Fracture Management

Bio Medicine Emergency Med Dr. Spencer Shimabukuro

Fracture Management

Introduction
Rarely

life-threatening

Proper

handling can reduce the amount of

pain
Future

function may depend on how the fracture was handled

Life or Limb Threatening Emergencies Condition

Open

Possible outcome
Osteomyelitis Amputation

fracture

Fracture/dislocation

with major vascular disruption

Major

pelvic fracture

Exsanguination

Hip

dislocation

Avascular

necrosis of the femoral head contracture, renal

Compartment

Ischemic

syndrome

Compartment Syndrome

Compartment Syndrome

A potential emergency condition where excess pressure builds up in an enclosed part of the body (or compartment)
The pressure may cut off blood to affected tissues May kill organs and tissues leading to amputation and even death May lead to irreversible muscle and nerve damage Legs, arms, and abdomen are most prone to compartment syndrome

Usually due to injury/wound such as a broken bone May take just several hours to develop

Fractures & Dislocations

Fracture: A break in a bone produced by excessive strain or force on the bone. Causes include a blow, a fall, a twisting movement, or even no apparent cause (spontaneous fracture).

Types of Fracture

Open Fracture (compound): has penetration of the skin and bleeding. Closed Fracture (simple): has the skin intact. Stress Fracture: is a small fracture usually in a weight bearing bone
It

is an overuse injury that is caused when muscles fatigue and excess physical stress is transferred to a bone. Tibia - runners Tarsals, calcaneus, and toes of the feet runners Vertebrae osteoporosis and cancer

CLASSIFICATION OF FRACTURES

Types of Fractures

Transverse - fracture runs perpendicular to the axis of the bone Greenstick in youth, bone bends and breaks Oblique fracture runs at an angle to the axis of the bone Comminuted bone is broken into several pieces (at least 3 different pieces) Stress bones fractures due to pressure or stress put on it Spiral due to twisting motion

DISLOCATION

Dislocation: is a separation or displacement of joint, with a structural loss of joint stability.

It

may or may not be accompanied by a fracture (fracture-dislocation). It is usually caused by an injury such as a hard blow or fall.

Treat a dislocation as a fracture, and seek medical attention immediately. You can cause a lot of damage by trying to reinserting a dislocation yourself

PERIPHERAL FRACTURES
Mechanisms of Injuries Variety of Forces
If

biomechanics is known it may be possible to predict.

Direct blow: injury at the point of impact. Indirect blow: injury caused did not occur at the point of impact, but rather at a point some distance away, due to forces transmitted along the bone.

PERIPHERAL FRACTURES
Mechanisms of Injury Twisting Forces: typically the distal part of the extremity remains fixed while torsion develops in a more proximal part of the limb.

Commonly occurs in football or skiing.

Violent muscle contractions

Avulsion fractures

Fatigue/stress fractures Pathologic conditions

PERIPHERAL FRACTURES
Signs and Symptoms
(General)

Pain at fracture site Patient heard the bone snap or pop. Deformity or unnatural movement SHORTENING of the extremity. Swelling/bruising Guarding/loss of use Crepitus Exposed bone ends

PERIPHERAL FRACTURES
Initial Treatment Keep the patient still ABCDS Call 911 Observe for signs of hypovolemic shock due to internal bleeding Immobilize broken bones and joints
Prevent further injury Minimize pain and discomfort Reduce swelling and bleeding

How to Test for Fractures

A 128 Hz tuning fork can be used to test for fractures Hit the tuning fork to cause it to vibrate Place on potential fracture The vibrations will vibrate the bones and cause it to hurt About 80% accurate
Mostly accurate on long bone and ribs May miss the toes the most

PERIPHERAL FRACTURES
Splinting Splints are applied to suspected fractures, dislocations and severe sprains. The objective is to immobilize the joints above and below the injury. Applying a splint reduces the movement of injured muscles and bones, and allows the patient to be transported with less pain and risk of further injury. It also reduces the risk of shock by decreasing internal bleeding.

PERIPHERAL FRACTURES
Splinting Splints can be made from a variety of rigid or firm materials, including cardboard, a tree branch, a broom handle, or a tightly rolled blanket or magazine. An injured limb can also be protected by Buddy Taping it to another part of the body.

PERIPHERAL FRACTURES
Splinting Procedure
1. 2. 3. Explain the procedure to the patient. Check PMSC (pulse, motor, sensory & capillary refill) before & after splinting. Control any bleeding, expose the fracture site by cutting clothing & removing shoes & socks (except for ankle/foot injuries). If you are splinting an upper extremity injury, remove rings, watches or other jewelry. Swelling may make it difficult to remove jewelry at a later time. Control bleeding Select an appropriate splint that is longer than the bone it will need to support. Measure the splint against the uninjured limb to obtain an approximation of the correct splint size.

4. 5.

6. 7.

Pad the splint with soft materials to relieve local pressure. Apply the splint

Use tape or binding to secure the splint in place above & below the injury site

PERIPHERAL FRACTURES
Treatment

Record status of distal pulse

PERIPHERAL FRACTURES
Treatment

Record status of capillary refill time

PERIPHERAL FRACTURES
Treatment

Record status of distal sensation

PERIPHERAL FRACTURES
Treatment

Record status of distal motion Record status of distal strength

PERIPHERAL FRACTURES
Treatment Splint joints as found

Do not try to realign a broken bone or reduce a dislocation yourself. You may damage the joint, muscles, nerves or blood vessels or even fracture a bone.

Do not push bone ends back beneath the skin. Immobilize the joints above and below the injury. Try not to move a victim unless absolutely necessary.

Immobilize all fractures before moving the patient.

PERIPHERAL FRACTURES
Treatment/Splinting

Pad rigid splints generously Leave distal pulses and fracture site accessible

PERIPHERAL FRACTURES Splinting

PERIPHERAL FRACTURES
Treatment/Splinting

Reassess distal pulse

PERIPHERAL FRACTURES
Treatment/Splinting

Reassess distal sensation

PERIPHERAL FRACTURES
Treatment/Splinting

Reassess motor/strength

PERIPHERAL FRACTURES
Treatment Elevate the injured extremity if possible Apply cold pack When in doubt, splint Continue to reassess vascular and neurologic status after splinting DO NOT give the victim food or fluids.
This

may delay any necessary surgery.

Specific Fractures:
Assessment and Treatment
Shoulder Clavicle fracture Scapula fracture Acromioclavicular separation Signs and Symptoms
Dropped shoulder Holding arm across the chest Inability to raise arm Point tenderness Distal numbness

Specific Fractures: Assessment and Treatment Shoulder Treatment

Have

the patient sit or lie down Support arm Sling and swath; position of comfort; pad or pillow under upper arm.

Specific Fractures: Assessment and Treatment Humerus Signs & Symptoms

Same

as general fracture Possible wrist drop Numbness or tingling

Treatment
Same

as general splinting and shoulder

Specific Fractures:
Assessment and Treatment Elbow Signs & Symptoms (same as general) Treatment
If

arm is bent

DO
If

NOT STRAIGHTEN Sling and swath

arm is straight
Do

not bend Place pad under armpit Splint elbow Lay patient down and elevate alarm

Specific Fractures: Assessment and Treatment Forearm and Wrist Signs & Symptoms
Same

as general as general

Treatment
Same

Specific Fractures: Assessment and Treatment

Hand

Signs & Symptoms

Same

as general

Treatment
Crush

Injury

Do

not cleanse wound Put ball of soft cloth in patients hand Split in bandage and imposition of function Support with sling Observe circulation
Closed

Fracture: same as general

Specific Fractures:
Assessment and Treatment
Hip Signs & Symptoms
Pain

at sight and proximal groin Pain and tenderness pressing on a greater trochanter Injured side foot turns out Affected limb shortened

Treatment
Assess

CSM Place folded blanket between the legs

Specific Fractures: Assessment and Treatment

Femur Signs & Symptoms
Severe

pain Loss of distal pulse Shortened leg Hypovolumic shock

Treatment
Control

bleeding Traction splint High flow oxygen

Specific Fractures: Assessment and Treatment Knee, Tibia/Fibula, Ankle and Foot Signs & Symptoms
Same

as general as general

Treatment
Same

FRACTURE MANAGEMENT
Summary Rarely an immediate threat to life. A fracture can wait, the airway or severe bleeding cannot. If you do not check for neurological deficit, you will not find it. When in doubt, treat the injury as a fracture.