Treatment&Management

First Aid
 Check the airway, breathing and circulation.
 If there is bleeding, treat it first.
 Squeeze a main artery if necessary.
 Immobilize the leg.
 REST
 ICE
 COMPRESSION
 ELEVATION

REST
 Have the injured person lie down. Head slightly lower than the trunk or elevate the leg. Reduces the risk of fainting by increasing blood flow to the brain.
 Immobilize the limb using anything that can support like newspaper, tree branch etc. Make sling using any rope, tree root or your shoelaces.
 2 splint- 1 inner and 1 outer part
 Tie the limb together for additional support.
 Do not try to realign the bone

Compression
 Stop any bleeding. Apply pressure to the wound with a sterile bandage, a clean cloth or a clean piece of clothing.
 Maintain pressure until the bleeding stops. Hold continuous pressure for at least 20 minutes without looking to see if the bleeding has stopped.
 Don't remove the gauze or bandage. If the bleeding continues and seeps through the gauze or other material you are holding on the wound, don't remove it. Instead, add more absorbent material on top of it.
 Squeeze a main artery if necessary. Apply pressure to the artery delivering blood to the area of the wound. Pressure points of the leg are just behind the knee and in the groin. Squeeze the main artery.


First Aid (Leg Fracture)
Check for pulses to the end of the limb
►Bandage any wounds that are bleeding
►Place the uninjured leg immediately adjacent to the fractured leg
►If available, a wooden splint can be used instead
►Tie both legs together
►Use padding between the natural hollows of the legs and the splint
►Tie the ankles with a figure of eight bandage, first making sure the feet are even
►Place a narrow/broad fold bandage above and below the fracture and place other bandages as necessary
►Handle gently and check circulation before and after splinting. This can be done by either checking the pulse past the injury or comparing skin colour of injured limb to the uninjured limb

(Knee dislocation)
 First aider should be more concern about possible injury to the popliteal artery that located behind the knee joint (popliteal area). Because this artery supply the leg below the knee.
 Check the ankle pulse (posterior tibialis) and if pulse absent make attempt to realign the leg to restore blood circulation (once only)
 Do not try realign the leg if pulse present.


Shock management

Various signs and symptoms appear in a person experiencing shock:
 The skin is cool and clammy. It may appear pale or gray.
 The pulse is weak and rapid. Breathing may be slow and shallow, or hyperventilation (rapid or deep breathing) may occur. Blood pressure is below normal.
 The eyes lack luster and may seem to stare. Sometimes the pupils are dilated.
 The person may be conscious or unconscious. If conscious, the person may feel faint or be very weak or confused. Shock sometimes causes a person to become overly excited and anxious.

If you suspect shock, even if the person seems normal after an injury:

 Have the person lie down on his or her back with feet higher than the head. If raising the legs will cause pain or further injury, keep him or her flat. Keep the person still.
 Check for signs of circulation (breathing, coughing or movement). If absent, begin CPR.
 Keep the person warm and comfortable. Loosen belt(s) and tight clothing and cover the person with a blanket. Even if the person complains of thirst, give nothing by mouth.
 Turn the person on his or her side to prevent choking if the person vomits or bleeds from the mouth.
 Seek treatment for injuries, such as bleeding or broken bones.


Surgical Intervention

 Surgical treatment of limb-threatening injuries must start as soon as life-threatening condition has been managed. Best done within 6 hours of injury.
 Prevention of wound infection and surgical approach to high-energy limb trauma:
 wound extension
 wound excision
 skeletal stabilization
 muscle compartment release

Treatment of a leg injury depends on the x-ray findings
 Contusions and minor fractures
- ice compresses, elevation, and rest.
- Acetaminophen, aspirin, or an anti-inflammatory (ibuprofen) are helpful in the management of pain.
 Fractures that are displaced or angulated
◦ Realignment : closed / open

Closed realignment ( if it’s a displaced fracture)
 Manipulate the pieces back into their proper positions before applying a splint — a process called reduction.
 Muscle relaxant, a sedative or even a general anesthetic before this procedure is needed depending on the amount of pain and swelling

Open realignment
First of all, to relate it back to James’ condition… He has a COMPOUND fracture
◦ Exposed through a skin laceration
◦ Increased likelihood for bacterial contamination
◦ Usually requires aggressive wound cleansing
◦ Fixation needed!
◦ ***Antibiotics intravenously before and after the operation

What can/ should be done?
FIXATION
 Intramedullary
◦ Inserting a rod (intramedullary nail) into the center of the bone
◦ Rod secured with surgical screws
◦ Rod provide support while the fracture heals

• Plating
 Securing a plate
 screws into the bone
 keep it in proper position while it heals

 External (James’ case)
◦ Frame aligned on the outside of the leg
◦ Secured with surgical pins
◦ Keep bones from moving while healing takes place

• Casting
 Treat tibia shaft fractures IF the bones are in good alignment
 People who are not suitable for surgery
 *Long leg cast (covers knee and ankle) – provide support and stability

Why internal fixation?
 Allows shorter hospital stays
 Enables individuals to return to function earlier
 Reduces the incidence of nonunion (improper healing) & malunion (healing in improper position).

Before going on to post-operative, it’s important to take note of pre-operative procedure =)
 examine the injury with the patient under anesthesia
 understand fracture stability without causing pain to the patient
 begin with extensive irrigation and debridement of devitalized tissue and bone
 successful treatment of contaminated open tibial fractures include radical debridement of necrotic tissue, pulsed lavage of the area to remove bacteria, and prophylactic intravenous antibiotics

Post-operative
 Patient should be monitored in the postanesthesia care unit until stable
 patient's vital signs should be monitored repeatedly, with careful attention paid to any abnormalities
 Prognosis improve with early detection
 First postoperative day, the patient should be examined by the surgical team and a complete blood count should be obtained

Follow up
 Patient usually is seen in a clinic 2-3 days after discharge
 Radiographs are taken to view the reduction.
 If the reduced fracture is still properly positioned, the patient returns on a regular, less-frequent basis for radiographic and clinical examination of the leg
 Many tibial nails are not removed and may remain in the patient indefinitely
 Also, physical therapy after surgery is important to…
Help gain
◦ strength
◦ motion
◦ function

Possible Complication – Tetanus

Treatment
 Directed toward the treatment of muscle spasm, prevention of respiratory and metabolic complications, neutralization of circulating toxin to prevent the continued spread, and elimination of the source.
 Consider prophylactic intubation in all patients with moderate-to-severe clinical manifestations. Intubation and ventilation are required in 67% of patients
 Tetanus immune globulin (TIG) is recommended for treatment of tetanus. It help remove unbound tetanus toxin BUT cannot affect toxin bound to nerve endings
Medication
 Anticonvulsants
 Skeletal muscle relaxants
These agents can inhibit both monosynaptic and polysynaptic reflexes at spinal level, possibly by hyperpolarization of afferent terminals.
 Antitoxins
These agents are used to neutralize any toxin that has not reached the CNS.
 Antibiotics
Administer to patients with clinical tetanus. However, efficacy is questioned
 Neuromuscular blocking agents
These agents inhibit the transmission of nerve impulses at neuromuscular junctions of skeletal muscles and/or autonomic ganglia.

Alternative Treatment ?
 Calming herbs are often useful for relief of pain and tension.
 Cups of chamomile (Matricaria recutitca), catnip (Nepeta cataria), or lemon balm (Melissa officinalis) tea can be given freely for a calming effect.
 Fifteen drops of skullcap (Scutellaria lateriflora), St. John's wort (Hypericum perforatum), or valerian (Valeriana officinalis) tincture can be given every half hour as needed.
 A tea to encourage the bone tissue to knit and heal. (Refer to blog).
 Application of contrast hydrotherapy to foot below the area of the fracture can be used to assist healing by enhancing circulation.
 Contrast hydrotherapy uses an alternating series of hot and cold water applications.


References
 http://www.indiaparenting.com/raisingchild/data/raisingchild146.shtml
 http://www.mayoclinic.com/health/first-aid-fractures/FA00058
 http://www.mayoclinic.com/health/first-aid-severe-bleeding/FA00038
 http://www.mayoclinic.com/health/first-aid-shock/FA00056
 http://firstaid.webmd.com/tetanus-treatment
 http://findarticles.com/p/articles/mi_g2603/is_0003/ai_2603000373/pg_2/?tag=content;col1
 http://members.medscape.com/article/826304-treatment
 Book : First aid, CPR and AED by Alton L Thygerson
 http://emedicine.medscape.com/article/786414-treatment
 http://orthoinfo.aaos.org/topic.cfm?topic=A00196
 http://m.sooperarticles.com/health-fitness-articles/first-aid-articles/learn-first-aid-home-how-treat-fractures-wounds-poisons-38-more-6277.html
 http://m.sooperarticles.com/article-tags/broken-leg-treatment/p/2
 http://www.catzpti.com/tabid/8653/mid/13865/ContentPubID/762/ContentClassificationGroupID/-1/Default.aspx
 http://www.health-care-information.org/injuries/leg-injury-fractures-contusions.html
 http://www.ncbi.nlm.nih.gov/pubmed/12584901
 www.jortho.org/2007/4/1/e10/index.htm