# CSMs for Open Fractures?



## Simusid (Sep 16, 2012)

[I'm reposting this from the EMS subreddit, which apparently doesn't get a lot of readership]

So you are dispatched to http://i.imgur.com/63xzp.png (caution - gore). Ultimately, I would apply a trauma dressing, pad and splint in place and transport. I'm BLS so obviously no pain management.

My question is how aggressively would you do CSMs here? I'd carefully take the shoe/sock off and try and find a pedal pulse (which I suck at btw), then ask to wiggle toes, then "can you feel this?" Wiggling toes is all I would ask... there's no reason to ask her to flex the ankle is there?

And suppose she can't wiggle toes or you can't get a pedal pulse? Would you try to reposition this injury and if so how would you approach it? traction or rotation?


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## DesertMedic66 (Sep 16, 2012)

Per what we teach at my college if it is an open fracture just keep it clean and splint in place. If there are distal pulses then great, if not then just make note of it and let the hospital know. 

The only time we realign a fractured bone is if it's a closed fracture on the bone and not the joint. Once again this is just how I learned it and what I have to teach at my college.

In the field setting and at the EMT level I would just ask her to wiggle her toes. Since muscles use bones as leverage to move the patient might not be able to flex or extend her ankle very much.


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## MSDeltaFlt (Sep 16, 2012)

I recently had a case just like this one.  Except it was the right lower extremity and it was completely out (the lateral aspect of the tibia was sticking out of the medial aspect of the ankle.  My thick gloves wouldn't let me feel a pedal pulse.  My pt also couldn't flex toes due to pain.  However, the foot was still warm, still the same color as the other foot, and the cap refill was 1 sec.  Not <2 sec.  One second.  Blanch a toe, let go, "1 one thousand", and back to pink.  To continuously monitor perfusion I put my pulse ox probe (if you're allowed) on a toe and maintained high SpO2 with good pleth waveform.


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## Simusid (Sep 16, 2012)

MSDeltaFlt said:


> To continuously monitor perfusion I put my pulse ox probe (if you're allowed) on a toe and maintained high SpO2 with good pleth waveform.



I would not have thought of that, but I'll remember it now! great idea!


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## Veneficus (Sep 16, 2012)

It is also common to check for a posterior tibial pulse as well.


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