Broken bones — simple and compound fractures

Assessing and managing possible fractures

Do not

• Do not use the following (HARM) in first 2 days (48 hours) — may make associated soft tissue injuries worse —
• Heat
• Alcohol, aspirin, anti-inflammatory medicines
• Running, strong exercise
• Massage

Ask

• Pain — when it started, is it getting worse
• Swelling and disability
• How did it happen, were there any witnesses
• What caused the break
• High speed (eg car accident) — could be more serious compound fracture
• Low speed (eg simple fall) — could be underlying pathological cause (eg osteoporosis)
• Repetitive movement causing pain (eg running) — could be stress fracture

Check

Compartment syndrome

• Surgical emergency
• Diagnosed using the Ps
• Pain keeps getting worse even after pain relief, worse than expected for injury
• Poor circulation (cool skin) — Pallor (hands, feet) and Pricking skin are late signs
• Passive movements make pain worse, especially bending toes or fingers back (extension)
• Paresthesia (tingling) and Progressive Paralysis follow
• Do not wait for loss of Peripheral Pulses — Figure 10.1. May be too late to save limb

Signs of fracture/dislocation

• Swelling 
• Most injuries swell. Keep checking to see how much swelling there is — very important if bandages, splints, casts or slabs used
• If swelling happens very quickly — consider fracture, dislocation, ligament/tendon rupture and torn artery
• Skin — compound fracture will have break in skin
• Bones — at wrong angle (deformity), tender when palpated on all sides
• Do not palpate obviously broken bone — causes pain
• Do not try to produce bone grating (crepitus) — causes pain
• Gently feel bones that may be broken
• Joints 
• On either side of injury (proximal and distal)
• Abnormal shape (deformity) or movement
• Movement — may be limited

Signs of problems caused by fracture/dislocation

• Cool or cold limbs — may mean arterial injury
• Peripheral pulses — Figure 10.1. Weak or none may mean damage to artery
• Sensation — reduced or altered feeling may mean nerve injury or compartment syndrome
• Worsening pain or muscle group feeling tense and firm — may mean compartment syndrome

Related injuries and complications

• Internal bleeding, organ damage, nerve damage
• Allergies or adverse reactions that will affect choice of analgesia, dressings, antibiotics
• Age 
• Children — consider greenstick fractures, growth plate injuries, physical abuse
• Elderly — bones weakened by disease (eg osteoporosis, cancer) can break with very little force (pathological fractures). Injury may be caused by existing medical condition — fall due to dizziness, sepsis, arrhythmia, stroke, internal bleeding, medicines

Do

• If signs of nerve or circulation problems (cool, pulseless limbs)
  
• Straighten limb, apply firm traction until pulse returns — maintain traction or apply splint and recheck pulse and capillary refill
• Medical consult — consider nil by mouth and IV fluids
• Give pain relief — medicines (analgesics), splints
• Take off any jewellery, watches, rings. Keep them somewhere safe
• If you suspect compartment syndrome
  
• Loosen bandages/slabs/splints
• Keep limb level with heart
• Medical consult

• Treat with RICE — relieves pain and swelling
• Rest — immobilise broken limb using sling, splint/slab
• Ice — apply ice or frozen peas for 15–20 minutes every 1–2 hours, then gradually less often over next 24 hours. Do not put frozen material directly on skin
• Compression — apply compression bandage over splint/slab to reduce swelling, give support, immobilise. Bandage should be firm but not tight enough to cause pain. Put on during and after ice
• Elevation — lift (elevate) in sling or with pillows after putting on splint/slab, to prevent swelling. Lower limb fracture should be higher than pelvis
• See Bandaging, Splinting, Slings, Plaster of Paris slabs
• See Fracture types

Keep checking

• End of limb for signs of poor circulation (blood supply) — see compartment syndrome
• Swelling — are bandages too tight

Compound fractures

If bone exposed to outside environment — compound or open fracture

• Bone does not always poke through skin, may just be small skin puncture
• Treat all wounds near broken bone as compound fracture — high risk of infection
• Treat facial fractures involving sinuses as compound fractures

Do not

• Do not poke or probe wound
• Do not suture wound if there could be fracture underneath, except for haemorrhage (bleeding) control
• Do not let person eat or drink anything — will need operation — consider IV fluids

Check

• Look for exposed bone
• Feel for distal pulse and sensation
• Immunisation status — tetanus

Do

• Control any bleeding — realign broken bone, apply pressure, suture if needed
• Clean and wash out wound with normal saline in syringe
• Cover wound with sterile, saline-soaked dressing
• Put on back slab or splint, depending on site of wound
• Medical consult about IV antibiotics and fluids — see Injuries — limbs

Fracture types

Fractured skull

• See Injuries — head

Fractured nose

• If nose broken and still crooked after 1 week or can't breathe through 1 side — may need to be straightened. Medical consult about surgery
• Broken nose usually sets by 2 weeks, so need to decide before then

Fractured jaw

• See Dental and oral problems

Fractured clavicle (collarbone)

• See Splinting collarbone

Fractured hand/arm

• See Splinting, Plaster of Paris (POP) slabs

Fractured fingers/toes

• See Splinting single finger/toe

Fractured ribs

• See Injuries — chest

Fractured pelvis

Note: Fracture at front of the pelvis (pubic rami) may present with no deformity or visible bruising, but tenderness and pain on weight bearing (standing and walking)

• It takes a lot of force to fracture pelvis
• If high impact trauma — often vascular, bladder and/or abdominal injuries as well

Do not

• Do not spring pelvis (pushing up and down on pelvic brim or iliac spines)
• Do not let person eat or drink anything — may need operation — consider IV fluids

Check

• Signs of haemorrhage (internal bleeding) — fast heart rate, low BP, poor perfusion (blood circulation). Can be immediately life threatening

• Signs of shock
• Increased RR
• Pulse weak and fast (adult more than 100bpm, child fast per age appropriate REWS) or difficult to feel, older people with heart problems may not get fast pulse
• Central capillary refill longer than 2 seconds
• Pale, cool, moist skin
• Restless, confused, drowsy, occasionally unconscious
• Low BP for age or relative to person's previously recorded values
• Posture — rotation/shortening of lower limb
• Pain around hips when moving
• Palpate for focal (localised) tenderness
• Blood coming from urethra, scrotal/perineal bruising
• Record if visible blood in the urine

Do

• If signs of shock — give high flow oxygen
• If multi-trauma without shock (eg chest or head injury) — give oxygen to target O₂ sats 94–98% OR if moderate/severe COPD 88–92%
• See — Splinting
• Put in IV cannula, largest possible. Start IV fluids to maintain blood volume and hydration
• Put in second cannula — largest possible
• Medical consult
• Consider indwelling urinary catheter — female, male

Fractured knee, ankle or foot

Check

• Use Ottawa rules (below) to help assess injury
• If x-ray not needed — see Sprains and strains

Ottawa knee rules

• Knee x-ray only needed if any of 
• Under 18 or over 55 years
• Tenderness of patella (knee cap) only — no bone tenderness in other parts of knee
• Tenderness at head of fibula
• Unable to bend knee to 90°
• Not able to weight bear straight after injury or when examined in clinic — takes 4 steps, can't weight bear twice on each leg even when limping

Ottawa ankle rules — Figure 10.2

• Ankle x-ray only needed if pain in malleolar zone AND any of
• Bone tenderness at A — posterior edge (6cm) or tip of lateral malleolus
• Bone tenderness at B — posterior edge (6cm) or tip of medial malleolus
• Not able to weight bear straight after injury or when examined in clinic — takes 4 steps, can't weight bear twice on each leg even when limping

Ottawa foot rules — Figure 10.2

• Foot x-ray only needed if pain in mid-foot zone AND any of
• Bone tenderness at C — base of 5th metatarsal
• Bone tenderness at D — navicular
• Not able to bear weight straight after injury or when examined in clinic — takes 4 steps, can't bear weight twice on each leg even when limping

Do

• If fracture likely — see Splinting, Plaster of Paris (POP) slabs