Casting a Fracture

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The diagnosis of a broken bone can be simple, as when the bone is obviously deformed, or difficult, as in a minimal, “hairline” fracture.  X-rays can be helpful to differentiate a small fracture from a severe sprain, but that technology won’t be available in a power-down situation.

Fractures in Long Term Survival Situations

In any long-term survival scenario, you will be likely to encounter traumatic injuries; knowing how to approach a possibly broken bone is important to helping your patient recover.

Suspect a fracture (as opposed to a sprain) in the following circumstances:

  • A fracture will manifest with severe pain and inability to use the bone (for example. The patient cannot put any weight whatsoever on a broken ankle).  Someone with a sprain can probably put some weight, albeit painfully, on the area.
  •  More pronounced swelling and bruising will likely be present on a fracture than a sprain.
  •  A grinding sensation may be felt when broken ends of a bone rub together.
  •  A deep cut in the area of the injury is a likely sign of an open fracture.
  •  Motion of the bone in an area where there is no joint is another dead giveaway that there is a fracture.  If you notice that your injured finger appears to have 5 knuckles, you’re probably dealing with a fracture.

How to Evaluate a Fracture

Dealing with a fractured bone involves first evaluating the injured area for the above signs and symptoms.  Use your bandage or EMT scissors to cut away the clothing over the injury.  This will prevent further injury that may occur if the patient was made to remove their own clothing.  First, check the site for bleeding and the presence of an open wound; if present, stop the bleeding before proceeding further.

Fractures may cause damage to the patient’s circulation in the limb affected, so it is important to check the area beyond the level of the injury for changes in coloration (white or blue instead of normal skin color) and for strong and steady pulses.  Usually, normal color returns to skin in the fingertips within 2 seconds of applying pressure and then releasing.  This is known as the “Capillary Refill Time”.

To find out what a strong pulse feels like, place two fingers on the side of your neck until you feel your neck arteries pulsing.  You will do this same action on, say, the wrist, if the patient has broken their arm.  Lightly prick the patient in the same area with a safety pin to make sure they have normal sensation.  If not, the nerve has been injured.

If the bone has not deformed the extremity, a simple splint will immobilize the fracture, prevent further injury to soft tissues and promote appropriate healing.  Oftentimes, however, the bone will be obviously bent or otherwise deformed, and the fracture must be “reduced” as we discussed with dislocations.  Although this will be painful, normal healing and complete recovery will not occur until the two ends of the broken bone are realigned to their original position.

Reducing a deformity is best performed with 2 persons and a sedated patient.  One supports and provides traction on the side closest to the torso, and the other exerts steady traction on the area beyond the fracture.  There are risks to this procedure and nerves and blood vessels can be damaged, but normal healing will not occur in a deformed limb. The earlier that reduction is performed, the easier it is. Often, some form of traction is needed to keep the broken ends of the bone in place.

Splint the extremity in place immediately after performing the reduction. In an open fracture, thorough washing of the wound is absolutely necessary to prevent internal infection. Infection will invariably occur in a dirty wound, even if the reduction is successful. Therefore, antibiotics are important to prevent complications such as osteomyelitis, a serious infection of the bone. Always check the pulses and capillary refill time after the reduction is performed; this will assure adequate circulation beyond the level of the injury.

It is very important to immobilize the fractured bone in such a fashion that it is allowed to heal.  When you are responsible for the complete healing of the broken bone, remember that the splint should immobilize it in a position that it normally would assume in routine function.

  • For legs:   The leg should be straight, with a slight bend at the knee.
  • For arms: The elbow should be flexed at a 90 degree angle to the upper arm.
  • For ankles: The ankle should be at a 90 degree angle to the leg.
  • For wrist:  The wrist should be straight or slightly extended upward.
  • For fingers: The fingers should be slightly flexed, as if holding a glass of water

Splints can be commercially produced (e.g., SAM splints), or may be improvised, using straight sticks with bandannas or T-shirt strips to immobilize the area.  Another option is to fold a pillow around the injury and duct tape it in place. For most fractures, however, you will want to consider the placement of a cast to enforce immobilization. A cast is a solid supportive bandage that is solid that encases the injured limb.  Casting material using plaster of paris or fiberglass is easy to obtain and lasts a long time. It’s a useful addition to any medical storage.

                                                                                                    Pillow Splint

As mentioned above, the most common types of cast material used are plaster and fiberglass.  Plaster is useful after a reduction as it can be molded in a fashion that keeps the bone in place.  Unfortunately, it is heavy and there are issues keeping the cast dry.  If the plaster cast becomes wet, it will weaken the immobilization of the injured extremity and negatively affect your patient’s comfort. Fiberglass casts (see image at top of this page)  are best used when the bone is in good position or if the healing process is already underway. Fiberglass casts are light weight, durable, and require less maintenance.

When placing a cast, you will first start with a liner of cotton known as a “stockinette”.  Then, you will need rolls of padding to form a barrier between the skin and the cast. Rolls of plaster of Paris or fiberglass are then immersed in water for 20 seconds or so.  Wring out the excess water (keep the end of the roll between your fingers or it will stick and be difficult to find). Then, you will begin to slowly roll the casting material around the area of the fracture, smoothing it out as you go along.  Advance one half of the thickness of the roll as you go from beyond the fracture towards the torso. You will want perhaps three layers of casting material on the area, more in places where there is a bony prominence, such as the wrist.

Each fracture is casted somewhat differently: Stockinettes, padding, and casting rolls are available in different widths and lengths appropriate to the particular fracture. Although oscillating saws are used today to remove casts, they require the availability of electricity. There are still special heavy-duty shears available for the purpose, although some effort is needed to perform the removal. References to books devoted to the subject are listed at the end of this volume.

To review: Your goal is to immobilize the fracture in a position of function.  Use padding under the splint or cast as possible to keep the injured area stable and protected. Most fractures require 6-8 weeks to form a “callus”; this is newly formed tissue that will reunite the broken ends of the bone.  Larger bones or more complicated injuries take longer.  If not well-realigned, the function of the affected extremity will be permanently compromised.

Dr. Bones

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