Chapter 31: Orthopaedic Injuries

The tibia

(Shinbone) is the larger of the two leg bones that are responsible for supporting the major weight-bearing surface of the knee and ankle. -The tibia connects to the patella (knee cap) via the patellar tenon just below the knee joint and runs down the front of the lower leg.

Atrophy

(n.) the wasting away of a body organ or tissue; any progressive decline or failure; (v.) to waste away

Glenohumeral joint

(shoulder joint) -Where the head of the humerus, the supporting bone of the upper arm, meets the glenoid fossa of the scapula

Acromioclavicular (AC) joint and it's injuries:

-A simple joint where the bony projections of the scapula and the clavicle meet at the top of the shoulder. -This joint is frequently separated during sports, such as football or hockey, when a payer falls and lands on the point of the shoulder, driving the scapula away from the outer end of the clavicle. -This dislocation is often called an AC separation. -The distal end of the clavicle will often stick out, and the patient will report pain, including point tenderness over the AC joint.

The skull

-A solid, vault like structure that surrounds and protects the brain

Cardiac Muscles

-Cardiac muscles contribute to the cardiovascular system. -This muscle makes up the hear and neither looks nor acts like skeletal or smooth muscles. -This muscle is a specially adapted INVOLUNTARY muscle with its own regulatory system

Medical Terms for specific types of fractures:

-Comminuted. A fracture in which the bone is broken into more than two fragments. -Epiphyseal. A fracture that occurs in a growth section of a child's bone and may lead to 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. A fracture that does not run completely though the bone; a non displaced partial crack. -Oblique. A fracture in which the bone is broken at an angle across the bone. This is usually the result of a sharp, angled blow to the bone. -Pathologic. A fracture of weekend or diseased bone, seen in patients with osteoporosis, infection, or cancer; often produced b minimal force. -Spiral. A fracture caused by a twisting or spinning force, causing a long, spiral-shaped break in the bone. This is sometimes the result of abuse in young children. -Transverse. A fracture that occurs straits across the bone. This is usually the result of a direct blow injury.

The way in which force may be applied to a limb:

-Direct Blows -Indirect Forces -Twisting Forces -High-Energy Injuries

Injuries to the Scapula

-Fractures of the scapula, or shoulder blade, occur much less frequently because this bone is well protected by many large muscles. -These fractures almost always occur as a result of a forceful, direct blow to the back, directly over the scapula, which may also inure the thoracic cage, lungs, and heat. -Its the associated chest injuries, not the fractured scapula itself, that pose the greatest threat of long-term disability.

The Skeleton

-Gives us out recognizable human form, protects our vital internal organs, and allows us to move, is made up of approximately 206 BONES. -The bones in the skeleton produce blood cells (in the bone marrow) and serve as a reservoir for important minerals and electrolytes.

The 6 Ps of Musculoskeletal Assessment

-Pain -Paralysis -Paresthesia (Numbness or tingling) -Pulselessness -Pallor -Pressure

Primary Assessment

-Should focus on identifying and managing life threats. -If patient has obvious life-threatening external hemorrhage, it should be addressed first (even before airway and breathing). -If you are unable to control arterial bleeding from extremities by using direct pressure, apply a tourniquet.

Skeletal Muscles (Voluntary)

-Skeletal muscles, also called STRIATED muscle because of its characteristic stripes, attach to the bones and usually crosses at least one join. -This type of muscle is also called VOLUNTARY MUSCLE because it is under direct voluntary control of the brain, responding to commands to move specific body parts. -Skeletal muscles make up the LARGEST portion of the body's MUSCLE MASS. -It's PRIMARY functions are movement and posture. -Skeletal muscle tissue is directly attached to the bone by tough, roselike structures known as TENDONS, which are extensions of the FASCIA (fibrous tissue) that covers all skeletal muscle. Fascia surrounds and supports the muscles and neurovascular structures.

Injuries of the Clavicle

-The clavicle, or the collarbone, is one of the MOST commonly fractured bones in the body. Commonly occurring in children when they fall on an outstretched hand. -A patient with a fracture of the clavicle will report pain in the shoulder and will usually hold the arm across the front of his or her body. Children will report pain throughout the entire arm and are unwilling to use any part of that limb. -Because the clavicle is subcutaneous (just beneath the skin), the skin will occasionally "tent" over the fracture fragments. THE CLAVICLE LIES DIRECTLY OVER MAJOR ARTERIES, VEINS, AND NERVES: THEREFORE, FRACTURE OF THE CLAVICLE MAY LEAD TO NEUROVASULAR COMPROMISE.

Radius

-The larger of the two forearm bones, lies on the thumb side of the forearm.

Formable Splints

-The most commonly used formable (soft) splint is the precontoured, inflatable, clear plastic air splint. -Some are zippered others are not. -Always inflate the splint AFTER applying it. -The air splint is comfortable, provides uniform contact, and has the added advantage of applying firm pressure to a bleeding wound. -Air spins ares used to stabilize injuries below the elbow or below the knee. -Significant weather changes affect the air pressure in the splint, which decreases a the environment grows colder and increases as the environment grows warmer. The same with altitude change. -The zipper can stick, clog with dirt, or freeze. STEPS For Zippered Air Splint 1. CSM 2. Support the injured limb, and apply mental traction as your partner applied the open, deflated splint. 3. Zip up the splint, inflate it by pump or by mouth, and test the pressure. Check CSM STEPS for Unzippered Air Splint 1. Assess CSM 2. Partner supports the injured limb. Place your arm through the splint to grasp the patients hand or foot. 3. Apply mental traction while sliding the splint onto the injured limb. 4. Partner inflates the splint by pump or by mouth. Assess CSM

Signs and Symptoms of a Sprain

-The patient is unwilling to use the limb (guarding) -Swelling and ecchymosis are present at the injured joint as a result of torn blood vessels. -Pain prevents the patient from moving or using the limb normally. -Instability of the joint is indicated by increased motion, especially at the knee; however, this may be masked by severe swelling and guarding.

The Arm

-composed of the upper arm (humerus), elbow, and forearm (radius and ulna) -The upper extremity joins the shoulder girdle at the GLENOHUMERAL joint.

Musculoskeletal

-refers to the bones and voluntary muscles of the body. -Musculoskeletal injuries are among the most common reasons why patients seek medical attention. Complains related to the musculoskeletal system result in almost 60 million visits to physicians annually in the US. Approx. 1 in 7 Americans will experience some type of musculoskeletal impairment, costing hundreds of billions of dollars yearly.

Caring for Musculoskeletal Injuries

1. Cover open wound with a dry, sterile dressing, and apply pressure to control bleeding. Assess distal pulse and motor and sensory function. If bleeding cannot be controlled, quickly apply a tourniquet. 2.Apply a splint, and ELEVATE THE EXTREMITY ABOUT 6in. (slightly above the level of the heart). Assess CSM. 3.Apply cold packs if theres is swelling, but DO NOT place them directly on the skin. 4. Position patient for transport, and secure the injured area.

General Principles of Splinting

1. Remove clothing from the area of any suspected fracture of dislocation so that you can inspect the extremity for DCAP-BTLS. 2.Note and record the patient's neuromuscular status distal to the site of the injury. (CSM) 3. Cover open wounds with a dry, sterile dressing before splinting. DON'T replace protruding bones. 4. Don't let patient move extremity before splinting 5. In a suspected fracture, stabilize the joints above and below fracture. 6. In a suspected joint injury, stabilize all bones above and below suspected injury site. 7. Pad all rigid splints 8. While applying splint, maintain manual stabilization to minimize movement of the limb. 9. If fracture of a long bone shaft has resulted in sever deformity, use constant, gentle manual traction to align the limb so that it can be splinted. This is especially important if the distal part of the extremity is cyanotic or pulseless. 10. If you encounter resistance to limb alignment, splint the limb in its deformed position. 11. Immobilize all spinal injuries 12. If patient has signs of shock (hypo perfusion), align the limb in the normal anatomic position, and provide transport (total body immobilization). 13. When in doubt, SPLINT

Ligaments

A band of fibrous tissue that connects bones to bones. It supports and strengthens a joint.

Sling

A bandage or material that helps to support the weight of an injured upper extremity. -Fractures of the clavicle and scapula and AC separations can all be splinted effectively using this material.

Swathe

A bandage that passes around the chest to secure an injured arm to the chest. -Used to fully stabilize the shoulder region. -It is tight enough to prevent the arm from swinging freely, but not tight enough to compress the chest and compromise breathing.

Fracture

A break in the continuity of a bone. -The break can occur anywhere on the surface of the bone and in many different types of patterns. -There is no difference e between a broken bone and a fractured bone. -Fractures are classified as either closed or open.

Osteoporosis

A condition in which the body's bones become weak and break easily. Very common amongst geriatric patients.

Pelvic Binder

A device to splint the bony pelvis to reduce hemorrhage from bone ends, venous disruption, and pain. -It is meant to provide temporary stabilization until definitive immobilization can be achieved.

Spiral Fracture

A fracture caused by a twisting or spinning force, causing a long, spiral-shaped break in the bone. This is sometimes the result of abuse in young children.

Displaced Fracture

A fracture in which bone fragments are separated from one another, producing deformity in the limb. -Often, the deformity is very obvious and can be associated with crepitus.

Oblique Fracture

A fracture in which the bone is broken at an angle across the bone. This is usually the result of a sharp, angled blow to the bone.

Comminuted Fracture

A fracture in which the bone is broken into more than two fragments.

Pathologic Fracture

A fracture of weekend or diseased bone, seen in patients with osteoporosis, infection, or cancer; often produced b minimal force.

Incomplete Fracture

A fracture that does not run completely though the bone; a non displaced partial crack.

Epiphyseal Fracture

A fracture that occurs in a growth section of a child's bone and may lead to growth abnormalities.

Transverse Fracture

A fracture that occurs straits across the bone. This is usually the result of a direct blow injury.

Crepitus

A grating or grinding sensation caused by fractured bone ends or joints rubbing together; also air bubbles under the skin that produce a crackling sound or crinkly feeling.

AC Seperation

A joint dislocation where the scapula is driven away from the outer end of the clavicle.

Sprain

A joint injury involving damage to supporting ligaments, and sometimes partial or temporary dislocation of bone ends. -Occurs when a joint is twisted or stretched beyond its normal range of motion. -As a result-, the supporting capsule and ligaments are stretched or torn, resulting in injury to the ligaments, articular capsule, synovial membrane, and tendons crossing the joint. -Considered to be a partial dislocation. -The most severe involve actual tearing of the ligament and may allow joint dislocation. -The mild are caused b ligament stretching rather than tearing. -Most often occurs in the knee, shoulder and ankle. -After the injury, the joint alignment generally returns to a fairly normal position, so the joint is not significantly displaced. -A fracture can look like a sprain, and vice versa. -In contrast with fractures and dislocations, sprains usually do not involve deformity, and joint mobility is usually limited by pain, not by joint incongruity.

Articular Cartilage

A pearly white layer of specialized cartilage covering the articular surfaces (contact surfaces on the ends) of bones in synovial joints.

Joint

A place in the body where two bones come together -They are held together in a tough fibrous structure known as a capsule, which is supported and strengthen in certain key areas by band of fibrous tissue called ligaments.

Splinting

A splint is a flexible or rigid device that is used to protect and maintain the position of an injured extremity -Unless the patient's life is in immediate danger, you should splint all fractures, dislocations, and sprains before moving the patient. -By preventing movement of fracture fragments, bone ends, a dislocated joint, or damaged soft tissues, splinting reduces pain and makes transportation easier. -Splinting will help to prevent the following: -Further damage to muscles, the spinal cord, peripheral nerves, and blood vessels from broken bone ends. -Laceration of the skin by broken bone ends. One of the primary indications for splinting is to prevent a closed fracture from becoming an open fracture (conversion). -Restriction of distal blood flow resulting from pressure of the bone ends on blood vessels. -Excessive bleeding of the tissues at the injury site caused by broken bone ends -Increased pain from movement of bone ends -Paralysis of extremities results from a damaged spine.

Nondisplaced Fracture

Also called a hairline fracture; It is a simple crack in the bone that has not caused the bone to move from its normal anatomic position.

Greenstick Fracture

An incomplete fracture that passes only partway through the shaft of a bone but may still cause substantial angulation; occurs in children.

Tarsals

Ankle Bones. 7 Bones

Open Fracture

Any break in a bone in which the overlying skin has been broken. -Complications of these fractures include increased blood loss and a higher likelihood of infection.

Closed Fracture

Any break in a bone in which the overlying skin is not broken.

Metacarpals

Bones of the hand beyond the carpals. 10 bones

Carpals

Bones of the wrist. 8 bones

Ecchymosis

Bruising or discoloration associated with bleeding within or under the skin.

Twisting Forces

Common cause of musculoskeletal injury, especially to the anterior cruciate ligament (ACL) or the medical cruciate ligament (MCL) of the knee. Skiing injuries often happen because of twisting.

The foot

Consists of three classes of bones: ankle bones (tarsals), foot bones (metatarsals), and toe bones (phalanges)

The Lower Leg

Consists of two bones, the tibia and the fibula

The hand

Contains three sets of bones: wrist bones (carpals), hand bones (metacarpals), and finger bones (phalanges).

Commonly Dislocated Joints

Fingers, shoulder, elbow, hip and knee.

Hazards of Improper Splinting

Hazards associated within improper splint application includes: -Compression of nerves, tissues, and blood vessels -Delay in transport of a patient 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.

Other formable Splints

Include vacuum splints, pillow splints, structural aluminum malleable (SAM) splints, a sling and swathe, and pelvic binders for pelvic fractures. -Just like an air splint, a vacuum splint can be easily shaped to fit around a deformed limb. Instead of pumping air in, however, you can use a hand pump to pull the air out through a valve. STEPS: 1. Assess CSM 2. Partner stabilizes and supports the injury. 3. Place the splint, and wrap it around the limb. 4. Draw the air out of the splint though the suction valve, and then seal the valve. Assess CSM

Muscular System Consists of:

Includes three types of muscles: skeletal, smooth, and cardiac. -Disease or trauma can result in the loss of a muscle's nervous supply; this, in turn, can lead to weakness and eventually atrophy, or a decrease in the size of the muscle and its inherent ability to function.

Ulna

Inner and larger bone of the forearm, attached to the wrist and located on the side of the little finger.

Musculoskeletal Injury Grading System

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 one 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 -Fractures of both long bones of the legs (bilateral femur fractures) CRITICAL INJURIES (SURVIVAL IS UNCERTAIN) -Multiple open fractures of the limbs -Suspected pelvic fractures with hemodynamic instability

False Motion

Movement that occurs in a bone at at point where there is no joint, indication a fracture; also called free movement

The Thoracic Cage

Protects the heart, lungs, and great vessels; the lower ribs protect the liver and spleen.

Rigid Splints

Rigid (nonformable) splints are made from film material and are applied to the sides, front, and/or back of an injured extremity to prevent motion at the injury site. -Common examples include padded board splints, padded wire ladder splints, and folded cardboard splints. -It take TWO EMTs to apply a rigid splint. STEPS 1.Provide gentle support and in-line traction for the limb. Assess CSM. 2.Place the splint alongside or under the limb. Pad between the limb and the splint as needed to ensure even pressure and contact. 3. Secure the splint to the limb with bindings. 4. Reassess CSM

Strain

Stretching or tearing of the muscle and/or tendons, causing pain, swelling, and bruising of the soft tissues in the area. -It occurs because of an abnormal contraction from excessive stretching. -May range from minute separation to complete rupture. -Unlike a sprain, no ligament or joint damage typically occurs. -Often no deformity is present and only minor swelling is noted at the site of the injury.

The Pelvis (pelvic girdle)

Supports the body weight and protects the structures within the pelvis: the bladder, rectum, and female reproductive organs. -The pelvic girdle is actually three separate bones, the ischium, ilium, and pubis, fused together to form the innominate (or hip) bone.

Point Tenderness

Tenderness that is sharply localized at the site of the injury, found by gently palpating along the bone with the tip of one finger.

Zone of Injury

The area of potentially damages for tissue, adjacent nerves, and blood vessels surrounding an injury to a bone or a joint.

Tourniquet

The bleeding control method used when a wound continues to bleed despite the use of direct pressure an elevation; useful if a patient is bleeding severely from a partial or complete amputation.

Clavicle

The collarbone, is a slender, s-shaped bone attached by ligaments to the sternum on one end and to the acromion process on the other. -The "collarbone" acts a a strut to keep the shoulder propped up; however, because it is slender and very exposed, this bone is vulnerable to injury.

Fascia

The fiber like connective tissue that covers arteries, veins, tendons, and ligaments.

Patella

The kneecap; a specialized bone that lies within the tendon of the quadriceps muscle.

Calcaneus

The largest of the tarsal bones is the heel bone

The pubis

The medial anterior portion of the pelvis -The two "bones" are connected anteriorly by equally tough ligaments to one another at the pubic symphysis.

Guarding

The muscles around the fracture contract in an attempt to prevent any movement of the broken bone.

Scapula

The shoulder blade, is a flat, triangular bone held to the rib cage by powerful muscles.

The Pectoral Girdle

The shoulder girdle, consists of two scapulae and two clavicles. -The scapula (shoulder blade) is a flat, triangular bone held to the rib cage by powerful muscles. -The clavicle (collarbone) is a slender, S-shaped bone attached by the ligaments to the sternum on one end to the acrominon process on the other.

Signs and Symptoms of a Dislocated Joing

The signs and symptoms of a dislocated joint are similar to those of a fracture: -Marked Deformity -Swelling -Pain that is aggravated by any attempt at movement -Tenderness on palpation -Virtually complete loss of normal joint motion (locked joint). -Numbness or impaired circulation to the limb or digit

The fibula

The smaller of the two leg bones and runs behind and beside the tibia. The fibula is an important anchor for ligaments surrounding the knee joint, and it forms the lateral side of the ankle joint.

The Golden Period

The time from injury to definitive care, during which treatment of shock and traumatic injuries should occur because survival potential is best.

Reduce

To return a dislocated joint or fractured bone to its normal position; to set. -A dislocated joint may sometimes spontaneously reduce, or return to its normal position before your assessment.

Tendons

Tough, roselike structures or bands that connect muscle to bone. -They are extensions of the fascia (fibrous tissue) that covers all skeletal muscles.

Traction Splints

Traction is the longitudinal force applied to a structure. Or basically, the act of pulling on a body structure in the direction of its normal alignment. -It is the most effective way to realign a fracture of the shaft of a long bone so that the limb can be splinted more effectively. -Traction Splints are used primarily to secure fractures of the shaft of the femur, which are characterized by pain, swelling, and deformity of the midthigh. The goals of inline 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. Types of traction splints include the Hare traction splint, the Sager splint, the Reel splint, and the Kendrick splint. -Traction splints are NOT suitable for use on the UPPER EXTREMITY because the major nerves and blood vessels in the patient's axilla cannot tolerate counteraction forces. DO NOT USE on the following conditions: -Injuries of the upper extremity -Injuries close to or involving the knee -Injuries of the pelvis -Partial amputations or avulsions with bone separation. -Lower leg, foot, or ankle injuries.

The expression "splinting to death"

Used to describe a situation in which time is wasted on prolonged musculoskeletal assessment or splinting fractures that are otherwise not life threatening. You are so involved in splinting fractures that the patient dies from other injuries.

Smooth Muscles

a component of other body systems, including the digestive system and the cardiovascular system. -Also called INVOLUNTARY MUSCLE, because it is not under voluntary control of the brain, performs much of the automatic work of the body. -This type of muscle is found in the walls of most tubular structures of the body, such as the gastrointestinal tract and the blood vessels. -These muscles contract and relax to control the movement of the contents within these structures.

Dislocations

a disruption of a joint in which ligaments are damaged and the bone ends are no longer in contact.

Paresthesia

abnormal tactile sensation often described as creeping, burning, tingling, or numbness

Amputation

an injury in which an extremity is completely severed from the body.

Fracture-Dislocation

an injury resulting in both the fracture of a bone and dislocation at the joint

Metatarsals

bones of the foot between ankle and toes; 10

Direct Blow

fractures the bone at the point of impact. An example is the patella (knee cap) that fractures when it strikes the dashboard in a motor vehicle crash.

Indirect Forces

may cause a fracture or dislocation at a distant point, as when a person falls and lands on an outstretched hand. The direct impact may cause a wrist fracture, but the indirect force can also cause dislocation of the elbow or a fracture of the forearm, humerus, or even clavicle.

The ilium

part of the hip bone -The two "bones" are joined posteriorly by tough ligaments to the sacrum path the sacroiliac joints.

The three basic types of splints:

rigid, formable and traction splints

Incongruity

state of not fitting

High-Energy Injuries

such as those that result form motor vehicle crashes, falls from heights, gunshot wounds, and other extreme forces, produce severe damage to the skeleton, surrounding soft tissues, and vital internal organs. -A patient may have multiple injuries to many body parts, including more than one fracture or dislocation in a single limb.

Phalanges

the bones of the fingers and toes; 14 in each hand or foot

Spinal Canal

the canal formed by the vertebrae that encloses the spinal cord and meninges. Protects the spinal cord.

Ischium

the lower, posterior portions of the pelvis

The femur

thigh bone; is a long, powerful bone that connects in the ball-and-socket joint of the pelvis and in the knee hinge joint of the knee. -The FEMORAL HEAD is the ball-shaped part that fits into the acetabulum. It is connected to the shaft (diaphysis), or long tubular portion of the femur, or the FEMORAL NECK. -The femoral neck is a common site for fractures, generally referred to as HIP FRACTURES.

Phalanges (foot)

toes; 14

Humerus

upper arm bone