chapter 32 - orthopaedic injuries

what is skeletal muscle and what is it attached to? what are tendons? what is movement?

• skeletal muscle [aka striated muscle or voluntary muscle]: attached to bone and usually crosses at least one joint

• skeletal muscle tissue is directly attached to bone by tough, rope like structures known as tendons, which are extensions of the fascia that covers all skeletal muscle

• fascia surrounds and supports the muscles and neurovascular structures

• movement is the result of several muscles contracting and relaxing simultaneously

what is cardiac muscle?

• cardiac muscle contributes to the cardiovascular system and is a specially adapted involuntary muscle with its own regulatory system

what is smooth muscle and what does it do? where is it found?

• smooth muscle [aka involuntary muscle]: component of other body systems, including digestive system and cardiovascular system

  • performs much of automatic work of the body

• smooth muscle is found in the walls of most tubular structures of the body, such as the GI tract and blood vessels

• smooth muscle contracts and relaxes to control movement of the contents within these structures

what does the skull and thoracic cage protect?

• skull: solid, vaultlike structure that surrounds and protects the brain

• thoracic cage: protects heart, lungs, and great vessels,

  • lower ribs protect liver and spleen

  • bony spinal canal encases and protects spinal cord

what is structures make up the pectoral girdle? where are they located and what do each of them do and?

• pectoral girdle [aka shoulder girdle] consists of:

  • 2 scapulae: flat, triangular bones held to the rib cage by powerful muscles that buffer it against injury

  • 2 clavicles: slender, S-shaped boens attached by ligaments to the sternum on one end and to the acromion process on the other

    • acts as a strut to keep shoulder propped up

    • very vulnerable to injury

what are the upper extremities? hoes the upper extremity connect to the shoulder girdle? how does the humerus attach to the forearm? what side is the radius and ulna on? what are the 3 types of hand bones and how are they often injured?

• upper extremities extends from shoulder to fingertips

• upper extremity joint the shoulder girdle at the glenohumeral joint and begins with the humerus [upper arm]

• humerus connects with the bones of the forearm at the elbow to form the hinged elbow joint

  • radius: larger of the two forearm bones lies on the thumb side

  • ulna: narrow and is on the pinky finger side of the forearm

  • because the radius and ulna are parallel, when one is broken, the other is often broken too

• hand contains 3 sets of bones

  • wrist bones [carpals]: vulnerable to fracture when a person falls on outstretched hand

  • hand bones [metacarpals]

  • finger bones [phalanges]: more apt to be injured in a crush injury, such as being slammed in a door

what is the pelvis? what are the 3 bones of the pelvic girdle? how do the iliac bones join each other? how do the pubic bones join each other?

• pelvis: supports the body weight and protects the bladder, rectum, and female reproductive organs

• pelvic girdle: 3 separate bones [ischium, ilium, and pubis [fused together to form the innominate [hip] bone

  • 2 iliac bones are joined posteriorly byt tough ligaments to the sacrum at the sacroiliac joints

  • 2 pubic bones: connected anteriorly by equally tough ligaments to one another at the pubic symphysis

  • these joints allow very little motion, so the pelvic ring is strong and stable

what are the lower extremities? how does the femur connect to the knee?

• lower extremity: thigh, leg, and foot

• femur is a long, powerful bone that connects in ball-and-socket joint of pelvis and hinge joint of the knee

  • femoral head is ball-shaped part that fits into acetabulum

  • femoral neck connects the femoral head to the shaft [diaphysis], which is the long portion of the femur

    • common site for fractures, generally referred to as hip fractures, especially in older pop

  • greater trochanter and lesser trochanter are the lateral and medial bony protuberances below the femoral neck and just above the shaft

what are the 2 bones of the lower leg and what do they do?

• lower leg consists of 2 bones:

  • tibia [shinbone]: larger of the 2 leg bones responsible for supporting the major weight-bearing surface of the knee and ankle

    • connects to the patella [knee cap] via the patellar tendon just below the knee joint and runs down the front of the lower leg

    • vulnerable to direct blows and can be felt just beneath the skin

  • fibula: serves as anchor for ligaments surrounding the knee joint and forms the lateral side of the ankle joint

    • runs behind and beside the tibia

what are the 3 bone types of the foot? what is the calcaneus?

• foot consists of 3 types of bones

  • ankle bones [tarsals]

    • calcaneus [heel bone]: largest of tarsal bones and subject to injury with axial loading injuries, such as when a person jumps from a height and lands on the feet

  • foot bones [metatarsals]

  • toe bones [phalanges]

• bone: a living tissue that contains nerves and receives oxygen and nutrients from arterial system

• bone marrow: constantly produces RBCs to provide oxygen and nutrients to the body and remove waste

what are joints held together by? what is articular cartilage? what are joints lubricated by? what are the 3 types of movement allowed by a joint? what do joints like the sutures in the skull do?

• joints: held together in a tough fibrous structure known as a capsule, which is supported and strengthened in certain key areas by bands called ligaments

  • in moving joints, the ends of bones are covered with articular cartilage: pearly white substance that allows ends of bones to glide easily

• joints are lubricated by synovial joint fluid

• joints allow for 3 types of movement

  • circular motion → shoulder

  • hinging motion → knee and elbow

  • minimum motion → sacroiliac joint in the lower back and sternoclavicular joints

• certain joints [like sutures in skull] fuse together during growth to create a solid, immobile, bony structure

what is the zone of injury? what does the extent of a musculoskeletal injury depend on? what should you do even when theres an obvious musculoskeletal injury?

• zone of injury: injury to surrounding soft tissues, especially to the adjacent nerves and blood vessels

• depending on amount of kinetic energy the tissues absorb from forces acting on body, zone may extend to a distant point

• do not be distracted by the obvious injury → first complete primary assessment to check for life-threatening injuries

what are 4 common MOIs of orthopaedic injuries? when is significant MOI not necessary to cause a bone fracture?

• common MOI of orthopaedic injuries:

  • direct blows: can result in fracture of bone at point of impact

  • indirect forces

  • twisting forces: common cause of musculoskeletal injury, especially to anterior cruciate ligament [ACL] or medial cruciate ligament [MCL] in knee

  • high-energy injuries: produce severe damage to skeleton, surrounding soft tissues, and vital internal organs

• significant MOI is not always necessary for bone fracture. slight force can fracture bone weakened by tumors, infection, or osteoporosis

what is a fracture? what is compartment syndrome? what is a closed fracture? what is an open fracture? what is a non-displaced fracture? what is a displaced fracture? what should you think about when responding to a pt with a fracture?

• fracture: break in the continuity of the bone, often due to an external force

• compartment syndrome: elevated pressure within a fascial compartment

• closed fracture: fracture in which the overlying skin is not damaged

• open fracture: fracture in which there is an external wound caused either by the blow responsible for the fracture, or the broken bone ends lacerating the skin

  • can be very small puncture to a gaping tear exposing bone and soft tissue

• non-displaced fracture [hairline fracture]: simple crack of the boen that may be difficult to distinguish from a sprain or simple contusion

  • radiograph exams are required for diagnosis

• displaced fracture: produces actual deformity of the limb by shortening, rotating, or angulating it → usually very obvious and with crepitus

• treatment:

  • treat any injury that breaks skin as a possible open fracture

  • complications of open fractures include increased blood loss and higher likelihood of infection

  • wear gloves in there are open wounds

what are the 7 types of fractures and their definitions?

• comminuted fracture: bone is broken into more than 2 fragments

• epiphyseal: occurs in growth section of child’s bone and can lead to growth abnormalities

• incomplete: fracture that does not run completely through the bone [non-displaced partial crack]

• greenstick: incomplete fracture that passes only partway through shaft of bone, but can still cause substantial angulation

  • occurs in children

• oblique: bone is broken at an angle across the bone, usually as the result of a sharp, angled blow to the bone

• pathologic: fracture of weakened or diseased bone, usually seen in pts with osteoporosis, infection, or cancer → minimal force

• spiral: caused by twisting or spinning force, causing a long, spiral-shaped break

  • sometimes result of abuse in young children

• transverse: occurs straight across bone, usually as the result of a direct blow injury

how is deformity a sign of fracture?

• deformity: limb may appear shortened, rotated, or angulated at a point where there is no joint

  • you should use opposite, uninjured limb for comparison

how is tenderness a sign of fracture?

• point tenderness on palpation in the zone of injury is most reliable indicator of an underlying fracture

  • does not tell you the type of fracture

how is guarding a sign of fracture?

• an inability to use extremity is the pt’s way of immobilizing it due to pain

  • muscles around fracture contract to prevent movement of broken bone, but this doesn’t occur with all fractures

how is swelling a sign of a fracture?

• rapid swelling usually indicates bleeding from a fracture and is usually followed by substantial pain

  • if severe, it may cause deformity

  • swelling from fluid buildup may occur several hours after injury

how is bruising a sign of a fracture?

• fractures are almost always associated with ecchymosis of surrounding soft tissues

  • may be present after almost any injury and may take hours to develop

  • discoloration associated with acute injuries is usually redness → after hours or days, blue, purple, and black discoloration will appear, followed by yellow and green

how is crepitus a sign of fracture?

• grating and grinding sensation can be felt and sometimes even heard when fractured bone ends rub together

how is false motion a sign of fracture?

• movement that occurs in a bone at a point where there is no joint is a positive indication of a fracture

  • also called free movement

how is exposed fragments a sign of fracture?

• in open fractures, bone ends may protrude through the skin or be visible within the wound

  • do not attempt to push end of a protruding bone back into place, as it increases risk of infection

how is pain a sign of fracture?

• pain, along with tenderness, bruising, and bleeding, commonly occurs in association with fractures

  • use OPQRST to assess pain

how is locked joint a sign of fracture?

• a joint that is locked into a position is difficult and painful to move

• crepitus and false motion appear only when a limb is moved or manipulated and are associated with extremely painful injuries

  • do not manipulate the limb excessively in an effort to elicit these signs

• this sign is more commonly the result of a soft-tissue injury within the joint [usually knee of elbow], but the presence of a locked joint should alert you to the possibility of a fracture

what is dislocation? what is a fracture-dislocation? what is spontaneous reduction in dislocated joints? why is it serious when dislocations do not spontaneously reduce? what are the signs and symptoms of dislocation?

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

• fracture-dislocation: combination injury at the joint in which the joint is dislocated and there is a fracture at the end of one or more of the bones

• dislocated joints may can spontaneously reduce, or return back to its normal position

  • dislocation that does not spontaneously reduce is a serious problem because the ends of the bone can be locked in a displaced position, making any attempt at motion of the joint difficult and painful

• signs and symptoms:

  • marked deformity

  • swelling

  • pain aggravated by attempted movement

  • tenderness on palpation

  • locked joint

  • numbness or impaired circulation to limb or digit

what is a sprain and what structures are involved in injury? what are the signs and symptoms? where do they most often occur? what limits mobility? why should you document MOI?

• spain: joint is twisted or stretched beyond its normal range of motion and the supporting capsule and ligament are stretched or torn, resulting in injury to:

  • ligaments, articular capsule, synovial membrane, and tendons crossing the joint

• signs and symptoms:

  • guarding

  • swelling and ecchymosis at injured joint due to torn blood vessels

  • pain prevents pt from moving or using limb normally

  • instability to the joint indicated by increased motion, especially at the knee [may be masked by severe swelling and guarding]

• occur most often in knee, shoulder, and ankle and usually does not involve deformity

• mobility is usually limited by pain, not joint incongruity

• document MOI, as some sprains and fractures occur more often with certain mechanisms

what is a strain? does it affect ligaments or joints? is it characterized by deformity? what symptoms may the pts report? what is treatment like?

• strain: a stretching or tearing of muscle and/or tendon, causing pain, swelling, and bruising of soft tissues in area → aka a pulled muscle

  • may range from minute separation to complete rupture

• no ligament or joint damage typically occurs

• doesn’t often result in deformity; minor swelling is more common

• pt may report following symptoms:

  • “snap” when a muscle tears

  • increased sharp pain with passive movement

  • severe weakness of the muscle

  • extreme point tenderness

• treatment: similar to prehospital management for sprains, dislocations, and fractures

• amputation: injury in which an extremity is completely severed from the body

  • can damage every aspect of musculoskeletal system [bone to ligament to muscle]

  • can result from trauma or surgery

what determines the likelihood of orthopedic injury complications? why does greater force lead to greater blood loss? how do you prevent contamination? how do you reduce risk or duration of long-term disability?

• likelihood of orthopedic injury complications is related to:

  • strength of force that caused the injury

  • injury’s location

  • pt’s overall health

• the greater the force that caused the injury, the greater the hemorrhage

  • sharp ends of bone may damage muscles, blood vessels, arteries, and nerves → ends can also penetrate skin to make an open fracture

  • a significant loss of tissue may occur at fracture site if muscle is severely damaged or if bone penetrates through skin

• brush away obvious debris on skin of open fracture before applying a dressing to prevent contamination

  • do not enter or probe open fracture to remove debris

• to reduce risk or duration of long-term disability:

  • prevent further injury

  • reduce risk of wound infection

  • transport pts with orthopedic injuries to an appropriate hospital

how do you assess the severity of an orthopedic injury?

• in an extremity with anything less than complete circulation, prolonged hypoperfusion can cause significant damage

• any suspected open fracture or vascular injury is a critical emergency

• if a pt has multi-system trauma, additional bleeding can increase problems with underlying injuries or overall perfusion

what is the musculoskeletal injury grading system from minor-serious?

• 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 pelvis fractures

  • dislocations of major joints

  • multiple digit amputations

  • laceration of major nerves or blood vessels

what is the musculoskeletal injury grading system for severe, life-threatening injuries and critical injuries?

• severe, life-threatening injuries: survival is probable

  • multiple closed fractures

  • limb amputations

  • fractures of both long bones of the legs [bilateral femur fractures]

• critical injuries: survival is uncertain

  • multiple open fractures of limbs

  • suspected pelvic fractures with hemodynamic instability

how do you conduct a scene size up for a pt with a possible orthopedic injury?

• try to identify forces associated with MOI

• consider possibility of hidden bleeding

• use standard precautions

  • may only need gloves; may need mask, eye protection, and gown

• evaluate need for additional resources and request them early

• look for indicators of MOI and be alert for primary and secondary injuries

• consider what injuries MOI would lead you to suspect

how to conduct a primary assessment of a pt with a orthopedic injury [LOC and MOI]?

• LOC:

  • use AVPU for responsiveness, and ask about CC for mental status

  • administer high flow oxygen via nonrebreather, or bag-mask if indicated, to all pts with a LOC less than alert and oriented, and provide rapid transport to ED

• MOI:

  • ask about MOI

  • fractures and sprains do not create airway/breathing problems

  • evaluating CC and MOI can help identify if pt has open airway/present and adequate breathing

how to conduct a primary assessment of a pt with a orthopedic injury [ABCs]?

• airway and breathing:

  • fractures and sprains do not create airway/breathing problems

  • evaluating CC and MOI can help identify if pt has open airway/present and adequate breathing

  • in unconscious pts, it is as simple as opening airway with appropriate technique

• circulation:

  • focus on whether pt has pulse, adequate perfusion, or bleeding

    • if unconscious, check pulse at carotid artery

  • shock and bleeding problems will be most likely the primary concern

    • if skin is pale, cool, or clammy and cap refill time is low, treat for shock

    • maintain normal body temp

  • if injury to extremities is suspected, they must be at least initially stabilized, if not splinted, prior to moving

how to conduct a primary assessment of a pt with a orthopedic injury [transport]?

• if there’s an airway/breathing problem or significant bleeding, rapidly transport after treating life threats

  • if MOI is significant but pt condition is otherwise stable, transport to closest appropriate hospital

• pts with bilateral fractures of long bones [humerus, femur, or tibia] have been subjected to high amount of kinetic injury → should have increased index of suspicion for serious unseen injuries

• when rapid transport is a must, use a backboard or splinting device to splint whole body instead of each extremity individually

  • apply individual splints en route if ABCs are stable and time permits

how should you handle injured extremities during assessment and transport?

• if there’s external bleeding, bandage extremity quickly to control bleeding

• keep dressings that cover wound and bone clear to reduce risk of infection

• bandages should be secure enough to control bleeding without restricting circulation distal to the injury

  • monitor tightness by assessing circulation, sensation, and movements distal to bandage

  • swelling from fractures and internal bleeding may cause bandages to become too tight

• use tourniquet if bleeding cannot be controlled

• handle fractures carefully while prepping for transport to limit pain and prevent sharp bone ends from breaking through skin, damaging nerves, or damaging blood vessels in the extremity

how to history take for a pt with an orthopedic injury?

• obtain SAMPLE → how much and in what detail you explore history depends on seriousness of condition and how quickly you need to transport

  • try to get the history without delaying transport

• OPQRST is of limited use in cases of severe injury and is usually too lengthy when ABCs and rapid transport require immediate attention

  • may be useful when MOI is unclear, pt condition is stable, and details of injury are uncertain

how to perform a secondary assessment [DCAP-BTLS] for a pt with an orthopedic injury?

• use DCAP-BTLS

  • identify any extremity deformities that indicate significant injury and stabilize them

  • contusions and abrasions may overlie subtler injuries → evaluate stability and neurovascular status of the limb

  • signs of penetrating injury should alert you to possibility of open fracture

  • identify and treat any burns

  • palpate for tenderness, which may be the only significant sign of underlying injury

  • when there are lacerations in an injury → suspect open fracture, control bleeding, and apply dressings

• if there are no external signs of injury, as pt to move each limb carefully, stopping if a movement causes pain

  • skip if pt reports neck or back pain due to possibility of permanent spinal cord damage

• if trauma is nonsignificant and you suspect a simple strain, sprain, dislocation, or fracture, focus your secondary assessment on that injury

  • remove clothing from the zone of injury and look/palpate for injuries → zone of injury generally extends from joint above and below, front and back

• if pt has 2 or more injured extremities, treat pt as significant trauma and rapidly transport

  • likelihood of other, more severe injuries is greater with 2 or more broken bones

how to perform a secondary assessment [neurovascular function and vitals] for a pt with an orthopedic injury?

• evaluate circulation, motor function, and abnormal sensations distal to injury

  • give priority to pts with impaired circulation from bone fragments

  • you cannot assess sensory and motor function in unconscious pt, but you can evaluate for deformity, swelling, ecchymosis, false motion, and crepitus

• any injury/deformity of bone may be associated with vessel or nerve injury

  • assess neurovascular function every 5-10 mins depending on pt condition

• recheck neurovascular function before and after splinting/manipulating limbs

• examination of injured limb should include 6 Ps of musculoskeletal assessment

  • pain

  • paralysis

  • paresthesia [numbness or tingling]

  • pulselessness

  • pallor

  • pressure

• obtain baseline vitals [HR, rhythm, and quality; RR, rhythm, and quality, BP, skin condition, and pupil size and reaction to light]

  • trending these helps track if pt condition is improving or worsening

  • shock/hypoperfusion is common in these injuries, so baseline vitals are very important

how to conduct reassessment of a pt with an orthopedic injury?

• if critically injured, secure pt to backboard to immobilize spine, pelvis, and extremities then provide transport to trauma center

  • perform primary assessment and transport, reassessing en route

  • if time allows, remove/cut away clothing to look for open fractures, dislocations, deformity, swelling, and/or ecchymosis

• apply a secure splint to stabilize injury prior to transport

  • joint above and below site of injury should be included in splint

  • to minimize potential for complications, splint should be well padded

• comfortable and secure splint characteristics are reduced pain, reduced shock, minimize compromised circulation

• check circulation, motor function, and sensation before and after splinting

• report the following:

  • description of problems found during assessment

  • problems with ABCs, open fractures, and compromised circulation that occurred before or after splinting

• additional details can be given during verbal report during transfer

• document presence or absence of circulation, motor function, and sensation distal to injury before moving it, after manipulation/splinting, and arrival time

steps to care for musculoskeletal injuries

1. cover open wounds with dry, sterile dressing and apply pressure to control bleeding. assess distal pulse and motor and sensory function. if bleeding cannot be controlled, apply a tourniquet

2. apply a splint and elevate extremity about 6 inches. assess distal pulse and motor and sensory function

3. apply cold packs if there is swelling, but don’t place them directly on the skin

4. position pt for transport and secure injured area