Full transcript
0:00This is Sarah with RegisteredNurseRN.
0:01com, and in this video I'm going to be doing a review over bone fractures.
0:06And this video is part of an NCLEX review series over the musculoskeletal system.
0:11And as always, at the end of this video you can access the quiz.
0:14So let's get started.
0:16First, let's start out talking about what is a bone fracture.
0:19It is where you have a break or crack in a bone.
0:23And here we have a bone which doesn't look normal.
0:26A bone should normally be continuous in its structure, but here it has been
0:30broken into 2, so we now have 2 bones.
0:33And here in a second, we're going to talk about those
0:35different types of bone fractures.
0:37So what causes this?
0:40Well, let's hit the highlights, okay?
0:41Number 1, trauma, of course.
0:43Trauma to that bone— it can't withstand the resistance that's coming upon it,
0:47like with a fall or an accident, like a car accident,
0:50or some type of twisting from an injury, like playing sports, or in abuse cases,
0:57especially with the pediatric children.
1:00So if a pediatric child comes in with like a twisting type fracture,
1:05need to rule out abuse.
1:07Another thing is disease, like with bone cancer or osteoporosis.
1:12And we talked about with osteoporosis why that happens, and a bone fracture
1:17all of a sudden sneaks up on them, and then they learn
1:20that they have osteoporosis.
1:22Now let's talk about some things with these bone fractures.
1:24Children tend to heal faster than adults when they experience a bone fracture.
1:29And why is that?
1:32Well, the periosteum, which is this dense fibrous membrane
1:36that covers the bone, tends to be stronger and thicker and more flexible
1:42in them than compared to an adult.
1:45Which, whenever we talk about bone fractures, why you're going to see
1:48that the greenstick fracture, where part of the bone is bent
1:51and the other part is broken, is more common in our
1:54pediatric population than in adults.
1:56Now, healing time.
1:58How long does it normally take for bone fractures to heal?
2:00Anywhere from 3 to 12 weeks.
2:02And of course, it's going to be a little bit shorter for the child,
2:07but it varies with adults depending on how healthy they are and what's going on,
2:11if they've developed complications and things like that.
2:14Speaking of complications, what are some complications
2:17that can happen with bone fractures?
2:19Because you just don't have a fracture and it heals.
2:22They're definitely at risk for things such as infection,
2:25like osteomyelitis, compartment syndrome, which we're going to talk
2:30about in this lecture.
2:32And you have to watch that with a bone fracture.
2:34And also if they have like a cast placement or traction, we're going to talk
2:38about how to monitor them for that.
2:40A fat embolism, and this is— patients are really susceptible to this who have those
2:45long bone fractures, like the femur.
2:48And also they can suffer nerve and vessel damage because remember in our bones we
2:52have compartments that have nerves and vessels and they can become damaged
2:57and cause issues to the bone's health.
2:59Now let's talk about the types of bone fractures.
3:01Now really pay attention to this part of the lecture because I can specifically
3:05remember questions about types of bone fractures where you're
3:09given this description and you have to select what type of fracture it is.
3:13Okay, so whenever you're analyzing these scenarios, you want to be
3:16asking yourself these questions.
3:17For instance, number 1, did the bone break through the skin?
3:21And a fracture where the bone breaks through the skin, as you can see here
3:25on the left, is called an open fracture.
3:28It also has another name called compound fracture, so remember that.
3:33However, on the flip side, you can have a fractured bone
3:35that does not penetrate through the skin, so the skin remains intact.
3:40And that's called a closed fracture, or also called a simple fracture.
3:45Then ask yourself, is the bone completely broken or part of it?
3:51Now, if the fracture completely separates the bone in 2, so you have 2 separate
3:55bones now where it was just one, that is called a complete fracture.
3:59So think of it like this, it completely breaks in 2.
4:03Now, if on the right over here, if the fracture does not break through
4:07the bone all the way, it just halfway breaks it,
4:10it's called an incomplete fracture.
4:12So it incompletely broke it.
4:13Then you want to look at the details or the pattern of that fracture.
4:18And over here on the left, we have a greenstick fracture.
4:22And this is where I was talking about where this is one of the most common
4:25fractures in a pediatric patient, again, because their bones tend to be a little
4:29bit more flexible and stronger.
4:31And this is where One side of the bone is bent while the other is broken,
4:36and it's an incomplete type of fracture because look, it didn't completely
4:39separate that bone in 2.
4:42Then here on the right, we have a comminuted fracture,
4:45and this is where the bone is broken into many fragments, like 3 or more.
4:52Then we can have a type of fracture known as transverse fracture,
4:58and this is a fracture that is straight across that bone shaft.
5:02Then flip it over on the other side with the picture on the right,
5:06which is oblique fracture.
5:08And this is a type of fracture that is slanted across the bone shaft.
5:13So it appears oblique, slanted.
5:15And lastly, we can have a spiral fracture.
5:19And this fracture twists around the bone shaft.
5:23And this can be from one of those twisting type injuries when we talked about
5:28the causes of bone fractures.
5:30Now let's talk about our signs and symptoms that you can see
5:33in a patient who has a bone fracture.
5:36And bone fractures are diagnosed with an x-ray.
5:39So the x-ray will help to determine if there is indeed a bone fracture.
5:43If so, what type, which will help the physician
5:46determine what type of treatment they should provide to that patient.
5:50So to help us remember, let's remember the word broken because we have broken bones.
5:55Okay, B for bruising with pain and swelling at the site.
5:59R for reduced movement.
6:02They're not going to be able to move that extremity very well.
6:05And as a nurse, your really first thing you want to do is make sure they're safe
6:08and stable, but you want to immobilize that affected area,
6:13the possible fracture, because we don't want them moving it
6:16because they can cause more muscle and tissue damage.
6:19They can displace the bone even further, which is going to alter the healing
6:24and can cause them more pain.
6:26O for odd appearance.
6:28It's going to look funny, and it can have a variety of looks
6:31depending on what type of fracture it is.
6:34If it's a compound fracture, possibly that bone's going to be sticking
6:37out of the skin, and that's a pretty gruesome scene to look at.
6:40Scares the patient, definitely.
6:43Another thing is, is it can be twisted, it can be
6:48flipped, it can have lots of appearances, but it's going to look very abnormal.
6:53K for crackling sound.
6:56Did a K instead of a C for crackling, and this is really where these bone
7:01fragments are rubbing together.
7:03And that was where we learned that comminuted type of fracture,
7:06when you have those bone fragments together, if the patient moves it,
7:09you can hear it, and it's called crepitus.
7:12E for edema or erythema at the site, redness or swelling.
7:17And then N, our last one, neurovascular impairment.
7:22And this is where we're going to be looking out for the 6 Ps.
7:26Whenever I was in nursing school, it was the 5, and they've
7:28decided to add one more on.
7:30So let's take a look at what those 6 Ps are.
7:32We have pain, pallor, paralysis, paresthesia, pulselessness,
7:40and poikilothermia, which is the one that they've added on, which makes it now 6 Ps.
7:45And here in a second, whenever we go over nursing interventions,
7:47specifically compartment syndrome, we're going to talk about these
7:50in depth and how you check for those.
7:52Now let's take a look at our nursing interventions.
7:55What are you going to do for this patient who's had a bone fracture?
7:57Say your patient got up without asking for assistance to go to the bathroom,
8:01and on their way back they tripped over the bedside table and it looks
8:05like they broke their leg.
8:06So you want to make sure that they're safe, they're not in any harm's way,
8:10that they're stable, and then you're going to immobilize that fractured leg.
8:15So what you're going to do is you're going to use some type of Splinting device
8:18to help with immobilizing it, and you're going to splint it
8:21above and below the fracture.
8:23And the reason we want to do this is because the goal
8:28of helping that bone heal back is to make sure that it gets put back into place
8:33so it can heal properly, naturally heal.
8:36And if the bone isn't immobilized, the patient's moving it around,
8:38that's going to increase the risk of it damaging other muscles
8:43and tissues and vessels.
8:44It's going to increase bleeding and increase the patient's pain.
8:47Because the patient is going to have some type of bone reduction performed,
8:51which we'll talk about a little bit later, either like an open or
8:54closed bone reduction.
8:56And this is just where they're gonna take the bone, put it back in its place,
9:00maybe use a cast or traction like that to help it heal.
9:03So we really want to immobilize.
9:05Next, we want to stop the bleeding if there is any bleeding.
9:10And it's always good to know which patients are taking those blood
9:14thinners and know what their lab values are, their INRs.
9:17Their PTT, PT/INRs, and all that. You want to know what that is.
9:22And if you have bleeding, apply pressure with a clean cloth to stop that.
9:26And say it's an open fracture, also called compound fracture.
9:31Sometimes the bone is sticking out, sometimes it's not, and the skin
9:36is not intact, so it's open.
9:38You want to cover this site with a sterile dressing because they're
9:43at risk for infection.
9:45They just have dramatically increased the risk of possibly developing
9:49osteomyelitis because all the germs that they possibly came in contact
9:53with on the floor because they fell on the floor can
9:56possibly get inside of where that skin is broken.
10:00Next, elevate that extremity to decrease swelling along with applying ice wrapped
10:07in a towel to help with the swelling.
10:09Because we don't want a lot of swelling going on, because
10:12have a lot of swelling that's compressing our compartments, which can
10:15lead to compartment syndrome. So we gotta watch out for that.
10:17Next, keep the patient nothing by mouth until evaluated by the physician who is
10:22going to order an x-ray to confirm the diagnosis, see how bad it is, because
10:27the patient may have to go for surgery.
10:30And pain management— this patient is going to hurt really bad, so the physician
10:34will order some pain medication.
10:36And you really want to watch as the nurse How effective this
10:41pain medication is being.
10:42So you want to document that and monitor it closely because, again, like I said,
10:47with compartment syndrome, one of those first signs you're going
10:49to see is that that patient isn't really getting relief from these powerful drugs
10:54that you're giving them, like morphine, those opioid-type medications.
10:58And instead they're going to say, you know, I'm hurting really bad,
11:00this isn't helping, it hurts with passive movement,
11:03when I stretch, when I elevate the arm.
11:07And that should be a red flag to you.
11:08So always make sure you're monitoring that pain because
11:11we want to catch compartment syndrome early, because if you don't within
11:166 hours of where the patient's experiencing ischemia,
11:20that it is irreversible.
11:22They cannot go and correct the damage done to that muscle or nerve.
11:25And another important thing that's going to tie in along with monitoring
11:29for that complication of compartment syndrome is conducting frequent
11:33neurovascular assessments.
11:35Now let's take a closer look at compartment syndrome because that goes
11:40along with why we're looking at these 6 Ps.
11:44Okay, so what is it? Let the name help you.
11:47Compartment syndrome is dealing with those individual compartments that are
11:52found within the fascia.
11:54Okay, let's talk a little bit about fascia because in order to understand compartment
11:58syndrome, we have to understand the fascia because it's Really what's
12:01causing our problem.
12:03Okay, if you took like the leg or the arm and you just like sliced it like this
12:07and you looked at it, you would see the bone,
12:10and then you would see these individual compartments which include muscles.
12:15And each compartment has its own blood supply and nerve supply.
12:19And surrounding it all and keeping it all in place is this
12:24connective membrane called fascia.
12:28and one of the key functions of fascia is to keep all that muscle, nerves
12:33all together in like this tight band.
12:36But the key about fascia is that it doesn't expand.
12:40It's super tough.
12:41So if any pressure starts increasing within these compartments,
12:46it's going to stay within the compartment.
12:48It's not going to expand outward to alleviate stress.
12:52So here's the problem.
12:54When you get a bone fracture, and compartment syndrome can happen
12:57with bone fractures, it can happen with cast placement, traction,
13:01burns, things like that.
13:03But here we're talking about fractures.
13:04So if you get a bone fracture, bone breaks, causes damage, and you
13:08have bleeding and you get swelling.
13:11And if it goes into these compartments, what happens— say it goes into this
13:15compartment and you have all this bleeding and swelling and it's increasing
13:19the pressure within that compartment.
13:21Now within that compartment is a nerve and blood supply,
13:25and all that pressure is going to stay within that compartment,
13:28and it's going to squeeze off the blood supply and the nerve
13:32supply to that muscle.
13:35And if it's not reversed within 6 hours, it's irreversible and the patient's
13:39going to lose that particular muscle.
13:42So what we have to be watching out for as
13:45a nurse is we have to watch out for that early sign, the pain.
13:49So We're going to be asking them, how's your pain?
13:52Did that pain medication help?
13:54And if the patient tells you, you know, that pain medication is not
13:59helping, this is hurting so bad, the pain has just been increasing,
14:03even when I passively just stretch my arms because they have a broken arm,
14:10or if I elevate it, it hurts. And why is that?
14:12Because just barely stretching or moving it is stretching that muscle that has
14:18that increased pressure in it within that compartment, and it's causing them pain.
14:24Other thing is the paresthesia.
14:27Paresthesia is where they're going to be feeling— say that it was they broke their
14:32arm in that distal extremity— they may be feeling
14:36pins and needles sensation, like a tingling sensation in that,
14:40and that's from where that nerve supply is being compromised.
14:44The pressure is in a sense squeezing it off, so they're having issues with that.
14:49Pallor— the extremity, maybe that hand of that affected
14:54fracture, is a dusky color, it's pale.
14:58Always compare it to the unaffected extremity.
15:01Go by that.
15:01Do they match in color or are they different in color?
15:04You want to always compare those.
15:07And that's again that decreased blood supply, losing the blood supply
15:10to that muscle in that arm.
15:13Paralysis— are they able to move their fingers?
15:18If not, you need to investigate that.
15:21And poikilothermia— this is where you're going to be looking at both extremities.
15:27Again, if they broke their right arm, and you're gonna feel the temperature and
15:31compare the temperature of those hands.
15:34Is the hand that has the fracture really cold compared to the hand
15:39that doesn't have the fracture? So look at that.
15:42And the pulselessness— and this is an absolute late sign,
15:46and if you get that sign, not good.
15:49And you want to be feeling the pulses in that affected extremity.
15:53Very important that you take like a black marker and you put an X over where
15:58that you felt that pulse, so when other nurses come in, your CNAs,
16:03you're getting your vital signs, they feel it as well.
16:05You want to make sure that everyone's feeling at the same
16:07spot and have a Doppler.
16:10You can get the Doppler, most floors have them,
16:13and it has a little ultrasound gel and you put it over the pulse and you can hear
16:16the swishing sound, which is the pulse, and just make sure it
16:20sounds the same, it's not sounding abnormal.
16:23So you want to look at those things.
16:24Another thing is you want to, if you suspect that the patient has
16:29compartment syndrome, of course the first thing you're going
16:31to do is you want to of course, notify the physician,
16:34but keep that extremity at heart level, not elevated above heart level.
16:41Keep it at heart level because we have ischemia going on and we don't want
16:46to compromise that anymore, and we want to main— maintain arterial pressure.
16:51So we're going to keep it at heart level.
16:54Loosen and remove any restrictive clothing that is around that site.
17:00And the cast may be bivalved, where they cut it in half to relieve the pressure.
17:06And of course, that'll be done by the physician.
17:08And if the patient was in traction, maybe decreasing the amount
17:13of weight that's on the traction.
17:14And this is like really in those early stages whenever you've caught it,
17:18to alleviate the pressure that's going on in that affected fracture.
17:22And if it's in a severe case, they will do what's called
17:26a fasciotomy, and that's where they go and slice that fascia open,
17:31which helps alleviate pressure within that compartment.
17:35And one thing of how they monitor this and diagnose this is that they can use
17:40a needle, insert the needle within this compartment, and measure the amount
17:44of pressure that is in there.
17:46And usually greater than 20 millimeters of mercury is concerning.
17:51So they can monitor this and make sure
17:54that that pressure isn't going too high compared to what it should
17:57be in the compartment.
17:58And another thing you want to watch out for other than compartment syndrome are
18:02signs and symptoms that a fat embolism may have happened.
18:07And you'll be looking for this especially in your patients who have had
18:10those long bone fractures.
18:12And this can manifest itself with changes in their mental status all
18:16of a sudden, they're getting progressively more
18:19confused, not normal what they should have been baseline,
18:23and they're restless, and they've had a change in their respiratory status.
18:27They're having more difficulty breathing, their respiratory rate has increased.
18:33Now let's look at our various treatments.
18:36Okay, so your patient has fractured their bone.
18:38What needs to be done?
18:40Well, they need a bone reduction, and this is just a fancy term for saying
18:45That the bone needs to be put back into its original state.
18:48And why is that?
18:49If it's become displaced, they want to make it come back together
18:52because this is going to allow that bone to naturally heal.
18:56And remember, it takes anywhere from 3 to 12 weeks for a bone to heal depending
18:59on the patient's health and what's going on.
19:02And there's various types of bone reductions, and let's
19:04go over those quickly.
19:06We have closed and we have open.
19:09Closed is where this is done manually.
19:13And usually general anesthesia is given to the patient so they don't feel
19:18really what's going on.
19:20And so they do that and put it back in its original place,
19:23and usually a cast is placed.
19:26And here's some things that you want to remember about casts, okay?
19:29Of course, watch for your 6 Ps because they're at risk for compartment syndrome.
19:33Another thing is watch out for infection.
19:36Patient have a temperature?
19:38Is there a foul-smelling smell coming out of the cast,
19:43and is there any hot spots on the cast?
19:45So you want to make sure there's no hot spots.
19:48Also, after the cast is newly placed, you want to elevate it above the heart
19:52to decrease swelling and ice it for about 2 days,
19:58again to help with decreased swelling, because we don't want compartment
20:01syndrome to develop.
20:03We're going to use our palms when handling the cast when it's Freshly placed.
20:08They can be fiberglass or plaster.
20:11So for those first hours of drying, we want to move it
20:15with the palm of our hands.
20:16We don't want to use our fingertips because our fingertips can cause dents,
20:21and those dents are going to stay, and they're going to rub on the skin
20:24and cause pressure ulcers.
20:25So make sure you're educating the family and other people who will be
20:29moving the cast.
20:31You're going to turn it every 2 hours during that drying period
20:34to make sure it's evenly dried.
20:36Also, a hair dryer on the cool setting can be used to dry it.
20:42Also, if the patient is having itching with the cast, because this happens a lot
20:45of times, they never need to stick anything in their cast to itch it.
20:48It can break off, cause a lot more problems.
20:51Instead, antihistamines can be prescribed, or the hair dryer can be used on the cool
20:56setting, never on a warm or hot setting, but the cool setting, to blow cool air
21:00into the cast to alleviate the itching.
21:04Skin integrity needs to be maintained because around the cast you can,
21:08they can get some skin breakdown.
21:11And usually what's placed around the cast is a soft tape made out of moleskin,
21:16and it's called petaling the cast.
21:18So make sure the patient doesn't pick at that or take it off because that helps
21:22protect the skin around that area.
21:26Also keep the cast dry, never get it wet.
21:30Another thing is our bone reduction with the open type.
21:33Okay, this is done surgically.
21:36Close is manually, this is surgically.
21:38So they do that and they put it back in its original state,
21:41and they use a fixation device to help with the bone, with its bone healing.
21:46And you can have an internal or external fixation device.
21:50So internal is where the bone, where it's attached to the bone
21:53in the inside of the skin.
21:55And this is with equipment like pins, rods, and plates.
21:58External is where it's attached on the outside of the skin,
22:02and this is with like metal braces and screws, and these can be adjusted.
22:07Now let's look over at traction.
22:10Traction, what does it do?
22:12It helps align the bone with a steady pulling action.
22:17So some things you want to remember with this as a nurse is you want
22:21those weights to hang freely.
22:23Never on the floor.
22:25And never remove the weights.
22:28Like, you want— the patient wants to get up and do something,
22:30just don't go and remove the weights.
22:33Never do it unless you have a physician's order.
22:36Also, try to get them an overhead trapeze bar to help with moving.
22:41And pin care, you want to— if they have pins,
22:44you want to make sure that there's no foul-looking drainage that's draining
22:49at those pins, and you want to maintain their skin integrity
22:53along with helping alleviate pressure on those pressure sites because these
22:58patients are going to be really immobile because they're in this traction.
23:01So you want to make sure you're relieving pressure on those areas,
23:04and you want to make sure that you're monitoring for those 6 Ps again because
23:08they're at risk for compartment syndrome.
23:10Okay, so that wraps up this lecture on bone fractures.
23:14Thank you so much for watching.
23:15Don't forget to take the free quiz and to subscribe to our channel for more videos.