Chapter 31 Orthopaedic Injuries

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.

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.

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.

Epiphyseal

. A fracture that occurs in a growth section of a child's bone and may lead to growth abnormalities.

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.

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.

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.

Comminuted.

A fracture in which the bone is broken into more than two fragments.

Pathologic.

A fracture of weakened or diseased bone, seen in patients with osteoporosis, infection, or cancer; often produced by minimal force.

Incomplete.

A fracture that does not run completely through the bone; a nondisplaced partial crack.

Transverse.

A fracture that occurs straight across the bone. This is usually the result of a direct-blow injury

Dislocations

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.

Crepitus

A grating or grinding sensation known as crepitus can be felt and sometimes even heard when fractured bone ends rub together.

Locked joint

A joint that is locked into position is difficult and painful to move. Crepitus and false motion appear only when a limb is moved or manipulated and are associated with injuries that are extremely painful. Do not manipulate the limb excessively in an effort to elicit these signs. This sign is more commonly the result of a soft-tissue injury within the joint (typically the knee or elbow), but the presence of a locked joint should alert you to the possibility of an underlying fracture.

Transportation

A patient with a pulseless limb must be given a higher priority. If the treatment facility is an hour or more away, a patient with a pulseless limb should be transported by helicopter or immediate ground transportation. If circulation in the distal limb is impaired, notify medical control so that proper steps can be taken quickly once the patient arrives in the ED.

acromioclavicular (AC) joint

A simple joint where the bony projections of the scapula and the clavicle meet at the top of the shoulder.

Skull

A solid, vaultlike structure that surrounds and protects the brain

Cardiac

A specially adapted involuntary muscle with its own regulatory system

Sprains

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.

Strains

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.

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.

False motion

Also called free movement, false motion is movement at a point in the limb where there is no joint. It is a positive indication of a fracture.

Smooth

Also called involuntary muscle because it is not under voluntary control of the brain Performs much of the automatic work of the body Found in the walls of most tubular structures of the body, such as the gastrointestinal tract and the blood vessels Contracts and relaxes to control the movement of the contents within these structures

Skeletal

Also called striated muscle (because of its characteristic stripes) or voluntary muscle (because it is under direct voluntary control of the brain) Attaches to the bones and usually crosses at least one joint Movement is the result of several muscles contracting and relaxing simultaneously. Skeletal muscle tissue is attached directly to the bone by tough, ropelike structures known as tendons, which are extensions of the fascia that covers all skeletal muscle. Fascia surrounds and supports the muscles and neurovascular structures.

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.

Fractures of the 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.

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.

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.

Guarding

An inability to use the extremity is the patient's way of immobilizing it to minimize pain. The muscles around the fracture contract in an attempt to prevent any movement of the broken bone. Guarding does not occur with all fractures; some patients may continue to use the injured part for a time.

Greenstick.

An incomplete fracture that passes only partway through the shaft of a bone but may still cause substantial angulation; occurs in children.

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)

Ankle injuries

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.

closed fracture

Any break in a bone in which the overlying skin is not broken.

Complicatins

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.

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.

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.

Traction Splints (continued)

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.

The Skeleton (continued)

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.

The term musculoskeletal refers to the bones and voluntary muscles of the body.

Bones and muscles are susceptible to external forces that can cause injury. Also at risk are the tendons, cartilage, and the ligaments.

Midshaft Fractures

Characteristics Gross angulation of the arm Marked instability and creptus of the fracture fragments Possible neurovscular compromise Possible entrapment of the raidal nerve Treatments Stabilize with a sling and swathe or shoulder stabilizer Use the chest wall as a splint, and secure the injured arm to the cehst wall Place a short, padded splint on the lateral side of the arm under the sling and swathe for additional support

Distal humeral fractures

Characteristics Significant swelling at the elbow Possible neurovascular compromise Possible injury to the ulnar or median nerve Treatments Stabilize in a splint, in addition to a sling and swathe or a shoulder stabilizer

Proximal humeral fractures

Characteristics significant swelling, but no significant deformity of the upper arm Neurovascular compromise uncommon If neurologic compromise present, any or all of the brachial plexus may be affected, depending on the degree of displacement Concurrent soft-tissue injuries possible Possible rotator cuff injury Treatments -stabilize in a sling and swathe or a shoulder stabilizer Use the chest wall as a splint, and secure the injured arm to the chest wall Place a short, padded board splint on the lateral side of the arm under the sling and swathe for additional support

Fractures of the clavicle occur commonly in:

Children when they fall on an outstretched hand Crush injuries of the chest

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)

Be aware of the hazards associated with the improper application of splints, including:

Compression of nerves, tissues, and blood vessels Delay in transport of a patient with a life-threatening injury Reduction of distal circulation Aggravation of the injury Injury to tissue, nerves, blood vessels, or muscles as a result of excessive movement of the bone or joint

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

signs of fracture include:

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

Musculoskeletal Injuries

Depending on the amount of kinetic energy the tissues absorb from forces acting on the body, the zone may extend to a distant point. Do not be distracted by a patient's obvious injury; you must first complete a primary assessment to check for life-threatening injuries.

Significant force may be applied to the limb in any of the following ways:

Direct blows Indirect forces Twisting forces High-energy injuries

Other orthopaedic injuries include:

Dislocation of the patella Injuries of the tibia and fibula Ankle injuries Foot injuries Sprains and strains Amputations

Serious Injuries

Displaced long bone fractures Multiple hand and foot fractures Open long bone fractures Displaced pelvic fractures Dislocation of major joints Multiple digit amputations Laceration of major nerves or blood vessels

Dislocation of the Knee (continued)

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. Notify medical control of the status of the distal pulse so that treatment can be arranged in advance.

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.

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.

Elbow injuries include:

Fracture of the distal humerus Dislocation of the elbow Elbow joint sprain Fracture of the olecranon process of the ulna Fracture of the radial head

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.

Bruising

Fractures are almost always associated with ecchymosis (discoloration) of the surrounding soft tissues. Bruising may be present after almost any injury and may take hours to develop; it is not specific to bone or joint injuries. The discoloration associated with acute injuries is usually redness. Within hours or days, blue, purple, and black discoloration will appear, followed by yellow and green.

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.

Several different types of lower extremity traction splints are commercially available, such as:

Hare traction splints Sager splints Reel splints Kendrick splints

Use DCAP-BTLS to assess the musculoskeletal system.

Identify any extremity deformities that may represent significant musculoskeletal injury and stabilize them appropriately. Contusions and abrasions may overlie more subtle injuries; evaluate the stability and neurovascular status of the limb. The presence of puncture wounds or other signs of penetrating injury should alert you to the possibility of an open fracture. Identify and treat any associated burns. Palpate for tenderness, which may be the only significant sign of an underlying musculoskeletal injury. When lacerations are present in an extremity, suspect an open fracture, control bleeding, and apply dressings. Carefully assess for swelling with comparison with the opposite limb.

Handling Injured Extremities During Assessment and Transport

If external bleeding is present, bandage the extremity quickly to control bleeding. Keep the dressings that cover the wound and bone clean to reduce the potential for bone infection. The bandage should be secure enough to control bleeding without restricting circulation distal to the injury. Monitor bandage tightness by assessing the circulation, sensation, and movement distal to the bandage. Swelling from fractures and internal bleeding may cause bandages to become too tight. If bleeding cannot be controlled, quickly apply a tourniquet. Also handle fractures carefully while preparing for transport to limit pain and prevent sharp bone ends from breaking through the skin or damaging nerves and blood vessels in the extremity.

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.

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.

Assessing Tenderness in the Pelvis

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.

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.

Review your knowledge of the material by answering the following questions. Select whether each statement listed is true or false. If you are unable to restore the distal pulse on scene, you should splint the limb in a straight position and provide prompt transport to the hospital. TrueFalse Lateral and medial dislocations to the knee are less common than posterior dislocations and are less likely to injure the popliteal artery. TrueFalse A fracture of the femoral shaft is best stabilized with a traction splint, such as a Sager splint. TrueFalse Fractures of the proximal femur usually involve the hip joint. TrueFalse

If you are unable to restore the distal pulse on scene, you should splint the limb in a straight position and provide prompt transport to the hospital. TrueFalse Correct. 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. Lateral and medial dislocations to the knee are less common than posterior dislocations and are less likely to injure the popliteal artery. TrueFalse Correct. Lateral and medial dislocations to the knee are less common than posterior dislocations and are less likely to injure the popliteal artery. A fracture of the femoral shaft is best stabilized with a traction splint, such as a Sager splint. TrueFalse Correct. A fracture of the femoral shaft is best stabilized with a traction splint, such as a Sager splint. Fractures of the proximal femur usually involve the hip joint. TrueFalse Correct. Fractures of the proximal femur are usually called hip fractures, but they rarely involve the hip joint.

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.

Secondary Assessment

If your assessment reveals no external signs of injury, ask the patient to move each limb carefully, stopping immediately if a movement causes pain. Skip this step if the patient reports neck or back pain; even slight motion could cause permanent damage to the spinal cord. When nonsignificant trauma has occurred and you suspect that your patient has a simple strain, sprain, dislocation, or fracture, take the time to focus your secondary assessment on that particular injury. Look for DCAP-BTLS. Assess the entire zone of injury by removing clothing from the area and looking and palpating for injuries. In musculoskeletal injuries, the zone of injury generally extends from the joint above (proximal) to the joint below (distal), front and back. Evaluate the circulation, motor function, and abnormal sensations distal to the injury. Extremity injuries that impair circulation or nerve function in distal tissues are urgent conditions. Patients with these injuries need careful assessment, prompt transport, and frequent reassessment of distal functions. It is also crucial to report this information in your initial radio contact with the hospital to allow personnel to prepare for a condition in which prompt surgery may be necessary to save the limb. Any injury or deformity of the bone may be associated with vessel or nerve injury, so assess neurovascular function every 5 to 10 minutes, depending on the patient's condition, until the patient is at the hospital. Recheck the neurovascular function before and after you splint or otherwise manipulate the limb. Failure to restore circulation can lead to death of the limb. Always give priority to patients with impaired circulation resulting from bone fragments. You will not be able to assess sensory and motor functions in an unconscious patient, but you can evaluate the limb for deformity, swelling, ecchymosis, false motion, and crepitus. Determine a baseline set of vital signs, including pulse rate, rhythm, and quality; respiratory rate, rhythm, and quality; blood pressure; skin condition; and pupil size and reaction to light. These need to be obtained as soon as possible. Trending these vital signs helps you to understand whether your patient's condition is improving or worsening over time, particularly during long transports. Shock or hypoperfusion is common in musculoskeletal injuries; therefore, baseline information is very important in assessing your patient's condition.

Reassessment

In a critically injured patient, secure the patient to a backboard to immobilize the spine, pelvis, and extremities and provide prompt transport to a trauma center. In this situation, a secondary assessment with extensive evaluation and splinting of limb injuries in the field is a waste of valuable time. Perform the primary assessment and transport, reassessing the patient en route to the ED. If possible, gently and carefully remove the patient's clothing to look for open fractures or dislocations, severe deformity, swelling, and/or ecchymosis. When you have finished assessing the extremity, apply a secure splint to stabilize the injury prior to transport. The joints above and below the site of injury should be included in the splint. To minimize the potential for complications, the splint should be well padded. A comfortable and secure splint will: Reduce pain Reduce shock Minimize compromised circulation Check the patient's circulation, motor function, and sensation before and after splinting. Report to the hospital: A description of the problems found during your assessment Problems with the patient's ABCs, open fractures, and compromised circulation that occurred before or after splinting Additional details, such as the mandated reporting of situations involving elder or child abuse, can be given during your verbal report at the hospital when you transfer care to the nursing staff or physician. Document the presence or absence of circulation, motor function, and sensation distal to the injury before you move an extremity, after manipulation or splinting of the injury, and on arrival at the hospital.

Assessing the Severity of an Injury

In an extremity with anything less than complete circulation, prolonged hypoperfusion can cause significant damage. Any suspected open fracture or vascular injury is considered a critical emergency. In a patient who has multisystem trauma, any additional bleeding can increase problems with underlying injuries or overall perfusion.

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. 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.

Exposed fragments

In open fractures, bone ends may protrude through the skin or be visible within the wound. Never attempt to push the end of a protruding bone back into place. This will increase the risk for infection.

Dislocations of Shoulder

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.

Foot Injuries

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.

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

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.

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.

The supporting capsule and ligaments are stretched or torn, resulting in injury to the:

Ligaments Articular capsule Synovial membrane Tendons crossing the joint

Complications of knee dislocation may include:

Limb-threatening popliteal artery disruption Injuries to the nerves Joint instability

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

Minor Injuriees

Minor Sprains Fractures or dislocation of digits

Severe, Life-Threatenning Injuries

Multiple closed fractures Limb amputations Fracture of both long bones of the legs

Critical Injuris

Mutliple open fractures of the limbs Suspected pelvic fractures with hemodynamic instability

History Taking

Obtain a SAMPLE history for all trauma patients. How much and in what detail you explore this history depends on the seriousness of the patient's condition and how quickly you need to transport the patient to the hospital. Make an attempt to obtain this history without delaying time to definitive care. OPQRST is of limited use in cases of severe injury and is usually too lengthy when matters of airway, breathing, circulation, and rapid transport require immediate attention. OPQRST may be useful when: The MOI is unclear The patient's condition is stable Details of the injury are uncertain This more detailed questioning for simple trauma may help you and the hospital staff to better understand the specific injury.

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.

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.

Moderate Injuries

Open fractures of digits Nondisplaced long bone fractures Nondisplaced pelvic fractures

Applying a Rigid Splint Common examples of rigid splints include:

Padded board splints Molded plastic and metal splints Padded wire ladder splints Folded cardboard splints Follow these steps to apply a rigid splint. Click on the arrow to the right to begin.

Examination of the injured limb should include the 6 Ps of musculoskeletal assessment:

Pain Paralysis Paresthesia (numbness or tingling) Pulselessness Pallor Pressure

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)

Pain

Pain, along with tenderness, bruising, and bleeding, commonly occurs in association with fractures. Remember to use the OPQRST mnemonic to assess pain: Onset, Provocation/palliation, Quality, Region/radiation, Severity, and Time (duration).

Dislocation of hip

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.

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.

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

Thoracic cage

Protects the heart, lungs, and great vessels; the lower ribs protect the liver and spleen The bony spinal canal encases and protects the spinal cord.

Swelling

Rapid swelling usually indicates bleeding from a fracture and is typically followed by substantial pain. Often, if the swelling is severe, it may mask deformity of the limb. Generalized swelling from fluid buildup may occur several hours after an injury.

Rearrange the injuries from least to most severe based on the musculoskeletal injury grading system. Bilateral femur fracture Pelvic fracture with hemodynamic instability Dislocated fingers Displaced pelvic fracture Nondisplaced long bone fracture

Rearrange the injuries from least to most severe based on the musculoskeletal injury grading system. Dislocated fingers Correct. You have correctly categorized these injuries. Nondisplaced long bone fracture Correct. You have correctly categorized these injuries. Displaced pelvic fracture Correct. You have correctly categorized these injuries. Bilateral femur fracture Correct. You have correctly categorized these injuries. Pelvic fracture with hemodynamic instability Correct. You have correctly categorized these injuries. Submit

Additional splinting devices include:

Reel splints Pelvic binders

General Principles of Splinting

Remove clothing from the area of any suspected fracture or dislocation so that you can inspect the extremity for DCAP-BTLS. Note and record the patient's neurovascular status distal to the site of the injury, including pulse, sensation, and movement. Continue to monitor the neurovascular status until the patient reaches the hospital. Cover open wounds with a dry, sterile dressing before splinting. Be sure to follow standard precautions. Do not intentionally replace protruding bones. Notify the receiving hospital of all open wounds. Do not move the patient before splinting an extremity unless there is an immediate danger to the patient or you. In a suspected fracture of the shaft of any bone, be sure to stabilize the joints above and below the fracture. With injuries in and around the joint, be sure to stabilize the bones above and below the injured joint. Pad all rigid splints to prevent local pressure and patient discomfort. While applying the splint, maintain manual stabilization to minimize movement of the limb and to support the injury site. If fracture of a long bone shaft has resulted in severe deformity, use constant, gentle manual traction to align the limb so that it can be splinted. This is especially important if the distal part of the extremity is cyanotic or pulseless. If you encounter resistance to limb alignment, splint the limb in its deformed position. Immobilize all suspected spinal injuries in a neutral in-line position on a backboard. If the patient has signs of shock (hypoperfusion), align the limb in the normal anatomic position and provide transport (total body immobilization). When in doubt, splint.

Three basic types of splints are:

Rigid Formable Traction

The muscular system includes three types of muscles:

Skeletal Smooth Cardiac

The skeleton can be divided into the following:

Skull Thoracic cage Pectoral girdle Upper extremity Pelvis Lower extremity

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.

Splinting

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

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

Which of the following are goals of in-line traction? Stabilize the fragments to prevent movement Align the limb for splinting Stop bleeding Avoid neurovascular compromise

Stabilize the fragments to prevent movement Align the limb for splinting Avoid neurovascular compromise

Applying a Sager Traction Splint

Step 1 After exposing the injured area, check the patient's pulse and motor and sensory functions. Adjust the thigh strap so that it lies anteriorly when secured. Step 2 Estimate the proper length of the splint by placing it next to the uninjured limb. Fit the ankle pads to the ankle. Step 3 Place the splint at the inner thigh, apply the thigh strap at the upper thigh, and secure snugly. Step 4 Tighten the ankle harness just above the malleoli. Secure the cable ring against the bottom of the foot. Step 5 Extend the splint's inner shaft to apply traction of about 10% of body weight. Step 6 Secure the splint with elasticized cravat bandages. Step 7 Secure the patient to a backboard. Check pulse and motor and sensory function.

Applying a Zippered Air Splint

Step 1 Assess distal pulse and motor and sensory function. Support the injured limb and apply gentle traction as your partner applies the open, deflated splint. Step 2 Zip up the splint, inflate it by pump or by mouth, and test the pressure. Check and record distal neurovascular function.

Applying an Unzippered Air Splint

Step 1 Assess distal pulse and motor and sensory function. Your partner should support the injured limb. Place your arm through the splint to grasp the patient's hand or foot. Step 2 Apply gentle traction while sliding the splint onto the injured limb. Step 3 Your partner will inflate the splint by pump or by mouth. Assess distal pulse and motor and sensory function.

Applying a Vacuum Splint

Step 1 Assess distal pulse and motor and sensory function. Your partner will stabilize and support the injury. Step 2 Place the splint and wrap it around the limb. Step 3 Draw the air out of the splint through the suction valve, and then seal the valve. Assess distal pulse and motor and sensory function.

Caring for Musculoskeletal Injuries

Step 1 Cover open wounds with a dry, sterile dressing, and apply pressure to control bleeding. Assess distal pulse and motor and sensory function. If bleeding cannot be controlled, quickly apply a tourniquet. Step 2 Apply a splint and elevate the extremity about 6 inches (15 cm), or slightly above the level of the heart. Assess distal pulse and motor and sensory function. Step 3 Apply cold packs if there is swelling, but do not place them directly on the skin. Step 4 Position the patient for transport and secure the injured area.

Applying a Hare Traction Splint

Step 1 Expose the injured limb and check pulse, motor, and sensory function. Place the splint beside the uninjured limb, adjust the splint to proper length, and prepare the straps. Step 2 Support the injured limb as your partner fastens the ankle hitch about the foot and ankle. Step 3 Continue to support the limb as your partner applies gentle in-line traction to the ankle hitch and foot. Step 4 Slide the splint into position under the injured limb. Step 5 Pad the groin and fasten the ischial strap. Step 6 Connect the loops of the ankle hitch to the end of the splint as your partner continues to maintain traction. Carefully tighten the ratchet to the point that the splint holds adequate traction. Step 7 Secure and check support straps. Assess pulse and motor and sensory functions. Step 8 Secure the patient and splint to the backboard in a way that will prevent movement of the splint during patient movement and transport.

Applying a Rigid Splint

Step 1 Provide gentle support and in-line traction for the limb. Assess distal pulse and motor and sensory function. Step 2 Place the splint alongside or under the limb. Pad between the limb and the splint as needed to ensure even pressure and contact. Step 3 Secure the splint to the limb with bindings. Step 4 Assess and record distal neurovascular function.

Splinting the Hand and Wrist

Step 1 Support the injured limb and move the hand into the position of function. Place a soft roller bandage in the palm. Step 2 Apply a padded board splint on the palmar side with fingers exposed. Step 3 Secure the splint with a roller bandage.

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.

Additional musculoskeletal injuries include:

Strains Amputations

Injuries to nerves and blood vessels are quite common in the elbow region.

Such injuries can be caused or worsened by inappropriate emergency care, particularly by excessive manipulation of the injured joint.

Fracture of the Humerus (continued)

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.

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.

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)

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.

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.

Deformity

The limb may appear to be shortened, rotated, or angulated at a point where there is no joint. Always use the opposite, uninjured limb as a mirror image for comparison.

sciatic nerve

The major nerve to the lower extremities; controls much of muscle function in the leg and sensation in most of the leg and foot.

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.

glenoid fossa

The part of the scapula that joins with the humeral head to form the glenohumeral joint

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.

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).

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

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.

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.

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.

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.

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.

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 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

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.

Scene Size-up

Try to identify the forces associated with the MOI. Consider the possibility of hidden bleeding. Standard precautions may be as simple as gloves. With a severe MOI or other risk factors, a mask and gown may be necessary. Eye protection also may be indicated. Evaluate the need for law enforcement support, advanced life support (ALS), or additional ambulances, and request them early based on your initial scene assessment. Look for indicators of the MOI and be alert for both primary and secondary injuries. Consider what injuries the MOI would lead you to expect.

MOI

Twisting forces are a common cause of musculoskeletal injury, especially to the anterior cruciate ligament (ACL) or the medial cruciate ligament (MCL) in the knee. High-energy injuries produce severe damage to the skeleton, surrounding soft tissues, and vital internal organs. A patient may have multiple injuries to many body parts, including more than one fracture or dislocation in a single limb. A significant MOI is not always necessary to fracture a bone. A slight force can fracture a bone that is weakened by a tumor, infection, or osteoporosis.

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.

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.

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.

Fractures to 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.

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.

Other formable splints include:

Vacuum splints Pillow splints Structural aluminum malleable (SAM) splints A sling and swathe Pelvic binders for pelvic fractures Follow these steps to apply a vacuum splint. Click on the arrow to the right to begin.

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.

Primary Assessment

When evaluating the patient's level of consciousness (LOC) and orientation, check for responsiveness using the AVPU scale and assess mental status by asking the patient about his or her chief complaint. Administer high-flow oxygen via a nonrebreathing mask (or a bag-valve mask [BVM], if indicated) to all patients whose LOC is less than alert and oriented, and provide rapid transport to the emergency department (ED). Ask about the MOI. If a spinal injury is suspected after evaluating the MOI and signs and symptoms, take the appropriate precautions and prepare for immobilization per local protocols. Fractures and sprains usually do not create airway and breathing problems. Evaluating the chief complaint and MOI will help you to identify whether the patient has an open airway and whether breathing is present and adequate. Circulatory assessment should focus on determining whether the patient has a pulse, has adequate perfusion, or is bleeding. If the patient is unconscious, make sure there is a pulse by palpating the carotid artery. Hypoperfusion (shock) and bleeding problems will most likely be your primary concerns. If the skin is pale, cool, or clammy and capillary refill time is slow, treat your patient for shock immediately. Maintain a normal body temperature. If musculoskeletal injuries in the extremities are suspected, they must be at least initially stabilized, if not splinted, prior to moving. Eliminating this cause of shock may need to be done later in your assessment. If the patient has an airway or breathing problem or significant bleeding, provide rapid transport to the hospital after quickly treating life threats. A patient who has a significant MOI but whose condition appears otherwise stable still should be transported promptly to the closest appropriate hospital. Patients with bilateral fractures of the long bones (humerus, femur, or tibia) have been subjected to a high amount of kinetic energy, which should increase your index of suspicion for serious unseen injuries. When a decision for rapid transport is made, you can use a long backboard as a splinting device to splint the whole body rather than splinting each extremity individually. Individual splints should be applied en route if the ABCs are stable and time permits.

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.

In which situations should you splint the limb in the position of deformity? When the deformity is the result of a dislocation and is severe When you encounter resistance or extreme pain when applying traction When distal pulses are absent When the fracture is an open fracture

When you encounter resistance or extreme pain When the fracture is an open fracture

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.

A fracture

is a break in the continuity of the bone, often occurring as a result of an external force.

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 splint

is a flexible or rigid device that is used to protect and maintain the position of an injured extremity.

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.

The zone of injury

is injury to the soft tissues surrounding the bones and joints, especially to the adjacent nerves and blood vessels.

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.

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. compartment syndrome Swelling within a confined anatomic compartment that produces dangerous pressure, characterized by extreme pain, decreased pain sensation, pain on stretching of affected muscles, and decreased power; frequently seen in fractures below the elbow or knee in children.

A sprain

occurs when a joint is twisted or stretched beyond its normal range of motion

Point tenderness

on palpation in the zone of injury is the most reliable indicator of an underlying fracture, although it does not tell you the type of fracture. Tenderness that is sharply localized at the site of the injury, found by gently palpating along the bone with the tip of one finger.

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.