As with many of the emergency medical topics covered in this column, hands-on experience is the key to successfully managing an on-board problem. Handling orthopaedic trauma is an especially "tactile" situation and hopefully some images of splinting techniques will fill in the "thousand words" the pictures are reportedly worth.
A figure-8 splint CAN be used for a clavicular fracture, but I do not believe it is required. The clavicle, especially in younger patients, may fracture in a manner known as a "Greenstick". The bone will only partially "break"-much like the splintering of a young tree branch-hence the term "Greenstick". Immobilization of this fracture is difficult at best and, in most instances, unnecessary. The Figure-8 splint helps to limit the mobility of the AC (acromioclavicular) joint at the shoulder. This can also be accomplished with a simple sling. A swath can be added to further restrict movement.
Humerus (upper arm):
A few specific injuries warrant special comment.
Scapular Fracture (Shoulder Blade):
Fracture of a shoulder blade will present with the usual signs of any fractured bone: pain, swelling, ecchymosis (bruising) and occasionally some deformity. Scapular fractures are rare and their importance is not the fracture itself, but rather the high potential for associated injuries. Considering the location of the scapulae, the intrinsic strength of a large, flat bone and the considerable protection offered by the overlying muscles and tissue, it is clear that a significant force must be imparted to fracture this structure. Given this sizeable mechanism of injury, there is increased likelihood that other, more serious, injuries are present. Adjacent structures such as cervical and thoracic vertebrae, spinal cord, posterior ribs and lung are all at risk for sustaining critical injuries. At the risk of boring you with repetition, return to the ABCs! A broken neck or collapsed lung will certainly take precedence of a fractured shoulder blade. Treatment of a scapular fracture can be adequately accomplished with a sling and swath, but given the preceding discussion, complete spinal immobilization would be appropriate. (Back injuries will be covered in a future article).
Fractures of the Distal Humerus:
Another special upper extremity injury is a fracture of the distal humerus also known as a "supracondylar fracture" (this is the portion of the arm just above the elbow). These fractures occur most commonly in children under 11 years of age. The mechanism is that of falling on to an outstretched hand with the arm fully extended. Because some bones have not reached full maturity (ossification) in the pre-pubescent years, they are somewhat more prone to fracture when subjected to these stresses. Because of the location of this fracture and the subsequent misalignment of the bone ends, there is an increased likelihood that there will be compression of both arterial and nervous structures. Specifically, pressure on the brachial artery may compromise blood flow to the forearm/hand and compression of the radial nerve may result in "wrist drop" (the inability to dorsiflex the hand). Additionally, prolonged compromise to the vascular bed can lead to Volkmann's Contracture. This consists of degeneration, contracture, fibrosis and atrophy of muscle secondary to vascular damage.
Assessment is the same as for any other orthopaedic injury. The elbow will be very swollen and painful with some deformity noted. The neurovascular assessment is VERY important and, if compromised, immediate medical attention should be sought. As with any suspected fracture to a joint, the extremity should be splinted in the position found. However, if there is clear evidence of neurovascular damage, cautious realignment should be attempted. If any resistance is met or there is a marked increase in pain, the attempt should be aborted and the splint applied. A Ladder or SAM splint would work well in this setting as they can be molded to the desired position. A sling and swath will further aid in immobilization.
Be sure to look for the next section of Splint Hints for the lower extremities and keep checking in to SailNet.com!
The author would like to thank students from the Williamsport Hospital Paramedic Training Institute for their help with the photos shown on this page.
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