A fracture or ‘broken bone’ is a break in the continuity of a bone (Langstaff 2000) as a result of direct or indirect trauma, underlying disease (pathological fracture) or repeated stress on a bone (stress fracture). It is described as a closed fracture when there is no communication between the external environment and the fracture site, and open when communication occurs. Stable fractures are those where the bone ends are lying in a position from which they are unlikely to move. In unstable fractures the bone ends are displaced or have the potential to be displaced. The edges of the broken bones may damage soft tissues or blood vessels/nerves at the time of the injury or later through poor handling of the limb.

Medical/surgical management

All fractures, regardless of their position or the size of the bone involved, are managed according to three principles: reduction, maintenance of position and rehabilitation. The aim is to allow bone healing to take place. The stages of bone healing are demonstrated in Figure 10.3.

Figure 10.3 Stages in bone healing.

Reduction of fractures

Fractures are said to be reduced when displaced bone fragments are pulled into their normal anatomical position. In many cases, a general anaesthetic will be necessary to overcome the protective muscle spasm and severe pain.

Maintenance of position

The fracture needs to be held in the correct position until bony healing takes place, which can take from 6 to 12 weeks depending on the fracture site. Position can be maintained by external splintage using an orthosis, i.e. a removable splint, plaster of Paris (POP) or synthetic (resin/plastic based) casts, skin or skeletal traction, or an external fixator frame. Operative reduction with internal fixation by metal pins, plates, screws or nails may also be used to hold the bony fragments in position. When the blood supply is grossly affected, it may be necessary to implant a prosthesis to replace the affected bone, e.g. in some cases of fractured neck of femur. Without adequate maintenance of position the fracture may heal with the bone ends not properly aligned (malunion), take longer to heal (delayed union) or not unite at all (non-union).

Restoration of function

Joints and muscles near to the fracture can become stiff and weak and physiotherapy and exercise is essential.

Patients require varying degrees of rehabilitation, involving a multidisciplinary team approach (see Ch. 32). It should be remembered that even when the physical damage is slight, the psychosocial impact may be considerable.

Traction

Orthopaedic traction occurs when a pulling force is applied to a part or parts of the body, and counter-traction, a pulling force in the opposite direction, is also applied (Lucas & Davis 2004). Counter-traction is usually supplied by the body weight of the patient. It is used in the following circumstances:

• to reduce and immobilise fractures/dislocations and maintain normal alignment of all injured tissues

• to prevent and correct deformity

• to reduce muscle spasm

• to relieve pain

• to immobilise an injured or inflamed joint

• to keep joint surfaces apart.

Traction is less used than in the past as alternative methods, in particular internal fixation, enable patients to become mobile more quickly and therefore avoid the problems of bed rest. However, it still has its place in treatment and nurses must know the principles of its use.

Types of traction

Balanced or sliding traction

This relies on the patient’s own body weight to produce the necessary counter-traction, usually by tilting of the bed. Skeletal pins may be used to provide a firm point of attachment (Figure 10.4), but the most common type of balanced traction uses skin traction. This is Buck’s traction which is used as a temporary measure for pain relief in patients with a fractured neck of femur (Figure 10.5). However, a Cochrane Review (Parker & Handoll 2006) could find no evidence which conclusively demonstrated the benefit of such traction for the outcome measures of pain relief or ease of fracture reduction at the time of surgery and its use has been discontinued in many orthopaedic centres.

Figure 10.4 Skeletal traction may be applied by: A, a Kirschner wire and traction stirrup; B, a Steinmann pin and traction stirrup; or C, a Steinmann pin and Böhler stirrup.

Figure 10.5 Buck’s traction for femoral neck fractures.

Fixed traction

This is the application of counter-traction acting through an appliance which obtains purchase on a part of the body (Figure 10.6). The most common is a Thomas’ splint, used for restricting movement of a fractured shaft of femur when transferring a patient, e.g. between hospitals, or in the treatment of fractures of the shaft of femur in children (Lucas & Davis 2004).

Figure 10.6 A. Fixed traction using skin traction and Thomas’ splint. B. Fixed traction using skeletal pin and Thomas’ splint.

Nursing management and health promotion: traction

In addition to the general principles outlined earlier for management of musculoskeletal disorders (p. 339), the following are specific to a patient in traction.

Health promotion

Patients need to understand the reasons for their traction and how to move safely within the bed.

Management of equipment

All parts of frames, pulleys, ropes and slings should be inspected at regular intervals every day to ensure that they are correctly positioned and in good working order; this is especially important when the patient has been moved, e.g. after using a bedpan.

Reducing the risk of complications

• Observation of colour, warmth, sensation and movement (CWSM) of the injured limb must be carried out throughout the patient’s stay in hospital for early detection of compartment syndrome (Lucas & Davis 2004).

• Potential skin breakdown around the traction and in vulnerable areas such as the sacrum should be monitored and appropriate pressure-relieving devices used.

• Observe for drop foot caused by excessive pressure on the common peroneal nerve located around the head of the fibula.

• Work with the physiotherapists to ensure that patients are aware of the importance of deep breathing exercises and exercise of limbs to prevent chest infection, DVT and muscle wasting.

Care of skeletal pin sites

A Cochrane Review (Lethaby et al 2008) concluded that there is little evidence as to which pin site care regimen best reduces infection rates but there are best practice guidelines available based on the available literature and expert opinion (Lee-Smith et al 2001). These indicate that:

• Pin sites do not need to be cleaned if there is no exudate present. However, when necessary, cleaning should be done using 0.9% saline

• Pin site crusts should be removed as this allows visualisation of the wound and free drainage of exudate

• Pin sites may be left exposed if there is no exudate, otherwise woven gauze should be used.

Purulent discharge, redness or inflammation suggests infection and a wound swab should be taken to identify the causative organisms. The appropriate antibiotics should be commenced and the pin sites cleaned with 0.9% saline and dressed with woven gauze, changed as necessary (Lee-Smith et al 2001).

Fundamental aspects of care

Patients on traction have limited mobility and may be on bed rest for 6 weeks or more. Fundamental nursing issues to consider are:

• maintaining adequate fluid and dietary intake to prevent constipation and urinary tract infection

• maintaining patient dignity when meeting patient hygiene and toileting needs

• helping patients to maintain their contact with partners, family and friends, providing privacy as required

• helping patients to find ways of alleviating the boredom of prolonged bed rest (Box 10.2).

Casts

A cast is a splinting device comprising layers of bandages impregnated with POP, fibreglass or resin, some of which are applied wet and solidify as they dry out. Their main uses areto immobilise and hold bone fragments in reduction and to support and stabilise weak joints. POP moulds more easily but it takes 48 h to dry and it is heavy. Synthetic casts set within 20 min and allow early weight-bearing but do not accommodate swelling and are not usually used in the initial stages of treatment, when a POP backslab is used. Other types of casts include adjustable focused rigidity primary casts which can be adjusted as swelling reduces (Large 2001) and cast braces which have hinges at the joints to allow restricted amounts of flexion or bend to stimulate cartilage nutrition (Dandy & Edwards 2009).

Nursing management and health promotion: casts

In addition to the general principles of nursing management for musculoskeletal disorders (p. 339), the following will also apply.

Care of the cast

POP casts should be handled carefully when drying, using the palms of the hands rather than the fingers to prevent indentations which may cause pressure points. Patients should understand that a cast should not get wet and that synthetic protective covers can be used to permit them to take a shower. Patients should be taught how to protect the cast when washing and when using bedpans and urinals.

Many patients will go home wearing casts and need clear verbal and written instructions specific to their cast (Box 10.3 outlines advice for a patient with a hand to elbow plaster).

Box 10.3 Information

Advice to a patient with a hand to elbow plaster

The plaster holds all the broken bones firmly in place to allow them to heal in the correct position. To prevent your fingers swelling, support your arm in the sling provided during the day and on pillows at night. It is important that you exercise the finger, elbow and shoulder joints of your injured arm at regular intervals, otherwise they will become stiff and painful to move.

The following exercises should be carried out at least four times each day:

• Make a firm fist then stretch the fingers as wide as possible.

• Try to touch each fingertip with the thumb of that hand.

• Bend and stretch the elbow joint.

• Lift your arm high above your head – use the other arm to help.

• Move your arm behind your back as if you wanted to scratch between your shoulder blades.

Do not wet, heat or otherwise interfere with the plaster and do not insert sharp objects between the plaster and the skin to scratch – this could cause skin damage and infection.

Report to the doctor or Emergency Department AT ONCE if:

• The plaster cracks, becomes loose or uncomfortable.

• There is pain.

• The fingers become numb or difficult to move.

• The fingers become more swollen, blue or very pale.

• There is discharge.

• You have any other problems.

Potential for neurovascular impairment

Swelling or a too tight cast may lead to neurovascular impairment such as CS. CWSM observations should be carried out for early identification of problems. If CS or neurovascular impairment is suspected the cast needs to be split or bivalved down to the skin. If a local pressure ulcer develops beneath a cast, usually identifiable by specifically located pain, an inspection window can be cut and the ulcer dressed before the window is taped or bandaged back into place.

Removal of a cast

Removal of a cast is a skilled activity and should only be carried out by nurses who have been deemed competent in this role. Removal can be achieved using plaster shears for POPs or an electric oscillating saw for POPs and synthetic casts.

External fixation

Bone fragments are held in position by skeletal pins inserted into the bone on either side of the fracture and held in alignment by a scaffold or a ring fixator (Figure 10.7). They are used for the treatment of some closed fractures, e.g. the pelvis, to stabilise open fractures with extensive soft tissue loss until the soft tissue has healed, for fractures that have not united by other methods, and for reconstructive surgery such as leg lengthening. Depending on the reason for their use they can be in place for as little as 6 weeks, e.g. for treatment of a closed fracture, or up to 1 year, e.g. in non-union of a tibial fracture.

Figure 10.7 An example of external fixation – Ilizarov frame.

(Courtesy of Barts and the London NHS Trust.)

Nursing management and health promotion: external fixation

The general principles relating to potential neurovascular impairment, positioning and potential for pin site infection that have already been discussed are important in the care of patients with an external fixator. In addition it is important that the patient, carers and community staff are confident in caring for the external fixator when the patient is discharged from hospital, including managing issues related to altered body image (Limb 2004). (See Further reading, e.g. Dandy & Edwards 2009.)

Internal fixation

Fractures may also be stabilised by surgical intervention where nails, plates, wires, screws or rods hold the bone fragments in place (Figure 10.8). Again this permits earlier mobilisation and reduces the potential for complications. The general principles of nursing management and health promotion of musculoskeletal disorders and of core potential complications (pp. 339–341) apply. In addition the perioperative principles of nursing management are also relevant (see Ch. 26).

Figure 10.8 Types of internal fixation. A, B. Intramedullary nails. C. Compression nail for fixation of femoral neck. D. Sliding nail fixation of the femoral neck.

Fractures of specific sites – lower limb

Any of the bones in the lower limb can be fractured due to trauma, and the principles of reduction, maintenance of position and restoration of function apply to all. The specific treatment and associated nursing care and health promotion depend on the exact nature of the fracture and the patient involved. Two of the commonest fractures are those of the femoral neck and the tibia/fibula, and these are discussed in more detail.

Fracture of neck of femur

There are approximately 70 000 fractures of the femoral neck, commonly known as a hip fracture or fractured neck of femur (and abbreviated as #NOF), in the UK each year (British Orthopaedic Association [BOA] 2007). They are most common in older people, particularly women who may have osteoporosis. There is much evidence that a coordinated approach to care of this patient group can improve patient outcomes (Box 10.4).

Box 10.4 Evidence-based practice

Hip fracture: the care of patients with fragility fracture: the ‘Blue Book’ guidelines

The British Orthopaedic Association and the British Geriatrics Society, together with other organisations including the Royal College of Nursing, has examined the evidence for the care of patients with a hip fracture and published good practice guidelines. The six standards are:

1. All patients with hip fracture should be admitted to an acute orthopaedic ward within 4 hours of presentation.

2. All patients with hip fracture who are medically fit should have surgery within 48 hours of admission, and during normal working hours.

3. All patients with hip fracture should be assessed and cared for with a view to minimising their risk of developing a pressure ulcer.

4. All patients presenting with a fragility fracture should be managed on an orthopaedic ward with routine access to acute orthogeriatric medical support from the time of admission.

5. All patients presenting with fragility fracture should be assessed to determine their need for antiresorptive therapy to prevent future osteoporotic fractures.

6. All patients presenting with a fragility fracture following a fall should be offered multidisciplinary assessment and intervention to prevent future falls.

(The British Orthopaedic Association, 2007.)

The patient will complain of severe pain in the hip or knee and there may be visible shortening and external rotation of the affected leg. Diagnosis will be confirmed by X-ray. A history of the fall is important as it may identify underlying conditions such as hypotension and indicate how long the patient may have been lying on the floor before receiving help.

Treatment

Depending on the site of the fracture, and the age and condition of the patient, the treatment will be either internal fixation with a plate and screws or replacement of the head of femur with a metal prosthesis if the fracture is inside the joint capsule and there is a risk of damage to the blood supply of the femoral head (Figure 10.9). The underlying osteoporosis needs to be treated (see p. 351).

Figure 10.9 Blood supply of the femoral head via the capsule, intramedullary vessels and ligamentum teres.

Nursing management and health promotion: fracture of neck of femur

In addition to the general principles relating to musculoskeletal injury and fractures, the following priorities need to be addressed.

Potential complications

As a result of age and general physical condition when found, the patient may be confused and fearful and need a great deal of comfort and reassurance. Measureswill be taken to reverse any hypothermia and dehydration (see Chs 20, 22). Risk assessment of the patient for skin breakdown using an approved scale such as the Waterlow scale (see Ch. 23) should be recorded and the patient may be nursed on a therapeutic bed. Vital signs will be monitored at least 4-hourly intervals to detect early signs of complications.

Pain

With an extracapsular fracture there is often extensive bruising which adds to the severe pain. Pain assessment and pain relief measures should be implemented (see Ch. 19) including repositioning and supporting the limb, and administering prescribed analgesics.

Increased risk of multisystem complications

For an older patient, such acute trauma and associated surgery may lead to multisystem failure (see Ch. 18).

Rehabilitation

Discharge planning should commence within 48 h of admission (Scottish Intercollegiate Guidelines Network [SIGN] 2002). The use of an integrated care pathway (ICP) can help to improve the standard of overall care by ensuring that each member of the multidisciplinary team knows the best available evidence for care and when that care should be carried out (Tarling et al 2002) (Table 10.1, Box 10.5). Early supported discharge schemes, often led by nurses, can help to ensure that patients are discharged rapidly but safely to their home environment (British Orthopaedic Association 2007).

Table 10.1 Extract from the integrated care pathway of a patient with a fractured neck of femur – postoperative day 1 (nursing part only)

Patient Problem/Need	Nursing Intervention	Expected Outcome
Recovery from anaesthetic	At least 4-hourly monitoring of vital signs	Vital signs within patient’s normal limits
Wound care	Check wound site dressing Check and record wound drainage	Dressing dry and intact Drain to be removed at 24 h after surgery as further drainage minimal
Neurovascular status of limb	Monitor neurovascular status of affected limb	No neurovascular deficit
Relief of pain	Use pain score with patient at least 4-hourly Administer analgesics as prescribed	Pain relief at level acceptable to patient
Risk of deep vein thrombosis (DVT)	Ensure antiembolism stocking in situ Thromboprophylaxis injection as prescribed Monitor for signs of DVT	Reduction in risk and early detection of problem
Reduced mobility	Ensure patient understands correct way to transfer and mobilise	Patient to sit in chair Patient to walk to end of bed with aid of Zimmer frame