Chapter 31: Orthopedic Emergencies

For a splint that has a zipper, follow the steps:

1. Assess distal pulse and motor and sensory function.2. Hold the injured limb slightly off the ground, applying gentle traction and supporting the site of injury. Have your partner place the open, deflated splint around the limb Step 1 .3. Zip up the splint, and inflate it by pump or by mouth. When this is done, test the pressure in the splint. With proper inflation, you should be able to compress the walls of the splint together with a firm pinch between the thumb and index finger near the edge of the splint. 4. Check and record pulse and motor and sensory functions, and monitor them periodically until the patient reaches the hospital Step 2 . If you use an unzippered or partially zippered type of air splint, follow the steps in Skill Drill 31-4 : 1. Assess distal pulse and motor and sensory function.2. Your partner supports the patient's injured limb until splinting is accomplished.3. Place your arm through the splint. Extend your hand beyond the splint, and grasp the hand or foot of the injured limb Step 1 .4. Apply gentle traction to the hand or foot while sliding the splint onto the injured limb. The hand or foot of the injured limb should always be included in the splint Step 2 .5. Your partner inflates the splint by pump or by mouth Step 3 .6. Test the pressure in the splint. This is something that you must do with either type of air splint. 7. Check and record pulse and motor and sensory functions, and monitor them en route.

Follow the stepsin SkillDrill31-5 toapplyavacuumsplint:

1. Assess distal pulse and motor and sensory function.2. Your partner supports and stabilizes the injured limb, applying traction if needed Step 1 .3. Gently place the injured limb onto the vacuum splint, and wrap the splint around the limb Step 2 .4. Draw the air out of the splint through the suction valve, and then seal the valve. Once the valve is sealed, the vacuum splint becomes rigid, conforming to the shape of the deformed limb and stabilizing it Step 3 . 5. Check distal circulation and nervous functions, and monitor them en route.

You can manage the wide spectrum of injuries to the ankle in the same way, as follows:

1. Dress all open wounds.2. Assess distal neurovascular function.3. Correct any gross deformity by applying gentle longitudinal traction to the heel. 4. 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.

Follow the steps below to apply a Sager splint

1. Expose the injured extremity. Using standard precautions as needed, assess and record the pulse, motor function, and sensation distal to the injury. 2. Before applying the splint, adjust the thigh strap so that it will lie anteriorly when secured in place Step 1 .3. Estimate the proper splint length by placing it alongside the uninjured limb, so that the wheel is at the level of the heel.4. Arrange the ankle pads to fit the size of the patient's ankle Step 2 .5. Place the splint along the inner aspect of the limb, and slide the thigh strap around the upper thigh so that the perineal cushion is snug against the groin and the ischial tuberosity. Tighten the thigh strap snugly Step 3 .6. Secure the ankle harness tightly around the patient's ankle just above the malleoli.7. Pull the cable ring snugly up against the bottom of the foot Step 4 .8. Pull out the inner shaft of the splint to apply traction of approximately 10% of body weight, using a maximum of 15 pounds (7 kg) Step 5 .9. Secure the limb to the splint using elasticized cravat bandages Step 6 . 10. Secure the patient to a backboard.11. Check pulse and motor and sensory functions

A bulky forearm dressing makes an effective splint for any hand or wrist injury.

1. Follow standard precautions.2. Cover open wounds with a dry, sterile dressing.3. Assess distal pulse and motor and sensory function.4. Supporting the injured limb, form the injured hand into the position of function, with the wrist slightly bent down and all finger joints moderately flexed. This is the position that is used to hold a can most comfortably. 5. Place a soft roller bandage into the palm of the hand Step 1 .6. Apply a padded board splint to the palmar side of the wrist, leaving the fingers exposed Step 2 .7. Secure the entire length of the splint with a soft roller bandage Step 3 . Assess distal pulse and motor and sensory function. 8. Apply a sling and swathe, or prop the splinted hand and wrist on a pillow or on the patient's chest during transport to the hospital.

How to apply a rigid splint

1. Gently support the limb at the site of injury as your partner prepares and begins to position the equipment. Apply steady, in-line traction if necessary. Maintain this support until the splint is completely applied Step 1 . Assess distal pulse and motor and sensory function. 2. Place the rigid splint under or alongside the limb.3. Place padding between the limb and the splint to make sure there is even pressure and even contact. Look for bony prominences, and pad them Step 2 .4. Apply bindings to hold the splint securely to the limb Step 3 . 5. Check and record the distal nervous and circulatory (neurovascular) function Step 4 . There are two situations in which you must splint the limb in the position of deformity—when the deformity is severe, as is the case with many dislocations, and 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 Figure 31-25 . Most dislocations should be splinted as found, but follow local protocols. Attempts to realign or reduce dislocations may lead to more damage.

Assess for tenderness by taking the following steps

1. 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. 2. With the patient lying supine, place a palm over the anterior aspect of each iliac crest, and apply firm downward pressure. 3. 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.

The following principles of splinting apply to most situations:

1. 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.

In the field, the goals of in-line traction are as follows:

1. Stabilize the fracture fragments to prevent excessive movement. 2. Align the limb sufficiently to allow it to be placed in a splint. 3. Avoid potential neurovascular compromise. Several different types of lower extremity traction splints are commercially available, such as the Hare traction splint, the Sager splint, the Reel splint, and the Kendrick splint Figure 31-26 . Each has its own unique method of application; therefore, it is important to practice using each method frequently. 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. Traction splints are not suitable for use on the upper extremity because the major nerves and blood vessels in the patient's axilla cannot tolerate counter-traction forces.

direct blow fractures

A direct blow fractures the bone at the point of impact. An example is the patella (knee cap) that fractures when it strikes the dashboard in a motor vehicle crash. Indirect force may cause a fracture or dislocation at a distant point, as when a person falls and lands on an outstretched hand. The direct impact may cause a wrist fracture, but the indirect force can also cause dislocation of the elbow or a fracture of the forearm, humerus, or even clavicle. Therefore, when you are caring for patients who have fallen, immediately identify the point of contact and the mechanism of injury (MOI) so that you decrease the chance of overlooking any associated injuries.

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 of the patella. As with recurrent dislocation of the shoulder, a minor twisting may be enough to produce the problem. Usually, the dislocated patella displaces to the lateral side. The displacement of the patella produces a 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 Figure 31-47 . Splint the knee in the position in which you found it; most often, this is with the knee flexed to a moderate degree. To stabilize the knee, apply 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, as you apply the splint, 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. The supporting ligaments are often torn, usually completely, allowing the bone ends to separate from each other Figure 31-21 . 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. Often, however, the joint surfaces remain completely separated from one another. A dislocation that does not spontaneously reduce is a serious problem. The ends of the bone can be locked in a displaced position, making any attempt at motion of the joint very difficult and very painful. Commonly dislocated joints include the fingers, shoulder, elbow, hip, and knee.

fracture vs sprain

A fracture can look like a sprain, and vice versa. You will frequently not be able to distinguish a nondisplaced fracture from a sprain. Therefore, it is important to document the MOI, because certain sprains and fractures occur more consistently with certain mechanisms. Your approach should always be to determine the MOI. The basic principles of prehospital management for sprains, dislocations, and fractures are essentially the same and are discussed later in the chapter.

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. Keep in mind that 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

how easy is it to fracture a bone?

A slight force can easily fracture a bone that is weakened by a tumor, infection, or osteoporosis, a generalized bone disease that is common among postmenopausal women. In geriatric patients with osteoporosis, minor falls or simple twisting injuries can cause a fracture, most often of the wrist, spine, or hip. You should suspect the presence of a fracture in any older patient who reports pain and has sustained even a mild injury.

history taking: orthopedic Injuries

After the life threats have been managed during the primary assessment, investigate the chief complaint. Obtain a medical history and be alert for injury-specific signs and symptoms and for any pertinent negatives, such as no pain or loss of sensation. 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. For patients with simple fractures, dislocations, or sprains, it is easier to obtain a SAMPLE history. At the scene you may have access to family members and others who have information about the patient's history. Make an attempt to obtain this history without delaying time to definitive care. OPQRST can be 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. However, OPQRST may be useful when the MOI is unclear, the patient's condition is stable, or 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.

Care of Elbow Injuries

All elbow injuries are potentially serious and require careful management. Always assess distal neurovascular functions periodically in patients with elbow injuries. If you find strong pulses and good capillary refill, splint the elbow injury in the position in which you found it, adding a wrist sling if this seems helpful. 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 Figure 31-39A . 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 Figure 31-39B . If necessary, you may add further support to the limb with a pillow.

false motion

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

Gaurding

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. Occasionally, non-displaced fractures are less painful, and there is minimal soft-tissue damage.

Traction Splints

Application of in-line traction is the act of pulling on a body structure in the direction of its normal alignment. It 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. Traction splints are used primarily to secure fractures of the shaft of the femur, which are characterized by pain, swelling, and deformity of the midthigh. Excessive traction can be harmful to an injured limb. When applied correctly, however, traction stabilizes the bone fragments and improves the overall alignment of the limb. Do not attempt to force the bone fragments back into alignment.

compartment syndrome

Be on the alert for compartment syndrome, which most commonly occurs with a fractured tibia in adults or forearm in children and can be overlooked, especially in patients with an altered level of consciousness. Compartment syndrome typically develops within 6 to 12 hours after injury, usually as a result of excessive bleeding, a severely crushed extremity, or the rapid return of blood to an ischemic limb. 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, and decreased power (ranging from decreased strength and movement of the limb to complete paralysis). Compartment syndrome must be managed surgically. If you have a patient with a fracture below the elbow or the knee, be on the lookout for extreme pain, decreased sensation or any tingling or numbness, pain on stretching of affected muscles, and decreased power. These are indicators that the pressure within a fascial compartment is elevated. If you suspect that a patient has compartment syndrome, splint the affected limb, keeping it at the level of the heart, and provide immediate transport, reassessing neurovascular status frequently during Compartment Syndrome transport.

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. Therefore, general treatment of sprains and strains is similar to that of fractures and includes RICES (Rest, Ice, Compression, Elevation, and Splinting as described in Chapter 26, Soft-Tissue Injuries). In addition, reduce or protect the limb from weight-bearing activity. Manage pain as soon as is practical.

to apply a hare traction split

Cut open the patient's pant leg, or otherwise expose the injured lower extremity. Follow standard precautions as needed. Be sure to assess and record the pulse and motor function and sensation distal to the injury. 2. Place the splint beside the patient's uninjured leg, and adjust it to the proper length, with the ring at the ischial tuberosity and the splint extending 12 inches (30 cm) beyond the foot. Open and adjust the four Velcro support straps, which should be positioned at the midthigh, above the knee, below the knee, and above the ankle Step 1 . 3. Manually support and stabilize the injured limb so that no motion will occur at the fracture site while your partner fastens the appropriate-sized ankle hitch about the patient's ankle and foot. Normally, the patient's shoe is removed for this procedure Step 2 . 4. Support the leg at the site of the suspected injury while your partner manually applies gentle longitudinal traction to the ankle hitch and foot. Use only enough force to align (reposition) the limb so that it will fit into the splint; do not attempt to align the fracture fragments anatomically Slide the splint into position under the patient's injured limb, making certain that the ring is seated well on the ischial tuberosity Step 4 . Pad the groin area, and gently apply the ischial strap Step 5 . While your partner continues to maintain traction, connect the loops of the ankle hitch to the end of the splint. Then apply gentle traction to the connecting strap between the ankle hitch and the splint, just strongly enough to maintain limb alignment. Use caution. This splint comes with a ratchet mechanism to tighten the strap. Overtightening can overstretch the limb and further injure the patient. Adequate traction has been applied when the leg is the same length as the other leg or the patient feels relief Step 6 . Once proper traction has been applied, fasten the support straps so that the limb is securely held in the splint. Check all proximal and distal support straps to make sure they are secure Step 7 . At this point, reassess distal pulses and motor function and sensation. Place the patient securely on a backboard for transport to the ED. You may need to load the patient feetfirst into the ambulance so that you do not shut the door against the splint

dislocation of the knee

Dislocations of the knee are true emergencies that may threaten the limb. When the knee is dislocated, the ligaments that provide support to it may be damaged or torn. When this happens, the proximal end of the tibia completely displaces from its juncture with the lower end of the femur, usually producing a significant deformity. Although substantial ligament damage always 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 the distal pulses are absent, contact medical control immediately for further stabilization and transport instructions. The direction of dislocation refers to the position of the tibia with respect to the femur. Posterior knee dislocations, which result from extreme hyperextension of the knee, are the most common, occurring in almost half of all cases. Commonly, the anterior and posterior cruciate ligaments are damaged, but 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. Because the deforming force causes the medial aspect of the knee to stretch apart, 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. Patients with a knee dislocation will typically report pain in the knee and report that the knee "gave out." If the knee did not spontaneously reduce, there may be evidence of significant deformity and decreased range of motion. Complications may include limb-threatening popliteal artery disruption, injuries to the nerves, and joint instability. Do not confuse this injury with a relatively minor patella dislocation, discussed below. 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 Figure 31-46A . 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 Figure 31-46B . Secure the limb to a backboard or stretcher with pillows and straps to eliminate any motion during transport. On rare occasions, and depending on local protocol, medical control may instruct you to realign a deformed, pulseless limb to reduce compression of the popliteal artery and, thus, restore distal circulation. Only make one attempt to do this. First, 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; otherwise, the limb will return to its deformed position. 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 then provide prompt transport to the hospital. Notify medical control of the status of the distal pulse so that treatment can be arranged in advance.

Fracture of Pelvis

Fracture of the pelvis often results from direct compression in the form of a heavy blow that literally crushes the pelvis. The blow may be from a motor vehicle crash, a weapon, a falling object, or a fall from a height. Injuries to the pelvis can also be caused by indirect forces. For example, when the knee strikes the dashboard in a motor vehicle crash, the impact of the force is transmitted along the line of the femur (thighbone), which is the longest and largest bone in the body. The head of the femur is driven into the pelvis, causing it to fracture. However, not all pelvic fractures result from violent trauma. Even a simple fall can produce a fracture of the pelvis, especially in older people with osteoporosis. Fractures of the pelvis may be accompanied by life-threatening loss of blood from the laceration of blood vessels affixed to the pelvis at certain key points. 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. For this reason, you must take immediate steps to treat shock, even if there is only minimal swelling. Often, there are no visible signs of bleeding until severe blood loss has occurred. Be prepared to resuscitate the patient rapidly if this becomes necessary.

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 of this bone are relatively common Figure 31-48 . Fractures of the tibia and fibula should be stabilized with a padded rigid long leg splint or an air splint that extends from the foot to the upper thigh. Once splinted, the affected leg should be secured to the opposite leg. Traction splints are not indicated for isolated tibial fractures. As with most other fractures of the shaft of long bones, you should 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. Fractures of the tibia and fibula are sometimes associated with vascular injury as a result of the distorted position of the limb following injury. 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.

Fractures About the Knee

Fractures about the knee may occur at the distal end of the femur, at the proximal end of the tibia, or in the patella. Because of local tenderness and swelling, it is easy to confuse a nondisplaced or minimally displaced fracture about the knee with a ligament injury. Likewise, a displaced fracture about the knee may produce significant deformity that makes it look like a dislocation. Manage these two types of injuries 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.

Elbow Injuries

Fractures and dislocations often occur around the elbow, and the different types of injuries are difficult to distinguish without radiographic examinations. However, they all produce similar limb deformities and require the same emergency care. Injuries to nerves and blood vessels are quite common in this region. Such injuries can be caused or worsened by inappropriate emergency care, particularly by excessive manipulation of the injured joint.

Bruising

Fractures are almost always associated with ecchymosis (discoloration) of the surrounding soft tissues Figure 31-19 . 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, as you may have seen with someone who has been punched. Within hours or days, blue, purple, and black discoloration will appear, followed by yellow and green.

displaced/nondisplaced fracture

Fractures are also described by whether the bone is moved from its normal position. 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, or distortion, of the limb by shortening, rotating, or angulating it. Often, the deformity is very obvious and can be associated with crepitus. However, in some cases the deformity is minimal. Be sure to look for differences between the injured limb and the opposite uninjured limb in any patient with a suspected fracture of an extremity

what are the types of fractures

Fractures are classified as either closed or open. In assessing and treating patients with possible fractures or dislocations, your first priority is to determine whether the overlying skin is damaged. If it is not, the patient has a closed fracture. However, making this determination is not always as easy as it sounds. 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. Regardless of the extent and severity of the damage to the skin, you should 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. Be sure to wear gloves if there are any open wounds.

femoral Shaft fractures

Fractures of the femur can occur in any part of the shaft, from the hip region to the femoral condyles just above the knee joint. Following a fracture, the large muscles of the thigh spasm in an attempt to "splint" the unstable limb. The muscle spasm often produces significant deformity of the limb, with severe angulation or external rotation at the fracture site. Usually, the limb also shortens significantly. Fractures of the femoral shaft may be open, and fragments of bone may protrude through the skin. As with any other open fracture, never attempt to push the bone(s) 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. Thus, 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 important nerves and vessels and produce significant damage. For this reason, you must carefully and periodically assess the distal neurovascular function in patients who have sustained a fracture of the femoral shaft. Remove the clothing from the affected limb so that you can adequately inspect the injury site for any open wounds. Remember to 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. You must provide rapid transport in this situation. 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 Table 31-2 . 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. With any severely angulated fracture, consider applying traction to realign the fracture fragments before splinting them. Check your local protocols for indications and techniques for applying traction to a severely angulated fracture. 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 Figure 31-36 . 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 Figure 31-37 . 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. Note that compartment syndrome, discussed later in this chapter, can develop in the forearm in children with these fractures

Fractures of the Proximal Femur

Fractures of the proximal (upper) end of the femur are common fractures, especially in older people and patients with osteoporosis. Although these fractures 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, or across 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 usually 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. In addition, 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 then transport the patient to the ED. The age of the patient and the severity of the injury will dictate how you splint the fracture. 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. Then secure the injured limb carefully to the device with long straps. All patients with hip fractures may have a significant amount of blood loss. Therefore, you should treat with high-flow oxygen, monitor vital signs frequently, and be alert for signs of shock

Secondary Assessment: Orthopedic Injuries

If significant trauma has likely affected multiple systems, start with a secondary assessment of the entire body to be sure that you have found all of the problems and injuries. Begin with the head and work systematically toward the feet, checking the head, chest, abdomen, extremities, and back. The goal is to identify hidden and potentially life-threatening injuries. This secondary assessment will also help you to prepare for packaging and rapid transport. Knowing if an arm or leg is broken will be important when log rolling and securing the patient onto a backboard. Use the DCAP-BTLS approach to assess the musculoskeletal system. Identify any extremity deformities that likely represent significant musculoskeletal injury, and stabilize them appropriately. Contusions and abrasions may overlie more subtle injuries and should prompt you to carefully 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. Associated burns must be identified and treated appropriately. Palpate for tenderness, which, like contusions or abrasions, may be the only significant sign of an underlying musculoskeletal injury. When lacerations are present in an extremity, an open fracture must be considered, bleeding controlled, and dressings applied. Careful inspection for swelling with comparison with the opposite limb may also reveal otherwise occult musculoskeletal injury. You may find a hematoma in the zone of injury during the 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 in your evaluation 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. Be sure to assess the entire zone of injury by removing clothing from the area and looking and palpating for injuries. In musculoskeletal injuries, this zone generally extends from the joint above (proximal) to the joint below (distal), front and back. Remember to evaluate the circulation, motor function, and abnormal sensations distal to the injury. Many important blood vessels and nerves lie close to the bone, especially around the major joints. Therefore, any injury or deformity of the bone may be associated with vessel or nerve injury. For this reason, you must assess neurovascular function every 5 to 10 minutes during the assessment, depending on the patient's condition, until the patient is at the hospital. Always recheck the neurovascular function before and after you splint or otherwise manipulate the limb. Manipulation can cause a bone fragment to press against or impale a nerve or vessel. Failure to restore circulation in this situation can lead to death of the limb. Always give priority to patients with impaired circulation resulting from bone fragments. Because many of the steps require patient cooperation, 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. Examination of the injured limb should include the 6 Ps of musculoskeletal assessment—pain, paralysis, paresthesia (numbness or tingling), pulselessness, pallor, and pressure. 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. Your patient may appear to be tolerating the injury well until you reassess these vital signs and they indicate otherwise. 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, this baseline information is very important in assessing your patient's condition.

exposed fragments

In open fractures, bone ends may protrude through the skin or be visible within the wound Figure 31-20 . Never attempt to push the end of a protruding bone back into place. This will increase the risk for infection.

Scene Size Up: Orthopedic Injuries

Information from dispatch may indicate the MOI, the number of patients involved, and any first aid procedures used prior to your arrival. This will be useful information for you to think about as you travel to the scene. Remember, the information given by the dispatcher is only as accurate as the patient's or bystander's report. In addition, the situation may change prior to your arrival at the incident. Dispatch information can still be used to help you consider whether spinal immobilization will be needed, the equipment you may need, and whether hazards might be present. As you arrive at the scene, try to identify the forces associated with the MOI. Could they have produced injuries other than the musculoskeletal injuries reported by dispatch? Consider the possibility of hidden bleeding; internal injuries that you cannot see and closed fractures of the femur are examples. 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 may also be indicated. Evaluate the need for law enforcement support, advanced life support, or additional ambulances, and request them early based on your initial scene assessment. When you assess a patient who has experienced a significant MOI, look for indicators of the MOI and be alert for both primary and secondary injuries. Primary injuries occur as a result of the MOI, whereas secondary injuries are the result of what happens after the initial injury. For example, being hit by a motor vehicle will often result in a primary pelvic injury and often a secondary head injury when the patient rolls onto the hood of the car. As you put together information from dispatch and your observations of the scene, consider what injuries the MOI would lead you to expect. For example, when you approach a rear-end motor vehicle crash, you should suspect head, neck, and chest injuries.

Injuries of the Wrist and Hand

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. Hand injuries vary widely, some with potentially serious consequences. Industrial, recreational, and home accidents often result in dislocations, fractures, lacerations, burns, and amputations. Because the fingers and hands are required to function in such intricate ways, any injury that is not treated properly may result in permanent disability, as well as deformity. For this reason, all injuries to the hand, including simple lacerations, should be evaluated by a physician. For example, do not attempt to "pop" a dislocated finger joint back in place Figure 31-42 . Always 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.

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. Injury often occurs when the patient falls or jumps from a height and lands directly on the heel. The force of injury compresses the calcaneus, producing immediate swelling and ecchymosis. If the force of impact is great enough, as from a fall from a roof or tree, there may also be other fractures. Frequently,theforceofinjuryistransmittedupthelegstothespine,producingafractureofthelumbarspine Figure31- 50 . 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. As in the hand, lacerations about the ankle and foot may damage important underlying nerves and tendons. Puncture wounds of the foot are common and may cause serious infection if not treated early. All of these injuries must be evaluated and treated by a physician. To splint the foot, apply a rigid padded board splint, an air splint, or a pillow splint, stabilizing the ankle joint and the foot Figure 31-51 . 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.

zone of injury

Injury to bones and joints is often associated with injury to the surrounding soft tissues, especially to the adjacent nerves and blood vessels. The entire area is known as the zone of injury Figure 31-11 . Depending on the amount of kinetic energy the tissues absorb from forces acting on the body, the zone may extend to a distant point. For this reason, do not be distracted by a patient's obvious injury; you must first complete a primary assessment to check for life-threatening injuries.

Fractures 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.

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).

pelvic binders

Pelvicbindersareusedtosplintthebonypelvistoreducehemorrhagefromboneends,venousdisruption,andpain Figure 31-29 . A pelvic binder is meant to provide temporary stabilization until definitive immobilization can be achieved. Generally, pelvic binders are 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.

Tenderness

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

implications of traction splint

Proper application of a traction splint requires a minimum of two EMTs. 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. Imagine where the uninjured limb would lie, and pull gently along the line of that imaginary limb until the injured limb is in approximately that position Figure 31-27 . Grasping the foot or hand and the initial pull of traction usually causes the patient some discomfort as the bone fragments move. A second EMT should support the injured limb directly under the site of the fracture. This initial discomfort quickly subsides, and you can then apply further gentle traction. However, if the patient strongly resists the traction or if it causes more pain that persists, stop and splint the limb in the deformed position.

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 Figure 31-18 . Generalized swelling from fluid buildup may occur several hours after an injury.

Handling Injured Extremities During Assessment and Transport

Recall that fractures can break through the skin and cause external bleeding. This may occur during the initial injury or during manipulation of the extremity while preparing for splinting or transport. Careful handling of the extremity minimizes this risk. If external bleeding is present, bandage the extremity quickly to control bleeding. The dressings that cover the wound and bone should be kept 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. Careful handling is necessary to limit pain and prevent sharp bone ends from breaking through the skin or damaging nerves and blood vessels in the extremity.

Follow the steps when caring for patients with musculoskeletal injuries:

Remove any jewelry. Completely cover open wounds with a dry, sterile dressing, and apply direct pressure to control bleeding. Assess distal pulse and motor and sensory function. If bleeding cannot be controlled, quickly apply a tourniquet.Onceyouhaveappliedasteriledressing,treatanopenfractureinthesamewayasaclosedfracture Step 1. 2. Apply the appropriate splint, and elevate the extremity. It is essential to splint the joint above and below the injury to ensure adequate stabilization. Patients with lower extremity injuries should lie supine with the limb elevated about 6 inches (15 cm) to minimize swelling. For any patient, be sure to position the injured limb slightly above the level of the heart. Never allow the injured limb to flop about or dangle from the edge of the backboard. Always assess pulse and motor and sensory functions before and after the application of splints. Assess the pulse by palpation, evaluate motor function by asking the patient to open his or her hand or flex his or her foot, and assess sensation and capillary refill on the flesh near the tip of the index finger. Finally, assess the skin color and condition, and evaluate sensory function by touch Step 2 .3. If swelling is present, apply cold packs to the area; however, avoid placing cold packs directly on the skin or other exposed tissues Step 3 .4. Prepare the patient for transport. A patient with an isolated upper extremity injury will most likely be more comfortable in a semiseated position rather than in a supine position; however, assuming there is no risk of spinal injury, either position is acceptable. Ensure that the extremity is elevated above the level of the heart and secured so that it does not dangle from the edge of the backboard or stretcher Step 4 . 5. Transport your patient to the most appropriate facility, and consider the use of advanced life support backup for pain management. 6. Inform hospital personnel about all wounds that have been dressed and splinted and any associated injuries treated by the EMS unit.

Reassessment: Orthopedic Injuries

Repeat the primary assessment to ensure your interventions are working as they should. Perform a reassessment every 5 minutes for an unstable patient and every 15 minutes for a stable patient. Because trauma patients often have multiple injuries, you must assess their overall condition, stabilize the ABCs, and control any serious bleeding before further treating the injured area. 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 the patient has no life-threatening injuries, you may take extra time at the scene to stabilize the patient's overall condition and more completely evaluate the injury. 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 joint 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, and minimize compromised circulation. A good rule is to check the patient's circulation, motor function, and sensation before and after splinting. Splint application will be discussed later in the chapter. The main goal in providing care for musculoskeletal injuries is stabilization in the most comfortable position that allows for maintenance of good circulation distal to the injury. This should be done whether you are preparing the patient for rapid transport or you have as much time as you need to assess and treat the patient. Your radio report to the hospital should include a description of the problems found during your assessment. In particular, you should report problems with the patient's ABCs, open fractures, and compromised circulation that occurred before or after splinting. Many times the hospital staff can arrange for specialists or consider antibiotics early if they are aware of problems. How much information you include in your radio report will depend on your local protocols. 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. It is important to 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. Hospital staff may refer to your notes to clarify confusing situations or communication problems. Your careful documentation becomes part of the patient's permanent medical record and may protect you from legal action that the patient may pursue later. Do not rely on your memory for details from situations; your memory is unreliable. Always document your findings.

Rigid Splints

Rigid (nonformable) splints are made from firm material and are applied to the sides, front, and/or back of an injured extremity to prevent motion at the injury site. Common examples of rigid splints include padded board splints, molded plastic and metal splints, padded wire ladder splints, and folded cardboard splints. As always, be sure to follow standard precautions. It takes two EMTs to apply a rigid splint.

assessing the severity of the injury

The Golden Period (the time from injury to definitive care) is critical not only for life, but also for preserving limb viability. In an extremity with anything less than complete circulation, prolonged hypoperfusion can cause significant damage. For this reason, 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.

Ankle Injuries

The ankle is a commonly injured joint. 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. As with other joints, it is sometimes difficult to tell a nondisplaced ankle fracture from a simple sprain without radiograph examination Figure 31-49 . Therefore, 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.

what is bones?

The bones of the skeleton provide a framework to which the muscles and tendons are attached. Bone is a living tissue that contains nerves and receives oxygen and nutrients from the arterial system. Therefore, 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.

Injuries of the Clavicle and Scapula

The clavicle, or collarbone, is one of the most commonly fractured bones in the body. Fractures of the clavicle occur Specific Musculoskeletal Injuries commonly in children when they fall on an outstretched hand. They can also occur with 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 Figure 31-30 . A young child often reports pain throughout the entire arm and is unwilling to use any part of that limb. These complaints may make it difficult to localize the point of injury, but, generally, swelling and point tenderness occur over the clavicle. Because the clavicle is subcutaneous (just beneath the skin), the skin will occasionally "tent" over the fracture fragment. The clavicle lies directly over major arteries, veins, and nerves; therefore, fracture of the clavicle may lead to neurovascular compromise. Fractures of the scapula, or shoulder blade, occur much less frequently because this bone is well protected by many large muscles. 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. For this reason, you must carefully assess the patient for signs of breathing problems. Provide supplemental oxygen and prompt transport for patients who are having difficulty breathing. Remember, it is the associated chest injuries, not the fractured scapula itself, that pose the greatest threat of long-term disability. Abrasions, contusions, and significant swelling may also occur, and the patient will often limit use of the arm because of pain at the fracture site. The scapula also has bony projections that may be fractured with a lesser degree of force.

dislocation of the shoulder

The glenohumeral joint (shoulder joint) is where the head of the humerus, the supporting bone of the upper arm, meets the glenoid fossa of the scapula. The glenoid fossa joins with the humeral head to form the glenohumeral joint. In shoulder dislocations, the humeral head most commonly dislocates anteriorly, coming to lie in front of the scapula as a result of forced abduction (away from the midline) and external rotation of the arm Figure 31-33 . Shoulder dislocations are extremely painful. The patient will guard the shoulder and try to protect it by holding the dislocated arm in a fixed position away from the chest wall Figure 31-34 . The shoulder joint will usually be locked, and the shoulder will appear squared off or flattened. The humeral head will protrude anteriorly underneath the pectoralis major on the anterior chest wall. As a result, the axillary nerve may be compressed, causing a numb patch on the outer aspect of the shoulder. Be sure to document this finding. Some patients may also report some numbness in the hand because of either nervous or circulatory compromise.

cardiac muscle

The heart neither looks nor acts like skeletal or smooth muscle. It is composed largely of cardiac muscle, a specially adapted involuntary muscle with its own regulatory system. The remainder of this chapter is concerned exclusively with skeletal muscle.

Dislocation of the Hip

The hip joint is a very stable ball-and-socket joint that dislocates only after significant injury. Most dislocations of the hip are posterior. The femoral head is displaced posteriorly to lie in the muscles of the buttock. Posterior dislocation of the hip most commonly occurs as a result of a motor vehicle crash in which the knee meets with a direct force, such as the dashboard, and the entire femur is driven posteriorly, dislocating the hip joint Figure 31-44 . Thus, you should suspect a hip dislocation in any patient who has been in a motor vehicle crash and has a contusion, laceration, or obvious fracture in the knee region. 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. Posterior dislocation of the hip is frequently complicated by injury to the sciatic nerve, which is located directly behind the hip joint. 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 Figure 31-45A . With the less common anterior dislocation, the limb is in the opposite position, extended straight out, externally rotated, and pointing away from the midline of the body.

AC joint

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, such as football or hockey, 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 Figure 31-31 . Fractures of the clavicle and scapula and AC separations can all be splinted effectively with a sling and swathe. 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 oftheslingshouldbetiedtoonesideofthenecksothatitdoesnotpressuncomfortablyonthecervicalspine Figure31-32A . 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 functionatregularintervals Figure31-32B Commercially available shoulder stabilizers or slings will provide adequate splinting for injuries of the shoulder region, as will triangular bandage slings.

Injuries to the knee ligaments

The knee is very vulnerable to injury; therefore, many different types of injuries occur in this region. Ligament injuries, for example, range from mild sprains to complete dislocation of the joint. The patella can also dislocate. In addition, all the bony elements of the knee (distal femur, upper tibia, and patella) can fracture. The knee is especially susceptible to ligament injuries, which occur when abnormal bending or twisting forces are applied to the joint. Such injuries are often seen in both 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, such as when a football player is tackled from the side.Usually, 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, and a 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. However, if you encounter resistance or pain when trying to straighten the knee, splint it in the flexed position. Then continue to monitor the distal neurovascular function until the patient reaches the hospital.

complications

The likelihood of a complication is often related to the strength of the force that caused the injury, the injury's location, and 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, and transporting patients with orthopaedic injuries to an appropriate medical facility.

Deformity

The limb may appear to be shortened, rotated, or angulated at a point where there is no joint Figure 31-16 . Always use the opposite, uninjured limb as a mirror image for comparison.

lower leg bones

The lower leg consists of two bones, the tibia and the fibula. The tibia (shinbone) is the larger of the two leg bones that are responsible for supporting the major weight-bearing surface of the knee and ankle. The tibia connects to the patella (knee cap) via the patellar tendon just below the knee joint and runs down the front of the lower leg. The tibia is vulnerable to direct blows and can be felt just beneath the skin. The much smaller fibula runs behind and beside the tibia. The fibula is an important anchor for ligaments surrounding the knee joint, and it forms the lateral side of the ankle joint.

The following signs and symptoms often indicate that the patient may have asprain

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

Dislocation of the hip is associated with very distinctive signs which are....

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. With some thin patients, you can palpate the femoral head deep within the muscles of the buttock. 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. As with any other extremity injury, 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 Figure 31-45B . Then secure the entire limb to the backboard with long straps so that the hip region will not move, and provide prompt transport.

Primary Assessment: Orthopedic Injuries

The primary assessment should focus on identifying and managing life threats. Treating the patient according to his or her level of consciousness and ABCs is always the priority. Threats to airway, breathing, and circulation are considered life threatening and must be treated immediately to prevent mortality. Significant bleeding, internal or external, is an immediate life threat. If the patient has obvious life-threatening external hemorrhage, it should be addressed first (even before airway and breathing), and then begin treating the patient for shock as quickly as possible. For example, if you are unable to control arterial bleeding from extremities by using direct pressure, apply a tourniquet (if possible). Arterial bleeding from a compound fracture should be treated prior to giving oxygen. When evaluating the patient's level of consciousness and orientation, check for responsiveness using the AVPU scale, and assess mental status by asking the patient about his or her chief complaint. If the patient is alert, this should help direct you to any apparent life threats. An unresponsive patient may have an underlying life-threatening condition. You should administer high-flow oxygen via a nonrebreathing mask (or a bag-valve mask (BVM), if indicated) to all patients whose level of consciousness is less than alert and oriented, and provide rapid transport to the emergency department (ED). Perform a primary assessment of the patient and ask about the MOI. Was it a direct blow, indirect force, twisting force, or high-energy injury? In many situations, the musculoskeletal complaints will be simple and usually not life threatening; however, some situations, such as those with a significant MOI, will include multiple problems that include musculoskeletal injuries. The initial interaction with your patient will provide you with a starting point and help you to distinguish the simple from the complex injuries. If there was significant trauma and multiple body systems were affected, the musculoskeletal injuries may be a lower priority. Scene time should not be wasted on prolonged musculoskeletal assessment or splinting fractures that are otherwise not life threatening. The expression "splinting to death" is used to describe such a situation; you are so involved in splinting fractures that the patient dies from other injuries. Fractures and sprains usually do not create airway and breathing problems. Other problems, such as injuries to the head, intoxication, or other related illnesses and injuries, may cause inadequate breathing. 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. In a conscious patient, this is as simple as noting whether the patient can speak normally. In an unconscious patient, it is as simple as opening the airway using the appropriate technique to check for breathing. Remember, very little else matters if the patient's airway and breathing are inadequate. Your circulatory assessment should focus on determining whether the patient has a pulse, has adequate perfusion, or is bleeding. If your patient is conscious, he or she will have a pulse. 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 concern. 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, because trauma patients can rapidly become hypothermic even in warm environments. 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 these life threats. A patient who has a significant MOI but whose condition appears otherwise stable should also 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 dramatically 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. If you take time to splint the patient's arms and legs individually, you may delay the prompt surgical intervention that may be needed for other injuries when a significant MOI has occurred. Individual splints should be applied en route if the ABCs are stable and time permits. Patients with a simple MOI, such as twisting of an ankle or dislocating a shoulder, may be further assessed and their condition stabilized on scene prior to transport if no other problems exist.

arm and hand bones

The radius and ulna make up the forearm. 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, the other is often broken as well. The hand contains three sets of bones: wrist bones (carpals), hand bones (metacarpals), and finger bones (phalanges) Figure 31-7 . The carpals are vulnerable to fracture when a person falls on an outstretched hand. Phalanges are more apt to be injured by a crush injury, such as being slammed in a door.

skeletal

The skull is a solid, vaultlike structure that surrounds and protects the brain. The 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. The pectoral girdle, also referred to as the shoulder girdle, consists of two scapulae and two clavicles Figure 31-5 . The scapula (shoulder blade) is a flat, triangular bone held to the rib cage by powerful muscles that buffer it against injury. The clavicle (collarbone) is a slender, S-shaped bone attached by ligaments to the sternum on one end and to the acromion process on the other. The clavicle acts as a strut to keep the shoulder propped up; however, because it is slender and very exposed, this bone is vulnerable to injury.

Elbow joint sprain

This diagnosis is often mistakenly applied to an occult, nondisplaced fracture, since it can be difficult to distinguish between sprains and fractures.

Fracture of the Olecranon Process of the Ulna

This fracture 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 Distal Humerus

This type of fracture, also known as a supracondylar or intercondylar fracture, is 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

This type of injury 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, the bone on the little finger side of the forearm, and the radius, the bone on the thumb side of the forearm, both join the distal humerus. The posterior displacement makes the olecranon process of the ulna much more prominent Figure 31-38 . The joint is usually locked, with the forearm moderately flexed on the arm; this position makes any attempt at motion extremely painful. As with a fracture of the distal humerus, there is swelling and significant potential for vessel or nerve injury.

Hazards of improper splinting

You must be aware of the hazards associated with the improper application of splints, including the following: ▪ 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

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. Surgeons today can occasionally reattach amputated parts Figure 31-52 . However, correct prehospital care of the amputated part is vital to successful reattachment. 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. The amputated part should be transported with the patient to the appropriate resource hospital.

smooth muscle

also called involuntary muscle because it is not under voluntary control of the brain, performs much of the automatic work of the body. This type of muscle is found in the walls of most tubular structures of the body, such as the gastrointestinal tract and the blood vessels. Smooth muscle contracts and relaxes to control the movement of the contents within these structures

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. Skiing injuries often happen because of twisting. A ski becomes caught, and the skier falls, applying a twisting force to the lower extremity.

Stabilizing an anterior shoulder dislocation is difficult

because any attempt to bring the arm in toward the chest will produce pain. You must 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 Figure 31-35 . Once the arm has been stabilized in this way, the elbow can usually be flexed to 90 degrees without causing further pain. At this point, you can apply a sling to the forearm and wrist to support the weight of the arm. Finally, secure the arm in the sling to the pillow and chest with a swathe. Transport the patient in a seated or semiseated position.

lower extremities

consists of the bones of the thigh, leg, and foot Figure 31-8 . 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.

foot

consists of three classes of bones: ankle bones (tarsals), foot bones (metatarsals), and toe bones (phalanges) Figure 31-9 . 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.

fracture

is a broken bone. More precisely, it is a break in the continuity of the bone, often occurring as a result of an external force Figure 31-13 . The break can occur anywhere on the surface of the bone and in many different types of patterns. Contrary to a common misconception, there is no difference between a broken bone and a fractured bone. A potential complication of fractures is compartment syndrome (discussed later in the chapter), which refers to elevated pressure within a fascial compartment.

splint

is a flexible or rigid device that is used to protect and maintain the position of an injured extremity Figure 31-24 . Unless the patient's life is in immediate danger, you should splint all fractures, dislocations, and sprains before moving the patient. 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. A splint is simply a device to prevent motion of the injured part. It can be made from any material on occasions when you need to improvise. However, you should have an adequate supply of standard commercial splints on hand. 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. The three basic types of splints are rigid, formable, and traction splints.

amputation

is an injury in which an extremity is completely severed 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.

What is a joint?

is formed wherever two bones come into contact. The sternoclavicular joint, for example, is where the sternum and the clavicle come together. Joints are held together in a tough fibrous structure known as a capsule, which is supported and strengthened in certain key areas by bands of fibrous tissue called ligaments. In moving joints, the ends of the bones are covered with a thin layer of cartilage known as articular cartilage. This cartilage is a pearly white substance that allows the ends of the bones to glide easily. Joints are bathed and lubricated by synovial (joint) fluid. Some joints, such as the shoulder, allow motion to occur in a circular manner. Other joints, such as the knee and elbow, act as hinges. Still other joints, including the sacroiliac joint in the lower back and the sternoclavicular joints, allow only a minimum amount of motion. 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

sprain

occurs when a joint is twisted or stretched beyond its normal range of motion. As a result, the supporting capsule and ligaments are stretched or torn, resulting in injury to the ligaments, articular capsule, synovial membrane, and tendons crossing the joint. A sprain should be considered a partial dislocation. can range from mild to severe, depending on the amount of damage done to the supporting ligaments. The most severe sprains involve actual tearing of the ligament and may allow joint dislocation. Mild sprains are caused by ligament stretching rather than tearing. A sprain can occur in any joint, but sprains most often occur in the knee, shoulder, and ankle. Most sprains occur after a person misjudges a step or landing. Evasive moves, like those done during a sporting event, commonly cause sprains in athletes. Some patients might report hearing a "snap" when the injury occurred. After the injury, the joint alignment generally returns to a fairly normal position, so the joint is not significantly displaced. In contrast with fractures and dislocations, sprains usually do not involve deformity, and joint mobility is usually limited by pain,notbyjointincongruity

Musculoskeletal system injuries are often easily identified because of

pain, swelling, and deformity. Although these injuries are rarely fatal, they often result in short- or long-term disability. By providing prompt assessment and treatment, such as splinting, EMTs may help reduce the disability period for patients. Despite the sometimes dramatic appearance of these injuries, do not focus solely on a musculoskeletal injury without first determining that no life-threatening injuries exist. Never forget the ABCs!

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. Some patients may report a "snap" when a muscle tears. Some may report increased sharp pain with passive movement of the injured extremity. Patients may report severe weakness of the muscle. Most patients also have extreme point tenderness. The general treatment of strains is similar to the prehospital management for sprains, dislocations, and fractures.

Muscles

skeletal, smooth, and cardiac. Skeletal muscle, also called striated muscle because of its characteristic stripes, attaches to the bones and usually crosses at least one joint. This type of muscle is also called voluntary muscle because it is under direct voluntary control of the brain, responding to commands to move specific body parts Figure 31-1 . Usually, movement is the result of several muscles contracting and relaxing simultaneously. Skeletal muscle makes up the largest portion of the body's muscle mass. Its primary functions are movement and posture. Cardiac muscle contributes to the cardiovascular system, and smooth muscle is a component of other body systems, including the digestive system and the cardiovascular system.

high energy injuries

such as those that result from motor vehicle crashes, falls from heights, gunshot wounds, and other extreme forces, 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.

all skeletal muscles are supplied with arteries, veins and nerves

supplied with arteries, veins, and nerves. Blood from the arteries brings oxygen, glucose, and nutrients to the muscles Figure 31-2 . Waste products, including carbon dioxide and lactic acid, are carried away in the veins. Disease or trauma can result in the loss of a muscle's nervous supply; this, in turn, can lead to weakness and eventually atrophy, or a decrease in the size of the muscle and its inherent ability to function. Skeletal muscle tissue is directly attached to the bone by tough, ropelike structures known as tendons, which are extensions of the fascia (fibrous tissue) that covers all skeletal muscle. Fascia surrounds and supports the muscles and neurovascular structures.

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

A cold, pale hand or a weak or absent pulse and poor capillary refill indicate....

that the blood vessels have likely been injured. Further care of this patient must be dictated by a physician. 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. Otherwise, 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 maneuver may restore the pulse. Be careful, because 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.

If there has been injury to the bladder or the urethra,

the patient will have lower abdominal tenderness and may have evidence of hematuria (blood in the urine) or blood at the urethral opening. Perform the primary assessment, and carefully monitor the general condition of any patient whom you suspect has a pelvic fracture, because he or she 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.

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, each time causing further neurovascular compromise and joint injury. In certain cases, surgical repair may be required. Some patients are able to reduce (set) their own dislocated shoulders. Generally, however, this maneuver must be done in a hospital setting and only after radiograph films have been obtained.

Because the pelvis is surrounded by heavy muscle, open fractures of the pelvis are....

uncommon. However, pelvis fracture fragments can lacerate the rectum and vagina, creating an open fracture that is often overlooked. Once the protective pelvic ring is broken, the structures it is designed to protect, including the urinary bladder, are more susceptible to injury. 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. You should 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.

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.

Significant force is generally required to cause fractures and dislocations. This force may be applied to the limb in any of the following ways

▪ Direct blows ▪ Indirect forces▪ Twisting forces▪ High-energy injuries

In addition, 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

Do not use traction splints for any of the following conditions:

▪ 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

The signs and symptoms of a dislocated joint are similar to those of a fracture

▪ 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