1) Complete Assessment:
The severe angulation of some orthopaedic injuries may distract you from other, more profound problems. Remember that orthopaedic trauma is rarely life threatening in the immediate setting. ALWAYS attend to the ABCs (Airway, Breathing, Circulation) first! Also, be sure to move the patient to a position of safety (for both the patient and the rescuers) before attempting to splint the injury. Obviously, care must be taken when moving the patient so as not to cause further damage. Seamanship issues are best discussed by other SailNet experts, but the common sense maneuvers could include shortening sail, bearing off and seeking safe harbor.
Remember that during splint application gentle traction should be applied in opposite directions along the plane of the injury. This should relieve pain and bring the bone ends into reasonable alignment. This traction should be maintained during splinting and must be reapplied if the splint is loosened or adjusted for any reason. Also, during the initial straightening of an angulated fracture, if pain is markedly increased or if resistance is encountered, it is best to splint the fracture in the position found.
Once the splint is applied, the job is not over. As previously discussed, frequent reassessment of the extremity is essential. In many instances, swelling is likely to occur and this could easily cause a properly applied splint to become too tight and compromise distal blood flow. Continued attention to the neurovascular status will give early indications of problems or give reassurance of proper management.
4) Pain Relief
There should be significant pain relief once the fracture is straightened/reduced and splinted. However, pain medication is certainly warranted in most situations. Tylenol #3 (with codeine), Percocet, Darvocet and occasionally injectable analgesics like Demerol and Morphine may be required.
Lower Extremity Injuries
In much the same manner as a scapular fracture, a pelvic fracture results from a significant force or impact being applied to the pelvis or surrounding structures. A few examples could be a crush injury to a crewmember caught between the boat and pier, a fall from a height (up the mast) or having a heavy object (a hard-bottomed tender or outboard motor) fall across the pelvis. The pelvis itself consists of several large, irregularly shaped flat bones that are connected together and to the base of the spine via ligaments. The important, and potentially life threatening, aspect of the pelvic fracture is not the fracture itself, but rather the hemorrhage associated with the injury. Up to 30% of the body's circulating blood volume can be lost into the pelvic cavity and surrounding tissues. Considering the highly vascular nature of the pelvis and its importance to red blood cell production, it is easy to see why such hemorrhage can occur. Additionally, this bleeding, sequestered in the pelvic cavity, will remain out of sight and can only be deduced through other physical signs of blood loss: a change in mental status, pallor, rising pulse rate and (a late sign) falling blood pressure.
Bone marrow is responsible for producing the cells that precede the formation of the different components of the blood. These consist of erythrocytes (red blood cells), leukocytes (white blood cells) and megakaryocytes (platelets). These components, along with plasma, make up our circulating blood volume. The pelvic bones, specifically the iliums, are so rich in marrow that they are the favored sites to harvest these precursor cells for a bone marrow transplant.
Immobilization for the pelvis essentially entails full body support. On land, this is managed with a long backboard. The patient is placed on the board and securely strapped, braced and padded to maintain full body alignment. This is also important from the perspective that the mechanism of injury sufficient to fracture the pelvis will certainly have transmitted the force to the lumbar and thoracic vertebrae. Another effective device for full body immobilization is the vacuum splint. This rather ingenious splint consists simply of a rectangular bag filled with plastic pellets. When the patient is placed on the bag, the malleable material conforms to the patient's body from head to toe. A suction hose is then attached to an outlet on the bag and the air is evacuated. As the air is removed, the bag hardens to a cement-like consistency and securely immobilizes the entire skeletal frame. The bag can then be lifted like a stretcher for secure patient transport.
At sea, the issue of total body immobilization is far more problematic. First, the patient needs to be moved with the least possible manipulation to the spine and pelvis. This can prove to be next to impossible in a seaway with limited help. Second, the choice for a suitable splinting device is limited. The seat from a dinghy or tender may offer a reasonable substitute for a long backboard, but they are usually much narrower and shorter in length. Though I have never seen this used, another alternative would be a packed sailbag. This would partially imitate the aforementioned vacuum splint. Your available sail inventory will dictate the choice, but my first thought would be to use the #1 spinnaker. This sail is clearly more "conforming" than a folded 150% genoa with the downside being that it would offer somewhat less support. A possible solution would be to use a makeshift "longboard" device and place the patient and rigid splint on to the sailbag. Straps (sailties would work) could then be brought up around the sailbag to give further support. Obviously, place the patient on the lee side as close to amidships as possible to limit movement. Don't forget about the patient when it comes time to tack!!
Lastly, in addition to checking the patient's vital signs, you must monitor urination. A pelvic fracture can cause obstruction to the urine flow for a number of reasons. If the patient has not urinated for 8-10 hours after the injury, a bladder catheter will need to be inserted and left in place. Not only will this relieve the obstruction but also the quality and quantity of urine will give important clues to the patient's overall status (more on urologic emergencies in a future article). Obviously, a suspected pelvis fracture will require outside assistance and your location will dictate the necessary arrangements to get the patient to advanced medical care as quickly and as safely as possible.
The femur is the largest and longest bone in the body. Additionally, it is surrounded by a large mass of the quadriceps and hamstring muscles. Because of this protection, a significant force must be applied directly to the thigh in order to cause a fracture. This fracture is almost never a subtle finding. It will be evidenced by shortening of the extremity, a mid-thigh mass or deformity and frequently some external rotation of the leg. There may also be some crepitus noted, but as the large thigh muscles contract, the bone ends will override each other and not grind together. As with the pelvis, femur fractures commonly have significant hemorrhage and can "hide" 2-3 units of blood in the thigh. Splinting the extremity will not only stabilize the bone and relieve/reduce pain, but it will also help control hemorrhage.
Splinting a femur fracture is unique in that a "traction splint" is frequently applied. This device is anchored at the ischial tuberosity and constant, longitudinal traction is applied via an ankle strap. Mechanical assistance to apply the traction is required because of the mass and strength of the thigh muscles (quadriceps). The forceful contraction of these muscles is the source of the pain and it is very difficult to apply ample long-term traction to the extremity without using an assist device. Unfortunately, these traction splints are inconvenient to store and (hopefully) would rarely be used onboard. An acceptable option to the traction splint would be a rigid or board splint. This can be fashioned using any long, flat rigid items (two oars or paddles would suffice). These boards must be well padded and are placed with one piece extending from the foot to beyond the hip joint on the lateral side of the leg. The other is then placed high in the groin (padding will be of particular interest to the patient with this placement) and again extends down to the foot. Straps are then placed to securely immobilize the extremity. In some cases, the boards may extend past the foot and a rudimentary "traction" splint can be devised using an ankle strap and anchoring at the distal end of the boards.
Lower Leg Fractures:
The two bones of the lower leg, the tibia (shinbone) and fibula, can be fractured from either direct or indirect forces. Most of the orthopaedic injuries discussed thus far result from direct forces and I would expect this to be the most common mechanism of injury onboard. However, the lower leg is susceptible to indirect forces as well. The most common example of this is seen in snow skiing. A "spiral" fracture of the tibia is commonly seen in this sport as the leg under goes rotational stress with the foot in a fixed position (attached to the ski by the binding). This type of injury would be less common on board as there are few circumstances that would keep the foot securely anchored as the leg was subjected to severe rotation. There are two significant complications associated with a tib/fib fracture. First, due to the minimal tissue and muscle covering the anterior aspect of the tibia, an open fracture is not uncommon when a direct blow is sustained. Remember an "open" fracture is one with an open wound overlying a broken bone; the bone does not have to be sticking out. Second, again because of the lack of excess room in the lower leg, the danger of a "Compartment Syndrome" is proportionally higher. These complications are dealt with by using proper splinting techniques and seeking medical care as quickly as possible.
The splinting options for a tib/fib fracture are varied and there are a number of useful items on board to help with immobilization. Keeping in mind the basic principles of immobilizing both above AND below the injury, the splint must extend upward past the knee and down below the ankle. A board splint (much like that used for a femur fracture) is an excellent choice. Sail battens, seat cushions and even folded navigational charts offer adequate rigidity. Remember to apply the splints firmly, but do not cinch the straps so tightly as to compromise circulation.
Compartment syndrome is caused by increased pressure within a closed space. In the case of the lower leg, bleeding and tissue swelling can cause the pressure in the extremity to compress nerves and blood vessels. The signs of impending compartment syndrome consist of the 6 "P"s: Pain, Pallor, Pulselessness, Paresthesia, Paresis/Paralysis and Puffiness. These are described in more detail below. Any of these signs are cause for concern and medical attention should be sought as quickly as possible. The treatment for compartment syndrome is a surgical incision into the muscle bed (known as a fasiotomy) which will release the pressure within the enclosed space.
Pain: While there will always be some pain with a fracture, compartment syndrome pain will have a distinctly different quality. It may also evidence by having a return of pain after it had been relieved with effective splinting. A reliable test is to elicit increased pain with passive extension of the fingers or toes of the affected limb.
Pallor: This is the loss of good skin color. There is decreased capillary refill and the skin will become very pale. While this may be difficult to appreciate in the deeply tanned patient, capillary refill assessment will tell the tale. The lips are also an excellent indicator of pallor.
Pulselessness: If there is complete occlusion of the distal blood flow, the extremity will lose pulses. The extremity will also become cooler than its uninjured counterpart. This is a late sign and is quite ominous.
Paresthesia: Numbness or "pins-and-needles" sensation in the extremity indicates compression of sensory nerve branches. As with some of these other signs, be sure an overly tightened splint is not causing the problem.
Paresis (weakness)/Paralysis: As with paresthesia, weakness or loss of motor function will indicate pressure on motor nerves.
Puffiness: Swelling is essentially the cause of compartment syndrome. As the pressure increases, the venous return of the blood from the extremity will be obstructed BEFORE the arterial supply. Arterial pressure is higher than venous pressure so the inflow can continue even if there is diminished or absent outflow.
As mentioned in an earlier article, an ankle sprain is treated as a fracture unless proven otherwise. An easy and effective splint in this situation is a pillow splint. It will conform to the angle of the ankle joint and (when used in combination with an ACE wrap) will offer adequate immobilization. It is also important to keep the ankle elevated above the level of the heart whenever possible to promote venous drainage and limit swelling. A crewmember with an ankle fracture will usually not be completely incapacitated and should still be able to stand a "lookout" watch. However, do not dismiss the serious nature of this injury as improper management or a recurrent injury could result in long term disability.
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