Distracting Injuries Mask Serious Symptoms

 

 
 
 

Edward T. Dickinson, MD, NREMT-P, FACEP | Jon Politis, MPA, NREMT-P | From the January 2011 Issue | Saturday, January 1, 2011

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Painful Distractions

The importance of splinting & managing the pain associated with fractures.
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This clinical review feature article is presented in conjunction with the Department of Emergency Medicine Education at the University of Texas Southwestern Medical Center, Dallas.

Learning Objectives
>> Discuss the importance of patient assessment as it pertains to orthopedic injuries.
>> Define and describe distracting injuries and their potential effect.
>> List the importance of, and strategies for, pain management in the orthopedic patient.
>> Explain the importance, purpose and methods of splinting.
>> Describe a common concern for open fractures.

Glossary Terms
Acetabulum: A cup-shaped cavity found on the hip bone that receives the head of the femur.
Brutacaine: A colloquialism that refers to simply holding a patient down and performing the necessary medical procedure. The result may be crying, thrashing, unpleasant memories and fatigue on behalf of the staff and patient. 
Colles fracture: A fracture of the distal radius with posterior displacement of the wrist.
Distracting injury: A painful or grotesque injury that draws the attention of a health-care provider or patient away from a more serious, life-threatening injury.
Hamstring: One of three posterior thigh muscles.
Quadriceps: A muscle found in the anterior thigh.
Somatic pain: Pain that originates from skeletal muscle, ligaments, vessels or joints.

It’s a quiet afternoon because ski lessons are in progress, and the conditions are great. Then, you’re called to a wreck on the bunny slope. It’s the quintessential beginner trail, and generations of skiers have made their first ski run there. As you approach with your gear on the sled, you see a 4-year-old lying in the snow and screaming.

The child’s mom tells you she was skiing down with her son when she accidentally fell on him. He’s so upset that any attempt to localize what hurts and obtain a reliable exam is almost impossible. His screams tell you he clearly has an open airway.

The Cascade (transport) sled arrives, and he’s immobilized to a backboard and transported to the ski-patrol base. Once he’s been moved onto the bed and is in a warm environment, you start to remove clothing to do a better examination. It’s hard to believe what you’re seeing: a 4-year-old with a huge, right thigh deformity and a leg that’s shortened. It looks like an obvious femur fracture. He’s in incredible pain, and although you’re a paramedic, you’re working on a BLS level. “Brutacaine” is the only drug you have. And in almost 40 years, it’s the first 4-year-old patient you’ve ever seen with a femur fracture. If that’s not enough of a stressor, a staff member tells you he cannot find the station’s traction splint.

Your lack of experience with pediatric femur fractures and a missing piece of equipment doesn’t matter; it’s time to rely on the muscle memory developed from many years of EMS and ski patrol refreshers. You need to use the child’s ski pole to improvise a traction splint.

Gentle manual traction is applied, which initially causes increased pain, as you anticipated. Then, the improvised traction splint is applied and the leg secured. Within five minutes the muscle spasm of the patient’s quadriceps and hamstring groups subsides, and his pain and crying both begin to subside as well.

The area’s EMS crew arrives and is amazed by the ski pole traction splint. Because the improvised splint has been so effective in controlling the young patient’s pain, they decide to leave it in place rather than trying to replace it.

Fracture Assessment
EMS providers frequently see extremity fractures and dislocations. They’re so common that we often become calloused and dismiss them as being routine. But fractures are often invisible to the assessor’s eyes and involve injury to muscles, blood vessels, tendons or ligaments. They can cause both short- and long-term disability.

Failing to properly splint and care for fractures is not only inhumane, but it can also result in unnecessary secondary injuries and long-lasting complications for a patient. A simple Colles fracture of the wrist can be extremely painful and cause an extended period of immobility for an individual, months of physical therapy and a loss of some wrist function.

EMTs and paramedics who have had extremity fractures usually look at these routine injuries in a completely different light and are aware of the pain, secondary injuries and complications that can occur. However, those who haven’t had the same personal experience frequently treat them incorrectly as simple, minor calls.

A fracture is often described as a distracting injury. In reality, a fracture is potentially distracting to the patient and the prehospital provider. For patients, a fracture’s associated pain may mask life-threatening injuries, such as a C-spine fracture or other internal injuries. For the rescuer, the grotesque presentation of the fractured extremity can influence field care when the provider falls in the trap of being mesmerized by the gross, non-life-threatening injury and misses the subtle signs of more serious injuries. The net result is that the distracting nature of fractures makes patient assessment more difficult.

Regardless of how much pain a patient presents to you, performing a good assessment is critical. Patients rarely die from extremity injuries, but they do succumb to injuries to the head, neck, chest, abdomen and pelvis. A hypotensive patient with an obvious fracture must be treated differently from one who’s stable. A good assessment indicates how much time the patient has.

The vast majority of patients with extremity injuries is stable and needs an orthopedic assessment, pain control and careful splinting. The unstable patient needs rapid immobilization with a spinal immobilization device, minimal scene time and a safe, smooth—but rapid—ride to an appropriate hospital facility.

EMS responders can become so focused on the injury that it’s easy to overlook other problems. In addition, painful injuries often cause patients to focus on one area of pain over another. A patient with a painful leg fracture may not reveal other areas of injury until palpated or inspected. This is one of the key reasons why it’s difficult to clear a patient’s spine if they have a long-bone fracture. A fracture is considered a painful distracting injury and makes the rest of the physical exam potentially unreliable. Although the patient will usually point you to the injured extremity, providers must first do a thorough head-to-toe examination.

Manage Pain
It’s been reported that 90% of the patients accessing the health-care system are doing so because of pain. Today, pain management must be an integral part of out-of-hospital orthopedic care. The pain from a fracture is referred to as somatic pain, which can be intense and easy for patients to localize, especially when the fracture is moved and sharp bone ends poke the soft tissue. Even without movement, pain associated with a break in the bone ranges from a dull ache, to an intense pain.

There are three strategies for pain control when treating fractures: distraction, splinting and pharmacology.

Distraction is a non-invasive and effective method of reducing pain. It usually involves carrying on an active, concerned dialogue with the patient and doing such things as placing a cold pack over the injury. Although not as good as many of the pharmacologic interventions, talking to a patient and getting them involved in conversation helps them focus their attention on things other than the fracture.
Some practitioners overlook distraction, but it’s a simple technique to help the patient. This is especially true when treating a patient in a situation where pharmacologic pain therapy will be delayed or isn’t available. Also keep in mind that a cold pack provides sensory input that can reduce pain and can help distract the patient, as well as reduce some of the swelling associated with the fracture.

Splinting is another critical intervention aimed at both pain control and prevention of additional soft tissue injury. When jagged bone ends move, it hurts and can damage soft tissue in the area. Although splinting does little to relieve the dull ache of a fracture, it reduces the pain and prevents further injury by minimizing movement of the broken bone ends and the pain that can be associated with that movement.

Femur fractures have an additional painful component: muscular spasm with bones that over-ride each other. The traction splint is designed to exert a gentle pull on the leg, which causes the muscle spasm to subside and brings the jagged bone ends closer to their anatomical position.

Pharmacology is the use of medications to control pain. The use of narcotic pain control is the third pillar of effective and humane fracture management. Modern advanced care paramedics have excellent medications for analgesia available to them. Studies have shown that despite having pain medications available to them, paramedics administer these medications to fracture patients less than 20% of the time. Nationally, many ALS protocols now allow providers to administer narcotic analgesics on standing orders, overcoming potential delays in pain medication administration encountered when an on-line medical director’s approval has to be obtained prior to drug administration.

Drug Therapy
Morphine, a time-honored analgesic, has a peak effect of about 20 minutes and duration of action of two to four hours. One disadvantage of morphine is the release of histamine and the potential to decrease blood pressure. In addition, morphine causes nausea and vomiting in some patients. Although morphine works well for long-duration pain control, its slow onset of action is sometimes frustrating in the field when trying to manage a patient in severe pain. Morphine is typically given intramuscularly or via IV. The dose is 0.1 mg/kg, with normal initial adult doses ranging from 4–8 mg.

Fentanyl, a synthetic narcotic, is considered by many to be the ideal EMS analgesic drug. It has a rapid onset with analgesic effects reaching their peak in three to five minutes, and it has a duration of action of only 30–60 minutes. It doesn’t cause the same level of histamine release as morphine and is much less likely to cause hypotension.

Fentanyl can be given intramuscularly, IV or intranasally using a mucasol atomization device. The intranasal method of delivery is ideal for providing a rapid onset, needleless analgesic. This is of particular advantage for treating pediatric patients because using a needle can add to their anxiety.

Fentanyl also comes in a lollipop form that was originally developed for pediatric pre-operative treatment but is now being adopted for pain control in austere and wilderness environments. The dose of fentanyl is 1–2 mcg/kg with normal initial adult doses ranging from 50–100 mcg.

A number of studies have shown that EMS providers under-treat patients with analgesics.1,2 Another factor is simply having analgesic protocols that are too cumbersome and create an impediment to field administration. In order for patients to receive the proper analgesia for fractures, medical directors need to ensure that protocols and practices don’t cause impediments to the appropriate utilization of narcotics. In New Mexico, transitioning morphine to paramedics as a standing order rather than requiring on-line medical direction has proven to reduce the time to drug administration without increasing drug utilization.3

Angulated Fractures
One of the most intimidating situations EMS providers encounter is the screaming patient with an angulated fracture. Despite extensive training to align the extremity to an anatomical position, many crews attempt a splint-in-position approach because they fear increasing pain or causing additional injury. In reality, returning the limb to the anatomic position prior to splinting significantly reduces the pain and prevents further damage from occurring.

For injuries to joints, providers need to immobilize in the position found, with the exception of when neurovascular compromise is evident. Splinting a joint in the position found can present a daunting challenge: keeping the joint immobile. Many splints aren’t adjustable or moldable to fit the angles or positions of injured joints, forcing the crew to move an extremity to anatomical position or align them enough to use the splint. Therefore, splinting joints can require some ingenuity in the field.
Major nerves, arteries and veins are bundled together and run alongside long bones.

They’re sort of like a bundle of conduit carrying wires. The muscles that surround the bones and cause movement through the actions of tendons are also bundled together by a fiberous covering called fascia. When a bone fractures and displaces out of the anatomical space, the bone ends poke into the neurovascular bundle and muscle compartments. Therefore, leaving a long-bone fracture out of anatomical alignment and attempting to splint it in that position actually increases the risk of neurovascular and muscle injury.

‘Splintable’ Position
The best method to use to move an angulated extremity to its anatomical position is to use gentle traction on the extremity until it moves into a “splintable” or anatomical position. This is a painful procedure, but it will decrease the patient’s pain in the long run. Ideally, start by administering a fast-acting analgesic, such as intranasal fentanyl. Otherwise, you’ll have to use brutacaine or distraction and some gentle traction to position the fracture in its anatomical position.

Fractures to the femur, tibia/fibula, humerus and radius/ulna are all long-bone injuries commonly encountered by EMS, which can be moved to their anatomical position by exerting gentle traction.

Open Fracture Dilemma
Another confounding situation is an angulated, open long-bone fracture. One of the most common is an open tibia/fibula fracture. In this case, be sure to remove any clothing near the open, jagged bone ends before attempting alignment with gentle traction. Once the bone is exposed through the skin, infection becomes a major concern.

Although EMS providers shouldn’t attempt to pull back broken bone ends, they may slip back under the skin during the process of aligning the fracture for splinting. If an open fracture is obviously contaminated and needs to be aligned, it should be irrigated with sterile saline to wash away any dirt or contamination prior to alignment. All patients with open fractures will go to surgery for cleaning and debridement, and they will be started on IV antibiotics to combat any infection.

Sometimes, an angulated open fracture won’t slip into alignment because the bone ends become caught on skin. In this case, do the best you can to cover the wound and immobilize in the position found.

Splinting Tips
Femur fracture: The traction splint evolved from the battlefield experiences of World War I. Then, a soldier sustaining a femoral shaft fracture on the battlefield had an 80% mortality rate. The quadriceps and hamstrings muscle groups would spasm, causing the bones to “over-ride,” and the sharp bone ends caused vascular injury resulting in exsanguination and death.

Two surgeons, Keller and Blake, invented the “full ring” traction splint, which was later modified into a half ring by Thomas. The traction splint significantly reduced battlefield mortality from 80% to 20%. Its invention was intended to control bleeding as much as it was to immobilize the fracture of the femur.

In the late 1960s, San Diego police officer Glenn Hare invented the first modern traction splint that was easy to apply and self-contained. In the late ’70s, a single-pole traction splint known as the Sager splint was invented. Both types of mechanical splints made it easy to apply traction splints.

Traction splints are intended for fractures of the femoral shaft and can also be used on some hip fractures.4 Femur fractures are painful because the quadriceps and hamstrings go into a spasm when the femur breaks, which causes the bones to over-ride. The leg becomes shortened, and the thigh often has a grotesque appearance. When traction is initially applied, it’s pulling against muscles that are in spasm or cramping. For a short time—often for many minutes—the pain actually increases. Once the spasm subsides, the pain is greatly improved through the combination of traction on the muscles and better stabilization of the fracture site.
Ironically, it’s often difficult for EMS providers to have the gumption to put a splint on a screaming patient even though they know the splint will reduce the patient’s pain and bleeding at the fracture site.

In some wilderness settings, the traction splint may need to be left on for many hours or days and can cause some complications. For this reason, it’s controversial to use traction splints for femur fractures in rural settings.

In some EMS settings, traction splints are a humane way of treating patients with femoral shaft injury. Regardless of what kind of traction splint you have, become familiar with how to use it and apply it without hesitation when indicated.

Fractured hip: A fractured hip is in fact a fracture of the proximal femur. Because of its location, hip fractures don’t cause the same kind of muscle spasm or pain associated with femoral shaft injuries. Simple immobilization on a spineboard, vacuum mattress or scoop stretcher works well.

Clavicular fractures: Fractured clavicles or collarbones are common injuries and can be easily splinted with a sling and swath. One potentially serious injury related to clavicle fractures is a sterno-clavicular dislocation in which the medial clavicle is posteriorly driven behind the sternum. This can result in the medial clavicular head compressing vital mediastinal structures, such as the aorta. Patients with this injury will have point tenderness and swelling at the articulation of the clavicle and the sternum and may lack the normal mid-clavicular deformity associated with a fracture.

Humeral shaft fractures: Fractures of the humeral shaft usually align themselves if the patient is sitting. The weight of the arm simply pulls the humerus into anatomical position. Splinting usually involves a sling and swath.

Joint injuries and dislocations: Joints are complicated structures with bones, ligaments, cartilage and tendons that are further complicated by the neurovascular bundle running around them. When confronted with most joint injuries, it’s often difficult to tell if there’s a fracture associated with the joint, sprain or dislocation. For this reason, the rule of thumb for “front country” EMS is to evaluate motor, sensory and circulatory function and immobilize in the position found.

Shoulder dislocation: Most injuries to the upper extremity are caused by simply falling on an outstretched arm. The shoulder dislocation is no exception. The head of the humerous stretches and disrupts the joint capsule, and the head of the humerus anteriorly dislocates. The anterior dislocation is a common yet painful injury. The longer it’s dislocated, the more likely vascular and tissue injury will occur, and the harder it is to reduce back to normal position due to muscle spasm.

In many rural contexts, protocols allow wilderness rescuers to attempt reduction in certain circumstances. In the front country, however, no attempt should be made to move the joint unless nervous or circulatory impairment exists. Follow your local protocols.

If the patient is found with their arm close to the chest, it can be immobilized with a sling, swath and some padding. If the arm is being held away from the chest, fill the space between the arm and the chest with a blanket roll that’s held in place with cravats or straps.

Elbow dislocation: Elbow fractures and dislocations are often associated with neurovascular injury. They should be splinted in the position in which they’re found and not manipulated unless there’s nervous or circulatory impairment. SAM and vacuum splints work well. It’s especially important to conduct ongoing assessment of the patient’s neurological and vascular status distal to the injury.

Patella dislocation: Dislocating the patella usually happens with a direct injury or when the foot is planted and there’s extension of the knee while twisting. It’s not the same as a knee dislocation. Patients with patellar dislocations are usually found with a knee locked in flexion and the dislocated patella visible lateral to the knee.

A patellar dislocation, while painful, isn’t likely to cause any injury to nerves or blood vessels due to the structures’ lack of proximity to the patella. They’re also relatively easy to reduce, and some front country EMS systems allow providers to reduce this type of injury. Most don’t, however, and the knee must be immobilized in the position found. This is best accomplished with use of an adjustable splint, pillows or a vacuum splint. Narcotic analgesia is especially useful in caring for these patients prior to reducing the patella.

Knee dislocation: Knees are usually dislocated when the ligaments of the knee are completely disrupted, which often requires high kinetic energy. Because the joint is completely disrupted, they can reduce themselves when the patient’s moved to anatomical position.

The main problem with a true knee dislocation is vascular and nerve injury. Even when the joint has been reduced, the injury carries with it a high likelihood of vascular impairment. The dislocated knee must be immobilized with an adjustable splint, pillows or vacuum splint, and the provider should continually assess the patient’s distal neurological and vascular status.

Hip dislocation, (see photo, pg. 54, JEMS, January 2011): Most hip dislocations encountered by EMS providers are caused by a force transmitted along the long axis of the femur, usually from a high-speed frontal impact of the knee into the dashboard. These patients frequently have suffered multiple trauma and although the dislocated hip is the most painful injury, careful assessment for other injuries is critical.

Because of the mechanism of injury, these patients can also present with associated injuries to the knee (dislocation) and fractures to femur and posterior wall of the acetabulum as the femoral head is posteriorly dislocated. The typical position of the patient is supine with their knee flexed and rotated internally, (see photo below).

Sometimes it isn’t clear what the problem is: femur fracture, hip dislocation or both. If a midshaft femur fracture is obvious, begin the process of traction splinting and alignment with gentle traction. If the leg is “locked” and can’t be easily moved to a splintable position, there may be an associated hip dislocation. Stop the traction and immobilize in the position found. Immobilization usually requires a spineboard, scoop-style stretcher or vacuum splint with padding and body positioning.

Conclusion
Fractures and dislocations are common and painful injuries. The force it takes to cause one of these injuries is usually significant, so always be alert to the potential for non-orthopedic injuries.

Never allow the fracture or dislocation to become a distracting injury that causes you to overlook more immediate life-threatning injuries. The three fundamental interventions to manage these injuries and reduce patient suffering are distraction, splinting and pharmacology. The appropriate use of these three components of patient care will ensure optimal and compassionate care of patients with significant orthopedic injuries. JEMS

References

1. White LJ, Cooper JD, Chamber RM, et al. Prehospital use of analgesia for suspected extremity fractures. Prehosp Emerg Care. 2000;4:205–208.

2. McEachin CC, McDermott JT, Swor R. Few emergency medical services patients with lower-extremity fractures receive prehospital analgesia.Prehosp Emerg Care. 2002;6:406–410.

3. Fullerton-Gleason L, Crandall C, Sklar DP. Prehospital administration of morphine for isolated extremity injuries: A change in protocol reduces time to medication. Prehosp Emerg Care. 2002;6:411–416.

4. AAOS. Emergency Care and Transport of the Sick and Injured, 8th Edition. Jones and Bartlett: Sudbury, Mass. 670. 2002.


Fracture Management 101

> Don’t forget to check motor-sensory-circulation before and after splinting.
> Effective splints immobilize adjacent joints and broken bone ends.
> Pad the splint.
> Long bones need to be moved to a “splintable,” or anatomic, position.
> Immobilize joints in the position found unless circulation is compromised.
> If the injury is too close to the joint, presume that it’s a joint injury.
> Reduction of joint injuries depends on context: front country, no; backcountry, maybe.
> Most upper extremity injuries can be splinted to the torso.
> Most lower extremity injuries can be splinted to the uninjured leg.

This article originally appeared in January 2011 JEMS as “Painful Distractions: How to treat orthopedic injuries.”



Painful Distractions

Gallery 1

Splinting 1

Photo Courtesy Ed Dickinson


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Splinting 2

This patient has a posterior hip dislocation from a motor vehicle crash.(Photo Courtesy Ed Dickinson)


Gallery 1

Splinting 3

A classic Colles fracture.Add padding to gently fill voids between the extremity and the splint. (Photo Courtesy Jon Politis)


Gallery 1

Splinting 4

This patient has an acute knee dislocation.(Photo Courtesy Ed Dickinson)


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Splinting 5

The Reel Splint has a dozen adjustment areas that allow you to easily and securely splint an angulated fracture or dislocation in position.(Photo Courtesy Art Vandalay)



Connect: Have a thought or feedback about this? Add your comment now
Related Topics: Patient Care, Pain Management, Trauma, somatic pain, Jon Politis, Ed Dickinson, distracting injury, Colles fracture, brutacaine, acetabulum, Jems Features

 

Edward T. Dickinson, MD, NREMT-P, FACEPis an associate professor and director of prehospital field operations in the Department of Emergency Medicine, Hospital of the University of Pennsylvania in Philadelphia.

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Jon Politis, MPA, NREMT-PJon Politis, MPA, NREMT-P, is the chief of the Colonie EMS Department in upstate N.Y. An active EMT since 1971, he has been a career firefighter, state EMS training coordinator for Vermont and New York and a paramedic training program coordinator. He has served on the National Registry of EMTs board and on the Committee on Accreditation for the EMS Professions.

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