Some reason not to disrobe femur fracture?

[DwayneEMTP]

Hi all,

I caught an episode of "Paramedic" the other night and had a question.

I will post it the best I remember..

Call was for an 80ish female, leg pain after a fall. No loc, not other pain, no other history relevent to the injury ( I believe )

They find a very thin lady on her bed with severe pain, mid femer. She screams in pain with any attempt to move her.

These are my questions:

The paramedic did not remove her pajama bottoms....when he palped her leg, pain seemed to be nearly dead center of her femur. Was there some reason not to cut away her pajamas to expose her leg?

I reviewed my basic manual and didn't see any contraindications for a traction splint relevant to geriatrics (Though it seems that you would need to expose it to reveal joint issues etc.) Yet with the little that was seen on the episode they didn't seem to consider using a traction splint. Are there age contraindications that I'm unaware of?

Pain meds were given and she was transported on her rt side (I believe it was position of comfort)

I will hope that it is obvious that the spirit of this post is not armchair quarterbacking...(I promise I've read those posts and know it's evil) and would not judge the paramedics based on my little bit of knowledge even if I thought I knew the whole story....

I was just curious about these two things.

P.S. Follow up at hospital confirmed mid-shaft femur fracture.

Thanks all!

Dwayne

[Asysin2leads]

Dwayne, I can give you my best guess at the situation. This sounds like a fracture of the femoral neck, a common injury in the elderly with weakened bones. The femoral neck, which sits just below the 'ball' of the femur which fits into the pelvis, is one of the weakest points of the leg structure and easily fractured especially in the elderly. When someone 'breaks their hip', this is usually the injury he was talking about. I have actually seen licensed, though obviously inexperienced ER personnel attempt to put a traction splint on this type of injury, which causes great pain as the top of the traction spint is forced into the injury. My guess is the paramedic upon palpation recognized the injury, but honestly I don't know why he wouldn't expose it, maybe he did it off camera, maybe he couldn't stand the sight of 80 year old cellulite.

Quite frankly it is very difficult to stabilize the injury, you can try the old pillow between the legs or try using a really long splint to immobilze the entire leg to the torso, but usually I've found I only succeed in causing the patient more pain and wasting time on scene. The orthopaedic scoop is very well suited for this situation, scoop 'em up gently, set 'em down gently, give them some nice pain meds and take a trip to the hospital. Don't forget to feed their cat on the way out.

Anybody have any luck in stabilizing this type of injury?

[MrSpykes]

The best way i have found to splint either a dislocated or fractured hip is to take a sheet and fold it lengthwise and lay it across a backboard, scoop stretcher, or just the cot. Then move the patient over onto it so that it is under the point of injury then wrap it around the patients hips and tie it. This will apply some pressure to keep the injury in place and relieves a lot of pain. Also the patient will probably want to be rolled on the injured side because that extra pressure helps the pain too. A lot of times when you find these patients the will have already rolled onto the injured side. Also make sure to give pain meds probably before attempting to move them.

[kevkei]

Clinically, there is no real reason to splint a suspected hip fracture or dislocation. Even for the femoral shaft, greater/lesser trochanter, etc. If you think about it, what is the recommended way to splint a suspected fracture? Splint the joint above and below the injury.

Well here you have a very stable orthopedic injury that is being splinted by very large and strong muscle groups around the joint itself. The area of the injury is not going to move. However, what will move is the areas pf the leg distal to the injury. Most pain is caused by people manipulating the leg by trying to adduct it back to the midline and then 'splint' the legs together by whatever means. This is the worst thing to do if they have evidence of internal rotation, the patient will be sure to SCREAM as to how much it hurts when you do that.

Talk to an orthopedic surgeon, they will tell you there is no real need to isolate a hip fracture/dislocation. Ususally the best method is to 'splint' by placing it in a position of comfort.

[PRPGfirerescuetech]

http://www.jems.com/tips/14768/

http://www.ncbi.nlm.nih.gov/entrez/query.f...p;dopt=Abstract

http://findarticles.com/p/articles/mi_qa37..._n16350756/pg_3

SHEET WRAP

Been using this bout 2 years now. Wonderful applications to this type of injury. They are working on a commercial product to mimic the technique for the immediate future.

PRPG

[redwolfef6]

You could pull this womans Pj bottoms off or leave her with her self-respect and cut up the seam on the injured side.

As far as a traction splint.... frankly why bother. With that in place you now have tranport issues. Stabilize the injured leg to the uninjured leg. Definetly pain control as lonas BP stable.

[PRPGfirerescuetech]

You could pull this womans Pj bottoms off or leave her with her self-respect and cut up the seam on the injured side.

As far as a traction splint.... frankly why bother. With that in place you now have tranport issues. Stabilize the injured leg to the uninjured leg. Definetly pain control as lonas BP stable.

Why bother? Transport issues?

Please clarify...

[Ridryder 911]

I have worked with several ortho's that suggest some good insight on "hip fxr.'s"... First I have learned if one actually reaches under the gluetal fold, and can palpate the "surgical neck" of the femur, just anterior of the ischium, it does not take much pressure on palpation to elicit pain, to see if it is "hip" versus traditional other fxrs. A pillow row or towel roll slightly under the hip, with the leg flexed (if possible at a 30[sup:d8db2fbf0d]0[/sup:d8db2fbf0d] ) it tends to relieve pressure on the neck area.

As well all fractures, after confirmation of adequate circulation, splint accordingly and analgesics.

R/r 911

[redwolfef6]

Why bother? Transport issues?

Please clarify...

Nothing like having an extra hunk of metal hanging out your ambulance.

[craig]

Hi all,

I caught an episode of "Paramedic" the other night and had a question.

I will post it the best I remember..

Call was for an 80ish female, leg pain after a fall. No loc, not other pain, no other history relevent to the injury ( I believe )

They find a very thin lady on her bed with severe pain, mid femer. She screams in pain with any attempt to move her.

These are my questions:

The paramedic did not remove her pajama bottoms....when he palped her leg, pain seemed to be nearly dead center of her femur. Was there some reason not to cut away her pajamas to expose her leg?

I reviewed my basic manual and didn't see any contraindications for a traction splint relevant to geriatrics (Though it seems that you would need to expose it to reveal joint issues etc.) Yet with the little that was seen on the episode they didn't seem to consider using a traction splint. Are there age contraindications that I'm unaware of?

Pain meds were given and she was transported on her rt side (I believe it was position of comfort)

I will hope that it is obvious that the spirit of this post is not armchair quarterbacking...(I promise I've read those posts and know it's evil) and would not judge the paramedics based on my little bit of knowledge even if I thought I knew the whole story....

I was just curious about these two things.

P.S. Follow up at hospital confirmed mid-shaft femur fracture.

Thanks all!

Dwayne

Just wondering as to why everyone keeps refering to the fact that this patient had a #NOF

I may just be a ambo from down under but my observations and diagnosis is a # femur (mid shaft) due to the fact the post said it WAS CONFIRMED AT HOSPITAL.

discounting that, the clinical signs at the scene lead more to a # of the femur than a # of the NOF due to the swelling and pain to the mid shaft and not the hip. Nothing listed as to the evidence of any shortening and rotation of the injured leg.

The standard for a fracture of the upper leg is normally a traction splint (choice of the officer as to what type and as to what is available). How ever on an elderly patient that has a very thin build and may have a bone disorder (oesteoarthritis or oesteoperosis etc as most 80 yo females have) the splint may cause more damage that is warranted, therefore it may be be better to just splint the leg with a large leg splint and make the patient comfortable for transport.

Therefore I see that the treatment that the officer did was not incorrect as everyone has to be treated as we find them and on the merit of the case that we are attending.

The action of removing the 80 yo females pj bottoms or cutting them off, well would you do this to you grandmother while a TV crew was holding a camera over your shoulder? even though you could make the relevant diagnosis with out this action?

my two bobs worth.....

stay safe