Fractures

Lecturer: Snow Gryphon, Dunvegan Physician
January, 2015
Basic Course, no prerequisites

Fractures

By touching this Dunvegan box here, you can obtain an organized folder with my class notes and supporting documents. Class notes, text and textures are the sole property of the creator. They are not to be shared, sold or used to teach others without the specific permission of the instructor.  This includes local chat.

In today’s lecture we will discuss Fractures, what they are and causes, classifications and treatments. 

I gratefully acknowledge the assistance of my Companion Lady El Macleod and kisu, our first girl, in the development, and presentation of this lecture.

Let us begin.

[photo 1]

At the Physician's Academy we make no effort to train you for any real life medical situations. We offer general information on medical topics, by the book and others, designed to better prepare you to role play as a Second Life Gorean physician. I make no claim to authoritative interpretation of the books by John Norman; nor am I trained in medicine in real life.  These lectures are offered as a resource to role play only.
Please type an @ if you wish to ask a question or make a comment.

In today’s lecture we will discuss Fractures, what they are and causes, classifications and treatments.  We also will have a short participatory RP.

There are not many quotes in the books dealing with the treatment of injuries, per se.   But we know that Gorean medicine was conducted at a reasonably high level, as indicated in the following quotes.

"On the other hand, you will learn that in lighting, shelter, agricultural techniques, and medicine, for example, the Mortals, or Men Below the Mountains, are relatively advanced." Tarnsman of Gor, page 31

"Be that as it may, the Priest Kings have limited man severely on this planet in many respects, notably in weaponry, communication, and transportation. On the other hand, the brilliance which men might have turned to destructive channels was then diverted, almost of necessity, to other fields, most notably medicine."
Assassin of Gor, page 30

So when researching and writing this lecture I have assumed that techniques that can reasonably be assumed to exist in most earth cultures 30-40 years ago when these books were written, also could exist on Gor.  I have not included advanced techniques that require the use of modern materials, electronics, imaging, communications, etc.  The main point being is that Goreans were not stupid, just limited by the Priest Kings in what they can do.

So with that background, let us begin.

1)    What is a Fracture?

    a)    A fracture is a medical term for a broken bone.
   
2)    Causes of Fractures

    a)    Fractures can be caused by falls, impacts (for example being hit by a war hammer), and other injuries where the force exerted on the bone is greater than the strength of the bone.   They also may be caused by stress and overuse, for example in athletes and warriors, and in scribe fingers.  Fractures are more common in children than adults since their bones are not fully developed.

3)    Classification of Fracture Types

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a)    Simple or Closed          
        i)      In a simple fracture, the skin barrier is not broken and hence there is no open wound, although there may be extensive internal damage to muscle and nerve tissue.

    b)    Compound or Open
        i)    An open fracture is one in which the bone breaks through the skin; however the bone may go back into the wound and not be visible.  There is a significant risk of wound and deep bone infection with this type of fracture.  
 
    c)    Displaced & Non-Displaced
        i)    This refers to the way in which the bone breaks.  In a displaced fracture, the bone breaks into two or more parts and moves so that the ends are not lined up. In a non-displaced fracture, the bone cracks either part or all of the way through, but does move and maintains its proper alignment.

Question: Is an open fracture always more serious than a closed fracture?  Explain and give examples.
Answer: No, for example a closed fracture with extensive internal damage.

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    d)    Additional Fracture Types      
        i)    Greenstick fracture: an incomplete fracture in which the bone is bent.   These are very common in children.
        ii)    Transverse fracture: a fracture with a horizontal fracture line.  For example, one at right angles to the axis of the bone.
        iii)    Oblique fracture: a fracture in which the break has an angled pattern.
        iv)   Comminuted fracture: a fracture in which the bone fragments into several pieces, a common result of crushing wounds.
        v)    An impacted fracture is one whose ends are driven into each other.  Often found with falls where the hand and arm bones are driven into each other.

    e)    Fracture Severity
        i)    Severity is dependent on the extent and location of the fracture and whether or not it is Open or Closed.  A rapid assessment of severity should be made when the patient is admitted.   For example, a crushed pelvis with open fractures and extensive internal damage is far more severe than a closed fracture of a finger digit.

    f)    Summary
        i)    There are a number of ways to classify fractures alone and in combination.   For example you can have a closed, displaced fracture from a fall off your kaiila, or an open, comminuted fracture as the result of being stomped by a herd of Kailiauk.  Not a pretty sight!

        ii)    Questions and Comments?
       
        iii)    Here is a question for you then: A patient comes in and complains of a sore forearm.   You have a look and see bruising and his forearm is at an odd angle, but he has no open wound.  Assuming he has a fracture, what is the likely classification?

Answer: Likely a simple(closed), displaced fracture.

4)    Initial Diagnosis of a Fracture

    a)    Many fractures are very painful and may prevent one from moving the injured area. Other common symptoms include:
    b)    Swelling and tenderness around the injury
    c)    Bruising
    d)    Deformity — a limb may look "out of place" or a part of the bone may puncture through the skin

Question:  In RP how would you first assess the classification and severity of a fracture?

Answer: IM with the patient and discuss alternatives and preferred outcomes.  Also listen very carefully to the symptom keywords emoted by the patient.  Be careful of godmodding!

    e)    Shock
        i)    Fracture injuries may be accompanied by shock. 
            (1)    What are the symptoms of shock? 
                (a)    They can include rapid heart rate, cool clammy skin, rapid, shallow breathing, and low blood pressure.     
            (2)    How do we treat shock? 
                (a)    Treat by laying the patient down, raising their legs and keeping the patient warm.   They also may need intravenous fluids.

    f)    Concussion
        i)    Fractures may also involve blows to the head, for example with a fall, so concussion and resultant brain injury is a possibility and must always be considered.
        ii)    What are the symptoms of a concussion?
            (1)    They include headache, dizziness, vomiting, nausea, lack of coordination, confusion and disorientation.
        iii)    How do we treat concussions?
            (1)    In most cases the symptoms of concussion will be resolved in a few days with rest.  An ice pack or cold compress can be used to reduce swelling on the site of impact.

Question:  A patient arrives with a broken ankle due to a fall off a cliff.  He also said he threw up the bosk stew that he had for lunch on the way over to see you.  In addition to treating his broken ankle, what else should you be looking for?  Why?

Answer: a concussion (nausea)

    g)    In summary, an initial diagnosis should include a determination of the nature of the injury, a rough classification of the fracture when present, and a determination if the patient also is suffering from shock and/or concussion.

Comments or Questions?

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5)    Treating a Simple (Closed) Fracture 

    a)    To start, wash your hands and have your infirmary slave, if you have one, prepare the following: a basin of cool water, clean towels, sterile rep cloth bandages, splints, fiber for tying, scissors, tweezers, scalpel, light tube, antibiotic salve or honey, a cool water compress.  Most or all of this should have been prepared ahead and available on demand.

    b)    Assuming initial diagnosis indicates a fracture; first aid should be used while further assessment is completed. The injured limb or bone should be elevated if possible to reduce swelling, and it should also be immobilized to prevent further injury. Rest, ice or a cold compress, and elevation can be used, but not if any of these actions cause pain or risk furthering the injury.  Any objects such as wrist bands or tight clothing should be removed if possible, as they can restrict blood circulation to the injury.

    c)    Meanwhile treat for shock and/or concussion when applicable and continue with a more detailed diagnosis to develop a treatment plan.   This will include further classification of the fracture.  For example, is it displaced or non-displaced, impacted, etc.   Assuming you don’t have an x-ray machine, you can do this by careful palpation (examine or explore by touching) and questioning the patient.   Be sure to listen carefully to your patient, always!

    d)    Treatment for a closed fracture varies depending on the severity of the injury; some minor injuries such as greenstick fractures may only require immobilization and rest in order to heal, while more severe injuries to the bone may require a surgery to repair.

    e)    If the fracture is non-displaced, immobilization to promote healing maybe all that is required.  If displaced, then a re-alignment of the bones will be necessary.  I most cases, you would stabilize the bone with one hand and pull and re-align with the other.  You can RP this easily with the patient and it can often be quite funny.  For example, Physician “Your arm is broken at a right angle, I must straighten it”; Patient “Can you leave it as is?  My FC likes it better this way.  It is good for hanging pots”.

    f)    Once the bones are re-aligned or not, they need to be immobilized to allow healing.   This is accomplished in a variety of ways depending on the broken bone.  For example, limbs are most often immobilized with splints or castes, ribs by taping, and collar bones by using an arm sling.

    g)    There are many types of splints from high to low tech, but generally on Gor when used for limbs they consist of two small wooden planks, with the splint tied around the fracture with rope, cloth, or rawhide.  It is important to not cover any open wounds with the splint material.  Splints are often the first thing you would use to immobilize a fracture.  They are quick and easy to apply, but provide less support and protection than casts.  A cast is just is a bandage coated in Plaster of Paris (roasted gypsum).  Goreans heal quickly, so a cast likely will not be required, except when splints are not practical, for example for a broken back.  Use your best judgment.  There are a number of bandages/casts available to put on your patient in SL and most patients enjoy wearing them. They will often walk around their sim telling everyone who will listen how they were injured. 

    h)    Finish your treatment by offering medication for pain and inflammation if required.  Fractures will heal on Gor in a few days, so be sure to book an appointment to remove the splints or cast before the patient leaves.

    i)    OK that was a lot to absorb.  Here is a quick Step by Step summary of the four steps to memorize when confronted with a fracture:

        i)    First Aid
Stop bleeding, RICE (rest, ice or cold compress, elevation)
       
        ii)    Shock or Concussion
Shock (lay down, raise legs, keep warm, IV)
Concussion (ice pack or cold compress)
       
        iii)    Classify the fracture
Simple (closed) vs Compound (open)
Displaced vs Non-Displaced
Assess Severity
       
        iv)   Treat the fracture
Wash hands
Clean wound if necessary
Re-align bones if necessary
Close (suture) wound if necessary and apply antibiotic slave
Immobilize the fracture (splint, cast, bandage, wire, etc.)
Provide pain/anti-inflammation medication

I have provided this Step by Step in the Fractures folder and encourage you to make similar “cheat sheets” as we used to call them for other routine treatments.

Question: A simple (closed) fracture can include broken ribs.  If that is your diagnosis, what other complicating symptoms should you watch for?

Answer: Punctured lung (collapsed lung), lacerated spleen, kidneys, liver.  Without getting too technical, look for internal pain and injuries.

Always look for complicating symptoms when treating a patient.  Often they will come in with one complaint, and you will discovers others as well, if you ask…and some may not be medical…so be prepared!

Question: How would you stabilize a broken jaw, assuming it is a simple fracture?

Answer:  Re-align and stabilize with wires or plates

[photo 5]  [photo 6]

6)    Treating a Compound (Open) Fracture

    a)    An open fracture is an injury that occurs when a broken bone is exposed through the skin. This may mean that the bone is actually sticking out of the skin, or it may mean that the skin and soft-tissue is disrupted and exposes a path to the site of the fracture.  An open fracture requires a different treatment approach compared with a closed fracture.

    b)    The first step is to surgically clean the bone and surrounding tissue to remove debris such as dirt, gravel, clothing, and broken bone pieces.  Non-viable soft tissue should be removed as well.  This is done by irrigating with sterile water and using tweezers, forceps and scalpel to remove objects.  Once the area is cleaned a better assessment of damage and treatment options is possible.

    c)    The bones can then be stabilized by using plates, screws or rods.  An alternative is the use of an exterior fixator.  It is like a metal brace and has the advantage of being easy to apply and offers less risk of infection  

    d)    Once the bones are stabilized the wound can be stitched closed and an antibiotic salve used for a few days.  If available, healing salve also could be used.  In addition, treat for pain and inflammation if required. The prognosis for successfully healing an open fracture depends largely on the severity of the injury and on infection control.

Question: A warrior arrives at your infirmary with his upper right arm broken in two places and one of the pieces is protruding through the skin.  He is bleeding profusely and seems to be going into shock.  What should you do first, assuming your hands are clean?  Which of the two breaks should you treat first and why?

Answer: Stop the bleeding, treat for shock then treat the open fracture first.
Final Questions or Comments?

Optional RP

7)    Role Playing the Treatment of a Simple Fracture

    a)    OK, now for some fun!  Let’s try RPing treating a simple fracture.   Here is the setup: a patient fell and injured his/her arm yesterday.  Today it is worse.  He/she needs a physician to have a look.     I will play the physician.  I need a patient to RP with.  Looks around for a volunteer and smiles.
We are going to RP this quickly and I will follow the Step by Step, so please everyone have that notecard open to follow along.
Patient please remember to RP a simple fracture with no complications, we don’t have time to hear about your migraines today…laughs.  All right let’s begin!

Optional Assignment

8)    Open Fracture Assignment   [photo 7]

    a)    Here is the setup:  The blacksmith was hammering metal on his anvil and the metal slipped and he hit his finger hard with the hammer.  His finger is very swollen and there appears to be some bone sticking out.  RP this with someone and record it on a notecard.  Apprentices may be able to use this for their Skills test.