Angulated Fracture With Good Circulation

[Legal Eagle]

Lets say you guys come across a patient with a fairly grossly angulated extremity fracture or a patient who was reluctant to move the limb into an easier to splint/transport position; but the limb has a good distal circulation.
Maybe the patient is lying supine with a shoulder injury and the arm is outstretched at a 90 degree angle. They don't want to bring the arm closer to the body due to the pain, would you splint and transport in this awkward position ?
How do you guys deal with these situations ?

 

[STXmedic]

If it has good circulation, splint it in the most comfortable position. Pain management if available, please.

 

[mycrofft]

Layperson 101: splint it as it lies. SAM splint, soft blanket and duct tape, couple of soft pillows…

90 degree angle…describe anatomically. Is it "extending" anteriorly, posteriorly, laterally or medially? Are we "extending" the entire arm, or just the forearm, or is this referring to a 90 deg angulation in the middle of an otherwise straight arm? Is it angulated at a joint, or humerus or forearm? If in a bone, at which point?

Or send us a good sketch .

 

[Handsome Robb]

Lots of splinting in the POC and lots of drugs.

When I destroyed my shoulder and my C and T spine 4 months ago I was more comfortable sitting up, I couldn't lay supine if I wanted to. Good thing I didn't ride in an ambulance to the hospital, they woulda been in for a fight if they tried to board me because I couldn't breathe laying down.

 

[mycrofft]

Hear hear!

 

[Handsome Robb]

Hear hear!

It was amusing having to talk to my dispatch center on a open 911 line answering A&O questions to refuse the helicopter that was lifting for me. Apparently my lights were on but no one was home when they got to me and then they saw the state of my helmet and called 911.

Somehow made them comfortable enough to cancel the response though. :unsure: I did get to talk to am ambulance crew who was waiting in the parking lot for us and AMA from them. They didn't like that.

 

[Legal Eagle]

Here's a poorly drawn MS Paint picture describing two possible splinting scenarios. Hopefully you can see the attachment.

 

[Handsome Robb]

Pillows, air splints and lots of tape. I've cut apart boxes before or swiped a piece of food to use as a solid base to put under the extremity for a foundation for the splint.

Shoulder injuries hurt, a lot, ask me how I know.

With that said it's pretty rare to have someone with a shoulder that's locked out in a position like that although not impossible. A lot of the resistance you'll feel is voluntary or involuntary muscle spasms to support the injured joint. The worst part about manipulating a shoulder like that is that it just feels wrong. Only way I can describe it. It feels like your shoulder is going to fall out and it's not pleasant. I've had a few that were in odd positions that I was able to place anatomically correct after fentanyl, midazolam, lots of coaching to get them to trust me and slow, deliberate movements. If you're meeting resistance or causing a severe exacerbation of pain though don't force anything. Accidentally reducing a shoulder incorrectly hurts worse than the injury itself. Lots of different types of dislocations in that region as well.

 

[Legal Eagle]

Pillows, air splints and lots of tape. I've cut apart boxes before or swiped a piece of food to use as a solid base to put under the extremity for a foundation for the splint.

Shoulder injuries hurt, a lot, ask me how I know.

With that said it's pretty rare to have someone with a shoulder that's locked out in a position like that although not impossible. A lot of the resistance you'll feel is voluntary or involuntary muscle spasms to support the injured joint. The worst part about manipulating a shoulder like that is that it just feels wrong. Only way I can describe it. It feels like your shoulder is going to fall out and it's not pleasant. I've had a few that were in odd positions that I was able to place anatomically correct after fentanyl, midazolam, lots of coaching to get them to trust me and slow, deliberate movements. If you're meeting resistance or causing a severe exacerbation of pain though don't force anything. Accidentally reducing a shoulder incorrectly hurts worse than the injury itself. Lots of different types of dislocations in that region as well.

Thanks for the reply.

 

[the_negro_puppy]

If the limb has to be moved slightly to facilitate splinting or extrication, then usually morphine / fentanyl and heavy use of methoxyflurane inhaler works wonders. If they use the inhaler properly for a short period they will forget they have a limb :rofl:

Recent example was elderly patient with obvious # NOF sitting on bed, any movement caused him severe pain, but we had to get him supine. 10mg IV morphine followed by heavy methoxy use put him in a short term but safe dazed state to be able to move him.

 

[mycrofft]

Here's a poorly drawn MS Paint picture describing two possible splinting scenarios. Hopefully you can see the attachment.

Thank you. I hope this is not a real time call for suggestions? (haha).

Still, the drawings help. You need to know true terminology for charting.


Air splint require straightening. Pillows, soft blankets, duct tape, SAM splint do not.

I've used SAM splints a couple times for anterior shoulder dislocations where the subject can't easily bring the humorous back down in line with the torso. Make a triangle, make it fit, crimp it, and fasten it like crazy. A figure eight support might help too? (Never hear about THOSE anymore).

Knee laterally dislocated at the joint: OK OP, which structures are damaged and how badly damaged ? Think maybe there's going to be a little swelling? (Heck, yayess). Fun part of that leg is going to be getting pt onto a litter and into the ambulance…or through a narrow house doorway.

 

[Handsome Robb]

If the limb has to be moved slightly to facilitate splinting or extrication, then usually morphine / fentanyl and heavy use of methoxyflurane inhaler works wonders. If they use the inhaler properly for a short period they will forget they have a limb :rofl:



Recent example was elderly patient with obvious # NOF sitting on bed, any movement caused him severe pain, but we had to get him supine. 10mg IV morphine followed by heavy methoxy use put him in a short term but safe dazed state to be able to move him.

I would kill for the green whistle here.

FDA hasn't approved it

 

[Akulahawk]

Lets say you guys come across a patient with a fairly grossly angulated extremity fracture or a patient who was reluctant to move the limb into an easier to splint/transport position; but the limb has a good distal circulation.
Maybe the patient is lying supine with a shoulder injury and the arm is outstretched at a 90 degree angle. They don't want to bring the arm closer to the body due to the pain, would you splint and transport in this awkward position ?
How do you guys deal with these situations ?

Generally, I'd splint how it was found. While the limb may be visually gruesome, if there's good distal sensation/motor/circulation, I'm not going to disturb a "good thing" unless I absolutely have to. What that means is there's no possible way to extricate or transport without disturbing the limb somehow out of the splinted position. If I have to do that, I'll "fall back" on my own education/training and make something work. Then again, while I'm no MD, I'm certainly a bit more educated than the average Paramedic in this kind of thing. There are a few medics here that have a similar education...

 

[Legal Eagle]

Great info everyone!

 

[blachatch]

So if you loose distal PMS how do you guys like to do things?? Heavy pain management and attempt to realign once?

Anyone have any good info on realigning fractures out in the field?

 

[Handsome Robb]

So if you loose distal PMS how do you guys like to do things?? Heavy pain management and attempt to realign once?



Anyone have any good info on realigning fractures out in the field?

Here's some midazolam...here's some fentanyl....this is gonna hur...no it's not he's sleeping.

 

[mycrofft]

1. Do your protocols allow purposeful realignment in the field (without X-ray and doppler)?
2. If I heavily medicated the pt and then started "realigning" stuff, I'd be afraid the pt couldn't tell me I've made it worse.

We used to use Valium in the ED for realignments. Dose them, watch them quietly for five minutes or so, then either we would realign or the weight we had attached already would do the job (shoulders particularly).

OP, rule of thumb: if what you do causes more pain, there's a fair chance it was not the right thing. Not "OWWoh, much better!", but "OWWWWWWWWWWWW". Follow your protocols.

 

[Medic Tim]

I would medicate with ketamine or a narc + benzo before I did any splinting or realigning . If there is distal pulse splint in the position of least discomfort for the pt. if there is no pulse it will depend on my transport time and what level hospital I am going to wether I will attempt to realign.

 

[mycrofft]

Demerol plus Valium used to work well when Demerol (meperidine) was in vogue. They both make you not care so much what's going on.

 

[Medic Tim]

Demerol plus Valium used to work well when Demerol (meperidine) was in vogue. They both make you not care so much what's going on.

Ketamine is great for procedural sedation. Especially if you add a benzo and or narcs with it .

I also have entonox which works well.