Arm and leg fractures
Arm and leg fractures usually result from trauma and commonly cause substantial muscle, nerve, and other soft-tissue damage. The prognosis varies with the extent of disablement or deformity, the amount of tissue and vascular damage, the adequacy of reduction and immobilization, and the patient’s age, health, and nutritional status. Children’s bones usually heal rapidly and without deformity. Bones of adults in poor health and with impaired circulation may never heal properly. Severe open fractures, especially of the femoral shaft, may cause substantial blood loss and life-threatening hypovolemic shock.
Causes and incidence
Most arm and leg fractures result from major traumatic injury, such as a fall on an outstretched arm, a skiing accident, or child abuse (suggested by multiple or repeated episodes of fractures). However, in a person with a pathologic bone-weakening condition, such as osteoporosis, bone tumors, or metabolic disease, a mere cough or sneeze can also produce a fracture. Prolonged standing, walking, or running can cause stress fractures of the foot and ankle — usually in soldiers, nurses, postal workers, and joggers.
Fractures are among the most common orthopedic problems; about 6.8 million people seek medical attention for fractures in the United States each year.
ELDER TIP Brittle bones make an older person especially vulnerable to fractures. A fall on an outstretched arm or hand or a direct blow to the arm or shoulder is likely to fracture the radius or humerus.
Signs and symptoms
Arm and leg fractures may produce any or all of the “5 Ps”: pain and point tenderness, pallor, pulse loss, paresthesia, and paralysis. (The last three occur distal to the fracture site.) Other signs include deformity, swelling, discoloration, crepitus, and loss of limb function. Numbness and tingling, mottled cyanosis, cool skin at the end of the extremity, and loss of pulses distal to the injury indicate possible arterial compromise or nerve damage. Open fractures also produce an obvious skin wound.
Complications of arm and leg fractures include:
❑ permanent deformity and dysfunction if bones fail to heal (nonunion) or heal improperly (malunion)
❑ aseptic necrosis of bone segments from impaired circulation
❑ hypovolemic shock as a result of blood vessel damage (this is especially likely to develop in patients with a fractured femur)
❑ muscle contractures
❑ renal calculi from decalcification (due to prolonged immobility)
❑ fat embolism (See Fat embolism.)
❑ compartment syndrome. (See Recognizing compartment syndrome, page 304.)
Diagnosis
A history of traumatic injury and the results of the physical examination, including gentle palpation and a cautious attempt by the patient to move parts distal to the injury, suggest an arm or leg fracture.
Note: When performing the physical examination, also check for other injuries.
CONFIRMING DIAGNOSIS Anteroposterior and lateral X-rays of the suspected fracture as well as X-rays of the joints above and below it confirm the diagnosis. (See Classifying fractures.)
Treatment
Emergency treatment consists of splinting the limb above and below the suspected fracture, applying a cold pack, and elevating the limb to reduce edema and pain.
In severe fractures that cause blood loss, apply direct pressure to control bleeding, and administer fluid replacement as soon as possible to prevent or treat hypovolemic shock.
After confirming a fracture diagnosis, begin treatment with reduction (which involves restoring displaced bone segments to their normal position).
After reduction, the fractured arm or leg must be immobilized by a splint or a cast or with traction. In closed reduction (accomplished by manual manipulation), a local anesthetic such as lidocaine and an analgesic such as I.V. morphine help relieve pain; a muscle relaxant such as I.V. diazepam or a sedative such as midazolam facilitates the muscle stretching necessary to realign the bone.
X-rays are ordered to confirm that the reduction was successful and that proper bone alignment was achieved.
When closed reduction is impossible, open reduction during surgery reduces and immobilizes the fracture by means of rods, plates, or screws. Afterward, a cast is usually applied.
When a splint or cast fails to maintain the reduction, immobilization requires skin or skeletal traction, using a series of weights and pulleys. In skin traction, elastic bandages and sheepskin coverings are used to attach traction devices to the patient’s skin. In skeletal traction, a pin or wire inserted through the bone distal to the fracture and attached to a weight allows more prolonged traction.
Treatment of open fractures also requires tetanus prophylaxis, prophylactic antibiotics, surgery to repair soft-tissue damage, and thorough debridement of the wound.
Special considerations
❑ Watch for signs of shock in the patient with a severe open fracture of a large bone such as the femur.
Alert Monitor vital signs and be especially alert for rapid pulse, decreased blood pressure, pallor, and cool, clammy skin — all of which may indicate that the patient is in shock.
❑ Administer I.V. fluids as ordered.
❑ Offer reassurance to the patient, who’s likely to be frightened and in pain.
❑ Ease pain with analgesics as needed.
❑ Help the patient set realistic goals for recovery.
❑ If the fracture requires long-term immobilization with traction, reposition the patient often to increase comfort and prevent pressure ulcers. Assist with active range-of-motion exercises to prevent muscle atrophy. Encourage deep breathing and coughing to avoid hypostatic pneumonia.
❑ Urge adequate fluid intake to prevent urinary stasis and constipation. Watch for signs of renal calculi (flank pain, nausea, and vomiting).
❑ Provide good cast care and support the cast with pillows. Observe for skin irritation near cast edges and check for foul odors or discharge. Tell the patient to report signs of impaired circulation (skin coldness, numbness, tingling, or discoloration) immediately. Warn him not to get the cast wet and not to insert foreign objects under the cast.
❑ Encourage the patient to start moving around as soon as he’s able. Help him to walk. (Remember, a patient who has been bedridden for some time may be dizzy at first.) Demonstrate how to use crutches properly.
❑ After cast removal, refer the patient to a physical therapist to restore limb mobility.
❑ If the patient is a child who sustained the fracture at or near the growth plate, have the family continue to follow-up with the child’s pediatrician to ensure that there are no problems as the limb grows.
Pictures
Book Source Details
- Book Title: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
Other Book Chapters Related to Arm symptoms
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Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2008 Williams & Wilkins.
More About Causes of Arm symptoms
» Next page: Arm pain (Professional Guide to Signs & Symptoms (Fifth Edition))
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