Introduction to Medical-Surgical Nursing, 6th ed.
44
Lesson Plans for
Fractures
CHAPTER LESSON PLANS & OBJECTIVES
Lesson 44.1:
2. Describe the five stages of the healing process.
4. Compare the types of medical treatment for fractures, particularly reduction and fixation.
Lesson 44.2:
7. Describe specific types of fractures, including hip fractures, Colles fractures, and pelvic fractures.
CHAPTER TEACHING FOCUS
• In this chapter, the student is presented with information about fractures, including signs and
symptoms, diagnosis, and treatment.
• Students will have the opportunity to learn the five stages in the healing process of fractures and
complications that may arise.
• Also included in this chapter are the medical management of fractures and the common therapeutic
measures taken to support the healing process.
• Finally, students are introduced to the modification of nursing care plans for patients who have
experienced a fracture.
CONCEPTS
The following conceptual themes and specific concepts match those presented in Giddens, J. R. (2013).
THEME: Protection and Movement
• Concept: Mobility
• Exemplar: Fractures, p. 971
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Introduction to Medical-Surgical Nursing, 6th ed.
CHAPTER PRETEST
Have the students answer these questions prior to covering this chapter to understand where they stand
in relation to the content.
1) Which of the following grades describes an open fracture with moderately severe injury, as well as
skin and muscle contusions?
a) Grade I
b) Grade II
c) Grade III
d) Grade IV
2) The stage of fracture healing during which the hematoma does not resorb but surrounds the fracture
to form a collar is __________.
a) hematoma formation
b) fibrocartilage formation
c) callus formation
d) ossification
3) After a fracture of the left femur, the patient develops tachycardia; anxiety; pallor; and cool, clammy
skin. What do you suspect?
a) Shock
b) Fat embolism
c) Deep vein thrombosis
d) Compartment syndrome
4) A patient has an open reduction and internal fixation of a hip fracture. What is the critical time to
assess the patient for a fat embolism?
a) 12 to 24 hours
b) 24 to 48 hours
c) 48 to 72 hours
d) 1 week
5) What is a serious complication that results from internal or external pressure on the fracture?
a) Shock
b) Fat embolism
c) Deep vein thrombosis
d) Compartment syndrome
6) Which of the following is an infection of the bone?
a) Posttraumatic arthritis
b) Osteomyelitis
c) Contracture
d) Poliomyelitis
7) Which of the following immobilizers may be unfamiliar to patients?
a) Cast
b) Splint
c) External fixator
d) Sling
8) Which of the following is traction applied to the skin?
a) Skeletal
b) Gardner-Wells
c) Crutchfield
d) Buck
9) Which of the following is used to reduce and immobilize a fracture of the cervical or high thoracic
vertebrae?
a) Skeletal
b) Gardner-Wells
c) Crutchfield
d) Buck
10) When a patient advances both crutches and the foot of the affected extremity together, followed by
the foot of the unaffected extremity, the ambulation technique is called a __________.
a) two-point gait
b) three-point gait
c) four-point gait
d) swing-to gait
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Introduction to Medical-Surgical Nursing, 6th ed.
Chapter Pretest Answers
CHAPTER BACKGROUND ASSESSMENT
Discuss these questions with your students prior to covering this chapter to understand where they stand
in relation to the content.
Question: A home health nurse is scheduled to see an 80-year-old woman with osteoarthritis who has
an unsteady left-sided gait. The nurse will reinforce the physical therapist’s instructions on the use of a
quad (four-prong) cane. What should the nurse know about the use of this cane?
Answer: Canes are used to provide minimal support and balance and to relieve pressure on weight–
Question: A patient admitted to the orthopedic unit has a fracture of the left tibia and fibula requiring an
open reduction and internal fixation without the insertion of pins or screws. The patient has a fiberglass
cast applied. What nursing care should be implemented for this patient?
Answer: The nurse should assess the affected lower extremity for adequate circulation by checking skin
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 44.1
Instructor Preparation
Textbook Objectives Covered
1. Identify the types of fractures.
3. Discuss the major complications of fractures, their signs and symptoms, and their management.
5. Describe common therapeutic measures for fractures, including casts, traction, crutches,
walkers, and canes.
Lesson Preparation Checklist
• Prepare lecture from TEACH lecture slides available on Evolve.
• Student performance evaluation of all entry-level skills required for student comprehension of
principles underlying fractures, including:
• The five stages in the healing process
• Assemble materials and supplies needed for each lesson as indicated below.
Materials and Supplies
• computer and PowerPoint
projector
Key Terms
• bone remodeling (p. 973)
• closed reduction or
manipulation (p. 976)
• comminuted fracture (p. 978)
• nonunion (p. 974)
• open or compound fracture
(p. 971)
• open reduction (p. 976)
Student Preparation
Assignments 2 hours
1
READ – Textbook (pp. 971-972)
REVIEW
• Figure 44-1: Common types of fractures (p. 972)
ANSWER – Text
• Review Questions for the NCLEX Examination: 1 (p. 988)
ANSWER – Study Guide
• Part IA: 1-8 (p. 285)
• Part IG: 1-5 (p. 290)
• Part II I: 1-3 (p. 592)
• Part IIIK: 2 (p. 295)
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 44.1
2
READ – Textbook (pp. 972-973)
REVIEW
• Figure 44-2: Stages of fracture healing (p. 973)
ANSWER – Text
• Review Questions for the NCLEX Examination: 2 (p. 988)
ANSWER – Study Guide
• Part IE: A-F (p. 288)
3
READ – Textbook (pp. 973-976)
REVIEW
• Box 44-1: Signs and Symptoms of Fractures and Their Causes (p. 975)
ANSWER – Study Guide
• Part IB: 1-10 (p. 288)
• Part IF: 1-9 (p. 289)
• Part II I: 4, 5, 33, 34 (pp. 292-294)
• Part IIIJ: 3-5 (p. 294)
4
READ – Textbook (pp. 976-977)
REVIEW
• Figure 44-3: Closed (manipulative) reduction (p. 976)
• Figure 44-4: Internal fixation devices (p. 976)
• Figure 44-5: External fixators (p. 977)
ANSWER – Text
• Review Questions for the NCLEX Examination: 10 (p. 989)
ANSWER – Study Guide
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 44.1
5
READ – Textbook (pp. 978-981)
REVIEW
• Table 44-1: Cast Types and Common Uses (pp. 978-979)
• Figure 44-7: Examples of skin traction (p. 980)
• Figure 44-8: Crutch pads (p. 981)
• Figure 44-9: Standing to sitting with crutches (p. 981)
ANSWER – Text
ANSWER – Study Guide
• Part IC: 1-8 (p. 286)
• Part ID: 1-11 (pp. 287-288)
• Part II I: 8, 10-15 (p. 292)
50-Minute Lesson Plan
Lecture Outline 20 minutes
Slide 1
Chapter 44
Fractures
1
Slide 2
Introduction
• Fracture is a break or disruption in the continuity of a bone
• Complete fracture: break extends across the entire bone, dividing into two separate
pieces
• Incomplete fracture: bone only breaks partway across
• Greenstick fracture: common in children. Bone is splintered on one side, but only bent on
the other side
Slide 3
Classification of Fractures
• Closed or simple fracture
• The bone does not break through the skin
• Open or compound fracture
• Fragments of the broken bone break through skin
• Open fractures have three grades of severity
TALKING POINTS:
• How are fractures classified as open or closed?
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 44.1
Slide 4
Classification of Fractures (cont.)
• Stress fracture
• Caused by either repeated or prolonged stress
• Pathologic fracture
• Occurs because of a pathologic condition in the bone, such as a tumor or disease
process, that causes a spontaneous break
TALKING POINTS:
• What commonly causes stress fractures?
Slide 5
Cause and Risk Factors
• Commonly caused by trauma to the bone, especially as a result of automobile accidents
and falls
• Bone disease; e.g., bone cancer, can lead to a fracture
• Hip fractures in older adults usually from falls
TALKING POINTS:
• The number of hip fractures in the United States has been rising, with 338,000 reported in
1999.
• How much is spent each year in direct and indirect costs associated with hip fractures?
2
Slide 6
Fracture Healing
• A bone begins to heal as soon as an injury occurs
• New bone tissue formed to repair the fracture, resulting in a sturdy union between the
broken ends of the bone
Slide 7
Healing Stages
• Stage 1: hematoma formation
• Immediately after a fracture, bleeding and edema occur
• In 48 to 72 hours, a clot or hematoma forms between the two broken ends of the bone
Slide 8
Healing Stages (cont.)
• Stage 2: fibrocartilage formation
• Hematoma that surrounds fracture does not resorb, as it does in other parts of the
body
Slide 9
Healing Stages (cont.)
• Stage 3: callus formation
• Within 1 to 4 weeks after injury, granulation tissue changes into a callus, which is made
up of cartilage, osteoblasts, calcium, and phosphorus. The callus is larger than the
diameter of the bone and serves as a temporary splint
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 44.1
Slide 10
Healing Stages (cont.)
• Stage 4: ossification
• Within 3 weeks to 6 months after the break, a permanent bone callus, known as
woven bone, forms
• During this stage, the ends of the broken bone begin to knit
Slide 11
Healing Stages (cont.)
• Stage 5: consolidation and remodeling
• Consolidation occurs when the distance between bone fragments decreases, then
closes
Slide 12
Fracture Healing
• Healing affected by location and severity of the fracture, type of bone, other bone
pathology, blood supply to the area, infection, and the adequacy of immobilization
• Also age, endocrine disorders, and some drugs affect healing
TALKING POINTS:
• In the absence of bone disease, most older adults eventually heal as well as younger
adults.
• What population is most at risk for loss of bone mass?
3
Slide 13
Infection
• Osteomyelitis: from contamination of the open wound associated with a fracture or from
contamination of indwelling hardware used to repair the broken bone
• When infection is inadvertently brought by surgery or other treatment, it is known as
Slide 14
Infection (cont.)
• Signs and symptoms
• Local pain, redness, purulent wound drainage, chills, and fever
• With gas gangrene, foul-smelling watery drainage with significant redness and
swelling
• Treatment
• IV antibiotics may be given for 4 to 8 weeks, followed by 4 to 8 weeks of oral drug
therapy
_____________________________________________________________________ Chapter 44Fractures 9
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 44.1
Slide 15
Fat Embolism
• Fat globules released from marrow of broken bone into bloodstream, then migrate to the
lungs
• They lodge in capillaries and obstruct blood flow
• The fat particles break down into fatty acids, which inflame the pulmonary blood vessels,
leading to pulmonary edema
• Common with fractures of the long bones, multiple fractures, and severe trauma
TALKING POINTS:
• Fat embolism occurs 24 to 48 hours after injury, most often in young men ages 20 to 40
years and in older adults ages 70 to 80 years.
• Who is at the highest risk for fat embolism?
Fat Embolism (cont.)
• Respiratory distress is the first sign of a fat embolism, followed by tachycardia, tachypnea,
fever, confusion, and decreased level of consciousness
TALKING POINTS:
• Where may petechiae appear with a fat embolism?
Slide 17
Deep Vein Thrombosis (DVT)
• Venous stasis, vessel damage, and altered clotting mechanisms contribute to formation of
blood clots (thrombi), most commonly in deep veins of the legs
• DVT increased with immobility often associated with a fracture
• Thrombi can break off and travel to the lungs, causing a pulmonary embolism
Slide 18
Compartment Syndrome
• Serious complication from internal or external pressure on the affected area
• Compartments: enclosed spaces made of muscle, bone, nerves, blood vessels wrapped
by fibrous membrane
• Internal pressure from bleeding/edema into a compartment; external pressure from a cast
or tight dressing
Compartment Syndrome (cont.)
• When bleeding or edema into a compartment, there is nowhere for drainage to go: it is
trapped in the space
TALKING POINTS:
• Although compartment syndrome is relatively rare, it is a serious condition and can create
an emergency situation.
• How soon after the onset of compartment syndrome does irreversible muscle damage
occur?
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LESSON 44.1
Slide 20
Compartment Syndrome (cont.)
• Primary symptom is pain, especially with touch or movement, that can’t be relieved with
opioids
• Other signs and symptoms: edema, pallor, weak or unequal pulses, cyanosis, tingling,
numbness, paresthesia, and finally, severe pain
• The goal of treatment is to relieve pressure
Slide 21
Shock
• After fracture, a risk of excessive blood loss
• Trauma may rupture local blood vessels; internal organs may be punctured; results in
Slide 22
Joint Stiffness and Contractures
• Joint fractures or dislocations may be followed by stiffness or contractures, especially in
older adults, due to immobility associated with fracture
• Prevention requires appropriate positioning and progressive exercise programs
• Treatment may include splints, traction, casts, surgical manipulation, and aggressive
physiotherapy
Slide 23
Malunion
• Expected healing time is appropriate, but unsatisfactory alignment of bone results in
external deformity and dysfunction
Slide 24
Delayed Union
Slide 25
Nonunion
• Occurs when a fracture never heals
• Treatment
• Osteogenic method: implantation of bone grafts
• Osteoconductive methods: synthetic materials to provide a matrix for bone growth
• Osteoinduction: substances such as platelet-derived growth factor
• Electric stimulation
• Internal or external; up to 10 hours a day for 3 to 6 months
• Time-consuming, but can prevent further surgery and bone grafts
Posttraumatic Arthritis
_____________________________________________________________________ Chapter 44Fractures 11
LESSON 44.1
Slide 27
Avascular Necrosis
• A variety of factors can interfere with blood supply after a bone injury
• Once bone cells are deprived of oxygen and nutrients, they die and their cell walls
collapse
• Signs and symptoms
• Pain, instability, and decreased function in the affected area
Avascular Necrosis (cont.)
• Treatment
• Relief of weight-bearing and removal of part of the bone to decrease pressure
Slide 29
Complex Regional Pain Syndrome Type 1 (CRPS—Type 1)
• Precipitated by a fracture or other trauma
• Symptoms
• Severe pain at the injury site despite no detectable nerve damage, edema, muscle
spasm, stiffness, vasospasms, increased sweating, atrophy, contractions, and loss of
bone mass
• Symptoms persist longer than expected with the type of injury suffered
Complex Regional Pain Syndrome Type 1 (CRPS—Type 1) (cont.)
• Treatment
• Nerve blocks; physical therapy; transcutaneous electrical stimulation; and analgesics,
Slide 31
Signs and Symptoms
• Depend on type and location of the break
• Some fractures have so few manifestations that they can be detected only with x-ray
• Signs and symptoms are swelling, bruising, pain, tenderness, loss of normal function,
abnormal position, and decreased mobility
• See Box 44-1
4
Slide 32
Diagnostic Tests and Procedures
• Standard radiographs
• Reveal bone disruption, deformity, or malignancy
• Computed tomography (CT)
Slide 33
Reduction
• The process of bringing the ends of the broken bone into proper alignment
Closed Reduction or Manipulation
• Nonsurgical realignment that returns bones to their previous anatomic position
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LESSON 44.1
Slide 35
Open Reduction
• A surgical procedure in which an incision is made at the fracture site
• Usually for open (compound) or comminuted fractures to clean the area of fragments and
debris
TALKING POINTS:
• Effective pain management of a fracture is essential for patient mobilization and healing.
Slide 36
Immobilization
• Necessary for healing to occur
• Prevents movement and increases union
• Accomplished in many ways, such as fixation, casts, splints, and traction
Slide 37
Fixation
• An attempt to attach the fragments of the broken bone together when reduction alone is
not feasible because of the type and extent of the break
• Promotes early mobilization; preferred for older adults who have brittle bones that may not
heal properly, or who may suffer the consequences of immobility
Internal Fixation
• Done during open reduction surgical procedure
• Rods, pins, nails, screws, or metal plates used to align bone fragments and keep them in
Slide 39
External Fixation
• Pins are inserted into the bone, above and below fracture
• Pins are then attached to an external frame and adjusted to align the bone
• If there is soft tissue damage or infection, external fixation allows access to the site and
facilitates wound care
TALKING POINTS:
• External fixation allows for early ambulation and mobility while relieving pain.
• Approximately what percentage of patients with external fixation have a pin track
infection?
_____________________________________________________________________ Chapter 44Fractures 13
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 44.1
5
Slide 40
Casts, Splints, and Immobilizers
• Hold the bone in alignment while allowing movement of other parts of the body
• Types of cast materials: plaster of Paris, fiberglass, thermoplastic resins, thermolabile
TALKING POINTS:
• To prevent swelling, a patient who is wearing an arm cast should keep the arm elevated
above the heart when lying in bed.
• Lower extremity casts are used for breaks in the upper and lower leg, ankle, and foot.
• After an adequate amount of healing has taken place and edema has subsided, cast
braces may be used for injury to the knee.
• Body or spica casts are used when a fracture is located somewhere in the trunk of the
body.
• How are casts removed?
Slide 41
Patient Teaching
• Keep plaster casts dry; follow instructions regarding wetting synthetic casts
• Do not remove padding or insert foreign object inside the cast
• Do not bear weight on a plaster cast for 48 hours; with synthetics, less than 1 hour
Slide 42
Traction
• Exerts a pulling force on a fractured extremity to align bone fragments
• Prevents or corrects deformity, decreases muscle spasm, promotes rest, and maintains
the position of the injured part
• May be applied directly to the skin (skin traction) or attached directly to a bone (skeletal
traction) with a metal pin or wire
Slide 43
Traction (cont.)
• Skin traction
• Buck’s traction
• For hip and knee contractures, muscle spasms, and alignment of hip fractures
• Weight used during skin traction should not be more than 5 to 10 pounds to
TALKING POINTS:
• Heavier weights can be used with skeletal traction, usually from 15 to 30 pounds.
• What complications may occur with traction?
• What important points should be remembered when a patient is in traction?
14 Chapter 44Fractures ______________________________________________________________________
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LESSON 44.1
Slide 44
Traction (cont.)
• Complications
• Impaired circulation, inadequate fracture alignment, skin breakdown, and soft tissue injury
• Pin track infection and osteomyelitis can occur with skeletal traction
Slide 45
Traction (cont.)
• Weights must always hang freely
• Ensure the correct weight is used, clamps are tight and ropes move freely over pulleys.
• Maintain body alignment so that the line of pull is correct
• Report skin breakdown or irritation
• Assess affected extremities for temperature, pain, sensation, motion, capillary refill time
and pulses
• With skeletal traction, assess pin sites for redness, drainage or odor
• Electrical bone stimulators about 80% effective; average healing time 16 weeks
Electrical Stimulation and Pulsed Electromagnetic Fields (PEMFS)
• Electrical stimulation may be used to promote bone healing.
Slide 47
Crutches
• Increase mobility and assist with ambulation
• Physical therapist measures patient for proper fit and instructs in crutch-walking
techniques
• Nurse reinforces the instructions and evaluates whether the crutches are being used
properly
TALKING POINTS:
• The success in crutch walking may depend on what factors?
• Axillary pressure could result in temporary or permanent numbness in the hands.
Slide 48
Crutches: Gait Patterns
• Two-point gait
• The crutch on one side and the opposite foot are advanced at the same time
• Used with partial weight-bearing limitations and with bilateral lower extremity
prostheses
• Three-point gait
• Both crutches and the foot of the affected extremity are advanced together, followed
by the foot of the unaffected extremity
TALKING POINTS:
• The type of gait used depends on the severity of the patient’s disability and the patient’s
physical condition, trunk strength, upper and lower extremity strength, and balance.
• All gaits begin with what position?
_____________________________________________________________________ Chapter 44Fractures 15
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 44.1
Slide 49
Crutches: Gait Patterns (cont.)
• Four-point gait
• The right crutch is advanced, then the left foot, then the left crutch, then the right foot
• Used if weight bearing is allowed and one foot can be placed in front of the other
• Swing-to gait
Slide 50
Crutches: Gait Patterns (cont.)
• Swing-through gait
• Both crutches are advanced together, then both legs are lifted through and beyond
the crutches and placed down again at a point in front of the crutches
• Used when adequate muscle power and balance in the arms and legs
TALKING POINTS:
• How does a patient sit down after walking on crutches?
• For stair climbing, the unaffected leg goes up the step first while the body is supported by
the crutches.
• To descend stairs, the affected leg and the crutches move down one step first, followed
by the unaffected leg.
Slide 51
Walker
• Used for support and balance, usually by older adults
TALKING POINTS:
Slide 52
cane tip and tripping or falling.
Canes
• Provide minimal support and balance, and relieve pressure on weight-bearing joints
• Placed on the unaffected side with the top even with the patient’s greater trochanter
TALKING POINTS:
• What gaits are used with a cane?