Fractures nursing: classification, 6 Ps, and complications

Fractures – breaks in the continuity of bone – are among the most common injuries nurses encounter across emergency departments, medical-surgical floors, orthopedic units, and long-term care settings. In the United States, approximately 6.3 million fractures occur annually. They range from minor stress fractures managed with rest and activity modification to life-threatening open long-bone fractures with massive hemorrhage requiring emergent surgery. Nurses must be proficient in fracture classification, neurovascular assessment, recognition of life-threatening complications, perioperative care, and patient education. This reference page provides the depth required for clinical practice and NCLEX preparation, with particular emphasis on the high-yield complications that appear most frequently on licensing examinations: compartment syndrome, fat embolism syndrome, and avascular necrosis.

Fast-scan summary

Fracture classification

Fractures are classified along several axes: pattern/morphology, displacement, completeness, and skin integrity. Understanding classification guides management decisions and nursing priorities.

Classification by fracture pattern

Classification by displacement and completeness

Classification by skin integrity: closed vs open fractures

The distinction between closed (simple) and open (compound) fractures has immediate management implications. Open fractures communicate with the external environment through a wound, dramatically increasing infection risk – including osteomyelitis, tetanus, and gas gangrene.

The Gustilo-Anderson classification is the standard system for grading open fracture severity:

Key nursing rule: Never remove dressings from open fractures in the ED to “take a look.” Expose once, cover with sterile dressing, and keep covered until the OR. Each exposure increases contamination.

High-yield fracture locations

Hip fractures

Hip fractures are among the most clinically significant fractures nurses encounter, particularly in older adults with osteoporosis. Approximately 300,000 hip fractures occur in the United States annually; 30-day mortality approaches 5–10%, and 1-year mortality reaches 20–30% in elderly patients.

Hip fractures are anatomically divided into two categories with different blood supply implications:

Garden classification grades femoral neck fractures by displacement, with Garden I (incomplete, valgus impacted) and Garden II (complete, non-displaced) carrying lower AVN risk, and Garden III (complete, partial displacement) and Garden IV (complete, full displacement) carrying the highest AVN risk.

Nursing assessment priorities for hip fracture:

• External rotation and limb shortening on the affected side
• Skin assessment (heels especially) – immobility + bony prominence = rapid pressure injury development
• Neurovascular assessment of the entire affected extremity
• Pain management – multimodal, opioid-sparing approach where possible
• DVT prophylaxis – chemical (LMWH, fondaparinux) + mechanical (compression devices) initiated promptly
• Urinary retention – common post-op; monitor output; catheterization if needed

Colles’ fracture

Colles’ fracture is a distal radius fracture with dorsal angulation and displacement of the distal fragment, producing the characteristic dinner fork deformity on lateral X-ray. It is the most common wrist fracture in adults and results from a FOOSH mechanism (Fall On OutStretched Hand), most commonly in postmenopausal women with osteoporosis.

Clinical features: dorsal displacement creating a visible deformity, radial deviation, wrist swelling and ecchymosis, point tenderness over the distal radius. Management ranges from closed reduction with casting (non-displaced or minimally displaced) to ORIF with volar locking plate (unstable or intra-articular fractures).

Nursing considerations: Elevate the extremity above heart level to reduce swelling; assess radial pulse and median nerve function (sensation in the thumb, index, and middle fingers); monitor cast fit – swelling post-reduction can cause cast tightness and early compartment syndrome.

Vertebral compression fractures

Vertebral compression fractures (VCFs) occur when the vertebral body collapses under compressive load. In the setting of osteoporosis, they can occur with minimal trauma – bending forward to pick up an object, a minor fall, or even a cough. The thoracolumbar junction (T12–L1) is most commonly affected.

Clinical features: acute onset of back pain, loss of height, progressive thoracic kyphosis (dowager’s hump), and restricted mobility. Neurologic deficit is uncommon in osteoporotic VCFs but must be assessed. Multiple VCFs produce cumulative height loss and can restrict pulmonary function due to thoracic cage compression.

Management options include conservative care (analgesics, bracing, activity modification) and minimally invasive procedures: vertebroplasty (injection of bone cement under fluoroscopy) and kyphoplasty (balloon inflation to restore height before cement injection).

Nursing considerations: Fall prevention is paramount; log-roll technique for repositioning; HOB positioning for comfort; assess respiratory function in multilevel VCFs; teach fall prevention and the importance of treating underlying osteoporosis.

Long bone fractures (femur shaft and tibia)

Femur shaft fractures are high-energy injuries requiring significant force in young adults (MVC, pedestrian injuries, falls from height). In elderly patients, lower-energy mechanisms suffice. Key concern: massive blood loss. The femoral shaft is surrounded by large muscle compartments and a thigh hematoma can accommodate 1–3 liters of blood – enough to cause hemorrhagic shock. Patients may present in hemodynamic compromise.

Tibial shaft fractures are among the most common long bone fractures and carry significant compartment syndrome risk due to the tight fascial compartments of the leg (anterior, lateral, superficial posterior, deep posterior). The tibia has limited soft tissue coverage anteriorly, making open fractures common.

Nursing priorities: IV access (large-bore, bilateral preferred); fluid resuscitation; continuous hemodynamic monitoring (see vital signs by age for age-adjusted targets); hourly neurovascular checks; traction splinting for femur fractures in the prehospital/ED setting.

Clavicle fractures

Clavicle fractures are among the most common fractures overall, accounting for approximately 5% of all fractures. The middle third is fractured in 80% of cases. Mechanism: direct blow to the shoulder or FOOSH. Management is typically non-operative with a sling or figure-of-8 brace.

Nursing neurovascular assessment focus: Brachial plexus (assess sensation and strength in the arm and hand), subclavian artery and vein (assess radial pulse, capillary refill, and venous congestion), and pneumothorax (auscultate bilateral breath sounds – displaced fragments can lacerate the apex of the lung or subclavian vessels).

Rib fractures

Rib fractures are painful and impair respiratory mechanics. The primary concern is splinting – shallow breathing to avoid pain – leading to atelectasis, retained secretions, and pneumonia.

Flail chest occurs when three or more consecutive ribs are fractured in two or more places, creating a free-floating segment that moves paradoxically (inward on inspiration, outward on expiration), impairing ventilation. Associated injuries include pulmonary contusion.

Complications of rib fractures: pneumothorax, hemothorax, pulmonary contusion, flail chest, splenic or hepatic laceration (lower rib fractures). Nursing interventions: incentive spirometry every 1–2 hours, adequate analgesia (regional nerve blocks are preferred over systemic opioids to avoid respiratory depression), positioning, and chest physiotherapy.

Clinical presentation and assessment

Signs and symptoms of fracture

The cardinal signs of fracture are recognizable and form the basis of initial assessment:

The 6 Ps: neurovascular assessment

Neurovascular assessment is the cornerstone of fracture nursing care. Perform a complete 6-P assessment on the affected extremity distal to the fracture or cast:

Frequency: Perform neurovascular checks every 1–2 hours for the first 24 hours post-injury or post-operatively, then every 4 hours when stable. For fresh casts: every 30 minutes for the first 4 hours, then hourly. Any deterioration in any parameter warrants immediate notification and escalation.

Fat embolism syndrome

Fat embolism syndrome (FES) is a serious complication occurring 24–72 hours after long bone fractures (particularly femur and tibia) or pelvic fractures, and less commonly after orthopedic surgery, total joint arthroplasty, liposuction, or prolonged corticosteroid use.

Pathophysiology: Two theories exist. The mechanical theory proposes that fat globules from disrupted marrow enter ruptured intramedullary veins and embolize to the pulmonary vasculature. The biochemical theory proposes that circulating free fatty acids (released by enzymatic hydrolysis of fat emboli) cause direct endothelial injury and inflammatory cascade activation in the lungs and brain.

Gurd criteria for diagnosis:

Nursing assessment: Monitor all long bone fracture patients for FES in the 24–72 hour window. Assess mental status changes, SpO₂ trends, and skin – the petechial rash (conjunctivae, axillae, upper chest) is the most specific finding. FES must be differentiated from pulmonary embolism; see pulmonary embolism nursing for the PE assessment. Key differential: PE typically presents suddenly; FES has a more gradual onset with the classic triad developing over hours.

Nursing interventions for FES: Supplemental oxygen (high-flow), positioning (semi-Fowler’s to optimize ventilation), prepare for possible intubation and mechanical ventilation, IV access, continuous SpO₂ monitoring, notify provider immediately. No specific pharmacologic treatment exists; management is supportive. Early surgical stabilization of long bone fractures has been shown to reduce FES incidence.

Diagnostics

Imaging

Laboratory values

In the context of fractures, key labs include:

• CBC: Hemoglobin and hematocrit to quantify blood loss; thrombocytopenia may indicate DIC (especially in polytrauma or fat embolism); WBC elevated in infection
• Type and screen / crossmatch: Mandatory for hip fractures, femur fractures, pelvic fractures, and anticipated surgery
• BMP: Baseline electrolytes, BUN/creatinine (renal function – relevant for contrast use, NSAID prescribing, and rhabdomyolysis monitoring)
• Coagulation (PT/INR, aPTT): Pre-op; anticoagulation status (patients on warfarin); DIC screen in polytrauma
• Serum lactate: In hemodynamically compromised patients – assess perfusion and response to resuscitation
• CK (creatine kinase): If rhabdomyolysis is suspected (crush injury, prolonged compartment syndrome); markedly elevated CK + myoglobinuria → acute kidney injury risk. See AKI nursing reference for full management
• Serum lipase: If fat embolism is suspected; lipemia (fat globules in serum) may be visible
• Urinalysis: Myoglobinuria appears as tea-colored or cola-colored urine with dipstick positive for blood but no RBCs on microscopy

Refer to the nursing lab values cheat sheet for normal reference ranges.

Management

Conservative management

Conservative (non-surgical) management is appropriate for many fractures, particularly non-displaced or minimally displaced fractures with intact neurovascular status.

Traction

Traction applies a pulling force to reduce and maintain fracture alignment. It is used less frequently today with advances in surgical fixation but remains relevant in specific scenarios (preoperative femur fracture stabilization, pediatric fractures, definitive management in some settings).

Universal traction rules (non-negotiable):

1. Weights must always hang freely – never resting on the bed, floor, or chair
2. Counter-traction (patient’s body weight against the pull) must be maintained – ensure correct bed position
3. Ropes must remain in the pulleys without knots or fraying
4. Do not lift weights to move the patient – move the patient toward the direction of pull

Surgical management

Complications

Complications are the highest-yield content for NCLEX and clinical practice. The nurse who can identify complications early and act decisively saves limbs and lives.

Compartment syndrome

Compartment syndrome is a medical emergency that occurs when pressure within a closed fascial compartment rises to a level that compromises tissue perfusion. Muscle ischemia begins within 4–6 hours of sustained elevated pressure; irreversible damage (Volkmann’s ischemic contracture in the forearm, foot drop from anterior compartment syndrome in the leg) follows within 8–12 hours. Amputation may result if fasciotomy is not performed promptly.

Most common sites: Anterior compartment of the leg (tibial shaft fractures), forearm (Colles’ fracture, supracondylar humeral fractures in children), and any compartment compressed by a tight cast or dressing.

Causes: Fracture (hematoma), crush injury, reperfusion injury after vascular repair, tight cast or dressing, prolonged compression (positioning during surgery, unconsciousness), burns, intraosseous infusion extravasation.

Assessment – the cardinal sign:

Pain with passive stretch that is disproportionate to the injury and unrelieved by opioids is the earliest and most reliable clinical sign of compartment syndrome.

To test passive stretch: gently extend the fingers (for forearm compartments) or dorsiflex the foot (for leg compartments). Severe pain with this maneuver in a post-fracture patient = compartment syndrome until proven otherwise.

Whitesides technique: Compartment pressure measurement using an 18-gauge needle connected to a pressure transducer or mercury manometer. Normal compartment pressure is 0–8 mmHg. Fasciotomy is indicated when:

• Absolute pressure ≥30 mmHg, OR
• Delta pressure (diastolic BP minus compartment pressure) ≤30 mmHg (more clinically relevant threshold)

Nursing actions when compartment syndrome is suspected:

1. Notify provider and charge nurse immediately – this is a limb-threatening emergency
2. Remove all circumferential dressings, cast padding, and the cast (bivalve or remove entirely)
3. Position the affected extremity at heart level – do NOT elevate (elevation reduces arterial perfusion pressure)
4. Do NOT apply ice – vasoconstriction worsens ischemia
5. Continue neurovascular checks every 15–30 minutes
6. Prepare for possible emergent fasciotomy

Fasciotomy: Surgical incision through the skin and fascia to relieve compartment pressure. Post-fasciotomy wounds are left open and managed with wet-to-dry dressings or wound VAC; delayed primary closure or skin grafting occurs after swelling resolves (typically 5–10 days).

Avascular necrosis (AVN)

Avascular necrosis – also called osteonecrosis – is death of bone due to interrupted blood supply. In the context of fractures, it most commonly affects the femoral head (after femoral neck fractures), the humeral head (after proximal humerus fractures), and the scaphoid (after scaphoid waist fractures).

Mechanism in femoral neck fractures: The blood supply to the femoral head travels primarily via the medial circumflex femoral artery, which runs along the femoral neck within the joint capsule. Displacement of a femoral neck fracture stretches or tears this vessel, causing ischemia. Rates of AVN following displaced femoral neck fractures range from 15–30%; Garden III and IV fractures carry the highest risk.

Timeline: AVN typically presents 6–24 months after injury. Patients may be pain-free initially and then develop progressive groin pain as the necrotic bone collapses. X-ray findings are late; MRI is the gold standard for early detection.

Nursing role: Patient education – patients who have undergone ORIF of a femoral neck fracture need to understand the ongoing risk of AVN and the importance of follow-up imaging; symptoms to report (groin pain, limping, decreased range of motion); compliance with weight-bearing restrictions.

Deep vein thrombosis and pulmonary embolism

Fractures activate all three components of Virchow’s triad: vessel wall injury from the fracture itself, venous stasis from immobility, and hypercoagulability from the systemic inflammatory response to injury. Hip and pelvic fractures carry among the highest DVT and PE risk of any clinical scenario.

DVT prophylaxis is mandatory. Evidence-based approaches include:

• Chemical: LMWH (enoxaparin) is first-line; fondaparinux, direct oral anticoagulants (rivaroxaban, apixaban), or warfarin as alternatives
• Mechanical: Sequential compression devices (SCDs) applied to both lower extremities (the unaffected leg at minimum) as long as patient is non-ambulatory; do not apply to a fracture extremity without orthopedic clearance
• Early mobilization: The most effective DVT prevention; initiate as soon as surgically and hemodynamically appropriate

See DVT nursing reference for complete DVT assessment and management, and pulmonary embolism nursing for PE recognition and emergent care.

Delayed union, non-union, and malunion

Infection and osteomyelitis

Open fractures, particularly Gustilo Type IIIB and IIIC, carry substantial infection risk. Osteomyelitis – infection of bone – is one of the most devastating orthopedic complications and is notoriously difficult to eradicate once established, often requiring months of antibiotic therapy and multiple surgical debridements.

Nursing role in infection prevention:

• IV antibiotics administered within 1–3 hours of open fracture; cefazolin for Type I/II; add gentamicin and/or metronidazole for Type III
• Tetanus prophylaxis per protocol (question patient about immunization history)
• Sterile technique for all wound care
• Monitor for signs of wound infection: increasing erythema, warmth, edema, purulent drainage, fever, rising inflammatory markers (WBC, CRP, ESR)
• Report hardware-related symptoms (persistent pain at implant site, wound breakdown) – these may indicate peri-implant infection requiring removal

Heterotopic ossification

Heterotopic ossification (HO) is the formation of bone in abnormal extraskeletal locations – in muscles and soft tissues around fractures or joints. It is most common after hip fractures or arthroplasty, elbow fractures, and traumatic brain injury. Presentation: decreased range of motion, pain, firmness palpable in periarticular tissues at 3–8 weeks post-injury.

Prophylaxis (used in high-risk cases): indomethacin or other NSAIDs for 6 weeks post-op, or single-dose radiation therapy. Nursing: range of motion exercises as ordered to maintain joint function; do not aggressively force passive ROM once HO is established.

Neurovascular injury

Direct injury to nerves and vessels can occur at the time of fracture or during surgical repair. High-yield nerve injuries by fracture location:

Nursing diagnoses and interventions

Pain management

Multimodal analgesia is the standard approach for fracture pain – combining agents with different mechanisms to achieve superior pain control with lower doses of each agent and reduced opioid-related adverse effects.

Components of multimodal analgesia:

• Acetaminophen (scheduled, not PRN): 1,000 mg q6h (max 4 g/day in healthy adults; reduce in hepatic impairment or heavy alcohol use)
• NSAIDs (if not contraindicated): ketorolac IV/IM in the acute setting; caution in renal impairment, GI history, elderly patients; note: some evidence that NSAIDs may impair fracture healing – discuss with orthopedic provider
• Regional nerve blocks: peripheral nerve blocks (femoral nerve block, adductor canal block for hip/knee fractures; fascia iliaca block for hip fractures; brachial plexus block for upper extremity) provide excellent analgesia without systemic opioid effects; epidural analgesia for thoracic and lumbar fractures
• Opioids: IV PCA (patient-controlled analgesia) in the acute setting; transition to oral opioids as tolerated; use lowest effective dose; monitor sedation and respiratory status

Opioid nursing monitoring:

• Sedation scale (Pasero Opioid-Induced Sedation Scale – POSS): Score 1 (awake, alert) is acceptable; Score 3 (difficult to arouse) requires dose reduction; Score 4 (unarousable) = respiratory emergency
• Respiratory rate and SpO₂ per protocol (hourly minimum in first 24 hours of PCA)
• Constipation prophylaxis: every opioid prescription warrants a laxative order (senna, docusate); do not wait for constipation to develop
• Assess for urinary retention: opioids reduce detrusor tone; monitor urinary output and bladder scan PRN

Non-pharmacologic strategies: Elevation of affected extremity (reduces edema and thereby pain); ice or cold therapy for first 48–72 hours (reduces inflammation; protect skin from frostbite – wrap in cloth; 20 minutes on, 20 minutes off); positioning with pillows; distraction and relaxation techniques; transcutaneous electrical nerve stimulation (TENS) in the rehabilitation phase.

Mobility and rehabilitation

Weight-bearing classifications

Weight-bearing orders from the orthopedic surgeon are based on fracture stability, fixation type, and bone quality. Nurses must understand these orders precisely to prevent re-injury, hardware failure, or non-union.

Hip precautions after arthroplasty

Following total hip arthroplasty or hemiarthroplasty via the posterior approach (the most common surgical approach), the following precautions reduce the risk of prosthetic dislocation:

• No hip flexion greater than 90 degrees – do not bend forward from the waist past a right angle; raised toilet seat required; do not sit on low chairs or sofas
• No internal rotation of the operative hip – do not turn the toes inward; do not cross the legs
• No adduction past the midline – do not cross the legs or let the knee fall inward; abduction pillow between legs when supine

Signs of hip dislocation: sudden severe groin pain, shortened and externally rotated leg (or internally rotated, depending on direction of dislocation), inability to bear weight. Dislocation is a surgical emergency. Do not attempt to relocate. Immobilize and notify surgeon.

Note: some surgeons use the anterior approach, which has different (or no) precautions and a different dislocation risk profile. Always confirm the surgeon’s specific precautions in the operative note and postoperative orders.

Transfer techniques and fall prevention

Fracture patients – particularly elderly hip fracture patients – are at extremely high fall risk. Fall prevention strategies:

• Call light within reach at all times
• Bed in lowest position; brakes locked
• Non-slip footwear
• Clear pathway to bathroom; bedside commode if needed
• Two-person transfer for the first 24–48 hours post-op
• PT/OT consultation on day of or day after surgery
• Cognitive assessment (post-op delirium is common in elderly fracture patients – see below)
• Hourly rounding

Post-operative delirium is a frequent complication in elderly patients after hip fracture surgery. Risk factors: age, pre-existing cognitive impairment, sleep deprivation, pain, opioid use, urinary retention, constipation, unfamiliar environment. Use a validated tool (CAM – Confusion Assessment Method) to screen daily. Non-pharmacologic interventions are first-line: reorientation, consistent nursing staff, natural light exposure, sleep protocols, hearing aids and glasses in place, early mobilization.

Patient education

Cast and splint care at home

Patients discharged with a cast or splint require comprehensive education:

• Keep the cast dry – waterproof cast liners are available; cover with plastic bag for showering; no submersion
• Do not insert objects under the cast – coat hangers and pencils to relieve itching cause skin breakdown and are a route for infection
• Elevate the extremity – above heart level for first 48–72 hours after discharge to minimize swelling
• Check circulation daily – compare fingers/toes to the unaffected side; report numbness, tingling, increased pain, or skin discoloration immediately
• Inspect the cast edges – pad with moleskin or soft cloth if cast edges are rough; report any drainage or foul odor soaking through the cast

When to seek emergency care

Patients must understand that the following warrant an immediate return to the ED – not a call to the office tomorrow:

1. Numbness or tingling in fingers or toes that is new or worsening
2. Increasing pain not controlled by prescribed medications, especially pain that worsens when moving the fingers or toes
3. Fingers or toes that are pale, blue, or cold compared to the other hand/foot
4. Cast feels too tight and cannot be relieved by elevation
5. Sudden severe joint pain post-arthroplasty (may indicate prosthetic dislocation)
6. Shortness of breath, chest pain, or leg swelling (may indicate DVT or PE)

Osteoporosis prevention in patients with pathologic fractures

Patients who fracture with minimal trauma should be evaluated for underlying osteoporosis. The Fracture Liaison Service (FLS) model provides systematic post-fracture osteoporosis assessment. Nursing education:

• Calcium (1,200 mg/day in women over 50) and vitamin D (800–1,000 IU/day) supplementation
• Weight-bearing exercise after healing is complete
• Smoking cessation, limit alcohol intake
• Discussion of bisphosphonate therapy – start after acute fracture healing; do not start IV zoledronate within 2 weeks of surgery (may interfere with fracture healing in some data)
• DEXA scan referral if not already done

Weight-bearing compliance

Non-compliance with weight-bearing restrictions is a leading cause of hardware failure and re-fracture. Teach patients:

• What weight-bearing as tolerated means in practice (use a bathroom scale demonstration)
• Why the restrictions exist – the hardware is not as strong as native bone; it needs time for bone to grow around it
• Signs of hardware failure: sudden increase in pain, deformity, clicking sensation, inability to bear weight that was previously tolerated

NCLEX-style practice questions

Key takeaways for clinical practice

Fracture nursing integrates orthopedic assessment skills, surgical care, complication recognition, and patient education into a high-stakes clinical specialty. The most important principles:

1. Neurovascular assessment is your primary safety tool. The 6 Ps performed consistently and documented accurately are how you catch compartment syndrome, vascular injury, and cast complications before they become irreversible.

2. Pain out of proportion + pain with passive stretch = compartment syndrome until proven otherwise. Do not give more analgesia. Remove the cast. Call the surgeon. This is a limb-threatening emergency that moves faster than most other complications.

3. Fat embolism syndrome and pulmonary embolism are clinical distinctions that matter. FES develops gradually, 24–72 hours post-fracture, with the petechial rash triad. PE develops suddenly. Both require oxygen, provider notification, and rapid escalation.

4. Hip fracture is as much a medical problem as a surgical one. The perioperative mortality and morbidity of hip fractures are driven by the patient’s age and comorbidities, not just the fracture. DVT prophylaxis, delirium prevention, early mobilization, and pressure injury prevention are equally important as the surgical repair.

5. Hip precautions post-arthroplasty are your responsibility to reinforce at every interaction. One dislocation is a setback of weeks. Reinforce, demonstrate, and verify understanding.

6. Open fractures require antibiotics within 1–3 hours. This is a time-sensitive intervention analogous to antibiotics in sepsis. Know the protocol and act on it immediately.

For nursing students working through musculoskeletal content, review osteoporosis nursing for fracture risk and prevention, osteoarthritis nursing for arthroplasty background, DVT nursing reference for thromboembolic complications, pulmonary embolism nursing for the PE differential, and AKI nursing reference for rhabdomyolysis and crush injury sequelae. For NCLEX preparation strategies, see NCLEX study tips.

Nursing care plans

NANDA-I nursing care plans for fractures organize clinical priorities into structured, evidence-based frameworks. Each care plan below follows the NANDA-I taxonomy with domain and class notation, fracture-specific interventions, and clinical rationale.

Acute pain (Domain 12, Class 1)

NANDA-I label: Acute pain related to tissue trauma from bone fracture, muscle spasm, soft tissue injury, and surgical intervention, as evidenced by verbal pain report, guarding behavior, elevated NRS score, and autonomic signs (tachycardia, diaphoresis).

Goal: Patient reports pain ≤3/10 on NRS at rest and ≤5/10 with movement within 24 hours; able to participate in repositioning and early rehabilitation activities.

Risk for peripheral neurovascular dysfunction (Domain 4, Class 4)

NANDA-I label: Risk for peripheral neurovascular dysfunction related to bone fracture, soft tissue edema, circumferential cast or dressing, and surgical swelling, with risk factors including displaced fracture, high-energy mechanism, and tight immobilization device.

Goal: Neurovascular status remains intact throughout hospitalization; peripheral pulses present and equal bilaterally; capillary refill <2 seconds; sensation and motor function intact distally.

Impaired physical mobility (Domain 4, Class 2)

NANDA-I label: Impaired physical mobility related to bone fracture, prescribed weight-bearing restrictions, pain, immobilization device, and post-operative state, as evidenced by limited range of motion, inability to bear weight independently, and altered gait.

Goal: Patient demonstrates safe mobility within prescribed weight-bearing restrictions; performs transfers safely with appropriate assistive device; maintains ROM in unaffected joints; no VTE events during hospitalization.

Risk for infection (Domain 11, Class 1)

NANDA-I label: Risk for infection related to open fracture wound, surgical incision, external fixator pin sites, disrupted skin integrity, and immunosuppression from trauma, with risk factors including high-grade open fracture (Gustilo Type IIIB/IIIC), contamination, and delayed antibiotic administration.

Goal: Patient remains afebrile; wound heals without purulent drainage, erythema, or dehiscence; WBC trending toward normal; negative wound cultures if obtained; pin sites clean and dry without signs of infection.

Deficient knowledge: cast/device care and activity restrictions (Domain 5, Class 4)

NANDA-I label: Deficient knowledge related to unfamiliarity with cast/splint care, weight-bearing restrictions, compartment syndrome warning signs, and activity limitations, as evidenced by questions, incorrect return demonstration, or non-compliant behaviors.

Goal: Patient and caregiver correctly verbalize cast care instructions, demonstrate correct assistive device use, identify warning signs requiring emergency evaluation, and state weight-bearing restrictions before discharge.

Frequently asked questions

What are the priority NANDA-I nursing diagnoses for fractures?

The highest-priority NANDA-I diagnoses for fractures are Acute pain (Domain 12, Class 1) and Risk for peripheral neurovascular dysfunction (Domain 4, Class 4). Pain management is the immediate patient priority, while neurovascular monitoring is the safety priority – a missed compartment syndrome is a limb-threatening emergency. Impaired physical mobility (Domain 4, Class 2), Risk for infection (Domain 11, Class 1) for open fractures, and Deficient knowledge (Domain 5, Class 4) complete the standard care plan. Priority order shifts based on fracture type: an open fracture elevates infection risk to co-equal priority, while a surgical fixation places VTE prevention within the mobility diagnosis at the forefront.

How do you assess for compartment syndrome in a fracture patient?

Compartment syndrome assessment centers on the 6 P’s neurovascular check combined with the passive stretch test. Pain with passive stretch of muscles in the affected compartment – for example, pain with gentle passive dorsiflexion of the toes in a tibial fracture – is the earliest and most reliable clinical sign. Pain disproportionate to the injury and unrelieved by opioids is the hallmark; if opioids do not control the pain, do not give more – escalate to the surgeon. Compartment pressure measurement (Whitesides technique) confirms the diagnosis: fasciotomy is indicated when absolute pressure exceeds 30 mmHg or the delta pressure (diastolic BP minus compartment pressure) falls to 30 mmHg or below.

What are the 6 P’s of neurovascular assessment?

The 6 P’s are Pain, Pallor, Pulselessness, Paresthesia, Paralysis, and Poikilothermia. Pain is assessed at rest and with passive stretch of distal muscles. Pallor is evaluated by comparing skin color and capillary refill (<2 seconds is normal) bilaterally. Pulselessness refers to absent or diminished distal pulses compared to the unaffected side. Paresthesia – numbness, tingling, or “pins and needles” – is often the first neurologic sign of ischemia. Paralysis (inability to move the digits) is a late finding indicating advanced ischemia. Poikilothermia describes a cool or cold extremity from reduced arterial flow. All six parameters are assessed at each check and compared bilaterally.

What is the nursing priority for an open fracture?

The two simultaneous nursing priorities for an open fracture are wound coverage and antibiotic administration. Cover the wound immediately with a sterile saline-moistened dressing and do not re-expose it – each exposure increases contamination. Administer IV antibiotics as soon as vascular access is established: cefazolin 2 g IV for Gustilo Type I and II fractures; add gentamicin for Type III. The goal is antibiotic delivery within 1–3 hours of injury, and within 6 hours at the absolute limit. Tetanus prophylaxis status must be assessed and addressed concurrently. The wound will be definitively managed with irrigation and debridement in the operating room.

How often should neurovascular checks be done after a fracture?

Neurovascular checks should be performed every 1–2 hours for the first 24 hours after fracture or orthopedic surgery, then every 4 hours once the patient is stable. For fresh casts applied in the emergency department or immediately post-operatively, checks are performed every 30 minutes for the first 4 hours, then hourly. Any deterioration in any parameter – new paresthesia, pallor, pulse change, pain with passive stretch, or increasing weakness – warrants immediate escalation regardless of the scheduled check interval. Neurovascular assessment frequency is a nursing judgment: high-energy fractures, displaced fractures, and fractures in tight fascial compartments (anterior leg, forearm) warrant the higher end of the frequency range.

What is the difference between a stress fracture and a pathological fracture?

A stress fracture results from repetitive mechanical loading below the threshold of a single acute injury – the bone fails gradually under cumulative microtrauma, as seen in metatarsal fractures in runners or tibial fractures in military recruits. The bone itself has normal composition; the problem is excessive or rapidly escalating load. A pathological fracture occurs through structurally compromised bone – bone weakened by osteoporosis, metastatic malignancy, primary bone tumor, Paget’s disease, or infection – with minimal or no trauma. A pathological fracture through an osteoporotic vertebra can occur with a cough; the same force would not fracture a healthy vertebra. The clinical distinction matters because a pathological fracture mandates investigation of the underlying disease, whereas a stress fracture mandates load modification and rehabilitation.

How do you prevent VTE (blood clots) in a patient with a fracture?

VTE prevention requires both mechanical and pharmacological measures, initiated as early as clinically safe. Sequential compression devices (SCDs) are applied to both lower extremities as soon as the patient is admitted and worn whenever the patient is not ambulating; apply to the unaffected leg if the fractured extremity cannot tolerate a device. Pharmacological prophylaxis – low-molecular-weight heparin (enoxaparin), unfractionated heparin, fondaparinux, or a direct oral anticoagulant – is started per the surgeon’s order, typically within 12–24 hours of surgical fixation when bleeding risk permits. Early ambulation is the most effective single intervention; hip fracture patients should ambulate on post-operative day 0 or 1. Adequate hydration reduces blood viscosity and should be maintained throughout the hospitalization.

When should a nurse escalate a patient with a fracture to the physician immediately?

Escalate immediately for any of the following: pain disproportionate to the injury that is unrelieved by opioids, especially if worsened by passive stretch (compartment syndrome); new or worsening paresthesia or paralysis in the distal extremity; absent or diminished distal pulse compared to baseline or the contralateral limb; capillary refill greater than 3 seconds; cool or mottled extremity (poikilothermia); fever greater than 38.3°C in an open fracture or post-operative patient (wound infection or osteomyelitis); sudden severe hip pain with external rotation and limb shortening post-arthroplasty (prosthetic dislocation); acute respiratory deterioration, hypoxia, or new confusion 24–72 hours after long bone fracture (fat embolism syndrome); or any sign of hemodynamic compromise. When multiple warning signs appear together, do not wait for laboratory confirmation before calling the surgeon.

References

1. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am. 1976;58(4):453–458.
2. Gurd AR. Fat embolism: an aid to diagnosis. J Bone Joint Surg Br. 1970;52(4):732–737.
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