attempt more than to ensure that the airway is clear, to control any external
haemorrhage, to cover any wound with a clean dressing, to provide some form
of immobilisation for a fractured limb, and to make the patient comfortable
while awaiting the arrival of the ambulance.
When it is necessary to move a patient with a long-bone fracture, it will be
found that pain is lessened if traction is applied to the limb while it is being
moved. If it is suspected that there may be a fracture of the spinal column,
special care is necessary in transport, lest injury to the spinal cord or cauda
equina be caused or aggravated. It is most important to avoid flexing the spine,
because flexion may cause or increase vertebral displacement, jeopardising the
spinal cord. In certain types of fracture, extension is also potentially dangerous
to the cord. Accordingly the patient should be lifted bodily on to a firm surface,
with care to avoid both flexion and extension. If a cervical collar is available, it
should be applied as a protection for the neck before moving the patient,
without allowing either flexion or extension of the neck during its application.
Temporary immobilisation for the long bones of the lower limb is
conveniently arranged by bandaging the two limbs together so that the sound
limb forms a splint for the injured one. In the upper limb, support may be
provided by bandaging the arm to the chest or, in the case of the forearm, by
improvising a sling.
Haemorrhage hardly ever demands a tourniquet for its control. All ordinary
bleeding can be controlled adequately by firm bandaging over a pad. Only if
profuse pulsatile (arterial) bleeding persists despite firm pressure over the
wound, with the patient recumbent, does the need for a tourniquet arise.
Pending its application, firm manual pressure over the main artery at the root
of the limb may be applied to control the bleeding. If a tourniquet is applied,
those attending the patient should be made aware of the fact and of the time of
its application. If necessary, a note to this effect should be sent with the patient
to ensure that the tourniquet is not inadvertently left in place for too long.
Ch03-F10297.qxd 3/27/07 11:26 AM Page 29If morphine or a similar drug is given at the scene of the accident a note to
that effect should be sent with the patient on admission to hospital.
Clinical assessment
It must be emphasised again that an immediate assessment of the whole
patient is required to exclude injuries to other systems before examination of
the skeletal injury. Examination of the limb should determine:
1. whether there is a wound communicating with the fracture
2. whether there is evidence of a vascular injury
3. whether there is evidence of a nerve injury
4. whether there is evidence of visceral injury.
Resuscitation
Many patients with severe or multiple fractures, or fractures associated with
other visceral injuries, are shocked on arrival at hospital. Time must be spent
on resuscitation and dealing with any other life-threatening injuries before
definitive treatment for the fracture is begun. Haemorrhagic shock can develop
rapidly when there has been a rapid loss of a large volume of blood. The mainstay of treatment is the immediate replenishment of the circulating blood volume,
either with transfused blood when time permits cross-matching, or alternatively
by the use of plasma expanders and blood substitutes. Electrolytes, such as
isotonic saline or Rimmer’s lactate solution, can be used to establish
intravenous infusion but are of little value in replacing lost blood. Colloid
solutions which remain within the circulation are of more value and include
dextran, a high-molecular-weight polysaccharide, gelatin solution derived
from animal protein, or a plasma protein fraction solution of human albumin
with a small proportion of globulin. Transfusion with colloids or whole blood
is usually only required in patients with blood loss greater than 1 litre.
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