| How
long has it been since you have splinted a bent knee due to a potential
or obvious fracture or dislocation? |
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Do
you really understand the seriousness of knee injuries?
It
is doubtful that somebody would die from a broken knee. However,
some literature suggests that 50% of knee injuries result in some
degree of neurovascular compromise.
There are quite a number of persons who have had their leg amputated
below the knee due to neurovascular compromise from a knee dislocation.
Patellar
dislocations, like the illustration to the right, are painful, but
generally benign. With the major vessels posterior to the knee joint
and the major nerve to the lateral side of the joint, neurovascular
compromise from a patellar dislocation is rare. It is the dislocation
of the knee joint itself that is most dangerous, followed by knee
fractures. |
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 |
In addition
to pain, the EMT books usually mention the possible compromise of
the popliteal artery from knee injuries. Running across the posterior
of the knee, the popliteal artery can be felt in the center of the
crease of the knee, and is a reliable pulse site. Obviously, joint
deformity due to fracture or dislocation is very possible, and the
potential for compressing or damaging the popliteal artery is very
real. Checking PMS (pulse, motor function & sensory function)
is essential in the assessment and ongoing assessment of any fracture.
|
| What
the textbooks and most other sources of medical literature fail to
mention is the peroneal nerve. The peroneal nerve runs across the
lateral (outside) of the knee joint, and supplies motor and sensory
function to the lower leg and foot. It is quite susceptible to injury
from pressure exerted on the lateral knee where the nerve crosses
the head of the fibula. Therefore, in the splinting process, care
should be taken to avoid excessive pressure at the head of the fibula,
and avoid movement of the knee joint itself. |
|
ASSESSMENT:
In assessing knee injuries, the primary symptom will be
pain. We have enough brothers & sisters in the department
that have had a torn ACL (Anterior Cruciate Ligament) from a knee
injury who can attest to the pain and disability of knee injury,
and pain from a torn ACL pales when compared to that of a knee dislocation.
Signs of knee injury include:
|
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- deformity
- swelling
- loss
of distal PMS
-
when the peroneal nerve is compromised, foot drop: The foot has
no muscle tone to maintain it in a neutral (level) or upward position.
- The
inability of the patient to wiggle their toes is another reliable
indicator of compromise of the peroneal nerve.
|
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| Emergency
Care for the injured knee: |
- Manually
stabilize the knee in the position found
- Expose
the knee – look for deformity and/or discoloration
- Assess
distal PMS. Remember, inability to wiggle the toes or
hold the foot in a horizontal position means the peroneal nerve
has been compromised to some degree.
- Splint
the knee, being careful to maintain effective manual
stabilization and not to cause any unnecessary movement of the
joint. Most knee fractures seem to be in a position of extension
or significantly flexed. Both positions are easily splinted. Other
angles of the knee may present splinting challenges and may require
repositioning of the joint.
- Reassess
distal PMS.
- Be
aware of any changes in position of the joint during patient care
or prior to your arrival (patient history). In the case of a dislocation
where the tibia is dislocated posteriorly, deformity may be minimal.
During the application of manual stabilization, the slightest
movement may cause the joint to pop back into place: THIS MUST
BE REPORTED TO THE RECEIVING HOSPITAL! What often happens is that
the popliteal artery is compromised when the joint goes back into
place, eliminating blood flow to the lower leg. So what seems
like a resolution (the joint going back into place) may actually
be a major complication of the injury. If the patient reports
that the knee was out of joint and went back in, splint the knee,
transport, and advise the hospital of what happened. Closely monitor
distal PMS frequently during treatment and transport.
- Consider
ALS for pain relief.
- Isolated
injury requiring pain relief is an indication for morphine
(Protocol pg 223). If the patient is in a lot of pain, especially
if the transport time is going to be long, ALS is a good idea.
If your patient is in an area inaccessible by ambulance or
off paved roads requiring a rough transport, morphine will
probably be necessary to provide some degree of patient comfort.
- If
any of the following contraindications are present, disregard
ALS if they are to be utilized for pain relief only:
- head
trauma
- undiagnosed
abdominal pain
- multiple
trauma
- COPD
with compromised respiratory effort
- hypotension
- sensitivity
to morphine, codeine or percodan
- ALS
dose for isolated trauma:
- 2-10
mg slow IVP in 1-2 mg/min increments until pain is relieved
up to a total of 10 mg. EMTP does not need to consult
to administer morphine for an isolated injury as long
as the patient has no contraindications. Medical consultation
is required if additional morphine is needed.
|
|
| Splinting
an Extended Knee: |
 |
The
method of using a single board posterior to the leg offers good support
and immobilization. It is important to be sure to fill the voids between
the leg and the splint. Even with the padded side of the board towards
the leg (!), the heel can still have really uncomfortable pressure.
|
A
solution is to use an 8”x10” dressing (5"x9"
works, too). Remove the dressing from the wrapper, but don't unfold
it.
Instead,
fold 1/3 of the pad lengthwise, and put the low part of the pad
under the heel, with the thicker part of the pad filling the void
proximal to the heel. |
 |
 |
This
serves 2 purposes very effectively: It fills the void and provides
cushioning for the heel, resulting in much greater patient comfort.
Try it! You can really feel the difference! |
| EMT
classes usually teach two methods of securing the foot to the board.
One is the old ARC sprained ankle bandage to secure the foot to the
board with a cravat. |
 |
 |
It
works, but it does have a strong potential for causing excessive movement
in order to get the cravat tight.
|
| A
better way is to wrap the foot & ankle using 6” gauze. Start
with one wrap around the board and lower leg just proximal to the
ankle. |
 |
| Then
bring the gauze up, under the arch of the foot, then over the instep,
and then down on the same side it started from. |
Then
take the gauze under the board, under the arch, over the instep,
and down. |
|
 |
 |
Repeat until the entire roll is used. If your patient has a very large
foot, use 2 rolls of 6” gauze.
It
is important to wrap in this sequence. If you were to wrap in the
opposite manner, over the instep and then under the arch, the gauze
will have a tenancy to pull the toe of the foot very uncomfortably
into an abnormal extended position, rather than maintain a relatively
comfortable neutral position.
This technique not only secures the foot firmly and comfortably to
the splint with minimal movement, it is also very effective to secure
the foot in a ‘boot-top’ fracture, a very unstable transverse
fracture of the tibia and fibula just above the ankle. |
|
After the foot is secured to the board, snugly wrap
the leg distal to proximal with 6” gauze nearly to the crotch,
advancing the gauze only about ½” with each wrap.
|
 |
 |
Be sure to pad behind the knee to support the joint.
DO
NOT use roller gauze as a filler or pad behind the knee: It will
result in pressure on the popliteal artery potentially occluding
blood flow to the lower leg. |
|
As
always, reassess PMS after securing the splint.
This
same splinting technique is also recommended for any potential fracture
of the lower leg as well as the extended knee.
|
|
 |
Take
a good look at the picture (left) of the ‘old’ (published
in the ARC First Aid book - 1948) method of splinting an extended
knee using 2 board splints placed laterally on the lower extremity
and secured with cravats. This method, still shown in current EMT
texts, is almost guaranteed to put pressure on the head of the fibula,
right where the peroneal nerve crosses it, and has a high potential
for compromising the peroneal nerve.
Note that the leg is not exposed and the patient is still
wearing a shoe! |
This
is NOT a good idea! |
|
| Splinting
a Flexed Knee: |
| For
the flexed knee, use 2 boards placed laterally on either side of the
leg and secured with cravats. Knowing what you know now, AVOID
the head of the fibula with your board placement. |
|
| Place
1 cravat over the center of a board splint. |
|
| Place
the splint against the patient’s leg, and flip a tail of the
cravat under the back of the knee and up over the top of the knee. |
|
| Put
the other board against the other side of the leg. The cravat should
be behind the knee without putting pressure on the back of the knee,
and across the top of both boards. |
|
 |
Tie
the 2 boards together with the cravat. |
 |
| With
another cravat, hold a short tail in one hand. |
 |
| With
the other hand, wrap the long tail of the cravat once around the thigh
and both boards... |
 |
| then
just around the 2 boards.... |
 |
| and
tie the tails tightly together. |
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| Move
the patient’s foot to a neutral position, and repeat the procedure
with a 3rd cravat distal to the patient’s knee. |
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| As
always, reassess distal pulses and motor and sensory function. |
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When the patient is on the ambulance cot, support the knee with a
pillow for comfort.
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|
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Remember,
extremity fractures are rarely a matter of life or death, but are
a common cause of disability, temporary AND permanent. If you, the
EMS provider, manage and immobilize knee fractures effectively, you
may do any or all of the following for your patient:
• Reduce pain
• Prevent a closed fracture from becoming an open one
• Prevent a permanent disability caused by mismanagement of
the injury
• Reduce the length of the patient’s temporary disability
The final three words to effective splinting:
practice,
practice, practice!
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COPYRIGHT
2004
MONTGOMERY COUNTY DIVISION
OF FIRE RESCUE SERVICES
MONTGOMERY COUNTY FIRE RESCUE TRAINING ACADEMY |
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