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Fractures Pathophysiology Treatment and Nursing Care

Fractures Pathophysiology Treatment and Nursing Care

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Page 58 Fractures multiple choice questionnaire Page 59 Read Yvonne Potter’s practice profile on caring for patients with syphilis Page 60 Guidelines on how to write a practice profile

Fractures:pathophysiology, treatment and nursing care
NS460 Whiteing NL (2008) Fractures: pathophysiology, treatment and nursing care. Nursing Standard. 23, 2, 49-57. Date of acceptance: August 5 2008.

Many nurses working in the primary and secondary sectors will care for patients who have sustained fractures. The ability to assess these patients systemically in addition to the injury is important in detecting complications and enhancing bone healing at the various stages of injury or treatment. This article describes different types of fracture and principles for their management. The nursing care of patients who has sustained a fracture is discussed from admission to discharge.

Outline the surgical and conservative treatment for fractures. Discuss the nursing care and management of a patient who has sustained a fracture. Identify potential immediate and early complications of fractures and describe the signs and symptoms of these.

Nicola L Whiteing is lecturer in adult nursing, City University, London. Email: nicola.whiteing.1@city.ac.uk

A fracture can be defined as a loss or break in the continuity of a bone (Kunkler 2002, McRae and Esser 2002, Judge 2005). Fractures refer to all bony disruptions, ranging from a small hairline fracture to a bone broken into many fragments. Patients often think that a fracture is more severe than a break, but medically there is no difference between the two terms (McRae and Esser 2002). Fractures are usually caused by trauma (Biswas and Iqbal 1998), which is either substantial as in the case of a fractured pelvis following a road accident, or minor and repeated as seen with fractures of the metatarsal bones of ballerinas or long-distance athletes. Pathological fractures occur as a result of underlying disease such as Paget’s disease, osteoporosis, osteomalacia or a tumour resulting in weakness of the bone. Fractures are common during childhood, young adult life and in older adults (Coote and Haslam 2004). Patients with a fracture may present to primary and acute care in inpatient and outpatient departments. Readers are encouraged to consult a general orthopaedic or accident and emergency textbook for further information as it is beyond the scope of this article to provide extensive detail of specific fracture types, treatment and associated complications. september 17 :: vol 23 no 2 :: 2008 49

Fractures; Nursing care; Rehabilitation; Trauma These keywords are based on the subject headings from the British Nursing Index. This article has been subject to double-blind review. For author and research article guidelines visit the Nursing Standard home page at nursingstandard.rcnpublishing.co.uk. For related articles visit our online archive and search using the keywords.

Aims and intended learning outcomes
This article aims to discuss fracture classification and assessment, treatment options, complications and nursing care for the patient who has sustained a fracture as a result of either a minor fall or major trauma. After reading this article, you should be able to: Define a fracture and describe some common fracture types based on their shape and mechanism of injury. Discuss the signs and symptoms of a fracture and list the injuries and patient groups in which these may be misleading. NURSING STANDARD

avulsion.learning zone orthopaedics Time out 1 Describe the following fractures. considering their shape and mechanism of injury: transverse. In addition. Dandy and Edwards 2003). The mechanism of injury dictates the fracture pattern and as such fractures are further classified according to the type. Spiral fractures are less stable than transverse fractures because the bone ends are more difficult to balance against each other. torus. the bone spikes can damage blood vessels. Spiral and oblique Most long bone fractures are caused by a violent twisting movement along the long axis of the bone (Dandy and Edwards 2003). Fracture classification A fracture is either ‘open’ or ‘closed’. nerves or skin. or break off causing what is known as a ‘butterfly’ fragment (Duckworth 1995). complexity and location of the break (Figure 1). Because of the shape of the bone ends in a transverse fracture. it is easier to maintain alignment as the bone ends often fit together neatly. which is usually caused by a direct force in which the bone breaks directly underneath the blow (McRae and FIGURE 1 Some examples of fracture classifications Esser 2002. for example when someone falls onto an outstretched hand and fractures the bones of the forearm. Indirect forces can also cause a transverse fracture when the bone is subjected to a pure angular force. An open fracture is characterised by a wound alongside the fracture with the potential for organisms to enter the fracture site from outside. Compare your answers with those in the following text. If a patient has superficial wounds that are unrelated to the fracture. greenstick. for example in impacted femoral neck fractures (McRae and Esser 2002). Comminuted Comminuted or multifragmentary fractures are much more difficult to manage as Transverse Spiral Oblique Impacted Comminuted Greenstick Avulsed 50 september 17 :: vol 23 no 2 :: 2008 NURSING STANDARD . spiral. impacted. Transverse The bone in a transverse fracture is fractured at right angles to the long axis. A closed fracture is characterised by the skin remaining intact. crush and fracture dislocation. resulting in the bone being twisted apart (spiral) or the fracture running at an angle of 30˚ or more (oblique) (McRae and Esser 2002). oblique. Impacted An impacted fracture occurs when one part of the bone is forcefully driven into another. it is classified as a closed fracture. comminuted. Impacted fractures often come adrift if fixation is not achieved. Oblique fractures are rare and are almost always radiological artefact (Dandy and Edwards 2003).

Patients presenting with multiple injuries should receive an early set of chest. september 17 :: vol 23 no 2 :: 2008 51 Pathophysiology of fracture healing Bone is the only tissue in the body that is able to replace itself. forming a solid bridge across the gap. Torus fractures are similar to greenstick fractures but heal more quickly (Brinker and Miller 1999). however a larger avulsion fracture may require surgery to re-attach the bone and may be associated with tendon or ligament damage. When the process occurs smoothly. also known as compression fractures. Greenstick Greenstick fractures occur in children. Greenstick fractures are often held in a cast for six weeks but can take a long time to heal because they tend to occur in the middle. The following stages occur to unite a fractured bone (Dandy and Edwards 2003): Immediately following injury and for the first 14 days the fracture site is filled with blood and the broken ends of the bone become necrotic. Patient presentation and diagnosis Depending on how the injury was sustained. These fractures are difficult to treat as there are no fragments left to manipulate back into position (Dandy and Edwards 2003). A small avulsion fracture normally heals well with a support bandage and rest. At this point the fracture is mobile. age. with the other side bending but remaining intact (Dandy and Edwards 2003). Comminuted fractures are most often caused by direct trauma. co-morbidities. slower growing parts of bone. it is not able to show severed nerves. osteoclasts (bone resorption cells) and osteoblasts (bone building cells) invade the blood clot.the bone is broken into two or more fragments (Dandy and Edwards 2003). X-rays of the injured part are taken once assessment has been completed. analgesia administered and transfer to the X-ray department arranged. ruptured blood vessels or torn ligaments. Fractures of the lower limbs can take up to double this time to heal. pelvic and abdominal X-rays. Torus Torus or buckle fractures are common injuries in children. Avulsion Avulsion fractures are caused by a sudden contraction or overstretching resulting in a bony fragment being torn off by either a ligament or tendon (McRae 2006). Common sites for this type of fracture include the vertebral bodies and the calcaneum following a fall from a height. Bone healing does not always occur without problems and the patient may have a mal-union or non-union of the fracture. a patient may present unconscious via an emergency team or on foot several days later. Macrophages. and the bone regains some of its mechanical strength. Over the next year remodelling occurs. In all cases. for example a dislocation of the shoulder joint alongside a fractured neck of humerus (McRae and Esser 2002). Time out 2 List the initial nursing interventions you would undertake to assess a patient who arrives in your clinical area with a suspected fracture. and fractures in children heal in half the time of adults (Dandy and Edwards 2003). bony prominences become smooth and normal bone architecture is restored. how the injury occurred or how it should be treated. Fracture-dislocation Fracture-dislocation occurs when a joint has dislocated and in addition there is a fracture of one of the bony components of the joint. The NURSING STANDARD . but fractures generally heal in eight weeks (Dandy and Edwards 2003). One side of the bone may buckle on itself without disrupting the other side (incomplete fracture). it is important to follow the ‘A to E’ approach to patient assessment (Table 1). The callus matures between 12 and 26 weeks and between six and 12 months the gap between the cortical ends is bridged. The fracture is incomplete as it affects the cortex on one side of the bone only. medication and smoking. with X-rays of any limb injury or injury to the skull or facial bones carried out if the circumstances dictate and allow (McRae and Esser 2002. crushed muscles. bone healing is simple. fracture becomes ‘sticky’ and movement is less obvious. Between six and 12 weeks ossification occurs. Crush Crush fractures. occur in cancellous bone as a result of a compression force. The healing process in fractures is influenced by several intrinsic factors such as the patient’s nutritional status. a contaminated wound. After two to six weeks osteoid tissue develops and forms a callus inside and outside the fractured bone and ossification begins. While an X-ray in most cases is able to show a bony injury. Solomon et al 2005). For more stable patients. These two terms are discussed under the fracture complications section of this article. Many patients are alarmed at the apparent deformity or swelling of bone and they should be reassured that it is a sign of a good fracture union. This means exact anatomical reconstruction is difficult or even impossible.

B Breathing C Circulation Time out 3 James returns from theatre following an open reduction and internal fixation of a severe pelvic fracture. Pain. nor will there be abnormal movement of the fracture site. What is the respiratory rate and depth? Is there any use of accessory muscles or nasal flaring? Is there symmetry of breathing or noisy breathing? What is the patient’s oxygen saturation? What is the heart rate. There are a number of fractures that are often missed including impacted femoral neck fractures. Patients are at risk of developing complications of avascular necrosis. providing the rationale for each step. The physical signs of a fracture are listed in Box 1. Tenderness over the fracture site. fractures of the scaphoid. and if there is an impacted fracture bone ends will not produce crepitus. A blood glucose test may be necessary to rule out hypoglycaemia. Impaired function. certain fractures and fractures in certain patient groups can easily be missed despite these signs.learning zone orthopaedics The fact that the patient has been diagnosed with a fracture does not make it the most serious injury that he or she may have sustained (Dandy and Edwards 2003) and the nursing assessment and care of patients with fractures should therefore take a systemic approach. Rehabilitation – either to restore normal function or to help the patient cope with disability. Unresponsive) score or a full GCS (Glasgow Coma Score) if indicated. (Dandy and Edwards 2003) fractures. For example. Are there any changes to skin colour and temperature? What is the urine output? Assess wound drainage and injury. bruising. Assess level of consciousness using the AVPU (Alert. undisplaced fractures of the pelvis and fractures of the odontoid process (Dandy and Edwards 2003). BOX 1 Physical signs of a fracture Abnormal movement in a limb as a result of movement at the fracture site. Crepitus or grating between the bone ends. wounds. McRae 2006). then no bruising will be seen as a result of the capsule preventing leakage of blood to the subcutaneous tissues (Duckworth 1995. facial fractures. Outline your initial assessment of James and your priorities of care over the next 24 hours. McRae 2006). NURSING STANDARD D Disability E Exposure (Adapted from Frazer 2007) 52 september 17 :: vol 23 no 2 :: 2008 . mal-union. Voice. Early management is directed towards converting any contaminated wounds to clean wounds. non-union. unconscious patients are unable to report pain. Based on these signs and the use of radiography it is often easy to know when a bone is fractured. listen and feel. Pain on stressing the limb by bending or longitudinal compression. Bruising around the fracture. Treatment of fractures Despite the many different types of fracture the principles for management remain the same (Coote and Haslam 2004. radial head fractures. arthritis and a decreased functional ability if left undiagnosed. A deformity that can be seen or felt. Swelling at the fracture site. An electrocardiogram may be required. However. Perform a pain assessment. rhythm and strength? What is the blood pressure? Capillary refill? Consider baseline if you have one. skin problems. Reduction A clinician can achieve reduction by closed manipulation – in which the displaced bone fragments are pulled into their anatomical position – restoring alignment or by open reduction through a surgical incision. Undisplaced fractures cause no deformity and if a fracture is within a capsule. Dandy and Edwards 2003. Are there any medications that may be affecting level of consciousness? What is the temperature? All over check for rashes. Immobilisation – to ensure that the reduced position is maintained until bone union has taken place. The main aims of fracture treatment are (Solomon et al 2005): Reduction – to restore normal alignment of the bone. seventh cervical TABLE 1 A to E assessment of the patient A Airway Is the patient talking? Does the airway need to be opened? Is an adjunct required? Are there any noises? Look. Judge 2005. for example intracapsular fractures of the neck of femur.

respiratory rate. for example when fractures involve joint surfaces. and what mobilisation aids. Observations should include regular assessment of pulse – noting rate. skin or skeletal traction and external fixator frames. Management of external fixation devices Casts Cast immobilisation may be carried out using plaster of Paris. partial weight-bearing. it is usual with new fractures to apply a backslab until swelling has subsided. The nature of the operation as well as the method of pain control will determine the regularity of these observations. the limb can be mobilised and range of movement exercises can begin (Coote and Haslam 2004). Plaster of Paris. Nursing care of patients with fractures Haemodynamic monitoring Whether a patient has experienced major trauma. whether this is fully weight-bearing. cast immobilisation. Pre-emptive analgesia should be provided so that patients’ pain is sufficiently managed before and during rehabilitation sessions. Monitoring for complications Nurses should have a good understanding of the potential complications associated with fractures. Immobilisation Immobilisation can be achieved by internal or external fixation devices which are available in many forms. side effects and dosages (Nursing and Midwifery Council 2007). Following healing or once the fracture is stable. Internal fixation is used in certain pathological fractures. rhythm and volume – blood pressure. If haemodynamic status is compromised. Solomon et al 2005). Internal fixation involves the patient undergoing a surgical procedure and includes devices such as intermedullary nails. However. irreversible tissue and organ damage may occur. Synthetic casts dry in 20 minutes and therefore allow early weight bearing (Judge 2005). surgery and the immobilisation devices used so that any problems are detected swiftly and dealt with accordingly. it should not be accepted as a normal and inevitable part of recovery from injury or surgery (Kitcatt 2005). External fixation can be achieved through both surgical and conservative techniques and includes non-rigid methods of support (slings). when it is important to allow early limb or joint movement. the most common method of supporting fractures (McRae and Esser 2002). so that they are able to continue mobilising patients when physiotherapy services are not available. Pain assessment and management While pain is a useful sensation in alerting us to disease or injury. Nurses have a responsibility to know what rehabilitation programme patients are undergoing. plaster cast and skin traction. urine output and neurological function (Pellino et al 2002). Non-pharmacological methods of pain control such as positioning. when sufficient reduction cannot be maintained by external fixation. are being used. compression nails. Plaster of Paris is heavy and takes up to 48 hours to dry. september 17 :: vol 23 no 2 :: 2008 53 . oxygen saturation. the monitoring of haemodynamic status is essential to detect any existing or potential complications such as haemorrhage. Synthetic casts are a good choice for older patients where early mobilisation is necessary. Deciding on the right time to begin physiotherapy is difficult. eventually leading to death if causative factors are not addressed or reversed. The nurse caring for the patient having sustained a fracture should have knowledge of the medications available and their actions. Because of the body’s physiological response to stress and the inherent surgical risk of shock and haemorrhage. for example pressure ulcers. synthetic materials or a cast brace. but it should also not begin too late resulting in a perfect union of bone but muscles that are unable to operate the limb (Dandy and Edwards 2003). constipation and urinary stasis (Kunkler 2002). or when trying to avoid long periods of immobilisation in bed (Judge 2005. What specific nursing interventions do you need to ensure take place for patients receiving treatment in these ways? You may wish to discuss your answers with a more senior colleague and make additional notes. Rehabilitation Restoration of the upright position and early mobilisation decrease cardiopulmonary and other immobility associated complications. temperature. Assessment of pain is essential to ensure that the correct analgesic for the condition is prescribed and administered. distraction techniques and massage may also benefit patients (Judge 2007a). if any. Rehabilitation should not commence too early as this may result in mal-union of the bone. undergone NURSING STANDARD surgery or is admitted for ongoing assessment. touch-toe-bearing or non weight-bearing. because scope for expansion is limited. The tissues must be well perfused to receive oxygen and nutrients required for healing and recovery.Time out 4 Why do you think it is important to immobilise the fractured limb? Outline the advantages and disadvantages of managing fractures in the following ways: internal fixation. skin temperature and colour. will allow for some expansion. and that it is having the desired effect with minimal side effects (Judge 2007a). plates and screws. regular post-operative observations are essential to ensure safe surgical practice.

It is likely that the patient will go home wearing the cast and it is therefore essential that he or she is given clear written and verbal instructions on how best to care for the cast. Judge 2005): The limb is elevated to prevent oedema and aid venous return. Time out 6 Undertake a neurovascular assessment of a patient who has sustained a fracture to an upper or lower limb and discuss your findings with a more experienced colleague. Lucas and Davis 2005): The traction system must be checked during every shift to ensure traction and counter traction are maintained. There are numerous types of traction and for the purposes of this article the commonly used methods of skin and skeletal traction are discussed. with weights attached to the pin by a cord. If signs and symptoms of neurovascular impairment are evident. and restrict the spread of a haematoma. The use of traction has diminished with the increased use of surgical internal and external fixation (Schoen 2000). Such supports are useful to elevate the upper limb to limit swelling of the hand and fingers. and that the cords and pulleys are in good working order. In addition. The use of bandages and adhesive strapping can constrict a limb. Judge 2005. Judge 2007b). to provide firm support which will help to limit swelling and oedema. Skeletal traction involves the insertion of a pin through a bone. Redemann 2002. and assessment of the digits and proximal and distal ends of any supports must be carried out to detect compromise. offensive odour and cast discolouration. Skeletal pin sites should be checked regularly for signs of infection and cleaned daily. corks may be required to be placed on the ends of a skeletal pin to prevent patients from injuring themselves. Depending on local policy. relieve or limit pain as a result of the restriction in 54 september 17 :: vol 23 no 2 :: 2008 .learning zone orthopaedics Unlike plaster of Paris the synthetic casts do not allow for swelling and should not be used when injury has just occurred. If the neurovascular assessment was normal. Skin traction can be applied by strapping the patient’s affected limb and attaching weights calculated on the patient’s body weight. bandages and adhesive strapping may be used either on their own or alongside another internal or external fixation device. Specific care for patients in traction includes (Schoen 2000. Think about what advice and/or information you would need to give to patients on discharge and how this could be delivered most effectively. Non-rigid supports Immobilisers. arm slings. the cast should be split down both sides (bivalved) immediately. Cast braces can be used on upper or lower limbs are moulded closely to the shape of the limb and fitted with hinges to allow joint movement (Judge 2005). Traction Traction is the application of a pulling force with a counter traction force applied in the opposite direction. and aid healing through minimising movement of the reduced fracture (McRae and Esser 2002. the padding cut and a medical opinion sought. NURSING STANDARD Time out 5 Discharge advice is important for patients with a cast. Heavier weights can be used in skeletal traction. the cast should be checked both distally and proximally for tightness and/or pain. and patients should be advised not to touch the pin or pin sites. Redemann 2002). and the patient should be advised to look out for these signs and report them immediately. The digits should be checked to ensure that circulation and nerve conduction are not impaired (Redemann 2002. movement. The cast should not be rested on a hard or sharp surface to prevent denting as this may cause pressure on the underlying skin. Consider your actions if any of these abnormalities were to arise. Weights should hang freely off the floor. For any patient with a cast it is paramount that the nurse carries out the following care (Altizer 2004. Does your department have an advice sheet for patients with casts? If not. making it the preferred option for long-term management (Lucas and Davis 2005). discuss with a colleague how one could be developed and implemented. consider what abnormalities there could have been for this injury and what this could mean. Skin traction should be removed at least daily for limb washing and skin inspection. Signs of pressure ulcer formation include a burning pain.

Provision of information – patients should be given advice and support in managing the external fixator. muscle wasting or foot drop. Time out 8 Reflect on a patient with a fracture. chest infection. Immediate complications Patients with a fracture are at risk of internal and external haemorrhage because of the highly vascular structure of bone (Duckworth 1995. if the infection is not treated it can progress along the pin tract to the bone with devastating effects. Nurses must observe for complications and take preventive measures. Judge 2005) Late Mal-union Delayed union Non-union Osteoarthritis Avascular necrosis september 17 :: vol 23 no 2 :: 2008 55 . There is conflicting evidence regarding pin site care protocols and therefore readers are advised to consult local policy before carrying this out. There are a number of different frames that can be used depending on the complexity of the injury: monolateral. which may require skin grafting or dressing changes. and pin site inspection must be undertaken at least daily. This can have a profound effect on the patient and it is important that nurses pay attention to the psychological care of these patients. allowing access to the soft tissues. Pin site inspection and cleaning – patients are at a high risk of developing pin site infections. Local policy and patient presentation will dictate how often pin site cleaning should be carried out. hybrid and circular. Nursing staff can detect early signs of development so that prompt treatment can be instigated to minimise the risk of deficit (Lucas and Davis 2005). The patient will require general nursing care and physiotherapy to prevent deep vein thrombosis (DVT). Dandy and Edwards 2003. Compare your answers with those listed in Table 2. External fixation provides realignment. patients should be encouraged to undertake pin site cleaning to help towards acceptance of the frame. Pressure area care is essential every two hours. However. Dandy and Edwards 2003). What actual and potential complications do you think he or she might experience. Many patients will have a frame in situ for a number of months and concordance with treatment is essential. Where possible. the sharp bone ends found in a spiral or comminuted TABLE 2 Fracture complications Immediate Soft tissue damage Nerve injury Haemorrhage Early Infection Neurovascular compromise Fat embolism Pulmonary embolism Deep vein thrombosis (DVT) Compartment syndrome Pressure ulcers Chest infection Exacerbation of generalised illness (McRae and Esser 2002. Besides the blood loss from the fractured bone. The use of external fixators is now more common. External fixators Where fractures cannot be reduced using a cast or by traction – or where the patient is judged to be unsuitable for either – surgical fixation is required. It is also important to ensure individuals understand any benefits such as early assisted mobilisation. particularly with regard to acceptance of the frame and body image issues. What is the evidence base for the content? Can you think of any additional information or changes that should be included? Patients who have sustained severe injuries to their limbs may be transferred straight to theatre and wake up with an external fixator frame in place. NURSING STANDARD Complications of fractures The complications associated with fractures can be classified as immediate.Neurovascular assessment should be carried out regularly. which may be superficial and treatable with antibiotics. especially in fractures where there is significant bone loss or extensive soft tissue damage. wound access and bone stabilisation of complex fractures (Kunkler 2002). In addition to this psychological care the following should be carried out (Judge 2005): Neurovascular assessment – patients are at risk of developing peripheral neurovascular deficit. early or late (Table 2). The external fixator holds the bone and bone fragments by metal pins attached to an external frame. Time out 7 Review your department’s policy and/or clinical guidelines for the management of external fixator pin sites.

learning zone orthopaedics fracture. Without this protection. resulting in severe blood loss into the soft tissues. and intermittent pressure devices (Pellino et al 2002. Pulselessness – absence of peripheral pulses or delayed capillary refill time. even though these are as important. Fat emboli usually occur between three and ten days after a fracture to a long bone and the patient may become confused or experience a change in mood. If a patient complains of a swollen. Dandy and Edwards 2003). Likewise. The following focuses on those complications that are of particular importance to fractures rather than discussing more general complications of immobility. usually in the immobilised leg. A patient may be at risk of developing compartment syndrome if his or her movement has been restricted through the application of a cast or a bandage. Paralysis – inability to move digits. Paraesthesia – altered sensation. this is difficult to assess because the initial injury will also cause these signs. In addition. Because of a period of immobilisation and the effects of surgery. This is referred to as a pulmonary embolism and can be fatal. The cause of a fat embolism is uncertain. Close haemodynamic monitoring of the patient is required to detect early signs of impending hypovolaemia. In assessing patients for compartment syndrome the nurse should use the ‘Five Ps’ (Dykes 1993. for example. It is important that the nurse is aware that a large percentage of DVTs occur without any associated signs or symptoms. In general. However. anti-embolic stockings. tachypnoea or respiratory difficulty as a result of progressing hypoxia (Dandy and Edwards 2003). If a DVT is not treated and the clot breaks off it will travel to the lungs. may damage the surrounding muscle or blood vessels. A patient with a fat embolism is at risk of death from a relatively simple transverse fracture of the tibia if it is not detected. tachycardia and tachypnoea (Coote and Haslam 2004). The patient will present with an acute shortness of breath. patients may receive one or more of the following: the administration of low molecular weight heparin via injection. a broken skull carries with it the potential for brain damage and a fractured face or mandible an obstructed airway. drowsiness. although it may occur elsewhere. A fat embolism is an uncommon but serious complication. pleuritic chest pain. Compartment syndrome occurs when the compartments of a limb containing nerves. for example damage to the aorta from a fourth or fifth thoracic fracture. but it may be caused by circulating fat globules being released from the fracture site (Duckworth 1995. numbness or pins and needles. Judge 2005). particularly tibial and supracondylar closed fractures. all patients should be taught to dorsi-flex and plantar-flex their ankles throughout the day to keep the skeletal calf muscle pump moving and perform deep breathing exercises to make optimum use of the respiratory system (respiratory pumps). Judge 2005). One of the essential functions of the musculoskeletal system is to support and protect soft tissue structures such as the brain. the femoral artery in fractures of the femur and the brachial artery in supracondylar fractures of the humerus in children (Dandy and Edwards 2003). although this is a very late sign. heart and lungs. Early complications Some of the early complications to which a patient may be exposed are listed in Table 2. or if the individual has undergone internal or external fixation (Pellino et al 2002. A broken rib can lead to a pneumothorax or ruptured liver. are at risk in addition to patients having undergone planned surgery to their limbs (Judge 2007b). painful limb the nurse should be alert to the possibility of a DVT. There is conflicting evidence within the literature regarding DVT prophylaxis and the reader should consult 56 september 17:: vol 23 no 2 :: 2008 local policy for guidance. there are several injuries that carry the risk of damage to particular arteries. patients are at risk of developing DVT. These immediate complications highlight the importance of a thorough patient assessment using the ‘A to E’ approach discussed earlier. or increased pain on doing so. Pallor – pale and cold in comparison to the other side. muscles and vasculature are crushed as a result of continuing swelling. If the swelling is not relieved. A petechial rash is seen which varies in severity and fat globules may be seen in the urine. there is the possibility of injury to these internal organs. It is beyond the scope of this article to discuss all of these and their nursing management in detail and the reader is therefore encouraged to seek additional information on these complications. Nurses play a vital role in minimising the risk of deficit and in detecting early signs of the development of compartment syndrome (Lucas and Davis 2005) so that prompt treatment can be instigated. oral anticoagulants. Judge 2007b): Pain – out of proportion to what is expected of the injury. NURSING STANDARD . helping to reduce deficits in venous blood flow (Love 1990. Those patients having sustained trauma. damage will ensue and the patient is at risk of amputation. Lucas and Davis 2005).

McRae R (2006) Pocketbook of Orthopaedics and Fractures. London. Davis P (2005) Why restricting movement is important. In Kneale J. Philadelphia PA. Edwards DJ (2003) Essential Orthopaedics and Trauma. 21. In Pudner R (Ed) Nursing the Surgical Patient. 6. NMC. Solomon L. Brinker MR. Salmond SW. Frazer A (2007) Major trauma: assessment. 302-323. 22. Esser M (2002) Practical Fracture Treatment. while if the bones have failed to unite at all they have a non-union. 110-138. Edinburgh. In Pudner R (Ed) Nursing the Surgical Patient. immobilisation or infection. Lucas B. Third edition. 86. 2. it is important that nurses have an awareness of potential problems and can carry out a systematic patient assessment to identify and treat complications rapidly should they occur. 467-495. Love C (1990) Deep vein thrombosis: methods of prevention. American Journal of Nursing. Redemann S (2002) Modalities for immobilisation. Bailli` ere Tindall.Observations must be documented on an appropriate chart. Judge NL (2007b) Neurovascular assessment. Saunders. NURSING STANDARD september 17 :: vol 23 no 2 :: 2008 57 . Avascular necrosis is a late complication that may take two years to develop. McRae R. Schoen DC (2000) Adult Orthopaedic Nursing. Haslam P (2004) Rheumatology and Orthopaedics. 39-44. Preston M. Davis P (Eds) Orthopaedic and Trauma Nursing. Edinburgh. leading to pain and stiffness (Solomon et al 2005). collapse and the joint is destroyed. In Evans C. If a fracture interrupts the blood supply to the bone the affected bone will die. Lippincott Williams and Wilkins. 51-57. Pellino TA (Eds) Orthopaedic Nursing. Guidelines to help you are on page 60. Duckworth T (1995) Lecture Notes on Orthopaedics and Fractures. Edinburgh. Pellino T. Second edition. Judge NL (2005) Patients requiring orthopaedic surgery. 105-139. 93. Salmond SW. Late complications Late complications may be seen if patients return to the outpatient clinic. Dykes PC (1993) Minding the five Ps of neurovascular assessment. Bailli` ere Tindall. Nursing Standard. Open University Press. A delayed union can be caused by generalised disease. A mal-union may lead to osteoarthritis as a result of abnormal distribution of load leading to early degenerative change (Dandy and Edwards 2003). Churchill Livingstone. While many of the complications discussed in this article are rare. Philadelphia PA. Bell N. Conclusion Patients can sustain a fracture at any time in their life and may require admission as an inpatient or References Altizer L (2004) Casting for immobilization. 97-115. Third edition. The impact of a fracture on a patient’s functional ability should not be underestimated and appropriate advice and assistance should be arranged NS Time out 9 Now that you have completed this article. Hodder Arnold. Edinburgh. 6. Hansen K (2002) Complications of orthopaedic disorders and orthopaedic surgery. Churchill Livingstone. Second edition. Third edition. Saunders. 136-141. A good understanding of the mechanisms of bone healing and fracture management is essential to ensure that patients receive holistic care to enable fracture healing and a safe discharge. Nayagam S (2005) Apley’s Concise System of Orthopaedics and Fractures. Pellino TA (Eds) Orthopaedic Nursing. In Maher AB. Newton M. Saunders. In Maher AB. prioritization and initial treatment. Judge NL (2007a) Assessing and managing patients with musculoskeletal conditions. 23. Salmond SW. 1. Miller MD (1999) Fundamentals of Orthopaedics. WB Saunders. 609-649. Tippins E (Eds) The Foundations of Emergency Care. Philadelphia PA. 45. Fourth edition. Philadelphia PA. Dandy DJ. Biswas SV. Philadelphia PA. Mosby. Coote A. Churchill Livingstone. Edinburgh. Kitcatt S (2005) Concepts of pain and the surgical patient. Nursing Times. Mosby. be treated conservatively in the emergency department and then discharged with appropriate follow up at a fracture clinic or from their GP. 230-268. Iqbal R (1998) Musculoskeletal System. you might like to write a practice profile. 52-55. In Maher AB. Maidenhead. If the patient’s bones have failed to align in the correct position they are said to have a mal-union. Fourth edition. or are admitted for further surgery. Orthopaedic Nursing. Third edition. Warwick DJ. London. Nursing and Midwifery Council (2007) Standards for Medicine Management. Nursing Standard. Second edition. and while the bone ends join it occurs very slowly. Kunkler C (2002) Fractures. London. Second edition. Blackwell Science. Oxford. Churchill Livingstone. Oxford. London. Third edition. Pellino TA (Eds) Orthopaedic Nursing. 38-39.

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