First aid for open fractures

Pre-hospital care algorithm

The main objective in an open fracture is to minimize risks to the patient's life and prepare them for transportation to the surgical department. Care is provided in a strict sequence:

1. Stopping bleeding. In case of severe arterial or venous bleeding, a tourniquet must be applied. If the venous bleeding is not massive, applying a pressure bandage is sufficient.
2. Wound care. The skin around the injury site is smeared with an iodine solution or iodopyrone (a complex of iodine and potassium iodide). Only freely lying large foreign bodies are allowed to be removed from the wound . Exploration of the wound tract with a finger or probe is unacceptable due to the high risk of infecting deep layers and damaging neurovascular bundles.
3. Bandage application. Sterile wipes, individual dressing kits (IDK), or cotton-gauze pads are used to cover the defect.
4. Transport immobilization. Indicated for any open fractures as well as extensive soft tissue injuries (lacerated and contused wounds). Standard or improvised makeshift splints are used to fix the limb.
5. Transportation. Carried out to the specialized surgical department.

Complications due to first aid errors

Incorrectly provided care can significantly worsen the victim's condition. The main causes of complications include careless patient transfer, improper application of a tourniquet and transport splints, as well as errors during transportation itself.

Such defects can lead to severe consequences:

• Secondary displacement of fragments. This can trigger skin perforation from the inside (turning an initially closed fracture into an open one).
• Damage to neurovascular bundles by the sharp edges of the displaced bone.
• Damage to internal organs or the spinal cord (which causes the development of paralysis).
• Resumption or increase of bleeding.
• Development of peritonitis (in case of combined abdominal organ trauma).

Criteria for assessing the quality of hospital care

After the patient is delivered to the admission department, the inpatient care algorithm is initiated. Using a humeral fracture as an example, the quality control checklist includes mandatory steps (evaluated as "Yes" or "No"):

• Initial examination: consultation by an orthopedic traumatologist immediately upon admission.
• Basic radiation diagnostics: radiography of the injured segment.
• Analgesia: administration of pain relief from the moment of admission (in the absence of contraindications).
• Advanced radiation diagnostics: computed tomography (CT) is performed exclusively when indicated.
• Treatment strategy: depending on the nature of the injury, the intervention is chosen—application of an immobilization bandage, fragment reposition, open or closed fracture treatment with internal fixation, or the use of external fixation devices.

Injury specifics using lower leg fractures as an example

To better understand the specifics of diagnosis and immobilization, it is advisable to examine fractures of the lower leg bones.

Isolated tibial shaft fractures (types A and B) These occur frequently and lead to severe functional impairments. The injury mechanism is usually direct. Displacement in length is not typical for them, as the intact fibula acts as a "natural spring/splint" (if tibiofibular syndesmoses remain intact). However, displacements in width (with a high risk of interposing muscle) or angular deformations often occur.

Diagnosis is facilitated by the subcutaneous location of the bone: axis curvature is visualized, a step-like deformity along the crest is palpated, and weight-bearing capacity is impaired. A positive axial load symptom is characteristic—pain upon percussion of the heel.

Treatment strategy: At the pre-hospital stage, splints are applied, general anesthesia is administered, and the patient is transported strictly in a supine position. In the hospital, for displaced fractures, local anesthesia is used (administration of 20 ml of a 2% novocaine solution into the hematoma) and a one-stage manual reduction is performed under fluoroscopic control. To eliminate displacement, one assistant performs traction by the foot, another creates counter-traction by the thigh, and the surgeon manually presses on the fragments. Finally, a split plaster cast is applied, which is converted into a circular cast 2–3 days after the edema subsides.

Isolated fibular fractures Proceed much more mildly and practically have no complications thanks to the splinting effect of the tibia. Patients are allowed to walk with a cane (with limited weight-bearing), and working capacity is fully restored in 5–6 weeks.

Class and exam questions

What else to study on this topic

• Technique of applying standard and improvised transport splints.
• Mechanisms and consequences of interposing muscle in displaced fractures.
• Indications for computed tomography in extremity trauma.
• Methods of surgical osteosynthesis: internal and external fixation.
• Rules and timing for converting a split plaster cast into a circular one.

Other topics in "CHAPTER 10. GENERAL ISSUES IN TRAUMATOLOGY"

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.