Table of Contents:
1. Fractures & Assessment
Findings
2. Emergency Care
3. Casting & Traction
4. Complications
5. Hip Fracture & Hip
Replacement
Fractures
1. Fractures & Assessment Findings
Risk factors
y Osteoporosis
y Corticosteroid use
y Bone cancer
Fracture types
y Closed (simple): Bone breaks, but skin
remains intact.
Open (compound): Bone breaks through skin.
risk for infection
y Further categorized as:
y Complete: Bone breaks completely into two
separate pieces.
y Incomplete: Bone is only partially broken;
fracture line doesn’t extend across entire bone.
FIGURE 1. HIP FRACTURE EXTERNAL ROTATION
Assessment findings
y Pain, tenderness, muscle spasms
y Loss of function, inability to bear weight
y Visible deformity or swelling
In hip fracture: Shortening and external rotation
of the affected leg (see FIGURE 1)
y Bruising, crepitation (grating sound on movement)
Evaluate for abuse if a child has a fracture
inconsistent with the reported injury or the child’s
developmental level (see INFANT & CHILD SAFETY
CHEAT SHEET).
2. Emergency Care
Priority interventions for fractures include supporting
perfusion and immobilizing the fracture.
1. Support perfusion:
Apply pressure to stop active bleeding and monitor
for internal bleeding (hypotension, tachycardia).
Assess for neurovascular impairment (6 Ps)
(see TABLE 1).
2. Immobilize and protect the fracture:
Immobilize the fracture with a splint before
moving the client to avoid further injury.
y For open fractures, cover visible bone with a
sterile dressing torisk of infection.
Following stabilization, interventions focus on pain
management and preventing complications.
y Prepare the client for an X-ray to confirm fracture.
Elevate the fracture above heart level to
reduce swelling.
y Apply ice packs to reduce inflammation and pain.
y Administer analgesics for pain.
y Administer a tetanus vaccine for clients with breaks
in skin integrity toinfection risk.
Emergent interventions: To prevent further injury, immobilize a fracture with a splint before moving
a client. Keep the injured extremity elevated to reduce pain and swelling.
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Musculoskeletal
A fracture is a break in bone continuity that requires
immediate intervention to prevent neurovascular
impairment (compartment syndrome).
2. Emergency Care, Continued
Finding
Description
Pain
Pain unrelieved by
analgesics
Paresthesias
Numbness and
tingling
Poikilothermia
Decreased
temperature
Pulselessness
Weakened or
absent pulses
Pallor
Pallor or cyanosis
Paralysis
Loss of function
3. Complications
The #1 priority for a fracture =
performing frequent neurovascular
assessments and monitoring for
changes.
Frequently assess skin color,
temperature, pulses, capillary
refill, and sensation distal to
the injury.
y Fracture complications include
compartment syndrome, deep vein
thrombosis, fat embolism syndrome,
and infection (osteomyelitis)
(see TABLE 2 & FIGURE 2).
If these complications are
suspected, immediately notify
the HCP.
TABLE 2. FRACTURE COMPLICATIONS
Complication
Findings
Interventions
Compartment
syndrome:
Limb-threatening
emergency
caused
bypressure
in the extremity
(FIGURE 2)
y Neurovascular
impairment
(6 Ps) (TABLE 1)
Loosen splint or cast
if present.
Prepare for possible
fasciotomy to relieve
pressure (FIGURE 3).
y Do not elevate
extremity if
compartment
syndrome is
suspected, which
can further decrease
perfusion.
Deep vein
thrombosis
(DVT): Clot
lodged in a deep
vein
y Most common
complication
of lower
extremity
injuries
y Pain, swelling,
erythema
y Administer
anticoagulants (see
DVT & PE CHEAT SHEET).
Fat embolism
syndrome:
Life-threatening
emergency that
occurs when fat
released from
a bone enters
the pulmonary
circulation
y risk with
long bone
fractures
(femur)
y Altered mental
status
y Sudden
dyspnea and
chest pain
y Petechiae
(pinpoint red
rash) to neck
and chest
y Administer oxygen.
y Anticipate possible
intubation.
Osteomyelitis:
Bone infection
y risk with
open fractures
y Fever
y Pain
y Warmth,
redness,
drainage
y Administer long-term
IV antibiotics.
y Anticipate possible
surgical debridement.
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Musculoskeletal
TABLE 1. 6 PS OF NEUROVASCULAR
IMPAIRMENT
2
3. Complications, Continued
FIGURE 2. COMPARTMENT SYNDROME
FIGURE 3. FASCIOTOMY
4. Casting & Traction
Reduction and fixation
y Reduction is the manual (closed) or surgical (open)
realignment of the bone.
y Fixation is the use of hardware to stabilize the
fracture after reduction.
y Internal fixation: Uses screws, plates, or rods
placed inside the body
y External fixation: Uses pins and frames that
extend outside the skin
Perform frequent pin site care to
prevent infection.
Frequently assess pin sites for signs of
infection like purulent drainage, redness, foul
odor, and increased pain.
Compartment syndrome: Monitor for signs of
compartment syndrome, which include the
6Ps: Pain, pallor, paresthesias, poikilothermia,
pulselessness, and paralysis. If suspected,
loosen the splint and prepare for a fasciotomy
to relieve pressure.
Cast care
y Casting immobilizes and protects the fracture
during healing.
y Teach client to:
Keep the cast dry.
y If the cast gets wet, dry it with a hairdryer on
the low setting until completely dry.
Elevate casted extremity: Position limb above
heart level to minimize swelling as much as
possible, especially in the first 24 hr.
y Place an ice pack over the cast to reduce
swelling for the first 24 hr.
Do not insert objects into the cast, which can
damage skin.
y Use a hairdryer on the cool setting to
manage itching.
y Monitor for compartment syndrome (see FIGURE 2).
Frequently reassess 6 Ps to recognize
compartment syndrome (see TABLE 1).
If compartment syndrome is suspected, do not
elevate the affected limb because it can further
decrease perfusion (see TABLE 2).
y Monitor for infection.
y Assess cast for “hot spots” or foul odor which
indicate infection.
Musculoskeletal
y Once stabilized, the fracture is immobilized with
a cast.
y Depending on fracture location and severity,
reduction, fixation, and traction may also be used
to realign the bone.
Cast care: Teach clients to keep the cast dry,
avoid inserting objects into casts, and elevate
the affected extremity.
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4. Casting & Traction, Continued
Traction
y Traction uses a weight and pulley system to keep
bones aligned and reduce muscle spasms.
y Traction types include:
y Skin traction: Applied to skin with soft
tape or wrap (Buck traction) (see FIGURE 4)
y Used for short-term stabilization
y Skeletal traction: Directly applied to the
bone with pins or wires (see FIGURE 5)
y When caring for a client in traction:
Maintain traction: Ensure weights hang
freely and are not resting on the floor to
maintain alignment and ensure proper
healing.
y Prevent skin breakdown: Inspect skin
frequently for signs of skin breakdown or
irritation (especially with skin traction).
Pin site care: For skeletal traction,
frequently clean pin sites to prevent
infection and assess for signs of infection.
FIGURE 4. SKIN TRACTION
FIGURE 5. SKELETAL TRACTION
y Hip fractures most commonly occur in older
adults from a fall injury.
y Teach clients fall prevention methods
to decrease the risk of hip fracture (see
SAFETY CHEAT SHEET).
y Hip fractures typically require surgical
repair (hip arthroplasty).
Perform frequent neurovascular assessments.
Clients are at high risk for DVT following
hip fracture.
Postoperative care
y Following hip arthroplasty using a posterior approach,
proper alignment of the affected leg is a high
priority to prevent hip dislocation.
Teach the client to avoid hip flexion and adduction.
y Avoid hip flexion >90°.
Use raised toilet seats and chairs.
Do not bend forward to put on shoes
or socks.
y Use an adaptive device instead (longhandled shoe horn).
Traction care: For clients in traction, maintain
proper body alignment and ensure weights
hang freely and are not placed on the floor. For
clients in skeletal traction, frequently clean pin
sites to prevent infection.
Musculoskeletal
5. Hip Fracture
y Avoid adduction of the hips.
Keep a pillow between the legs when
lying down.
Do not cross the legs.
y Notify HCP immediately for signs of hip
dislocation (intense pain, leg shortening,
or rotation).
y Encourage gradual mobility with weight-bearing
as tolerated.
y Encourage strength and range of motion exercises
to strengthen leg muscles.
Hip arthroplasty: Following hip arthroplasty
using a posterior approach, joint alignment is a
priority to prevent hip dislocation. Avoid hip
flexion >90 degrees by using raised toilet seats
and chairs. Avoid adduction by keeping a pillow
between the legs when lying down.
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Before moving a client with a fracture, the nurse
should use a splint to _____ the fracture to
prevent further injury. Keep the injured extremity
_____ to reduce pain and swelling.
What are the 6 Ps that indicate compartment
syndrome? If suspected, loosen the _____ and
prepare for a _____ to relieve pressure.
What are important teaching points for clients
with casts?
For clients in traction, ensure weights are
always _____. How do you prevent infection in
clients in skeletal traction?
Following hip arthroplasty, joint alignment is
a priority to prevent _____. Avoid _____ >90
degrees by using raised chairs and toilet seats.
Avoid _____ by keeping a pillow between the
legs when lying down.
Musculoskeletal
Answers: 1. immobilize; elevated 2. Pain, pallor, paresthesias, poikilothermia, pulselessness, paralysis; splint, fasciotomy 3. Keep cast dry, avoid
inserting objects into cast, elevate the affected extremity 4. hanging freely; Frequently clean pin sites 5. hip dislocation; hip flexion; adduction
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Attributions:
y Fasciotomy: Sarte at the English-language Wikipedia, CC BYSA 3.0, via Wikimedia Commons
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