Chapter_29.ppt

Chapter 29
Orthopaedic Injuries

Anatomy and Physiology of the
Musculoskeletal System
(1 of 5)
• Three types of muscles: skeletal, smooth,
and cardiac
• Skeletal muscle attaches to the bones and
usually crosses at least one joint.
– Forms the major muscle mass of the body
– Called voluntary muscle because it is under
direct voluntary control of the brain

(2 of 5)

(3 of 5)
• All skeletal
muscles are
supplied with
arteries, veins, and
nerves.
• Skeletal muscle
tissue is directly
attached to the
bone by tendons.

(4 of 5)
• Smooth muscle
performs much of
the automatic work
of the body.
– Not under voluntary
control of the brain
– Contracts and
relaxes to control the
movement of the
contents within
tubular structures

(5 of 5)
• Cardiac muscle is a specially adapted
involuntary muscle with its own regulatory
system.

The Skeleton (1 of 11)
• Gives us our recognizable human form
• Protects our vital organs
• Allows us to move
• Produces blood cells
• Made up of approximately 206 bones

• The skull protects the brain.
• The thoracic cage protects the heart, lungs,
and great vessels.
• The pectoral girdle consists of two scapulae
and two clavicles.

• The upper
extremity extends
from the shoulder
to the fingertips.
– Composed of the
arm (humerus),
elbow, forearm
(radius and ulna),
wrist, hand, and
fingers

• The hand contains
three sets of
bones:
– Wrist bones
(carpals)
– Hand bones
(metacarpals)
– Finger bones
(phalanges)

• The pelvis supports the body weight and
protects the structures within the pelvis: the
bladder, rectum, and female reproductive
organs.
• The lower extremity consists of the bones of
the thigh, leg, and foot.

• The foot consists of
three classes of
bones:
– Ankle bones
(tarsals)
– Foot bones
(metatarsals)
– Toe bones
(phalanges)

• The bones of the skeleton provide a
framework to which the muscles and
tendons are attached.
• A joint is formed wherever two bones come
into contact.
– Joints are held together in a capsule.
– Joints are lubricated by synovial fluid.

Musculoskeletal Injuries (1 of 5)
• A fracture is a broken bone.
– A potential complication is compartment
syndrome.
• A dislocation is a disruption of a joint in
which the bone ends are no longer in
contact.

• A subluxation is similar except the
disruption of the joints is not complete.
• A fracture-dislocation is a combination injury
at the joint.

• A sprain is an injury to ligaments, articular
capsule, synovial membrane, and tendons
crossing the joint.
• A strain is a stretching or tearing of the
muscle, causing:
– Pain
– Swelling
– Bruising

• An amputation is an injury in which an
extremity is completely severed from the
body.
• Injury to bones and joints is often
associated with injury to the surrounding
tissues.
– Entire area is known as the zone of injury

Mechanism of Injury
• Significant force is generally required to
cause fractures and dislocations.
– Direct blows
– Indirect forces
– Twisting forces
– High-energy forces

Fractures (1 of 8)
• Classified as either closed or open
• Your first priority is to determine whether
the overlying skin is damaged.
– Treat any injury that breaks the skin as a
possible open fracture.

Fractures (2 of 8)
• Fractures are described by whether the
bone is moved from its normal position.
– A nondisplaced fracture is a simple crack of the
bone.
– A displaced fracture produces actual deformity,
or distortion, of the limb by shortening, rotating,
or angulating it.

Fractures (3 of 8)
• Medical personnel
often use the
following special
terms to describe
particular types of
fractures.

Fractures (4 of 8)
• Greenstick
– An incomplete fracture that passes only partway
through the shaft of a bone
• Comminuted
– A fracture in which the bone is broken into more
than two fragments
• Pathologic
– A fracture of weakened or diseased bone

Fractures (5 of 8)
• Oblique
– A fracture in which the bone is broken at an
angle across the bone
• Transverse
– A fracture that occurs straight across the bone

Fractures (6 of 8)
• Spiral
– A fracture caused by a twisting force, causing
an oblique fracture around the bone and
through the bone
• Incomplete
– A fracture that does not run completely through
the bone

Fractures (7 of 8)
• Suspect a fracture
if one or more of
the following signs
are present:
– Deformity
– Tenderness
– Guarding
– Swelling

Fractures (8 of 8)
• Signs of fractures
(cont’d)
– Bruising
– Crepitus
– False motion
– Exposed fragments
– Pain
– Locked joint

Dislocations (1 of 3)
• Sometimes a dislocated joint will
spontaneously reduce before your
assessment.
– Confirm the dislocation by taking a patient
history.
– A dislocation that does not reduce is a serious
problem.

• Signs and symptoms
– Marked deformity
– Swelling
– Pain that is aggravated by any attempt at
movement
– Tenderness on palpation

• Signs and
symptoms (cont’d)
– Virtually complete
loss of normal joint
motion
– Numbness or
impaired
circulation to the
limb or digit
Source: © Dr. P. Marazzi/Photo Researchers, Inc.

Sprains (1 of 3)
• A sprain occurs when a joint is twisted or
stretched beyond its normal range of
motion.
– Alignment generally returns to a fairly normal
position, although there may be some
displacement.
– Severe deformity does not typically occur.

Sprains (2 of 3)
• Signs and
symptoms
– Point tenderness
– Swelling and
ecchymosis
– Pain
– Instability of the
joint
Source: © Sean Gladwell/Dreamstime.com

Strain
• A strain is an injury to a muscle and/or
tendon that results from a violent muscle
contraction or from excessive stretching.
– Often no deformity is present and only minor
swelling is noted at the site of the injury.

Compartment Syndrome (1 of 2)
• Most often occurs with a fractured tibia or
forearm of children
• Typically develops within 6 to 12 hours after
injury, as a result of:
– Excessive bleeding
– A severely crushed extremity
– The rapid return of blood to an ischemic limb

• This syndrome is characterized by:
– Pain that is out of proportion to the injury
– Pain on passive stretching of muscles within the
compartment
– Pallor
– Decreased sensation
– Decreased power

Amputations
• Can occur as a result of trauma or a
surgical intervention
• You must control bleeding and treat for
shock.
• Be aware of the victim’s emotional stress.

Complications (1 of 3)
• Orthopaedic injuries can also lead to
systemic changes or illnesses.
• The likelihood of having a complication is
often related to the:
– Strength of the force that caused the injury
– Injury’s location
– Patient’s overall health

• To prevent contamination following an open
fracture:
– Brush away any debris on the skin
– Do not enter or probe the site
• Long-term disability is one of the most
devastating consequences of an
orthopaedic injury.

• You can help reduce the risk or duration of
long-term disability by:
– Preventing further injury
– Reducing the risk of wound infection
– Minimizing pain by the use of cold and
analgesia
– Transporting patients to an appropriate medical
facility

Assessing the Severity of
Injury (1 of 2)
• The Golden Period is critical for life and for
preserving limb viability.
– Prolonged hypoperfusion can cause significant
damage.
– Any suspected open fracture or vascular injury
is a medical emergency.
• Most injuries are not critical.
– Use a grading system.

Assessing the
Severity of Injury
(2 of 2)

Patient Assessment (1 of 2)
• Patient assessment steps
– Scene size-up
– Primary assessment
– History taking
– Secondary assessment
– Reassessment

Patient Assessment (2 of 2)
• Always look at the big picture.
– Distinguish mild injuries from severe injuries.
– Severe injuries may compromise neurovascular
function, which could be limb threatening.

Scene Size-up (1 of 2)
• Scene safety
– Observe the scene for any hazards.
– Identify the forces associated with the MOI.
– Standard precautions involve gloves, a mask,
and a gown.
– Consider that there may be hidden bleeding.
– Evaluate the need for additional support.

Scene Size-up (2 of 2)
• Mechanism of injury/nature of illness
– Look for indicators of the MOI.
– Be alert for both primary and secondary injuries.
– Consider how the MOI produced the injuries
expected.

Primary Assessment (1 of 5)
• Focus on identifying and managing life
threats.
• Form a general impression.
– Introduce yourself.
– Check for responsiveness using the AVPU
scale.
– Ask about the chief complaint.

• Form a general impression (cont’d).
– Administer high-flow oxygen to all patients
whose LOC is less than alert and oriented.
– Perform a rapid scan and ask about the MOI.
– If there was significant trauma, the
musculoskeletal injuries may be a lower priority.

• Airway and breathing
– Evaluate the chief complaint and MOI.
– If a spinal injury is suspected, take the
appropriate precautions and prepare for
stabilization.
– Oxygen may be given to relieve anxiety and
improve perfusion.

• Circulation
– Determine whether the patient has a pulse, has
adequate perfusion, or is bleeding.
– If the skin is pale, cool, or clammy and capillary
refill time is slow, treat for shock.
– Maintain a normal body temperature and
improve perfusion with oxygen.
– Fractures can break through the skin and cause
external bleeding.

• Transport decision
– Provide rapid transport if the patient has an
airway or breathing problem, or significant
bleeding.
– A patient who has a significant MOI but whose
condition appears otherwise stable should also
be transported promptly.
– Patients with a simple MOI may be further
assessed.

History Taking
• Investigate the chief complaint.
– Obtain a medical history and be alert for injury-
specific signs and symptoms and any pertinent
negatives.
• Obtain a SAMPLE history for all trauma
patients.
– OPQRST is too lengthy when matters of ABCs
require immediate attention.

Secondary Assessment (1 of 4)
• More detailed examination of the patient to
reveal hidden injuries
• Physical examinations
– If significant trauma has occurred, start with a
full-body scan
– Begin with the head and work systematically
toward the feet.
– Assess the musculoskeletal system.

• Physical examinations (cont’d)
– When lacerations are present in an extremity,
consider an open fracture.
– Any injury or deformity of the bone may be
associated with vessel or nerve injury.
– To assess neurovascular status, follow the
steps in Skill Drill 29-1.

• Vital signs
– Determine a baseline set of vital signs,
including:
• Pulse rate, rhythm, and quality
• Respiratory rate, rhythm, and quality
• Blood pressure
• Skin condition
• Pupil size and reaction to light

Reassessment (1 of 3)
• Repeat the primary assessment.
– Every 5 minutes for an unstable patient
– Every 15 minutes for a stable patient
• Interventions
– Assess the overall condition, stabilize the ABCs,
and control any serious bleeding.
– In a critically injured patient, secure the patient
to a long backboard and transport.

• Interventions (cont’d)
– If the patient has no life-threatening injuries,
take extra time at the scene to stabilize his or
her condition.
– The main goal is stabilization in the most
comfortable position that allows for
maintenance of good circulation distal to the
injury.

• Communication and documentation
– Include a description of the problems found
during your assessment.
– Report problems with the ABCs, open fractures,
and compromised circulation.
– Document complete description of injuries and
the MOIs associated with them.

Emergency Medical Care
• Perform a primary assessment.
• Stabilize the patient’s ABCs.
• Perform a rapid scan or focus on a specific
injury.
• Follow standard precautions.
• Suspect internal bleeding.
• Follow the steps in Skill Drill 29-2.

Splinting (1 of 7)
• A splint is a flexible or rigid device that is
used to protect and maintain the position of
an injured extremity.
– Splint all fractures, dislocations, and sprains
before moving the patient, unless he or she is in
immediate danger.
– Splinting reduces pain and makes it easier to
transfer and transport the patient.

Splinting (2 of 7)
• Splinting will help to prevent:
– Further damage to muscles, the spinal cord,
peripheral nerves, and blood vessels
– Laceration of the skin
– Restriction of distal blood flow
– Excessive bleeding of the tissues
– Increased pain
– Paralysis of extremities

Splinting (4 of 7)
• General principles of splinting
– Remove clothing from the area.
– Note and record the patient’s neurovascular
status.
– Cover all wounds with a dry, sterile dressing.
– Do not move the patient before splinting an
extremity, unless there is danger.

Splinting (5 of 7)
• General principles of splinting (cont’d)
– Pad all rigid splints.
– Maintain manual stabilization.
– If you encounter resistance, splint the limb in its
deformed position.
– Stabilize all suspected spinal injuries in a
neutral, in-line position.
– When in doubt, splint.

Splinting (6 of 7)
• General principles of in-line traction
splinting
– Act of pulling on a body structure in the direction
of its normal alignment
– Goals of in-line traction:
• To stabilize the fracture fragments
• To align the limb sufficiently
• To avoid potential neurovascular compromise

Splinting (7 of 7)
• In-line traction
splinting (cont’d)
– Imagine where the
uninjured limb
would lie, and pull
gently along the line
of that imaginary
limb until the injured
limb is in
approximately that
position.

Rigid Splints (1 of 4)
• Made from firm material
• Applied to the sides, front, and/or back of an
injured extremity
• Prevent motion at the injury site
• Takes two EMTs to apply

Rigid Splints (4 of 4)
• Two situations in which you must splint the
limb in the position of deformity:
– When the deformity is severe
– When you encounter resistance or extreme pain
when applying gentle traction to the fracture of a
shaft of a long bone

Formable Splints (1 of 2)
• Most commonly used formable splint is the
precontoured, inflatable, clear plastic air
splint
– Comfortable
– Provides uniform contact
– Applies firm pressure to a bleeding wound
– Used to stabilize injuries below the elbow or
knee

Formable Splints (2 of 2)
• Drawbacks:
– The zipper can stick, clog with dirt, or freeze.
– Significant changes in the weather affect the
pressure of the air in the splint.
• Follow the steps in Skill Drills 29-4, 29-5,
and 29-6.

Traction Splints (1 of 4)
• Used primarily to secure fractures of the
shaft of the femur
• Several different types:
– Hare splint
– Sager splint
– Reel splint
– Kendrick splint

• Do not use for any of these conditions:
– Injuries of the upper extremity
– Injuries close to or involving the knee
– Injuries of the hip
– Injuries of the pelvis
– Partial amputations or avulsions with bone
separation
– Lower leg, foot, or ankle injury

• Proper application requires two well-trained
EMTs.
• To apply a Hare splint, follow the steps in
Skill Drill 29-7.
• To apply a Sager splint, follow the steps in
Skill Drill 29-8.

Pelvic Binder
• Used to splint the bony pelvis to reduce
hemorrhage from bone ends, venous
disruption, and pain
• Meant to provide temporary stabilization
– Should be light, made of soft material, easily
applied by one person, and should allow access
to the abdomen, perineum, anus, and groin

Pneumatic Antishock
Garments (1 of 3)
• Use as a splinting device if a patient has
injuries to the lower extremities/pelvis.
• Do not use the PASG if any of the following
conditions exist:
– Pregnancy
– Pulmonary edema
– Acute heart failure

Pneumatic Antishock
Garments (2 of 3)
• Do not use the PASG if (cont’d):
– Penetrating chest injuries
– Groin injuries
– Major head injuries
– A transport time of less than 30 minutes

Pneumatic Antishock
Garments (3 of 3)

Hazards of Improper Splinting
• Compressions of nerves, tissues, and blood
vessels
• Delay in transport of a patient with a life-
threatening injury
• Reduction of distal circulation
• Aggravation of the injury
• Injury to tissue, nerves, blood vessels, or
muscles

Transportation
• Very few, if any, musculoskeletal injuries
justify the use of excessive speed during
transport.
– A patient with a pulseless limb must be given a
higher priority.
– If the treatment facility is an hour or more away,
transport by helicopter or immediate ground
transportation.

Injuries of the Clavicle and
Scapula (1 of 3)
• The clavicle is one
of the most
commonly fractured
bones in the body.
– Occur most often in
children
– A patient will report
pain in the shoulder
and will hold the
arm across the front
of the body.
Source: © Shea, MD/Custom Medical Stock Photo

Scapula (2 of 3)
• Fractures of the scapula occur much less
frequently because the bone is well
protected by many large muscles.
– Almost always the result of a forceful, direct
blow to the back
– The associated chest injuries pose the greatest
threat of long-term disability.

Scapula (3 of 3)
• These fractures can be splinted effectively
with a sling and swathe.

Dislocations of the Shoulder
• The humeral head most commonly
dislocates anteriorly.
• Shoulder dislocations are very painful.
– Stabilization is difficult because any attempt to
bring the arm in toward the chest wall produces
pain.
– Splint the joint in whatever position is more
comfortable for the patient.

Fractures of the Humerus (1 of 2)
• Occur either proximally, in the midshaft, or
distally at the elbow
• Consider applying traction to realign the
fracture fragments before splinting them.
– Splint the arm with a sling and swathe.

Fractures of the Humerus (2 of 2)

Elbow Injuries (1 of 5)
• Different types of injuries are difficult to
distinguish without x-ray examinations.
• Fracture of the distal humerus
– Common in children
– Fracture fragments rotate significantly,
producing deformity and causing injuries to
nearby vessels and nerves.

• Dislocation of
the elbow
– Typically
occurs in
athletes
– The ulna and
radius are
most often
displaced
posteriorly.

• Elbow joint sprain
– This diagnosis is often mistakenly applied to an
occult, nondisplaced fracture.
• Fracture of olecranon process of ulna
– Can result from direct or indirect forces
– Often associated with lacerations and abrasions
– Patient will be unable to extend the elbow.

• Fractures of the radial head
– Often missed during diagnosis
– Generally occurs as a result of a fall on an
outstretched arm or a direct blow to the lateral
aspect of the elbow
– Attempts to rotate the elbow or wrist cause
discomfort.

• Care of elbow injuries
– All elbow injuries are potentially serious and
require careful management.
– Always assess distal neurovascular functions
periodically.
– Provide prompt transport for all patients with
impaired distal circulation.

Fractures of the Forearm
• Common in people of all age groups
• Seen most often in children and elderly
• Usually, both the radius and the ulna break
at the same time.
– Fractures of the distal radius are known as
Colles fractures.
– To stabilize fractures, you can use a padded
board, air, vacuum, or pillow splint.

Injuries of the Wrist and Hand
• Must be confirmed by x-ray exams
• Dislocations are usually associated with a
fracture.
• Any questionable wrist injury should be
splinted and evaluated in the ED.
• Follow the steps in Skill Drill 29-10 to splint
the hand and wrist.

Fractures of the Pelvis (1 of 3)
• Often results from direct compression in the
form of a heavy blow
– Can be caused by indirect forces
– Not all pelvis fractures result from trauma.
• May be accompanied by life-threatening
loss of blood
• Open fractures are quite uncommon.

• Suspect a fracture of the pelvis in any
patient who has sustained a high-velocity
injury and complains of discomfort in the
lower back or abdomen.
• Assess for tenderness.

Dislocation of the Hip (1 of 3)
• Dislocates only after significant injury
• Most dislocations are posterior.
• Suspect a dislocation in any patient who
has been in an automobile crash and has a
contusion, laceration, or obvious fracture in
the knee region.

• Posterior dislocation is frequently
complicated by injury to the sciatic nerve.
• Distinctive signs
– Severe pain in the hip
– Strong resistance to movement of the joint
– Tenderness on palpation

• Make no attempt to reduce the dislocated
hip in the field.
– Splint the dislocation.
– Place the patient supine on a backboard.
– Support the affected limb with pillows.
– Secure the entire limb to the backboard with
long straps.
– Provide prompt transport.

Fractures of the Proximal
Femur (1 of 2)
• Common fractures, especially in elderly
• Break goes through the neck of the femur,
the interochanteric region, or across the
proximal shaft of the femur
• Patients display a certain deformity.
– They lie with the leg externally rotated, and the
injured limb is usually shorter than the opposite,
uninjured limb.

Fractures of the Proximal
Femur (2 of 2)
• Assess the pelvis for any soft-tissue injury
and bandage appropriately.
• Assess pulses and motor and sensory
functions.
• Splint the lower extremity and transport to
the emergency department.

Femoral Shaft Fractures (1 of 2)
• Can occur in any part of the shaft, from the
hip region to the femoral condyles just
above the knee joint
• Large muscles of the thigh spasm in an
attempt to “splint” the unstable limb.
• Fractures may be open.
• There is often significant blood loss.

Femoral Shaft Fractures (2 of 2)
• Bone fragments may penetrate or press on
important nerves and vessels.
– Carefully and periodically assess the distal
neurovascular function.
• Cover any wound with a dry, sterile
dressing.
• These fractures are best stabilized with a
traction splint.

Injuries of Knee Ligaments
(1 of 2)
• Many different types of injuries occur in this
region.
– Ligament injuries
– Patella can dislocate.
– Bony elements can fracture.

Injuries of Knee Ligaments
(2 of 2)
• When you examine the patient, you will
generally find:
– Swelling
– Occasional ecchymosis
– Point tenderness at the injury site
– A joint effusion
• Splint all suspected knee ligament injuries.

Dislocation of the Knee (1 of 2)
• These are true emergencies that may
threaten the limb.
• Ligaments may be damaged or torn.
• Direction of dislocation is the position of the
tibia with respect to the femur.
– Anterior dislocations
– Posterior dislocations
– Medial dislocations

Dislocation of the Knee (2 of 2)
• Complications may include:
– Limb-threatening popliteal artery disruption
– Injuries to the nerves
– Joint instability
• If adequate distal pulses are present, splint
the knee and transport promptly.

Fractures About the Knee (1 of 2)
• May occur at the distal end of the femur, at
the proximal end of the tibia, or in the
patella
• Management
– If there is an adequate distal pulse and no
significant deformity, splint the limb with the
knee straight.

Fractures About the Knee (2 of 2)
• Management (cont’d)
– If there is an adequate pulse and significant
deformity, splint the joint in the position of
deformity.
– If the pulse is absent below the level of injury,
contact medical control.
– Never use a traction splint.

Dislocation of the Patella
• Most commonly occurs in teenagers and
young adults in athletic activities
• Usually, the dislocated patella displaces to
the lateral side and exhibits a significant
deformity.
• Splint the knee in the position in which you
find it.

Injuries of the Tibia and Fibula
• Tibia (shinbone) is the larger of the two leg
bones, and the fibula is the smaller.
• Fracture may occur at any place between
the knee joint and the ankle joint.
– Usually, both fracture at the same time.
• Stabilize with a padded, rigid long leg splint
or an air splint.

Ankle Injuries (1 of 2)
• The ankle is a very commonly injured joint.
– Range from a simple sprain to severe fracture-
dislocations
• Any ankle injury that produces pain,
swelling, localized tenderness, or the
inability to bear weight must be evaluated
by a physician.

Ankle Injuries (2 of 2)
• Management
– Dress all open
wounds.
– Assess distal
neurovascular
function.
– Correct any gross
deformity by applying
traction.
– Before releasing
traction, apply a
splint.

Foot Injuries (1 of 2)
• Can result in the dislocation or fracture of
one or more of the tarsals, metatarsals, or
phalanges of the toes
• Frequently, the force of injury is transmitted
up the legs to the spine.
• If you suspect a foot dislocation, assess for
pulses and motor and sensory functions.

Foot Injuries (2 of 2)
• Injuries of the foot are associated with
significant swelling but rarely with gross
deformity.
• To splint the foot, apply a rigid padded
board splint, an air splint, or a pillow splint.
– Leave the toes exposed.

• If you have a pediatric patient with a
fracture below the elbow or knee, be on the
lookout for these signs/symptoms:
– Extreme pain
– Decreased pain sensation
– Pain on stretching of affected muscles
– Decreased power

• If you suspect the patient has compartment
syndrome, splint the affected limb and
transport immediately.
– Reassess neurovascular status frequently
during transport.
• Compartment syndrome must be managed
surgically.

Amputations (1 of 2)
• Surgeons can occasionally reattach
amputated parts.
• Make sure to immobilize the part with bulky
compression dressings.
– Do not sever any partial amputations.
– Control any bleeding to the stump.
– If bleeding cannot be controlled, apply a
tourniquet.

Amputations (2 of 2)
• With a complete amputation, wrap the clean
part in a sterile dressing and place it in a
plastic bag.
– Put the bag in a cool container filled with ice.
– The goal is to keep the part cool without
allowing it to freeze or develop frostbite.

Strains and Sprains (1 of 4)
• Strains
– Often no deformity is present and only minor
swelling is noted.
– Patients may complain of:
• Increased sharp pain with passive movement
• Severe weakness of the muscle
• Extreme point tenderness

• Strains (cont’d)
– General treatment is similar to that of fractures
and includes the following:
• Rest; immobilize or splint injured area
• Ice or cold pack over the injury
• Compression with an elastic bandage
• Elevation
• Reduced or protected weight bearing
• Pain management as soon as practical

• Sprains
– Usually result from a sudden twisting of a joint
beyond its normal range of motion
– Majority involve the ankle or the knee
– Err on the side of caution and treat every sprain
as if it is a fracture.

• Sprains (cont’d)
– Sprains are typically characterized by:
• Pain
• Swelling at the joint
• Discoloration over the injured joint
• Unwillingness to use the limb
• Point tenderness
– General treatment is the same for strains.

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