As a paramedic it is common to attend a person who has a fractured limb. Whenever there is significant enough trauma to cause a fractured limb it is important not to focus solely on that injury but complete a full head to toes assessment and keep a high index of suspicion of other fractures or injuries to the person’s body. All too often a paramedic will attend a person who has a clearly deformed tibia/fibula and completely miss the fact that they have fractured their spine.
When a patient has a clearly deformed limb or compounded fracture the first thing that I do is acknowledge that I can see that they have fractured their leg, but want to assess from top to bottom to see if there are any other injuries.
What is a Fracture?
A fracture is any break in the continuity of a bone. Fractures are relatively common and as per the WHO statistics in 2012 the average person is likely to suffer a fractured bone two times in a lifetime. Like most illness and injuries bone fractures are more likely to occur in young children, who are more adventurous and have not yet suffered the consequences; and the elderly who have brittle bones.
There are multiple types of fractures and largely paramedics do not need to know the specific names of each. It is important to understand a basic background about the types of fractures and whether or not the fracture is open or closed. At a very basic level, fractures can be simplified into terms of open or closed fractures. An open fracture occurs when part or multiple parts of the bone break the skin, leading to a much greater risk of infection; whereas a closed fracture does not keeps the skin intact protecting the area from serious infection.
All fractures can be further simplified into the following two categories: displaced and non-displaced fractures. A displaced fracture is where the break causes the now separate pieces of bone to not line up straight. If there are multiple breaks in which each section of the bone no longer lines up, this is called a comminute fracture is normally much more complicated to repair. A non-displaced fracture is where a break has occurred, but the two ends of the bone have maintained their natural alignment.
The following are types of limb fractures that you see, learn about and read about in patient’s notes, but are not necessarily required when performing your duties as a paramedic:
– Greenstick fracture, which is an incomplete crack in the bone where the bone then becomes bent;
– Comminute fracture, where multiple complete breaks in the bone, causing entire sections of the bone to become fragmented;
– Oblique fracture, where the break causes the bone to form a curve;
– Pathological fracture, where a form of pathology such as cancer has caused the fracture as opposed to a direct or indirect force;
– Impacted fracture, where two ends of the bone become compressed during impact.
Steps in Fracture Assessment
As a paramedic, these are the steps that I take to assess a limb fracture and the things that I consider while treating a patient with a suspected limb fracture:
1. Complete the normal steps of assessing any patient through checking the patient’s Airway, Breathing, Circulation, Disability and Exposure.
2. Ask fracture specific history questions, such as:
– What caused the injury?
– Was there a direct or indirect impact?
– Have you ever fractured this limb injury before?
3. Perform a head to toes secondary assessment.
4. Provide adequate analgesia (normally IV morphine or fentanyl).
5. Assess the limb itself – is there obvious deformity, discontinuity to the limb, swelling, pain, discolouration, tenderness on palpation, or any loss of movement or function?
6. Is the fracture open or close? If it is an open fracture it is important to try and keep the area as clean as possible. If there is dirt in the wound (for example the motor cyclist who has broken his leg into dirt) it is important to remove this as much as possible before dressing the wound.
7. Is the fracture in alignment or does it require realignment and traction?
8. Expose the wound and clean with saline soaked dressing if compounded.
9. Assess the colour, warmth, movement and sensation of the limb distally. Compare the injured limb with the uninjured limb. Mark the pedal pulse if the injury is to the leg so that you can easily reassess this later.
10. Splint the fractured limb to provide support and reduce further injury to the surrounding blood vessels, tissues, and muscles.
11. Keep reassing distal perfusion and the patient’s level of pain and analgesia requirements.
The following patients are more susceptible to bone fractures: people have a known diagnosis of osteoporosis, vitamin D deficiency, hypothyroidism, and people who regularly take corticosteroids.