BLS 2014 – Orthopedic Emergencies

1. BLS 2014 – Orthopedic Emergencies

2. 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 Describe how to evaluate orthopedic injuries 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 Course Objectives

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 • 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. 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. Related Structures

7. 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 Joint

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 • 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 dorsalispedis 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 movementof 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. 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

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. 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 Scapula

34. 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

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 deformityof 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 • Midshaftfractures 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

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 canbe very serious

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