10.3 Fractures, Immobilization, Compartment Syndrome & Spinal Precautions

10.3 Fractures, Immobilization, Compartment Syndrome & Spinal Precautions

Quick Answer: Fractures require immediate emergency splinting immobilizing the joint above and below the fracture site, with distal neurovascular checks before and after application. Acute Compartment Syndrome (ACS) presents with severe, unyielding pain out of proportion to injury that is intensely exacerbated by passive muscle stretching; paresthesia is an early sign, whereas pulselessness is a late and irreversible indicator. ACS requires keeping the limb at heart level (never elevated or dependent), bivalving casts completely to the skin, and immediate decompressive fasciotomy. Skeletal traction weights must hang freely without resting on the floor. Cervical spine injury requires continuous rigid collar immobilization and 4-person log-rolling; neurogenic shock manifests as hypotension with bradycardia and warm extremities due to loss of sympathetic tone.

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Fracture Classification and Clinical Manifestations

A fracture is a disruption in the structural continuity of bone and overlying periosteum. In trauma, accurate classification guides immediate stabilization, infection risk stratification, and definitive orthopedic repair.

Primary Structural Classifications

• Closed (Simple) Fracture: The overlying skin remains intact, without direct communication between the fracture hematoma and the external environment.
• Open (Compound) Fracture: A breach in the skin and soft tissues directly communicates with the fractured bone. Open fractures carry a high risk of bacterial contamination, deep osteomyelitis, and tetanus. Open fractures are stratified using the Gustilo-Anderson Classification:
  • Grade I: Clean skin wound <1 cm in length, typically caused by a bone spike piercing the skin from within; minimal soft-tissue contusion.
  • Grade II: Laceration >1 cm and <=10 cm without extensive soft-tissue stripping, flaps, or avulsions; moderate contamination.
  • Grade III: High-energy injury with extensive soft-tissue disruption >10 cm, significant muscle devitalization, periosteal stripping, and high contamination (e.g., farmyard injuries, high-velocity gunshot wounds). Subdivided into:
    • IIIA: Adequate soft-tissue coverage of the fractured bone despite extensive laceration;
    • IIIB: Extensive soft-tissue loss with periosteal stripping and bone exposure, requiring local or free-flap surgical reconstruction;
    • IIIC: Any open fracture associated with an arterial injury requiring vascular repair to salvage the limb.

Morphological Patterns

• Complete vs. Incomplete: In a complete fracture, the bone is broken entirely across into separate fragments. An incomplete fracture involves disruption of only one cortex (e.g., Greenstick fracture, unique to pediatric pliable bones where one cortex bends while the opposite cortex fractures).
• Direction of Fracture Line: Transverse (straight horizontal across the shaft), Oblique (angled across the shaft), Spiral (helical fracture resulting from rotational or torsional stress; in non-ambulatory infants, spiral fractures suggest non-accidental trauma/physical abuse), Comminuted (bone splintered into three or more fragments).
• Pathological Fracture: Fracture occurring through bone weakened by an underlying systemic or localized disease process (e.g., osteoporosis, primary bone tumors, osteomyelitis, or skeletal metastases).

Cardinal Clinical Manifestations

• Pain and Localized Tenderness: Immediate, intense pain exacerbated by voluntary movement or weight-bearing;
• Deformity: Visible limb shortening, angular rotation, or abnormal curvature compared to the contralateral limb;
• Loss of Function: Inability to bear weight or move the extremity distal to the lesion;
• Abnormal Mobility & Crepitus: Palpable or audible grating sensation produced by fractured bone ends rubbing against each other. Never deliberately elicit or manipulate a limb to demonstrate crepitus, as this causes sharp bone fragments to lacerate adjacent neurovascular bundles and muscle.

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Principles of Emergency Splinting and Immobilization

Emergency splinting must occur at the scene of injury before the patient is moved or transported:

1. Immobilize Where They Lie: Do not move the patient until the injured extremity is stabilized, unless an immediate environmental hazard threatens life.
2. The Joint Above and Below Rule: To achieve effective mechanical stabilization, a splint must immobilize the joint immediately above and the joint immediately below the fractured bone (e.g., for a tibial fracture, immobilize both the knee and the ankle).
3. Neurovascular Checks: Always assess and document neurovascular status (the 6 Ps, distal pulse presence and quality, skin color, temperature, capillary refill time, motor power, and sensory function) both before and immediately after applying any splint, bandage, or traction device.
4. Open Fracture Care: Cover exposed bone ends with sterile saline-soaked gauze dressings. Never push protruding bone fragments back into the wound. Inadvertent reduction draws contaminated foreign debris into the deep fascial compartments. Administer IV broad-spectrum antibiotics (e.g., cefazolin plus an aminoglycoside for Grade III) and evaluate tetanus immunization status immediately.

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Acute Compartment Syndrome (ACS): Pathophysiology and Clinical Hallmarks

Acute Compartment Syndrome (ACS) is a time-critical, limb-threatening orthopedic emergency. It occurs when increased tissue fluid pressure within an inelastic, unyielding osteofascial compartment exceeds capillary perfusion pressure, leading to muscle and nerve ischemia.

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|                    COMPARTMENT SYNDROME PATHOPHYSIOLOGY                           |
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| Fracture / Crush Injury / Tight Cast -> Interstitial Fluid & Hematoma Accumulate  |
|                                          |
|                                          v
| Elevated Intracompartmental Pressure (>30 mmHg) Exceeds Capillary Perfusion       |
|                                          |
|                                          v
| Venous Collapsing & Outflow Obstruction -> Capillary Flow Ceases                  |
|                                          |
|                                          v
| Anoxic Ischemia -> Muscle Necrosis (4-6h) & Irreversible Nerve Death (12-24h)     |
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Etiology and Risk Factors

• Internal Fluid Expansion: Tibial shaft fractures (highest overall incidence), supracondylar humerus fractures in children, crush injuries, severe muscle contusions, reperfusion following arterial bypass, and snake envenomation (Bitis arietans).
• External Compartment Compression: Constrictive circumferential plaster casts, tight splinting bandages, pneumatic antishock garments, or prolonged limb entrapment.

The 6 Ps of Acute Compartment Syndrome

[!CAUTION] Clinical Pearl: The Hallmarks of Impending Necrosis The classic diagnostic hallmark of Acute Compartment Syndrome is excruciating pain out of proportion to the apparent injury, which is intensely aggravated by passive stretching of the affected muscle groups (e.g., passively flexing the fingers in volar forearm syndrome, or passively plantarflexing the foot in anterior tibial syndrome). Normal peripheral pulses do NOT rule out compartment syndrome; capillary perfusion halts long before major arterial pulses disappear!

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Emergency Nursing and Surgical Interventions for Compartment Syndrome

1. Eliminate External Constriction: Immediately bivalve (split) any circumferential plaster or fiberglass cast. Cut the cast along both lateral margins from top to bottom, and use scissors to cut all layers of underlying cotton cast padding completely down to the bare skin. Splitting the plaster alone relieves only 30–40% of pressure; cutting the cotton lining relieves up to 85–90% of external constriction.
2. Limb Positioning: Position the affected extremity AT HEART LEVEL.
   • Do NOT elevate the limb above the heart: Elevation reduces mean arterial driving pressure and decreases microvascular perfusion into the compromised compartment, accelerating tissue necrosis.
   • Do NOT lower the limb into a dependent position: Placing the limb below heart level increases venous pooling, raising compartment pressure further.
3. Avoid Cold Compresses: Do not apply ice packs. Hypothermia causes localized vasoconstriction, further reducing tissue perfusion.
4. Urgent Decompressive Fasciotomy: Notify the orthopedic surgeon immediately. Definitive therapy is emergency fasciotomy—longitudinal surgical incisions extending through the skin, subcutaneous tissue, and tight fascial envelopes to decompress all involved compartments (e.g., double-incision 4-compartment fasciotomy of the lower leg). The wounds are left open and covered with sterile dressings or a negative-pressure wound therapy (wound VAC) dressing, followed by delayed primary closure or split-thickness skin grafting 5–7 days later.

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Traction Modalities and Nursing Management

Traction applies a continuous pulling force to a fractured extremity to realign bone fragments, relieve muscle spasms, overcome shortening, and immobilize the limb.

                                    [TRACTION MODALITIES]
                                              |
                     +------------------------+------------------------+
                     |                                                 |
                     v                                                 v
             [SKIN TRACTION]                                  [SKELETAL TRACTION]
        (e.g., Buck's Extension)                           (e.g., Steinmann / K-Wire)
  - Non-invasive; foam boots / tape                  - Invasive; pin drilled through bone
  - Temporary pre-op stabilization                   - Long-term definitive management
  - Max weight: 2-3 kg (5-7 lbs)                     - Higher weights: up to 10-15 kg
  - High risk of skin breakdown                      - High risk of pin site infection
  - Assess peroneal nerve at fibular head            - Weights must hang freely 24/7

Skin Traction (e.g., Buck's Traction)

• Application: Applied directly to intact skin using adhesive tape, moleskin, or commercial foam boots attached to a spreader bar, rope, and pulley system.
• Indication: Temporary immobilization for hip fractures or proximal femur fractures before definitive surgical repair.
• Weight Limit: Traction weight must not exceed 2 to 3 kg (5 to 7 lbs). Heavier weights cause shear forces that peel the epidermis, creating severe skin sloughing and blisters.
• Nursing Checks: Inspect skin integrity over the Achilles tendon, heel, and malleoli daily. Ensure the foam boot does not compress the common peroneal nerve as it crosses the fibular head; peroneal nerve compression produces foot drop and paresthesias over the dorsum of the foot.

Skeletal Traction

• Application: Applied directly to the skeleton by surgically drilling a sterile stainless steel Steinmann pin or Kirschner wire (K-wire) transversely through bone distal to the fracture (e.g., distal femur or proximal tibia for femoral shaft fractures), attached to a Bohler or Thomas splint.
• Weights: Permits heavier loads (up to 10–15 kg, or 10–15% of total body weight) to overcome strong femoral muscle spasms.
• Pin Site Care: Pin sites represent open pathways for bacteria into bone marrow. Clean each pin-skin interface daily using sterile technique with chlorhexidine or sterile 0.9% saline. Do not forcefully scrub serous crusts. Inspect daily for signs of pin tract infection: localized erythema, purulent drainage, tenting of skin, or pin loosening.

The Cardinal Rules of Traction Maintenance

• Weights Must Hang Freely: Traction weights must hang freely suspended in mid-air at all times. They must never touch the floor, rest on bed frame rungs, or catch on adjacent equipment.
• Continuous Force: Traction must remain continuous unless specifically ordered otherwise. Never remove, lift, or alter traction weights without a physician's order (except during acute cardiopulmonary resuscitation).
• Alignment: Ropes must remain centered in pulley grooves, unfrayed, and free of knots other than securing ties. The patient's body must remain aligned along the longitudinal axis of traction pull.
• Counter-traction: The patient's body weight acts as counter-traction. Maintain the foot of the bed elevated (Trendelenburg position) if ordered to prevent the patient from sliding downward against the footboard.

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Plaster of Paris (POP) and Fiberglass Cast Care

• Cast Application and Handling: When applying a damp Plaster of Paris (POP) cast, the material generates heat through an exothermic crystallization reaction. The nurse must handle the damp cast using only the flat, open palms of the hands. Never use the fingertips; fingertip pressure produces indentations on the inner surface of the plaster that harden into rigid ridges, causing localized pressure necrosis and ulcers.
• Drying Protocol: A POP cast requires 24 to 72 hours to dry completely; fiberglass casts cure within 20–30 minutes. Plaster casts must dry uncovered, exposed to circulating room air. Never cover a damp cast with blankets or plastic. Do not use direct heat lamps or artificial hair dryers, which can cause severe burns beneath the cast.
• Neurovascular Monitoring: Conduct neurovascular checks every 30–60 minutes for the first 4 hours, and then every 2–4 hours for the first 24 hours post-application.
• Detecting Complications: Inspect for "hot spots"—localized areas of warmth over the plaster surface accompanied by burning pain and a foul or musty odor, indicating underlying skin necrosis or tissue breakdown.
• Patient Education: Instruct the patient to keep the cast dry. Emphasize that foreign objects (such as knitting needles, coat hangers, or pens) must never be inserted inside the cast to scratch itchy skin. Scratches disrupt the skin barrier, introducing bacteria that cause cellulitis. For itching, direct the cool airflow of a hair dryer down the cast opening.

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Spinal Cord Trauma: Continuous Immobilization and Log-Rolling Protocol

Spinal cord injury (SCI) carries catastrophic risks of permanent tetraplegia or paraplegia. In any patient presenting with high-energy blunt trauma (e.g., motor vehicle collisions, falls from height, diving accidents, or unconscious trauma victims), the spinal column must be presumed unstable until cleared radiologically and neurologically.

Cervical Spine Immobilization

• Triple Immobilization: Maintain continuous immobilization using a rigid, properly sized cervical collar (Philadelphia or Miami J collar), bilateral supportive head blocks or sandbags, and adhesive tape securing the forehead and chin to a rigid long spine board.
• Removal from Spine Board: The long spine board is an extrication tool, not a therapeutic bed. To prevent severe pressure ulcers (which can develop over the occiput and sacrum within 2 hours), the patient must be transferred off the hard spine board onto a firm emergency mattress as soon as the initial primary survey and log-roll are accomplished.

Coordinated 4-Person Log-Rolling Protocol

Repositioning or assessing the posterior torso of a patient with suspected spinal injury requires a strict 4-person log-roll:

1. Person 1 (Team Leader): Positioned at the head of the bed, holding the patient's head and neck in neutral manual in-line stabilization. Person 1 is the sole commander who gives all verbal movement directives (e.g., "We will roll on three: 1, 2, 3").
2. Person 2: Positioned at the patient's chest and shoulders, crossing arms with Person 3.
3. Person 3: Positioned at the patient's pelvis and hips.
4. Person 4: Positioned at the lower extremities, guiding the legs and feet.

• Execution: The patient's spine is maintained as a single, rigid anatomic column. The body is rolled synchronously without twisting, bending, or cervical rotation while the examiner inspects and palpates the entire spinal column for step-offs, bruising, or localized tenderness.

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Hemodynamic & Neurologic Crises: Neurogenic Shock vs. Spinal Shock

Distinguishing between neurogenic shock and spinal shock is essential for prompt resuscitation and neurological prognosis:

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|                         NEUROGENIC SHOCK vs. SPINAL SHOCK                         |
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|  NEUROGENIC SHOCK: Hemodynamic / Distributive Crisis                              |
|  - Loss of sympathetic vascular tone (T1-L2) -> Massive Vasodilation              |
|  - Classic Triad: HYPOTENSION + BRADYCARDIA + WARM, DRY SKIN                     |
|  - Treat with IV Fluids, Vasopressors (Norepinephrine), and Atropine              |
|                                                                                   |
|  SPINAL SHOCK: Neurological / Electrical Reflex Failure                           |
|  - Temporary complete loss of all spinal cord reflex and motor activity below level|
|  - Presentation: Flaccid paralysis, absent deep tendon & bulbocavernosus reflexes |
|  - Resolves in days to weeks (marked by return of anal wink / spasticity)         |
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