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Fracture Management
Paramedics save lives, the saying goes, and EMTs save paramedics. That's glib and debatable, but it's certainly true that the role of the EMT-Basic is a vital one, and that there's relatively little out there in the way of information and tools to help him do it better. This new column, which will appear several times a year, is a resource for EMT-Basics. It will cover everything from reviews of basic skills to assisting ALS providers with more advanced interventions in a way designed to enhance understanding and develop a more complete provider. As always, we welcome your comments; send thoughts, feedback and ideas for future columns to nancy.perry@cygnusb2b.com.
Fractures are commonly encountered in the prehospital environment, and the mechanisms that can create them are as varied as the types and locations of the fractures themselves. The proper methods of identifying and effectively managing fractures are extremely important in treating patients.
As with any other situation in the prehospital environment, the primary concern with fractures is the safety of the provider. Infection control and BSI should be used at all times. Disposable gloves should always be worn, and special attention should be paid to any fracture that may cause bleeding or the exposure of sharp edges. In situations where there's significant bleeding, it may be appropriate to utilize a mask with eye protection and a gown. Furthermore, providers should make sure the patient has a patent airway and adequate breathing and circulation prior to assessing and treating any fractures.
Fracture Types
Fracture, by definition, means break.1 However, there are different types of fractures that are commonly encountered (see Figure 1).
Simple (closed) fracture-The bone is fractured, but there is no significant deformity of the bone, and it has not broken the skin. The majority of fractures you'll encounter fall into this category.
Compound (open) fracture-The bone is fractured, with breaking/laceration of the skin. Bone may or may not show from the wound.
Transverse fracture-The fracture is across the bone, and at a right angle to its long axis.
Greenstick fracture-This type of fracture is named after the breaking of a green tree branch. One side of the bone is fractured, while the other side is only bent. These types of fractures occur commonly in children, as their bones aren't as brittle as adults'.
Comminuted fracture-This is a fracture involving three or more bone fragments.2
Signs & Symptoms
There are various signs and symptoms that can be exhibited by patients with fractures. It's often obvious to the patient, either from sound, feeling or both, that there's been a fracture, and they will let you know: "I heard a snap."
Signs and symptoms include deformity, discoloration, crepitus (a cracking, grating or scraping type noise made when bone ends rub together), tenderness, swelling, inability to move the affected extremity, pain when moving the affected extremity, bleeding and/or bone protrusion.3 If nerve, muscle or vessel compromise exists, then numbness, tingling and loss of sensation and/or pulses may be encountered.
If a significant amount of blood is lost, either through a wound or internally, the patient may exhibit signs and symptoms of shock. Obviously, there are situations where it is impossible to truly determine if a fracture exists in the prehospital setting. If you are unsure whether a fracture exists, treat the patient as if it does.
Treatment
The main purpose of splinting is to prevent movement in the joints and bones above and below the fracture site. This is to prevent bone edges from moving and creating additional injuries by cutting tissue, muscle, vessels or nerves, potentially turning closed fractures into open fractures and creating open wounds. For splinting to be effective, it must immobilize adjacent joints and bone ends. The provider must ensure that both the fracture site and the joints above and below it are immobilized.
The EMS provider has many tools at his disposal to properly immobilize fractures.
Splinting Devices
Basically, any splint incorporates rigidity. Whether that's achieved by using a piece of wood or even air, rigidity is where splinting begins.
In the early days of splinting, sticks and tree limbs were used to splint injured areas. They were secured with items like belts, rope and even torn strips of cloth. Slings and swathes were also created from belts or cloth.
Today, sticks and tree limbs have been replaced with wooden boards. These are usually padded, and triangular cloth bandages are commonly used to sling and swathe fractures. In addition to those methods, vacuum splints, traction splints, pneumatic anti-shock garments (PASGs) and pelvic wrap splints are also used.
Padded boards and rigid splints made of foam or cardboard are commonly used for upper- and lower-extremity fractures. Additionally, there are types of rigid splints, such as ladder splints, that can be bent to better conform to the shape of the affected extremity.
Vacuum splints are essentially large air bladders that wrap around the affected extremity and are inflated to provide rigidity. Vacuum splints are effective, relatively easy to use and quick to apply.
Traction splints are used to immobilize fractures of the femur. These types of splints use tension that's created by pulling straps to place the bone in alignment. This was done in the past with long boards and cloth straps, but today bipolar splints (such as the Hare Traction Splint) and unipolar splints (such as the Sager Splint) are widely used.
The PASG has commonly been used to immobilize pelvic fractures, but many EMS systems no longer allow its use. Recently, pelvic wrap devices have replaced PASGs as the method of choice to immobilize pelvic fractures.
There are several different types of pelvic wrap splints, but they all essentially work the same way, by providing circumferential stabilization of the entire pelvic cavity. If your agency does not carry these devices, you can achieve the same effect by simply wrapping a sheet around the patient's pelvis.4
Splinting Methods
As stated above, for splinting to be effective, the joints above and below the fracture must be immobilized. If possible, remove any clothing that may impede the splint's working properly. If there are open wounds or exposed bone, bandage appropriately. The injured area must be manually stabilized, which prevents movement. This can be done by simply holding the affected area, preventing movement above and below it. For example, for a radius/ulna fracture, the arm should be held at the wrist and elbow.
Assessing motor function-After exposure, the pulses, sensation and movement of the injured area need to be assessed. If they are absent, then manual traction should be applied to realign the bone.
Manual traction and alignment-In most situations, the injured area needs to be returned to as close to a normal anatomical position as possible. Usually, this is done by having one provider hold manual traction, applying tension to the affected extremity, to return fractured bone to a more normal position. This is to cut down on damage to the affected area and assist the effectiveness of the splint. If this creates resistance or causes any further injury, or looks like it might, stop immediately and splint in the position the affected area is in. Do not push protruding bone back into place.5
Fractures of the humerus and radius/ulna-After assessing motor function and alignment, splint the arm under or along the fractured area. For a fractured humerus, the board should rest at the upper arm and span the length between the shoulder and elbow. For a fracture to the radius and/or ulna, the board should rest under or along the forearm and span the length between the elbow and wrist. The board should be secured above and below the fracture. Use triangular bandages to make a sling (supporting the shoulder and arm) and swathe (holding the arm against the chest) to immobilize the limb. Reassess motor function after applying the splint. A roll of gauze should be placed in the hand of the affected arm to limit movement of the fingers and wrist.
Tibia/fibula fractures-Lower leg fractures are immobilized without traction splints. After assessing motor function and alignment, place a long board under or along the side of the affected leg. Immobilize above and below the fracture, and secure the foot in the position of function.
Vacuum splints-When using vacuum splints, place the injured extremity inside the splint. The pump is used to draw air out of the splint, which compresses it, making it rigid. It also conforms to the patient and reduces pressure on the area. When using vacuum splints, make sure to keep the patient's fingers and/or toes exposed to assess motor function.6 Additionally, the splint should be checked periodically during transport to ensure there are no leaks. Leaks in the splint diminish its rigidity and effectiveness.
Traction splints-Bipolar and unipolar types of traction splints work in similar ways. After assessing motor function, one provider maintains manual traction, usually by pulling on the leg from the ankle. Measure the splint to a length slightly longer than the affected leg. Apply the strap that's most proximal (closest) to the hip. Apply the ankle strap, then, using the splint, apply manual traction. Then apply the remaining straps above and below the fracture. Reassess motor function and secure the patient to a long spineboard for transport.
Pelvic fractures-The simplest way to immobilize pelvic fractures is to stabilize the patient's lower legs. Place a folded blanket between the patient's legs and secure it with cravats.7 If using the PASG, place the patient in the PASG, but do not inflate the legs, only the pelvic region. When using the PASG, be sure to assess vital signs prior to application and every five minutes after.
When using a sheet as a pelvic wrap, place the sheet around the patient's pelvis, then gently stabilize the pelvis by pulling the two ends together. Then tie the two ends together. Commercial pelvic wrap devices should be used per manufacturer guidelines.
Summary
Fractures are commonly encountered in the prehospital setting. Using some very basic methods and equipment, as well as some advanced equipment options, prehospital providers have the ability to recognize and treat many of these fractures.
The author gratefully acknowledges the assistance of Jodi Kuhn, Greg Neiman and Karen Owens from the Virginia Office of EMS.
Timothy J. Perkins, BS, EMT-P, is the EMS systems planner for the Virginia Department of health's Office of EMS. He has over 17 years of EMS operations and management experience. E-mail him at tjperkins5@yahoo.com.
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