# Ankle dislocation + distal fibula fx



## rhan101277 (May 13, 2014)

Had this the other day, just decided to lay in on a pillow and use some seat belts.  Fall from stairs, -loc, pain 6/10, pms intact.  No other trauma noted.  Just wanted to get some thoughts on splinting, I didn't believe there was much more I could do and it isn't often that I am splinting bones.  Also moving the patient further up the stretcher would have caused the foot to move more so I left in that position on the edge.  Pt seemed to tolerate, I did give 25mcg Fentany IN then 75 Fentanyl after I could establish IV access.


----------



## LondonMedic (May 13, 2014)

If it looked like that picture I'd by thinking about reducing it before transport because the skin over that mal looks pretty threatened. But, of course, that depends on your transport time.

Other than that, not much else you can do, resting on a pillow seems reasonable.


----------



## mycrofft (May 13, 2014)

I know reduction is not an EMT-Basic skill here since reduction requires radiology, sometimes muscle relaxant, and ride time maybe be under twenty minutes.
Is it a paramedic USA skill anywhere?


----------



## LondonMedic (May 13, 2014)

mycrofft said:


> I know reduction is not an EMT-Basic skill here since reduction requires radiology, sometimes muscle relaxant, and ride time maybe be under twenty minutes.
> Is it a paramedic USA skill anywhere?


Requires what now?

Having x-rays is nice, but it's not necessary and in the case of a time-critical ischemic limb it's absence shouldn't delay reduction.

I've never seen a fracture or fracture/dislocation (posterior shoulder dislocations are, however, an obvious exception) that requires muscle relaxant, I use a lot of sedation because it's easier and I'm nice like that, but if needs be you can do it with just some analgesia - I think Fent is ideal.


----------



## Tigger (May 13, 2014)

mycrofft said:


> I know reduction is not an EMT-Basic skill here since reduction requires radiology, sometimes muscle relaxant, and ride time maybe be under twenty minutes.
> Is it a paramedic USA skill anywhere?



It's an EMT level skill here if distal perfusion is compromised or extrication is impossible. 

Also most relocations do not require any sort of muscle relaxation, especially if done somewhat promptly. It's unfortunate that many simple dislocations cannot be reduced in the field as the longer they stay out, the harder it will be to reduce them. This of course is when relaxation is required, if not actual conscious sedation.


----------



## Anjel (May 13, 2014)

I've had two of these recently.  I used a pillow and tape both times. PMS was present so I wasn't worrying about reducing. 

The first patient received 200mcg of fent and the second got 20mg of morphine. 

Here are the X-rays from the first patient:


----------



## Medic Tim (May 13, 2014)

As long as there is distal perfusion I would pillow splint and treat the pain. I probably would have went with ketamine and added a benzo and or fentanyl as needed. (I have a long transport time)


----------



## mycrofft (May 13, 2014)

Ok.
…...


----------



## OnceAnEMT (May 13, 2014)

Would y'all vacuum splint if you had one available? 

I always heard as a Basic I get 1 shot to reduce. If its too much pain or fails to reduce, then just transport. Never talked about what to do if CMS was compromised. I'm sure that's on the protocol side of things.

That said, I'm curious how it works for ATs. I'll have to ask. Guess it just depends on the MD.


----------



## Tigger (May 13, 2014)

Grimes said:


> Would y'all vacuum splint if you had one available?
> 
> I always heard as a Basic I get 1 shot to reduce. If its too much pain or fails to reduce, then just transport. Never talked about what to do if CMS was compromised. I'm sure that's on the protocol side of things.
> 
> That said, I'm curious how it works for ATs. I'll have to ask. Guess it just depends on the MD.



Absolutely. I'd probably then put that on top of a pillow just to keep it from bouncing on a hard surface. That's the great thing about vacuum splints, they require little manipulation to get it on.


----------



## OnceAnEMT (May 13, 2014)

Tigger said:


> Absolutely. I'd probably then put that on top of a pillow just to keep it from bouncing on a hard surface. That's the great thing about vacuum splints, they require little manipulation to get it on.



Roger that, noted. Was wondering if I was about to start keeping a pillow in my AT gear  Y'all seemed to have a lot of faith in it, I've never used a pillow before. Certainly makes sense though.


----------



## rhan101277 (May 13, 2014)

We can reduce dislocations in the field but only when distal pulses are not felt.  Also I would be concerned about performing one with an associated fibula fx.


----------



## Tigger (May 14, 2014)

Grimes said:


> Roger that, noted. Was wondering if I was about to start keeping a pillow in my AT gear  Y'all seemed to have a lot of faith in it, I've never used a pillow before. Certainly makes sense though.



The thin about sports medicine is that if the vac splints come out a lot of times you aren't responsible for moving them...the ambulance crew is.


----------



## Akulahawk (May 14, 2014)

Grimes said:


> Roger that, noted. Was wondering if I was about to start keeping a pillow in my AT gear  Y'all seemed to have a lot of faith in it, I've never used a pillow before. Certainly makes sense though.





Tigger said:


> The thin about sports medicine is that if the vac splints come out a lot of times you aren't responsible for moving them...the ambulance crew is.



Not only that, but once you break out the vac splint, there's a chance you may never recover the splint... and if you do, it may not be functional.


----------



## the_negro_puppy (May 18, 2014)

Akulahawk said:


> Not only that, but once you break out the vac splint, there's a chance you may never recover the splint... and if you do, it may not be functional.



We have vac splints on all our trucks, so when we lose one at hospital / with a patient we just raid the stores area where the hospitals clean and return the splints. Sometimes we end up with splints labelled with stations across the other side of the state (if theyve been flown down), makes for an interesting collection. Luckily we have aservice that covers the whole state.


----------



## Household6 (May 18, 2014)

Reduction is an EMTB skill here, as long as there is no pedal pulse felt or circulation is compromised..

They say we get one chance to set it because the pt probably won't allow for a second attempt. I've never had to set one, I've always been able to find a pulse. I mark an X on the pulse location in pen. Pillows work great.

The most difficult thing I've come across is having to cut shoes off. Feet swell right away, and slip ons don't seem to slip off..


----------



## zmedic (Jun 3, 2014)

I would have actually taped the pillow around the ankle, otherwise you hit a bump and it would hurt a heck of a lot. Agree that if decreased CSMs you need to pull inline and try to reduce. 

In the ER i'd reduce it with propofol, after proper analgesia. More so they don't remember it than for muscle relaxation. For shoulder dislocations I inject the joint, try two or three methods for doing it without sedation, then they get propofol. Shoulders are one where preventing the patient from tensing up really helps the reduction.


----------



## Handsome Robb (Jun 3, 2014)

If CMS was compromised and we were further than 15-20 minutes out I'd try to reduce it after a fent/midaz cocktail. Only can try once per protocol though.

Otherwise splint in place if CMS is good, cryotherapy, pain management PRN and a nice smooth ride.


----------



## NomadicMedic (Jun 3, 2014)

Cryotherapy. Paramedic speak for an ice pack. 

Jeez. Really?


----------



## Handsome Robb (Jun 3, 2014)

Seemed easier to type since the phone spelled it for me 

With that said why not use proper medical terminology? With this push to be recognized as a profession and all?


----------



## NomadicMedic (Jun 3, 2014)

Well, because it's JUST an ice pack. 

I'm all about increasing education standards and working towards professional education... But let's just call an ice pack an ice pack.


----------



## Handsome Robb (Jun 3, 2014)

DEmedic said:


> Well, because it's JUST an ice pack.
> 
> I'm all about increasing education standards and working towards professional education... But let's just call an ice pack an ice pack.



Our ePCR software calls them "cold pack applied" in the flow chart. 

I guess cryotherapy would probably be a better term to describe the ice machine I have for my shoulder that circulates ice water through pads designed to fit on certain anatomical areas. 

Best. Thing. Ever. Post surgery haha


----------



## NomadicMedic (Jun 3, 2014)

Handsome Robb said:


> Our ePCR software calls them "cold pack applied"




Wait... It doesn't say "cryotherapy"?


----------



## Handsome Robb (Jun 3, 2014)

DEmedic said:


> Wait... It doesn't say "cryotherapy"?



I don't wanna hear it! There used to be "cryotherapy used" or "cold pack applied" but they decided the first one was too complex for some people and there were too many items in the drop down to begin with. 

I'm gonna call it cryotherapy from now on just cause it annoys you


----------



## Handsome Robb (Jun 3, 2014)

Nice sig by the way haha.


----------



## Tigger (Jun 4, 2014)

Handsome Robb said:


> Our ePCR software calls them "cold pack applied" in the flow chart.
> 
> I guess cryotherapy would probably be a better term to describe the ice machine I have for my shoulder that circulates ice water through pads designed to fit on certain anatomical areas.
> 
> Best. Thing. Ever. Post surgery haha



Sadly cryotherapy can be used to refer to just applying ice packs. Once got into an argument with a former boss about whether or not pressure was required, apparently not.

The GameReady is the best thing to happen to rehab and sports medicine, I'm assuming that's what you have?


----------



## Handsome Robb (Jun 4, 2014)

It's called the Cold Rush therapy system or something like that?


----------



## Akulahawk (Jun 4, 2014)

zmedic said:


> I would have actually taped the pillow around the ankle, otherwise you hit a bump and it would hurt a heck of a lot. Agree that if decreased CSMs you need to pull inline and try to reduce.
> 
> In the ER i'd reduce it with propofol, after proper analgesia. More so they don't remember it than for muscle relaxation.* For shoulder dislocations I inject the joint, try two or three methods for doing it without sedation, then they get propofol. Shoulders are one where preventing the patient from tensing up really helps the reduction*.


By the time the patient gets to see you, the window of opportunity to reduce without sedation is gone. With those, you have to reduce pretty much right away before muscular splinting occurs or you have to cause sufficient sedation and muscular relaxation to allow the reduction to happen relatively easily.


----------



## zmedic (Jun 5, 2014)

Akulahawk; said:
			
		

> By the time the patient gets to see you, the window of opportunity to reduce without sedation is gone. With those, you have to reduce pretty much right away before muscular splinting occurs or you have to cause sufficient sedation and muscular relaxation to allow the reduction to happen relatively easily.



It's harder the longer it goes, but I've had some good results with some prone positioning and scapular manipulation, some hanging with weights. Often these are patients with multiple previous dislocations and are pretty loose. But if it doesn't go easily it's sedation time.


----------



## Akulahawk (Jun 5, 2014)

zmedic said:


> It's harder the longer it goes, but I've had some good results with some prone positioning and scapular manipulation, some hanging with weights. *Often these are patients with multiple previous dislocations and are pretty loose*. But if it doesn't go easily it's sedation time.


And that's why the prone positioning, scapular manipulation with hanging weights works well in those patients. They're already loose and they know how things go. Of course with the first-time shoulder dislocations, you need to rule out fracture so...

But I'm glad you're willing to properly sedate patients to allow their musculature to relax enough to allow a relatively easy reduction. 

Incidentally, I have a textbook that should work quite well as a hanging weight, and I would imagine most students would have such a book on hand, or more correctly, at hand to use!


----------

