© 2010 seattle / king county ems cbt302-emt11 – orthopedic emergencies

CBT302-EMT11 – Orthopedic Emergencies

Introduction

• Skeletal system - complex structure of bones and connective tissue

• Provides shape & form for our bodies• Protects internal organs• Allows bodily movement• Produces blood & stores minerals

Course Objectives1. Identify the structures of the skeletal system. 2. Identify the definition of perfusion.3. Identify signs and symptoms of shock.4. Identify the four components required for

adequate perfusion.5. Demonstrate an understanding of the

physiology of shock.6. Identify prehospital treatment for shock.7. Identify the characteristic injuries of specific

bones.8. Identify proper application of the principles

of splinting.

Termsamputation - removal of a body extremity by trauma or surgery. As a surgical measure, it is used to control pain or a disease process in the affected limb, such as malignancy or gangrenecompartment syndrome — Elevation of pressure within fibrous tissue that surrounds & supports muscles and neurovascular structures, characterized by extreme pain, pain on movement, pulselessness, and pallor. It is most frequently seen in fractures below the elbow or knee. compensated shock — early stages of shock in which the body is able to compensate for blood loss or injurycrepitus — Grating or grinding sensation caused by fractured bone ends or joints rubbing together. It also can be caused by rubbing of irregular cartilage tissue or scar tissue. dislocation — Disruption of a joint in which ligaments are damaged & the bone ends are completely displaced.

Terms, continueddistal — The more distant of two or more structures. fascia — Sheets or bands of fibrous connective tissue that lie deep under the skin forming the outer layer of a muscle.hypotension — Blood pressure that is lower than the normal range — generally a systolic blood pressure less than 90 mmHg in an appropriate clinical setting.hypoxia — Condition in which the body tissues and cells do not have enough oxygen. ligament — A band of fibrous tissue joining two bones together in a joint. osteoporosis — Generalized degenerative bone disease common among postmenopausal women in which there is a reduction of bone mass making the bones fragile and susceptible to injury. perfusion — Circulation of blood within an organ or tissue in adequate amounts to meet cellular needs.

Terms, continuedpoint tenderness — Tenderness sharply localized at the site of the injury. Found by gently palpating along the bone with the tip of one finger. proximal — Nearer to a point of reference such as a point of attachment or the midline of the body.sprain — Joint injury in which there is some partial or temporary dislocation of the bone ends and partial stretching or tearing of the supporting ligaments. strain — A stretching or tearing of the muscle, causing pain, swelling, and bruising of the soft tissue in the area. Also called a “pulled muscle.”tendon — Extension of a skeletal muscle that connects the muscle to bone.

New Termscrush syndrome - Serious medical condition characterized by major shock and renal failure following a crushing injury to skeletal muscle. Cases commonly occur in catastrophes such as earthquakes or war, where victims have been trapped under fallen masonry.

impaled objects - The driving of objects through the body, causing deep stabbing wounds.

• Specialized form of connective tissue – very strong & yet resilient

• Produce blood cells• Store important minerals and

electrolytes• Human skeleton – made up of 206

bones• Supports the body & protects

internal organs

Related Structures• Bones & muscles work together to create

movement • Muscles – attached to bones by tendons• Tendons – extension of fascia that cover

all skeletal muscles• Fascia – sheets or bands of tough, fibrous

connective tissue that lie deep under skin form an outer layer of the muscles• Supplied with arteries, veins & nerves.

Joint – location where two bones come together

Immovable joints – those between the bones of the skull

Slightly movable joints – those in the front of the pelvis

Movable joints – for example, elbow & knee

Types of Cartilage• Immovable joints – held together by

strong, fibrous cartilage • Slightly movable joints – held together

by elastic cartilage• Movable joints – consist of layer of

fibrous cartilage connected to ligaments that support bones

• Bones of movable joints – covered with smooth cartilage & lubricated by synovial fluid

Perfusion

• Cells of the body require constant supply of oxygen & nutrients

• Cells also eliminate waste products such as carbon dioxide & metabolic acids

• Provided by the circulatory, respiratory & gastrointestinal systems.

PerfusionBody depends on four things to maintain adequate perfusion: • Pump (heart) to move blood throughout the tissues• Pipes (which are the blood vessels) to transport materials to the cells• Fluids (adequate blood volume)• Oxygen (adequate oxygenation).

Shock• Life-threatening condition develops when

circulatory system cannot deliver sufficient blood to body’s tissues

• Many causes:• Blood loss• Cardiac failure• Respiratory failure• Spinal cord injury

• Inadequate tissue perfusion• Common factor in all types of shock is

ShockCharacterized by:• Reduced cardiac output• Rapid heart rate• Circulatory insufficiency

Signs & Symptoms• Anxiety• Altered LOC• Delayed capillary refill• Weak, thready/absent peripheral pulses• Pale, cool, clammy skin• Increased pulse rate• Decreased blood pressure

UPPER BODY

Clavicle • Someone with fractured clavicle complains of shoulder pain

• Attempt to guard injured shoulder by holding affected arm across chest• Pain, swelling & point tenderness over clavicle signs of fracture

• Difficult to determine if a clavicle is fractured without an x-ray

• Separation at the acromio-clavicular joint can resemble a clavicle fracture.

Clavicle injuries

• Fractured – serious injury • Bone positioned over major arteries, veins

& nerves• When fractured…cause nerve & muscular

damage

• Treatment includes • Application of a sling & swathe• Evaluation by a physician.

Clavicle

Scapula• Scapula, also called shoulder blade, less often injured due to location & protection by large muscles• Fan-shaped bone hard to crack• Fractures usually occur from direct blow

• For example, baseball bat striking the back

Blunt trauma to scapula

Scapula

• Fractures usually are result of significant trauma to back

• Injury to chest cavity & its components (e.g., the heart and lungs) can accompany injured scapula

• Examine chest for evidence of other injuries

• Assess patient's ability to breathe & auscultate breath sounds

Shoulder

• Shoulder joint – junction between humerus & scapula

• Remarkably complex joint• Allows us to do many things

• Throw a ball• Cradle a baby• Scratch your back

• Because of its complexity shoulder easily injured

Shoulder• Most commonly dislocated joint

• Usually, the humeral head will dislocate anteriorly• Posterior dislocations can happen but are much less common

• Very painful & patient will exhibit aggressive guarding by holding affected extremity away from the body• Observe injury by deformity of shoulder & mechanism of injury

Dislocated shoulder

Shoulder

Treatment

• Application of a sling & swathe• Evaluation by a physician.

Humerus• Can be fractured at midshaft, elbow or shoulder• Midshaft fractures seen more often in young

• Result of direct trauma

• Fractures of proximal humerus common in elderly patients who have fallen

Fractures of the humerus

Compartment Syndrome

• Elevation of pressure within fibrous tissue that surrounds & supports muscles & neurovascular structures

• Characterized by extreme pain, pain on movement, pulselessness & pallor

• Fractures of the forearm or lower leg are the most common injuries that cause compartment syndrome

Elbow• Result of a direct force or twisting of arm

• Elbow dislocations rare—but very serious injuries

• Often lead to nerve & vascular damage • Makes olecranon process of ulna much

more prominent• Joint usually locked with forearm

moderately flexed on arm• This position makes any movement

extremely painful

• Often swelling, significant pain & potential for vessel & nerve damage • Treatment includes either sling & swathe or splinting in place depending on situation

Dislocated elbow

Radius/Ulna• Fractures of radius & ulna are common• Occur as a result of a fall on an outstretched arm, excessive twisting, or from direct blow • Fracture of distal radius sometimes called Colles or "silver fork" fracture

• Can occur in the growth plate & cause future complications in children

Ulna & radius fracture

Wrist and Hand• Hand & wrist fractures common & usually result of fall or direct blow• Falls on outstretched hand can crack scaphoid bone (at the base of the thumb)• Fistfight can fracture fourth or fifth metacarpal• Excessive force can dislocate fingers or thumb

• Immobilize hand & wrist injuries with rigid splint• Wrist & hand contain many small bones & ligaments• Most injuries will require examination by physician

LOWER BODY

Pelvis• Often result from motor vehicle, pedestrian accidents or falling from a height

• In elderly can occur simply by falling

• Vital blood vessels & nerves passing near pelvis & femur • Vital organs in pelvic area

• Bowel, bladder & Uterus)

• Injuries to this region can be very serious

Pelvis• Sometimes an indirect force may be

transferred through the femur & hip, causing a pelvic fracture

• Because major blood vessels located in pelvic cavity susceptible to further injury

• Splint & immobilize all suspected pelvic fractures as quickly as possible to prevent further blood loss

• Stabilize patient on a backboard• Anticipate development of shock.

Hip Dislocation

• Head & neck of femur, along with the greater trochanter, meet pelvis to form hip

• Hip joint ball-and-socket joint that is quite strong

• Hip dislocations rare – extremely serious injury

Hip Dislocation• Hip dislocations can damage large vessels & nerves• Most common cause – motor vehicle accidents

• Knee strikes dashboard femur can dislocate backwards

• Posterior hip dislocations: leg shortened & rotated internally• Anterior dislocations: leg lengthened & externally rotated

• Treatment includes splinting extremity in the position it is found• Do not attempt to reduce a hip dislocation

Femur (Hip Fractures)• Fractures of the proximal femur, also called "hip" fractures, most common femoral fractures

• Especially in geriatric population

• Osteoporosis & reduced muscle mass contribute to high incidence of this type of fracture• Break usually occurs at neck or across proximal shaft

• Hip fractures typically cause patient's leg to rotate externally• Leg is also shortened• Falls most common reason for this type of fracture

Femur (Hip Fracture)• Lead to loss of moderate amount of blood • Monitor for signs of shock• Follow these steps when caring for suspected hip fracture:

• Check for other injuries (e.g., c-spine or head injury)• Use scoop stretcher to move patient to padded backboard or stretcher • Keep patient warm • Treat patient gently & minimize movement • Immobilize injured leg in place, if possible • Pad generously to immobilize femur (including between legs) • Carefully move patient to stretcher or backboard (with scoop stretcher, if available)

Treatment of Hip Fracture

• First, assess patient & immobilize spine, if mechanism of injury indicates

• No reason to suspect cervical spine injury, c-collar is not necessary• For example, fall from standing position

onto hip with no trauma to head

Key points for treating fractured hip:• Minimize movement of injured limb• Immobilize injured leg in place, if possible • Pad generously to immobilize femur including between legs • Pad generously under leg if femur elevated• Secure legs together• Consider using scoop stretcher to lift to backboard (padded

with blanket) • Pad well for comfort • Keep patient warm • Treat patient gently & minimize movement

• Scoop stretcher or clamshell stretcher –excellent choice for moving someone with hip fracture

• Movement minimized with scoop stretcher when compared with using backboard where you must log roll the patient

• Place patient directly on padded backboard from scoop stretcher Note: Use traction splint for mid-shaft femur

fractures onlyNote: Use traction splint for mid-shaft femur

fractures only

Femur (Shaft)• Fractures of femur also occur in shaft & femoral condyles just above the knee joint• When femur fractured, large muscles of thigh can go into spasms

• Can cause shortening & deformity of limb with severe angulation or external rotation at fracture site

Femur fracture

Femur (Shaft)

• Broken ends of femur can pierce skin & cause open fracture

• Blood loss can be significant • Lead to hypovolemic shock

• Bone fragments & deformity can damage important nerves & vessels• Long lasting effects• Delay recovery

Femur (Shaft) Treatment• Reduce angulation of open femur

fracture after removing foreign matter as well as possible

• Apply manual traction & gently attempt to move limb to achieve normal alignment

• Use sterile dressings to cover open wounds at fracture site

• Anticipate signs of shock• Check distal CMS at regular intervals• Provide rapid transport

Knee• Knee joint, like the shoulder joint, extremely complex & easily injured• Ligament or cartilage damage commonly seen with twisting injuries• Injuries to ligaments of knee range from mild sprains to complete dislocation of bone ends

Knee injuries

• Patella (kneecap) susceptible to injury such as fracture or dislocation

• Pulseless knee dislocation true medical emergency• Requires emergent transport to facility• Vascular surgery on hand

Tibia and Fibula• Two bones of the lower leg• Fibula smaller of the two• Located near surface of skin

• Open fractures are common

• Mid-shaft fractures of tibia & fibula usually result in gross deformity with significant angulation & rotation

Tibia-fibula fracture

Tibia and Fibula

• Often accompanied by vascular injury• Realigning & splinting limb may restore

adequate blood flow to foot• Need to realign an angulated tib/fib

fracture• Check distal CMS before & after

realignment

• Rapid transport• Physician evaluation

Ankle• Twisting – most common mechanism of injury to ankle• Often impossible to distinguish fractured bone from severe ankle sprain

• Both will lead to swelling & pain• Typically, fractures cause more pain & often limits ability to walk

• Lateral & medial malleolus are distal ends of fibula & tibia respectively

• Often crack if twisting force applied to ankle is sufficient

Ankle fractures

Ankle• As with all joint injuries, difficult to tell a

non-displaced ankle fracture from a simple sprain without an x-ray

• Ankle injuries that produce pain, swelling, localized tenderness, or inability to bear weight • Need physician evaluation

• Immobilize ankle by securing foot & lower leg• Pillow splint one technique effective in

immobilizing ankle

Foot• Foot injuries common

• Falls from heights• Excessive twisting motions

• Calcaneus bone (heel bone) may be fractured if patient falls from sufficient height & lands on heels• If calcaneus fractured may be enough force to have

other associated fractures such as vertebral fractures

• Pain, swelling & ecchymosis may be seen with fractures of foot

Amputation• Rare occurrences but life altering events• In 1999, an estimated 19,700 occupational amputation cases were treated in a hospital emergency department

• About 0.5% of all injuries and illnesses treated in hospital emergency departments among workers aged 15 and older

Finger amputation in factory

Mechanism of Injury• Significant force is usually required to

fracture a bone or dislocate a joint• Many types of forces can cause these

injuries• Direct

• Fall on the tail bone that cracks coccyx

• Indirect• Person falling & landing on feet causing vertebral

fracture

• Twisting• Skiing causes twisting injuries – can crack ankle or tibia

• High-energy forces• Car striking another car

Mechanism of Injury

• An important aspect of patient care: assess mechanism of injury & determine which forces have been applied to patient's body

• Consider signs of blunt or penetrating trauma

• Consider which underlying structures may have been impacted by force

Trauma and the Elderly• Risk of fatality from multi-system trauma is three times greater at age 70 than age 20• Happens because elderly body does not compensate effectively from trauma• Most trauma deaths in seniors caused by falls & motor vehicle accidents

• Consider following factors:

• Elderly patients often lie in extreme environments for long periods of time before help arrives leading to hypothermia or hyperthermia• Elderly patients more often dehydrated & malnourished • Chest trauma more likely to cause lung damage because chest wall is less flexible

Osteoporosis• Extreme force or transfer of energy is not

always necessary to fracture a bone• Osteoporosis – loss of bone density

• Usually caused by calcium loss• Common in women who have gone through

menopause

• Insignificant force can easily fracture a bone weakened by a tumor or osteoporosis

• Geriatric patients with osteoporosis• Minor fall, simple twisting injury or even a violent

muscle contraction may cause a fracture

Assessment

• Start assessment by assessing mechanism of injury• Try to determine which forces acted on the

body & to what degree

• Patient SICK, care of orthopedic injuries is not the highest priority• Must assure ABCs

• Patient NOT SICK, you have a little more time to investigate MOI• Perform physical exam & focused history

AssessmentSigns of orthopedic injury include:

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

Don’t focus solely on obvious injuries – may overlook other potential injuries:• Spinal trauma• Damage to internal organs• Pre-existing medical conditions

CMS• Mnemonic: circulation, motor, & sensory

function• Indicators of proper vessel & nerve function• Any extremity with injury or deformity may

have underlying damage to important blood vessels & nerves.

• Always check CMS of an extremity before & after splinting• Note any changes

CMS – Circulation• Upper extremity injuries check radial pulse & capillary refill

• Check capillary refill by gently squeezing & releasing nail bed of a finger• Full color should return within two seconds• These tell you state of perfusion to tissues in extremity

• Poor circulation may be caused by shock or damaged blood vessels

• Lower extremity injury using posterior tibial or dorsalis pedis pulse• Check capillary refill by blanching nail bed of a toe

CMS – Motor Function

• Ask patient to wiggle his or her fingers (or toes) to check for proper motor function

• Lack of movement may reveal tissue or nerve damage

CMS – Sensory Function

• Lightly touch fingers or toes (remembering that the bottom of the patient's foot belong to them)

• Ask patient to distinguish exact location of sensation

• Numbness or tingling distal to injury may indicate nerve damage

Treatment of ShockPrehospital treatment for hypovolemic shock includes following steps:

• Evaluate mechanism of injury• Determine SICK or NOT SICK• Maintain airway, assist ventilations if needed• Control bleeding• Administer high flow oxygen• Place in Trendelenburg position• Splint fractures• Consider use of Pneumatic Anti-Shock Garment (PASG) for stabilization• Maintain body temperature• Monitor vital signs• Rapid transport

Video demonstration available at EMS Online:

http://www.emsonline.net/ortho2011/treatment.asp

Splinting Procedures• Primary reason for applying a splint is to prevent movement of a fractured bone• Proper splinting in field can decrease pain & bleeding which in turn can reduce patient's hospital stay & speed recovery

• There are six principles for applying a splint:

• Support the fracture site • Bone fracture: Immobilize the joint above and below the fracture site • Joint injury: Immobilize the bones above and below the dislocation • Check CMS before and after splinting • Pad the splint well • Elevate the extremity after splinting, if possible

Benefits of Splinting• Splint will provide many benefits when

properly applied – immobilize fractured bone ends

• Loose bones ends can cause the following problems: • Damage to muscles, nerves, and blood vessels• Lacerations to the skin• Impeded blood flow• Increased bleeding• Increased pain

Treatment of Hip Fracture• First, assess patient & immobilize spine if mechanism of

injury indicates• No reason to suspect a cervical spine injury, c-collar not

necessary• For example, fall from standing position onto hip with no trauma

to head

• In most cases, splint fracture without repositioning the leg: • Place a pillow or rolled blanket between patient's legs to prevent

hip from moving laterally • Pad under leg generously if femur is elevated • Secure legs together • Use scoop stretcher to lift patient onto a backboard (padded with

a blanket)• Pad well for comfort & secure patient

Realigning Joint Injuries & Dislocations• Splint dislocations or other joint injuries in

position found• Exceptions include:

• Loss of a distal pulse and neurological function where definitive care is delayed

• In these cases: • Attempt to straighten into anatomical position until pulse

returns, excessive pain felt, or resistance encountered• Support with blanket, pillow, or well-padded splint• Elevate the limb• Pack injured area in ice or use ice pack• Document attempts to re-align injury

Realignment of Long Bone Fractures• You can attempt to realign fractures of

long bones that occur in the middle 1/3 of the bone only

• Long bone fractures, which occur in the proximal or distal 1/3, may be realigned only if compromise of distal circulation or nerve function is detected and definitive care is delayed

Traction Splinting

• Use traction splint for mid-shaft femur fractures only

• They stabilize bone ends & help reduce muscle spasms in large thigh muscles

• Helps prevent further injury to vessels, nerves & tissues

• Reduces pain

Traction Splinting

Contraindications for the use of a traction splint include:

• Injury close to or involving the knee • Hip injury • Pelvis injury • Partial amputation or avulsion with

bone separation • Lower leg or ankle injury

Traction SplintingThe key points for applying a traction splint are: • Do not apply if there is a destabilizing injury to hip, knee or ankle• Support fracture site when limb is lifted• Apply manual traction & hold until splint is secured• Check CMS before & after apply splint

http://www.emsonline.net/ortho2011/traction.asp

Treating Pelvic InjuriesImmobilization of pelvic fractures can be accomplished by use of a

bed sheet or an approved, commercially-available splinting device.

Instructions for splinting with a bed sheet are as follows: • Fold the sheet lengthwise into an 8" to 14" width.• Place the sheet beneath the patient. Wrap the ends around the

patient and twist while crossing over the pelvic area.• Tie the sheet with square knot or plastic ties to apply moderate

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

Pelvic sheeting technique

Case Studies

Video Case Study #1http://www.emsonline.net/ortho2011/case1.asp

Video Case Study #2http://www.emsonline.net/ortho2011/case2.asp

Summary

• Muscles are attached to bones by tendons

• Fascia are sheets or bands of fibrous connective tissue that cover muscles

• Joint is a location where two bones come together

• Bones of movable joints are covered with cartilage

Summary• Common factor in all types of shock is

inadequate tissue perfusion• Perfusion is circulation of blood within an

organ or tissue• To maintain adequate perfusion the body

requires four intact components:• Pump (heart)• Pipes (blood vessels)• Fluids (adequate blood volume)• Oxygen (adequate oxygenation

SummarySigns and symptoms of shock include: • Anxiety • Altered LOC • Delayed capillary refill • Weak, thready or absent peripheral pulses • Pale, cool, clammy skin • Increased pulse rate (an early sign) • Decreased blood pressure (a late sign)

SummaryTreatment of hypovolemic shock includes: • Assess the MOI• Determine SICK or NOT SICK• Maintain airway, assist ventilations if needed• Control bleeding• Administer high flow oxygen• Place in shock position• Splint fractures• Maintain body temperature• Monitor vital signs• Rapid transport

SummaryPrinciples of splinting are: • Support the fracture site • Bone fracture - immobilize the joint above

and below the fracture site • Joint injury - immobilize the bones above and

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

Summary• You can attempt to realign fractures of long bones that

occur in the middle 1/3 of the bone only• Splint dislocations or other joint injuries in position

found except in cases of loss of a distal pulse & neurological function where definitive care is delayed

• Outcome of most traumatic injuries does not rest with us but in our ability to transport to a Trauma Center in an expeditious fashion

• The old adage still applies:

We don't save trauma victims the operating room does!

Questions

Dr. Mickey EisenbergMedical DirectorAsk the Doc: http://www.emsonline.net/doc.asp

EMS OnlineGuidelines and Standing Ordershttp://www.emsonline.net/downloads.asp

Susan KolwitzProgram ManagerEmail support: help@emsonline.net

© 2010 seattle / king county ems cbt302-emt11 – orthopedic emergencies

scar tissue

soft tissue

band of fibrous tissue

skeletal muscle

fractured bone ends

joint injury

irregular cartilage

blood loss

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