Fractures: A Comprehensive Guide for Healthcare Professionals | Cheat Sheet Nursing

Fractures

Fracture – Any break in the continuity of the bone

Common in people who have sustained trauma and in older adults

Vary in severity according to the location and type of fracture

May result from a direct blow, a crushing force (compression), a sudden twisting motion (torsion), a severe muscle

contraction or disease that has weakened the bone (stress)

Classifications of Fractures

Closed (simple)– Skin remains intact

Open (compound)– Skin integrity is interrupted; breaks through the skin

Reducing a fracture means putting it in place

Complete- Involves the entire width of the bone

Incomplete- Involves only a part of the width of the bone

Fracture Healing (5 Stages) 3

1. 24 to 72 hours- hematoma (swelling + cardinal signs of inflammation) formation; its bringing in the increase

vasculature, nutrients, cells & building blocks

2. 3 days to 2 weeks- Granulation (new tissue) tissue begins to invade the hematoma and begins the formation of

fibrocartilage (framework)

3. 3 to 6 weeks- Fracture site is surrounded by vascular tissue called a callus

4. 3 to 8 weeks- Callus is resorbed and transformed into bone

5. 4 weeks to 1 year- Consolidation and remodeling of bone (getting stronger);

6 wks for most people, older people can heal for up to 1 yr; might not reach

100% healing in some people

Bone Healing

Please note this stages are a continuous process and do not happen

necessarily in single phases

Induction- granulation tissue invades the hematoma; prompts fibrocartilage

which is the foundation of bone healing

Inflammation brings vascular and cellular proliferation

Callus- the new vascular tissue is referred to as the callus which starts

bridging the nonbony union

Ossification (hardening)- the callus is reabsorbed and starts being

transformed into bone/30/2023

Remodeling- consolidation and remodeling occur up to a year

On average 4-6 wks in a young child to 3 months for those that are older, closer to 70 years old

Women after menopause is a population that has delayed healing due to loss of estrogen production; might need

calcium, phosphorus, vitamin D & protein supplementation

Factors that affect healing

Age- older the patient, the more complicated their healing will be

Severity of trauma- if it’s a clean break it’s a lot easier for healing to occur

Type of bone injured- smaller bones can heal a lot quicker

How the fracture is managed

Possible infections

Blood supply

Fall incidence

CDC reports- falls are the leading cause of injury deaths in older adults. This has risen sharply in the last decade

1 out of 4 older adults (65 and older) fall each year but less than half talk to their healthcare providers about it

Every 19 minutes an older adult dies from a fall

2.8 million nonfatal falls among older adults are treated in emergency departments yearly

Of these 800,000 require hospitalization, 300,000 hip fractures

Effects/Outcomes of Falls

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Fractures  Fracture – Any break in the continuity of the bone  Common in people who have sustained trauma and in older adults  Vary in severity according to the location and type of fracture  May result from a direct blow, a crushing force (compression), a sudden twisting motion (torsion), a severe muscle contraction or disease that has weakened the bone (stress) Classifications of Fractures  Closed (simple)– Skin remains intact  Open (compound)– Skin integrity is interrupted; breaks through the skin Reducing a fracture means putting it in place  Complete- Involves the entire width of the bone  Incomplete- Involves only a part of the width of the bone Fracture Healing (5 Stages) 3

24 to 72 hours- hematoma (swelling + cardinal signs of inflammation) formation; its bringing in the increase vasculature, nutrients, cells & building blocks
3 days to 2 weeks- Granulation (new tissue) tissue begins to invade the hematoma and begins the formation of fibrocartilage (framework)
3 to 6 weeks- Fracture site is surrounded by vascular tissue called a callus
3 to 8 weeks- Callus is resorbed and transformed into bone
4 weeks to 1 year- Consolidation and remodeling of bone (getting stronger); 6 wks for most people, older people can heal for up to 1 yr; might not reach 100% healing in some people Bone Healing  Please note this stages are a continuous process and do not happen necessarily in single phases  Induction - granulation tissue invades the hematoma; prompts fibrocartilage which is the foundation of bone healing  Inflammation brings vascular and cellular proliferation  Callus- the new vascular tissue is referred to as the callus which starts bridging the nonbony union  Ossification (hardening) - the callus is reabsorbed and starts being transformed into bone/30/  Remodeling- consolidation and remodeling occur up to a year  On average 4-6 wks in a young child to 3 months for those that are older, closer to 70 years old Women after menopause is a population that has delayed healing due to loss of estrogen production; might need calcium, phosphorus, vitamin D & protein supplementation Factors that affect healing  Age- older the patient, the more complicated their healing will be  Severity of trauma- if it’s a clean break it’s a lot easier for healing to occur  Type of bone injured- smaller bones can heal a lot quicker  How the fracture is managed  Possible infections  Blood supply Fall incidence  CDC reports- falls are the leading cause of injury deaths in older adults. This has risen sharply in the last decade  1 out of 4 older adults (65 and older) fall each year but less than half talk to their healthcare providers about it  Every 19 minutes an older adult dies from a fall  2.8 million nonfatal falls among older adults are treated in emergency departments yearly  Of these 800,000 require hospitalization, 300,000 hip fractures Effects/Outcomes of Falls

 > 95% of hip fractures are caused by falls  Rate of hip fracture increases with age - 85yrs and older, 10 -15 times greater rate  25% require nursing home care for at least 1 yr following hip fracture- hip fracture have higher mortality rates due to complications and surgeries; half of all pts after a hip fracture will not be able to live independently alone because their recovery won’t allow it; a lot of them die with the first yr of hip fracture Economic Impact 2023  31 billion dollars for fall injuries (CDC) Risks Associated with Falls/Fractures  Lower extremity weakness (de-conditioned/arthritis)- OA, RA  History of falls  Gait and balance problems, associated often with other conditions: o DM- due to neuropathy o Parkinson’s Disease o CVA  Using an assistive device  Visual impairment  Taking 4 or more meds or an anticonvulsant or benzodiazepine  Dementia/Cognitive Impairment  Depression  Osteoporosis (more common in women)  Fear of falling  Home hazards- rugs, darkness, clutter, decrease sensations due to proprioception, ice/snow  Alcohol/substance abuse Think Like A Nurse  Based on the statistics related to hip fractures how will you use this information in the planning of care to the medical- surgical and geriatric patients? Fall precautions (bed alarm, move room closer to nursing station) Prevention of falls/fractures  Fall risk assessment use Morse Fall Risk Assessment  Implement: fall reduction measures… which are? Communicate with family & social work  Discharge (home) assessment- rugs & clutter removed, adequate lighting in every room, grab bars in shower, shower chair, non-slip bath mats, don’t leave house when it’s snowing or raining Hip Joint Acetabulum “socket”- hip joint Hip Fracturs- Sites  Femoral Neck Fracture- intracapsular most common site- between the greater trochanter & lesser trochanter  Intertrochanteric Fracture- extracapsular- femoral neck to the outside Clinical Manifestations Intrascapular Extracapsular

Hip Precautions  Must not allow internal rotation of legs (adduction), use abduction pillow (not necessary if anterior incision)  Do not allow hip to flex >90 degrees  Do not cross legs  Do not put on own shoes/socks up to 8 weeks  Hips should not be lower than knees  No tub baths or driving for 6 weeks after surgery  Avoid bending to pick up  Raised toilet seat Complications S/P ORIF or Total Hip Replacement Hip Dislocation  Posterior dislocation  Anterior dislocation Hip Dislocation S/S  Increased hip pain  Shortening of the affected leg  Leg rotation

If this occurs, keep patient in bed and notify M.D. immediately Discharge Planning  Begins on admission  Multidisciplinary team  Assess assets o Social support o Physical assessment o Functional assessment  Economic factors Complications of Fractures  Compartment Syndrome  Fat Embolism- happens to long bones  Hypovolemic shock  Pulmonary embolism  Infection  Crush Syndrome- leads to shock and Rhabdomyolysis (breakdown of the muscle) pt can develop kidney injury  Complex regional pain syndrome  Others related to immobility Fat Embolism  Fractures of the hip pose highest risk because of the femur  Fat globules are released from the bone marrow and clog blood vessels that supply organs ; leads to capillary leakage and increase in lipids and platelet aggregation. If it makes its way to the lungs it gets misdiagnosed with Pulmonary Edema- lungs fill up with fluids ( tx: clot buster meds)  Most common in 20-40 yo and 70-80 yo.  Clinical Manifestations o Altered mental status (earliest) o Hypoxemia pulse ox will drop, draw ABG- PaO2 will be low o Dyspnea o Chest pain o Petechiae over neck, upper arms and chest (50%-60%) late symptom; draw lab work: ESR & serum lipids are going to be high. SL are going to be high because its leaking into the blood. Serum calcium, RBCs, & platelets are going to be low.

Compartment Syndrome Concept-Alteration in Tissue Perfusion= medical emergency! CS- hands and legs (most common), happens with body’s own natural healing process so through edema that occurs when there’s a fracture, so you have an accumulation of pressure and it leads to hypoxemia. Tissues will become ischemic and starts to die. Involves: bone, muscles, blood vessels & fascia. It can be internal or external. Increase in capillary and venous pressure that leads to edema & that puts pressure on the nerve endings. Appear pale, might not be able to a feel pulse. Pt complains of pain. Worst case scenario leads to an amputation. Only way to relieve pressure is through a fasciotomy. Most of the time it will be left open because it can come back if we close the patient back up. There will be a lot of swelling so we won’t be able to close it back up. Concerned about infection. Causes  Fracture (75%) ◦ Acute trauma  Infection  Skin traction  Exercise can lead to swelling  Tight cast  Prolonged pressure  Bleeding (internal)  Swelling  Burns Clinical Manifestations of Compartment Syndrome Think of the 5 P’s  Pain (early symptom)  Paresthesia (early symptom)  Pallor (late sign)  Pulselessness (late sign)  Paralysis (irreversible damage) If assessing pulses we are going to be using a doppler. If pts pain is a 9 out of 10 doesn’t necessarily mean that CS is worse. Sedate & intubate pt before the fasciotomy. Nursing Management Compartment Syndrome  Diligent assessment of extremity involved, and using unaffected extremity as a comparison!!!!  Muscle damage will be irreversible after 4-6 hours, and nerve damage 12-24 hours.  Prevention-assess for causes, early detection; assess 5 Ps specifically the pulse & looking for swelling  Special attention is necessary to identify pathologic pain in the presence of good pain control Nursing Interventions  Relieve the source of pressure o Remove constrictive bandage o Bivalve a cast cutting into it, in half. If you remove it, it will cause swelling which could lead to CS; make window into the cast, if you want to assess o Elevate extremity at heart level o Adequate hydration (not ice water or cubes) o Fasciotomy if necessary (longitudinal incision) 1/30/ 32

Fractures: A Comprehensive Guide for Healthcare Professionals, Cheat Sheet of Nursing

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