View Full Version : Resetting compound fractures
hawaiian126
09-22-13, 15:07
Hi
a quick question and I know that it is very dependent on the situation, but in the case of a compound fracture is it necessary to reset the bone.
I would rather wait for emergency personnel but like when I was hiking yesterday and the guy slipped off the side into a ravine, best to control the bleeding and not reset it. But if help isnt coming for quite a while say 6 hours to a day or more , should it be reset and splinted?
Thanks Guys
Control bleeding, dress it, splint it (just to immobilize if no one is coming for awhile). Don't reset it. Leave it alone.
I don't see how re-setting it could be beneficial in any way, even if rescue is a long ways off, or even non-existent. You can't improve upon a compound fracture in the field. It would be unimaginably painful and could quite possibly do a lot more damage than good- severing more/more important blood vessels, further splintering the bone, enlarging the wound, etc. Control the bleeding as best as possible, immobilize as best as possible, and do what has to be done.
BruceLeroy
09-24-13, 22:42
Sam splint guaze and some ace wraps will fix almost anything. There is almost no need for most of the high dollar stuff in most situations. These items are the 550 c8rd and duct tape of the medic world. And dont forget training and practice! I would not reset anything! Too much liability and you most likely cant maintain traction.
Infection is the worry, not fracture reduction. Aligning the bones can happen anytime in the first two weeks. Leave that to the professionals. The patient's going to he OR anyway.
As the previous posters have stated. Control bleeding, immobilize, treat for shock, cold packs and check below the Injury for a pulse. Due to the nature of the of compound fractures, they general require an open reduction to glue the puzzle pieces/fragments together with plates, screws, pins and mesh.
I wish I still had access to my xrays of my left forearm I broke in three places. Within 20 minutes, my left arm was 4" shorter than my right from just muscle contraction. The swelling wasn't bad but the pain from the splinters grinding around inside even after be splinted would test you. The bleeding wasn't bad but it was fresh bone that poked through and I was worried about infection.
Infection is the worry, not fracture reduction. Aligning the bones can happen anytime in the first two weeks. Leave that to the professionals. The patient's going to he OR anyway.
Control bleeding, dress it, splint it (just to immobilize if no one is coming for awhile). Don't reset it. Leave it alone.
Me thinks Hmac is an SME on this one.
My own experience with open fractures echoes the above. Adding... The amount of pain and bleeding depends on the structures involved. A recent one didn't bleed much, nor did the patient experience much pain until later. Except for the emotional response, you might even have found it downright underwhelming.
I agree with all of the recommendations. However, there is one instance where an attempt at reduction is reasonable even by a layperson:
If the extremity is pulseless AND definitive treatment is more than a few hours away, a single attempt at reduction via gentle traction to restore anatomical alignment is not unreasonable. The goal is to restore blood flow and nothing else at that point. This goes for open or closed fractures where circulation is compromised. Once aligned, the extremity should be splinted. If pulses are not restored with this single attempt, do not try again - just splint it and get them to a hospital
I am repeating for emphasis that this should only be done when access to care is going to be significantly delayed.
Hi
a quick question and I know that it is very dependent on the situation, but in the case of a compound fracture is it necessary to reset the bone.
I would rather wait for emergency personnel but like when I was hiking yesterday and the guy slipped off the side into a ravine, best to control the bleeding and not reset it. But if help isnt coming for quite a while say 6 hours to a day or more , should it be reset and splinted?
Thanks Guys
Leave it. Infection alone can be a killer, not to mention pain, tearing up more tissue, etc. You can realign a bit if needed to get onto a stretcher or something, but just let the orthopod do what s/he gets paid to do.
It was my understanding that resetting the fracture is supposed to relieve pain and that, along with re-establishing a distal pulse, are the reasons for resetting a fracture. Not realignment of the bones.
Although in our current protocol it is not an injury to focus on, unless it is the sole injury or we need to care for the pt over an extended period of time, we are taught how to reset fractures and to splint/fix them. Although personally I would be very catious if I was resetting a fracture without a dedicated piece of equipment. Ideally I would have either a Kendrick splint or a Vacuum Splint available.
Only ever dealt with a closed ankle fracture myself, although I did not know it at the time. Treated it as a fracture, as the pt presented with swelling, discoloration, severe pain and reduced function. Splinted it and evac'd to the doctors office. They established it to be a fracture, sent him to hospital where x-rays showed it to be extremely complicated, resulting in the pt being dismissed from his conscript service after the surgery.
Splint it and cover it/dress it. Reducing it will drag more bacteria and foreign material into the wound making infection a higher probability.
It was my understanding that resetting the fracture is supposed to relieve pain and that, along with re-establishing a distal pulse, are the reasons for resetting a fracture. Not realignment of the bones.
Resetting any fracture in a civilian setting is a bad idea. I know all you guys have your fancy 20-lb IFAKs strapped to your rifle stocks, but resist. Just resist. Splint it so that the patient can be moved comfortably. If it's a compound fracture, cover it...and get the patient to someone who knows what they're doing.
Relieve pain? Give morphine. No morphine? Keep the patient still until the ambulance arrives with morphine. Restore blood supply? Sheesh. I recall a thread recently here of extensive mental masturbation where it was finally decided (I think) that we could apply tourniquets for hours on end without ill effect. So you have a kinked artery. What happens when your attempt at reduction lacerates that artery? (Wait....I know....apply a touriquet.)
Compound fractures are serious shit and the ability to screw them up vastly exceeds the ability of any first responder to improve anything. Leave them alone. What the patient needs above all else is X-rays, antibiotics, an orthopedic surgeon, an operating room, and someone who can drive an ambulance safely.
This subject has been beaten into submission IMHO.
Hmac- What are your feelings on the use of traction splints on open femur fractures? Open fracture is a contraindication in some systems and outside protocol. Allowable, in others. Some backcountry/WEMS programs teach improvised traction splints for long hauls or long waits. Your thoughts?
In this rural ALS EMS environment, we don't use traction splints on open femur fractures primarily because of the manipulation necessary to get it on, not to mention the vociferous request of our Orthopedic Department. Immobilization for comfort for a long ambulance ride is good, but personally I'm opposed to splinting an open fracture.
I've seen almost everything but a compound and thankfully I can say that. I think really bad compounds I have seen in training pics and on the web give me goosebumps and chills :/
Resetting any fracture in a civilian setting is a bad idea. I know all you guys have your fancy 20-lb IFAKs strapped to your rifle stocks, but resist. Just resist. Splint it so that the patient can be moved comfortably. If it's a compound fracture, cover it...and get the patient to someone who knows what they're doing.
Relieve pain? Give morphine. No morphine? Keep the patient still until the ambulance arrives with morphine. Restore blood supply? Sheesh. I recall a thread recently here of extensive mental masturbation where it was finally decided (I think) that we could apply tourniquets for hours on end without ill effect. So you have a kinked artery. What happens when your attempt at reduction lacerates that artery? (Wait....I know....apply a touriquet.)
Compound fractures are serious shit and the ability to screw them up vastly exceeds the ability of any first responder to improve anything. Leave them alone. What the patient needs above all else is X-rays, antibiotics, an orthopedic surgeon, an operating room, and someone who can drive an ambulance safely.
This subject has been beaten into submission IMHO.
Copy.
Appreciate the reply, despite the facetious tone ;-)
And yes, we do have Kendrick splints and vacuum splints available.
Fractures are not high on the list of priorities in our current protocol, so it's not something we spend much time focusing on. Most of my focus is on first aid in a military setting.
With that, if we look at a military setting and you have a casualty with a compound fracture, and you have to evacute the pt over a long distance; what would your recommendation be then? We are not always in areas where eeither ground vehicles or helicopters can get in or out of, due to either terrain or tactical situation.
Do you splint it? Can't that cause the same issues you are worried about, with regards to lacerating vessels? Do you leave it alone, with the knowlegde that rough handling can cause the same issues with regards to causing further injuries, in addition to causing more pain?
Prolonged pain will also compromise the immune system, affecting pt's ability to fight off infections. Sure, we have pain meds and antibiotics, but not in an unlimited supply. Not every patrol/squad has a medic with medication either.
Not being confrontational, sincerely asking a question.
Not everyone has the luxury of calling 911 and waiting for the ambulance.
Copy.
Appreciate the reply, despite the facetious tone ;-)
And yes, we do have Kendrick splints and vacuum splints available.
Fractures are not high on the list of priorities in our current protocol, so it's not something we spend much time focusing on. Most of my focus is on first aid in a military setting.
With that, if we look at a military setting and you have a casualty with a compound fracture, and you have to evacute the pt over a long distance; what would your recommendation be then? We are not always in areas where eeither ground vehicles or helicopters can get in or out of, due to either terrain or tactical situation.
Do you splint it? Can't that cause the same issues you are worried about, with regards to lacerating vessels? Do you leave it alone, with the knowlegde that rough handling can cause the same issues with regards to causing further injuries, in addition to causing more pain?
Prolonged pain will also compromise the immune system, affecting pt's ability to fight off infections. Sure, we have pain meds and antibiotics, but not in an unlimited supply. Not every patrol/squad has a medic with medication either.
Not being confrontational, sincerely asking a question.
Not everyone has the luxury of calling 911 and waiting for the ambulance.
Not a practical consideration. In civilian US practice, just do the job as it occurs 99.9% of the time. If you're any good at it, you will be able to improvise, adapt and overcome the rest of the time. You want to poke into the extremes. Waste of time. We can postulate "what ifs" all day.
You want to poke into the extremes. Waste of time. We can postulate "what ifs" all day.
With all due respect, "what if's" are the foundation of every military plan.
[QUOTE=Arctic1;1763195]
With that, if we look at a military setting and you have a casualty with a compound fracture, and you have to evacute the pt over a long distance; what would your recommendation be then? We are not always in areas where eeither ground vehicles or helicopters can get in or out of, due to either terrain or tactical situation.
Do you splint it? Can't that cause the same issues you are worried about, with regards to lacerating vessels? Do you leave it alone, with the knowlegde that rough handling can cause the same issues with regards to causing further injuries, in addition to causing more pain?
QUOTE]
FWIW, you're thinking too hard.
Compound fractures = splint. Doesn't really differ than a closed fracture. The only difference, as mentioned above, is if there's a pulseless extremity (and in real world, you're looking at 4-6 hours before limb loss is a possibility - ideally). Really, that's about the only time you're justified in attempting to straighten a limb. And even then, you only manipulate enough to restore pulse, not maintain anatomic alignment.
As for pain, it's from the muscle contraction. They hurt. Get over it. Have your medic/corpsman give some morphine, or a fentanyl pop, and drive on. Traction more than realignment will help. But the only bone that's regularly tractioned is the femur, and that's because you can bleed 1-2 liters into the thigh and not know it (hello, stage 2 shock).
Infection? It's infected the second it happens. Cover the open area with as sterile a bandage as you have, pop your combat pill pack (Which has an antibiotic) and get to higher care. Try not to screw it up with more dirt, grass, bullets, etc.
Long transport? That's WHY you splint, to prevent further damage. Yes, lacerated vessels happen. By splinting it, you try and prevent further damage. Typically traction isn't going to cause much tissue damage, since the sharp bone fragments are being pulled 'backwards' and not being allowed to slice.
To Skintop specifically, protocols vary, but if you take a contaminated bone fragment that's in the environment, and jam it back into a closed muscle and let it seal up, you just introduced all sorts of pathogens back into a patient. IMO, it's a horrible idea. let the ortho docs wash it off then realign. Literally, they can go through gallons of fluid irrigating a joint or bone fragment.
With all due respect, "what if's" are the foundation of every military plan.
I'm not talking about "military plans". I'm talking about civilian EMS in the United States. This has nothing to do with your management of a compound fracture on the battlefield under enemy fire. You're on your own there, and you will have to use your training, experience, and imagination to deal with it. Good luck.
I'm not talking about "military plans". I'm talking about civilian EMS in the United States. This has nothing to do with your management of a compound fracture on the battlefield under enemy fire. You're on your own there, and you will have to use your training, experience, and imagination to deal with it. Good luck.
Ok, point taken, thanks.
FWIW, you're thinking too hard.
Compound fractures = splint. Doesn't really differ than a closed fracture. The only difference, as mentioned above, is if there's a pulseless extremity (and in real world, you're looking at 4-6 hours before limb loss is a possibility - ideally). Really, that's about the only time you're justified in attempting to straighten a limb. And even then, you only manipulate enough to restore pulse, not maintain anatomic alignment.
As for pain, it's from the muscle contraction. They hurt. Get over it. Have your medic/corpsman give some morphine, or a fentanyl pop, and drive on. Traction more than realignment will help. But the only bone that's regularly tractioned is the femur, and that's because you can bleed 1-2 liters into the thigh and not know it (hello, stage 2 shock).
Infection? It's infected the second it happens. Cover the open area with as sterile a bandage as you have, pop your combat pill pack (Which has an antibiotic) and get to higher care. Try not to screw it up with more dirt, grass, bullets, etc.
Long transport? That's WHY you splint, to prevent further damage. Yes, lacerated vessels happen. By splinting it, you try and prevent further damage. Typically traction isn't going to cause much tissue damage, since the sharp bone fragments are being pulled 'backwards' and not being allowed.
Not really overthinking it, as much as trying to apply the advice given by Hmac for civilian care to a military setting. And as he pointed out, it doesn't.
And I am aware of the treatment protocols, and like I said previously I won't usually bother with fractures unless I am caring for the pt over an extended period of time.
Gutshot John
10-04-13, 10:19
I think it's always worth remembering that as medics we should always be governed by calculated risks.
"Do no harm" means you don't attempt anything without a reasonable expectation of improving survivability/outcome.
Femur fractures suck and are extremely painful. Reducing a fracture/dislocation sucks and are both extremely painful.
What are you gaining by causing that much pain without the appropriate equipment/capability?
An MCI/Battlefield conditions will profoundly impact that calculus, as does having a stocked ambulance with a trauma center within 10-15 miles.
1. In general I see no virtue of even thinking of reducing a compound fracture without a lack of distal pulse.
2. Once you've made the decision that it might make sense, you have to consider whether conditions preclude taking such a risk.
Even if conditions 1. and 2. were satisfied, I'd have a hard time justifying taking the time to do it if a trauma center/OR were within the hour.
A lot more other things I'd be working on first if I was on a battlefield or in the midst of an MCI.
Just because you CAN do something, doesn't mean you SHOULD do something.
I'd also say that reducing any kind of fracture or dislocation can result in significantly worse outcome if you don't know what precisely you're doing. I would really only consider a traction splint for a closed femur fracture.
A lot more other things I'd be working on first if I was on a battlefield or in the midst of an MCI.
Completely agree.
LowSpeed_HighDrag
10-05-13, 04:48
I had a proximal femur fracture (jagged break in half). Medics attempted to set it/splint it, talking about it being a hip dislocation. A few hours later, the real docs stated something to the effect of them causing more damage than good with their nonsense. Not sure how much that helps, but that was my painful experience.
Gutshot John
10-05-13, 08:13
I had a proximal femur fracture (jagged break in half). Medics attempted to set it/splint it, talking about it being a hip dislocation. A few hours later, the real docs stated something to the effect of them causing more damage than good with their nonsense. Not sure how much that helps, but that was my painful experience.
Sadly a not-uncommon mistake with those that don't know any better.
I'm guessing one leg was shorter than the other and they didn't pay attention to the rotation or lack thereof.
Did they try to use a traction splint?
Resetting any fracture in a civilian setting is a bad idea. I know all you guys have your fancy 20-lb IFAKs strapped to your rifle stocks, but resist. Just resist. Splint it so that the patient can be moved comfortably. If it's a compound fracture, cover it...and get the patient to someone who knows what they're doing.
Relieve pain? Give morphine. No morphine? Keep the patient still until the ambulance arrives with morphine. Restore blood supply? Sheesh. I recall a thread recently here of extensive mental masturbation where it was finally decided (I think) that we could apply tourniquets for hours on end without ill effect. So you have a kinked artery. What happens when your attempt at reduction lacerates that artery? (Wait....I know....apply a touriquet.)
Compound fractures are serious shit and the ability to screw them up vastly exceeds the ability of any first responder to improve anything. Leave them alone. What the patient needs above all else is X-rays, antibiotics, an orthopedic surgeon, an operating room, and someone who can drive an ambulance safely.
This subject has been beaten into submission IMHO.
Nothing more then this needs to be said.... this is exactly what I would recommend.. I am an Emergency Room attending at a trauma center...
I was an EMT back in the late 80's, Two times in the field before transport came I set , or stretched a leg back . No one wants to be the one putting the leg back. With out pain meds. in and working there are some very tense moments , but pain is less with the leg is in traction and stretched back. Not out in the woods stuff. Every Bear in miles will hear the screams and smell a hot lunch. Be ready !
We all did stupid stuff back in the 80's. Thank god we know better now.
Not really overthinking it, as much as trying to apply the advice given by Hmac for civilian care to a military setting. And as he pointed out, it doesn't.
And I am aware of the treatment protocols, and like I said previously I won't usually bother with fractures unless I am caring for the pt over an extended period of time.
I disagree; civilian care is essentially the same as military. I'd lean towards civilian EMS as "better" for this, since most medics/corpsmen don't see many fractures . Nothing I said directly contradicts HMAC. The only difference between most military care and civilian is evac times (excluding, of course, MCI, active firefight, etc).
LowSpeed_HighDrag
10-10-13, 05:28
Sadly a not-uncommon mistake with those that don't know any better.
I'm guessing one leg was shorter than the other and they didn't pay attention to the rotation or lack thereof.
Did they try to use a traction splint?
On scene I have limited knowledge/memory of what they did. I want to say that I was in traction in the ambulance as I remember my foot elevated and a sever burning pain in my foot for some reason.
I disagree; civilian care is essentially the same as military.
Without getting into a lengthy argument, I'll just say that I disagree and that in my opinion TACMED is totally different from civilian medicine, with regards to situation, training/skill level, personnell and resources. It's akin to a civilian health worker rejecting pediatrics on the premise that children are nothing more than miniature adults.
Without getting into a lengthy argument, I'll just say that I disagree and that in my opinion TACMED is totally different from civilian medicine, with regards to situation, training/skill level, personnell and resources. It's akin to a civilian health worker rejecting pediatrics on the premise that children are nothing more than miniature adults.
We'll have to agree to disagree. Priorities change (direct pressure vs TQ, evac times, care under fire), but physiology doesn't. Blood goes around and around, air goes in and out, messing with either causes trouble. It's not that the treatment or equipment is all that different, it's just applied in a different order. Wilderness EMS is probably closer to TACMED, but overall you're using a skillset to keep someone alive and prevent further injury.
Physiology doesn't change, but the very essence of prehospital care is defined by the environment and circumstances in which it's provided.
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