Fractures

Introduction

A fracture is classified when the integrity of the bone is compromised. A crack or break is synonymous with fracture. So many of my patients come in and when I ask about past history of fractured bones they say, “No, I just cracked it.” A break is a fracture, a cracked bone is a fracture. When there is a break in the skin along with a fracture this is determined to be an open fracture. In terms of concern for infection, there is no difference in diagnosis with a bone sticking out of the skin vs skin disruption and the break being deep and not protruding. Both are considered an open fracture. The distinction is important for antibiotic therapy to avoid bone infection (osteomyelitis.) This is very important in the outdoors for transport and the importance of expediting the transport depending on the severity of the potential fracture.

Pathophysiology of bones

I will keep this as simple as possible. Inside bones, the bone marrow is a spongy substance where stem cells are born. Stem cells are immature red and white blood cells as well as platelets. When bones break they bleed and this can be a helpful assessment to determine if it might be broken. (Especially when you are days from transport.) If the area becomes very swollen and black and blue within 24 hours, there is a good chance you are dealing with a fracture.

Fracture Symptoms

The individual will clearly have pain and possibly swelling. It is a myth when someone says, “ I know I did not break it because I can move it.” There are so many supporting structures around bones that it is the vast majority that can move an extremity even when broken. I had a 60 year old male walk into the clinic unsupported with a fractured hip. So, nothing surprises me. Check with the non-injured side of the body and compare. Is there a change or deformity? Measure. If you do not have a measuring tape, use para-chord or string to measure the non injured circumference and then the injured. You can do this over time to see how much worse the swelling is. Check for cold of the skin farthest away from the fracture as well as sensation. You are checking for neuromuscular stability. Did the bone effect a major vessel or did it nick a nerve?

Fracture Treatment

1. Assess for severity and check joints above and below injured area. If someone had a rock or log fall on their forearm, it is important to assess the wrist joint and elbow joint for any diminished motion and/or pain.
2. Remove clothing from the effected area to assess skin and the severity of injury. Is the skin broken? How much bleeding, (if any), and visual deformity? Is there a foreign body impaled in the injured area?
3. If bleeding, you should irrigate. Bandage with or without pressure dressing depending on severity and splint the injured area making sure you splint one joint above and below the injured area.
4. Elevate as much as possible within the comfort level of the injured party.
5. Apply ice if available. Cold water in containers can also be helpful.
6. Pain management. Ibuprofen and Tylenol as discussed in Wilderness Medicine Kits.
7. Reduce or not to reduce? Literally 99% of these will not be reduced in the field nor should they. The only time that should be attempted is if you are greater than 7-10 days out from reaching care. This usually only occurs in long mountain expeditions. It is not uncommon for may orthopedic surgeons to wait and reduce for about seven days as it allows swelling to decrease. Remember to be diligent and thorough but not to rush through the above interventions. When someone is in pain the one rendering care often panics. Slow down and reassure the injured party as well as yourself.