Fractures
Can be closed (bone broken, but skin still closed) or open (bone broken and is
sticking out of skin and communicating with open world; risk for infection)
Stable fractures: bone breaks but periosteum is intact and can be placed
back/ fixed
Unstable: bone grossly displaced and fractured in pieces that are difÏcult to
fix/ reconnect
Closed reduction: bone fragments realigned under local or general
anesthesia, then casted or placed in traction for immobilization till healed
Open reduction: correction of bone alignment through surgical incision for
fractured pieces. This may include internal fixation and use of wires, screws,
pins, rods, nails, etc.
o Disadvantage: potential for infection
o Advantage: early ambulation, faster healing
Stages of bone healing
o Break of bone > bleed > hematoma forms and it starts to heal >
collagen accumulates at site, starts to reconstruct the bone > new
callus (bone cells) grow > bone becomes solid
Break immobilized so natural process occurs
New solid bone might be weaker than rest and may have
arthritis at site
Ossification begins 3 weeks after injury and full healing/ union
can take up to a year
Casts
o Casts used to immobilize site of fracture to encourage healing
o Knee immobilizer used to prevent further disalignment
o External fixators is best for bones with multiple little breaks; there's a
risk for infection
o Cast care
Arm cast should be elevated in sling (on shoulder) to prevent
edema
Axillary region should be well padded
Sling should be placed on shoulder to avoid stress on
neck
Body jacket brace used to stabilize spine (fractured vertebrae
but SC not injured), thoracis, and lumbar areas
Worry with breathing, distension from eating
Pressure on mesenteric artery (feeds guts) can cause cast
syndrome emergency
Cast syndrome:
Present with nausea and vomiting, pain,
pressure
Management: place NG tube to suction in
order to decompress stomach so more room
available to breathe
Assess respiratory, bowel, and bladder function (since its
all being compressed)
6 small meals a day to prevent stomach distension
Hip spica used for femoral and pelvic fractures; mostly seen with
children
, Pt. should not lay prone (should be on their back) while
spica is drying so cast doesn't break
Once dry, turn regularly
Don't turn pt. using support bar or the cast can break and
pt. will need to be re-casted
Utilize fracture bedpan
Leg casts
Elevate extremity above heart level for first 24 hrs. to
prevent edema/ circulatory issues
After cast is dry, avoid dependent position to prevent
edema
Don't try to scratch inside cast because any little cut
inside can be infected (dark and moist area)
Initially no weight baring activity with cast but later can
have walking heel placed which allows ambulation
o Generalized cast care
Pain management: Advil, Tylenol; no opioids
Ice for first 24 hrs. in 20-30 min intervals with 15 min breaks
Breaks between because too much cold can stiffens joints
Vitamins to grow bone: protein, vit C, calcium, fiber
Lots of fluid since they're less mobile (2-3 L/ day)
Neurosensory assessment distal to site; ex. check finger
sensation if arm is broken, check toes if leg is broken
Turn Q2h
Expect heat from plaster; will cool off
Avoid putting fingertips on cast, use palms instead
Pedal edges so it's not sharp/ prevent abrasions
Avoid scratching for risk of infection
ROM to unaffected joints
Elevate extremity above heart to prevent edema
Enhance venous return
Compartment Syndrome
o Two types
Compartment size decreases (cast too small)
Compartment contents increase (edema)
When skin can't stretch any more, it compresses the
arteries. This leads to ischemia and poor blood flow. Cell
death and loss of function of limb can occur is problem is
not fixed
o Manifestations as 6 Ps: pain, pressure, paresthesia (numbness and
tingling), pallor, paralysis, pulselessness
o Collaborative care
No elevation above heart because this makes it harder for
circulation to push through edematous tissue
Want them to lay straight on bed
No use of ice
Loosen bandage and split cast (bivalve) if that's what's causing
issue
Reduce traction weight if it's too tight and causing issue
Can be closed (bone broken, but skin still closed) or open (bone broken and is
sticking out of skin and communicating with open world; risk for infection)
Stable fractures: bone breaks but periosteum is intact and can be placed
back/ fixed
Unstable: bone grossly displaced and fractured in pieces that are difÏcult to
fix/ reconnect
Closed reduction: bone fragments realigned under local or general
anesthesia, then casted or placed in traction for immobilization till healed
Open reduction: correction of bone alignment through surgical incision for
fractured pieces. This may include internal fixation and use of wires, screws,
pins, rods, nails, etc.
o Disadvantage: potential for infection
o Advantage: early ambulation, faster healing
Stages of bone healing
o Break of bone > bleed > hematoma forms and it starts to heal >
collagen accumulates at site, starts to reconstruct the bone > new
callus (bone cells) grow > bone becomes solid
Break immobilized so natural process occurs
New solid bone might be weaker than rest and may have
arthritis at site
Ossification begins 3 weeks after injury and full healing/ union
can take up to a year
Casts
o Casts used to immobilize site of fracture to encourage healing
o Knee immobilizer used to prevent further disalignment
o External fixators is best for bones with multiple little breaks; there's a
risk for infection
o Cast care
Arm cast should be elevated in sling (on shoulder) to prevent
edema
Axillary region should be well padded
Sling should be placed on shoulder to avoid stress on
neck
Body jacket brace used to stabilize spine (fractured vertebrae
but SC not injured), thoracis, and lumbar areas
Worry with breathing, distension from eating
Pressure on mesenteric artery (feeds guts) can cause cast
syndrome emergency
Cast syndrome:
Present with nausea and vomiting, pain,
pressure
Management: place NG tube to suction in
order to decompress stomach so more room
available to breathe
Assess respiratory, bowel, and bladder function (since its
all being compressed)
6 small meals a day to prevent stomach distension
Hip spica used for femoral and pelvic fractures; mostly seen with
children
, Pt. should not lay prone (should be on their back) while
spica is drying so cast doesn't break
Once dry, turn regularly
Don't turn pt. using support bar or the cast can break and
pt. will need to be re-casted
Utilize fracture bedpan
Leg casts
Elevate extremity above heart level for first 24 hrs. to
prevent edema/ circulatory issues
After cast is dry, avoid dependent position to prevent
edema
Don't try to scratch inside cast because any little cut
inside can be infected (dark and moist area)
Initially no weight baring activity with cast but later can
have walking heel placed which allows ambulation
o Generalized cast care
Pain management: Advil, Tylenol; no opioids
Ice for first 24 hrs. in 20-30 min intervals with 15 min breaks
Breaks between because too much cold can stiffens joints
Vitamins to grow bone: protein, vit C, calcium, fiber
Lots of fluid since they're less mobile (2-3 L/ day)
Neurosensory assessment distal to site; ex. check finger
sensation if arm is broken, check toes if leg is broken
Turn Q2h
Expect heat from plaster; will cool off
Avoid putting fingertips on cast, use palms instead
Pedal edges so it's not sharp/ prevent abrasions
Avoid scratching for risk of infection
ROM to unaffected joints
Elevate extremity above heart to prevent edema
Enhance venous return
Compartment Syndrome
o Two types
Compartment size decreases (cast too small)
Compartment contents increase (edema)
When skin can't stretch any more, it compresses the
arteries. This leads to ischemia and poor blood flow. Cell
death and loss of function of limb can occur is problem is
not fixed
o Manifestations as 6 Ps: pain, pressure, paresthesia (numbness and
tingling), pallor, paralysis, pulselessness
o Collaborative care
No elevation above heart because this makes it harder for
circulation to push through edematous tissue
Want them to lay straight on bed
No use of ice
Loosen bandage and split cast (bivalve) if that's what's causing
issue
Reduce traction weight if it's too tight and causing issue
