LEARNING OBJECTIVE: Select the appropriate stabilization and treatment procedure for the management of bone injuries.

A break in a bone is called a fracture. There are two main kinds of fractures. Aclosed fracture is one in which the injury is entirely internal; the bone is broken but there is no break in the skin. An open fracture is one in which there is an open wound in the tissues and the skin. Sometimes the open wound is made when a sharp end of the broken bone pushes out through the flesh; sometimes it is made by an object such as a bullet that penetrates from the outside.

Figure 4-34 shows closed and open fractures.

Open fractures are more serious than closed fractures. They usually involve extensive damage to the tissues and are quite likely to become infected. Closed fractures are sometimes turned into open fractures by rough or careless handling of the victim.

It is not always easy to recognize a fracture. All fractures, whether closed or open, are likely to cause severe pain and shock; but the other symptoms may vary considerably. A broken bone sometimes causes the injured part to be deformed or to assume an unnatural position. Pain, discoloration, and swelling may be localized at the fracture site, and there may be a wobbly movement if the bone is broken clear through. It may be difficult or impossible for the victim to move the injured part; if able to move it, there may be a grating sensation (crepitus) as the ends of the broken bone rub against each other. However, if a bone is cracked rather than broken through, the victim may be able to move the injured part without much difficulty. An open fracture is easy to recognize if an end of the broken bone protrudes through the flesh. If the bone does not protrude, however, you might see the external wound but fail to recognize the broken bone.

General Guidelines
If you are required to give first aid to a person who has suffered a fracture, you should follow these general guidelines:

If there is any possibility that a fracture has been sustained, treat the injury as a fracture until an X-ray can be made.
Get the victim to a definitive care facility at the first possible opportunity. All fractures require medical treatment.
Do not move the victim until the injured part has been immobilized by splinting (unless the move is necessary to save life or to prevent further injury).

Figure 4-34.-Fractures: A. Closed; B. Open.

Treat for shock.
Do not attempt to locate a fracture by grating the ends of the bone together.

Do not attempt to set a broken bone unless a medical officer will not be available for many days.
When a long bone in the arm or leg is fractured, the limb should be carefully straightened so that splints can be applied, unless it appears that further damage will be caused by such a maneuver. Never attempt to straighten the limb by applying force or traction with any improvised device. Pulling gently with your hands along the long axis of the limb is permissible and may be all that is necessary to get the limb back into position.

Apply splints. If the victim is to be transported only a short distance, or if treatment by a medical officer will not be delayed, it is probably best to leave the clothing on and place emergency splinting over it. However, if the victim must be transported for some distance, or if a considerable period of time will elapse before treatment by a medical officer, it may be better to remove enough clothing so that you can apply well padded splints directly to the injured part. If you decide to remove clothing over the injured part, cut the clothing or rip it along the seams. In any case, be careful! Rough handling of the victim may convert a closed fracture into an open fracture, increase the severity of shock, or cause extensive damage to the blood vessels, nerves, muscles, and other tissues around the broken bone.

If the fracture is open, you must take care of the wound before you can deal with the fracture.

Bleeding from the wound may be profuse, but most bleeding can be stopped by direct pressure on the wound. Other supplemental methods of hemorrhage control are discussed in the section on wounds of this chapter. Use a tourniquet as a last resort. After you have stopped the bleeding, treat the fracture.

Now that we have seen the general rules for treating fractures, we turn to the symptoms and emergency treatment of specific fracture sites.