Table of Contents:

1. Fractures & Assessment 4. Complications

Findings 5. Hip Fracture & Hip
2. Emergency Care Replacement
3. Casting & Traction

Fractures

1. Fractures & Assessment Findings

A fracture is a break in bone continuity that requires Assessment findings
immediate intervention to prevent neurovascular y Pain, tenderness, muscle spasms
impairment (compartment syndrome). y Loss of function, inability to bear weight
Risk factors y Visible deformity or swelling
y Osteoporosis
In hip fracture: Shortening and external rotation
y Corticosteroid use of the affected leg (see FIGURE 1)
y Bone cancer y Bruising, crepitation (grating sound on movement)

Evaluate for abuse if a child has a fracture
Fracture types inconsistent with the reported injury or the child’s
y Closed (simple): Bone breaks, but skin developmental level (see INFANT & CHILD SAFETY
remains intact. CHEAT SHEET).

Open (compound): Bone breaks through skin.

risk for infection 2. Emergency Care
y Further categorized as:
Priority interventions for fractures include supporting
y Complete: Bone breaks completely into two
perfusion and immobilizing the fracture.
separate pieces.
y Incomplete: Bone is only partially broken; 1. Support perfusion:

Musculoskeletal
fracture line doesn’t extend across entire bone.
Apply pressure to stop active bleeding and monitor
for internal bleeding (hypotension, tachycardia).
FIGURE 1. HIP FRACTURE EXTERNAL ROTATION
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 torisk 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 toinfection 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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2. Emergency Care, Continued

TABLE 1. 6 PS OF NEUROVASCULAR TABLE 2. FRACTURE COMPLICATIONS

IMPAIRMENT
Complication Findings Interventions
Finding Description
Compartment y Neurovascular
Loosen splint or cast
Pain unrelieved by syndrome: impairment if present.
Pain
analgesics Limb-threatening (6 Ps) (TABLE 1)
Prepare for possible
emergency fasciotomy to relieve
Numbness and caused pressure (FIGURE 3).
Paresthesias
tingling bypressure y Do not elevate
in the extremity extremity if
Decreased (FIGURE 2) compartment
Poikilothermia
temperature syndrome is
suspected, which
Weakened or can further decrease
Pulselessness perfusion.
absent pulses

Pallor Pallor or cyanosis Deep vein y Pain, swelling, y Administer

thrombosis erythema anticoagulants (see
Paralysis Loss of function (DVT): Clot DVT & PE CHEAT SHEET).
lodged in a deep
vein
3. Complications y Most common

Musculoskeletal

The #1 priority for a fracture = complication
performing frequent neurovascular of lower
assessments and monitoring for extremity
changes. injuries

Frequently assess skin color,
temperature, pulses, capillary Fat embolism y Altered mental y Administer oxygen.
refill, and sensation distal to syndrome: status y Anticipate possible
the injury. Life-threatening y Sudden intubation.
y Fracture complications include emergency that dyspnea and
compartment syndrome, deep vein occurs when fat chest pain
thrombosis, fat embolism syndrome, released from y Petechiae
and infection (osteomyelitis) a bone enters (pinpoint red
(see TABLE 2 & FIGURE 2). the pulmonary rash) to neck

If these complications are circulation and chest
suspected, immediately notify y risk with
the HCP. long bone
fractures
(femur)

Osteomyelitis: y Fever y Administer long-term

Bone infection y Pain IV antibiotics.
y risk with y Warmth, y Anticipate possible
open fractures redness, surgical debridement.
drainage

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3. Complications, Continued

FIGURE 2. COMPARTMENT SYNDROME FIGURE 3. FASCIOTOMY

4. Casting & Traction

y Once stabilized, the fracture is immobilized with Cast care
a cast. y Casting immobilizes and protects the fracture
y Depending on fracture location and severity, during healing.
reduction, fixation, and traction may also be used y Teach client to:
to realign the bone.
Keep the cast dry.

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Reduction and fixation y If the cast gets wet, dry it with a hairdryer on
y Reduction is the manual (closed) or surgical (open) the low setting until completely dry.
realignment of the bone.
Elevate casted extremity: Position limb above
y Fixation is the use of hardware to stabilize the heart level to minimize swelling as much as
fracture after reduction. possible, especially in the first 24 hr.
y Internal fixation: Uses screws, plates, or rods y Place an ice pack over the cast to reduce
placed inside the body swelling for the first 24 hr.
y External fixation: Uses pins and frames that
Do not insert objects into the cast, which can
extend outside the skin damage skin.

Perform frequent pin site care to y Use a hairdryer on the cool setting to
prevent infection. manage itching.

Frequently assess pin sites for signs of y Monitor for compartment syndrome (see FIGURE 2).
infection like purulent drainage, redness, foul
Frequently reassess 6 Ps to recognize
odor, and increased pain. 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.

 Compartment syndrome: Monitor for signs of  Cast care: Teach clients to keep the cast dry,
compartment syndrome, which include the avoid inserting objects into casts, and elevate
6Ps: Pain, pallor, paresthesias, poikilothermia, the affected extremity.
pulselessness, and paralysis. If suspected,
loosen the splint and prepare for a fasciotomy
to relieve pressure.
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4. Casting & Traction, Continued
Traction FIGURE 4. SKIN 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
FIGURE 5. SKELETAL TRACTION
irritation (especially with skin traction).

Pin site care: For skeletal traction,
frequently clean pin sites to prevent
infection and assess for signs of infection.

5. Hip Fracture
y Hip fractures most commonly occur in older
adults from a fall injury.

Musculoskeletal
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.
y Avoid adduction of the hips.

Clients are at high risk for DVT following

Keep a pillow between the legs when
hip fracture.
lying down.
Postoperative care
Do not cross the legs.
y Following hip arthroplasty using a posterior approach, y Notify HCP immediately for signs of hip
proper alignment of the affected leg is a high dislocation (intense pain, leg shortening,
priority to prevent hip dislocation. or rotation).

Teach the client to avoid hip flexion and adduction. y Encourage gradual mobility with weight-bearing
y Avoid hip flexion >90°. as tolerated.

Use raised toilet seats and chairs. y Encourage strength and range of motion exercises

Do not bend forward to put on shoes to strengthen leg muscles.
or socks.
y Use an adaptive device instead (long-
handled shoe horn).

 Traction care: For clients in traction, maintain  Hip arthroplasty: Following hip arthroplasty
proper body alignment and ensure weights using a posterior approach, joint alignment is a
hang freely and are not placed on the floor. For priority to prevent hip dislocation. Avoid hip
clients in skeletal traction, frequently clean pin flexion >90 degrees by using raised toilet seats
sites to prevent infection. 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  For clients in traction, ensure weights are
should use a splint to _____ the fracture to always _____. How do you prevent infection in
prevent further injury. Keep the injured extremity clients in skeletal traction?
_____ to reduce pain and swelling.
 Following hip arthroplasty, joint alignment is
 What are the 6 Ps that indicate compartment a priority to prevent _____. Avoid _____ >90
syndrome? If suspected, loosen the _____ and degrees by using raised chairs and toilet seats.
prepare for a _____ to relieve pressure. Avoid _____ by keeping a pillow between the
legs when lying down.
 What are important teaching points for clients
with casts?

inserting objects into cast, elevate the affected extremity 4. hanging freely; Frequently clean pin sites 5. hip dislocation; hip flexion; adduction
Answers: 1. immobilize; elevated 2. Pain, pallor, paresthesias, poikilothermia, pulselessness, paralysis; splint, fasciotomy 3. Keep cast dry, avoid

Musculoskeletal
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y Fasciotomy: Sarte at the English-language Wikipedia, CC BY-

SA 3.0, via Wikimedia Commons
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