(c) 1995, Willis Lamm, TrailBlazer Magazine

By Willis Lamm

Reprinted with permission of TrailBlazer Magazine for non-commercial use.

There are 206 bones in the human body, and every fall brings with it the possibility of breaking one. While most of the time we dust ourselves off and climb back on with little more than bruised muscles and bruised egos, there are a few instances where fractures do occur, which can prove to be serious emergencies. Whether in the barn or out on the trail, it is important to understand the physiology of fractures and take the correct steps early on after the accident.

What happens during a fracture:

When a fracture occurs, a portion of a bone may chip or crack away or the bone may be completely broken. In any event, the bone fragments will damage nearby tissues and blood vessels, causing swelling and blood clots in the area of the fracture. Nearby tissue cells which lose their blood supply will die.

Undamaged tissue cells nearby the fracture site will respond to the injury by rapidly dividing in an attempt to form a collar of tissue surrounding the fracture site. New bone is generated from this mass of tissue in order to eventually heal the damaged bone.

If the fracture site is mishandled early after the injury, more soft tissues could be damaged which could significantly prolong healing. If the bone ends are disturbed, the disruption to the normal healing process could result in a permanent disability.

More critically, arteries and nerves run parallel to bones in the arms and legs. A mishandled severe fracture could result in a bone end severing an artery or major nerve creating a potentially fatal bleed or paralysis. Even small fractures, such as in a finger, can lead to a frustrating disability if not treated correctly.

Accordingly, all fractures (or suspected fractures), no matter how minor, should be taken seriously.

As there is not enough column space to discuss all of the possible fractures, here are some common situations and basic care concepts. Remember that each situation is different, so utilize common sense when caring for any fracture until professional help can be obtained.

There are two classifications of fractures, closed fractures and open fractures. Closed fractures include any fracture where the bone does not penetrate the skin (the skin stays closed). In such instances, proper treatment includes immobilizing the fracture and seeking medical help. Open fractures occur when a bone or bone fragment breaks through the skin or the skin and bone are broken in a traumatic, crushing injury. Proper treatment for open fractures must also include concern for possible infection.

Recognizing Fractures:

An open fracture will typically be self evident due to the exposed bone. The following clues suggest you are dealing with a probable closed fracture:

  1. The patient felt a bone break or heard a "snap".

  2. The patient feels a grating sensation when he/she moves a limb. (This condition is known as crepitus.)

  3. One limb appears to be a different length, shape or size than the other, or is improperly angulated.

  4. Reddening of the skin around a fracture may appear shortly after the fall.

  5. The patient may not be able to move a limb or part of a limb (e.g., the arm, but not the fingers), or to do so produces intense pain.

  6. Loss of a pulse at the end of the extremity.

  7. Loss of sensation at the end of the extremity.

  8. Numbness or tingling sensations.

  9. Involuntary muscle spasms.

  10. Other unusual pain, such as intense pain in the rib cage when a patient takes a deep breath or coughs.

If you discover any of these symptoms and cannot attribute them to any other obvious cause, assume them to be symptomatic of a fracture.

Initial Care for Fractures:

In treating fractures, an unhurried and careful approach is best. Few fractures are life threatening unless mishandled. Check the patient for any more serious injuries. Make sure someone is going for help, or call 9-1-1. Ensure your patient is breathing and that excessive bleeding is controlled and that all open wounds are protected as best you can from contamination. After these elements are satisfied you can deal with stabilization of the fracture.

If you can, carefully cut away all clothing near the fracture site. You need to make sure the fracture hasn't broken the skin and you may be able to use the cut away material to aid in splinting. If you find an open fracture, protect the wound from contamination as you would any other.

No matter how soon you expect to get medical help, you should immobilize all fractures to prevent additional injuries due to accidental movement or muscle spasms. Immobilization can be achieved many ways; the key points being not to worsen the situation while immobilizing and making sure to also immobilize the joints above and below any limb fracture.

In general, don't try to reposition fractured limbs. Unless you know what you are doing, you could sever an artery or nerve. If out on the trail with help a long way off, practicality may necessitate slight repositioning in order to accommodate make-do splinting. In such situations if a limb has no pulse or is turning purple, repositioning may relieve some unnatural pressure which is pinching off an artery, however the rescuer must consider that a mishandled attempt could result in a jagged bone end severing the compressed artery, making a bad situation much worse!

To put this tricky situation in perspective, Brady's Emergency Care, 6th Edition states: "Angulations make splinting and transport more difficult. They can pinch or cut through blood vessels and are painful for the patient. They must, however, be repositioned so they can be splinted. Not to splint would be more dangerous."

DO NOT try to straighten angulations of the wrist, ankle or shoulder or attempt to straighten any dislocated joint!

When splinting using sticks or other "found" objects, try make padding between the injured limb and splint using a jacket, shirt filled with grass, anything which can be reasonably secured and can help fill in the gaps between the limb and the splint material. Don't get carried away with this concept, but if you can handily make something up without delaying the splinting process, it will be more comfortable to the patient.

Long bone fractures in the legs and arms can benefit from mild traction when splinting. For arm fractures where you have help during splinting, one person can grasp the arm above and below the fracture site and apply a smooth, steady pull until your helper can apply the splint. If you encounter a firm resistance, crepitus or the patient experiences a significant increase in pain, do not attempt traction. Do the best you can to splint in the position found. Once you successfully apply traction, do not release it until the splint is securely supporting the limb, otherwise the retracting bone end will cause additional tissue damage and possibly injure a nerve or artery.

A fractured forearm should be splinted from the hand through the elbow and can be secured across the chest with a sling if more comfortable for the patient. Upper arm fractures should be immobilized from shoulder through the elbow and can be secured against the body.

Traction for leg injuries is more difficult, and the risk of injury resulting from a failed traction attempt is even greater. Do not attempt leg traction until your helper is ready to apply a splint. Legs should be secured to splints using several ties from the ankle to the pelvis, but not directly over the fracture. If a long smooth board is available (e.g., a fence board), it can be secured all the way up to the armpit to improve stability.

Hip Fractures:

Hip fractures can be very serious since they actually involve the upper portion of the femur, the large bone of the upper leg. Hip fractures are more common in older persons, and any elderly riders who sustain a fall and complain of hip pain should be suspect for this injury.

Symptoms of hip fractures include sensitivity when pressure is exerted on the prominence of the hip, swelling with or without discoloration of the surrounding tissues, the patient is unable to move his/her leg when on his/her back, the suspect limb appears shorter or is rotated (usually outward).

Patients with suspected hip fractures should only be moved on a stretcher. The injured limb can be secured to the uninjured limb to provide splinting. If medical help is a long way off and someone can spell you if you tire, you may find that manual traction provides significant relief for your patient.

Fractured Hands and Ankles:

These extremities should be splinted in "positions of mechanical function", that is in as natural of a position as possible. The natural position of a hand is as if one were gently grasping a softball. A roll of clothing or other padded material can become the "ball" which can be placed in the palm before the hand is wrapped. Hands, ankles and wrists should be secured in whatever manner is necessary to protect them from being bumped or moving about while the patient is being rescued.

Fractured Ribs:

The primary concern of a suspected rib fracture is to prevent a loose piece of rib from puncturing a lung. The best course of action here is to keep the patient from moving around, pad and gently wrap the chest, and apply a sling and swathe to secure the arm on the injured side so it lays comfortably across the chest. Padding and wrapping the chest on the trail may be awkward, and it is not worth unnecessarily moving the patient around to accomplish this task. In such instances simply make the patient comfortable and discourage unnecessary movement.

Skull and Facial Fractures:

Fractures to the face and skull are serious emergencies, obviously involving the brain in the case of skull fractures, but also compromising the airway and breathing ability in the case of facial fractures. If you find evidence of skull or facial fractures you should presume the possibility of cervical spine injury also.

Decreased consciousness, deep lacerations or severe bruising, deformity, fluid from the ears, unequal pupils, "raccoon's eyes", and a sunken eye are all symptoms of possible skull or facial injury. If you find any of these signs you should presume the possibility of cervical spine injury also.

Care for skull and facial fractures includes maintaining an open airway, immobilizing the neck and spine, and treating wounds. Do not apply pressure, however, to any suspected fracture site! Note the patient's change in level of consciousness prior to the arrival of medical help as these observations may assist in the diagnosis of the extent of the injury.

Recap of Actions:

  1. Get assistance from competent bystanders.

  2. Check patient; ensure airway, breathing and circulation.

  3. Have someone go for help or call 9-1-1.

  4. Protect possible spinal injuries.

  5. Treat life threatening conditions.

  6. Protect open wounds, including open fractures.

  7. Splint fractured limbs and/or extremities, in natural or functional position, if feasible.

  8. Avoid unnecessary movement of fractured extremities.

  9. Apply mild traction if practical and it relieves pain while splinting is taking place.

  10. Keep patient quiet and treat for shock.

  11. If you have to move a patient for his/her survival, be careful and methodical, support splinted injuries to prevent further movement, bumping, etc., and don't move the patient any further than necessary without proper professional equipment.

Our thanks to TrailBlazer Magazine for permission to post this series on our web page.
You can visit the TrailBlazer website at www.horsetrails.com.

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