Ch. 32 Orthopedic Injuries

fascia

fibrous tissue

how man bones are in the body

206

skeletal muscle

• also called striated muscle or voluntary muscle

• attaches to bones + usually crosses at least one joint

• makes up the largest portion of the body’s muscle mass

• primary functions: movement + posture

cardiac muscle

cardiovascular system

smooth muscle

• also called involuntary muscle

• found in the walls of most tubular structures of the body

• contracts + relaxes to control the movement of the contents within the structures

bone marrow produces:

• red blood cells

• white blood cells

• platelets

joint

forms wherever two bones come into contact

ligaments

• band of fibrous tissue that connect bones to bones

• support and strengthen a joint

articular cartilage

• pearly white substance

• covers ends of bones

• allow ends of bones to glide easily

joints are lubricated by _____ fluid

synovial (joint)

zone of injury

the area of potentially damaged soft tissue, adjacent nerves, and blood vessels surrounding an injury to a bone or a joint

force may be applied to the limb in the following ways

• direct blows

• indirect forces

• twisting forces

• high-energy injuries

osteoporosis

a disease that weakens bones, making them brittle and more prone to fracture

displaced fracture

• deformity or distortion of the limb

• often can be associated with crepitus

• check for differences in the injured limb vs. the uninjured limb

nondisplaced (hairline) fracture

• a simple crack of the bone

• may be difficult to distinguish from a sprain or simple contusion

comminuted fracture

• a fracture in which the bone is broken into more than two fragments

epiphyseal fracture

• a fracture that occurs in a growth section of a child’s bone and may result in growth abnormalities

greenstick

• an incomplete fracture that passes only partway through the shaft of a bone but may still cause substantial angulation

• occurs in children

incomplete fracture

• a fracture that does not run completely through the bone

• a nondisplaced partial fracture

oblique fractures

• a fracture in which the bone is broken at an angle across the bone

• usually the result of a sharp, angled blow to the bone

pathologic fracture

• a fracture of weakened or diseased bone

• seen in pt.s with osteoporosis, infection, or cancer

• produced by minimal force

spiral fracture

• a fracture caused by a twisting or spinning force

• causes a long, spiral-shaped break in the bone

• sometimes the result of abuse in young children

transverse

• a fracture that occurs straight across the bone

• usually the result of a direct and relatively high-energy blow

suspect fractures if pt. presents with:

• deformity

• tenderness

• guarding

• swelling

• bruising

• crepitus

• false motion

• exposed fragments

• pain

• locked joint

point tenderness

• pain elicited by palpation with a finger at the site of an injury

crepitus

• a grating or grinding sensation

• can be felt and sometimes heard when fractured bone ends rub together

NEVER push the ends of a ______ ______ back into place

protruding bone

OPQRST

• O = Onset

• P = Provocation

• Q = Quality

• R = Region/radiation

• S = Severity

• T = Time

dislocation

• disruption of a joint in which the bone ends are no longer in contact

  • supporting ligaments are often torn

signs + symptoms of a dislocated joint

• marked deformity

• swelling

• pain that worsens with movement

• tenderness on palpation

• loss of normal joint motion

• numbness or impaired circulation

sprain - partial dislocation

• occurs when a joint is twisted or stretched beyond its normal range of motion

  • supporting capsule and ligaments are stretched or torn - results in injury to the ligaments, articular capsule, synovial membrane, and tendons

• can range from mild - severe

• some pt.s might hear a “snap”

• do not involve deformity

signs + symptoms of a sprain

• guarding

• swelling and ecchymosis

• pain prevents pt. from moving limb

• instability of the joint

strain (mulled muscle)

• a stretching or tearing of the muscle and/or tendons

  • occurs because of an abnormal contraction or from excessive stretching

• may range from from minute separation to complete rupture

• no ligament or joint damage typically occurs

• no deformity is present

• pt. may report a “snap” when muscle tears

signs + symptoms of a strain

• pain

  • report increased sharp pain with passive movements

• swelling

• bruising

• severe weakness of the muscle

• tenderness

preventing contamination following an open fracture:

• brush away any obvious debris on the skin surrounding the fracture

• do NOT try and get debris directly out of the fracture site

minor injuries

• minor sprains

• fractures or dislocations of digits

moderate injuries

• open fractures of digits

• nondisplaced long bone fractures

• nondisplaced pelvic fractures

• major sprains of a major joint

serious injuries

• displaced long bone fractures

• multiple hand and foot fractures

• open long bone fractures

• displaced pelvic fractures

• dislocations of major joints

• multiple digit amputations

• laceration of major nerves or blood vessels

severe, life-threatening injuries

• multiple closed fractures

• limb amputations

• bilateral femur fractures

critical injuries

• multiple open fractures of the limbs

• suspected pelvic fractures with hemodynamic instability

6 Ps of musculoskeletal assessment

• pain

• paralysis

• paresthesia (numbness or tingling)

• pulselessness

• pallor

• pressure

what should you do before and after applying a splint

• assess the pt.s circulation, motor function and sensation

  • document whether they are absent or present

caring for musculoskeletal injuries

1. cover open wounds with dry, sterile dressings + apply pressure. Apply tourniquet if bleeding can’t be controlled

2. asses pulse, motor, and sensory function

3. apply a splint + elevate extremity approximately 6 in

4. reassess pulse, motor, and sensory function

5. apply cold packs if there is swelling - do NOT place directly on skin

6. position pt. for transport

7. secure injured area

always splint extremities prior to moving pt. unless they are in _____ ______

immediate danger

splinting helps prevent:

• further damage

• laceration of the skin from broken bones

• restriction of distal blood flow

• excessive bleeding of the tissues

• increased pain from movement

if you encounter resistance to limb alignment, _________

splint the limb in its deformed position

rigid (nonfarmable) splints

• applied to the sides, front, and/or back of an injured extremity

• requires 2 people

applying a rigid splint

1. provide gentle support + in-line traction for the limb

2. asses distal pulse, motor, and sensory function

3. place splint alongside or under the limb

4. pad between the limb and splint as needed

5. secure the splint to the limb with bindings

6. asses + record distal pulse, motor, and sensory function

most dislocations should be splinted __ _____

as found

formable splints

• structural aluminum malleable splints (SAM) + vacuum splints

• can be molded and remolded as needed

• becomes rigid when molded into “T” shape

applying a vacuum splint

*still asses distal pulse, motor, and sensory function before applying splint

pelvic binders

• used to splint the bony pelvis to reduce hemorrhage

hazards of improper splinting

• compression of nerves, tissues, and blood vessels

• delay in transport of pt. with a life-threatening injury

• reduction of distal circulation

• aggravation of the injury

• injury to tissue, nerves, blood vessels, or muscles as a result of excessive movement of the bone or joint

injuries to the scapula:

• almost always the result of a forceful direct blow to the back

• could possibly injure thoracic cage, lungs, and heart

• carefully asses these pt.s for difficulty breathing

  • provide supplemental O2

• abrasions, contusions, and swelling are also common

• can be splinted with a sling

Acromioclavicular (AC) joint separations

• common in sports

• distal end of the clavicle will often stick out

• pt. will report pain

• can be splinted with a sling

sling

• sling must apply gentle upward support to the olecranon process of the ulna

• knot of sling should be tied to one side of the neck

• swathe should be used to bind the arm to the chest wall

• leave fingers exposed

• asses distal pulse, motor, and sensory function before + after applying sling

glenoid fossa

the part of the scapula that joins with the humeral head to form the glenohumeral joint

shoulder dislocations

• humeral head most commonly dislocates anteriorly

• pt. will guard shoulder and often hold it in a fixed position away from chest wall

• shoulder will appear squared off or flattened

• humeral head will protrude anteriorly underneath the pectoralis major in the anterior chest wall

  • axillary nerve may be compressed - causes a numb patch on the outer aspect of the shoulder

  • document this finding

• numbness in the hand may occur

splinting shoulder dislocations

• splint in position most comfortable for pt.

  • consider placing pillows/blankets between arm and chest wall

  • then, apply a sling + swathe

splinting a fractured humerus

1. apply traction to realign the fracture fragments

2. support fracture site with one hand and use the other to hold the two humeral condyles just above the elbow

3. pull gently in line with the normal axis of the limb

4. splint with a sling and swathe supplemented by a padded board + splint on lateral aspect of arm

nursemaid’s elbow

fracture of the olecranon process of the ulna

• can result from direct pressure or indirect forces

• often associated with lacerations + abrasions

• pt. will be unable to extend elbow

fractures of the radial head

• generally occurs as a result of a fall on an outstretched arm or direct blow

• attempts to rotate elbow will cause discomfort

care of elbow injuries

• asses distal neurovascular functions periodically

  • splint elbow in position of strong pulses and good cap refill

• 2 padded boards, one applied to each side of the limb secured with roller bandages is usually best

  • bones above + below elbow should also be immobilized

  • SAM splints can also be molded to fit the arm

• cold, pale hand or weak/absent pulse - further care should be dictated by physician

• pulseless + significantly deformed - apply gentle manual traction in line with the long axis of the limb

  • if no pulse returns, splint arm in most comfortable position

nightstick fracture

an isolated fracture to the ulna shaft

colles fractures

fractures of the distal radius

stabilizing fractures of the forearm or wrist

• padded boards, air vacuums, or pillow splints can be used

• if possible, elevate the injured limb above the heart to help with swelling

splinting the hand and wrist

1. support the injured limb + move the hand into position of function

2. place a soft roller bandage in the palm

3. apply a padded board splint on the palmar side with fingers exposed

4. secure the splint with a roller bandage

pelvis fractures

• several liters of blood may drain into pelvic space and retroperitoneal space

• can result from direct compression or indirect forces

• immediately treat for shock

• most reliable sign is simple tenderness and instability on palpation

assess pelvic tenderness by:

1. place the palms of your hands over the lateral aspect of each iliac crest, apply firm + gentle inward pressure on pelvic ring

2. place palm over the anterior aspect of each iliac crest, and apply firm downward pressure

3. use palm of hand to firmly but gently palpate the pubic symphysis

dislocations of the hip

• takes significant force

• most dislocations are posterior

  • commonly occurs when knees hit dashboard in MVCs

• injury to the sciatic nerve often occurs

• pt. will have severe pain, tenderness, and will resist any attempt to move joint

• posterior dislocation - pt. typically lie with knee drawn up and thigh rotated inward over the other leg

• anterior dislocation - pt.’s leg is extended straight out, externally rotated away from midline

sciatic nerve

• largest peripheral nerve in the body

• controls the activity of muscles in the posterior thigh, below the knee, and sensation in the leg and foot

• how to check for injury:

  • carefully assess sensation + motor function in the lower extremity

splinting dislocated hips

• splint in position of dislocation

• support injured limb with pillows and rolled blankets - especially under the knee

• secure entire limb to backboard with long straps

fractures of the proximal femur

• characteristic deformity - leg externally rotated, injured leg is usually shorter than the other leg

• gentle rolling will cause pain but no further damage

• pain might be referred to knee

splinting proximal femur fractures

• assess pulse, motor, and sensory function

• age + severity will dictate method of splinting

• geriatrics with isolated hip fractures do NOT require a traction splint

femoral shaft fractures

• 500 - 1,000 mL of blood loss is possible

• handle these pt.s with extreme care

• periodically assess distal neurovascular function

• remove clothing from affected limb

splinting a femoral shaft fracture

• apply gentle longitudinal traction

• gradually turn leg from the deformed position

• apply traction splint

goals of in-line traction

1. stabilize the fracture fragments to prevent excessive movement

2. align the limb sufficiently to allow it to be placed in a splint

3. avoid potential neurovascular compromise

applying a traction splint

1. expose injured limb + check pulse, motor, and sensory function

2. place splint beside uninjured limb to find correct length

3. support the injured limb as partner fastens the ankle hitch above the foot

4. continue to support the limb as your partner applies gentle in-line traction to the ankle/foot

5. slide the splint in position under the injured limb

6. pad the groin + fasten the ischial strap

7. connect the loops of the ankle hitch to the end of the splint. Then, tighten ratchet to the point that the splint holds adequate traction

8. secure + check the support straps

9. asses pulse, motor, and sensory functions

10. secure pt. to backboard

applying a sager traction splint

1. after exposing the area, asses distal pulse, motor, and sensory function.

2. position splint against the medial aspect of the injured leg, with perineal cushion resting against the ischial tuberosity

3. adjust thigh straps so that it lies anteriorly when secured

4. secure thigh strap

5. apply padded ankle harness just above the ankle

6. attach harness to the crossbar

7. extend the splint’s inner shaft to apply traction of abt 10% of body weight (up to 15 lbs)

8. secure splint with elasticized cravat bandages

9. secure pt. to a backboard with a figure 8 configuration

10. use the pedal pinion strap to secure the feet together

11. reassess distal pulse, motor, and sensory function

injuries to the knee ligaments

• occur when abnormal bending or twisting occurs

• pt. will report pain in joint and be unable to move it

• swelling, ecchymosis, point tenderness, and a joint effusion are common

joint effusion

excessive fluid in the joint

splinting knee ligament injuries

• several different splints can be used

• splint should extend from hip joint to the foot

• splint in bent position if there is too much pain when trying to straighten leg

knee dislocations

• may threaten the limb

• may be associated with vascular occlusion

• ligaments may be damaged or torn

• severe pain + inability to move joint

• posterior knee dislocations - occur from extreme hyperextension; high risk of injury to the popliteal artery

• medial dislocations - direct blow to the lateral part of the leg; high risk of injury to the medial ligaments

vascular occlusion

a blockage in a blood vessel (artery or vein) that cuts off or severely reduces blood flow, depriving tissues of vital oxygen and nutrients, leading to potential damage

splinting knee dislocations

• splint knee in position if was found if there are strong distal pulses

  • do not attempt to move if these distal pulses are good

• straight leg - apply rigid splints to both sides of the limb

• bent knee - use parallel padded boards secured at hip and ankle joints

fractures about the knee

• adequate distal pulse + no significant deformity → splint with knee straight

• adequate pulse + significant deformity → splint in position of deformity

• pulse is absent below injury → contact medical control

• NEVER use a traction splint of you suspect a fractured knee

dislocation of the patella

• splint knee in position found

  • stabilize + apply padded board splints to the medial and lateral aspects of the joint

• patella may go back into place spontaneously

  • use a long padded leg splint

  • report to hospital staff

injuries to the tibia and fibula

• should be stabilized with a padded rigid long leg splint or an air splint

  • after splinted, affected leg should be secured to the opposite leg

• apply gentle traction

ankle injuries

• hard to tell the difference between a sprain and a fracture

• dislocations of the ankle is commonly associated with fractures of one or both malleoli

• most frequent MOI = twisting

managing ankle injuries

1. dress open wounds

2. asses distal neurovascular function

3. correct any gross deformity by applying gentle longitudinal traction to the heel

4. before releasing traction, apply a splint - can use a rigid, air, or pillow splint (must extend up the leg to the level of the knee joint)

foot injuries

• heels - injury occurs from falls or jumps

  • force may be transmitted up the legs to the spine

  • treat for spinal injuries

• dislocated feet - take off shoe and assess distal neurovascular functions

  • stabilize extremity but leave toes exposed

• significant swelling

• never allow foot/leg to dangle off of the stretcher

treatment for sprains + strains

• treat as if they are fractures

• RICES

• protect from weight-bearing activity

compartment syndrome

• limb-threatening condition

• localized tissue swelling within a compartment

• ischemia results and anaerobic metabolism compensates for the loss of O2

• often develops between 6-12 hours after injury

• early signs + symptoms

  • pain that is out of proportion to injury, pain on passive stretch of muscles within the compartment, altered sensation, pallor, decreased power

how to treat suspected compartment syndrome

1. splint affected limb - keeping at level of heart

2. provide immediate transport

   1. reassess neurovascular status frequently

amputations

• control bleeding

• partial amputations - stabilize part with bulky compression dressings and splint

• complete amputation - wrap clean part in sterile dressing and place in a bag. Place bag on top of ice

atrophy

• the wasting away, shrinking, or decrease in size and strength of a body part, organ, or tissue

• causes: disease, disuse, malnutrition, nerve damage, or hormonal changes

• effects: weakness + reduced function

skeletal muscle tissue is directly attached to bones by _____

tendons

characteristics of proximal humeral fractures

• significant swelling, but no significant deformity of the upper arm

• neurovascular compromise uncommon

  • if present, any or all of the brachial plexus may be affected

• concurrent soft-tissue injuries possible

• possible rotator cuff injury

characteristics of a midshaft humeral fracture

• gross angulation of the arm

• marled instability + crepitus of fracture fragments

• possible neurovascular compromise

• possible entrapment of the radial nerve

  • pt. cannot extend or dorsiflex the wrist/fingers and may report numbness on the dorsum of the hand; classic wrist drop