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BLS 2014 – Orthopedic Emergencies

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1 BLS 2014 – Orthopedic Emergencies

2 Course Objectives Identify the structure and function of bone
Describe how to evaluate orthopedic injuries Describe energy transmission as it applies to fractures Predict injuries based on mechanism of injury Review splinting principles Describe how to choose and apply a splint to treat various orthopedic injuries Prioritize splinting in patients who are severely traumatized Understand, recognize, and treat shock

3 Mechanics

4 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

5 Functions of bone Support Movement Physiologic processes
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

6 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.

7 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

8 Mechanism of Injury

9 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

10 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

11 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

12 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

13 Evaluation

14 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

15 Assessment Start by assessing mechanism of injury Patient SICK
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

16 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!

17 Focused history “What happened?” (mechanism of injury) Chief complaint
Associated complaints Medical history Medications Allergies

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

19 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

20 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

21 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

22 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

23 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

24 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

25 Treatment

26 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

27 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

28 Specific Injuries and Treatment
Upper Body Lower Body

29 Upper Body

30 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

31 Clavicle Fractured – serious injury Treatment includes
Bone positioned over major arteries, veins & nerves When fractured…cause nerve & muscular damage Treatment includes Application of a sling & swathe Transport to medical facility 

32 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

33 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

34 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

35 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

36 Shoulder Treatment Application of a sling & swathe
Transport to medical facility

37 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

38 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

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

40 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

41 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

42 Lower Body Orthostatic hypotension is a sudden fall in blood pressure that occurs when a person moves to an upright position. It is generally related to hypovolemia and caused by blood loss, diuretics, vasodilators or dehydration. To assess for orthostatic hypotension you should perform a postural vital signs check. Consider performing this check in patients who complain of abdominal pain with associated light-headedness or with the possibility of volume depletion including: Suspected GI bleeding or internal hemorrhage Generalized weakness Dizziness, light-headedness or fainting Prolonged vomiting or diarrhea

43 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 Orthostatic hypotension is a sudden fall in blood pressure that occurs when a person moves to an upright position. It is generally related to hypovolemia and caused by blood loss, diuretics, vasodilators or dehydration. To assess for orthostatic hypotension you should perform a postural vital signs check. Consider performing this check in patients who complain of abdominal pain with associated light-headedness or with the possibility of volume depletion including: Suspected GI bleeding or internal hemorrhage Generalized weakness Dizziness, light-headedness or fainting Prolonged vomiting or diarrhea

44 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

45 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

46 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

47 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

48 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  

49 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

50 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

51 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

52 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:

53 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

54 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

55 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

56 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

57 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

58 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

59 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

60 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

61 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

62 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

63 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

64 Prioritizing

65 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

66 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 

67 Shock Characterized by: Signs & Symptoms: 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

68 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 Video demonstration available at EMS Online:

69 Case Studies Video Case Study #1 Video Case Study #2
Video Case Study #2

70 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

71 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!

72 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

73 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)

74 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

75 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.

76 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.

77 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.

78 Questions EMS Online Guidelines and Standing Orders
Susan Kolwitz Program Manager support: Dr. Mickey Eisenberg Medical Director Ask the Doc:


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