Fractures

Closed fractures are those where the cortex of the bone has been broken but the integrity of the skin has not been interrupted. When this integrity has been breached, the fracture is termed as open (formally “compound”). This is usually caused by bone fragment or a laceration to the skin. If a fracture and a wound exist in the same limb segment then this should then be treated as an open fracture.

Fractures are painful due to the bone deformity and the associated damage to soft tissue and possibly nerves and blood vessels. Immobilising the fracture reduces the likelihood of further injury and reduces pain by limiting unnecessary movement.

Early reduction of the fracture to near its normal anatomical position reduces pain and also vessel, nerve and soft tissue damage. Reduction should be done as soon as possible by a competent clinician (try to avoid prolonged attempts) after giving adequate analgesia. Adequate traction of the fracture should then be followed by immobilisation (Lee and Porter 2005), (Payne, Kinmont and Moalypour 2004). It is imperative to assess and document the neuro-vascular status of the limb before and after reduction. Often, it is useful (if possible) to take a picture of the injury before and after reduction, especially if the area is subsequently covered, to prevent unnecessary removal of dressings etc. to inspect the area by those who were not present initially.

There are governance issues related to taking photographs of injuries, particularly if the patient is not able to give consent. Practitioners must be familiar with these and ensure they act appropriately.

Complications of fractures include:

  • Haemorrhage
  • Nerve and muscle damage (including compartment syndrome in closed fractures)
  • Infection (especially in open fractures)
  • Fat embolism.

Wounds should be thoroughly cleaned with normal saline (assume that the pitch/surface is contaminated). Those overlying an open fracture should be covered with a clean, saline-soaked, dressing. A bolus of intravenous antibiotic should be considered for an open fracture to reduce the risk of infection if the transfer to the emergency department is likely to be prolonged. Tetanus vaccination status should be ascertained and passed to the emergency department staff.