Broken bone question

[Informed Decision]

I had a thought pop into my head after reading about hoosierdoc setting a dislocated arm in a previous thread. Way back when.. Maybe further than that, when someone broke an arm or leg, they would go to the hospital & get an X-ray to confirm the break. After the attending physician saw a break, they would set if needed & put a cast on the broken appendage & away you went with a marker in hand for people to sign the new canvas. Now days, I believe they hold up on the cast to let some swelling go down (correct me if wrong). Some times surgery is called for but not immediately. Why? Other than a compound fracture I don't recall that happening in the old days. I would say that a lot of people should be crippled by now if the old way didn't work! Or maybe everyone just wants a piece of the action cause it's available? How does every break warrant erring to caution. Are medical institutions & Doctors so afraid of being sued so all bases must be covered or is there a true medical reason for delaying treatment?

 

[hoosierdoc]

wow, lots of ground covered here

Standard practice for most fractures: diagnose them, splint them if needed and refer to orthopedist for evaluation and definitive treatment planning. Few broken bones need immediate surgery, though anything compromising the skin, open skin, vascular compromise, nerve compromise, massive swelling causing pressure problems, etc can qualify.

If you put a rigid cast on a broken ankle two hours after it happens and send the guy home, it's going to swell, and swell, and swell. Now you run the risk of causing severe pressure wounds to the area that you confined into a fixed volume despite the acute injury. The splints allow swelling but keep the fracture immobilized.

Some nasty fractures will go to the OR same day if you're at a trauma center with an ortho-trauma team and in-house OR staff 24x7. For non-academic/trauma centers those capabilities are usually not present so rather than call in an after-hours call team for the OR and anesthesia teams, they do them urgently in the next few days, often as an out patient. Back to swelling, if you swell something up big time and then cut the skin, you're never going to get it closed after surgery. You can't pull hard enough with suture to reapproximate massively swollen skin. So the options are surgery within a few hours before swelling gets bad, or splint, refer, and plan surgery soon.

Regarding lacerations and tendon injury: it's often OK to defer surgery up to 10-14 days to repair lacerated tendons. Clean it out, close the wound, splint, antibiotics, see surgeon later.

Cut your finger tip off? We will clean it up, close up the bone with tissue if we can, bandage you, oral antibiotics, and refer you to a hand surgeon. Those can be done in the next day or two in the office (cutting bone back further and making a stump)

 

[Informed Decision]

Thanks for that input. Believe it or not I actually understood what you said... Can't repeat it, but did follow the game. I would assume that when I broke my bone in my foot & they put the cast on ( way back when), that the trick was to not make the cast too tight so as not to cause the pressure wounds you spoke of. My DIL broke a bone in her calf near her ankle & she walked (hobbled) around on crutches for a couple of days with no splint before they had her come back in for a splint but luckily no surgery. She ended up in a cast.

 

[Alamo]

I suspect if you go back and read a good selection of case studies you will find out they did in fact defer some casts to deal with swelling. I had a number of friends break bones when I was a kid (40+ years ago), and I remember that some of them got splints and ace bandages, or a temporary cast (which I now suppose was probably sized to accommodate the swelling), then had to go back in a few days and get a "real" cast. Then we got to sign the cast.

Some things were done differently in "the old days" but not always for the better. My Dad broke his arm, simple fracture, in WWII on some hot sweaty island in the Pacific. He went to the medical tent and got it set and casted pretty quickly -- in fact, so quickly they did not even wash his arm. Thus his arm started itching like crazy, and he had a stick shoved down into the cast to scratch the itches. Said it wasn't long until he had pulled out all the cotton gauze that padded between the cast and his arm. Said everyone had a stick in their cast for the same purpose.

Hoosierdoc didn't mention washing the limb before casting, but I suspect that's somewhere in the procedure nowadays. I hope!

 

[Informed Decision]

If you put a rigid cast on a broken ankle two hours after it happens and send the guy home, it's going to swell, and swell, and swell. Now you run the risk of causing severe pressure wounds to the area that you confined into a fixed volume despite the acute injury. The splints allow swelling but keep the fracture immobilized



Yea, but John Wayne did it in "The Longest Day " Wasn't a cast but it was a boot!