Lisbon Fire Department Standard Operating Guidelines and Policies

– MUSCULOSKELETAL INJURIES

2. To apply manual stabilization and utilize appropriate splinting techniques

3. To determine the presence or absence of circulation, movement and sensation distal to the injury site

4. To restore normal circulation distal to injury sites whenever possible and appropriate, with one attempt to align with gentle traction before splinting

5. To reduce the potential of further injury to nerves, blood vessels and soft tissue surrounding the injury site

6. To reduce hemorrhage and pain at the injury site and thereby reduce and/or minimize the potential of injury related shock

1. 
   Control external bleeding, as needed
   
2. 
   Prevent further wound contamination and reduce the potential of subsequent infection by covering open wounds with a sterile dressing
   
3. 
   Assess circulation, movement and sensation (CMS) prior to and following splint application; loosen splint, if necessary, to regain pulse
   
4. 
   Prevent further injury and reduce pain by immobilizing the joint above and below the long bone injury
   
5. 
   Prevent further injury and reduce pain by immobilizing the bone above and below the joint injury
   
6. 
   Remove clothing from affected area prior to splinting
   
7. 
   Pad as appropriate to prevent pressure and discomfort to patient
   
8. 
   Consider application of cold packs to injury site to reduce swelling
   
9. 
   Always consider the Mechanism of Injury (MOI)
   
10. 
    Suspect cervical spine injury with significant MOI
    
11. 
    Consider shock and prevent/treat as appropriate: oxygen, patient positioning, maintenance of body temperature
    
12. 
    Use of commercial splints should be in accordance with manufacturer’s directions
    

2. Monitor patient closely for signs and symptoms of a pneumothorax

3. Stabilize chest wall injuries at the patient’s maximum point of exhalation

4. In injuries involving the shoulder girdle, it is important to immobilize the entire shoulder girdle

5. Immobilize in position found, or position where pulse is regained

1. Position forearm of injured side across chest, hand slightly elevated toward opposite shoulder and secure with roller bandage or sling and swathe

2. If using a sling and swathe, place triangular bandage under and over arm with point at elbow and two ends tied around patient’s neck. Knot should be to the side of the neck

4. Transport in sitting or semi-sitting position, if patient’s condition allows

1. Immediately apply manual stabilization of the flail segment

2. Secure the flail segment with a bulky dressing

3. Place patient in the supine position or on injured side while maintaining spinal immobilization as appropriate

4. Provide oxygen and assist ventilations as necessary

1. Check CMS distal to the injury.

2. Splint the arm and shoulder in position found, or the position where a distal pulse is regained. Pad void between arm and chest as appropriate

3. Wrap wide bandage around injured arm and body to serve as a swathe to pull shoulder back and secure injured arm to body

4. Recheck CMS distal to injury

1. Sling and Swathe method

a. Check CMS in the extremity on the injured side

b. Position the forearm of the injured side across the chest, hand slightly elevated toward opposite shoulder

d. Pin or tie pointed end to form a cup to support elbow

e. Leave fingers exposed to facilitate circulation check

f. Wrap wide bandage around injured arm and body as swathe to pull injured shoulder back and secure extremity to body

g. Recheck CMS in the extremity on the injured side

h. Transport in sitting or semi-sitting position, if patient’s condition permits

a. Check CMS in the extremity on the injured side

b. Begin bandage on top of injured shoulder and carry diagonally downward across shoulder blades to opposite armpit

c. Continue through and around armpit, over shoulder and down across shoulder blades to armpit on injured side

d. Proceed through armpit and up, over shoulder, to starting point

e. Repeat procedure for three or more additional turns, overlapping the preceding turn by one-third its width

f. Hold shoulders up and back with finished bandage, immobilizing fracture

g. Recheck CMS in the extremity on the injured side

h. Transport in sitting or semi-sitting position, if patient’s condition permits

1. Check CMS in the extremity on the injured side

2. Immobilize with sling and swathe as for clavicle fracture

3. Recheck CMS in the extremity on the injured side

4. Transport in sitting or semi-sitting position, if patient’s condition permits

2. Align severely angulated fractures with gentle traction unless resistance is felt

3. Do not attempt to replace protruding bone ends into the wound, if present

4. Injuries involving joints should be immobilized in the position found

5. Make one attempt to restore circulation distal to an injury site

6. Avoid applying pressure to the injury site, whenever possible

7. Remove jewelry from injured extremities, place hands in position of function

8. Transport patient in sitting or semi-sitting position, as patient’s condition permits

1. Check CMS distal to injury site

2. Stabilize manually proximal and distal to injury site

3. First EMT will straighten any severe angulation with gentle traction above and below the fracture site

5. Apply wrist sling and swathe to the injured arm to hold the arm in place, elevating the hand and immobilizing the shoulder

6. Recheck CMS distal to injury site

Slings should support the hand and wrist, but should not encompass the elbow

1. Check CMS distal to injury site

2. Stabilize manually proximal and distal to injury site

3. Immobilize elbow joint, upper arm and forearm with rigid splint

5. Recheck CMS distal to injury site

1. Check CMS distal to injury site

2. Stabilize manually proximal and distal to injury site

3. Place a rigid splint on the entire anterior aspect of the forearm to maintain alignment and secure in place

4. Wrap splint and forearm with bandage leaving finger tips exposed

5. Apply sling and swathe to keep elbow immobilized and hand pointing slightly upward toward opposite shoulder

6. Recheck CMS distal to injury site

1. Check CMS distal to injury site

2. Stabilize manually proximal and distal to injury site

3. Immobilize wrist with hand in position of function

4. Secure splint and forearm with bandage leaving wrist and finger tips exposed

5. Recheck CMS distal to injury site

1. Check CMS distal to injury site

2. Stabilize manually proximal and distal to injury site

3. Immobilize hand in position of function

4. Place a rigid splint on the entire anterior aspect of the forearm to maintain alignment and secure in place, leaving finger tips exposed

5. Keep hand elevated

6. Recheck CMS distal to injury site

2. Align severely angulated fractures with gentle traction unless resistance is felt

3. Do not attempt to replace protruding bone ends into the wound, if present

4. Injuries involving joints should be immobilized in the position found

5. Make one attempt to restore circulation distal to an injury site

6. Avoid applying pressure to the injury site, whenever possible

7. Watch for the development of hypovolemic shock due to internal hemorrhage associated with pelvic, hip and femur fractures

2. Immobilize legs by tying knees and ankles together with bandages, padding between thighs and knees, unless this increases patient’s pain

3. Lift and/or slide the patient as a unit on to a long spinal immobilization device or use orthopedic stretcher. DO NOT log roll patient

4. Flex the patient’s knees with pillows underneath for comfort, if possible, and secure patient to long spineboard or orthopedic stretcher

5. Recheck CMS in both lower extremities

1. Check CMS in both lower extremities

2. Lift and/or slide the patient as a unit onto a long spinal immobilization device or use an orthopedic stretcher. DO NOT log roll patient

3. Support the extremity in the position found using blankets, pillows or similar materials.

4. Secure the patient to the long spinal immobilization device

5. Recheck CMS in both lower extremities

TRACTION SPLINT (Hare style)

First EMT:

1. Take position at injured extremity out of the way of person applying splint

2. Check CMS distal to injury site

3. The ankle hitch may be applied at this time

4. Grasp and support the calf with one hand. With the other hand, grasp ankle, or ankle hitch strap, in preparation for lifting

5. Apply traction sufficient to stabilize the injured thigh until traction can be assumed by splint

1. Adjust the length of the splint by measuring against the length of the uninjured leg and lock securely in place

2. Position leg support straps on splint with two proximal to the knee, one distal to the knee and one just proximal to the ankle hitch

3. Release traction mechanism and extend traction strap

4. Position splint under injured extremity

5. Extend or attach heel stand to support splint

6. Verify the ischial pad is firmly against the ischial tuberosity

7. Firmly secure groin strap using care not to pinch the external genitalia

8. If not previously done, apply ankle hitch to patient’s ankle so as to maintain foot at right angle to leg when traction is applied

9. Attach traction mechanism to ankle hitch

10. Tighten traction mechanism until:

a. First EMT reports mechanical traction equals manual traction

b. Patient acknowledges pain relief

11. Readjust leg support straps if necessary with two proximal to the knee, one distal to the knee and one proximal to the ankle hitch

12. Secure leg support straps

13. Recheck CMS distal to injury site

14. Secure patient and splint to long spinal immobilization device

Do not place support strap over fracture site

1. Check CMS distal to injury site

2. Adjust length of splint

3. Slide groin strap under injured leg. NOTE: Splint may be applied to either the lateral or medial aspect of the leg

4. Secure the groin strap using sufficient padding to insure patient comfort

5. Estimate the size of the ankle and fold down the number of pads needed

6. Apply the ankle harness snugly around the patient’s ankle

7. Extend the inner shaft of the splint by holding the shaft lock in the open position and pulling the inner shaft out until the desired amount of traction, per manufacturer’s recommendations, is noted on the calibrated wheel

8. Apply the longest strap as high up on the thigh as possible

9. Apply the second longest strap as low as possible on the thigh

10. Apply the shortest strap over the ankle harness and lower leg

11. Apply figure eight strap around both ankles by slipping the strap under the ankles. Cross strap over the heel and secure buckle snugly

12. Recheck CMS distal to injury site

1. Check CMS distal to injury site

2. Apply ankle hitch tightly around the leg, slightly above the ankle

3. Tighten stirrup by pulling the green tabbed strap, until snug under patient’s heel

4. Apply upper thigh system by sliding the pronged portion of buckle under the leg, at the knee, and seesaw upward until positioned in groin area. Secure buckle

5. Cinch the groin strap until traction pole receptacle is positioned in line with the iliac crest

6. Extend the traction pole

7. Place traction pole along the lateral aspect of the injured leg, extending approximately eight (8) inches (one pole section) beyond the bottom of the foot

8. Insert pole end(s) into traction pole receptacle

9. Secure yellow elastic strap around knee

10. Place yellow tab end of blue cinch strap (located on ankle hitch) over the dart end of traction pole

11. Apply traction by pulling the red tab end of cinch strap until patient comfort improves

12. Apply upper (red) elastic strap and lower (green) elastic strap around patient’s leg and traction pole

13. Recheck CMS distal to injury site

1. Check CMS distal to injury site

2. Splint the knee in the position found

3. Immobilize knee joint with rigid splints

4. Recheck CMS distal to injury site

1. Check CMS distal to injury site

2. Stabilize manually proximal and distal to the injury site.

3. Immobilize with rigid splint(s)

4. Secure in place

5. Recheck CMS distal to injury site

When using board splints, apply one medial and one lateral to the leg

If using one board splint, apply to the posterior aspect of the leg

1. Check CMS distal to injury site

2. Stabilize manually proximal and distal to injury site

3. Immobilize with pillow, blanket, or appropriate commercial splinting device, leaving toes exposed

4. Elevate foot and ankle to reduce edema

5. Recheck CMS proximal and distal to injury site.