Med-Surg - Musculoskeletal System, part 7: Fractures

Hi. I'm Cathy with Level Up RN. In this video, I'm going to talk about fractures. And at the end of the video, I'm going to give you guys a little quiz to test your understanding of some of the key facts I'll be covering in this video. So definitely stay tuned for that. And if you have our Level Up RN medical-surgical nursing flashcards, definitely pull those out so you can follow along with me.

Let's start by taking a look at different types of fractures. So this illustration can be found in our medical-surgical nursing flashcard deck.

So with a closed fracture, it does not break the skin surface as opposed to an open fracture, which breaks the skin surface, which greatly increases the patient's risk of infection.

With a transverse fracture, the fracture occurs perpendicular to the long axis of the bone.

With an impacted or compression fracture, this occurs when two or more bones are crushed together due to a loading force.

A comminuted fracture is when the fracture results in two or more pieces.

An oblique fracture occurs at an angle, so it's kind of slanted.

A spiral fracture is a fracture that occurs from a twisting motion.

So this is a definite sign of abuse. So if you see a spiral fracture, then you should definitely assess for the potential of an abuse situation.

And then we have a green stick fracture. This is a partial fracture, so only one side of the bone is broken.

This is most common in children, and the bone bends and cracks, but doesn't fracture all the way through.

Risk factors that place a patient at increased risk for fractures includes osteoporosis, Paget's disease, long-term steroid use, substance abuse, trauma such as a fall, and bone cancer.

In terms of signs and symptoms, the patient will likely have pain, swelling, a chemosis. They may have deformity in the affected area, and they may also have muscle spasms.

We can diagnose a fracture by using an X-ray, CT, or MRI.

Medications that may be prescribed include analgesics for pain. If the patient had an open fracture, then we may provide them with antibiotics to help prevent infection. Also, if the patient is having muscle spasms, then we may need to give them muscle relaxants.

In terms of procedures, we can do a closed reduction, which means that the bones are put back into their normal position without cutting the skin open. So we have a closed reduction and then we will immobilize the area with a cast, a splint, or traction. We can also do an external fixation to try to fix the situation. This is where screws and pins are inserted into the bone and they are attached to an external frame.

So I sometimes have to do wound vac dressing changes underneath this frame, which is a little tricky. Then we have open reduction and internal fixation, ORIF. This is where the surgeon goes inside and inserts screws, pins, rods to correct the fracture internally and then closes the skin back up.

Let's now talk about nursing care. So emergency care includes cutting the clothing away from the area, removing jewelry, controlling bleeding, and immobilizing the fracture through splinting. Then we want to perform a thorough neurovascular check. So we want to assess the patient's pain level. We want to assess their sensation in the area. We want to monitor their skin temperature, their color. We want to check for capillary refill, check their pulses, and see if they can move that extremity.

We also want to monitor for complications, which can include osteomyelitis, which is a bone infection. Another complication is a venous thromboembolism or blood clot, and then a fat embolism, and compartment syndrome or other complications that we're going to talk a little bit more in detail about right now.

So a fat embolism is a fat globule that comes out of the bone marrow in the bone and travels up into the lungs. And it's more common in long bone and hip fractures.

Signs and symptoms of a fat embolism include dyspnea, confusion, tachypnea, tachycardia, petechiae, which are those red dots that show up in the skin, and a decrease in oxygen saturation.

Treatment is supportive, so usually includes bed rest, IV fluids, and oxygen.

Compartment syndrome is another important complication to know when it comes to fractures. So compartment syndrome is where we have an increase in pressure in the muscle compartment that impairs circulation to that extremity.

So signs and symptoms include the five PS, which we have here as a cold chicken hint on our card. So those five Ps include intense pain. So the patient will have pain with passive movement, and it will be unrelieved by medications. The second P is paresthesia, which is that pins and needles sensation. The third P is paralysis. The fourth is pallor, so pale skin. And then the fifth is pulselessness. In addition, the affected extremity will be hard and swollen.

So if you suspect that your patient has compartment syndrome, you absolutely do not want to apply cold to the area because we already have impaired circulation to the extremity and by applying cold that would cause vasoconstriction, which is not what we want to do. We also do not want to elevate the extremity because that would also impair circulation into that extremity. You, of course, want to notify the provider.

Treatment of compartment syndrome includes a fasciotomy, which is where they perform the deep incision into the muscle compartment to relieve that pressure. And amputation may be necessary as well.

All right. It's time for quiz. I have three questions for you. First question. What type of fracture is caused by a twisting motion and is a sign of possible abuse? The answer is a spiral fracture.
Question number two. A patient with a hip fracture has petechiae on their chest, dyspnea, and a decrease in oxygen saturation. What fracture complication do you suspect? The answer is a fat embolism.
Question number three. What are the five Ps of compartment syndrome? This one's a little harder. The five Ps include pain, paresthesia, paralysis, pallor, and pulselessness.

All right. I hope you enjoyed this video and that quiz. In my next video, I will be covering immobilization devices such as traction and cast. So definitely stay tuned for that.