ACCORDING TO THE NATIONAL CENTER for Health Statistics, in 1 year, 1.3 million U.S. patients had fractures requiring hospitalizations and nearly 7,000 of these patients died.1 In the United States, 492,000 tibia, fibula, and ankle fractures occur each year, with tibia fractures being the most common long bone fracture.2
This article describes fractures, explains the difference between open and closed fractures, and tells how to care for a patient who's had an open fracture.
The hard facts
A fracture, or a break in the continuity of a bone, occurs when a strain or force is applied to it. Fractures can occur anywhere in the bone and are classified by the extent of the break. In a complete fracture, the width of the bone breaks, resulting in two distinct sections of bone. An incomplete fracture doesn't divide the bone into two parts.3
Fractures are also described by the amount of associated soft-tissue damage accompanying the injury. Closed fractures (simple) may be associated with an area of ecchymosis and edema in tissue around the fracture, but the skin is intact. Open fractures (compound) are accompanied by a disruption in the skin or mucous membrane in the area over the fracture, resulting in an open wound that lets the fractured bone communicate with the environment.4
Most fractures are caused by trauma, such as falls; osteoporosis, which leaves bones thinned and weakened; or repetitive stress, which is associated with athletics.5 Low-velocity injuries include falls from a standing height, athletic injuries, stab wounds, and shotgun injuries. High-velocity injuries are associated with motor vehicle crashes, pedestrian versus automobile injuries, falls from a height, and handgun injuries.3 The higher and faster an object or body moves, the greater the velocity and the more severe the resulting injury.
Open fractures usually result from high-energy trauma.6 This article focuses on open fractures because they're always considered contaminated, require complex care in the hospital, and place the patient at risk for life-threatening complications. Now let's look at open fractures in more detail.
Grading the damage
Several classification systems are available to grade open fractures, but the most widely used system was developed by Gustilo and Anderson. This system classifies open fractures into one of three types according to the amount of associated soft-tissue damage. The third type, which indicates moderate to massive damage, is then further divided into subtypes A, B, and C, depending on the amount and severity of tissue loss. (See Classifying the damage.)
Now let's consider the diagnosis and treatment of a typical patient admitted to the hospital with an open fracture.
A breaking case
Patrick Morgan, 37, a commercial house painter, falls from a 12-foot ladder while painting the exterior of a house. He first lands on the brick patio wall, then continues to fall, coming to rest in a flower bed. Mr. Morgan has an obvious open fracture of the left tibia and fibula, which is contaminated with dirt and debris, and multiple lacerations and contusions of the left forearm, shoulder, and forehead.
Emergency medical technicians (EMTs) arrive and find Mr. Morgan alert and oriented to person, place, and time. His initial vital signs are BP, 120/64; heart rate, 120; respirations, 28; and pulse oximetry, 97%. He has a moderate amount of bleeding from his left lower extremity, with bone protruding from his skin. Performing a primary survey, the EMTs evaluate his Airway, Breathing, and Circulation (ABCs). They evaluate his Disability by assessing his neurologic status.7 To gain Exposure, they cut his pant leg open to evaluate the extent of the injury to his leg.
Immediately following the injury, most patients with an open fracture have an obvious deformity of the involved extremity. The examiner may notice displaced bones or an unusual angulation or rotation of bone fragments. The fracture may be obvious if a portion of the bone is protruding from the skin, but if the patient has extensive soft-tissue injury with bleeding and lacerations, the deformity may not be noticeable until the extremity is palpated and compared with the uninjured one. To accurately evaluate the neurovascular status of the involved limb, assess the six P's: pain, pulses, paralysis, pallor, paresthesias, and polar (for cold temperature).8
Following the initial injury or insult, the patient will experience continuous and increasingly severe pain until the bone fragments are immobilized. Muscle spasms can occur within 20 minutes of the injury, increasing the pain.8
An open fracture should be stabilized immediately after the initial assessment. Splinting and bleeding control usually occur before the patient reaches the hospital. In Mr. Morgan's case, the EMTs apply gentle, direct manual pressure with a dressing to the bleeding extremity and immediately immobilize it with a disposable splint. As after any serious fall, they also immobilize the patient's cervical spine and place him on a backboard for safe transport. Next, they obtain vascular access by inserting a large-gauge peripheral I.V. catheter, start an infusion of 0.9% sodium chloride solution, and transport him to the ED.
External gross blood loss can be visualized on exam, but large amounts of blood can also be lost internally within soft tissues. Trauma and associated bleeding into the tissue cause edema and skin discoloration. These signs may develop shortly after the injury or may be delayed for hours, depending on the type and amount of bleeding and the amount of associated trauma that occurred at the time of injury.
Anticipate hypovolemia when your patient has a fracture, especially an open fracture.8 Monitor vital signs frequently, assessing for signs of hypovolemic shock, such as an increase in pulse rate and a decrease in pulse pressure. When the patient first arrives in the ED, assess ABCs and apply immediate and direct pressure to sites of any visible external hemorrhage. Early and adequate blood transfusions help prevent patient deterioration and the development and progression of shock. Fluid replacement with crystalloids, and colloids if needed, will be used to replenish the intravascular volume.
If the patient has life-threatening injuries, such as pulmonary contusions, brain or spinal cord injuries, and hemodynamic instability, surgical management of the fracture may be delayed until the patient is stabilized.3 The timing of surgical intervention is important to preserve function and prevent complications. The healthcare provider's decision about the timing of operative treatment depends on the extent of the soft-tissue injury and associated life-threatening injuries.
Edema, ecchymoses, and abrasions from soft-tissue injuries may delay operative interventions. Severe edema, manifested by tight, tense skin, may interfere with wound healing and can delay definitive or reconstructive surgery for weeks.
After Mr. Morgan arrives in the ED, the staff conducts another primary survey and reassesses him for life-threatening injuries. Because he fell from a height, his neck and spine are imaged. Results show that his cervical spine has no acute fracture. Spinal imaging may not be necessary if the trauma patient is alert and has no mental status changes, neurologic deficits, neck pain, or distracting pain.9 In Mr. Morgan's case, imaging is necessary because he has an open fracture that causes distracting pain.
Mr. Morgan's rigid collar and backboard are removed. The ED team then completes a secondary survey to identify less immediately life-threatening and hidden (occult) injuries by conducting a thorough head-to-toe assessment.10
Assessment reveals a 5-cm laceration and a visible open fracture of the left tibia and fibula, surrounded by a large area of ecchymosis. Mr. Morgan can't move his left lower extremity. He also complains of constant, throbbing pain in his left lower extremity that he rates as a 10 on a 0 (no pain) to 10 (worst pain imaginable) pain intensity rating scale. His left arm has no obvious deformity, but he has two 3-cm lacerations to the forearm and complains of pain on palpation that he rates as 10 on a scale of 0 to 10. The healthcare provider determines that Mr. Morgan has a type II open fracture of the left tibia and fibula.
Normal extremity movement depends on the flexion and extension of muscles and ligaments moving the bone to which they're attached. Once the bone is disrupted, movement is disrupted or absent and the patient loses function.11
Pain also contributes to the loss of functioning. A comprehensive pain assessment should also include questions following the P-Q-R-S-T method or similar method. (See Using the P-Q-R-S-T method to assess pain.) The patient may describe crepitus, a grating or cracking sensation that indicates broken bones are moving, sometimes along an uneven surface.
Motor function can best be assessed by both passive range-of-motion and active range-of-motion of the affected extremity. To prevent further injury and vascular compromise, don't move an extremity with open fractures. Compare the injured extremity with the unaffected extremity. Note limitations of movement or abnormal movement, looking for hidden injuries such as dislocations. Pulses should be assessed before and after movement. Sometimes full movement is limited by pain. Ask the patient to rate the pain on a scale of 0 to 10.
Shortening of the affected extremity is associated with long-bone injuries. The shortening results from contractions of muscles that are attached distal and proximal to the fractures. This contraction can cause the fractured portions of bone to overlap 2.5 to 5 cm (1 to 2 inches). This contraction also causes loss of functioning and increased pain.8
Assessing for neurovascular compromise
Evaluate capillary refill time, pulses, and skin color and temperature to assess the injured extremity's vascular status. Normal capillary refill time is less than 2 to 3 seconds; a longer filling time may indicate vascular compromise.
When you assess pulses proximal and distal to the injury, note the intensity of pulses and compare them to pulses in the unaffected extremity. The absence of a pulse or decrease in pulse intensity in comparison to the unaffected extremity also suggests vascular compromise.
Note the color of the extremity both proximal and distal to the injury. Pallor suggests a disruption in arterial blood supply, while a blue or dusky color suggests venous injury and congestion.
Assess the skin temperature. A cool or cold extremity may indicate decreased or absent arterial blood flow.
Mr. Morgan's left foot is pale, capillary refill time is greater than 3 seconds, and left posterior tibial and dorsalis pedis pulses aren't palpable but can be located using a Doppler. Manually palpate bilateral popliteal and femoral pulses. Assess pulses proximal and distal to the injury. Assess the patient's skin temperature, keeping in mind that core body temperature, room temperature, and shock will affect circulatory status.12
Assess sensation by checking the patient's response to light touch and pain. Paresthesias, such as a burning or a pins-and-needles sensation, may indicate a neurocompression injury. When you document, use verbatim quotes from the patient whenever possible.
Fighting infection
Because all open orthopedic injuries are considered contaminated, the patient is at risk for wound infection. Early fluid resuscitation and prevention of microbial growth are keys to proper healing and a better long-term prognosis. Trauma patients lose large amounts of blood and other fluids, making them prone to hypovolemic shock due to the decrease in circulating volume. Hypovolemic shock decreases the number of red blood cells, which carry oxygen to the cells, in turn causing hypoxia and ischemia of organs, such as kidneys, intestines, and skin, and resulting in more complications.13
Initial treatment in the ED includes administering tetanus prophylaxis as indicated and prophylactic I.V. antibiotics according to surgeon preference, often a broad-spectrum agent.14 Antibiotics are administered at the peak of tissue contamination at the start of surgery. Long-term use may result in the development of antimicrobial resistance.13
The healthcare provider removes gross contaminants with sterile saline solution via low-pressure lavage. High-pressure lavage can cause structural and macroscopic damage to the bone and let bacteria penetrate more deeply, interfering with soft-tissue healing.
After contaminants are removed, exposed soft tissue should be covered with a sterile saline dressing until further debridement can occur in the OR.8,13,15
An inside look
Once the patient is initially managed and stabilized, imaging studies are performed to help determine the extent of the injuries, including musculoskeletal injuries.
In the case of an open fracture, plain view X-rays are required to determine the degree of angulation and displacement of the involved bones. Computed tomography or magnetic resonance imaging is used to confirm or rule out a hidden or minimally displaced fracture and soft-tissue injuries. In type II and higher open fractures, angiography may be ordered to help assess the degree of vascular injuries.13
Going to the OR
Because of the size and contamination of Mr. Morgan's open fracture, the surgeon has decided to take him immediately to the OR to surgically debride the wound and stabilize the fracture. Surgical debridement is one of the most important interventions in the treatment of open fracture because it removes foreign material and nonviable tissues, which encourage bacterial growth. Studies show that OR procedures lasting longer than 90 minutes are associated with increased infection rates.13
For some of the surgical repair options, see Tuning in to rods and pins. Then consider how the wound will be closed.
Getting closure
Negative-pressure wound therapy may be used:
* for wounds that are too large to be surgically closed
* for wounds that don't have adequate soft tissue for wound closure
* while the fracture is being stabilized with an external fixation device.
Negative-pressure wound healing therapy reduces edema, increases local blood flow, and facilitates granulation tissue formation to optimize wound healing.
Mr. Morgan returns from the OR with an external fixation device to his left lower extremity and negative-pressure wound therapy. Monitor the neurovascular status of the extremity every 2 to 4 hours. Assess the pin site for signs of infection, such as erythema, pain, tenderness, and purulent drainage. Also assess for other complications to skin, nerves, and blood supply from pressure exerted by the fixation device. Although a small amount of serosanguineous exudate is normal, document and report any increase in amount or change in exudate characteristics.
Pin care, usually ordered two times a day, requires each pin to be cleaned according to your hospital's policies and procedures. Assess pins for signs of loosening as well as bowing or bending.16 Report any signs of loosening immediately to the healthcare provider so pins can be adjusted appropriately.3
Looking for trouble
Be alert for signs of complications.
Hypovolemia can occur with any musculoskeletal injury, regardless of whether the fracture is open or closed. Hypovolemia is usually the result of blood loss, which depends on the type, location, and number of injuries. Open fractures can be associated with loss of three or more units of blood.13
Fat emboli syndrome (FES) is associated with fractures of long bones, multiple ribs, pelvic bones, and multiple bones. Developing 24 to 72 hours after injury, FES signs and symptoms are similar to those of acute respiratory distress syndrome: hypoxemia, changes in mental status or behavior, tachycardia, tachypnea, dyspnea, and hypotension.
The hallmark sign of FES is hypoxemia. Monitor for and immediately report abrupt changes in behavior or mental status. Arterial blood gases show a PaO2 of less than 60 mm Hg. Other early signs and symptoms include tachycardia, tachypnea, dyspnea, hypotension, and a productive cough. Also maintain accurate intake and output records. Oliguria may occur because of inadequate circulating volume and decreased renal perfusion.8 Classic signs of FES include a rapid temperature spike to 101.4[degrees] F to 104[degrees] F (38deg; C to 40deg; C).
Petechiae over the upper body, especially in the axillae, are caused by occlusion of dermal capillaries by fat globules and increased capillary fragility.10 Subconjunctival and oral petechiae and hemorrhages may also be present.10 Carefully monitor the patient for bleeding because thrombocytopenia occurs as platelets aggregate around fat globules.
Treatment consists of supportive measures, such as correcting fluid deficits, improving oxygenation, and managing injuries. Endotracheal intubation and mechanical ventilation with positive end-expiratory pressure may be needed for extreme hypoxemia.13
Compartment syndrome is a risk for patients with orthopedic injuries, whether they're open or closed, casted or not. The muscles and nerves of an extremity are enclosed in a tough, inelastic fascial envelope called a muscle compartment. Compartment syndrome develops when the pressure within a muscle compartment rises to a level that compromises the blood supply to nerve and muscle cells. The increase in pressure can be caused by a cast or muscle fascia that's too tight, or an increase in size of compartment contents from edema or hemorrhage.
Compartment syndrome is characterized by pain, aching, and tightness in a muscle. Typically, the patient will report a deep, throbbing pain that's not relieved by opioids. This pain, which is out of proportion to the injury, increases with active or passive range-of-motion. If the pressure isn't relieved, compression of the nerves and blood supply to the extremity can cause permanent disability as well as rhabdomyolysis and acute renal failure.
Treatment of compartment syndrome includes measures to relieve pressure, for example, by removing the restrictive cast or evacuating accumulated fluid. Fasciotomies may be needed to relieve the pressure and preserve function. To prevent compartment syndrome, perform frequent neurovascular assessments. If you don't suspect compartment syndrome, elevate Mr. Morgan's extremity to reduce edema. If compartment syndrome is suspected or diagnosed, keep the extremity at the level of the heart to avoid further compromise of compartment perfusion.8,13
Venous thromboembolism (VTE), which includes deep vein thrombosis and pulmonary embolism, is a risk for any patient with traumatic injuries and immobility. The factors that predispose the patient to VTE are explained by Virchow's triad: venous stasis from reduced blood flow and decreased muscular activity, hypercoagulability from the trauma, and vascular damage from the injury. Frequently assess the patient for signs and symptoms, such as unilateral edema and erythema, unexplained tachycardia, dyspnea, chest pain, hemoptysis, and low-grade fever. Anticipate orders for VTE prophylaxis, such as low-molecular-weight heparin.13
Nonunion, malunion, delayed union, and broken hardware are other complications that may occur in patients with open fractures; the surgeon will assess for these on follow-up visits. Nonunion means the ends of the fractured bone fail to unite. Malunion results when the ends of the bone fail to unite in normal alignment. In delayed union, the bones fail to unite at a normal rate for the fracture's size and location. Factors such as infection, nonadherence to weight-bearing restrictions, poor nutrition, and smoking can impair bone healing.3
Take a break from breaks
Preventing fractures involves avoiding high-risk behavior and using common sense. Public awareness programs such as ladder safety and playground safety can help teach people how to decrease the risk of injury.17 For older adults, who are at a higher risk for falls, emphasize environmental modifications, such as removing loose rugs and clutter and improving poor lighting.
Bone health is also important for avoiding fractures. Regular weight-bearing exercise and good nutrition are keys for joint stabilization and balance, which help reduce the risk of falls. Calcium, a vital component of strong bones, should be consumed as much as possible before the age of 25, when bone mass is still increasing. Young people ages 14 to 18 should consume 1,300 mg/d; people ages 19 to 50, 1,000 mg/d; and those 51 to 70, 1,200 mg/d.1 Vitamin D is also needed to ensure calcium absorption. The National Osteoporosis Foundation recommends that adults under age 50 have a daily intake of 400 to 800 international units and those over the age of 50, 800 to 1,000 international units.
Low calcium intake also increases the risk of developing osteoporosis after age 50, which itself increases the risk of fracture.1 While men and women of all ages and ethnicities can develop osteoporosis, some of the risk factors for osteoporosis include being female, white, postmenopausal, or small and eating a diet low in calcium and being physically inactive.
Boning up
Mr. Morgan was discharged 5 days after his open fracture was surgically stabilized. He's been taught to refrain from bearing weight on his injured leg for 6 to 8 weeks. A follow-up visit with the orthopedic surgeon will determine if adequate bone healing has occurred so that he can begin to bear 50% of his weight. Before discharge, he learned how to walk with crutches and perform activities of daily living while avoiding weight bearing on his injured leg. His discharge instructions also stressed the signs and symptoms of infection and nonunion. His wound is clean with no indication of infection and his recovery should be uneventful, thanks to the proper nursing care he received while hospitalized.
Classifying the damage
Here's the Gustilo-Anderson classification of open fractures:
Type I-Least severe. Minimal skin damage with a small wound less than 1 cm in length. Moderately clean.
Type II-Accompanied with skin and muscle contusions. Laceration more than 1 cm in length. Moderate contamination. Moderate soft-tissue damage.
Type III-Moderate to massive in size. High-energy wound. High degree of contamination. Extensive soft-tissue damage, involving nerve, muscle, and blood vessel damage.
IIIA-Adequate soft tissue to cover fracture.
IIIB-Extensive loss of soft tissue, periosteal stripping. Inadequate soft tissue to cover fracture.
IIIC-Associated with arterial injury.
Sources: McQuillan KA, Flynn Makic MB, Whalen E. Trauma Nursing:From Resuscitation Through Rehabilitation. 4th ed. St. Louis, MO: Saunders/Elsevier; 2009, and Miller NC, Askew AE. Tibia fractures. An overview of evaluation and treatment. Orthop Nurs. 2007;26(4):216-223.
Using the P-Q-R-S-T method to assess pain
Ask the patient these questions:
P-What provokes or palliates the pain? What causes the pain and what relieves it?
Q-What's the quality of the pain? Is it a sharp, dull, burning, aching, or stabbing pain?
R-In what region is the pain experienced? Does the pain radiate?
S-What's the severity of the pain intensity (on a 0 to10 rating scale)?
T-What's the timing of the pain? When did the pain start and how long does it last?
Tuning in to rods and pins
Inserted into the bone marrow canal of long bones in the extremities,
intramedullary (IM) rods are used to stabilize and align fractures. A significant advantage of IM rods over other methods of fixation is that the rods share the load with the bone rather than entirely supporting the bone, letting patients use the extremity faster. The drawbacks are that IM rods can't be used for all fractures and they're associated with more complaints of pain at the insertion site.8
External fixators are used to manage complicated open fractures with soft-tissue injury, stabilizing the fracture and giving clinicians access to the external wound for care of soft-tissue damage. Fractures of the humerus, femur, tibia, and pelvis are aligned and stabilized by a series of pins inserted into the bone. A rigid, portable, external frame attaches to the pins and maintains proper pin positioning. The fixator provides support for the fractures so the patient can experience early mobility and exercise uninvolved joints and muscles.
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