Fracture Nursing Care Management: Study Guide

A fracture is rarely just a broken bone. Damage to one part of the musculoskeletal system throws off the adjacent muscles, joints, and tendons, so your job is to immobilize early, watch perfusion, and catch the complications that kill (hemorrhage, fat embolism, compartment syndrome).

What Is a Fracture?

A fracture is a complete or incomplete disruption in the continuity of bone, classified by type and extent. It happens when the bone takes more stress than it can absorb. When the bone breaks, the structures around it suffer too: soft tissue edema, hemorrhage into muscles and joints, joint dislocations, ruptured tendons, severed nerves, and damaged blood vessels.

Classification

• Complete: a break across the entire cross-section of the bone, frequently displaced.
• Incomplete: a break through only part of the cross-section.
• Comminuted: produces several bone fragments.
• Closed: does not break the skin.
• Open: the skin or mucous membrane wound extends to the fractured bone.

Causes

Fractures come from direct blows, crushing forces, sudden twisting motions, and extreme muscle contractions that exceed what the bone can absorb.

Clinical Manifestations

Not every sign appears in every fracture. Pain is continuous and worsens until the fragments are immobilized. The extremity loses function because muscle action depends on intact bone. Displacement, angulation, or rotation produces a visible deformity when compared with the uninjured limb, and the extremity may be shortened from compression of the fractured bone. Gentle palpation may reveal crepitus (a crumbling sensation), and localized edema and ecchymosis follow from trauma and bleeding into the tissues.

Complications

Hypovolemic shock from hemorrhage is most common in pelvic fractures and in displaced or open femoral fractures. Fat embolism syndrome can develop after fracture of long bones or pelvic bones, or after crush injuries. Compartment syndrome is a limb-threatening emergency that occurs when perfusion pressure falls below tissue pressure inside a closed anatomic compartment.

Assessment and Diagnostic Findings

X-rays determine the location and extent of the fracture and may reveal preexisting undiagnosed fractures. Bone scans, tomograms, CT, and MRI visualize fractures, bleeding, and soft-tissue damage and distinguish stress or trauma fractures from bone neoplasms. Arteriograms are used when occult vascular damage is suspected. On CBC, hematocrit may be increased (hemoconcentration) or decreased (hemorrhage at the fracture site or distant organs in multiple trauma), and an increased WBC count is a normal stress response after trauma. Urine creatinine clearance rises because muscle trauma increases the creatinine load on the kidneys. The coagulation profile may shift from blood loss, multiple transfusions, or liver injury.

Medical Management

Care is emergent or post-emergent. If a fracture is suspected, immobilize the body part before moving the patient. Adequate splinting prevents movement of the fragments. Cover an open fracture with a sterile dressing to prevent contamination of deeper tissues. Fracture reduction restores the fragments to anatomic alignment and position and can be open or closed depending on the fracture.

Nursing Management

Assessment

Differentiate closed from open. In a closed fracture, confirm there is no skin opening at the site. In an open fracture, assess the risk for osteomyelitis, tetanus, and gas gangrene. Assess the site for signs and symptoms of infection.

Diagnosis

• Acute pain related to fracture, soft tissue injury, and muscle spasm
• Impaired physical mobility related to fracture
• Risk for infection related to the skin opening in an open fracture

Planning and Goals

• Relieve pain
• Achieve a pain-free, functional, stable body part
• Maintain asepsis
• Keep vital signs within normal range
• Show no evidence of complications

Interventions

Teach the patient proper methods to control edema and pain. Teach exercises that keep unaffected muscles healthy and build the strength needed for transfers and assistive devices. Help the patient modify the home environment for safety, such as clearing obstructions from walking paths. Begin wound irrigation and debridement as soon as possible. Elevate the affected extremity to minimize edema, and assess for signs and symptoms of infection.

Evaluation

Care is effective when the patient meets the planned goals: pain relieved, a pain-free and functional stable body part, asepsis maintained, vital signs within normal range, and no evidence of complications.

Discharge and Home Care

The patient or caregiver should be able to reduce swelling and pain (elevate the extremity, take analgesics as prescribed), manage immobilization devices or incision care, eat a diet that promotes bone healing, use mobility aids and assistive devices safely, and avoid excessive use of the injured extremity while observing weight-bearing limits.

Documentation

Document the patient's description of pain and acceptable pain level, prior medication use, level of function, ability to participate in desired activities, signs and symptoms of infection, the wound or incision site, the plan of care, the teaching plan, responses to interventions and teaching, attainment of or progress toward outcomes, modifications to the plan, and long-term needs.