The term fracture describes a loss of continuity of bone. It can occur when the force applied to the bone exceeds its strength. The microarchitecture, cortical shell thickness and bone density are important components of bone quality, which influence the risk of fracture. Bone quality, integrity and strength may be affected by diet, exercise, medication, and disease processes. Common pathologies affecting bone include tumours (primary or metastatic disease), infection, and conditions that directly affect the remodelling process, such as osteoporosis and Paget's disease (Stillwagon and Ostrum, 2021).
The prospect of a fracture occurring is determined by the quality and strength of the bone along with the mechanics of the force applied to it (Komisar and Robinovitch, 2021). The applied force may be a singular event (such as with a fall), or through repetitive overloading of the bone (e.g. when running). The force applied to the bone can be defined as high energy (e.g. a fall from a height or road traffic collision), or low energy (e.g. a fall from standing height, or less). Fractures that occur due to low energy forces are commonly referred to as fragility fractures. Approximately 549 000 new fragility fractures occur each year (National Osteoporosis Guideline Group (NOGG), 2021). Most fractures that occur in adults aged over 65 are due to a fall from a standing height or lower (Komisar and Robinovitch, 2021). The most common sites of fragility fractures are the hip, distal radius and vertebra (NOGG, 2021).
A fracture can have significant impact on physical, psychological and social wellbeing for up to 12 months after injury (Visser at al, 2021). Fractures are associated with immediate, early and late complications:
- Immediate: haemorrhage, soft tissue damage, nerveinjury
- Early: embolism (fat, pulmonary), compartment syndrome, infection
- Late: mal-union, delayed union, non-union, avascular necrosis, osteoarthritis, chronic pain, complex regional pain syndrome.
The overall aim of fracture management is to return the site to its full function and minimise the risk of complications. Poor management can result in the inability to resume previous levels of activity, lost productivity and increased burden on society and the NHS (National Instititute for Health and Care Excellence (NICE), 2016a). It is well recognised that fragility fractures are associated with significant morbidity and mortality and therefore, a multidisciplinary approach is needed to ensure frailty is addressed alongside the injury in order to obtain optimal outcomes (British Geriatrics Society, 2007). Ortho-geriatric collaboration has been shown to significantly reduce both in-hospital and long-term mortality in hip fractures (Grigoryan et al, 2014).
Assessing the injury
When assessing a patient following a fall or trip in the community setting, a rapid assessment should be undertaken to determine if urgent intervention is needed due to immediate life-threatening problems such as epileptic seizure, cardiac arrest or airway obstruction. Basic life support and life saving measures should be prioritised over fracture management, although care should be taken to limit movement and preserve cervical spine position, if feasible.
An initial assessment of pain and inspection for bleeding from the injury will help determine the urgency of action. Where possible, gaining a brief history of events from the patient or someone who witnessed the injury will help determine the approach to further assessment. The nature of the impact can influence the fracture pattern and may help identify the presence of other injuries. For example, a forward fall on to outstretched hand may also result in injury to forearm, humerus, or head, whereas a sideways fall may suggest injury to the hip and shoulder (Komisar and Robinovitch, 2021). Where there is concern that there may be a fracture, the patient is unable to mobilise, or has active bleeding from the injury, the patient will need to be transferred to hospital for further assessment and management. Being able to walk on a lower limb injury decreases the likelihood of serious injury; however, this does not exclude the presence of a fracture. Keep the patient warm with a blanket till the emergency services arrive.
Examination of potential fractures should encompass the following:
- Inspection of the site, comparing both limbs, inspecting for deformity, open wounds, swelling, bruising, or pallor (Kyriacou et al, 2021). Immediate swelling may be suggestive of bleeding at the site
- Palpate the site to detect maximum point of tenderness and differentiate between soft tissue or bony tenderness. Potential damage to soft tissue structures such as tendons, ligaments and muscle should be considered as these maintain joint stability
- Assessment of the neurovascular status, including pulses, capillary refill time, motor function and sensation (NICE, 2016b)
- Suspected fractures should be x-rayed in hospital using at least two different planes to identify any discontinuity of the bone.
Open fractures can be complex injuries with damage to soft tissue and local blood supply. These injuries are at risk of developing infection of soft tissue or bone (osteomyelitis) and need transferring to a major trauma centre (NICE, 2016b). Irrigation of open fractures is not recommended as part of pre-hospital initial management, although a saline soaked dressing covered by an occlusive layer may be applied (NICE, 2016b).
Fracture classification
Fractures are usually described by stating the bone involved, anatomic location (e.g. proximal (higher) or distal (lower)), type of fracture and any displacement. Displacement is described as the position of the distal fracture segment in relation to the proximal segment. Displacement may also be described using details of angulation, rotation, impaction or distraction. Common terms used to describe fractures are as follows:
- Avulsion fracture: detachment of a fragment of bone, which is typically attached to the ligament, tendon or capsule
- Comminuted fracture: the bone is fractured in more than two places, usually as a result of high energy forces
- Compound (open) fracture: fracture fragment breaks through the skin
- Dislocation: displacement of the bones at the joint
- Intra-articular fracture: fracture across the joint surface
- Periprosthetic fracture: fracture at the site of an implant (i.e. knee replacement).
Fracture classification systems can also be used to characterise features, describe the extent of injury, guide treatment and predict outcomes of the injury. There are a number of fracture classification systems that can be used, although they can be broadly considered as universal fracture classifications, such as the Arbeitsgemeinschaft für Osteosynthesefragen (AO) system (Meinberg et al, 2018). There also exist fracture specific classifications, such as the Garden (1961) classification of femoral neck fractures, or systems that consider the injury patterns of bone and soft tissue, such as the Weber (1972) classification for lateral malleolar fractures, which evaluates both the fracture and the tibiofibular syndesmosis.
Management of injury
The aim of fracture management is to achieve healing without deformity and to restore function. Fractures may need repositioning to restore the normal alignment. Where there is significant displacement, this may require manipulation under sedation (MUS) or manipulation under anaesthetic (MUA) to achieve good position.
Conservative treatment of fractures using splints and casts will be chosen as the first option where possible, as this is less costly and does not involve the risks of surgery or anaesthetic (NICE, 2016a). Advantages of casts and splints are that they are quick and easy to apply, although immobilisation can result in muscle atrophy, joint stiffness and gait abnormalities (You et al, 2020). Other complications of casts and splints include ischemia and nerve injury if applied too tightly, and pressure ulcers or skin breakdown from poor fit. Should the fracture alignment become displaced during conservative treatment, surgical intervention may be required to reduce and stabilise the fracture.
Where injuries are complex, have open wounds or vascular injury, surgical intervention will be required to stabilise it (NICE, 2016a). Where there are known risks of not healing due to poor blood supply, such as with intracapsular hip fractures, the fracture may be treated with arthroplasty (replacement of the joint). Occasionally the joint may not be salvageable, and arthrodesis (fusion) may be required.
Community nurses are able to review the patient in their usual settings, identifying where there may be problems with the expected recovery progress, or where immobilisation devices are not effective and may potentially cause complications. Management of soft tissue injury (either surgical or traumatic), will predominately be overseen by the community team, reviewing wound healing and monitoring for signs of infection.
Fracture healing
A fracture can heal through direct (primary) or indirect (secondary) methods. Direct healing requires reduction of the fracture and rigid fixation with devices such as plates and screws to keep the bone immobilised. This permits healing through the normal bone remodelling process (Marsell and Einhorn, 2011). Surgical implants that hold the bone in place to allow healing are no longer required once the fracture has healed, although they may not be routinely removed due to risks of additional surgery. Most fractures heal through indirect healing, which can be divided in to four stages:
- Inflammation: A haematoma forms at the fracture site and the inflammatory response to injury stimulates the migration of macrophages and mesenchymal cells to the injury. Immobilisation of the fracture prevents disruption of the haematoma and facilitates the healing process. The acute inflammatory response peaks at 24 hours and lasts up to 7 days (Marsell and Einhorn, 2011)
- Soft callus formation: phagocytosis of necrotic tissue occurs and the gap between fracture sites are closed through formation of a fibrocartilage callus
- Hard callus formation: mineralisation of the fibrocartilage structure to create calcified tissue. Osteoblasts are stimulated by loadbearing exercise; hence, fracture healing is enhanced through weight bearing activity (Craig et al, 2023)
- Remodelling: once union of the fracture site has occurred, the bone is gradually remodelled and the excess callus is resorbed. Remodelling can start at 3–4 weeks, but may last several years (Marsell and Einhorn, 2011).
Several factors can impede healing, such as older age, poor blood supply, excessive movement at the fracture site, infection, smoking, poor nutritional status and medication (Craig et al, 2023). Medication known to inhibit inflammation such as non-steroidal anti-inflammatory drugs (NSAIDs), immunosuppressants and corticosteroids may impact on the initial phase of bone healing and potentially hinder the effectiveness of the repair process (Kovach et al, 2015; Wheatley et al, 2019).
Open wounds, soft tissue injury and the presence of comorbidities increase the risk of infection, particularly when fractures have been surgically managed (British Orthopaedic Association (BOA), 2019a). The use of systemic antibiotics and local antimicrobial prophylaxis, such as the insertion of antibiotic beads or the use of antimicrobial coatings on implants, can be used to minimise the risk of infection and prevent the formation of biofilms (Rupp et al, 2020). Patients with non-union of the fracture site, late presenting (i.e. after the initial wound has healed) or recurrent infections may have underlying bone or implant infection and should be reviewed by the multidisciplinary team (BOA, 2019a).
Diabetic patients are known to have a higher risk of developing infection as well as other complications such as impaired wound healing, and mal- or non-union of the fracture (Kyriacou et al, 2021). Patients should be encouraged to be mindful of good glycaemic control to optimise healing. The principles of good diet, medication use and self-care should be reinforced where possible and advice should be given on wound management to minimise the risk of infection, or allow early identification if it does occur.
Patients with recent surgical repair who are suspected of having fracture site infection should be reviewed by the consultant in clinic within 48 hours; however, they should not be commenced on antibiotics before the review as this will make it more challenging to identify the causative organism (BOA, 2019a).
Pain
Nurses play an important role in assessing pain and advising on pain management across acute and rehabilitation phases of care. Poor assessment of pain can result in inadequate relief, which can subsequently impact on recovery progress and quality of life. Pain should be assessed regularly using pain assessment tools, which are appropriate for the developmental stage and cognitive function of the person (NICE, 2016a). A multifaceted approach to pain assessment should include noting behavioural indicators such as changes in facial expression, agitation, loss of appetite, and reduced mobility to identify the presence of pain.
Community nurses are well-placed to review the effectiveness of medication, determining if it allows patients to engage with daily activities, but also advising on how to reduce medication as pain improves. Side effects from medication can be problematic and should be monitored by the community team, where possible, giving advice on how to manage these proactively.
Severe pain—such as with open fractures or major trauma—will initially be managed with intravenous morphine (NICE, 2016c), while less severe pain associated with other fractures may be managed with paracetamol and supplemented with codeine, where necessary (NICE, 2016a). Non-steroidal anti-inflammatory drugs (NSAIDs) may only be considered as supplementary analgesics due to concerns regarding their effects on bone healing (Wheatley et al, 2019). They are not recommended for frail or older adults due to the increased risk of gastrointestinal bleeding and impaired renal function, which may precipitate acute kidney injury (NICE, 2016a). Alongside the assessment of pain and effectiveness of analgesia, the side effects of medication should be reviewed regularly, such as nausea and constipation.
The type and severity of pain experienced will alter across the acute and recovery phases. Analgesia will need to be titrated in response to recovery and gradual reduction in pain, although it is important to ensure that pain assessment considers pain at rest and during activity to help encourage mobilisation and the return to usual daily activities. Patients may find it helpful to know how long pain will last for and the cause of the pain, as this is commonly a cause for concern (van de Boom, 2022). Providing information on how to reduce or discontinue medication as pain improves and any side effects to look out for will help empower patients to proactively manage their recovery.
Rehabilitation
Fractures can have significant impact on sleep, social and family life, sense of independence and psychological wellbeing. Rehabilitation aims to restore the range of movement and function, and reduce the risk of complications (Givens and McMorris, 2021). Recovery and outcome measures should include patient goals rather than a singular focus on the anatomical alignment of the x-ray. Patients commonly experience difficulty completing activities of daily living such as personal care, work, household tasks and leisure activities (McKeown et al, 2020). Weight bearing restrictions and the use of walking aides can make mobilisation slow and difficult, resulting in the inability to carry things (McKeown et al, 2020). Understanding the patient's experience and challenges will help implement patient-centred rehabilitation strategies. The use of validated tools to report Patient Reported Outcome Measures are helpful in measuring progress from the patient, rather than the clinician's stance.
Patients’ perspectives on their injury and recovery can change across the rehabilitation period (Jensen et al, 2022). There needs to be a balanced approach between providing optimistic and motivating messaging and providing a realistic outlook (van de Boom et al, 2022). While patients may initially adapt a pragmatic attitude, this may change over time, especially if still in pain and worried about the future (Jensen et al, 2022). Feelings of depression, low mood, and increased emotional liability are not uncommon following injury (McKeown et al, 2020). Patients who have required an intensive care admission commonly have high levels of depression and anxiety post-injury. However, those who still have high levels of depression, anxiety and stress at 3 months are at r isk of long-ter m symptoms (Wiseman et al, 2015). Where there is concern about maladaptive thoughts, emotions and behaviours, cognitive behavioural therapy may help to improve self-efficacy (You et al, 2020).
Many fractures will result in a period of restricted mobility, with some pelvic and lower limb injuries also requiring a period of bed rest. This can cause deconditioning, reduced muscle function and joint stiffness, which, in turn, can delay recovery, and potentially increase the risk of falls and further injury. Common complications associated with immobility include venous thromboembolism, muscle wasting, respiratory infection, pressure ulcers and constipation. Where possible, reassurance and education should be provided to encourage safe and regular mobilisation. While disturbed sleep and increased effort to mobilise can cause increased fatigue (McKeown et al, 2020), simple measures such as sitting in a chair for meals and performing simple physiotherapy exercises at regular intervals can help with limiting complications and assist with resuming usual activity.
Meal preparation and shopping can be problematic due to restricted function. Occupational therapy and social services referrals may be required to provide assistive devices or provide additional support to address the deficit in function. Advice on nutrition should include guidance on nutritional requirements to support fracture healing with calcium and vitamin D required for effective mineralisation of bones, vitamin A for effective osteoblast function and vitamin C to support collagen synthesis (Waugh and Grant, 2018). Where sufficient intake is not possible through dietary means, nutritional supplements can be suggested. Existing pathologies may result in insufficiency in absorption and utilisation of nutrients, resulting in poor nutritional status. Where there is concern about nutritional status, dietetics’ review should be considered.
Community nurses are ideally placed to review the patient in their own surroundings and identify actual or potential problems that may occur during the rehabilitation period and discuss with the patient how these challenges may be overcome. Input from the community nurse may range from encouragement, developing adaptive strategies, or referring to other services for additional support, such as with meals or personal hygiene.
Risk of future fractures can be calculated using Fracture Risk Assessment Tool or QFracture assessment tools (NICE, 2012). As sustaining a fragility fracture is a significant risk for future fractures (Kanis et al, 2004), proactive intervention is needed to reduce such risk. Fracture liaison services aim to reduce this risk by identifying patients with fragility fractures and offering assessment for osteoporosis, and where appropriate, the review of compliance and success of treatment (NOGG, 2021). As falls are a significant risk factor for future fractures, managing falls risks is essential and conducted as part of integrated fall and fracture services (NOGG, 2021). Frail older patients need coordinated multidisciplinary working to address the injury, existing co-morbidities and prevention of further injury (BOA, 2019b).
Patient information should include the anticipated outcomes and permanent effects from the injury, such as pain and loss of function, as well as the anticipated time before return to usual activities (NICE, 2016a). While patients often receive detailed information during the acute management of fractures, patients have reported less specific information regarding the rehabilitation process and what to expect (Jensen et al, 2022). Good quality information can enable patients to manage their care and prevent unnecessary readmissions due to concerns. Discussing apprehensiveness can help to overcome concerns and hesitancy in using the affected site and is an important part of rehabilitation (Blomstrand et al, 2023). Reporting of disproportionate pain, oedema, loss of movement and delayed recovery should be encouraged as these can be indicative of complications, or an indication that further education or rehabilitation is needed.
Conclusion
Fractures can have a significant impact on health and wellbeing for a considerable period after the injury, especially where there are existing comorbidities. Fracture management requires a multidisciplinary approach to recovery. Nurses can facilitate a patient centred approach to recovery, goal setting, education and monitoring of progress, although more research is needed on the care and experience outside of the acute care setting to develop the evidence base in this area.
Key points
- Sustaining a fracture can result in disruption to physical, psychological and social wellbeing 12 months after injury
- Fractures can have immediate, short- and long-term complications, which can impact on recovery and quality of life
- A patient-centred multidisciplinary approach to rehabilitation is required for optimal outcomes
- Fragility fractures should be followed up with assessment of bone health and fall risks to minimise the risk of future fracture.
CPD reflective questions
- How can patient information be improved to assist with proactive engagement with rehabilitation? Is there scope to extend the use of digital platforms to deliver this information?
- Inconsistent information from health professionals can cause distress and confusion for the patient. Reflect on your own practice and consider how communication between the multidisciplinary team can be enhanced to facilitate a unified approach
- There is limited research available on fracture management within primary care and patient experience out of hospital. What areas of practice have you identified that would benefit from a more rigorous evidence base to underpin practice?