CH 31:

Dislocation of the patella

A dislocated patella most commonly occurs in teenagers and young adults who are engaged in athletic activities. Some patients have recurrent dislocations. A minor twisting may be enough to produce the problem. Usually, the dislocated patella displaces to the lateral side. Displacement produces significant deformity in which the knee is held in a moderately flexed position, and the patella is displaced to the lateral side of the knee. Splint the knee in the position in which you found it; most often, this is with the knee flexed to a moderate degree. Add padded board splints to the medial and lateral aspects of the joint, extending from the hip to the ankle. Use pillows to support the limb on the stretcher. Occasionally the patella will return to its normal position spontaneously. When this occurs, stabilize the limb as for a knee ligament injury in a padded long leg splint, and transport the patient to the ED. Report the spontaneous reduction as soon as you arrive at the hospital so that the medical staff is aware of the severity of the injury.

Dislocations

A dislocation is a disruption of a joint in which the bone ends are no longer in contact. Often, the supporting ligaments are torn, usually completely, allowing the bone ends to separate from each other. A fracture-dislocation is a combination injury at the joint in which the joint is dislocated and there is a fracture of the end of one or more of the bones. A dislocated joint may sometimes spontaneously reduce, or return to its normal position, before your assessment. In this situation, you will be able to confirm the dislocation only by taking a patient history. A dislocation that does not spontaneously reduce is a serious problem because the ends of the bone can be locked in a displaced position, making any attempt at motion of the joint very difficult and painful. Commonly dislocated joints include the fingers, shoulder, elbow, hip, and knee. The signs and symptoms of a dislocated joint are similar to those of a fracture and include: Marked deformity Swelling Pain that is aggravated by any attempt at movement Tenderness on palpation Virtually complete loss of normal joint motion (locked joint) Numbness or impaired circulation to the limb or digit

fracture

A fracture is a break in the continuity of the bone, often occurring as a result of an external force. Compartment syndrome, a potential complication of fractures, refers to elevated pressure within a fascial compartment. If the overlying skin is not damaged, the patient has a closed fracture. With an open fracture, there is an external wound, caused either by the same blow that fractured the bone or by the broken bone ends lacerating the skin. The wound may vary in size from a very small puncture to a gaping tear that exposes bone and soft tissue. Treat any injury that breaks the skin as a possible open fracture. Complications of open fractures include increased blood loss and a higher likelihood of infection. Wear gloves if there are any open wounds. A nondisplaced fracture (also known as a hairline fracture) is a simple crack of the bone that may be difficult to distinguish from a sprain or simple contusion. Radiograph examinations are required for physicians to diagnose a nondisplaced fracture. A displaced fracture produces actual deformity of the limb by shortening, rotating, or angulating it. Often, the deformity is very obvious and can be associated with crepitus. Look for differences between the injured limb and the opposite uninjured limb in any patient with a suspected fracture of an extremity.

Fractures of the Forearm

A nightstick fracture is an isolated fracture of the shaft of the ulna; it may occur as the result of a direct blow to it. Fractures of the distal radius, which are especially common in older patients with osteoporosis, are known as Colles fractures. The term silver fork deformity is used to describe the distinctive appearance of the patient's arm. In children, this fracture may occur through the growth plate and can have long-term consequences. To stabilize fractures of the forearm or wrist, you can use a padded board, air, vacuum, or pillow splint. If the shaft of the bone has been fractured, be sure to include the elbow joint in the splint. Splinting of the elbow joint is not essential with fractures near the wrist; however, the patient will be more comfortable if you add a sling or pillow for more support. If possible, elevate the injured extremity above the heart to help alleviate swelling.

Slings and Swathes

A sling is any bandage or material that helps support the weight of an injured upper extremity, relieving the downward pull of gravity on the injured site. To be effective, a sling must apply gentle upward support to the olecranon process of the ulna. The knot of the sling should be tied to one side of the neck so that it does not press uncomfortably on the cervical spine. To fully stabilize the shoulder region, a swathe, a bandage that passes completely around the chest, must be used to bind the arm to the chest wall. The swathe should be tight enough to prevent the arm from swinging freely but not so tight as to compress the chest and compromise breathing. Leave the patient's fingers exposed so that you can assess neurovascular function at regular intervals.

Splinting

A splint is a flexible or rigid device that is used to protect and maintain the position of an injured extremity. By preventing movement of fracture fragments, bone ends, a dislocated joint, or damaged soft tissues, splinting reduces pain and makes it easier to transfer and transport the patient. Splinting will help to prevent the following: Further damage to muscles, the spinal cord, peripheral nerves, and blood vessels from broken bone ends Laceration of the skin by broken bone ends. One of the primary indications for splinting is to prevent a closed fracture from becoming an open fracture (conversion). Restriction of distal blood flow resulting from pressure of the bone ends on blood vessels Excessive bleeding of the tissues at the injury site caused by broken bone ends Increased pain from movement of bone ends Paralysis of extremities resulting from a damaged spine When no splinting materials are available, the arm can be bound to the chest wall, and an injured leg can be bound to the uninjured leg to provide temporary stability. Three basic types of splints are: Rigid Formable Traction

Sprain

A sprain occurs when a joint is twisted or stretched beyond its normal range of motion. The supporting capsule and ligaments are stretched or torn, resulting in injury to the: Ligaments Articular capsule Synovial membrane Tendons crossing the joint A sprain can occur in any joint, but sprains most often occur in the knee, shoulder, and ankle. Some patients might report hearing a "snap" when the injury occurred. In contrast with fractures and dislocations, sprains usually do not involve deformity, and joint mobility usually is limited by pain, not by joint incongruity. Signs and symptoms of a sprain include: The patient is unwilling to use the limb (guarding). Swelling and ecchymosis are present at the injured joint as a result of torn blood vessels. Pain prevents the patient from moving or using the limb normally. Instability of the joint is indicated by increased motion, especially at the knee; however, this may be masked by severe swelling and guarding. It is important to document the MOI because certain sprains and fractures occur more consistently with certain mechanisms. A strain (pulled muscle) is a stretching or tearing of the muscle and/or tendon, causing pain, swelling, and bruising of the soft tissues in the area. It occurs because of an abnormal contraction or from excessive stretching. Strains may range from minute separation to complete rupture. Unlike a sprain, no ligament or joint damage typically occurs. Often no deformity is present and only minor swelling is noted at the site of the injury. Patients may report: A "snap" when a muscle tears Increased sharp pain with passive movement of the injured extremity Severe weakness of the muscle Extreme point tenderness The general treatment of strains is similar to the prehospital management for sprains, dislocations, and fractures.

Pectoral girdle

Also referred to as the shoulder girdle Consists of: Two scapulae (shoulder blades) Flat, triangular bones held to the rib cage by powerful muscles that buffer it against injury Two clavicles (collarbones) Slender, S-shaped bones attached by ligaments to the sternum on one end and to the acromion process on the other Act as a strut to keep the shoulder propped up Because they are slender and very exposed, these bones are vulnerable to injury.

Fractures of Proximal Femur

Although fractures of the proximal femur are usually called hip fractures, they rarely involve the hip joint. Instead, the break goes through: The neck of the femur The intertrochanteric (middle) region The proximal shaft of the femur (subtrochanteric fractures) These three fracture types may also be a result of high-energy injuries in younger patients. Patients with displaced fractures of the proximal femur display a very characteristic deformity: they lie with the leg externally rotated, and the injured leg is usually shorter than the opposite, uninjured limb. When the fracture is not displaced, this deformity is not present. With any kind of hip fracture, patients typically are unable to walk or move the leg because of pain in the hip region or in the groin or inner aspect of the thigh. The hip region is tender on palpation, and gentle rolling of the leg will cause pain but will not do further damage. On occasion, the pain is referred to the knee, and it is not uncommon for a geriatric patient with a hip fracture to report knee pain after a fall. Assess the pelvis for any soft-tissue injury and bandage appropriately. Assess pulses and motor and sensory functions, looking for signs of vascular and nerve damage. Once your assessment is complete, splint the lower extremity of an older patient who has fallen and reports pain in either the hip or the knee, even if there is no deformity, and transport the patient to the ED. A geriatric patient with an isolated hip fracture does not require a traction splint. You can effectively stabilize such a fracture by placing the patient on a backboard or scoop stretcher, using pillows or rolled blankets to support the injured limb in the deformed position. Secure the injured limb carefully to the device with long straps.

Dislocation of the Knee

Although substantial ligament damage occurs with a knee dislocation, the more urgent injury is often to the popliteal artery, which is frequently lacerated or compressed by the displaced tibia. When gross deformity, severe pain, and an inability to move the joint cause you to suspect a dislocation of the knee, always check the distal circulation carefully before taking any other step. If distal pulses are absent, contact medical control immediately for further stabilization and transport instructions. Posterior knee dislocations, which result from extreme hyperextension of the knee, are the most common, occurring in almost half of all cases. The anterior and posterior cruciate ligaments are damaged. There is also a high risk of injury to the popliteal artery. Medial dislocations result from a direct blow to the lateral part of the leg. There is a high likelihood of injury to the medial ligaments. When the force is applied from the medial direction, a lateral dislocation occurs and the lateral part of the knee is stretched apart, injuring the lateral ligament. Lateral and medial dislocations happen far less commonly and are less likely to injure the popliteal artery. Complications of knee dislocation may include: Limb-threatening popliteal artery disruption Injuries to the nerves Joint instability Do not confuse a dislocation injury with a relatively minor patella dislocation. If adequate distal pulses are present, splint the knee in the position in which you found it and transport the patient promptly. Do not attempt to manipulate or straighten any severe knee injury if there are good distal pulses. If the limb is straight, apply standard rigid long leg splints to at least two sides of the limb to stabilize it. If the knee is bent and the foot has a good pulse, splint the joint in the bent position, using parallel padded board splints secured at the hip and ankle joint to provide a stable A-frame. Secure the limb to a backboard or stretcher with pillows and straps to eliminate any motion during transport. If medical control instructs you to align a limb: Straighten the limb by applying gentle longitudinal traction in the axis of the limb. Once you apply manual traction, maintain it until the limb is fully splinted. If traction significantly increases the patient's pain, do not continue. As you apply traction, monitor the posterior tibial pulse to see whether it returns. Splint the limb in the position in which you feel the strongest pulse. If you are unable to restore the distal pulse, splint the limb in the position that is most comfortable for the patient and provide prompt transport to the hospital. Notify medical control of the status of the distal pulse so that treatment can be arranged in advance.

Amputation

Amputations An amputation is an injury in which an extremity is severed completely from the body. This injury can damage every aspect of the musculoskeletal system—from bone to ligament to muscle. Amputations can occur as a result of trauma or a surgical intervention.

Ankle Injury

Ankle injuries occur in people of all ages and range in severity from a simple sprain, which heals after a few days of rest, to severe fracture-dislocations. It is sometimes difficult to tell a nondisplaced ankle fracture from a simple sprain without radiograph examination. Any ankle injury that produces pain, swelling, localized tenderness, or the inability to bear weight must be evaluated by a physician. The most frequent mechanism of ankle injury is twisting, which stretches or tears the supporting ligaments. A more extensive twisting force may result in fracture of one or both malleoli. Dislocation of the ankle is usually associated with fractures of one or both malleoli. Manage injuries as follows: Dress all open wounds. Assess distal neurovascular function. Correct any gross deformity by applying gentle longitudinal traction to the heel. Before releasing traction, apply a splint. You can use a padded rigid splint, an air splint, or a pillow splint. Make sure it includes the entire foot and extends up the leg to the level of the knee joint

Assessing Tenderness in the Pelvis

Assess for tenderness in the pelvis by taking the following steps: Place the palms of your hands over the lateral aspect of each iliac crest and apply firm, but gentle, inward pressure on the pelvic ring. With the patient lying supine, place a palm over the anterior aspect of each iliac crest and apply firm downward pressure. Use the palm of your hand to firmly but gently palpate the pubic symphysis, the firm cartilaginous joint between the two pubic bones. This area will be tender if there is injury to the anterior portion of the pelvic ring. If there has been injury to the bladder or the urethra, the patient will have lower abdominal tenderness and may have evidence of hematuria or blood at the urethral opening. Any patient who you suspect has a pelvic fracture is at high risk for hypovolemic shock. Patients in stable condition can be secured to a backboard or a scoop stretcher to stabilize isolated fractures of the pelvis.

Sprains and strains

Because it may be difficult to differentiate among the various types of injuries in the field, it is best to err on the side of caution and treat every severe sprain as if it is a fracture. General treatment of sprains and strains is similar to that of fractures and includes RICES (Rest, Ice, Compression, Elevation, and Splinting). In addition, reduce or protect the limb from weight-bearing activity. Manage pain as soon as is practical.

Skeleton, motion

Bone is a living tissue that contains nerves and receives oxygen and nutrients from the arterial system. When a bone breaks, a patient typically experiences severe pain and bleeding. Bone marrow, located in the center of each bone, constantly produces red blood cells to provide oxygen and nourishment to the body and remove waste. White blood cells and platelets are also produced in the marrow cavity. Joints are held together in a tough fibrous structure known as a capsule, which is supported and strengthened in certain key areas by ligaments. In moving joints, the ends of the bones are covered with articular cartilage. This cartilage is a pearly white substance that allows the ends of the bones to glide easily. Joints are bathed in and lubricated by synovial (joint) fluid. Joints allow for motion such as: Circular (the shoulder) Hinge (the knee and elbow) Minimum motion (the sacroiliac joint in the lower back and the sternoclavicular joints) Certain joints, such as the sutures in the skull (present until about 18 months of age), fuse together during growth to create a solid, immobile, bony structure.

Compartment Syndrome

Compartment syndrome most commonly occurs with a fractured tibia in adults or forearm in children and can be overlooked, especially in patients with an altered LOC. This syndrome is characterized by: Pain that is out of proportion to the injury Pain on passive stretch of muscles within the compartment Pallor (pale skin) Decreased sensation Decreased power (ranging from decreased strength and movement of the limb to complete paralysis) Compartment syndrome must be managed surgically. If you suspect that a patient has compartment syndrome: Splint the affected limb, keeping it at the level of the heart. Provide immediate transport. Reassess neurovascular status frequently during transport.

Signs of Fracture

Deformity Tenderness Guarding Swelling Bruising Crepitus False motion Exposed fragments Pain Locked joint

Upper extremity

Extends from the shoulder to the fingertips The arm is composed of the upper arm (humerus), elbow, and forearm (radius and ulna). The upper extremity joins the shoulder girdle at the glenohumeral joint and begins with the humerus. The humerus connects with the bones of the forearm—the radius and ulna—at the elbow to form the hinged elbow joint. The radius, the larger of the two forearm bones, lies on the thumb side of the forearm. The ulna is narrow and is on the little-finger side of the forearm. Because the radius and the ulna are parallel, when one is broken, often the other is broken as well. The hand contains three sets of bones: Wrist bones (carpals) The carpals are vulnerable to fracture when a person falls on an outstretched hand. Hand bones (metacarpals) Finger bones (phalanges) Phalanges are more apt to be injured by a crush injury, such as being slammed in a door.

Elbow Injuries

Fracture of the distal humerus: Also known as a supracondylar or intercondylar fracture Common in children Frequently, the fracture fragments rotate significantly, producing deformity and causing injuries to nearby vessels and nerves. Swelling occurs rapidly and is often severe. Dislocation of the elbow: Typically occurs in athletes and rarely in young children It can occur in toddlers when they are lifted or pulled by the arm (sometimes called "nursemaid's elbow"), although it is not technically a joint dislocation. The ulna and radius are most often displaced posteriorly relative to the humerus. The ulna and radius join the distal humerus. The posterior displacement makes the olecranon process of the ulna much more prominent. The joint is usually locked, with the forearm moderately flexed on the arm; this position makes any attempt at motion extremely painful. There is swelling and significant potential for vessel or nerve injury. Elbow joint sprain: This diagnosis is often mistakenly applied to an occult, nondisplaced fracture, as it can be difficult to distinguish between sprains and fractures. Fracture of the olecranon process of the ulna: This can result from direct or indirect forces and is often associated with lacerations and abrasions. The patient will be unable to actively extend the elbow. Fracture of the radial head: Often missed during diagnosis, this fracture generally occurs as a result of a fall on an outstretched arm or a direct blow to the lateral aspect of the elbow. Attempts to rotate the forearm will cause discomfort.

Injuries of the tibia and fibula

Fracture of the shaft of the tibia or the fibula may occur at any place between the knee joint and the ankle joint. Often both bones fracture at the same time. Even a single fracture may result in severe deformity, with significant angulation or rotation. Because the tibia is located just beneath the skin, open fractures are relatively common. Stabilize the fracture with a padded, rigid long leg splint or an air splint that extends from the foot to the upper thigh. Once splinted, secure the affected leg to the opposite leg. Traction splints are not indicated for isolated tibial fractures. Correct severe deformity before splinting by applying gentle longitudinal traction. The goal is to restore a position that will take a standard splint; it is not necessary to replace the fracture fragments in their anatomic position. These fractures are sometimes associated with vascular injury as a result of the distorted position of the limb, so realigning the limb frequently restores an adequate blood supply to the foot. If it does not, transport the patient promptly and notify medical control while you are en route.

Injuries to the Clavicle and Scapula

Fractures of the clavicle occur commonly in: Children when they fall on an outstretched hand Crush injuries of the chest A patient with a fracture of the clavicle will report pain in the shoulder and will usually hold the arm across the front of his or her body. A young child often reports pain throughout the entire arm and is unwilling to use any part of that limb. Swelling and point tenderness occur over the clavicle. Skin will occasionally "tent" over the fracture fragment. Because the clavicle lies directly over major arteries, veins, and nerves, it may lead to neurovascular compromise. Fractures of the scapula are almost always the result of a forceful, direct blow to the back, directly over the scapula, which may also injure the thoracic cage, lungs, and heart. Assess the patient for signs of breathing problems. Provide supplemental oxygen and prompt transport for patients who are having difficulty breathing. A danger of a scapular fracture is the associated chest injuries, which pose the greatest threat of long-term disability, not the fractured scapula itself. The joint between the outer end of the clavicle and the acromion process of the scapula is called the acromioclavicular (AC) joint. This joint is frequently separated during sports when a player falls and lands on the point of the shoulder, driving the scapula away from the outer end of the clavicle. This dislocation is often called an AC separation. The distal end of the clavicle will often stick out, and the patient will report pain, including point tenderness over the AC joint.

Femoral Shaft Fractures

Fractures of the femoral shaft may be open, and fragments of bone may protrude through the skin. Never attempt to push bone back into the skin. There is often a significant amount of blood loss, as much as 500 to 1,000 mL, after a fracture of the shaft of the femur. With open fractures, the amount of blood loss may be even greater. It is not unusual for hypovolemic shock to develop. Handle patients with these fractures with extreme care because any extra movement or fracture manipulation may increase the amount of blood loss. Because of the severe deformity that occurs with these fractures, bone fragments may penetrate or press on nerves and vessels and produce significant damage. Carefully and periodically assess the distal neurovascular function. Remove the clothing from the affected limb so that you can adequately inspect the injury site for any open wounds. Follow standard precautions when any blood or body fluids are present. Monitor the patient's vital signs closely, and continue to watch for the onset of hypovolemic shock. Provide rapid transport. Cover any open wound with a dry, sterile dressing. If the foot or leg below the level of the fracture shows signs of impaired circulation (is pale, cold, or pulseless), apply gentle longitudinal traction to the deformed limb in line with the long axis of the limb. Gradually turn the leg from the deformed position to restore the limb's overall alignment. Often, this restores or improves circulation to the foot. If it does not, the patient may have sustained a serious vascular injury and may be in need of prompt medical attention. A fracture of the femoral shaft is best stabilized with a traction splint, such as a Sager splint.

Fracture of the Humerus

Fractures of the humerus occur either proximally, in the midshaft, or distally at the elbow. Fractures of the proximal humerus resulting from falls are common among older people. Fractures of the midshaft occur more often in young patients, usually as the result of a violent injury. Support the site of the fracture with one hand, and with the other hand, grasp the two humeral condyles (its lateral and medial protrusions) just above the elbow. Pull gently in line with the normal axis of the limb. Once you achieve gross realignment of the limb, splint the arm with a sling and swathe, supplemented by a padded board splint on the lateral aspect of the arm. If the patient reports significant pain or resists gentle traction, splint the fracture in the deformed position with a padded wire ladder or a padded board splint, using pillows to support the injured limb. Compartment syndrome can develop in the forearm in children with these fractures.

Splinting the Hand and Wrist

Injuries of the wrist, ranging from dislocations to sprains, must be confirmed by radiograph examination. Dislocations are usually associated with a fracture, resulting in a fracture-dislocation. Another common wrist injury is the isolated, nondisplaced fracture of a carpal bone, especially the scaphoid. Any questionable wrist sprain or fracture should be splinted and evaluated in the ED or an orthopaedic surgeon's office. Do not attempt to "pop" a dislocated finger joint back in place. Take any amputated parts to the hospital with the patient. Be sure to wrap the amputated part in a dry or moist sterile dressing, depending on your local protocol, and place it in a dry, plastic bag. Put the bag in a cooled container; do not soak the part in water or allow it to freeze. A bulky forearm dressing makes an effective splint for any hand or wrist injury. Follow these steps to splint a hand and wrist. Click on the arrow to the right to begin

Foot injuries

Injuries to the foot can result in the dislocation or fracture of one or more of the tarsals, metatarsals, or phalanges of the toes. Toe fractures are especially common. Of the tarsal bones, the calcaneus, or heel bone, is the most frequently fractured, usually due to falls or jumps from a height. If the force of impact is great enough, as from a fall from a roof or tree, there may also be other fractures. The force of injury is transmitted up the legs to the spine, producing a fracture of the lumbar spine. When a patient who has jumped or fallen from a height reports heel pain, ask him or her about back pain and carefully check the spine for tenderness and deformity. If you suspect that the foot is dislocated, immediately assess for pulses and motor and sensory functions. If pulses are present, stabilize the extremity using a commercially available splint or a pillow splint, leaving the toes exposed so that you can periodically assess neurovascular function. If pulses are absent, contact medical control and discuss reduction of dislocation if the local scope of practice permits. Injuries of the foot are associated with significant swelling but rarely with gross deformity. Vascular injuries are uncommon. Lacerations about the ankle and foot may damage important underlying nerves and tendons. Puncture wounds to the foot are common and may cause serious infection if not treated early. To splint the foot, apply a rigid padded board splint, an air splint, or a pillow splint, stabilizing the ankle joint and the foot. Leave the toes exposed so that you can periodically assess neurovascular function. When the patient is lying on the stretcher, elevate the foot approximately 6 inches (15 cm) to minimize swelling. All patients with lower extremity injuries should be transported in the supine position to allow for elevation of the limb. Never allow the foot and leg to dangle off the stretcher onto the floor or ground. If a patient has fallen from a height and reports heel pain, use a backboard to immobilize any suspected spinal injury in addition to splinting the foot.

Injuries to the Knee Ligaments

Ligament injuries are often seen in recreational and competitive athletes. The ligaments on the medial side of the knee are most frequently injured, typically when the foot is fixed to the ground and the lateral aspect of the knee is struck by a heavy object. A patient with a knee ligament injury will report pain in the joint and be unable to use the extremity normally. When you examine the patient, you will generally find: Swelling Occasional ecchymosis Point tenderness at the injury site Joint effusion (excess fluid in the joint) Splint all suspected knee ligament injuries. The splint should extend from the hip joint to the foot, stabilizing the bone above the injured joint (the femur) and the bone below it (the tibia). A variety of splints can be used, including a padded, rigid long leg splint or two padded board splints securely applied to the medial and lateral aspects of the limb. A backboard, a pillow splint, or simply binding the injured limb to its uninjured mate is an acceptable—but less effective—splinting technique. The patient will usually be able to straighten the knee to allow you to apply the splint. If you encounter resistance or pain when trying to straighten the knee, splint it in the flexed position. Continue to monitor the distal neurovascular function until the patient reaches the hospital.

Fractures of the Knee

Manage nondisplaced and minimally displaced fractures about the knees as follows: If there is an adequate distal pulse and no significant deformity, splint the limb with the knee straight. If there is an adequate pulse and significant deformity, splint the joint in the position of deformity. If the pulse is absent below the level of the injury, suspect possible vascular and nerve damage and contact medical control immediately for further instructions. Never use a traction splint if you suspect a fractured knee.

Types of Fractures

Medical personnel often use the following special terms to describe particular types of fractures: Comminuted. A fracture in which the bone is broken into more than two fragments. Epiphyseal. A fracture that occurs in a growth section of a child's bone and may lead to growth abnormalities. Greenstick. An incomplete fracture that passes only partway through the shaft of a bone but may still cause substantial angulation; occurs in children. Incomplete. A fracture that does not run completely through the bone; a nondisplaced partial crack. Oblique. A fracture in which the bone is broken at an angle across the bone. This is usually the result of a sharp, angled blow to the bone. Pathologic. A fracture of weakened or diseased bone, seen in patients with osteoporosis, infection, or cancer; often produced by minimal force. Spiral. A fracture caused by a twisting or spinning force, causing a long, spiral-shaped break in the bone. This is sometimes the result of abuse in young children. Transverse. A fracture that occurs straight across the bone. This is usually the result of a direct-blow injury.

Dislocation of the Hip

Most dislocations of the hip are posterior. The femoral head is displaced posteriorly to lie in the muscles of the buttock. Very rarely does the femoral head dislocate anteriorly; in this circumstance, the legs are suddenly and forcibly spread wide apart and locked in this position. The limb is extended straight out, externally rotated, and pointing away from the midline of the body. The sciatic nerve is the largest nerve in the lower extremity; it controls the activity of muscles in the posterior thigh and below the knee and the sensation in most of the leg and foot. When the head of the femur is forced out of the hip socket, it may compress or stretch the sciatic nerve, leading to partial or complete paralysis of the nerve. The result is decreased sensation in the leg and foot and frequently weakness in the foot muscles. Generally, only the dorsiflexors, the muscles that raise the toes or foot, are involved, causing the "foot drop" that is characteristic of damage to the peroneal portion of the sciatic nerve. Patients with a posterior dislocation of the hip typically lie with the hip joint flexed (the knee joint drawn up toward the chest) and the thigh rotated inward toward the midline of the body over the top of the opposite thigh. Dislocation of the hip is associated with very distinctive signs: The patient will have severe pain in the hip and will strongly resist any attempt to move the joint. The lateral and posterior aspects of the hip region will be tender on palpation. Check for a sciatic nerve injury by carefully assessing sensation and motor function in the lower extremity. Occasionally, sciatic nerve function will be normal at first and then slowly diminish. Do not attempt to reduce the dislocated hip in the field unless medical control directs you to do so. Splint the dislocation in the position of the deformity, and place the patient supine on a backboard. Support the affected limb with pillows and rolled blankets, particularly under the flexed knee. Secure the entire limb to the backboard with long straps so that the hip region will not move, and provide prompt transport.

Complications

Often, the likelihood of a complication is related to the following: The strength of the force that caused the injury The injury's location The patient's overall health Any injury to a bony structure is likely to be accompanied by bleeding. In general, the greater the force that caused the injury, the greater the hemorrhage will be. Following a fracture, the sharp ends of the bone may damage muscles, blood vessels, arteries, and nerves, or the ends may penetrate the skin and produce an open fracture. A significant loss of tissue may occur at the fracture site if the muscle is severely damaged or if the penetration of the bone into the skin causes a large deformity. To prevent contamination following an open fracture, brush away any obvious debris on the skin surrounding an open fracture before applying a dressing. Do not enter or probe the open fracture site in an attempt to retrieve debris because this may lead to further contamination. Long-term disability is one of the most devastating consequences of an orthopaedic injury. In many cases, a severely injured limb can be repaired and made to look almost normal. Unfortunately, many patients cannot return to work for long periods because of the extensive rehabilitation required and because of chronic pain. As an EMT, you have a critical role in mitigating the risk of long-term disability; you can help reduce the risk or duration of long-term disability by: Preventing further injury Reducing the risk of wound infection Minimizing pain by the use of cold and analgesia Transporting patients with orthopaedic injuries to an appropriate medical facility

Applying a Vacuum Splint

Other formable splints include: Vacuum splints Pillow splints Structural aluminum malleable (SAM) splints A sling and swathe Pelvic binders for pelvic fractures

Common examples of rigid splints include:

Padded board splints Molded plastic and metal splints Padded wire ladder splints Folded cardboard splints

Reel splints The Reel splint is a traction splint that is also used by the US military. Many devices used in combat eventually appear in the ambulance and are used by EMTs in the field. This splint is designed to be used on a lower extremity.

Pelvic binders Used to splint the bony pelvis to reduce hemorrhage from bone ends, venous disruption, and pain A pelvic binder is meant to provide temporary stabilization until definitive immobilization can be achieved. It is lightweight; made of soft material; easily applied by one EMT; and should allow access to the abdomen, perineum, anus, and groin for examination and diagnostic testing. Because there are various manufacturers of pelvic binder devices, you should be familiar with the manufacturer's instructions for your specific device.

factors effecting exposure

Physical condition Age Nutrition and hydration Environmental conditions

Pelvis

Supports the body weight and protects the structures within the pelvis: the bladder, rectum, and female reproductive organs The pelvic girdle is actually three separate bones—the ischium, ilium, and pubis—fused together to form the innominate (or hip) bone. The two iliac bones are joined posteriorly by tough ligaments to the sacrum at the sacroiliac joints. The two pubic bones are connected anteriorly by equally tough ligaments to one another at the pubic symphysis. These joints allow very little motion, so the pelvic ring is strong and stable.

zone of injury

The area of potentially damaged soft tissue, adjacent nerves, and blood vessels surrounding an injury to a bone or a joint.

Dislocations of the Shoulder

The glenoid fossa joins with the humeral head to form the glenohumeral joint. In shoulder dislocations, the humeral head commonly dislocates anteriorly, coming to lie in front of the scapula as a result of forced abduction and external rotation of the arm. When you assess a patient with a possible shoulder dislocation, position yourself behind the patient and compare the shoulders. The dislocated side is often lower than the uninjured side. Stabilizing an anterior shoulder dislocation is difficult because any attempt to bring the arm in toward the chest will produce pain. Splint the joint in whatever position is most comfortable for the patient. If necessary, place a pillow or rolled blankets or towels between the arm and chest to fill up the space between them. Once the arm has been stabilized, the elbow can usually be flexed to 90 degrees without causing further pain. Apply a sling to the forearm and wrist to support the weight of the arm. Secure the arm in the sling to the pillow and chest with a swathe. Transport the patient in a seated or semi-seated position. Dislocation of the shoulder disrupts the supporting ligaments of the anterior aspect of the shoulder. Often, these ligaments fail to heal properly, so dislocation recurs, causing further neurovascular compromise and joint injury. In certain cases, surgical repair may be required. Posterior dislocation is less common. Football players, especially linemen, are susceptible to this injury. The arm will often be locked in adduction (toward the midline), so it cannot be rotated. Reducing the dislocation usually requires medical supervision.

Applying a Zippered Air Splint

The most commonly used formable (soft) splint is the precontoured, inflatable, clear plastic air splint. Always inflate the splint after applying it. Air splints are used to stabilize injuries below the elbow or below the knee. Drawbacks include: The zipper can stick, clog with dirt, or freeze. Significant weather changes affect the air pressure in the splint, which decreases as the environment grows colder and increases as the environment grows warmer. The same thing happens when there are changes in altitude, which can be a problem with helicopter transport of patients. Carefully monitor the splint and let air out if the splint becomes overinflated.

When Not to Splint

There are two situations in which you must splint the limb in the position of deformity: When the deformity is severe When you encounter resistance or extreme pain when applying gentle traction to the fracture of a shaft of a long bone In either situation, apply padded board splints to each side of the limb and secure them with soft roller bandages. Most dislocations should be splinted as found, but follow local protocols. Attempts to realign or reduce dislocations may lead to more damage.

Traction Splints

Traction is the most effective way to realign a fracture of the shaft of a long bone so that the limb can be splinted more effectively. The goals of in-line traction are to: Stabilize the fracture fragments to prevent excessive movement Align the limb sufficiently to allow it to be placed in a splint Avoid potential neurovascular compromise Several different types of lower extremity traction splints are commercially available, such as: Hare traction splints Sager splints Reel splints Kendrick splints Each has its own unique method of application. Consult with your agency on which traction splint you will use in the field, and make sure that you are comfortable applying this device to a patient. Do not use traction splints for: Injuries of the upper extremity Injuries close to or involving the knee Injuries of the pelvis Partial amputations or avulsions with bone separation Lower leg, foot, or ankle injuries Before you apply a traction splint, be sure to control any external bleeding. The amount of traction that is required varies but often does not exceed 15 pounds (7 kg). Use the least amount of force necessary. Grasp the foot or hand at the end of the injured limb firmly; once you start pulling, do not stop until the limb is fully splinted. Releasing manual traction before the limb is secured will allow the muscles to contract, allowing the bone fragments to cause more damage to surrounding tissue. Always apply the direction of traction along the long axis of the limb. Grasping the foot or hand and the initial pull of traction usually causes the patient some discomfort as the bone fragments move, so a second EMT should support the injured limb directly under the site of the fracture. Initial discomfort quickly subsides, and then you can apply further gentle traction. If the patient strongly resists the traction or if it causes more pain that persists, stop and splint the limb in the deformed position.

Care of Elbow Injuries

Two padded board splints, one applied to each side of the limb and secured with soft roller bandages, usually are enough to stabilize the arm. Make sure the board extends from the shoulder joint to the wrist joint, stabilizing the entire bone above and below the injured joint. Alternatively, you can mold a padded wire ladder splint or a SAM splint to the shape of the limb. If necessary, you may add further support to the limb with a pillow. A cold, pale hand or a weak or absent pulse and poor capillary refill indicate that the blood vessels have been injured. Notify medical control immediately. If you are within 10 to 15 minutes of the hospital, splint the limb in the position in which you found it and provide prompt transport. Medical control may direct you to try to realign the limb to improve circulation in the hand. If the limb is pulseless and significantly deformed at the elbow, apply gentle manual traction in line with the long axis of the limb to decrease the deformity. This may restore the pulse. Excessive manipulation may only worsen the vascular problem. If no pulse returns after one attempt, splint the limb in the most comfortable position for the patient. If the pulse is restored by gentle longitudinal traction, splint the limb in whatever position allows the strongest pulse. Provide prompt transport for all patients with impaired distal circulation.

Fractures of the Pelvis

Up to several liters of blood may drain into the pelvic space and the retroperitoneal space, which lies between the abdominal cavity and the posterior abdominal wall. The result is significant hypotension; shock; and, sometimes, death. Take immediate steps to treat shock, even if there is only minimal swelling. Be prepared to resuscitate the patient rapidly if this becomes necessary. Because the pelvis is surrounded by heavy muscle, open fractures of the pelvis are uncommon. Pelvis fracture fragments can lacerate the rectum and vagina, creating an open fracture that is often overlooked. The bladder may be lacerated by pelvic bone fragments, or it may tear as a result of direct pressure on the bladder itself or tension on the urethra. Suspect a fracture of the pelvis in any patient who has sustained a high-velocity injury and reports discomfort in the lower back or abdomen. Because the area is covered by heavy muscle and other soft tissue, deformity or swelling may be very difficult to see. The most reliable sign of fracture of the pelvis is simple tenderness or instability on firm compression and palpation. Firm compression on the two iliac crests will produce pain at a fracture site in the pelvic ring.

Amputations

You must control bleeding and treat for shock when dealing with traumatic amputations. Complete traumatic amputations may occasionally not bleed much if the cut vessels go into spasm, reducing blood loss. With partial amputations, make sure to stabilize the part with bulky compression dressings and a splint to prevent further injury. Do not sever any partial amputations; this may complicate later reattachment. Hemorrhage from complete or incomplete amputations can be severe and life threatening. Control any bleeding from the stump. If bleeding is severe, quickly apply a tourniquet. With a complete amputation, make sure to wrap the clean part in a sterile dressing and place it in a plastic bag. Follow your local protocols regarding how to preserve amputated parts. In some areas, dry, sterile dressings are recommended for wrapping amputated parts; in other areas, dressings moistened with sterile saline are recommended. Put the bag in a cool container filled with ice. Lay the wrapped part on a bed of ice; do not pack it in ice. The goal is to keep the part cool without allowing it to freeze or develop frostbite. Transport the amputated part with the patient to the appropriate resource hospital.

Lower Extremeties

consists of the bones of the thigh, leg, and foot The femur (thighbone) is a long, powerful bone that connects in the ball-and-socket joint of the pelvis and in the hinge joint of the knee. The femoral head is the ball-shaped part that fits into the acetabulum. It is connected to the shaft (diaphysis), or long tubular portion of the femur, by the femoral neck. The femoral neck is a common site for fractures, generally referred to as hip fractures, especially in the older population. The greater trochanter and lesser trochanter are the names given to lateral and medial bony protuberances below the femoral neck and just above the shaft of the femur. The lower leg consists of two bones: Tibia (shinbone) The larger of the two leg bones responsible for supporting the major weight-bearing surface of the knee and ankle Connects to the patella (knee cap) via the patellar tendon just below the knee joint and runs down the front of the lower leg Is vulnerable to direct blows and can be felt just beneath the skin Fibula Runs behind and beside the tibia Serves as an anchor for ligaments surrounding the knee joint and forms the lateral side of the ankle joint The foot consists of three classes of bones: Ankle bones (tarsals) The largest of the tarsal bones is the heel bone, or calcaneus, which is subject to injury with axial loading injuries, such as when a person jumps from a height and lands on the feet. Foot bones (metatarsals) Toe bones (phalanges)