Life-threatening problems identified during the primary survey in the multiply injured patient are managed first. Only then should attention be turned to the extremity injury.The specific management of complications such as vascular injury, compartment syndrome, traumatic amputation, and open wounds have been discussed earlier in this chapter.
Severely angulated fractures should be aligned. Gentle traction should be applied to the limb to facilitate alingment, particularly when immobilising long-bone fractures. Splints should extend one joint above and below the fracture site. Perfusion of the extremity, including pulses, skin colour, temperature, and neurological status, must be assessed before and after the fracture is aligned. Radiographs, including arteriograms, should not be obtained until the extremity is splinted.
When aligning a fracture, analgesia is usually necessary. Entonox or intravenous opiates should be used. In femoral fractures, femoral nerve block is very effective - the technique is discussed in Chapter 24.
Fractures (or suspected fractures) should be immobilised to control pain and prevent further injury. Splintage is a most effective way of controlling pain and subsequent doses of analgesia may be reduced. If pain increases after immobilisation, then an ischaemic injury and/or compartment syndrome must be excluded. Emergency splinting techniques for various injured extremities are described below.
Hand Splinted in the position of function with the wrist slightly dorsiflexed and the fingers slightly flexed at all joints. This is best achieved by gently immobilising the hand over a large roll of gauze.
Forearm and wrist Splinted flat on padded pillows or splints.
Elbow Immobilised in a flexed position with a sling which may be strapped to the body.
Arm Immobilised by a sling, which can be augmented with splints for unstable fractures. Circumferential bandages should be avoided as they may be the cause of constriction, particularly when swelling occurs.
Shoulder Immobilised by a sling.
Femur Femoral fractures should be treated in traction splints. Ipsilateral femoral and tibial fractures can be immobilised in the same splint. Excess traction may cause perineal injury and neurovascular problems, and should be avoided.
Tibia and ankle Tibial and ankle fractures should be aligned and immobilised in padded box splints. Foot perfusion should be assessed before and after application of the splint.
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