Ankle dislocation + distal fibula fx

[rhan101277]

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]

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]

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]

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]

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]

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]

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]

Ok.
…...

 

[OnceAnEMT]

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]

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]

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]

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]

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]

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.

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]

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]

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]

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]

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]

Cryotherapy. Paramedic speak for an ice pack.

Jeez. Really?

 

[Handsome Robb]

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?