Orthopaedic Injuries

Figured I would start making blog posts on some of my other endeavors and let my blog be more of a smorgasbord of my interests. I thought I would make some informative posts on some of the Emergency Medical Technician material I am reading right now. This last piece of information I have learned about is orthopaedic. Please keep in mind that nothing on this blog is medical advice, and always seek a professional in cases of emergency.

Let’s start with the anatomy. With around 206 bones in your body, you may encounter many situations where there are problems with these. Most injuries to these bones do not classify as serious injuries, and therefore taking some time to stop and splint at the scene can seriously reduce pain. Though most injuries are not considered severe or life-threatening, there are a few exceptions, those being: multiple closed fractures, limb amputations, fractures of both long bones of the legs (bilateral femur fractures), multiple open fractures of the limbs, and suspected pelvic fractures with hemodynamic instability. When dealing with one of these major injuries, you can use a long backboard as a splinting device to splint the whole body rather than splinting each extremity. Do not splint to death.

Damage to the skeletal system can occur in a few different ways: direct blows, indirect or twisting forces, or high-energy injuries. These can result in fractures, dislocations, amputations, sprains, and strains.

A fracture is classified as either open or closed. When it is open, there is a break in the skin; when it is closed, there is no break in the skin. There are many different types of fractures. There is comminuted, where the bone is broken into two or more fragments. There is epiphyseal, where the fracture occurs in a growth section of a child’s bone and may result in growth abnormalities. There is greenstick, which is an incomplete fracture that passes only partway through the shaft of the bone. There is an incomplete fracture, which does not run completely through the bone. There is an oblique fracture, in which the bone is broken at an angle. Pathologic is a fracture of weakened or diseased bone, seen in patients with osteoporosis. Spiral is a fracture caused by a twisting or spinning force. Transverse is a fracture that occurs straight across the bone.

Dislocations are a disruption of a joint in which the bone ends are no longer in contact. Supporting ligaments are often torn, allowing the bone ends to separate from each other. Dislocated joints may sometimes spontaneously reduce, or return to their normal position, before the assessment.

Sprains can be thought of as partial dislocations. The supporting capsule and ligaments are stretched or torn, resulting in injury to the ligaments, articular capsule, synovial membrane, and tendons crossing the joint. Mild sprains are caused by stretching rather than tearing of the ligament. A sprain can occur in any joint but is most common in the knee, shoulder, and ankle.

A strain is the pulling of a muscle or the stretching or tearing of the muscle and/or tendon, causing pain, swelling, and bruising of the soft tissues in the area.

An amputation is when an extremity is completely separated from the body. When addressing this, try to find the missing part and take it with you to the ER. Make sure to wrap it with moist gauze and store it on ice. Do not bury it in the ice, but just store it on it to make sure there is no damage. Oftentimes, an extremity can be reattached, restoring partial function.

When arriving on scene, you should always do a scene size-up to make sure the situation is safe and that you are not going to get hurt in any way. After sizing up the scene, you should follow with the primary assessment. This is where you check XABC to identify and rectify any immediate life threats, such as bleeding out. Afterwards comes gathering patient history. It is important to identify allergies, medications, events leading up to the incident, related medical history, as well as when they last consumed something, in addition to the symptoms. When getting the symptoms, it is important to get information about when it started, to palpate the area, a description of the pain, where the pain is located, the severity of the pain, and how often it occurs. When evaluating a limb, you should include the 6 Ps of musculoskeletal assessment: pain, paralysis, paresthesia, pulselessness, pallor, and pressure. Also determine a baseline set of vital signs.

To care for musculoskeletal injuries:
Step 1: Cover open wounds with a 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.
Step 2: Apply a splint and elevate the extremity approximately 6 inches. Assess distal pulse and motor and sensory function.
Step 3: Apply cold packs if there is swelling, but do not place them directly on the skin.
Step 4: Position the patient for transport and secure the injured area.

Applying a rigid splint:
Step 1: Provide gentle support and in-line traction for the limb. Assess distal pulse and motor and sensory function.
Step 2: Place the splint alongside or under the limb. Pad between the limb and the splint as needed to ensure even pressure and contact.
Step 3: Secure the splint to the limb with bindings.
Step 4: Assess and record distal neurovascular function.

Applying a vacuum splint:
Step 1: Assess distal pulse and motor and sensory function. Your partner stabilizes and supports the injury.
Step 2: Place the splint and wrap it around the limb.
Step 3: Draw the air out of the splint through the suction valve and then seal the valve. Assess distal pulse and motor and sensory function.

Care for elbow injuries: Use two padded board splints, one applied to each side of the limb and secured with soft roller bandages. If there is a cold, pale hand, weak or absent pulse, or delayed capillary refill, this may indicate blood vessel injury; contact medical control.

Fracture of the forearm: Normally both bones break at the same time. An isolated fracture to the shaft of the ulna is known as the nightstick fracture. If the shaft of the bone has been fractured, be sure to include the elbow joint in the splint. This is not essential for fractures near the wrist. The patient may feel more comfortable if you add a sling for more support, elevating the injury above the heart to alleviate swelling.

When there are injuries to the wrist or hands, make sure to have the patient hold a roll of gauze before splinting.

Fractures of the pelvis are often closed. The most reliable sign of a pelvic fracture is tenderness or instability on firm compression and palpation. It can potentially lacerate the rectum, bladder, and/or vagina. A dislocation of the hip most often happens when the knee hits the dashboard and should be suspected whenever there is a contusion on the knee after a motor vehicle crash. The sciatic nerve is the largest peripheral nerve in the body and controls the activity of the thigh and below the knee, as well as sensation in the leg and foot. Posterior dislocations frequently complicate this nerve.

Fractures to the femur: When there are fractures to the femur, 500–1000 mL of blood can be lost rapidly. To address this, you use a traction splint. Do not attempt to force bone fragments back into alignment. Oftentimes, a traction splint will require two EMTs. Carefully and periodically assess the distal neurovascular function of the patient.

Applying a Hare traction splint:
Step 1: Expose the injured limb and check pulse and motor and sensory function. Place the splint beside the uninjured limb, adjust it to the proper length, and prepare the straps.
Step 2: Support the injured limb as your partner fastens the ankle hitch around the foot and ankle.
Step 3: Continue to support the limb as your partner applies gentle in-line traction to the ankle hitch and foot.
Step 4: Slide the splint into position under the injured limb.
Step 5: Pad the groin and fasten the ischial strap.
Step 6: Connect the loops of the ankle hitch to the end of the splint as you continue to maintain traction. Carefully tighten the ratchet until adequate traction is achieved.
Step 7: Secure and check support straps. Assess pulse and motor and sensory function.
Step 8: Secure the patient and splint to the backboard in a way that prevents movement of the splint during patient movement and transport.

Injuries to the knee: Splint with two boards like you would splint the elbow. If the knee is fractured and there is an adequate distal pulse, splint the knee straight. If there is an adequate pulse and significant deformity, splint the joint in the position of deformity. If the pulse is absent, contact medical control. Never use a traction splint if you suspect a knee fracture. If it dislocates, it usually displaces to the lateral side. Stabilize with padded board splints to the medial and lateral aspects of the joint. When dislocated, on rare occasions you may be asked to reset it. Only make one attempt.

When treating, general principles are:

• Remove clothing from the area
• Record the patient’s distal status, including pulse, sensation, and movement, and continue to monitor neurovascular status
• Cover open wounds with a dry, sterile dressing before splinting
• Do not move the patient before splinting an extremity unless there is immediate danger (XABCDE) that you are unable to correct
• Suspected fractures of the shaft of any bone should be stabilized by immobilizing the joints above and below the fracture
• With injuries in and around joints, stabilize the bone above and below the injured joint
• Pad all rigid splints to prevent local pressure and patient discomfort
• Maintain manual stabilization to minimize movement of the limb
• If the shaft has severe deformity, use constant, gentle manual traction to align the limb so that it can be splinted, especially if the distal pulse is absent
• If resistance is encountered during alignment, splint the limb in its deformed position
• Immobilize all suspected spinal injuries in a neutral, in-line position on a backboard or other spinal motion restriction device such as a vacuum mattress
• If there are signs of shock, align the limb in the normal anatomic position and provide transport
• When in doubt, splint