Clinical solution: Broken leg on the soccer field
You arrived to find a 17-year-old girl lying with a 45-degree fracture to her right leg; did you get the treatment right?
By Patrick Lickiss
This month's winner is Kevin Young. Kevin correctly identified the need to provide manual traction and realignment to the fractured extremity before splinting. There was some discussion on Facebook about the need to apply oxygen to this patient. Given that this is a BLS patient (waiting on ALS for transport) I think that it is important to utilize all BLS pain management procedures which can include low-flow oxygen. Congratulations again to Kevin!
In the previous scenario, you were presented with a 17-year-old female suffering from what appears to be a fractured tibia and fibula. The injury was isolated to her leg.
The remainder of her secondary exam was unremarkable except that she had lost pulses distal to the fracture. The patient’s leg appeared angulated and you had to decide what to do next.
With any trauma patient, the first areas of focus are managing the airway and breathing and controlling any major bleeding. In addition to the basics, confirming the presence or absence of spinal injury is of equal importance.
Our 17-year-old patient appears mostly stable with no spinal injury or major external bleeding. While it is true that long bone fractures can result in significant blood loss, these types of hemorrhages are more frequent in fractures of the femur.
After ruling out immediate life threats, you can turn your attention to the patient’s comfort and stabilization for transport. Obviously in an ALS environment, this patient would be indicated for pharmaceutical management of pain, but what about BLS treatments for pain?
Often, positioning of an injured extremity, splinting, ice packs or just a kind word can reduce a patient’s perception of pain.
Think back to your first exposure to splinting during your initial training. You were likely told two “important” things: Splint the patient as you find them and attempt to realign the limb only if there are absent pulses distal to the injury site.
First, think about the possible difficultly in splinting a patient in the position you find her. Many of the splints carried by EMS providers are designed to offer support in a straight line.
Even flexible, foam-covered splints provide limited support along a curve or angle. If it is safe to do so, realigning the patient’s extremity may make splinting easier and more effective.
Many EMS providers were taught only to realign the extremity if pulses were absent. What if the patient does have good pulses?
In addition to providing a more effective method to splint, realigning a fractured extremity may improve the patient’s level of comfort. If a fracture is displaced, any level of movement can increase soft tissue damage resulting in pain.
Additionally as the time from an initial injury passes, muscle spasms become more and more significant. This increases damage to the surrounding tissue and can make ultimately realigning the fractured bone more difficult.
Finally, a patient may experience psychological relief: seeing a straightened out leg is far less traumatic than seeing a significantly angled one.
If you elect to straighten an angulated fracture (and it is approved by your medical director), be sure to check and document pulse and neurologic findings before and after.
Apply some traction away from the site of the injury and gently reposition. Stop immediately if you meet resistance. Once the extremity is back in anatomical position, splint as you normally would.
The goal of splinting is to provide stabilization to the site of a fracture. Doing so reduces the amount of movement of the separate bone pieces and reduces pain and additional injury. The rule of thumb when splinting should be to support the length of the injured bone and to immobilize the proximal and distal joints.
In the case of the patient in the scenario, a proper splint would run the length of the lower leg on both sides and would reduce movement in the knee and ankle. As always, check and document circulation and sensory and motor function before and after the procedure.
Once you have cleared the patient’s cervical spine, you ask your partner to take the long spine board to the ambulance and return with the splinting kit. You tell the patient that she has broken her leg and that you would like to straighten it out. You say that doing so will help you support the leg and reduce the amount of pain she is feeling.
With the help of the trainer, you pull traction on the distal half of the lower leg and gently guide it back to a neutral position. You check for distal pulses and find that the patient has a strong pedal pulse in each foot.
After your partner returns with the splint bag, you select a cardboard splint that will reach from the patient’s mid-thigh to her ankle. After padding around the leg you secure the splint.
The patient’s CSM is unchanged and you apply several ice packs. The ALS unit arrives and after taking a report they establish an IV and give pain medication before transporting to the ED.
The patient reports that her pain is manageable en route to the ED. After her arrival, an X-Ray confirms a fracture of the tibia and fibula.
She goes to surgery for placement of a plate and screws to provide stabilization to the fracture. While she will miss the remainder of her soccer season, she is expected to make a full recovery.