bls 2014 – orthopedic emergencies. course objectives 1.identify the structure and function of bone...

© 2013 Seattle / King County EMS

BLS 2014 – Orthopedic Emergencies


Course Objectives1. Identify the structure and function of bone2. Describe how to evaluate orthopedic injuries3. Describe energy transmission as it applies to fractures4. Predict injuries based on mechanism of injury5. Describe how to evaluate orthopedic injuries 6. Review splinting principles7. Describe how to choose and apply a splint to treat various orthopedic injuries8. Prioritize splinting in patients who are severely traumatized9. Understand, recognize, and treat shock


Mechanics


Bones

Bones are made of calcium, collagen, and living cells Collagen is strong and lightweight,

and provides elasticity Calcium is a mineral that maintains

bone density Bones contain living cells and have

their own blood supply


Functions of bone

Support Bones are the scaffolding of the body

and provide protection to underlying organs and body systems

Movement Bones provide a framework for the

attachment of muscles, tendons, and ligaments, allowing movement

Physiologic processes Bones produce blood cells and

hormones


Related StructuresBones & 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 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


Mechanism of Injury


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


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


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 may 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; ribs can break and lacerate lungs


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 osteoporosis Geriatric patients with osteoporosis

Minor fall, simple twisting injury or even a violent muscle contraction may cause a fracture


Evaluation


Arriving at a Trauma Scene

Keep yourself safe! Take appropriate BSI: gloves, gown,

goggles, depending on your assessment of risk

Traffic: is the scene safe for you to enter?

Scenes of violence: is the scene secure?

Initial assessment: mechanism of injury


Assessment

Start by assessing mechanism of injury Try to determine the forces acting on

the body Patient SICK

ABCs and bleeding control have priority

Orthopedic injuries are secondary Patient NOT SICK:

Perform physical exam and focused history

more time to investigate MOI


Rapid trauma exam

Assess the patient’s airway Determine level of consciousness Check for life-threatening bleeding Assess perfusion Check for other major injuries

Practice the steps of a rapid trauma exam on every trauma patient!


Focused history

“What happened?” (mechanism of injury)

Chief complaint Associated complaints Medical history Medications Allergies


Physical exam

ABCs HEENT (head, eyes, ears, nose) Neck, back Chest Abdomen Extremities Vital signs Skin signs


Directed orthopedic exam

Notice position of the patient/injured extremity

Inspect for deformity, swelling, bruising

Inspect for open wounds, lacerations, bone fragments

Compare an injured extremity to the uninjured one

Check distal circulation, motor, and sensory function


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 Ask patient to distinguish exact

location of sensation Numbness or tingling distal to

injury may indicate nerve damage


Reassessment

Continued reassessment of the injured patient is critical Recheck vital signs Ask the patient about increasing

or decreasing pain Ask about changes in sensation

such as tingling or numbness Re-check distal circulation,

motor, and sensory function


Treatment


Splinting

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


Splinting Principles Prioritize ABCs over splinting Immobilize the site of injury Pad the splint well If a bone is fractured, immobilize the

joint above and below the injury If a joint is injured, immobilize the bones

above and below the injury Evaluate distal circulation, motor, and

sensory function before and after splinting

Elevate the extremity if practical


Specific Injuries and Treatment

Upper BodyLower Body


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 Transport to medical facility

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, the shoulder is 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 deformityof shoulder & mechanism of injury

Dislocated shoulder


Shoulder

Treatment Application of a sling &

swathe Transport to medical facility


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


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


Elbow

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 from a ground-

level fall Vital blood vessels & nerves passing

near pelvis & femur Vital organs in pelvic area (Bowel,

bladder & uterus) Injuries to this region can

be very serious


Treating Pelvic Injuries Immobilization 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


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


Treatment of Hip Fracture

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


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 traction splint if appropriate (mid-shaft femur fracture)

Use sterile dressings to cover open wounds at fracture site

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


Traction Splinting

Use traction splint for mid-shaft femur fractures only

Traction splints 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 Splinting

The 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 Video demonstration available at EMS Online:

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

Video demonstration available at EMS Online:

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

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





Hip Dislocation

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

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

Hip dislocations are 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


Knee Knee joint, like the shoulder joint, is

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


Knee

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

Pulseless knee dislocation is a 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


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 limit

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


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 is fractured, there may be

enough force to have other associated fractures such as vertebral fractures

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


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


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


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


Prioritizing


Prioritize

Orthopedic injuries can be dramatic and distracting – consider the whole patient!

Prioritize ABCs over treatment of orthopedic injuries

Prioritize serious orthopedic injuries (such as pelvic fractures) over more minor injuries (such as a broken ankle)

Anticipate and treat for shock


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


Shock Characterized 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


Treatment of Shock Pre-hospital 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 Maintain body

temperature Monitor vital signs Rapid transport










Case StudiesVideo Case Study #1

http://www.emsonline.net/ortho2011/case1.asp

Video Case Study #2





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!


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


Summary

Signs 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)


Summary

Treatment 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


Terms Amputation - 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 gangrene

Compartment 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 injury

Crepitus — 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, continued Distal — 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, continued Point 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.


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: [email protected]

http://www.emsonline.net/doc.asp

http://www.emsonline.net/downloads.asp

http://www.emsonline.net/downloads.asp

http://www.emsonline.net/

bls 2014 – orthopedic emergencies. course objectives 1.identify the structure and function of bone...

Documents

bones bones

force slide

car slide

bone density bones

mechanism of injury

mechanics slide

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