You may wonder why I would seem so bold to even suggest fracture treatment in a home-like setting. The reasons are twofold. First, many are completely unable to afford the expenses of emergency room care or the services of an orthopedist today.

Second, many fractures occur in a remote rural setting in countries where medical services are not available. Therefore, it is advisable to know some of the basic principles of diagnosis and management, not only to alleviate acute suffering, but also to prevent residual deformity as the fractured bone heals.

Fractures of the bones may be classified in several ways. The greenstick fracture is one in which only a portion of the bone is broken, leaving the major segment intact. This is more typically seen in children, since their bones are soft and still growing. Perfect diagnosis can only be obtained with x-ray.

The closed fracture, formerly called simple fracture, is one in which the skin is not broken, and the bone is fractured in only one place. No other fragments are seen, and displacement is usually slight. A comminuted fracture, on the other hand, is one in which multiple fragments of the bone are present.

It is usually caused by a more severe, shattering type of injury. Open (compound) fractures are those in which a sharp fragment of bone actually penetrates the skin, allowing contamination and a high risk of severe infection. Osteomyelitis of the bone is a common sequel of these extensive injuries.

The degree of displacement as well as the kind of fracture helps determine the appropriate treatment. Many traumatic injuries crack the bone either as a simple or greenstick fracture and leave no deformity at all. This can be seen particularly at the elbow with an impacted fracture of the radial head, or in the shoulder where fractures are caused by falling on an outstretched arm impacting the shoulder while fracturing the humerus.

The most common fracture seen in children involves the collarbone or clavicle. Usually some “overriding” (overlapping of fracture ends) is present. Prolonged fixation of the shoulders in a “figure of eight” splint is recommended, with manual evaluation or X-ray pictures determining the degree of shoulder stretching required to keep the bones fairly well aligned.

Fractures of the wrist are the second most common type. They may be seen at any age. Often the deformity produced appears as a “silver fork.” In order to avoid limitation of wrist motion afterward, with residual arthritis, careful setting of the bone is required.

The easiest way to evaluate an injured extremity for a suspected fracture is to feel with one finger along the involved bones. A fractured bone will usually be exquisitely tender right over the area of fracture. If the patient is seen before undue swelling has set in, the diagnosis can often be pinpointed.

Fractures about the ankle are also fairly common. However, X-rays are necessary to evaluate the extent of injury. Some can be treated with a compression type cast for 6-8 weeks, while others require the placement of pins or screws for accurate reduction. The goal is to restore complete weight bearing on the affected leg.

Unless obvious deformity exists, it is difficult to distinguish skull fractures from contusions or concussions. The presence or absence of unconsciousness is not always reliable in distinguishing skull fractures. Any fractures that cause slow bleeding into the space beneath the skull (subdural) are particularly dangerous.

They may develop a symptomatic clot (hematoma) over a period of days to weeks, putting pressure on the brain. Any prolonged impairment of consciousness or nerve function after a head injury should be evaluated by a physician, with the appropriate x-rays taken.

Asymmetry of the eyes, double vision, an altered appearance of the facial bones, bleeding or clear discharge from the nose or ears should always alert one to the possibility of facial (orbital) fracture. Pain on biting or chewing, or altered position of the teeth may indicate a possibly fractured jaw.

That also should be evaluated radiologically and appropriately stabilized. Initial first-aid treatment of fractures is familiar to most emergency medical technicians and nursing instructors. The injured extremity should be put at rest, with appropriate splints.

Boards, pillows, rolled newspaper, or the modern inflatable plastic splints should be used to immobilize completely the affected part. Ice packs should be applied to reduce pain and swelling during transportation. Ice may even permit appropriate manipulations for setting the bone, if the area has been rendered cold enough.

No weight bearing should be put on an ankle, leg, or hip suspected of fracture, until appropriate examination and X-rays have established the absence of such injury. When a fracture is well-aligned and stabilization is indicated, casts or splints can be manufactured.

Bone setting, or the reduction of displaced fractures, is beyond my scope to teach here. Aluminum splints may be trimmed or cut, and shaped to conform to the injured part, making a suitable stabilizer to use with appropriate padding and an elastic bandage.

Cast materials are available with plaster-impregnated gauze available in rolls or strips for the preparation of a cast. Usually a stockinette-type material or cotton padding about 1/8” thick is used to protect the skin, while the plaster on the outside provides stabilization.

When the usual plaster rolls are used, wrinkles and excessive pressure over bony prominences must be avoided. Plaster casts are quite durable. Newer light cured epoxy materials and fiberglass casts are lightweight, but considerably more expensive.

Naturally, all plaster casts must be kept dry and free from weight bearing or pressure that exceeds the strength and thickness of the cast. When prepared plaster rolls are not available, an acceptable substitute may be prepared from roller gauze soaked in moist plaster of Paris.

This is applied in the usual manner. Gauze strips may be laid in plaster and applied, gradually developing the cast. Be careful to avoid pressure over bony prominences. A general rule of fractured long bones is to immobilize the joints above and below the involved bone.

Thus, a fractured forearm frequently requires casting above the elbow and down to the fingers. Exceptions to this are the ankle and wrist, both of which can frequently be stabilized with a shorter arm or leg cast. The healing time of broken bones varies considerably, with babies’ bones healing the fastest, children next, and adults more slowly.

The aged take the longest. As a rule, a forearm in a child might heal well in 3—4 weeks, an adolescent or young adult in 6 weeks, and an elderly person 2—3 months. Nonunion is more common in the elderly, particularly in fractures of the leg bone (tibia), due to its less abundant blood supply.

The removal of a cast is quite easy. Without the usual equipment, such as cast saws and special scissors, a cast can be removed by soaking it in water until it softens. Another way of removal is with a knife or file. More commonly in a doctor’ s office, an oscillating cast saw is used, cutting the cast lengthwise on two sides, then taking it off in halves.

After a cast is removed, begin using the extremity gradually. Hot and cold contrast baths or whirlpool baths are often helpful to improve circulation. Dependent areas, such as the leg and ankle, need to be wrapped for several weeks with an elastic bandage.

Gradual weight bearing and ambulation will once again restore the normal venous and lymphatic return, preventing fluid collection or edema formation. With few exceptions, bones begin to heal from the time they are broken. After appropriate stabilization and care, a healed fracture can be as good as new within a short time.