Chapter 29. Orthopedics

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.

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.)

Using Tuning Forks/Percussion

One of the most persistent myths in orthopedics is that fractures can be diagnosed using a stethoscope with a tuning fork or percussion. This fallacy continues to be sustained by experts in academia and wilderness medicine.6-9 Yet our forbears knew that this was nonsense. Stimson, for example, wrote in 1910 that even under the best circumstances, this adds nothing to the diagnosis. "Auscultatory percussion," he wrote, "the stethoscope being moved from one fragment to the other while percussion is made upon the first, will sometimes give a marked change in the sound as the line of fracture is crossed; but it is rarely significant, except in cases in which the diagnosis can be made by other means."10 What Stimson didn't mention is that the percussion usually hurts over the fracture site: not a great finding, but enough to suggest that there might be a fracture.

No study has demonstrated the validity or reliability of the tuning fork test in detecting simple acute fractures.11 My own tests, done with naïve optimism, used not only percussion, but also tuning forks of various recommended frequencies. These tests demonstrated that while percussive diagnosis works occasionally—usually in cases where the fracture is clinically obvious anyway—there are many false positives and false negatives, making the method virtually worthless. False negatives were especially frequent when hematomas overlaid the fracture site.

Using Ultrasound

See Chapter 18, Radiology/Imaging, for information about how to use ultrasound for orthopedic injuries.

Physical Diagnosis

The balance of this section deals with the physical diagnosis of fractures and dislocations, which is an art seemingly lost to a reliance on imaging. Physical diagnosis consists of (a) observation, (b) measurement, and (c) palpation. Using these three modalities, the clinician can diagnose many acute orthopedic disorders without imaging.

Upper Extremity

Carpal Bone Fractures

Unlike many other fractures, carpal bone fractures may not produce much deformity, or even edema. After trauma, the patient's wrist pain, limitation of motion, and tenderness on palpation should provide enough information, without imaging, to treat an injury as a probable fracture and immobilize it. Even with imaging, some fractures, especially those of the scaphoid, may not be seen.

If all the following signs are present, they have 100% sensitivity and 74% specificity for a scaphoid fracture.12 Assume that there is a scaphoid fracture, even if it appears normal on imaging, when there is:

1. Tenderness when pressing the anatomical snuffbox. The anatomical snuffbox is the groove between the tendons of extensor pollicis longus (on the ulnar side) and of extensor pollicis brevis and abductor pollicis longus (on the radial side).

2. Tenderness when pressing on the scaphoid tubercle. The scaphoid tubercle is the palpable prominence visible at the distal flexor crease when the wrist is extended and radially deviated.

3. Tenderness when longitudinally pushing the thumb toward the scaphoid while holding the wrist.

Shoulder Dislocation

Diagnosing a shoulder dislocation without a radiograph is quite simple: Just feel for the "hole" when your finger falls into the now-empty joint at the glenoid (Fig. 29-1). If there is any doubt, feel the other side. Other signs include a flattening of the shoulder, projection of the elbow with the impossibility of bringing it to the side of the body, and, most important, the presence of the head of the bone in an abnormal situation, usually below the coracoid process. If measured from the tip of the acromion to the external condyle of the humerus, the affected arm will be shorter than the other; this difference is increased by abducting the arm.13

Fracture of the Proximal Humerus

Patients with a fracture of the proximal humerus usually have localized pain, especially when pressing the elbow upward. If the elbow is rotated slightly, the tuberosities fail to move. With marked displacement, the arm appears to be at an abnormal angle, with the axis of the humeral shaft pointing medially. Any movement usually produces pain at the groove between the pectoralis and the deltoid near the coracoid. Dislocation of the shoulder is excluded by recognizing that the humeral head is still in place.14

Elbow Injuries

With injuries at the elbow, the clinician must differentiate between fracture, dislocation, and sprain. If signs of the first two are not present, the diagnosis of exclusion—which must be given with caution—is sprain. History is usually of no help, so you must rely on the clinical exam.

Examination of the elbow is much easier if done early, before significant swelling impedes the exam. If there is swelling, try to reduce it by having the patient hold his arm down or by using an elastic bandage. When doing the exam, concentrate on the area where the swelling first appeared or where it remains after reducing it.

If the anatomical relationship of the olecranon and epicondyles and the radial head is normal, the elbow is not dislocated. So, to begin the exam, simultaneously hold the two epicondyles and the tip of the olecranon to determine if their relative positions are normal. At 90-degree flexion and viewed from the back (posteriorly), the three should look like an isosceles triangle—with the two equal sides being from the olecranon to the condyles. Next, palpate the radial head to determine its position.

If the exam shows no dislocation, and if the patient can cooperate with the exam, test to see what areas are painful. Grasping the elbow with one hand and the humeral shaft with the other, first press the two together and then sideways. Then, with your thumb and fingers on the epicondyles, check the distal humerus for abnormal mobility and trace the humeral shaft downward to determine its relation to the condyles. If a supracondylar fracture is suspected, confirm its presence by palpating the condyloid ridge for points of pain and irregularity.

Supracondylar fractures also have abnormal lateral mobility. If examined on an extended arm, abnormal adduction and abduction of the forearm can be demonstrated. Grasp the condyles firmly with one hand and the shaft with the other to demonstrate free mobility of one upon the other, usually with crepitus. Pressing upward with the hand under the flexed elbow causes pain, but pressing the condyles together does not cause pain unless the line of the fracture also runs between them (T-fracture), nor can the condyles be moved independently of each other.15

If there is no evidence of a supracondylar fracture, press the condyles together and then hold each separately to check for pain or abnormal movement. If either moves independently, often with crepitus, a fracture is present. Local, regional, or general anesthesia may greatly facilitate this examination—for both the patient and the clinician.16

Pelvis/Hip

Pelvic Trauma

Many trauma protocols require pelvic radiographs, but in situations of scarcity, access to imaging may be limited or nonexistent. The following information is helpful to determine which trauma patients really need radiographs.

A clinically significant pelvic fracture will exist only if a trauma patient has at least one of the following findings: (a) Glasgow Coma Score <14, (b) complaint of pelvic pain, (c) pelvic tenderness on physical examination, (d) distracting injury, or (e) clinical intoxication. One study found that if one or more of the above criteria were present in adult patients after blunt trauma meeting Level 1 (serious) criteria, those patients had a 12% chance of having a significant fracture.17 After trauma, the presence of diastasis (separation) at the pubic symphysis or movement when the iliac wings are simultaneously pressed posteriorly ("rocked") suggests a fracture, whether or not the patient has pain.

Hip Dislocation

Since long-term disability can be lessened by the quick recognition and treatment of hip dislocations and the treatment may depend on the type of dislocation, rely on the patient's clinical appearance to determine the type of dislocation (Figs. 29-2 and 29-3). Palpating the femoral head in the groin is also a common clue to the correct diagnosis. If there is severe pain in the hip without rotation, consider femoral neck fracture.

Hip Fracture

Unlike many other areas of orthopedics, patient history may play a large role in the diagnosis of a hip fracture—especially in an elderly patient. As Helferich noted, "One should always think of the possibility of a fracture of the femoral neck when an old person, after a fall on the knee or side of the body, cannot stand up, and when the injured limb is shortened and rotated outward. In the diagnosis, contusions and dislocations of the hip and fractures of the pelvis have to be considered. It is hardly possible to mistake the injury for a dislocation (with outward rotation only a forward dislocation could be possible)."20 A confounder is that elderly hip fracture patients may complain about knee, rather than hip, pain.

With hip fractures, normally (a) the patient cannot lift his leg off the bed, (b) the leg is shortened to various extents (you may need to measure the limbs, see "Measuring Legs for Diagnosis" below), (c) passive motion of the foot laterally and medially causes hip pain, (d) crepitus is felt unless the fracture is impacted or the fragments are widely separated, (e) the leg may be externally rotated, and (f) the greater trochanter can be felt above Nélaton's line, an imaginary line from the anterior superior iliac spine to the ischial tuberosity (Fig. 29-4).20

Measuring Legs for Diagnosis

Measuring limbs to detect a discrepancy between the two sides after an acute injury is a technique that has been lost over time. However, it is still useful, especially when imaging is not available and the clinician must rely solely on the physical exam to diagnose fractures and dislocations—of any extremity.

With regard to hip fractures, Stimson wrote that leg length discrepancy "may vary in extent from a small fraction of an inch to two or three inches." It may occur immediately or "appear gradually or suddenly after the lapse of a few hours or days." He added that it is vital "to have them form the same angle with the pelvis, that each is in the same position of extension and abduction…. The measurements are usually made between the anterior superior spine of the ileum and a malleolus."22

Lower Extremity

Femur, Mid-Shaft Fracture

This injury nearly always shows the typical signs of a fracture. It may, however, be confused, on occasion, with a large hematoma.

Knee and Ankle Fractures

The Ottawa Knee Rule, the Ottawa Ankle-Foot Rule, and the Pittsburgh Knee [Decision] Rule (discussed below) are validated diagnostic criteria for two commonly injured joints. They are useful when radiographic imaging is present, but limited. If there is no imaging, the clinician must assume that patients who are "positive" using these rules have a fracture that must be treated with immobilization or by providing non-weight-bearing assistance with crutches or other devices.

Use and Limitations of the Rules

These rules are for patients with blunt trauma, including twisting injuries, falls, and direct blows. These rules have not been validated in children (<18 years old), pregnant women, or those with diminished ability to follow the test (e.g., head injury, intoxication).23

The knee and ankle-foot rules all have nearly 100% sensitivity and are modestly specific.24,25 The Pittsburgh Knee [Decision] Rule is 99% sensitive and 60% specific for the diagnosis of knee fractures. Of patients in whom the rule indicated a fracture, 24% had a knee fracture. For patients in whom the rule suggested no fracture, 99.8% had no fracture. The Ottawa Knee Rule was 97% sensitive and 27% specific for knee fractures.26

Ottawa Ankle-Foot Rule

There is a high suspicion of fracture (obtain an ankle radiograph, if available) if there is pain near a malleolus plus one of the following:

• Bone tenderness at the posterior edge of the distal 6 cm or at the tip of either malleolus.
• The patient could not bear weight for at least four steps immediately after the injury and still cannot at the time of evaluation.

There is a high suspicion of fracture (obtain a foot radiograph, if available) if there is pain in the mid-foot plus one of the following:

• Bone tenderness at the navicular or the base of the fifth metatarsal.
• The patient could not bear weight for at least four steps immediately after the injury and still cannot at the time of evaluation.

Ottawa Knee Rule

A knee radiograph is required only if a knee injury patient has one of the following27:

• Age >55 years
• Isolated tenderness of the patella
• Tenderness at the head of the fibula
• Inability to flex to 90 degrees
• Inability to walk four weight-bearing steps immediately after the injury and at the time of the evaluation

Pittsburgh Knee [Decision] Rule

A patient with a knee injury following blunt trauma or a fall needs a radiograph only if they have either28:

• Age <12 years or >50 years, or
• Inability to walk four weight-bearing steps at the time of the evaluation

Tibia-Fibula Fractures

Because the tibia is subcutaneous for much of its length, the clinician can diagnose fractures of the tibial spine by palpating the entire shin.

As with all procedures in this book, the techniques described for fracture and dislocation reduction and treatment are for use only by medically trained personnel who are in wilderness, isolated, Third World, or disaster settings in which more expert help, the normal equipment, or another needed resource is not available. In these settings, treating fractures and dislocations is often complicated because radiographs are not available.

The three goals of fracture treatment are:

1. Reposition bone fragments. Correct any bone angulation and pull the limb out to length, especially when there are no pulses below the site of the injury or when the patient must be moved and the limb's position will interfere with that effort. The best time to undertake a dislocation reduction is immediately after the injury, when there is minimal muscle spasm and resistance. Try to minimize pain during this process by using local, regional, or general sedation/anesthesia. (See Chapter 13, Analgesics, and Chapter 14, Anesthesia—Local and Regional.)

2. Immobilize the fragments. Keep the limb at length if required (traction) and immobilize it while the bone heals.

3. Restore function. This requires evaluating the limb's (and the patient's) neurovascular status before and after any manipulation.

Reduction and Treatment Without X-Rays

In resource-poor settings, the closest x-ray machine may be located hours away; often radiographs are not available at all. In such cases, you will have to rely on physical signs (such as remeasuring limbs, see below) to achieve the treatment goals above.

Battlefield Management

As Husum and colleagues wrote, battlefield fracture management means

Immediate reduction! Every fracture, open as well as closed, should be reduced as soon as possible after injury…. Early fracture reduction improves the local circulation, reduces pain and improves the general condition. During the first 1–2 minutes after the injury, manipulation of the fracture is less painful, and any fracture may be aligned without anesthesia. Reduction more than two minutes after the time of injury, should be done with local anesthesia (10–20 mL lidocaine injected into the fracture hematomas; or low-dose IV ketamine anesthesia).29

Remeasure

After any attempted fracture reduction where shortening of the extremity has occurred, measure the two extremities again. Generally, if the shortening continues to be > 0.5 inch, reduction is unsatisfactory: Either the fragments have not been restored to their normal position or the muscles have distracted them again. At that point, make another attempt to reduce the fracture under better anesthesia or, if that fails, splint to await additional intervention—which may include surgery.30

Open Fractures

For open fractures, the first step is to control bleeding. Direct pressure on soft-tissue bleeding sites usually works best. If absolutely necessary, a tourniquet can be used. (See Chapter 21, Surgery/Trauma.)

Irrigate the wound extensively: at least 5 to 10 L of fluid are needed for the typical open fracture. Use the cleanest fluid possible. Tap water works well if the water supply is relatively clean (i.e., can be used for drinking). If not, boil the water first. Prepackaged sterile fluids are not necessary. Since dilute iodine solution is useful for wound irrigation in open fractures, adding a single povidone-iodine pad to each liter of water is thought to provide the equivalent antibacterial efficacy; however, this has not been proven.31,32

A continuous fracture irrigation system (that may also be used, if desired, for continuous antibiotic instillation into a wound) can be improvised using any closed drainage system. The most commonly available, other than intravenous (IV) systems, is a urethral catheter drainage system: just insert a small-gauge urethral catheter into the wound and hang the drainage bag to drip in fluids for irrigation.

After cleaning the wound, reduce the fracture as well as possible, and put the bone beneath the skin. This can be done either by extending the limb or by pulling the skin aside with the fingers, with the handle of a metal spoon, the blunt end of a tweezers ("pickup") or similar firm instrument.33 Experience shows that these methods work well to lift skin over extruding segments of bone in an open fracture. "If these measures do not succeed, the skin may be slit open freely … Enlarging the opening does not generally complicate the case—sometimes it is even advantageous."33

Don't close the wound. Pack it open with gauze; soak the gauze in a dilute iodine solution if you have some. Change the packing at least twice a day and do not let the wound close until there is no sign of infection and there is good granulation tissue. Then, allow the wound to close by secondary intent—bottom-up and inside-to-outside without the skin closing over the wound, until it fills in with granulation tissue.

If available, give antibiotics, immobilize the limb using plaster or traction, and begin rehabilitation as soon as practicable.

Upper Extremity

Shoulder Reduction

Anterior shoulder dislocations are common. Clinicians need a "bag of tricks" to reduce these deformities, since any single method does not seem to work in every case. Especially in austere circumstances, methods that do not require sedation are helpful. When sedation is needed, consider using hypnosis or intra-articular injection, which have both worked well for joint reductions.34,35 (See also Chapter 14, Anesthesia—Local and Regional.)

The shoulder reduction technique first described by Stimson in 1900 may be the easiest one to use in the midst of multiple casualties or limited resources. With the patient prone, extend the affected arm vertically from the exam table. Attach a 10- to 15-lb weight to the wrist and allow it to hang there for approximately 6 to 20 minutes to achieve reduction. Stimson used a cot with a hole in it for the patient's arm to go through or "two tables placed end to end, so that the body would rest on one and the head on the other, the arm hanging down between."36

The easier, and faster, Snowbird traction technique has the patient sit facing the back of the chair, with their affected arm draped over the back. Place a pad under the axilla and flex the elbow to 90 degrees. Drape a stockinet or cloth loop over the proximal forearm and let it hang to the floor. Using the chair back as counter-traction, the clinician should place his foot in the loop and apply a firm, steady downward traction. This way, his hands are free to apply pressure or to rotate the arm, as needed (Fig. 29-5). This method has been reported to be successful in 97% of cases without complications; >90% can be done without sedation or narcotic analgesia.37 Alternatively, have the cooperative patient keep his arm straight while the clinician (with strong arms and a good back) applies traction in line with the arm. As the muscles relax, have the patient stand; this increases the traction.38

Cooper first described the Milch technique in 1825. With the patient supine, the clinician abducts the affected arm while simultaneously applying pressure to the humeral head. External rotation and traction are applied when the arm is fully abducted, that is, straight "up" so that the arm is in line with the body. Few patients require sedation or analgesia for this procedure.39,40

The Hippocratic method of shoulder reduction is very old and some have suggested that this method is dangerous, since it can cause nerve damage to the axilla. However, recent studies show that the Hippocratic method may actually be safe, but it often requires sedation or significant analgesia to be successful. Place the patient supine, and put traction on the patient's hand and forearm while an assistant provides counter-traction at the axilla with a sling. Pull the arm along its axis in approximately 30 degrees of abduction to move the humeral head from its dislocated position into apposition with the rest of the joint.41

The scapular manipulation/rotation method, often used along with other methods, supposedly has a success rate of >90% when used alone, although that presumes significant relaxation. With the patient sitting, have an assistant hold the affected arm straight out from the patient with the palm up (the patient's shoulder should be flexed to an angle of 90 degrees) while resting his other hand on the patient's ipsilateral clavicle. This applies gentle traction. The clinician then pushes the tip of the scapula medially and upward while pushing the superior part of the scapula laterally. A palpable "clunk" confirms reduction. The patient can also be positioned prone, with the arm dangling and an assistant maintaining gentle traction with the hand in supination.42

The external rotation maneuver is a modification of the Kocher maneuver. It can be performed in any position with the assistance of only one person or by the patient himself. If the patient is very cooperative, he can sit and allow the muscles to relax. Then, flex the elbow at a 90-degree angle, stabilize it against the trunk, and, slowly, externally rotate the arm at intervals. This allows time for any muscle spasms to subside. Most dislocations are reduced after about 5 minutes of external rotation.43

Supracondylar Fractures

Both open and closed supracondylar fractures can be successfully treated with traction and splinting. As Stimson wrote,

In the higher fractures in adults and the late lateral angular deviation in the low ones in children, the overriding can be corrected by traction, preferably with the elbow at a right angle, and its recurrence effectively opposed by anterior and posterior molded splints, or a plaster encasement, aided sometimes by a weight attached to the forearm close by the elbow, with the wrist supported by a sling. In the low form in children … even very marked deformity disappears rapidly in the young by absorption of projecting bone and the filling up of hollows, and functional limitations are rarely caused by it. In compound [open] fractures, I always use vertical suspension of the limb for about a fortnight [two weeks] unless the wound heals sooner. It is of great value in controlling reaction as well as preventing gross displacements; minor adjustments can still be made after the wound has healed or has become unimportant.44

Colles' (Distal Radial) Fractures

A Colles' (or other similar) fracture can be reduced by suspending the arm. A hematoma block helps relieve discomfort. Make a finger trap by forming a girth hitch with bandage material, other cloth, or thick rope (Figs. 29-6 and 29-7). Loop these around the thumb and index finger, or the index and long fingers, and suspend the material from a hook or an IV pole. Traditional Chinese finger traps used as toys also work well to hold fingers aloft. Usually made of folded paper, they may not be good for more than a few patients before they need to be replaced.45 Do not use string, wire, or anything else that might compromise circulation to the fingers, even if you are not using any added weight to assist fracture reduction. From 2.3 to 4.5 kg can be suspended from a padded cloth at the proximal forearm to speed the reduction. After 20 to 30 minutes, return and make any necessary minor adjustments. To make life simple, keep the arm suspended while the splint or cast is applied.

Metacarpal Fractures

The usual treatment for most metacarpal fractures and dislocations is nonoperative. The goal is to preserve function. This section describes nonoperative management and refers to surgery only when that is the only option. In austere circumstances, that may mean operating outside your comfort zone, waiting or referring for treatment, or advising the patient that there may be a poor outcome.

If you cannot splint the hand or reduce the fractures, the hand can be treated using an old and less-than-optimal method46:

Fill the palm with a mass of tightly packed cotton or similar substance or with a ball, over which the fingers are closed and fastened down with a bandage or adhesive plaster. If there is no displacement or tendency thereto, a simple immobilizing dressing of cotton held snugly with a roller-bandage is sufficient; the fingers being left free to prevent their stiffening. The flexion of the finger over the firm mass tends to draw the knuckle downward, and thus prevent shortening. The support furnished by the adjoining bones is an additional aid against displacement, and the back of the hand can be left partly uncovered for inspection.

Proximal Metacarpal (Base) Fractures

Reduce these fractures if there is >2 mm of articular surface displacement or if there is significant angular deformity or dislocation of the carpometacarpal joint. Hematoma blocks usually don't work, so a regional block or sedation may be necessary. Use traction and direct digital pressure with the clinician's thumb to reduce the fracture. Although fractures of the base of the fifth metacarpal are usually pinned, in austere circumstances, treat it like the others until or unless orthopedic services are available. Splint the wrist in 20- to 30-degree extension with the metacarpophalangeal (MCP) joints flexed for ≥4 weeks, with continued active motion of the finger interphalangeal (IP) joints.47

Metacarpal Shaft Fractures

Reduce metacarpal shaft fractures if there is significant palmar angulation (>10 degrees for second or third metacarpals, 20 degrees for fourth metacarpals, 30 degrees for fifth metacarpals) or any rotational angulation. To reduce the fracture, anesthetize it with a hematoma block and flex the affected finger's MCP joint and the proximal IP joints to 90 degrees. Apply upward pressure on the middle phalanx and downward pressure over the dorsal apex of the fracture. Use the finger to control or correct any rotation. Splint for <4 weeks, followed by active range of motion.47

Fractures at the Distal End

Splint non-displaced fractures of the metacarpal head (distal end) for 3 weeks, and follow with gentle motion. Use an ulnar gutter splint for the most common fractures, those of the fourth and fifth metacarpal heads. For fractures of the neck (just proximal to the head), such as a Boxer's fracture, you can splint most of them for 3 or 4 weeks. If there is too much palmar angulation (≤15 degrees in the second or third metacarpals; ≤45 degrees in the third, fourth, or fifth metacarpals) or any rotational deformity, reduce it like a shaft fracture. A splint maintains about 50% of the initial correction.47

Metacarpophalangeal Dislocations

Attempt to reduce MCP dislocations under local or regional anesthesia. The easy ones still will be in extreme (60 to 90 degrees) hyperextension. Flex the wrist and IP joints; gently put traction on the finger and bring the joint toward the palm. If it doesn't go in, the only option is to wait for a surgeon, since soft tissue or the volar plate is keeping it dislocated. Splint it dorsally for a short while, so that flexion can occur.47

Splinting Metacarpal Injuries

Once these fractures or dislocations are reduced, apply a forearm-based splint that covers both the dorsal and palmar surfaces of the metacarpal, but allows the IP joints to move. The dorsal splint should extend to the IP joints; the volar aspect should end at the distal palmar crease. The wrist should be in 20 to 30 degrees of extension and the MCP joints in 70 to 90 degrees of flexion. Buddy-tape the fingers of the involved metacarpal to maintain rotational control. Encourage the patient to begin moving the IP joints immediately and, as soon as the splint is removed, encourage active movement of the fingers and wrist.47

Pelvis/Hip

Risk of Bleeding from Pelvic Fractures

Unstable pelvic fractures may cause life-threatening hemorrhage. Patients with a high risk (>60%) of pelvic arterial bleeding are those with a pulse of ≥130/min, a hematocrit ≤30%, ≥1 cm diastasis of the pubic symphysis, and displacement of an obturator ring fracture. A patient with three or more indicators has a high (>60%) probability of major arterial pelvic hemorrhage. Those with one indicator have a 14% risk; those with two have a 46% risk.48 An unconscious patient may be hypotensive on arrival. A conscious patient may splint the fracture with his muscles, so significant bleeding may not occur until after he is paralyzed for intubation, which causes the pelvis to fall open and the patient to become hypotensive. If pelvic fracture bleeding is a real or potential concern, apply a pelvic binder.

Pelvic Binder

A pelvic binder tightly encircles the entire pelvis at the level of the iliac wings (or the greater trochanters if the patient will soon go to surgery for an external fixator). The technique is first, to fold a long sheet or other strong cloth lengthwise to get a width of 15 cm; this will be used as a draw sheet. Next, tightly roll a pillow and tape it, and place this behind the patient's knees. Then secure the patient's lower thighs and calves together with gauze or a similar bandage. This internally rotates both lower limbs, which act as levers on the displaced pelvis.

Ease the draw sheet beneath the patient. The two people applying the binder should stand on either side of the patient, lean toward each other, and pull on an end of the sheet while they each simultaneously push their side of the pelvis. When it is tight, secure the sheet with a cable tie or square knot. Then place a dowel, wooden branch, or metal bar against the knot and tie another square knot. Use the rod as a windlass to tighten the sheet. A tight belt or webbing may also be used, but these usually cannot be tightened enough to get a good effect.49

Hip Fractures Without Surgery

If the patient has a non-displaced intracapsular fracture and surgery is not available, don't fret. There seems to be little difference in outcome between surgery and conservative treatment in these cases.50,51

Lower Extremity

Ankle Fracture-Dislocations

A fracture-dislocation of the ankle (Fig. 29-8) is a devastating injury that, if not properly aligned, can be disabling when healed. Use a Dupuytren's splint to achieve and maintain alignment (Fig. 29-9). Apply the splint to the inner side of the leg; the foot will be pulled toward the splint when the bandage is wrapped around it. Note that there is no padding under the ankle joint.52

Hip Fracture

In austere conditions without the availability of x-ray or operative intervention, closed reduction and traction are the only options for treating hip fractures.

Fractures of the neck of the femur are the most common fractures seen in the elderly. These fractures can heal with bed rest, but patients often have chronic pain and may not be able to walk. Our forbears got good results with traction. Helferich wrote that extension and inward rotation should be secured with weight extension by means of strapping. A weight of 12 to 15 lb is usually required to overcome thigh muscle spasm, with the leg slightly abducted. Maintain traction for 2 weeks; then use crutches and physical therapy for 10 weeks or so. Have the patient change position on a regular basis to avoid decubitus ulcer formation.53

Fractures of the femoral head, if not displaced, usually heal fairly well with 8 to 12 weeks of bed rest. If the femoral head is displaced, the patient will probably have avascular necrosis, a loss of range of motion, and chronic hip pain. However, if there is a central fracture-dislocation (the femoral head has pushed through the acetabulum), use 25 lb or more of traction in each of two directions: pulling the hip both laterally away from the body and in line with the body. This traction is needed for 6 to 10 weeks, followed by crutches. Even after this prolonged therapy, don't expect a great result from this major injury.54

Hematoma under the Nail

Subungual hematomas should be drained if they are painful. Use either a sharp, sterile tool (such as a needle or pin) or a thin wire (such as a paperclip) heated with an open flame. Neither of these requires anesthetizing the digit as long as the "drilling" stops as soon as blood exudes from the hole.

Do not remove the nail and repair the nail bed, even if the hematoma occupies >50% of the nail surface. It uses additional resources and causes increased patient morbidity.55 The original nail can be used to protect a nail bed after an injury, as can artificial nails if the original nail is gone.

Compression Dressing

For patients with major fracture dislocations who cannot have an immediate operation, apply a Robert Jones dressing to control and minimize edema. Easily improvised, in addition to reducing edema and fracture blisters, it makes the patient more comfortable and improves surgical results by permitting better visualization of the tissues. The technique for applying this dressing can be found in Chapter 10, Circulation/Cardiovascular, where it is described for use as a treatment for peripheral edema.

Improvised External Fixator

Used for the treatment of complicated lower-leg fractures with soft-tissue damage, an external skeletal fixator can be easily improvised using wood. In each of two wooden boards (3.5 cm × 2 cm × 45 cm), drill holes about 1 cm apart, the same diameter as 5-mm Steinmann pins. The apparatus has greater strength if the holes are drilled across, rather than through, its width. The holes in the two boards must line up exactly with each other. Under appropriate local anesthesia or sedation, cleanse the wound and reposition the fracture. Then drill two Steinmann pins through the bone on both sides of the fracture, keeping a safe distance from injured tissues. Apply the boards to both sides of the leg. Place the pins through the holes in the wooden board that most closely match the anatomical position. As soon as the wounds heal, usually within 3 to 4 weeks, remove the external fixator and replace it with a plaster cast. The primary problem with this device is that it is not strong enough to allow walking exercises and weight bearing.56

Vacuum Dressing

To make a vacuum (negative-pressure) dressing, pack the wound with soap-free surgical sponges retrieved from single-use scrub brushes. Make holes in a sterile suction tube or in IV tubing with a small (#15 or #11) scalpel. Place the tubing over the sponges and seal the wound with a plastic adhesive dressing or similar airtight dressing. Connect the tubing to a continuous suction device.57

Amputation

Emergency amputations may need to be done outside a medical facility either to extricate trapped people or to complete a nearly complete amputation.

Mass casualty situations may precipitate more amputations than might otherwise occur. As Husum wrote, "Mass casualties are different! Attempts to salvage seriously damaged limbs are time- and staff-consuming; the clinic capacity will influence the reasons to do primary amputation."58

Indications

According to the US Army's Medical Corps, the "goals for initial care are to preserve life, prepare the patient for evacuation, and leave the maximum number of options for definitive treatment." The Medical Corps lists the following as indications for amputation59:

1. Partial or complete traumatic amputation.

2. Irreparable vascular injury or failed vascular repair with an ischemic limb.

3. Life-threatening sepsis due to severe local infection, including Clostridial myonecrosis.

4. Severe soft-tissue and bony injury to the extremity precluding functional recovery. "The surgeon must balance the realistic likelihood of ultimate reconstruction of a functional extremity against the risk of death associated with attempts to preserve a limb."

One should remember, though, that there are functional differences between arms and legs. As Husum and colleagues wrote, "Arms and legs are different! An arm with permanent nerve injury and partial loss of skin sensation may well be useful; a leg is not. An arm with bone loss and/or contracted joints may well be useful; a leg of that kind cannot bear weight—and is useless."58

Stressing the need not to procrastinate when an amputation is indicated, Dr. Gross wrote, "The results of the military surgery in the Crimea show that the success of amputations was very fair when performed early, but most unfortunate when they were put off for any length of time."60

One caveat is that cold injuries are not an indication for amputation—wait until the edges demarcate.

Emergency Prehospital Technique

In a dire emergency when on-scene amputation needs to be done, give whatever anesthesia is available and safe for the patient. Ketamine (IM or IV) or an opiate works well. (See Chapter 14, Anesthesia—Local and Regional, and Chapter 15, Sedation and General Anesthesia, for more detailed options.) The limb can also be infiltrated with a local anesthetic, although this generally will be less than optimal.

Control the bleeding by pressing on the pressure point, or by using a tourniquet and then tying the vessels. Cut through the limb or what remains of it as far distally as possible. Cut the tissues using a sharp knife. The bone can be more difficult to remove if a comminuted fracture is not present at that site. Use a carpenter's saw, a sharp chisel, or a straight gouge to cut the bone. An alternative is to make small-caliber drill-holes close to each other around the bone at the level to be amputated, and then manually fracture the bone transversely. Another option is to make a track in the outer cortex around the entire circumference of the bone by hitting the knife with light hammer blows, and then manually breaking the bone. Then apply a firm pressure dressing to the stump to control any bleeding.61,62

Method

Emergency amputations should be done as low as possible, with a final amputation done by experts later. Preserve as much viable skin and soft tissues distal to the bone amputation as possible; it can be used to later close the amputation stump; this eventually translates to a better fitting and more functional prosthetic.

US Army's Amputation Technique63,64

Surgically prepare the entire limb, since the injured tissues may extend much higher than initially thought. Especially in blast injuries, explosive forces drive debris proximally along fascial planes. To ensure adequate debridement, the incision may need to be extended proximally. Tourniquet control is mandatory. If a tourniquet is in place for hemorrhage control, prep it within the surgical field.

1. Make a circumferential incision through the skin and deep fascia at the lowest viable level. Allow this layer to retract.

2. Expose the muscle bundles and then divide circumferentially at the new level of the skin edge. The muscle bundles then promptly retract, exposing the bone.

3. Excise nonviable tissue, including necrotic skin and subcutaneous tissue or skin without vascular support; muscle that is friable, shredded, grossly contaminated, or non-contractile (this muscle is usually at the level of the retracted skin); and bone that is grossly contaminated or is devoid of soft-tissue support.

4. Place upward pressure on the proximal muscle stump and transect the bone at a still higher level. Cut the bone at a level that can be covered with skin. The surgical wound will have the appearance of an inverted cone.

5. Isolate, clamp, and ligate blood vessels as they are encountered, to prevent and control hemorrhage. Apply bone wax to the open ends of bone to prevent oozing.

6. Transect major nerves. Identify major nerves, apply gentle traction on them, and ligate and cut them proximally at the highest level possible.

7. Do not suture preserved muscle flaps, but rather hold them in position with a dressing.

8. Do not construct flaps during the initial surgery or close an amputation primarily.

For makeshift anesthesia for amputations using refrigeration, see "Refrigeration Anesthesia: Amputations" in Chapter 14, Anesthesia—Local and Regional.

Care after an Amputation

Place a layer of fine mesh gauze over the wound and pack the recess loosely with fluffed gauze. Apply a stockinet over the stump, securing it with tape. Wrap the stump with elastic wraps (Ace bandage) using compression decreasing proximally and applying 5 to 6 lb of traction. Continued traction results in secondary skin closure over the stump.64

Provide analgesics, as available, in sufficient quantities to lessen the patient's postoperative pain. To prevent possible hemorrhage from the surgical site, for the first week post-injury, keep a tourniquet at the patient's bedside and during transport.

While surgeons working in a relatively stable environment may be able to treat post-amputation patients by delayed primary closure, many patients will need to be transferred for definitive treatment. Place these patients in skin traction to leave the wound open and prevent skin retraction. Ideally, skin traction will be maintained throughout the treatment course (Fig. 29-10). One way to maintain skin traction, while also maintaining traction on the residual limb, is by using a cast. The cast should be well padded, with integral skin traction maintained by use of an "outrigger."65

Outpatient treatment of fractures, sprains, and strains, as well as postoperative treatment for various soft-tissue repairs, relies on immobilization to aid the healing process. Improvised immobilizers for extremities can be divided into (a) non-rigid splints, (b) rigid splinting materials that are not suitable for circumferential casting, and (c) casting materials. Casting materials can be used for circumferential casting, and include plaster of Paris and its many alternatives.

Non-Rigid Splints

Sling (Arm)

A sling is the most basic extremity support. If nothing else is available, improvise a sling by putting the patient's wrist inside his shirt and buttoning the buttons around it. For more support, and if using a long-sleeved shirt, pin the sleeve containing the affected arm to the shoulder area on the opposite side of the shirt. Or double up the bottom of a short-sleeve shirt or a T-shirt over the forearm and pin it to both shoulder areas of the shirt.

A more formal sling can be made of any available material. A strip of material pinned so there is a loop around the wrist and around the neck makes a "collar-cuff" sling, which is ideal when movement of the shoulder can be tolerated or is desired to avoid a frozen shoulder. Alternatively, use any strip of cloth, webbing, belt, and so forth.

Buddy Taping

One of the simplest effective methods of splinting an injured finger or toe is to tape it to the adjacent digit. The key to success is to put absorbent cloth or gauze between the digits before taping and to change the material at least three times a day, or any time it gets wet, to avoid macerating the tissues. Keep it on until it feels better without it than with it.

Buddy taping can also be used for humerus fractures in infants. Bandage the arm to the torso and it will quickly heal. (Consider child abuse in these cases.)

A field-expedient method of stabilizing long-bone fractures in a lower extremity is to buddy tape the legs together, preferably with some padding between them. This may be more comfortable for a patient than a rigid splint.

Pillow Splints

Splints for joint fractures, dislocations, or other injuries can be made from pillows, blankets, sleeping bags, sleeping pads, or any similar items (Figs. 29-11 and 29-12). Wrap the pillow or multiple layers of other items around the injured part. Secure it tightly with any bandaging material. This is often a more comfortable method of splinting than using traditional materials.

Sandbag Splints

Extremities can be effectively splinted using a garbage bag, fanny pack, or similar soft-sided container filled with sand or dirt. Mold it to the extremity and tape or bandage it in place. Since this is heavy, the patient tends to move the extremity less than with a pillow splint.

Heel Pad

A heel pad made from thick foam with a hole cut in the center can be placed in a shoe or boot beneath the heel to help ameliorate pain in the calcaneal area. Long thought to be due to exostosis (extra bone growth), this pain is probably due to nonspecific inflammation.

Rigid Splints Not for Circumferential Casting

Fixation splints may be made of plaster of Paris; celluloid; pasteboard; wood; stiffened felt, paper, or leather; gutta-percha; wire; polyvinyl chloride (PVC) pipe; aluminum; or other available materials. Keep splints in place with bandages or other similar ties.

Metal

Caused by disruption of the extensor tendon to the distal phalanx, a mallet or dropped finger can be managed by splinting the affected joint in full extension with a paperclip for 8 weeks. The splint should be worn at all times. Pad the paperclip with soft cloth and tape it to the dorsal surface of the finger so the digit can still be used. A disposable plastic spoon or a section of a Popsicle stick can also be used.66

A metal can makes a useful splint for a broken wrist or to help support an injured knee or ankle. Carefully open the can at both ends, cut it up the side, and tape the sharp edges so they don't injure the patient. Then bend the metal to fit the patient's wrist, enclose in cloth for padding, and wrap in place with a bandage or tape. Likewise, a car's hood support is just the right length to make a long leg splint. Bandage it onto the injured leg.

Splints made of galvanized wire or tin mesh (Fig. 29-13) can easily be fashioned to support arm, knee, or ankle injuries. "They can be readily made from sheets of wire by taking a strip of suitable size and cutting it partly through at the angle, and tying together the meshes which overlap where it is bent."67

Plastic Pipe

Durable splints have also been made from pieces of appropriately sized plastic (PVC) drainpipes (Fig. 29-14). First, saw them in half, and then shape them so they conform to the extremity. To do this, heat the pipe by placing it in boiling water or using a welding torch or other low-intensity flame. (See Chapter 27, Ophthalmology, for additional instructions on how to work with PVC pipe). If a flame is used, take care not to burn the plastic or to inhale the toxic fumes.68

Tongue Depressors

The lowly tongue depressor (or Popsicle sticks) can be useful as splinting material in many situations and may also be used to make a metatarsal arch bar. These remarkably simple devices lessen toe pain, especially from injuries to the large toe (hallux), and pain from metatarsal fractures or pain over the metatarsal heads or sole of the foot. This can be invaluable when treating patients who must keep walking to survive, such as on a trek or in combat. The metatarsal arch bar functions by eliminating much of the stress of rotating and pushing off from the forefoot and hallux—a key part of walking. The arch bar can be quickly and easily made to use over shoes. (Of course, some patients may not be able to obtain shoes.)

Make an arch bar by breaking or cutting three tongue depressors or other material to the width of the widest part of the shoe or boot. Tape the tongue depressors together. Then tape the entire piece across the sole of the shoe at its widest part by wrapping the tape around the bar and the outside of the shoe (Fig. 29-15). If the patient has more than one pair of shoes, it is easy to re-tape the arch bar onto a different shoe or to make another bar for that shoe.

Pediatric Fracture Treatment

Removable splints may be as good as casts for minor, or "buckle," fractures of the wrist, particularly in toddlers and preschool infants. These splints even allow for the final removal at home with no further follow-up. Removable splints, either plastic or plaster, generally keep the fractures aligned as well as casts but provide greater comfort and less restriction, allowing children to bathe and participate in other activities.69 Some orthopedic surgeons, however, are concerned that such small children will not keep their splints in place.

Rigid Circumferential Casting Material

Because of its lightness, porosity, and ability to rapidly harden, plaster of Paris is the best, most commonly available material for making splints that are molded to the body. There are many ways to use plaster of Paris; some are discussed in the following paragraphs. In addition, there are a multitude of alternative materials that can be used to make casts. For how to make plaster bandages for casting and splinting, see "Making Plaster of Paris Bandages" in this section.

Some Ways to Use Plaster of Paris

Plaster Box

If no other option is available, try this old method using liquid plaster of Paris to immobilize an extremity. Make a box of cardboard or wood into which the extremity (usually the forearm) will fit. Coat the skin with oil or lubricant or, better yet, wrap it with thin cloth to protect the skin from the heat and irritation from the plaster, and to prevent it from adhering to the skin when removed. Pour enough plaster into the box to surround the arm completely. When the plaster sets, remove the box. These casts are too heavy and cumbersome for patients to be ambulatory and must be removed with a mallet and chisel.70

Plaster Cream

An alternative method that may be easier to use than preparing rolled plaster bandages is to immerse large pieces of cloth in a plaster cream (Fig. 29-16). Prepare this cream by sifting dry plaster into water (3 parts water and 4 parts plaster of Paris). Take previously cut splint/cast material and either soak it in the cream or spread the cream onto it just before you apply it to the limb. Note that the plaster cream must be thoroughly worked into the material.71,72

Hamilton described the use of plaster cream at New York's Bellevue Hospital in the 19th century: "The usual practice has been to envelop the limb with a dry roller, and to apply the plaster with a paint brush as the successive turns of the roller are laid upon the limb. It hardens very quickly, and in this regard it has an advantage over flour paste or starch; but it is heavy, and not so generally accessible, and for this reason its use is more restricted."73

Making Plaster of Paris Bandages

Commercial plaster bandages are excellent, but they may not be available due to general scarcity or cost. Homemade plaster bandages are about one-tenth as expensive. To make them:

1. Get plaster of Paris (dried calcium sulfate; or use hemi-hydrate gypsum plaster). Although it is readily available as a building material, the best type for casts and splints is dental casting plaster. (Other types work, but they set more slowly.) Since it becomes inert if exposed to moisture or cold, keep the plaster in a tightly sealed container and, if possible, in a warm, dry location. To get plaster to set more quickly, add one-twentieth-part Portland cement (1:20 mixture), which may also strengthen the cast and make it lighter.75 Mixing the plaster with water in the proportion of 75 to 100 by weight, and adding 2 parts of boiled starch may produce a similar result.73

2. Obtain bandage material. Crinoline, a high-quality open-mesh cloth, or muslin (30 to 35 threads/inch) works best, but good quality gauze with about 8 to 10 holes/cm2 (20 holes/inch2) also works well. If necessary, cheesecloth also can be used.75,76 One group in India finally found that suitable gauze has about 16 threads per inch; and that the thickness is also important. If the gauze is too thin, it does not hold the plaster powder; if it is too thick, the plaster takes too long to set and dry.77

3. If using gauze or cheesecloth, dip it into a weak laundry starch solution or a bucket of rice water (left over from cooking rice) and let it dry. This helps maintain the bandage's shape.77

4. Cut the cloth into strips of the desired length and width. Some workers have found that 12-foot lengths are easy to handle; the width will depend on the need, but generally 4 or 6 inches are sufficient.77

5. Rub plaster powder into the cloth by unrolling a portion of the bandage on a dry table with a smooth top and gently but firmly rubbing the powder into the cloth mesh (Fig. 29-17). Rub the plaster in by hand or scrape it in with a straight-edged knife or stick. It is important that neither too much nor too little plaster be used; the proper amount is just enough to thinly cover the fabric mesh.75 As one section is covered in plaster, roll it up and begin the same process with the next section until the entire roll has been powdered.

6. If you are making many plaster bandages, such as for a hospital or large clinic, a simple plaster application machine is worth constructing (Fig. 29-18). Developed in India, the large inclined tray, with plaster powder at three places, allows workers to easily impregnate the bandages with plaster as they are pulled across the top. Construct an 8- to 10-inch-wide tray, on a base that is inclined at 15 degrees and that has an open-top catch box at the end. Stretch three strands of #8 rubber tubing (8 mm diameter) across the tray to hold the bandage down and distribute the plaster powder. Place strips of wood along the sides to hold the tubing in place and help keep the plaster on the tray. Place a pile of plaster powder above each length of rubber tubing. When the bandage material is pulled under the taut tubing, it becomes impregnated with plaster powder; the open box in the base will catch any loose plaster.77

7. As the bandage is finished, loosely roll it up. Use immediately or store it in a dry place for future use. Be careful not to roll it too tight as this will prevent the water from penetrating it sufficiently when the bandage is dipped in water before application.75,76

8. To store premade bandages, roll them loosely. If you need to make slabs for splinting, double the plaster over itself in strips, wrap in old newspapers or plastic bags, and put these in an airtight container. Do not prepare too many at a time. They can absorb moisture and harden.78

Applying Homemade Plaster Bandages

A common problem with homemade plaster bandages is that the gauze does not hold enough powdered plaster. If enough plaster is in the bandages, rubbing each wet bandage layer into the next should make the threads of cloth disappear into the smooth, plaster surface. If this is not the case, there is not enough plaster and it will not set hard. A possible solution is to try the method used by Antonius Mathijsen, a 19th-century Dutch Army physician. Rather than soaking them in water, he used a wet sponge or brush to moisten homemade plaster-impregnated bandages as he applied them to the patient, rubbing them by hand until they hardened.70 Another useful trick is to have some dry plaster powder ready while casting, then sprinkle it over each layer of bandage and rub it smooth with your wet hands. Add more to the final layer and rub it in to form a polished surface.

To reduce the amount of plaster lost into the water, dip the bandage gently into water and then take it out and let it drip. If you must squeeze it, hold the ends of the roll and squeeze gently toward the center. To speed drying, use hot water or else add salt or zinc oxide to the water. If the plaster has been exposed to the air before use, dry it in an oven; this may make it more useable and speed its setting.72

Homemade plaster casts are heavier than casts made with proprietary bandages, but they work well in all circumstances and are much cheaper.77

Improvised and commercial plaster bandages can be made water resistant by painting the dried plaster of Paris with a mixture of shellac dissolved in alcohol, or by varnishing them or pouring melted wax on them.72,79

Alternatives to Plaster of Paris

Although plaster of Paris is the preferred casting material, it may not be available in any particular situation. There are a number of alternative materials that may be used for casts. Most have the disadvantage that they take a long time to harden.

Sand

In the early 1800s, German physicians treated leg fractures by aligning them in a long box that was then filled with firmly packed moist sand.70 Unfortunately, this is not a very practical method, since the patient must remain immobile while the fracture heals.

Thick Cardboard

Louis Jean Seutin, the Belgian Army's chief surgeon who fought against Napoleon, developed a rigid splint made of cardboard pieces that, after being moistened, were conformed to the injured extremity, and then wrapped with wet bandages that had been soaked in a solution of laundry starch. It required 2 to 3 days to dry, but this was shortened to about 6 hours when the 19th-century French anatomist/surgeon, Alfred-Armand-Louis-Marie Velpeau, replaced the starch with dextrin (i.e., starch gum, vegetable gum).80

In his 1899 text, Stimson wrote81:

Pasteboard [thick cardboard] is used by softening one or two strips of suitable size by immersion in hot water, and then molding them to the limb by binding them on snugly with a roller bandage. Temporary support must usually be given by other splints until the pasteboard has become hard by drying. When it is necessary to bend the pasteboard at a sharp angle, cuts should be made in it in suitable directions and places and the overlapping portions stitched together. Leather and felt are prepared in the same manner.

Papier Mache

Folklore abounds with tales of using papier mache as a splint or a cast. Our test showed that it was time consuming and extremely messy; the resulting casts were heavy and took from many hours to days to dry. Papier mache is useless for orthopedic purposes, but might be a fun activity for children.

Traction is generally applied to leg fractures, particularly the femur or hip. It can, however, also be applied to the arm or the finger.

General principles for using traction on the leg are to apply 10 to 15 lbs of weight, or the amount needed to reduce the affected leg to the same length as the other leg. Always take care to ensure that traction does not compromise the extremity's pulses, perfusion, or neurological status, especially in the foot below the ankle hitch. Traction should also maintain anatomic position, including reducing any rotation and angulation.

Improvised traction includes many of the methods taught in first-aid classes, including using ski or tent poles, canoe paddles, ice axes taped together at the handles, a piece of wood, a tree branch, or, most commonly, the foot of a litter. In reality, with many of these makeshift devices, it may be difficult to secure them proximally at the hip to ensure that they provide adequate counter-traction and do not cause the patient pain. Ankle hitches often go over the boot or shoe, and can be made from webbing or rope as long as they don't compromise blood flow to the foot. Traction can be tightened by winding the ankle traction with any short, rigid piece of equipment, such as a sheathed knife, wooden ruler, or solid stick. Once tightened, secure it so it does not unwind. Check this periodically, since the patient may move and loosen the traction or the neurovascular status could become compromised.

Improvised traction also includes techniques that can be used in medical facilities that lack either clinicians comfortable with doing invasive orthopedic procedures for traction or the necessary orthopedic equipment.

Improvised Traction in the Field

Sock/Plaster Boot Traction

The US Army described a field-expedient traction method (Fig. 29-19) during World War I:

An excellent traction may be obtained by a light-weight army sock. The lower leg, ankle, and foot, with the exception of the toes and the plantar surface, are painted with glue [cyanoacrylate can be used] and the sock slipped on. The toe of the sock is cut off and a piece of light splint wood or the ladder splint material, cut the length of the foot, is inserted between the sole and the sock. Traction may then be made on this by means of pieces of bandage or cord passed through the sock and around the wood or the rods of the ladder splinting.82

Rather than gluing the sock to the foot (a rather drastic measure), after placing the splint to be used for traction, cover the sock with plaster or, if that is unavailable, a non-stretch bandage.

Traction Using a Crutch

A crutch makes an excellent traction device (Fig. 29-20). Use a crutch that is 8 to 12 inches longer than the affected leg (or adjusted to that length); measure it against the good leg. Remove the rubber piece from the bottom (ground end) of the crutch and securely tape the axillary pad to the crutch. Remove the handgrip and screw it into the lowest hole at the bottom of the crutch. Securely tie four pieces of gauze, fabric, or belting material, beginning just below the axillary pad, on each side of the crutch. These should be evenly spaced and opposite each other, since they will be used to secure the leg to the splint. Then wind gauze around the crutch to support the leg. The crutch/splint can then be positioned under the patient's legs, so that the top (padded) end of the crutch lies under the ischial tuberosity, with the other end extending at least 12 inches beyond the foot.

Apply ankle traction by securing a wide piece of tape to either side of the leg, from just below the knee and extending past the end of the crutch. Use tincture of benzoin, if available, so the tape will adhere more securely to the leg. Use wide tape or an elastic bandage around the lower leg to help hold the long pieces in place. Place some gauze or fabric over both ankles, so the tape doesn't stick to them. Just below the foot, cut a small hole in each piece of tape and insert three tongue blades or a small dowel through the holes to hold the two pieces of tape apart. Tape these tongue blades to the long pieces of tape. Then, below the tongue blades, bring the two long pieces of tape together and firmly attach the end of the tape to the crutch handle at the bottom of the splint. Cut a hole midway in this joined piece of tape and insert three tongue blades or an equivalent sized dowel. Twist these to provide traction on the leg. When adequate traction is achieved, tape the tongue blades to the sides of the crutch. Secure the leg to the splint with the fabric tied to each side of the crutch.83

Skin Traction

Skin traction requires pressure on the skin to maintain the pulling force across the bone. A maximum of 5 kg of weight may be applied using this method if the skin is in reasonable condition. More than 5 kg of weight causes the tightly wrapped strapping to slip, resulting in skin excoriation with blistering and pressure sores. If the straps are wrapped more tightly to prevent slipping, it can cause a compartment syndrome.76

If more than 5 kg of weight is needed to control the fracture, use an alternate form of traction.

Do not apply traction to skin with abrasions, lacerations, surgical wounds, or ulcers. In addition, do not apply traction to areas with loss of sensation, or in patients with peripheral vascular disease or a tape allergy.

Technique76

1. Clean the limb with soap and water and dry it. Gather adhesive tapes, traction cords, spreader bar, and foam or other material to protect the malleoli.

2. Use adhesive bandages in place of standard traction bandages. Shave the skin and use benzoin to increase bandage adhesion to the skin. Then wrap a nonadhesive bandage around the extremity. Wrapping an adhesive bandage can make it too tight.

3. Measure the appropriate length of adhesive strapping and place it on a level surface with the adhesive side up. The tape should extend on both sides of the limb up to, but not above, the fracture.

4. Place a piece of wood in a loop of the long wraps to keep the bandage from rubbing against the malleoli and to provide a site to secure the weights for traction.

5. Gently elevate the limb off the bed while applying longitudinal traction. Apply the strapping to the medial and lateral sides of the limb, allowing the spreader to project 15 cm below the sole of the foot.

6. Pad bony areas with felt or cotton and wrap crepe or ordinary gauze bandage firmly over the strapping.

7. Elevate the end of the bed, and attach a traction cord through the spreader with enough weight, up to 5 kg, to reduce and align the fracture (Fig. 29-21).

8. The traction cord can be any strong cord or wire. If the area that the cord drapes over is not smooth, attach a 60-cc syringe barrel to the site and run the cord through it. The weight can be bags of water or sand, bricks, or other heavy objects. Be certain that, whenever possible, the weights are measured, not just estimated. (The weight of water is 1 kg [2.2 lbs] per liter; if you know the volume, you can figure out the weight.)

9. Skin traction also can be used on the arm (e.g., Dunlop's traction for supracondylar fractures) (Fig. 29-22).

"Gallows" Traction in Children

In children weighing <12 kg, vertical or "gallows" traction using skin traction works well for femur fractures. Both legs are generally kept in traction taut enough to just raise the buttocks off the bed (Fig. 29-23).

Another way to treat fractures in newborns and small children, and certainly the simplest, "consists in fixing the thighs, strongly flexed upon the abdomen, by means of a broad band of strapping passed round the back and thigh."84

Skin Traction in Adults

There are several makeshift skin traction devices for adults. Figures 29-24 and 29-25 show the easily constructed Volkmann's apparatus, which allows the foot piece to slide as weight is applied: counter-traction is best obtained by raising the foot of the bed and using a wooden block to stabilize the uninjured limb.

Traction Using Plaster

Similar in principle to skin traction, using plaster has fewer restrictions and can accommodate more weight without causing complications (Fig. 29-26). Taylor described the technique86:

[Apply plaster] to the leg, which is fastened by buckles to a stirrup carrying a cord passing over a pulley to a weight, the patient being in bed … The adhesive plasters should be evenly applied nearly to the groin; if they do not reach high enough injurious strain comes upon the knee. If the thigh is flexed or adducted, the leg is placed upon an inclined plane, and the weight and pulley so arranged as to pull in the line of the deformity; the knee should be slightly flexed. Symptoms are frequently aggravated by pulling against the hip deformity. As the muscles gradually relax to the traction, the pulley is lowered until the pull is in line with the bed and the body. Five or six pounds in a sand or shot bag, flat iron, or brick are usually sufficient for a child; ten or twelve pounds for an adult. It is important that the feet should not touch the foot of the bed or the weight touch the floor; a metal bedstead is the most convenient, and should be long enough to allow six or eight inches space below the foot; the mattress should be hard to prevent sagging. If necessary, thin boards may be placed under the mattress. To prevent the patient from being drawn downward by the pull of the weight, the foot of the bed should be elevated six to eight inches, or the patient should have counter-traction from perineal straps attached to a frame or to the bed…. In addition to raising the foot of the bed, a towel is pinned around the patient below the ribs, and the back of this is fastened to the head of the bed by a bandage.

Plaster of Paris traction is also useful to treat femur fractures when you need to quickly ambulate the patient, to treat patients with delirium tremens, or to treat young children. Ambulatory treatment of fractures of the femur has many detractors, but one method of doing it with some success is to ambulate patients using a Thomas splint. The Thomas splint is commonly available worldwide and, besides its usefulness for treating femur fractures in adults and children, it can also be used as part of "ambulatory" fracture treatment after the patient has been in traction for 3 or 4 weeks. Do not attempt to do this if the fracture site is in the upper one-third of the femur.87

Pseudoarthrosis

When absolutely no other option is available, treat fractures of the neck of the femur by promoting the development of a pseudoarthrosis (false joint). Inject the joint with 5 mL of 2% lidocaine and encourage the patient to walk with crutches or a walker. The claim is that, while the result will not be perfect, it will be better than traction or inexpert nailing.88 This is complex treatment because it is so foreign to most medical standards.

Improvised Traction Pins

Husum and colleagues recommend that an ordinary awl and drill be used to make a hole for a traction pin. The pin itself can be a thick welding rod inserted by careful blows with a hammer. Others have suggested that any strong wire that has been sterilized will work. Apply corks against the skin at the rod ends and attach plain ropes tied to sandbags for traction. For olecranon traction (arm fractures) and trochanter traction (pelvic acetabular fractures), Husum recommends that carpenter's eye screws be used for about 4 to 6 weeks, although they may cause some irritation.62

Healing time is the generally expected interval of time for physiological wound repair following an injury or surgery. This differs from the time to overcome injury-related disability, that is, the time required to return to pre-injury activity level. The time to overcome the disability is always longer than the healing time.

Fractures take varying lengths of time to heal, depending on the patient's age and physical condition, simultaneous disease or injury, and overlying soft-tissue damage. Table 29-3 shows estimated healing times in patients who do not have open reductions and fixation of their fractures.

Trigger Point Injections

This is easy: Don't bother. There is no rationale for, or benefit from, injecting so-called trigger points, even though this has often been the cornerstone of myofascial pain treatment.92 How you explain this to the patient who has been receiving injections for years is another matter.

Intra-Articular Injections

When oral analgesics are not readily available, intra-articular injections may be used. The injections are relatively easy to do at the knee, elbow, shoulder, and any joint that is dislocated. However, they are not very good at providing immediate analgesia.

Although immediate analgesic effects may not be significant, intra-articular morphine injections can result in up to 3 days of analgesia due to its low lipid solubility and the joint's low blood flow.93 After arthroscopy, the addition of bupivacaine 0.25% (20 to 30 mL) into the knee joint provides significant pain relief. Intra-articular morphine instillation may also reduce postoperative pain; clonidine (1 to 2 micrograms/kg [mcg/kg]) adds to morphine's analgesic effect. Adding an injectable NSAID, however, is not effective.94

Postoperative Infusions of Local Anesthetics

When local anesthetics are more readily available than other analgesics, postoperative infusions of local anesthetics can reduce pain. Local anesthetics have been shown to provide relief following bone graft harvest when infused into the cavity made in the anterior superior iliac spine. At the end of surgery, place the infusion catheter (usually an epidural catheter) in the bed of the bone graft donor site in proximity to the periosteum. Inject local anesthetic, usually 0.25% bupivacaine, through the catheter either intermittently (10 mL q6hr) or by continuous infusion at 10 mL/hr. Clamp any vacuum drainage tube during the intermittent boluses. Local anesthetics have provided analgesia when infused into the subacromial space after acromioplasty and rotator cuff repair. Insert the catheter close to the incision site and infuse 0.25% bupivacaine 2 mL/hr or 2% lidocaine 2 mL/hr.94

Angle Measurement Using a Goniometer

A goniometer measures a joint's angle during its range of motion. It can also be used on radiographs to measure the angle of fracture deformities. Acutely, the clinician can use it to assess the joint's movement and, during rehabilitation, to document improvement in range of motion. A homemade goniometer can easily be constructed using a piece of wood, such as a ruler, with a hole drilled in one end (Fig. 29-27). Cut a circular piece of cardboard and mark degree gradations (0 to 350 degrees) in 10-degree increments around the side. Punch a hole in the center of the cardboard and cement it to the wood with the 0-degree mark over the wood and the hole in the cardboard fitting over the hole in the wood. Then tie a string to the hole. The wood is placed parallel with the extremity above the joint and the string follows the extremity below the joint. The string should align with the angle of flexion/extension.95