EMS World

AUG 2011

EMS World Magazine is the most authoritative source in the world for clinical and educational material designed to improve the delivery of prehospital emergency medical care.

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Page 62 of 71

ORTHOPEDIC TRAUMA neurovascular compromise and may indi- cate a limb-threatening injury. Deficits in C/S/M function should be considered a true emergency. A thorough assessment of an ortho- pedic injury must also consider the impact on other systems and/or organs. Remember that the force that broke the rib may also have injured the underlying lung. Beware the potential for spinal injury in forces great enough to fracture bones such as the pelvis and femur. Emergency Medical Care With most orthopedic injuries, other life-threatening problems need to be treated first. Use a thorough primary assessment to identify critical priorities before moving on to the treatment of orthopedic injuries. As stated previously, some orthopedic injuries in and of them- APPLIED PATHOPHYSIOLOGY 1. List the “Six Ps of Assessment” that might indicate a fracture. 2. Why is a fractured femur considered a potentially life- threatening injury? How is this fracture potentially diff erent from a tibia or fi bula fracture? 3. How might your scene size- up and assessment of a potential fracture for an 85-year-old patient diff er from that for a 35-year-old patient? selves may be life threatening. However, shock associated with blood loss from pelvic or femur fractures should be iden- tified when assessing circulation in the primary survey and not based solely on a secondary assessment of an extremity. After addressing immediate life threats, the basic principles of treating an orthopedic injury include immobiliza- tion, application of cold, and elevation. Remember that even in potentially critical orthopedic injuries, the basic application of these principles will generally provide the necessary immediate care that will help maximize outcomes. IMMOBILIZATION A key principle of treating (and trans- porting) a patient with an orthopedic injury is immobilization. Immobilization prevents jagged bone ends from damaging adja- cent soft tissue, nerves, and blood vessels. It helps maintain normal circulation and prevents occlusion of vessels through movement. Immobilization can help slow and stop bleeding associated with a frac- ture and, fi nally, immobilization decreases pain. All these elements help improve both short-term and long-term outcomes of orthopedic injury and, as a result, should be important priorities of prehospital care. In some cases, immediate treat- ment of airway and breathing may be your first priority. Remember that even in these cases, minimal immobilization may contribute to improved outcomes. Simply preventing movement is important. In short-term settings, this may mean using manual stabilization or fixation to a long board or another extremity. These simple steps should be considered even when larger priorities redirect your attention. For example, with a patient with multisystem trauma, you might have an untrained person simply hold an obvi- ously fractured femur in place while you complete your primary assessment. Although this would not be considered proper splinting, that quick manual immobilization might prevent jagged bone ends from damaging soft tissue as the leg moves. It might also help slow bleeding from the fractured area. In a larger sense, immobilization refers to splinting or the application of a device to limit movement. Splinting can be accomplished with commercial or improvised devices. It is important to be creative when accomplishing the objectives of splinting. Immobilization of fractures and dislocations often requires nontraditional methods. Key elements of splinting include the following: • Assess C/S/M functions in the distal extremity prior to application of the splint. This assessment not only provides a baseline but will also help you identify changes that might occur as a result of the splinting process. • Remove jewelry and cut away clothing before application of a splint. Edema associated with the injury can rapidly turn these items into constricting bands that limit circulation. Figure 3: A commercially available pelvic splint may be used to immobilize a pelvic fracture. • Apply a dressing to open wounds prior to splinting. Often the direct pres- sure of splinting can aid in bleeding control. Clean dressings will also mini- mize the threat of infection. The goal of splinting is to immobilize the joint above and the joint below the injury site. In a joint injury, you should immobilize the bone above and the bone below the injured joint. These goals can be accomplished in a variety of ways. Padded board splints, traction splints, vacuum splints, and air splints can all be used to accomplish the objectives of splinting. Remember to be creative. SPECIAL SPLINTING CIRCUMSTANCES Pelvis Fractures: Always consider other internal injuries in association with a pelvic fracture. Typically, massive forces have been applied to cause such an injury. Spinal injuries are common in pelvis fractures; therefore, you should consider using a backboard to immo- bilize the patient. Various commercially available pelvic binders are available to splint these types of fractures (see Figure 3). Such devices are used to limit lateral movement of an unstable pelvis. You may also consider (when local protocol allows) using a pneumatic anti-shock garment (PASG) to immobilize the pelvis. Femur Fractures: Recall that femur fractures alone can result in serious bleeding. Splinting not only treats the orthopedic injury but also potentially addresses a circulation problem. As a result, splinting such an injury might be a slightly higher priority than treating other isolated musculoskeletal trauma. EMSWORLD.com | AUGUST 2011 59

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