Ankle injuries are quite common in camp and other settings. Our staff member, Laura Carney, had the distinction of being the first fracture of 2015. She managed to injure herself before the campers even arrived. I will be reviewing the management of suspected and obvious fractures of the ankle, using Carney's injury as an example. I will review her treatment in the health center using the APIE (assess, plan, intervene, evaluate) nursing process. This article was written with the permission of Carney, who was a good sport about everything even though this injury really ruined her summer.
A knock on my bedroom door woke me up at 10pm. I had turned in early, as I was expecting a long day of setup tomorrow. I knew a knock at this hour meant only one thing, business. I got out of bed and opened the door to find a staff member with a concerned look on his face. The look was different from the “Sorry I woke you for a minor problem” look I usually see. I hate the serious looks at this point in the season; we don't have a doctor on camp and the rest of the support staff are still in orientation, so anything above my pay grade is just that much harder to handle. “Carney hit the tower on the zip line and hurt her leg bad.” I breathed a sigh of relief that only her leg was hurt, "ok where is she?" I asked, while putting on my shoes, as well as my “I'm not panicked so you shouldn't be either face." “They are bringing her down now” he replied in a hurried voice. We walked to the front room as the door flew open, and in came Carney being carried by two of our adventure staff. Her ankle already visibly swollen.
Assessment: Carney was seated on a chair and the injured foot was elevated using another chair with a pillow on the seat. Her shoe was removed very gently. I then began to assess her injury site. When assessing an extremity injury, I evaluate for deformity, open wounds, bruising, swelling, pulses and distal perfusion, ability to move fingers or toes, and sensation in the injured extremity.
The ankle was not grossly deformed, but was already noticeably swollen. She had good capillary refill, and skin was warm to touch. Upon palpation she had extreme pain in the malleolar area. I also felt crepitus, which is the grinding feeling when two bone ends rub together. I evaluated Carney using the Ottawa ankle rules, an easy to use tool useful in guiding nurses in identifying ankle injuries at high risk for fracture.
Using the ankle rules, Carney was absolutely a high suspicion of fracture based on the malleolar pain and inability to walk. Feeling the crepitus removed all doubt that she had some form of fracture and need immediate evaluation.
Plan: Carney's ankle injury was absolutely in need of a higher level of care. Her plan of care was elevation, ice, PO OTC pain medication, and splinting/stabilization of the injury prior to transport to the local general hospital.
Intervention: Elevation, ice, and ibuprofen were provided. The next step in her treatment plan is to apply a splint. Splinting is a first aid skill used for the treatment of fractures or suspected fractures. The goal of splinting is to immobilize potentially broken bones and prevent further pain and injury from unnecessary movement. Splinting an injury is also often the most effective form of pain control available to nurses in the camp setting, as pharmacological interventions are very limited in the camp setting.
For injuries of the ankle I prefer a pillow splint, this is simply wrapping a pillow around the ankle with gentle pressure that will support the injury, and securing with cravats or tape.
Care should be taken leave toes exposed so circulation can be assessed. Other types of splints that can be easily used on an ankle such as Carney's are a padded board, or preferably a molded SAM splint.
Splinting is often as much of an art as a science, any combination of materials that accomplishes the goals of immobilization and support of the injury are acceptable. The rule in first aid has long been to splint fractures in the position in which they're found, especially if the injury involves a joint. However, current textbooks recommend that, except for joint injuries, extremities should be splinted in their correct anatomical position unless resistance is met while repositioning the injury. Carney's ankle was not deformed, however if it had been, I would have gently returned it to its anatomical position. Most orthopedic specialists feel that the anatomical position occurs when the body naturally rests to alleviate stress, exertion and pain and argue that repositioning protects against further injury and makes the patient more comfortable. This is even done in cases of compound fractures involving exposed bone. If bone ends re-enter the body, note this and cover the wound with a dressing prior to transport.
In Carney's situation a splint was obviously necessary, in other less easily distinguished injuries splinting is always a safe treatment choice if there is any suspicion of fracture.
Evaluation: after all interventions Carney's pain remained uncontrolled but was slightly improved from her arrival. The injury was splinted and her foot continued to have good capillary refill, sensation, and motor ability. All interventions were as successful as could be expected in the camp setting. She was loaded into a camp vehicle to be transported to the hospital.
Carney's fracture was severe, she required surgery with pin and plate placement. She was casted for the duration of camp and non weight bearing for a few weeks. Unfortunately her injuries made her unable to serve in her original role, she was reassigned to the health center as an assistant, where she served admirably for the summer using a leg scooter and crutches. My attempts to nickname her Scoots were not successful, much to my disappointment. She returned home to Australia and was discharged from physical therapy in late December 2015.
I hope this detailed explanation of the assessment and treatment of Carney's ankle injury helps guide you in planning your nursing process for similar injuries. Ankle injuries are very common in camp settings, and camp nurses of all experience levels should be comfortable in assessing and treating these injuries.
All opinions expressed here are my own and do not represent those of my employer. Remember anyone can pretend to be anyone on the internet, so please verify all information presented. NEVER take advice from strangers.