Bone and Joint First Aid
Jun 28, 2015 18:05:46 GMT
Post by fortunateson on Jun 28, 2015 18:05:46 GMT
INITIAL MANAGEMENT
Before definitive treatment of a fracture is undertaken, attention must be directed to first aid treatment (Advanced Trauma Life Support (ATLS) principles), to the clinical assessment of the patient with special reference to the possibility of associated injuries or complications, and to resuscitation.
First aid
The doctor who chances to be at the scene of an accident should seldom attempt more than to ensure that the airway is clear, to control any external haemorrhage, to cover any wound with a clean dressing, to provide some form of immobilisation for a fractured limb, and to make the patient comfortable while awaiting the arrival of the ambulance.
When it is necessary to move a patient with a long-bone fracture, it will be found that pain is lessened if traction is applied to the limb while it is being moved. If it is suspected that there may be a fracture of the spinal column, special care is necessary in transport, lest injury to the spinal cord or cauda equina be caused or aggravated. It is most important to avoid flexing the spine, because flexion may cause or increase vertebral displacement, jeopardising the spinal cord. In certain types of fracture, extension is also potentially dangerous to the cord. Accordingly the patient should be lifted bodily on to a firm surface, with care to avoid both flexion and extension. If a cervical collar is available, it should be applied as a protection for the neck before moving the patient, without allowing either flexion or extension of the neck during its application.
Temporary immobilisation for the long bones of the lower limb is conveniently arranged by bandaging the two limbs together so that the sound limb forms a splint for the injured one. In the upper limb, support may be provided by bandaging the arm to the chest or, in the case of the forearm, by improvising a sling.
Haemorrhage hardly ever demands a tourniquet for its control. All ordinary bleeding can be controlled adequately by firm bandaging over a pad. Only if profuse pulsatile (arterial) bleeding persists despite firm pressure over the wound, with the patient recumbent, does the need for a tourniquet arise. Pending its application, firm manual pressure over the main artery at the root of the limb may be applied to control the bleeding. If a tourniquet is applied, those attending the patient should be made aware of the fact and of the time of its application. If necessary, a note to this effect should be sent with the patient to ensure that the tourniquet is not inadvertently left in place for too long.
TREATMENT OF UNCOMPLICATED CLOSED FRACTURES
The three fundamental principles of fracture treatment—reduction, immobilisation and preservation of function—are well known, and there is still no better way of discussing the treatment of a fracture than under these three headings.
REDUCTION
This first principle must be qualified by the words ‘if necessary’. In many fractures reduction is unnecessary, either because there is no displacement or because the displacement is immaterial to the final result (Fig. 3.1). A considerable experience of fractures is needed before one can say with confidence whether or not reduction is advisable in a given case. If it is judged that perfect function can be restored without undue loss of time, despite some uncorrected displacement of the fragments, there is clearly no object in striving for perfect anatomical reduction. Indeed, meddlesome intervention may sometimes be detrimental, especially if it entails open operation.
In general, it may be said that imperfect apposition of the fragments can be accepted much more readily than imperfect alignment (Fig. 3.1). For example, in the shaft of the femur a loss of contact of half a diameter might be acceptable whereas an angular deformity of 20o would usually demand an attempt at improvement. When a joint surface is involved in a fracture, the articular fragments must always be restored as nearly as possible to normal, to lessen the risk of subsequent osteoarthritis.
METHODS OF REDUCTION
When reduction is decided upon it may be carried out in three ways:
1. by closed manipulation
2. by mechanical traction with or without manipulation
3. by open operation.
Manipulative reduction
Closed manipulation is the standard initial method of reducing most common fractures. It is usually carried out under general anaesthesia, but local or regional anaesthesia is sometimes appropriate. The technique is simply to grasp the fragments through the soft tissues, to disimpact them if necessary, and then to adjust them as nearly as possible to their correct position.
Reduction by mechanical traction
When the contraction of large muscles exerts a strong displacing force, some mechanical aid may be necessary to draw the fragments out to the normal length of the bone. This particularly applies to fractures of the shaft of the femur, and to certain types of fracture or displacement of the cervical spine. Traction may be applied either by weights or by a screw device, and the aim may be to gain full reduction rapidly at one sitting with anaesthesia, or to rely upon gradual reduction by prolonged traction without anaesthesia.
See www.us.elsevierhealth.com/media/us/samplechapters/9780443102974/9780443102974.pdf
Before definitive treatment of a fracture is undertaken, attention must be directed to first aid treatment (Advanced Trauma Life Support (ATLS) principles), to the clinical assessment of the patient with special reference to the possibility of associated injuries or complications, and to resuscitation.
First aid
The doctor who chances to be at the scene of an accident should seldom attempt more than to ensure that the airway is clear, to control any external haemorrhage, to cover any wound with a clean dressing, to provide some form of immobilisation for a fractured limb, and to make the patient comfortable while awaiting the arrival of the ambulance.
When it is necessary to move a patient with a long-bone fracture, it will be found that pain is lessened if traction is applied to the limb while it is being moved. If it is suspected that there may be a fracture of the spinal column, special care is necessary in transport, lest injury to the spinal cord or cauda equina be caused or aggravated. It is most important to avoid flexing the spine, because flexion may cause or increase vertebral displacement, jeopardising the spinal cord. In certain types of fracture, extension is also potentially dangerous to the cord. Accordingly the patient should be lifted bodily on to a firm surface, with care to avoid both flexion and extension. If a cervical collar is available, it should be applied as a protection for the neck before moving the patient, without allowing either flexion or extension of the neck during its application.
Temporary immobilisation for the long bones of the lower limb is conveniently arranged by bandaging the two limbs together so that the sound limb forms a splint for the injured one. In the upper limb, support may be provided by bandaging the arm to the chest or, in the case of the forearm, by improvising a sling.
Haemorrhage hardly ever demands a tourniquet for its control. All ordinary bleeding can be controlled adequately by firm bandaging over a pad. Only if profuse pulsatile (arterial) bleeding persists despite firm pressure over the wound, with the patient recumbent, does the need for a tourniquet arise. Pending its application, firm manual pressure over the main artery at the root of the limb may be applied to control the bleeding. If a tourniquet is applied, those attending the patient should be made aware of the fact and of the time of its application. If necessary, a note to this effect should be sent with the patient to ensure that the tourniquet is not inadvertently left in place for too long.
TREATMENT OF UNCOMPLICATED CLOSED FRACTURES
The three fundamental principles of fracture treatment—reduction, immobilisation and preservation of function—are well known, and there is still no better way of discussing the treatment of a fracture than under these three headings.
REDUCTION
This first principle must be qualified by the words ‘if necessary’. In many fractures reduction is unnecessary, either because there is no displacement or because the displacement is immaterial to the final result (Fig. 3.1). A considerable experience of fractures is needed before one can say with confidence whether or not reduction is advisable in a given case. If it is judged that perfect function can be restored without undue loss of time, despite some uncorrected displacement of the fragments, there is clearly no object in striving for perfect anatomical reduction. Indeed, meddlesome intervention may sometimes be detrimental, especially if it entails open operation.
In general, it may be said that imperfect apposition of the fragments can be accepted much more readily than imperfect alignment (Fig. 3.1). For example, in the shaft of the femur a loss of contact of half a diameter might be acceptable whereas an angular deformity of 20o would usually demand an attempt at improvement. When a joint surface is involved in a fracture, the articular fragments must always be restored as nearly as possible to normal, to lessen the risk of subsequent osteoarthritis.
METHODS OF REDUCTION
When reduction is decided upon it may be carried out in three ways:
1. by closed manipulation
2. by mechanical traction with or without manipulation
3. by open operation.
Manipulative reduction
Closed manipulation is the standard initial method of reducing most common fractures. It is usually carried out under general anaesthesia, but local or regional anaesthesia is sometimes appropriate. The technique is simply to grasp the fragments through the soft tissues, to disimpact them if necessary, and then to adjust them as nearly as possible to their correct position.
Reduction by mechanical traction
When the contraction of large muscles exerts a strong displacing force, some mechanical aid may be necessary to draw the fragments out to the normal length of the bone. This particularly applies to fractures of the shaft of the femur, and to certain types of fracture or displacement of the cervical spine. Traction may be applied either by weights or by a screw device, and the aim may be to gain full reduction rapidly at one sitting with anaesthesia, or to rely upon gradual reduction by prolonged traction without anaesthesia.
See www.us.elsevierhealth.com/media/us/samplechapters/9780443102974/9780443102974.pdf
