Fractures: Types, Complications, and Nursing Management

Fractures are a high-yield orthopedic topic on nursing exams because they require rapid assessment, recognition of life- and limb-threatening complications, and detailed patient education. This note reviews fracture types, classic presentations, healing phases, complications, and nursing priorities.

Definition

A fracture is a break in the continuity of a bone. It can be caused by trauma, repetitive stress, or underlying bone disease.

Fracture Types

• Closed (simple): Bone breaks but does not penetrate the skin. Lower infection risk than open fractures.
• Open (compound): Bone breaks and penetrates the skin. High risk of osteomyelitis; requires immediate irrigation and antibiotics.
• Greenstick: Incomplete break — one side bends, one side breaks. Common in children (more flexible bones).
• Comminuted: Bone fragments into three or more pieces. Often requires surgical fixation.
• Transverse: Fracture line is straight across the bone. Caused by a direct blow.
• Oblique: Fracture line is diagonal. Caused by a twisting force.
• Spiral: Fracture line twists around the bone. Highly suspicious for abuse in children.
• Impacted: One bone fragment is driven into another. Common in hip fractures.
• Pathologic: Fracture through weakened bone (tumor, osteoporosis); occurs with minimal trauma.
• Stress: Tiny hairline crack from repetitive force. Common in athletes and military recruits.

Classic Fracture Presentations

Certain fracture patterns have characteristic exam findings that allow rapid identification and prevention of complications.

• Colles fracture: "Dinner fork deformity" of the distal radius.
• Scaphoid fracture: Tenderness in the anatomical snuffbox; high risk of avascular necrosis (AVN).
• Hip fracture: Leg is shortened and externally rotated; risk of hemorrhagic shock.
• Rib fracture: Pain with breathing; risk of pneumothorax or flail chest.
• Pelvic fracture: Unstable pelvis; high risk of hemorrhagic shock (high mortality).

Pathophysiology: Bone Healing Process

1. Hematoma formation — first 24 to 72 hours.
2. Inflammation — days 1 to 7.
3. Soft callus formation — days 7 to 21.
4. Hard callus formation — weeks 3 to 16.
5. Bone remodeling — months to years.

Emergency Management (First Actions)

• Assess ABCs, immobilize the fracture, assess neurovascular status, and apply ice.
• Do not attempt to reduce the fracture in the field — splint in the position found.
• Open fractures require a sterile dressing and immediate IV antibiotics.

Early Complications (0–72 Hours)

Compartment Syndrome

• Increased pressure within a muscle compartment causing ischemia and nerve damage.
• Most common in the lower leg and forearm.
• Pain out of proportion to the injury is the earliest sign.
• Pain with passive stretch (dorsiflexion of foot or fingers) is a key finding.
• The 6 P's: Pain, Pallor, Paresthesia, Paralysis, Pulselessness, Poikilothermia.
• Pulselessness is a late sign — do not wait for it to diagnose.
• Medical emergency requiring immediate fasciotomy.

Fat Embolism Syndrome

• Fat globules enter the bloodstream after a long bone fracture (femur, tibia, pelvis).
• Onset 24 to 72 hours after injury.
• Classic triad: respiratory distress, neurologic changes, and petechial rash on the chest, axillae, and conjunctivae.
• Treatment is supportive: oxygen, mechanical ventilation, fluids.

Hemorrhagic Shock

• Occurs with femur or pelvic fractures due to significant blood loss.
• Signs: hypotension, tachycardia, pallor, decreased urine output.

Neurovascular Injury

• Fracture fragments can damage nerves or blood vessels — immediate neurovascular assessment is required.

Late Complications (Weeks to Months)

• Deep vein thrombosis (DVT): Clot from immobility. Prevent with anticoagulation, compression devices, and early mobilization.
• Osteomyelitis: Bone infection; more common in open fractures. Treat with IV antibiotics and sterile wound care.
• Avascular necrosis (AVN): Bone death from loss of blood supply. Common sites: femoral head, scaphoid, talus.
• Delayed union, nonunion, malunion: Slow healing, failure to heal, or healing in abnormal position. May require bone grafting or surgical fixation.

Fracture Management

• Closed reduction: Manipulates bone fragments into alignment without surgery.
• Open reduction with internal fixation (ORIF): Uses surgical hardware; allows early mobilization.
• External fixation: Pins connected to an external frame; used for severe open fractures.
• Neurovascular checks are critical after any immobilization.

Cast and Splint Care

• Keep the cast dry; do not insert objects inside to scratch.
• Elevate the casted extremity above heart level for the first 24 to 48 hours.
• Notify the provider for increased pain, numbness, inability to move digits, fever, foul odor, or drainage.
• Bivalving (splitting the cast) relieves pressure if compartment syndrome is suspected.

Exam Traps

• Open fractures require immediate IV antibiotics and tetanus prophylaxis.
• Compartment syndrome pain worsens with passive stretch; pulselessness is a late sign.
• Fat embolism occurs 24 to 72 hours after fracture; petechial rash appears on chest, axillae, and conjunctivae.
• Colles fracture → dinner fork deformity; hip fracture → shortened and externally rotated leg.
• Scaphoid fracture → high risk of AVN; tenderness in the anatomical snuffbox is a key sign.
• Early complications occur hours to days; late complications occur weeks to months.

Key takeaways

• Open fractures are orthopedic emergencies — give IV antibiotics and tetanus prophylaxis immediately.
• Compartment syndrome presents with pain out of proportion and pain with passive stretch; fasciotomy is the definitive treatment.
• Fat embolism syndrome appears 24–72 hours after long bone fracture with respiratory distress, neuro changes, and petechial rash.
• Recognize classic patterns: Colles = dinner fork, scaphoid = snuffbox tenderness + AVN risk, hip = shortened/externally rotated leg.
• Femur and pelvic fractures carry a high risk of hemorrhagic shock.
• Nursing priorities: pain control, frequent neurovascular checks, complication monitoring, and patient education on cast care.