1 NCM116a: Alterations in Coordination-Injuries: Fracture

Fracture
A fracture is a complete or incomplete disruption in the continuity of bone structure
and is defined according to its type and extent. Fractures occur when the bone is subjected
to stress greater than it can absorb. Fractures may be caused by direct blows, crushing
forces, sudden twisting motions, and extreme muscle contractions. When the bone is
broken, adjacent structures are also affected, resulting in soft tissue edema, hemorrhage
into the muscles and joints, joint dislocations, ruptured tendons, severed nerves, and
damaged blood vessels. Body organs may be injured by the force that caused the fracture or
by fracture fragments
Causes of Fracture
1. Direct Force - There is direct trauma to the bone.
2. Bone Diseases - There are certain conditions that may predispose an individual to have
fracture.

3. Repeated or prolonged Stress

Types of Fracture: General Classification
a. Closed-skin remains intact-bone does not protrude through the skin.
b. Compound or Open -bone fragments protrude through the skin and it is associated with
open wound. An open fracture (compound, or complex, fracture) is one in which the skin or
mucous membrane wound extends to the fractured bone (Whiteing, 2008). Open fractures
are graded according to the following criteria:
1. Grade I is a clean wound less than 1 cm long.
2. Grade II is a larger wound without extensive soft tissue damage.
3. Grade III is highly contaminated, has extensive soft tissue damage, and is the most
severe.
c. Incomplete or Partial-only one side of the bone breaks thru the periosteum.
d. Complete Fracture-the break completely disrupts the continuity of the tissue across the
entire width of the bone involved.
e. Complicated-structures surrounding the fracture are injured. There may be damage to
the veins, arteries or nerves, and there may also be injury to the lining of the bone (the
periosteum). When a bone fragment has penetrated an internal structure such as the lungs.
Types of Fracture: Appearance
1. Simple-can be complete or incomplete.
2. Comminuted-the break is in three or more pieces and fragments are present at the
fracture site.
3. Impacted-in this type of fracture the bone shatters into a number of pieces that are
driven into one another at the point of the break. Fragments of bone may surround
the
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2 NCM116a: Alterations in Coordination-Injuries: Fracture

site of the break and the two ends are compacted together, possibly forming a bulge
in the bone
4. Depressed-a depressed skull fracture is a type of fracture usually resulting from blunt
force trauma, such as getting struck with a hammer, rock or getting kicked in the
head. These types of fractures—which occur in 11% of severe head injuries—are
comminuted fractures in which broken bones displace inward.
5. Compressed-the bone is crushed, causing the broken bone to be wider or flatter in
appearance.
Type of Fracture: Pattern
1. Transverse- a fracture that is straight across the bone, usually caused by force
applied to the site at which fractures occurs.
2. Oblique- break runs in slanting direction on bone cause by sharp angled blow to the
bone.
3. Spiral (Torsion)- break run across the bone and occur as a result of twisting.
4. Comminuted- break is in three or more pieces and fragments are present at the
fracture site.
5. Segmental-the same bone is fractured in two places, so there is a "floating" segment
of bone.
Type of Fracture: Cause
1. A pathologic (spontaneous) fracture occurs after minimal trauma to a bone that has
been weakened by disease. For example, a patient with bone cancer or osteoporosis
can easily have a pathologic fracture.
2. A fatigue (stress) fracture results from excessive strain and stress on the bone. This
problem is commonly seen in recreational and professional athletes.
3. Compression fractures are produced by a loading force applied to the long axis of
cancellous bone. They commonly occur in the vertebrae of older patients with
osteoporosis and are extremely painful.
Special Types of Fracture:
Colles Fracture
A distal radius fracture almost always occurs about 1 inch from the end of the bone.
The break can occur in many different ways, however. One of the most common distal
radius fractures is a Colles fracture, in which the broken fragment of the radius tilts upward.
This fracture was first described in 1814 by an Irish surgeon and anatomist, Abraham Colles
-- hence the name "Colles" fracture. It is caused by Fall on Outstretch Hand (FOOSH).
Smith’s Fracture
A Smith's fracture, also sometimes known as a reverse Colles' fracture is a fracture of
the distal radius. It is caused by a direct blow to the dorsal forearm or falling onto flexed
wrists, as opposed to a Colles' fracture which occurs as a result of falling onto wrists in
extension. Smith's fractures are less common than Colles' fractures.

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3 NCM116a: Alterations in Coordination-Injuries: Fracture

Pott’s Fracture
A Pott’s fracture is a fracture affecting one or both of the malleoli. During activities
such as landing from a jump (volleyball, basketball) or when rolling an ankle, a certain
amount of stress is placed on the tibia and fibula and the ankle joint. When this stress is
traumatic, and beyond what the bone can withstand, a break in the medial, lateral, or
posterior malleolus may occur
Monteggia’s Fracture
Dislocations consist of a fracture of the ulnar shaft with concomitant dislocation of
the radial head. Also caused by FOOSH.
Bennett’s Fracture
Fracture of the Base of the thumb, associated with dislocation of metacarpal joint or
thumb.

Pilon Fracture
Pilon fracture is a fracture of the lower end of the tibia bone that forms the ankle
joint by articulating with the talus. This fracture was first described by Destot in 1911. This
fracture occurs when the talus bone hits the tibia bone with a force directed upwards.
Cooton/Trimalleolar
A trimalleolar ankle fracture, or tri-malleolar fracture, is a fracture of the ankle
involving the medial malleolus, lateral malleolus, and the lower part of the tibia (the
posterior malleolus).
Galeazzi fracture
The Galeazzi fracture is a fracture of the radius with dislocation of the distal
radioulnar joint. It classically involves an isolated fracture of the junction of the distal third
and middle third of the radius with associated subluxation or dislocation of the distal radio-
ulnar joint; the injury disrupts the forearm axis joint.
Malgaigne’s Fracture
Double fracture of the pelvic ring causing instability in the pelvis. It is named
after Joseph-François Malgaigne (1806-1865), a French surgeon.
Hangman’s Fracture
This is the fracture of the posterior element of the cervical vertebra with dislocation
of C1 or C2. Hangman’s Fracture is a fracture of the arc in 2nd cervical spine which also
make the 2nd cervical spine dislocate from the 3th cervical spine. Usually it is happens in a
neck injury.

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4 NCM116a: Alterations in Coordination-Injuries: Fracture

ASSESSMENT

Clinical Manifestations
The clinical signs and symptoms of a fracture include acute pain, loss of function,
deformity, shortening of the extremity, crepitus, and localized edema and ecchymosis. Not
all of these are present in every fracture (Whiteing, 2008).
1. Pain: The pain is continuous and increases in severity until the bone fragments are
immobilized. The muscle spasms that accompany a fracture begin within 20 minutes
after the injury and result in more intense pain than the patient reports at the time
of injury. The muscle spasms can minimize further movement of the fracture
fragments or can result in further bony fragmentation or malalignment.
2. Loss of Function: After a fracture, the extremity cannot function properly because
normal function of the muscles depends on the integrity of the bones to which they
are attached. Pain contributes to the loss of function. In addition, abnormal
movement (false motion) may be present.
3. Deformity Displacement, angulation, or rotation of the fragments in a fracture of the
arm or leg causes a deformity that is detectable when the limb is compared with the
uninjured extremity.
4. Shortening: In fractures of long bones, there is actual shortening of the extremity
because of the compression of the fractured bone. Sometimes muscle spasms can
cause the distal and proximal site of the fracture to overlap, causing the extremity to
shorten.
5. Crepitus: When the extremity is gently palpated, a crumbling sensation, called
crepitus, can be felt. It is caused by the rubbing of the bone fragments against each
other.
6. Localized Edema and Ecchymosis: Localized edema and ecchymosis occur after a
fracture as a result of trauma and bleeding into the tissues. These signs may not
develop for several hours after the injury or may develop within an hour, depending
on the severity of the fracture.
Diagnostic Examination
Diagnosis is the first step in the care of fractures and is based on history and physical
manifestations. X-ray examination is used to confirm the diagnosis and direct the treatment.
1. Laboratory Assessment. No special laboratory tests are available for assessment of
fractures. Hemoglobin and hematocrit levels may often be low because of bleeding
caused by the injury. If extensive soft-tissue damage is present, the erythrocyte
sedimentation rate (ESR) may be elevated, which indicates the expected
inflammatory response. If this value and the white blood cell (WBC) count increase
during fracture healing, the patient may have a bone infection. During the healing
stages, serum calcium and phosphorus levels are often increased as the bone
releases these elements into the blood.

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5 NCM116a: Alterations in Coordination-Injuries: Fracture

2. Imaging Assessment. The health care provider requests standard x-rays to confirm a
diagnosis of fracture. These reveal the bone disruption, malalignment, or deformity.
If the x-ray does not show a fracture but the patient is symptomatic, the x-ray is
usually repeated with additional views. The CT scan is useful in detecting fractures of
complex structures, such as the hip and pelvis. It also identifies compression
fractures of the spine. MRI is useful in determining the amount of soft-tissue damage
that may have occurred with the fracture.

DIAGNOSIS

 Acute pain, related to fractured left femoral neck and muscle spasms
 Impaired physical mobility, related to bed rest and fractured left femoral neck
 Risk for ineffective tissue perfusion, related to unstable bones and swelling
Physiology of Bone Healing
I. Hematoma Formation
When a bone breaks, blood vessels in the bone and surrounding tissues are torn and
bleed into and around the fragments of the fractured bone, forming a blood clot
(Hematoma)
The hematoma facilitates the formation of the fibrin meshwork that seals off the
fracture site and serves as a framework for the influx of inflammatory cells, the ingrowth of
fibroblasts, and the development of new capillary buds (vessels. It is also the source of
signalling molecules that initiate the cellular events that are critical to the healing process.
Hematoma formation occurs during the 1 to 2 days after the fracture. In 2 to 5 days, the
hemorrhage forms a large blood clot.
II. Fibrocartilaginous Callus Formation
As new capillaries infiltrate the hematoma at the fracture site, it becomes organized into
a form of granulation tissue called procallus. Fibroblasts from the periosteum, endosteum,
and red bone marrow proliferate and invade the procallus. The fibroblasts produce a
fibrocartilaginous soft callus bridge that connects the bone fragments. Although this repair
tissue usually reaches its maximum girth at the end of the 2nd or 3rd week, it is not strong
enough for weight bearing.
III. Bony Callus Formation
Ossification represents the conversion of fibrocartilaginous cartilage to bony callus. In
areas close to well vascularized bone tissue, osteogenic cells develop into osteoblasts or
bone-building cells which now produces spongy bone trabeculae. The newly formed
osteoblasts first deposit bone on the outer surface of the bone on the outer surface of the
bone at the fracture site. The formation of bone progress toward the fracture site until a
new bony sheath covers the fibrocartilage is converted to spongy bone, and the callus is
then referred to as bony callus. Gradually, the bony callus calcifies and is replaced by mature
bone. Bony callus formation begins 3 to 4 weeks after injury and continues until a firm bony
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union is formed months later.

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IV. Remodelling
During remodelling of the bony callus, dead portions of the bone are gradually removed
by osteoclasts. Compact bones replaces spongy bone around the periphery of the fracture,
and there is reorganization of mineralized bone along the lines of mechanical stress. During
this period, the excess material on the outside of the bone shaft and within the medullary
cavity is removed and compact bone is lays down to reconstruct the shaft. The final
structure of the remodelled area resembles that of the original unbroken bone; however, a
thickened area on the surface of the bone may remain as evidence of healed fracture.
Emergency Management
RICE: Treatment depends on the general condition of the person, the presence of
associated injuries, the location of the fracture and its displacement, and whether the
fracture is open or closed.

Emergency Management: Immediately after injury, if a fracture is suspected, it is

important to immobilize the body part before the patient is moved. Adequate splinting is
essential. Joints proximal and distal to the fracture must be immobilized to prevent
movement of fracture fragments. Immobilization of the long bones of the lower extremities
may be accomplished by bandaging the legs together, with the unaffected extremity
With an open fracture, the wound is covered with a sterile dressing to prevent
contamination of deeper tissues. No attempt is made to reduce the fracture, even if one of
the bone fragments is protruding through the wound. Splints are applied for immobilization
When fracture is suspected, the injured part should always be splinted before it is
moved. This is essential in preventing further injury.
There are three objectives for treatment of fracture:
 Reduction of Fracture
 Immobilization
 Preservation and restoration of the function of the injured

Reduction
Fracture Reduction refers to restoration of the fracture fragments to anatomic alignment
and positioning. Either closed reduction or open reduction may be used to reduce a
fracture. The specific method selected depends on the nature of the fracture; however, the
underlying principles are the same.
Typically, the physician reduces a fracture as soon as possible to prevent loss of elasticity
from the tissues through infiltration by edema or hemorrhage. In most cases, fracture
reduction becomes more difficult as the injury begins to heal. Before fracture reduction and
immobilization, the patient is prepared for the procedure; consent for the procedure is

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obtained, and an analgesic is administered as prescribed. Anesthesia may be administered.

The injured extremity must be handled gently to avoid additional damage.

Open Reduction
Some fractures require Open Reduction. Through a surgical approach, the fracture
fragments are anatomically aligned. Internal fixation devices (metallic pins, wires, screws,
plates, nails, or rods) may be used to hold the bone fragments in position until solid bone
healing occurs. These devices may be attached to the sides of bone, or they may be inserted
through the bony fragments or directly into the medullary cavity of the bone. Internal
fixation devices ensure firm approximation and fixation of the bony fragments.
Immobilization
After the fracture has been reduced, the bone fragments must be immobilized and
maintained in proper position and alignment until union occurs. Immobilization may be
accomplished by external or internal fixation. Methods of external fixation include
bandages, casts, splints, continuous traction, and external fixators.

Closed Reduction
In most instances, closed reduction is accomplished by bringing the bone fragments
into anatomic alignment through manipulation and manual traction. The extremity is held in
the aligned position while the physician applies a cast, splint, or other device. Reduction
under anesthesia with percutaneous pinning may also be used. The immobilizing device
maintains the reduction and stabilizes the extremity for bone healing. X-rays are obtained to
verify that the bone fragments are correctly aligned. Traction (skin or skeletal) may be used
until the patient is physiologically stable to undergo surgical fixation
Immobilizing Devices
Splint
Thermoplastic, a durable, flexible material for splinting, allows custom fitting to the
patient's body part. Splints for lower extremities are also custom-fitted using flexible
materials and held in place with elastic bandages (e.g., ACE wrap). When possible, splints
are preferred over casts to prevent the complications that can occur with casting. Splints
also allow room for extremity swelling without causing decreased arterial perfusion.
1. A cast is a rigid device that immobilizes the affected body part while allowing other
body parts to move. It also allows early mobility and reduces pain. Although its most
common use is for fractures, a cast may be applied for correction of deformities
(e.g., clubfoot) or for prevention of deformities (e.g., those seen in some patients
with rheumatoid arthritis).
2. Traction is the application of a pulling force to a part of the body to provide
reduction, alignment, and rest. It is also used as a last resort to decrease muscle
spasm (thus relieving pain) and prevent or correct deformity and tissue damage.

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9 NCM116a: Alterations in Coordination-Injuries: Fracture

A patient in

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Fracture

traction is often hospitalized, but in some cases, home care is possible even for
skeletal traction.
Cast
The condition being treated influences the type and thickness of the cast applied.
Generally, the joints proximal and distal to the area to be immobilized are included in
the cast
A cast is a rigid device that immobilizes the affected body part while allowing
other body parts to move. It also allows early mobility and reduces pain. Although its
most common use is for fractures, a cast may be applied for correction of
deformities (e.g., clubfoot) or for prevention of deformities (e.g., those seen in some
patients with rheumatoid arthritis).
Casts made of plaster are less costly and achieve a better mold than fiberglass
casts; however, they are not as durable and take longer to dry. Rolls of plaster of
Paris-impregnated bandages are wet in cool water and applied smoothly to the
body. These will also cause an exothermic reaction, similar to that seen with
fiberglass casts. The crystallization process produces a rigid dressing in 15 to 20
minutes.
After the plaster sets, the cast remains wet and somewhat soft. It does not
have its full strength until it is dry. The plaster cast requires 24 to 72 hours to dry
completely, depending on its thickness and the environmental drying conditions. A
freshly applied cast should be exposed to circulating air to dry and should not be
covered with clothing or bed linens or placed on plastic-coated mats or bedding. A
wet plaster cast appears dull and gray, sounds dull on percussion, feels damp, and
smells musty. A dry plaster cast is white and shiny, resonant to percussion, odorless,
and firm.
Fiber Glass Cast
Fiberglass casts are composed of water-activated polyurethane materials that
have the versatility of plaster but are lighter in weight, stronger, and more durable
than plaster. In addition, they are water resistant (Altizer, 2004). They consist of an
open-weave, non- absorbent fabric impregnated with cool water–activated
hardeners that bond and reach full rigid strength in minutes. Heat is given off (an
exothermic reaction) while the cast is applied.
Therefore, a newly applied fiberglass cast should not be placed on a plastic
surface. The heat given off during this reaction can be uncomfortable, and the nurse
should prepare the patient for the sensation of increasing warmth so that the
patient does not become alarmed. While the cast is setting, it can be dented.
Therefore, it must be handled with the palms of the hands and not allowed to rest
on hard surfaces or sharp edges. Cast dents may press on the skin, causing irritation
and skin breakdown.

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 11 NCM116a: Alterations in Coordination-Injuries:
Fracture

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 12 NCM116a: Alterations in Coordination-Injuries:
Fracture

Plaster is the traditional material used for casts but is not as commonly used today
for management of most fractures. It requires application of a well-fitted stockinet under
the material. If the stockinette is too tight, it may impair circulation. If it is too loose,
wrinkles can lead to the development of pressure ulcers. Padding is applied over the
stockinette, followed by wet plaster rolls wrapped around the extremity or other body part.
The cast feels hot because an immediate chemical reaction occurs, but it soon becomes
damp and cool. This type of cast takes at least 24 hours to dry, depending on the size and
location of the cast. A wet cast feels cold, smells musty, and is grayish. The cast is dry when
it feels hard and firm, is odorless, and has a shiny white appearance.
Braces
Braces (orthoses) are used to provide support, control movement, and prevent
additional injury. They are custom fitted to various parts of the body. The orthotist adjusts
the brace for fit, positioning, and motion so that movement is enhanced, any deformities
are corrected, and discomfort is minimized. Braces are generally indicated for longer use
than splints
General Nursing Management of Patient in a Cast, Splint or Brace
1. When moving a patient with a wet plaster cast, handle it with the palms of the hands
to prevent indentations and resulting areas of pressure on the skin.
2. Turn the patient every 1 to 2 hours to allow air to 3023 circulate and dry all parts of
the cast.
3. If the health care provider requests that the cast be elevated to reduce swelling, use
a cloth-covered pillow instead of one encased in plastic, which could cause the cast
to retain heat and prevent drying.
Elevation of the casted extremity reduces edema but may impair arterial circulation to
the affected limb. Therefore performing a neurovascular assessment of the limb distal to
(below) the cast is very important. Check the "5 P's"--pain, pulse, pallor, paresthesia, and
paralysis.
a. Pain. Determine where the pain is located and if it is worse or better? Worsening
pain may indicate increased edema, lack of adequate blood supply, or tissue
damage. Pain may be indicative of complications. Pain associated with compartment
syndrome is relentless and is not controlled by modalities such as elevation,
application of cold if prescribed, and usual dosages of analgesic agents. Severe
burning pain over bony prominences, especially the heels, anterior ankles, and
elbows, warns of an impending pressure ulcer. These may also occur from too-tight
ace wraps used to hold splints in place. Pain decreases when ulceration occurs.
Discomfort due to pressure on the skin may be relieved by elevation that controls
edema or by positioning that alters pressure. It may be necessary to modify the
dressing, ace wrap, or cast, or to apply a new cast.
b. Pulse. Check the peripheral pulses, especially those distal to the fracture site.
Compare all pulses with those on the unaffected side. Pulses should be strong and
equal. Early recognition of diminished circulation and nerve function is essential to
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Fracture

prevent loss of function. The nurse adjusts the extremity so that it is no higher than

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heart level to enhance arterial perfusion and control edema and notifies the
physician at once if signs of compromised neurovascular status are present.
c. Pallor. Observe the color and temperature of the skin, especially around the
fracture site. Perform the capillary refill (blanching) test.
d. Paresthesia. Examine the injured area for increase or decrease in sensation. Can the
patient detect tactile stimulation such as a blunt touch or a sharp pinprick? Does the
patient complain of numbness or tingling?
e. Paralysis. Check the patient's mobility. Can he wiggle his toes and fingers? Can he
move his extremities?
1. Check to ensure that any type of cast is not too tight, and frequently monitor
neurovascular status—usually every hour for the first 24 hours after
application if the patient is hospitalized. You should be able to insert a finger
between the cast and the skin.
2. Teach the patient to apply ice for the first 24 to 36 hours to reduce swelling
and inflammation
3. Exercise: Every joint that is not immobilized should be exercised and moved
through its range of motion to maintain function. If the patient has a leg cast,
brace, or splint, the nurse encourages toe exercises. If the patient has an arm
immobilized, the nurse encourages finger exercises. This is to prevent disuse
syndrome as well.
4. Document the presence of any drainage on the cast. However, the evidence is
not clear on whether drainage should be circled on the cast because it may
increase anxiety and is not a reliable indicator of drainage amount.
Immediately report to the health care provider any sudden increases in the
amount of drainage or change in the integrity of the cast. The nurse monitors
circulation, motion, and sensation of the affected extremity, assessing the
fingers or toes of the affected extremity and comparing them with those of
the opposite extremity. Normal findings include minimal edema, minimal
discomfort, pink color, warm to touch, rapid capillary refill response, normal
sensations, and ability to exercise fingers or toes
Traction
Traction is the application of a pulling force to a part of the body to provide
reduction, alignment, and rest. It is also used as a last resort to decrease muscle spasm (thus
relieving pain) and prevent or correct deformity and tissue damage. A patient in traction is
often hospitalized, but in some cases, home care is possible even for skeletal traction.
Traction may be classified as running traction or balanced suspension. In running
traction, the pulling force is in one direction and the patient's body acts as countertraction.
Moving the body or bed position can alter the countertraction force. Balanced suspension
provides the countertraction so that the pulling force of the traction is not altered when the
bed or patient is moved. This allows for increased movement and facilitates care

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15 NCM116a: Alterations in Coordination-Injuries: Fracture

Drug Therapy
1. After fracture treatment, the patient often has pain for a prolonged time during the
healing process. The health care provider commonly prescribes opioid and non-
opioid analgesics, anti-inflammatory drugs, and muscle relaxants. For patients with
chronic, severe pain, opioid and non-opioid drugs are alternated or given together to
manage pain both centrally in the brain and peripherally at the site of injury.
2. For severe or multiple fractures, patient-controlled analgesia (PCA) with morphine,
fentanyl, or hydromorphone (Dilaudid) is used. Meperidine (Demerol) should never
be used for older adults because it has toxic metabolites that can cause seizures and
other complications. Most hospitals no longer use this drug for patients of any age.
Oxycodone and oxycodone with acetaminophen (Percocet) are common oral opioid
drugs that are very effective for most patients with fracture pain. NSAIDs are given to
decrease associated tissue inflammation.
3. For patients who have less severe injury, the analgesic may be given on an as-needed
basis.
4. Collaborate with the patient regarding the best times for the strong analgesics to be
given (e.g., before a complex dressing change, after physical therapy sessions, and at
bedtime). Assess the effectiveness of the analgesic and its side effects. Constipation
is a common side effect of opioid therapy, especially for older adults.
5. Assess for frequency of bowel movements, and administer stool softeners as needed.
6. Encourage fluids and activity as tolerated.
Surgical Intervention
Open reduction with Internal Fixation (ORIF)
This is one of the most common methods of reducing and immobilizing a fracture.
External fixation with closed reduction is used when patients have soft-tissue injury (open
fracture). Although nurses do not decide which surgical technique is used, understanding
the procedures enhances patient teaching and care. Because ORIF permits early mobility, it
is often the preferred surgical method. Open reduction allows the surgeon to directly view
the fracture site. Internal fixation uses metal pins, screws, rods, plates, or prostheses to
immobilize the fracture during healing. The surgeon makes one or more incisions to gain
access to the broken bone(s) and implants one or more devices into bone tissue after each
fracture is reduced. A cast, boot, or splint is placed to maintain immobilization during the
healing process, depending on the body part affected.
External Fixation
An alternative modality for the management of fractures is the external fixation
apparatus. External fixation is a system in which pins or wires are inserted through the skin
and affected bone and then connected to a rigid external frame. The system may be used
for upper or lower extremity fractures or for fractures of the pelvis, especially for open
fractures when wound management is needed. After a fixator is removed, the patient may
be placed in a cast or splint until healing is complete. External fixation has several
advantages over other surgical techniques:
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16 NCM116a: Alterations in Coordination-Injuries: Fracture

a. there is minimal blood loss compared with internal fixation;

b. the device allows early ambulation and exercise of the affected body part
while relieving pain; and
c. the device maintains alignment in closed fractures that will not maintain
position in a cast and stabilizes comminuted fractures that require bone
grafting.
Monitoring and Managing Potential Complications
Potential complications related to casts, braces, and splints include compartment
syndrome, pressure ulcer formation, and disuse syndrome. These most commonly occur
when a cast is applied, because the cast is not easily removable, and are least commonly
associated with use of a splint, because splints tend to be used for the short term.
Compartments are areas in the body in which muscles, blood vessels, and nerves are
contained within fascia. Most compartments are located in the extremities. Fascia is an
inelastic tissue that surrounds groups of muscles, blood vessels, and nerves in the body.
The most common sites for this problem in patients with musculoskeletal trauma are
the compartments in the lower leg (tibial fractures) and forearm (Hershey, 2013). The
pathophysiologic changes of increased compartment pressure are sometimes referred to as
the ischemia-edema cycle. Capillaries within the muscle dilate, which raises capillary
(arterial) pressure and venous pressure (Hershey, 2013). Capillaries become more
permeable because of the release of histamine by the ischemic muscle tissue, and venous
drainage decreases (Friedrich & Shin, 2012). As a result, plasma proteins leak into the
interstitial fluid space and edema occurs.
Compartment Syndrome
Edema increases pressure on nerve endings and causes pain. Perfusion to the area is
reduced, and further ischemia results. Sensory perception deficits or paresthesia generally
appears before changes in vascular or motor signs. The color of the tissue pales, and pulses
begin to weaken but rarely disappear. The affected area is usually palpably tense, and pain
occurs with passive motion of the extremity. If the condition is not treated, cyanosis,
tingling, numbness, paresis, necrosis, and severe pain can occur. Nursing Action: Relieve
edema
Hypovolemic Shock
Bone is very vascular. Therefore, bleeding is a risk with bone injury. In addition,
trauma can cut nearby arteries and cause hemorrhage, resulting in rapidly developing
hypovolemic shock.
Pressure Ulcers
Cast or an inappropriately applied brace on soft tissues may cause tissue anoxia and
pressure ulcers. Lower extremity sites most susceptible to pressure ulcers are the heel,
malleoli, dorsum of the foot, head of the fibula, and anterior surface of the patella. The
main pressure sites on the upper extremity are located at the medial epicondyle of the
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17 NCM116a: Alterations in Coordination-Injuries: Fracture

humerus and the ulnar styloid

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18 NCM116a: Alterations in Coordination-Injuries: Fracture

Usually, the patient with a pressure ulcer reports pain and tightness in the area. A
warm area on the cast or brace suggests underlying tissue erythema. Skin breakdown may
occur. The drainage may stain the cast or brace and emit an odor. Even if discomfort does
not occur with skin breakdown and tissue necrosis, there may still be extensive loss of
tissue. The nurse must monitor the patient with a cast or brace for pressure ulcer
development and report findings to the physician.
Fat Embolism Syndrome
Fat embolism syndrome (FES) is another serious complication in which fat globules
are released from the yellow bone marrow into the bloodstream within 12 to 48 hours after
an injury or other illness (mechanical theory). These globules clog small blood vessels that
supply vital organs, most commonly the lungs, and impair organ perfusion. The biochemical
theory for FES may be considered as a separate cause or as an additive process to the
mechanical theory. The embolized fat degrades into free fatty acids and C-reactive protein,
which results in capillary leakage, lipid and platelet aggregation, and clot formation.
The earliest manifestations of FES are a low arterial oxygen level (hypoxemia),
dyspnea, and tachypnea (increased respirations). Nonpalpable, red-brown petechiae—a
macular, measles-like rash—may appear over the neck, upper arms, and/or chest. This rash
is a classic manifestation but is usually the last sign to develop. MGNT: O2 and Fluid
replacement. Fat emboli will resolve on its own.
Impaired Bone Healing
Delayed union is a fracture that has not healed within 6 months of injury. Some
fractures never achieve union; that is, they never completely heal (nonunion). Others heal
incorrectly (malunion). These problems are most common in patients with tibial fractures,
fractures that involve many treatment techniques (e.g., cast, traction), and pathologic
fractures. Union may also be delayed or not achieved in the older patient. If bone does not
heal, he or she typically has chronic pain and immobility from deformity
Malunion is healing with deformity, angulation, or rotation that is visible in xray
films. Mal-union at the early healing can be corrected by traction or reimmobilization. Mal-
union after healing is treated with surgery.
Delayed union is the failure of a fracture to unite within normal period (20 weeks of
fracture of the tibia or femur in an adult).
Non-union is failure to produce union and cessation of normal process of bone repair. It is
characterized by mobility of the fracture site and pain on weight bearing. Muscle atrophy
and loss of range of motion may occur. Nonunion is usually established 6 to 12 months after
the time of the fracture.

EVALUATION

The expected outcomes include that the patient:

• states that he or she has adequate pain control;
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19 NCM116a: Alterations in Coordination-Injuries: Fracture

• has adequate blood flow to maintain tissue perfusion and function;

• is free of infection;
• is free of physiologic consequences of impaired mobility; and
• ambulates or moves independently with or without an assistive device.

Post Assessment: A 20-item quiz will be given to you via your mVLE

Assignment: Research on the following concepts/topics:

1. Sports related injuries
a. Strains
b. Sprains
c. Dislocations
d. Contusions
2. Classification of strain according to severity
3. Grading system for strains
4. Diagnostics procedures
5. Treatments
6. Nursing managements

Prepared:
ROEL M. BELJAMIN
Instructor

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