Orthopedic and related soft-tissue injuries are some of the most common reasons for doctor visits. These injuries are likely to present problems 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
This chapter discusses the diagnosis and treatment of fractures and dislocations, including emergency amputations. To reduce edema, soft tissue joint injuries are best treated with compression dressings and cold packs (usually crushed or cubed ice). Interrupt the cold application every 20 minutes, or more often if the cold causes discomfort.
WHO has developed a list of essentials for treating extremity trauma at facilities with different levels of treatment capability throughout the world (see "Facilities" in Chapter 5, Basic Equipment). Table 29-1 suggests what equipment and skills may need to be improvised in situations of scarcity.
Table 29-1 Worldwide Essentials for Diagnosing and Treating Extremity Injuries |Favorite Table|Download (.pdf)
Table 29-1 Worldwide Essentials for Diagnosing and Treating Extremity Injuries
|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|
|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|
|Hand injury debridement and repair||I||PR||E||E|
|Fasciotomy for compartment syndrome||I||PR||D||E|
Lacking radiographs or other imaging capability, clinicians need to rely on physical signs and symptoms to make presumptive diagnoses of fractures and dislocations. Table 29-2 lists the common signs and symptoms of fractures, with a comment about their diagnostic utility. (Radiographs are included in the list to identify their relationship with the physical exam. Many factors affect the usefulness of radiographs as diagnostic tools, including their technical quality and the skill of those interpreting the images.)
Table 29-2 Usefulness of Clinical Information for Diagnosing Fractures (10 = Most Useful, 1 = Least Useful)
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