Resetting compound fractures

[ftbear]

Splint it and cover it/dress it. Reducing it will drag more bacteria and foreign material into the wound making infection a higher probability.

[Hmac]

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.

[ST911]

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?

[Hmac]

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.

[Javelin]

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 :/

[Arctic1]

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.

[Hmac]

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.

[Arctic1]

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.

[Caduceus]

[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.

[Hmac]

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.