Orthopedic Trauma

Orthopedic Trauma Andrea L. Williams, PhD, RN Emergency Education & Trauma Program Specialist Associate Clinical Professor UWHC & UW-SON

Name that Injury!

Associated Conditions • Hemorrhage – Shock (~2L pelvis, 1L thigh & 500 ml tibia) • Instability • Loss of tissue • Laceration with contamination • Interrupted blood supply – Ischemia • Nerve damage • Long-term Disability

Sprains • Partial tear of a ligament by twisting & stretching of a joint beyond normal ROM • 1st Degree Sprain – No instability, few fibers torn. Minimal hemorrhage & swelling • 2nd Degree Sprain – No instability, ligaments partally torn, swelling and hemorrhage • 3rd Degree Sprain – Unstable, ligaments completely, with significant swelling & hemorrhage.

Sprained Knee

Strains & Ruptures • Strain - Injury to a muscle or tendon from overexertion (back, arms, calf) • Severe strains can cause bone avulsion

Joint Dislocations • Dislocation – Articulating surfaces of 2 bones are displaced • Luxation – Complete dislocation • Subluxation – Incomplete dislocation • Rotator Cuff injuries – Usually deltoid • Common sites • Shoulders, elbows, fingers, knees, & ankles • Complications • Posterior popliteal injury

Principles of Splinting (p. 1238) • Splint joints and fractures above & below injuries • Cover open fractures • Document pulses, sensation, motor function before & after splinting • Stabilize the limb with gentle in-line traction to a position of normal alignment • Immobilize dislocations in a position of comfort with • Ice, cold compresses • Elevation – to or just below level of heart

Shoulder Injuries • Dislocations • Subluxations • Rotator cuff tendon injuries • Sternoclavicular strain • Treatment • Neurovascular status • Splint in position found or • Sling & secure to body • Ice or cold compresses

Elbow Injuries • Falling on an outstretched arm or flexed elbow • Pulled elbow – Nursemaids elbow from a sudden lateral force • Athletic injury • Complications • Volkmann’s contracture – Claw-like contraction of hand & arm deformity from ischemia • Laceration of brachial artery • Ulnar nerve damage • Treatment • Check neurovascular status • Splint in position found • Ice or cold compresses

Radial, Ulnar, Wrist Injuries • Check neurovascular status • Splint in position found (rigid or formable • Ice & elevation

Hand Injury • Boxer’s fracture 5th metatarsal bone • Treatment • Check neurovascular status • Splint (rigid or semiformable) in position of function • Ice & elevation

Finger Injuries • Assess neurovascular status • Splint in foam filled aluminum splint, with tongue blades, or tape to adjacent finger • Ice & elevation

Pelvic Injuries Signs & Symptoms • Pain • Hypovolemic shock • Shortening or abnormal rotation of affected extremity • Associated with injuries to the bladder, urethra, reproductive organs & sacral nerves

Pelvic Injuries Treatment of Pelvic Fractures/Ring Injuries • Open book – Vacuum mattress, Pelvic Binder, or sheet • Control hemorrhage – Direct pressure or close pelvic ring • Fluid volume replacement – Normal Saline (ED - PRBC, FFP, Platelets., Factor VII A &/or embolization) External fixation/ORIF

Classification of Long Bone Injuries • Fractures • Complete or incomplete • Open or closed • Epiphyseal – Cause bending or deformity • Comminuted – Several breaks in the bone • Greenstick - Break in periosteum w/i bowing or buckling • Spiral – Twisted or circular break. ↑ child abuse • Oblique – Diagonal, slanting break • Transverse – Right angle fracture • Pathological

Long Bone Fractures Pathophysiology • Femur fractures result from major force • Long bone fractures from falls, MVC, MCC • Femur neck fractures common in elderly • Blood loss into a femur – 1,000-1,500 ml

Long Bone Fractures Signs & Symptoms • Pain • Ecchymosis & edema of the site • Deformity at the site • Shortening of affected extremity • Internal or external rotation • Hypovolemia or hypovolemic shock

Long Bone Fractures Assessment • Circulation – Hemorrhage or ischemia • Neurovascular status • Pulses • Deformity – Edema, hematoma, wounds • Compartment Syndrome • 6 P’s – Pain, Pallor, Parasthesia, Pulses, Paralysis, Pressure

Long Bone Fractures Treatment • Immobilize • Splint • Control pain • Realign – In ED • Skeletal traction – (In ED) Usually temporary. Weights must hang free, meticulous skin care • External fixators • ORIF

Splinting • Types of splints • Rigid splint – body part fit to splint design • Soft or formable splint – molded to shape or configuration of the body part • Traction splint – (Femur fractures) – traction to stabilize and align

Open Fractures Signs & Symptoms • Evidence of skin disruption over a fracture • Protrusion of bone through an open wound • Pain • Neurovascular compromise • Bleeding

Open Fractures Treatment • Cover the wound • Splint • ED or OR Wound cleansing & debridement • Realignment • Splint/Cast • External fixation • ORIF • Complications -osteomyelitis, cellulitis

Techniques for Realignment • Finger realignment • Shouldar realignment • Hip realignment • Knee realignment • Ankle realignment

Jumper Syndrome • Vertical deceleration • Forces transmitted upwards from lower extremities, pelvis, spine, chest • Lower extremity fractures & spinal cord injuries • Retroperitoneal hemorrhage is the most common cause of shock

Amputations Classification • Partial • Complete • Usually involves digits, foot, lower leg, hand or forearm • Life over limb considerations

Amputations Classification • Partial • Complete • Usually involves digits, foot, lower leg, hand or forearm • Life over limb considerations • Re-implantation (Favorable in Peds & with guillotine-type amputations)

Amputations Signs & Symptoms • Obvious tissue loss • Pain • Bleeding • Hypovolemic shock

Amputations Treatment • Reattachment • Amputation • Rehabilitation • Prosthesis Clinic Assessment & Care • Keep body part bagged not directly on ice

Compartment Syndrome Signs & Symptoms • Pain disproportionate to injury • Sensory deficit • Progressive muscle weakness • Tense swollen area • Elevated compartment pressures • Loss of pulses

Compartment Syndrome Treatment • Elevation of limb not above heart level • Placement of an intracompartmental monitor • <20 = normal • >20 = ischemia • > 30 = necrosis • Fasciotomies to release the pressure

Orthopedic Trauma