Episode 15: Fractures And Broken Bones

First Aid Podcast Disclaimer

This podcast provides general information and guidance on first aid treatment. It is not a substitute for professional medical advice or certified first aid training. Always seek the advice of a qualified healthcare professional for any medical concerns or before making any decision related to your health or treatment. In a medical emergency, always call for immediate medical help.

Episode 15: First Aid Unboxed – Fractures and Broken Bones

Mark
Hi and welcome to episode 15 of First Aid Unboxed, our first aid podcast. I am purely the person here who asks the questions that I hope that you want asked, but the person who answers the questions and our expert is Louise Madeley. Good morning, Louise. Morning. Right then, what are we going to be talking about this time?

Louise
We are talking about fractures.

Mark
Fractures and bones.

Louise
Yes, bones.

Mark
Dem bones, dem bones, I think someone once sung, but not me. Right.

Louise
Yeah, please do not.

Mark
Will that make the edit? Let us see, shall we? So you used to work in accident and emergency in London at one time. How common is it for people to come in with broken bones?

How Common Are Broken Bones in Accident and Emergency?

Louise
Very, extremely.

Mark
Really.

Louise
Yes.

Mark
And... I suppose people break bones in all kinds of bizarre and weird ways as well. It is not just sports injuries or tripping over a chair or something like that.

Louise
Yeah, absolutely. The way I tend to think of the body is it is a bit like having crumple zones.

Mark
Right, okay.

Louise
You have got... the main core of your body that is essential, that you cannot damage without severe outcome, shall we say. So your brain, your heart, your liver, your lungs, you know, all these things.

Mark
All your internal organs, basically.

Louise
Your essential organs. And they are all kept either in your skull, in your vertebra, or in the top half of your torso. That is where you keep the most important organs.

Mark
Yeah.

Louise
And because of that, you have strong bones that protect it. A skull is an exceptionally strong bone, but it is breakable, as are all bones.

Mark
Yeah.

Louise
But you have crumple zones as well. So when somebody falls over and their arms go outstretched, we call it foosh, fallen outstretched hand, they are likely to break. their ulna and radius, the two bones.

Mark
The lower half of your arm.

Louise
The lower half, yeah. The same with your legs, you are more likely to break the bottom half of your legs.

Mark
Okay.

Louise
The same with your collarbone. So something happens, car accident, you know, the first thing that is going to go are those collarbones. They are very small, delicate, little bones. the lower ribs as well. These are much smaller, more delicate bones as opposed to this enormous strong sternum that.

Mark
You have got in front. Has nature sort of designed them to break to a certain extent, to take the impact?

Louise
Exactly, that is why I call them crumple zones.

Mark
Yeah.

Louise
You know, like with a car. They are there to protect the more important organs that are the ones inside.

Mark
Nature is a wonderful thing.

Louise
Oh, it is incredible. The body is an incredible thing.

Mark
Yeah.

Louise
You know, it is all those things that we do not think about that the body naturally does on a daily basis to keep us alive and functioning.

Mark
I am surprised I have got the energy to keep awake with the amount of things that my body has to do on a daily basis.

Louise
That is my excuse for tiredness every day.

Most Common Broken Bones and ‘Crumple Zones’

Mark
Okay, so what is, in your experience, certainly through accident and emergency, what is the most, I am not going to say popular, what is the most common? What is the, because no bone breaks are popular are they? What is the most common break?

Louise
Well we will not include digits particularly because they are treated slightly differently but digits all the time. Your fingers, your toes, fingers more than toes. Again because you are using them and because if an accident does happen those are the first things to go out.

Mark
It is your first line of defence against anything really, is it not?

Louise
Yeah exactly. So yeah all your fingers and toes are probably the first, closely followed by your lower arms.

Mark
Your forearm, yeah.

Louise
Yeah, absolutely.

Mark
Okay, and there is two bones in there, is not there? Two major bones in your forearm.

Louise
There are, your ulna and your radius.

Mark
Okay, one on the outside, one of the inside sort of things, is not it?

Louise
Sort of, yeah.

Mark
Top and bottom.

Louise
As you turn them, you will see them both interacting with each other.

Mark
I am sort of doing that now, I am feeling that, yeah, I can feel that, yeah.

Louise
Absolutely.

How Do You Know If a Bone Is Broken?

Mark
So how do we know when we have broken a bone? I know it might sound really obvious, but I know people who have broken bones and not realised it for quite some time. So what sort of things you need to look out for?

Louise
Okay, well, firstly, it is distinguishing what sort of fracture it is. Is it an open fracture or a closed fracture?

Mark
Has it come through the skin or not?

Louise
Exactly. That is all that means. A closed fracture is where it has not pierced through the skin and it has not created a wound. The wound does not have to be right on the fracture. It could be a little bit further up, a little bit further down. But if there is a wound near the fracture, that is classed as an open fracture. We used to call them compound fractures.

Mark
Yeah.

Louise
That phrase has gone now. It is just either open or closed. It does not necessarily mean that because it is closed, you are not bleeding.

Mark
Okay, so it can create internal bleeding.

Louise
Absolutely, yeah. So you may not be able to, sometimes you can see that, quite often you cannot, but you need to know what to look for if there is a closed fracture and there is a risk there could be a bleed there. We have a huge vascular system within our bones, so we can bleed out of bones very significantly, very quickly. Particularly the bigger, longer bones.

Mark
Every day is a school day. I never realised that.

Louise
Yeah. Yeah.

Mark
I did not realise there was blood in your bones as well.

Louise
Yep. We do something, you know, when you put a cannula into the arm, for example, into the veins, we do that into bones if necessary. So instead of doing things into the vein and giving fluids into the vein, we may give them intraosseous, which is into the bone itself.

Mark
That sounds so painful.

Louise
Yes and no. We do give something to relieve the pain just before doing it. But again, actually it is a lot more effective and we use it when there is quite significant amount of trauma, could be lots of blood loss, et cetera. Yeah. We do do it in resus. It is done more frequently now, I would say in pre-hospital emergency medicine. As first aiders, it is about recognizing a fracture as much as anything. You have to remember when it comes to anything to do with first aid, you have to assess the situation and make sure that you are safe first. That is always top priority. So check that you and the injured person are not in any danger. You come first. If you cannot look after yourself and do not look after yourself, you cannot help the person that is injured. Been through this 100 times, I cannot say it enough.

Mark
It is the thing on an aeroplane when the oxygen mask comes down and you have got a child with yours, you are always putting yours on first.

Louise
Absolutely.

Mark
Because if you cannot breathe, you are no use to the child, are you?

Louise
Precisely. You must look after yourself first. Make sure that the situation is safe as possible. It may be that you may need to move that person, for example. Ideally, you do not want to move them, but... Danger comes first. You need to make them safe. Okay, so always prioritise your airway, breathing, circulation. I know we are talking about fractures, but it still always comes back as first aid to airway, breathing, circulation. Prior to that, it is danger response. Any dangers, is the patient up and talking to you and alert. If they are not, then you really need to start working on your airway, breathing, circulation and you do not leave that. Fractures do not take priority over airway, breathing, circulation is what we are saying.

Mark
Okay, so it is airway, breathing, cardiopulmonary resuscitation.

Louise
Cardiopulmonary resuscitation, absolutely. And follow resuscitation guidelines, as we have said before, if cardiopulmonary resuscitation is the case. A fracture is serious, but it is not immediately life-threatening in the way an obstructed airway or cardiac arrest is, if that makes sense. If appropriate, call for immediate help. Certainly if you suspect that somebody has broken something, has fractured. When we talk about breaks, they are all fractures. There is no such thing as a break is a break and a fracture is a fracture. Some people mistake fracture as being a crack and a break as being the bone has broken in half, for example. All of them are fractures. So a break does not actually exist.

Sprain vs Fracture: What Is the Difference?

Mark
What is the difference between a sprain and a fracture?

Louise
Lots. A fracture is to the bone. So the bone has been broken in some way or cracked. There is damage to the bone. A sprain is to do with the soft tissue. So it is tendon and ligament damage. And unfortunately, often takes a lot longer to recover than bones do.

Mark
Right, okay. And they often treat them similar, do they not? Put them in a boot or, I have seen severe strains being plastered up and things like that.

Louise
Depends on what it is. If it is damaged to the Achilles, for example, which is at the back of your heel, then yes. It just depends on the type of sprain and how severe it is and whether something has ruptured or snapped. A snapped Achilles, for example, that is surgery. When it comes to, certainly when you are doing sport or anything else, if you have got soft tissue injury, take it seriously, is what I am saying.

Mark
The Achilles thing, it is making me wince just thinking about it.

Louise
Yes. So call for help immediately, dial 999. State that you suspect that something is fractured. Let them know where it is, give the location. If it is less severe and the pain is not extreme, there is no obvious deformity, the person can move a little. And if you are sure then, or if you are unsure rather, then you can phone 111. It does not necessarily mean that it is going to be a 999 emergency ambulance. It could be that you just need some advice from 111.

Mark
Will it swell up?

Louise
Now that varies. Generally we do say that it swells and yes it can. What is actually happening is a combination of the inflammatory response that you would expect and there may be bleeding occurring as well. Now with children, they do not have the amount of blood in their bones that adults do. So if it is a child that has fallen over, you suspect that they may have fractured their arm, for example, but there is no swelling, do not think that cannot be a fracture, because it can. But with adults, generally, yes, it does tend to swell.

Mark
So always err on the side of caution with all these things.

Louise
Always. Yeah. Yeah. So call for emergency help. Advise the casualty to remain still. You do not want them up and moving around, apart from the fact that any movement could make it significantly worse. Support the injured part. Gently support it in the position that you have found it in. Do not try and manipulate anything. Do not try and move anything. Do not think, I have got to get this arm into a sling. The way I tend to think about it, especially when somebody has been injured, the body and the brain is an amazing piece of kit. You get pain for a reason. Pain is there as a part of your body to tell you that you have been damaged and not to make it worse. That is what it is there about.

Mark
It is your alarm system, is it not?

Louise
Absolutely, yeah. You have got pain receptors everywhere telling you that you are in pain, therefore you have a damaged part of your body and where the location is that is damaged. So always go with somebody who says, this hurts here, if I do this, it hurts more, if I do that, it hurts less. Do not try and get them into a sling, for example, and it well supported if it causes them more pain to do that. If it is causing them more pain to do that, then you are probably making the situation worse. And as a first aider, you are not there to do that. You are there to stop the situation from getting any worse. So I always let somebody who is in pain get themselves out of pain first. So if they are, for example, an anterior dislocation, which of the shoulder, which is when it is sticking out of the front?

Mark
So your arm has popped out basically.

Louise
Exactly. Popped out of the joint, tendons are stretched and it is sitting outside of the joint and it looks really deformed. The first thing they will do, the person who has injured it, is they will turn their arm slightly, put it in front of them and hold on tight in a certain position and that is absolutely fine. You are not moving that whatsoever. They will stand up generally or they will sit in the chair and open their legs and put the arm through their legs so they are holding on to their arm. That is the position that you are taking them to accident and emergency or calling an ambulance and getting them escorted to accident and emergency. Let them get themselves out of pain first. Obviously, if you can see that there is a huge open fracture and you can see that the bone is sticking out and they are trying to move themselves, that is not a good thing. You want to immobilise them in the position they are in. But for a lesser fracture, shall we say, they will be able to gauge just how badly they are broken.

Crepitus and Other Signs of a Fracture

Mark
How common is it for you to hear the break?

Louise
Oh, it is common, but if you do not hear it, it does not mean it is not broken. It depends on the fracture. It is called crepitus, and you can hear a sort of grinding noise. It is the best way to describe it. And again, it just completely depends on what type of fracture is involved.

Mark
This is the 15th podcast we have done in this series, and it is the one that is making me wince more than any other one.

Louise
Yeah. It does for a lot of people. It is a bit like the noise when you put your fingers down a blackboard. Showing my age now. You know, everybody goes, oh, it sets your teeth off. It is that sort of noise that you hear when somebody has fractured and you hear that crack.

Mark
It is funny because I get that noise, not that noise, but a noise on my knees a lot. They pop and grind a bit because I am just old. Wear and tear. Wear and tear, exactly. But it is quite cringy as well sometimes and you think, oh no, I do not like the sound of that.

Louise
Yeah, absolutely. So support the injured part, you could use if it is an arm for example, popping it up onto a pillow, anything, just popping the pillow around the injured part more than anything. If it is comfortable to go into a sling then use a sling. It could be that you just need to...

Mark
But that is not your first port of call, is it?

Louise
No. No, absolutely. Immobilise it as best you can. As first aiders there are certain commercial splints that can be used. We use SAM splints, certainly in rugby we use SAM splints quite a lot. These are mainly for the crumple zones, shall we say. So generally you would use them for lower leg and lower arm. They are more for the simple fractures that you can just quickly immobilise, pop a dressing around it, and you are taking them to accident and emergency. Simple as that. You can use improvised splints, using a rolled up magazine for example, to put either side of the injured part. That is fine. And then just a dressing around it. Either way, the most crucial thing is you are not attempting to straighten the limb or push any bone back into place. That is not happening. That is not your responsibility. That is not the role of a first aider at all.

Mark
That is all the hospital's job.

Louise
Absolutely, yeah. That is when the medical guys arrive and they decide if it is compromised. So if the blood flow is not getting down to the toes or the fingers, in which case they need to do something before they move. but that is entirely a medical opinion on that. You are not doing anything. You can test the pulse, so the pedal pulse in the foot or the radial ulnar pulse in the forearms, but all you are doing is relaying that information to the ambulance. They will need to get there so much quicker if there is a compromise. But they will know that and they will deal with that. Controlling any bleeding for open fractures. If a bone has broken through the skin, cover the wound carefully with a sterile dressing. One of the biggest risks is infection when it comes to open fractures. Never, ever try and clean out that wound. Sometimes it is instinct that people want to squeeze a little bit of saline on it, something like that. Please do not. You do not do anything with it whatsoever.

Mark
You literally just cover it with a sterile dressing.

Louise
Sterile, non-fluffy dressing. So in your first aid pack, you should have non-fluffy dressings in there anyway. Just use one of those.

Mark
And it will tell you on the dressing what it is.

Louise
Yes. Yeah, absolutely. The sterile wound dressings that we talked about before, those are the ones that you are going to be putting on there.

Mark
Right, okay, because obviously there is a break in the skin, so that is what you need.

Louise
Exactly, yeah. So yeah, control bleeding for open fractures. If the bone has broken through the skin, cover the wound carefully with a sterile dressing. Needs to be clean, non-fluffy dressing. Put pressure around the wound, but not directly on the protruding bone. That is the key. So you do want to put some pressure there, but it is not onto the bone itself where it is protruding.

Mark
I assume it is going to hurt the patient quite a lot if you do.

Louise
Absolutely, you are going to do more damage. It is just about controlling any bleeding that is there. That is the only reason you are doing that. And just secure the dressing. Certainly if it is an open fracture, you need to manage for shock. A lot of fractures can lead to shock. They may be internally bleeding and you are totally unaware of it, you never know. So if necessary, if the face is pale, raise the tail, if you can. If they have fractured their lower limb, you do not really want to put them on their back and lift up that leg. Monitor their breathing, monitor their level of response, and treat for shock if you need to. So once you have done that, make sure you do not give them anything to eat or drink. It may be that they are going to require surgery once they get to the hospital, anaesthesia, et cetera, so nothing to eat and drink. When the ambulance gets there, if necessary, they will give them fluids into the vein. So it is not going to be long before they are going to have fluids, but you must not give them anything orally. And reassure the casualty, maintain that communication, keep them calm. As I say on most podcasts, people do feed off your calm. If you are nice and calm and your voice is low, and you appear relaxed and knowing what you are doing, then they will feed off that calm and they will in turn feel much more relaxed.

Mark
Do people suffer from shock often when they have broken a bone?

Louise
It depends on how much fluid they have lost really.

Mark
Right.

Louise
Obviously there is emotional shock that people can go into, but when we are talking about hypovolaemic shock, et cetera, then really it depends on whether they have lost fluids.

Mark
And the thing we must stress is that before you do any of this stuff, call 999.

Louise
Absolutely.

Mark
You know, that is your first thing. It is call 999. And then if you are first aid trained, then do the things that you are trained to do.

Louise
Yeah. If it is a minor fracture, then 111, that is absolutely fine. And get medical advice. If you think that it is a severe fracture, and certainly if it is an open fracture, then absolutely it is... Call 999. They will advise you further and get the medics over to you as quickly as possible.

Mark
Okay.

How Hospitals Treat Fractures and Broken Bones

Louise
So once you have reassured the casualty, help is on the way, they will then be transferred over to the hospital. Ambulance will arrive, they will decide whether or not they need to immobilise, splint, et cetera. Get them into the ambulance, whether they need fluids, they will then be transferred to the hospital. They can also give pain relief as well, either into the vein or they can give gas and air, entonox, et cetera. Splint is usually applied at this point just to prevent movement. Once they get to the hospital, it could be that they need a different type of splint. It could be that they actually need immobilisation and certain types of traction. We use several different types of traction, actually. Thomas splints are always a good one once we get to the hospital. So it could be that they are casted, splinted, braced to hold the bones, whatever is appropriate. It may be once they have had an X-ray that they need to do a reduction if the bones are misaligned. So if you have got one bone where it should be and then the other bone has gone off on an angle and it is a proper break if you like. they may need to put them back, which can be done either through anaesthesia in resus, it could be that they need to go into surgery and have it done under general anaesthetic and usually come out with a cast or a splint, certain type of boot, can be lots of different treatments.

Mark
Do they use casts as much these days, like plaster of Paris or is it mainly boots and things like that?

Louise
No, still use them. Generally, because there is a lot of swelling immediately when you have a fracture, we tend to use a special type of cast which is not fully sealed. So it does not go all the way around the limb. It is open at the front with a bandage across it, which means that it can move with the swelling. And we leave it like that for about 48 hours just to allow the swelling to happen, then go down. Then once we are happy the swelling has improved, you can then look at putting them into a cast.

Mark
And on average, how long do you have to leave a cast on for? I mean, in my head it is six weeks, but I am sure it is not six weeks.

Louise
No, six to eight weeks for minor fractures, can be longer for severe breaks, but generally six to eight weeks.

Mark
And traction, is that a thing for broken legs?

Louise
It can be.

Mark
And broken arms.

Louise
Yeah. So it is somebody who has got a fractured femur, for example, which is your long bone in your thigh. What happens is when you break that bone, your muscle and your tendons are very, very strong down there. They are holding you upright and they will close up together. So you can end up with half of your femur in one angle and the other half in another angle. The only thing they can do is use traction to pull the two apart.

Mark
Oh, so they are actually pulling your leg?

Louise
It literally pulls the two apart and then they can put it into the right position so that the two can then fuse together, if that makes sense.

Mark
Yeah, yeah, yeah, yeah, oh wow.

Louise
But we actually start that in resus.

Mark
Oh really? That is an early thing.

Louise
Trauma and orthopaedics come down, they take over.

Mark
In accident and emergency, is there X-ray in accident and emergency or have they got to go down to the X-ray department to have the X-rays done?

Louise
X-ray department has its own accident and emergency X-ray department.

Mark
Oh right, which is always available.

Louise
Which is right at the back of the clinic. So you have got accident and emergency and it is right behind it, basically. Certainly at Royal Shrewsbury, all of it is in that one area. Yeah. But there is a specialist part that is used to filter accident and emergency patients into...

Mark
Because I assume they have to make a diagnosis quite quickly to know what they have got to do, whether it is surgery or whatever.

Louise
Absolutely. Yeah.

Mark
Thanks for that, Louise. It is really, really handy and really useful. Like I say, we have done a number of these podcasts. This is number 15, and it is the one that has made me wince most out of all of them. When you are talking about bones being pulled apart and put together again, I do not even want to think about it. Right then, what are your takeaways for this particular situation?

Key Takeaways: Recognising and Managing Fractures

Louise
We have had quite a few off-air conversations, have we not?

Mark
There has been a lot edited out of this, I will tell you. Anyway, anyway, let us get back on track.

Louise
The main take-homes are key signs and symptoms really of a fracture. How to recognise that somebody has fractured a bone. Firstly, severe pain. Often worsens when you move it. So if you imagine somebody has fractured their arm or you think they may have, the minute they try and turn that arm at all, it gets...

Mark
And listen to their pain response, yeah.

Louise
Absolutely, yeah. Trust the person that you are dealing with. You know, they know how much pain they are in. Their brain is getting that pain response for a reason. It is telling them that they have been damaged. Okay. So always work with it. There can be swelling, there can be bruising, less so with children. You are less likely to get swelling and bruising with children. But just because you do get swelling and bruising with children, do not think that it is not a fracture. Still treat, they may have a fracture if they are in pain on the bone. Tends to develop around the injured area. One thing I have always noticed with kids is when you say, Where does it hurt? They will take their index finger and point straight at it. Then it is more likely to be a fracture. If they sort of put their hand around it and say, well, it is this general area, it is more likely to be soft tissue. They tend to use a finger and go, ouch there.

Mark
There is a definite pain point.

Louise
Yes, absolutely. There could be a deformity. It may look bent, twisted, or just generally not quite right, out of place. Inability to bear weight or move the limb, so they may not be able to stand on it. Very strong indicator, especially in legs and arms. Tenderness might be very painful to touch on the area that is fractured in particular. We were mentioning before about the crepitus, that grating, grinding sensation. You may be able to hear it if they do try to move there.

Mark
Crepitus is a very onomatopoeic word, is it not? Because you could imagine it making that sort of noise.

Louise
Yeah, I think it is a great word. It is brilliant. It just sums it up. Everybody knows what you mean when you say there is crepitus.

Mark
Yes.

Louise
Obviously, if it is an open wound, significantly concerning, that is accident and emergency, that is an ambulance every time. We call it an open or compound fracture. Compound is not really used anymore. It is an open fracture, in which case it has pierced the skin. You are calling for an ambulance. Any numbness, tingling, pins and needles, generally below the injury site, then that would suggest that there may well be a fracture there. And if the skin is cold and sweaty or there is a fast or weak pulse as well, keep looking out for shock. Always check the pulse below the injury, just to make sure. If you suddenly see that their fingers have gone quite pale and there is a blue tinge under the fingers.

Mark
There could be a circulation issue.

Louise
Absolutely. It could be that it is compromised there somewhere. Okay. In which case it is more urgent than if it is not. And again, just treat, treat for shock.

Mark
And we have got a whole episode about shock. So go back and listen to that if you are not sure about how to treat someone for shock or what to do.

Louise
Absolutely.

About Madeleys First Aid Plus and How to Learn More

Mark
So Louise has been a fully trained nurse for 30 odd years now. So this is purely for advice, obviously. If you are in any doubt, contact a medical professional or call 999 if you are in the United Kingdom or whatever the emergency number is in your country. Louise also runs Madeleys First Aid Plus, which is a first aid training company. So tell us a little bit about that and how people can get in contact with you.

Louise
Yes, so anybody who wants to get in contact with me, it is enquiries@madeleysfirstaidplus.co.uk

‍