CBT302-EMT11 – Orthopedic Emergencies

1. CBT302-EMT11 – Orthopedic Emergencies

2. 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

3. Course Objectives • 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.

4. 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.

5. 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.

6. 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.

7. 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.

8. 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

9. 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.

10. 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

11. 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

12. 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.

13. 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).

14. 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

15. 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

16. UPPER BODY

17. 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

18. 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.

19. 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

20. 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

21. 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

22. 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

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

24. 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

25. 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

26. 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

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

28. 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

29. 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

30. LOWER BODY

31. 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

32. 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.

33. 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

34. 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

35. 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

36. 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)

37. 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

38. 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

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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

47. 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

48. 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

49. 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

50. 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