Chapter 42

Fractures

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 Learning Objectives
• Identify the types of fractures.
• Describe the five stages of the healing process.
• Discuss the major complications of fractures, their signs
and symptoms, and their management.
• Compare the types of medical treatment for fractures,
particularly reduction and fixation.
• Describe common therapeutic measures for fractures,
including casts, traction, crutches, walkers, and canes.
• Discuss the nursing care of a patient with a fracture.
• Describe specific types of fractures, including hip fractures,
Colles’ fractures, and pelvic fractures.

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 Classification of Fractures
• Closed or simple fracture
• The bone does not break through the skin
• Open or compound fracture
• Fragments of the broken bone break through skin
• Open fractures have three grades of severity
• Grade I: least severe injury, with minimal skin damage
• Grade II: moderately severe injury, with skin and muscle
contusions (bruises)
• Grade III: most severe injury (wound larger than 6 to 8 cm), with
skin, muscle, blood vessel, and nerve damage

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 Classification of Fractures
• Stress fracture
• Caused by either repeated or prolonged stress
• Pathologic fracture
• Occurs because of a pathologic condition in the
bone, such as a tumor or disease process, that
causes a spontaneous break

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 Figure 42-1

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 Etiology and Risk Factors
• Commonly caused by trauma to the bone, especially as a result of
automobile accidents and falls
• Bone disease, e.g., bone cancer, can lead to a fracture
• Hip fractures in older adults usually from falls
• Risk factors for hip fractures: osteoporosis, advanced age, white
race, use of psychotropic drugs, and female
• In adults, ribs most commonly fractured
• Fractures of the femur most common in young and middle-aged
adults
• Hip and wrist fractures are most common in older adults

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 Fracture Healing
• A bone begins to heal as soon as an injury
occurs
• New bone tissue formed to repair the fracture,
resulting in a sturdy union between the broken
ends of the bone

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 Healing Stages
• Stage 1: hematoma formation
• Immediately after a fracture, bleeding and edema
occur
• In 48 to 72 hours, a clot or hematoma forms
between the two broken ends of the bone

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 Healing Stages
• Stage 2: fibrocartilage formation
• Hematoma that surrounds fracture does not resorb,
as it does in other parts of the body
• Instead, other tissue cells enter the clot, and
granulation tissue replaces the clot
• The tissue then forms a collar around each end of
the broken bone, gradually becoming firm and
forming a bridge between the two ends

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 Healing Stages
• Stage 3: callus formation
• Within 1 to 4 weeks after injury, granulation tissue
changes into a callus, which is made up of cartilage,
osteoblasts, calcium, and phosphorus. The callus is
larger than the diameter of the bone and serves as
a temporary splint

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 Healing Stages
• Stage 4: ossification
• Within 3 weeks to 6 months after the break, a
permanent bone callus, known as woven bone,
forms
• During this stage the ends of the broken bone begin
to knit

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 Fracture Healing
• Stage 5: consolidation and remodeling
• Consolidation occurs when the distance between
bone fragments decreases, then closes
• During bone remodeling, immature bone cells are
gradually replaced by mature bone cells
• Excess bone is chiseled away by stress to the
affected part from motion, exercise, and weight
bearing
• Bone then takes on its original shape and size

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 Figure 42-2

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 Fracture Healing
• Healing affected by location and severity of the fracture,
type of bone, other bone pathology, blood supply to the
area, infection, and the adequacy of immobilization
• Also age, endocrine disorders, and some drugs affect
healing
• Healing time increases with age; it may take six times
as long for the same type of fracture to heal in an older
adult as in an infant

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 Complications

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 Infection
• Osteomyelitis: from contamination of the open wound
associated with a fracture or from contamination of
indwelling hardware used to repair the broken bone
• When infection is inadvertently brought by surgery or
other treatment, it is known as iatrogenic
• Any infection can interfere with normal healing
• Common after an open fracture and surgical repair and
may become chronic
• In deep, grossly contaminated wounds, gas gangrene
may develop

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 Infection
• Signs and symptoms
• Local pain, redness, purulent wound drainage, chills, and fever
• With gas gangrene, foul-smelling watery drainage with
significant redness and swelling
• Treatment
• IV antibiotics may be given for 4 to 8 weeks, followed by
4 to 8 weeks of oral drug therapy
• Wound care: irrigation, treatment with antibiotic beads, and
surgical removal of dead bone tissue and/or hardware

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 Fat Embolism
• Fat globules released from marrow of broken bone into
bloodstream, then migrate to the lungs
• They lodge in capillaries and obstruct blood flow
• The fat particles break down into fatty acids, which
inflame the pulmonary blood vessels, leading to
pulmonary edema
• Common with fractures of the long bones, multiple
fractures, and severe trauma

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 Fat Embolism
• Respiratory distress is the first sign of a fat
embolism, followed by tachycardia, tachypnea,
fever, confusion, and decreased level of
consciousness
• Treatment: bed rest, gentle handling, oxygen,
ventilatory support, and fluid restriction and
diuretics for pulmonary edema

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 Deep Vein Thrombosis
• Venous stasis, vessel damage, and altered
clotting mechanisms contribute to formation of
blood clots (thrombi), most commonly in deep
veins of the legs
• DVT increased with immobility often associated
with a fracture
• Thrombi can break off and travel to the lungs,
causing a pulmonary embolism

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 Compartment Syndrome
• Serious complication from internal or external
pressure on the affected area
• Compartments: enclosed spaces made of
muscle, bone, nerves, blood vessels wrapped
by fibrous membrane
• Internal pressure from bleeding/edema into a
compartment; external pressure from a cast or
tight dressing

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 Compartment Syndrome
• When bleeding or edema into a compartment,
there is nowhere for drainage to go: it is
trapped in the space
• Increased fluid puts pressure on tissues,
nerves, and blood vessels, so that blood flow is
decreased, resulting in pain and tissue damage.
External pressure also can decrease blood
flow to the area

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 Compartment Syndrome
• Primary symptom is pain, especially with touch or
movement, that can’t be relieved with opioids
• Other signs and symptoms: edema, pallor, weak or
unequal pulses, cyanosis, tingling, numbness,
paresthesia, and finally, severe pain
• The goal of treatment is to relieve pressure
• When internal pressure, a surgical fasciotomy, which entails
making linear incisions in the fascia, may relieve pressure on
the nerves and blood vessels
• For external pressure, cast or dressings are replaced

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 Shock
• After fracture, a risk of excessive blood loss
• Trauma may rupture local blood vessels; internal
organs may be punctured; results in internal bleeding
• Loss of blood leads to shock, evidenced by tachycardia,
anxiety, pallor, and cool, clammy skin
• Immobilizing fractures reduces risk of hemorrhage
• If severe external bleeding, external pressure should
be applied and medical assistance summoned
immediately

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 Joint Stiffness and Contractures
• Joint fractures or dislocations may be followed by
stiffness or contractures, especially in older adults, due
to immobility associated with fracture
• Prevention requires appropriate positioning and
progressive exercise programs
• Treatment may employ splints, traction, casts, surgical
manipulation, and aggressive physiotherapy

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 Malunion
• Expected healing time is appropriate but
unsatisfactory alignment of bone results in
external deformity and dysfunction

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 Delayed Union
• Failure of a fracture to heal in the expected
time
• The bone usually heals eventually; it may just
be slower

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 Nonunion
• Occurs when a fracture never heals
• Treatment
• Osteogenic method: implantation of bone grafts
• Osteoconductive methods: synthetic materials to provide a
matrix for bone growth
• Osteoinduction: substances such as platelet-derived growth
factor
• Electric stimulation
• Internal or external; up to 10 hours a day for 3-6 months
• Time consuming but can prevent further surgery and bone grafts

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 Post-Traumatic Arthritis
• Weight-bearing joints are most vulnerable to
posttraumatic arthritis
• Excessive stress and strain on the joint or
fracture must be avoided to reduce the risk of
this complication
• Can be a result of nonunion of a fracture

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 Avascular Necrosis
• A variety of factors can interfere with blood
supply after a bone injury
• Once bone cells are deprived of oxygen and
nutrients, they die and their cell walls collapse
• Signs and symptoms
• Pain, instability, and decreased function in the
affected area

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 Avascular Necrosis
• Treatment
• Relief of weight bearing and removal of part of the
bone to decrease pressure
• If conservative measures fail, surgical procedures
may be recommended
• Sometimes amputation is necessary

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 Complex Regional Pain Syndrome
Type 1 (CRPS—Type 1)
• Precipitated by a fracture or other trauma
• Symptoms
• Severe pain at the injury site despite no detectable
nerve damage, edema, muscle spasm, stiffness,
vasospasms, increased sweating, atrophy,
contractions, and loss of bone mass
• Symptoms persist longer than expected with the
type of injury suffered

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 Complex Regional Pain Syndrome
Type 1 (CRPS—Type 1)
• Treatment
• Nerve blocks, physical therapy, transcutaneous
electrical stimulation, and analgesics, muscle
relaxants, and antidepressants

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 Signs and Symptoms
• Depend on type and location of the break
• Some fractures have so few manifestations
that they can be detected only with x-ray
• Signs and symptoms are swelling, bruising,
pain, tenderness, loss of normal function,
abnormal position, and decreased mobility
• See Box 42-1, p. 918

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 Diagnostic Tests and Procedures
• Standard radiographs
• Reveal bone disruption, deformity, or malignancy
• Computed tomography (CT)
• Detect fractures of complex structures, such as the hip and
pelvis, or compression fractures of the spine
• Bone scan
• Detect small bone fractures or fractures caused by stress or
disease

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 Medical Treatment

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 Reduction
• The process of bringing the ends of the broken bone
into proper alignment

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Closed Reduction or Manipulation
• Nonsurgical realignment that returns bones to
their previous anatomic position
• No surgical incision is made; however, general
or local anesthesia is given
• By using traction, manual pressure, or a
combination
• After reduction of a fracture, x-ray taken and a
cast usually applied

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 Figure 42-3
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 Open Reduction
• A surgical procedure in which an incision is
made at the fracture site
• Usually for open (compound) or comminuted
fractures to clean the area of fragments and
debris

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 Immobilization
• Necessary for healing to occur
• Prevents movement and increases union
• Accomplished in many ways, such as fixation,
casts, splints, and traction

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 Fixation
• An attempt to attach the fragments of the
broken bone together when reduction alone is
not feasible because of the type and extent of
the break

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 Internal Fixation
• Done during open reduction surgical procedure
• Rods, pins, nails, screws, or metal plates used
to align bone fragments and keep them in
place for healing
• Promotes early mobilization; preferred for older
adults who have brittle bones that may not heal
properly, or who may suffer the consequences
of immobility

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 Figure 42-4
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 External Fixation
• Pins are inserted into the bone, above and below fracture
• Pins are then attached to an external frame and adjusted to align
the bone
• If there is soft tissue damage or infection, external fixation allows
access to the site and facilitates wound care
• Pin care is extremely important to prevent the migration of
organisms along the pin from the skin to the bone
• Patients should be taught to do their own pin care and to
recognize signs of infection

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 Figure 42-5

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 Figure 42-6

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Therapeutic Measures

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 Casts, Splints, and Immobilizers
• Hold the bone in alignment while allowing movement of
other parts of the body
• Types of cast materials: plaster of Paris, fiberglass,
thermoplastic resins, thermolabile plastic, and
polyester-cotton knit impregnated with polyurethane
• Variety of materials used for splints/immobilizers
• Four main groups of casts: (1) upper extremity, (2)
lower extremity, (3) cast brace, and (4) body or spica
cast

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 Traction
• Exerts a pulling force on a fractured extremity
to align bone fragments
• Prevents or corrects deformity, decreases
muscle spasm, promotes rest, and maintains
the position of the injured part
• May be applied directly to the skin (skin
traction) or attached directly to a bone (skeletal
traction) with a metal pin or wire

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 Traction
• Skin traction
• Buck’s traction
• For hip and knee contractures, muscle spasms, and alignment of
hip fractures
• Weight used during skin traction should not be more than
5 to 10 pounds to prevent injury to the skin
• Skeletal traction
• Provides a strong, steady, continuous pull and can be used for
prolonged periods
• Examples of skeletal traction are Gardner-Wells, Crutchfield,
and Vinke tongs and a halo vest, in which pins are inserted
into the skull on either side

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 Figure 42-7
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 Figure 29-8
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 Traction
• Complications
• Impaired circulation, inadequate fracture alignment,
skin breakdown, and soft tissue injury
• Pin track infection and osteomyelitis can occur with
skeletal traction

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 Assistive Devices

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 Crutches
• Increase mobility and assist with ambulation
• Physical therapist measures patient for proper fit and
instructs in crutch-walking techniques
• Nurse reinforces the instructions and evaluates
whether the crutches are being used properly
• A properly fitted crutch should reach to three
fingerbreadths below the axilla to avoid pressure on
the axilla and nerves when walking

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 Figure 42-8

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 Crutches: Gait Patterns
• Two-point gait
• The crutch on one side and the opposite foot are advanced at
the same time
• Used with partial weight-bearing limitations and with bilateral
lower extremity prostheses
• Three-point gait
• Both crutches and the foot of the affected extremity are
advanced together, followed by the foot of the unaffected
extremity
• This gait requires strength and balance
• Used for partial or no weight bearing on affected leg

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 Crutches: Gait Patterns
• Four-point gait
• The right crutch is advanced, then the left foot, then
the left crutch, then the right foot
• Used if weight bearing is allowed and one foot can
be placed in front of the other
• Swing-to gait
• Both crutches are advanced together, then both legs
are lifted and placed down again on a spot behind
the crutches
• The feet and crutches form a tripod

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 Crutches: Gait Patterns
• Swing-through gait
• Both crutches are advanced together, then both legs
are lifted through and beyond the crutches and
placed down again at a point in front of the crutches
• Used when adequate muscle power and balance in
the arms and legs

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 Figure 42-9

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 Walker
• Used for support and balance, usually by older
adults

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 Canes
• Provide minimal support and balance, and
relieve pressure on weight-bearing joints
• Placed on the unaffected side with the top
even with the patient’s greater trochanter

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 Electrical Stimulation
• Electrical stimulation may be used to promote bone
healing by promoting bone growth
• An electrical current is delivered through one of three
methods
• A surgically implanted device
• Device with pins that are inserted through the skin to the
fracture site
• Pack of electrical coils applied to skin around fracture
• Electrical bone stimulators successful in 80% of cases,
with an average healing time of 16 weeks

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 Assessment
• Health history
• The cause, type, and extent of the injury
• Symptoms associated with the injury
• Other medical problems that may have been related
to the cause of the fracture

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 Assessment
• Physical examination
• Deviations in bone alignment
• Inspect the skin over the fracture for lacerations,
bruising, or swelling
• Neurovascular checks (pulse, skin color, capillary
refill time, sensation) in the areas distal to the
wound to compare circulation and sensation.
Assess pulse rate and volume, as well as capillary
refill time in the nails distal to the injury

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 Interventions
• Acute Pain
• Ineffective Tissue Perfusion
• Risk for Infection
• Impaired Physical Mobility
• Risk for Impaired Skin Integrity
• Activity Intolerance

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Management of Specific Fractures

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 Fracture of the Hip
• Medical diagnosis
• Radiography
• Medical treatment
• Traction and surgical repair (internal fixation,
femoral head replacement, or total hip replacement)
• Patients may begin physical therapy as early as 1
day after surgery, depending on the type of repair;
begin by sitting in a chair and then progress to a
walker

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 Figure 42-10
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 Fracture of the Hip
• Assessment
• Pain, impaired peripheral circulation on the affected
side, complications of immobility, skin breakdown,
and ability to carry out activities of daily living

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 Fracture of the Hip
• Interventions
• Relieving pain, promoting mobility and
independence, and preventing complications
• Proper body alignment is extremely important in
preventing injury to the fracture area
• Turn patients from side to side as ordered
• Affected hip must not be adducted or flexed more
than 90 degrees because excessive
flexion/adduction can dislocate the prosthesis

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 Colles’ Fracture
• A break in the distal radius (wrist area)
• Medical diagnosis
• Radiography
• Medical treatment
• Closed reduction or manipulation of the bone and
immobilization in either a splint or a cast

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 Colles’ Fracture
• Assessment
• Pain and swelling following treatment of the fracture
• Interventions
• Extremity should be supported and protected and can be
elevated on a pillow during the first few days
• Encourage patients to move their fingers and thumb to
promote circulation and reduce swelling, and to move their
shoulders to prevent stiffness and contracture
• Teach proper cast care

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 Fracture of the Pelvis
• Medical diagnosis
• Radiography

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 Fracture of the Pelvis
• Medical treatment
• A less severe non–weight-bearing fracture treated with bed
rest on a firm mattress or bed board for a few days to 6 weeks
• Severe weight-bearing fracture may require a pelvic sling,
skeletal traction, double hip spica cast, or external fixation
• Monitor patient so injuries can be treated immediately
• Check for presence of blood in urine and stool, and watch
abdomen for signs of rigidity or swelling

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 Fracture of the Pelvis
• Assessment
• Signs of bleeding, swelling, infection,
thromboembolism, and pain
• Assess urine output because the absence of urine
may indicate a perforated bladder

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 Fracture of the Pelvis
• Interventions
• When handling patients, take extreme care to
prevent displacement of the fracture fragments
• Turn patient only on the order of a physician
• Provide back care when patient raised from the bed
using the trapeze or with adequate assistance from
others
• Ambulation may be encouraged even though
painful; follow physician’s orders

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