Medicine: Fractures: 1. Medicine: Fractures

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1. Medicine: Fractures


This article is meant to give some pointers to authors. It is not intended to be comprehensive, and it simplifies many complicated issues. In other words, unless you are trained to do this, don't try this at home! If you find something inaccurate, please email me. If you have questions that are not addressed, I'd be glad to add information to address them.

Warning! Some of this is moderately graphic in a fairly clinical way. Not for the very squeamish.


Skull: Breaking the skull is a problem only when a fragment is pushed down, so that it might harm the brain; or when the break crosses where a blood vessel runs, which runs the risk of a lot of bleeding. Otherwise the break in the skull is not important, what is more important is what happens to the brain underneath. Therefore you can give a character a skull fracture if you like, and still have them make an uneventful recovery. I will cover brain injury in a later section.

Face: There are many bones to break in the face; I'll discuss only a few. Breaking a nose is fairly easy to do with a direct blow or fall. If it is moved out of place it can be put back immediately, or if swollen, wait 4 to 5 days for the swelling to go down, then put it back. This usually heals well. If you want to deform a character, a break can cause a blood clot on the wall that divides the nose into two nostrils (the septum). If this is not drained, it can put pressure on the cartilage and destroy it, leaving a very strange looking nose. (The same thing can happen to an ear, giving a 'cauliflower' ear.) Breaking a cheekbone (zygoma) is also usually from a blow or fall, and also usually heals well. If it is moved out of place there may be permanent deformity, but it would not affect the character in any other way. A broken jaw needs either surgery, or wiring the teeth to stabilize it. I would guess a skilled healer in Middle-earth could wire the teeth together if it is the kind of jaw fracture where that would work. The patient would need to eat soft food for a few weeks, and the healer would have to worry about the teeth meeting properly if the pieces weren't in perfect position.

Neck: These run the gamut from instant killers to merely painful. Assume that any neck fracture that is from a fall from a height or a heavy weight is a potential killer. One can break the bones of the spine without injuring the spinal cord, but if those broken ends are not stable, and move around, they may sever the spinal cord with the movement. If you want to cut a character's spinal cord, an injury high on the neck, say above the 4th cervical vertebra (the stacking bones of the spine) will likely kill, as it will cause your character's breathing to stop. The lower the injury, the more function remains. Therefore a 5th cervical vertebra (C5) injury may leave shoulder and upper arm motion, but no function of hand, forearm or wrist. When you make the injury level below the first thoracic vertebra (T1) your character has full hand, forearm, etc. use, but no leg function. He or she will have trouble sitting up well unless the injury is lower than T9. Be aware if you want to keep that character alive, and the injury is even as low as the sacral nerves just above the tailbone, someone will have to do some fancy things to ensure that the character can get rid of wastes, since the nerves involved in the sphincters of the bladder and bowel are gone. Before antibiotics, most paraplegics and quadriplegics eventually died of urinary tract infections.

Collarbone (clavicle) : This is a short to medium term disabler. It occurs from a direct blow or fall onto the area, or a fall onto an outstretched hand. It will keep your character from using the arm on that side for 3 weeks on average. It is treated with either a sling, or a "figure of eight" bandage, which is wrapped around and under each arm like the circles of an "8". It connects behind the neck, as the waist of the "8".

Ribs: Broken ribs will hurt a lot and keep the character from lifting or carrying anything heavy for at least 1 week, often 2 or more. They will hurt for several weeks; a good estimate is 4-6 weeks. Over that time the pain will decrease to a mild soreness, felt only with lifting heavy objects, laughing, or extreme motions. Broken ribs as a result of extreme force (think a Mumak running into you, or a troll falling on you) can move the broken rib end/ends out of place and puncture a lung.
Bruised ribs will hurt for a few weeks but will permit more activity.

Limbs: If you want a broken bone that still permits a character to do all the normal activities, break a toe (not the big one), finger (not a thumb) or the thin outside bone of the lower leg (the fibula). One can walk on a broken fibula depending on where it is broken, but it will hurt. People sometimes break their fibula and don't realize it. Some breaks around the ankle can be splinted by lacing a pair of stiff boots fairly tight. It is not ideal, and will still hurt a lot, but the character can bear some weight on that leg, preferably with the help of a cane. Don't expect him or her to move fast or far.
Breaking the big bone in the lower leg (the tibia), or the thigh bone (the femur), usually means your character can't bear weight on that leg.
This will take about 3-4 months to heal, again depending on where the break is. With a really messy break they can be permanently disabled. A fracture high on the femur (more toward the hip than the knee) can kill from blood loss, although that is not usual.
Breaking the upper arm bone (humerus), means your character can't use it for about 6 weeks. These are often treated with a simple sling, easy to do in Middle-earth. Breaking the forearm bones, the radius or ulna, gives you a bit more leeway, as some breaks are not as bad as others. A milder one would be a small break of the radius at the elbow. It will hurt some, and may swell, but it doesn't need to be completely immobilized (splinted) for long, about 1 to 2 weeks.

Pelvis: This occurs as a result of a heavy weight falling on or running into someone. In real life a car accident would be a usual way to do this, in Middle-earth think of the troll or mumak again, or a fall from a height. Break the pelvis in certain places in the front, one break only, and it will be painful, but your character can walk on it in with moderate pain in about 2 weeks. Someone who really needed to could probably walk on it right away as it will hold the weight, but it will hurt a lot. Break the pelvis in more than one place and your character is down for a while, maybe left with permanent disability, and could die. Smash it and they'll be disabled for life or more likely dead given the state of medicine in Middle-earth.

Shoulder: I've seen lots of use of this in fan fiction. Most shoulder dislocations involve the ball shaped end of the arm bone winding up in front of and below its socket. There are some unusual ones where it is behind the socket, or beneath the socket and the arm sticks straight up. If you want someone to fix it in Middle-earth, make it the common one. The dislocation usually happens when the character falls onto an outstretched hand, or they get a blow to the back of the shoulder. Someone with a dislocated shoulder CAN'T use it! Because the 'ball' is out of the 'socket', it simply won't work. It also hurts, and the patient will resist attempts to move it. There are several ways to fix it. The most ancient and familiar is to have the patient lie face up, anchored, say by someone holding a cloth tied around their chest, while the healer exerts a slow pull on the arm. A good modern variant is for the healer to have patient's arm bent 90 degrees at the elbow while one of the healer's hands is on the forearm near the elbow, and one is on the wrist. The healer then pulls down toward the patient's feet and slightly away from the patient's body. When the healer has achieved a good pull, rotate the shoulder by leaving the elbow where it is and bringing the forearm outward to lie flat. If the reduction is sucessful, the healer and patient may feel a click. If this doesn't work, you can put the patient face down on something high like a rock, and let the dislocated arm dangle off the edge. Tie something weighing about 5 kg (10 lb) to the wrist, and as the arm dangles the weight can cause the muscles to relax and allow the shoulder to slip back into place. Relocating a shoulder is a lot easier when the muscles are relaxed and the patient is medicated for pain, but I don't know of any good muscle relaxers prior the 20th century, so I can't expect Middle-earth to have them. It is reasonable to postulate opium poppies in the south of Middle-earth, so pain medication is possible. Once the shoulder is relocated, put that arm in a sling and tie a bandage around the chest to immobilize the arm to the chest. This is called a sling and swathe. The character should stay immobilized for 3 weeks.
Finger or toe: Usually easy to relocate, though painful without local anesthetic.
Patella (kneecap): This is very painful, often as a result of twisting and falling or another sports type injury. It can be reduced by manipulation and will feel better, but will require that the knee be immobilized with the leg straight for about 3 weeks. The patient can walk on it when it is immobilized, but will obviously be slower to travel and very limited in climbing over things.
Other: I don't recommend dislocating a knee or ankle or hip or elbow. Too difficult to fix, not that common, and too many chances for permanent damage. A dislocated jaw is not hard to fix with manipulation, but is uncommon.

Easily Fixed Things That Make the Healer Look Good: this has been moved to the Misc. section.


Story Information

Author: Lyllyn

Status: General

Completion: Complete

Era: Other

Genre: Research Article

Rating: General

Last Updated: 12/17/02

Original Post: 10/18/02

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