Our country suffers from a significant percentage of preventable morbidity and mortality from musculoskeletal injuries.1Theseinjuries range from simple fractures to polytrauma including multisystem involvement. Quick initial assessment and immediate primary management provided to the patient at the injury site and after reaching health care setup by the primary care physician can significantly change the final outcome of these patients.2
Scene safetyPrimary care physician should ensure scene safety and safe access to the patient. He should be aware of potential violence and the possibility of a crime scene. One should follow standard precautions, putting on a minimum of gloves and eye protection. Scenes with multiple patients may require additional pairs of gloves in the event of tears. Number of patients should be quickly determined and need for additional resources such as utility services, fire department or additional ambulances should be assessed. The mechanism of injury may suggest the injury extent and type; consider the possibility that the patient may have internal bleeding.
Mechanism of InjuryObserve the scene and determine the mechanism of injury. The nature of the problem may not be readily apparent until more information is gathered. Falls, assaults, and motor vehicle crashes are common mechanisms in skeletal trauma. One should be alert for primary and secondary injuries. Spinal immobilization should be considered in any trauma patient with a high velocity mechanism of injury like motor vehicle accidents or fall from heinght.3
Form a General ImpressionImmediate threats to life should be identified and managed. 3 A rapid scan of the patient will help to identify and manage life threatening conditions. Patient’s level of consciousness should be assessed and if he is able to communicate, obtain the chief complaint and type of injury that occurred. A non-lethal orthopaedic injury should not distract the physician from the more important ABCs.Airway and BreathingEnsure the airway is open, clear, and self-maintained. Unresponsive patients will need the airway opened and maintained using a modified jaw-thrust man0euvre if a spinal injury is suspected. A patient with an altered level of consciousness may need emergency airway management; consider inserting a properly sized oropharyngeal or nasopharyngeal airway.4Evaluate the patient’s ventilatory status for rate and depth of breathing, and respiratory effort. Patients breathing at a rate of less than 12 breaths/min or more than 20 breaths/min may have inadequate breathing that requires assistance. Orthopaedic injuries are not common causes of breathing problems; if a breathing problem exists, assess the patient for other injuries. Continuously monitor the patient’s oxygen saturation levels and for additional signs of hypoxia. Administer high flow oxygen at 15 L/min, providing ventilatory support as needed.CirculationObserve skin colour and temperature. Assess capillary refill time; if greater than 2 seconds, treat aggressively for shock.5 Open fractures may cause bone ends to protrude through the skin and may result in life-threatening bleeding. If bleeding in an extremity is not controlled with a pressure dressing then a tourniquet may be applied. Fractures may cause internal bleeding leading to shock. Be alert for signs and symptoms. Evaluate the distal pulse rate, quality (strength), and rhythm. Tachycardia may be an early indicator of shock.Transport DecisionIf the patient has an airway or breathing problem, signs and symptoms of bleeding, or other life threats, manage them immediately and consider rapid transport, performing the secondary assessment en route to the specialized centre. Do not delay transport to perform a lengthy assessment
to desired length and shape to achieve immobilization. Adequate cotton padding is applied to part being splinted followed by application of splint and finally wrapping the bandage circumferentially around the limb accompanying splint. (Fig-1)POP splint or POP slab: Plaster of Paris can be used in the form of slab to provide splintage to injured limb instead of crammer wire. It provides better immobilization as there is minimal movement at injury site.POP bandage is first opened in form of layers. Usually 15 to 18 layers provide
sufficient strength. Length of slab is identified using opposite normal limb as guide. Cotton padding is wrapped around limb followed by applying the water soaked POP slab and finally wrapping the bandage circumferentially around limb. Excess water is rinsed from the slab before application.Thomas splint: Traction splints like Thomas splint are used to immobilize fractures of the femur. These types of splints use tension that’s created by pulling straps to place the bone in alignment. It consists of padded oval metal ring covered with soft leather to which attached outer and inner side bars, are of unequal length so that padded ring is set an angle of 120 to inner side bar. The diameter of padded ring is calculated by measuring oblique circumference of thigh at level of gluteal fold and adding 2 inches to it. Length of side bars is measured as distance from crotch to heel and adding 6 to 9 inches to it.Manual traction and alignment-In most situations, the injured area needs to be returned to as close to a normal anatomical position as possible. Usually, this is done by having one provider giving manual traction, applying tension to the affected extremity, to return fractured bone to a more normal position. This is to cut down on damage to the affected area and assist the effectiveness of the splint. Fractures of the humerus and forearm bones-After assessing motor function and alignment, splint the arm under the fractured area. For a fractured humerus, the splint should rest at the upper arm and span the length between the shoulder and elbow. For a fracture to the radius and/or ulna, the splint should rest under or along the forearm and span the length between the elbow and wrist. Use triangular bandages to make a sling (supporting the shoulder and arm).Reassess motor function after applying the splint. Tibia/fibula fractures-After assessing motor function and alignment, place a long leg splint under the affected leg. Immobilize above and below the fracture, and secure the foot in the neutral position.Pelvic fractures-The simplest way to immobilize pelvic fractures is to stabilize the patient’s lower legs. When using a sheet as a pelvic wrap, place the sheet around the patient’s pelvis, then gently stabilize the pelvis by pulling the two ends together. Then tie the two ends together. Open fractures-Fracture management begins after initial trauma survey and resuscitation is complete. Active bleeding should be controlled by direct pressure. Gross debris from wound should be removed and thoroughly wash the wound with copious amount of saline or running tap water and place sterile saline-soaked dressing on the wound. Early IV antibiotics should be initiated along with tetanus prophylaxis as indicated. Fracture should be gently aligned and kept in well padded splint.Compartment SyndromeIf compartment syndrome is suspected (pain out of proportion to the injury, pallor, decreased sensation, decreased power), splint the affected limb, keep it at or above the level of the heart, and transport immediately(9).Surgical intervention is required to manage this injury.AmputationEnsure that bleeding is controlled at the stump, using a tourniquet if necessary and if local protocols allow. Manage life threats first; do not focus only on trying to save an amputated part. If life threats are under control and if the amputation is complete, wrap the part in a sterile dressing and place it in a plastic bag. The bag containing the amputated part should be placed on top of ice (10).Transport the amputated part with the patient, but do not delay transport of a seriously injured patient to do so.