Chapter 16: Fractures, Dislocations, Sprains, and Strains

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Overview

Although musculoskeletal injuries are typically painful, they are rarely life-threatening. However, when not recognized and treated promptly, they can result in permanent disability or death. Musculoskeletal injuries are especially dangerous when a bone breaks and the fractured ends cause damage to other internal structures such as vital organs or blood vessels. They are also dangerous when a displaced part of the bone puts pressure on blood vessels, resulting in vascular compromise and tissue death. In these cases, the soft tissue injury is the life-threatening condition, but the cause is the fracture.

Types of Musculoskeletal Injuries

Injuries to the musculoskeletal system can be classified according to the type of structure that is damaged. They are also classified by the nature and extent of the trauma caused to that structure. The four basic types of musculoskeletal injuries are: fractures, dislocations, sprains, and strains. Some injuries may also involve more that one type of injury, for example, a direct blow to the knee may injure both ligaments and bones.

Fractures. A fracture is a partial or complete break in bone tissue. Fractures include chipped or cracked bones, as well as bones that are broken completely into separate pieces (see figure below). Because bones are made of hard, ridgid tissues, any force that causes a bone to bend is likely to result in a fracture. This force could be from a blunt impact, or it could be caused by a movement of the body (e.g., a strong twisting motion). Even a powerful muscular contraction can result in a fracture. Although fractures are rarely an immediate life-threat, any fracture involving large bones can cause hypovolemic shock because of the hemorrhaging that can result.

Fractures can be classified as open or closed:

• Closed fractures leaves the skin unbroken. They are more common than open fractures and can be displaced or simple. They may cause internal hemorrhaging.
• Open fractures breaks the skin. They are more serious than closed fractures because of the risk of infection and hemorrhage.

Fractures are not always easy to recognize without a telltale sign, such as an open wound with a protruding bone end, or a severely deformed body part. The mechanism of injury is often the best indicator of weather you should suspect a fracture.

Dislocations. A dislocation is a displacement or separation of a bone from its normal position at a joint (see figure below). Dislocations are usually caused by powerful forces that push the joint beyond its normal range of motion, such as twisting the joint or falling in an awkward position. Some joints, such as the shoulders and knees, are more prone to dislocations because they are less protected from injuries and are often exposed to strong forces. Other joints, such as the joints of the spine, are well protected and therefore dislocate less often.

When, in a dislocation, the ligaments around a joint are forced apart enough to stretch and tear, subsequent dislocations of the joint are more likely to occur.

Dislocations are more obvious that fractures because the joint will be visibly deformed. Often, the end of the displaced bone causes an abnormal lump, ridge, or depression beneath the skin. An injured patient will be unable to move a joint that is dislocated. A force violent enough to cause a dislocation can also cause a fracture and can damage nearby nerves and blood vessels.

Do not attempt to reinsert a dislocated joint, as this can cause additional damage.

Sprains. A sprain is the partial or complete stretching or tearing of ligaments at a joint. A sprain is usually a result when the bones that form a joint are forced beyond their normal range of motion (see figure below).

Mild sprains, which only stretch ligament fibres, generally heal quickly. The patient may have only a brief period of pain or discomfort (7-10 days) and quickly return to activity with little or no lingering effects. Severe sprains usually cause pain when the joint is moved. A force that results in a severe sprain can also involve a fracture of the bones that form the joint.

Often, a sprain is more disabling than a fracture. When fractures heal, they usually leave the bone as strong as it was before; it is unlikely that a repeat break will occur at the same location. Once ligaments have been stretched or torn, however, the joint may become unstable and more vulnerable to re-injury, especially if the initial sprain is not cared for properly. It is important that patients have even minor sprains examined to reduce the risk of lifelong complications.

Strains. A strain is the stretching and tearing of muscle or tendon fibres. Because tendons are tougher and stronger than muscles, tears usually occur in the muscle itself or where the muscle attaches to the tendon. Strains are often the result of overexertion, such as lifting an object that is too heavy or stretching a muscle beyond its normal range when exercising (see figure below). They can also result from sudden or uncoordinated movements, such as twisting to avoid falling on a patch of ice. Strains commonly involve the muscles in the neck or back, the thigh, or the back of the lower legs. Strains of the neck and lower back can be particularly painful and disabling.

Like sprains, strains are often neglected, which makes them very susceptible to reinjury. Strains sometimes recur chronically, especially those involving the muscles of the neck, lower back, and back of the thigh. These injuries can often be prevented by using proper body mechanics and ergonomics for repeated or high-risk tasks.

Signs and Symptoms of Musculoskeletal Injuries

Five common signs and symptoms of musculoskeletal injuries are:

1. Pain.
2. Swelling.
3. Deformity.
4. Discoloration of the skin.
5. Inability to use the affected part normally.

Irritation and damage to nerve endings in the injured area cause pain. The injured area may be painful when touched, when moved, or both.

Swelling is often caused by bleeding from damaged blood vessels in the injured area. Swelling may also occur due to excessive fluid production by the synovial capsule surrounding the joint. This swelling may appear rapidly at the site of injury, develop gradually, or not appear at all. Therefore, swelling alone may not be a reliable indicator of which structures are involved or of the severity of an injury.

Internal bleeding may discolour the skin in surrounding tissues, but it may take hours or days to appear. At first, the skin may only look red. As blood seeps to the skin’s surface, contusions will usually appear.

Deformity may also be a significant sign of injury (see figure below). Abnormal lumps, ridges, depressions, or unusual bends or angles in the body parts are examples of deformities that can indicate a musculoskeletal injury. Comparing the injured part with the corresponding part on the uninjured side can help you identify abnormalities.

An injured patient’s inability or unwillingness to move or use an injured part may also indicate a significant injury. The patient may tell you that they are unable to move it or that it is simply too painful to move. Moving or using injured body parts can disturb tissues and further irritate nerve endings, which causes or increases pain. Often, the muscles of an affected area will spasm in an attempt to keep the injured part from moving.

An injured patient will usually support an injured part in the most comfortable position. To care for musculoskeletal injuries, try to avoid causing patients additional pain: do not move an injured part unless it is necessary for assessment or interventions.

Sprains and strains are fairly easy to differentiate based on where the signs of injury are located. Because a sprain involves the soft tissues at a joint, any pain, swelling, and deformity are usually confined to the joint area. Strains involve the soft tissue structures that, for the most part, lie between joints.

The most serious musculoskeletal injuries are fractures, as they are most likely to cause additional damage to internal structures or result in permanent impairment without prompt treatment. If a bone is fractured, you may detect crepitus, which is a grating, popping, or crackling sound or sensation beneath the skin in the injured area. It can have multiple causes but is commonly caused by fractured pieces of bone rubbing against one another.

Other signs and symptoms that suggest a fracture include:

• A significant deformity.
• A snapping or popping sounds at the moment of injury.
• A mechanism of injury that suggests the trauma may be severe.
• Crepitus.
• Moderate to severe swelling and/or discoloration.
• An inability to move or use the affected body part.
• Visible broken bones protruding from the skin.
• Loss of circulation or sensation in a extremity.

General Care for Musculoskeletal Injuries

While it can be difficult to identify the exact nature of a musculoskeletal injury in the field, the general care for all musculoskeletal injuries is similar. Performing a focused assessment on the injured area will help you to determine the nature of the injury. If the injury involves more than minor bleeding, apply direct pressure until the bleeding stops. Movement of a fractured bone can cause additional tissue damage: avoid putting more pressure on the injured area than is necessary to control the bleeding.

Remember the acronym RICE:

Rest: Avoid any unnecessary actions that cause the patient pain. Help the patient find the most comfortable position. If you suspect a head and/or spinal injury, leave the patient lying flat. Do not move the patient unless it is absolutely necessary.

Immobilize: If you suspect a serious musculoskeletal injury, you must immobilize the injured part before giving additional care, such as applying ice or elevating the injury. To immobilize, apply a splint, sling, or bandage to reduce movement of the injured body part (see the sub-chapter below for Splints and Slings).

The purpose of immobilizing an injury is to:

• Reduce pain.
• Reduce the risk of hemorrhage.
• Reduce potential loss of circulation to the injured part.
• Prevent further damage to soft tissues.
• Prevent closed fractures from becoming open fractures.

If possible, always splint a musculoskeletal injury before moving the patient. Fractures of large bones especially can cause internal hemorrhaging, which may lead to shock.

Cold: If the injury is not an open wound, apply ice or a cold pack. Cold helps ease pain and discomfort. Place a thin layer of gauze or cloth between the source of cold and the skin to prevent skin damage. Do not apply an ice or cold pack directly over a fracture because the pressure could cause discomfort to the patient. Instead, place cold packs around the site of injury. In general, cold should be applied for 15 to 20 minutes every hour for the first 24 to 48 hours.

Elevate. Elevating the injured area above the level of the heart helps to reduce swelling. Always immobilize a seriously injured limb before elevating. Do not elevate an injured area if doing so causes the patient additional pain, as this may aggravate the injury.

Musculoskeletal injuries are rarely life-threatening, unless other tissues are damaged as well, but the patient should be examined by a physician to reduce the risk of complications.

However, a patient in the following situations requires rapid transport:

• The injury involves a hemorrhage.
• The injury involves trauma to the skull or spine.
• The injury impairs the patient’s respiration.
• There is severe angulation with reduction in or loss of sensation and/or circulation.
• There are multiple major musculoskeletal injuries suspected (e.g. two long-bone fractures).

Splints and Slings

A splint is used to immobilize an injured extremity to reduce the risk of additional injury and help reduce pain for the patient.

Types of Splints

There are four types of splints:

1. Soft.
2. Ridged.
3. Anatomical.
4. Traction.

Soft Splints: Soft splints include folded blankets, towels, pillows, slings, and triangular bandages (first figure below). A blanket can be used to splint an injured ankle (second figure below). A folded triangle bandage is used to secure dressings or splints in place.

 

Left: Soft splints include folded blankets, towels, and triangular bandages. Right: A blanket can be used to splint an injured ankle.

Rigid Splints: Rigid splints are made of hard, inflexible materials that hold the extremity firmly in one position. Commercial rigid splints include a range of sizes, including longer models for leg injuries and shorter models for arm injuries. Some have a moldable aluminium core surrounded by padding: these can be shaped to the affected area to increase support and comfort (see figure below).

Anatomical Splints: Anatomical splints use the patient’s own body to support an injured part. For example, an arm can be immobilized against the chest, or an injured leg can be immobilized using the uninjured leg for support (see figure below).

Traction Splints: A traction splint is used primarily to immobilize fractures of the femur. One end attaches to the patient’s hip and the other to the patient’s ankle. When traction is engaged, a constant, steady pull is applied to opposite ends of the leg, stabilizing the fractured bone’s ends and keeping them from causing any further damage to soft tissues in the thigh (see figure below). Each commercial brand of traction splint has its own unique method of application. Only apply traction splints that you are proficient with.

Rule of Thirds

Some injuries require special splinting considerations. To determine which type of splint is most appropriate for an injury, you should determine whether the injury is a joint injury or mid-shaft injury.

To determine this, use the Rule of Thirds. Each long bone can be divided into thirds. If the injury is located in the upper or lower third of the bone, treat the injury as a joint injury. If the injury is in the middle third of the bone, treat it as a mid-shaft injury.

How to Splint

When using a splint, follow these basic principles:

1. Use appropriate equipment.
2. Splint only if it can be done without causing further injury.
3. Immobilize the joints above and below the injury site in the splint.
4. Check for normal circulation and sensation before and after splinting.
5. Familiarize yourself with the manufacturer’s directions before using a commercial splint.

Before splinting, cover any open wounds with dressings and bandages to help control bleeding and prevent infection.

When applying a splint, support the injured body part to reduce pain and mitigate the risk of additional injuries.

If the injury involves an extremity, check for normal sensation in the digits distal to the injury. You should also check distal circulation: check the patient’s pulse, as well as the colour, temperature, and capillary refill in the digits below the injury. Abnormalities can be identified more easily by comparing the injured extremity against the uninjured one.

If you are using a ridgid or anatomical splint, pad the splint so that it is shaped to the injured part. Using the uninjured limb as a guide to normal positioning will help prevent further injury and increase comfort for the patient. If using a moldable splint, shape the splint to the uninjured extremity then transfer it to the injured side.

To effectively immobilize an injured part, a splint must extend above and below the injury site and include the joint above and below the injury (see figure below).

Secure the splint in place with an elastic roller bandage or the straps provided with the splint. Always move from stable to unstable when attaching a splint: This means first anchoring the splint to strong, uninjured areas, and then wrapping towards the injured part. For example, if a patient has a broken elbow, begin securing the splint at the axilla (armpit) and work distally towards the elbow, stopping short of the injury site. Next, secure the splint from below the wrist, working proximally towards the elbow and again stopping short of the injury. Finally, carefully wrap the injured area with a separate elastic roller bandage. This last bandage can then be removed to allow an examination of the injury without compromising the stability of the splint.

Recheck circulation and sensation below the injury to ensure that they have not been restricted due to the pressure from the splint. If either circulation or sensation has changed, loosen the splint slightly and reassess. You should also loosen the splint if the patient complains of numbness or if the fingers or toes turn blue or become cold. If there are signs of pooling fluids, loosen the bandages.

After a musculoskeletal injury has been immobilized, recheck the patient’s ABCs and vital signs, and take steps to care for shock. Shock is likely to develop as a result of a serious musculoskeletal injury. Help the patient rest in the most comfortable position, apply ice or a cold pack to the injured area, maintain normal body temperature, and offer reassurance to the patient.

With the patient’s willingness, a single attempt may be made to straighten a fractured limb if more advanced medical care is not available within 30 minutes and the patient is exhibiting signs of the following:

• A decrease or absence of distal circulation, sensation, and/or mobility
• Gross angulation of the limb
• Tenting of the skin
• Severe pain

Using gentle traction, straighten the limb into anatomical position. Grasp the limb above and below the site of injury and pull gently. Reassess circulation and sensation below the injury once you have realigned the limb. If either is still impaired, the patient should be in the rapid transport category.

Do not attempt this if you suspect a joint injury, such as a dislocation, or if you observe firm resistance to movement, a significant increase in pain, or the sound or feeling of bone fragments grating.

Slings

A sling is used to support an upper extremity if a musculoskeletal injury damages the usual support structures. For example, a patient with a dislocated right shoulder will require a sling to support his or her right arm. A sling may also be applied to a splinted arm to provide additional support.

The Arm Sling – for Injuries of the Forearm. An arm sling holds the forearm in a raised or horizontal position and can support an injured upper arm, forearm and wrist. What to do:

1. Ask the casualty to support their arm with their other hand. Gently slide the triangular bandage underneath the arm. The point of the triangle should be underneath the elbow of the injured arm. Bring the top end of the bandage around the back of the neck.
2. Fold the lower end of the bandage up over the forearm to meet the top of the bandage at the shoulder of the injured side.
3. Tie the two ends of the bandage together in a reef knot above their collar bone and tuck in the free ends.
4. Adjust the sling so that it supports their arm all the way to the end of their little finger.
5. Make sure that the edge of the bandage by the elbow is secured by twisting the fabric and tucking it in, or using a safety pin to fasten.
6. Check the circulation in their fingertips every 10 minutes. Press their nail for 5 seconds until it turns pale, then release to see if the colour returns within 2 seconds.

How to tie an arm sling – for injuries of the forearm.

The Elevated Sling – For Injuries of the Shoulder. The elevated sling supports the victim’s arm with the elbow beside the body and the hand extended towards the uninjured shoulder. What to do:

1. Ask the casualty to support their injured arm, across the chest, with their fingers resting on the opposite shoulder.
2. Lay the triangular bandage over their chest, on top of the injured arm, with one end over their uninjured shoulder. Hold the point of the bandage just below the elbow on the injured side.
3. Tuck the lower part of the bandage underneath the injured arm. Bring it diagonally across their back to meet the other end of the bandage at their shoulder.
4. Tie the two ends of the bandage together in a reef knot above their collar bone and tuck in the free ends.
5. Make sure that the edge of the bandage by the elbow is secured by twisting the fabric and tucking it in, or using a safety pin to fasten.
6. Check the circulation in their thumb every 10 minutes. If it’s too tight, then loosen the sling and readjust.

How to tie an elevated sling – for injuries of the shoulder.

The Collar and Cuff Sling – For Injuries of the Upper Arm and Ribs. The collar and cuff sling allows the elbow to hang naturally at the side with the hand extended towards the shoulder on the uninjured side. What to do:

1. Make a clove hitch using a narrow fold bandage.
2. Put the loops over the wrist of the injured arm.
3. Gently elevate the injured arm against the casualty’s chest to a position of comfort.
4. Tie the bandage ends together around the neck on the uninjured side using a reef knot.
5. Place a pad under the knot.
6. For extra support apply a broad bandage below the fracture site over the arm & around the body.

Upper Extremity Injuries

The upper extremities are the arms and hands. Upper extremity bones include the clavicle, scapula, humerus, radius and ulna, carpals and metacarpals, and phalanges. The three figures below shows the major structures of the upper extremities.

The major structures of the upper extremities.

The upper extremities are the most commonly injured areas of the body. Injuries to the upper extremities occurs in many different ways. The most frequent cause is falling on the hand of an outstretched arm. Since the hands are rarely protected, abrasions occur easily. A falling person instinctively tries to break the fall by extending the arms and hands, so these areas receive the force of the body’s weight.

When caring for serious upper extremity injuries, minimize any movement of the injured area. If the patient is holding the arm securely against the chest, do not attempt to change the position. Holding the arm against the chest is an effective method of immobilization because it keeps an injured body part from moving. Allow the patient to continue to support the arm in this manner. You can further assist the patient by binding the injured arm to the chest. This eliminates the need for special splinting equipment and still provides an effective method of immobilization.

Injuries to the upper extremities may also damage blood vessels, nerves, and several soft tissues. It is particularly important to ensure that blood flow and nerve function have not been impaired. Always check the peripheral pulse and ensure that sensation below the injury site is normal both before and after splinting. Sometimes, when a splint is applied too tightly, circulation may be impaired. If this occurs, loosen the splint. If you suspect that either the blood vessels or the nerves have been damaged, minimize movement of the area and obtain more advanced medical care immediately.

Shoulder Injuries. The shoulder consists of three bones that meet for form the shoulder joint: the clavicle, the scapula, and the humerus. The most common shoulder injuries are sprains. However, injuries of the shoulder may also involve a fracture of one or more of these bones, or a dislocation of the shoulder joint.

The most frequently injured bone of the shoulder is the clavicle (see figure below), though this is more common in children than adults. Typically, the clavicle is fractured as a result of a fall. The patient usually reports pain in the shoulder area that may radiate down the arm. A patient with a fractured clavicle usually attempts to ease the pain by holding the arm against the chest. Since the clavicle lies directly over major blood vessels and nerves, it is important to immobilize the injured area to prevent injury to these structures.

Scapular fractures are not common. You are less likely to see deformity of the scapula: The most significant signs and symptoms are extreme pain and the inability to move the arm. It takes a great deal of force to break the scapula, so an MOI that results in a fractured scapula is likely to injure the ribs or internal organs in the chest as well. This is often indicated by dyspnea.

A dislocation is another common type of shoulder injury. Like fractures, dislocations often result from falls. This happens frequently in contact sports, such as football and rugby. A player may attempt to break a fall with an outstretched arm or may land on the tip of the shoulder, forcing the arm against the joint formed by the scapula and clavicle (this is commonly referred to as a separation). This can result in ligaments tearing, causing the end of the clavicle to displace. Dislocations also occur at the joint where the humerus meets the socket formed by the scapula. For example, when a patient’s arm is struck while raised in the throwing position, the arm is forced to rotate backward, tearing ligaments and causing the upper end of the arm to dislocate from its normal position in the shoulder socket. Shoulder dislocations are painful and can often be identified by the deformity present. As with other shoulder injuries, the person often tries to minimize the pain by holding the arm in the most comfortable position.

Specific Care for Care for Shoulder Injuries. Help the patient to keep the injured arm in the position that he or she is naturally holding it in. An elevated sling will usually suffices, however if the patient is holding the arm away from the body or down by their torso, place a soft object such as a pillow or folded blanket between the arm and the torso to provide support. Immobilize the injured arm by binding it to the chest or by placing the arm in a sling and then binding it to the chest with a triangular bandage folded into a broad bandage.

Upper Arm Injuries. The humerus is a long bone that can be fractured at any point, although fractures most often occur near the shoulder or in the middle of the bone. The upper third of the humerus fractures more often in older adults and young children, often as a result of falls. Fractures in the middle third occur mostly in young adults.

A fractured humerus can cause damage to the blood vessel and nerves supplying the entire arm. Most humerus fractures are very painful and prevent the person from using their arm. These fractures can cause considerable deformity.

Specific Care for Care for Upper Arm Injuries. If you suspect a fracture, apply a moldable long splint from the axilla to the wrist in the position found to prevent movement of the elbow. If a fracture is not suspected (or if the position of the splinted arm allows it), place the arm in a sling. If necessary, provide additional support by binding the forearm to the chest with triangular bandages (so long as this doesn’t cause discomfort or risk aggravating the injury.

Elbow Injuries. Like other joints, the elbow can be sprained, fractured, or dislocated. Since all the nerves and blood vessels of the forearm and hand pass through the elbow, injuries to the elbow can cause permanent disability. Like all joint injuries, elbow injuries can be made worse by movement. Use caution when assessing an injured elbow to reduce the risk of causing further damage.

Specific Care for Care for Elbow Injuries. If the patient indicates an inability to move the elbow, do not try to move it. Support the arm and immobilize it in the position found with a long moldable splint from the axilla to the hand (including the fingers). Once the arm is immobilized, and if the angle of the elbow allows it, place the arm in a sling and secure it to the chest (see figure below).

Forearm, Wrist, and Hand Injuries. The forearm is the part extending from the elbow to the wrist. Fractures of the two forearm bones, the radius and ulna, are most common in children and older adults. If a person falls on the palmar surface of an outstretched arm, both bones of the lower arm may break, but not always in the same place. A fracture of both bones can cause the arm to appear S-shaped (see figure below). Because the radial artery and nerve are near these bones, a fracture may cause a hemorrhage or a loss of movement in the wrist and hand. Sprains of the wrist are also common.

The hands are very susceptible to injury because they are used so often in daily activities.

Specific Care for Care for Forearm, Wrist, and Hand Injuries. If a single finger is damaged, it can be immobilized by taping it to the adjacent finger. You can also place a tongue depressor (padded with gauze) along the underside of the finger and immobilize it with tape (see figure below).

If multiple fingers or the hand itself is damaged, you should attempt to immobilize the hand and fingers in a position of function. This is the natural, gentle curve of the fingers and palm when at rest. If the fingers are bleeding, place gauze between them. If the hand is bleeding, wrap it in gauze. Next, splint the patient’s forearm from the elbow to just beyond the fingertips. Beginning at the elbow, attach the splint firmly to the forearm with a roller bandage, avoiding excessive pressure. A moldable splint is best suited. Leave a gap in the bandage that will allow you to assess the radial pulse. When you reach the hand, place a roll of non-sterile gauze in the patient’s palm to increase comfort and maintain the position of function (see figure a and b below), then wrap the hand with a roller bandage. Once it is immobilized, support the injured hand with a sling and secure it to the patient’s chest.

Care for an injured forearm or wrist by immobilizing the injured area. Place a splint underneath the forearm. When using a rigid splint, extend the splint beyond the hand, and immobilize the elbow by splinting to the shoulder. Place a roll of gauze or a similar object in the palm to keep the palm and fingers in a position of function. Place the arm in a sling and secure it to the patients chest (see figure below).

Lower Extremity Injuries

Bones of the leg include the femur, patella, tibia and fibula, as well as the tarsals, metatarsals, and phalanges. Because of the size and strength of the bones in the thigh and lower leg, a significant amount of force is required to cause a fracture.

Thigh Injuries. The femurs are the largest bones in the body and the most important for walking and running. The upper end of the femur meets the pelvis at the hip joint (figure below). Most femur fractures involve the upper end of the femur. Even though the hip joint itself is not usually involved, these injuries are often referred to as hip fractures.

A fracture of the femur usually produces a characteristic deformity. When a fracture occurs, the thigh muscles begin to contract. The thigh muscles are so strong that they can pull the broken bone ends together, causing them to overlap (see figure below). This may cause the injured leg to be noticeably shorter that the other leg. The injured leg may also be turned outward. Other signs and symptoms of a fractured femur may also include severe pain and swelling, and the inability to move the leg.

The femoral artery is the major supplier of blood to the legs and feet. If it is damaged, as may happen with a fracture of the femur, the blood can be rapidly life-threatening. A weak or absent pulse distal to the injury is a sign of damage to the femoral artery.

Specific Care for Care for Thigh Injuries. If the upper or lower third of the femur is fractured, treat the injury as a joint injury (hip or knee). Because of the risk of an internal hemorrhage, a patient with a fractured femur should always be placed in the rapid transport category.

Control any external bleeding before immobilizing the injured area. Keep the patient in the most comfortable position.

If a patient’s femur is broke, apply a long rigid splint from the armpit to the foot on the lateral side, and a second rigid splint on the medial side from the groin to the bottom of the foot (or just beyond). Commercial traction splints should be used if available.

Another method involves securing the injured leg to the uninjured leg. This should only be used if the patient is in a rapid transport situation when speed is crucial. Roll a blanket so that it fills the space from groin to ankle without putting unnecessary pressure on the injured area. Measure the blanket against the outside of the uninjured leg before placing it between the legs. Bring the uninjured leg to the injured leg, and bind the legs together in several places above and below the site of the injury using wide elastic straps and broad bandages. Ensure that there is sufficient padding between the legs to maximize comfort for the patient and reduce the risk of injury. If the patient is not on a ridgid device such as a backboard, ensure that the knees are supported from behind so they will not bend when the patient is moved.

Lower Leg Injuries. A fracture in the lower leg may involve one or both bones (fibula and tibia). Like the bones in the forearm, they are often fractured simultaneously. However, a blow to the outside of the lower leg can cause an isolated fracture of the fibula. Open fractures are common because the fibula and tibia lie just beneath the skin. A lower leg fracture may cause a severe deformity in which the lower leg is bent at an unusual angle (angulated). These injuries are painful and result in an inability to move the leg. However, fractures of the fibula, and small fractures of the tibia, may not cause any deformity, and the patient may even be able to use the leg.

Specific Care for Lower Leg Injuries. If the upper or lower third of the tibia or fibula is fractured, treat the injury as a joint injury (knee or ankle).

If the tibia or fibula is fractured, apply a rigid long splint to the lateral side of the injured leg, extending from just below the hip to below the food. Place a shorter padded splint on the medial side of the leg, extending from the groin to the foot (see figure below).

Knee Injuries. The knee joint includes the lower end of the femur, the upper ends of the tibia and fibula, and the patella (kneecap). This joint is very vulnerable to injury. The patella is a bone that moves on the lower front surface of the thigh bone. Sprains, fractures, and dislocations of the knee are common in athletic activities that involve quick movements or exert unusually force on the knees.

The knee joins the two longest bones of the body, the femur and the tibia. Four ligaments attach to the bones and hold the knee together. Two cartilage discs serve to increase joint stability, facilitate joint lubrication, and absorb shock. This cartilage can be torn due to a torsion injury. Repeated and excessive shocks to the knee can also splinter the cartilage pads and stretch or fray the ligaments.

The kneecap is unprotected in that it lies directly beneath the skin. This part of the knee is very vulnerable to bruises and lacerations, as well as dislocations. Any violent trauma to the front of the knee can cause fractures of the patella.

Specific care for Knee Injuries. For a soft tissue injury, such as a sprain, apply an elastic roller bandage using a figure-eight pattern. In the case of a fracture, splint the knee in the position found. If the knee is bent, support it in the bent position (see figure below). If the knee is straight, splint the leg from the foot to the axilla on the lateral side, and from the foot to the groin on the medial side (as you would for an injury of the thigh).

Ankle and Foot Injuries. Ankle and foot injuries are commonly caused by twisting forces. Injuries range from minor sprains with little swelling and pain, to fractures and dislocations. As with other joint injuries, you cannot always distinguish between minor and severe injuries. You should initially care for any ankle or foot injury as if it is serious. As with other lower extremity injuries, a physician should evaluate an ankle or foot injury if it appears swollen, is unable to bear weight, or causes pain when moved.

Fractures are possible when any great force is applied, such as falling from a height and landing on the feet. The force of the impact may also be transmitted up the legs. This can result in an injury elsewhere in the body, such as the thigh, pelvis, or spine. If the MOI suggests that these serious injuries may be present, take necessary precautions (e.g. spinal motion restriction). Foot injuries may also involve the toes. Although these injuries are painful, they are rarely serious.

Specific Care for Ankle and Foot Injuries. If the ankle is injured, immobilize it in the position found. This can be done with a commercial or a pillow splint. The pillow splint is made by placing the ankle in the centre of a pillow and folding the sides of the pillow around the ankle. Secure the pillow to the ankle with elastic straps or broad bandages. YOu may also immobilize an injured ankle with two well-padded rigid splints, one lateral and one medial, extending from above the knee to the foot.

A pillow splint is generally effective for most foot injuries as well. If the injury was caused by crushing forces to the toes (tarsals), place gauze between the toes before splinting to absorb fluid and prevent the toes from adhering to one another.