Diseases and Conditions: Fracture (arm or leg)

Fracture (arm or leg)

Revised: October 4, 2019

Overview
A crack or break in one of the arm or leg bones, most commonly resulting from significant force
Prognosis varies depending on extent of injury to bone, muscle, nerves, and other soft tissue; vascular
damage; extent of deformity; adequacy of reduction and immobilization; and patient's age, health, and
nutritional status
Can result in amputation and other complications that can significantly decrease quality of life
Severe open fractures (those that penetrate the skin), especially those of the femoral shaft and pelvis,
possibly causing substantial blood loss and hypovolemic shock

Pathophysiology
A direct or indirect force is applied to a bone that is greater than the strength of the bone, causing a
disruption in bone integrity.
The fracture causes disruption of the periosteum and blood vessels in the cortex, marrow, and
surrounding soft tissue.
A hematoma forms between the broken ends of the bone and beneath the periosteum.
Granulation tissue eventually replaces the hematoma.
Damage to bone tissue triggers an intense inflammatory response in which cells from surrounding soft
tissue and the marrow cavity invade the fracture area. Blood flow to the entire bone also increases.
Osteoblasts in the periosteum, endosteum, and marrow produce osteoid (collagenous young bone that
hasn't yet calcified; also called callus).
The osteoid hardens along the outer surface of the shaft and over the broken ends of the bone.
Osteoclasts reabsorb material from previously formed bones, and osteoblasts form and rebuild bone.
The osteoblasts then transform into osteocytes (mature bone cells).
The osteocytes are responsible for bone remodeling, which achieves a normal configuration of the bone
at the healed fracture site.

Causes
Traumatic injury, commonly caused by falls, motor vehicle accidents, penetrating injuries, and sports
(most common cause)
Bone-weakening conditions, such as osteoporosis, bone tumors, and metabolic diseases, such as
hypoparathyroidism, hyperparathyroidism, and Paget disease (pathologic fractures)

Age Factor

In elderly people, fractures of the proximal femur, proximal humerus, and distal radius are
commonly associated with osteoporosis.

Medications that cause iatrogenic osteoporosis, such as corticosteroids, anticonvulsants, and thyroid
hormone replacement drugs
Repetitive force on a bone, such as prolonged standing, walking, or running, which may be experienced
by joggers, postal workers, nurses, and soldiers (can result in stress fractures of the tibia, fibula, or
metatarsals)
 Risk Factors
Participation in contact sports
Trauma
Falls
Osteoporosis
Osteoarthritis
Elderly
Young male

Incidence
The incidence of fractures is higher among young patients and elderly patients.
Among young males, specifically those ages 15 to 24, most fractures are due to trauma (most
commonly the tibia, clavicle, and distal humerus).

Complications
Permanent deformity and dysfunction if the bone fails to heal (nonunion) or heals improperly
(malunion)
Peripheral nerve damage
Fat embolism
Pulmonary embolism
Aseptic avascular necrosis of bone segments (due to impaired circulation)
Compartment syndrome
Muscle contractures
Renal calculi from decalcification (due to prolonged immobility)
Soft-tissue infection
Osteomyelitis
Hypovolemic shock resulting from blood vessel damage (most likely with a fractured femur)
Amputation

Assessment

History
Traumatic injury, commonly related to a fall on an outstretched arm or a skiing or bicycling accident
History of abuse (suggested by multiple or repeated fractures)
Mechanism of injury (“What were you doing when you got hurt?”) reflecting direct or indirect force
Osteoporosis
Bone tumors
Metabolic disease (such as hyperthyroidism, hypothyroidism, or Paget disease)

Physical Findings
Signs of compartment syndrome: Pain disproportionate to the injury, pain on passive stretching of the
fingers or toes, pallor, loss of pulse distal to the fracture, paresthesia distal to the fracture, paralysis
distal to the fracture (See Recognizing compartment syndrome.)
Pain (and point tenderness) at the involved area

WARNING!
 Progressive, uncontrollable pain or pain on passive movement accompanied by
altered sensation, loss of active motion, diminished capillary refill time, and
pallor indicates neurovascular compromise.

Deformity
Swelling
Discoloration
Crepitus
Loss of limb function
Obvious skin wound (in open fracture)

Recognizing compartment syndrome

Compartment syndrome occurs when pressure within the muscle compartment, resulting from
edema or bleeding, increases to the point of interfering with circulation. Crush injuries, burns,
bites, and fractures requiring casts or dressings may cause this syndrome. Compartment
syndrome most commonly occurs in the lower arm, hand, lower leg, and foot.

Symptoms include:

increased pain
decreased touch sensation
increased weakness of the affected part
increased swelling and pallor
decreased pulses and capillary refill time.

Treatment includes:

placing the limb at heart level

removing constricting forces
monitoring neurovascular status and compartment pressures
emergency fasciotomy.

Diagnostic Test Results

Imaging
Anteroposterior, oblique, and lateral X-rays of the suspected fracture as well as X-rays of the joints
above and below the suspected fracture confirm the diagnosis. (See Classifying fractures.)
Magnetic resonance imaging or computed tomography scanning (bone) may confirm the diagnosis if not
conclusive on X-ray.

Classifying fractures

One of the best-known systems for classifying fractures involves combining several descriptive
terms that take into account degree of severity and fragment position (for example, a simple,
nondisplaced, oblique fracture).
Classification by degree of severity

Simple (closed): Bone fragments don't penetrate the skin.

Compound (open): Bone fragments penetrate the skin.

Incomplete (partial): Bone continuity isn't completely interrupted.

Complete: Bone continuity is completely interrupted.

Classification by fragment position

Comminuted: Bone breaks into small pieces.

Displaced: Fracture fragments separate and are deformed.

Overriding: Fragments overlap, shortening the total bone length.

Angulated: Fragments lie at an angle to each other.

Nondisplaced: The two sections of bone maintain essentially normal alignment.

Avulsed: Fragments are pulled from their normal position by muscle contractions or ligament
resistance.

Impacted: One bone fragment is forced into another.

Segmental: Fractures occur in two adjacent areas with an isolated central segment.

Linear: The fracture line runs parallel to the bone's axis.

Spiral: The fracture line crosses the bone at an oblique angle, creating a spiral pattern.

Longitudinal: The fracture line extends in a longitudinal (but not parallel) direction along the
 bone's axis.

Transverse: The fracture line forms a right angle with the bone's axis.

Oblique: The fracture line crosses the bone at roughly a 45-degree angle to the bone's axis.

Diagnostic Procedures
Arthroscopy reveals joint involvement.

Treatment

General
Immobilization: Splinting of the limb above and below the suspected fracture; casting
Possible skeletal traction until the patient's condition stabilizes sufficiently to tolerate surgery or until the
fracture heals (used only in rare cases, such as for serious fractures in critically ill patients)
Skin traction
Cold therapy
Wound care, such as dressing changes and assessment of wound site
Closed reduction: Manual manipulation without skin incision to restore displaced bone segments to their
normal positions (for less-severe fractures), after which a cast, splint, or other type of immobilization
device is applied
External fixation device for severe fractures with significant soft-tissue injury to immobilize the fracture
and allow for access to the wound for dressing changes and monitoring for infection
Venous thromboembolism (VTE) prophylaxis if the patient is hospitalized

Diet
Nothing by mouth if surgery needed
Healthy diet; may require assistance with arm fracture
High-fiber diet if immobilized or activity level is decreased; ensure adequate fluid intake
 Activity
Varied, depending on the severity of the fracture and type of reduction used
Possible long-term immobilization if traction is applied
Activity resumption as soon as possible for a patient using crutches for a leg fracture
Physical and occupational therapy

Medications
Analgesics, such as nonsteroidal anti-inflammatory drugs (ibuprofen) for mild to moderate pain or
opioids (morphine sulfate) for severe pain
Muscle relaxants to ease closed or open reduction
Tetanus prophylaxis
For open reduction, broad-spectrum antibiotics before surgery (preoperative antibiotics must be
administered within 60 minutes of the first skin incision; postoperative antibiotics must be administered
within 24 hours of the preoperative dose)
For closed reduction, analgesics, such as IV morphine sulfate, to relieve pain and a muscle relaxant,
such as IV diazePAM, or a sedative to facilitate the muscle stretching necessary to realign the bone
Regional nerve block (bupivacaine or lignocaine)

Surgery
Open reduction and internal fixation: Surgical reduction and fracture immobilization using rods, plates,
or screws; used when closed reduction is impossible
Wound debridement to repair soft-tissue damage

Nursing Considerations

Nursing Interventions
Offer reassurance to the patient, who's likely to be frightened and in pain.
Screen for and assess the patient's pain using facility-defined criteria that are consistent with the
patient's age, condition, and ability to understand.
Treat the patient's pain, as needed and ordered, using nonpharmacologic, pharmacologic, or a
combination of approaches.
Administer analgesics for pain, as ordered.
Monitor closely if the patient is at high risk for adverse outcomes related to opioid treatment if
prescribed.
Elevate the extremity and apply cold compresses as appropriate.
Reassess and respond to the patient's pain by evaluating the response to treatment and progress
toward pain management goals.
Urge adequate fluid intake to prevent urinary stasis and constipation.
Administer IV fluids, as indicated. Ensure patency of the IV catheter.
Perform dressing changes, as appropriate, if open wounds are present. Inspect wounds for redness,
irritation, and drainage.
Assist with closed reduction, as appropriate. Administer preprocedural medication, such as a sedative,
as indicated.
Encourage a high-fiber diet if the patient will be immobilized; ensure adequate fluid intake.
Apply an antiembolism stocking or intermittent compression device if the patient will be immobilized for
a prolonged period. Apply it only to the unaffected lower extremity if the other lower extremity is
fractured.
Assess lung sounds for changes; administer supplemental oxygen based on pulse oximetry levels, as
indicated. Encourage coughing and diaphragmatic breathing exercises and the use of incentive
 spirometry if the patient will require prolonged bed rest for immobilization.
Assess neurovascular status; check for pain, pallor, pulselessness, and paresthesias in the affected
extremity.
Assess for signs and symptoms of fat or pulmonary embolism.

WARNING!

Be alert for early signs and symptoms of fat emboli, including restlessness,
confusion, irritability, and disorientation, and report them immediately.

If a fracture requires long-term immobilization with traction:

Ensure proper weight use for traction.
Reposition the patient often to increase comfort and prevent pressure injury.
Assist with range-of-motion exercises to prevent muscle atrophy.
Encourage coughing and diaphragmatic breathing exercises to avoid hypostatic pneumonia.
Perform pin site care if skeletal traction or an external fixation device is used.
If the patient requires a cast:
Provide good cast care.
Support the cast with non-plastic-covered pillows.
Handle wet casts only with the palms.
Leave wet casts open to air to facilitate drying.
Observe for skin irritation near cast edges, and check for foul odors and discharge.
Tell the patient to immediately report signs of impaired circulation.
Perform frequent neurovascular checks.
Assist the patient with mobility as soon as possible. Help the patient walk, and demonstrate how to use
crutches or other assistive devices, reinforcing any teaching performed by the physical therapist.
Assist with resumption of weight bearing only as directed because full weight bearing can interfere with
osteoblast recruitment to the fracture site or cause the fracture to collapse on itself.
Discourage use of an overhead trapeze for a patient with an upper extremity fracture; encourage use of
a trapeze if the patient is bedbound with a lower extremity fracture.
Encourage the patient to participate in care as much as possible to promote feelings of control.
Perform pin site care as indicated if a skeletal traction or external fixation device is being used.
Inspect the skin, pin insertion sites, and wounds for signs and symptoms of infection. Obtain cultures of
any drainage.

Monitoring
Vital signs, as ordered, postreduction
Pain level and effectiveness of interventions
Signs of shock, especially if the patient has a severe open fracture of a large bone, such as the femur
Fluid intake and output, as appropriate

WARNING!

Be especially alert for a rapid pulse, decreased blood pressure, pallor, and cool
clammy skin, all of which may indicate that the patient is in shock.

Casted limb for skin irritation, foul odor, and signs of impaired circulation (such as skin coldness,
numbness, tingling, and discoloration)
 Neurovascular status
Level of consciousness
Bowel elimination status
Skin integrity

Associated Nursing Procedures

Alignment and pressure-reducing device application
Antiembolism stocking application, knee-length
Antiembolism stocking application, thigh-length
Cast application, cotton-polyester
Cast application, fiberglass
Cast application, plaster
Cast removal, assisting
Cold application
Coughing and diaphragmatic breathing exercises
Crutches use training
External fixation management
Fall prevention
Incentive spirometry
Internal fixation care and management
IV catheter insertion
IV pump use
IV secondary line drug infusion
Oral drug administration
Pain and comfort management, PACU
Pain assessment
Pain management
Postoperative care
Preoperative care
Pressure injury prevention
Relaxation and stress management techniques
Rigid splint application
Safe medication administration practices, general
Sequential compression therapy
Traction, care of patient
Traction frame preparation, claw-type frame
Traction frame preparation, IV-type Balkan frame
Traction frame preparation, IV-type basic frame
Traction splint application
Wound assessment

Patient Teaching

General
Include the patient's family or caregiver in your teaching, when appropriate. Be sure to cover:
fracture and its repair (reduction), including prereduction and postreduction care
cast care, including the need to monitor for foul odors, discharge, skin irritation, and signs of impaired
circulation and the need to report immediately signs of impaired circulation
fact that the cast must not get wet and that no foreign object should be inserted under the cast
signs and symptoms of complications, such as infection
how to check neurovascular status
 pain management plan and adverse effects of pain management treatment
safe use, storage, and disposal of opioids, if prescribed
importance of moving around as soon as possible
proper use of crutches or other assistive devices and adaptations for routine activities
weight-bearing status
range-of-motion exercises for unaffected limbs
methods of safe ambulation
prevention of future trauma and fractures
need for a balanced diet to promote bone and soft-tissue healing
measures to prevent constipation, including increased fiber and fluid intake
follow-up care and physician's visits
importance of regaining limb mobility after treatment and participating in physical therapy as
recommended.

Discharge Planning
Participate as part of a multidisciplinary team to coordinate discharge planning efforts. The team may
include a bedside nurse, pharmacist, social worker, case manager, nutritionist, physical therapist,
occupational therapist, and orthopedic surgeon.
Assess the patient's and family's understanding of the diagnosis, treatment, prognosis, follow-up, and
warning signs for which to seek medical attention.
Assess the patient's level of independence before admission.
Evaluate how the patient's current illness will impact independence.
Determine the appropriate posthospital setting to which the patient will be discharged.
Identify the patient's formal and informal supports.
Identify the patient's and family's goals, preferences, comprehension, and concerns about discharge.
Confirm arrangements for initial follow-up visits.
Provide a list of prescribed drugs, including the dosage, prescribed time schedule, and adverse reactions
to report to the practitioner. Provide the patient (and family or caregiver, as needed) with written
information on the medications that the patient should be taking after discharge.
Assess the patient's and family's understanding of prescribed medication, including dosage,
administration, expected results, duration, and possible adverse effects.
Assess the patient's ability to obtain medications; identify the party responsible for obtaining
medications.
Instruct the patient to provide a list of medications to the practitioner who will be caring for the patient
after discharge; to update the information when the practitioner discontinues medications, changes
doses, or adds new medications (including over-the-counter products); and to carry a medication list
that contains all of this information at all times in the event of an emergency.
Ensure arrangements for home health services and rehabilitation services, if needed.
Ensure that the patient and caregivers have been given medical contact information.
Document the discharge planning evaluation in the patient's clinical record, including who was involved
in discharge planning and teaching.
Document the patient's understanding of the teaching provided and any need for follow-up teaching.

Resources
American Academy of Orthopaedic Surgeons: www.aaos.org
American Orthopaedic Association: www.aoassn.org
National Association of Orthopaedic Nurses: www.orthonurse.org
Orthopaedic Trauma Association: www.ota.org

Selected References
 1. Beutler, A. General principles of fracture management: Bone healing and fracture description. (2018). In:
UpToDate, Eiff, P., & Asplund, C. A. (Eds.).
2. Blum, M., et al. (2015). Subclinical thyroid dysfunction and fracture risk: A meta-analysis. JAMA, 313(20),
2055–2065. (Level I)
3. Buckley, R. (2018). “General Principles of Fracture Care” [Online]. Accessed September 2019 via the Web
at http://emedicine.medscape.com/article/1270717-overview
4. Fields, K. B. Overview of tibial fractures in adults. (2018). In: UpToDate, Eiff, P. (Ed.).
5. Forsberg, A., et al. (2014). People's experiences of suffering a lower limb fracture and undergoing surgery.
Journal of Clinical Nursing, 23(1-2), 191–200. (Level VI)
6. Gao, Y., et al. (2013). Surgical interventions for treating radial head fractures in adults. Cochrane Database
of Systematic Reviews, 2013(5), CD008987. (Level I)
7. Graham, P. (2017). Tibial plateau fracture. Orthopedic Nursing, 36(4), 303–305.
8. Graham, P. (2018). Tibial stress fracture in a runner. Orthopedic Nursing, 37(6), 382–384.
9. Griffin, X. L., et al. (2014). Ultrasound and shockwave therapy for acute fractures in adults. Cochrane
Database of Systematic Reviews, 2014(6), CD008579. (Level I)
10. Griffioen, M. A., & O'Brien, G. (2018). Analgesics administered for pain during hospitalization following
lower extremity fracture: A review of the literature. Journal of Trauma Nursing, 25(6), 360–365. (Level V)
11. Handoll, H. H. G., & Borson, S. (2015). Interventions for treating proximal humeral fractures in adults.
Cochrane Database of Systematic Reviews, 2015(11), CD000434. (Level I)
12. Howe, A. S. General principles of fracture management: Early and late complications. (2018). In:
UpToDate, Eiff, P. (Ed.).
13. Konowalchuk, B. K. (2018). “Tibial Shaft Fractures” [Online]. Accessed September 2019 via the Web at
http://emedicine.medscape.com/article/1249984-overview
14. Nettina, S. (2019). Lippincott manual of nursing practice (11th ed.). Philadelphia, PA: Wolters Kluwer.
15. Nicklebur, S. (2018). “Calcaneus Fractures” [Online]. Accessed September 2019 via the Web at
http://emedicine.medscape.com/article/1232246-overview
16. Roberts, C. L. (2014). Improving the management of tibia stress fractures: A collaborative, outpatient
clinic-based quality improvement project. Orthopedic Nursing, 33(2), 75–83, quiz 84-85. (Level VI)
17. Salvi, A. E., et al. (2016). Smoking effects in a distal tibia fracture treated with external fixation.
Orthopaedic Nursing, 35(6), 426–428.
18. Srivastava, A. K. (2015). “Humerus fracture” [Online]. Accessed September 2019 via the Web at
https://emedicine.medscape.com/article/825488-overview