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Extremity Conditions

On-field Management of Emergent and Urgent Extremity Conditions

Flinn, Scott D. MD

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Current Sports Medicine Reports: October 2006 - Volume 5 - Issue 5 - p 227-232
doi: 10.1097/01.CSMR.0000306420.85919.d5
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Abstract

Introduction

Athletes competing in sporting events are at risk for injuries to the extremities and the physician caring for these athletes in the field should be prepared to manage such injuries. General principles of management include evaluating to develop a field diagnosis, checking the neurovascular status distal to the injury, reducing the injury as appropriate using proper technique, immobilizing for pain control and to maintain neurovascular status, and appropriate referral for definitive diagnosis and treatment.

Reduction of injuries in the field using proper technique by a knowledgeable person is useful and sometimes necessary to attempt to prevent long-term sequelae. Radiographs are often impractical or unnecessary prior to reduction provided proper technique is applied. Usually, in-line traction is a safe reduction method, although some specific injuries require a particular technique. Care must be taken not induce neuro-vascular injury when reducing fractures. Open fractures should not be reduced in the field.

Certain injuries have specific complications that need to be treated or prevented. If the complications cannot be lessened, treatment should at the very least not make them worse. Complications include neurologic or vascular injuries, chronic instability, and chronic pain. If there is a neurologic or vascular injury, it may be relieved by reduction of the initial injury. Vascular compromise that persists warrants immediate vascular evaluation. Neurologic injuries that persist may resolve over time depending on the injury and are often treated with observation and physical therapy to prevent contractures. The acute injuries discussed in this article, their common complications, and preventive measures are listed in Table 1. The joint above and below the injury should be evaluated also, as pain may be referred or mask another injury.

Table 1
Table 1:
Acute extremity injuries, complications, and prevention

Splinting

The best pain control is stabilization. In general, splints should be well padded, longer than the injury they are splinting, and immobilize above and below the injury. Initial stabilization for shoulder, arm, and elbow injuries is usually accomplished with a sling and swath. If the sling one is using does not have a swath, any means to attach the sling to the chest may be used, including pins, buttons, and tape. More distally, splints can be made from various materials, including flexible metal encased in foam, air-containing devices, prefabricated braces, and padded plaster or fiberglass. Improvised field splints can be made with any rigid material such as wood, fiberglass, or plastic that is also padded appropriately and secured with whatever means possible (eg, duct tape). If no material is available, securing the injured leg to the contralateral leg may work. Injured fingers or toes should be splinted with padding between the digits. Buddy-tape fingers so that the pinkie and index fingers are not free-floating (ie, 2nd with 3rd, and 4th with 5th finger), not middle with ring finger. Femur fractures require a splint that can provide distal traction.

When covering an event, splints and the means to secure them should be either at the site or brought by the physician or other health care team member. In addition to stabilization, pain medication may also be indicated in the acute setting, especially for more severe injuries. However, pain medications do not substitute for adequate stabilization prior to transport. Once proper stabilization has occurred, the patient should be transported for definitive diagnosis and appropriate care.

This article reviews select urgent and emergent extremity injuries and their field management. Particular attention is paid to field diagnosis, complications associated with the injury, treatment options, and the potential morbidity. Although not a comprehensive review, this paper focuses on common injuries and those with well-known complications that may be prevented or alleviated.

Shoulder Dislocations

Glenohumeral dislocation is the most commonly seen dislocation in the emergency room [1••,2,3••]. Most shoulder dislocations are the result of the arm being abducted/externally rotated. Therefore, the humeral head slides anteriorly and inferiorly, sometimes taking part of the glenoid fossa with it'the bony Bankart lesion. The differential diagnosis includes shoulder subluxation, fracture of the clavicle, scapula, or humerus, and acromioclavicular (AC) separation. It is often possible to make a firm diagnosis in the field so that proper treatment may be rendered. Careful palpation should be performed along the bones to rule out fractures and AC separations. In contrast, humerus surgical neck fractures usually have swelling and erythema distal to the shoulder joint. A prominent acromion is seen with a shallow defect apparent where the humeral head usually resides. The athlete holds the arm at his or her side and may state that it felt like it “came out of joint” and the arm cannot be internally or externally rotated. First-time dislocators cannot reduce their own shoulder dislocations. Dislocation, a complete slippage of the humeral head out of the joint, is different than a subluxation, which is a partial slip out of the joint. In subluxers (and recurrent dislocators), the humeral head can slip back into place spontaneously or with little effort by the patient. This is an important distinction to make in the field because it often relates to the treatment options and prognosis, as subluxations generally incur much less tissue damage and fewer long-term problems than true dislocations. Another key test to perform in the field is to have the athlete attempt to touch the opposite shoulder with his or her affected arm. Because the humeral head is wedged anteriorly and inferiorly, the athlete will be unable to touch the opposite shoulder.

Once the field diagnosis has been made, complications should be looked for and treatment options considered. Complications of shoulder dislocation include entrapment of the axillary nerve and fracture of the greater tuberosity of the humerus [1••,2,3••,4]. To test for axillary nerve entrapment, sensation to the lateral shoulder should be compared with the contralateral side and documented. Palpation of the lateral humeral head with point tenderness suggests a greater tuberosity fracture.

The two treatment options are to splint and send for radiographs and treatment, or to perform a field reduction and then send the patient for radiographs and follow-up evaluation. There is some controversy as to whether or not to reduce the dislocation in the field. Reasons to do field reduction include the fact that it is much easier to relocate the shoulder before muscle spasm has set in, there is much faster resolution of the patient's pain and anxiety, and the procedure is low risk. If the patient is referred before reduction, there are multiple delays before reduction can be performed, including registration and administrative work, evaluation, radiographs, interpretation of films, administration of medication to facilitate the reduction (with the concomitant risk associated with the medication administration), and then the actual reduction procedure itself. Reasons to delay reduction until radiographs can be obtained include confirming the diagnosis and preventing complications. The most commonly cited complication and reason for not reducing in the field is to prevent a nondislocated fracture from becoming worse'namely a fracture of the humerus. The properly performed field evaluation can differentiate a humeral surgical neck or shaft fracture from a shoulder dislocation.

The other rare fracture that may be encountered is the humeral greater tuberosity fracture. Some fear that by attempting reduction, a nondisplaced humeral greater tuberosity fracture may become displaced by more than a centimeter, thereby necessitating surgery. However, the reduction of the shoulder actually helps to approximate the humeral head and the greater tuberosity [5]. Furthermore, a 5-year study in an emergency department with 190 dislocations analyzed showed that although 29% of patients did have an associated fracture with their dislocation, most were of the Hill-Sachs type. In all cases the emergency department reduction was successful and the associated fractures did not become operative lesions [3••]. Interestingly in the same study, 12% had neurologic deficits that persisted after reduction, but reduction caused no neurologic deficit. This is in keeping with most reported rates of neurologic deficit from glenohumeral dislocation. If reduction is performed in the field and it is found that there is an axillary nerve entrapment that persists after reduction, which is usually the case, this should be noted and appropriate follow-up care arranged with an orthopedic surgeon and/or neurologist.

There are numerous techniques for shoulder reduction described in the literature but most are focused on the clinic or emergency department and involve the use of equipment and/or medication [6,7]. I use a technique taught by Dr. John Aronen (former physician at the US Naval Academy) that involves just the patient, the physician, and the ground, making it useful in any situation, and is similar to a waterskiing motion (Fig. 1) [8]. The patient lies supine and lets the arm rest at his side. The affected axilla is padded with a shirt or other available means if possible. The provider then sits next to the patient on the ground with his unshod foot placed in the patient's axilla with same-sided hips touching (Fig. 1). Remembering that the dislocation is anterior and inferior, the provider grasps the patient's affected-side wrist, and keeping firm, steady traction (likened to pulling a worm out of the ground) slowly leans back and “water skis,” maintaining firm gentle traction with the hands on the wrist with the counter-traction provided by the foot in the axilla. This provides in-line traction. In a few minutes, especially if done immediately after the dislocation, the muscles relax and the humeral head releases and pops back into joint. The ease and simplicity of this technique make it ideal for the field environment and it can be used anywhere, anytime, without any support. I have used this technique for 16 years with 100% success, even when other techniques by other providers have failed.

Figure 1
Figure 1:
Water ski method for reducing shoulder dislocations. Note important points: foot in padded axilla for counter traction (A); patient and provider with hips touching (B); provider leaning back while grasping wrist to provide consistent pull (B).

Regardless of the technique employed, once the shoulder is relocated, the arm should be placed across the patient's chest and secured there for transport using a sling and swath or any other means that will prevent abduction/external rotations and a redislocation. Following reduction all patients should have radiographs and evaluation of their neurovascular status.

Acromioclavicular Separations

AC separations usually occur from a direct blow to the shoulder from landing on the ground. There is tenderness to palpation of the AC joint and often a deformity. Field treatment consist of a sling and swath and referral for further evaluation. Complications are rare for types I through III, whereas operative treatment is often needed for the uncommon types IV through VI to prevent long-term pain and weakness. Therefore, all patients with AC joint injuries should be referred for further radiographs and evaluation on a routine basis following field treatment.

Humerus Fractures

Fractures of the surgical neck occur commonly in the elderly, whereas midshaft fractures are more common in younger patients. The diagnosis is usually apparent with pain, swelling, and erythema at the fracture site. Field management consists of sling and swath and pain medication as needed for comfort. Rarely there is vascular compromise, but radial nerve involvement is not uncommon. Care should be taken to check and document radial nerve function prior to and after any manipulation and transport.

Elbow Dislocation

Posterior elbow dislocation often occurs from a fall on the out-stretched hand (FOOSH). It is the second most common dislocation and is common in children and young adults [9]. There is pain and obvious deformity. Reduction should be attempted as soon as possible and may be attempted in the field prior to radiographs. If the examination reveals no obvious fracture, quick field anesthesia may be obtained by injecting local anesthetic into the joint using sterile technique. If there is doubt, radiographs should be obtained prior to reduction. For field reduction, the patient's arm should be held at 45° of extension and slow steady traction applied downward in line with the humerus. As with shoulder relocations, after a few minutes of traction the muscles fatigue and the elbow snaps back into place. The range of motion should be checked to confirm relocation, taking care not to redislocate at extension. The elbow should then be splinted at no more than 90° of flexion with the forearm pronated and the patient referred for radiographs and further treatment as needed. Vascular problems can result following relocation so neurovascular function should be checked prior to transport [10].

Wrist Injuries

Wrist injuries commonly occur from FOOSH injuries and may have occult injuries that may be missed without careful examination and referral for further study and treatment. Two injuries in particular that must be looked for in the field to prevent long-term sequelae from an otherwise diagnosed “wrist sprain” are scaphoid fractures and ligamentous injuries.

Scaphoid fractures are the most common fracture in children over the age of 10 and are extremely common in the adult population [11]. A high index of suspicion and knowledge of the anatomy is necessary to evaluate patients and properly refer for further evaluation. The scaphoid bone is the most radial proximal carpal bone and can be easily palpated between the first and third dorsal compartments, the so-called “snuffbox.” With the patient actively extending the thumb, the tendons in these two compartments become pronounced and one can feel in between these two tendons to get a firm grip on the scaphoid (Fig. 2). Tenderness in the snuffbox on the scaphoid represents an injury that needs further radiographic evaluation and treatment. If only the tendons are tender, a scaphoid fracture is not likely and field management with splinting, ice, and anti-inflammatory drugs for pain may suffice. As the scaphoid is one of the most commonly mismanaged fractures in the emergency room, the field physician should be absolutely certain of the anatomy and examination if the patient is not going to be referred for further radiographs and treatment [1••].

Figure 2
Figure 2:
The snuffbox is easily palpated between the first and third compartments when the thumb is extended.

Ligament injuries to the wrist commonly involve the lunate bone and are often missed. The lunate bone is just ulnar from the scaphoid bone and third dorsal compartment. The common mechanism of injury is also the FOOSH. Tenderness in the lunate area, especially when the patient clenches the fist, indicates the possibility of a serious ligamentous injury to the lunate stabilizers. These patients should be splinted and referred for further radiographic and clinical assessment as chronic pain and instability often result from these injuries [1••].

Hand Injuries

The hand is a fascinatingly complex structure that can be injured in a number of ways. In general, the injured area should be evaluated for stability and possible fracture, reduced in the case of simple dislocations, splinted as appropriate, and the patient referred for radiographs and further assessment as needed. Splinting should be done in a position of comfort with a bulky dressing applied if needed for padding during transport. Certain injuries have long-term complications that should be actively evaluated for in athletic injuries to the hand. Among these are “gamekeeper's thumb” and disruptions of the tendons in the hand.

Gamekeeper's thumb is an injury to the ulnar collateral ligament (UCL) of the first metacarpal phalangeal (MCP) joint. The usual mechanism is a fall onto the hand and the patient notes thumb pain at the ulnar aspect of the MCP joint. Unlike many other injuries, when evaluating a patient with a sprained MCP joint, it is important not to valgus stress the joint prior to taking radiographs [12]. Occasionally the UCL also has a bony avulsion that may or may not be displaced. Valgus stressing may cause a nondisplaced nonoperative lesion to become an operative displaced lesion. Once the thumb is stabilized in the field, the patient should be transported for radiographs and further treatment as needed.

Finger injuries should be evaluated to ensure active range of motion (ROM) in the isolated proximal interphalangeal joint (PIP) and distal interphalangeal (DIP) joints. Inability to actively flex the DIP suggests a flexor digitorum profundus tear. Also known as a “jersey finger,” this tear will result in a loss of flexion and grip without prompt surgical repair. The finger should be splinted in flexion and referred. The flexor digitorum superficialis (FDS) tear at the PIP is more subtle to detect. An inability or decreased ability to flex the finger while the others are extended indicates a possible tear in the FDS and the patient should be referred for evaluation. An extensor tendon insertion tear at the DIP, also known as a “mallet finger,” is diagnosed by an inability to actively extend the isolated DIP. This injury should be splinted and the patient referred for radiographs and further treatment as a large (> one third) joint line fracture may result in a volar slip of the distal phalanx. Failure to properly treat this injury results in a chronic inability to extend the DIP, which can be particularly troublesome in the index and middle fingers. Ruptures of the central slip of the extensor hood may result in boutonniere deformity and likewise should be splinted and the patient referred for further evaluation [13].

Hip Dislocations

The hip is usually dislocated posteriorly as the result of a high-energy trauma. The patient is in pain and the hip is adducted and flexed. Neurologic status should be evaluated in all dermatomes as small branches of the sciatic nerve may be injured. Distal pulses should be evaluated. These injuries should be stabilized and transported as quickly as possible for radiographs and treatment as the risk of sciatic nerve injury and avascular necrosis of the femoral head increases with time to relocation [14]. Pain medicine may be needed en route as these injuries are somewhat difficult to stabilize during transport.

Femur Fractures

Midshaft femur fractures are usually associated with other high level trauma. An isolated femur fracture presents challenges in treatment in the field. Complications include neurovascular compromise and potential for fatal outcome in the near term from fat embolism or severe hemorrhage. The best method of immobilization is using a commercially available Hare, Kendrik, or Sager traction device. This enables the provider to put sufficient traction on the leg to overcome the muscles of the thigh, restore some alignment, decrease pain during transport, decrease bleeding, and sometimes restore neurovascular compromise. As with other gear used in field coverage, the provider should be familiar with the application of the particular device carried for femur fractures. If no splint is available, securing the affected leg to the contralateral one may be the only field splint to use. A study that examined the use of traction devices found that they were often difficult to use and that other means such as immobilizing in conjunction with a back board may be easier to accomplish and effective for transport [15].

Knee Dislocation

An unusual and painful injury, a knee dislocation occurs when at least three of the four major knee ligaments are disrupted, causing gross instability, with the anterior cruciate ligament and posterior cruciate ligament and a collateral ligament being torn [16]. The lower leg rotates and the athlete has an obvious deformity with the foot pointing in the wrong direction and the femoral condyles prominent under the skin. Sensation and distal pulses should be checked as often there is a vascular compromise [16,17]. Field reduction is usually indicated and is accomplished by supporting the femur and then slowly rotating the leg back into position. The leg is then firmly splinted and neurovascular status checked. Immediate transport and referral for vascular damage to the popliteal vessels is indicated as this can be a limb-threatening injury. Compartment syndrome may also occur.

Ankle Injuries

Ankle injuries are among the most common injuries in sports. Field evaluation should look specifically for signs of fracture and neurovascular compromise. The Ottawa rules for determining the need for radiographs of the ankle or foot following an ankle sprain are useful for determining if an otherwise nondeformed ankle needs routine radiographs. Although the utility of the Ottawa rules has sometimes been questioned, two recent studies looking at over 15,000 patients determined the rules to be extremely sensitive but not specific in the primary care setting, eliminating 30% to 40% of unnecessary radiographs while missing very few [18•,19]. The Ottawa ankle rules have also been validated for children over 2 years [20•]. The need for an ankle radiograph is determined by inability to ambulate four steps or pain to palpation in the posterior aspect of the medial or lateral malleolus. The Ottawa rules also apply to the foot. Foot radiographs are indicated if the patient is unable to ambulate four steps or has pain at the base of the fifth metatarsal or navicular bone. Otherwise, the patient may be safely splinted in the field and referred for routine care.

Foot injuries

In addition to the Ottawa foot rule described above, another injury that must be looked for is the midfoot sprain or fracture. Also known as the Lisfranc joint, the tarsal-metatarsal junction can be injured in athletic competition when the foot is axially loaded while planter flexed and rotated. Pain and swelling is distal to the ankle on the dorsal aspect at the tarsal metatarsal junction. This injury needs stabilization and urgent referral to prevent long-term consequences of instability and pain [1••,21].

Compartment Syndrome

It is unclear as to the incidence of compartment syndrome in the extremities following trauma but it can occur in the acute setting [1••]. Failure to properly diagnose and transport for definitive evaluation and treatment can have devastating consequences. Compartment syndrome occurs when the pressure inside a fascial compartment increases to the point where blood flow is compromised and tissue is damaged. This can occur from internal means, such as a fracture or blunt tissue damage, or from an external cause such as a cast applied too tightly or a burn eschar. Common traumatic causes are fractures of the tibia, humerus, and forearm, as well as crush injuries including those to the hands and feet [22]. The earliest sign is often pain out of proportion to the injury and the most reliable sign may be loss of sensation [23]. Passive range of motion is usually extremely painful. When there is a suspicion of a compartment syndrome in the field, emergent transport for further evaluation and treatment is mandatory to prevent tissue death and resulting sequelae including ischemic contractures.

Conclusions

Field management of urgent and emergent extremity conditions entails knowledge of some basic principles to follow and pitfalls to avoid. By properly evaluating the injury, determining a field diagnosis, then properly treating and referring the patient, preventable sequelae may be avoided.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

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    Details some of the most commonly missed orthopedic injuries seen in emergency rooms and how to avoid missing them. Excellent read.

    2. Quillen DM, Wuchner M, Hatch RL: Acute shoulder injuries.Am Fam Physician 2004, 70:1947–1954.
      3.•• Perron AD, Ingerski MS, Brady WJ, et al.: Acute complications associated with shoulder dislocation at an academic emergency department.J Emerg Med 2003, 24:141–145.

        Original research that showed that although there may be fractures associated with shoulder dislocations, none of them were made worse by reduction. Conversely, many were actually improved, thus suggesting that field reduction after proper field evaluation is safe.

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            Meta analysis showing that Ottawa rules do indeed work.

            19. Bachmann LM, Kolb E, Koller MT, et al.: Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review.BMJ 2003, 326:417–419.
              20.• Plint AC, Bulloch B, Osmond MH, et al.: Validation of the Ottawa ankle rules in children with ankle injuries.Acad Emerg Med 1999, 6:1005–1009.

                One of the sentinel studies allowing extrapolation of Ottawa rules to children, potentially saving unnecessary cost and radiation exposure to children with ankle sprains.

                21. Mullen JE, O'Malley MJ: Sprains--residual instability of subtalar, Lisfranc joints, and turf toe.Clin Sports Med 2004, 23:97–121.
                  22. Bednar DA: Post-traumatic compartment syndrome of the foot.Can J Surg 1991, 34:179–181.
                  23. Mars M, Hadley GP: Raised intracompartmental pressure and compartment syndromes.Injury 1998, 29:403–411.
                  © 2006 American College of Sports Medicine