23.8 — Fractures, Dislocations and Head Injury

A person falls from a ladder, hits their head, gets up, says they are fine, and walks into the house.

Three hours later they are drowsy and confused, and by the time they reach hospital they need emergency surgery.

That is an extradural haematoma, and the pattern — a knock, apparent recovery, then deterioration — is the reason head injury advice exists in the form it does. The lucid interval is not reassurance. It is the bleed filling up.

Most head injuries are minor and most fractures are not emergencies. This page is mostly about telling those apart from the ones that are.

Fractures

Recognising one

Pain, worse on movement or on bearing weight.

Swelling and bruising.

Deformity — an unnatural angle, a shortened or rotated limb.

Loss of function.

Grating or a snapping sound at the time.

And the sign people rely on that does not work: "you can move it, so it isn't broken" is wrong. Many fractures can be moved. A scaphoid fracture in the wrist, a hairline fracture of the tibia, and a fractured rib all move perfectly well.

A hip fracture in an older person classically produces a shortened, externally rotated leg — the foot turned outwards — with an inability to weight-bear. And in some cases the person can still walk on it, which delays diagnosis.

The kinds

Closed — skin intact.

Open (compound) — the bone has broken the skin, or a wound reaches the fracture. These are urgent, because infection reaching bone is very difficult to treat. Antibiotics within an hour and surgical cleaning are the standard.

Greenstick — a partial break in children, whose bones are more flexible.

Growth plate fractures in children — worth knowing because they can affect future growth and need proper assessment even when they look minor on an X-ray.

Pathological — through a bone weakened by disease. A fracture from a trivial injury should raise the question of osteoporosis or something else (Chapter 21.6).

Stress fractures — from repetitive loading, common in runners and military recruits, and frequently invisible on early X-rays.

What to do

1. Do not move them unnecessarily.

Especially with a suspected spinal, pelvic or hip fracture.

2. Control any bleeding with pressure around the wound, not on the bone (Chapter 23.3).

3. Immobilise in the position found.

Do not try to straighten a deformed limb. Realignment is done by professionals with pain relief, and attempting it can damage nerves and vessels.

The exception is a limb with no pulse or a clearly compromised blood supply — cold, white, numb, no pulse beyond the injury — where gentle realignment may be needed and is a decision made with the emergency services on the phone.

Support the joint above and the joint below.

For an arm: a sling. A broad arm sling for the forearm; an elevation sling for a collarbone or shoulder injury or a hand needing elevation.

For a leg: pad around it and, if a long journey is unavoidable, secure it to the other leg with padding between.

Improvised splints: a rolled newspaper or magazine, a piece of cardboard, a walking stick, or the person's own body.

4. Ice for 20 minutes, wrapped in a cloth, which reduces pain and swelling.

5. Elevate if possible.

6. Nothing to eat or drink, since surgery may be needed.

7. Watch for shock. A femur fracture can bleed over a litre internally; a pelvic fracture several litres (Chapter 23.3).

Specific fractures to know

Hip fracture — usually in an older person after a minor fall. A hospital emergency, and the timing matters: surgery within 24 to 48 hours improves survival and recovery. One-year mortality is around 20 to 30 percent, mostly from the consequences of immobility rather than the bone.

Pelvic fracture — potentially life-threatening from bleeding. Do not rock or press the pelvis to test it. A pelvic binder — or a folded sheet tied firmly around the level of the hips — reduces the internal volume and reduces bleeding, and is applied by ambulance crews.

Rib fractures — very painful, and the danger is not the bone.

Pain stops people breathing deeply and coughing, so the lung bases collapse and pneumonia follows, particularly in older people. Good pain relief is the treatment, precisely so that breathing stays effective.

Flail chest — several ribs broken in two places, so a segment moves paradoxically, sucking in on inspiration. A serious injury needing urgent care.

And rib fractures with abdominal pain raise the question of liver or spleen injury underneath.

Skull fracture — see below.

Spinal fracture — see below.

Compartment syndrome

A limb-threatening emergency that develops hours after an injury, and it is missed regularly.

Swelling within a closed muscle compartment raises pressure until blood cannot get in. Muscle and nerve begin to die within hours.

The signs, and the first is the one that matters:

Pain out of proportion to the injury, and pain that keeps increasing despite immobilisation and painkillers.

Pain on passive stretching of the muscles in that compartment.

Tense, swollen, hard compartment.

Numbness and tingling.

And the classic late signs — pulselessness, pallor, paralysis — appear when the damage is already done. Waiting for an absent pulse means waiting too long.

Commonest after tibial fractures, forearm fractures, crush injuries, and tight casts.

Treatment is emergency surgery to release the compartment.

Which produces a rule worth carrying: escalating pain after a fracture, particularly in a cast, is an emergency and not a request for stronger painkillers.

Dislocations

A joint forced out of position.

Signs: severe pain, obvious deformity, inability to move the joint, and swelling.

Commonest: shoulder, finger, patella, elbow, and hip — the last usually after major trauma or in a hip replacement.

What to do: do not attempt to relocate it.

Reduction requires knowing what you are doing and knowing what else might be injured — nerves and vessels run close to joints, and a fracture-dislocation handled as a simple dislocation causes real harm.

Immobilise in the most comfortable position, apply ice, and go to hospital.

Check circulation and sensation beyond the joint, and report if either is abnormal — that raises the urgency considerably.

The exception people ask about: a patella dislocation frequently reduces itself when the knee is gently straightened, and if it does not, do not force it.

Head injury

What is happening

The brain sits in fluid inside a rigid box (Chapter 11.10).

Which is protective, and it creates the fundamental problem: the box cannot expand. Anything that takes up space inside — blood, swelling — raises the pressure and compresses the brain.

Primary injury happens at the moment of impact and cannot be undone.

Secondary injury develops over minutes to hours — from bleeding, swelling, low oxygen and low blood pressure. This is what treatment prevents, and it is the whole reason for urgency.

The kinds of bleed

Extradural haematoma — arterial bleeding between the skull and the tough outer membrane, usually from a torn artery under a temple fracture.

The classic pattern: a knock to the head, brief loss of consciousness, then a lucid interval where the person seems fine, then rapid deterioration as arterial blood accumulates.

Highly treatable with prompt surgery, and rapidly fatal without. It is the single strongest argument for the observation advice below.

Subdural haematoma — venous bleeding beneath that membrane, from torn bridging veins.

Acute after significant trauma.

Chronic — and this is the one to know about. In older people and heavy drinkers, whose brains have shrunk slightly so the bridging veins are stretched, a minor bump — sometimes not even remembered — can cause a slow bleed that presents weeks later with headache, confusion, drowsiness, personality change or weakness.

It is frequently mistaken for dementia or a stroke, and it is treatable (Chapter 20.4).

Anticoagulants substantially increase the risk of both.

Subarachnoid haemorrhage — bleeding into the fluid space, from trauma or from a ruptured aneurysm (Chapter 20.1).

Intracerebral haemorrhage — bleeding into brain tissue itself.

Diffuse axonal injury — widespread shearing of nerve fibres from rotational forces, which may show little on a scan and cause severe lasting disability.

Concussion

A temporary disturbance of brain function after an impact, with no structural damage visible on standard imaging.

Symptoms: headache, dizziness, confusion, feeling "in a fog", nausea, sensitivity to light and noise, blurred vision, balance problems, irritability, and difficulty concentrating or remembering.

Loss of consciousness occurs in a minority — most concussions involve no loss of consciousness at all, which is a common misunderstanding.

Amnesia for events before or after the impact is a more useful marker of severity.

And the sports rule that has become standard everywhere: if in doubt, sit them out.

Anyone with a suspected concussion is removed from play immediately and does not return that day.

Because of second impact syndrome — a second head injury before the first has recovered, which can cause catastrophic and sometimes fatal brain swelling, particularly in adolescents.

Return to activity is graded, with a stepwise progression through rest, light activity, sport-specific exercise, contact practice and full return, moving up only if symptoms do not recur.

And the modern advice is not complete rest. Two to three days of relative rest, then gradual reintroduction of activity below the symptom threshold, produces better recovery than prolonged rest in a dark room.

Most people recover in 1 to 4 weeks. A minority have persistent symptoms, and those benefit from specific rehabilitation rather than more rest.

And repeated head injury over years is associated with chronic traumatic encephalopathy, which has changed how contact sports handle heading, tackling and head impacts.

When a head injury needs hospital immediately

Call an ambulance for any of these:

Unconsciousness at any point, even briefly.

Deteriorating consciousness — increasing drowsiness, difficulty waking.

Confusion that is getting worse rather than better.

Repeated vomiting — more than once or twice.

A seizure.

Weakness, numbness or problems with speech, vision or balance.

Unequal pupils, or a pupil that does not react to light.

Clear fluid from the nose or ears — cerebrospinal fluid, indicating a skull base fracture.

Blood from the ear.

Bruising behind the ears (Battle's sign) or around both eyes (panda eyes) — both signs of a base of skull fracture, appearing hours later.

A severe or worsening headache.

Any suspected skull fracture — a depression, a boggy swelling, or a visible wound to the bone.

And regardless of how well the person seems:

Anyone on anticoagulants or antiplatelets who has hit their head. A slow bleed may take hours to declare itself, and this group needs assessment and often a scan even after a minor knock (Chapter 22.7).

Anyone with a bleeding disorder.

A baby or infant.

Anyone who was intoxicated, where assessment is unreliable.

Anyone injured in a high-energy mechanism — a fall over one metre or five stairs, a road collision, or ejection from a vehicle.

Anyone with no one to observe them for the next 24 hours.

What to do

Sit or lie them down with the head and shoulders slightly raised.

Apply pressure around, not on, any wound with a suspected underlying skull fracture.

Do not remove anything embedded.

Apply a cold pack to a bump, wrapped.

Do not give aspirin or ibuprofen, which increase bleeding. Paracetamol is fine.

Do not let them drink alcohol, drive, or be left alone.

And observe for 24 to 48 hours.

They can sleep. The old advice about keeping someone awake all night is not current practice — sleep is fine, and someone should check they can be roused normally every few hours.

Spinal injury

Suspect it after: a fall from height, a road collision, a dive into shallow water, a sports impact, any significant head injury, and any unconscious trauma casualty.

Signs: neck or back pain; tenderness over the spine; numbness, tingling or weakness in the limbs; loss of bladder or bowel control; and a burning or electric sensation.

And in an unconscious casualty, assume it.

What to do:

Do not move them unless there is immediate danger, or their airway is compromised.

Support the head and neck in the position found, with your hands either side of the head, keeping the head, neck and spine in line.

Kneel behind or beside them and hold steady until help arrives.

Airway always takes priority. If they are not breathing, or vomiting and at risk of aspirating, you move them — ideally with several people log-rolling as a unit, and if necessary alone. A protected airway in a possibly injured spine is better than an unprotected airway in a well-aligned one.

And if you must move them alone, use a jaw thrust to open the airway rather than a head tilt (Chapter 23.1).

Do not attempt to fit any kind of collar. Improvised collars do more harm than good, and even manufactured rigid collars are now used more selectively by professionals than they used to be, because they can raise pressure inside the skull and can worsen certain injuries.

Manual in-line stabilisation with your hands is what a bystander does.

The general rules

Do not straighten deformed limbs.

Do not relocate dislocations.

Do not remove embedded objects.

Do not move a suspected spinal injury unless the airway or safety demands it.

Do watch for escalating pain after a fracture, which means compartment syndrome until proven otherwise.

And do treat any head injury in someone on blood thinners as needing assessment, no matter how well they look.

What the next page fixes

Chapter 23.9 covers bites and stings — snakes, spiders, marine animals and insects, with the specific things that help and the traditional remedies that cause harm.