Introduction to fracture The first step in describing a fracture is whether it is

open or closed. If the skin over the break is disrupted,

Bones form the skeleton of the body and allow the body then an open fracture exists. The skin can be cut, torn, or
to be supported against gravity and to move and function abraded (scraped), but if the skin's integrity is damaged,
in the world. Bones also protect some body parts, and the potential for an infection to get into the bone exists.
the bone marrow is the production center for blood Since the fracture site in the bone communicates with
products. the outside world, these injuries need to be cleaned out
aggressively and many times require anesthesia in the
Bone is not a stagnant organ. It is the body's reservoir of operating room to do the job effectively.
calcium and is always undergoing change under the
influence of hormones. Parathyroid hormone increases Next, there needs to be a description of the fracture line.
blood calcium levels by leeching calcium from bone, Does the fracture line go across the bone (transverse), at
while calcitonin has the opposite effect, allowing bone to an angle (oblique) or does it spiral? Is the fracture in
accept calcium from the blood. two pieces or is it comminuted, in multiple pieces?

What causes a fracture? Finally, the fracture's alignment is described as to

whether the fracture fragments are displaced or in their
When outside forces are applied to bone it has the normal anatomic position. If the bones fragments aren't
potential to fail. Fractures occur when bone cannot in the right place, they need to be reduced or placed back
withstand those outside forces. Fracture, break, or crack into their normal alignment.
all mean the same thing. One term is not better or worse
than another. The integrity of the bone has been lost and Fracture
the bone structure fails.
Common Types and Locations of Fractures
Broken bones hurt for a variety of reasons including:
There are a variety of types and locations that bone
 The nerve endings that surround bones contain fractures that can occur. Common types and locations of
pain fibers and and these fibers become irritated fractures include:
when the bone is broken or bruised.
 greenstick fracture,
 Broken bones bleed, and the blood and  spiral fracture,
associated swelling (edema) causes pain.  comminuted fracture,
 transverse fracture,
 Muscles that surround the injured area may go  compound fracture,
into spasm when they try to hold the broken  vertebral compression fracture,
bone fragments in place, and these spasms cause  stress fracture,
further pain.  compression fracture,
 rib fracture, and
Often a fracture is easy to detect because there is  skull fracture.
obvious deformity. However, at times it is not easily
diagnosed. It is important for the physician to take a What are common types of fractures?
history of the injury to decide what potential problems
might exist. Moreover, fractures don't always occur in Stress fracture
isolation, and there may be associated injuries that need
to be addressed.
A stress fracture is an overuse injury. Because of
repeated micro-trauma, the bone can fail to absorb the
Fractures can occur because of direct blows, twisting shock that is being put upon it and become weakened.
injuries, or falls. The type of forces on the bone may Most often it is seen in the lower leg, the shin bone
determine what type of injury that occurs. Descriptions (tibia), or foot. Athletes are at risk the most, because
of fractures can be confusing. They are based on: they have repeated footfalls on hard surfaces. Tennis
players, basketball players, jumpers, and gymnasts are
 where in the bone the break has occurred, typically at risk. A March fracture is the name given to a
stress fracture of the metatarsal or long bones of the foot.
 how the bone fragments are aligned, and (It is named because it often occurs in soldiers who are
required to march long distances.)
 whether any complications exist.
Diagnosis is made by history and physical exam, though Rib fracture
on occasion a bone scan may be done to confirm the
diagnosis. The ribs are especially vulnerable to injury and are prone
to breaking due to a direct blow. Rib x-rays are rarely
Treatment is conservative, rest, ice, and anti- taken as it doesn't matter if the rib is broken or just
inflammatory medication like ibuprofen. These fractures bruised. A chest x-ray is usually taken to make certain
can take six to eight weeks to heal (as long as the there is no collapse or bruising of the lung.
fracture can be seen on x-ray). Trying to return too
quickly can cause re-injury, and may also allow the When we breathe, it is like a bellows. We inhale air into
stress fracture to extend through the entire bone. our lungs and the ribs move out and the diaphragm
moves down. When a person has a rib injury, the pain
Shin splints may have very similar symptoms as a stress associated with it makes breathing difficult, and the
fracture of the tibia but they are due to inflammation of person has a tendency to not take deep breaths. If the
the lining of the bone, called the periosteum. Shin splints lung underlying the injury does not expand, it is at risk
are caused by overuse, especially in runners, walkers, for infection. The person is then susceptible to
dancers, including those who do aerobics. Muscles that pneumonia (lung infection),which is characterized by
run through the periosteum and the bone itself may also fever, cough, and shortness of breath.
become inflamed.
As opposed to other parts of the body that can rest when
Treatment is similar to a stress fracture and physical they are injured, it is very important to take deep breaths
therapy can be helpful. to prevent pneumonia when rib fractures are present.
The treatment for bruised and broken ribs is the same:
ice to the chest wall, ibuprofen as an anti-inflammatory,
deep breaths and pain medication. Even if all goes well,
there will be significant pain for four to six weeks.

Compression fracture With lower rib fractures, there may be concern about
organs in the abdomen that the ribs protect. The liver is
As people age, there is a potential for the bones to located under the ribs on the right side of the chest, and
develop osteoporosis, a condition where bones lose their the spleen under the ribs on the left side of the chest.
calcium content. This makes bone more susceptible to Many times your doctor may be more worried about
breaking. One such type of injury is a compression abdominal injury than about the broken rib itself.
fracture to the spine, most often the thoracic or lumbar Ultrasound or CT scan may help diagnosis intra-
spine. Since we are an upright animal, if the bones of the abdominal injuries.
back are weaker than the force of gravity these bones
can crumple. Pain is the major complaint, especially Skull fracture
with movement.
With the wide availability of CT scans, skull x-rays are
Compression injuries of the back may or may not be rarely taken to diagnose head injury. If a head injury
associated with nerve or spinal cord injury. An x-ray of exists, the physician will feel or palpate the scalp and
the back can reveal the bone injury, however, sometimes skull to determine if there may be a skull fracture. He
a CT scan or MRI will be used to insure that no damage will also look into the ears to see if there is blood behind
is done to the spinal cord. the ear drumm and he will also complete a neurologic
examination.
Treatment includes pain medication and often a back
brace. Some compression fractures can also be treated The skull is a flat, compact bone and it takes significant
with vertebroplasty. Vertebroplasty involves inserting a force to break it. If a skull fracture exists, there is an
glue-like material into the center of the collapsed spinal increased likelihood of bleeding in the brain, especially
vertebra in order to stabilize and strengthen the crushed in children. There are guidelines that are available to
bone. The glue (methylmethacrylate) is inserted with a decide whether a CT scan is indicated (needed).
needle and syringe through anesthetized skin into the
midportion of the vertebra under the guidance of
specialized x-ray equipment. Once inserted, the glue
soon hardens, forming a cast-like structure with the
locally broken bone.
Minor head injury is defined as witnessed loss of may be evidence on x-ray of the healing calcium to
consciousness, definite amnesia, or witnessed confirm the fracture.
disorientation in patients with a GCS (Glasgow Coma
Score) score of 13-15. With minor head injury, the Growth plate fractures are classified by Salter-Harris
following risk groups are considered when evaluating category. When a break occurs through the growth plate,
need for CT brain scan: it can involve different parts of the bone on each side of
the plate. It is important that these fractures are aligned
High risk for potential neurosurgical operation properly so that the bone grows properly as the child
ages. For more, please read the Growth Plate Fractures
 Abnormal neurologic exam within two hours in Children article.
after injury
Children are more flexible than adults until the calcium
 Suspected open or depressed skull fracture completely solidifies their bone. If you think of an arm
or leg bone as tubular, sometimes only one side of the
 Any sign of basal skull fracture (blood behind bone breaks, just like an immature branch on a tree. This
the ear drum, blackened eyes, clear fluid running is referred to as a greenstick fracture, and may need to
from the ears, or bruising behind the ear) be "set" so that it heals properly. Sometimes the bones
can bend but not break because they are so pliable. This
 Vomiting - two episodes is called a plastic deformity and again will need to be set
or aligned to allow proper healing.
 65 years of age or older
How is a fracture diagnosed?
Medium risk (for brain injury on CT)
When you arrive for medical care, the doctor will take a
 Amnesia before impact - more than 30 minutes history of the injury. Where, when, and why did the
injury occur? Did the person trip and fall, or did they
 Dangerous mechanism (pedestrian struck by pass out before the fall? Are there other injuries that take
motor vehicle, occupant ejected from motor precedence over the fracture? For example, a person
vehicle, fall from height greater than 3 feet or who falls and hurts their wrist because they had a stroke
five stairs) or heart attack will have their fracture care delayed to
allow care for the life threatening illness. The injured
Fracture in children area will be examined and a search will happen for
potential associated injuries. These include damage to
Children can break bones and yet have normal x-rays. skin, arteries and nerves.
Fractures appear as clear lines through the bone on an x-
ray through the bone. If calcium hasn't yet accumulated Pain control is a priority and many times, pain
in the repairing bone, the break may not be apparent. medication will be prescribed before the diagnosis is
This lack of calcification happens in two ways. made. If the doctor believes that an operation is likely,
pain medication will be given through an intravenous
1. Bones mature at different times in a child's (IV) line or by an injection into the muscle. This allows
development and while the bony structure is the stomach to remain empty for potential anesthesia.
there, it may have more cartilage than calcium.
2. The second situation is associated with growth A decision will be made whether x-rays are required,
plates. Each bone has an area where cell activity and which type of x-ray should be taken to make the
is maximal and where the bone grows. These diagnosis and better assess the injury. There are
areas appear as lucent lines on x-ray. It may be guidelines in place to help doctors decide if an x-ray is
one of the weaker points in the bone as well, and necessary. Some include the Ottawa ankle and knee x-
a fracture through the growth plate may not be ray rules.
seen.
The body is three dimensional, and plain film x-rays are
The doctor needs to match the history and physical exam only two dimensional. Therefore, two or three x-rays of
with what is seen on x-ray to make to a diagnosis. the injured areas may be taken in different positions and
Sometimes, the child is placed in a cast for a period of planes to give a true picture of the injury. Sometimes the
time to protect the broken limb. As fractures heal, the fracture will not be seen in one position, but is easily
body lays down extra calcium as building material and seen in another.
then remodels it to normal shape. After 7-10 days, there
There are areas of the body where one bone fracture is staying where it is) once the bone fragments have been
associated with another fracture at a more distant part. aligned. If the surgeon is concerned that the bones will
For example, the bones of the forearm make a circle and heal improperly, an operation will be needed. Sometimes
it is difficult to break just one bone in that circle. Think bones that appear to be aligned normally are splinted,
of trying to break a pretzel in just one place, it is difficult and at a recheck appointment, are found to be unstable
to do. Therefore broken bones at the wrist may be and require surgery.
associated with an elbow injury. Similarly, an ankle
injury can be accompanied by a knee fracture. The Surgery can include closed reduction and casting, where
doctor may x-ray areas of the body that don't initially under anesthesia, the bones are manipulated so that
appear to be injured. alignment is restored and a cast is placed to hold the
bones in that alignment. Sometimes, the bones are
Occasionally, the broken bone isn't easily seen, but there broken in such a way that they need to have metal
may be other signs that a fracture exists. In elbow hardware inserted to hold them in place. Open reduction
injuries, fluid seen in the joint on x-ray is an indicator of means that, in the operating room, the skin is cut open
a subtle fracture. And in wrist injuries, fractures of the and pins, plates, or rods are inserted into the bone to
scaphoid or navicular bone may not show up on x-ray hold it in place until healing occurs. Depending on the
for one to two weeks, and diagnosis is made solely on fracture, some of these pieces of metal are permanent
physical examination with swelling and tenderness over (never removed), and some are temporary until the
the snuffbox at the base of the thumb. healing of the bone is complete and surgically removed
at a later time.
In children, bones may have numerous growth plates
that can cause confusion when reading an x-ray. References: Stiell IG, et al. The Canadian CT head rule
Sometimes, the doctor will choose to x-ray the opposite for patients with minor head injury. Lancet May 5,
arm or leg to determine what normal is for the child 2001;357:1391-6. Stiell IG, et al. The Canadian CT head
before deciding whether a fracture exists. rule for patients with minor head injury. Lancet May 5,
2001;357:1391-6.
What is the treatment of a fracture?

Initial treatment for fractures of the arms, legs, hands

and feet in the field include splinting the extremity in the D. Assessment Findings
position it is found, elevation and ice. Immobilization
will be very helpful with initial pain control. For injuries . Clinical Manifestations
of the neck and back, many times, first responders or
paramedics may choose to place the injured person on a  The five “Ps” – pain, pulse, pallor,
long board and in a neck collar to protect the spinal cord paresthesia, and paralysis are seen
from potential injury. with all types of fractures.
 Other characteristic findings include
Once the fracture has been diagnosed, the initial deformity, swelling, bruising, muscle
treatment for most limb fractures is a splint. Padded spasms, tenderness, pain, impaired
pieces of plaster or fiberglass are placed over the injured sensation, loss of function, abnormality,
limb and wrapped with gauze and an elastic wrap to crepitus, shock or refusal to walk (in
immobilize the break. The joints above and below the small children).
injury are immobilized to prevent movement at the
fracture site. This initial splint does not go completely 2. Laboratory and diagnostic findings
around the limb. After a few days, the splint is removed
and replaced by a circumferential cast. Circumferential  Radiographic examination reveals initial
casting does not occur initially because fractures swell injury and subsequent healing progress.
(edema). This swelling would cause a build up of A comparison film of an opposite,
pressure under the cast, yielding increased pain and the unaffected extremity is often used to
potential for damage to the tissues under the cast. look for subtle changes in the affected
extremity.
Surgery  Blood studies reveal bleeding
(decreased hemoglobin and hematocrit)
Surgery on fractures are very much dependent on what and muscle damage (elevated aspartate
bone is broken, where it is broken, and whether the transaminase (AST) and lactic
orthopedic surgeon believes that the break is at risk (for dehygrogenase (LHD).
E. Nursing Management detection is critical to prevent tissue
damage.
1. Provide emergency management when situation o Causes of compartment
warrants, for a new fracture. syndrome include tight
dressings or casts, hemorrhage.
 Assess the five “Ps”. trauma, burns and surgery.
 Determine the mechanism of injury. o Treatment entails pressure
 Immobilize the part. Move injured parts relief, which sometimes require
as little as possible. performing a fasciotomy.
 Cover any open wounds with a sterile,
or clean dressing. 8. Prevent infection, including osteomyelitits, bys using
 Reassess the five “Ps”. infection control measures.
 Apply traction if circulatory
compromise is present. 9. Prevent renal calculi by encouraging fluids,
 Elevate the injured limb, if possible. monitoring I&O, and mobilizing the child as much as
 Apply cold to the injured area. possible.
 Call emergency medical services.
10. Prevent pulmonary emboli by carefully monitoring
2. Assess for circulatory impairment (cyanosis, coldness, adolescents and children with multiple fractures. Emboli
mottling, decreased peripheral pulses, positive blanch generally occur within the first 24 hours.
sign, edema not relieved by elevation, pain or cramping).
Nursing Interventions
3. Assess for neurologic impairment (lack of sensation
or movement, pain, or tenderness, or numbness and 1. Evaluate the client’s general physical condition
tingling). 2. Splint extremity in position found before
moving the client; consider all suspected
4. Administer analgesic medications. fractures until X-ray films are available.
3. Cover open wound with sterile dressing if
5. Explain fracture management to the child and family. available.
Depending on the type of break and its location, repair 4. Observe for signs of emboli, severe chest pain,
(by realignment or reduction) may be made by closed or dyspnea, pallor, and diaphoresis.
open reduction followed by immobilization with a splint, 5. Observe for signs of circulatory impairment
traction or a cast. such as change in skin temperature or color,
numbness and tingling, unrelieved pain,
6. Maintain skin integrity and prevent breakdown. decrease in pedal pulse, prolonged blanching of
Institute appropriate measures for cast and appliance toes after compression or inability to move toes.
care. 6. Protect the cast from damage until dry by
elevating it on a pillow.
7. Prevent Complications 7. Promote drying of the cast by leaving it
uncovered; a light may be used with care to
 Prevent circulatory impairment by promote drying.
assessing pulses, color and temperature, 8. Maintain bed rest until the cast is dry and
and by reporting changes immediately. ambulation is permitted.
 Prevent nerve compression syndromes 9. Observe for swelling and notify the physician if
by testing sensation and motor function, necessary.
including subjective symptoms of pain, 10. Check that weights are hanging freely and that
muscular weakness, burning sensation, the affected limb is not resting against anything
limited ROM, and altered sensation. that will impede the pull of the traction.
Correct alignment to alleviate pressure if 11. Maintain in proper alignment.
appropriate, and notify the health care 12. Observe for foot drop on clients with Russel
provider. traction or Buck’s extension, since this may
 Prevent compartment syndrome by indicative of nerve damage.
assessing for muscle weakness and pain 13. Observe for signs of thrombophlebitis.
out of proportion to injury. Early 14. Encourage high protein, high vitamin diet to
promote healing.
15. Encourage fluids to help prevent constipation,
renal calculi, and urinary tract infection.
16. Teach isometric exercises to prevent muscle
strength and tone for crutch walking.
17. Teach appropriate crutch-walking technique;
non-weight bearing; weight bearing progressing
to use of cane.

18. Nursing Management

19. – RICES Management

20. R- Rest

I- Ice Compress

C- Cast

E- Elevation

S- Safety
21. – Give meds as ordered
22. – Prevent infection
23. – Cover any breaks in the skin with clean or
sterile dressings
24. – Safety of the client during transfer