Understanding Bone Fractures

• A fracture is a bone break caused by trauma or a pathological condition. Trauma-induced fractures are the most common. Pathological fractures result from metastatic cancer, osteoporosis, or Paget’s disease.

• Bone remodeling involves osteoclasts (cells that dissolve bone) releasing calcium and osteoblasts (cells that form new bone). Bone remodeling rates are equal until the age of thirty when osteoclast activity surpasses osteoblast activity, increasing the risk of osteoporosis and subsequent fractures, especially after menopause.

Common Types of Fractures

• Comminuted: The bone is fragmented.
• Oblique: The fracture occurs at an oblique angle across the bone.
• Spiral: The fracture results from a twisting motion and is common in physical abuse cases.
• Impacted: The fractured bone is wedged inside the opposite fractured fragment.
• Greenstick: The fracture occurs on one side (cortex) but doesn't extend completely through the bone; it's most common in children.
• Hip fractures are common in older adults, usually from falls.

Nursing Care

• Provide immediate emergency care, focusing on maintaining ABCs (Airway, Breathing, Circulation).
• Monitor vital signs and neurological status to detect injuries to vital organs from bone fragments, especially in pelvis or rib fractures.
• Check urine for blood.
• Stabilize the injured area, including joints above and below the fracture, using a splint to avoid unnecessary movement.
• Ask about the cause of injury to assess for other potential internal injuries.
• Properly align the affected extremity.
• Elevate the limb above the heart and apply ice.
• Assess for bleeding, applying pressure if needed.
• Cover open wounds with a sterile dressing.
• Remove clothing and jewelry near the injury or on the affected extremity.
• Keep the client warm.
• Assess pain frequently and follow pain management protocols, both pharmacological and non-pharmacological.
• Conduct neurovascular checks at least every hour, reporting any changes immediately.
• Prepare the client for appropriate immobilization procedures.
• Utilize nonpharmacological pain control methods such as ice or heat packs, electrical stimulation, or iontophoresis.

Patient-Centered Care

• Neurovascular assessment should be performed hourly for the first 24 hours and then every 1 to 4 hours.
• Assess pain level, location, and frequency using a 0 to 10 pain scale.
• Assess for numbness or tingling, as loss of sensation can indicate nerve damage.
• Check the temperature of the affected extremity, ensuring it's warm to the touch to indicate adequate arterial perfusion. Cool skin suggests decreased arterial perfusion.
• Check Capillary refill by pressing nail beds, with blood return expected within 3 seconds. Prolonged refill suggests decreased arterial perfusion, and cyanotic nail beds indicate venous congestion.
• Ensure pulses are palpable and strong, equal to the unaffected extremity. Doppler ultrasonography may be required if edema makes palpation difficult.
• Ensure the client can actively move the affected extremity.

Nutrition

• Provide a diet high in protein and calcium to facilitate bone healing.
• Encourage iron-rich foods if blood loss occurred.
• Vitamin and mineral supplements promote healing.

Diagnostic procedures

• Standard radiographs, CT scans, or MRI can identify the fracture type and location.
• CT scans are used to detect fractures of the hip and pelvis.
• MRI determines soft tissue damage around the fracture.
• Bone scans using radioactive material determine hairline fractures and complications/delayed healing:

Lab tests

• CBC (complete blood count) detects bleeding (decreased hemoglobin, hematocrit) or infection (increased WBC).
• ESR (erythrocyte sedimentation rate) can be elevated if inflammation is present.

Expected findings

• History of trauma, metabolic bone disorders, chronic conditions, and possible use of corticosteroid therapy are all key findings.
• Pain and reduced movement at or distal to the fracture site are expected.

Physical Assessment Findings

• Examine upper extremities with the client standing or sitting, and lower extremities and pelvis with the client lying down.
• Crepitus is a grating sound from rubbing bone fragments.
• Deformity involves internal or external rotation, shortened extremity, visible bone in open fractures, or asymmetrical limb appearance.
• Muscle spasms are due to pulling forces on misaligned bones.
• Edema (swelling) results from trauma.
• Ecchymosis (bleeding into soft tissues) results from trauma.
• Subcutaneous emphysema, or air bubbles under the skin, is a late finding.

Risk factors

• Risk factors include osteoporosis, falls, motor vehicle crashes, substance use disorder, bone cancer, Paget’s disease, contact sports, hazardous recreational activities, physical abuse, lactose intolerance, malnutrition, and advanced age.

Health promotion

• Ensure adequate calcium intake for the appropriate developmental stage.
• Ensure adequate vitamin D intake and/or sunlight exposure.
• Monitor for osteoporosis, especially in postmenopausal clients and those with thyroid disorders.
• Engage in regular weight-bearing exercises.
• Take bisphosphonates if prescribed to slow bone resorption and treat osteoporosis.
• Use caution to prevent falls or accidents.
• Prevent injury by using seat belts and helmets.

Medications

• Opioid and non-opioid analgesics control pain.
• NSAIDs decrease tissue inflammation, but long-term use can delay bone healing.
• Muscle relaxants relieve muscle spasms.
• Stool softeners prevent constipation.
• Prophylactic antibiotics decrease infection risk in open fractures.

Immobilizing interventions

• Immobilization prevents further injury, promotes healing/circulation, reduces pain, and corrects deformity.
• Types of immobilization devices include braces, casts, splints/immobilizers, traction, external fixation, internal fixation, and orthopedic shoes and boots.
• Closed reduction involves manual traction to realign bone fragments, followed by immobilization for healing.

Splint and immobilizer use

• Splints and immobilizers support, control movement, reduce pain, correct deformity, and prevent additional injury.
• Splints are removable for monitoring skin swelling or integrity and can support injured areas until casting occurs.
• Casting is used for post-paralysis injuries to avoid joint contracture.
• Immobilizers are prefabricated and fasten with hook-and-loop straps.

Traction

• Traction uses pulling force to promote and maintain alignment.
• Traction prescriptions should specify the type of traction, amount of weight, and whether it can be removed for nursing care.
• Goals of traction include preventing soft tissue injury, realigning bone fragments, decreasing muscle spasms and pain, and correcting or preventing deformities.

Types of Traction

• Manual: A pulling force is applied by the hands of the provider for temporary immobilization, usually with sedation or anesthesia, in conjunction with the application of an immobilizing device.
• Straight or running: The counter traction is provided by the client’s body by applying a pulling force in a straight line. Movement of the client’s body can alter the traction provided.
• Skin: Used to decrease muscle spasms and immobilize the extremity prior to surgery, using light (5 to 10 lb) weights. The pulling force is applied by weights attached by rope to the client’s skin with tape, straps, boots, or cuffs. Examples include Bryant’s traction (for congenital hip dislocation in children) and Buck’s traction (preoperatively for hip fractures in adults).
• Balanced suspension produces counter traction using devices like slings or splints to support the fractured extremity off the bed while pulling with ropes and weights.
• Skeletal Uses screws inserted into the bone (such as halo traction), allowing heavier weights (15 to 30 lb) and longer traction time to realign the bone. Frequent pin site care is necessary to prevent infection.

Education

• Report pain not relieved by analgesics or increasing in intensity.
• Report numbness, tingling, or changes in extremity color.

Complications

Compartment syndrome

• Compartment syndrome occurs when pressure within muscle compartments compromises circulation, causing an ischemia-edema cycle.
• Increased edema causes pressure on nerve endings, leading to pain and reduced blood flow, compromising neurovascular status.
• Pressure sources can be external (tight cast) or internal (blood or fluid accumulation).

Manifestations

• Compartment syndrome is assessed using the five P's: pain, paralysis, paresthesia, pallor, and pulselessness.
• Increased pain is unrelieved by elevation or pain medication, with intense pain upon passive movement.
• Paresthesia (numbness, burning, tingling) is an early sign.
• Paralysis, motor weakness, or inability to move the extremity are late signs of nerve damage.
• Pallor affects the tissue, and nail beds become cyanotic.
• Pulselessness is a late sign.
• Palpated muscles are hard and swollen due to edema.
• Untreated tissue necrosis can result. Neuromuscular damage occurs within 4 to 6 hours.

Treatment

• Surgical treatment involves a fasciotomy to relieve pressure and restore circulation.
• The open wounds require sterile packings and dressings until secondary closure, possibly needing skin grafts.
• Negative pressure wound therapy can be used to reduce edema.

Fat embolism

• Adults aged 70 to 80 and assigned male at birth between 20 and 40 years are at increased risk, commonly following hip fractures or within 72 hours after pelvic fracture or surgery.
• Fat globules released into vasculature travel to small blood vessels, especially in the lungs, causing acute respiratory insufficiency and impaired organ perfusion. A cardiac diagnosis should differentiate between fat embolism and pulmonary embolism.

Manifestations

• Early signs include dyspnea, increased respiratory rate, decreased oxygen saturation, headache, decreased mental acuity, respiratory distress, tachycardia, confusion, and chest pain.
• Late signs include cutaneous petechiae (pinpoint-sized subdermal hemorrhages) on the neck, chest, upper arms, and abdomen, a discriminating finding from pulmonary embolism.

Venous thromboembolism

• Deep-vein thrombosis (DVT) and pulmonary embolism are common after trauma.

Osteomyelitis

• Osteomyelitis is a bone infection from infectious organisms following trauma or surgical repair.

Manifestations

• Manifestations include constant, pulsating, localized bone pain worsened by movement; erythema and edema at the infection site; fever (though older adults might not have elevated temperature); leukocytosis; and possible elevated sedimentation rate.
• Many manifestations will disappear when the infection becomes chronic.

Avascular Necrosis

• Avascular necrosis results from circulatory compromise after a fracture.
• Disrupted blood flow leads to ischemia and bone necrosis.
• Commonly found in hip fractures or fractures with bone displacement.
• Risk factors include long-term corticosteroid use, radiation therapy, rheumatoid arthritis, and sickle cell disease.
• Bone graft or prosthetic replacement could be necessary.

Failure of fracture to heal

• Delayed union: A fracture that hasn't healed within 6 months of injury.
• Malunion: Fracture heals incorrectly.
• Nonunion: Fracture never heals.
• Electrical bone stimulation and bone grafting can treat nonunion.
• Low-intensity pulse ultrasound can promote healing.
• Occurs more frequently in older adults.

Hemorrhage

• Due to bones being highly vascular, bleeding is a risk following fracture and can lead to hypovolemic shock.

Complex regional pain syndrome (CRPS)

• Severe chronic pain typically follows musculoskeletal trauma with motor, autonomic nervous system, and sensory changes and can progress to osteoporosis.

Heterotopic ossification

• Growth of bone in soft tissue areas, causing pain and joint stiffness.
• Surgery can be indicated if ROM is significantly decreased.