Resetting compound fractures

[Arctic1]

@Hmac

I’m not talking about “military plans”. I’m talking about civilian EMS in the United States. This has nothing to do with your management of a compound fracture on the battlefield under enemy fire. You’re on your own there, and you will have to use your training, experience, and imagination to deal with it. Good luck.

Ok, point taken, thanks.

[Arctic1]

@Caduceus

FWIW, you’re thinking too hard.

Compound fractures = splint. Doesn’t really differ than a closed fracture. The only difference, as mentioned above, is if there’s a pulseless extremity (and in real world, you’re looking at 4-6 hours before limb loss is a possibility - ideally). Really, that’s about the only time you’re justified in attempting to straighten a limb. And even then, you only manipulate enough to restore pulse, not maintain anatomic alignment.

As for pain, it’s from the muscle contraction. They hurt. Get over it. Have your medic/corpsman give some morphine, or a fentanyl pop, and drive on. Traction more than realignment will help. But the only bone that’s regularly tractioned is the femur, and that’s because you can bleed 1-2 liters into the thigh and not know it (hello, stage 2 shock).

Infection? It’s infected the second it happens. Cover the open area with as sterile a bandage as you have, pop your combat pill pack (Which has an antibiotic) and get to higher care. Try not to screw it up with more dirt, grass, bullets, etc.

Long transport? That’s WHY you splint, to prevent further damage. Yes, lacerated vessels happen. By splinting it, you try and prevent further damage. Typically traction isn’t going to cause much tissue damage, since the sharp bone fragments are being pulled ‘backwards’ and not being allowed.

Not really overthinking it, as much as trying to apply the advice given by Hmac for civilian care to a military setting. And as he pointed out, it doesn’t.

And I am aware of the treatment protocols, and like I said previously I won’t usually bother with fractures unless I am caring for the pt over an extended period of time.

[Gutshot_John]

I think it’s always worth remembering that as medics we should always be governed by calculated risks.

“Do no harm” means you don’t attempt anything without a reasonable expectation of improving survivability/outcome.

Femur fractures suck and are extremely painful. Reducing a fracture/dislocation sucks and are both extremely painful.

What are you gaining by causing that much pain without the appropriate equipment/capability?

An MCI/Battlefield conditions will profoundly impact that calculus, as does having a stocked ambulance with a trauma center within 10-15 miles.

1. In general I see no virtue of even thinking of reducing a compound fracture without a lack of distal pulse.

2. Once you’ve made the decision that it might make sense, you have to consider whether conditions preclude taking such a risk.

Even if conditions 1. and 2. were satisfied, I’d have a hard time justifying taking the time to do it if a trauma center/OR were within the hour.

A lot more other things I’d be working on first if I was on a battlefield or in the midst of an MCI.

Just because you CAN do something, doesn’t mean you SHOULD do something.

I’d also say that reducing any kind of fracture or dislocation can result in significantly worse outcome if you don’t know what precisely you’re doing. I would really only consider a traction splint for a closed femur fracture.

[Arctic1]

A lot more other things I’d be working on first if I was on a battlefield or in the midst of an MCI.

Completely agree.

[LowSpeed_HighDrag]

I had a proximal femur fracture (jagged break in half). Medics attempted to set it/splint it, talking about it being a hip dislocation. A few hours later, the real docs stated something to the effect of them causing more damage than good with their nonsense. Not sure how much that helps, but that was my painful experience.

[Gutshot_John]

@LowSpeed_HighDrag

I had a proximal femur fracture (jagged break in half). Medics attempted to set it/splint it, talking about it being a hip dislocation. A few hours later, the real docs stated something to the effect of them causing more damage than good with their nonsense. Not sure how much that helps, but that was my painful experience.

Sadly a not-uncommon mistake with those that don’t know any better.

I’m guessing one leg was shorter than the other and they didn’t pay attention to the rotation or lack thereof.

Did they try to use a traction splint?

[jknopp44]

@Hmac

Resetting any fracture in a civilian setting is a bad idea. I know all you guys have your fancy 20-lb IFAKs strapped to your rifle stocks, but resist. Just resist. Splint it so that the patient can be moved comfortably. If it’s a compound fracture, cover it…and get the patient to someone who knows what they’re doing.

Relieve pain? Give morphine. No morphine? Keep the patient still until the ambulance arrives with morphine. Restore blood supply? Sheesh. I recall a thread recently here of extensive mental masturbation where it was finally decided (I think) that we could apply tourniquets for hours on end without ill effect. So you have a kinked artery. What happens when your attempt at reduction lacerates that artery? (Wait…I know…apply a touriquet.)

Compound fractures are serious shit and the ability to screw them up vastly exceeds the ability of any first responder to improve anything. Leave them alone. What the patient needs above all else is X-rays, antibiotics, an orthopedic surgeon, an operating room, and someone who can drive an ambulance safely.

This subject has been beaten into submission IMHO.

Nothing more then this needs to be said… this is exactly what I would recommend… I am an Emergency Room attending at a trauma center…

[john58e]

I was an EMT back in the late 80’s, Two times in the field before transport came I set , or stretched a leg back . No one wants to be the one putting the leg back. With out pain meds. in and working there are some very tense moments , but pain is less with the leg is in traction and stretched back. Not out in the woods stuff. Every Bear in miles will hear the screams and smell a hot lunch. Be ready !

[Hmac]

We all did stupid stuff back in the 80’s. Thank god we know better now.

[Caduceus]

@Arctic1

Not really overthinking it, as much as trying to apply the advice given by Hmac for civilian care to a military setting. And as he pointed out, it doesn’t.

And I am aware of the treatment protocols, and like I said previously I won’t usually bother with fractures unless I am caring for the pt over an extended period of time.

I disagree; civilian care is essentially the same as military. I’d lean towards civilian EMS as “better” for this, since most medics/corpsmen don’t see many fractures . Nothing I said directly contradicts HMAC. The only difference between most military care and civilian is evac times (excluding, of course, MCI, active firefight, etc).

[LowSpeed_HighDrag]

@Gutshot_John

Sadly a not-uncommon mistake with those that don’t know any better.

I’m guessing one leg was shorter than the other and they didn’t pay attention to the rotation or lack thereof.

Did they try to use a traction splint?

On scene I have limited knowledge/memory of what they did. I want to say that I was in traction in the ambulance as I remember my foot elevated and a sever burning pain in my foot for some reason.

[Arctic1]

@Caduceus

I disagree; civilian care is essentially the same as military.

Without getting into a lengthy argument, I’ll just say that I disagree and that in my opinion TACMED is totally different from civilian medicine, with regards to situation, training/skill level, personnell and resources. It’s akin to a civilian health worker rejecting pediatrics on the premise that children are nothing more than miniature adults.

[Caduceus]

@Arctic1

Without getting into a lengthy argument, I’ll just say that I disagree and that in my opinion TACMED is totally different from civilian medicine, with regards to situation, training/skill level, personnell and resources. It’s akin to a civilian health worker rejecting pediatrics on the premise that children are nothing more than miniature adults.

We’ll have to agree to disagree. Priorities change (direct pressure vs TQ, evac times, care under fire), but physiology doesn’t. Blood goes around and around, air goes in and out, messing with either causes trouble. It’s not that the treatment or equipment is all that different, it’s just applied in a different order. Wilderness EMS is probably closer to TACMED, but overall you’re using a skillset to keep someone alive and prevent further injury.

[Hmac]

Physiology doesn’t change, but the very essence of prehospital care is defined by the environment and circumstances in which it’s provided.