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Lesson Outlines Chapter 15 Lesson 15: Extremity Injuries Lesson Objectives After completing this lesson, participants should be able to: List signs of a possible bone fracture. Describe the care for a possible fracture. Describe the proper care for joint and muscle injuries. Describe the RICE (rest, ice, compression, and elevation) procedures for bone, joint, and muscle injuries. Points Extremity Injuries Injuries to the extremities are common because people are involved in active lifestyles that include sports and wilderness activities. Extremity Injury Assessment Look for signs and symptoms of fractures and dislocations. Examine the extremities, using D-O-T-S. Compare one extremity with the other to determine size and shape differences. Use the “rule of thirds” for extremity injuries. Consider the cause of injury (COI) when evaluating the possibility of a fracture and its location. Use the mnemonic CSM as a reminder to check for Circulation, Sensation, and Movement of fingers or toes. Types of Injuries Types of injuries to the extremities range from simple contusions to complex open fractures: o Contusions Bruising of tissue o Strains Muscles are stretched or torn o Sprains Involves the tearing or stretching of the joints, causing mild to severe damage to the ligaments and joint capsules o Tendinitis Inflammation of a tendon due to overuse o Fractures Breaks in bones that may or may not be accompanies by open wounds Care for Extremity Injuries 1 of 18 Lesson Outlines Chapter 15 Use the RICE procedure. Apply a splint to stabilize fractures and dislocations. RICE Procedure for Bone, Joint, and Muscle Injuries R = Rest. o Injuries heal faster if rested. o Rest means the victim does not use or move the injured part. I = Ice. o An ice pack should be applied to the area as soon as possible after the injury for 20 to 30 minutes every 2 or 3 hours during the first 24 to 48 hours. C = Compression. o Compressing an injured area squeezes fluid out of the injury site. o Compression limits the ability of the skin and of other tissues to expand and reduces internal bleeding. E = Elevation. o Gravity slows the return of blood to the heart from the lower parts of the body. o Elevating the injured area, in combination with ice and compression, limits circulation to that area, which in turn helps limit internal bleeding and minimize swelling. RICE Procedure R = Rest I = Ice C = Compression E = Elevation Shoulder Injuries Three bones come together at the shoulder: o The scapula o The clavicle o The humerus The shoulder is the most freely moveable joint in the body. Shoulder Dislocation A dislocation of the shoulder occurs when the bones of the shoulder come apart as a result of a blow or a particular movement. Shoulder dislocation is second only to finger dislocations. Recognizing Shoulder Dislocation In about 95% of shoulder dislocation, the victim holds the upper arm away from the body, supported by the uninjured arm. 2 of 18 Lesson Outlines Chapter 15 The dislocated arm cannot be brought across the chest wall to touch the opposite shoulder. Extreme pain in the shoulder area In a dislocation, the shoulder looks squared off, rather than rounded. An injury to the shoulder resulting in complete loss of function is more apt to be a dislocation than a fracture. The victim may describe a history of previous dislocations. Numbness or paralysis in the arm from pressure, pinching blood vessels or nerves Care for a Shoulder Dislocation Do not try to force, twist, or pull the shoulder back in place because it may cause bone, nerve or blood vessel injury. Place folded or rolled blankets or a pillow between the upper arm and the chest to support the arm. Apply an arm sling and swathe (binder). Apply an ice pack for 20 minutes. Seek immediate medical care. Clavicle Fracture Fractures of the clavicle (collarbone) are common and usually are the result of falling with the arm and hand outstretched. Most clavicle fractures (80%) occur in the middle third of the bone. Recognizing a Clavicle Fracture Usually the fracture is easy to detect because the clavicle lies immediately under the skin and a deformity can be seen. o The victim fell on an outstretched arm. o The victim received a direct blow to the clavicle or shoulder. o AND if the victim has: Severe pain over the injured area Been holding the injured arm against the chest with the uninjured arm to stabilize the injury Not moved the arm because of the pain Swelling Visible deformity Tenderness Dropped or drooped shoulder Bruising Care for a Clavicle Fracture Treat for shock. Apply arm sling and swathe. Apply an ice pack to the area for 20 minutes, three to four times during the next 24 hours. Seek immediate medical care. 3 of 18 Lesson Outlines Chapter 15 Contusions Direct blows cause contusions, or bruises, around the shoulder. Often called shoulder pointers, contusions of this type may cause severe discomfort. Recognizing Contusions Swelling Pain at the injury site Feeling of firmness when pressure is exerted on the shoulder Tenderness Discoloration under the skin (black and blue) Care for Contusions Apply an ice pack to the area for 20 minutes, three to four times during the first 24 hours. Place the arm in a sling and swathe. Tendinitis The general cause of tendonitis (inflammation) in the shoulder is continuous overuse or unusual use. o Repeated movement often results in painful shoulders o Examples include throwing sports and swimming Recognizing Tendinitis Constant pain or pain with motion of the shoulder Limited motion of the shoulder “Crackling” sounds when the joint is moved Tenderness over the area Care for Teninitis Use an ice massage for 10 minutes before and after exercise. Use a sling and swathe to rest the shoulder. Use pain medication such as ibuprofen. Seek medical advice if needed. Humerus Fracture The shaft of the humerus (upper arm) can be felt throughout its entire length along the inner side of the upper arm. Recognizing a Humerus Fracture The victim received a: o Direct blow to the area o Twist and feel on the outstretched arm AND any one or a combination of these occurred: 4 of 18 Lesson Outlines o o o o o o Chapter 15 Severe pain Swelling Visible deformity Tender if touched May be unable to move the arm Will hold the arm against the chest for comfort Care for a Humerus Fracture Treat for shock. Apply an ice pack for 20 minutes Stabilize the arm by applying one rigid splint on the part of the arm away from the body. Seek immediate medical care. Elbow Injuries Elbow Fractures and Dislocations o All elbow fractures and dislocations should be considered serious and treated with extreme care. o Inappropriate care can result in injury to the nearby nerves and blood vessels. Recognizing Elbow Fractures and Dislocations Immediate swelling Severe pain Possible visible deformity; compare it with the uninjured elbow Restricted, painful motion Numbness or coldness of the hand and fingers below the elbow Care for Elbow Fractures and Dislocations Do not move the elbow. Treat for shock. Splint the elbow in the position found in order to prevent nerve and blood vessel damage: o If straight, keep the splinted elbow straight o If bent, keep the elbow bent Apply an ice pack for 20 minutes. Seek immediate medical care. Tennis Elbow Tennis elbow results from sharp, quick twists of the wrist (not just from playing tennis). It is an inflammation of the tendons on this outer side of the elbow o Can be very painful whenever the wrist and the elbow are used 5 of 18 Lesson Outlines Chapter 15 Recognizing Tennis Elbow Pain increases while using the arm Causes gradual grip weakness The injured elbow fatigues quicker than normal Very tender on outer protrusion of elbow Care for Tennis Elbow Apply heat before an activity; the victim might wear a brace or rubber sleeve on the sore elbow. Apply an ice pack for 20 minutes after completion of the activity. Seek medical advice for appropriate rehabilitation program. Golfer’s Elbow Repetitive motion produces pain. This injury is the equivalent of the more common tennis elbow but with pain on the inside of the elbow. It is tendonitis affecting the tendons attached to the bony protrusion. Recognizing Golfer’s Elbow Pain increases while using the arm Causes gradual grip weakness The injured elbow fatigues quicker than normal. Care for Golfer’s Elbow Apply heat before an activity; the victim might wear a brace or rubber sleeve on the sore elbow. Apply an ice pack for 20 minutes after completion of the activity. Seek medical advice for appropriate rehabilitation program. Radius and Ulna Fractures The radius and ulna are the two large bones in the forearm, and either or both may be broken. When only one bone is broken, the other acts as a splint and there may be little or no deformity. When both these bones are broken, the arm usually appears deformed. Recognizing Radius and Ulna Fractures The victim has pain in the forearm or wrist from: o A direct blow o Falling on an outstretched hand AND has: o A visible deformity o Severe pain radiating up and down from the injury site o An inability to move the wrist or it is painful while moving the wrist 6 of 18 Lesson Outlines Chapter 15 OR o The wrist is painful on the thumb side and pain continues into next day. Care for Radius and Ulna Fractures Treat for shock. Apply an ice pack to the area for 20 minutes. Apply tow rigid splints on both sides of the arm from the tip of the elbow to the fingers. o Place the arm in a sling and swathe with the hand in a thumb-up position. Seek medical care. Wrist Fracture The wrist is usually broken when the victim falls with the arm and hand outstretched. Recognizing a Wrist Fracture Injury to the wrist associated with a snapping or popping sensation within the wrist Pain in the wrist that is aggravated by movement Tenderness Swelling Unable or unwilling to move the wrist Lump-like deformity on the back of the wrist Care for a Wrist Fracture Use the RICE procedures. Stabilize the wrist with a splint. Seek medical care. Hand Injuries—Crushed Hand The hand may be fractured by a direct blow or by a crushing injury. Recognizing a crushed hand o Pain o Swelling o Loss of motion o Open wounds o Broken bones Care for a Crushed Hand Control the bleeding. Apply an ice pack for 20 minutes. Seek medical care. Finger Injuries 7 of 18 Lesson Outlines Chapter 15 The three bones that make up each finger are the most commonly broken bones in the body. Many of the tendons attached to the finger bones can tear with or without a fracture and the three joints can also be injured. A so-called finger sprain may be a complicated fracture or dislocation. Finger Fracture Contrary to popular belief, broken bones—especially the fingers—can move when they are broken. Recognizing Finger Fractures The finger or thumb has: o A visible deformity; finger has a twisted look o Immediate pain and hurts with or without movement o Numbness o Swelling o Pinpointed tenderness that usually indicates a fracture Test for a finger fracture: o If possible, straighten the fingers and place them on a hard surface. o Tap the tip of the injured finger toward the hand. Pain lower down in the finger or into the hand can indicate a fracture. Care for Finger Fractures Do not try to realign the finger. Gently apply an ice pack. Splint the finger by either: o Buddy taping the fractured finger to another for support. o Keeping the hand and fingers in the position of function with extra padding in the palm. Secure the hand, fingers, and arm to a rigid splint. Seek medical care. Finger Dislocation Finger dislocations are common. The same causes of fractured fingers can also cause a dislocated finger. Recognizing Finger Dislocation The finger or thumb has: o A visible deformity o Immediate pain o Swelling o Shortening of the finger o May be unable to bend the finger in the injured area; motion is impossible Care for Finger Dislocation Do not try to realign the dislocation. Apply an ice pack 8 of 18 Lesson Outlines Chapter 15 If possible, splint the finger by either: o Buddy taping o Keeping the hand and fingers in the position of function with extra padding in the palm. Seek medical care. Sprained Finger The upper joints of the fingers have a ligament on each side of the joint. Recognizing a Sprained Finger The finger or thumb has been: o Jammed, or compressed o Stepped on o Forced or twisted sideways And the victim: o Has pain and swelling over a joint—especially tenderness on both sides of a joint o Is unable to make a fist o Has a weakness while curling the injured finger alone o Experiences a weakness or pain when gripping Care for a Sprained Finger Apply an ice pack for 20 minutes. Reevaluate after the ice pack application and seek medical care if pain and weakness exist. Tape fingers with buddy taping. Nail Avulsion An injury in which a nail is partly or completely torn loose is known as a nail avulsion. Recognizing a nail avulsion o The nail may be completely detached or partially held in place by the skin. Care for a Nail Avulsion Secure the damaged nail in place with an adhesive bandage. If part or all of the nail has been completely torn away, apply antibiotic ointment. Secure a partly torn loose nail with an adhesive bandage. Do not trim away the loose nail. o Consult a physician for further advice. Splinters Sharp splinters can be impaled into the skin or under a fingernail or toenail. Recognizing splinters o There is a small puncture wound. o The sliver may be seen or in other cases, not seen nor can it be felt. 9 of 18 Lesson Outlines Chapter 15 Care for Splinters If embedded in the skin, use tweezers to remove it. o You may need to tease it out with a sterile needle until the end can be grasped with tweezers or fingers. Clean the wound with soap and water. If the splinter is impaled under a fingernail or toenail and breaks off flush, cut a V-shaped notch in the nail to gain access to the splinter. o Remove the embedded splinter by grasping its end with tweezers. Blood Under a Nail Blood collects under a fingernail when underlying tissues are bruised. Recognizing blood under a nail o Excruciating pain exists because of the pressure of the blood pushing against the nail. o Pain does not disappear until the collection of blood is drained. Care for Blood Under a Nail Immerse the finger in ice water or apply an ice pack with the hand elevated to reduce pain and swelling. Relieve the pressure under the injured nail by using one or more of the following methods: o Straighten the end of a metal paper clip or use the blunt end of a sewing needle. Hold the paper clip or needle with pliers, and use a match or cigarette lighter to heat it until the metal is read hot. Press the glowing end of the paper clip or needle against the nail so it melts through. Little pressure is needed. o By using a rotary action, carefully drill through the nail with sharp point of a knife. o Apply a dressing to absorb the blood and protect the nail. Ring Strangulation Ring strangulation can be a serious problem if it cuts off the blood supply long enough. o Permanent damage may result within 4 or 5 hours. Recognizing ring strangulation o The ring has become tight on the finger after an injury or other cause of swelling such as a bee sting. Care for Ring Strangulation Try one or more of the following to remove a ring: o Lubricate the finger with oil, butter, or some other slippery substance, and try to remove the ring. o Immerse the finger in cold water or apply an ice pack for several minutes to reduce swelling. 10 of 18 Lesson Outlines Chapter 15 o Liberally spray window cleaner onto the finger, and try to remove the ring. o Massage the finger from the tip toward the hand to move the swelling; lubricate the finger again. o Cut the narrowest part of the ring with a ring saw, hacksaw, or jeweler’s saw, taking care to protect the exposed parts of the finger. Hip-Joint Injuries Hip Dislocation o A hip can be dislocated by a fall, a blow to the thigh, or direct force to the foot or knee. o Often a hip is dislocated when the knee strikes the dashboard during a motor vehicle crash. It is difficult to differentiate a hip dislocation from a hip fracture. Recognizing Hip Dislocation Severe pain at the injury site Swelling at the injury site Hip is flexed and the knee bent and rotated inward toward the opposite hip Injury usually quite visible Care for Hip Dislocation Treat for shock. Stabilize the injury Check for an ankle pulse (posterior tibial). Seek medical care. o This injury is best transported by EMS. Hip Fracture A hip fracture is a fracture of the upper end of the femur (thighbone), not the pelvis. A fractured hip is usually caused by a fall. Elderly people, especially women, are susceptible to this type of injury because of brittle bones (osteoporosis). Recognizing a Hip Fracture Severe pain in the groin area Inability to lift the leg Leg may appear shortened and be rotated with the toes pointing abnormally outward Care for a Hip Fracture Treat for shock. Stabilize the injured leg against movement. Monitor the ankle pulse. Seek immediate medical care. 11 of 18 Lesson Outlines Chapter 15 o This injury is best transported by the EMS. Thigh Injuries Femur fracture Muscle contusion Muscle strain Femur Fractures Because the femur is the largest bone in the body, considerable force is required to break it. Femur injuries can occur in any part of the femur, from the hip to just above the knee joint. A fracture of the femur is usually caused by a fall or a direct blow. Femur fractures often include open wounds and external bleeding may be severe. Recognizing a Femur Fracture Severe pain at the injury site Deformity may occur. o The leg may appear shorter. Swelling comes from severe damage to blood vessels. Victim may report having heard or felt a severe pop or snap at the time of the injury. Care for a Femur Fracture Treat for shock. Cover a wound with s sterile dressing. Stabilize the injured leg against movement. Monitor the ankle pulse. Seek immediate medical care. o This injury is best transported by the EMS. Muscle Contusion The muscle group on the front of the thigh is the quadriceps group and often gets bruised. Depending on the force of impact and muscles involved, the contusion may be of varying degrees of severity. Recognizing a Muscle Contusion The victim received a direct hit producing: o Swelling o Pain and tenderness o Tightness or firmness of site when pressed o Visible bruise that may appear hours later 12 of 18 Lesson Outlines Chapter 15 Care for a Muscle Contusion Follow the RICE procedures. o Apply an ice pack for 20 minutes, three to four times daily for the next 48 hours. Stretch the muscle by bending the knee toward the victim’s chest. Muscle Strain When a muscle is overstretched, it can result in a tear, called a strain. Difference degrees of strains occur, but first aiders will be unable to determine their degree. Recognizing a Muscle Strain While running or jumping the victim: o Feels a pop or pulling sensation And later has: o Tenderness o Stiffness and pain during movement o Swelling o A visible bruise appearing days later Care for a Muscle Strain Follow RICE procedures. o Apply an ice pack for 20 minutes, three to four times daily for the next 48 hours. Stretch the muscle but do not force stretching. Knee Injuries Knee injuries are among the most serious joint injuries. Their severity is difficult to determine, thus medical care is necessary if the injury is from being hit or twisted and not from overuse. Knee Fracture A fracture of the knee generally occurs as a result of a fall or a direct blow. Fractures about the knee may occur at the end of the femur, at the end of the tibia, or in the knee cap. Recognizing a Knee Fracture Determining if a fracture exists is difficult. Some fractured knees may look like a dislocation. Other signs include: o Deformity o Tenderness o Swelling 13 of 18 Lesson Outlines Chapter 15 Care for a Knee Fracture If a pulse can be felt in the ankle with no deformity, splint the leg with the knee straight. If a pulse can be felt in the ankle with significant deformity, splint the knee in the position found. Seek medical care. o However if a pulse is absent in the ankle, immediately seek medical care. Knee Dislocation A knee dislocation is a serious injury. Recognizing a knee dislocation o Excruciating pain o Deformity o Pulse may be absent in the ankle o Do not confuse a knee dislocation with a patella dislocation. Care for a Knee Dislocation Stabilize the knee in the position found. Seek medical care immediately. Patella Dislocation A dislocated patella can be a very painful injury and must be treated immediately. Some people have repeated kneecap dislocation, just as others have a tendency for shoulder dislocations. A dislocated patella most commonly occurs in teenagers and young adults who are engage in athletic activities. Recognizing a Patella Dislocation A blow or twisting cause the kneecap to be moved outside of the knee joint and there is: o Possible swelling o An inability to bend or straighten the knee o Pain o Deformity; compare with other kneecap Care for a Patella Dislocation Follow the RICE procedures. Do not try to relocate a dislocated kneecap (sometimes the kneecap replaced itself). Splint the knee in the position found. Seek medical care. Knee Sprain Ligament injuries occur most often in sports. The knee is very prone to injury, ranging from mild sprains to complete tearing. 14 of 18 Lesson Outlines Chapter 15 Recognizing a Knee Sprain At the time of injury, the victim has: o Severe pain o The feeling of a pop or snap o A locking sensation Or, the victim may not be able to walk without limping, or may not be able to bend the knee. Later there may be swelling in the knee and bruising. Care for a Knee Sprain Follow the RICE procedures. Seek medical care. Knee Contusion Contusions of the knee are caused by a direct blow or by falling on the knee. Recognizing a knee contusion o Pain o Swelling o Tenderness o Bruise marks Care for a knee contusion o Follow the RICE procedures. Lower-leg Injuries Tibia and fibula fractures Tibia and fibula contusions Muscle cramps Shin splints Ankle and foot injuries Toe injuries Tibia and Fibula Fractures Tibia and fibula fractures can occur at any place between the knee joint and the ankle joint. Injuries to the blood vessels, caused by extreme deformity, are common with injuries of the tibia and fibula. The pain is usually severe. Recognizing Tibia and Fibula Fractures Severe pain Swelling Visible deformity Tenderness when touched 15 of 18 Lesson Outlines Chapter 15 Care for Tibia and Fibula Fractures Stabilize the leg using a splint, either improvised by tying the legs together or a rigid splint. Apply an ice pack. Seek medical care. Recognizing a Tibia and Fibula Contusion Victim received a hit directly on the shin Tender when touched Sharp pain Later has: o Discoloration o Difficulty moving ankle up and down o Numbness or coldness in toes or foot Care for a Tibia and Fibula Contusion Expose the injury. Apply the RICE procedures. o Use an ICE pack for 20 minutes, three or four times daily for first 48 hours. If numbness or tingling exists, seek medical care. Muscle Cramp Muscle spasm or cramping usually occurs in the calf and sometimes in the thigh or hamstring. It is a temporary condition of little consequence. Recognizing a Muscle Cramp Happens during or after intense exercise sessions Painful, muscle contraction or spasm which disables the victim Care for Muscle Cramps There are many treatments for cramps. Try one or more of the following: o Have the victim gently stretch the affected muscle. o Relax the muscle by applying pressure to it. o Apply ice to the cramped muscle to make it relax (unless you are in a cold environment). o Pinch the upper lip hard (an acupressure technique) to reduce calf-muscle cramping. o Drink lightly salted, cool water or a commercial sports drink. Shin Splints Shin splints is a term that describes pain in the front of the lower leg, also called the shin. Shin splints are caused by repetitive stress in the leg such as running and extensive walking. 16 of 18 Lesson Outlines Chapter 15 Recognizing Shin Splints The shin aches during activity but: o The ache subsides significantly after activity stops o The ache is a result of an increase in the workout routine o Usually a chronic problem that gets worse Care for Shin Splints Apply an ice pack before an activity. o Heat can be applied later, when the victim is well on the way to recovery. Apply pressure with a 3-inch elastic bandage over the sorest point (start below the sore area and spiral wrap up and around the leg). Apply an ice pack for 20 minutes after the activity. Ankle and Foot Injuries The ankle and foot are frequently injured, mainly by twisting, which stretches or tears the supporting ligaments. In some cases, surgical intervention is required. Most ankle injuries are sprains; about 83% of sprains involve the outside ligaments and are caused by the ankle having turned or twisted inward. Recognizing Foot and Ankle Injuries Press along the bones to check for pain and tenderness. Ask the victim, “Have you tried standing on it?” o Putting some weight on the foot may hurt a little, but if the victim is able to do that and take four or more steps, most likely the ankle or foot is sprained. A few additional signs and symptoms may help determine whether an injured ankle or foot is sprained or fractured. o If the victim hops on the good foot and injured ankle cannot tolerate the jarring, suspect a fracture. Foot injuries usually lead to substantial swelling. o It has been observed that ankle sprains tend to swell on only one side of the foot, whereas swelling on both sides of the foot usually accompanies fractures. Care for Foot and Ankle Injuries Controversy exists about whether to remove a shoe from an injured foot it may act as a splint and help retard swelling. Taking the shoe off allows for better examination, better checking of the CSM, and better care. In addition, footwear left in place will thwart efforts to apply an ice pack and an elastic bandage. Use RICE procedures to limit the swelling. 17 of 18 Lesson Outlines Chapter 15 18 of 18