1. CBT/OTEP 302 Orthopedic Injuries

2. Introduction
• Skeletal system provides shape and form
• Protects internal organs
• Allows bodily movement
• Produces blood
• Stores minerals
This course will refresh your knowledge of skeletal structures and injuries that can occur to them.

3. New Terms
compartment syndrome - Elevation of pressure within the fibrous tissue that surrounds and supports muscles and neurovascular structures, characterized by extreme pain, pain on movement, pulselessness, and pallor.
fascia - Sheets or bands of fibrous connective tissue that lie deep under the skin forming the outer layer of a muscle.

4. New Terms, continued
osteoporosis - Generalized degenerative bone disease in which there is a reduction of bone mass making the bones fragile and susceptible to injury.
point tenderness - Tenderness sharply localized at the site of the injury.

5. Bones 206 bones – support body, protect organs
Muscles – attached to bones by tendons
Tendons – extension of fascia
Fascia – bands of tough, fibrous connective tissue that form outer layer of muscles

6. Joints Location where two bones come together
Bone ends of movable joints are covered with smooth cartilage and are lubricated by synovial fluid

7. Perfusion
Human body requires a constant supply of oxygen and nutrients

8. Adequate Perfusion Pump (heart) Pipes (blood vessels)
Fluids (adequate blood volume)
Oxygen (adequate oxygenation)
Image credit: Copyright 2005 Seattle/King County EMS

9. Shock
Caused by blood loss, cardiac failure, respiratory failure, or spinal cord injury
Defined as inadequate tissue perfusion

10. Causes of Shock Pump failure (AMI)
Pipe dilation (spinal cord injury, allergic reaction)
Blood/body fluid loss (trauma, GI bleed, dehydration)
Lack of oxygen (drowning, strangulation or CHF)
Image credit: Copyright 2005 Seattle/King County EMS

11. Signs of Shock • Anxiety • Altered LOC • Delayed capillary refill
• Weak, thready, absent peripheral pulses
• Pale, cool, clammy skin
• Increased pulse rate (early sign)
• Decreased BP (late sign)

12. Clavicle • Commonly fractured • Shoulder pain
• Point tenderness, swelling
• Guarding of injured shoulder
Image used with permission of Jones and Bartlett Publishers, Sudbury, MA, (Academy of Orthopaedic Surgeons, Trauma Slide Set, ©2002

13. Scapula • Less often injured due to location
• Fracture results from direct blow
• Look for injury to chest cavity and its contents

14. Shoulder Dislocation • Joint between humerus and scapula
• Remarkably complex
• Easily injured
• Anterior dislocation of humeral head common

15. Humerus • Fractures at elbow, midshaft, or shoulder
• Common in elderly who have fallen
Image used with permission of Jones and Bartlett Publishers, Sudbury, MA, (Academy of Orthopaedic Surgeons, Trauma Slide Set, ©2002

16. Elbow Dislocation • Result of direct force or twisting of arm
• Very serious injuries
• Olecranon process of ulna more prominent
• Swelling, significant pain, vessel/nerve damage

17. Forearm • Fractures of radius and ulna are common
• Direct blow, excessive twisting
Image used with permission of Jones and Bartlett Publishers, Sudbury, MA, (Academy of Orthopaedic Surgeons, Trauma Slide Set, ©2002

18. Wrist and Hand • Result of fall or direct force
• Many small bones and ligaments
• Use rigid splint

19. Pelvis • Result of MVA/pedestrian, falls
• Vessels, nerves, organs in pelvic area
• Indirect force transferred through femur

20. Hip Fractures/Dislocations
• Result of MVA/pedestrian, falls
• Damage large vessels and nerves
• Splint extremity in position found
Image credit: LifeART(R) image, Copyright 1998, Lippincott Williams & Wilkins. All rights reserved.

21. Hip Fracture – Treatment
Check for other injuries (c-spine/head injury)
Use a scoop stretcher to move patient to padded backboard or stretcher
Keep patient warm
Treat patient gently and minimize movement
Immobilize injured leg in place, if possible
Pad generously to immobilize femur (including between the legs)
Carefully move pt to a stretcher or backboard

22. Femur • Result of significant force • Large thigh muscles can spasm
• Open fracture – significant blood loss

23. Femur Fracture – Treatment
• Mid-shaft (middle 1/3)
• Do not apply if destabilizing injury to hip, knee or ankle
• Support fracture site when limb is lifted
• Do not lose traction once applied
• Hold manual traction until splint is secured
• Check CMS before and after splinting

24. Knee • Extremely complex ,easily injured joint
• Ligament or cartilage damage common
• Patella fracture or dislocation
Image used with permission of Jones and Bartlett Publishers, Sudbury, MA, (Academy of Orthopaedic Surgeons, Trauma Slide Set, ©2002

25. Tibia and Fibula • Open fx common, bones near skin • Vascular injury
• If need to realign, check distal CMS before and after realignment

26. Ankle • Common MOI is twisting • Pain, swelling, localized tenderness
• Difficult to distinguish fx from sprain
• Immobilize by securing foot and the lower leg

27. Foot • MOI – twisting and falls from height
• Pain, swelling, localized tenderness
• If calcaneus fractured may be other associated injuries (spinal fracture)

28. Mechanism of Injury
• Significant force required to fracture a bone or dislocate a joint
• Types of forces: direct, indirect, twisting, and high-energy forces

29. Assessing Mechanism of Injury
• Determine which forces were applied to body
• Signs of blunt or penetrating trauma
• Determine which underlying structures might have been impacted by the force

30. Trauma and the Elderly
• Death from multi-system trauma is three times greater at age 70 than 20
• Elderly body does not compensate effectively
• Slower to react, less agile, weaker, poor vision and hearing

31. Osteoporosis
• Insignificant force can easily fracture bone weakened by tumor or osteoporosis
• Minor fall, simple twisting injury, or even violent muscle contraction can cause fracture
Image credit: LifeART(R) image, Copyright 1998, Lippincott Williams & Wilkins. All rights reserved.

32. Signs of Orthopedic Injury
• Deformity or angulation
• Pain and tenderness
• Grating (crepitus)
• Swelling
• Bruising (discoloration)
• Exposed bone ends
• Joint locked into position

33. Shock – Treatment • Evaluate MOI • Determine SICK or NOT SICK
• Maintain airway, assist ventilations if needed
• Control bleeding
• Administer high flow oxygen

34. Shock – Treatment, continued
• Shock position
• Splint fractures
• Maintain body temperature
• Monitor vital signs
• Rapid transport

35. Splinting Principles • Support fracture site
• (Long bone fracture) immobilize joint above and below fracture site
• (Joint injury) - Immobilize bones above and below the joint injury
• Check CMS before and after splinting
• Pad splint well
• Elevate extremity after splinting

36. Realigning Joint Injuries/Dislocations
• Splint dislocations or other joint injuries in position found
• Exception: loss of distal pulse and/or neurological function and where definitive care is delayed

37. Realigning Joint Injuries/Dislocations
Loss of distal pulse and/or neurological function and definitive care is delayed:
1. Attempt to straighten into anatomical position until pulse returns, excessive pain, or resistance encountered.
2. Support with blanket, pillow or well-padded splint.
3. Elevate limb.
4. Pack injured area in ice or use ice pack.
5. Document attempts to re-align.

38. Realigning Long Bone Fractures
• Middle 1/3 of bone only
• Proximal or distal 1/3 may be realigned if compromise of distal circulation and/or nerve function and definitive care delayed
Image credit: Copyright 2005 Seattle/King County EMS

39. Traction Splint • Support fracture site when limb is lifted
• Apply manual traction and hold until splint is secured
• Check CMS before and after apply splinting

40. Traction Splint – Contraindications
• Injury close to or involving knee
• Hip injury
• Pelvis injury
• Partial amputation or avulsion with bone separation
• Lower leg or ankle injury

41. Pelvic Injury – Treatment
• Immobilize with bed sheet or commercial splinting device
Splinting with bed sheet:
1. Fold sheet lengthwise into 8" - 14" width.
2. Place sheet beneath patient. Wrap ends around patient and twist while crossing over pelvic area.
3. Tie sheet with square knot or plastic ties to apply moderate pressure around circumference of pelvis.
4. Secure ends of sheet to backboard, if possible.

42. Summary Muscles attached to bones by tendons
Fascia are bands of fibrous connective tissue that cover muscles
Common factor in all shock is inadequate perfusion
Perfusion is circulation of blood within organ or tissue

43. Summary, continued To maintain adequate perfusion: Pump (heart)
Pipes (blood vessels)
Fluids (adequate blood volume)
Oxygen (adequate oxygenation)

44. Summary, continued Signs and symptoms of shock: Anxiety Altered LOC
Delayed capillary refill
Weak, thready, or absent peripheral pulses
Pale, cool, clammy skin
Increased pulse (early sign)
Decreased BP (late sign)

45. Summary, continued Hypovolemic shock: Assess MOI
Maintain airway, assist ventilations if needed
Control bleeding
High flow oxygen
Shock position
Splint fractures
Maintain body temp
Monitor vital signs

46. Summary, continued Principles of splinting: Support fracture site
(Long bone fracture) immobilize joint above and below fracture site
(Joint injury) immobilize bones above and below the joint injury
Check CMS before and after splinting
Pad splint well
Elevate extremity after splinting, if possible

47. Summary, continued
Attempt to realign fractures of long bones in the middle 1/3 of bone only
Splint dislocations/joint injuries in position found except with loss of distal pulse and/or neurological function and where definitive care is delayed