Injuries — limbs

• Large amounts of blood can be lost with fractured femur (thigh) or other long bones
• Injuries to hands or fingers can cause long-term problems if not treated properly. If not sure what to do always talk with someone more experienced

Ask

• About pain
• What happened and when it happened

Check

• Head-to-toe exam — with attention to
• Pain, swelling and limb deformity, may mean fracture, damaged ligaments or tendons
• Joint movement — if less or more movement than normal or painful, may mean injury to tendon or joint 
• Compare one side of the body with other
• Check hand or foot of injured limb for
• Pulses and warmth. If no pulse or skin cool — may mean damage to artery (blood vessel)
• Sensation (feeling). If numb (no feeling) — may mean damage to nerve

Do

• If signs of nerve or circulation problems (cool, pulseless limb)
  
• Straighten limb, apply firm traction until pulse returns
• Splint limb to maintain position after reduction
• Medical consult
• Give pain relief

Fractured major bones

Fractures to femur (thigh bone), humerus (upper arm)

Do First

• Put in 2 large bore IV cannula or intraosseous access in unaffected limb if unable to get IV access
• If in shock — give fluid boluses — adult 250mL, child 20mL/kg and assess response
• Treat as closed fracture or compound fracture, as needed

Closed fractures

No skin wounds over fractured bone

Do — if pulses weak, absent or reduced sensation

• Urgent medical consult

Do — if pulses, movement and sensation normal

• Medical consult to send to hospital
• Give pain relief
• Try to put limb back into normal shape. If pulse, sensation or movement no longer feeling normal — stop
• Splint limb, put on back slab or strap to other limb or body so person can’t move joint above or below fracture
• Recheck pulses and sensation
• Keep limb elevated

Compound fractures

Fracture is compound (open) if bone or haematoma (fracture bruise) exposed to outside environment in any way

• When skin broken — high risk of tissue and bone infection
• Bone doesn't always poke through skin. May just be small skin puncture
• If not sure — treat all wounds near broken bone as compound fracture
• Treat facial fractures involving sinuses as compound

Do not

• Do not poke or probe wound
• Do not close or suture
• Do not let person eat or drink anything — will need surgery — consider IV fluids

Check

• Look carefully at broken skin over or near suspected fracture for bone underneath
• Immunisation status — tetanus

Do — manage as closed fracture AND

If signs of shock, altered mental state, more pain than expected, visible necrosis or gas crepitus — urgent medical consult

• Medical consult to send to hospital
• Control any bleeding
• Clean and wash out wound with normal saline
• Cover with sterile dressing soaked in normal saline, then cling wrap laid lengthways
• Give cefazolin IV or intraosseous — adult 2g, child 50mg/kg/dose up to 2g — doses — every 8 hours (tds) until sent to hospital. Can give IM if needed but painful
• If heavily contaminated with material embedded in bone or deep soft tissues — ADD metronidazole IV — adult 500mg, child 12.5 mg/kg up to 500mg twice a day (bd)
  
• If wound has been immersed in water — ADD ciprofloxacin oral — adult 750mg, twice a day (bd)
  
• If allergy to penicillin or cephalosporins medical consult for clindamycin IV — adult 600mg, child 15mg/kg/dose up to 600mg — doses — every 8 hours (tds) until sent to hospital
  
• If injury happened in water — ADD ciprofloxacin oral — adult 750mg, child 20 mg/kg up to 750 mg twice a day (bd)