▷ The FIRST AID: for FRACTURES. What IS? TREATMENT

Fractures are classified as:

• Incomplete fractures: these are sometimes a simple fissure (crack) in the bone matrix, a typical injury to the long bones of children, which are called greenstick fractures. This type of fracture is characterized by the bone being partly broken and partly bent, as happens when a green stick is strongly bent.

• Complete or closed fractures: these are those that occur when the skin covering the ends of the fractured bone is intact.

• Open fractures: these are when the bones pierce the skin or the fracture site communicates with the outside. They are also called exposed or compound fractures.

• Complicated fractures: these are those in which, in addition to the bone injury, there is injury to an important blood vessel, a nerve or some organ, etc.

• Wedged fractures: these are where one of the fragments penetrates the other.

• Epiphyseal fractures: these are when the fracture is located at the end of the bone. Diaphyseal fractures: these occur when the fracture is in the body of a long bone.

• Articular fractures: these occur when an epiphyseal fracture penetrates a joint.

• Comminuted fractures: also known as comminuted fractures, these occur when the fracture generates two or even more fragments in the bone.

• Transverse, oblique and longitudinal fractures: these are classified according to the direction of the fracture line.

Fractures are generally caused by blows, falls or sudden impacts, such as car crashes, and violent muscle contractions.

The fracture can occur at the same place where the injury occurred (direct fracture) or, more frequently, at a distance (indirect fracture). Indirect fractures can occur due to bending, crushing or pressure, and by twisting.

On the other hand, causes that also influence a fracture are advanced age and some diseases of the bones and nervous system. Likewise, fractures can occur due to any common movement, such as turning over in bed, putting on shoes, etc.

The main symptoms of fractures are: pain, functional impotence (inability to move the limb or region), deformation, crepitation and abnormal mobility.

The first two symptoms have been called subjective, as they are perceived exclusively by the patient. The others are called objective, as they can be verified by the observer.

Not all of these symptoms are always present and the last two should not be provoked to avoid further harm to the patient.

The pain of fractures is extremely intense, deep, localized, and increases with movement. When the fractured bone is palpated with the tip of a finger, pain is felt when reaching the fracture line.

Functional impotence, that is, the inability to make movements with the affected part, although it may not exist in incomplete or embedded fractures, and may appear with dislocations and sprains (twists). It is a useful principle to consider as affected by a fracture any person who cannot use one of their limbs after a trauma.

Deformation occurs when a bone is fractured and the fragments move. The bones may cross (overlap), in which case, when compared with the healthy limb, the fractured limb will be shortened.

In other cases, what is called angulation occurs, in which each of the fragments adopts a different axis, forming an angle between them, which will manifest in the fractured limb as an abnormal bend.

Finally, a rotation of the fragments may occur due to muscular action or the weight of the limb. This is especially common in femur fractures, where the foot and leg can be seen to be rotated outwards on the fractured side.

Crepitation is more than a noise, it is a tactile sensation of rough friction, produced by the rubbing of the bone ends against each other. Sometimes it is discovered when moving the traumatized limb, but although it is very valuable in diagnosing the fracture, it should not be looked for.

Abnormal mobility is another symptom that allows us to confirm that there is a complete fracture, because for a thigh, arm, forearm or leg to be able to move in a place without articulation, there must inevitably be a fracture of the bones that normally give it rigidity.

This important sign should not be provoked, because the extremity of the bone fragments can injure vessels or nerves and also increase the pain. It is advisable, however, to observe carefully, in case it occurs during the examination or emergency treatment of the trauma.

Other less common symptoms of fractures are traumatic shock, late ecchymosis (bruises that appear hours or days after the fracture), blisters that are seen more frequently in the case of tibia fracture and even an increase in body temperature for a few days.

The first aid procedure and treatment for an open fracture is:

• If there is significant bleeding, stop it. Try to avoid shock.

• If the bone comes out through the skin, do not push it back in. Let the surgeon decide what to do.

• If you have it on hand, place sterile gauze or dressings over the wound, and cover everything with sterile gauze. If sterile gauze is not available, use a handkerchief or other clean cloth. Keep everything in place with a bandage.

• Immobilize the fracture.

• The fractured person should be taken to the doctor as soon as possible after the accident.

• If for any reason medical help is delayed, give penicillin injections.

The first aid treatment for closed fractures is:

• First of all, immobilize the affected limb or limb segment in a normal position. The only exceptions are if there is a lot of bleeding or shock, which of course must be treated as soon as possible.

• If possible, also immobilize the joint above and below the fracture. To immobilize, use whatever material is closest at hand: cardboard, thin boards, especially plywood, thick tree bark, pita leaves with the prickly edge removed, folded newspapers or magazines, pillows reinforced with boards, walking sticks, umbrellas, branches, rifles, tin, etc.

• The material used for immobilization is called splints. When applying them, try to move the fractured limb as little as possible. If it is absolutely necessary, the pain will be less intense if you move it en masse, trying not to bend it at the fracture site. If there are several people, one person can hold the upper limb of the limb, while others hold the lower limb slightly taut. The person giving first aid prevents the fracture from moving.

• It is advisable to pad the points where the bones are under the skin and must come into contact with the splints with cotton, wool, rags, bran bags, etc., where the bones are under the skin and must come into contact with the splints.

• When the fracture occurs in the upper limb, once the splints have been placed and held in place with bandages or handkerchiefs, the arm is usually held against the body by means of a wide sling.

• Make sure that the bandages, handkerchiefs, etc., with which the splints are fixed to the fractured limb, are not too tight, thus compromising the circulation and vitality of the limb. Watch the fingers of the fractured limb. If they become cold, or numb, or swell or turn blue, it is very likely that the compression is excessive and the bandage must be loosened immediately. Try to keep the patient as comfortable as possible. Avoid letting him get cold. Calm him down. It is not always essential to remove the clothing, unless it is bothersome or if you suspect there is a wound or bleeding.

• If the affected part has to be undressed, it is preferable to cut the clothing near a seam or unstitch it, rather than make him suffer by removing it in the usual way.

• If you cannot find a doctor or ambulance, it may be necessary to transport the injured person to a hospital for definitive treatment, which is always a job for a doctor and not for some amateur.

In clavicle fractures, the fractured person cannot normally use the arm on the affected side, and holds it with the other arm at the elbow. By looking at and touching the affected clavicle area, the symptoms of a fracture can be checked.

First aid for a clavicle fracture is:

• Fold two scarves diagonally. Make a ring with each of them, tying the ends together. Pass one of these rings through each arm up to the shoulder. Join the two rings behind the back with another scarf, or better yet with some elastic material. By lifting and holding the shoulders back, the fracture is reduced and at the same time immobilized.

• Support the upper limb on the fractured side with a sling.

• A similar result can be obtained by passing a bandage in the shape of an 8 over both shoulders and crossing it at the back.

• Be careful not to press too much at the armpit level, thus disturbing the circulation in the arms. Put the arm on the affected side in the sling.

• Hold the patient's elbow at a right angle and the forearm across the chest.

• Place 2 padded splints on the arm, one from the armpit to the elbow and the other from the shoulder to the elbow on the outside of the arm, and keep them in place by tying a handkerchief near the armpit and another near the elbow.

• Support the wrist with a narrow sling, so that the weight of the arm itself tends to hold the bone fragments in place.

• It is advisable to secure the arm to the trunk by means of a bandage or a piece of cloth folded along its length.

• If the arm is extended (which is usual), the first aider would do well to keep it in this position with a splint that extends the entire length of the arm and forearm from the armpit. Although flexing the elbow at an acute angle usually keeps the bones in a more correct position, there is a possibility of injuring nerves and blood vessels in doing so.

First aid for a fractured forearm bone

• Provisionally immobilize the forearm by placing two well-padded splints on the forearm, bent at a right angle and with the thumb pointing upwards. One runs from just below the elbow crease to the base of the fingers and the other on the anterior side, following the back of the forearm and hand.

• Hold in place with a bandage or a couple of handkerchiefs.

• Support the forearm with a sling.

• A satisfactory and very simple way of immobilizing the forearm is as follows: on a folded newspaper or magazine of appropriate size, place a thin towel or thin handkerchief in the place corresponding to the lower or thinnest part of the forearm. Apply the magazine or newspaper, wrapping it around the forearm, securing it with a bandage or handkerchief and keeping the arm in a sling.

First aid for a wrist fracture

One of the most common fractures is the fracture of the lower end of the radius, called a Pouteau-Colles fracture, in which a deformation of the wrist is observed that is comparable to that of the back of a fork.

First aid for a wrist fracture is the same as for a forearm fracture, although one bone fragment is often embedded in another, with little tendency for the fracture site to move.

• Provisionally immobilize on a wooden tongue depressor or other thin board or strip of strong cardboard, placed on the palmar surface of the finger and held in place with a bandage.

• A large hairpin placed on top of a small bandage on the finger and held in place with another similar bandage can be used for the same immobilization purpose.

• The hip and the lower limbs must be temporarily immobilized.

• Place a wide, tight bandage over the hip to prevent the fractured parts from separating.

• Pad a board and place it under the fractured person, lying face up, securing the hip and lower limbs to it with circular bandages.

• If a suitable board cannot be found, in addition to the tight bandage, bind both lower limbs together with strips of cloth.

• For transport, take precautions similar to those applied in the case of a fractured spine, to avoid possible damage to soft tissue (urethra, bladder, etc.).

First aid for a femur fracture

Fractures of the femur can occur in the neck (upper end), in the diaphysis or long part of the bone, or in the lower end. The first occurs most frequently in older people, sometimes as a result of a simple fall. Fractures of the femur are difficult to immobilize and treat.

For this reason, first aid in the case of a fracture of the femur is:

• The best temporary immobilization is obtained with the so-called Thomas splint, which we do not describe, because where there is one, there will also be someone who knows how to use it.

• If the Thomas splint is not available, two boards of about 15 cm wide and one centimeter thick can be prepared instead. The shortest will be the distance between the upper part of the thigh on its inner side and the sole of the foot, and the longest, the distance from the sole of the foot to a little above the waist.

• Pad both boards, placing the shorter one on the inside of the lower limb and the longer one on its outside. Fasten the short board to the thigh with wide strips of cloth and the long board to the body in the same way.

• Care must be taken to ensure that no bone protrusion is excessively compressed by the boards.

• If boards cannot be obtained, a tree branch, broomstick, umbrella, cane or any other similar object must be applied to the outside of the lower limb, from the foot to as high as possible on the trunk.

• Using pieces of cloth, fasten the broken limb and the trunk, and then join the two lower limbs together in the same way. Patella fractures are temporarily immobilized in the same way.

Spinal fractures can occur from a fall from a height, a direct blow to the spine, a car crash, diving into shallow water, or bending the spine too far forward.

Trying to sit the injured person up, or trying to lift him or her lying down between two people on a regular basis, can aggravate spinal cord injuries.

Here is first aid for a spinal fracture:

• Particular care must be taken to keep the head and neck upright, preferably slightly stretched upwards.

• The first aider should do this while two or three strong men place the injured person on a straight board, or failing that, on a door that has been taken off its hinges. The injured person should then be padded.

    If the fracture is in the thoracic or lumbar spine

• The spine must be carefully prevented from flexing, that is, from becoming more convex towards the back, which would increase the risk of spinal cord injury.

• Do not use ordinary stretchers, which tend to sink in the middle.

• If the patient is face down on the stretcher, this will not increase the flexion of the spine.

• A wide board should be used, or alternatively, a door should be removed from its hinges and used for the same purpose.

• The best method of temporarily immobilizing a fractured spine for transport to a medical facility consists of making a special apparatus in a few minutes from two boards about two meters long, about 15 cm wide and one inch thick, which are joined together with three pieces of the same type of board.

• If necessary, the part corresponding to the fracture can be padded.

• To place the patient on this apparatus, he can be turned on one side "en masse" by several people, who rotate him simultaneously, in such a way that the fractured part does not move.

• Once the apparatus is placed on the floor next to the fractured patient, perform the reverse maneuver, with the same precautions.

• Then lift the patient onto this improvised stretcher and place his legs on two chairs, so that he can be firmly fixed to the stretcher by means of bandages and ties, which immobilize the shoulders, chest, abdomen, pelvis and lower limbs. Sometimes it is also necessary to immobilize the head.

• Another way of lifting the fractured patient is to have him lifted by six people who place their hands under the patient and place him on the stretcher already described above, which will have been kept high with chairs or drawers.

First aid for a ankle fracture

Here is how to apply first aid for a ankle fracture:

• Ankle fractures are treated in the same way as femur fractures, only making sure that the splints reach lower than the sole of the foot.

• It is very practical to use a feather pillow placed under the leg and foot, from below the knee until it protrudes about 20 cm below the heel.

• These splints are fixed towards the front, with safety pins, the edges of the pillow, supporting the foot with the pillow part that protrudes at the bottom.

• Make the whole thing rigid by fixing a splint on each side.