Fracture is defined as a break of continuity of a bone. It is almost always associated with soft tissue injuries (skin, subcutaneous tissue, muscles, blood vessels and nervous tissue) that surround the bone that fractured. There is associated severe pain, loss of blood and limitation of movement of the relevant joint.
Causes of fractures can be broadly categorized into traumatic, pathological or stress related causes.
- Traumatic fractures occur due to either direct or indirect forces sustained by the bones in events like falls, road traffic accidents, assault etc.
- Pathological fractures are fracture of an abnormal/weak bone with trivial trauma that is insufficient to cause fractures in a normal individual or even without any trauma at all (spontaneous fractures).
Causes for pathological fractures can be categorized in to two broad categories as generalized bone diseases and localized bone diseases.
- Generalized bone diseases are senile osteoporosis, postmenopausal osteoporosis, Paget’s disease of bone, osteogenesis imperfecta, osteomalacia, rickets, primary hyperparathyroidism etc.
- Localized bone diseases are multiple myeloma, metastases from carcinomas of breast, lung, kidney, thyroid, prostate; primary bone tumors like osteosarcoma, Ewing’s sarcoma, chondrosarcoma, osteoclastoma, bone cysts, etc.
- Stress fractures are caused by sustained force (that itself insufficient to cause a fracture) applied on to a bone for a long period. E.g. fractures of bones of feet in in military recruits due to marching long distances with heavy weights.
Classification of fractures according to clinical presentation is important in first aid management of the patient that may change the outcome; there are two main sub categories
- Closed fractures- fracture does not communicate with the external environment.
- Open (compound) fractures-fracture communicates with the external environment; there is very high risk of contamination and later infection of bone; hence it is a medical emergency.
Signs and symptoms
- Swelling of the area
- Restriction of movements
- Deformity apparent in respective area (sometimes there won’t any)
- Loss of function
- Bleeding (+/-)
First aid Management
Depends on type and site of the fracture
- Calm down the victim and ensure safety of victim, yours and others.
- Call for emergency services.
- Do a quick overview survey in a few seconds to identify victim’s condition, sites and type of fractures, bleeding/not, possibility of a head/neck injury and other injuries.
- If the victim is not breathing, check patency of the airway and attend to basic life support. Start CPR immediately.
- If there is a possibility of a head/neck injury with a high degree of suspicion of a cervical spinal fracture, do not move the patient. If you have to, use log rolling maneuvers.
- If there is bleeding from the fracture site try to arrest the bleed; dress the wound with a wad if gauze or a clean towel and press firmly applying constant pressure on the wound. But if there is no active bleeding do not press fracture site because it is very painful and may lead to more damage to fracture site.
- Take photographs if possible with the permission for further management issues and for forensic purposes.
- Keep assessing the vital signs including airway, breathing and circulation until medical help is available.
- Immobilize the fractured limb by splinting. Can use some hard material (e.g. a flat piece of wood) to stabilize the limb. Never try to push or realign the bone.
- Apply splints above and below the fracture to further reduce the movement.
- Apply ice to reduce pain and swelling but do not apply directly to the wound.
- Do not massage the fractured limb.
- Keep the patient fasting; do not give any thing by mouth.
- Observe and treat for shock- lay the person down and elevate the legs only if possible. Cover the patient with a blanket.
- For shoulder or arm injury put a broad arm sling using a large cloth like a towel.
- Give painkillers for severe pain as instructed by doctor over the phone.
Complications of fractures
- Bleeding and shock
- Soft tissue injury [skin, nerves, muscles, blood vessels, viscera (e.g. heart, liver, lung etc.)]
- Respiratory distress syndrome
- Deep vein thrombosis
- Fat embolism
- Compartment syndrome
- Delayed union
- Non union
- Mal union
- Avascular necrosis