CBT 302 EMT 11 Orthopedic Emergencies 2010 Seattle

CBT 302 -EMT 11 – Orthopedic Emergencies © 2010 Seattle / King County EMS

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 © 2011 Seattle / King County EMS

Course Objectives 1. 2. 3. 4. 5. 6. 7. 8. Identify the structures of the skeletal system. Identify the definition of perfusion. Identify signs and symptoms of shock. Identify the four components required for adequate perfusion. Demonstrate an understanding of the physiology of shock. Identify prehospital treatment for shock. Identify the characteristic injuries of specific bones. Identify proper application of the principles of splinting. © 2011 Seattle / King County EMS

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. © 2011 Seattle / King County EMS

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 mm. Hg 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. © 2011 Seattle / King County EMS

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. © 2011 Seattle / King County EMS

New Terms crush 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. © 2011 Seattle / King County EMS

Bones • 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 © 2011 Seattle / King County EMS

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. © 2011 Seattle / King County EMS

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 © 2011 Seattle / King County EMS

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 © 2011 Seattle / King County EMS

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. © 2011 Seattle / King County EMS

Perfusion Body 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). © 2011 Seattle / King County EMS

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 © 2011 Seattle / King County EMS

Shock Characterized by: • Reduced cardiac output • Rapid heart rate • Circulatory insufficiency © 2011 Seattle / King County EMS 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 © 2011 Seattle / King County EMS

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 acromioclavicular joint can resemble a clavicle fracture. © 2011 Seattle / King County EMS Clavicle injuries

Clavicle • 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. © 2011 Seattle / King County EMS

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 © 2011 Seattle / King County EMS 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 © 2011 Seattle / King County EMS

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 © 2011 Seattle / King County EMS

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 © 2011 Seattle / King County EMS Dislocated shoulder

Shoulder Treatment • Application of a sling & swathe • Evaluation by a physician. © 2011 Seattle / King County EMS

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 © 2011 Seattle / King County EMS 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 © 2011 Seattle / King County EMS

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 © 2011 Seattle / King County EMS

Elbow • Often swelling, significant pain & potential for vessel & nerve damage • Treatment includes either sling & swathe or splinting in place depending on situation © 2011 Seattle / King County EMS 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 © 2011 Seattle / King County EMS 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 © 2011 Seattle / King County EMS • Immobilize hand & wrist injuries with rigid splint • Wrist & hand contain many small bones & ligaments • Most injuries will require examination by physician

LOWER BODY © 2011 Seattle / King County EMS

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 © 2011 Seattle / King County EMS

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. © 2011 Seattle / King County EMS

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 © 2011 Seattle / King County EMS

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 © 2011 Seattle / King County EMS • 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 © 2011 Seattle / King County EMS • 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: © 2011 Seattle / King County EMS • Check for other injuries (e. g. , cspine 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, ccollar is not necessary • For example, fall from standing position onto hip with no trauma to head © 2011 Seattle / King County EMS

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 • • • © 2011 Seattle / King County EMS

Treatment of Hip Fracture • 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 only © 2011 Seattle / King County EMS

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 © 2011 Seattle / King County EMS 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 © 2011 Seattle / King County EMS

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 © 2011 Seattle / King County EMS

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 © 2011 Seattle / King County EMS Knee injuries

Knee • 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 © 2011 Seattle / King County EMS

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 © 2011 Seattle / King County EMS 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 © 2011 Seattle / King County EMS

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 © 2011 Seattle / King County EMS Ankle fractures

Ankle • As with all joint injuries, difficult to tell a nondisplaced 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 © 2011 Seattle / King County EMS

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 © 2011 Seattle / King County EMS

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 © 2011 Seattle / King County EMS 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 © 2011 Seattle / King County EMS

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 © 2011 Seattle / King County EMS

Trauma and the Elderly • Risk of fatality from multi • Consider following factors: -system trauma is three • Elderly patients often lie in extreme environments for times greater at age 70 long periods of time before than age 20 help arrives leading to • Happens because elderly hypothermia or hyperthermia body does not • Elderly patients more often dehydrated & malnourished compensate effectively • Chest trauma more likely to from trauma cause lung damage because • Most trauma deaths in chest wall is less flexible seniors caused by falls & motor vehicle accidents © 2011 Seattle / King County EMS

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 © 2011 Seattle / King County EMS

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 © 2011 Seattle / King County EMS

Assessment Signs of orthopedic injury include: • • Deformity or angulation Pain and tenderness Grating (crepitus) Swelling Bruising (discoloration) Exposed bone ends Joint locked into position © 2011 Seattle / King County EMS 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 © 2011 Seattle / King County EMS

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 © 2011 Seattle / King County EMS • 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 © 2011 Seattle / King County EMS

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 © 2011 Seattle / King County EMS

Treatment of Shock Prehospital 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 © 2011 Seattle / King County EMS Video demonstration available at EMS Online: http: //www. emsonline. net/ortho 2011 /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 © 2011 Seattle / King County EMS • 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 © 2011 Seattle / King County EMS

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 © 2011 Seattle / King County EMS

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 © 2011 Seattle / King County EMS

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 © 2011 Seattle / King County EMS

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 © 2011 Seattle / King County EMS

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 © 2011 Seattle / King County EMS

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 © 2011 Seattle / King County EMS Video demonstration available at EMS Online: http: //www. emsonline. net/ortho 2011 /traction. asp

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 © 2011 Seattle / King County EMS

Case Studies Video Case Study #1 http: //www. emsonline. net/ortho 2011/case 1. asp Video Case Study #2 http: //www. emsonline. net/ortho 2011/case 2. asp © 2011 Seattle / King County EMS

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 © 2011 Seattle / King County EMS

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 © 2011 Seattle / King County EMS

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) © 2011 Seattle / King County EMS

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 © 2011 Seattle / King County EMS

Summary Principles 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 © 2011 Seattle / King County EMS

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! © 2011 Seattle / King County EMS

Questions EMS Online Guidelines and Standing Orders http: //www. emsonline. net/downloads. asp Susan Kolwitz Program Manager Email support: help@emsonline. net Dr. Mickey Eisenberg Medical Director Ask the Doc: http: //www. emsonline. net/doc. asp © 2011 Seattle / King County EMS