Page 65 - 2022 Ranger Medic Handbook

Orthopedic Trauma
Trauma to the extremities is common and can range from simple sprains to massive soft tissue injury and bony destruc-
tion associated with explosive devices. The sensation of a “pop” or “crack” is often misleading and should not be relied
on. The patient’s exam is often the key to diagnosis and initiating proper treatment. Any bleeding, even a small amount,
should indicate an open fracture. Examine joints for dislocation and splint any obvious deformity in two planes.
TCCC Application
Care Under Fire: Control massive life-threatening hemorrhage. SECTION 2
Tactical Field Care: Initially splint any fractures in position of function or immobilize in current position. Generally,
splinting in position of function will reduce overall pain to patient. Use traction on indicated fractures but stop if it is
causing worse pain. By splinting and reducing fractures, attempt to restore any vascular compromise. If possible, clean
and irrigate any gross contaminated wounds/fractures. If conscious, administer combat wound pill pack. Administer
antibiotics: ertapenem 1g IV/IM qd OR cefazolin 1–2g IV q8hr for open fractures. Reassess neurovascular status every
5–10 minutes and document changes. Dislocations with distal pulse may be reduced based on evacuation time and
training/experience in procedure. Consider pain management, local/regional anesthesia, or dissociative agents prior to
manipulating dislocations. Splint and/or sling/swathe as appropriate.
Tactical Evacuation: Reassess splints, interventions, and neurovascular status after any evacuation movements. If
previously unable to provide traction or adequate splinting, apply as appropriate.
Extended Care
Orthopedic injuries often accompany other significant injuries. Prioritize patient management based on severity of
multiple injuries. Vital signs should be monitored regularly to include color, temperature, motor and sensory function.
Conduct repeat motor and sensory exams in conjunction with vital sign checks. IV fluids administered to maintain SBP
of 90–100mmHg or as indicated by other conditions. Focus extended care efforts on extremity perfusion. Splinting in
anatomical position of function will optimize improved blood flow. If tourniquets have been applied, consider tourniquet
conversion if hemorrhage can be controlled through other means.
Consider patient comfort for extended timeframes and re-splint as necessary. Use hematoma blocks, local, or regional
anesthesia for pain control. Consider padding points of contact on splinting devices. Treat IAW Pain Management Pro-
tocol; consideration of effect on other injury patterns. Contaminated wounds should be flushed with normal saline or
clean water. The intent is to remove gross contamination such as dirt and debris.
Monitor for development of compartment syndrome. Be suspicious of compartment syndrome in the following con-
ditions: fractures, crush injuries, vascular injuries, or multiple penetrating injuries (fragmentation). The classic clinical
signs of compartment syndrome: pain out of proportion to injury, pain with passive motion of muscles in the involved
compartment, pallor, paresthesia, and pulselessness are late findings. Be aware that peripheral pulses are present in
90% of patients with compartment syndrome. Monitor closely and be aware of any pain out of proportion. Compart-
ment syndromes make take hours to develop. For patients with suspected compartment syndrome, reevaluate every 30
minutes for 2 hours, then every hour for 12 hours, then every 2 hours for 24 hours, then every 4–6 hours for 48 hours.
Extremity compartment syndromes may occur in the thigh, lower leg/calf, foot, forearm, and hand.
Compartment syndrome management: maintain extremity at level of heart. Do not elevate. Loosen encircling
dressings. Urgent evacuation. Only attempt fasciotomy if evacuation is delayed 6 hours or longer and with online
medical direction. Fasciotomy is not within the independent scope of the Ranger Medic.

2022 RANGER MEDIC HANDBOOK 51