closed fractures - icrc.aoeducation.org fileclosed fractures scenario closed fracture management pop...
TRANSCRIPT
CLOSED FRACTURES
SCENARIOCLOSEDFRACTUREMANAGEMENT
POPIMMOBILIZATIONPOPAFTER-CAREANDFOLLOWUP
REMOVINGCASTSTRACTION
PAEDIATRICCONSIDERATIONSTRANSFERS
MANAGEMENTOFCLOSEDFRACTURESWITHINTERNALFIXATION
SUGGESTEDRESOURCESREFERENCES
7
70 MANAGEMENT OF LIMB INJURIES DURING DISASTERS AND CONFLICTS
CHAPTER 7 I CLOSED FRACTURES
TYPE 1
• Treatnon-displacedclinicalfractureswithimmobilization(backslab,splint-ing)butNOTcircumferentialcasts.
• Provideanalgesiaandmobilityaidssuchascrutchesorwalkingframesfortheelderly.
• Referpatientstohigherlevelsofcarewith:limbdeformities,neurovascularinjury,majortrauma(tibial/femoralfractures)oranyinjurythatcannotbemanagedlocally.
• Ifavailable,radiographymaypreventunnecessarytransfers.
TYPE 2
• Plainradiographyrequired• Treatwithimmobilization(splints/
plaster),tractionwithpinsandexter-nalfixation
• Earlyphysicaltherapytoimprovefunctionaloutcomesandpreventcomplications
TYPE 3
• Noopenreductionandinternalfixation(ORIF)intemporary(tent)structures.• Treatcomplexfracturesthatmaybenefitfrominternalfixation(periarticularor
intraarticular),onlyiftheteamisintegratedintothelocalinfrastructure.• Providehigherlevelsofmedicalandintensivecare.
SCENARIOIt is 5 days post earthquake.
A25-year-oldmanwithaclinicaldiagnosisofaclosedfractureofthemid-shaftoftheleftfemurisbroughttothemedicalfacility.
Anelderlywomanwithaswollen,unstablekneepresents.Shefellduringtheearthquakeandhasbeenunabletobearweightsinceherfall.
A 6-year-old girl presents after a fall fromadamagedbuilding thenight prior.Her leftelbow isgrosslyswollen,deformed,andnoradialpulseispalpable.
The goals of treatment of closed fractures should include:
» Avoid infection – first do no harm (such as through unsafe internal fixation).
» Optimize functional outcomes and minimize pain.
» Promote fracture union with acceptable length, rotation and alignment.
» In the upper limb, mobility is a priority over stability.
» In the lower limb, stability is a priority over mobility.
71
CHAPTER 7 I CLOSED FRACTURES
MANAGEMENT OF LIMB INJURIES DURING DISASTERS AND CONFLICTS
CLOSED FRACTURE MANAGEMENT
TYPE 1
Iflimbalignmentisnormalbutafractureissuspectedorconfirmedonradiology,asplintorcastshouldbeappliedtomaintainthepositionandreducepain.
NON-DISPLACED FRACTURES» Applicationofcastsandsplintsforfractureswithacceptablepositioninthewrist,forearmand
humerusmaybeappliedwithoutsedation.
» Applicationofcastsfornon-displacedfracturesofthetibiaisdifficultandshouldbeperformedinadesignatedroomwheresedationcanbeprovidedifnecessary.
TYPE 2
Allpatientswhorequireclosedreductionoffracturesandapplicationofsomeformofimmobilizationshouldbemanagedinadesignatedareawheresafeanaesthesiaorsedationcanbeprovided.
DISPLACED FRACTURES REQUIRING REDUCTION » Intheimmediatepostinjuryperiod,backslabsratherthanfullcircumferentialcastsarepreferred.
» Abi-valvedplastercastofthistypeiseasierforfamilytoremoveifnecessary,buthasahigherincidenceoflossoffracturereduction.
» Onmostoccasionsthisbivalveapproachisthesaferoptioniffollowupisofconcern.
» Followupwithallpatientswithlimbsimmobilizedinfullcastsisessential.
» Ifthisisnotpossible,selectthosepatientsmostlikelytohavecomplicationsduringthehealingprocess:
• Patientswithfracturesthatrequiredreduction• Allpatientswithcircularcastsinordertoruleoutissueswithcastpressure• Patientswithfracturesinvolvingtheelbow• Patientswithfracturestreatedveryclosetothetimeofinjury,asthesecanhaveanincreasedriskofproblematicswelling.
• Patientswhounderwentclosedreductionwhileasignificantamountofswellingandoedemawerestillpresent.
72 MANAGEMENT OF LIMB INJURIES DURING DISASTERS AND CONFLICTS
CHAPTER 7 I CLOSED FRACTURES
SPECIALIST SURGICAL TEAMS» If possible, all closed fractures should be initially treated in a closed fashion to minimize
complications, particularly infection, despite the longer treatment times associated with thisapproach.
» Articularandperiarticularfractureswhichcouldbenefitfromdelayedinternalfixationshouldonlybeperformedinfacilitieswiththeexpertise,sterilityandequipmenttodothissafely.
» Surgical techniques must be adapted to the local environment. Exceeding the local technicalcapabilityinfracturemanagementcreatesproblemsforpatientsandstaffalikewhencomplicationsarise.Any patient that has a fracture immobilized must have a follow up plan for review.
» Internal fixation uses up limited resources and carries a high risk of infection in disasters and in conflict.
» ORIF should only be performed at appropriate facilities with a safe water supply, sterile of equipment, specialist surgical teams, appropriate nursing support, and physical therapy following surgery.
» Non-operative fracturemanagement andavoiding internal fixationmethods in the initial threeweekspostdisaster isnota reflectionof the technical capabilityof the surgeonbutof relatedresourcessuchas:
• contaminatedwatersupplies• co-locationof“clean”patientsinwardswithpatientswhohavewoundinfections.
TYPE 1
EMTtype1Facilitiesshouldhavetheequipmentandexpertiseavailabletoapplyandmanagearangeoflowerandupperlimbimmobilizationtechniquesinclud-ingsplintsandPlasterofParisbackslabsorcasts.
APPLYING CASTSCASTING MATERIALS
» Plaster of Paris (POP) is the casting and splinting material of choice.
» Itcanberemovedbysoakingandcuttingthewetplaster.
» Medicalteamswhocarryfiberglassasafracturemanagementsolutionshouldonlyusethismaterialforsplintsandnever for full castsinadisasterorinaconflictzone.
» Powerfailures,plastersawbreakage,andtransferofthepatienttoafacilitywithoutaplastersawallplacethepatientatriskofhavingacastthatcannotberemovedwithoutseriousrisktothecastedlimb.
73
CHAPTER 7 I CLOSED FRACTURES
MANAGEMENT OF LIMB INJURIES DURING DISASTERS AND CONFLICTS
PATIENT INFORMATION
» Patientswho have splints or casts appliedmust be providedwith a plain language statement,in theirfirst language, regardingcarewhile in thesplintorcast.Emphasis shouldbeplacedonreturningformedicalcareifpainisnotcontrolledbytheanalgesicsprovided.
» Patientsshouldbeencouragedtomobilizeevenwithoneextremitysplintedorcasted.
» Write the POP calendar on the cast –includingdateofapplicationofthecast,dateofremovalandX-ray.
DIFFERENT EXPECTATIONSWrite on tape secured to the cast the suspected diagnosis, name of provider,place, date, and a line drawnwhere thefracture is. This transcends languagebarriers and helps patient and familyunderstandthediagnosis. Figure 1.PlasterofPariscastwithpatientinforecordedonit.(ICRC)
POP IMMOBILIZATIONFABRICATION PROCEDURE OF POP CASTS AND SLABS PREPARATION OF THE NECESSARY MATERIALS » Prepareagoodnumberofplasterbandagesratherthanjustafewrolls,asthePOPshouldbemade
allatoncetoassurethecontinuityofitsstructure.
POSITION OF THE PATIENT » Adjustpositionwithcushionsandpillowsifrequired.» Morethanonepersonmayberequiredtosupportthefracturedlimb.» Themedicalprofessionalshouldbeinasuitablepositiontoworkwithoutobstructionordifficulty.
PROTECTION OF SENSITIVE AREAS » Cleananddrytheskinaswellaspossibletoavoidodouranddiscomfortinsidethecast. » ApplythestockinetovertheentireareatobecoveredwithPOP,plusanextralengthforfolding
backatbothextremities.
APPLY ADDITIONAL PADDING (COTTON WOOL OR SOFT BAND) OVER SENSITIVE AREAS» Areasthatshouldneverbecompressedandmustbewellpadded:
• Fracture site • Bonyprominences
• Nerves• Vessels
• Wounds
74 MANAGEMENT OF LIMB INJURIES DURING DISASTERS AND CONFLICTS
CHAPTER 7 I CLOSED FRACTURES
GENERAL PRINCIPLES» Neverputplasterdirectlyonunprotectedskin.» TheedgesofthePOPshouldbecoveredandnotchafeorpuncturetheskin.» Moldingshouldbedonewiththepalmsofthehandsandnotthefingertips.» Applicationshouldbecontinuoustoallowthecasttodryasasingle,solidpiece.» Checkanddocumenttheanatomicalandfunctionalpositionofthelimb.» ForunstablepatientsimmobilizationwithaPOPbackslaborskeletaltractionisfasterandeasier
thanplacinganexternalfixator.
DURATION OF IMMOBILIZATION» Ifproperlydiagnosedandtreatedwithimmobilization,fractures
ofdifferentbonesrequirevaryingperiodsofimmobilizationtoachieveunion.
BONEMOST COMMON
IMMOBILIZATION PROTOCOLS WITH
NO COMPLICATIONS
AVERAGE HEALING PERIOD WITH NO COMPLICATIONS
ADULT CHILD < 10 YEARS ADULT CHILD < 10
YEARS
Metacarpal 4-6weeks 2-3weeks 6weeks 4-6weeks
Scaphoid 8-12 weeks
8-10 weeks
15-20 weeks 12weeks
Carpal 4-6weeks 2-3weeks 6weeks 4-6weeks
Ulna 4-6weeks 3-4weeks 6-8weeks 4-6weeks
Radius 4-6weeks 3-4weeks 6-8weeks 4-6weeks
Humerus 4-6weeks 3-4weeks 6-8weeks 4-6weeks
Clavicie 4weeks 2-3weeks 4weeks 2-3weeks
Scapula 4weeks 2-3weeks 4weeks 2-3weeks
Ribs 4-6weeks 2-4weeks 4weeks 2-3weeks
Vertebral bones 6-8weeks 4-6weeks 12weeks 6-8weeks
Pelvic bones 6-8weeks 4-6weeks 6-8weeks 4-6weeks
Femur 6-8weeks 4-6weeks 12weeks 6-8weeks
Tibia 6-8weeks 4-6weeks 12weeks 6-8weeks
Talus 6-8weeks 4-6weeks 12weeks 6-8weeks
Calcaneus 6-8weeks 4-6weeks 12weeks 6-8weeks
Phalanges 4-6weeks 2-3weeks 6weeks 4-6weeks
Figure 2.LengthofImmobilizationtimes.(ICRC)
» When applying POP, the drying time depends on the quantity of water left in the plaster.
» If there is too much water in the plaster, the POP becomes fragile after drying.
» Increasing the water temperature shortens the drying time. For long POP, cold water should be used to allow the different layers to dry as one solid cast.
» The higher the water temperature, the higher the temperature generated inside the cast:
» If the water temperature is 24°C, the POP temperature increases to 38°C. If the water temperature is 38°C, the POP temperature increases to 57°C.
» With a water temperature over 50°C, the heat produced inside the POP could burn the skin.
75
CHAPTER 7 I CLOSED FRACTURES
MANAGEMENT OF LIMB INJURIES DURING DISASTERS AND CONFLICTS
APPLYING BACK SLABS» Position thepatient appropriately, obtain
materials,andpreptheskin.» Stockinetisappliedtothelimbtocoverall
jointssurroundingfracture.» Padding is applied over the stockinet to
padhighriskpressurepoints.» The first wetted plaster slab is applied
alongthelengthoftheposterioraspectoftheinjuredlimb.
» A second slab is applied in the samefashionas thefirstusingafigure-of-eightorX-crossingof thetwoslabstogivethelightweightposteriorsplintitsstrength.
» Anyexcessplaster is trimmed forpatientcomfortandtopreventanyskinirritation.
» Gauze or elastic bandage is gently butfirmlyappliedtokeeptheslabsinposition.
» Thebackslabishelduntiltheplasterhassetwith theappropriate jointposition tofacilitatefracturehealing.
APPLYING CIRCULAR CASTS» Theskinshouldbethoroughlywashedand
driedbeforeapplication.» Stockinet is applied and the necessary
amountofpaddingforprotectionofboneyprominencesisapplied.
» The plaster bandages should be appliedby rollingwithout tension. Eachbandagecovers one-half of the previous bandagewithoutwrappingcircumferentially.
» The palm of the hand is used, not thefingers,tomoldthewetbandagestoavoidpressuresoresthroughthecast.
» The limb is held in the appropriate jointpositioninguntilthecastisset.(Figure5)
» When dry, the calendar time, fracturelocation, and other documentation iswrittenonthecast.
Figure 3.Forearmslabwithfingerssplintedinthesafeposition.(ICRC)
Figure 4.Moldingatibialcastbyindentingthumbsintobothsidesofthepatellartendon.(ICRC)
Figure 5.Allowingtheplastertosetonatibialcast.(ICRC)
76 MANAGEMENT OF LIMB INJURIES DURING DISASTERS AND CONFLICTS
CHAPTER 7 I CLOSED FRACTURES
POP AFTER-CARE AND FOLLOW UPADVICE AND INSTRUCTION FOR PATIENTS
Givethefollowingadvicetothepatientandhisorherfamily.» Respectdryingtimebeforeambulation.» POPshouldnotbecoveredwithcloth,varnish,orablanketuntilitisdry.» ThePOPmustnotcomeincontactwithwateroranyotherliquid.» RaiseorelevatethelegwithPOPonapillowtodecreaseswelling.» PerformisometriccontractionunderthePOPtoprotectagainstmuscleatrophyandphlebitis.» Mobilizefreejoints.» Neverwalkonthecastwithoutarockerortip.
CAST VITAL SIGNS
» Pain » Strength» Odour » Colour,heat,sensationandmobilityofextremities» Cleanliness » Generalfeverandheartrate
DANGER SIGNS IN CASTED FRACTURES
» Increasing pain » Increasingswelling» Motor or sensory changes » Seepage through or around the cast
FOLLOW UP AND SUPERVISION
» Ideallyhaveonefollowupafter24hours» Providebasicphysicaltherapyexercisesifneeded» Tellthepatient(andfamily)toreturnifthereareanyconcerns» AllPOPnottoleratedbythepatientshouldberemoved» Ensurepatientshaveplansthatallowforclinicalreviewandcastremoval» Ensuremobilityaidsareprovidedifneeded
POSSIBLE COMPLICATIONS
» Skin(pain,burns,soresduetopressure)» Bones(secondarydisplacement,
osteomyelitis)» Joints(stiffness,osteoporosis)» Musclesatrophy(amyotrophy)» Neurovascularcomplications(complex
regionalpainsyndrome,localcompressions, compartment syndrome, thromboembolism). Figure 6.SkinreactiontoPOP.(ICRC)
77
CHAPTER 7 I CLOSED FRACTURES
MANAGEMENT OF LIMB INJURIES DURING DISASTERS AND CONFLICTS
REMOVING CASTSIMMEDIATE REMOVAL OF THE POP
» Ifswelling,diffusepainor lackofsensationoccurs,immediatelysplitthePOPalongitslength.
» Should localpainoccur,openawindowandchecktheskin.ClosethewindowwithanelasticbandageorPOPifthereisnowound.Theincidentshouldberecordedinwritingonthecast.
REMOVING CAST TECHNIQUES
» The cast may be removed by an electric cuttingdeviceorplastershears.
» Forchildren,orifelectricityisnotavailable,plastershearsarenecessary.
» Priortoremoval,gatherallmaterialsneeded.Theseincludescissors, removal tools (Figure7),materialstowashthelimbafter,andsupportivematerial.
» Positionanddrapethepatient.Forupperextremitycasts the patient can be in the sitting or supineposition.Forthelowerextremitythepatientshouldbeinthesupineposition.
» Determinecuttinglines,anddonotcutoverboneyprominences.
» When using plaster shears, ensure correct bladealignmentwitheachcut,andafter4-6cutscleartheblades,utilizethebenders,andcontinue.Nevercutaroundcorners,removethebladeandcutfromtheoppositedirection.
» Whenusinganelectriccutter,ensurethepatientiscomfortableandunderstandsthebladewillnotcuttheirskin.
» After the cast is removed, assess the skin for anydamage from removal and assess the form of thelimbfollowingimmobilization.
» Wash and dry the area, and apply oil or lotion toassistinrestorationofnormalskinnutrition.
» The patient needs to be educated about care oftheskinandoftheinjuredlimbasthemuscletonereturns.
» Areferralforrehabilitationisstronglyadvised.
Figure 7.ToolsneededforremovalandmanipulationofPOP.Fromtoptobottom,oscillatingsaw,castspreader,plastershears,castbreaker.(ICRC)
If a window is cut to assess the skin under a cast, or for treatment of a small (type 1) open fracture, the plaster should be reapplied and fixed in place with elastic bandage to prevent the formation of "window edema".
78 MANAGEMENT OF LIMB INJURIES DURING DISASTERS AND CONFLICTS
CHAPTER 7 I CLOSED FRACTURES
TRACTION
TYPE 2
Surgicalteamsprovidingcareindisasterresponseandinconflictzonesmust be familiar with the principles of managing patients with fractures in traction,whichmaybeusedasatemporarymethodtomanageafractureorasadefinitivetechnique(SeeICRCmanualonPOPandTractionforadditionalinformation).
SKIN TRACTION» Skin traction can be used temporarily in adultswith femur fractures (for nomore than 48–72
hours).
» Itcanserveasamethodtoallowforplacementoftractionfortransfertoahigherlevelofcare.
» Skin traction can serve as a definitivemethod of treatment formany femoral fractures in thepaediatricgroup.
SKELETAL TRACTION» Skeletaltractioncanbeusedasdefinitivemanagementforadultswithopenlongbonefractures,
although external fixation provides better stabilization and optimizesmanagement of the softtissueinjury(seechapteronopenfractures).
» Skeletaltractionforchildrenwithhipfracturesiseffectiveandcommonlyused.
» Althoughdefinitivetreatmentwithtractionisnotaseffectiveinadults,itmaybetheonlylocallyavailabletreatmentforadultswhosustainfracturesoftheproximalfemur,andismoreeffectivethanskintraction.
PLACEMENT OF TRACTION PINS» Traction pins should have a centrally
threaded section, as this will preventslippinginthebone.
» Thiscanbeinsertedunderlocalanesthesiawithahanddrill(forsafepininsertionseethesectiononopenfractures).
» Traction should not be applied across anunstablejoint.
» When placing a Denham pin for skeletal traction in a deployment scenario, place a piece of tape on the pin and write “threaded.” This is important as you cannot guarantee that you will be the one to remove the pin.
» Always check the stability of the knee joint prior to placing a traction pin for a femoral shaft fracture.
79
CHAPTER 7 I CLOSED FRACTURES
MANAGEMENT OF LIMB INJURIES DURING DISASTERS AND CONFLICTS
TECHNICAL ASPECTS» Tractionpinsshouldnotpassthroughasynovialjointspaceoranopenphysealplate.
» Bewaretheproximalextentofthekneejointandtheproximaltibialphysisinchildren.
» Checkstabilityofthekneepriortoinsertingatractionpinforafemoralshaftfracture.
» Ifthekneeisunstable,insertthepininthedistalfemoralmetaphysis.
» Duringinsertion,startfromthesafeside—wherethevesselsandnervesatriskcanbelocalizedandavoidedbycarefulselectionoftheinsertionpoint.
» Distal femoral traction pins should beinserted frommedial to lateral to avoidtheadductorcanalandfemoralartery.
» Proximal tibial pins should be insertedfrom lateral to medial to avoid thecommon peroneal nerve as it passesaroundtheneckofthefibula.
» Calcanealpinsshouldbeinsertedmedialto lateral to avoid the posterior tibialneurovascularbundle.
» AThomassplintorvariantcanbeusedfortemporary stabilization, or for definitivecare for a patient with a femoral shaftfracture.
• Thesearecommonlyusedfortemporarytreatment, either until femoral nailingcanbesafelyperformed,ortotransportapatienttoanothersurgicalcentre.
» If using a Thomas splint as a treatmentoption (more common in children), thering must fit the patient, and attentionmust be paid to correctly padding andadjusting the traction equipment topreventpressureareasinthegroin.
Figure 8.Thomassplint.(ICRC)
Figure 9.Tractionpinplacedinthefemoralmetaphysisandanemptyvialusedasapinguard.
(ICRC)
Figure 10.Thelargerforceappliedinskeletaltractionistransmittedalongtheaxisofthelimbviaa
pin,pulleyandaweight.(ICRC)
80 MANAGEMENT OF LIMB INJURIES DURING DISASTERS AND CONFLICTS
CHAPTER 7 I CLOSED FRACTURES
» AdultswithfemoralshaftfracturesbeingmanagedinskeletaltractionareoftenonaBöhler-Braunframe.
» Thisallowselevationofthelowerlimb,andkneeflexionduringtraction.Theframemustfitthepatientandbesuitablylined.
» IntheabsenceofaBöhler-Braunframe,asplitHamiltonRusselloraThomassplintcanbeusedfortraction.
Figure 12.Alternativemethod to a Böhler-Braunframeforaproximalfemurfracture.(ICRC)
Figure 13.PreparationofaBohler-BraunFrame.(ICRC)
Figure 11.Constructionofatractionframeinthefield.(J. von Schreeb)
» Patients in traction often develop an equinus deformity of the foot.
» This can be prevented with active and passive physiotherapy using bands and/or foot slings.
» Pressure sores of the heel and sacrum should be prevented, and DVT prophylaxis, if available, is indicated.
81
CHAPTER 7 I CLOSED FRACTURES
MANAGEMENT OF LIMB INJURIES DURING DISASTERS AND CONFLICTS
PAEDIATRIC CONSIDERATIONSTRACTION AS DEFINITIVE CARE
» Childrenwhohavefemoralshaftfracturesarecommonlytreatedintractionwithunionoccurringinapproximatelythepatient'sageinyearsplusoneweek.
» Patients less than 8 should be treated with early Spica casting under sedation 1-3 days afterfracture.
» Fixed traction using adhesive skin or skeletal traction in a Thomas splint is possible. HamiltonRussellTractionispossibleaswellanddoesnotrequireaThomassplint.
» SomesurgeonsviewtheThomassplintasprimarilyusefulfortransportasthedevicecanleadtopressuresoresinthegroin.
» Childrenundertheageof2yearswithafemoralshaftfracturecanbemanagedinGallowstraction.» Children under the ageof 6months canbemanaged in a "Soft Spica" builtwith padding and
bandagesorbyusingaPavlikharnessifavailable.» Weightsrequiredareminimal(1-2kg)andshouldbeoverapulleyonanoverheadbar,nottiedoff
tothebar.
SKELETAL TRACTION
» Skeletaltractionforchildrenwithhipfracturesiseffectiveandcommonlyused.» Skeletaltractionisthebestchoicefor:
• Initialimmobilizationofmostfemoralandsometibialandhumeralfractures• Definitiveimmobilizationoffracturesofthefemur• Definitiveimmobilizationofparticularlydifficultfracturesofthetibianearthekneeandofthe
humerusneartheelbow• Tractionpinsinchildrenshouldnotbeplacednearthetibialtuberosityastheymaycausean
anterior growtharrestand subsequent recurvatumdeformity. They shouldbeplaced in thedistalfemur1cmproximaltothegrowthplate.
Figure 14.Gallowstractionfromabeam.(ICRC)
Figure 15.Patientinskeletaltraction.(ICRC)
DISADVANTAGES OF SKELETAL TRACTION AND CONSIDERATIONS
» Theprincipaldisadvantageofskeletaltractionisprolongedbedrest,alongwithincreaseddemandsonbothnursingandphysiotherapycare.
82 MANAGEMENT OF LIMB INJURIES DURING DISASTERS AND CONFLICTS
CHAPTER 7 I CLOSED FRACTURES
TRANSFERS» Aninjuredpatientmayhavetheopportunityforevacuationfromthefirsthospitaltoahigherlevel
ofcare.
» Thepatientneedstobeconsultedaboutatransferandthetransfershouldbediscussedwiththeirfamilyorsupportsystem.
SKIN TRACTION AND TRANSFERS
» Transportofapatientwithalongbonefracturecanbefacilitatedbyusingskintractionforalimitedamountoftimeduringthetransport.Skintractionfortransportshouldbeadhesiveinchildrenandnon-adhesiveintheadult.
» Femoralshaftfracturesinadultscanbemanagedduringashortdistancetransferbycontinuingtractionwithaweightonatractionpin,butthisshouldbeavoidedifpossible.
» AnalternativeistheapplicationofaDonway,HareorThomassplint.These splints cannot be used in the presence of ipsilateral pelvic fracture.
» Anotheroptionisbandagingthefracturedlimbtotheintactlimbwithslingsorstripsoffabric.
AIR TRANSPORT
» Consideraprophylacticfasciotomyofthecalfpriortotransferduetopressurechanges.
TRANSFERS IN CASTS
» Anypatientinafullcastshouldhavethecastsplittoskinfortransfer.
• This isdoneduetoswellingandtominimizetheriskofatightcast/compartmentsyndromeduringthetransfer.
» Elevatethepatient’shandorfootasappropriatetopreventdistallimbswelling.
» Avoidhanginganarminfabriconapolebesidethebed.
• Theedgeof that fabricwill causeanulnarnerveneuropathy if it isallowedtocompress theposterio-medialaspectoftheelbow.
• Simplyelevatethehandontheabdomen,orpropittobewellabovetheelbowatrest.
83
CHAPTER 7 I CLOSED FRACTURES
MANAGEMENT OF LIMB INJURIES DURING DISASTERS AND CONFLICTS
MANAGEMENT OF CLOSED FRACTURES WITH INTERNAL FIXATION
TYPE 3BEWARE THE RISKS OF INTERNAL FIXATION
LIMITED INDICATIONS IN DISASTER AND EMERGENCY SITUATIONS
» Onlyindicatedifthesituationhasstabilizedandatype3teamisintegratedintoalocalfacilitywithpriorhistoryofperforminginternalfixation.
» Incidenceof50-80%ofinfectionhasoccurredwheninternalfixationwasusedasaprimarymeansoftreatment.
» Considertransferringthepatienttoamoreadvancedfacilityifinternalfixationisnecessary.
» Evaluationofpatient’snormalenvironment,safety,riskofcomplications,andavailableresourcesmustbeconsideredbeforeclosedfractureinternalfixationisperformed.
» TheprincipalmethodsofPlaster-Of-Paris,skeletaltraction,andexternalfixationareviableoptionsformanyfracturesandshouldbethefirstchoiceindisasterandconflicts.
Figure 16.Puspoursfromawoundtreatedwithinternalfixation.Theplatesandscrewsmustnowberemoved.(ICRC)
84 MANAGEMENT OF LIMB INJURIES DURING DISASTERS AND CONFLICTS
CHAPTER 7 I CLOSED FRACTURES
SUGGESTED RESOURCES
1. Gosselin RA. War injuries, trauma, and disaster relief. Techniques in Orthopaedics 2005; 20(2): 97-108.
2. Ngota DO, Friedel F. Plaster of Paris and Limb Traction: ICRC Physiotherapy Reference Manual. ICRC; 2009. p.101.
REFERENCES1. Giannou C, Baldan M. War surgery: Working with limited resources
in armed conflict and other situations of violence, Volume 2. Geneva: International Committee of the Red Cross; 2013.
2. Giannou C, Baldan M. War surgery: Working with limited resources in armed conflict and other situations of violence, Volume 1. Geneva: International Committee of the Red Cross; 2009.
3. Norton I, Von Schreeb J, Aitken P, Herard P, Lajolo C. Classification and minimum standards for foreign medical teams in sudden onset disasters. Geneva: World Health Organization; 2013.
4. Herard P, Boillot F. Amputation in emergency situations: indications, techniques and Médecins Sans Frontières France’s experience in Haiti. International Orthopaedics 2012: 1-3.
5. Dufour D, Jensen SK, Owen-Smith M, Salmela J, Stening GF, Zetterström B. Surgery for victims of war. 1998.
6. Coupland RM. War wounds of limbs: surgical management. 1993.
7. Hayward-Karlsson J, Jeffery S, Kerr A, Schmidt H. Hospitals for the War Wounded: a practical guide for setting up and running a surgical hospital in an area of armed conflict. Geneva: International Committee of the Red Cross; 2005.
8. ICRC Guidelines for Teaching Nursing Care. Internal Document: International Committee of the Red Cross ICRC.
EMT Website: https://extranet.who.int/emt/page/homeAO/ICRC/WHO Training Resources: http://www.aofoundation.org/icrc