LEARNING OBJECTIVE: Select the appropriate stabilization and treatment procedure for the management ofjoint and muscle injuries.
Injuries to joints and muscles often occur together, and it is sometimes difficult to tell whether the primary injury is to a joint or to the muscles, tendons, blood vessels, or nerves near the joint. Sometimes it is difficult to distinguish joint or muscle injuries from fractures. In case of doubt, always treat any injury to a bone, joint, or muscle as though it were a fracture.
In general, joint and muscle injuries may be classified under four headings: (1) dislocations, (2) sprains, (3) strains, and (4) contusions (bruises).
When a bone is forcibly displaced from its joint, the injury is known as a dislocation. In some cases, the bone slips back quickly into its normal position, but at other times it becomes locked in the new position and remains dislocated until it is put back into place. Dislocations are usually caused by falls or blows but occasionally by violent muscular exertion. The most frequently dislocated joints are those of the shoulder, hip, fingers, and jaw.
A dislocation is likely to bruise or tear the muscles, ligaments, blood vessels, tendons, and nerves near a joint. Rapid swelling and discoloration, loss of ability to use the joint, severe pain and muscle spasms, possible numbness and loss of pulse below the joint, and shock are characteristic symptoms of dislocations. The fact that the injured part is usually stiff and immobile, with marked deformation at the joint, will help you distinguish a dislocation from a fracture. In a fracture, there is deformity between joints rather than at joints, and there is generally a wobbly motion of the broken bone at the point of fracture.
As a general rule, you should not attempt to reduce a dislocationthat is, put a dislocated bone back into placeunless you know that a physician cannot be reached within 8 hours. Unskilled attempts at reduction may cause great damage to nerves and blood vessels or actually fracture the bone. Therefore, except in great emergencies, you should leave this treatment to specially trained medical personnel and concentrate your efforts on making the victim as comfortable as possible under the circumstances.
The following emergency measures will be helpful:
You should NEVER attempt to reduce the more serious dislocations, such as those of the hip. However, if it is probable that the victim cannot be treated by a physician within a reasonable time, you should make a careful effort to reduce certain
dislocations (such as those of the jaw, finger, or shoulder) if there is no arterial or nerve involvement (pulse will be palpable and there will be no numbness below the joint). Treat all other dislocations as fractures, and evacuate the victim to a definitive care facility.
DISLOCATION OF THE JAW.—When the lower jaw is dislocated, the victim cannot speak or close the mouth. Dislocation of the jaw is usually caused by a blow to the mouth; sometimes it is caused by yawning or laughing. This type of dislocation is not always easy to reduce, and there is considerable danger that the operator’s thumbs will be bitten in the process. For your own protection, wrap your thumbs with a handkerchief or bandage. While facing the victim, press your thumbs down just behind the last lower molars and, at the same time, lift the chin up with your fingers. The jaw should snap into place at once. You will have to remove your thumbs quickly to avoid being bitten. No further treatment is required, but you should warn the victim to keep the mouth closed as much as possible during the next few hours. Figure 4-45 shows the position you must assume to reduce a dislocated jaw.
Figure 4-45.—Position for reducing a dislocated jaw.
DISLOCATION OF THE FINGER.—The joints of the finger are particularly susceptible to injury, and even minor injuries may result in prolonged loss of function. Great care must be used in treating any injury of the finger.
To reduce a dislocation of the finger, grasp the finger firmly and apply a steady pull in the same line as the deformity. If it does not slip into position, try it again, but if it does not go into position on the third attempt, DO NOT TRY AGAIN. In any case, and whether or not the dislocation is reduced, the finger should be strapped, slightly flexed, with an aluminum splint or with a roller gauze bandage over a tongue blade. Figure 4-46 shows how a dislocated finger can be immobilized by strapping it to a flat, wooden stick, such as a tongue depressor.
Figure 4-46.—Immobilizing a dislocated finger.
DISLOCATION OF THE SHOULDER.— Before reduction, place the victim in a supine position. After putting the heel of your foot in the victim’s armpit, grasp the wrist and apply steady traction by pulling gently and increasing resistance gradually. Pull the arm in the same line as it is found. After several minutes of steady pull, flex the victim’s elbow slightly. Grasp the arm below the elbow, apply traction from the point of the elbow, and gently rotate the arm into the external or outward position. If three reduction attempts fail, carry the forearm across the chest and apply a sling and swathe. An alternate method involves having the patient lie face down on an examining table with the injured arm hanging over the side. Apply prolonged, firm, gentle traction at the wrist with gentle external rotation. A water bucket with a padded handle placed in the crook of the patient’s elbow may be substituted. Gradually add sand or water to the bucket to increase traction. Grasping the wrist and using the elbow as a pivot point, gently rotate the arm into the external position.
Sprains are injuries to the ligaments and soft tissues that support a joint. A sprain is caused by the violent wrenching or twisting of the joint beyond its normal limits of movement and usually involves a momentary dislocation, with the bone slipping back into place of its own accord. Although any joint may be sprained, sprains of the ankle, wrist, knee, and finger are most common.
Symptoms of a sprain include pain or pressure at the joint, pain upon movement, swelling and tenderness, possible loss of movement, and discoloration. Treat all sprains as fractures until ruled out by X-rays.
Emergency care for a sprain includes application of cold packs for the first 24 to 48 hours to reduce swelling and to control internal hemorrhage; elevation and rest of the affected area; application of a snug, smooth, figure-eight bandage to control swelling and to provide immobilization (basket weave adhesive bandages can be used on the ankle); a follow-up examination by a physician; and X-rays to rule out the presence of a fracture.
After the swelling stops (24 to 48 hours), moist heat can be applied for short periods (15 to 30 minutes) to promote healing and reduce swelling. Moist heat can be warm, wet compresses, warm whirlpool baths, etc.
Heat should not be applied until 24 hours after the last cold pack.
Contusions, commonly called bruises, are responsible for the discoloration that almost always accompanies injuries to bones, joints, and muscles. Contusions are caused by blows that damage bones, muscles, tendons, blood vessels, nerves, and other body tissues. They do not necessarily break the skin.
The symptoms of a contusion or bruise are familiar to everyone. There is immediate pain when the blow is received. Swelling occurs because blood from the broken vessels leaks into the soft tissue under the skin. At first the injured place is reddened due to local skin irritation from the blow. Later the characteristic “black and blue” marks appear. Perhaps several days later, the skin turns yellowish or greenish before normal coloration returns. The bruised area is usually very tender.
As a rule, slight bruises do not require treatment. However, if the victim has severe bruises, treat for shock. Immobilize the injured part, keep it at rest, and protect it from further injury. Sometimes the victim will be more comfortable if the bruised area is bandaged firmly with an elastic or gauze bandage. If possible, elevate the injured part. A sling may be used for a bruised arm or hand. Pillows or folded blankets may be used to elevate a bruised leg.
Injuries caused by the forcible overstretching or tearing of muscles or tendons are known as strains. Strains may be caused by lifting excessively heavy loads, sudden or violent movements, or any other action that pulls the muscles beyond their normal limits.
The chief symptoms of a strain are pain, lameness or stiffness (sometimes involving knotting of the muscles), moderate swelling at the place of injury, discoloration due to the escape of blood from injured blood vessels into the tissues, possible loss of power, and a distinct gap felt at the site.
Keep the affected area elevated and at rest. Apply cold packs for the first 24 to 48 hours to control hemorrhage and swelling. After the swelling stops, apply mild heat to increase circulation and aid in healing. As in sprains, heat should not be applied until 24 hours after the last cold pack. Muscle relaxants, adhesive straps, and complete immobilization of the area may be indicated. Evacuate the victim to a medical facility where X-rays can be taken to rule out the presence of a fracture.