Treating orthopedic and related soft-tissue injuries can be problematic when medical equipment is scarce, especially in settings with high levels of injury (e.g., wilderness, war) or where having a disability is a threat to survival (e.g., treks, battles, subsistence economies). Extremity injuries are the primary cause of injury-related disability in many countries, especially in the developing world.1 In developed countries, they account for about 6% of all adult emergency department visits.2
The World Health Organization (WHO) has developed a list of essentials for treating extremity trauma at facilities with different levels of treatment capability throughout the world (see the “Facilities” section in Chapter 5). Table 32-1 suggests what equipment and skills may need to be improvised in situations of scarcity.
TABLE 32-1Worldwide Essentials for Diagnosing and Treating Extremity Injuries |Favorite Table|Download (.pdf) TABLE 32-1 Worldwide Essentials for Diagnosing and Treating Extremity Injuries
| ||Facility Level |
|Resources ||Basic ||GP ||Specialist ||Tertiary |
|Ability to recognize neurovascular and disability-prone injuries ||E ||E ||E ||E |
|Basic immobilization (sling, splint) ||E ||E ||E ||E |
|Wrap pelvic fractures for hemorrhage control ||E ||E ||E ||E |
|Hand injury assessment and basic splinting ||E ||E ||E ||E |
|Spine board availability/use ||D ||E ||E ||E |
|Proper management of immobilized patient ||D ||E ||E ||E |
|Radiology available ||D ||D ||E ||E |
|Closed reduction of fractures/dislocations ||PR ||PR ||E ||E |
|Compartment pressure measurement ||I ||D ||D ||E |
|Operative wound management ||I ||PR ||E ||E |
|External fixation (or pins and plaster) ||I ||PR ||E ||E |
|Skeletal traction ||I ||PR ||E ||E |
|Skin traction ||I ||PR ||E ||E |
|Tendon repair ||I ||PR ||E ||E |
|Hand injury debridement and repair ||I ||PR ||E ||E |
|Amputation ||I ||PR ||E ||E |
|Fasciotomy for compartment syndrome ||I ||PR ||D ||E |
|Internal fixation ||I ||I ||E ||E |
This chapter discusses the diagnosis and treatment of fractures and dislocations, including emergency amputations.
DIAGNOSIS OF FRACTURES, DISLOCATIONS, AND SOFT-TISSUE INJURIES
Lacking radiographs or other imaging capability, clinicians need to rely on physical signs and symptoms to make presumptive diagnoses of fractures and dislocations. Table 32-2 lists the common signs and symptoms of fractures, with a comment about their diagnostic utility. Radiographs and ultrasound are included in the list to identify their relationship with the physical examination. Many factors affect the usefulness of imaging as a diagnostic tool, including its technical quality and the skill of those interpreting the images.
TABLE 32-2Usefulness of Clinical Information for Diagnosing Fractures (10 = Most Useful, 1 = Least Useful) |Favorite Table|Download (.pdf) TABLE 32-2 Usefulness of Clinical Information for Diagnosing Fractures (10 = Most Useful, 1 = Least Useful)
|Open fracture with observable bone ...|
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