Immobilization I
Immobilization (lat. immobilis motionless)
creating immobility (rest) of any part of the body in case of certain injuries (bruises, wounds, dislocations, etc.) and diseases. A distinction is made between transport and medical I. Transport I. is carried out, as a rule, at the outpatient stage of treatment with the help of special means, standard (produced by industry) and improvised (from improvised materials). Therapeutic I. requires the use of special, sometimes quite complex devices (for example, compression-distraction devices). It is performed both in outpatient and inpatient settings. Transport I. is understood as temporary immobilization of the affected area of the body for the period of transportation of the victim (usually until medical institution). The most common for transport I. - bones, extensive soft tissues, deep, damage to large blood vessels and nerve trunks, some acute inflammatory processes (for example, deep thigh). In case of bone fractures, transport I. prevents secondary bone fragments and perforation of the skin. By ensuring the immobility of bone fragments and reducing trauma to soft tissues in the fracture area, it avoids increased pain and prevents the development of traumatic shock. In addition, transport I. serves to prevent damage to blood vessels and, consequently, bleeding, nerve trunks, fat embolism, as well as the development and spread of infection in the wound. For extensive soft tissue injuries and deep burns, as well as for acute inflammatory processes on the extremities, transport I. reduces, prevents the development of traumatic shock and the spread of infection. In case of damage to large blood vessels, it reduces the risk of thromboembolism and re-bleeding. I.'s technique is determined by the characteristics of the pathological process and the conditions in which it is carried out. At the scene of an incident, in the absence of standard (service) tires, improvised tires (sticks, boards, etc.) are used. You can immobilize the injured arm by tying it to the body, and the injured leg to the healthy one. Standard tires are used in accordance with their purpose and design (see Splinting) .
In case of spinal injuries, the victim is placed on a hard surface (board), which prevents mobility in the area of the fracture and injury. spinal cord. In case of pelvic fractures, the victim is placed on a hard surface, his hips are separated, and a bolster is placed under his knees. This promotes maximum relaxation of the pelvic muscles, prevents secondary displacement of bone fragments and trauma to the pelvic organs. When performing transport I., two basic principles are observed: the principle of external fixation of a limb segment with the obligatory exclusion of movements in two or three joints adjacent to the area of injury, and the principle of traction of the damaged limb segment. When using means of transport, I. are guided by the following rules: immobilization is carried out as quickly as possible early dates; the victims are first given painkillers; transport splints are applied over clothing and shoes or on a bare surface, in the latter case protecting the bony protrusions (ankle bones, iliac crests, humeral condyles, etc.) with a cotton pad; before fixing the limbs with a splint, aseptic precautions are applied to open fractures and wounds; a hemostatic tourniquet, if necessary, must be applied in such a way that it can be removed without disturbing the I. (the hemostatic tourniquet cannot be covered with a splint or bandage); transport splints are secured to the limbs with soft bandages throughout. Errors when performing transport I. lead to severe complications. Unreasonably short transport tires are ineffective. A common mistake is less than two joints adjacent to the damaged segment of the limb, or the application of rigid standard splints without first wrapping them with cotton wool and gauze. Insufficient fixation of the splints with a soft bandage along the entire length of the limb leads to the formation of constrictions, compression and disruption of blood supply. Therapeutic I. is most often used for the treatment of fractures in order to create immobility of bone fragments until they heal and form callus. The principles and rules for the implementation of therapeutic I. are the same as for transport immobilization. The means of medical treatment are varied. IN outpatient practice I. is often carried out using plaster and soft tissue bandages (for example, for fractures without displacement or with slight displacement of fragments). One of the most common types of therapeutic surgery are plaster casts, cribs, corsets, and splints (see Plaster equipment) .
Plaster is well modeled and relatively easily tolerated by patients. Despite numerous attempts to replace plaster cast various plastic splints, it still remains the simplest and most reliable method. The disadvantage of a plaster cast is that it contributes to the development of joint stiffness and muscle wasting in the affected limb. This can be compensated to a large extent by early administration. therapeutic exercises and physiotherapy. Another type of therapeutic I. is Traction ,
which eliminates the displacement of bone fragments and fixes them in the achieved position for the period necessary for healing of the fracture. The disadvantage of this method of immobilization is long term the patient's stay in bed. A type of therapeutic I. is the fixation of bone fragments with various metal or plastic structures (knitting needles, screws, pins, plates, etc.) inserted intraosseously or extraosseously (see Osteosynthesis) .
The disadvantage of this type of therapeutic And. is the need reoperation to remove the structure, as well as the possibility of suppuration after surgery. The methods of therapeutic surgery also include the rapidly developing method of compression-distraction osteosynthesis. Its essence lies in the fact that with the help of special devices and knitting needles, mutual pressure or stretching of bone fragments is created, as well as their fixation until the fracture heals (see Distraction-compression devices) .
Splints made of various plastic materials (polymer, polyethylene, foamed polyethylene, etc.) are widely used as therapeutic I. Bibliography: Rusakov A.B. Transport immobilization, M., 1975; Tkachenko S.S. and Shapovalova M. Rendering first aid in case of damage to the musculoskeletal system, p. 53, L., 1984; Shestakova N.A. and Malkis A.I. , With. 63, T., 1981. creating immobility (immobility) of a limb or other part of the body during damage, inflammatory or other painful processes, when the damaged (sick) organ or part of the body needs. It can be temporary, for example, for the period of transportation to a medical facility, or permanent, for example, to create the conditions necessary for the fusion of fragments, wound healing, etc. Permanent immobilization, often called therapeutic, is carried out (less commonly). The most common method of such I. is the application of a plaster cast. There are many other methods of I., for example, using special orthopedic devices, pneumatic tires, which are inflated, devices for connecting bones, axial traction injured limb behind a bracket with a needle passed through it (the so-called skeletal). Transport I. is one of the most important first aid measures for dislocations, fractures, wounds and other severe injuries. It should be carried out at the scene of the incident in order to protect the damaged area from additional trauma during the delivery of the victim to a medical facility, where this temporary immobilization, if necessary, is replaced with one or another permanent immobilization. Carrying and transporting victims without immobilization, especially those with fractures, is unacceptable, even over a short distance, because this can lead to increased displacement of bone fragments, damage to nerves and blood vessels located next to the moving bone fragments. With large wounds of soft tissue, as well as with open fractures, I. of the damaged part of the body is prevented rapid spread infections, with severe burns (especially of the extremities) contributes to a less severe course in the future. Transport I. occupies one of the leading places in the prevention of such a formidable complication of severe injuries as. At the scene of an incident, it is most often necessary to use improvised means for I. (for example, boards, branches, sticks, skis), to which the damaged part of the body is fixed (bandaged, strengthened with bandages, belts, etc.). Sometimes, if there are no available means, you can ensure sufficient immobilization by pulling the injured arm to the body, hanging it on a scarf, and in case of a leg injury, bandaging one leg to the other ( rice.
). The main method of I. of an injured limb during the period of transportation of the victim to a medical institution is. There are many different standard transport splints that are usually applied medical workers, such as ambulance services. However, in most cases of injury, you have to use so-called improvised splints, which are made from scrap materials. It is very important to carry out transport I. as early as possible. The splint is placed over clothing. It is advisable to wrap it with cotton wool or some other soft cloth, especially in the area bony protrusions(ankles, condyles, etc.), where the pressure exerted by the tire can cause abrasion and bedsores. If there is a wound, for example in cases open fracture It is better to cut limbs, clothes (you can cut them at the seams, but in such a way that everything becomes easily accessible). Then a sterile bandage is applied to the wound and only after that immobilization is carried out (the belts or bandages securing the splint should not put too much pressure on the wound surface). At heavy bleeding from the wound, when there is a need to use a hemostatic tourniquet (hemostatic tourniquet), it is applied before splinting and is not covered with a bandage. You should not overtighten the bandage (or its substitute) in separate rounds for “better” fixation of the splint, because This may cause circulatory or nerve problems. If, after transporting the splint, it is noticed that a constriction has occurred, it must be cut or replaced by applying the splint again. In winter or in cold weather, especially during long-term transportation, after splinting, the damaged part of the body is wrapped warmly. When applying improvised splints, you must remember that at least two joints located above and below the damaged area of the body must be fixed. If the splint does not fit well or is not sufficiently fixed, it does not fix the damaged area, slips and can cause additional injury. creating complete immobility or reduced mobility of one or more parts of the body in case of damage and certain diseases. Transport immobilization- I., created during the transportation of the patient.
1. Small medical encyclopedia. - M.: Medical encyclopedia. 1991-96 2. First aid. - M.: Great Russian Encyclopedia. 1994 3. Encyclopedic Dictionary of Medical Terms. - M.: Soviet Encyclopedia. - 1982-1984.
See what “Immobilization” is in other dictionaries:
- (lat.). Immobility of any part of the body, achieved by applying appropriate bandages. Dictionary of foreign words included in the Russian language. Chudinov A.N., 1910. IMMOBILIZATION 1) in medicine. bringing Ph.D. organ into perfect rest, in... Dictionary of foreign words of the Russian language
- (from Latin immobilis immovable): in medicine, as a section of Desmurgy, studies the rules of treating wounds, dressings and methods of applying them. in economics: Immobilization of working capital, diversion, withdrawal by an enterprise, firm, company... Wikipedia
Immobilization- inclusion of transuranium radioactive waste into embedded elements (transforming them into a long-term, inert physicochemical form that is stable with respect to radiation and thermal effects) and placement of embedded elements in glass melt, representing... ... Dictionary-reference book of terms of normative and technical documentation
Immobilization- using improvised means. Immobilization using available means: a, b for a spinal fracture; c, d hip immobilization; d forearms; e collarbone; f shins. Immobilization creating immobility... ... First aid - popular encyclopedia
IMMOBILIZATION, immobilization, pl. no, female (from Latin immobilis immovable). 1. In surgery, immobilizing some part of the body. Immobilization of the leg using a plaster cast. 2. Transformation ( working capital) in the main... ... Ushakov's Explanatory Dictionary
immobilization- and, f. immobilization f. lat. immobilis motionless. 1. In surgery, giving a fixed position to what n. body parts. I. legs with a plaster cast. Ush. 1934. 2. econ. Converting working capital into fixed capital. I. capital. Ush. 1934.… … Historical Dictionary of Gallicisms of the Russian Language
IMMOBILIZATION- IMMOBILIZATION, or the creation of conditions of rest and immobility, has its greatest indications in relation to the organs of movement and the spine. I. has long been used for fractures of the limbs, until its value was shaken by the opposite... ... Great Medical Encyclopedia
- (from Latin immobilis motionless) healing method creating immobility of a body part, limb in case of bone fractures, joint diseases, extensive wounds etc. Achieved by applying bandages and splints, as well as traction... Big Encyclopedic Dictionary
A process used to secure enzymes, cells, or fragments thereof to a solid support. I. is achieved by imprisonment in semi-permeable membranes; encapsulation in a polymer material; adsorption onto charged or porous media; covalent... ... Dictionary of microbiology
Immobilization of the upper limb is carried out in the presence of signs of shoulder fractures and damage to adjacent joints, burns, injuries large vessel(brachial artery).
Immobilization with a ladder splint is the most effective and reliable way transport immobilization for shoulder injuries.
The splint should cover the entire injured limb - from the shoulder blade of the healthy side to the hand on the injured arm and at the same time protrude 2-3 cm beyond the fingertips. Immobilization is performed with a 120 cm long ladder splint. The upper limb is immobilized in the position of slight anterior and lateral abduction of the shoulder. To do this, a ball of cotton wool is placed in the axillary area on the side of the injury, elbow joint bent at a right angle, the forearm is positioned so that the palm of the hand faces the stomach. A cotton roller is placed into the brush (Fig. 1).
Rice. 1. Position of the fingers when immobilizing the upper limb
Preparing the tire (Fig. 2):
Measure the length from the outer edge of the victim’s shoulder blade to shoulder joint and bend the tire at an obtuse angle at this distance;
Measure the distance from the upper edge of the shoulder joint to the elbow joint along the back surface of the victim’s shoulder and bend the splint at this distance at a right angle;
The person providing assistance additionally bends the splint along the contours of the back, back of the shoulder and forearm.
It is recommended to bend the part of the splint intended for the forearm into the shape of a groove.
Having tried the curved splint on the victim’s healthy arm, the necessary corrections are made.
If the tire is not long enough and the brush hangs down, its lower end must be extended with a piece of plywood tire or a piece of thick cardboard. If the length of the tire is excessive, its lower end is bent.
Two gauze ribbons 75 cm long are tied to the upper end of the splint wrapped in gray cotton wool and bandages (Fig. 3).
The splint prepared for use is applied to the injured arm, the upper and lower ends of the splint are tied with braids and the splint is strengthened with bandages. The arm along with the splint is suspended on a scarf or sling (Fig. 4).
Rice. 4. Transport immobilization of the entire upper limb with a ladder splint:
a – applying a splint to the upper limb and tying its ends; b – strengthening the splint with bandaging; c – hanging a hand on a scarf
To improve fixation of the upper end of the splint, two additional pieces of bandage 1.5 m long should be attached to it, then pass the bandage around the shoulder joint of the healthy limb, make a cross, circle it around the chest and tie it (Fig. 5).
Rice. 5. Fixation of the upper end of the ladder splint when immobilizing the upper limb
In the absence of standard tires immobilization is carried out using a medical scarf, improvised means or soft bandages. Immobilization with a medical scarf. Immobilization with a scarf is carried out in the position of slight anterior abduction of the shoulder with the elbow joint bent at a right angle. The base of the scarf is wrapped around the body about 5 cm above the elbow and its ends are tied on the back closer to healthy side. The top of the scarf is placed upward on the shoulder girdle of the injured side. The resulting pocket holds the elbow joint, forearm and hand. The top of the scarf on the back is tied to the longer end of the base. The damaged limb is completely covered by a scarf and fixed to the body. Immobilization using improvised means. Several planks and a piece of thick cardboard in the form of a trench can be laid on the inner and outer surfaces of the shoulder, which creates some immobility during a fracture. The hand is then placed on a scarf or supported by a sling. Immobilization with Deso bandage. In extreme cases, immobilization for shoulder fractures and damage to adjacent joints is carried out by bandaging the limb to the body with a Deso bandage. Correctly performed immobilization of the upper limb significantly alleviates the condition of the victim and special care during evacuation, as a rule, it is not required. However, the limb should be periodically examined so that if swelling in the area of injury increases, compression does not occur. To monitor the state of blood circulation in peripheral parts limbs, it is recommended to leave the end phalanges of the fingers unbandaged. If signs of compression appear, the bandage should be loosened or cut and bandaged.
Transportation is carried out in a sitting position, if the condition of the victim allows.
Immobilization with a ladder splint is the most reliable and efficient look transport immobilization for forearm injuries. The ladder splint is applied from the upper third of the shoulder to the fingertips, the lower end of the splint stands at 2–3 cm. The arm should be bent at the elbow joint at a right angle, and the hand should be facing the stomach and slightly retracted to the back; a cotton swab should be placed in the hand. a gauze roller to hold the fingers in a semi-flexed position (Fig. 6a).
Rice. 6. Transport immobilization of the forearm: a – with a ladder splint; b - using improvised means (using planks)
A ladder splint 80 cm long, wrapped in gray cotton wool and bandages, is bent at a right angle at the level of the elbow joint so that the upper end of the splint is at the level of the upper third of the shoulder; the section of the splint for the forearm is bent in the form of a groove. Then they apply it to the healthy hand and correct the defects of the modeling. The prepared splint is applied to the sore arm, bandaged along its entire length and hung on a scarf. Upper part The splint intended for the shoulder must be of sufficient length to reliably immobilize the elbow joint. Insufficient fixation of the elbow joint makes immobilization of the forearm ineffective. In the absence of a ladder splint, immobilization is carried out using a plywood splint, a plank, a scarf, a bundle of brushwood, and the hem of a shirt (Fig. 6 b).
TEST CONTROL QUESTIONS 20. BELOW 5 OUT OF 20 QUESTIONS.
1. The shoulder girdle has:
1. two areas;
2. three areas;
3. four areas.
2. Upper limit of the shoulder:
1. bottom edge is large pectoral muscle;
2. the lower edge of the latissimus dorsi muscle;
3. a horizontal line drawn along the lower edge of the pectoralis major muscle and the latissimus dorsi muscle.
3. Maximum terms, on which a tourniquet can be applied in the warm season:
1. no more than 120 minutes;
2. no more than 90 minutes;
3. no more than 60 minutes.
4. To support the injured upper limb after application soft bandage or transport immobilization bandages are used:
1. Deso bandage;
2. scarf bandage for suspending the upper limb;
3. converging tortoiseshell bandage.
5. For hand injuries, use:
1. converging turtle bandage;
2. spiral ascending bandage;
3. scarf.
1. If your fingers and hands are damaged, you can use a small ladder splint, a plank or a plywood splint.
2. For injuries in the area of the wrist joint and forearm, immobilization
3. For injuries in the area of the elbow joint, shoulder and shoulder joint, a large scale splint is best for immobilization.
Fig.6 Fig.7
The position of the limb is brought towards the body and slightly extended forward (a small abductor roller can be used in the axillary region). Length of immobilization: from the metacarpophalangeal joints (base of the fingers) to the scapula of the healthy side. The splint is modeled on itself by the one who applies it (Fig. 6). Two bands of bandage are tied to the upper end of the splint: one is passed through the shoulder girdle, the other through armpit healthy side and tied to the lower end of the splint. These bands provide preliminary fixation of the splint and prevent its upper end from moving towards the back of the head (Fig. 7). The splint is secured with bandage bandages (spiral, tortoiseshell, spica), its lower end and hand are hung on a belt, strap or scarf.
Immobilization of the lower limb
1. Immobilization for a tibia fracture is carried out in upright position legs or slight flexion at the knee joint. The foot is fixed in dorsiflexion at a right angle to the shin. An exception to this situation may be a wound to the calf muscle, where, in order to reduce pain, a slight flexion of the foot can be maintained. It is advisable to use at least 2 splints applied in 2 planes for immobilization. Wooden splints are placed on both the outer and inner surfaces of the leg, and ladder splints - one on the back, the other on the outer surface. If 3 splints are used, the last one is placed on the back of the leg, preferably a ladder splint (Fig. 8).
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2. Transport immobilization for injuries of the knee and hip joints and femur is usually carried out using a Dieterichs splint; in addition, there are other splints (Goncharov, Thomas-Vinogradov, etc.)
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1. Before applying the splint, adjust it according to height, with the lower ends of the crutches protruding beyond the “sole” by 15-20 cm.
2. The fitted crutches are tied with bandages at the level of the pegs.
3. The plantar part of the splint is fixed to the foot with a figure-of-eight bandage, carefully strengthening the heel area.
4. The lower ends of the crutches are passed through the metal eye of the plantar part of the splint and applied to the lateral surfaces of the limb and torso.
5. Place cotton wool in the area of the protrusions of the greater trochanter and knee joint.
6. The splint is attached to the body with scarves or belts threaded through the slots of the crutches on the lower leg, thigh, abdomen and chest.
7.The ends of the twist laces are threaded through the hole in the transverse strap of the inner branch and inserted into the rings of the sole, brought back through the hole of the strap and tied around the twist.
8. The leg is pulled out by the foot until the transverse bars of the branches rest against the groin and armpit.
9.After traction, the splint is fixed along the entire length of the limb with circular rounds of bandage.
To improve fixation, a ladder or plywood splint with thick pads is placed under the back surface of the leg and pelvis in the area of the popliteal cavity and Achilles tendon. Under favorable conditions, the Dieterichs splint can be reinforced with plaster rings.
Transport immobilization for spinal fractures in the cervical and upper thoracic regions is carried out on the back with a bolster under the neck. The most reliable immobilization for severe, especially multiple fractures can be performed using immobilizing vacuum stretchers (Fig. 11, 12).
Fig. 11. Preparation for immobilization Fig. 12. Lacing the cover
using NIV-2
Transport immobilization in case of damage to the thoracic and lumbar spine and transportation must be carried out on a rigid stretcher. The victim is placed on a stretcher and secured together with a solid pad to the stretcher. A small cushion is placed under the knees, and if paraplegia is present, a rubber inflatable or cotton-gauze circle is placed under the sacrum.
If the victim has to be transported on a regular soft stretcher, then he should be laid on his stomach, which ensures some extension of the spine. Some kind of cushion (coat, etc.) is placed under the chest. In case of gunshot wounds of the spine, lordosis should not be created, but it is better to place the victim flat on his stomach.
For pelvic fractures, the victim can be transported on a regular stretcher, but preferably on a rigid stretcher. Legs should be bent at the knees and hip joints, for which a cushion is placed under the victim’s knees. The victim must be secured to the stretcher.
Currently, the Kashtan anti-shock pneumatic suit is used in the prehospital and early hospital stages (Fig. 13).
The pneumatic anti-shock fixation suit "Kashtan" is intended for emergency use to prevent and relieve hypovolemic shock at the prehospital and resuscitation stages. The action of the suit is based on the principle of controlled circular external pressure. When inflated, controlled pressure in the suit (up to 100 mm Hg) redistributes blood from the lower extremities and abdomen to the heart and vital organs of the upper half of the body. Simultaneously with Thus, external pneumatic compression often helps to stop the fluid, significantly reduce internal and external bleeding, and also provides stable immobilization of fractures lower limbs and pelvis.
Indications for use are:
1. Systolic blood pressure 100 mm Hg, accompanied by symptoms of shock (pallor, cyanosis, cold sticky sweat, tachycardia, tachypnea) or systolic pressure below 80 mm Hg, regardless of the cause, serve as absolute indications for the use of the suit, provided there are no contraindications.
2. Traumatic shock II - IV degree with multiple fractures and amputations of the lower extremities, pelvic fractures.
3. Internal and external bleeding of the lower half of the body: internal abdominal bleeding as a result of blunt or penetrating abdominal trauma; postpartum, uterine, gastrointestinal bleeding; bleeding or ruptured abdominal aortic aneurysms.
Contraindications:
1. Respiratory failure as a result of pulmonary edema, tension hemopneumothorax.
2. Massive uncontrolled bleeding of the upper half of the body.
3. Loss internal organs.
4. Cardiac tamponade, acute heart failure, cardiogenic shock.
5. Pregnancy (due to the threat of miscarriage).
If there are contraindications, you cannot inflate only the abdominal section of the suit, but you can inflate the leg and pelvic sections.
Sticks, boards, skis and any similar objects can be used as improvised means for transport immobilization. When immobilizing with these objects, it should be borne in mind that they are hard, inflexible and cannot be modeled on the surface on which they are applied. Therefore, improvised means should be applied only to the outer and inner surfaces of the limb, always with soft pads in the area of the ankles and knee joint. Available means, like standard ones, should immobilize 2 joints - above and below the fracture.
If there are no means at hand to carry out transport immobilization, then the injured arm can be immobilized with a jacket, bandaged to the chest, and the leg is fixed to the other, healthy leg (Fig.). Leg-to-leg immobilization is a last resort and is not very reliable for hip fractures, especially in the middle and upper third.
STOPPING BLEEDING (HEMOSTASIS).
With almost any injury, blood vessels are injured. In this case, bleeding varies in intensity and depends on the type and nature of the damaged vessel.
Anatomically distinguish:
Arterial bleeding characterized by intense blood loss. The blood is bright red (scarlet) in color and flows in a pulsating stream under high pressure. If large vessels (aorta, femoral artery, etc.) are damaged, blood loss that is incompatible with life may occur within a few minutes.
Venous bleeding. The blood is dark cherry in color and flows out slowly, evenly, in a continuous stream. This bleeding is less intense than arterial bleeding and therefore less likely to lead to irreversible blood loss. However, it must be taken into account that if, for example, the veins of the neck and chest are injured, air may enter their lumen at the moment of inhalation. Air bubbles entering the heart through the bloodstream can cause an air embolism and cause death.
Capillary bleeding observed when superficial wounds, shallow skin cuts, abrasions. Blood flows out slowly from the wound drop by drop, and with normal clotting, the bleeding stops on its own.
Mixed bleeding occurs when arteries and veins are simultaneously injured, most often with deep wounds.
Parenchymal bleeding in case of damage to parenchymal organs (liver, spleen, kidneys), which have a developed network of arterial and venous vessels, the walls of which do not collapse when damaged.
By time of occurrence:
1.primary
2.secondary
Early (from several hours to 5 days)
Late (after 5 or more days)
In relation to the external environment:
1.external (if blood flows outside the body)
2. internal (if blood accumulates in cavities and tissues)
Open - if the cavity has an anatomical connection with environment(nasal, pulmonary, uterine, gastric, intestinal)
Closed – if the cavity has no anatomical connection with the environment (hemothorax, hemoperitoneum, hemarthrosis, hematoma)
3.intrastitial
Petechiae - small hemorrhages in the skin
Ecchymoses - pinpoint hemorrhages in the skin
Hematomas are accumulations of blood in tissues and organs.
According to the clinical course:
Chronic
By intensity:
Profuse
Moderate
A distinction is made between temporary and permanent stopping of bleeding.
Temporary stop of bleeding used when providing first aid and first aid. It can be achieved by pressing the damaged vessel in the wound or along it, by maximally bending and fixing the limb in this position, by applying a pressure bandage, by giving an elevated position to the damaged part of the body, by applying a hemostatic tourniquet (twist) and a clamp on the vessel.
Pressing the vessel along its length is carried out by squeezing the bleeding vessel above the site of bleeding when an artery is injured and below when a vein is injured. Pressing with a finger (fingers) on the underlying bone formations is carried out in case of damage to large arterial or venous vessels, when it is necessary to immediately stop the bleeding and gain time to prepare for stopping the bleeding in other ways that allow transporting the victim. Besides, finger pressure a bleeding vessel requires significant effort; even a physically strong person can perform this procedure for no more than 15-20 minutes.
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For every major arterial vessel there are typical places where it is pressed with fingers (Fig. 10). However, stopping bleeding with finger pressure should be replaced as quickly as possible by pressing the bleeding vessel in the wound with a tight tamponade, squeezing it with a clamp or applying a tourniquet. If digital pressure on a bleeding vessel can be performed as a form of mutual aid, then tight wound tamponade should only be performed by a doctor. A tampon that has tightly filled the wound must be secured on top with a pressure bandage. It should be remembered that tight tamponade is contraindicated for wounds in the popliteal fossa, as it often leads to gangrene of the limb. |
Fig.10 (1-temporal, 2-mandibular, 3-carotid, 4-subclavian, 5-axillary, 6-brachial, 7-ulnar, radial, 8-femoral, 9-popliteal, 10-dorsalis pedis)
The fastest way to temporarily stop arterial bleeding is to apply a hemostatic tourniquet. This manipulation is indicated only for massive arterial (not venous!) bleeding from the vessels of the limb. In the absence of an elastic rubber band, you can and should use available material: a rubber tube, a towel, a belt, a rope. The tourniquet is applied above (central) the bleeding site and as close to the wound as possible (Fig. 11).
The tourniquet is applied as follows:
the place where the tourniquet is supposed to be applied is wrapped in a towel, a piece of cloth, or several layers of bandage;
the tourniquet is stretched and made 2-3 turns around the limb along the specified substrate, the ends of the tourniquet are secured either with a chain and hook, or tied with a knot;
the limb should be tightened until the bleeding stops completely;
the time of application of the tourniquet must be indicated in a note attached to the victim’s clothing, as well as in medical documents accompanying the victim.
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With a correctly applied tourniquet, bleeding from the wound stops and the peripheral pulse in the limb cannot be detected by palpation. You should know that the tourniquet can be kept for no more than 2 hours on the lower limb and no more than 1.5 hours on the shoulder. During the cold season, these periods are reduced. A longer stay of the limb under the tourniquet can lead to its necrosis. It is strictly forbidden to apply bandages over the tourniquet. The tourniquet should be positioned so that it is conspicuous. After applying a tourniquet, the victim must be immediately transported to a medical facility to completely stop the bleeding. If evacuation is delayed, then after the critical time for the tourniquet to partially restore blood circulation, it is necessary to remove or loosen it for 10-15 minutes, and then reapply it slightly higher or lower than the place where it was located. During the period of freeing the limb from the tourniquet, arterial bleeding is prevented by pressing the artery with fingers along its length. Sometimes the procedure for loosening and applying a tourniquet has to be repeated: every 30 minutes in winter, every 50-60 minutes in summer. |
Fig.11 Places of overlap
hemostatic tourniquet to stop bleeding from the arteries. 1-foot; 2-shin and knee joint; 3-hands and forearms; 4-shoulder and elbow joint; 5-neck and head; 6-shoulder joint and shoulder; 7-hips.
To stop arterial bleeding, you can use the so-called twist from improvised means (belt, scarf, towel). When applying a twist, the material used should be loosely tied at the required level and form a loop. A stick is inserted into the loop and, rotating it, twisted until the bleeding stops. After which the specified stick is fixed. It must be remembered that applying a twist is quite painful procedure, and possible skin pinch. To prevent pinching of the skin when twisting and to reduce pain, place some kind of dense pad under the knot. All rules for applying a twist are similar to the rules for applying a tourniquet.
To temporarily stop bleeding at the scene of an accident, it is sometimes possible to successfully apply sharp (maximum) flexion of the limb with subsequent fixation in this position. This method of stopping bleeding is advisable to use in cases of intense bleeding from wounds located at the base of the limb. Maximum flexion of the limb is performed in the joint above the wound and the limb is fixed with bandages in this position. So, when the forearm and lower leg are wounded, the limb is fixed in the elbow and knee joints; in case of bleeding from the vessels of the shoulder, the arm should be pulled all the way behind the back and fixed; if the thigh is wounded, the leg is bent in hip and knee joints and the thigh is fixed in a position adducted to the stomach.
Often the bleeding can be stopped with a pressure bandage. Several are applied to the wound sterile wipes, over which a thick roll of cotton wool or bandage is tightly bandaged.
To temporarily stop venous bleeding, in some cases it is effective to create an elevated position by placing a pillow, a roll of clothing or other suitable material under the injured limb. This position should be given after applying pressure bandage on the wound. It is advisable to place an ice pack and a moderate weight, such as a bag of sand, on top of the bandage on the wound area.
Final stop bleeding carried out in the operating room, ligating the vessel in wound or throughout, suturing the bleeding area, applying a temporary or permanent shunt.
ANESTHESIA
Pain relief for bone fractures and associated injuries has the following goals:
eliminate pain impulses;
minimize negative consequences psycho-emotional stress;
prevent or normalize neuroendocrine disorders that occur in response to severe mechanical damage.
Methods and means of prehospital anesthesia have a number of specific features and the following requirements must be met:
high analgesic and hypnotic activity of the drugs used;
quickly occurring and quickly passing action;
sufficient simplicity and reliability of the methods used;
greater therapeutic breadth and absence of pronounced side effects.
It is important that the duration of any pain management method used for trauma in the prehospital phase does not exceed the time required to complete evacuation from the scene and transport the patient to a medical facility. This is due to the fact that the presence of spontaneous reflex activity remains the basis for making a correct diagnosis.
For pain relief in emergency conditions, in addition to immobilization and rational positioning of the patient, analgesics, hypnotics, inhalational and intravenous anesthetics are fundamentally applicable.
Most often, narcotic (opioid) analgesics are used for pain relief for injuries in the prehospital stage.
The reference opioid is traditionally considered to be M orphin. Its main effect, analgesic, develops against the background of preserved consciousness. The average dose is 1-2 ml of a 1% solution, however, morphine has a number of side effects, such as dose-dependent depression of the respiratory center, nausea, and vomiting. They try to avoid respiratory depression by observing the recommended dosages of the drug; nausea and vomiting are stopped by administering metoclopramide.
In emergency situations, P is widely used and available. romedol. In terms of analgesic activity, the drug is approximately 10 times inferior to morphine, but depresses the respiratory center to a lesser extent. The average dose is 1-2 ml of a 2% solution. Preference is given to the intravenous route of administration of the drug, since in conditions of shock absorption from subcutaneous tissue and muscles are slow.
Drugs from the group of opioid agonists-antagonists or partial agonists of opioid receptors are quite widely used. The main distinctive feature of drugs in this group is that the analgesic effect and respiratory depression increase with increasing dose up to a certain level, and then change little (plateau effect). A prominent representative of the group of agonists-antagonists is Nalbuphine(nubain). The drug is characterized by a distinct analgesic, sedative effect and a limited inhibitory effect on breathing. Nalbuphine can be combined, if necessary, with midazolam or etomidate for ultra-short anesthesia during manual simultaneous reposition of bone fragments.
Easy to use herd, which is 5 times superior to morphine in analgesic activity (used in a dose of 2-4 mg). Stadol is not on the official list of drugs subject to strict control and is an opioid that can be prescribed for traumatic brain injury.
For minor damage, use is indicated. Tramalol(tramal) at a dose of 50-100 mg. The analgesic effect lasts for 2.5-3 hours, the drug does not suppress external respiration, and does not have a significant effect on central and peripheral hemodynamics.
It must be remembered that any analgesic used at the prehospital stage can mask the clinical appearance of intracavitary injuries. Therefore, before making a decision about their introduction, it is necessary to reliably exclude an intra-abdominal catastrophe.
In cases of excessive pain of certain types of injuries (burns of the face, hands), narcotic analgesics are added Diazepam (relanium) at a dose of 5-10 mg, midazolam(flormidal, dormicum) at a dose of 0.15 mg/kg or a non-narcotic analgesic (analgin, ketorolac).
Inhalational anesthetics are not used so often in the prehospital setting, but they have one important advantage - their effect is easily dosed and controlled, which makes it possible to correct the diagnosis when delivering the victim to the hospital at a minimum level of analgesia.
Previously, the most often used in ambulances was Z nitrous oxide. When mixed with oxygen (1:2, 1:3), nitrous oxide has a slight negative effect on hemodynamics, but often causes strong stimulation, which is extremely undesirable in case of injury due to the danger of displacement of bone fragments, secondary damage to large vessels and nerves. In addition, this anesthetic has a small breadth of therapeutic action, which requires some experience of the anesthesiologist when working with it.
Ftorotan It has properties that are valuable for anesthesia precisely at the prehospital stage: a powerful anesthetic effect, rapid switching off of consciousness, and the absence of a masking effect on the clinical picture of abdominal injuries. However, its use requires a special evaporator, which must be carefully calibrated. In addition, the use of fluorotane has several more negative aspects: a small breadth of therapeutic action, the need for preliminary administration of atropine, the risk of serious heart rhythm disturbances (tachycardia, fibrillation).
Methoxyflurane (pentran, inhalan) has a good analgesic effect for injuries. For its inhalation, a special evaporator (Analgizer, AP-1) has been designed, convenient for pre-hospital anesthesia. The device is used for autoanalgesia. The method is extremely simple (the “smoking pipe” principle), safe and associated with a small consumption of anesthetic (15 ml for 2-2.5 hours). The evaporator is secured to the patient's wrist with a loop of ribbon. With the onset of anesthesia sleep and muscle relaxation, the hand and the device fall down and self-analgesia is interrupted until the moment of awakening. With this technique, an overdose of methoxyflurane is excluded. After stopping inhalation of anesthetic vapors, pain sensitivity remains reduced for 8-10 minutes. The main disadvantage of autoanalgesia with methoxyflurane for prehospital analgesia is the late stages of its development - 5-12 minutes after the start of inhalation.
The method of inhalation autoanalgesia can be used when removing a victim from under a rubble or from a damaged vehicle, when performing transport immobilization of fractures and applying bandages to burned surfaces, less often during transportation.
Among intravenous anesthetics used at the prehospital stage Ketamine, which is used here not as an anesthetic agent, but as an analgesic, therefore doses of ketamine should not exceed 0.5 mg/kg at intravenous administration and 1.5 mg/kg intramuscularly. The administration of ketamine in recommended doses for bone fractures, closed injuries, wounds and burns is accompanied by either complete disappearance or a sharp decrease in pain without a noticeable effect on the state of consciousness. Sometimes doubtfulness and disorientation develop, which, as a rule, disappear by the time of delivery to the hospital. Ketamine is the drug of choice for hypovolemic conditions, because it does not reduce blood pressure, and often even slightly increases it. In small doses (up to 0.5 mg/kg), ketamine does not increase intracranial pressure, therefore, it can also be used for traumatic brain injuries. Relative contraindications to its use are alcohol intoxication and concomitant hypertension. Sometimes, when using ketamine, psychomotor agitation develops, which is relieved with diazepam at a dose of 0.15-0.3 mg/kg.
In recent years, hypnotic therapy has become widespread in the prehospital stage. Etomidate (hypnomidate), which is characterized by its rapid action and insignificant effect on hemodynamics. It is administered once in a dose of 0.2 - 0.3 mg.
Local anesthesia in its various variants specifically and reliably suppresses pain reactions: superficial, infiltration, regional.
With a purpose local anesthesia sometimes used novocaine blockades fracture sites (40 - 80 ml of 0.5% novocaine solution in the area of each fracture).
Intercostal nerve block indicated for rib fractures and severe bruises of the chest. It is performed with the patient lying on his back or on the healthy side. After anesthesia of the skin, the needle is inserted until it comes into contact with the surface of the lower edge of the rib. With a slight advance deeper, the end of the needle enters the area of the neurovascular bundle, where 10-30 ml of a 0.25% novocaine solution is injected.
Brachial plexus block indicated for upper limb injury. It is performed with the patient in the supine position. With the left index finger, press outward from the middle of the clavicle downwards and backwards in order to push back the subclavian artery. Skin anesthesia is carried out at the upper edge of the clavicle, after which the needle is advanced posteriorly, downward and inward at an angle of 30 degrees towards the first rib. Inject 30 - 60 ml of 0.25% novocaine solution. Then the end of the needle is brought to the lateral edge of the first rib and an additional 20-30 ml of 0.25% novocaine solution is injected.
Pelvic ring block carried out with the patient lying on his back or side with his knees pulled up to his stomach. The skin in the area between the coccyx and the anus is numbed, then a long needle is inserted along the midline parallel to the anterior surface of the sacrum. Inject 100 - 200 ml of 0.25% novocaine solution.
For fractures and associated injuries, DO NOT:
Central (opioid) analgesics should NOT be administered for traumatic brain injury (other than stadol) and signs of organ damage abdominal cavity. It is not recommended to administer diphenhydramine.
DO NOT lift a victim lying on the ground, on the road, or on the floor until the nature of the injury has been established.
DO NOT tilt the victim’s head back or turn it if a spinal fracture is suspected. cervical spine; lift and lay down an adult patient alone or together in case of a fracture of the cervical or thoracic spine; Only 3-4 people can place such a victim on a hard stretcher and secure him.
DO NOT carry or transport a victim with obvious and possible fractures of large bones without transport immobilization.
It is IMPOSSIBLE to transport a victim with signs of shock without initial compensation of blood loss with a jet infusion of 1-1.5 liters of crystalloids; when installing a plastic cannula in a peripheral vein or catheterization of the subclavian vein infusion therapy(colloidal solutions) can be continued during transportation.
It is IMPOSSIBLE to transport a victim with loss of consciousness without an inserted airway or endotracheal tube.
Immobilization for fractures is the main first aid measure to ensure bone immobility. The fact is that the movements, whether they are voluntary or not, that the victim makes during delivery to the doctor, cause him serious harm. Immobilization minimizes additional trauma to soft tissues and blood vessels from sharp bone fragments at the fracture site, and reduces the possibility of shock, significant bleeding, or development of infectious complication. The timing of immobilization depends on the distance to the medical institution and ranges from several hours to 2-3 days.
Types of fractures and the need for first aid
It is customary to distinguish between pathological fractures that occur when various diseases bones, and traumatic, occurring as a result of exposure to a large dynamic load on the bone during injury. Chronic fractures occur somewhat less frequently when the load on the bone was, although not excessive, prolonged.
Traumatic fractures are usually divided into:
- closed;
- open, when in addition to a broken bone there is also a wound;
- intra-articular, in which blood accumulates in the joint capsule.
Each of the types, in turn, can be with or without displacement of bone fragments.
There are obvious signs that can be used to determine whether a victim has a fracture:
- severe pain at the site of injury;
- in case of a limb injury - a change in shape and size compared to the uninjured one;
- mobility of the bone at the site of injury, which is in good condition not observed;
- inability to move the injured limb.
Open fractures also pose a danger because pathogens can enter the wound and become infected. Damage to tissue from bone fragments causes bleeding, often significant. If the fracture is open, the bleeding is external, but if it is closed, it develops internal bleeding, which is no less dangerous. If there are several fractures, or they are open and severe, traumatic shock often develops, requiring emergency medical measures. One of the important points in the treatment of fractures is qualified first aid, the main activities of which are:
- anesthesia;
- stopping bleeding if the fracture is open:
- prevention of shock or measures to combat it;
- ensuring immobility of the injury site by immobilization, reducing pain and preventing shock;
- urgent delivery of the victim to a medical facility.
Using splints for fractures
Types of splints for fractures
Standard ready-to-use tires vary in size and design features. They are often intended for immobilization of the upper or lower extremities, and in some cases for their traction.
Standard tires are made from various materials:
- made of steel mesh or wire, such as flexible ladder-type Kramer tires;
- wood: from slatted wooden structures, such as Dieterichs tires;
- plastics;
- thick cardboard.
If transport immobilization is required for a relatively long period, plaster bandages or splints are used. The peculiarity of such tires is that they are made individually for each victim. They fix bone fragments well and fit snugly to the body. A relative disadvantage of this immobilization option can be considered the difficulty of transporting a victim in frosty weather, while the tire is still wet.
It often happens that ready-made standard tires are not at hand. In this case, it makes sense to use scrap materials located nearby. Usually boards or thick rods are used; thin rods can be tied in the form of a bundle for convenience.
It must be borne in mind that if rescuers or a medical team are already on their way to help the victim, there is no need to construct an improvised splint from scrap material; it is more advisable to wait for professional help.
Rules for applying a splint for immobilization
Algorithm for applying an immobilization splint to the upper limbs
- the injured arm is bent at an angle of 90 degrees;
- under your arm, in the axillary fold, you need to place a roll of clothing or soft material, about 10 cm in size;
- if a bone in the shoulder is broken, it is most convenient to use a flexible standard Kramer splint; in its absence, available hard materials are used;
- fix the shoulder and elbow joints with one improvised hard and hard splint, and the second – the elbow and wrist joints;
- the bent arm needs to be suspended on a scarf.
When the bones of the forearm are fractured, the elbow and wrist joints, a roller measuring 8-10 cm is placed in the armpit. The arm is bent at an angle of 90 degrees and suspended on a scarf. Sometimes it happens that a solid object for making an improvised tire cannot be found. In this case, the broken forearm bone can be fixed by bandaging it to the body.
If the upper limbs are fractured, it is better not to bandage the fingertips, as it is more convenient to control blood circulation.
Immobilization for other types of fractures
At a fracture femur one splint is applied on the inside of the injured limb, fixing the knee and ankle joint. Such a splint should reach the groin, where a soft cushion with a diameter of about 10 cm must be placed. outside The leg splint is placed so as to fix all three joints: hip, knee and ankle. Joints should be grasped to prevent movement in them; otherwise it will be transmitted to the area of the broken bone. In addition, such fixation prevents dislocation of the head of the damaged bone.
This is how a splint is applied for a hip fracture
In case of a tibia fracture, splints are also applied along the inner and outer surface injured limb, fixing the knee and ankle joint. If it is not possible to find material at hand to construct an immobilization splint, the injured leg can be fixed by bandaging it to the uninjured leg. However, such a measure is considered not reliable enough and is used in extreme cases.
It is unacceptable to transport victims with fractures, even over short distances, without immobilization.
If the clavicle is fractured, you need to hang the victim’s arm in a scarf. If before medical institution to get far enough, you need to apply a figure-of-eight bandage to pull the shoulder girdle back and fix it in this position.
If immobilization is required for rib fractures, a tight fixing bandage is applied to the chest, after first anesthetizing the victim. Rib cage bandages as you exhale, with the tightened ribs making only minimal movements during breathing. This reduces pain and eliminates the risk of additional soft tissue injury from debris. Uncomplicated rib fractures heal quickly, but complications when internal organs are injured by broken ribs pose a serious danger.
When the foot is broken, a flexible Kramer splint is applied to the upper third of the lower leg, modeling it along the contour of the posterior surface.
First aid for severe fractures
Fractures of the pelvic bones are a severe, life-threatening injury characterized by sharp pain, inability to walk, stand, or raise a leg. To provide first aid, the victim is placed on a rigid stretcher with his back down, while his legs are left in a bent state. Soft cushions should be placed under the knees.
The most severe injury is considered to be a spinal fracture, which can occur when strong impact in the back or during a fall from a height. The victim experiences sharp pain, swelling and protrusion of the damaged vertebrae occurs.
When providing assistance, you need to be extremely careful, since displacement of the vertebrae often leads to damage to the spinal cord and its rupture.
The victim is placed on a hard surface, doing this on command, and without allowing kinks in the spine. Then they are secured with wide straps. In case of fracture upper sections spine, it is necessary to place soft cushions in the neck area.
When a limb is immobilized (plastered) for several weeks, a decrease is observed. muscle mass and decreased function. Decreased level of physical activity. A number of studies in humans and animals have examined adaptive responses associated with limb immobilization. When the rat hindlimb was immobilized for 4 weeks, a significant decrease in activity (EMG) was observed in the soleus and medial gastrocnemius muscles.
It should be noted that the degree of EMG decrease depended on the duration of muscle immobilization; the maximum reduction was observed with short immobilization. Integrated EMG decreased by 77% in the soleus and 50% in the medial gastrocnemius muscles with minimal immobilization duration. The decrease in EMG was accompanied by a decrease in the mass of the soleus muscle by 36%, and the mass calf muscle- by 47%.
The degree of atrophy (decreased muscle mass) when a limb is immobilized can vary. Maximum indicator(50%) observed by Fournier et al. (1983). Maximum area reduction cross section muscle fiber is about 42% (Nicks, Beneke, Key, Timson, 1989).
Other researchers have observed a more significant decrease in wet mass of 17% (Robinson, Enoka, Stuart, 1991), and a decrease in the average diameter of type I (but not type II) muscle fibers of about 14% (Gibson et al., 1987). Atrophy appears to be caused by a decrease in both the rate of protein synthesis (Gibson et al., 1987) and the number of muscle fibers (Oishi, Ishihara, Katsuta, 1992).
Despite the decrease in EMG and muscle atrophy due to limb immobilization, these results are difficult to interpret due to the lack of association between decrease in EMG and muscle atrophy, or between muscle atrophy and loss of function. Part of the lack of relationship between muscle atrophy (mass loss) and strength decline can be explained by using mass loss as an indicator of atrophy.
As noted, the maximum force produced by a muscle is closely related to its cross-sectional area, and not to the amount of muscle mass (weight). When muscle atrophy is expressed in terms of cross-sectional area, it is more closely correlated with shrinkage (Lieber, 1992). At the same time, the absence of interconnection was noted in the S and FR type motor units of the cat hindlimb muscle (Nordstrom, Enoka, Callister et al., 1993).
A decrease of almost 25% in the cross-sectional area of type I muscle fibers and PA was observed, as well as a decrease in maximum isometric force of 40% in FR motor units and by 52% in S type motor units. Apparently, remodeling of the neuromuscular system during short-term mobilization - more complex process than simply a linear relationship between decreased EMG, muscle mass, and impaired physical performance.
Neuromuscular adaptations. Given sufficient load, most elements of the system adapt. For example, 7-day immobilization of the rat soleus muscle (short length) resulted in a 37% decrease in muscle mass, a 5 mV depolarization of fiber membranes, a 60% decrease in miniature end plate potentials, and a 25% decrease in Na+-K+ translocation across the membrane (Zemkova et al., 1990).
Most of these studies report muscle fiber conversion. There is a decrease in the number of MO type muscle fibers and an increase in the number of BOG type fibers, which apparently involves the conversion of the structure of enzymes of the BOG type fibers (Fitts, Brimmer, Heywood-Cooksey, Tirnmermann, 1989; Oishi et al., 1992).
This adaptive reaction can be explained by the fact that as a result of immobilization, the fibers whose activity decreases the most, i.e., “suffer” the most. muscle fibers type MO. Muscle atrophy, caused by immobilization of the limb, leads to a significant decrease in strength and impairment of basic functions.
For example, immobilization for 6 weeks (limb fracture) resulted in a 55% decrease in the force of maximum voluntary contraction and a 45% decrease in maximum voluntary EMG contraction in the arm muscle (Duchateau and Hainaut, 1991). When immobilized for such a duration, a person's ability to implement impulses in the central nervous system sufficient for maximum activation of the arm muscle is inhibited.
However, such changes do not impair the subjects' ability to maintain maximum force for 60 s. The consequences of immobilization are also evident at the motor unit level. Immobilization for 6-8 weeks changes the properties and behavior of motor units of the human arm muscles (Duchatean, Hainant, 1990).
When the recruitment threshold was expressed relative to maximum force, an increase in the number of motor units was noted high threshold in an immobilized muscle. However, the average force generated by these units was less; in addition, the peak amplitude of motor unit action potentials decreased. An increase in the range of recruitment and a decrease in the range of modulation of discharge intensity were also observed.
Suspension of the hind limb. When astronauts first went into space, experts were concerned about two problems: whether astronauts would be able to move outside the spacecraft and what physiological adaptations would occur in their bodies as a result of being in zero gravity. Both problems have been carefully studied. In particular, biomechanical studies of the dynamics of movements under weightless conditions were carried out.
To study physiological adaptations, scientists used a model in which an animal (usually a rat) was suspended from hind limbs for a few weeks. The animal could move its limbs freely without touching support and carry out many of its daily functions with minimal stress (Thomason and Booth, 1990).
Limb immobilization
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