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Last updated May 26, 1999
The Cascade Hospital is a resource website designed specifically to help FANFIC and other FICTION WRITERS who want to make their stories more medically authentic. It is NOT for people seeking answers to personal medical questions -- that is a job for your private physician.
~ Disorders of bones and joints: fractures, dislocations, etc. ~
Please read the Sentinel and Medical Disclaimers.
Splinting and Casting
Pinning (surgical setting of a fracture)
You usually know when you've broken something because you feel the arm/leg "give way" and sometimes you hear/feel an audible "cracking". It hurts A LOT when it happens. After that, people control the pain by not moving the injured limb. But try to move it or use it and that causes lots and lots of pain. Within an hour or so, the broken limb swells up usually. Ice may bring some relief while you're waiting to go to the hospital. The important thing is to splint or immobilize the limb on something stiff and get to the doctor so it can be set.
The management of a broken arm depends on how badly the arm is broken. If you've just got a standard fracture (the bone is not coming out through the skin), when they get back to a hospital, the doctor would take x-rays, set the bone so it was straight, and then put a cast on it. They have nice light-weight casts now days (much better than those white plaster-of-paris ones they used to use), though they aren't as easy to write on! When I broke my arm (when I was little) I had to wear the cast for about 2 months, but the time frame is probably a little flexible. Arms are usually cast with the elbow bent, by the way. After the two months (or however long) are over, the cast gets cut off with a special circular saw that won't cut the skin underneath. It's pretty cool.
If the break is a "compound fracture", that is where the bone is poking through the skin (yuk!), that kind requires surgery. For one thing it would hurt way too much to set that fracture without being under general anesthesia (where they put you to sleep) and you also need the general anesthesia to relax the muscles enough to manipulate the bone into the proper position. You also sometimes have to clean off the bone if it has gunk and dirt on it, remove any bone splinters, that type of stuff. I haven't actually seen this done yet because I haven't done my orthopedics rotation yet, so I don't know all the details. If the bone is actually splintered into many pieces (a "comminuted fracture"), they might actually have to put in a metal (titanium) rod. That definitely requires surgery. But you'd have to be hurt pretty badly to get a comminuted fracture (your arm gets run over by a car or something like that).
If you have a compound fracture, one must also be worried about infection setting in from the dirt and junk around the wound. Signs of serious infection can set in within 24 hours, which is very very dangerous. By the way, anyone with a compound fracture will be given a dose of intravenous (IV) antibiotics (the one they use at my hospital is Ancef). People with compound fractures are also more likely to have bleeding in their arm (a hematoma) so their arm may look like it has a big bruise on it. If the bleeding is bad enough it can cause a "compartment syndrome" where the arm swells up so tightly from the blood that it cuts off its own blood supply and tissue begins to die. Doctors have to always be on the lookout for this problem because it's an emergency and the treatment is to make a long incision down the swollen part of the arm to relieve the pressure.
As for the timetable, my understanding is that a compound fracture must be repaired in surgery ASAP, as soon as the patient is stabilized from any other injuries. The longer you wait, the more chance that the blood supply to the arm bones could be compromised (bad, bad). Broken arms do not usually require you to stay in the hospital in traction like a broken leg might. I wouldn't think that you would have to stay in the hospital more than a day if you had to have surgery. Of course, often people with that bad of an arm fracture do have other injuries, so they're in the hospital anyway for those problems.
After the bone heals, the patient often has to do some physical therapy (this could be formal or just exercises you do by yourself at home) to regain flexibility of the arm. Believe me, after your arm has been in the bent position for 2 months, it does not want to straighten out. You have to try to straighten your arm out several times every day until your arm does straighten out. This hurts, but you've gotta do it.
Oh, another thing is that everybody who's ever worn a cast knows that after a week or so your arm starts itching like crazy because it starts flaking off dry skin underneath the cast and you can't do anything about it because it's out of reach. I found myself searching for any long sharp object (butter knives or metal coat hangers work well) that I could get between the cast and my skin and using it to scratch myself and get some relief. It drives you nuts!
There are several nerves that can be damaged with a broken arm -- if you break your humerus (the arm bone above the elbow), there is a nerve that goes right next to the arm bone that can be injured (the radial nerve). If you want more information on that, just let me know.
The boot should be taken off and wrapped in enough material to stabilize the joint (immobilizing the joint will make the person most comfortable), and a splint should be fashioned if possible and the ankle strapped to it with more bandaging to further immobilize the joint. You might think that the boot should be left on until you get help because it would provide support and protection, but that would *not* be a good idea because a broken bone swells a *lot* within hours of the fracture, and the foot would probably swell up so badly that you'd have to cut the boot off to get the foot out. Furthermore, the circulation could be cut off by the pressure generated by the boot on the swollen foot, and that could result in losing the foot (not good). Which brings me to another tip: the foot should be padded (a sock) and wrapped snugly enough to keep it from moving, but not too tightly to cut off circulation when it swells. There is nothing wrong with unwrapping and re-wrapping the joint more loosely if the swelling progresses and the person complains of more pain. In fact, this *should* be done. If something is available to make a cold pack (such as snow), that can help to bring down swelling and relieve some pain. Make sure you put the snow in something (preferably a bag) and don't put it directly on bare skin. That could cause a burn (frostbite).
Return to the ER for a cast check tomorrow morning.
Keep cast dry at all times.
No weight bearing on a walking cast for 48 hours.
Elevate cast extremity to lessen swelling.
If part swells greatly or gets cold, blue or numb or if pain increases markedly, have it checked promptly.
If you continue with persistent or unusual symptoms, contact the emergency department at once.
The simple mnemonic "RICE" is an easy way to remember how to treat something like a joint sprain or strain.
R -- Rest. Don't use the injured part as much as possible.
I -- Ice. Helps relieve swelling and pain. Ice should always be in a bag and never placed directly on skin, because that can cause burns. Bags of soft blue ice work very well. Jim and Blair obviously prefer bags of frozen peas <g>.
C -- Compression. Wrapping the injured joint with something like an ACE bandage (not too snugly; just enough to give a little extra support) often makes the joint feel better.
E -- Elevation. Propping the injured limb above the level of the heart decreases swelling. At night, pillows can be used to elevate the injured area.