Copyright 2008 Seattle/King County EMS CBT/OTEP 302 Orthopedic Injuries

Copyright 2008 Seattle/King County EMS

CBT/OTEP 302Orthopedic Injuries


Introduction

This course will refresh your This course will refresh your knowledge of skeletal structures knowledge of skeletal structures

and injuries that can occur to them.and injuries that can occur to them.

This course will refresh your This course will refresh your knowledge of skeletal structures knowledge of skeletal structures

and injuries that can occur to them.and injuries that can occur to them.

• Skeletal system provides shape and form

• Protects internal organs• Allows bodily movement• Produces blood• Stores minerals


New Terms

compartment syndrome - Elevation of pressure within the fibrous tissue that surrounds and supports muscles and neurovascular structures, characterized by extreme pain, pain on movement, pulselessness, and pallor.

fascia - Sheets or bands of fibrous connective tissue that lie deep under the skin forming the outer layer of a muscle.


New Terms, continued

osteoporosis - Generalized degenerative bone disease in which there is a reduction of bone mass making the bones fragile and susceptible to injury.

point tenderness - Tenderness sharply localized at the site of the injury.


Bones• 206 bones – support body, protect

organs

• Muscles – attached to bones by tendons

• Tendons – extension of fascia

• Fascia – bands of tough, fibrous connective tissue that form outer layer of muscles


Joints

• Location where two bones come together

• Bone ends of movable joints are covered with smooth cartilage and are lubricated by synovial fluid


Perfusion

Human body requires a constant supply of oxygen and nutrients


Adequate Perfusion

• Pump (heart)• Pipes (blood vessels) • Fluids (adequate blood volume)• Oxygen (adequate oxygenation)

Image credit: Copyright 2005 Seattle/King County EMS


Shock

• Caused by blood loss, cardiac failure, respiratory failure, or spinal cord injury

• Defined as inadequate tissue perfusion


Causes of Shock

• Pump failure (AMI) • Pipe dilation (spinal cord injury, allergic

reaction) • Blood/body fluid loss (trauma, GI bleed,

dehydration) • Lack of oxygen (drowning, strangulation

or CHF)



Signs of Shock• Anxiety • Altered LOC • Delayed capillary refill • Weak, thready, absent peripheral pulses • Pale, cool, clammy skin • Increased pulse rate (early sign) • Decreased BP (late sign)


Clavicle• Commonly fractured • Shoulder pain• Point tenderness, swelling• Guarding of injured shoulder

Image used with permission of Jones and Bartlett Publishers, Sudbury, MA, www.jbpub.com (Academy of Orthopaedic Surgeons, Trauma Slide Set, ©2002


Scapula

• Less often injured due to location • Fracture results from direct blow • Look for injury to chest cavity and its

contents


Shoulder Dislocation

• Joint between humerus and scapula • Remarkably complex• Easily injured• Anterior dislocation of humeral head

common


Humerus

• Fractures at elbow, midshaft, or shoulder

• Common in elderly who have fallen



Elbow Dislocation

• Result of direct force or twisting of arm • Very serious injuries • Olecranon process of ulna more

prominent • Swelling, significant pain, vessel/nerve

damage


Forearm

• Fractures of radius and ulna are common

• Direct blow, excessive twisting



Wrist and Hand

• Result of fall or direct force• Many small bones and ligaments• Use rigid splint


Pelvis

• Result of MVA/pedestrian, falls• Vessels, nerves, organs in pelvic

area• Indirect force transferred through

femur


Hip Fractures/Dislocations

• Result of MVA/pedestrian, falls• Damage large vessels and nerves • Splint extremity in position found

Image credit: LifeART(R) image, Copyright 1998, Lippincott Williams & Wilkins. All rights reserved.


Hip Fracture – Treatment • Check for other injuries (c-spine/head injury) • Use a scoop stretcher to move patient to

padded backboard or stretcher • Keep patient warm • Treat patient gently and minimize

movement • Immobilize injured leg in place, if possible • Pad generously to immobilize femur

(including between the legs) • Carefully move pt to a stretcher or

backboard


Femur

• Result of significant force• Large thigh muscles can spasm• Open fracture – significant blood loss


Femur Fracture – Treatment• Mid-shaft (middle 1/3)• Do not apply if destabilizing injury to hip,

knee or ankle• Support fracture site when limb is lifted• Do not lose traction once applied• Hold manual traction until splint is secured• Check CMS before and after splinting


Knee

• Extremely complex ,easily injured joint

• Ligament or cartilage damage common

• Patella fracture or dislocation



Tibia and Fibula

• Open fx common, bones near skin• Vascular injury • If need to realign, check distal CMS

before and after realignment


Ankle

• Common MOI is twisting• Pain, swelling, localized tenderness • Difficult to distinguish fx from sprain • Immobilize by securing foot and the

lower leg


Foot

• MOI – twisting and falls from height• Pain, swelling, localized tenderness • If calcaneus fractured may be other

associated injuries (spinal fracture)


Mechanism of Injury

• Significant force required to fracture a bone or dislocate a joint

• Types of forces: direct, indirect, twisting, and high-energy forces


Assessing Mechanism of Injury• Determine which forces were applied

to body • Signs of blunt or penetrating trauma • Determine which underlying

structures might have been impacted by the force


Trauma and the Elderly

• Death from multi-system trauma is three times greater at age 70 than 20

• Elderly body does not compensate effectively

• Slower to react, less agile, weaker, poor vision and hearing


Osteoporosis • Insignificant force can easily

fracture bone weakened by tumor or osteoporosis

• Minor fall, simple twisting injury, or even violent muscle contraction can cause fracture

Image credit: LifeART(R) image, Copyright 1998, Lippincott Williams & Wilkins. All rights reserved.


Signs of Orthopedic Injury • Deformity or angulation • Pain and tenderness • Grating (crepitus) • Swelling • Bruising (discoloration) • Exposed bone ends • Joint locked into position


Shock – Treatment

• Evaluate MOI• Determine SICK or NOT SICK• Maintain airway, assist ventilations

if needed• Control bleeding• Administer high flow oxygen


Shock – Treatment, continued

• Shock position• Splint fractures• Maintain body temperature• Monitor vital signs• Rapid transport


Splinting Principles • Support fracture site • (Long bone fracture) immobilize joint above

and below fracture site • (Joint injury) - Immobilize bones above and

below the joint injury • Check CMS before and after splinting • Pad splint well • Elevate extremity after splinting


Realigning Joint Injuries/Dislocations • Splint dislocations or other joint

injuries in position found• Exception: loss of distal pulse

and/or neurological function and where definitive care is delayed


Realigning Joint Injuries/Dislocations Loss of distal pulse and/or neurological

function and definitive care is delayed:

1. Attempt to straighten into anatomical position until pulse returns, excessive pain, or resistance encountered.

2. Support with blanket, pillow or well-padded splint.

3. Elevate limb.4. Pack injured area in ice or use ice pack.5. Document attempts to re-align.


Realigning Long Bone Fractures • Middle 1/3 of bone only • Proximal or distal 1/3 may be realigned

if compromise of distal circulation and/or nerve function and definitive care delayed



Traction Splint

• Support fracture site when limb is lifted

• Apply manual traction and hold until splint is secured

• Check CMS before and after apply splinting


Traction Splint – Contraindications• Injury close to or involving knee • Hip injury • Pelvis injury • Partial amputation or avulsion with

bone separation • Lower leg or ankle injury


Pelvic Injury – Treatment• Immobilize with bed sheet or commercial splinting

device

Splinting with bed sheet: 1. Fold sheet lengthwise into 8" - 14" width.2. Place sheet beneath patient. Wrap ends around patient and

twist while crossing over pelvic area.3. Tie sheet with square knot or plastic ties to apply moderate

pressure around circumference of pelvis. 4. Secure ends of sheet to backboard, if possible.


Summary

• Muscles attached to bones by tendons• Fascia are bands of fibrous connective

tissue that cover muscles • Common factor in all shock is

inadequate perfusion • Perfusion is circulation of blood within

organ or tissue


Summary, continued

To maintain adequate perfusion:• Pump (heart)• Pipes (blood vessels)• Fluids (adequate blood volume)• Oxygen (adequate oxygenation)


Summary, continued

Signs and symptoms of shock: • Anxiety • Altered LOC • Delayed capillary refill • Weak, thready, or absent peripheral

pulses • Pale, cool, clammy skin • Increased pulse (early sign) • Decreased BP (late sign)


Summary, continued

Hypovolemic shock: • Assess MOI• Maintain airway, assist ventilations if

needed• Control bleeding• High flow oxygen• Shock position• Splint fractures• Maintain body temp• Monitor vital signs


Summary, continued

Principles of splinting: • Support fracture site• (Long bone fracture) immobilize joint

above and below fracture site• (Joint injury) immobilize bones above

and below the joint injury• Check CMS before and after splinting • Pad splint well• Elevate extremity after splinting, if

possible


Summary, continued

• Attempt to realign fractures of long bones in the middle 1/3 of bone only

• Splint dislocations/joint injuries in position found except with loss of distal pulse and/or neurological function and where definitive care is delayed

Documents

Copyright 2008 Seattle/King County EMS CBT/OTEP 302 Orthopedic Injuries