Understanding Bone Fractures and Types

• A fracture is a break in a bone due to trauma or a pathological condition.
• Trauma-induced fractures are the most common, while pathological fractures can result from metastatic cancer, osteoporosis, or Paget's disease.
• Bone remodeling involves osteoclasts dissolving bone and releasing calcium, and osteoblasts building new bone.
• Remodeling occurs at equal rates until individuals reach their thirties, after which osteoclast activity surpasses osteoblast activity, increasing osteoporosis risk.
• Following menopause, women may experience fractures due to osteoporosis earlier.

Types of Fractures

• A closed (simple) fracture does not break the skin.
• An open (compound) fracture disrupts the skin, causing an open wound, tissue injury, and infection risk.
• Open fractures are graded by tissue injury extent:
  • Grade I involves minimal skin damage.
  • Grade II includes skin and muscle contusions without extensive soft tissue injury.
  • Grade III involves excessive damage to skin, muscles, nerves, and blood vessels.
• A complete fracture goes through the entire bone, dividing it into two parts, while an incomplete fracture goes through part of the bone.
• A simple fracture has one fracture line, while a comminuted fracture has multiple fracture lines, splitting the bone.
• A displaced fracture has bone fragments out of alignment, and a non-displaced fracture maintains alignment.
• A fatigue (stress) fracture results from excess strain, like from recreational or athletic activities.
• A pathological (spontaneous) fracture occurs in bones weakened by disease, such as bone cancer or osteoporosis.

Specific Fracture Types

• Compression fractures occur from loading forces on cancellous bone and are common in older adults with osteoporosis.
• Comminuted fractures are fragmented bones.
• Oblique fractures occur at an oblique angle across the bone.
• Spiral fractures result from twisting motions, often associated with physical abuse.
• Impacted fractures involve one bone fragment wedged inside another.
• Greenstick fractures occur on one side of the bone (cortex) without completely breaking it, common in children.
• Hip fractures are common in older adults and linked to falls.

Disease Prevention

• Recommended calcium intake should be ensured during developmental stages.
• Adequate vitamin D intake and/or sunlight exposure is important.
• Monitor for osteoporosis, particularly in postmenopausal women and those with thyroid disorders.
• Regular weight-bearing exercise is beneficial.
• Bisphosphonates can be prescribed to slow bone resorption and treat osteoporosis.
• Take precautions to prevent falls and accidents.
• Use seat belts and helmets to prevent injury.

Risk Factors

• Osteoporosis
• Falls
• Motor vehicle crashes
• Substance use disorder
• Diseases like bone cancer or Paget's disease
• Contact sports and hazardous recreational activities such as football or skiing
• Physical abuse
• Lactose intolerance or malnutrition
• Age, as bone density decreases

Expected and Physical Assessment Findings

• Gather history of trauma, metabolic bone disorders, chronic conditions, and corticosteroid use.
• Expect pain and limited movement at or distal to the fracture.
• Position clients to examine upper extremities while standing or sitting, and legs and pelvis while lying down.
• Crepitus indicates bone fragments rubbing.
• Deformities include extremity rotation, shortening, visible bone, and asymmetry.
• Muscle spasms result from bone pulling forces when unaligned.
• Edema comes from trauma
• Ecchymosis results from bleeding into soft tissues.
• Subcutaneous emphysema may occur late.

Lab Tests

• A complete blood count (CBC) detects bleeding (low hemoglobin, hematocrit) or infection (high WBC).
• Erythrocyte Sedimentation Rate (ESR) can be elevated with inflammation.

Diagnostic Procedures

• Standard radiographs and computed tomography (CT) imaging scans detect hip and pelvic fractures.
• Magnetic resonance imaging (MRI) is also used.
• Diagnostic procedures help in identifying fracture type, location, and pathological fractures.
• MRI helps determine soft tissue damage
• Bone scans use radioactive material to identify hairline fractures and delayed healing.

Initial Nursing Care

• Provide emergency care immediately.
• Maintain airway, breathing, and circulation (ABCs).
• Monitor vital signs and neurological status.
• Check urine for blood.
• Stabilize the injured area with a splint, including joints above and below the fracture.
• Ask about the injury cause to determine other possible internal injuries.
• Maintain proper extremity alignment.
• Elevate the limb above the heart and apply ice.
• Assess for bleeding and apply pressure if needed.
• Cover open wounds with sterile dressings.
• Remove clothing and jewelry near the injury.
• Keep the client warm.
• Assess pain and follow pain management protocols.
• Conduct neurovascular checks hourly and report changes.
• Prepare for immobilization procedures.
• Provide nonpharmacological pain control with ice or heat packs and electrical or transdermal stimulation.

Nursing Care and Neurovascular Assessment

• Essential throughout immobilization
• Frequency: every hour for the first 24 hours, then every 1-4 hours after initial trauma
• Assess pain level, location, and frequency using a 0-10 scale.
• Immobilization, ice, and elevation of the extremity should relieve most pain with analgesics
• Assess for numbness or tingling, which indicates nerve damage.
• Check skin temperature; cool skin suggests decreased arterial perfusion.
• Monitor capillary refill by pressing nail beds; refill should occur within 3 seconds, delayed indicates decreased arterial perfusion, while cyanotic indicates venous congestion.
• Pulses are palpable and strong, matching the unaffected extremity; Doppler may be needed if edema is present. Ultrasonography might be needed
• Assess active movement of the affected extremity.

Nutrition

• Diet should include protein and calcium to facilitate bone healing.
• Encourage iron-rich foods if blood loss occurred.

Therapeutic Procedures: Immobilizing Interventions

• Prevent further injury.
• Promote healing/circulation.
• Reduce pain.
• Correct a deformity.

Types of Immobilization Devices

• Braces
• Casts
• Splints/immobilizers
• Traction
• External fixation
• Internal fixation
• Orthopedic shoes and boots

Closed Reduction

• It employs manual pulling to realign bone fragments.
• After reduction, immobilization facilitates healing.

Splint and Immobilizer Use

• Provide support, control movement, reduce pain, correct deformity, and prevent additional injury.
• They are removable for monitoring swelling or integrity.
• Used initially to support fractured areas until swelling decreases, then casting is used.
• Immobilizers are prefabricated and have hook-and-loop fasteners.

Client Education for Immobilization

• Adhere to the application protocol regarding full-time or part-time use.
• Observe for skin breakdown at pressure points.
• Casts are more effective because clients cannot remove them.

Casts

• Applied once swelling subsides to avoid compartment syndrome.
• A cast can be split (univalved or bivalved) if swelling continues
• A window allows skin inspection, wound drainage, or pulse checks.
• Moleskin protects skin from rough areas of the cast.
• A fitted stockinette is placed under the plaster cast.

Types of Casts

• Short and long arm and leg casts.
• Walking casts include rubber pads for ambulation.
• Spica casts include a portion of the trunk and one or two extremities, typically used on children with congenital hip dysplasia.
• Body casts encircle the trunk.

Casting Materials

• Plaster of Paris casts are heavy and take 24-72 hours to dry
• Synthetic fiberglass casts are light, strong, water-resistant, and dry quickly in about 30 minutes

Nursing Actions for Cast Care

• Hour neurovascular checks and pain assessment for the first 24 hours.
• Apply ice for 24-48 hours.
• Handle plaster casts with palms to prevent denting, and avoid placing them on hard surfaces.
• Clean and dry the area before applying the cast.
• A tubular cotton web roll is placed over the affected area to maintain skin integrity.
• Position the client so the cast can air dry and prevent pressure that changes the shape of the cast.
• Wear gloves until cast is dry.
• Elevate the cast for the first 24-48 hr to prevent edema using cloth-covered pillows.
• Ensure one finger fits between the skin and cast.
• Document drainage and report increases, but circling it is unreliable and can increase anxiety.
• Provide assistive devices like slings or cast shoes/boots.
• Inspect the cast every 8-12 hours and monitor/report drainage.

Client Education for Casts

• Do not place foreign objects inside the cast.
• Itching can be relieved by blowing cool air inside the cast.
• Cover the cast with plastic to avoid soiling or keep it dry.
• Report painful areas, hot spots, increased drainage, warmth, or odor, which could indicate infection
• Report changes in mobility, shortness of breath, skin breakdown, or constipation.
• Casts may need replacement if they get too loose as swelling subsides.

Traction

• Uses pulling force to align the injured area.
• Prescriptions include traction type, weight, and whether removal is permitted.

Goals of Traction

• Prevent soft tissue injury
• Realign bone fragments
• Decrease muscle spasms and pain
• Correct or prevent deformities

Types of Traction

• Manual: Provider applies pulling force for temporary immobilization, often with sedation or anesthesia.
• Straight or running: Counter traction uses the client's body, and movement can alter traction.
• Skin: It uses light (5 to 10 lb) weights to decrease muscle spasms and immobilize the extremity before surgery. Examples include Bryant's traction for congenital hip dislocation and Buck's traction for hip fractures.
• Balanced suspension: It supports the fractured extremity off the bed with slings or splints while pulling with ropes and weights, allowing client movement without altering traction.
• Skeletal: Screws are inserted into the bone with heavier weights (15 to 30 lb).

Medications

• Analgesics:
  • Opioid and non-opioid analgesics control pain.
  • Non steroidal anti-inflammatory drugs (NSAIDs) decrease inflammation, but long-term intake can delay bone healing.
• Muscle relaxants: Relieve muscle spasms.
• Stool softeners: Prevent constipation.
• Antibiotics: Prophylactic to prevent infection in open fractures.

Client Education for Medication

• Report unrelieved or increasing pain.
• Report numbness, tingling, or extremity color changes.

Interprofessional Care

• Counseling services: Assist clients experiencing anxiety or depression from long rehabilitation or life-altering injuries.
• Physical and occupational therapy: Required for ambulation assistance of crutches, a walker, or a cane, and for activities of daily living.
• Physical therapy: Help with range of motion, strengthening exercises, and adjusting to the injury.
• Case management: Coordinate discharge planning, especially if inpatient rehabilitative care is required.
• Social workers: Assist with financial concerns, especially if a long recovery period is expected.
• Home health care: Provides follow-up care and assistance with activities of daily living (ADLs).
• Vocational counselor: Assist if the injury affects the client's ability to return to prior employment.

Compartment Syndrome

• It occurs when muscle compartment pressure compromises circulation, leading to an ischemia-edema cycle.
• Increased edema puts pressure on nerves, reducing blood flow and leading to ischemia.
• Pressure results from tight casts or internal accumulation of blood/fluid.

Fat Embolism

• Those aged 70-80 or males aged 20-40 are at increased risk.
• Occurs within 72 hours of a pelvic fracture or surgery, or 12-48 hours after a long bone fracture.
• Fat globules from bone marrow enter the vasculature, leading to respiratory insufficiency and impaired organ perfusion.

Venous Thromboembolism

• Deep-vein thrombosis and pulmonary embolism are common complications after trauma, surgery, or immobility.

Osteomyelitis

• It is an infection of the bone due to infectious organisms entering from trauma or surgery.

Avascular Necrosis

• It results from disrupted blood flow to the fracture site, leading to tissue (bone) necrosis.
• Commonly found in hip fractures or fractures with displacement.
• Risk factors include corticosteroid use, radiation therapy, rheumatoid arthritis, and sickle cell disease.

Failure of Fracture to Heal

• A fracture not healed within 6 months is considered delayed union.

Hemorrhage

• Bones are highly vascular, so bleeding is a risk following fracture, potentially leading to hypovolemic shock.