If there is an opening in the lung or chest wall, air will be sucked into the pleural space , producing a pneumothorax. In the presence of a flap-valve effect, this may become a tensi on pneumothorax, especially if the patient is receiving positive pressure ventilation or as sistance. During expiration, the diaphragm reaches the fifth intercostal space (equivalent to the mal e nipple level), although it can reach even higher if the patient is in a crouched position . The heart is positioned slightly to the left of the midline and is covered by the pericar dium. Stab wounds to the heart may result in bleeding into the space within the pericardium , producing cardiac tamponade. The heart, major blood vessels, trachea, and esophagus are p ositioned in the central part of the chest (mediastinum) and trauma to this region is often life threatening or rapidly fatal. Pathophysiology Normally, respiratory physiology relies on a concentration of oxygen flowin g into the alveoli (ventilation), where it is separated from blood flowing in the pulmonary capillaries (perfusion) by a thin membrane that facilitates oxygen (O2) and carbon dioxide (CO2) transfer (diffusion) between the alveoli and the capillaries. To maintain normality, the bal- ance between ventilation and perfusion is important. Impairment will lead to hypo xia and hypercarbia. Ventilation In a normal fit adult, 7 \200\2238ml/kg of air (approximately 500ml) is taken i nto the lungs with each breath. This amounts to approximately 5L per minute for a 70kg pati ent at rest. Only 70% (350ml) of each tidal volume reaches the terminal bronchioles where g as exchange occurs. The remaining 150ml remains in the upper airway and constitutes the ana tomical dead space. In addition, areas of ventilation without perfusion with blood constitu te the physiological dead space. In healthy adults, the anatomical and physiological dead s pace are approximately equal. Pulmonary perfusion There is a difference in blood flow between the apex and base of the lu ng because the pressure in the pulmonary circulation is much lower than the systemic circul ation. This results in under-perfusion of apical alveoli and over-perfusion of basal alveol i. At the bases, therefore, there is inadequate elimination of CO2 and uptake of oxygen. Th is blood is known as shunted blood. The effects of this are compensated by hypoxic pulmonar y vasoconstriction which diverts blood to better ventilated areas. CHEST INJURIES1 211 Diffusion The close proximity of the alveoli and pulmonary capillaries facilitates gas exch ange by passive diffusion due to a pressure gradient across the respiratory membrane. pO2 (alveoli) 100mmHg l pO2 (capillaries) 40mmHg pCO2 (pulmonary capillaries) 45mmHg l pCO2 (alveoli) 40mmHg The partial pressure is much smaller in relation to carbon dioxide exchange but this is not a problem because carbon dioxide is 20 times more soluble than oxygen. In the healthy adul t, exchange of both gasses takes place at the same rate. The lung has a pulmonary membrane surface equivalent to half a tennis court, making it ideal for gas exchange. Lung function may be compromised by poor ventilation (smoke inhalation, pain inhibition), reduced diffusi on (pneumothorax), or increased thickness of the respiratory membrane (pulmonary oedema). Patient assessment There are six immediate life-threatening conditions (ATOMIC) that should be detected in the primary survey. These are: - Airway obstruction - Tension pneumothorax - Open chest wound - Massive haemothorax - FlaIl chest - Cardiac tamponade. All patients wi th chest trauma require high-flow oxygen and this should be administered at 15L per minute after ascertaining that the airway is clear. A mask and non-rebreathable reservoir bag shou ld be used. Examination of the neck may reveal important physical signs suggestive of time- critical injury and must, therefore, take place before a collar is applied. The neck is exa mined for: - Tracheal position - Neck vein distension - Wounds - Surgical emphysema - Laryn geal crepitis - Spinal tenderness. Depending on clinical urgency, it may be more appropriat e to maintain inline cervical stabilization whilst completing the primary survey and to app ly a collar after it has been completed. Examination of the chest Where possible, the chest should be exposed, although this may be difficult in entrapments. A systematic examination should follow the sequence: - Inspection - Palpation - Percussion - Auscultation. CHAPTER 3 Trauma 212 DO NOT FORGET THE BACK The specific determents of the primary survey are summarized in Table 3.2. The back should always be checked for evidence of injury. In victims of assault, posterior stab wounds are relatively common. If it is impossible or untimely to turn the patient onto their side to i nspect their back, the gloved hand of the rescuer should be run down the back of the patien t \200\231s chest whilst in a supine position and then inspected for blood. Extreme care sh ould be used if there are fragments of broken glass about. Tension pneumothorax A tension pneumothorax may arise following blunt or penetrating trauma . Air is sucked into the plural space either through a hole in the chest wall or through a perforation in the visceral pleura, and a pneu- mothorax is produced. Should a flap be form ed, from pleura or other soft tissue, a one-way valve may result. This may allow air to pas s into the pleural space during inspiration but prevent it from leaving during expiration. The pneumothorax therefore increases in size, and the pressure inside the thorax rises. Thi s situation is worsened by coughing and positive pressure ventilation. Eventually, the pati ent becomes shocked because of impeded venous return and diminished cardiac output. The cla ssical features of a tension pneumothorax are: - Rapid respiratory rate - Decreased air ent ry - Hyper-resonant hemithorax - Rapid, weak pulse - Decreasing level of consciousness - De viated trachea (late sign) - Raised jugular venous pulse (if there is no accompanying hypov olaemia) - Cyanosis (very late). This condition can be rapidly fatal and the rescuer should have a high index of suspicion for the diagnosis. The treatment is a needle thoraco- cente sis using a 16 gauge cannula connected to a 10ml syringe. This is inserted into the second intercostal space in the midclavicular line. A rapid release of air confirms the diagnosis. The syringe and needle should be removed and the cannula left in situ and secured in posit ion. This cannula may become blocked or dislodged, particularly during patient transfer. If the patient deteriorates, reassessment using the primary survey is necessary. If it appear s that a tension pneumothorax is re-accumulating, a second cannula should be immediately in serted. Depending on clinical competence, the clinical situation, and the distance to a hospital, i t may (rarely) be necessary to consider a formal tube thoracocentesis. Thoracostomy with an Aschermann chest seal is an alternative. If needle thoracocentesis fails to demonstrate a tension pneumothorax, the needle should still be left in place. If it is likely that the needle may not have reached the pleural cavity and the possibility of tension pneumothorax is high, a second cannula can be inserted behind the pectoralis in the anterior axillary li ne high in the axilla. CHEST INJURIES1 213 Table 3.2 Primary survey for chest injury Inspection Palpation Percussion Auscultation Respiratory Rate Crepitus or surgical emphysema Increased resonance (pneumothorax) Listen: axilla \200\224lower half, upper half Rib tenderness Depth of respiration Decreased resonance (haemothorax, lung contusion) Determine: air entry Symmetry of air entry Rib crepitus Effort of breathing Flail chest Symmetry of movement Bruising Abrasions Wounds Fig. 3.13 Pathophysiology of tension pneumothorax. Reprinted with permission from Greaves I et al. (2005) Emergency care: a textbook for paramedics, 2nd edn. W.B. Saunders Co. Ltd. CHAPTER 3 Trauma 214 Open chest wound Open chest wounds commonly follow stab and gunshot wounds, although they c an occur following road traffic and industrial accidents. An open chest wound will produce an open pneumothorax on the side of the injury. If the size of the wound is greater than tw o thirds the diameter of the patient \200\231s own trachea, air will preferentially pass th rough the hole in the chest wall during inspiration (a \200\230sucking wound \200\231). Th e open wound may be preventing the accumulation of a tension pneumothorax and should not, t herefore, be sealed. The best treatment is the application of an Aschermann chest seal, a lthough a dressing, sealed on three sides only, may be used. Massive haemothorax A massive haemothorax may complicate both blunt and penetrating trauma. The clinical features are: - Decreased air entry on the affected side - Dull percussion no te over the affected side - Clinical features of shock - Low jugular venous pulse. The management includes high-flow oxygen and judicious fluid replacement to maintain a palp able radial pulse. If other injuries allow, the patient should be positioned with the injur ed side uppermost (to optimize gas exchange) and rapidly transferred to hospital. Tube thor acocentesis should not normally be undertaken in the pre-hospital environment as this may r esult in catastrophic uncontrollable bleeding. Flail chest This occurs when two or more adjacent ribs are broken in two places, resulting in a flail segment which moves paradoxically on inspiration (in on inspiration, out on expi ration). It occurs after compression injuries to the chest and, in frontal impacts, may inv olve the whole of the anterior chest wall. Massive anterior flail segments are often missed and a detailed and specific look at the chest wall is required to make the diagnosis. Look ing tangentially at the chest from the patient \200\231s feet may be helpful. Lateral flail segments are usually more obvious. The pre-hospital treatment includes oxygen therapy, ana lgesia, and manual or positional stabilization. Cardiac tamponade This occurs most commonly following a stab wound to the heart. Blood coll ects within the pericardial sac and this leads to a compromise of ventricular filling and a fall in cardiac output. Venous return to the heart is reduced and the jugular venous press ure is elevated. The heart sounds are muffled and an ECG may display a low amplitude trace. The patient requires urgent transportation to hospital for emergency management. Needle pe ricardiocentesis is usually inneffecitive. However, it may be considered if the transfer ti me is likely to be prolonged. If blood is aspirated, the cannula should be left in the peri cardial space, aspirated periodically, and allowed to drain freely. CHEST INJURIES1 215 Penetrating weapons or foreign bodies still in situ MUST NOT be removed. No attempt should be made to stop a weapon or foreign body which is moving with the heart cycle, as doing so this may worsen cardiac damage. Table 3.3 Clinical signs in life-threatening chest injuries Position of the trachea in relation to the side of injury Chest wall movement on the side of injury Percussion note on the side of injury Breath sounds on the side of injury Flail chest Central Decreased Paradoxical movements Decreased with pain on palpation Central/away Normal/ Decreased Decreased Massive haemothorax decreased Central Decreased Increased Decreased Open pneumothorax Away Decreased Increased Decreased Tension pneumothorax CHAPTER 3 Trauma 216 The secondary survey Re-examination of the chest forms part of the detailed head-to-toe sec ondary survey. Immediately, life-threatening injuries should have been identified during th e primary survey, although their development can be delayed. The secondary survey may pick up potentially life-threatening conditions including: - Simple or closed pneumothorax - Pul monary contusion - Diaphragmatic rupture - Fractured ribs - Fractured sternum - Surgical em physema. Simple or closed pneumothorax This commonly occurs in blunt trauma and is often associated with damage to the lung from a fractured rib. It is more often than not a diagnosis made on X-ray in hospital as the clinical signs may be difficult to detect. They include: - Reduce d chest movement in the affected side - Decreased air entry - Decreased breath sounds - Hyp er-resonance to percussion. Importantly, the trachea is not deviated and the jugular venous pressure is not elevated. Pre-hospital management includes oxygen therapy, anal- gesia, ap propriate patient positioning, and transfer to hospital. Pulmonary contusion Pulmonary contusion is often a diagnosis that is made in hospital and o n X-ray. In cases of prolonged entrapment, it is a diagnosis to consider. Alerting features include the mechanism of injury, the presence of chest wall contusion, rib fractures, and flail chest. The patient is often tachy- cardic and tachypnoeic with decreased air entry bu t a normal percussion note. There are no features to suggest a pneumothorax or a haemothora x. Diaphragmatic rupture Diaphragmatic rupture commonly follows blunt or penetrating trauma; t he latter following stab wounds. Blunt trauma to the abdomen may lead to a rupture of the l eft hemidiaphragm through its central tendon (weakest point). Clinical features include inc reasing respiratory distress and a decreasing abdominal girth. Fractured ribs These commonl y occur following blunt trauma, producing localized areas of pain, tenderness, and sometime s crepitus. Pre-hospital treatment includes manual splintage and analgesia. The patient sho uld be observed for the development of intrathoracic complications, in particular pneu- mot horax. CHEST INJURIES1 217 Fractured sternum Sternal fractures follow blunt trauma to the front of the chest. The most important clinical feature is pain which is often severe but can be treated by manual supp ort and analgesia. Complications are unusual but can include cardiac dysrhythmias. Surgical emphysema Surgical emphysema is indicative of an air leak and may suggest an under lying pneumothorax. No treatment is necessary but the patient should be assessed carefully for an obvious pneumothorax and the risk of developing a tension pneumothorax. Pain relief The common feature of all chest injuries is pain. Appropriate analgesia is esse ntial to ensure adequate breathing, which will reduce the risk of subsequent chest infectio n and facilitate patient handling and packaging for transportation to hospital. Entonox s hould not be used because of the risk of worsening an occult pneumothorax. The analgesia of choice is an opiate titrated to clinical response. CHAPTER 3 Trauma 218 Abdominal and genitourinary trauma The abdomen has three main regions: - The peritoneal cav ity - The retroperitoneum - The pelvis. The peritoneal cavity can be divided into intra-tho racic and intra- abdominal components. The intra-thoracic component is the area under the c ostal margin and lower ribs; its upper thoracic boarder is the mobile diaphragm. The size o f the intra-thoracic component, therefore, varies with respiration \200\224increasing in ex piration and decreasing during inspiration. It contains the diaphragm, liver, spleen, stoma ch, and transverse colon. The relaxed diaphragm may reach the fifth intercostal space during expiration. Therefore an y blunt or penetrating injury at or below this region may produce intra-abdominal trauma. T ransdiaphragmatic stab wounds from higher in the chest are uncommon. Fractures of the lower ribs may damage the underlying organs, particularly the spleen on the left and the liver o n the right side. The abdominal compartment contains the small and large intestine. These are particularly at risk from shear forces which may tear the bowel or its blood supply. Penetrating injuries may produce multiple gut per- forations. Behind the abdominal compartment is the retroperitoneal space which contains the following structures: - Ascending and descending colon - Duodenum - Pancreas - The kidney - Ureters - Aorta - Inferior vena cava. These structures receive some protectio n from the anterior organs and injuries in this region may, therefore, be occult. The pelvis contains the bladder, rectum, and iliac blood vessels in addition to the uterus, ovaries, and vagina in the female and the prostate in the male. Whilst the pelvis may offe r some protection, the underlying organs are frequently damaged by displaced bony pelvic fr agments. Mechanism of injury Blunt trauma, particularly from road accidents, significant falls, and industrial trauma are the main causes of abdominal injuries. Penetrating trauma, particular ly from stabbing and gunshot, is on the increase in the UK and USA. ABDOMINAL AND GENITOURINARY TRAUMA1 219 (b) (a) Upper border demarcated by diaphragm Vertebral column Peritoneal sac Spinal canal Costal margin Peritoneum Retro peritoneal space Peritoneal sac Umbilicus Pelvic brim Lower border demarcated by pelvic floor Sacrum Pubis Extra peritoneal pelvic organs (rectum, bladder) Inguinal ligament (c) Lower end of esophagus Liver Spleen (lying behind stomach) Costial margin Stomach (upper part covered by liver) Colon Small bowel Appendix Bladder Fig. 3.14 Anatomy of the abdomen: (a) front view; (b) side view; (c) the peritoneal cavity. Reprinted with permission from Greaves I et al. (2005) Emergency care: a textbook for para medics 2nd edn. W.B. Saunders Co. Ltd. Blunt trauma Blunt trauma may result from compression, crush, and shear forces. Sudden comp ressive forces may increase intra-abdominal pressure result- ing in bowel rupture. This typ e of injury may follow lap belt injuries. Direct crushing may rupture the underlying organs , for example, the liver, spleen, pancreas, and the fixed retroperitoneal structures. Shear forces, commonly due to sudden deceleration, produce injuries at the interface of fixed an d mobile structures including vascular pedicles. Penetrating injuries Penetrating injuries may occur through the anterior and posterior abdo mi- nal wall, the flanks, buttocks, and perineum and also through the diaphragm from above. Multiple stab wounds are not uncommon. Gunshot wounds are traditionally divided into low-e nergy and high-energy transfer wounds. The latter are associated with cavitation and contam ination with a high incidence of morbidity and mortality. Any penetrating injury which perf o- rates the bowel wall will result in fecal soiling and peritonitis. CHAPTER 3 Trauma 220 Patient assessment It is vital that the carer remembers that they are not concerned with es tablishing a specific anatomical diagnosis but that their priority is to decide, based on t he mechanism of injury and clinical findings, whether there is a possibility of abdominal t rauma being present. Clinically significant solid organ trauma (liver and spleen) and major blood vessel trauma (aorta and inferior vena cava) may present with severe shock at the outset. Trauma producin g hollow viscus injury may lead to an insidious development of peritonitis, sometimes over several hours or days. THINK MECHANISM OF INJURY Assessment follows the ABCDE system. The first suspicion of abdominal trauma may occur duri ng the circulatory assessment. Hypotension must be explained. Sources of major blood loss i nclude: - External hemorrhage - Major long bone fractures - The chest - The abdomen - The p elvis and retroperitoneum. In the absence of obvious external bleeding, major long bone fra ctures or chest injuries, the abdomen, pelvis, and retroperitoneum are implicated as the po ssible location of blood loss. During the primary survey, the detec- tion of abdominal tend erness to palpation or pain on a single pelvic bony assessment is significant. It must be r emembered that abdominal viscus and solid organ trauma may not initially be associated with any abnormal physical signs. The assessment is made more difficult in the unconscious patient or patient with head traum a, spinal cord injury, major distracting injuries, or who has ingested drugs or alcohol. Penetrating wounds are an obvious indicator of abdominal injury. In blunt trauma, bruising and contusion to the abdominal wall may be pathomnemonic of internal injury. Blood per uret hram confirms renal tract trauma. The classic signs of intra-abdominal trauma include tende rness, guarding, and rigidity. Bowel sounds are frequently absent following trauma, even in the absence of specific intra-abdominal injury. The clinical examination should include: Adequate exposure of the abdomen - Inspection of the abdomen, lower chest, flanks, pelvis, and perineum - Inspection and palpation of the posterior abdominal wall - A single palpatio n of the pelvis. ABDOMINAL AND GENITOURINARY TRAUMA1 221 Management Blunt trauma In the presence of hypotension, fluid replacement should be tailore d to maintain or restore the radial pulse (systolic BP 80 \200\22390mmHg), ensuring essenti al organ perfusion. Excessive fluid resuscitation will lead to accelerated bleeding or rebleeding, dilutional c oagulopathy, and hypothermia in patients with non-compressible, non-controllable internal b leeding. Opiate analgesia titrated to clinical response, preceded by an antiemetic, should be consid ered. There is NO justification for withholding analgesia pending surgical assessment. Penetrating trauma In the case of penetrating trauma, the wound should be covered with a mo ist sterile pad. This should be large enough to keep extruded bowel (if present) moist. Cli ng movie may help retain dressings by covering the whole abdomen. The hypotensive patient \200\231s fluid replacement should follow the controlled hypotension principle. Impaling injuries Impaling objects should be left in place as their removal frequently prod uces major bleeding. External bleeding should be controlled by direct pres- sure. The objec t should be supported and prevented from moving during transfer by bulky dressings. Objects which are moving in time with the pulse should not be immobilized. Evisceration The passage of part of the intestine or other organ through a wound may occur. The protruding part should be kept moist using sterile pads and saline. No attempt should be made to relocate a protruding organ. Pelvic fractures There is a common association between pelvic fractures and abdominal organ trauma. Bleeding from pelvic fractures, particularly open book fractures (diastasis of the symphysis pubis), can be reduced by external splintage. A number of commercially available wrap-around pelvic splints are now available, or an improvised splint can be fashioned fro m a sheet, FRAC Straps , or triangular bandages. The pneumatic antishock garment (MAST Sui t) has lost popularity as it has been shown to increase morbid- ity and mortality in patien ts suffering head and chest trauma and cannot be used in patients with diaphragmatic ruptur e, those who are pregnant, and those with impalement and evisceration injuries. Genitourinary trauma Genitourinary trauma commonly occurs in conjunction with abdominal and pelvic trauma. Anatomy The kidneys and ureters lie in the retroperitoneal space gaining some protection fr om anterior abdominal trauma. The diagnosis of injury is often delayed. Wounds or contusion s to the loin or flank area raise the possibility of renal or renal tract trauma. CHAPTER 3 Trauma 222 Injuries to the bladder and urethra are usually more obvious. Bladder trauma is often assoc iated with anterior pelvic fractures. Blood per urethra suggests lower urinary tract trauma . The external genitalia, especially in the male, are at risk from direct injury such as ki cks and straddle injuries. Mechanism of injury As with abdominal trauma, injuries may be either blunt or penetrating, blunt being the more common. The bladder and urethra are frequently damaged at the time of pelvic fractures when they are exposed to both compression and shear forces. Urethral injuries Urethral injuries are commonly associated with direct injuries to the per ineum. Injuries to the bulbous urethra are seen in straddle injuries and those to the membr anous urethra, in pelvic fractures. Bladder injuries Bladder injuries follow both blunt and penetrating trauma. As a result of a compressive force, the intra-vesical pressure is acutely elevated leading to acute bladde r rupture which can be intra-abdominal or extra- abdominal. At the time of displacement of anterior pelvic fragments there may be direct injury to the underlying bladder. This is also seen in abdominal stabbing injuries. An inability to pass urine, lower abdominal tenderness, and blood per urethra are suggestive of significant inju ry. Ureteric injuries Because of its protected position in the retroperitoneal area, a diagnosi s of injury to the ureter is normally made following specific investigation in hospital. Renal injuries Blunt injuries are most commonly associated with road traffic collisions but are seen in sport (for example, in rugby and football). The patient presents with loin ten derness, and, because of the association with more significant trauma, there may be general ized abdominal tenderness and hypovolaemia. Penetrating injuries are usually associated wit h stab wounds and gunshot wounds. Genital injuries Genital injuries are most commonly due to blunt trauma and the bruised tes ticle is made more comfortable by an ice pack and good supporting underwear. Severe blunt t rauma may rupture the testicle. The pain is severe and the patient requires urgent surgical opinion. Not surprisingly, the patient tends to be extremely anxious. Skin avulsions to the genitalia and penis require replacement in situ with a supportive dressing and transfer to hospital. This page intentionally left blank CHAPTER 3 Trauma 224 Bone and joint injuries Limb injuries (including bone and joint trauma) are the most common injuries encountered in pre-hospital care. Although rarely immediately life-threatening, t hey require careful assessment, appropriate pain relief, realignment, and splintage if nece ssary, followed by safe extrication and transportation. Mechanism of injury Fractures occur when the force applied to a bone exceeds its tensile st rength. Bone is strongest under loading and weakest if distracted or twisted. The causative force may be direct, as in a kick to the tibia or associated with rotation and twisting as in the majority of ankle fractures. If the force is significant, fractures will occur in n ormal bones. However, in the elderly, many of whom are osteoporotic. Fractures may occur fo llowing relatively minor falls, fracture of the neck of the femur is a classic example. Fracture classification Many of the fracture classification systems relate to the X-ray app earances (for example, spiral butterfly oblique). The most important classification in pre- hospital care is: - Simple (closed) - Compound (open). Each limb must be examined for any a ssociated neurovascular deficit. Simple (closed) fractures occur when there is no overlying wound com- municating with the fracture. Compound fractures, however, have an overlying or related wound which communicates with the fracture. Careful patient handling will prevent simple fractures from becoming compound. Children, by virtue of their immature skeleton and growth potential have different fracture types. These include \200\230greenstick \200\231 fractures and epiphyseal fractures (grow th plate injuries). Although biologically and pathologically different, the clinical mode o f presentation (pain, tenderness, swelling deformity, and loss of function) are common to b oth children and adults. Dislocations A dislocation is a complete disruption of a joint such that normally con- gruo us joint surfaces are no longer in contact. Incomplete dislocations are known as subluxatio ns. Common examples of dislocations include patella dislocations and dislocations of the sh oulder. Fractures may occur in conjunction with dislocations, for example, posterior disloc ation of the hip with fracture of the posterior wall of the acetabulum. Patient assessment The initial assessment follows the ABCDE system. Fractures can present a s immediately life-threatening injuries either directly or indirectly. BONE AND JOINT INJURIES1 225 Airway compromise - Skull fractures: the unconscious patient unable to protect their own airway Facial fractures, including impacted maxillary fractures and bilateral mandibular fractures Laryngeal fracture - Posterior sternoclavicular dislocation. Breathing compromise - Rib fractures and flail chest - High spinal cord injuries. Circulatory compromise - Compound fractures with bleeding - Multiple long bone fractures - Pelvic fractures - Fractures with damage to underlying organs (liver and spleen). Disability/neurological compromise - Major skull fractures - Depressed skull fractures - Sp inal injuries. Limb-threatening injuries It may be obvious at the outset that a patient has sustained a ca tastrophic limb injury with a high risk of subsequent amputation. Examples include extensiv e soft tissue injuries or soft tissue loss, major compound fractures, or major neurovascula r deficit. Optimal pre-hospital care will maximize the chance of limb salvage. Examination of the musculoskeletal system must be systematic and follow the \200\230look, feel, and move \200\231 system. - Look \200\224wounds, swelling, deformi ty. - Feel \200\224tenderness, swelling, deformity, neurovascular deficit. - Move \200\224c an the patient move the limb (avoid moving limbs that have obvious fractures)? Limb-threatening complications such as compartment syndrome do not normally occur in the pr e-hospital environment unless there is a delay in transfer to hospital. Principles of management The principles of management of musculoskeletal injuries are: - Li fe-threatening injuries should be identified and treated. - All patients who have sustained a major long bone fracture require oxygen. Unless there are time-critical injuries, all fractures and dislocations should be splinted. The joint above and the joint below the injury should be immobilized. - Appropriate pain re lief should be given \200\224Entonox (care in chest injuries!) or an opiate titrated to clinical response. CHAPTER 3 Trauma 226 Closed fractures Where possible, significant deformity should be corrected by traction, res toring length, and rotation, followed by limb splintage. Pre-extrication splintage may not be possible other than companion support (broad bandages, FRAC Straps ). Splintage has a number of important beneficial effects: Reduces pain - Reduces blood loss - Reduces the risk of neurovascular damage - Reduces pres sure on skin - Reduces the risk and magnitude of fat embolism - Facilitates packaging Compound fractures Good wound care at the outset will reduce the risk of soft tissue and bo ny infection. Gross contamination should be removed and the bone ends irrigated with saline and relocated in or as near the normal anatomical position as possible. The wound should b e covered with a sterile dressing and splintage applied to the limb. Life-threatening bleed - ing should be controlled by direct or indirect pressure, wound packing, or a tourniquet. Dislocations The treatment of a dislocation is the prompt restoration of joint congruity if the patient \200\231s other injuries permit. A good example is fracture dislocation of the ankle where there may be ischaemic skin due to local pressure and major vascular compromis e. The timing and place of reduction will depend on the skills of the carer, the availabili ty of drugs, and the transfer time to hospital. If pre-hospital reduction is impossible or inappropriate, the patient should be given analg esia, the limb splinted as much as possible, and the patient transported to hospital. Reduc tion under analgesia aims to restore normal anatomical position by reversing the forces whi ch caused the original injury. This may not always be possible, (for example, due to soft t issue interposition) and undue force should not be used. In inexpe- rienced hands, the corr ect approach is usually to arrange urgent transfer to hospital. Splintage The principles of splintage involve - Padding to protect any vulnerable bony poin ts - Splintage of the joint above and below the fracture - Checking the circulation before manipulation and splintage - Regular reassessment of the neurovascular status. Methods of splintage include - Self help, for example, supporting the arm in the presence o f a fracture of the clavicle or neck of humerus - Broad arm slings \200\224wrist and forearm in juries - Broad bandages or FRAC straps to secure the upper limb to the trunk or the lower limbs together BONE AND JOINT INJURIES1 227 Box splints \200\224padded, solid surrounding supports short leg, long leg,or forearm for long bone fractures Traction splints \200\224suitable for femoral shaft fractures - Vacuum splints \200\224to p rovide contoured splintage for limb fractures - Spinal boards \200\224principally designed as an extrication device but frequently used in spinal trauma. Splintage is discussed more detail in individual topics on fractures. CHAPTER 3 Trauma 228 Regional injuries: upper limb Clavicular fractures Cause The vast majority are caused by a direct blow on the point of the shoulder. Less commonly, clavicular fracture follows a fall on an outstretched hand due to force transmitted up the arm. Signs and symptoms - Tenderness - Swelling - Visible deformity - The patient frequently sup ports the weight of their arm Treatment Relieve the weight of the arm by providing support either manually or with a broa d arm sling. Potential problems Very occasionally, the fracture may be compound, particularly if it is t he result of a direct injury. There is a small risk of injury to the subclavian artery or t he brachial plexus. Because of the close proximity of the chest wall, there may be an under lying chest injury. REGIONAL INJURIES: UPPER LIMB1 229 Sternoclavicular dislocations Cause Sternoclavicular dislocations occur following a fall or a direct injury to the front of the shoulder. They are seen quite frequently in rugby scru mming injuries. The joint can sublux or dislocate both anteriorly or posteriorly. Signs and symptoms - Pain - Tenderness - Swelling - Asymmetry at the inner end of the clavi cle. Treatment Support in a broad arm sling. Potential problems Posterior sternoclavicular dislocations are occasionally associated with acute airway obstruction, producing stridor and respiratory distress. The treatment is to lever the clavicle forward using the fingers. If this is unsuccessful, the patient should b e transported urgently to hospital. Rarely, posterior dislocations are associated with damage to underlying major vessels and they can present with shock.