William W. Forgey, MD
Orthopedics part 3 - Fractures
Updated: Nov 13, 2020
Excerpt from The Prepper's Medical Handbook. Page reference numbers point to more in-depth treatment and self-reliant care available within the book.
A fracture is a medical term meaning a broken bone. It is not true that “if you can move the part, it is not broken." Pain will prevent some movement, but this does not aid in the diagnosis between a fracture and a contusion. Fractures may consist of a single crack in the bone and be rather stable, or there may be many cracks and pieces, consequently becoming very unstable. There may be no way of telling which is present, or even if a fracture is there at all, without an X-ray. Deformity indicates either a fracture or contusion causing swelling with soft tissue bleeding if located in the middle of a long bone area, or a possible dislocation or severe sprain with or without a fracture if located at a joint. The hallmark of a fracture is point tenderness or pain to touch over the site of the break. Swelling over the break site is further evidence of a fracture. Another way to deduce the presence of a fracture is to apply gentle torsion or longitudinal compression to the bone in question, with either technique causing increased pain at the fracture site. Each fracture has several critical aspects in its management to consider: (1) correct loss of circulation or nerve damage due to deformity of the fracture; (2) prevent the induction of infection if the skin is broken at or near the fracture site; (3) prevent further soft tissue damage; and (4) obtain reasonable alignment of bone fragments so that adequate healing takes place. The nonskilled practitioner is limited to the first three management techniques. The first aid approach to a fracture is to “splint them as they lie.” This, however, is not an appropriate response in remote areas. Straighten gross deformities of angulated fractures with gentle in-line traction, as in figure 7-1. Before straightening, check and compare the pulses beyond the fracture site on the left and right side of the victim and check for any abnormality of sensation. After correcting the angulation, circulation should improve. As arteries and veins are hollow tubes, their lumens will stretch and narrow if they are forced to bend around a corner, thus decreasing blood flow. When this bend is eliminated, the vessel will return to its normal size and blood flow will improve. As the person could be in shock, it might be difficult to feel the pulses on either side. It is much more accurate to evaluate the circulation by examination of both sides and comparing the results.
Grossly angulated fractures also allow sharp ends of bone to project against the skin surface. Even with careful padding, jostling along during an evacuation may cause one of these bone spicules to penetrate the skin surface, causing an open fracture and increasing the chance of serious wound and bone infection. The chance of causing harm while straightening an angulated fracture would be extremely low. It is possible for a blood vessel or nerve to become trapped within the fracture site, but gentle repositioning into slight deformity should correct this. Pad splints well to prevent skin damage. Pneumatic splints are available from many outfitters. Fracture splinting is generally well covered in first aid courses. Such a course should be taken before any major expedition into the bush. Improvisation is the name of the game in fracture immobilization, and having an adequate first aid course provides one with information upon which to improvise. In general, splint fractures to immobilize the joint above and below the fracture site. Any wound in the skin near a broken bone increases the chance of a bone infection. Follow the principles of thorough wound cleansing as indicated on page 122. With proper splinting, the pain involved with a fracture will decrease dramatically. Provide pain medication when possible. Pain control is discussed on page 31. The Rx Atarax can be given to aid in muscle spasm control. Mild sedation with diphenhydramine (Benadryl) may help its sedating effects. At times there will be uncertainty about whether a fracture exists. When in doubt, splint and treat for pain, avoiding use of the involved part. Within a few days the pain will have diminished and the crisis | may be over. If not, the suspicion of a fracture will loom even larger. OPEN FRACTURE Even a laceration or puncture wound near a broken bone is a cause for alarm. Such a wound can allow bacteria into the fracture site, causing a serious bone infection. This wound requires aggressive cleansing, as indicated on page 123. The wound should not be closed, as this increases the chance of infection. Wet dressings are best over an open wound. Soak the sterile dressing in sterile water, and cover with a clean, dry dressing. Change this dressing twice daily. If a piece of bone is protruding from the skin, the break is called an open fracture. The first aid approach is to splint in position and cover with a sterile dressing. In a remote area this approach will not work. This wound requires aggressive irrigation with surgical scrub or soap as described on page 124. The aggressiveness of this cleansing action should be done in such a manner as not to cause further damage, but the area must be free of foreign particulate matter and as antiseptic as possible. Cover the wound with triple antibiotic ointment. Protect with sterile gauze dressings, with only enough pressure to control bleeding. Straighten the gross angulation of the fracture with gentle in-line traction (see figure 7-1). This will cause the protruding bone to disappear under the skin surface, unless the fragment is loose from the main bone; allow this wound to remain open and dress as indicated above. In all cases of a laceration or puncture wound near a fracture, place the victim on oral antibiotics when available. From the Rx Oral/ Topical Medication Module, use Levaquin, 500 mg daily. However, if the Rx Injectable Medication Module is carried, give Rocephin, 500 mg IM twice daily. Continue the medication until the patient is evacuated or the medication runs out. DIAGNOSIS AND CARE PROTOCOLS The diagnosis of these injuries will be difficult due to lack of experience or the benefit of X-ray equipment. Uncertainties of diagnosis will exist, and therefore a systematic approach to the evaluation and treatment of the injured patient has to be developed that will handle most common injuries appropriately. The orthopedic evaluation is made easier because human beings have equal sides that can be compared. Take the clothing off both the injured and normal sides and compare, weather permitting. Look for swelling or different configuration. When examining the injured side, touch lightly. A fracture or sprain is very tender and will not require hard poking to elicit obvious pain. Swelling results from localized bleeding, which a fracture will almost always cause. Several days after the injury, a bruise may appear near it or lower on the person. Gravity, as well as various muscle groups and local anatomy, can cause this spilled blood to migrate to a place at a different location from the injury site. This does not mean that the injury is spreading; it just represents the displacement of blood and part of the reabsorption process of healing. Don't be concerned about the appearance of bruising and its spread in the days after the injury.
Next week's Orthopedic post will focus on specific treatment for various fractures beginning with the head, neck and spine.