Fractures

WHAT WENT WRONG?
Excess stress or direct trauma is placed on a bone, causing a break. This results in
damage to surrounding muscles and tissue, leading to hemorrhage, edema, and local
tissue damage. Initially after the fracture, bleeding in the area leads to hematoma
formation at the site. Inflammatory cells enter the area. Granulation tissue replaces
the hematoma. Cellular changes continue and a non-bony union known as a callus
develops. Osteoblasts continue to enter the area. Fibrous tissue in the fractured
area changes to bone.
The fracture site may be just a crack in the bone, without displacing any of the
bone itself. A fracture that does not go all the way through the bone is considered
an incomplete fracture. The fracture may also go all the way through a bone, break-
ing it into two (or more) pieces, which is referred to as a complete fracture. The
surrounding muscle tissue that attaches above and below the fracture area in a limb
will continue to create tension on their attachment points to the bone and pull the
pieces further out of alignment. Some fractured bone pieces may penetrate through
the skin; this is known as an open or compound fracture. Those that do not pene-
trate the skin are considered closed or simple fractures.


PROGNOSIS
The area of fracture needs to be identified (via an x-ray) and properly treated in
order to heal. The fractured area typically needs to be realigned and then immobi-
lized to allow for proper healing. During this time of immobilization, the bone
cells come into the area to rebuild new bone to repair the damaged area. The period
of immobilization typically lasts for 6 to 8 weeks, depending on the site and degree
of damage. The full structural strength is not typically restored until months after
the break, depending on the size and location of the fracture. Time for full healing
varies from 6 weeks in young healthy adults with simple fractures to a couple of
months in older patients with other health problems. Older patients have a signif-
icant increase in both morbidity and mortality following a hip fracture.
Complications following fractures include compartment syndrome, fat embo-
lism, deep vein thrombosis (DVT), delayed union, nonunion, or misalignment.
Compartment syndrome occurs when excess pressure builds up within a muscle
compartment sheath. The pressure may be coming from internal or external
sources of pressure. This is most common with fractures involving the lower leg
or lower arm. Fat globules may be released from the yellow bone marrow into the
bloodstream and embolize to other areas of the body. The risk for this is highest in
the elderly and in men between 18 and 40. Decrease in mobility following fracture
will increase the risk for DVT. Smoking, obesity, heart disease, and lower extrem-
ity surgery all increase this risk. Delayed union is when a fracture has not joined
within 6 months, despite appropriate treatments. Nonunion is a fracture site that
fails to completely heal. Misalignment is when the fracture site heals, but the
anatomic alignment is not as it should be.
Muscle wasting may occur in the area that has been immobilized. Physical ther-
apy can be very helpful for the patient to regain full functional strength of the area.

SIGNS AND SYMPTOMS

• Local bleeding—may or may not see skin level discoloration; it depends on
amount of blood loss and distance between fracture and skin
• Edema at site due to inflammatory reaction to tissue damage
• Abnormal range of motion—need intact bone in order for muscle to pull and
create movement; if fracture occurs near joint, swelling may limit ROM
• Shortening of the leg and external rotation is common following hip fracture

TEST RESULTS

• X-ray shows fracture—may be displaced or not.
• CT scan shows fracture—useful when patient’s body part cannot be turned
or positioned for imaging (e.g. the neck).
• Bone scan will show increased cellular activity in area of fracture—useful
for sites where fracture not easily seen or for hairline fractures not previously
diagnosed.

TREATMENT
• Immobilize broken bone—to stabilize area, initially may be done with splint
until fracture reduced (replaced into proper position) and cast applied or fix-
ation device applied surgically.
• Open reduction is the surgical repair and direct visual realignment of fracture.
• Pain management as needed.


NURSING DIAGNOSES
• Risk for impaired skin integrity
• Risk for activity intolerance
• Impaired physical mobility

NURSING INTERVENTION
• Monitor circulation: check peripheral pulses, capillary refill, and skin tem-
perature distal to the break. Compromise of blood flow will diminish pulses,
slow capillary refill and cause cool skin temperature. Compare bilateral areas
for symmetry.
• Monitor vital signs: check for elevated pulse, low BP, and elevated respira-
tory rate. The broken bone ends can lacerate a vessel causing internal bleed-
ing; monitor for signs of shock. May see elevated temperature with infection
from open fracture.
• Explain to the patient:
• How to provide self-care—depending on the fracture area, the patient’s
ability to care for himself or herself may be compromised.
• The importance of performing range-of-motion exercise to maintain mus-
cle tone in the areas not immobilized.
• Not to insert anything into the cast. The padding may become dislodged,
causing pressure points under the hard cast which would lead to skin
breakdown. The skin integrity may also be broken when scratching under
the cast, leading to an infection.