Fractures: Nursing process (ADPIE)

Malaya Tanglao is a 15-year-old female who presented to the ED with her father, Ulan, after being unable to bear weight on her left lower extremity following a skiing accident.

X-ray confirms that she sustained a closed transverse midshaft fracture to her left tibia that is displaced with resulting soft tissue injury. Malaya is now being admitted to the pediatric orthopedic unit for pain management and preparation for surgical intervention.

A fracture is defined as a complete or partial break in a bone, which occurs when the physical force applied to the bone is stronger than the bone itself. Most often, this occurs due to trauma associated with a fall, sports injury, or motor vehicle crash.

Fractures may also result from overuse during repetitive activities, such as running or jumping. Finally, some conditions, such as osteoporosis or cancer, can weaken the bones and cause spontaneous fractures. There are some factors that can put an individual at risk for fractures.

Modifiable risk factors that may weaken the bones include low vitamin D, smoking, alcohol, and glucocorticoid use; while nonmodifiable risk factors include increasing age, as well as congenital disorders like osteogenesis imperfecta, and malabsorption problems that may impair the ability to absorb important nutrients for bone health, like calcium and vitamin D.

Now, most commonly, we talk about closed or simple fractures, which occur when the bone breaks, but the overlying skin remains intact. On the other hand, open or compound fractures occur when the fractured ends pierce through the overlying skin.

There are many different types of fractures, such as greenstick fractures, which occur when one side of the bone breaks, while the other side of the bone bends. Impacted fractures occur when a piece of one bone gets wedged into another bone.

Comminuted fractures are where the bone breaks into multiple fragments. Finally, in spiral fractures, the fracture line follows the projection of a strong, twisting force that is applied to the bone.

Spiral fractures are most commonly seen in non-accidental traumas, such as physical abuse, like when someone forcefully grabs and twists an arm. Now, the broken bone typically requires several weeks to months to heal.

The process starts with the inflammatory phase, in which the body responds to the trauma by sending immune cells to the location of the fracture.

Immune cells remove dead and damaged tissue, thereby enabling the body to enter the second phase, called the reparative phase. In this stage, the body activates osteoblasts to form a callus, which is a new bone tissue that connects the fractured ends.

In the last phase, which is also known as the remodeling phase, the callus is replaced by regular bone, and the healing process is completed. Now, fractures typically present with signs and symptoms like localized pain, especially when trying to move, as well as swelling, and bruising.

If the fracture is displaced, the affected part of the body can look misaligned, shortened, or even deformed. Fractures can also lead to some serious complications.

Soon after the injury, the broken ends of the bone may damage surrounding structures, such as blood vessels, resulting in bleeding; as well as nearby nerves, leading to altered sensation; and tears to the muscles or tendons.

Another acute complication is compartment syndrome, which is when bleeding or edema from the fracture leads to increased pressure inside the section of the limb that contains muscles, nerves, and blood vessels, and results in the reduction of blood supply and tissue necrosis.

Fractures of long bones may lead to fat embolism, which is when a piece of fat breaks off from the fractured bone and then travels through the bloodstream and gets lodged within a blood vessel in organs like the heart, lungs, or brain, obstructing their blood flow.

Fractures may also have long-term complications, such as healing abnormalities that may result in bone deformity. This includes malunion, which occurs when the fractured ends are not adequately aligned; delayed union, which is when a bone requires more time to complete the healing process; and nonunion, which occurs when a bone completely fails to connect broken ends of the bone.

Some clients might also develop mobility complications, such as joint stiffness or instability. On rare occasions, they can also develop contractures, where muscles and tendons get shortened and the range of motion gets limited.

Finally, clients who are immobilized and are spending too much time in bed can develop a pressure injury, which typically occurs over bony prominences like the sacrum or heels.

Immobilized individuals are also at risk for developing deep vein thrombosis, or DVT for short, which typically occurs in deep veins of the lower extremities.

The blood clot can break off and travel all the way to the lungs, ultimately causing a pulmonary embolism. Diagnosis of fractures is typically done performing an X-ray in two different planes, most commonly anteroposterior and lateral planes.

If the X-ray finding appears normal, and the clinical presentation suggests a possible fracture, MRI or CT should be used to confirm the diagnosis.

Treatment of bone fractures generally involves rest and immobilization of the affected limb, in addition to the use of removable splints, or casts, to allow the bone to heal.

In addition, displaced fractures require reduction, which is the alignment of fractured ends into their proper position. Closed reduction refers to the alignment without surgical intervention, while open reduction is done with surgery.