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06.02 Fractures

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Overview

Fractures of skull and vertebrae require massive force

Nursing Points

General

  1. Facial Fractures
    1. Risks:
      1. Airway concerns
      2. Vision loss
  2. Basilar Skull Fractures
    1. Base of skull = where brain sits
    2. May not show up on X-ray/CT for 2-3 days
    3. Risks:
      1. Meningitis
      2. Cranial nerve damage
      3. Blood vessel damage
      4. Brainstem injury
  3. Vertebral Fractures
    1. Cervical
    2. Thoracic = most common
    3. Lumbar
    4. Sacral = least common
    5. Risks:
      1. Spinal cord injury
      2. Nerve damage

Assessment

  1. Facial Fractures
    1. Unstable midface
    2. Raccoon Eyes
    3. Obvious deformity or ecchymosis
    4. Mandible fracture = teeth don’t line up or jaw doesn’t close
  2. Basilar Skull Fractures
    1. Raccoon Eyes
    2. Battle’s Sign
    3. Bleeding from ears/nose
      1. Halo Sign = CSF Leak
  3. Vertebral Fracture
    1. Tenderness on palpation of spine
    2. Back/Neck pain
    3. Known mechanism of injury
    4. Obvious deformity

Therapeutic Management

  1. Facial Fractures
    1. Airway management due to swelling
      1. May require trach
    2. Surgical repair
  2. Basilar Skull Fracture
    1. Avoid nose blowing
    2. Surgical repair if prolonged CSF leak
  3. Vertebral Fracture
    1. Immobilization
      1. Cervical Collar
      2. Halo Brace
      3. Spinal Precautions
    2. Traction
    3. Surgical Repair

Nursing Concepts

  1. Comfort
    1. Maintain spinal precautions – pad with pillows on sides
    2. Administer analgesics
  2. Safety
    1. Protect Airway
    2. Prevent skin breakdown if immobilized
  3. Functional Ability
    1. Log Roll for spinal precautions
      1. Prevent spinal cord injury
    2. Assess movement and sensation distal to injury

Patient Education

  1. Importance of maintaining braces, immobilizers, or traction
  2. Plan of care, course of treatment
  3. Signs to report to provider (worsening battle sign, severe headache, vision changes, numbness, tingling)

Reference Links

Study Tools

Video Transcript

Okay, let’s talk about fractures that affect the neurological system. Specifically we’ll talk about facial fractures, basilar skull fractures, and vertebral fractures. All of these things would result from some form of trauma like a fall or motor vehicle collision. We’re going to point out the most important things you need to know here.

Facial fractures, obviously, are a result of trauma to the face. You may not be able to tell externally, so a few things we might see are an unstable midface. That means if you push on their cheeks or upper jaw it actually moves – which it normally wouldn’t. If they have a mandible fracture, we might see that their jaw is misaligned or they can’t clench their teeth like normal. Facial fractures can affect the facial and cranial nerves so we may see vision changes. And the most important thing to keep in mind here is that there could be significant swelling which could cause airway issues, so we always need to keep a close eye on this for these patients. These lines are just a couple examples of where the face could break, including through the eye sockets.

When we talk about basilar skull fractures, we are referring to the base of the skull where the brain sits. Breaking this requires pretty significant force. Of course, the rest of the skull could break as well, but there are extremely important structures down here, which is what makes us a bit more concerned. Think of the skull like a peanut M&M. The peanut inside is the brain, the chocolate is the meninges and CSF that is protecting it, and the candy shell is the skull. While it takes much more force to crack the skull, you can still imagine what happens when it does break. A superficial crack may not affect the chocolate at all, a deeper crack may expose the chocolate, and a really bad crack is going to expose down to the peanut. So when those meninges are exposed, we have a risk for meningitis. If there’s damage to them, we also have a chance for CSF to leak out. And as you can see, the cranial nerves and brainstem all exit from out of the base of the skull, so if there’s a fracture here, there’s a risk for dysfunction if those structures are also damaged.

Now, basilar skull fractures may take a couple of days to actually be obvious on an x-ray or CT scan, so there are a couple of things we might see in our patient that can indicate a basilar skull fracture. One is raccoon eyes, also known as periorbital ecchymosis or bruising around the eyes. This is especially common with facial fractures. We may also see battle’s sign. If you can see in this scan, there’s a fracture right over the mastoid sinus. So Battle’s sign is also known as mastoid ecchymosis – we see bruising over the mastoid process behind the ears. We may also see bleeding or fluid leaking from the nose or ears.

A few key nursing points for a patient with skull fractures – they should NOT blow their nose. We can wipe and dab, and even pack the nose, but they should NEVER blow their nose. It can cause a severe CSF leak or bleeding at the site of the fracture, plus it increases ICP. We will also check any nosebleeds or fluid from the ears for a CSF leak. We do that with something called the Halo test. We’ll get a piece of dry gauze *click* and dab a drop of the blood or fluid onto it. *click* What we’ll see is a yellow ring begin to form, *click* and the blood cells migrate to the middle. That yellow ring indicates that there is, indeed, CSF in that drainage. CSF leaks may clear up in a few days, if they don’t, the patient may require surgery. And then of course we’re going to be assessing their airway and breathing and their LOC in case of increased ICP.

Okay, fractures of the vertebrae can be very scary for patients because there’s obviously a high risk for nerve damage. These bones are complex and there are quite a few places they could fracture. The big concern is if damage protrudes into the spinal column where the spinal cord is, or if it affects any of these nerve roots coming off the spinal cord. A fracture of the transverse process or spinous process may not actually involve spinal cord injury. The important thing to find out from the neurosurgeon is whether or not this fracture is stable. If it is unstable, there is a high risk for spinal cord damage and immobilization is extremely important.

If you have a patient come in who MAY have a vertebral fracture, they need to be placed in full spinal precautions. That means a cervical collar and lying completely flat. We don’t want their spine to bend or twist in any way. Eventually after multiple scans, the neurosurgeon may say that the patient’s spine is stable and will tell you how high their head of bed can be, but until you have that order in writing, keep them flat and still. One thing the neurosurgeons may also do for unstable C-spine fractures is what’s called a Halo brace. They will have 4 pins in their skull and this brace will be attached and secured by this vest to prevent even the slightest rotation of their neck. We just need to be sure to clean those pins daily and watch for infection. And finally when a patient has or may have a vertebral fracture, we need to assess distal sensation and motor regularly so we can catch it if something begins to worsen.

Our priority nursing concepts here would be safety, protecting their airway, comfort because of the pain or positioning, and functional ability because we want to prevent nerve damage and preserve as much function as possible. Make sure you check out the care plan attached to this lesson as well as the Spinal Cord Injury lesson to get a bigger picture of taking care of these patients.

So let’s recap our priorities. For facial fractures we worry about airway swelling. Basilar skull fractures we look for raccoon eyes, battle’s sign, and assess for CSF leaks. For vertebral fractures we want to focus on stability and immobilization. And we prioritize safety and preserving the patient’s functional ability.

So that’s it for fractures, let us know if you have questions. Have a fabulous day. And, as always, happy nursing!

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