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ACKNOWLEDGEMENTS Thank you to: Pat Standen and Di Woods for reviewing the document and providing their expert advice, and Ambulance Victoria for so generously allowing their clinical practice guidelines to be used as a guide.
For information regarding this Guide contact: Pat Standen Department of Human Services PO Box 712 Ballarat 3353 Email: pat.standen@dhs.vic.gov.au Phone: 03 5333 6026 http://www.dhs.vic.gov.au/regional/grampians/
Version 1.0
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DISCLAIMER: Care has been taken to confirm the accuracy of the information presented in this guide, however, the authors, editors and publisher are not responsible for errors or omissions or for any consequences from application of the information in the guide and make no warranty, express or implied, with respect to the contents of the publication. Every effort has been made to ensure the clinical information provided is in accordance with current recommendations and practice. However, in view of ongoing research, changes in government regulations and the flow of other information, the information is provided on the basis that all persons undertake responsibility for assessing the relevance and accuracy of its content.
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The purpose of this guide is to assist educators in the Grampians Region to design their own Health Service specific package for Registered Nurses Division 1 & 2 required to manage patients in an emergency situation. The aim of this guide is to provide generic information based on principles of care. It is the responsibility of each individual practitioner and Health Service to ensure appropriate education for all equipment and that competency in the use of the equipment is maintained.
The following package will review the relevant anatomy and physiology that is required for an understanding of the practice of splinting and bandaging. It will then cover what is commonly in clinical practice and why; as well as looking at the machinery of splinting. Although splinting and bandaging can be used in a variety of clinical settings, this package will primarily focus on their use in acute musculoskeletal injuries related to the extremities.
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TABLE OF CONTENTS
INTRODUCTION..5 Overview Anatomy and Physiology...7 Stages of healing..10 Musculoskeletal tissue.11 Soft tissue injuries.12 Principles of management...13 Types of soft tissue injuries.14 Strains and sprains...16 Dislocations and subluxations.16 Fractures16 General principles of splinting.19 Indications, contraindications and cautions..19 Splints.20 Soft Non-rigid splinting.22 Other general use rigid and semi-rigid splints..30 Semi-rigid formable splints......32 Traction splints..41 Pelvic sling/splints.53 Clinical Practice Guidelines and competencies...64 References and suggested further reading..76
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Introduction
Splinting and bandaging plays an important role in the management of musculoskeletal injuries and for definitive therapy of soft tissue injuries, particularly those involving extremity fractures and joint dislocations. Splinting may be the definitive treatment or a temporising measure until the time of reevaluation and/or casting. Immobilisation facilitates the healing process by decreasing pain and protecting the extremity from further injury. Other benefits of splinting are specific to the particular injury or the problem that is being treated. For example, in the treatment of fractures, splinting helps maintain bony alignment. Splinting deep lacerations that cross joints reduces tension on the wound and helps prevent wound dehiscence. Immobilising tendon lacerations may facilitate the healing process by relieving stress on the repaired tendon. The discomfort of inflammatory disorders such as tenosynovitis is greatly reduced by immobilisation. Deep space infections of the hands or feet as well as cellulitis over any joint should similarly be immobilised for comfort. Limiting early motion also may reduce oedema and theoretically improve the immune systems ability to combat infection. Hence, puncture wounds and animal bites of the hands and feet may be immobilised until the risk of infection has passed. Splinting large abrasions that cross joint surfaces prevents movement of the injured extremity and reduces the pain that is produced when the injured skin is stretched. Patients with multiple trauma should have fractures and reduced dislocations adequately splinted while other diagnostic and therapeutic procedures are completed. Immobilisation decreases blood loss, minimizes the potential for further neurovascular injury, decreases the need for analgesia, and may decrease the risk of fat emboli from long bone fractures. The primary objective of splinting is to prevent motion of fractured bone fragments or dislocated joints and thereby to prevent the following complications.
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1. Laceration of the skin by broken bones, which will increase the risk of contamination and infection 2. Damage to local blood vessels causing excessive bleeding into surrounding tissue, ischaemia, and even tissue death 3. Restriction of blood flow to an area as a result of pressure of bone ends on blood vessels 4. Damage to nerves by inadvertent excessive traction, contusion, or laceration resulting in possible permanent loss of sensation and paralysis 5. Damage to muscles with subsequent necrosis, scarring, and permanent disability 6. Increased pain associated with movement of bone ends 7. Shock 8. Delayed union or non-union of fractured bones or dislocated joints
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The mature human body has approximately 206 bones. These bones provide the architectural framework for the body.
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Other structures such as tendons, cartilage, ligaments, soft tissue and muscle allow the bones to perform many functions such as support, serving as a reservoir for minerals and haemopoietic function (production of red blood cells), shielding internal organs, and activities such as protection, work, and play which are coordinated by involuntary and voluntary muscle movement.
Bone is dynamic and can adapt itself when forces are applied to it. Bones can be grouped based on shape, such as flat (innominate pelvis), cuboidal (vertebrae) or long (tibia). Furthermore, bones can be classified as cancellous (spongy or trabecular bone) or cortical (compact). Cortical bone is found where support matters most, in shafts of long bones and outer walls of other bones. Cancellous bone is honeycomb in appearance and makes up the internal network of all bones.
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Periosteum surrounds bone and contains a substantial network of blood vessels that supply the bone with blood and nutrients. Inside the long bones of the extremity is the medullary cavity containing yellow marrow (mostly fat) and red marrow (responsible for blood cell production). Therefore, when a long bone is fractured, blood loss occurs and fat can be released from the medullary cavity potentially causing fat embolism.
Injuries to the soft tissue, which includes muscle, skin and subcutaneous fat, can occur in combination with fractures. Sometimes soft tissue injuries are more significant and have more serious ramifications than the fracture itself.
Healing of an uncomplicated fracture may take from 6 weeks to 6 months. Vascular compromise, infection and other injuries may lengthen the healing process and in some cases, non-union may occur.
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The five stages of fracture healing do not occur independently, but overlap as progression of the healing process occurs.
II: Granulation
3 days 2 weeks
The fracture becomes sticky due to plasma and white blood cells entering the granulation tissue. This material assists in keeping bone fragments together. Parathyroid hormone increases and calcium is deposited. This is the most important stage; slowing or interruption at this stage means that the last two stages cannot progress, leading to delayed healing or non-union Osteoblasts and connective tissue are prolific, bringing the bone ends together. Bridging callus envelops the fracture fragment ends and moves towards the other fragments. Medullary callus bridges the fracture fragments internally thus creating a connection with the marrow cavity and cortices of the fracture fragment. Trabecular bone replaces callus along the stress lines. Unnecessary callus is absorbed. Bony union is thus achieved
2-6 weeks
3 weeks 6 months
V: Remodelling
Re-establishment of the medullary canal. Fragments of bone are united. Surplus cells are absorbed, bone is remodelled and healing is complete
6 weeks 1 year
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Musculoskeletal tissue
There are two types of tissue in the musculoskeletal system, muscle and connective tissue. Connective tissue is specified as tendon, fascia, ligaments, and cartilage.
Skeletal Muscle Skeletal muscle tissue is a voluntary muscle and has a unique ability to contract, therefore providing the body with the ability to move. Skeletal muscle has high metabolic demands and is provided with a rich blood supply by arteries and veins that penetrate the epimysium (fascia), and are finally embedded in the innermost sheath, the endomysium.
Muscles are enclosed within fascial compartments, which protect the muscle from damaged tissue swelling. Pressure within the compartment can increase so much that muscle ischaemia occurs, resulting in compartment syndrome.
Nerve Supply One or two nerves supply muscle. Each nerve includes efferent (motor) and afferent (sensory) fibres. Nerves provide movement and sensation. Sensory nerves carry impulses to the central nervous system (CNS). Motor nerves carry impulses away from the CNS. Traction, compression, ischaemia, laceration, oedema or burning can damage nerves, resulting in nerve deficit distal to the site of injury.
Vascular Supply The nutrient artery provides bone marrow and some cortex in adult long bones with a rich blood supply. The large ends of long bones are supplied by circulus vasculosus. Because of the close proximity of nerves and vessels to bony structures, any musculoskeletal injury can potentially cause vascular and/or neurological compromise. This is a result of these systems being extremely sensitive to compression and impaired circulation. If vascular supply is impaired, tissue perfusion is reduced and ultimately will lead to ischaemia. Irreversible damage to nerves, vascular structures and muscles can occur within 6 to 8 hours if
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progression from ischaemia to muscle necrosis occurs. Poor arterial perfusion is evidenced by pallor, and cyanosis is suggestive of venous congestion. Improper handling of fractures can complicate further care of the patient and increase the degree of injury, as well as causing further bleeding, pain, increased incidence of fat embolism and further damage to soft tissues, nerves and vessels.
Soft tissue injuries incorporate many structures, namely blood vessels, nerves, muscle, skin, ligaments and tendons. Contusions, blistering, burns and crushed areas of skin are an indication of a transfer of a large amount of energy. Major contamination from grass, soil or other foreign material should be removed if accessible. Copious lavage with sterile saline should be used in grossly contaminated wounds before a sterile dressing is applied. Where applicable, the limb should be splinted in normal alignment.
Penetrating: penetrating objects such as bullets, knives, or fracture ends can completely divide blood vessels causing vascular damage.
Tension: tension forces result when the skin is struck by a blunt object. This causes the skin to be torn away from its subcutaneous base, which can produce avulsions or lacerations.
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Compression/crushing: tissues can be crushed between an object and underlying bone, which can produce significant devitalisation of tissue. Compression forces on blood vessels can cause intimal damage, rupture and sometimes sever the vessels completely. Spasm can result following intimal damage.
Stretching: skin can be stretched at the moment of impact and the damaged skin may perish. Fracture blisters can result from transient ischaemia of the skin. Fracture blisters develop within 48 hours of injury, which in turn complicates internal fixation, as they are a potential source of infection. Blood vessels can be stretched when a bone is fractured and this can cause intimal damage to the vessel, which is common near the knee or elbow.
Injection injury: although not common, this is a serious injury, generally to the hand/digit. Such injuries are caused by accidental high-pressure injection of grease, water, solvent or paint. Devitalisation of tissue is immediate and extensive tissue destruction can lead to necrosis within 48 hours if left untreated.
Human bites: although relatively rare, are serious injuries, particularly if they involve tendons, joints or ligaments in the hand. Fist fights can produce wounds around the knuckles if they come into contact with teeth. When the anaerobe from a tooth is sealed into a joint or around the capsule, serious infection develops which can lead to destruction of the joint and stiffness. The human mouth is a veritable reservoir of bacteria. If left untreated, these bites can become grossly infected with a myriad of organisms.
Principles of management
Elevation: elevating a limb in a non-dependent position (on pillow or frame, no higher than the level of the heart) will assist in improving venous return and reducing oedema. Over elevation can contribute to poor venous return and associated complications.
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Cooling: (cryotherapy) should be concurrent with elevation. Cooling is accepted as a fundamental part of acute soft tissue injury treatment. By reducing tissue temperature, cryotherapy can decrease pain and metabolic processes, thereby minimising inflammation. Assess the patient at regular intervals to monitor for signs of potential thermal injury resulting from cooling therapy. Generally, cooling therapy is applied for a duration of 10 to 30 minutes every 1 to 3 hours for the first 24 to 48 hours.
Protection: splinting of a joint can control pain and reduce further injury to soft tissue by decreasing movement.
Nerves: can also be damaged by crushing, penetrating and stretching with most injuries to nerves occurring with a combination of all three. Nerves must always be tested subsequent to any significant trauma. Acute nerve injuries can be missed therefore it is important to ask the patient if they have weakness, numbness or tingling in the specified area. If a nerve injury is diagnosed, always look for associated vascular injury. Classification of nerve injuries: Neurapraxia is a transient loss of function caused by external pressure or simple contusion and has an early recovery. Axonotmesis is seen classically after dislocations and closed fractures and is due to severe compression resulting in loss of function. Recovery may take weeks to months. New axonal processes grow 1 to 2 mm per day. Neurotmesis is due to complete division of the nerve. It has no recovery unless surgically repaired, and function may be adequate post surgical repair, but is rarely normal.
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Muscles: are extremely vascular and their blood supply crucial. If the muscles blood supply is impeded by compartment syndrome, arterial damage or tight plasters/dressings, the muscle becomes ischaemic. Ischaemic muscle becomes fibrous tissue. This is a major issue in fracture management as fibrous tissue contracts and pulls the associated joint out of anatomical alignment. Coincidentally, muscle crushed by direct force can also become fibrous tissue, which shortens the muscle and hampers joint movement. Lacerated muscle is difficult to repair, as sutures will not hold well enough to stop contraction of the muscle, therefore pulling the edges apart.
Skin: can be damaged by a number of forces as well as direct trauma. If a force is great enough to fracture a bone, the skin at the fracture site is bound to be injured.
Ligaments: connect bone to bone. They provide stability and guidance for joints. Ligaments have enormous tensile strength that can withstand forces of up to 226 kg before rupturing. There are a large number of ligaments in the body. There are four ligaments in the knee alone: posterior cruciate, anterior cruciate, lateral collateral and medial collateral. The three grades of ligament injuries are: Sprain: where stability is maintained Partial rupture: where some fibres remain and there is some loss of stability. Complete rupture: where continuity of the ligament is ruptured and there is complete loss of stability. Some patients may say they heard a snap. Pain is severe and bleeding under the skin will cause swelling and haemarthrosis (only if bleeding occurs into the joint). Most ligament ruptures can be treated nonoperatively, but there are some exceptions where the ligament needs to be repaired surgically. Nursing management of these patients includes splinting the joint and cooling/ice packs.
Tendons: connect muscle to bone and permit conduction of force by muscle to bone which results in joint movement. Tendons and ligaments have much
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lower oxygen consumption than skeletal muscle. This low metabolic rate means that they are slow healing after injury.
Fractures
Bone has some degree of elasticity. A fracture results from stress/force placed on the bone which it cannot absorb. It may be caused by direct or indirect trauma, stress or weakness of the bone, or may be pathological in origin. The types of force used to cause fractures are direct violence, indirect (generally a twisting injury), pathological (generally a weak bone from tumour or osteoporotic bone) and fatigue (repeated stress on the bone, for example from military marches).
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Classification
Fractures are classified as stable or unstable. Stable fractures are unlikely to be displaced, whereas unstable fractures are likely to be displaced. Fractures are also classified as open, or closed. With closed fractures, there is no penetration of the skin by bone. Conversely in open fractures, the bone breaches the skin or one of the body cavities, or the force that caused the fracture penetrates the soft tissue.
Type
Transverse fractures cross the bone at a 90o angle and are generally stable post reduction. Oblique/spiral fractures are at a 45o angle to the axis, usually from a twisting force causing upward thrust. Most long bone fractures are due to violent twisting motions, such as a sharp twist to the leg, when the foot is stuck in a hole, producing a spiral fracture. Comminuted fractures are high-energy injuries where the bone is splintered in more than two fragments. These are generally associated with significant soft tissue injury. Impacted fractures occur when one fragment is forced into another. The fracture line may be difficult to visualise. Crush fractures occur when cancellous bone is compressed or crushed. Avulsion fractures occur when soft tissue and bone are torn away from the insertion site. Greenstick fractures occur when the compressed cortex bends/buckles. If the force persists, the cortex will fracture. These are usually seen in children as their bones are much more porous and soft. Epiphyseal or growth plate fractures (Salter-type) may affect future bone growth because of early closure of the epiphyseal plate and resultant limb shortening. Angulation may occur with partial growth plate fractures because bone growth continues in the noninjured area.
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