Limb and/or soft tissue injuries

Question 1

The general principles of relocating/realigning a dislocated joint/displaced fracture are:

Answer 1

ū Provide adequate analgesia.
ū Provide sedation or dissociation if required.
ū Apply sustained traction in the longitudinal direction of the limb.
ū Have an assistant provide counter-traction above the injury site.

Question 2

A patient should receive a recommendation to have an x-ray following an ankle or foot injury if any of the following from the Ottawa ankle/foot rules are present:

Answer 2

ū Bony tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus.
ū Bony tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus.
ū Bony tenderness at the base of the 5th metatarsal.
ū Bony tenderness over the navicular bone.
ū Inability to weight bear for four steps, both immediately and when being
assessed.

Question 3

Rupture of the Achilles tendon usually occurs

Answer 3

during exercise, is usually associated with sudden onset of sharp pain behind the ankle and the patient may have felt a ‘pop’. The pain associated with a complete rupture may not be severe.

Question 4

The ability to plantar flex (push down) the foot does not

Answer 4

rule out a ruptured Achilles tendon.

Question 5

calf squeeze test steps

Answer 5

ū Ask the patient to lie face down on a stretcher or bed, with their feet hanging off the end, and to relax.
ū Squeeze the unaffected calf muscle and observe the foot to plantar flex.
ū Squeeze the affected calf muscle and if the foot does not plantar flex the
Achilles tendon is ruptured.

Question 6

explain RICE

Answer 6

Rest is recommended for a day or two. After this, gentle mobilisation should occur provided this is not associated with worsening of symptoms. Prolonged rest delays recovery and increases loss of function. Recommend the patient regularly moves the affected area, for example gentle flexion and extension of the joint, and movement of fingers and toes.
ū Ice is recommended for significant pain. Ice (or a cold pack) should be applied for approximately 20 minutes and may be repeated approximately hourly. Do not apply ice or a cold pack directly to the skin as this may cause skin injury.
ū Compression is recommended for significant bruising or swelling, in the same way that we compress external bleeding.
ū Elevation is recommended for significant swelling for the first day or two, but should not interfere with gentle mobilisation and exercises as above.

Question 7

The patella dislocates to the lateral (outwards) aspect of the knee and this needs to be confirmed by

Answer 7

palpating it

Question 8

Relocation of the patella will usually be indicated by

Answer 8

ū Relief of pain, and
ū Return of a normal knee shape, and
ū Return of an improved range of motion of the knee joint.

Question 9

An
attempt to relocate a dislocated shoulder may occur provided:

Answer 9

a) The patient has had a previous dislocation of the same joint, and
b) The shoulder is dislocated anteriorly, and
c) There is no clear evidence of acromioclavicular joint dislocation, and
d) There is no clear evidence of a fracture involving the humerus, and
e) The dislocation is a result of malpositioning and/or a relatively minor force.

Question 10

To attempt relocation of a dislocated shoulder:

Answer 10

a) Administer fentanyl IV.
b) Administer low dose midazolam IV if required, provided the patient can
obey commands at all times.
c) Use either the Stimson or modified Kocher’s technique.
d) A maximum of two attempts may be made.
e) Place the arm in a sling post relocation.

Question 11

If the shoulder relocates:

Answer 11

a) Place the arm in a sling.
b) Recommend the patient keeps their arm in a sling, avoids using the arm
unnecessarily, and sees their GP within 48 hours.
c) Provide advice on taking analgesia. Regular paracetamol and/or an anti-
inflammatory (following advice on the packet instructions) is usually appropriate.

Question 12

Shoulder relocation is usually indicated by:

Answer 12

ū A palpable or audible clunk, and
ū Relief of pain, and
ū Return of a normal shoulder shape, and
ū Return of normal (or near normal) motion of the shoulder joint.

Question 13

steps of The modified Kocher’s technique for shoulder relocation

Answer 13

a) Bend the elbow to 90°.
b) Apply traction to the humerus and slowly externally rotate the arm until
resistance is felt (usually approximately 45°).
c) Slowly abduct the arm, as if to scratch the back of the head with the
patient’s hand.

Question 14

The Stimson technique steps for shoulder relocation

Answer 14

• Place the patient prone on the stretcher with their affected arm hanging down, ensuring the stretcher height is such that their arm does not touch the ground.
• Apply continuous downward traction on the hand or wrist for several minutes.
• Maintain traction and gently rotate (supinate) the hand and wrist outwards if the shoulder does not relocate after several minutes. Maintain this position for several minutes.
• Apply scapular rotation if the shoulder does not relocate after several minutes. Push the lower pole of the scapula (shoulder blade) towards the spine, whilst maintaining downward traction on the arm.

Question 15

how to relocate digits

Answer 15

Apply longitudinal traction until relocation occurs.

Question 16

If the digit relocates

Answer 16

Splint the digit to the adjacent digits.
An x-ray is always required as there is a high association with fracture. This is non-urgent, and may occur within 24 hours provided there are no signs of a compound fracture, and the digit is aligned with normal distal perfusion.

Question 17

An attempt to relocate/realign a dislocated or severely deformed wrist, elbow, knee or ankle joint should usually occur, particularly when there is impaired sensation or perfusion distal to the injury, unless

Answer 17

time to hospital is less than 15 mins

Question 18

A dislocated elbow is an emergency because it may be associated with

Answer 18

damage to the brachial artery or associated nerves.

Question 19

The presence or absence of fractures, including compound fractures, does not alter

Answer 19

the need to relocate/realign the ankle if clinically indicated, and the technique is the same.

Question 20

If midazolam or ketamine is being administered for relocation:

Answer 20

ū Routinely administer oxygen and task one person to continually monitor the patient’s SpO2, breathing and level of consciousness.
ū Have a manual ventilation bag and mask immediately available.
ū During midazolam administration the patient must be able to obey
commands at all times.
ū During ketamine administration the aim is to achieve a dissociated state.
This usually requires approximately 1 mg/kg of ketamine IV, up to a maximum of 100 mg.