FRACTURE: ARM AND COLLARBONE

Open and Closed Fractures and How to Treat Them

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 victim felt a bone break or heard a “snap”.
  2. The victim 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 victim 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 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 911. 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.

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

When splinting using sticks or other “found” objects, try to 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.

It is not always possible to tell with the naked eye if a bone has been fractured. In case of doubt, it is best to assume the victim has received a fracture and treat it accordingly.

First Aid to Arm, and Collarbone Fractures

Collarbone Fractures:

  A collarbone fracture is commonly caused by indirect force resulting from a fall on an outstretched hand or the point of the shoulder.
  Collarbone fracture due to a direct force are rare.

Symptoms and Signs:

  General symptoms and signs of fracture.
  Casualty may support the arm on the injured side at the elbow and may keep the head inclined towards the injured side to relieve pain.

Treatment:

  1. Gently place the limb on the injured side across the casualty’s chest with the fingertips almost resting on the opposite shoulder.
  2. Place padding between the limb and chest on the affected side.
  3. Support the limb and padding in an elevation sling.
  4. For additional support, secure the limb to the chest by applying aboard bandage over the sling, tie the knot in front on the uninjured side.
  5. Remove to hospital.

Arm Fractures:

Fractures can occur anywhere along the length of the upper-arm bone or the two forearm bones, and may involve the elbow and upper arm bone.

Treatment:

  1. Place a pad in the person’s armpit.
  2. Use a padded splint.
  3. Support the lower arm with a narrow pad around the neck and wrist.
  4. Use a wide bandage to bind the upper arm to the chest.

JAW FRACTURE

  JAW FRACTURE

The term “jaw fracture” usually refers to fracture of the lower jaw (mandible). A fractured jaw causes pain and usually changes the way the teeth fit together. Often, the mouth cannot be opened wide, or it shifts to one side when opening or closing.

Fractures of the upper jaw (maxilla) are usually considered facial fractures. These may cause double vision (because the muscles of the eye attach nearby), numbness in the skin below the eye (because of injuries to nerves), or an irregularity in the cheekbone that can be felt when running a finger along it.

Any injury forceful enough to fracture the jaw may also injure the spine in the neck or cause a concussion or bleeding within the skull. Jaw fractures cause swelling, which rarely becomes severe enough to block the airway. Sometimes a fracture extends through a tooth or its socket (called an open fracture), creating an opening into the mouth that can allow oral bacteria to infect the jaw bone.

If people suspect their jaw is fractured, they should hold the jaw still with the teeth together. Emergency personnel may wrap a bandage under the jaw and over the top of the head several times (Barton’s bandage). When wrapping the bandage, people must be careful not to cut off breathing.

Symptoms of Jaw Fracture

Symptoms include Pain in the face or jaw, located in front of the ear on the affected side(s), worse with movement, inability to close your mouth, drooling because of inability to close the mouth. difficulty speaking, jaw may protrude forward, your teeth may not align normally, your ite feels “off” or crooked

Causes of Jaw Fracture

The most common cause of broken or dislocated jaw is accident or trauma involving a blow to the face. This may be the result of a motor vehicle accident, industrial accident, recreational/sports injury, or other accident. It may also result from assault. The goal of treatment is proper alignment of the jaw bone so the upper and lower teeth come together normally. Surgery is often required for moderate to severe fractures to align and immobilize the bone so it can heal.

Treatment of Jaw Fracture

Treatment for conservative Jaw Fracture

This means that patients whose fracture does not affect mastication must rest the areas of the broken bone. This usually includes unfitness for work, the duration of which will be determined by the treating doctor.
In fractures affecting the jaws, immobilisation of the jaws is necessary for conservative treatment, and this can be ensured by retaining screws or encirclement of the teeth with strong wire.

Operative therapy

If operative treatment is necessary, this involves an operation that is usually performed under general anaesthesia. The broken fragments of bone are exposed at the operation and the fractured parts of the bone are joined together firmly in their original position using plates and screws. Various systems are available depending on the fracture site and fracture type: titanium plate systems are used in fractures subject to much stress, especially in the mandible, while absorbable plate systems (dissolving plates) can be used in fractures in less stressed areas, especially in the maxilla and zygomatic area and in the frontal region. The treating doctor decides on the procedure and treatment plan in each case.

The fundamental goals of treatment are restoration of the original form and function, facial shape and mastication. This eliminates pain caused by the fracture and diminishes the risk of infection with its possible sequelae (chronic bone inflammation).

Treatment of Jaw Fracture

Treatment for conservative Jaw Fracture

This means that patients whose fracture does not affect mastication must rest the areas of the broken bone. This usually includes unfitness for work, the duration of which will be determined by the treating doctor.
In fractures affecting the jaws, immobilisation of the jaws is necessary for conservative treatment, and this can be ensured by retaining screws or encirclement of the teeth with strong wire.

Operative therapy

If operative treatment is necessary, this involves an operation that is usually performed under general anaesthesia. The broken fragments of bone are exposed at the operation and the fractured parts of the bone are joined together firmly in their original position using plates and screws. Various systems are available depending on the fracture site and fracture type: titanium plate systems are used in fractures subject to much stress, especially in the mandible, while absorbable plate systems (dissolving plates) can be used in fractures in less stressed areas, especially in the maxilla and zygomatic area and in the frontal region. The treating doctor decides on the procedure and treatment plan in each case.

The fundamental goals of treatment are restoration of the original form and function, facial shape and mastication. This eliminates pain caused by the fracture and diminishes the risk of infection with its possible sequelae (chronic bone inflammation).

FRACTURE

FRACTURE

A fracture is a broken bone. It requires medical attention. If the broken bone is the result of major trauma or injury, call  your local emergency number. Also call for emergency help if:

  • The person is unresponsive, isn’t breathing or isn’t moving. Begin cardiopulmonary resuscitation (CPR) if there’s no respiration or heartbeat.
  • There is heavy bleeding.
  • Even gentle pressure or movement causes pain.
  • The limb or joint appears deformed.
  • The bone has pierced the skin.
  • The extremity of the injured arm or leg, such as a toe or finger, is numb or bluish at the tip.
  • You suspect a bone is broken in the neck, head or back.
  • You suspect a bone is broken in the hip, pelvis or upper leg (for example, the leg and foot turn outward abnormally).

Don’t move the person except if necessary to avoid further injury. Take these actions immediately while waiting for medical help:

  • Stop any bleeding. Apply pressure to the wound with a sterile bandage, a clean cloth or a clean piece of clothing.
  • Immobilize the injured area. Don’t try to realign the bone or push a bone that’s sticking out back in. If you’ve been trained in how to splint and professional help isn’t readily available, apply a splint to the area above and below the fracture sites. Padding the splints can help reduce discomfort.
  • Apply ice packs to limit swelling and help relieve pain until emergency personnel arrive. Don’t apply ice directly to the skin — wrap the ice in a towel, piece of cloth or some other material.
  • Treat for shock. If the person feels faint or is breathing in short, rapid breaths, lay the person down with the head slightly lower than the trunk and, if possible, elevate the legs.

Fractures

A fracture is a complete or partial breakage of a bone. Fractures may be:

  • Simple, where the broken ends of the bone do not cut open the skin
  • Compound, where the broken end of the bone may be in contact with the external air
  • Complicated, where in addition to the fracture an important internal organ may also be injured. A complicated fracture may also be simple or compound.

 

Signs and Symptoms of a Fracture

  • Pain at or around the site of the fracture.
  • Tenderness (pain on gentle pressure) over the area. Do not press hard.
  • Swelling over the area with discoloration.
  • Loss of normal movements of the affected part.
  • Deformity of the limb may be caused. The limb may lose its normal shape and there may be apparent shortening of the limb.
  • If, as in the leg bone, the break is just under the skin, the irregular outline of the bone can be felt easily.
  • When one end of the broken bone moves against the other, a crackling sound may be heard. This is called crepitus (grating). This should never be elicited by the person giving First Aid.
  • Unnatural movements may be felt at the site of the fracture. This too should never be elicited by the First-Aid provider.

 

In addition the victim may himself say that he heard the snap of the bone. It is important to compare the injured limb with the normal limb while making an assessment.

Management  of Fractures

The aims of First Aid here are:

  • To prevent further damage
  • To reduce pain
  • To make the patient feel comfortable
  • To get medical aid as soon as possible
  • Fractures often occur along with other injuries. So the rescuer must assess for other injuries and decide which of them requires care on priority. Heavy bleeding is more urgent and requires higher priority care over a fracture.
  • If there is no danger to life then temporary attention to the fracture is often sufficient.
  • Handle the patient very gently. Avoid all unnecessary movement.
  • Treat for shock if present.
  • If the broken ends of the bones show out, do not wash the wound or apply antiseptics to the end of the bone.
  • Do not handle the fracture unnecessarily.
  • Never attempt to reduce the fracture or to bring the bones to the normal position.
  • Stabilise and support the injured part so that no movement is possible. This stops further injury and helps to control the bleeding.
  • Immobilise the fracture area and the joints on both sides of the fracture site (above and below) by using bandages or by using splints wherever available. It is essential that the rescuer be familiar with the use of bandages and splints.

 

A: Using Bandages

Usually it is enough to use the other (uninjured) limb or the body of the victim as the splint. The upper limb can be supported by the body, and the lower limb by the other limb provided that also is not fractured. Most fractures except those of the forearm can be immobilised in this manner:

  • Do not apply bandage over the area of the fracture.
  • The bandaging should be firm so that there is no movement of the fractured ends but should not be too tight as blood circulation to the affected area could be reduced. If there is further swelling of the injured area, the bandage may be too tight and therefore may need to be loosened.
  • Always place padding material between the ankles, knees and other hollows if they have to be tied together so that when the limbs are bound together they are comfortable and steady.
  • If the patient is lying down, the bandage should be passed through the natural hollows like the neck, the lower part of the trunk, knees, just above the ankles etc., so that the patient’s body is not jarred.
  • Always tie the knots on the sound side.

B: Using Splints

Splints are used only when necessary expertise is there.

  • A splint is a rigid piece of wood or plastic material or metal applied to a fractured limb to prevent movement of the broken bone.
  • Reasonably wide splints are better than narrow ones.
  • Splints should be long enough so that the joints above and below the fractured bones can be made immobile.
  • The splints should be well padded with cotton or cloth so as to fit snugly and softly on the injured limb.
  • Splints are best applied over the clothing.
  • In an emergency, splints can be improvised using a walking stick, an umbrella, a piece of wood, a book or even a firmly folded newspaper.
  • Use of splints becomes obligatory only when both legs or both thigh bones are broken.

Fractures involving the back (vertebral column) require special care. In such cases, the victim should not be allowed to get up. Further, movement must be avoided as much as possible and emergency medical help must be sought.

SQUARE LASHING

SQUARE LASHING

SQUARE LASHING

 

Square lashings are used to bind together two spars that are at right angles with one another.

i) Place the poles on the ground in the shape of a cross. Tie a clove hitch around the bottom pole near the crosspiece. Twist the free end of the rope around its standing part and tuck it out of the way. 
ii) Make three or four wraps around the spars, keeping the rope very tight. As you form the wraps, lay the rope on the outside of each previous turn around the crosspiece, and on the inside of each previous turn around the bottom pole. 
iii) Then wind three or four frapping turns around the wrapping to tighten the lashing as much as you can.  
iv) Finish it off with another clove hitch.

SLINGS

Slings

Slings are used to support an injured arm, or to supplement treatment for another injury such as fractured ribs. Generally, the most effective sling is made with a triangular bandage. Every first aid kit, no matter how small, should have at least two of these bandages as essential items.

Although triangular bandages are preferable, any material, ex. tie, belt, or piece of twine or rope, can be used in an emergency. If no likely material is to hand, and injured arm can be adequately supported by inserting it inside the casualty’s shirt or blouse. Similarly, a safety pin applied to a sleeve and secured to clothing on the chest may suffice.

There are essentially three types of sling; the arm sling for injuries to the forearm, the St John sling for injuries to the shoulder, and the ‘collar-and-cuff’ or clove hitch for injuries to the upper arm and as supplementary support to fractured ribs.

On application of any sling, always check the circulation to the limb by feeling for the pulse at the wrist, or squeezing a fingernail and observing for change of color in the nail bed.

The Arm Sling

1. Support the injured forearm approximately parallel to the ground with the wrist slightly higher than the elbow.

2. Place an open triangular bandage between the body and the arm, with its apex towards the elbow.

3. Extend the upper point of the bandage over the shoulder on the uninjured side.

4. Bring the lower point up over the arm, across the shoulder on the injured side to join the upper point and tie firmly with a reef knot.

5. Ensure the elbow is secured by folding the excess bandage over the elbow and securing with a safety pin.

St John Sling

1. Support the casualty’s arm with the elbow beside the body and the hand extended towards the uninjured shoulder.

2. Place an opened triangular bandage over the forearm and hand, with the apex towards the elbow.

3. Extend the upper point of the bandage over the uninjured shoulder.

4. Tuck the lower part of the bandage under the injured arm, bring it under the elbow and around the back and extend the lower point up to meet the upper point at the shoulder.

5. Tie firmly with a reef knot.

6. Secure the elbow by folding the excess material and applying a safety pin, then ensure that the sling is tucked under the arm giving firm support.

‘Collar-and-Cuff’ (Clove Hitch)

1. Allow the elbow to hang naturally at the side and place the hand extended towards the shoulder on the uninjured side.

2. Form a clove hitch by forming two loops — one towards you, one away from you.

3. Put the loops together by sliding your hands under the loops and closing with a “clapping” motion. If you are experienced at forming a clove hitch, then apply a clove hitch directly on the wrist, but take care not to move the injured arm.

4. Slide the clove hitch over the hand and gently pull it firmly to secure the wrist.

5. Extend the points of the bandage to either side of the neck and tie firmly with a reef knot.

6. Allow the arm to hang comfortably. Should further support be required, ex. For support to fractured ribs, apply triangular bandages around the body and upper arm to hold the arm firmly against the chest.

ROLLER BANDAGES

Roller Bandages
Roller bandages are long strips of material which are rolled up for easy use.  They come in different widths and material.

Roller Bandages: Gauze or Cotton Roller Bandage
Gauze and cotton bandages are non-conforming.
This means that they do not stretch, and will not mould around the part of the body to which they are applied.

Non-conforming bandages do not stay on very well.
If you have both types of bandage in your first aid kit, it is best to use the conforming bandages first. 

Roller Bandages: Conforming Roller Bandage
Conforming bandages are designed to stretch.
This allows them to mould to the shape of the parts to which they are applied.

Conforming bandages can be used on their own to provide support to an injured joint or muscle.
They can also secure pads and dressings, when this is necessary to control bleeding.

Applying Roller Bandages
All roller bandages should be applied in the following manner.

        1.  Hold the bandage so that the head or rolled part is on top and the tail is pointing inward.

        2.  Pass the rolled part from hand to hand, allowing it to unroll as you go. Make sure that each turn overlaps the last by two thirds of its width.

        3.  Fasten the end with tape or tuck the end in and check that the bandage is not too tight. 

Improvising
There may be occasions where you need to give first aid to a sick or injured person but no first aid kit is available. 

If a kit is not available, you will need to improvise first aid equipment, by using whatever you can find.

For example, a broomstick or umbrella could be used to splint a fractured limb.
A couple of T-shirts could be used as padding around an injury. 

You should not let the absence of a first aid kit prevent you from offering first aid to a casualty. 

Improvising
If you needed to improvise a dressing for a person with a cut on their hand you would use a handkerchief. A clean handkerchief makes an excellent pad or dressing for small wounds.

If you needed to improvise a bandage you could use stockings. Clean pantyhose or stockings make excellent short bandages.

If you needed to improvise a splint for a suspected fractured arm you would use a newspaper. A newspaper makes a useful splint because when it is folded and creased it becomes quite solid and will support and immobilise a fracture very well.

If you needed to improvise a sling for a person with an injured upper arm you would use a belt. The belt would make an ideal sling because it will easily take the weight of the arm. Because it is fairly wide, it is also less likely to interfere with circulation.
 

TRIANGULAR BANDAGES

Triangular Bandages
A First Aid Kit will typically contain triangular bandages which are large, triangular pieces of material, with two sides about 1 metre long, and the third about 1.4 metres. 

Triangular bandages can be used as:
        ·       Collar & Cuff Sling
        ·       St John Sling
        ·       Full Arm Sling
        ·       Broad Bandage
        ·       Narrow Bandage
        ·       Pad

Triangular bandages: Collar & Cuff Sling 
The collar and cuff sling is useful for a casualty with a fracture of the upper arm or an injured hand.

Triangular bandages: St John Sling
The St John sling is useful for a casualty with an injured shoulder, collar bone, hand or fingers.

It is the best sling for shoulder and collarbone injuries because it supports the whole arm and takes the weight of the arm off the injured shoulder or collar bone.  In the case of hand or finger injuries, it can be used to elevate the injured part.

Triangular bandages: Full Arm Sling 
The full arm sling is used to support an injured forearm or wrist.

It is the best sling for these injuries because it forms a comfortable cradle which spreads the weight of the forearm evenly along its whole length.  This prevents the damaged parts from pushing together or pulling apart as they would if the other slings were used.

Triangular bandages: Broad Bandage
A broad bandage is simply a triangular bandage which is folded and used to tie on splints and dressings. 

First, you fold it in half, point to base. 

Then you fold it in half again.

You now have a broad bandage. 

Triangular bandage: Narrow Bandage
A narrow bandage has one more fold than the broad bandage and is mainly used for the collar & cuff sling. 

First, you fold it in half, point to base. 

Then you fold it in half again to make a broad bandage. 

Then you fold it in half again.

You now have a narrow bandage. 

Triangular bandage: Pad
If you do not have a sterile pad in your First Aid Kit, you can use a triangular bandage as a pad.

First, you fold it in half, point to base. 

Then you fold it in half again to make a broad bandage. 

Then you fold it in half again.

You now have a narrow bandage. 

Then fold the two ends into the middle. 

Now fold both ends into the middle again. 

Fold what is left in half to make a pad.

When a triangular bandage is folded like this, it is easy to store it in a first aid kit.

You can also use it in this form if you need to control bleeding.