Broken Bones, Dementia, and the End of the World – Introduction

Drawing of a human femur.

Image via Wikipedia

Twice so far I’ve ignored this blog for months on end.  Both times were for serious medical problems. There’s nothing like a crisis to interrupt your disaster planning!

The first time, in 2010, my son was severely injured in a motorcycle accident (see article below).  In 2015 it’s my mother who’s been devastated by dementia.  Eventually I’ll get to an article on the terrible toll this disease will take at TEOTWAWKI.  For now we’re just trying to cope day by day.

What follows is from my original article in December 2010.

A few regular readers have questioned the lack of recent updates on this site.

Here’s the scoop.

Four weeks ago my son was involved in a motor vehicle accident in which he fractured his femur and wrist.   His surgery, hospitalization, and subsequent on-going recovery have left little time for writing.  But of course, family comes first.

His injuries raise the question of fracture care when no doctor is available.  Will the bones heal?  How will you know without an X-ray?  If there is no obvious deformity nor bone sticking through the skin, how is a fracture diagnosed?  Are all broken bones serious?  Will a permanent disability result?

I still remember a lecture from medical school 30 years ago when they discussed hip fractures in gorillas (or maybe chimpanzees).  Post-mortem exam revealed healing of old fractures.  At least some heal well enough to survive and thrive.

Clearly this topic could fill a textbook, or several.  If there are any orthopedic or sports doctors among the readership, you are welcome to contribute.

In an era where modern medical care is unavailable, severe and compound fractures present a serious problem.  My son would not be treated with a rod down the middle of his femur if this could not be visualized via X-ray.  On the other hand, small fractures (avulsion fractures, buckle fractures, compression fractures) could be treated adequately with good healing, so that’s where we’ll begin on the next post.

I am so thankful that my son was not injured worse.  A broken neck or a child’s death would surely be “the end of the world as we know it,” at least for many a mother.   And this brings up another topic:  mental health issues in times of devastation.  Anxiety, fear, depression, delirium, psychosis, and anger flourish in times of stress.  All the more reason to find inner peace now.

Let all that I am wait quietly before God, for my hope is in him.  Psalm 62:5 (New Living Translation)

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About Cynthia J. Koelker, MD

CYNTHIA J KOELKER , MD is a board-certified family physician with over twenty years of clinical experience. A member of American Mensa, Dr. Koelker holds degrees in biology, humanities, medicine, and music from M.I.T., Case Western Reserve University School of Medicine, and the University of Akron. She served in the National Health Service Corps to finance her medical education.
This entry was posted in Broken bones-see fractures, Fractures, Injuries, Medical archives and tagged , , , , , , . Bookmark the permalink.

8 Responses to Broken Bones, Dementia, and the End of the World – Introduction

  1. Beth says:

    Doc C,
    So sorry to hear about your son’s accident, but grateful that he will recover! I heard recently that the FDA plans to restrict access to injectible veterinary antibiotics in early 2014. With the new guidelines these would be available only by Rx. These are currently available in most farm/feed stores, but who knows for how long. It wouldn’t surprise me if the same happens with fish antibiotics, just in case any of you are interested in “keeping your fish healthy”. Has anyone done research on manual/foot pedal suction machines, and Doc C, do you have any thoughts or recommendations?

    • pa4ortho says:

      I have used some new machines from India. Do a search on alibaba. India has good manufacturing capability and still has a need for surgical equipment in areas with limited power.

      I have 2 older US mil surplus foot suction units in the surgical sets. They are adaquate but the India units are better.

      Consider that solar panels are at an all time price low and powered suction as well as cautery is a very valuble tool that most US surgeons are acustomed to using. Some US surgeons may not attempt some surgical procedures without cautery. Suction pulls the most amp hours as its on all the time.
      headlamp bateries need to be recharged as well.

      If you really need to improvise
      -set up an quality belows type inflatable boat pump with reversed hoses for moderately adequate suction. I have also used these with hoses in the normal position to blow air through a nebulizer. So dont just set a trap bottle but filter the line as well and change tubing so as to not cross contaminate.

  2. pa4ortho says:

    Austere Fx management part 1 (abreviated)

    Complications of Fractures

    Open Fracture
    – wash scrub and wash any and all exposed bone with rediculous quantities of clean water asap.
    -clean water includes city tap water (not well water), backpacking filtered water, Steripen UV treated water, boiled water,
    -scrub the ends of the bone with a soft brush boiled or sterile nail brush being carefull to not disrupt any intact periostium. (the nutrient layer on the outside of the bones)
    – IV Vanco or Linezolid with rifampin is ideal with cultures to dictate specific therapy. Low tech options include PO septra DS, augmentin, and cipro, and continuous irrigation.
    – off grid irrigation option – place a chest tube or foley cath or an IV cath in the wound next to the bone, based on wound size. Alternatively a stainless steel perforated tube can be placed. Using IV tubing drip clean fluid throught the wound for 3 days or until the fluid runs clear.
    place the patient on a mesh litter over a plactic sheet funnel to a catch basin. A plastic bag on the extremity can also catch water and drip from the lowest corner into a jug.
    – if suction is available a negative preasure wound system can help with edema and fluid management.
    – Early amputation at the usual levels if sepsis develops.

    Fracture Blisters
    -blood blisters may form over a fracture from rapid swelling causing shear forces.
    -keep intact, provide local wound care, pad cast over them.

    Compartment Syndrome
    – Spend just a couple bucks and get tarascon pocket orthopaedica by Damian Rispoli MD its small and cheap. Page 56 to 62 covers the releases. Take a pen and trace them on your body. This way you memorize the incisions to make so you wont forget yrs later when tierd and cold and you are doing this on a floor in dim lighting on a poncho with a small blade removed from a shaving razor. .
    – Dont forget to over hydrate with a camel back or IV to flush myoglobin through the kidneys.

    • pa4ortho says:

      Austere Fx management part 1 (abreviated)
      Reduction of fractures

      – There are multiple manuvers for different fractures to reduce angulation along with multiple casting positions to prevent loss of reduction in a cast. When I teach a class on this I reveiw some of the more common ones. Suffice to say increasing the angle to remove traped soft tissue and traction while reducing the angulation along with direct pressure are the basics.
      – For austere management, having a simple protocol for managing impractical to splint angulated fractures (think foot behind head), fractures that due to position are very painfull for a long extraction from remote areas, and dislocations is needed. Reduction may also benifit that rare patient with neuro vascular compromise.
      -If available injecting Lidocaine or marcaine into the fracture as a hematoma block is a great idea. (seperate class) Regional blocks are also an option for those with that skill set.
      – I teach a simple longitudinal traction meathod that can be performed by anyone. If you want to make a string of pearls straight just pull on the ends of the string. This is the same principle.
      – For any upper extermity fracture or shoulder dislocation, lay the patient down, grasp the patients right (left) hand around the base of the thumb with your right (left) hand wrap your other hand over this grip. place your right (left) foot without a shoe on into the axilla (armpit) and while in a long sitting position lean back using your entire torso not your arms to provide longitudinal traction. Fractures will be roughly reduced. For dislocation take your time. Apply prolonged traction. If after 10-15 min the shoulder dislocation has not reduced try pressing anteriorly with your toes on the front surface of the shoulder. If that does not work try bending the elbow to 90 deg while keeping traction on by wrapping your Left (right) forearm around the elbow and pointing the hand to the ceiling. Next rotate the palm down towards the patients belly to try to rotate the shoulder back into place. If it does not reduce then just keep applying traction. Its all about getting the muscles to relax. Meds like ketamine really help. Also consider injecting the shoulder joint with lidocaine marcaine if you have that skill (another class). Pain releif may lessen guarding.
      – following arm reduction of a fracture apply a splint (another class).
      -following shoulder dislocation reduction lift and invert a t shirt bottom hem up over the arm held against the torso and pin over the oposite shoulder.

  3. pa4ortho says:

    Austere Fx management part 1 (abreviated)

    Evaluation for Fracture.
    History of trauma.
    -note direction of mechanical forces and intensity.
    -Note perceived pain and function before compared to after injury.
    -assess any perceived sensation changes. (rare)

    -before you touch, look. position, swelling, bruising, guarding,
    -tenderness to bony palpation, start exam away from main pain and then touch main pain last.
    -palpate for bony step off,
    -press on your wrist bone or skull and rub across the bone, feel the smooth surface of the bone as the skin slide over it. imagine if there was a step of like rubbing on a cracked egg vs a smooth one.
    – stress the bone and feel for crepitus or pain
    -squeeze the bone and apply gradual pressure with ofset hands.
    -vibration. fractures can be very tender to vibration from a tuning fork or theraputic ultrasound.
    -x-ray off grid x ray systems can be had for 20k. look at the vetrenary systems as they are waterproof and rugged for use in barns with horses. For fingers and small joints like ankles a dental x ray system can be very effective. Older Flouroscopic systems can be had that may lack full diagniscic clarity but newer systems cam produce dramatic clarity. mini c arm Flouro is probably the cheapest solution.
    -a skilled operator with a diagnostic ultrasound can visualize displaced fractures.

    When in doubt treat as a fracture with imobilization and reasess in 3-10 days. Many sprains will resolve or become less symptomatic in that time making your exam more accurate. Often the initial injury looks worse than it is in the acute phase of injury.

  4. Dr Prepper says:

    Surprised you haven’t mentioned IV antibiotics in the event of a compound fracture.

  5. Cynthia Sherlock says:

    Enjoyed the article and especially the pictures. Compound fractures could certainly be the end without medical intervention.

    Especially identified with the end part of the article.

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