First aid: fractures

In the fifth part of our series, Martin Roth and colleagues explain the classification of fractures and give some basic advice about managing them in a first aid setting

We can define a fracture simply as the breaking of bone. Whenever you apply more pressure than the bone can stand it will break. The size shape and consistency of bone varies with age. Old bones need less force to break them than young ones because they are more brittle and may be affected by osteoporosis. Bone is a living tissue with a generous blood supply and can bleed profusely after injury. Blood loss from limb wounds and bleeding from fractures can be severe enough to cause hypovolaemic shock (table). Haemorrhage from multiple fractures, especially pelvic and femoral, may result in an excessive loss of blood.¹ For an open fracture the blood loss will be two to three times greater.

Classification of fractures

Although you can classify fractures in several ways, one important way to define them is either open or closed (box 1). Fractures in which the broken bone protrudes through the skin or communicates with a wound are called "open" or compound fractures. Exposure of the fracture to the external environment produces local contamination and increases the risk of infection.

If the skin over the broken bone is intact then you can classify the fracture as closed. However, there may still be other important soft tissue injuries which are affected. These include arteries, veins, nerves, muscles, and organs. Fractures are usually extremely painful because of the extensive sensory nerve supply to the periosteum.

Fractures are termed complete if the break is completely through the bone. They are described as incomplete or "greenstick" if the fracture occurs partly across a bone shaft. The mechanism and result is like bending a fresh branch. These types of fractures are often the result of bending or crushing mechanisms on the bone. Such fractures are commonly found in children, as their bones are more pliable and may bend without breaking.

Fractures are also named according to the specific portion of the bone involved and the nature of the break. The identification of the fracture line can further classify fractures. Types include linear, oblique, transverse, longitudinal, and spiral fractures. Fractures can be further subdivided by the positions of bony fragments and are described as comminuted, non-displaced, impacted, overriding, angulated, displaced, avulsed, and segmental (box 2).

Diagnosing fractures

High risk people

People with a high activity level are at a greater risk of fractures.² This group includes children and athletes participating in contact sports. Because of an increase in bone brittleness that occurs with the ageing process, elderly people also have an increased risk. Up to the age of 50, more men have fractures than women because of occupational hazards. However, after the age of 50, more women suffer fractures than men. This is because after the menopause the ovaries no longer produce oestrogen, which protects bone density. Specific diseases causing an increased risk of fractures include Paget's disease, rickets, osteogenesis imperfecta, and osteoporosis as well as prolonged disuse of a limb, for example after a stroke.²

Feel the force

The force capable of generating a fracture does not have to be violent. The force could be directly over the site of fracture or away from the site, as a result of a lever, torsion, or traction mechanism. Repetitive forces, such as those produced in aerobic sports can also produce a fracture. One thing to remember is that you do not have to be 100% certain that you have found a fracture in order to treat it. Suspicion from the signs and symptoms is enough, until you are in a situation where x ray examinations can be done (box 3).

Emergency management

A systematic approach

After ensuring your own personal safety and assessing the ABC you can start checking for fractures. Do not forget to treat haemorrhage first with a compressive pad. To avoid missing any fractures it is important to follow the same order when you do the physical examination. Start with the head by palpating the head with your full hand—you should be wearing gloves—looking for lumps or depressions.

Skull fractures

Fractures to the face and skull are serious emergencies as they may compromise the airway and breathing. If you find evidence of skull or facial fractures you should presume the possibility of cervical spine injury also.

Decreased consciousness, deep lacerations or severe bruising, deformity, fluid from the ears, unequal pupils, and a sunken eye are all symptoms of possible skull or facial injury. If you find any of these signs you should presume the added possibility of cervical spine injury.

Symptoms of a basilar skull fracture include blood or cerebrospinal fluid arising from the ear or nose, racoon eyes (bruising around the eyes), and battle's sign (bruising behind the ears).

Care for skull and facial fractures includes maintaining an open airway, immobilising the neck and spine, and treating wounds. Note the patient's change in level of consciousness before the arrival of medical help as these observations may help in the diagnosis of the extent of the injury.

In people with multiple injuries always assume that there is an associated spinal injury. There may be no signs of an obvious fracture, but you must always suspect brain injury. The presence of a head injury is the strongest independent risk factor for injury of the cervical spine.³

Keep a close eye on the person's airway since the incidence of vomiting is higher in people with brain injury. If this happens, roll the person's head, neck, and torso as a unit in case cervical injury is present—this will avoid creating a spinal cord lesion.

The chest

Palpate the clavicles and ribs with your fingers. Check for contusions, abrasions, and flail chest. This results when multiple rib fractures allow the chest wall to become unstable. As the patient breathes in, the negative pressure "sucks in" the unstable segment—this is the opposite of what is meant to happen and is sometimes called paradoxical respiration. Flail chest generally requires a substantial force diffused over a large area to create multiple anterior and posterior rib fractures. A flail segment may be temporarily stabilised with towel rolls, tape, or sandbags placed against it. It is important to realise that many of these patients will also have internal thoracic injuries.

Pelvic fractures

Pelvic springing resulting in tenderness indicates a pelvic fracture. Pelvic springing involves applying alternating gentle compression and distortion over the iliac crests. Disruption of the pelvic ring (consisting of the ilium, ischium, and pubis) requires significant energy and often involves injury to internal organs. As the pelvis is supplied with a rich venous plexus as well as major arteries, fractures may also produce substantial bleeding.

The limbs

Comparing the injured limb with the uninjured one helps to identify angular or rotational abnormalities and shortening. For example, if a leg is in external rotation and shorter than the other, this indicates a hip fracture.

Certain injury patterns are common. A direct blow to the knee for example in a seated car occupant may produce a knee and femoral fracture but also result in hip dislocation or an acetabular fracture. A person landing from a height may sustain compression fractures of the calcaneum ankle, tibial plateau, and cervical and thoracolumbar spine fractures.¹

Careful inspection of the whole limb circumference for swelling and bruising is important. Gently palpate along the axes of all long bones feeling for tenderness, crepitus, and abnormal mobility. Adjacent joints should not be overlooked. The vascular state distal to any injury is important for limb survival. Local contusion and or penetrating injuries can disrupt blood vessels. Examination of skin colour and temperature in association with palpation of pulses may help to exclude a vascular injury. If distal ischaemia is identified more proximal pulses should be checked. It may be important to correct a gross deformity at the fracture site to improve the circulation.

First aid: principles

Evaluation of limb injuries cannot be started until all life threatening conditions have been dealt with. Here are a few general measures that can be applied for any fractures. If you can, carefully cut away all clothing near the fracture site. You need to make sure the fracture has not broken the skin, and you may be able to use the cut away material to aid in splinting. If you find an open fracture, protect the wound from contamination as you would any other.

Splinting

A fracture is immobilised using splinting to prevent the sharp edges of the bone from moving and cutting tissue, muscle, blood vessels, and nerves. This reduces pain and helps prevent or control shock. In a closed fracture, immobilisation keeps bone fragments from causing an open wound, which can become contaminated and subject to infection.

Several principles apply in splinting. Splints should be well padded to avoid damage to skin and superficial tissues. This is often accomplished by using a soft material to cover the injured limb.

When possible, the joints above and below the injury should be immobilised with the splint. Any rigid material such as wood, plastic, or metal can be used to make a splint. The splint should be longer than the bone it is splinting and extend above and below the injury.

MIKE ENGLISH/CUSTOM MEDICAL STOCK, PHOTO/SPL

Surgery to remove scar tissue from a previous fasciotomy

A broken leg should be strapped to the other leg. A broken arm should be strapped to the chest. Broken fingers or toes should be strapped to the neighbouring ones.

Elastic bandages can be used to apply the splint. Care must be taken to avoid applying these dressings too tightly and thus impairing distal perfusion. It is important to reassess the neurovascular status after applying the splint and while awaiting definitive care.

Keep in mind that improvisation is often necessary. For example, if no appropriate splinting material is readily available, a lower leg injury can often be protected by "buddy strapping" the leg to the uninjured leg. Similarly, an injured finger can be secured to the adjacent finger for temporary protection. The injured extremity should also be raised to minimise swelling.

Realigning a joint

In general, do not try to reposition fractured limbs. Unless you know what you are doing, you could sever an artery or nerve. There are two indications for your realigning a deformed long bone fracture (including open fractures). They are to correct or at least improve a sensory or vascular deficit secondary to the fracture (if numbness, tingling, weakness, or lack of pulse beyond fracture) and to align severely deformed long bone fractures to allow splinting with adequate immobilisation.

If a limb has no pulse or is turning purple, repositioning may relieve some unnatural pressure that is pinching off an artery—however, you must consider that a mishandled attempt could result in a sharp bone end severing the compressed artery, making a bad situation much worse.

Angulated fractures make splinting and transport more difficult. They can pinch or cut through blood vessels and are painful for the patient. These must be repositioned so that they can be splinted, as not to splint would be more dangerous. However, it is probably best not to try to straighten angulations of the wrist, ankle, or shoulder or attempt to straighten any dislocated joint.

The primary concern of a suspected rib fracture is to prevent a loose piece of rib from puncturing a lung and causing a pneumothorax. The best course of action here is to keep the patient from moving around, pad and ­gently wrap the chest, and apply a sling to secure the arm.

Remove rings, watches, bandages, or any other object that can compromise the circulation. You can also apply ice or a cold compress to lessen the magnitude of the swelling. In open fractures, time is of the essence, never touch the exposed bone—do not even try to clean it. Manipulation of the fracture without sterility will only ­create problems.

Compartment syndrome

Patients with multiple injuries and reduced tissue perfusion and oxygenation are at high risk of developing compartment syndrome. Compartment syndrome is a clinical condition usually caused by trauma in which increased pressure develops within a closed anatomical space. For example, the deep fascia may envelope the limb and the other fascial planes divide the limbs into compartments. A fascial compartment compromises the circulation and function of the tissues within that space. This compromise in circulation may result in temporary or permanent damage to muscles and nerves.^2-3

Compartment syndrome is normally seen with 48 hours of injury. Typical clinical features include increasing pain despite immobilisation of the fracture; altered sensation in the distribution of nerves passing through the compartment; muscle tenderness; excessive pain on passive movement; and peripheral pulses still being present.¹

Although removing any dressings, casts, or splints may improve things, the patient may require a fasciotomy—a surgical procedure that cuts away the fascia to relieve the pressure.

Summary

The assessment and management of fractures is always secondary to resuscitation and management of the airway, cervical spine, breathing, and circulation. Frequent reassessment of circulation and neurological function of an injured limb are essential. Brain injury, haemorrhages, spinal injury, pneumothorax, and other life threating lesions may be associated. Always look for them and treat them as a priority.

Martin S Roth, first year anesthesia resident, Hospital Italiano de Buenos Aires
Email: Martin.roth@hospitalitaliano.org.ar

Fernando D Perin, first year traumatology resident, Hospital Belgrano

Fabian J Garcia, resident instructor, Hospital Municipal de San Isidro

Isabel Pincemin, clinician, Hospital Municipal de San Isidro

Samena Chaudhry, senior house officer in cardiothoracic surgery, University Hospital North Staffordshire


studentBMJ 2005;13:265-308 July ISSN 0966-6494

1. Driscoll P, Skinner D, Earlam R. ABC of major trauma. 3rd ed. London: BMJ Publishing Group, 2000.
2. Driscoll P, Gwinnutt CL, Jimmerson C, Goodall O. Trauma resuscitation. London: Macmillan, 1993.
3. Morris CG, McCoy EP, Lavery GG. Spinal immobilisation for unconscious patients with multiple injuries. BMJ 2004;329:495-9.