Fractures

Managing Fractures at Specific Sites

Maximum functional recovery is the goal of management.

Clavicle

• Fracture of the clavicle (collar bone) is a common injury that results from a fall or a direct blow to the shoulder.
• Monitor the circulation and nerve function of the affected arm and compare with the unaffected arm to determine variations, which may indicate disturbances in neurovascular status. 
• Caution the patient not to elevate the arm above shoulder level until the fracture has healed (about 6 weeks).
• Encourage the patient to exercise the elbow, wrist, and fingers as soon as possible and, when prescribed, to perform shoulder exercises.
• Tell the patient that vigorous activity is limited for 3 months.

Humeral Neck

• With humeral neck fractures (seen most frequently in older women after a fall on an outstretched arm), perform neurovascular assessment of the involved extremity to evaluate the extent of injury and possible involvement of the nerves and blood vessels of the arm.
• Teach the patient to support the arm and immobilize it by a sling and swathe that secure the supported arm to the trunk.
• Begin pendulum exercises as soon as tolerated by the patient. Instruct the patient to avoid vigorous activity for an additional 10 to 14 weeks. 
• Inform the patient that residual stiffness, aching, and some limitation of range of motion may persist for 6 or more months.
• When a humeral neck fracture is displaced with required fixation, exercises are started only after a prescribed period of immobilization.

Humeral shaft fractures

• The nerves and brachial blood vessels may be injured, so neurovascular assessment is essential to monitor the status of the nerve or blood vessels.
• Use well-padded splints to initially immobilize the upper arm and to support the arm in 90 degrees of flexion at the elbow, use a sling or collar and cuff to support the forearm, and use external fixators to treat open fractures of the humeral shaft.
• Functional bracing may also be used for these fractures.
• Teach patient to perform pendulum shoulder exercises and isometric exercises as prescribed.

Elbow

• Elbow fractures (distal humerus) may result in injury to the median, radial, or ulnar nerves.
• Evaluate the patient for paresthesia and signs of compromised circulation in the forearm and hand.
• Monitor closely for Volkmann’s ischemic contracture (an acute compartment syndrome) as well as for hemarthrosis (blood in the joint). 
• Reinforce information regarding reduction and fixation of the fracture and planned active motion when swelling has subsided and healing has begun.
• Explain care if the arm is immobilized in a cast or posterior splint with a sling. Encourage active finger exercises.
• Teach and encourage patient to do gentle range of motion exercise of the injured joint about 1 week after internal fixation. 

Radial head fractures

• They are usually produced by a fall on the outstretched hand with the elbow extended.
• Instruct patient in use of a splint for immobilization.
• If the fracture is displaced, reinforce the need for postoperative immobilization of the arm in a posterior plaster splint and sling.
• Encourage the patient to carry out a program of active motion of the elbow and forearm when prescribed

Wrist

• Wrist fractures (distal radius [Colles’ fracture]) usually result from a fall on an open, dorsiflexed hand.
• They are frequently seen in elderly women with osteoporotic bones and weak soft tissues that do not dissipate the energy of a fall.
• Reinforce care of the cast, or with more severe fractures with wire insertion, teach incision care. 
• Instruct patient to keep the wrist and forearm elevated for 48 hours after reduction.
• Begin active motion of the fingers and shoulder promptly by teaching patient to do the following exercises to reduce swelling and prevent stiffness:
• Hold the hand at the level of the heart. Move the fingers from full extension to flexion. Hold and release. Repeat at least 10 times every hour when awake.
• Use the hand in functional activities. 
• Actively exercise the shoulder and elbow, including complete range-of-motion exercises of both joints
• Assess the sensory function of the median nerve by pricking the distal aspect of the index finger, and assess the motor function by testing patient’s ability to touch the thumb tot he little finger.
• If diminished circulation and nerve function is noted, treat promptly. 

Hand and Fingers

• Hand trauma often requires extensive reconstructive surgery.
• The objective of treatment is always to regain maximum function of the hand.
• With a non displaced fracture, the finger is splinted for 3 to 4 weeks to relieve pain and protect the fingertip from further trauma, but displaced fractures and open fractures may require open reduction with internal fixation, using wires or pins. 
• Encourage functional use of the uninvolved portions of the hand
• Evaluate the neurovascular status of the injured hand.
• Teach the patient to control swelling by elevating the hand.

Pelvis

• Pelvic fractures may be caused by falls, motor vehicle crashes, or crush injuries. At least two thirds of these patients have significant and multiple injuries.
• Monitor for symptoms, including ecchymosis; tenderness over the symphysis pubis, anterior iliac spines, iliac crest, sacrum, or coccyx; local edema; numbness or tingling of the pubis, genitals, and proximal thighs; and inability to bear weight without discomfort. 
• Complete a neurovascular assessment of the lower extremities to detect injury to pelvic blood vessels and nerves.
• As pain resolves, instruct patient to resume activity gradually, using assistive mobility devices for protected weight bearing. Patients with unstable pelvic fractures may be treated with external fixation or open reduction and internal fixation (ORIF).
• Promote hemodynamic stability and comfort, and encourage early mobilization. 
• Examine urine for blood to assess for urinary tract injury. In male patients, do not insert a catheter until the status of the urethra is known.
• Monitor for diffuse and intense abdominal pain, hyperactive or absent bowel sounds, and abdominal rigidity and resonance (free air) or dullness to percussion (blood), which suggest injury to the intestines or abdominal bleeding. 
• Monitor for hemorrhage and shock, two of the most serious consequences that may occur. Palpate both lower extremities for absence of peripheral pulses, which may indicate a torn iliac artery or one of its branches.
• Assess for injuries to the bladder, rectum, intestines, other abdominal organs, and pelvic vessels and nerves. 
• If patient has a stable pelvic fracture, maintain patient on bed rest for a few days and provide symptom management until the pain and discomfort are controlled.
• Provide fluids, dietary fiber, ankle and leg exercises, antiembolism stockings to aid venous return, logrolling, deep breathing, and skin care to reduce the risk for complications and to increase comfort.
• Monitor bowel sounds. If patient has a fracture of the coccyx and experiences pain on sitting and with defecation, assist with sitz baths as prescribed to relieve pain, and administer stool softeners to prevent the need to strain on defecation.

Femur and Hip

• Femoral shaft fractures are most often seen in young adults involved in a motor vehicle crash or a fall from a high place.
• Frequently, these patients have associated multiple trauma and develop shock from a loss of 2 to 3 units of blood.
• Assess neurovascular status of the extremity, especially circulatory perfusion of the lower leg and foot (popliteal, posterior tibial, and pedal pulses and toe capillary refill time as well as Doppler ultrasound monitoring). 
• Note signs of dislocation of the hip and knee, and knee effusion, which may suggest ligament damage and possible instability of the knee joint
• Apply and maintain skeletal traction or splint to achieve muscle relaxation and alignment of the fracture fragments before ORIF procedures, and later a cast brace. 
• Assist patient in minimal partial weight bearing when indicated and progress to full weight bearing as tolerated.
• Reinforce that the cast brace is worn for 12 to 14 weeks
• Instruct in and encourage patient to perform exercises of lower leg, foot, and toes on a regular basis. 
• Assist patient in performing active and passive knee exercises as soon as possible, depending on the management approach and the stability of the fracture and knee ligaments.