Fractures (buckle or break in the bone) often occur following direct or indirect injury, e.g. twisting, violence to bones. Clinically, fractures are either:

• closed, where the skin is intact, or
• compound, where there is a break in the overlying skin

Dislocation is where a bone is completely displaced from the joint. It often results from injuries away from the affected joint, e.g. elbow dislocation after falling on an outstretched hand.
Sprain is a partial disruption of a ligament or capsule of a joint.

Simple Fracture of Limbs

Immediate management:

• Halt any external haemorrhage by pressure bandage or direct pressure
• Immobilise the affected area
• Provide pain relief

Clinical assessment:

• Obtain complete patient history, including circumstances and method of injury
  – medication history – enquire about anticoagulant use, e.g. warfarin
• Perform standard clinical observations. Examine and record:
  – colour, warmth, movement, and sensation in hands and feet of injured limb(s)
• Perform physical examination
  Examine:
  – all places where it is painful
  – any wounds or swelling
  – colour of the whole limb (especially paleness or blue colour)
  – the skin over the fracture
  – range of movement
  – joint function above and below the injury site
  Check whether:
  – the limb is out of shape – compare one side with the other
  – the limb is warm
  – the limb (if swollen) is throbbing or getting bigger
  – peripheral pulses are palpable

Management:

• Splint the site of the fracture/dislocation using a plaster backslab to reduce pain
• Elevate the limb – a sling for arm injuries, a pillow for leg injuries
• If in doubt over an injury, treat as a fracture
• Administer analgesia to patients in severe pain. If not allergic, give morphine (preferable); if allergic to morphine, use fentanyl
• Consider compartment syndrome where pain is severe and unrelieved by splinting and elevation or two doses of analgesia
• X-ray if available

Drug Therapy Protocol:
Authorised Indigenous Health Worker (IHW) must consult Medical Officer (MO) or Nurse Practitioner (NP).
Scheduled Medicines Rural & Isolated Practice Registered Nurse may proceed.

Use the lower end of dose range in patients ≥70 years.
Provide Consumer Medicine Information: advise can cause nausea and vomiting, drowsiness.
Respiratory depression is rare – if it should occur, give naloxone.

Technique for plaster backslab for arm fractures – use same principle for leg fractures

1. Measure a length of non-compression cotton stockinette from half way up the middle finger to just  below the elbow. Width should be 2–3 cm more than the width of the distal forearm.
2. Wrap cotton padding over top for the full length of the stockinette — 2 layers, 50% overlap.
3. Measure a length of plaster of Paris 1 cm shorter than the padding/stockinette at each end. Fold the roll in about ten layers to the same length.
4. Immerse the layered plaster in a bowl of room temperature water, holding on to each end. Gently squeeze out the excess water.
5. Ensure any jewellery is removed from the injured limb.
6. Lightly mould the slab to the contours of the arm and hand in a neutral position.
7. Do not apply pressure over bony prominences. Extra padding can be placed over bony prominences if applicable.
8. Wrap crepe bandage firmly around plaster backslab.

Questions