Arm or Leg Fractures

An arm or a leg fracture is a break in the continuity of the bone. usually caused by major trauma. A fracture can result in substantial muscle, nerve, and other soft-tissue damage. The prognosis varies with the extent of disability or deformity, the amount of tissue and vascular damage, the adequacy of reduction and immobilization. and the patient's age, health. and nutritional status. Children's bones usually heal rapidly and without deformity; the bones of adults in poor health or those with osteoporosis or impaired circulation may never heal properly.

Causes

Most arm and leg fractures result from major trauma, such as a fall on an outstretched arm, a skiing or motor vehicle crash, and child, spouse, or elder abuse (shown by multiple or repeated episodes of fractures). However, in a person with a pathologic bone-weakening condition, such as osteoporosis, bone tumor, or metabolic disease, a mere cough or sneeze can cause a fracture. Prolonged standing, walking, or running can cause stress fractures of the foot and ankle - usually in nurses, soldiers, and joggers.

Diagnostic tests

Anteroposterior and lateral X-rays of the suspected fracture, as well as X-rays of the joints above and below it, confirm the diagnosis. Angiography can help assess concurrent vascular injury.

Treatment

The primary goals of treatment are to return the injured limb to maximal function, to prevent complications, and to obtain the best possible cosmetic results.

Emergency treatment consists of splinting the limb above and below the suspected fracture where it lies, applying a cold pack, and elevating the limb, all of which reduce edema and pain. A severe fracture that causes blood loss calls for direct pressure to control bleeding. The patient with a severe fracture also may need fluid replacement (including blood products) to prevent or treat hypovolemic shock.

After a fracture is confirmed, treatment begins with reduction (restoring displaced bone segments to their normal position). This is followed by immobilization with a splint, a cast, or traction.

In closed reduction (manual manipulation), a local anesthetic such as lidocaine and an analgesic such as morphine I.M. minimize pain; a muscle relaxant such as diazepam I.V. or a sedative such as Midazolam facilitates the muscle stretching necessary to realign the bone. (An X-ray confirms reduction and proper bone alignment.) General anesthesia may be needed for closed reduction.

When closed reduction is impossible, open reduction during surgery reduces and immobilizes the fracture by means of rods, plates, or screws. Afterward, the patient usually must wear a plaster cast.

When a splint or cast fails to maintain the reduction, immobilization requires skin or skeletal traction, using a series of weights and pulleys. In skin traction, elastic bandages and moleskin coverings are used to attach the traction devices to the patient's skin. In skeletal traction, a pin or wire inserted through the bone distal to the fracture and attached to a weight allows more prolonged traction.

Treatment for an open fracture also requires careful wound cleaning, tetanus prophylaxis, prophylactic antibiotics and, possibly, additional surgery to repair soft-tissue damage.

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