Transportation of an Athlete With Fracture or Dislocation
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The need for and mode of transporting an injured athlete is determined following primary and secondary evaluations by the first responder. It must always be executed so that further injury is prevented.
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Planning the mode of transport and necessary equipment can help ensure that an appropriate technique is used (see Chapter 4 , Sideline Preparedness and Emergencies on the Field).
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An athlete with a suspected spinal injury should not be moved by anyone other than certified medical personnel with appropriate stabilization. An ambulance should be contacted immediately (see Chapter 46 , Neck Injuries), if not already present.
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If a serious fracture, such as that of the tibia, femur, or pelvis, is suspected, the safest and most efficient mode of transportation for a short distance is by means of a stretcher that is taken onto a utility vehicle or preferably by an ambulance.
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Suspected extremity fractures must be immobilized before transport ( Fig. 58.1 ).
Figure 58.1
Prehospital care of fractures.
Emergency Splint Equipment
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The ability to take care of an acute fracture in an athlete is directly related to one’s level of preparedness and experience.
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Timely application of a splint to a fractured extremity minimizes the overall surrounding soft tissue injury and allows for safe transportation of the athlete for definitive care.
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Sports medicine providers (physician and trainers) should carry lightweight, easy-to-apply splint material in their sport medicine bag (see Chapter 4 , Sideline Preparedness and Emergencies on the Field).
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Basic mobile splint kit for a medicine bag ( Table 58.1 ):
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Arm sling/shoulder immobilizer (medium and large sizes)
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Alumafoam padded splints (several lengths that can be cut to size)
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Structural aluminum malleable (SAM) splint
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Knee immobilizer (universal size)
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Webril (cast padding) and ace wraps (4 and 6 inches)
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Plaster or fiberglass splinting material for self-made splints (prepackaged splints are available)
TABLE 58.1
SPLINTS USED PER INJURY LOCATION
Clavicle and Acromioclavicular (AC) Joint
Arm sling
Shoulder and Proximal Humerus
Arm sling and a 6-inch ace wrap swathe
Distal Humerus and Elbow
Air or vacuum splint
Forearm and Wrist
Fiberglass/plaster splint, structural aluminum malleable (SAM) splint, prefabricated orthosis
Hand
Buddy taping, Alumafoam splint
Spine
Cervical collar and spine board
Hip and Femur
Femoral traction splint
Knee and Proximal Tibia
Knee immobilizer
Tibial Shaft, Ankle, and Foot
Air or vacuum splint
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Advanced facility kit (available at all high-volume sports complexes or via emergency medical services [EMS]):
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Extremity vacuum splints or air splints (total body kits)
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Cervical collar
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Spine board
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Femoral (Hare) traction splint
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Crutches
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General Principles
Overview
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Braces or orthoses stop or limit range of motion, facilitate movement, or guide a joint through an arc of motion.
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Splints are used to immobilize and position one or several joints (see Fig. 58.1 ).
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Splints and braces are prescribed after a fracture to protect a partially healed fracture or to prevent the pain and soft tissue damage that occurs with motion.
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A cast is a stress-sharing device, allowing limited fracture motion and callus formation as a result of secondary bone healing. The joints above and below a fracture should be immobilized to prevent rotation and translation of the fracture fragments.
Splint Treatment
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Splints are beneficial because they provide some stabilization at the fracture site, but they may be removed for rehabilitation treatment.
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After a cast is initially removed, splints are frequently used during activity or at night to reduce pain and discomfort and allow additional fracture consolidation.
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Joint stiffness is very common after cast removal and resolves after weeks to months of aggressive, but appropriate, rehabilitation.
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Immobilization of the joints above and below the fracture site often leads to stiffening and the need for a prolonged rehabilitation program.
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A cast brace can provide partial immobilization while allowing some range of motion and weight bearing on a limb.
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Once a fracture achieves an appropriate degree of stability as a result of callus formation, the cast can be replaced with a splint or brace, allowing motion of the joints proximal and distal to the fracture, without compromising the support at the fracture site.
Initial Evaluation
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Immediately after an athlete sustains a fracture or dislocation, the neurologic and vascular status must be evaluated and documented.
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Temporary immobilization measures should be employed as the patient is transported to the hospital (see Fig. 58.1 ).
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The mechanism of injury can provide clues regarding what type of injury has occurred.
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In all upper extremity fractures, assess the following:
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Open or closed fracture
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Patient complaints of pain, swelling, or paresthesias
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Vascular status distal to the injury
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Active and passive range of motion of wrist and/or digits
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Radial, median, and/or ulnar nerve function and possible compression; axillary nerve function should also be documented with shoulder injuries
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In all lower extremity fractures, assess the following:
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Open or closed fracture
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Patient complaints of pain, swelling, or paresthesias
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Vascular status distal to the injury (pulses, color, and capillary refill)
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Active and passive range of motion of all metatarsophalangeal and interphalangeal joints
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Nerve function and possible compression
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Upper Extremity Injuries
Distal Humerus Fractures
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Fractures that have minimal displacement and are in near anatomic alignment can be treated with casting or splinting if they are stable enough to allow early elbow motion.
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Elbow stiffness and permanent motion loss are significant risks following elbow trauma.
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Cast or splint treatment of these injuries should initially allow no motion at the elbow.
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Most distal humerus fractures require surgical stabilization, followed by early functional motion of the elbow.
Olecranon Fractures
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Minimally displaced fractures of the olecranon with <2-mm displacement and intact elbow extensor mechanism can be treated with cast or splint immobilization.
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Early elbow motion is necessary for good functional results.
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The cast should be adequately padded to avoid skin breakdown at the edges of the cast or splint.
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The cast should volarly extend to the distal palmar crease and dorsally to the metacarpophalangeal joints to allow full motion at the interphalangeal and metacarpophalangeal joints.
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Once there is early evidence of healing, the elbow should be mobilized to prevent stiffness.
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An elbow-hinged brace can protect the fracture and maintain motion of the elbow. Often, some terminal extension is lost, but functional range of motion is maintained.
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Aggressive rehabilitation is critical as the loss of some terminal extension may have implications on athletic performance even if it does not affect activities of daily living.
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Displaced fractures of the olecranon require open reduction and internal fixation (ORIF), followed by early elbow range of motion to minimize the development of elbow stiffness.
Radial Head Fractures
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Minimally displaced fractures can be treated in a sling with early elbow range of motion.
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For fractures requiring ORIF, short-term immobilization is needed, followed by early bracing mobilization.
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A hinged elbow brace is typically used to allow protection of the fixation during initiation of early range of motion.
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Most severe fractures have better outcomes with radial head replacement than with ORIF, even in young patients.
Distal Radius Fractures
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Minimally displaced fractures can be treated with a long-arm or Münster cast, followed by a short-arm cast.
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Rigid immobilization for 4–6 weeks, followed by a removable splint, is recommended.
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Displaced fractures require reduction before splinting and should be immobilized in a long-arm splint.
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The cast should be volarly trimmed to the proximal palmar crease and distally to the metacarpophalangeal prominences to allow free finger movement. The cast should be trimmed to allow the thumb full opposition with the small finger.
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Distal radius fractures requiring ORIF require long-arm splints in the immediate postoperative period, followed by short-arm casting or removable gauntlet splint depending on the pattern of injury.
Scaphoid Fractures
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For nondisplaced or minimally displaced fractures, thumb spica cast immobilization is recommended. The wrist should be in a neutral position relative to flexion, extension, and radial deviation.
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Fractures requiring open reduction should be immobilized in a thumb spica splint in the immediate postoperative period, followed by a thumb spica cast.
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Athletes—and other high-activity and high-demand patients—frequently have better outcomes with ORIF of scaphoid fractures.
Metacarpal and Phalangeal Fractures
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Dislocations of the proximal interphalangeal (PIP) joint should be immobilized using static dorsal extension splinting ( Fig. 58.2A ).
Figure 58.2
Upper extremity fractures and dislocations (proximal interphalangeal, clavicle, and humeral shaft).
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It is important to secure the proximal phalanx to the splint to ensure that the PIP joint does not extend when a patient flexes the metacarpal phalangeal joint.
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Metacarpal neck and shaft fractures are best treated with a cast or splint.
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The splint is applied with the hand in “safe” position with the wrist in extension, the metacarpal phalangeal joints flexed, and the proximal and distal interphalangeal joints in extension. Displaced fractures require reduction before splinting.
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Phalanx fractures that are minimally displaced can be treated with “buddy taping,” wherein the fractured finger is taped to an adjacent finger. The adjacent finger functions as a splint but allows continued range of motion. Displaced fractures require reduction before splinting.
Clavicle Fractures
Description: The most common fracture, accounting for approximately 5%–10% of all fractures; 85% involve the middle third of the clavicle ( Fig. 58.2B )
Mechanism of injury: Most result from a fall onto the ipsilateral shoulder.
Initial on-field management: The fracture displacement and pain level is significant and clinical diagnosis can be made on the field; the athlete should be assisted off the field with the arm held at his or her side. Initial management with a sling with or without a swathe is sufficient. A 6-inch ace wrap can be used for a swathe and improves comfort by supporting the elbow and immobilizing the arm to the body.
Evaluation:
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Inspection: Look for obvious deformity and inspect for skin breakdown or tenting.
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Palpation: Check for neck, sternoclavicular joint, midclavicle, acromioclavicular joint, scapula, and proximal humerus tenderness.
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Neurovascular examination: Evaluate the upper extremity including the axillary nerve. Sensation may not be completely reliable, so motor function of the deltoid should be carefully assessed.
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Radiographs: An anteroposterior (AP) and an AP with a cephalic tilt of 20 degrees are sufficient.
Treatment: Nonsurgical treatment for several closed clavicle fractures with application of a figure-of-eight collar or arm sling. Indications for surgical treatment include skin compromise secondary to severe displacement, open fractures, and a floating shoulder with neurovascular compromise. Level I studies have shown that ORIF has improved results with significantly displaced clavicle fractures. Shortening and overlap of >2 cm in an active individual should usually be treated surgically. The method of fracture stabilization is generally with a contoured plate or an intramedullary device. Problems with conservative care include a higher incidence of both nonunion and malunion.
Prognosis and return to sport: Several recent reports suggest a faster return to sport with surgical intervention than with conservative care. One report with intramedullary fixation reported a return to training in 6 days and a return to competition in 17 days with 12 high-performance athletes. Prognosis for athletes is very good following clavicle fractures.
Humeral Shaft Fractures
Overview: Uncommon, accounting for approximately 1% of fractures in trauma registries (see Fig. 58.2C )
Mechanism of injury: More frequently from a fall onto the involved extremity but can occur from a direct blow; on occasion, rotational injuries can also occur in certain sports such as arm wrestling
Presentation: Painful, unstable extremity with swelling and bruising
Physical examination: Gentle palpation of the shaft of the humerus should be performed, noting any areas of malalignment and severe pain
Associated injuries: Associated nerve injuries are relatively common and should be documented; radial nerve injuries are most common. Most common fracture type associated with a nerve injury is a transverse mid-diaphyseal fracture. Document a motor neurologic examination of the axillary, musculocutaneous, radial, median, and ulnar nerves. Skin should also be examined to rule out any open fractures. Shoulder and elbow joints should be examined and imaged.
Diagnostics: AP and lateral radiographs of the entire humerus should be obtained. In addition, radiographs of the shoulder and elbow should also be recorded to help evaluate for associated pathology.
Treatment: In most cases, nonsurgical management of midshaft fractures is appropriate. Treat with functional bracing and by allowing active flexion and extension of the elbow during the healing process to prevent elbow stiffness; motion helps reduce the fracture and aids in the healing process. Isometric muscle exercises in the functional brace can aid in maintaining alignment and assist in fracture healing. Patients who have sustained significant nerve injuries that prevent active range of motion are not candidates for functional bracing. The humerus can heal with an angulation of up to 30 degrees and shortening of 2–3 cm without functional problems in most patients. However, the functional needs of a high-performance athlete are different, and accepting that degree of malalignment is discouraged. If functional bracing is elected to treat an athlete, special care should be taken to follow the healing process and evaluate the alignment. If alignment is not maintained in the dominant arm of a skilled athlete, consideration should be given to surgical stabilization of the fracture. Surgical treatment usually involves either plating or use of an intramedullary nail (see Fig. 58.2C ).
Prognosis and return to sport: Prognosis for healing and good functional recovery following isolated humerus shaft fractures is good. Patients who have associated nerve injuries or shoulder dislocations have a less favorable prognosis but may still be able to return to competition if the nerve injury resolves.
Forearm Fractures
Description: Forearm injuries represent approximately 5% of all fractures and include isolated ulnar fractures and fractures of both the radius and ulna. Monteggia and Galeazzi fractures involve the proximal and distal radioulnar joints, respectively (see Fig. 58.3A, B, and C ). Monteggia fractures involve fracture of the ulna with dislocation of the radial head. Galeazzi fractures involve fracture of the radius shaft (usually at the level of the junction of the middle and distal third) with injury to the distal radial ulnar joint.
