Fractures: Complete Overview

(a) Signs & Symptoms of Fracture

• Pain and tenderness - sharp, well-localized pain at the fracture site, worsened by palpation or movement
• Swelling and edema - due to hemorrhage into surrounding tissues from the fracture hematoma
• Bruising / ecchymosis - discoloration develops over hours to days as blood tracks through tissues
• Deformity - visible angulation, shortening, or rotation of the limb; may be obvious or subtle
• Loss of function - inability to use or bear weight on the affected limb
• Abnormal mobility - movement at a site where none should exist
• Crepitus - grating sensation felt or heard when fracture fragments rub together (do not deliberately elicit this)
• Open wound - in open (compound) fractures, a wound communicating with the fracture site may show hematoma or bone fragments draining through
• Neurovascular changes - numbness, tingling, pallor, or absent pulses distal to the fracture (indicates nerve or vascular injury)
• Muscle spasm - involuntary protective muscle contraction around the fracture site

• Pain out of proportion to the injury
• Pain on passive stretch of the involved muscle
• Paresthesias and weakness (late signs)

(b) Types of Fracture

By Skin Integrity

By Fracture Pattern

By Location on the Bone

By Cause / Special Types

By Temporal Classification

• Acute - sharp, well-defined fracture edges on X-ray; clear injury mechanism
• Subacute - callus formation beginning; edges softening
• Chronic / Nonunion - typically >6 months old; sclerotic edges, persistent fracture line

(c) First Aid Management of Fracture

Step-by-Step First Aid

1. Ensure safety - Remove the patient and yourself from any ongoing danger (e.g., traffic, falling objects).
2. Call for emergency help - Activate emergency medical services immediately for significant fractures.
3. Assess the patient (ABC)
   • Airway, breathing, and circulation must be checked first
   • Control any active bleeding with direct pressure
   • Do not remove objects impaled near a fracture site
4. Immobilize the fracture
   • This is the most important first aid step
   • Immobilize the fracture including the joint above and below the fracture site
   • Use a splint, rigid object (boards, rolled newspaper), or improvised material
   • Pad the splint well to reduce pressure and swelling
   • Do not attempt to realign or straighten the limb - splint it in the position found
   • The rationale for immobilization is threefold: (i) it stabilizes soft tissues, reducing further bleeding and swelling; (ii) it prevents further soft tissue injury to the already traumatized area; (iii) it reduces the patient's pain and facilitates safe transport
5. Check and document neurovascular status
   • Check pulse, sensation, and movement distal to the fracture before and after splinting
   • Note any pallor, coolness, or numbness distal to the injury
6. For open (compound) fractures
   • Cover the wound with a clean/sterile dressing; do not push protruding bone back in
   • These require urgent hospital care and antibiotic prophylaxis
7. Elevate the limb (if possible and not contraindicated) to reduce swelling
8. Apply ice/cold pack wrapped in cloth to reduce swelling and pain - do not apply ice directly to skin
9. Do not allow weight-bearing on the injured limb
10. Transport safely to hospital for X-ray, definitive reduction, and fixation

Postreduction radiographs must confirm acceptable alignment once the patient reaches the emergency department. Most nondisplaced fractures are splinted initially; circumferential casts are applied later once swelling subsides.

(d) Role of a Health Worker in Prevention of Handicaps

1. Primary Prevention (Preventing the Injury)

• Health education - Educate the community about risk factors for fractures: falls in the elderly, road traffic accidents, occupational hazards, sports injuries
• Safety promotion - Advocate for use of helmets, seatbelts, protective footwear, and safety rails
• Fall prevention programs - Identify at-risk individuals (elderly, those with osteoporosis, visual impairment) and initiate fall-prevention strategies
• Nutritional counseling - Promote adequate calcium and vitamin D intake to maintain bone density and prevent fragility fractures
• Immunization and antenatal care - Prevent infections (e.g., poliomyelitis) that can cause disability; screen for conditions in pregnancy that may lead to birth-related handicaps

2. Secondary Prevention (Early Diagnosis and Prompt Treatment)

• Timely recognition - Identify fractures early and refer immediately to prevent complications such as malunion, nonunion, nerve damage, or compartment syndrome that lead to permanent disability
• Proper first aid - Correct immobilization prevents secondary injury to nerves and blood vessels
• Neurovascular monitoring - Regular checks of pulse, sensation, and movement ensure early detection of vascular compromise or compartment syndrome
• Prevention of infection - Proper wound care in open fractures; ensuring antibiotic administration to prevent osteomyelitis

3. Tertiary Prevention (Rehabilitation and Limiting Disability)

• Physiotherapy referral - Encourage early mobilization and range-of-motion exercises once the fracture is stable to prevent joint stiffness and muscle wasting
• Occupational therapy - Help patients adapt to daily activities during recovery
• Psychological support - Fractures, especially in children or the elderly, can cause depression and loss of independence; the health worker can provide counseling and support
• Follow-up and compliance - Ensure patients attend follow-up appointments and comply with weight-bearing restrictions and exercises
• Assistive devices - Provide or facilitate access to crutches, wheelchairs, prosthetics, or orthoses as needed
• Community-based rehabilitation (CBR) - Coordinate with social services and community health workers to support rehabilitation in the home environment
• Screening programs - Organize bone density screening (DEXA) for at-risk populations to identify osteoporosis before fractures occur
• Record keeping and surveillance - Maintain accurate records of injury patterns to help public health bodies plan prevention programs

Definition of Fracture (2 Marks)