Transcript BLS 2014 – Orthopedic Emergencies

BLS 2014 – Orthopedic Emergencies
Course Objectives
1. Identify the structure and function of bone
2. Describe how to evaluate orthopedic injuries
3. Describe energy transmission as it applies to
fractures
4. Predict injuries based on mechanism of injury
5. Describe how to evaluate orthopedic injuries
6. Review splinting principles
7. Describe how to choose and apply a splint to
treat various orthopedic injuries
8. Prioritize splinting in patients who are severely
traumatized
9. Understand, recognize, and treat shock
Mechanics
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
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
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.
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
Mechanism of Injury
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
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
Trauma and the Elderly
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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
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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
Osteoporosis
 Extreme force or transfer of energy is not always
necessary to fracture a bone
 Osteoporosis – loss of bone density
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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
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Minor fall, simple twisting injury or even a violent
muscle contraction may cause a fracture
Evaluation
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
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
Rapid trauma exam
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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!
Focused history
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“What happened?” (mechanism of injury)
Chief complaint
Associated complaints
Medical history
Medications
Allergies
Physical exam
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ABCs
HEENT (head, eyes, ears, nose)
Neck, back
Chest
Abdomen
Extremities
Vital signs
Skin signs
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
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
CMS – Circulation
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Upper extremity injuries
check radial pulse &
capillary refill
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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
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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
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
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
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
Treatment
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
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
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Specific Injuries and Treatment
Upper Body
Lower Body
Upper Body
Clavicle
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Someone with fractured clavicle complains of shoulder
pain
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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
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Separation at the acromio-clavicular joint can resemble a
clavicle fracture.
Clavicle injuries
Clavicle
 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
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
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For example, baseball bat striking the back
Blunt trauma to scapula
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
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
Shoulder
 Most commonly dislocated joint
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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
Shoulder
 Treatment
 Application of a sling & swathe
 Transport to medical facility
Humerus
 Can be fractured at midshaft, elbow or shoulder
 Midshaft fractures seen more often in young
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Result of direct trauma
 Fractures of proximal humerus common in
elderly patients who have fallen
Fractures of the humerus
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
Elbow
 Often swelling, significant pain &
potential for vessel & nerve damage
 Treatment includes either sling & swathe
or splinting in place depending on
situation
Dislocated elbow
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
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Can occur in the growth plate & cause future
complications in children
Ulna & radius fracture
Wrist and Hand
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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
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Immobilize hand & wrist
injuries with rigid splint
Wrist & hand contain
many small bones &
ligaments
Most injuries will require
examination by physician
Lower Body
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
Treating Pelvic Injuries
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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:
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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
Femur (Hip Fractures)
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Fractures of the
proximal femur, also
called "hip" fractures,
most common femoral
fractures
 Especially in geriatric
population
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Osteoporosis & reduced
muscle mass contribute
to high incidence of this
type of fracture
Break usually occurs at
neck or across proximal
shaft
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Hip fractures typically
cause patient's leg to
rotate externally
Leg is also shortened
Falls most common
reason for this type of
fracture
Treatment of Hip Fracture
 Key points for treating fractured hip:
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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
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
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
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
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
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
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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:
http://www.emsonline.net/ortho2011/
traction.asp
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
Hip Dislocation
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Hip dislocations can
damage large vessels &
nerves
Most common cause –
motor vehicle accidents
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Knee strikes dashboard
femur can dislocate
backwards
Posterior hip
dislocations: leg
shortened & rotated
internally
Anterior dislocations: leg
lengthened & externally
rotated
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Treatment includes
splinting extremity in the
position it is found
Do not attempt to reduce
a hip dislocation
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
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
Tibia and Fibula
 Two bones of the lower leg
 Fibula smaller of the two
 Located near surface of skin
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Open fractures are common
 Mid-shaft fractures of tibia & fibula usually
result in gross deformity with significant
angulation & rotation
Tibia-fibula fracture
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
Ankle
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Twisting – most common mechanism of injury to ankle
Often impossible to distinguish fractured bone from
severe ankle sprain
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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
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Often crack if twisting force applied to ankle is sufficient
Ankle fractures
Foot
 Foot injuries common
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Falls from heights
Excessive twisting motions
 Calcaneus bone (heel bone) may be fractured if
patient falls from sufficient height & lands on
heels
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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
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
Realigning Joint Injuries & Dislocations
 Splint dislocations or other joint injuries in
position found
 Exceptions include:
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Loss of a distal pulse and neurological function where definitive
care is delayed
 In these cases:
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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
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
Prioritizing
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
Shock
 Life-threatening condition develops when
circulatory system cannot deliver sufficient
blood to body’s tissues
 Many causes:
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Blood loss
Cardiac failure
Respiratory failure
Spinal cord injury
 Inadequate tissue perfusion
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
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Treatment of Shock
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Pre-hospital treatment for hypovolemic shock includes
following steps:
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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
Video demonstration available at EMS
Monitor vital signs
Online:
Rapid transport
http://www.emsonline.net/ortho2011/
treatment.asp
Case Studies
Video Case Study #1
http://www.emsonline.net/ortho2011/case1.asp
Video Case Study #2
http://www.emsonline.net/ortho2011/case2.asp
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
Summary
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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:
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We don't save trauma victims the operating room does!
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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:
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Pump (heart)
Pipes (blood vessels)
Fluids (adequate blood volume)
Oxygen (adequate oxygenation
Summary
Signs and symptoms of shock include:
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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)
Summary
Treatment of hypovolemic shock includes:
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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
Terms
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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.
Terms, continued
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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.
Terms, continued
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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.
Questions
EMS Online
Guidelines and Standing Orders
http://www.emsonline.net/downloads.asp
Susan Kolwitz
Program Manager
Email support: [email protected]
Dr. Mickey Eisenberg
Medical Director
Ask the Doc: http://www.emsonline.net/doc.asp