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Hi, my name is Chris Boyle and I'm an emergency medicine registrar. This talk on fractures and dislocations is part of a series of talks designed to prepare you for the wilderness first responder course. So before we start, we have some intended learning outcomes to cover. The first is to explain how fractures and dislocations are managed in the trauma patient to revise the principles of fracture reduction and splinting. To discuss the importance of history taking and clinical assessment in trauma patients to explain the common types of fractures and dislocations and how they are managed and explain the importance of checking for movement, circulation and sensation. Abbreviated to MC NS, fractures and dislocations are extremely common and management is dependent on several factors of which we'll discuss. As we go through this talk, it's really important to identify time, critical injuries and fractures and dislocations can cause significant pain. So always think analgesia when thinking about a patient who has suffered a fracture and or a dislocation, we must always consider that this is a trauma patient and there may be other injuries that we have not found yet. With this in mind. We should approach a trauma patient with AC ABCD E approach. So in this primary survey, the first C, we should always think about catastrophic hemorrhage and address this in the right way. C spine should therefore be considered as well following this airway breathing and circulation, circulation. To note is pelvis and long bone injuries, which we will come to in this talk following this disability and exposure. It's only after we've completed the C ABCD E approach that we can consider our secondary survey, which looks at head to toe physical examination. At this point. We'll pick up injuries in the peripheral limbs of the upper limb and the lower limb. This talk today will focus on upper limb and lower limb injuries but also have elements of other injuries which are significant. These include the pelvis and long bones. Therefore, we must always remember that the C ABCD approach is the first step and then the peripheral limb injuries should be the next being able to complete a history and clinical examination is essential. The rescuer must remain calm, listen to the patient and record the details of their assessment is equally essential to not endanger other members of the group or other people in the party. And remember, first of all, do no harm in general, it is unwise to manipulate an injured injured limb if the extremity is deformed, but circulation is intact. M CMS do not attempt to straighten instead splint in the position in which you found it. But remember a trauma patient should be approached with the C ABCD E approach and Splint um as they lie is a good way to remember that afterwards, reduction or relocation is only indicated if their M CNS is compromised, they're in extreme pain or there is gross deformity. And if you are going to do this, remember to do a pre and post MC NS, it is important to understand the principles of fracture reduction and splinting. A splint should be applied to any broken bone, bad's brain or severely lacerated body part. After gross deformity is corrected, it is important to splint in the normal resting position or the position of function. This is to maintain proper position and immobilize the injured part, all parts so that it can be, cannot be displaced if it is too painful splint in the position found and don't carry out reduction. This prevents further nerve blood vessel and muscle damage and keeps broken bone ends from grating against each other or from poking through your skin. A sling and swathe combination helps to further immobilize a limb. Pain may be lessened or relieved by eliminating unnecessary motion, allowing more rapid transfer. This talk will focus on fractures and dislocations. Albeit there are sprains and strains that can occur with these injuries or on their own. So before we start, let's think about the must dos of fractures and dislocations. So always check for an open fracture. And if so consider antibiotics if you have them and just cover the wound, always check motor circulation and sensation as this will dictate. Your intervention, always provide analgesia. And this is in addition to immobilization, as fractures and dislocations can be extremely painful and always be suspicious for other injuries and approach a trauma patient with the ABCDE approach. So this slide showcases what the normal anatomical position is. And as reference, this is seen as the position of function for the upper limb and lower limb when considering splinting and mobilization of these limbs. So let's first focus on the upper limb. Can you name some upper limb injuries that you commonly see in the wellness setting? I'm gonna give you 10 seconds to write a few down. So these are some of the injuries that you may see of the upper limb clavicle fracture, shoulder dislocation, humeral fracture, elbow dislocation or fracture, radius, plus or minus ulnar fracture and then wrist hand and finger injuries. So first up is a clavicle fracture. So let's think about the mechanism and the assessment usually occurs from a fall onto the shoulder or the clavicle or a fall on an outstretched hand. There is a visible or palpable deformity and it's tender over the clavicle for management. We can think about using a sling and swathe. A figure of eight bandage or both. And these are shown in the images below. Both can provide support to the clavicle and provide immobilization to the injury and support. An alternative is to wear a backpack with shoulder straps and around 15 kg in weight to provide some support and immobilization to the clavicle. The key points are to give analgesia and to ensure that support is provided. So next up is shoulder dislocation mechanism and assessment. So it usually occurs due to a fall onto the shoulder or an outstretched arm or the arm is twisted or pulled forcefully. You can see a depression on the lateral aspect of the shoulder and the arm is often held in abduction and elbow flexion. And you can see that in the diagram on the side and in this picture here. So where's the management? So ideally transfer the patient in a sling swath to hospital if the hospital is less than three hours away and the arm or the arm is grossly deformed suggesting fracture. You may consider reduction if there is significant pain, the hospital was greater than three hours away or this is a recurrent dislocation suggesting that it might go in easier. So there are plenty of reduction techniques for shoulders and everyone has their own preferences. What we're gonna talk about today is the cocker technique. Although spaso Hippocratic, Stimson's and milk are also um potential reduction techniques. So with the cocker technique, you wanna bring the elbow in flexion and adduction into ex the shoulder into external rotation slowly. Once you've done this, you want to bring the elbow or the shoulder into slight flexion. And once you've done this, you may be able to see that the humoral head reduces back into its glenoid. At this point, you want to internally rotate the arm and place it on the patient's lap. The key points here are as ever give analgesia and once again, remember, no one dies from a shoulder dislocation. So next up are humeral fractures, the mechanism and assessment. They're usually careful on a direct fall onto the upper arm. The arm is often held close to the chest following this. So the management a sugar tong splint is used to immobilize the upper arm. As you can see here, ideally, the arm should be kept in elbow flexion at 90 degrees and the arm abducted to the body, you should then be able to transfer the patient in a sling wave to hospital. As you can see in the image opposite. There are. However, other methods means to make a sling of note, a tshirt hammock sling can be used and this is seen in the pitch opposite. You can also use a shirt sleeve hammock sling and this is also seen in the picture opposite. The key points are give analgesia and remember to immobilize and transfer the patient to hospital hospital for definitive care. So next up are elbow dislocations, the mechanism and assessment. So 90% of elbow dislocations are posterior. They usually occur following a fall on an outstretched hand with the elbow and extension on impact. As you can see in the picture opposite, you can also see an image of a posterior dislocation in the picture opposite. You can see where the humerus moves in relation to the radio Sonoma in the posterior and anterior dislocation, the management of elbow dislocations. So they are difficult to reduce. And there's a high risk of neurovascular injury. For this reason, it's common that splinting the limb in the position found is the primary treatment. However, if reduction is required, hold the elbow at 90 degrees in supination, use the lever motion to pull the bones of the forearm back into position whilst holding the upper arm in a fixed countertraction. And you can see this in the picture above. There is another version of this and that it can occur in the prone position and this is known as the pars method, but we will not touch on this today. Key points here are remember to give analgesia and the posterior dislocations are the most common. Remember, they are difficult to reduce and there is a high risk of neurovascular injury. So, splint in the limb in the position you found is the primary indication of treatment, elbow fractures, the mechanism and assessment they often occur following a fall on an outstretched hand or a direct blow to the elbow. It's important to mention that by identifying an elbow dislocation, you cannot always rule out an elbow fracture and you should have a high suspicion for this management, the splint should include the wrist and the shoulder. And ideally it should be, uh, with a 90 degree bend at the elbow. As you can see here, a casualty found with the elbow bent should be immobilized from the shoulder to the wrist. However, if the casualty is found with the arm straight and they are unable to bend it to 90 degrees, they should be splinted in this position. At this point, the patient should be transferred in a sling and suave to the hospital. The key points are remember give analgesia and splint in the position found as if it's too painful. It may be worse or to the patient's detriment to try and move the elbow, forearm fractures. So the mechanism or assessment of these usually follow a direct blow to the forearm. And once again, a fall on the outstretched hand management, it was based on splinting to immobilize the wrist and bent elbow. As you can see in the image opposite the sam splint is used to keep the area at 90 degrees and to secure the forearm. In this position, you use a sugar tong style spin to do this and then you can transfer the patient in a sling swathe to hospital. Remember once again, the key points are to give analgesia and a sling wave is there to ensure safe extrication and no further injury to the patient. The wrist, hand and fingers is a huge topic for fractures and dislocations. We will focus on some of the common presentations and at a later date, we can discuss any further injuries. So the mechanism and assessment usually occur once again following a fall on an outstretched hand or a direct blow in the management. So, splint to immobilize the rest, the fingers should rest around a padded object to maintain a normal position. As shown in this diagram, a ridge splint is usually placed under the hand, wrist and forearm. As you can see in the image opposite fingers. If a finger is dislocated at the middle or distal joint as shown here, then apply a steady firm traction to the fingertip as shown here. Indeed. So fingers can be splinted following this independently or body strapped the extrication. Then following this transfer, the patient once again in the slinger wave to hospital, as you can see here, once again, the key points are to give analgesia and remember, keep fingers exposed to assess for the mcs. That's all for the upper limb. So let's move on to the lower limb. I'm gonna give you 10 seconds just to jot down some lower limb injuries that can occur. No. So ones we're gonna talk about in this presentation are femoral fractures, hip dislocation, pelvi fractures, knee and patellar dislocations and ankle fractures. So, femoral fractures, they usually care following a fall from height or an object falling onto the leg. They can and will cause severe pain. An inability to weight, bear deformity and rapid swelling. No, the management rests on remembering to do the C ABCD approach and understanding that there may be other injuries to this patient. This injury requires traction and splinting from the hip to the ankle. Traction itself controls the bleeding, maintains the position of the leg and decreases pain. As you can see in the image here, this is a femoral fracture and with reduction, there's better alignment of the bony parts, traction can be applied from the ankle in a um cordal um distribution oh direction. Sorry. It is important cos 2 L of blood can be lost quite rapidly into the femur. And it's common to use a Kendrick traction device to do this. And the next slide, we'll talk about that. After this, we'll prioritize extrication as these patients can rapidly deteriorate. So the key points here are to give an analgesia as we always would remember, see ABCD approach and think significant blood loss. So with femoral fractures, let's talk about the Kendrick traction device which is commonly used in the field. E three do a great video on how to apply AK TD. But for now, let's talk through the components of the K TD and how it can be applied. So it comes up in a bag and is made up of five different parts. You have the pole in yellow, then you have three straps that go around the leg. You also have an ankle hitch and then you have an additional hitch for attaching to a boot and then the blue strip, blue strap attaches around the groin area uh connecting the pole to the patient. This should be the final product with the leg strapped by three different straps and one at the ankle. And the traction device been applied by the pole and the bottom of the foot. Initially reduction is needed. So a person is usually holding the ankle and pulling the leg in a corded direction or cordal direction. Sorry. Prior to this, the leg is measured with the pole and the pole should extend below the ankle itself. The strap is attached to the groin area providing the pole um to be close to the patient's leg. The ankle is the strap is then placed and the um yellow part is attached to the pole. The red strap is then pulled once the reduction has taken place to ensure the traction is maintained and this is the finished product. Alternatives are out there. One can be used as a boot hitch as shown in this diagram where the boot is kept on, but the strap is placed around the boot itself. Another one is an improvised traction device and these are something that can be used in the field using ski poles, rope and some sticks. You can also use some foam to strap around the bottom part of the leg to allow a similar outcome. These take time and AK TD is lightweight and we carry it with you and is the preference for reducing a femoral fracture in the field. So remember the key points once again of to give analgesia, remember do the C ABCD approach and think significant blood loss and extricate that patient as quickly as possible. Next up are hip dislocations. So mech mechanism and assessment, they usually follow a fall with force onto the knee. They can occur in a posterior dislocation where the leg appears shorter and bent at the knee or an anterior dislocation where the leg is shorter and externally rotated. It's important to identify this dislocation as the blood supply to the head of femur can be disrupted. So the management of these patients, if there's no medical help in less than an hour attempt relocation unless concerns of a fracture. Posterior hip relocation technique is as follows. Apply forceful traction to the fine and once relocated, splint the legs together and evacuate a picture of how this is completed is shown opposite. The key points here are to give analgesia and that posterior dislocations are the most common pelvic fractures often occur from falls from significant height or objects falling on to the patient. Remember, we should not spring the pelvis as this can cause a rapid decline in the patient's condition and a worsening of their injuries. The management should initially focus on the C ABCD approach as previously mentioned following this to address the pelvic injury. We should think about immobilizing the pelvis. A pelvic binder is often used and can be seen in the image opposite. This enables us to immobilize and close the pelvis, stopping and preventing any further bleeding. This is important as significant internal injuries and bleeding can occur from a pelvic injury. We may not always have these devices in the field and improvised techniques are often used first, a jacket, a jacket can be placed in a similar position over the greatest recants of both legs and tightens to close the hips. A sheet can also be used but also commonly a trouser leg can be used to enable the same outcome. The trousers are cut from bottom so to near the groin and then wrapped around the greater canter. As mentioned previously, to close the pelvis, a patient should be prioritized to be evacuated as these are significant injuries and they may deteriorate very quickly. So the key points are give analgesia remember to prioritize doing AC ABCD approach, I think significant blood loss. So next up are knee and patella dislocations. These can occur for a strong valgus force to the leg. In particular patella dislocations cause the patella to move laterally. Management of a dislocated knee requires relocation. If neurovascular status is compromised, attraction to attempt to re line a leg in the position of function is indicated and carried out. As you can see here, a dislocated patella can be relocated with an attempt as shown in the picture above by gently straighten the leg and pushing the patella immediately. Post relocation is really important to splint from hip to ankle with a leg straight or at least 15 degrees knee bend as in normal and topical functional positions. This is an example of how the leg can be immobilized in the field. Yeah, the key points here are to remember to give analgesia as always and to splint the hip splint, the leg from hip to ankle. Ankle injuries in the field are common and ankle fractures in themselves occur due to inversion or aversion mechanisms to manage these patients. The lower limb should be immobilized and this can be achieved using a syrup splinted or a wrapped mechanism as shown in the pictures opposite. If the patient must walk, it is important to replace the footwear before the swelling makes this impossible. The key points here are as ever to give analgesia but ensuring that the toes are visible to continuously assess the MC NS. If it's a significant injury, another fracture dislocation area to talk about would be jaw fractures and jaw dislocations. Jaw fractures often occur for a fall or a blow to the face and they can lead to pain, swelling and an inability to close the mouth with an improper bite. Jaw dislocations can occur following a blow to the face, but they can also occur simply by yawning or even during sleep. A patient may describe teeth not being able to fit together properly. It's managed jaw fractures. We'll wrap a bandage over the top of the head and under the jaw for support. And I click through here to show you the pictures as you can see opposite jaw relocation. As you can see in this image above with the jaw dislocated. The idea is to place the thumbs inside the mouth against the lower molars. As shown below. You can use some gauze to place inside the mouth to protect your thumbs if needed. At this stage, you apply steady pressure down until you feel the mandible pop and then you should have the jaw back into place. You may then still use the bandage wrapped around the top of the head and under the jaw to provide support to the relocated jaw. The key points here are to give analgesia and remember, patients may be nauseated and the bandage should be able to be removed in case of vomiting. Finally, I think it's important to talk about how we extricate these patients in the field. And there are several techniques with limited materials to your disposal. This technique uses a rope and a coil rope to wrap around your shoulders and the patient's legs and back to enable a single rescuer to transfer a patient off the field. This technique uses two people and uses a figure of four hands to cross over to enable a patient to be lifted from the field. If you're in a position where you have hiking poles or ski poles. These can be strapped through two of your bags and between your bag and your bag. The patient then can sit on this pole between the two individual rescuers and extricated from the field. Another rope technique is to get a um length of the rope, wrap it into one point and then split the two separate parts of the rope in half. The patient can then step through this and then this can go around the rescue shoulders and provide a seat for the patient to be extricated on. And finally, just to recap the intended learning outcomes today are below. And these are also our take home messages. So we should be able to explain how fractures and dislocations are managed in a trauma patient. We revise the principles of fracture reduction and splinting. We've discussed the importance of history taking and clinical assessment in trauma patients. We've explained the common types of fractures and dislocations and how they are managed. And now we can explain the importance of checking movement, circulation and sensation. Thank you very much for listening. If you've got any questions, feel free to contact me. And I'm happy to discuss any of these uh slides or topics when we're on the course. And these are the references I used to put together this presentation. Thank you.