Fractures

What is a Fracture?

  • Definition: A fracture is defined as a broken bone, which can either be completely broken or merely cracked.

  • Importance: By the end of the session, participants should be able to recognize fractures and manage patients accordingly.

Causes of Fractures

  • Direct Fracture: Occurs at the point of impact (e.g., fall).

  • Indirect Fracture: Where force is transmitted along the bone, causing injury at a distant point (e.g., femur or hip fractures when knees hit the dashboard during a car accident).

  • Importance of understanding the Mechanism of Injury (MOI).

Mechanism of Injury

  • Twisting Injuries: Proximal part of the limb rotates while the distal part remains fixed (e.g., injuries from football or skiing).

  • Pathological Fractures: Occur from minimal force in patients with underlying conditions like cancer or osteoporosis.

  • Stress Fractures: Common in legs/feet from prolonged activity (e.g., running).

  • Avulsion Fracture: Muscle and tendon units pull off a fragment of bone (common in children and athletes).

Types of Fractures

  • Transverse: Horizontal fracture line at a right angle to the long axis, often from direct injury.

  • Spiral: Curves around the bone, caused by torsion forces.

  • Comminuted: Bone shatters into three or more pieces, typical in high-energy injuries.

  • Oblique: Fracture at an angle to the long axis of the bone.

  • Impacted & Compression: Ends of bones jam together, often without functional loss.

  • Greenstick: In pediatric patients, one side splinters without a complete break.

Open vs. Closed Fractures

  • Closed Fracture: Bone does not pierce the skin.

  • Open (Compound) Fracture: Bone pierces the skin; greater risk of infection due to exposure.

Stability of Fractures

  • Unstable Fractures: Bone ends can move easily, risking damage to nerves, blood vessels, or organs.

  • Stable Fractures: Ends of the bone remain properly aligned, even if the bone is not completely broken.

Limb Fractures

  • Upper Extremity Fractures: Generally not life-threatening but may cause long-term impairment.

  • Lower Extremity Fractures: Associated with severe injuries, potential for significant blood loss (e.g., femur fractures).

  • Management: Realignment of long bones using traction and splinting methods (e.g., box or vacuum splint).

Specific Fractures

  • Pelvic Fractures: Can break in two places due to direct or indirect forces; at risk of damaging internal structures.

  • Patella Fractures: Resulting from direct impact.

  • Calcaneal Fractures: Caused by falls; may include lumbar-sacral compression.

  • Mid-Shaft Femur Fractures: Can cause hypovolemia; traction splinting is essential.

  • Neck of Femur Fractures: Leg may shorten and rotate outward; typically minimal blood loss due to the joint capsule.

Signs and Symptoms of Fractures

  • Support or hold the affected area.

  • Swelling near the fracture site.

  • Loss of function/ability to use the limb.

  • Irregularity or deformity of the limb surface.

  • Pain on injury site or upon movement.

  • Consider tenderness (bony) when pressure is applied.

Clinical Examination

  • Look for deformity, swelling, bruising, and wounds.

  • Feel for deformity and bony tenderness.

  • Move joints carefully, assessing range of motion; stop if it causes pain.

  • Examine joints above and below the injury.

  • Special Tests: Assess motor function, sensation, and circulation distally to the injury.

  • Red Flag: If complications are found, the fracture may be complex or complicated.

Vascular Compromise Assessment

  • Assess for vascular injury in all fractures/dislocations.

  • Check distal to the injury for:

    • Pallor: Paleness of skin.

    • Pulselessness: Absence of pulse.

    • Paraesthesia: Sensation changes.

    • Paralysis: Inability to move.

Management of Fractures

  • Immobilization: Critical to prevent further damage, reduce bleeding, avoid open fractures, and minimize pain. It’s vital for long bone fractures to prevent fat embolism.

  • Fracture Management Protocols:

    • Provide analgesia.

    • Apply a splint to joints above and below the injury.

    • Dress open fracture sites.

    • Conduct neurovascular assessments before and after splinting.

    • Apply gentle in-line traction for alignment where necessary.

Pain Management Strategies

  • Entonox: Nitrous oxide for immediate pain relief.

  • Paracetamol: For pain management.

  • Morphine: Administered via IV, titrated to ensure effective pain relief without compromising BP and respiratory function. Monitor pain scores before and after interventions.

Haemorrhage Management

  • Direct Pressure: Most effective way to control bleeding.

  • Pressure Bandages: To assist in controlling hemorrhage.

  • Elevation: Use alongside direct pressure.

  • Pressure Points: Utilize pressure points like the brachial, femoral, and carotid for additional control.

  • Tourniquet: A last resort option, rarely required in practice.