MSK: PART 5

A fracture is a break in bone continuity requiring immediate intervention to prevent neurovascular impairment or compartment syndrome. Risk factors include osteoporosis (where bone resorption exceeds formation), long-term corticosteroid use (decreasing calcium absorption and increasing excretion), and bone cancer, which weakens bones.

Fractures are categorized as closed (skin intact) or open/compound (bone penetrates skin, increasing infection risk). They can also be complete (bone in two separate pieces) or incomplete (partially broken). Assessment findings include pain, tenderness, muscle spasm, loss of function, inability to bear weight, visible deformity, swelling, bruising, and crepitation (grating sound). For hip fractures, shortening and external rotation of the affected leg are key signs. Child abuse should be evaluated if the injury is inconsistent with the reported event or developmental level.

Priority interventions include supporting perfusion by applying pressure to stop bleeding and monitoring for internal bleeding (signs of shock). Neurovascular impairment is assessed using the 'six Ps': pain (unrelieved by analgesics), paresthesia (numbness/tingling), poikilothermia (decreased temperature), pulselessness (weak/absent pulse), pallor/cyanosis (bluish discoloration), and paralysis (loss of function). The fracture should be immobilized with a splint before moving the client to prevent further injury. Open fractures require sterile dressing to decrease infection risk.

At the hospital, nursing interventions focus on pain management and preventing complications. These include preparing for X-rays, elevating the fractured limb above heart level to reduce swelling, applying ice packs for the first 24 hours, administering analgesics, and giving tetanus vaccines for open fractures. Frequent neurovascular assessments are crucial to monitor skin color, temperature, pulses, capillary refill, and sensation. Potential complications include compartment syndrome, deep vein thrombosis (DVT), fat embolism syndrome, and osteomyelitis (bone infection).

Compartment syndrome is a limb-threatening emergency caused by increased pressure in an extremity, cutting off blood flow. The 'six Ps' of neurovascular impairment are key signs. Nursing interventions involve loosening splints or casts, preparing for a fasciotomy (surgical incision to relieve pressure), and importantly, *not* elevating the affected extremity as it further decreases perfusion.

DVT is a common complication of lower extremity injuries, characterized by pain, swelling, and erythema due to blood stasis from immobility. Treatment involves anticoagulants like warfarin and heparin to prevent clot formation (not dissolve existing clots, which requires thrombolytics). Fat embolism syndrome is a life-threatening emergency, particularly with long bone fractures (e.g., femur), where fat is released into the pulmonary circulation. Symptoms include sudden dyspnea, chest pain, altered mental status, and petechiae (pinpoint red rash) on the neck and chest. Nursing intervention involves administering oxygen and anticipating intubation.

Osteomyelitis, a bone infection, is a risk with open fractures, presenting with fever, pain, warmth, redness, and drainage. Treatment requires long-term IV antibiotics and possible surgical debridement. Once the patient is stabilized, fracture treatment involves casting, reduction (realigning the bone), fixation (stabilizing the bone), and traction. Reduction can be manual (closed) or surgical (open). Fixation uses hardware either internally (screws, plates, rods inside the body) or externally (pins and frames extending outside the skin).

External fixation involves pins and frames extending outside the skin, increasing infection risk. Nursing considerations include frequent pin site care to prevent infection. Pin sites should be assessed for purulent drainage, redness, foul odor, and increased pain. Pin site care is performed daily to weekly by an RN or LPN (not delegated to NA), assessing every shift, and using a new sterile gauze for each wipe and each pin, cleaning from the site outwards.

Casts immobilize and protect fractures during healing. Clients must keep the cast dry to prevent skin irritation, maceration, infection, and impaired healing. If wet, use a hair dryer on a low setting. Elevate the casted extremity above heart level to reduce swelling. Apply ice packs for the first 24 hours. Do not insert objects into the cast; use a hair dryer on a cool setting for itching. Closely monitor for compartment syndrome (reassessing the six Ps) and infection (hot spots, foul odor).

Traction uses a weight and pulley system for bone alignment and muscle spasm reduction. Skin traction (e.g., Buck's traction) applies tape or wrap to the skin for short-term stabilization. Skeletal traction applies pins or wires directly to the bone. When caring for a client in traction, ensure weights hang freely and do not rest on the floor to maintain proper alignment. Prevent skin breakdown by frequently inspecting the skin, especially with skin traction. For skeletal traction, perform meticulous pin site care as described for external fixation.

Hip fractures are common in elderly clients due to falls. Nurses should teach fall prevention methods (assistive devices, removing rugs, adequate lighting, grab bars). Hip fractures often require surgical repair, specifically hip arthroplasty (total hip replacement). Post-operatively, frequent neurovascular assessment is crucial. Clients are at high risk for DVT due to immobility. For a posterior approach hip arthroplasty, preventing hip dislocation is paramount. Teach clients to avoid hip flexion greater than 90° (using raised toilet seats, high chairs) and hip adduction (keeping a pillow between legs, not crossing legs). Notify the healthcare provider for signs of hip dislocation (intense pain, leg shortening/rotation). Encourage gradual, weight-bearing mobility and strength/range of motion exercises.

General treatment for fractures includes pain management, 'RICE' (Rest, Ice, Compression, Elevation), and immobilization (cast, splint, brace). For casts, closely monitor perfusion. Traction is used temporarily for alignment and healing, particularly in hip dislocations.