Learning Objectives
By the end of this section, you will be able to:
- Discuss the pathophysiology, risk factors, and clinical manifestations for bone fractures
- Describe the diagnostics and laboratory values associated with bone fractures
- Apply nursing concepts and plan associated nursing care for patients with bone fractures
- Evaluate the efficacy of nursing care for patients with bone fractures
- Describe the medical therapies that apply to the care of bone fractures
A break in the bone structure, or a bone fracture, is one of the most common types of musculoskeletal traumas. Worldwide in 2019, 178 million fractures occurred, in addition to 455 million existing cases of acute or chronic symptoms related to a fracture (GBD 2019 Fracture Collaborators, 2021). Fractures affect the entire population, regardless of demographic factors such as age or sex. However, certain risk factors are associated with different types of fractures. For example, older adults are at higher risk for experiencing hip fractures than their younger counterparts.
Pathophysiology
The underlying pathophysiology of fractures involves stress placed on a bone that results in a break in the bone’s structure. Several different forces can result in bone fractures, including direct trauma, twisting movements, and crushing forces. Some of the most common causes of fractures include motor vehicle accidents, sports injuries, and falls. Usually when a bone fracture occurs, the soft tissue surrounding the bone is also affected. This can result in edema, hemorrhage, tendon damage, and severed nerves—all collectively referred to as soft tissue injuries.
Types of Fractures
Fractures are classified by their complexity, location, and other features (Figure 13.10; Table 13.3). Some fractures have the features of more than one type of fracture and therefore may be described using more than one term (e.g., an open transverse fracture).
| Type of Fracture | Description |
|---|---|
| Closed (or simple) | Fracture in which the skin remains intact |
| Comminuted | Fracture with several breaks, resulting in many small pieces between two large segments |
| Greenstick | Partial fracture in which only one side of the bone is broken |
| Impacted | Fracture in which one fragment is driven into the other, usually as a result of compression |
| Oblique | Fracture that occurs at an angle that is not 90 degrees |
| Open (or compound) | Fracture in which at least one end of the broken bone tears through the skin; carries a high risk of infection |
| Spiral | Fracture in which bone segments are pulled apart by a twisting motion |
| Transverse | Fracture that occurs straight across the long axis of the bone |
Clinical Manifestations
The specific clinical manifestations of fractures will vary depending on the anatomic location affected, but there are certain symptoms associated with nearly all fracture types, including
- pain and tenderness,
- edema,
- inability to move the affected body part,
- bruising or hematoma formation, and
- deformity of the affected extremity.
Assessment and Diagnostics
The only definitive way to diagnose a bone fracture is to visualize the break in the bone structure. This can be done with several different types of imaging tests, including x-ray, magnetic resonance imaging (MRI), and computed tomography (CT) scanning. X-rays are typically performed first, as they can quickly and easily visualize bone structure. A CT scan or MRI may be used if there are suspected soft tissue injuries that the provider or surgeon needs to see in more detail.
Read the Electronic Health Record
Assessment of a Patient with a Tibia Facture
Patient’s Name: Jaun
Age: 17 years
Sex: Male
Chief Complaint:
- pain in the left lower leg after collision playing hockey
- presents with the inability to bear weight and deformity of the left lower leg
- diagnosed with concussion two years ago: sport (hockey) injury
- forty-two stitches applied to chin last year: sport (hockey) injury
- tonsillectomy at age four
- temperature: 93.3 °F
- heart rate: 132 bpm
- blood pressure: 152/94 mm Hg
- respiratory rate: 32 breaths per minute
- oxygen saturation: 98 percent on room air
- BMI: 28
- WBC count: 10,000/µL (normal)
- hemoglobin: 13.5 g/dL (normal)
- hematocrit: 40.5 percent (normal)
- platelets: 250,000/µL (normal)
- electrolytes:
- sodium: 138 mmol/L (normal)
- potassium: 4.0 mmol/L (normal)
- chloride: 102 mmol/L (normal)
- Imaging includes full-length AP and lateral views of the affected area; also AP, lateral, and oblique views of the ipsilateral knee and ankle.
- Fracture noted to left distal tibia.
- Patient reports sudden onset of sharp pain in lower leg after colliding with another player in a hockey game, followed by throbbing when attempting to walk.
- Mild diaphoresis was observed upon admission.
- Patient otherwise presents as an active young adult with no other health disparities.
- acetaminophen: 500 mg every night as needed for pain
Nursing Care of the Patient with Bone Fractures
Most of the nursing care for patients with fractures focuses on controlling pain and ensuring patient comfort. It is also important for the nurse to assess for and intervene if complications develop such as compartment syndrome, a condition caused by increased pressure within an area of tissue and resulting in muscle and nerve damage (discussed more later in this section).
Recognizing Cues and Analyzing Cues
There are several key assessments the nurse should perform on patients with bone fractures. First, it is important for the nurse to perform frequent neurovascular examinations on the affected extremity. Neurovascular checks involve assessing the extremity for the 5 P’s:
- pain (on a scale of 1 to 10);
- pulse (weak pulses may indicate insufficient blood supply to the affected extremity);
- pallor (pale, blue, or purple tone in the affected extremity may indicate compromised blood flow);
- paresthesia (numbness or tingling in the extremity may indicate nerve damage); and
- paralysis, or inability to move the affected extremity.
Link to Learning
Review this article to learn more about the 5 P’s acronym for circulation assessment.
In addition to frequent neurovascular checks, the nurse must also assess for signs and symptoms of an embolism. With fractures, especially those in the long bones like the femur, there is an increased risk that a fat embolism, or clot, will form. This occurs because the break in the bone allows pieces of fatty tissue to leak out into the systemic circulation. The fat embolism can travel through the body’s systemic circulation, get lodged in the brain or lungs, and quickly cause a life-threatening ischemic stroke or pulmonary embolism. These clots most commonly develop between 24 and 72 hours after the initial fracture, so the nurse should monitor closely for signs of neurological changes or shortness of breath (Adeyinka & Pierre, 2022).
Prioritizing Hypotheses, Generating Solutions, and Taking Action
If the nurse assesses symptoms such as shortness of breath, chest pain, or neurological changes following a fracture, the nurse will hypothesize that the patient is potentially experiencing a fat embolism. If this condition is suspected, the nurse must act quickly to mitigate complications. Priority actions would include notifying the provider, calling a rapid response team if indicated, and applying oxygen as necessary. Additionally, the nurse should carefully follow orders given by the treating provider, such as administering medication or providing other interventions.
There are many important nursing interventions that should be implemented as part of the care provided to patients with bone fractures. First, the nurse will attempt to promote mobility of the affected extremity as much as possible. Though the patient may be in a cast or splint, there are typically certain exercises the patient should perform to maintain as much mobility as possible. The nurse can help educate patients about these exercises and ensure that the patient is prepared to perform them on their own at home upon discharge.
Another important aspect of nursing care for these patients is education about how to care for their cast at home. If the cast is not made of a water-safe material, the nurse should demonstrate how to wrap the cast with plastic before taking a shower so that the plaster does not get wet and re-mold itself. The nurse will also counsel the patient on the importance of not sticking any foreign objects inside the cast. The skin underneath the cast tends to become dry and itchy, and patients are often tempted to stick items inside to scratch the skin and relieve the itching. This can result in skin breakdown and should be avoided while the cast is in place.
Evaluation of Nursing Care for the Patient with Fractures
After removal of the cast or splint, the nurse should perform a thorough assessment of the fractured extremity to determine whether the treatment was successful. In some cases, the patient may require another cast or splint placement, but in most cases the bone will have healed completely.
Evaluating Outcomes
While evaluating the patient after cast removal, the nurse will assess for signs indicating that the treatment was effective. These signs include
- lack of deformities to the bone or extremity,
- decreased swelling,
- improved pain,
- ability to move distal parts of the affected extremity,
- normal skin color, and
- strong pulse distal to the fracture.
Additionally, a follow-up x-ray will be performed to evaluate the healing status of the fracture and determine whether further treatment is indicated.
Medical Therapies and Related Care
The specific treatment plan for a bone fracture depends on the anatomic location of the affected area. In some cases, the fracture will heal on its own; in other cases, more invasive interventions such as immobilization, reduction, fixation, or surgery may be required. In addition to the manual treatments mentioned in subsequent sections, it is also important for the nurse to promote a diet that will aid in the healing of the bone fracture. Encouraging the patient to consume a well-rounded, healthy diet that is high in protein, which assists in bone and tissue healing.
Immobilization
For mild fractures, immobilization of the fracture with a cast or splint may be all that is required. The duration of the immobilization varies depending on the affected bone, but it typically ranges anywhere from three to eight weeks. Splints cover only part of the affected area and typically do not have to be worn as long as hard casts.
Closed Reduction
More-severe fractures may require the use of a closed reduction procedure. The goal of this procedure is to set the fractured bone and realign it into a normal position. The provider manually adjusts the bone from the outside to line up the broken parts of the bone correctly (Figure 13.11). Because this procedure can be quite painful, the patient will often receive a combination of local anesthesia, sedatives, and analgesics. After closed reduction is performed, a cast or splint for immobilization is applied.
Surgical Care
The most-severe fractures usually require surgical intervention. There are several types of surgery for fractures, including internal and external fixation and arthroplasty.
Internal Fixation
A surgery of internal fixation involves the placement of metal pieces into the bone to help it heal as it grows back together (Figure 13.12). The types of metal pieces vary depending on the fracture’s location and size, but they can be rods, plates, screws, or pins. In some cases, the metal pieces are removed after healing occurs; in other cases, the metal pieces are left in place forever.
External Fixation
Another surgical procedure that can be performed to treat fractures is an external fixation, which involves the internal placement of screws on either side of the fracture by drilling pins into the bone and then connecting them to an external brace or bracket (Figure 13.13). The external brace is temporary but stays in place long enough for the fractured bone to heal. Typically, an internal fixation procedure is performed after removal of the external device to complete the healing process.
One of the most important aspects of nursing care for a patient with an external fixation device is performing meticulous pin care to prevent infection. The nurse should clean the pin sites daily with soap and water and dab to dry, as rubbing can create friction and skin breakdown. It is important for the nurse to monitor the pin sites carefully for signs of infection including redness, drainage, swelling, or pain. The nurse will follow any provider orders regarding special care, such as physical therapy or follow-up with the external fixator.
Arthroplasty
Joint replacement, known as arthroplasty, may be required if the fracture occurs in a joint such as the shoulder, elbow, hip, or knee. The fractured joint is removed from the body and replaced with an artificial joint, which is usually made of metal, plastic, or ceramic materials.
Compartment Syndrome
A common and serious complication that may occur with bone fractures and soft tissue injuries is compartment syndrome. With a fracture or injury to the surrounding tissue, pressure builds within the skin and muscles, leading to decreased blood flow to the affected extremity (Figure 13.14). Without adequate blood supply, the extremity becomes malnourished and can quickly become necrotic without medical intervention. In severe cases, a fasciotomy, or incision into the skin and fascia to relieve pressure, will be required.
Signs and symptoms of compartment syndrome include
- diminished distal pulses in the affected extremity,
- swelling and taut skin in the extremity,
- numbness or “pins and needles” feeling in the extremity, and
- difficulty moving the extremity.
If the nurse suspects that the patient is experiencing compartment syndrome, they must alert the treating provider immediately. If quick intervention does not take place, the limb is at risk of necrosis because the internal pressure of the extremity results in a diminished blood supply to the extremity.