Fractures: disruptions in the continuity of bone as the result of trauma or various disease processes, such as Cushing’s syndrome or osteoporosis, that weaken the bone structure.
1. Types:
  1. Open or compound - fractured bone extends through skin and mucous membranes; increased potential for infection.
  2. Closed or simple - fractured bone does not protrude through skin.
  3. Complete - fracture extends through entire bone, disrupting the periosteum on both sides of the bone, producing two or more fragments.
  4. Incomplete - fracture extends only part way through bone; bone continuity is not totally interrupted.
  5. Greenstick or willow-hickory stick - fracture of one side of bone; other side merely bends; usually seen only in children.
  6. Impacted or telescoped - fracture in which bone fragments are forcibly driven into other or adjacent bone structures.
  7. Comminuted - fracture having more than one fracture line and with bone fragment broken into several pieces.
  8. Depressed - fracture in which bone or bone fragments are driven inward, as in skull or facial fractures.
2. Methods used to reduce/immobilize fractures: reduction or setting of the bone - restores bone alignment as nearly as possible.
  1. Closed reduction - manual traction or manipulation. Usually done under anesthesia to reduce pain and muscle spasm. Maintenance of reduction and immobilization is accomplished by casting (fiberglass or plaster of Paris).
  2. Open reduction - operative procedure utilized to achieve bone alignment; pins, wire, nails, or rods may be used to secure bone fragments in position; prosthetic implants may also be used.
  3. Traction reduction - force is applied in two directions: to obtain alignment, and to reduce or eliminate muscle spasm. Used for fractures of long bones. May be:
    1. Continuous - used with fractures or dislocations of bones or joints.
    2. Intermittent - used to reduce flexion contractures or lessen pain and muscle spasm.
    3. Applied as follows:
      1. Skin - traction applied to skin by using a commercial foam-rubber Buck’s traction splint or by using adhesive, plastic, or a moleskin strip bound to the extremity by elastic bandage; exerts indirect traction on bone or muscles (e.g., Bryant’s, Buck’s extension, head, pelvic, Russell’s).
      2. Skeletal - direct traction applied to bone using pins (Steinman), wires (Kirschner). Pin is inserted through the bone in or close to the involved area and usually protrudes through skin on both sides of the extremity. Skeletal traction for fractured vertebrae accomplished with tongs (e.g, Crutchfield tongs, Gardner- Wells tongs) .
    4. Specific types of traction:
      1. Cervical - direct traction applied to cervical vertebrae using a head halter or Crutchfield, Gardner-Wells, or Vinke tongs that are inserted into the skull. Traction is increased with weights until vertebrae move into position and alignment is regaine After reduction is obtained, weights are decreased to the amount needed to maintain reduction. Weight amount is prescribed by physician.
      2. Balanced suspension - countertraction produced by a force other than patient’s body weight; extremity is suspended in a traction apparatus that maintains the line of traction despite changes in the patient’s position (e.g., Russell’s leg traction, Thomas’ splint with Pearson’s attachment).
      3. Running - traction that exerts a pull in one plane; countertraction is supplied by the weight of the patient’s body or can be increased through use of weights and pulleys in the opposite direction (e.g., Buck’s extension, Russell’s traction).
      4. Halo - an apparatus that employs both a plastic and metal frame; molded frame extends from the axilla to iliac crest and houses a metal frame. The struts of the frame extend to skull and attach to round metal (halo) device. The halo is attached to skull by four pins - two located anterolaterally and two located posterolaterally. They are inserted into external cortex of the cranium. Used to immobilize the cervical spine following spinal fusion, give some correction to scoliosis before spinal fusion, and immobilize nondisplaced fracture of spine.
  4. Immobilization - maintains reduction and promotes healing of bone fragments. Achieved by:
3. Assessment:
  1. Subjective data:
    1. Pain, tenderness.
    2. Tingling, numbness.
    3. Nausea.
    4. History of traumatic event.
    5. Muscle spasm.
  2. Objective data:
    1. Function: abnormal or lost.
    2. Deformities.
    3. Ecchymosis, increased heat over injured part.
    4. Localized edema.
    5. Crepitation (grating sensations heard or felt as bone fragments rub against each other).
    6. Signs of shock.
    7. Indicators of anxiety.
    8. X-ray: fracture - positive interruption of bone; dislocation - abnormal position of bone.
4. Analysis/nursing diagnosis:
  1. Pain related to interruption in bone.
  2. Impaired physical mobility related to fracture/treatment modality.
  3. Risk for injury related to complications of fractures.
  4. Knowledge deficit regarding cast care, crutch walking, traction.
  5. Constipation related to immobilization.
  6. Risk for impaired skin integrity related to immobility or friction from materials used to immobilize the fracture during healing.
5. Nursing care plan/implementation:
  1. Goal: promote healing and prevent complications of fractures.
    1. Diet: high protein, iron, vitamins, to improve tissue repair; moderate carbohydrates to prevent weight gain; no increase in calcium, to prevent kidney stones (decalcification and demineralization occur when patient is immobilized).
      1. Encourage increased fluid intake, to prevent kidney stones.
      2. Prevent or correct constipation through increasing bulk foods, fruits, and fruit juices, or using prescribed stool softeners, laxatives, or cathartics as necessary.
    2. Provide activities to reduce perceptual deprivation - reading, handcrafts, music, special interests/hobbies that can be done while maintaining correct position for healing.
  2. Goal: prevent injury or trauma in relation to:
    1. Fracture care:
      1. Maintain affected part in optimum alignment.
      2. Maintain skin integrity; check all bony prominences for evidence of pressure q4h and prn, depending on amount of pressure.
      3. Monitor: circulation in, sensation of, and motion of (CSM) affected part ql5min for first 4 hr; qlh until 24 hr; q4h and prn, depending on amount of edema.
      4. Maintain mobility in unaffected limb and unaffected joints of affected limb by active and passive ROM; prevent footdrop by using ankle-top sneakers.
    2. Skin traction:
    3. Skeletal traction:
      1. Maintain affected part in optimum alignment:
        
        Ropes on pulleys.
        
        Weights hang free.
        
        Elevate head of bed as prescribed.
        
        Check knots routinely.
      2. Maintain skin integrity:
        
        Frequent skin care.
        
        Keep bed linens free of crumbs and wrinkles.
      3. Prevent infection: special skin care to pin insertion site tid. Keep area around pins clean and dry. Use prescribed solution for cleansing.
      4. Monitor circulation in, sensation of, and motion of affected part.
      5. Maintain mobility in unaffected limb and unaffected joints; prevent footdrop of affected limb.
    4. Running traction:
      1. Keep well centered in bed.
      2. Elevate head of bed only to point of countertraction.
      3. No turning from side to side - will cause rubbing of bony fragments.
      4. Check distal circulation frequently.
      5. Frequent back care to prevent skin breakdown.
      6. Fracture bed pan for toileting.
      7. Avoid excessive padding of splints in groin area to prevent tissue trauma.
    5. Balanced suspension traction:
      1. Maintain alignment and countertraction:
        
        Ropes on pulleys.
        
        Weights hang free.
        
        Elevate head of bed as prescribed.
        
        Check knots routinely.
      2. May move patient, but turn only slightly (no more than 30 degrees to unaffected side).
      3. Heel of affected leg must remain free of the bed.
      4. 20-degree angle between thigh and bed.
      5. Check for pressure from sling to popliteal area.
      6. Provide foot support to prevent footdrop.
      7. Maintain abduction of extremity.
      8. Check for signs of infection at pin insertion sites; cleanse tid as ordered.
      9. If tape or moleskin is used, shave extremity and apply benzoin to improve adherence of strip and reduce itching.
    6. Cervical traction:
      1. May be placed on specialized bed, e.g., Stryker frame.
      2. Position: maintain body alignment.
      3. Keep tongs free from bed, and keep weights hanging freely to allow traction to function properly.
    7. Halo traction:
      1. Several times a day, check screws to the head and screws that hold the upper portion of the frame, to determine correct position.
      2. Pin sites cleansed tid with bacteriostatic solution to prevent infection.
      3. Monitor for signs of infection.
      4. Position as any other patient in body cast, except no pressure to rest on halo - pillows may be placed under abdomen and chest when patient is prone.
      5. Institute ROM exercises to prevent contractures.
      6. Turn frequently to prevent development of pressure areas.
      7. Allow patient to verbalize about having screws placed in skull.
      8. Postapplication nursing care same as pin insertion for other traction.
    8. External fixation devices:
      1. Pin care same as for skeletal traction.
      2. Teach clothing adjustment.
      3. Teach to adjust for size of apparatus.
    9. Internal fixation devices:
      1. Monitor for signs of infection/allergic reaction to materials used for maintenance of reduction (drainage, pain, increased temperature).
      2. Position as ordered to prevent dislocation.
    10. Casts:
      1. Support drying cast on firm pillow; avoid finger imprints on cast.
      2. Elevate limb to reduce edema.
      3. Prevent complications of fractures as listed.
      4. Closely monitor circulation (blanching, swelling, decreased temperature); sensation (absence of feeling; pain or burning); and motion (inability to move digits of affected limb).
      5. Be prepared to notify MD or cut cast if circulatory impairment occurs.
      6. Protect skin integrity: avoid pressure of edges of cast; petal prn.
      7. Monitor for signs of infection if skin integrity impaired.
  3. Goal: provide care related to ambulation with crutches.
  4. Goal: provide safety measures related to possible complications following fracture.
  5. Goal: health teaching.