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Old 12-26-1999
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Orthopaedic Injuries: Fractures

As discussed in the previous article, sprains and strains can and do occur in all boating situations. While the same is true for fractures, there is an increased probability of these injuries occurring during heavy weather. Fracture management is a lengthy and somewhat complicated topic. The type of fracture, the affected bone(s), and any associated injuries must all be taken into account. However, the marine setting adds another important variable to the formula: Location. The emergency steps taken when the boat is in the marina are very different from those needed when you're ten days from port. In Part II, we will get an overview of the principles of fracture management.

Mechanism of Injury
Crews on sailing vessels are particularly susceptible to traumatic injury given the very nature of the activity. There are a multitude of common on-board situations that could easily result in damage to the skeletal system. A sailing vessel, by definition, is an unstable platform with a wide variety of moving apparatus that can inflict injury. The forces and pressures exerted on the standing and running rigging can be enormous. (The upper running backstays of the J-Class sloop SHAMROCK V routinely handled 50,000 lbs. of strain under sail.) An accidental gybe, loss of a spinnaker pole downhaul, getting a hand caught between sheet and winch drum or a fall down a companionway can all result in serious orthopaedic trauma. It is necessary to consider the mechanism of injury when assessing the patient as this will give important clues as to the nature and extent of the trauma as well as the likelihood of associated injuries. Another aspect of orthopaedic injuries is the effect they have on the caregiver. In many instances, a severely angulated fracture will immediately divert the attention of the rescuer causing them to focus on this rather grotesque injury and skip over other important assessment steps; i.e. the ABCs.

General Assessment
Given the scope of this forum, it would be an unmanageable undertaking to review the assessment specifics for the wide range of possible fractures. Instead, it is more useful to describe general concepts and management techniques. It is also helpful to separate the myriad of fracture types into two broad categories: Closed and Open fractures (previously referred to as simple and compound).

Closed Fractures:
Thankfully, these comprise the vast majority of the orthopaedic trauma that will be encountered on-board. A closed fracture does not involve damage to the integrity of the skin. Also, further specific description of the "type" of closed fracture (spiral, oblique, transverse, comminuted, etc.) does not usually affect the emergency management.

Open Fractures:
As the name implies, these fractures are more severe as the broken bone ends have penetrated through the overlying muscle and skin. It is important to realize that a "closed" fracture in association with an overlying laceration is considered and treated as an open fracture, even though it was not the broken bone that was responsible for disrupting the skin integrity. For obvious reasons, these wounds are more serious as the risk of blood loss, infection, nerve and muscle damage are greater than for a closed fracture.
Location of the fracture is also an important consideration and it is convenient to categorize them into upper and lower body injuries. An upper body injury will frequently involve the clavicle (collarbone), humerus (upper arm), radius/ulna (forearm), wrist, hand or fingers. In the lower body, injuries may involve the pelvis, femur (thigh), tibia/fibula (lower leg), ankle and foot. Obviously, orthopaedic trauma to the lower body will disable the patient to a greater degree because of damage to weight-bearing structures. This will put added pressures on fellow crewmembers when it comes to moving and positioning the patient. All of these factors; mechanism of injury, associated injuries and underlying medical problems, location and type of fracture, location of the vessel and availability of medical assistance must be taken into account to successfully manage the situation.

A patient with a fracture will have the following signs: pain, tenderness, deformity, loss of use, swelling, ecchymosis (bruising) and crepitus (grating sensation). They are usually all present to a greater or lesser degree, but the first four invariably point to a fracture. However, the best course of action is to treat ANY SUSPECTED fracture like a true fracture until proven otherwise. It is also imperative to assess the patient's vascular and neurologic function distal to (below or beyond) the injury. Any force sufficient to break a bone may have also damaged blood vessels and nerve tissue. Even more likely is that the displaced end of a fractured bone has lacerated or impinged one of these vascular or nerve structures leading to a far more serious injury.

Vascular Assessment:
It is primarily the arterial blood supply beyond the injury that needs to be maintained. Should the fracture disrupt the blood flow to the rest of the extremity, all of the tissues below the injury are in jeopardy. The easiest assessment technique is simply to check for a pulse. If one is present, then you can be relatively certain that the vascular bed is intact. Other indicators would be temperature, color and capillary refill (see sidebar 1). It is also imperative to frequently reassess these vascular signs as any movement of the fracture, especially during splinting, may acutely affect vascular status. Furthermore, after a splint has been applied, continued swelling may cause sufficient pressure within the tissues to affect distal blood flow as well. It is important to note that while the loss of the pulse is a serious indicator of arterial damage, the blood flow may only be temporarily obstructed by the displaced fracture. In many instances, splinting the fracture will realign the structures sufficiently to restore blood flow. In addition to the loss of perfusion, we must also consider where the blood is going since it is no longer contained within the vascular bed. There can be a significant amount of blood loss even though there is no break in the skin. A pelvic fracture can lead to life-threatening hemorrhage and a femur fracture can "hide" several units of blood loss in the thigh.

Vascular Practice:
The skin temperature should be warm and the distal extremity should be pink. A good reference for these two parameters would be to compare the injured extremity to the uninjured one. In the absence of a palpable pulse, a cold and pale extremity is a confirmation of loss of blood flow. Capillary refill is a test to see how well the blood supply is reaching the most distal part of the extremity. This test is performed by examining the nailbeds (fingers or toes). They usually have a pink coloring (it will be necessary to remove nail polish to assess this function). The nailbed will "blanche" or turn whitish when the nail is compressed with your finger. After releasing the pressure, it will usually take 3-5 seconds for the pinkish color to return. If it takes longer than 10 seconds for the color to return, delayed capillary refill is present. It is important to note that temperature, color and capillary refill will ALL be affected in cold weather since the body is automatically shunting blood away from the periphery to conserve heat. Therefore, the patient must be adequately warmed up for these signs to have reliability.

Neurologic Assessment:
Evaluation of the patient's distal neurologic status is also warranted in the case of a severely angulated or open fracture. Evaluation of the sensory and motor functions of the extremity is essential to fully assess the injury. (In this instance we are referring ONLY to fractures of the extremities. Orthopaedic trauma to the spine and vertebrae will be covered in another article). There are specific distributions for the major nerves of the upper and lower extremities. However, from a practical standpoint, the sensory evaluation need only check "pinprick sensation" of the fingertips, over the back of the hand, the heel and the top surface of the foot. The motor evaluation is simply to test for dorsi and palmar flexion of the hand and dorsi/plantar flexion of the foot.

Neurologic Practice*:
Assess circulation to the limb
Peripheral pulse(s) Temperature, Color, Capillary Refill
Assess nerve damage to the limb
Upper extremities
Sensory- Pinprick sensation over fingertips and dorsum (back) of hand.
Motor- Dorsiflexion (flexing the joint away from the body) and palmar flexion of wrist (flexing the joint toward the body. This movement is done when you hold your hand up to indicate someone to "stop").
Lower extremities
Sensory- Pinprick sensation over heel and top of foot
Motor- Dorsiflexion and plantar flexion of foot.
*Adapted from "Emergency Care in the Streets", 4th ed. By Dr. Nancy Caroline

Principles of Fracture Management
1) Prevent further injury/damage
2) Relieve pain
3) Prevent a closed fracture from becoming an open fracture
4) Control bleeding
5) Prevent infection (in the case of an open fracture)

With the exception of #5, these are all addressed with the application of a splint. There are several types of splints and, while it is important to choose the correct splint for a given fracture, even homemade devices can adequately meet the first four principles. Rigid splints, pillow splints, ladder splints, air splints and traction splints are all useful for a wide variety of fractures. There are numerous commercially available splinting devices but there are also plenty of on-board items that can used for the same purpose. Oars, winch handles, pillows, seat cushions and folded navigation charts to name a few. Using on-board materials also has the advantage of saving valuable stowage space (though there are some rigid/air/ladder splints that fold flat and are easy to store in out-of-the-way locations.) For extended voyaging, ALL of the complete medical kits include adequate splinting material. I even know of one sailor who carried "casting tape" and then ended up using it to repair the mizzen boom after a storm (Hey, it was fractured!).

The following are general principles for fracture immobilization. It is essential to remember that, as with some of the more advanced medical techniques, splinting is a skill that needs hands-on instruction. There are different approaches to each fracture type and location and only through direct experience in splint application will you feel comfortable with the emergency situation.

Expose the injury. Get a good look at the fracture site and evaluate for associated injuries.
Dress any wounds BEFORE splinting. In the case of an open fracture, cover the exposed bone ends with a sterile dressing and moisten with sterile saline. If there is a laceration or skin avulsion, be sure to clean and debride any foreign material from the wound, as you will be placing padding and pressure over the injury. A warm, dark, immobile wound is a microbe's delight!
Assess the distal neurovascular status. You will need to determine if there is any compromise to the circulation before the splint is in place. You will also have a baseline for future evaluations.
Now the hard part. Straighten severely angulated fractures. This maneuver will relieve pain, restore blood flow (if it was compromised) and allow for a fairly straightforward splinting technique. Grasp the extremity above and below the fracture site and gradually exert steady longitudinal traction to the limb until it is realigned. The patient will feel an initial increase in pain, but it will be markedly reduced once the bone ends are realigned. A few notes of caution. If you encounter resistance while attempting realignment- STOP! You may cause more damage. Also, never attempt to realign fractures associated with a joint (shoulder, elbow, wrist, knee, and ankle). Simply splint the limb in the position it is found. Management of dislocations will be addressed in a future article.
As mentioned, do not attempt to push the bone ends beneath the skin in an open fracture. Unfortunately, with an angulated open fracture, the bones may be drawn back into the wound when the extremity is straightened. This is another good reason to clean and debride an open wound before splinting. In my opinion, it is better to straighten an angulated fracture and risk the infection (which you can treat) than to risk the neurovascular compromise of splinting in the angulated position. Also, on a boat, the likely pathogens are far less prolific than on land. If there is an open fracture, regardless of exposed or retracted bone ends, you will still want to start antibiotics (preferably intravenous) until you get definitive treatment.
When splinting, be sure to immobilize the joint above AND below the fracture (e.g. A humeral (upper arm) fracture requires immobilization of both the shoulder and elbow.).
Remember to use adequate padding for the splint. Prolonged skin contact on these hard surfaces can lead to skin ulcers and tissue damage.
Reassess the distal neurovascular status AFTER the splint is applied (you have a reference since you checked it before). Loosen the splint if there seems to be any compromise of the circulation. Also remember to frequently reassess this function as swelling can have a delayed effect on circulation.
Contrary to standard practice, it is frequently necessary to move the crewmember before assessing the injury and applying a splint. It will be impossible to appropriately treat an orthopaedic injury while the patient is lying on a wet, pitching foredeck in the middle of the night. Use as much assistance as possible and take great care not to cause further injury. Obviously, you will want to take up the least demanding point of sail until the situation is under control.
Finally, elevate the extremity when possible. Give pain medication and start antibiotic therapy if indicated. Clearly, any serious fracture will need advanced medical intervention. However, by following the basic guidelines, you can provide adequate pain control, restore circulation and prevent further injury to the orthopaedic trauma patient.

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