Musculoskeletal Trauma

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Ch 30: Musculoskeletal Trauma Objectives After reading this chapter you should be able to: 30.1 Define key terms introduced in this chapter. 30.2 Describe the anatomy of elements of the musculoskeletal system. (pp. 696-702, 703-704) 30.3 Associate mechanisms of injury with the potential for musculoskeletal injuries. (p. 702) 30.4 Describe the four types of musculoskeletal injury (fracture, dislocation, sprain, and strain) and define open and closed extremity injuries. (p. 706) 30.5 Discuss the a…

Pelvic Injuries

1. Move the patient as little as possible. If you must move the patient, move him as a unit. Never lift the patient with the pelvis unsupported. Warning: Use caution when using a log roll to move a patient with a suspected pelvic fracture. Roll the patient gently to
the uninjured side, when possible.
2. Determine CSM distal to the injury site.
3. Straighten the patient's lower limbs into the anatomical position if there are no injuries to the hip joints and lower limbs and if it can be done without meeting resistance or causing excessive pain.
4. Prevent additional injury to the pelvis by stabilizing the lower limbs. Place a folded blanket between the patient's legs, from the groin to the feet, and bind them together with wide cravats. Thin rigid splints can be used to push the cravats under the patient. The cravats can then be adjusted for proper placement at the upper thigh, above the knee, below the knee, and above the ankle.
5. If permitted by local protocol, apply a pneumatic anti-shock garment (PASG) to stabilize the pelvis in a patient with hypotension (blood pressure below 90).
6. Assume that there are spinal injuries. Immobilize the patient on a long spine board. When securing the patient, avoid placing the straps or ties over the pelvic area.
7. Reassess distal CSM.
8. Care for shock, providing high-concentration oxygen.
9. Transport the patient as soon as possible.
10. Monitor vital signs.

To apply a sheet as a pelvic wrap:

1. Complete a scene size-up and primary assessment.
2. Once you determine the patient is a candidate for a pelvic wrap (unstable pelvis with or without signs of shock or positive MOI), prepare a backboard with a sheet, folded flat, approximately 10 inches wide and lying across the backboard.
3. Carefully roll the patient to the backboard. Center the sheet at the patient's greater trochanter (the bony prominence at the proximal end of the femur). This will position the sheet lower than the iliac "wings." This is the correct position.
4. Bring the sides of the sheet around to the front of the patient. As you bring the sides of the sheet together and tie them, you will cause compression and stabilization of the pelvis. The sheet should feel firm enough on the pelvis to keep it in normal position without overcompression (Figure 30-18C).
5. Secure the sheet using ties or clamps so that the compression is maintained.
NOTE: Some EMS services prefer to apply the pelvic wrap to the patient before movingthe patient to the backboard to reduce the pain of that move.

(A) For a pelvic wrap, lay a sheet, folded flat, approximately 10 inches wide onto the backboard.
(B) Bring the sides of the sheet together.
(C) Tie the sheet firmly without overcompression to
complete the pelvic wrap.

...

Pneumatic Anti-Shock Garment

also known as a MAST garment) may be used (where available) for splinting a suspected pelvic fracture in a patient with hypotension (blood pressure below 90).Some EMS systems also use the anti-shock garment for splinting hip,femoral, and multiple leg fractures.An anti-shock garment is to be applied in accordance with local protocols. In many localities, its application requires an order from a physician.

Describe the anatomy of elements of the
musculoskeletal system. (pp. 696-702, 703-704)

The musculoskeletal system is composed of all the body's bones, joints, and muscles, as well as cartilage, tendons, and ligaments.
The bones of the axial skeleton include the skull (including the cranium and face), the sternum, the ribs, and the spine including the cervical, thoracic, and lumbar vertebrae, the sacrum, and the coccyx. pay special attention to the appendicular skeleton, particularly the extremities —the upper extremities (clavicles, scapulae, arms, wrists, and hands) and the lower extremities (pelvis, thighs, legs, ankles, and feet)

The muscular system

Rectus abdominis
Sartorius
Vastus medialis
Masseter
Deltoid
Sternocleidomastoid
Pectoralis major
Biceps
External oblique
Triceps
Quadriceps femoris
Tibialis anterior

Three types of muscle

Skeletal muscle
Cardiac muscle
Smooth muscle

Tendons

tie muscle to bone

Ligaments

tie bone to bone.

Tendons

are bands of connective tissue that bind the muscles to bones. The tendons allow for the power of movement across the joints.

Ligaments

are connective tissues that sup-
port joints by attaching the bone ends and allowing for a stable range of motion.

There are basically three types of mechanisms that cause musculoskeletal injuries:

direct force, indirect force, and twisting force.

Components of Musculoskeletal System

Bones
Joints
Muscles
Cartilage
Ligaments
Tendons

Physiology of Musculoskeletal System

Bones: framework
Joints: bending
Muscles: movement
Cartilage: flexibility
Ligaments: connect bone to bone
Tendons: connect muscle to bone

Bones

framework. Bones provide the body with structure, store salts and metabolic materials, and provide a site for the production of red blood cells.

Joints

bending

Muscles

movement

Cartilage

flexibility

Shapes of Bones

Irregular
Long
Short
Flat

Self-Healing Nature of Bone

Because of the self-healing property of bones, it is very important for a broken bone to be immobilized quickly and to remain immobilized to heal properly. Break causes soft tissue swelling and a blood clot in the fracture area. Interruption of blood supply causes the bone section to die. Cells further from fracture divide rapidly forming tissue that heals the fracture and develops into new bone.

Injury to Bones and Connective Tissue

Fracture: any break in a bone (open or closed)
Comminuted—broken in several places
Greenstick—incomplete break
Angulated—bent at angle
Dislocation: "coming apart" of a joint

Traction splint

Sager
Hare

contreindicators Traction splint

...

A closed extremity injury

is one in which the skin has not been broken.

An open extremity injury

is one in which the skin has been broken.

Injury to Bones and Connective Tissue

Sprain: stretching and tearing of ligaments
Strain: overstretching of muscle

Sprain

stretching and tearing of ligaments

Strain

overstretching of muscle

Injury to Bones and Connective Tissue

Not all injuries can be confirmed as a fracture in the field
Splinting an extremity with a suspected fracture helps prevent blood loss from bone tissues

Assessment Musculoskeletal Injuries

...

Compartment Syndrome

Serious condition caused when tissues such as blood vessels and nerves are constricted from swelling, tight dressing or cast
Assessment will involve your sight, hearing, and touch. Compartment syndrome results from increased swelling in the muscle compartment/area, which progresses to cellular death from loss of blood flow. The best treatment if it is suspected is to treat the underlying injury; i.e., splint the wound.

Musculoskeletal Injuries Assessment

Rapidly identify and treat life-threatening conditions
Be alert for injuries besides grotesque wound
Pain and tenderness
Deformity and angulation
Grating (crepitus)
Swelling
Bruising
Exposed bone ends
Nerve/blood vessel compromise (decreased CMS)
Compartment syndrome

Six P's of Assessment

Pain or tenderness
Pallor (pale skin)
Parasthesia (pins and needles)
Pulses diminished or absent
Paralysis
Pressure

Musculoskeletal Injuries Treatment

Take standard precautions
Perform primary assessment
Take spinal precautions, if necessary
Splint any suspected extremity fractures after treating life-threatening conditions
Cover open wounds with sterile dressings
Effective splinting immobilizes adjacent joints and bone ends and minimizes the movement of disrupted joints and broken bone ends.

Advantages of Splinting

Minimizes movement of disrupted joints and broken bone ends
Prevents additional injury to soft tissues (nerves, arteries, veins, muscles)
Decreases pain
Minimizes blood loss
Can prevent a closed fracture from becoming an open fracture
For any splint to be effective, it must immobilize adjacent joints and bone ends. A deformed extremity can be realigned if necessary to restore effective circulation or fit it into a splint. Effective splinting may require some ingenuity. Splints often come in either rigid, formable, or traction style.

Realigning Deformed Extremity

Assists in restoring effective circulation to extremity and to fit it to splint
If not realigned, splint may be ineffective, causing increased pain and possible further injury
If not realigned, increased chance of nerves, arteries, and veins being compromised
Increased pain is only momentary

Principles of Splinting

Care for life-threatening problems first
Expose injury site
Assess distal CSM
Align long-bone injuries to anatomical position
Do not push protruding bones back into place
Immobilize both injury site and adjacent joints
Choose splinting method based on severity of condition and priority decision
Apply splint before moving patient to stretcher
Pad voids

Hazards of Splinting

"Splinting patient to death"—splinting before life-threatening conditions addressed
Not ensuring ABC's
Too tight—compresses soft tissues
Too loose—allows too much movement
Splinting in deformed position

Splinting Long Bone and Joints Treatment

Select splint appropriate to injury
Standard precautions
Manually stabilize injury site
Assess circulation, sensation, and motor function
Realign injury if deformed or if distal extremity is cyanotic or pulseless
Measure or adjust splint; move it into position
Apply and secure splint to immobilize injury site, adjacent joints
Reassess CSM distal to injury

Traction Splint Treatment

Used for splinting a femur injury
Provide counter traction in the field
Contraindicated if Pt has pelvis, hip, knee, avulsion or partial amputation

A traction splint counteracts

the muscle spasms and greatly reduces the pain associated with a long-bone femur fracture. Steps for using traction splint: (1) Take Standard Precautions. Expose area to be splinted. (2) Manually stabilize leg. Apply manual traction. (3) Assess CSM distal to injury. (4) Adjust splint to proper length. Position it at or under injured leg. (5) Apply proximal securing device (ischial strap). (6) Apply distal securing device (ankle hitch). (7) Apply mechanical traction. (8) Position and secure support straps. (9) Re-evaluate proximal and distal securing devices. Reassess CSM distal to injury. (10) Secure patient's torso and traction splint to long spine board to immobilize hip and prevent movement of splint.

Shoulder Girdle Injuries

Assessment
Pain in shoulder
Dropped shoulder
Severe blow to back over scapula
Describe how you would use a sling and swathe. List the steps of application.

Shoulder Girdle Injuries

Treatment
Assess distal CSM
Use sling and swathe
Do not attempt to straighten or reduce
Reassess distal CSM

Pelvic Injuries Assessment

Assessment
Pain in pelvis, hips, or groin
Pain when pressure applied
Cannot lift legs
Lateral rotation of foot
Unexplained pressure in bladder
Bleeding from the urethra, rectum or vagina.

Pelvic Injuries Treatment

Move patient as little as possible
Determine CSM distal to injury
Straighten lower limbs to anatomical position
Stabilize lower limbs
Assume spinal injuries
Treat for shock
Consider using a pelvic wrap, pneumatic anti-shock garments, or a pelvic binder to immobilize an unstable pelvis.

Hip Dislocation/Fracture Assessment

Anterior hip dislocation
Posterior hip dislocation
Rotation of leg and foot
Pain and unable to stand

Hip Dislocation/Fracture Treatment

Treatment
Assess distal CSM
Move patient onto spine board
Immobilize limb with pillows and blankets
Secure patient to spine board
Reassess distal CSM
Be sure to assess for distal circulatory, sensory, and motor functions before and after immobilizing a hip dislocation. To immobilize a hip fracture, consider using padded boards, binding the legs together, or applying pneumatic anti-shock garments.

Femoral Shaft Fracture Assessment

Assessment
Intense pain
Possibly open fracture
Injured limb may be shortened
Use a traction splint to immobilize isolated femoral shaft fractures.

Femoral Shaft Fracture Treatment

Treatment
Control bleeding
Assess distal CSM
Apply traction splint
Reassess distal CSM
Treat for shock
Use a traction splint to immobilize isolated femoral shaft fractures.

Knee Injury

Assessment
Pain and tenderness
Swelling
Deformity with swelling
Treatment
Assess distal CSM
Immobilize in current position
Reassess distal CSM

Tibia/Fibula Injury

Assessment
Pain and tenderness
Swelling
Possible deformity
Treatment
Air inflated splint
Two-splint method
Single splint with ankle hitch

Ankle/Foot Injury Assessment

Assessment
Pain
Swelling
Possible deformity

Ankle/Foot Injury Treatment

Treatment
Assess distal CSM
Stabilize limb
Lift limb
Place cravats under ankle
Lower limb into pillow
Tie pillow around ankle
Apply ice pack as needed
Describe the assessment findings and immobilization techniques for the following types of injuries: shoulder girdle injury, pelvic fracture, hip dislocation/fracture, femoral shaft fracture, knee injury, tibia/fibula fracture, ankle/foot injury. Improvise splints. Assemble common household items and ask students to create splints.

Forearm, Wrist, and Hand Injuries

Signs
Forearm: deformity and tenderness
Wrist: deformity and tenderness
Hand: deformity and pain; dislocated fingers

Splinting Forearm, Wrist, and Hand Injuries

Padded rigid splint
From elbow past fingertips
Roll of bandage placed in hand
Sling and swathe

Splinting Forearm, Wrist, and Hand Injuries

Soft splint
Roll of bandage placed in hand
Tie forearm, wrist, and hand into fold of one pillow or between two pillows
Tape finger to adjacent uninjured finger

Bones bleed

Fractures cause blood loss within the bone.

Splinting of long bone fractures

involves immobilizing adjacent joints.

Splinting

protects the patient from further injury.

Injuries to bones and joints

should be splinted prior to moving the patient.

If patient has multiple trauma or appears to have shock

do not waste time splinting individual fractures. Place patient on long spine board and secure limbs to board. Splint individual fractures en route if time and priorities allow.

Bones, joints, muscles, cartilage, tendons, and ligaments make up the

musculoskeletal system.

Bones provide the body with

structure, store metabolic materials, and produce red blood. Joints are the places where bones articulate to create movement.

Fractures, dislocations, sprains, and strains are musculoskeletal injuries that are caused by

direct force, indirect force, and twisting force. Injuries should be splinted prior to moving the patient.

A closed extremity injury

is one in which the skin has not been broken. An open extremity injury is one in which the skin has been broken.

Pelvic fractures and femoral shaft fractures

often indicate more severe internal injuries

...

EMTs must learn specific techniques for immobilizing particular injuries but at the same time must foster creativity while applying the general rules of splinting.

Have I fully addressed life threats and maintained my priorities even in the presence of a grossly deformed extremity?
Does the patient have an injury that requires splinting?

Remind students that they need to use their senses of sight, touch, and hearing during their assessment of patients with musculoskeletal injuries. They will need to look past obvious signs and probe for multiple injuries in order to make a complete assessment of the patient.

Does the patient have multiple fractures, multiple trauma, or shock?

...

Does the patient have adequate CSM distal to the musculoskeletal injury?

...

Should I align the angulated extremity fracture?

...

To splint long-bone or joint injuries, follow these guidelines

1. Take appropriate Standard Precautions and, if possible, expose the area to be splinted.
2. Manually stabilize the injury site. This can be done either by you or by a helper.
3. Assess circulation, sensation, and motor function (CSM). Check for pulses and see if the patient can feel your touch distal to the injury. Ask the patient to wiggle his fingers or toes to assess movement. Do not ask the patient to grasp, press, or pull an extremity you believe may be fractured. This will cause unnecessary pain and may aggravate the injury.
4. Realign the injury if deformed or if the distal extremity is cyanotic or pulseless. Be sure to attempt to realign an injured joint only if the distal extremity is pulseless or cyanotic.
5. Measure or adjust the splint and move it into position under or alongside the limb. Maintain manual stabilization or traction during positioning and until the splinting procedure is complete.
6. Apply and secure the splint to immobilize adjacent joints and the injury site.
7. Reassess CSM distal to the injury.

If the distal extremity is pulseless or cyanotic

try to align it to the anatomical position using gentle traction. As with longbone splinting, get all of your equipment ready before starting the splinting process.

10% of the patients body weight not exceeding 15 pounds

...

Purposes and general procedures
for splinting

Emergency care for all suspected extremity fractures starts by splinting. For any splint to be effective, it must immobilize adjacent joints and bone ends.Effective splinting minimizes the movement of disrupted joints and broken bone ends, and it decreases the patient's pain. It helps prevent additional injury to soft tissues such as nerves, arteries, veins, and muscles. It can prevent a closed fracture from becoming an open fracture, a much more serious condition, and it can help to minimize blood loss. In the case of the spine, splinting on a backboard prevents injury to the spinal cord and helps to prevent permanent paralysis.

The object of realignment (straightening)

is to assist in restoring effective circulation to the extremity and to fit it to a splint. Some injuries, such as certain wrist fractures, may be
easily splintable because they are only slightly deformed. In this case, the only reason to attempt realignment is to restore circulation to the hand if it appears to be cyanotic or lacks a pulse.

The thought of realigning an angulated injury can be a frightening one. However, remember these points:

• If the extremity is not realigned, the splint may be ineffective, causing increased pain and possible further injury (including an open fracture) during transportation.
• If the extremity is not realigned, the chance of nerves, arteries, and veins being compromised increases. When distal circulation is compromised or shut down, tissues beyond the injury become starved for oxygen and die.
• Pain is increased for only a moment during realignment under traction. Pain is reduced by effective splinting.

The general guidelines for realigning an extremity are as follows

1. One EMT grasps the distal extremity, while a partner places one hand above and one hand below the injury site.
2. The partner supports the site while the first EMT pulls gentle manual traction in the direction of the long axis of the extremity. If you feel resistance or if it appears that bone ends will come through the skin, stop realignment and splint the extremity in the position found.
3. If no resistance is felt, maintain gentle traction until the extremity is properly aligned and splinted.
Generally, injured joints should be splinted in the position found unless the distal extremity is cyanotic or lacks pulses. If these conditions are present, try to align the joint to a neutral anatomical position using gentle traction, provided that no resistance is felt.

Inside and Fracture

Bones are vascular. Bone marrow is involved in the production
of red blood cells.
There are many types of fractures. Greenstick fractures,
comminuted fractures, and fractures without displaced bone
ends do not appear deformed.
Swelling and inflammation are the body's natural responses to
injury. The body sends blood and cells to the affected area to
fight infection. This causes a swollen, often warm extremity
around the injury.

Fracture from the Outside

Patients with skeletal injuries—especially those involving
long bones and multiple bones—will experience shock.
You may see patients who have fractures without obvious
deformity. This is why you splint all actual and suspected
musculoskeletal fractures.
Some patients may appear to have a fracture but actually
don't. The swelling—especially in areas where the bone is
close to the skin—can cause the appearance of fracture.

Some patients may appear to have a fracture but actually
don't. The swelling—especially in areas where the bone is
close to the skin—can cause the appearance of fracture.

...

Shoulder Girdle Injuries
The following are common signs and symptoms of an injury to the shoulder girdle

■ Pain in the shoulder may indicate several types of injury. Look for specific signs.
■ A dropped shoulder, with the patient holding the arm of his injured side against the chest, often indicates a fracture of the clavicle.
■ A severe blow to the back over the scapula may cause a fracture of that bone. (All the bones of the shoulder girdle can be felt except the scapula. Only the superior ridge of the scapula, called its spine, can be easily palpated. Injury to the scapula is rare but must be considered if there are indications of a severe blow at the site of this bone.) Check the entire shoulder girdle. Feel for deformity and tenderness where the clavicle joins the anterior scapula (the acromion). Feel and look along the entire clavicle for deformity from the sternum medially to the shoulder laterally. Note if the head of the humerus can be felt or moves in front of the shoulder. This is a sign of possible anterior dislocation or fracture.

Fractures of the pelvis may occur with falls, in motor-vehicle collisions, or when a person is crushed by being squeezed between two objects. Pelvic fractures may be the result of direct or indirect force. The following are common signs and symptoms of a pelvic injury:

■ Complaint of pain in the pelvis, hips, groin, or back. This may be the only indication, but it is significant if the mechanism of injury indicates possible fracture. Usually, obvious deformity is associated with the pain.
■ Painful reaction when pressure is applied to the iliac crests (wings of the pelvis) or to the pubic bones.
■ Complaint that the patient cannot lift his legs when lying on his back. (Do not test for this, but do check for sensation.)
■ Foot on the injured side may turn outward (lateral rotation). This also may indicate a hip fracture.
■ Patient has an unexplained pressure on the urinary bladder and the feeling of having to empty the bladder.
■ Bleeding from the urethra, rectum, or vaginal opening in the setting of a high-impact mechanism of injury. Blood at the meatus of the penis (opening of the urethra) is a finding unique to pelvic trauma/fracture.

...

(A) Blood at the meatus of the penis is a sign of a pelvic fracture. (B) A pelvic wrap can help to stabilize
a fractured pelvis. Shown here is a commercial pelvic binding device placed on a severely injured patient with an open
pelvic fracture.

One method of treating pelvic injuries is the pelvic wrap. Performed with commercially available devices or formed from a sheet (these steps are described in the following text), the wrap reduces internal bleeding and pain while providing stabilization to the pelvis. It may also prevent further injury. Since many systems no longer carry the pneumatic anti-shock garment (PASG), the pelvic wrap provides an alternative treatment for suspected pelvic fracture.

To apply a sheet as a pelvic wrap:
1. Complete a scene size-up and primary assessment.
2. Once you determine the patient is a candidate for a pelvic wrap (unstable pelvis with or without signs of shock or positive MOI), prepare a backboard with a sheet, folded flat, approximately 10 inches wide and lying across the backboard.
3. Carefully roll the patient to the backboard. Center the sheet at the patient's greater trochanter (the bony prominence at the proximal end of the femur). This will position the sheet lower than the iliac "wings." This is the correct position.
4. Bring the sides of the sheet around to the front of the patient. As you bring the sides of the sheet together and tie them, you will cause compression and stabilization of the pelvis. The sheet should feel firm enough on the pelvis to keep it in normal position without overcompression.
5. Secure the sheet using ties or clamps so that the compression is maintained.
NOTE: Some EMS services prefer to apply the pelvic wrap to the patient before moving the patient to the backboard to reduce the pain of that move.

The following are common signs and symptoms of a hip dislocation:

■ Anterior hip dislocation. The patient's entire lower limb is rotated outward and the hip is usually flexed.
■ Posterior hip dislocation (most common). The patient's leg is rotated inward, the hip is flexed, and the knee is bent

indirect force

can be just as powerful. For example, a well-known injury pattern occurs when people fall from heights and land on their feet. Pelvic fractures may be the result of direct or indirect force. Usually cause injuries to the knees, femurs, pelvis, and spinal column. In fact, most injuries to the upper extremities are caused by forces applied to an
outstretched arm. In the course of a fall, the person reaches out with an arm in an effort to break the fall and, in doing so, often breaks the radius, ulna, or clavicle, or dislocates the shoulder.

Twisting or rotational forces

can cause stretching or tearing of muscles and ligaments, as well as broken bones, such as occur when a ski digs into the snow while the skier's body rotates. Sporting activities such as football, basketball, soccer, in-line skating, skiing, snowboarding, and wrestling—in addition to motor-vehicle collisions—account for many musculoskeletal injuries. a rapid deceleration causes the knees
to strike the dash of a car; a fall on ice causes a twisting force to the ankle

direct force

is a person being struck by an automobile, causing crushed tissue and fractures.

Traction splints come in two basic varieties

bipolar and unipolar

the half-ring splint, Hare, and Fernotrac

A bipolar splint cradles the leg between two metal rods

the Sager and the Kendrick traction devices

a unipolar splint has a single metal rod that is placed
alongside the leg

The indications for a traction splint

are a painful, swollen, deformed mid-thigh with no joint or lower leg injury.A traction splint is contraindicated if there is a pelvis, hip, or knee injury; if there is an avulsion or partial amputation where traction could separate the extremity;or if there is an injury to the lower third of the leg that would interfere with the ankle hitch.

angulated fracture

fracture in which the broken bone segments are at an angle to each other.

bones

hard but flexible living structures that provide support for the body and protection to vital organs.

cartilage

tough tissue that covers the joint ends of bones and helps to form certain body parts such as the ear.

closed extremity injury

an injury to an extremity with no associated opening in the skin.

comminuted fracture

...

Shoulder girdle injuries (pp. 717-718)
b. Pelvic injuries (pp. 718-720)
c. Hip dislocation (pp. 720-721)
d. Hip fracture (pp. 721-723)
e. Femoral shaft fracture (pp. 723-724)
f. Knee injury (p. 724)
g. Tibia or fibula injury (pp. 725-726)
h. Ankle or foot injury (pp. 726-727)

...

angulated fracture, p. 706
bones, p. 696
cartilage, p. 702
closed extremity injury,
p. 706
comminuted fracture, p. 706 compartment syndrome,
p. 708
crepitus, p. 708
dislocation, p. 706
extremities, p. 696
fracture, p. 706 greenstick fracture, p. 706
joints, p. 696
ligaments, p. 702
manual traction, p. 710
muscles, p. 702
open extremity injury, p. 706 sprain, p. 706
strain, p. 706
tendons, p. 702
traction splint, p. 705

...

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