01.06 Fractures

Okay guys we're going to finish up our musculoskeletal course by talking about fractures and some of the common issues we see with these patients.

First we want to be clear about the difference between a strain and a sprain and a fracture. A strain is an overstretched muscle while a sprain is an overstretched ligament. That's really the only difference between the two, and neither one involves any damage to the phone. For strains and sprains we simply use the RICE method. RICE stands for rest, ice, compression, and elevation. that will help to ease any pain and swelling around those muscles or ligaments. A fracture happens when enough force is applied to the bone to actually break it. You may or may not see an obvious deformity or bruising around the area. But it's also possible that a fracture could displace and put pressure on blood vessels or nerves, so we want to check circulation and sensation distal to the injury. We also want to ask the patient how the injury happened, because that will help us understand what type of fracture to expect.

Let's briefly review the types of fractures. A fracture is either closed or open. If the skin is intact, it's closed. If the bone pierces the skin, then it's considered an open or compound fracture. Transverse fractures are when the bone breaks straight across. Spiral fractures happen because of twisting. This is actually a common fracture to see in domestic or child abuse, because one person is holding the other person's arm while they try to pull away, and it twists and breaks. Comminuted fractures have multiple pieces of bone within the broken area. Impacted fractures or when one piece of bone shoves into the other because of a vertical impact, like jumping off of a building. Greenstick fractures occur when the bone doesn't break all the way through. This is common in children because their bones are still relatively flexible. And finally, oblique fractures are ones that break at an angle.

These oblique fractures are the most likely to displace. you can see how not only has this person's ulna dislocated, but their radius has an oblique fracture that has displaced. That means it's no longer in alignment. This is how we end up with cut off nerves and blood vessels. Before we do anything, the provider needs to reset this phone to be in alignment again. They can do that manually or they may have to take the patient to surgery to realign and insert screws to hold it in place.

We can use plaster casts like this one to help align and immobilize fractures. this will allow for proper and straight healing of the bone. I'm sure you or a friend or a family member has had one of these at some point in your life. And I'm sure someone signed your cast, so I will sign this one, for old time’s sake. When patients do have a cast, they could have swelling underneath the cast that could cause problems. So we want to assess for swelling, pain, circulation, and sensation distal to the cast to make sure that blood flow isn't being restricted.

Another method we used to align and immobilize fractures is called traction. This is where we pull on the leg or arm away from the body to force it into alignment and force it to be immobile. There are two main types of traction we use. Bucks traction is when we apply a splint of some sort and then pull the splint away from the body, which pulls the extremity as well. Skeletal traction is when a pin is inserted through the bone, like you see here, and then the traction weight is applied to that PIN. We see this a lot with femur and hip fractures because of the force required for traction. Essentially, if this is the patient's bed, and this is their leg, we insert the pin through the bone, then attach it to a device that has a pulley system and hang weights from that pulley. The orthopedic doctor will decide how much weight is required. The big thing that you need to know is that the weights need to hang freely off the bed. You should not allow them to hit the floor. now, as nurses we are not allowed to remove the weights without a provider order, however you will need to have someone to support the weights when you slide the patient up in bed, and consult the provider if you need to travel anywhere because the weights shouldn't be swinging.

Now we just went to quickly review a couple of more severe complications of fractures. The first is fat embolism. this is a risk with any patient who has a long bone fracture. Essentially, fat moves from the bone marrow into the bloodstream, just like any other embolus and it can move to the lungs, heart, or brain. The reason this happens, as you see here if the fracture goes through the bone, then it exposes the bone marrow to the blood vessels. That is why some fat from the bone marrow could potentially get into the bloodstream. Usually fat emboli end up in the lungs, so you could see tachycardia, hypotension, restlessness, tachypnea, anxiety - very similar to a pulmonary embolism. Unfortunately there is no specific treatment, so we just want to support the patient's hemodynamics, and possibly give corticosteroids to decrease the symptoms. Eventually, the patient's body will dissolve the fat embolus.

The second major risk with fractures is called compartment syndrome. As with any injury, there will be an inflammatory response and swelling at the area. So if this is the patient's bone, and this is the muscle, and skin around the bone. As swelling occurs, it increases pressure within this muscle compartment. Well, we know that there are also blood vessels and nerves in here, right? So, as the pressure increases, this blood supply can be cut off. Some of the signs we might see would be pale skin, cold skin, possibly blistering like you see here. And we may see a loss of pulses or sensation below the injury. This requires emergent intervention, otherwise the patient could lose that limb. We need to relieve the pressure within that muscle cavity so that we can restore circulation. The way that we do that is with a fasciotomy.

A fasciotomy is when the surgeon literally takes a scalpel and cuts through the skin, through the fascia, and to or even through the muscle. That allows the pressure to be relieved, so that circulation can be restored. We want to leave these open as long as it takes for the swelling to go down. Once the swelling goes down, we could potentially close the wound with staples or sutures, and sometimes even a wound vac. Or If the swelling doesn't go down far enough, the patient could receive a skin graft to cover the area, like what you see here.

This should be pretty obvious to you by now, with everything we've talked about. The priority nursing concepts for patient with fracture is mobility, or specifically alignment and immobility of the fracture. Perfusion, because of the risk for impaired circulation. And of course comfort, we do want to address any pain that the patient has.

Just to recap quickly. Fractures occur when significant force is applied to the Bone, causing it to break. We want to make sure the bone gets realigned because displaced bones can cut off blood supply or nerves, and it needs to be aligned in order to heal properly. We need to immobilize the fracture using a cast or traction. And we want to make sure we're addressing circulation at all times, and watching for a fat embolus and the possible development of compartment syndrome. Remember even swelling within the cast could cause a problem with perfusion. And of course don't forget to address the patient's pain.

So that's it for fractures, and our musculoskeletal course. Let us know if you have any questions. Now go out and be your best selves today. And, as always, happy nursing!