# discerning Sprain vs. Broken vs. Dislocated



## ryujinn (Nov 11, 2009)

Hello all,

I was just curious as to how you recognize a sprain vs. a break. To me, it's just hard to tell. Angle of rotation? Can you tell by their pain when you start touching it? Is there a point where you can tell by your application of pressure that it would be a break or a sprain? (of course aside from the obvious like a open fracture or such). Dislocation I'm sure if you'd see weird orientation or for example one shoulder uneven with the other because it popped out of its sockets, etc.

Or is it impossible to completely discern because we don't have x-rays on the field? But I guess I am just asking how can I measure the severity of a ankle/arm/etc. injury by just touch, asking questions, color, pulse, motor, sensory, etc.

Thank you for the tips! I look forward to hearing your responses.


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## Melclin (Nov 11, 2009)

You just listed all the ways you would evaluate it. You already know. ^_^

Unless its obvious, then its not. They will need an X-ray.

With most a lot of breaks and dislocations there is an obvious angle or length to the area, that makes you think, "Well that should be". 

Break mostly hurt more than sprains, for the most part, but everyone's different and pain is subjective. 

Numbness/Parasthesia is typically associated with a break rather than a strain.

Typically a sprain can be moved and stood on with discomfort. A break, however, will generally cause unbearable pain. 

Always a good idea to check the pedal and tibialis pulses with any injury to the legs.

That being said, none of what I have listed is definitive. Minor fractures to the tarsals might present like a sprain, but I don't know, I'm not orthopaedic surgeon, just don't go taking 'rules' like the above to be absolute.


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## Sarah (Nov 11, 2009)

Femur fx's-check for shortening and rotation.


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## mycrofft (Nov 11, 2009)

*Good ones.*

Following with a dustpan...
There are sprains, strains, dislocs and fx's. At the curb, in the living room or the field, note mech of injury for he folks at the ER.

Remember what my EMT instructor said, "Don't get on your radio telling me from the field about the tib fib spiral fracture or whatever, if it's broke, it's broke and you splint it" or some such. 

None will be harmed by judicious splinting. Most will do better with local cooling, but do not cause cold injuries (i.e., put cold sources under a splint or large obscuring bandage).
"Judicious splinting" means following your protocols, but remembering:
A. "Splinting where it lies", if effective and practicable for pt movement, is an example of "Do no harm". That damage is already done, splinting in the field is not treatment but preventing harm and alleviating pain while transporting.
B.  It is possible to splint so well that you cannot move the pt.
C. Padding, padding, padding. In fact, a beanbag or pillow with ties or ductape can be your best field splint for wrists and ankles and distal.
D. Distal S/S and c/o and "target fixation": Don't be so fixated on that fx stepoff that you miss the cold white foot or hand distal to it. What can you do about that? Make sure your splint has not turned into a TK from swelling or pt movement, etc.

Femurs will do best with traction splint all other factors being in favor of it (i.e., pelvis not fx and other injuries not impeding the application of straps needed to make the splint work, spinal and more-life threatening injuries being treated first).

Google "Ottawa Rules for Xray", especially wikipedia, for more on DDX for fx versus non-fx (actually, more aimed to let a doc know when to xray and when to maybe not xray).


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## Aidey (Nov 11, 2009)

mycrofft said:


> Femurs will do best with traction splint all other factors being in favor of it (i.e., pelvis not fx and other injuries not impeding the application of straps needed to make the splint work, spinal and more-life threatening injuries being treated first).



I just want to add that the last femur fracture I had got so much relief from the traction splint he refused IV pain meds. 

Ask the pt if they have broken a bone before, and how the current injury compares. While not definitive by any means, some people flat out know when something is broken. If I have a pt that has broken a bone before and tells me "I think it's broken" I tend to trust them on it.


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## mycrofft (Nov 11, 2009)

*Lookingat my sweepings above...*

It looks oxymoronic to refer to splinting and pt movement in one sentence.
I meant moving the pt from the scene.:blush:

Any of our bush medics have something to say about practical ortho DDX and movement off the beaten path?


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## VentMedic (Nov 11, 2009)

Aidey said:


> I just want to add that the last femur fracture I had got *so much relief* from the traction splint he *refused IV pain meds.*


 
I've noticed the word "refused" gets used alot in EMS and it usually follows with some negative meaning especially if used in medical documentation with will need to be explained further. 

When assessing for pain, there should be some quantifying or assessment system in place to allow for discision making based on patient need. The word "refused" should be reserved for the times a patient states they do not want a treatment or therapy that is ordered or warranted. However, if you are the one who believes the patient should take the pain medication and the patient "refuses", you should do adequate documentation as to why you felt the pain medication was necessary be it objective or subjective.


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## exodus (Nov 11, 2009)

VentMedic said:


> I've noticed the word "refused" gets used alot in EMS and it usually follows with some negative meaning especially if used in medical documentation with will need to be explained further.
> 
> When assessing for pain, there should be some quantifying or assessment system in place to allow for discision making based on patient need. The word "refused" should be reserved for the times a patient states they do not want a treatment or therapy that is ordered or warranted. However, if you are the one who believes the patient should take the pain medication and the patient "refuses", you should do adequate documentation as to why you felt the pain medication was necessary be it objective or subjective.



I would just put the pt declined IV meds.


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## Seaglass (Nov 11, 2009)

This one's pretty obvious, but since nobody's mentioned it, watch for deviation that happens between joints, instead of at them. 

Other than that, everyone's mentioned all the ways I know. You're not going to be able to tell pretty often. That's what hospitals are for.


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## JCampbell (Nov 11, 2009)

Maybe I'm wrong but we were taught not to make a field diagnosis, that is the hospitals job.  We are told that whether fracture or sprain: access PMS, splint according to protocols, access PMS again, and transport.


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## RyanMidd (Nov 11, 2009)

As long as you're trying to differential Dx sprains/strains and dislocations, look up 'subluxation' as well. I've encountered two (told after the fact), but I treated both as dislocations. I.E. splint it where it is, and ask them if they'd like some Ento.


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## Epi-do (Nov 11, 2009)

As someone who has broken multiple bones, and had more sprains/strains than I can count, you aren't always going to know what you are dealing with.  

I had a broken arm, just above the wrist when I was a kid that had no swelling or pain for the first couple days.  It wasn't until I put a substantial amount of stress on it that I had pain and swelling.  The doc was able to see where it was beginning to heal on the x-ray.

On the flip side, I had one sprain in particular that everyone, including the docs, were amazed wasn't broken.  It was much more painful than any of the breaks I have had.

Basically, if you suspect any sort of ortho-type injury, treat it appropriately.  The only way to know for sure when it isn't obvious is to get some imaging done.


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## Aidey (Nov 11, 2009)

VentMedic said:


> I've noticed the word "refused" gets used a lot in EMS and it usually follows with some negative meaning especially if used in medical documentation with will need to be explained further.
> 
> When assessing for pain, there should be some quantifying or assessment system in place to allow for decisions making based on patient need. The word "refused" should be reserved for the times a patient states they do not want a treatment or therapy that is ordered or warranted. However, if you are the one who believes the patient should take the pain medication and the patient "refuses", you should do adequate documentation as to why you felt the pain medication was necessary be it objective or subjective.




I'm going to take "warranted" as treatment that my protocol states a patient with a certain condition either should receive or is eligible to receive. So pain medication wouldn't be warranted in a patient with a bloody nose, but it would be with chest pain non-responsive to nitro/ASA/O2. Is that a fair interpretation of warranted or were you using it another way? (I don't mean that as snarky as it sounds, I'm asking seriously)

I can't remember verbatim what the pt said but I think refused is an accurate description in this case. I told him that as we got closer to the hospital the road was going to get rougher (it is REALLY bad near the hospital we were going to) and he was going to have to be moved when we got to the hospital and that pain medication could make things more comfortable for him. He said something like "I'm fine, I don't need anything, it really doesn't hurt at all anymore." 

The RN at the ED was surprised that he hadn't had anything, and right after I got done giving report she turned to the pt and asked him if he would like any pain medication and he again stated that he didn't want anything and was ok.


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## VentMedic (Nov 11, 2009)

Aidey said:


> I'm going to take "warranted" as treatment that my protocol states a patient with a certain condition either should receive or is eligible to receive. So pain medication wouldn't be warranted in a patient with a bloody nose, but it would be with chest pain non-responsive to nitro/ASA/O2. Is that a fair interpretation of warranted or were you using it another way? (I don't mean that as snarky as it sounds, I'm asking seriously)
> 
> I can't remember verbatim what the pt said but I think refused is an accurate description in this case. I told him that as we got closer to the hospital the road was going to get rougher (it is REALLY bad near the hospital we were going to) and he was going to have to be moved when we got to the hospital and that pain medication could make things more comfortable for him. He said something like "I'm fine, I don't need anything, it really doesn't hurt at all anymore."
> 
> The RN at the ED was surprised that he hadn't had anything, and right after I got done giving report she turned to the pt and asked him if he would like any pain medication and he again stated that he didn't want anything and was ok.


 

Was the patient informed that it was part of your protocols and that his stating "no" would be considered a "refusal" rather than a decline of something that really should be optional unless you see there is a reason to justify altered mental status? 

I have no issue with not giving pain medication but rather the terminology some in EMS use especially when the patient hasn't had a chance to read your protocols to know that they are "refusing" what you are directed to do. 

The same holds true when someone when a suspected sprained ankle is advised by EMS they can go by POV rather than ambulance. Yet, the EMT(P)s have the patient sign a "refusal of care" form.


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## mycrofft (Nov 11, 2009)

*But the crux is immobilize approprtiately and go.*

Refusal and refusal forms are tricky, a good form and training should guide you, a bad form and no training can put you and the pt in bantha dudu.

Plus, say the pt is refusing/declining a given aspect of tx but still requesting tranport. I've seen EMT's throw up their hands, but I've seen them explain to the pt that if measure abc isn't done the EMT would possibly cause more injury or pain, and the pt will go along on that basis.

A thread on refusals and refusal forms would seem appropriate. Where are our resident lawyers?


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## Akulahawk (Nov 13, 2009)

Another thread swerved from the original question... Given that we're discussing the sprain/dislocation/fracture injuries, the majority of them will be limb/joint injuries. Discerning sprains, dislocations, and fractures is just not something that _most_ field providers are ever taught. If you do know what to look for, know how to do the testing, and have experience doing those evaluations, then yes, you can discern pretty accurately whether or not your patient has a sprain, dislocation/subluxation, or a fracture.

As a Paramedic, will that knowledge change my field Tx? No. Paramedics aren't _allowed_ to do anything other than treat as if it's a fracture. In another field that I have significant training in, it would, in fact, change the Tx plan.


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## mycrofft (Nov 13, 2009)

*To really get off thread..*

Pragmatic basic prehospital EMS is supposed to be fairly simple, and we're going to dogpile a post once in a while (well, fairly frequently) because there _are_ that many of us on here once in a while and (shhhh) _it isn't rocket science_. 
I think folks should (and I do) report excremento like pinup pictures or uncivil responses, or send an IM to the poster. 

And three is five and five is four.<_<


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## Akulahawk (Nov 13, 2009)

The question still had not been answered... and I quote


ryujinn said:


> Hello all,
> 
> I was just curious as to how you recognize a sprain vs. a break. To me, it's just hard to tell.


My answer is: Generally as a field provider, you won't have to. With proper training and education, it _is_ possible to learn how to do it quite accurately. I do know how to do it. In my own personal experience, many Physicians do not know how to do this well. As a Paramedic, I can't do the testing necessary to confirm my evaluation. If I take that particular hat "off" (as in off-duty)... then yes, I can, and have, done precisely that.


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## VentMedic (Nov 13, 2009)

mycrofft said:


> Pragmatic basic prehospital EMS is supposed to be fairly simple, and we're going to dogpile a post once in a while (well, fairly frequently) because there _are_ that many of us on here once in a while and (shhhh) _it isn't rocket science_.
> I think folks should (and I do) report excremento like pinup pictures or uncivil responses, or send an IM to the poster.
> 
> And three is five and five is four.<_<


 
But why would one consider pain management to be so "off track" on a thread involving breaks and dislocations?  Just because some feel left out if their county or service does not allow for it does not mean it should be totally ignored and not discussed in fear of be scrutinized by someone who believes the laws of this forum are the Word.    Even EMT-Bs can provide some pain relief to the patient.


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## Aidey (Nov 13, 2009)

It wasn't turning into a discussion on pain management though, it was turning into a discussion on the semantics of the word "refusal". I ceased replying because of the fact that it was leading the thread off topic. Which this discussion is also doing.


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## Melclin (Nov 14, 2009)

Akulahawk said:


> The question still had not been answered... and I quote
> 
> My answer is: Generally as a field provider, you won't have to. With proper training and education, it _is_ possible to learn how to do it quite accurately. I do know how to do it. In my own personal experience, many Physicians do not know how to do this well. As a Paramedic, I can't do the testing necessary to confirm my evaluation. If I take that particular hat "off" (as in off-duty)... then yes, I can, and have, done precisely that.



The question was answered. You didn't say anything new. Given that a simple question has been succinctly answered it's not at all unreasonable for the conversation to expand beyond the original strict parameters, to a related and important topic.

That said, I don't really understand what Vent is talking about with the difference between refusal and declination. I assume its some American hyper-litigious BS, that I don't have to worry about. 

If a pt wants pain relief, then they'll get it, if they don't, then they won't (Assuming a legitimate cause of pain: clinical judgment and relevant documentation). The obvious extenuating circumstance being if their pain is so bad it's clouding their judgment. In which case I will relieve their pain enough to return them to what I judge, as a competent and well educated clinician, to be a state of sound mind. Document accordingly. What's the issue? Is it the difference between a pt asking for meds and you refusing, and you asking the pt if they want meds and them refusing?


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## Akulahawk (Nov 15, 2009)

Melclin said:


> The question was answered. You didn't say anything new. Given that a simple question has been succinctly answered it's not at all unreasonable for the conversation to expand beyond the original strict parameters, to a related and important topic.
> 
> That said, I don't really understand what Vent is talking about with the difference between refusal and declination. I assume its some American hyper-litigious BS, that I don't have to worry about.
> 
> If a pt wants pain relief, then they'll get it, if they don't, then they won't (Assuming a legitimate cause of pain: clinical judgment and relevant documentation). The obvious extenuating circumstance being if their pain is so bad it's clouding their judgment. In which case I will relieve their pain enough to return them to what I judge, as a competent and well educated clinician, to be a state of sound mind. Document accordingly. What's the issue? Is it the difference between a pt asking for meds and you refusing, and you asking the pt if they want meds and them refusing?


I didn't get into the specific ways to evaluate whether someone has a sprain or Fx because I'd have to basically re-write "the book", there isn't adequate space to do it here, and as a field EMS provider, you don't have to worry about it. Even if you DO get the book, read it cover to cover, and even take a class specifically for it... you still will need to have a LOT of practical experience before you develop the feel necessary to accurately grade the level of injury. Of course that's even after you've had a good course in Anatomy.

The lack of hands-on experience is what makes most physicians very poor (in my experience) at evaluating these injuries clinically. Thus, they send the patient out for image studies such as x-ray or MRI.

Of course I didn't post anything "new"... I was learning to do this 18 years ago, and it was "old" news back then!

In GENERAL, though, it does involve palpation of specific structures and stress testing in a number of different ways. This skillset is like intubating... it doesn't take all that long to learn, it takes a long time to master, and it's perishable.

I also don't see any difference between a patient refusing or declining to take any pain meds... it's the same thing. The patient was offered pain control and the patient decided not to use it. Documentation of that is easy. If the patient declines and you give it anyway... or the patient asks for it and YOU withhold (and you could have given it)... Those are different matters entirely.


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## VentMedic (Nov 15, 2009)

Akulahawk said:


> I also don't see any difference between a patient refusing or declining to take any pain meds... it's the same thing. The patient was offered pain control and the patient decided not to use it. Documentation of that is easy. If the patient declines and you give it anyway... or the patient asks for it and YOU withhold (and you could have given it)... Those are different matters entirely.


 
Negative documentation, patient rights and alternative options should have been covered in your paramedic class.  Don't wait until an attorney rips you a new hole to learn the difference.   If the patient is not fully aware that your protocols mandate that they must take what you are offering, it can not and should not be counted against them negatively.


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## mycrofft (Nov 16, 2009)

*Sorry been gone, like, at work.*

We covered the question about sprain versus fx. Only wrinkle I can guess might arise is if a poorly written protocol says "If fracturd do this, if sprained do that" becuase that bases action on diagnosis instead of upon signs and symptoms.

I deal with a LOT of refusals. Hrer is how it was explained to me:
1. The pt refuses specific items. If you make the pt specify you may find out what their problem is and resolve it you may find that you will be able to go ahead with your course of action.
2. If other actions can and should be taken for the pt's safety and comfort, they should not be witheld if they can be safely accomplished without the refused items. (i.e., if the pt refuses vitals or an exam, you can withold certain drugs due to "I can't give you narcs because they might be contraindicated"; that will fly. Refusal of a history would not be grounds to withold or reverse application of a clinically obvious need for a traction splint if you could exam the pt enough to determine NEED and SAFETY.  
3. The pt can change their mind.
4. The pt must *understand*.
5. Document their undestanding with a handwritten codacil to the standard form if it is inadequate, then have the pt sign the addendum.


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## triemal04 (Nov 16, 2009)

VentMedic said:


> Negative documentation, patient rights and alternative options should have been covered in your paramedic class.  Don't wait until an attorney rips you a new hole to learn the difference.   If *the patient is not fully aware that your protocols mandate that they must take what you are offering, it can not and should not be counted against them negatively*.


You really haven't worked outside a hospital in a very long time, if ever, have you?  Perhaps you should not comment on things that you no longer have any understanding of.

Not to speak for anyone else, but with an alert, informed pt who is capable of making informed decisions, I'm not "mandated" to give them anything; they can refuse whatever they want, whenever they want.  (as an aside, I haven't seen any of the previous posters mention anything about them being REQUIRED to give pn meds to pt's, just that they can.  chalk another one up for venty...:lol


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## mycrofft (Nov 16, 2009)

*Shin kicking again are we? Personally I'm switching to decaff.*

The response was to show we can be *liable* if we spring a trap on the pt by denying or withdrawing care because the pt does not accept it initially, or does not accept certain portions of it; the pt needs to be aware, and capable of understanding consequences. I can't deny care if the pt refuses part of the package, but I will withold care ("Step 2", say, adminsiter a drug) which may LIKELY do harm if a preliminary part of the care ("Step 1", such as vital signs or a list of current meds or allergies) is not done.

My response earlier was to show we are *ethically and morally* deficient if we use the "take it all or leave it all " approach without regard to actual necessity of each and every measure.

Once we are engaged with the pt (and in some states driving by engages you), you are *ethically, morally and often legally bound *to help them and to do no harm nor cause unnecessary suffering. This is part of the price we pay for the *privilige* of being a care provider of some sort.

Just imagine you are the pt and you say NO to part of the EMTs' approach, then they pack it up and drive off, or turn off the O2, stop the IV, or refuse to give meds because you won't do everything they say, or you are a little dazed or obtunded.


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## triemal04 (Nov 16, 2009)

mycrofft said:


> The response was to show you can be *liable* if you spring a trap on the pt by denying or withdrawing care because the pt does not accept it initially, or does not accept certain portions of it; the pt needs to be aware, and capable of understanding consequences. I can't deny care if the pt refuses part of the package, but I will withold care ("Step 2", say, adminsiter a drug) which may LIKELY do harm if a preliminary part of the care ("Step 1", such as vital signs or a list of current meds or allergies) is not done.



I don't disagree; that's where the "alert, informed pt who is capable of making informed decisions" comes into play.  Usually it's more of an issue when it's not a drug given for pn, but it happens with them too.  Regardless, if the pt is capable, it is still their decision.  Of course they can change their decision at any time (and telling them that is part of making them an "informed" pt) and I'll abide by it.

But, for the given situation (which isn't that rare really), I'll explain to the pt what I can do for them for pn management, explain how rough a ride it may be, and that they may not be able to immediately get pn meds on arrival at the hospital, and, if they still refuse, that they can change their mind whenever they want.  Some do, some don't.  Sometimes I repeatedly offer, sometimes I don't.  Any problem with that?


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## mycrofft (Nov 16, 2009)

*Problem immaterial. (Have none, anyway).*


But back to the original post, was I the only one who thought about the Ottawa Rules? Or did I remember to mention them?
Ah, well, same field tx, but an interesting subject if you want to know more.


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