Paramedics save lives, the saying goes, and EMTs save paramedics. That's glib and debatable, but it's certainly true that the role of the EMT-Basic is a vital one, and that there's relatively little out there in the way of information and tools to help him do it better. This new column, which will appear several times a year, is a resource for EMT-Basics. It will cover everything from reviews of basic skills to assisting ALS providers with more advanced interventions in a way designed to enhance understanding and develop a more complete provider. As always, we welcome your comments; send thoughts, feedback and ideas for future columns to firstname.lastname@example.org.
Fractures are commonly encountered in the prehospital environment, and the mechanisms that can create them are as varied as the types and locations of the fractures themselves. The proper methods of identifying and effectively managing fractures are extremely important in treating patients.
As with any other situation in the prehospital environment, the primary concern with fractures is the safety of the provider. Infection control and BSI should be used at all times. Disposable gloves should always be worn, and special attention should be paid to any fracture that may cause bleeding or the exposure of sharp edges. In situations where there's significant bleeding, it may be appropriate to utilize a mask with eye protection and a gown. Furthermore, providers should make sure the patient has a patent airway and adequate breathing and circulation prior to assessing and treating any fractures.
Fracture, by definition, means break.1 However, there are different types of fractures that are commonly encountered (see Figure 1).
Simple (closed) fracture-The bone is fractured, but there is no significant deformity of the bone, and it has not broken the skin. The majority of fractures you'll encounter fall into this category.
Compound (open) fracture-The bone is fractured, with breaking/laceration of the skin. Bone may or may not show from the wound.
Transverse fracture-The fracture is across the bone, and at a right angle to its long axis.
Greenstick fracture-This type of fracture is named after the breaking of a green tree branch. One side of the bone is fractured, while the other side is only bent. These types of fractures occur commonly in children, as their bones aren't as brittle as adults'.
Comminuted fracture-This is a fracture involving three or more bone fragments.2
Signs & Symptoms
There are various signs and symptoms that can be exhibited by patients with fractures. It's often obvious to the patient, either from sound, feeling or both, that there's been a fracture, and they will let you know: "I heard a snap."
Signs and symptoms include deformity, discoloration, crepitus (a cracking, grating or scraping type noise made when bone ends rub together), tenderness, swelling, inability to move the affected extremity, pain when moving the affected extremity, bleeding and/or bone protrusion.3 If nerve, muscle or vessel compromise exists, then numbness, tingling and loss of sensation and/or pulses may be encountered.
If a significant amount of blood is lost, either through a wound or internally, the patient may exhibit signs and symptoms of shock. Obviously, there are situations where it is impossible to truly determine if a fracture exists in the prehospital setting. If you are unsure whether a fracture exists, treat the patient as if it does.
The main purpose of splinting is to prevent movement in the joints and bones above and below the fracture site. This is to prevent bone edges from moving and creating additional injuries by cutting tissue, muscle, vessels or nerves, potentially turning closed fractures into open fractures and creating open wounds. For splinting to be effective, it must immobilize adjacent joints and bone ends. The provider must ensure that both the fracture site and the joints above and below it are immobilized.