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FRACTURES

A fracture is any bone breakage generally caused by trauma (bangs, falls, etc.) that, according to their severity, may or may not cause fragment deviation. Depending on the skin's integrity, they are classified as:

• Closed fractures, when the bone is broken but there are no wounds in the skin.
• Open fractures, when there is a wound which links the bone and the outside through an opening, and even small bony fragments may be seen. An open fracture is always infected, or may be, that is why it is more severe and urgent than a closed one of the same kind.
  
  
  
  
  
  Picture 7-42: Open and closed fractures.

CLINICAL SYMPTOMS

• Pain, which increases when pressing on the lesion point.
• Deformity of the area, in displaced fractures.
• Swelling, heat and redness of the area.
• Functional impairment, normal movements cannot be made or are restricted.
• Abnormal movements, crackle and snap, or noise when the fracture occurs. These signs should never be checked since they aggravate the lesion.
• Haemorrhage: in closed fractures there will be haematoma (bruise).
• Shock: caused by haemorrhage or pain (refer to Chapter 2.1, SHOCK).

GENERAL ADVICE ON TREATMENT

When we suspect there is a fracture, the subject should avoid any movement of the area. Undress to check any other possible lesions (wounds, haemorrhage, other fractures), trying to cut the clothes carefully so as no to move the patient, and to avoid an increase of pain

In case the fracture is with displacement of bone fragments, do not try to put them in place (reduction), unless there are no arterial pulses beyond the fracture area or there is loss of sensibility, in such cases ask for MEDICAL ADVICE VIA RADIO immediately.

Once the accident victim has been examined treat the pain and immobilise the affected area (refer to the item IMMOBILISATION AND BANDAGES), taking into account that it must block the joints proximal and distal to the fracture, following precautions such as:

• If the accident victim needs to be moved, first apply traction to the injured limb pulling it smoothly and firmly away from the body, before trying to move it.



• If a long bone from the arm or leg bone has been fractured and there is important fragment displacement, it has to be straightened carefully.
  
  Apply traction to the hand or foot and try to put the limb in place once more. (see pictures 7-43 and 7-44). Open joint fractures should not be displaced.
  
  
  
  
  Picture 7-43: Alignment of a fractured forearm.
  
  
  
  
  Picture 7-44: Alignment of a fractured leg.

• If the fracture involves the upper limbs, remove the watch, rings and bracelets as, after a few hours, swelling occurs which might inhibit blood flow to the tissues compressed by such objects.



• Check that the pressure caused by immobilisation is not excessive. Leave fingers or toes exposed to check sensibility (ask the accident victim if he feels anything when we touch or prick him with a needle), mobility (ask him to move his fingers), and blood flow (check skin colour and temperature, and if pallor or coldness appears we will have to take action). If any of these symptoms occur, immobilisation should be released.



• In case of open fracture, stop the bleeding: block and immobilise. In such cases, the inflatable splint may help stop the haemorrhage.

SPINAL COLUMN FRACTURES

Spinal column fractures are severe due to the functional impairment of mobility and stability and the risk of irreversible spinal cord damage. The severing of the spinal cord is caused by displacement of fractured vertebral bodies, and depending on the height of lesion (the closer to the skull, the more severe), it may cause anything from immediate death to limb paralysis.

Column fractures are difficult to diagnose on the accident site. Therefore, we should suspect them depending on the way they occurred (fall from a ladder, back bang, fall from a height, etc.). Under the slightest suspicion, we should act as if there is a column fracture:

• Never bend the subject, (see picture 2-15).
• Do not allow him to sit or move.
• He should never be carried by a single person.
• Do not allow him to bend or twist his head.
• Move as a block, (see Chapter 7.6, IMMOBILISATION AND BANDAGES).
• Immobilise on a hard surface. (see Chapter 7.6, IMMOBILISATION AND BANDAGES).

In case of doubt, it is preferable to ask for MEDICAL ADVICE VIA RADIO before acting

SKULL FRACTURES

These kinds of fractures are important due to the possible involvement of the brain and other important structures inside the skull.

The symptoms may appear afterwards and vary according to the affected area:

• Skull vault (simple or with deformity). There is a head deformity and symptoms range from immediate death to slight headache. Fits and loss of consciousness are common, besides the local symptoms of any fracture.



• Skull base (skull area below the brain which communicates with face bones and neck vertebrae). Fractures in this area may be related to those affecting the first cervical vertebrae, so these accident victims must be handled with care. The symptoms that are indicative of this lesion are:
  
  
  • Loss of blood or transparent liquid similar to water from the nose, ears or both.
  • Haematoma around the eyes, simulating a monocle or pilot glasses, or behind the ears.

Brain lesions can occur with the knock, even if there is no skull fracture.

In case of skull trauma we must:

• Check if there is breathing and heart beat, starting immediately with cardiopulmonary resuscitation if there is not (ver Chapter 1.1 , ASSESSMENT OF LIFE THREATENING SITUATION).
• Explore consciousness level, pupils (size and reactivity to light), kind of breathing and essential life processes (see Chapter 3, PATIENT EXAMINATION).
• Immobilise the neck with a collar, if associated lesion is suspected (see IMMOBILISATION ACCORDING TO BODY AREA).
• Keep in lateral recumbent position (see Chapter 1.5).
• Do not give anything by mouth.
• Warm the patient.
• Ask for MEDICAL ADVICE VIA RADIO as soon as possible and prepare for evacuation.
• Check essential life processes and consciousness level periodically.

PELVIS OR HIP FRACTURES

The subject may complain of pain in the abdomen, groin, thighs or kidneys.

Apply pressure to the hipbones, from the front, downwards and inwards; it should cause pain (see picture 7-45).

Proceed to mobilise as if it were a spinal column fracture and immobilise (see IMMOBILISATION ACCORDING TO BODY AREA).

In these kinds of fractures, bleeding is abundant, so we must prevent a hypovolemic shock (see Chapter 2.1, SHOCK).