This study guide is about fractures, management of fractures, and 2 nursing care plans for fractures. Use it to create educational care plans for fractures.
What is a fracture?
A fracture is a traumatic injury interrupting bone continuity.
What are the types of fractures?
- Closed simple, uncomplicated fractures – do not cause a break in the skin.
- Open compound, complicated fractures – involve trauma to surrounding tissue and break in the skin.
- Incomplete fractures– are partial cross-sectional breaks with incomplete bone disruption.
- Complete fractures – are complete cross-sectional breaks severing the periosteum.
- Comminuted fractures – produce several breaks of the bone, producing splinters and fragments.
- Greenstick fractures – break one side of a bone and bend the other.
- Spiral (torsion) fractures – involve a fracture twisting around the shaft of the bone.
- Transverse fractures – occur straight across the bone.
- Oblique fractures – occur at an angle across the bone (less than a transverse)
What are the risk factors of fractures?
- From crushing force or direct blow
- Sudden twisting motion; persons with osteoporosis are at a particular risk
- Extremely forceful muscle contraction can cause fractures
- Pathological fractures result from a weakness in bone tissue, which may be caused by neoplasm or a malignant growth
What is the pathophysiology of fractures?
A fracture occurs when stress placed on a bone exceeds the bone’s ability to absorb it.
Stages of normal fracture healing include:
- Cellular proliferation
- Callus formation
- Callus ossification
- Mature one remodeling
What will happen if a fracture is left untreated?
- Life-threatening systemic fat embolus, which most commonly develops within 24 to 72 hours after a fracture.
- Compartment syndrome which is a condition involving increased pressure and constriction of nerves and vessels within an atomic compartment.
- Nonunion of the fracture side
- Arterial damage during treatment
- Infection and possibly sepsis
- Hemorrhage, possibly leading to shock
What are the clinical manifestations of fractures?
- Abnormal movement and crepitus
- Loss of function
- Visible deformity
- Paresthesias and other sensory abnormalities
Laboratory and diagnostic study findings
- Radiographs and other imaging studies may identify the site and type of fracture.
Management of Fractures
How do you manage fractures?
Medical Management of Fractures
The principles of fracture treatment include reduction, immobilization, and regaining of normal function and strength through rehabilitation.
- The fracture is reduced “setting” the bone using a closed method (manipulation and manual traction (e.g. splint or cast) or an open method (surgical placement of internal fixation devices like pins, wires, screws, plates, and nails) to restore the fracture fragments to anatomic alignment and rotation. The specific method depends on the nature of the fracture.
- After the fracture has been reduced, immobilization holds the bone in the correct position and alignment until union occurs. Immobilization is accomplished by external or internal fixation.
- The function is maintained and restored by controlling swelling by elevating the injured extremity and applying ice as prescribed.
- Restlessness, anxiety, and discomfort are controlled using a variety of approaches (e.g. reassurance, position changes, pain relief strategies, including analgesic agents).
- Isometric and muscle-setting exercises are done to minimize disuse atrophy and to promote circulation.
- With internal fixation, the surgeon determines the amount of movement and weight-bearing stress the extremity can withstand and prescribes the level of activity.
Nursing Diagnosis of Fractures
- Pain-related to fracture, soft tissue damage, muscle spasm, and surgery
- Impaired physical mobility related to a fractured hip
- Impaired skin integrity related to surgical incision
- Risk for impaired urinary elimination related to immobility
- Risk for disturbed thought process related to age, the stress of trauma, unfamiliar surroundings, and drug therapy
- Risk for ineffective coping related to injury, anticipated surgery, and dependence
- Risk for impaired home maintenance related to fractured hip and impaired mobility
Nursing Management of Fractures
- Prevent infection
- Cover any breaks in the skin with a clean or sterile dressing.
- Provide care during client transfer.
- Immobilize a fractured extremity with the splint in the position of the deformity before moving the client; avoid strengthening the injured body part if a joint is involved.
- Support the affected body part above and below the fracture site when moving the client.
- Provide client and family teaching.
- Explain prescribed activity restrictions and necessary lifestyle modification because of impaired mobility.
- Teach the proper use of assistive devices, as indicated.
- Administer prescribed medications, which may include opioid or nonopioid analgesics and prophylactic antibiotics for an open fracture.
- Prevent and manage potential complications.
- Observe for symptoms of life-threatening fat embolus, which may include personality change, restlessness, dyspnea, crackles, white sputum, and petechiae over the chest and buccal membranes. Assist with respiratory support, which must be instituted early.
- Observe for symptoms of compartment syndrome, which include deep, unrelenting pain; hard edematous muscle; and decreased tissue perfusion with impaired neurovascular assessment findings.
- Monitor closely for signs and symptoms of other complications.
- Patient education regarding different factors that affect fracture healing
- Factors that enhance fracture healing
- Immobilization of fracture fragments
- Maximum bone fragment contact
- Sufficient blood supply
- Proper nutrition
- Exercise: weight-bearing for long bones
- Hormones: growth hormone, thyroid, calcitonin, vitamin D, anabolic steroids
- Factors that inhibit fracture healing
- Extensive local trauma
- Bone loss
- Inadequate immobilization
- Space or tissue between bone fragments
- Local malignancy
- Metabolic bone disease (Paget’s disease)
- Irradiated bone (radiation necrosis)
- Avascular necrosis
- Intra-articular fracture (synovial fluid contains fibrinolysis, which lyse the initial clot and retard clot formation)
- Age (elderly persons heal more slowly)
- Corticosteroids (inhibit the repair rate)
2 Nursing Care Plans for Fractures
What are some of the available nursing care plans for fractures?
Nursing Care Plan 1
- Risk for Trauma
Risk factors may include
- Loss of skeletal integrity (fractures)/movement of bone fragments
- Getting up without assistance
- Maintain stabilization and alignment of fracture(s).
- Display callus formation/beginning union at fracture site as appropriate.
- Demonstrate body mechanics that promote stability at fracture site.
- Maintain bed rest or limb rest as indicated. Provide support of joints above and below fracture site, especially when moving and turning.
- Rationale: Provides stability, reducing possibility of disturbing alignment and muscle spasms, which enhances healing.
- Secure a bedboard under the mattress or place patient on orthopedic bed.
- Rationale: Soft or sagging mattress may deform a wet (green) plaster cast, crack a dry cast, or interfere with pull of traction.
- Support fracture site with pillows or folded blankets. Maintain neutral position of affected part with sandbags, splints, trochanter roll, footboard.
- Rationale: Prevents unnecessary movement and disruption of alignment. Proper placement of pillows also can prevent pressure deformities in the drying cast.
- Use sufficient personnel for turning. Avoid using abduction bar for turning patient with spica cast.
- Rationale: Hip, body or multiple casts can be extremely heavy and cumbersome. Failure to properly support limbs in casts may cause the cast to break.
- Observe and evaluate splinted extremity for resolution of edema.
- Rationale: Coaptation splint (Jones-Sugar tong) may be used to provide immobilization of fracture while excessive tissue swelling is present. As edema subsides, readjustment of splint or application of plaster or fiberglass cast may be required for continued alignment of fracture.
- Maintain position or integrity of traction.
- Rationale: Traction permits pull on the long axis of the fractured bone and overcomes muscle tension or shortening to facilitate alignment and union. Skeletal traction (pins, wires, tongs) permits use of greater weight for traction pull than can be applied to skin tissues.
- Ascertain that all clamps are functional. Lubricate pulleys and check ropes for fraying. Secure and wrap knots with adhesive tape.
- Rationale: Ensures that traction setup is functioning properly to avoid interruption of fracture approximation.
- Keep ropes unobstructed with weights hanging free; avoid lifting or releasing weights.
- Rationale: Optimal amount of traction weight is maintained. Note: Ensuring free movement of weights during repositioning of patient avoids sudden excess pull on fracture with associated pain and muscle spasm.
- Assist with placement of lifts under bed wheels if indicated.
- Rationale: Helps maintain proper patient position and function of traction by providing counterbalance.
- Position patient so that appropriate pull is maintained on the long axis of the bone.
- Rationale: Promotes bone alignment and reduces risk of complications (delayed healing and nonunion).
- Review restrictions imposed by therapy such as not bending at waist and sitting up with Buck traction or not turning below the waist with Russell traction.
- Rationale: Maintains integrity of pull of traction.
- Assess integrity of external fixation device.
- Rationale: Hoffman traction provides stabilization and rigid support for fractured bone without use of ropes, pulleys, or weights, thus allowing for greater patient mobility, comfort and facilitating wound care. Loose or excessively tightened clamps or nuts can alter the compression of the frame, causing misalignment.
- Review follow-up and serial x-rays.
- Rationale: Provides visual evidence of proper alignment or beginning callus formation and healing process to determine level of activity and need for changes in or additional therapy.
- Administer alendronate (Fosamax) as indicated.
- Rationale: Acts as a specific inhibitor of osteoclast-mediated bone resorption, allowing bone formation to progress at a higher ratio, promoting healing of fractures and decreasing rate of bone turnover in presence of osteoporosis.
- Initiate or maintain electrical stimulation if used.
- Rationale: May be indicated to promote bone growth in presence of delayed healing or nonunion.
Nursing Care Plan 2
- Risk for Peripheral Neurovascular Dysfunction
Risk factors may include
- Reduction/interruption of blood flow
- Direct vascular injury, tissue trauma, excessive edema, thrombus formation
- Maintain tissue perfusion as evidenced by palpable pulses, skin warm/dry, normal sensation, usual sensorium, stable vital signs, and adequate urinary output for individual situation.
- Remove jewelry from affected limb.
- Rationale: May restrict circulation when edema occurs.
- Evaluate presence and quality of peripheral pulse distal to injury via palpation or Doppler. Compare with uninjured limb.
- Rationale: Decreased or absent pulse may reflect vascular injury and necessitates immediate medical evaluation of circulatory status. Be aware that occasionally a pulse may be palpated even though circulation is blocked by a soft clot through which pulsations may be felt. In addition, perfusion through larger arteries may continue after increased compartment pressure has collapsed the arteriole or venule circulation in the muscle.
- Assess capillary return, skin color, and warmth distal to the fracture.
- Rationale: Return of color should be rapid (3–5 sec). White, cool skin indicates arterial impairment. Cyanosis suggests venous impairment. Note:Peripheral pulses, capillary refill, skin color, and sensation may be normal even in presence of compartmental syndrome because superficial circulation is usually not compromised
- Maintain elevation of injured extremity(ies) unless contraindicated by confirmed presence of compartmental syndrome.
- Rationale: Promotes venous drainage and decreases edema. Note: In presence of increased compartment pressure, elevation of the extremity actually impedes arterial flow, decreasing perfusion.
- Assess entire length of injured extremity for swelling or edema formation. Measure injured extremity and compare with uninjured extremity. Note appearance and spread of hematoma.
- Rationale: Increasing circumference of injured extremity may suggest general tissue swelling or edema but may reflect hemorrhage. Note: A 1-in increase in an adult thigh can equal approximately 1 unit of sequestered blood.
- Note reports of pain extreme for type of injury or increasing pain on passive movement of extremity, development of paresthesia, muscle tension or tenderness with erythema, and change in pulse quality distal to injury. Do not elevate extremity. Report symptoms to physician at once.
- Rationale: Continued bleeding and edema formation within a muscle enclosed by tight fascia can result in impaired blood flow and ischemic myositis or compartmental syndrome, necessitating emergency interventions to relieve pressure and restore circulation. Note: This condition constitutes a medical emergency and requires immediate intervention.
- Investigate sudden signs of limb ischemia (decreased skin temperature, pallor, and increased pain).
- Rationale: Fracture dislocations of joints (especially the knee) may cause damage to adjacent arteries, with resulting loss of distal blood flow.
- Encourage patient to routinely exercise digits and joints distal to injury. Ambulate as soon as possible.
- Rationale: Enhances circulation and reduces pooling of blood, especially in the lower extremities.
- Investigate tenderness, swelling, pain on dorsiflexion of foot (positive Homans’ sign).
- Rationale: There is an increased potential for thrombophlebitis and pulmonary emboli in patients immobile for several days. Note: The absence of a positive Homans’ sign is not a reliable indicator in many people, especially the elderly because they often have reduced pain sensation.
- Monitor vital signs. Note signs of general pallor, cyanosis, cool skin, changes in mentation.
- Rationale: Inadequate circulating volume compromises systemic tissue perfusion.
- Test stools or gastric aspirant for occult blood. Note continued bleeding at trauma or injection site(s) and oozing from mucous membranes.
- Rationale: Increased incidence of gastric bleeding accompanies fractures and trauma and may be related to stress or occasionally reflects a clotting disorder requiring further evaluation.
- Perform neurovascular assessments, noting changes in motor and sensory function. Ask patient to localize pain and discomfort.
- Rationale: Impaired feeling, numbness, tingling, increased or diffuse pain occur when circulation to nerves is inadequate or nerves are damaged.
- Test sensation of peroneal nerve by pinch or pinprick in the dorsal web between the first and second toe, and assess ability to dorsiflex toes if indicated.
- Rationale: Length and position of peroneal nerve increase risk of its injury in the presence of leg fracture, edema or compartmental syndrome, or malposition of traction apparatus.
- Assess tissues around cast edges for rough places and pressure points. Investigate reports of “burning sensation” under cast.
- Rationale: These factors may be the cause of or be indicative of tissue pressure, ischemia, leading to breakdown and necrosis.
- Monitor location of supporting ring of splints or sling.
- Rationale: Traction apparatus can cause pressure on vessels and nerves, particularly in the axilla and groin, resulting in ischemia and possible permanent nerve damage.
- Apply ice bags around fracture site for short periods of time on an intermittent basis for 24–72 hr.
- Rationale: Reduces edema and hematoma formation, which could impair circulation. Note: Length of application of cold therapy is usually 20–30 min at a time.
- Monitor hemoglobin (Hb), hematocrit (Hct), coagulation studies such as prothrombin time (PT) levels.
- Rationale: Assists in calculation of blood loss and effectiveness of replacement therapy. Coagulation deficits may occur secondary to major trauma, presence of fat emboli, or anticoagulant therapy.
- Administer IV fluids and blood products as needed.
- Rationale: Maintains circulating volume, enhancing tissue perfusion.
- Split or bivalve cast as needed.
- Rationale: May be done on an emergency basis to relieve restriction and improve impaired circulation resulting from compression and edema formation in injured extremity.
- Assist with intracompartmental pressures as appropriate.
- Rationale: Elevation of pressure (usually to 30 mm Hg or more) indicates need for prompt evaluation and intervention. Note: This is not a widespread diagnostic tool, so special interventions and training may be required.
- Review electromyography (EMG) and nerve conduction velocity (NCV) studies.
- Rationale: May be performed to differentiate between true nerve dysfunction, muscle weakness and reduced use due to secondary gain.
- Prepare for surgical intervention (fibulectomy, fasciotomy) as indicated.
- Rationale: Failure to relieve pressure or correct compartmental syndrome within 4–6 hr of onset can result in severe contractures or loss of function and disfigurement of extremity distal to injury or even necessitate amputation.