Archive for the ‘splinting’ Category

New! From The Wilderness Medicine Newsletter

February 10, 2012

For decades the Wilderness Medicine Newsletter has provided up-to-date information to pre-hospital and definitive care providers. Since becoming an on-line journal, the readership of the WMN has become international. Now the WMN has it’s own web site: www.wildernessmedicinenewsletter.com

Subscribers pay the same $15 a year subscription rate but have access to more than 165 articles from back issues as well as current issues. You can search the site either by category, or by key words making the Wilderness Medicine Newsletter site a much more useful reference for everything from reviewing splinting to the prevention and treatment of tropical diseases.

Check it out!

LOWER EXTREMITY INJURIES

January 4, 2008

Lower Leg Fracture – Tibia/Fibula:

May be an angulated fracture with impairment of circulation distal to the site of the fracture.
If angulated the fracture can be easily reduced into proper anatomical alignment with gentle Traction-In-Line (TIL).
Splint the lower leg in proper anatomical alignment with distal pulses intact.
A splint can be easily improvised with an ensolite pad or well-padded sticks held in place with cravats.
Splint with the foot held at 90 degrees.
Monitor circulation every 15 – 30 minutes.

Ankle Injuries:

“Ottawa Rules” can be used to help determine if the injury is a fracture or not.
The Ottawa Rules are:
Need to be an adult (i.e. good historian).
1. No tenderness over the malleoli (the lateral and medial aspects of the ankle).
2. No laxicity on inversion, eversion, or drawer test of the ankle.
3. They can walk 3 steps without pain or sensation that the ankle is going to collapse.
If suspicious of a fracture then treat the same way as a tibia/fibula fracture.
If a sprain then RICE the ankle and support with a sprained ankle bandage.

Video demonstration of applying a sprained ankle bandage:


Foot Fractures:

A “March Fracture” is a stress fracture of the 5th metatarsal that is caused by a long march or hike.
Diagnosis – pain and tenderness over the center of the lateral arch of the foot.
Treatment is to support the foot well with a firm boot.

Fractured Toes:

May be angulated, is so apply TIL to straighten, move into proper anatomical position.
Splint the injured to by “buddy taping” the injured toe to the adjacent toe, with padding in between the toes for comfort and support.
Support the fractured toes by wearing a stiff-soled shoe to prevent flexion of the toes.

This blog is powered by the Wilderness Medicine Newsletter, now celebrating 20 years of publication. The WMN is published and distributed online six times each year by TMC Books, and subscriptions cost as little as $10 per year. To find out more, or to subscribe online, click here.

UPPER EXTREMITIES TRAUMA:

September 10, 2007

Dislocated Shoulder:
The shoulder was forced past the normal range of motion.
The shoulder is locked in position and painful to motion.

Techniques of reduction:
Depends upon the position of the humerus.
If the humerus is abducted past 60 degrees then use the Mosher Technique.

Mosher Technique is a gentle passive technique using position and gravity.
1. Have them place the hand of the affected arm on top of their head.
2. Have them place their other hand on top of their head also and interlock their fingers.
3. Lay them flat on their back, and then allow the elbows slowly relax, under the tug of gravity, towards the ground. The dislocated shoulder will spontaneously reduce back into proper anatomical position over then next 5 – 15 minutes.

If the humerus is hanging down next to the body then use the Traction at the Elbow Technique.
Traction Sling at the Elbow:
1. Have them sit up in a chair or on a rock, whatever is comfortable.
2. Have someone else stand behind them and place their hands on the patient’s shoulders to support them sitting up straight.
3. With the affected arm beside the body and with the elbow flexed at 90 degrees, place a wide sling at elbow.
4. The sling needs to be in a loop to support your foot.
5. Place one foot in the loop and apply gently in-line traction to the upper arm. Do not move the arm, keep the forearm bent at 90 degrees and maintain gentle traction.
6. After about 5 minutes of gentle traction, without straightening the forearm, externally rotate the arm, if there is sufficient traction the shoulder will reduce and pop back into place.
7. If not then continue to maintain traction, if necessary slowly increase the traction-in-line.
8. After about 5 minutes again externally rotate the forearm to about 90 degrees or until the shoulder reduces.
9. Once the shoulder has reduced back into proper anatomical position, place in a sling and swathe and monitor circulation.
10. Transport, may walk if comfortable.

Fractured Humerus: 
May be angulated, if angulate straighten out with traction-in-line.
Treatment:
Apply a sling and swathe to support the humerus and forearm.

Fracture/Dislocation of the Elbow: 
Fractures and dislocations very painful.
Treatment is to support with sling & swathe.
May have to straighten if circulation impaired distal to injury.
Straighten with traction-in-line, initially maintain elbow at 90 degrees,
Once under traction, and the elbow has slid into proper anatomical position, you may slowly extend the forearm until circulation restored (pulse at wrist).

Fractured Radius/Ulna:
Fractures with deformity arm common (Colles’ and Smith’s deformities)
May need to straighten if circulation is impaired, but this is unusual.
Splint with wrist at 30degrees of extension, and the fingers at the MCP joints relaxed at about 60 degrees of flexion.

Fractured Wrist:
Most common carpal fracture is of the scaphoid,
Pain in the anatomical snuffbox can indicate a fracture scaphoid.
Splint with wrist at 30 degrees extension & fingers at 60 degrees of flexion.

Fracture/Dislocation of the Hands/Fingers:
Reduce dislocated fingers with TIL, may require ant/post pressure.
Buddy tape fractured fingers.
Splint fingers in position of function, flexed as if holding a soda can.

This blog is powered by the Wilderness Medicine Newsletter, now celebrating 20 years of publication. The WMN is published and distributed online six times each year by TMC Books, and subscriptions cost as little as $10 per year. To find out more, or to subscribe online, click here.

Wilderness Orthopedics – Sprains and Strains

April 18, 2007

Sprains & Strains:Sprains and strains are by far the most common backcountry injuries.
Sprains and strains are injuries to muscles, tendons, ligaments, and the supporting structures of joints.

Signs & Symptoms of a Sprain/Strain:
Think of how a sprained ankle appears.
There is generalized pain and tenderness around the affected joint.
Unlike a fracture that is no point tenderness, if there is then suspect a fracture.
There is pain with movement of the affected joint.
There is pain with weight-bearing or use of the affected joint.
Swelling can be rapid and dramatic because of bleeding from the damaged blood vessels.
The area may become discolored over several hours, “black and blue” = ecchymosis.

Evaluation of a sprain/strain:
Consider the mechanism of injury.
Expose the injured area to look at the injury and the skin.
That includes removing boots and socks.
You cannot properly evaluate an injury that is hidden by clothing.
Gently palpate the area for pain, tenderness, and crepitation.
Put the injured joint through passive range of motion, that is, you gently move the joint and monitor for pain, loss of motion, or crepitation.
Loss of motion, a locked joint, indicates a dislocation.
Crepitation indicates a fracture.

Treatment: 
The goal is to minimize swelling. The less the sprain swells the faster it will heal. We use the acronym RICE to remind us of the principles to control swelling:
REST, ICE, COMPRESSION, & ELEVATION  
Rest, put the affected joint at rest. This will minimize blood flow and chance of further injury.
Ice, keep the area cool, this causes vasoconstriction thus reducing bleeding into the damaged tissues.
Compression, with a wide ACE wrap applies counter pressure to damaged tissues, again helping to control bleeding.
Elevation, raise the affected area above the level of the heart to decrease blood pressure and aid in the control of bleeding.
Immobilize & support affected joint. Splinting the affected area puts the injury at rest allowing the healing process to begin and continue.

This blog is powered by the Wilderness Medicine Newsletter, now celebrating 20 years of publication. The WMN is published and distributed online six times each year by TMC Books, and subscriptions cost as little as $10 per year. To find out more, or to subscribe online, click here.

MUSCULOSKELETAL TRAUMA

March 28, 2007

The next series of blogs will be an in-depth review of the recognition and management of musculoskeletal trauma in the wilderness, marine, disaster, and military environments.  This body of knowledge is the best example of the difference between urban, or street medicine, and the extended care environment. 

In the urban realm, typically, the ER is just minutes away and the primary concern is to stabilize the fracture or dislocation in the position found, and transport. Once outside the golden hour, the primary concern becomes circulation distal to the site of the injury. This may require straightening out angulated fractures, reducing dislocations, proper long-term splinting with big, ugly, fat, fluffy splints, and monitoring the circulation every 15 minutes for the duration of the evacuation.

ANATOMY AND PHYSIOLOGY OF THE MUSCULOSKELETAL SYSTEM

ANATOMY:

Bones:
Consist of a dense cortex surrounding an inner, soft marrow and they provide the rigid framework to which everything attaches. Bones also store calcium, an essential electrolyte, and produce the blood cells in the bone marrow.
Cartilage:
Acts as a lubricated durable cap on the ends of the bones so that your joints can
flex and rotate smoothly and without friction. Cartilage also provides support for muscle in areas where more flexibility than bone offers is needed.
Periosteum:
Is the tough fibrous layer that covers the bones and which contains the nerves that produce the pain associated with injuries.
Synovial fluid:
Is the lubricant in the joint space produced by the synovial lining of the joint capsule that surrounds the joint, allowing for friction-free movement.
Muscles:
Are like bundles of bungee cords. In response to signals sent from your brain through your central nervous system, they contract and relax, which flexes your joints and allows you to move. All muscles work by contracting, 
Tendons:
Are the ties connecting muscles to bone. They span joints and allow for movement.
Ligaments:
Are like nylon cords and attach bones to other bones. They span joints, maintaining proper alignment and setting the limits of range of motion.

PHYSIOLOGY:  Musculoskeletal system functions:

Movement: 
The contraction of muscles provides us with purposeful movement.
Heat Production:
The contraction of muscles produces heat.
Protection: 
The strength and flexibility of  muscle protects many internal structures including the bundles of nerves, arteries, and veins beneath the muscles.
Calcium storage: 
The bones act as a large calcium store.  Calcium is an electrolyte that allows for the contraction of muscle, including the heart muscle, and the conduction of nerves impulses.
Hematopoiesis: 
The process by which the various blood cells (red blood cell, white blood cell, and platelets), are produced in the bone marrow.
Cosmesis: 
The muscular and skeletal structures contribute greatly to how we look.

This blog is powered by the Wilderness Medicine Newsletter, now celebrating 20 years of publication. The WMN is published and distributed online six times each year by TMC Books, and subscriptions cost as little as $10 per year. To find out more, or to subscribe online, click here.

Reducing a dislocated patella

November 11, 2006

How to Reduce a Dislocated Patella

A dislocated patella typically occurs when a force is applied to the medial side of the patella forcing it laterally out of the femoral groove in which it rides. The patella is held in place inferiorly by the patella tendon and supported on the sides by the medial and lateral patella femoral ligaments.

The patella almost always dislocates laterally. When this occurs, the patient will be in significant pain with their knee flexed and the patella displaced laterally. As with most dislocations, the longer the patella remains out of joint, the more swelling there will be in and around the joint. This swelling makes it harder to reduce. So, the sooner the joint can be reduced back into normal anatomical position, the better.

reducing dislocated petella

Treatment:

Examine closely

Palpate the patella for fractures

Gently check the stability of the knee

To reduce the patella:

With one hand grasp the ankle. Place the other hand on the lateral aspect of the knee with the fingers in the popliteal space and the thumb against the lateral aspect of the patella.

As you push against the patella with your thumb, slowly straighten out the leg with the hand that is on the ankle. As the leg extends, the patella will reduce back into normal anatomical position.

Once reduced, wrap the knee with a 6” ace wrap for gentle compression and to minimize swelling, then splint the leg straight. Because of the risk that the medial patella ligament has been partially torn and there may be other ligamentous damage, the knee has to be splinted straight. Once the knee is wrapped and splinted, the patient may try to walk with the leg stiff and straight. If the injury was only a dislocated patella and ligamentous sprain, walking should be pain free.

Please note: in the event that the patella does not reduce, splint the leg in the position found and transport in a litter.

For more information see the Sept/Oct 2004 issue of the Wilderness Medicine Newsletter.

This blog is powered by the Wilderness Medicine Newsletter, now celebrating 20 years of publication. The WMN is published and distributed online six times each year by TMC Books, and subscriptions cost as little as $10 per year. To find out more, or to subscribe online, click here.

Wilderness Medicine: managing a fractured femur

November 10, 2006

Improvised Traction Splintmid-shaft fractured femur: A mid-shaft fracture of the femur is a very painful injury which commonly has associated muscle spasms of the quadriceps and adductor muscles of the upper leg. A significant blood loss into these surrounding tissues can occur; typically 1000 – 1500cc can be lost in 15 – 20 minutes. There is an even more significant long-term risk of fat emboli from the mid-shaft fractured femur. Once these emboli get into the circulatory system, they will collect in the lungs and can cause death from pulmonary emboli. Studies indicate that a there is up to a 50% mortality rate at 4 hours for fractured femurs that are not treated with traction. A traction splint not only splints the fracture, it provides pain control by relaxing the muscles in spasm, and, when ACE wrapped, it also helps minimize the internal blood loss from the fracture. Contrary to some people’s opinion, traction splints do fit into litters and other evacuation devices-countless rescue missions can attest to this.

Recognition of a fractured femur:

MOI:
Trauma to the legs

PE:
Pain with muscle spasm of the upper leg
Swelling, bruising, tenderness, and crepitation at the fracture site
Unable to weight bear

VS:
Can indicate shock, tachycardia, tachypnea, hypotension

Treatment of a fractured femur:

A, B, C, and since it takes a lot of force to fracture a femur, look closely for other injuries.

Place in manual traction, ASAP.

Place in traction splint, commercial or improvised.

Apply gentle compression with wide elastic bandages to help control internal bleeding-wrap the splint and the entire leg with 6″ wide elastic bandages, starting at the ankle and progressing to the hip.

Monitor for shock and regularly check circulation distal to the site of the injury.

Click here to see a step-by-step diagram of creating a traction splint for a femur fracture:

traction splint for fractured femur

For more information on fractured femurs and orthopedic emergencies, see the Sept/Oct 2006 issue of the Wilderness Medicine Newsletter.

This blog is powered by the Wilderness Medicine Newsletter, now celebrating 20 years of publication. The WMN is published and distributed online six times each year by TMC Books, and subscriptions cost as little as $10 per year. To find out more, or to subscribe online, click here.


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