Fractures and Dislocations

A fracture is a break, either partial or total, in a bone, which is usually produced by injury or violence. Fractures, however, may be the result of old age, or of diseases such as paralysis, or of bone diseases such as tuberculosis or cancer; the fracture is then said to be ‘spontaneous’.

Causes. Fractures May Be Caused By:

  1. direct violence, when the bone breaks at the site of the blow.
  2. indirect violence, when the bone is broken at some distance from the point of impact; in long bones the fracture is then often oblique or spiral.
  3. muscular action, which causes fractures of some small bones such as the knee-cap (patella), or the olecranon of the humerus at the elbow joint.

Types of Fractures

A Simple Fracture is one in which the bone is broken without much injury to the surrounding parts, and without any wound of the flesh. This is also called a 'closed fracture'. A complete fracture may be T-shaped, transverse, oblique, longitudinal, or spiral.

Greenstick Fractures occur in children when the bone bends, and only partially breaks, owing to its soft immature structure (Fig. 1, b).

A Comminuted Fracture is one in which the bone is broken or splintered into several pieces, necessitating great care in handling (Fig. 2, c).

A Compound Fracture consists of a fracture in continuity with an external wound; an end of the broken bone may protrude through the flesh and skin, or the wound may communicate with the bone below, as in a bullet wound. The fracture may be transverse, oblique, spiral, or longitudinal.

A Complicated Fracture is one in which, besides the breaking of the bone, there is dislocation of a joint, injury of blood vessels or nerves, the extensive tearing of the soft parts, or injuries of the bowels, lungs, or some other internal organ. The fracture itself may be transverse, oblique, spiral, or longitudinal.

Fractures of the skull may be stellate, fissured, depressed, etc.

Diagnosis

A fracture can generally be diagnosed by the patient's symptoms, by the signs of appearange of the part, and the history of the accident or injury. When characteristic signs are absent, the diagnosis may be made from a history of sudden severe pain, followed by deformity and local tenderness on pressure; the fracture must be confirmed by X-ray examination. When the injured part is examined, great care must be used so that further damage or pain is not caused; the part should be compared with the corresponding region on the opposite side of the body.

History

The patient's own account may provide some clues as to the likely extent of the injury. Severe crush injuries often cause fractures, and sometimes the bone may have been heard to snap at the time of the accident.

Symptoms

The chief symptom of a fracture is generally pain at or near the site of the injury, with tenderness on pressure. There is also disability of movement or use of the part, with pain on attempted movement. Swelling and deformity may be seen, but are not necessarily present in all fractures. In some cases swelling may mask the deformity, especially at the ankle.

The limb or part may be misshapen or held in an unnatural position, or there may be obvious shortening. If the fractured bone is near the surface of the skin it may be seen to be irregular in outline or shape.

Grating of the bony fragments (crepitus) may be heard when the bone is moved slightly or is examined, but this should never be tested for except by a doctor, since a com-pound fracture or further damage may be produced by unskilled handling.

X-ray Examination

When there is any doubt, the case should be treated as a fracture until an X-ray exam-ination has been made or the patient has been seen by a doctor.

Transport

When the patient is unconscious or when there are signs of injury to the head or spine, especial care must be taken in moving or transporting him.

Associated Disorders due to Fractures

A fracture, apart from the local injury, usually also results in shock; in some cases there may be hmmorrhage, or later there may be reactionary fever, delirium tremens in alcoholic subjects, and other systemic dis-turbances.

Complications

A fracture may also cause injury to surrounding tissues, organs, or other parts of the body immediately after injury, in the course of healing, or as a result of unsatisfactory healing.

Arteries

Hxmorrhage, gangrene, or aneurysm may follow a fracture causing damage to a main artery.

Veins

Clotting, or swelling of the part, may be caused by injury of a vein near a fracture. This may lead later to a contrao-ture of the muscles.

Nerves

There may be immediate loss of sensation or power of movement as a result of a fracture causing injury to a nerve, or later symptoms of nerve involvement may follow, such as tingling, numbness, weakness, or even paralysis.

Joints

Adhesions and loss of movement may lead to arthritis, or dislocation may occur.

Other Organs

In fractures of the skull, pelvis or ribs, injuries to the brain or abdominal organs or lungs may be severe.

An Impacted Fracture is one in which the broken ends of the bone are driven into one another.

Separation of an Epiphysis (the developing end of a bone) may occur in young persons under the age of twenty-five, when the parts of the bone are not all ossified (or joined together by bony tissue). Growth of the bone may be affected, and deformity produced.

Spine

In fractures of the spine the great danger is injury to the spinal cord, which may be followed by paralysis or even death.

First-aid Treatment

The aim of first-aid treatment of a fracture is to prevent further injury being done to the part, especially to prevent a simple fracture from becoming compound or complicated, or a compound fracture from becoming infected or complicated.

  1. Promptness. As a general rule the patient should be attended to on the spot, since careless or inexpert handling in moving him might increase the effects of the injury. Often a provisional stretcher, splint, sling or other support can quickly be found and applied, as when someone is injured in a busy street, or when it is necessary to take a patient to hospital. Unless the patient is in danger from hfemorrhage or some other form of risk, therefore, always render the part im-movable by some splint or support, before removing him.
  2. Haemorrhage. When bleeding occurs it must be attended to at once. Place the patient in a comfortable or suitable position, expose the injury and apply pressure by means of the fingers and thumb on the appropriate pressure point. Then use a sterile pad and bandage to control the bleeding.
  3. Support the injured part, placing it with great care in as natural a position as possible.
  4. Splints, Bandages and Slings should be used as required in individual cases.

Splints should be firm, and sufficiently long to support the joints above and below the fracture. They should be light and strong, and at least as wide as the limb. Wooden or light metal splints are generally used, but sticks, strong cardboard, brooms or umbrellas etc. may be used as temporary emergency substitutes. Whatever form of support is used should be well padded on the surface next to the limb with cotton wool, tow, or other soft material. When no splint is available for first aid, an injured arm may be very carefully bound to the body; a fractured leg should always be tied to its fellow for additional support, with wide bandages round the thighs, above and below the knees, at the ankles and round the feet.

Great care must be used when applying the splints and bandages so that the injured part is kept well supported and the bones are not further displaced. Bandages must be applied firmly but not too tightly, to hold the splints in position. The upper bandage should always applied first.

A Stretcher may be improvised in an emergency by using a hurdle, shutter, door, or broad piece of wood covered with rugs, coats or straw; over these is laid a piece of sacking, a rug or blanket which is useful for lifting the patient off the stretcher.

An alternative method is to pass two poles through the sleeves of two or three coats turned inside out. The coats are buttoned up. Strips of wood bound to the ends of the poles complete the stretcher.

A stretcher of some sort must be obtained as soon as possible and should be covered with padding, blankets or garments; the stretcher should be gently slid beneath, and the patient laid on it by a sufficient number of people to raise him easily from the ground. The stretcher should then be carried by four people, two at each end, moving steadily with great care, and keeping exact step with each other. If these persons take hold of the ends of two poles fixed under the stretcher, they will find they can carry it much more easily.

Union of Fractures

The union of fractured bones is slower than that of severed skin or muscle. If the ends or parts of the bone are kept steadily in position together, they soon become surrounded by a blood clot called 'primary callus' which gradually becomes converted into bone.

Callus is formed between the bone and the outer covering membrane or periosteum (external callus), in the marrow cavity (internal callus), and between the bone ends (permanent callus). An internal or external callus gradually disappears after union of the bone fragments. Callus takes from two to three weeks to form, and is converted into bone in about six or eight weeks in favourable cases. In old persons, union of the broken bone fragments may, however, be delayed for weeks or months, or there may be fibrous union, or non-union.

Time Required for Union. Fractures of the ribs and collar-bones normally unite with comparative firmness in about a month; fractures of the arm unite in six weeks and those of the thigh and leg in eight weeks. A broken bone will unite much sooner in a robust and healthy person than in a debilit-ated patient, and sooner in young than in old people.

The time required for the splint or plaster case to be worn varies with the part injured, the severity of the injury, the health of the patient and any associated complications.

Massage is generally required and should be started as soon as possible; this must be given by a skilled exponent.

Delayed Union or Non-Union, in which the fracture fails to unite within a reasonable time, may occur.

Non-union may be absolute, with no formation of new bone, or there may be fibrous union, or a false join. Non-union may be due to great destruction of part of a bone, to imperfect fixation, or to the pressure of some soft tissues between the bone ends. An inadequate blood supply, old age, rickets, syphilis, or some other bone disease also favour non-union. Non-union is said to be present when the bones are not united twelve months after a fracture has occurred. Massage should always be given, and the general health must be improved.

Surgical treatment by bone-grafting, wiring, or other methods may be required to assist the union of the bone fragments.

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