Compromise
Monitor neurovascular status for compression of nerve, diminished circulation,
development of compartment syndrome.
Pain—progressive, localized, deep throbbing, persistent, unrelieved by immobilization
and medications
Pain on passive stretch
Weakness progressing to paralysis
Altered sensation, hypothesia, paresthesia
Poor capillary refill (> 3 seconds)
Skin color—pale, cyanotic
Elevated compartment pressure—palpable tightness of muscle compartment, elevated
measured tissue pressure
Pulselessness—a late sign
Reduce swelling.
Elevate injured extremity (unless compartment syndrome is suspected—may
contribute to vascular compromise).
Apply cold to injury if prescribed.
Relieve pressure caused by immobilizing device as prescribed (such as bivalving cast,
rewrapping elastic bandage, or splinting device).
Relieve pressure on skin to prevent development of pressure sore.
Frequent repositioning.
Skin care—do not massage bony prominences.
Special mattresses.
NURSING ALERT
Monitoring the neurovascular integrity of the injured extremity is essential. Development of
compartment syndrome (increased tissue pressure causing hypoxemia) leads to permanent loss
of function in 6 to 8 hours. This situation must be identified and managed promptly.
Preventing Development of Thromboembolism
GERONTOLOGIC ALERT
Older adults with fractures, trauma, immobility, obesity, or history of thrombophlebitis are at
high risk for developing thromboembolism.
Encourage active and passive ankle exercises.
Use elastic stockings, foot pumps, or SCDs, as prescribed.
Elevate legs to prevent stasis, avoiding pressure on blood vessels.
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Encourage mobility; change position frequently; encourage ambulation.
Administer anticoagulants as prescribed.
Monitor for development of thrombophlebitis.
Note complaint of pain and tenderness in calf.
Report calf pain.
Report increased size and temperature of calf.
Homans' sign has not been proved to be an effective screen for deep vein thrombosis
(DVT); therefore, it is no longer an acceptable measure for assessing DVT.
Relieving Pain
Perform a comprehensive pain assessment.
Have patient describe the pain, location, characteristics (dull, sharp, continuous,
throbbing, bony, radiating, aching).
Ask patient what causes the pain, makes the pain worse, relieves pain. Evaluate patient
for proper body alignment, pressure from equipment (casts, traction, splints).
Initiate activities to prevent or modify pain.
Assist patient with pain-reduction techniques—cutaneous stimulation, distraction,
guided imagery, TENS, biofeedback.
Immobilize injured part.
Position patient in correct alignment.
Support splinted fracture above & below fracture when repositioning or moving
patient.
Reposition patient with slow and steady motion; use additional personnel as needed.
Elevate painful extremity to diminish venous congestion.
Apply heat or cold modalities as prescribed. Heat versus cold is controversial. One
randomly controlled trial found significantly less edema with cold packs versus heat 3
to 5 days post-injury.
Modify environment to facilitate rest and relaxation.
Administer prescribed pharmaceuticals as indicated. Encourage use of less potent drugs
as severity of discomfort decreases.
Establish a supportive relationship to assist patient to deal with discomfort.
Encourage patient to become an active participant in rehabilitative plans.
NURSING ALERT
Meperidine (Demerol) may cause toxicity as it breaks down into the metabolite normeperidine,
which has a 15- to 20-hour half-life, especially in patients with impaired renal function or elderly
patients.
Monitoring for Development of Infection
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Clean, debride, and irrigate open fracture wound, as prescribed, as soon as possible to
minimize risk of infection.
All open fractures are contaminated.
Begin prescribed antibiotic therapy promptly after wound culture obtained.
Use sterile technique during dressing changes to minimize infection of wound, soft
tissues, and bone.
Evaluate patient for elevation of temperature every 4 hours.
Note and report elevated white blood cell (WBC) counts.
Report areas of inflammation and swelling around incision or open wound.
Report purulent odiferous drainage.
Obtain specimens for culture and sensitivity to determine causative organism.
Administer antibiotic therapy as prescribed.
Promoting Adequate Hygiene
Encourage participation in care.
Arrange patient area and personal items for patient convenience and to promote
independence.
Modify activities to facilitate maximum independence within prescribed limits.
Allow time for patient to accomplish task.
Teach safe use of mobility and necessary aids.
Assist with ADLs as needed.
Teach family how to assist patient while promoting independence in self-care.
Promoting Physical Mobility
Perform active and passive exercises to all non-immobilized joints.
Encourage patient participation in frequent position changes, maintaining support to
fracture during position changes.
Minimize prolonged periods of physical inactivity, encouraging ambulation when
prescribed.
Administer prescribed analgesics judiciously to decrease pain associated with movement.
Preventing Disuse Syndrome
Teach and encourage isometric exercises to diminish muscle atrophy.
Encourage use of immobilized extremity within prescribed limits.
Minimizing the Psychological Effects of Trauma
Monitor patient for symptoms of posttraumatic stress disorder.
Memory of event; anger, helplessness, vulnerability, mood swings, depression,
cognitive impairment, sleep disturbance, increased dependency, and social withdrawal.
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Assist patient to move through phases of posttraumatic stress (outcry, denial,
intrusiveness, working through, completion).
Establish trusting therapeutic relationship with patient.
Encourage patient to express thoughts and feelings about traumatic event.
Encourage patient to participate in decision making to reestablish control and overcome
feelings of helplessness.
Teach relaxation techniques to decrease anxiety.
Encourage development of adaptive responses and participation in support groups.
Refer patient to psychiatric liaison nurse or refer for psychotherapy, as needed.
Community and Home Care Considerations
Assist patient to actively exercise joints above and below the immobilized fracture at
frequent intervals.
Isometric exercises of muscles covered by cast—start exercise as soon as possible after
cast application.
Increase isometric exercises as fracture stabilizes.
After removal of immobilizing device (eg, cast, splint), have patient start isotonic
exercises and continue with isometric exercises.
Assess the home for any fall hazards when patient ambulates.
Obtain PT/OT consultation for assistance with ADLs, transferring technique, gait
strengthening, and conditioning after lengthy immobilization, as needed.
Assess orthostatic BP when patient begins to ambulate to prevent falls.
Patient Education and Health Maintenance
Explain basis for fracture treatment and need for patient participation in therapeutic.
Promote adjustment of usual lifestyle and responsibilities to accommodate limitations
imposed by fracture.
Instruct patient on exercises to strengthen upper extremity muscles if crutch walking is
planned.
Instruct patient in methods of safe ambulation—walker, crutches, cane.
Emphasize instructions concerning amount of weight bearing that will be permitted on
fractured extremity.
Discuss prevention of recurrent fractures—safety considerations, avoidance of fatigue,
proper footwear.
Encourage follow-up medical supervision to monitor for union problems.
Teach symptoms needing attention, such as numbness, decreased function, increased
pain, elevated temperature.
Encourage adequate balanced diet to promote bone and soft tissue healing.
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Evaluation: Expected Outcomes
Vital signs within normal parameters; urine output at least 30 mL/hour
Respirations unlabored; alert and oriented
No signs of neurovascular compromise (ie, circulation, motor, sensory intact)
No calf pain reported
Reports decreased pain with elevation, ice, and analgesic
Afebrile; no wound drainage
Performing hygiene and dressing practices with minimal assistance
Performing active ROM correctly
Using affected extremity for light activity as allowed
Denies acute symptoms of stress; reports working through feelings about trauma
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