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, this should then be treated as an open fracture.

Fractures are painful due to bone deformity and the associated damage to soft tissues 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 a fracture to near its normal anatomical position reduces pain and also vascular, nerve and soft tissue damage. Reduction should be done as soon as possible by a competent clinician (try to avoid prolonged or multiple attempts) after giving adequate analgesia. Adequate traction of the fracture should be followed by immobilisation (Lee and Porter 2005), (Payne, Kinmont and Moalypour 2004). It is imperative to assess and document the neurovascular status of the limb before and after reduction. Often, it is useful (if possible) to take a photograph of an injury before and after reduction, especially if the area is subsequently covered, to prevent unnecessary removal of dressings etc. to allow the area to be seen 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 or muscle damage (including compartment syndrome in closed fractures)
• Infection (especially of 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 an intravenous antibiotic should be considered for an open fracture to reduce the risk of infection. Tetanus vaccination status should be ascertained and passed to the emergency department staff.