Fractures

[spenac]

This sounds like a skill that should at least be discussed in more detail and then require to at least observe it being done by a Doctor while doing clinicals, probably be hard to get doctor to allow you to perform it. I know we would still not be skilled at it but we could at least make an educated attempt at salvaging the extremity. If close to hospital probably still better off loading and hauling butt to ER but not an option for all on the site. I have reestablished circulation on one fractured extremity, but probably only successful as had been able to observe doctors do it on several occasions, don't know if I did it completely right but person still walking on it, would have lost it otherwise. Thankfully all other fractures and dislocations have still had good circulation so just splinted and monitored for good circulation enroute to the hospital.

[CBEMT]

Our protocol:

Contact Medical Control if distal pulses are absent. Medical Control may authorize movement of the extremity.

Not that most providers know how, as has been covered already.

[scope2776]

Thank you Doczilla and AZCEP for the resources and your insight!!!

[FireMedic65]

I was going to make a new post about this because of a case I had the other day. So, instead of making a new post I searched and came across this.

My patient, 17yr old fell while skateboarding at a skate park and had an obvious fracture to his right arm (looked like a praying mantis). He had no distal pulses in his wrist and color was starting to fade away. Friends said it happened around an hour or so before we go there and were afraid to call for help because of getting in trouble.

Anyway, obvious fracture, absent distal pulses. Negative impact to head (wearing helmet also) followed commands and answered appropriately. Only complaint was the forearm. We were taught way back in EMT school that if there was a fracture and had no distal pulses, we were to "attempt" to put back in the anatomical position in hopes of regaining a pulse. Nothing was taught on proper techniques on how to do so, just that it should be done gently. The same thing was taught in medic school, with no formal techniques on how to do so.

I applied gentle traction (after he was given 4mg morphine for pain) and did my best to align the bones back to how they would look normally. Once this was done, the patient said he was still in pain, but it felt better (not sure if he felt better because I was pulling on his 'broken' arm and I had stopped, or it felt better being back in place). We regained a pulse in his wrist and splinted his arm with a gauze roll in his hand. Color returned to normal when we got to the ER, which was about a 50min transport to the trauma center.

The reason I posted this, was not to brag, it was because I had questions about doing this. Our protocol states this:

"Straighten severely angulated fractures if distal extremity has signs of decreased perfusion"

that's all... straighten out.

I was curious, if there is any formal training out there to perform these techniques properly, instead of just "attempt". I have not heard of anything regarding this for pre-hospital care providers. Every time there was a case of this in the hospital when I was doing my clinical, I tried to get involved and observe the MD do it. Pretty much all that was said to me by them in how to do it, was what Zilla had explained. Is that all there really is to it? I feel this is not enough though, meaning "attempt to straighten".

[tniuqs]

I had a case last tonight that made me think of you guys (man, I have no life ). If you have a pt in the field with say an ankle fracture with vascular compromise, are you allowed to reduce it?

Ok first off agreed ... bout the no life ... LOL.

Getting in late on the thread, in my experience with ankle fracture's of this severity most cases were Trimalleolar in nature and included dislocation (s) ie those with vascular comprise

Messing with that in the field is ill advised in my books without pictures and an orthopod looking over ones shoulder.

One should have about 90 minutes before irreversible damage could be incurred if I remeber back to school days.

cheers and lots of rx ... ouch.

[scubanurse]

We are allowed to reduce I believe if no distal pulses, but I would be very hesitant to do so. I have some extensive training in wilderness and ocianic medicine (as extensive as they can provide... two two week courses in each) and with such have been trained in the reduction of numerous scenarios. I have also witnessed them both in ER and OR and I still would have a problem doing it myself. Without x-rays it is sometimes difficult to know which way the bones need to be manipulated and such. I also work in an area where I can be at a Level II trauma center in <10 minutes and a local ED with Ortho in <5 so I would have to seriously weigh the risks and benefits of attempting to reduce in the field.

I have however "assisted" a baseball player with reducing his own shoulder. He threw it out at a game, had dislocated countless times before, and knew how to do it himself, I just assisted when he asked me to and that I felt comfortable doing.

I also have a habit of reducing my own joints on a daily basis, so reductions of dislocated joints I'm pretty darn good at Shoulders, knees, and jaws are my specialty as those happen on a daily basis... fingers are starting too... lol but that is a different story... it is on my own body and I fully consented to myself

For those of you in a more suburban/urban setting would you actually attempt a reduction? I know protocol says so, but I have never been the type of provider who will blindly follow the "book" with out using my own brain as well.

[Kiwiology]

You know this very was just in an episode of Emergency! I saw the other week and no no I would not attempt it beyond the reduction we apply with the traction splints (Hare or Seger).

I don't want to go playing with moving broken bones and risking lacerating an artery or nerves; those x ray glasses that came with my Marvel Man comic suck balls. I'm not an orthopedist.

[WelshMedic]

Over here it's reduction with midazolam/alfentanyl if time allows, otherwise it's just reduction.....Ouch!!!!

WM

[HellsBells]

And BE, the only fracture I would use a Sager for would be mid-shaft femur ( non-compound)...... :wink:

I little off topic... but why not use a sager to reduce a compund fracture?

[northernmedic]

I think tniuqs raised a good point about associated dislocations. I completely concur with his statement. It is a bit of a different cup of tea realigning a mid third humerus fracture vs. an ankle. I will be the devil advocate and make a point that in most cases it probably isn't necessary. In a lot of situations EMS should be able to have the pt at the hospital promptly and advance notification should stream line the process. In super rural areas this may not be an option but for limb threatening injuries aeromedical EMS could potentially be an option (which may bring providers with greater experience and training).

We use Sager splints on compound fractures and have been doing so since we invented it around 20 years ago. I checked with an orthopedic surgeon at our trauma center here in Vancouver after reading this thread and he completely agreed it is an acceptable practice, in fact the surgeons are big fans of proper application of traction splints to reduce tissue damage and stabilize limbs in place prior to surgery.