tangent
02-26-02, 18:45
The following is from the 95 procedings of NASAR
ORTHOPEDIC IMPROVISATION
GENERAL PRINCIPLES:
By necessity, management of orthopedic injury, specifically fractures and
dislocations, differs greatly in the prolonged care situation. If the care giver has the
knowledge and skills, and is acting under medical control endorsement, virtually every
fracture and dislocation should be reduced in the field. To do otherwise is akin to overt
torture. Additionally, in some specific injuries, such as a hip dislocation, to leave
unreduced may actually produce significant harm to the patient. Proper orthopedic
stabilization requires the care giver to perform three basic maneuvers.
1. Traction into position. ( traction stable )
2. Manually hold in position. (hand stable)
3. Splint into position. ( splint stable )
These three maneuvers are the same whether applied by a physician in the
emergency department, or an EMT in the field.
The appropriateness of a splint is based upon how well it performs function #3. Not upon
it's materials or construction.
The basic splinting principles are the same regardless of the circumstances surrounding it's
application.
(Medical kit)
One of the most useful low weight items around is the Sam Splint. This can be
customized to a variety of situations and applications.
There are a number of methods for securing a splint to the patient. One universal
precaution that needs to be kept in mind is that of the splint turning into a
tourniquet. The normal swelling curve is 12 - 24 hours. Splints, bandages, or
anything that circumferentially wraps the area of an injury can turn into a
constricting device within a few hours. This is a classic example of good initial care
gone bad, in face of a prolonged care situation. ANYTIME A
CIRCUMFERENTIAL DEVICE IS APPLIED ON AN INJURED EXTREMITY,
CLOSE MONITORING IS MANDATORY. This caution is of double emphasis if
the patient has injuries or illnesses that affect mental status, or if potent analgesics
are being given, or if an associated spinal injury is suspected/possible.
Some of our team medics like to carry fiberglass casting tape for the manufacturing
of splints in the field. This stuff is excellent for this purpose. It should not be
applied directly to the skin, and requires some padding be placed between it and the skin. I am opposed to placing circumferential casts overlying the site of orthopedic
injury to extremities in the field. The reasoning being, if a constricting
complication should occur, it would be difficult if not impossible to remove safely.
There are, however, situations where a regular cast can be of significant value.
Usually to assist in traction, and then not applied overlying the site of injury.
Both the Sam Splint, and fiberglass casting tape can have uses beyond immobilizing
extremity injuries. Both can be used to fashion C - spine immobilization devices.
Fiberglass can be used to make expedient repairs to various outdoor equipment.
The Sam Splint can be used in conjunction with a B/P cuff to make an IV pressure
infuser. Undoubtedly, other uses could be thought up, these are just some from my
own personal experience.
Any wilderness medic with any experience will invariably have a walking stick or
pair of ski poles just about any time they venture into the wilds. There are some very
good reasons to do this. 1) An ambulatory assisting device ( A.A.D. ?) Can take up
to 30% of the wear and tear normally imposed upon your legs and feet. This could
potentially add up to 30% distance you might cover in a day, or at the very least
make your feet feel much better at the end of your day. 2) AAD's can significantly
reduce the incidence of falls and associated injury, especially in rough or steep
terrain, or in any terrain when a heavy load is being carried. 3) AAD's have a
multiplicity of non - ambulatory uses. I have used mine as a tracking stick, for self
defense, as an avalanche probe, as an emergency shelter pole, as an improvised
fishing pole, in conjunction with a bandana for a wind marker on a helicopter LZ,
as snow anchors for my tent, and as an antenna pole when just a little more height
was needed to hit the repeater. 4) If you have this item, you have with you just
about all the splinting material you would ever need for splinting the lower
extremities. If you use the adjustable ski poles ( my personal preference ), you can
even shorten the pole and make it applicable for upper extremity use. If you are
inventive, an AAD can be used to fashion a traction splint. This should be standard
equipment for people responding to a backcountry medical incident.
Traction splint devices are usually to cumbersome to have any real application in a
back country response. One exception is the Kendric Traction Device This item is
telescopic and made from tubular aluminum. This is quite a workable little device
that takes up about as much room as a single tent pole. However, if you
understand what effective traction requires, traction can be readily developed
using field expedient materials. Believe it or not, only about ten pounds of traction,
constantly applied, is needed to maintain fracture alignment in a femur fracture.
In the field, this can be difficult to determine. There can be some significant
complications result from prolonged traction. 1) pressure necrosis to the
underlying the skin, 2) pressure neuropathy, 3) distal ischemia, 4) venous flow
impairment, resulting in accelerated swelling and associated complications ( such as
DVT). Nevertheless, prolonged traction can be safely applied. In fact, in the earlier
days of this century, before surgical orthopedics reached the contemporary level of sophistication, a good many femur fractures were managed entirely by traction
immobilization. Even today, the use of prolonged traction using skeletal traction
techniques is common. The fundamental rule is to disperse the weight of the
traction over the largest amount of surface possible. This will limit or possibly
eliminate the potential long term consequences of traction that will invariably result
if commercial traction devices are used for more than a couple of hours. ( remember
we talked about appropriate short term interventions that can cause significant
harm if used in prolonged care settings, well here is another one.) Remember that
whenever a splint of any type is applied, and it is secured by circumferential wraps,
close monitoring is mandatory. The warning is doubled in the case of a traction
splint because of the pressure effect inherently present to the underlying tissues.
ORTHOPEDIC IMPROVISATION
GENERAL PRINCIPLES:
By necessity, management of orthopedic injury, specifically fractures and
dislocations, differs greatly in the prolonged care situation. If the care giver has the
knowledge and skills, and is acting under medical control endorsement, virtually every
fracture and dislocation should be reduced in the field. To do otherwise is akin to overt
torture. Additionally, in some specific injuries, such as a hip dislocation, to leave
unreduced may actually produce significant harm to the patient. Proper orthopedic
stabilization requires the care giver to perform three basic maneuvers.
1. Traction into position. ( traction stable )
2. Manually hold in position. (hand stable)
3. Splint into position. ( splint stable )
These three maneuvers are the same whether applied by a physician in the
emergency department, or an EMT in the field.
The appropriateness of a splint is based upon how well it performs function #3. Not upon
it's materials or construction.
The basic splinting principles are the same regardless of the circumstances surrounding it's
application.
(Medical kit)
One of the most useful low weight items around is the Sam Splint. This can be
customized to a variety of situations and applications.
There are a number of methods for securing a splint to the patient. One universal
precaution that needs to be kept in mind is that of the splint turning into a
tourniquet. The normal swelling curve is 12 - 24 hours. Splints, bandages, or
anything that circumferentially wraps the area of an injury can turn into a
constricting device within a few hours. This is a classic example of good initial care
gone bad, in face of a prolonged care situation. ANYTIME A
CIRCUMFERENTIAL DEVICE IS APPLIED ON AN INJURED EXTREMITY,
CLOSE MONITORING IS MANDATORY. This caution is of double emphasis if
the patient has injuries or illnesses that affect mental status, or if potent analgesics
are being given, or if an associated spinal injury is suspected/possible.
Some of our team medics like to carry fiberglass casting tape for the manufacturing
of splints in the field. This stuff is excellent for this purpose. It should not be
applied directly to the skin, and requires some padding be placed between it and the skin. I am opposed to placing circumferential casts overlying the site of orthopedic
injury to extremities in the field. The reasoning being, if a constricting
complication should occur, it would be difficult if not impossible to remove safely.
There are, however, situations where a regular cast can be of significant value.
Usually to assist in traction, and then not applied overlying the site of injury.
Both the Sam Splint, and fiberglass casting tape can have uses beyond immobilizing
extremity injuries. Both can be used to fashion C - spine immobilization devices.
Fiberglass can be used to make expedient repairs to various outdoor equipment.
The Sam Splint can be used in conjunction with a B/P cuff to make an IV pressure
infuser. Undoubtedly, other uses could be thought up, these are just some from my
own personal experience.
Any wilderness medic with any experience will invariably have a walking stick or
pair of ski poles just about any time they venture into the wilds. There are some very
good reasons to do this. 1) An ambulatory assisting device ( A.A.D. ?) Can take up
to 30% of the wear and tear normally imposed upon your legs and feet. This could
potentially add up to 30% distance you might cover in a day, or at the very least
make your feet feel much better at the end of your day. 2) AAD's can significantly
reduce the incidence of falls and associated injury, especially in rough or steep
terrain, or in any terrain when a heavy load is being carried. 3) AAD's have a
multiplicity of non - ambulatory uses. I have used mine as a tracking stick, for self
defense, as an avalanche probe, as an emergency shelter pole, as an improvised
fishing pole, in conjunction with a bandana for a wind marker on a helicopter LZ,
as snow anchors for my tent, and as an antenna pole when just a little more height
was needed to hit the repeater. 4) If you have this item, you have with you just
about all the splinting material you would ever need for splinting the lower
extremities. If you use the adjustable ski poles ( my personal preference ), you can
even shorten the pole and make it applicable for upper extremity use. If you are
inventive, an AAD can be used to fashion a traction splint. This should be standard
equipment for people responding to a backcountry medical incident.
Traction splint devices are usually to cumbersome to have any real application in a
back country response. One exception is the Kendric Traction Device This item is
telescopic and made from tubular aluminum. This is quite a workable little device
that takes up about as much room as a single tent pole. However, if you
understand what effective traction requires, traction can be readily developed
using field expedient materials. Believe it or not, only about ten pounds of traction,
constantly applied, is needed to maintain fracture alignment in a femur fracture.
In the field, this can be difficult to determine. There can be some significant
complications result from prolonged traction. 1) pressure necrosis to the
underlying the skin, 2) pressure neuropathy, 3) distal ischemia, 4) venous flow
impairment, resulting in accelerated swelling and associated complications ( such as
DVT). Nevertheless, prolonged traction can be safely applied. In fact, in the earlier
days of this century, before surgical orthopedics reached the contemporary level of sophistication, a good many femur fractures were managed entirely by traction
immobilization. Even today, the use of prolonged traction using skeletal traction
techniques is common. The fundamental rule is to disperse the weight of the
traction over the largest amount of surface possible. This will limit or possibly
eliminate the potential long term consequences of traction that will invariably result
if commercial traction devices are used for more than a couple of hours. ( remember
we talked about appropriate short term interventions that can cause significant
harm if used in prolonged care settings, well here is another one.) Remember that
whenever a splint of any type is applied, and it is secured by circumferential wraps,
close monitoring is mandatory. The warning is doubled in the case of a traction
splint because of the pressure effect inherently present to the underlying tissues.