EMT: Chapter 31 [orthopaedic injuries]

how to control bleeding:

- bandage extremity quickly - assess circulation, sensation, movement distal to bandage - apply tourniquet if bleeding cannot be controlled

hazards of improper splinting

- compression of nerves, tissues, blood vessels - delay in transport of a pt with life-threatening injury - reduction of distal circulation - aggravation of the injury - injury to tissue, nerves, blood vessels, muscles due to excessive mvt of bone/joint

signs of fracture:

- deformity - *point tenderness - guarding - swelling - bruising - *crepitus (grating/grinding sensation when fractured bone rubs together) - *false motion (movement at a point in the lib where there is no joint) - exposed fragments - pain - locked joint (locked into position and difficult to move; result of soft-tissue injury)

MOIs

- direct blows - indirect blows - twisting forces (ACL, MCL tears) - high-energy injuries high-energy injuries hurt skeleton, soft tissues, vital internal organs pt may have multiple injuries significant MOI not necessary to fracture a bone

other orthopedic injuries

- dislocation of the patella - tibia and fibula injuries - ankle injuries - foot injuries - sprains and strains - amputations

serious injuries

- displaced long bone, pelvic fractures - open long bone fractures - multiple digit amputations - laceration of major nerves/vessels - multiple hand/foot fractures

primary assessment

- hypoperfusion and bleeding problems will be primary issues (check for pale, cool, clammy skin with slow cap refill time) - stabilize musculoskeletal injuries before transport (include joints above and below site of injury in the splint) - transfer any pts with significant MOI - increase index of suspicion for serious unseen injuries (ex. bilateral femur fractures) *highest transport priority given to pts with pulseless limbs

scene size-up

- identify forces associated with MOI - consider hidden bleeding

when to splint deformities:

- if deformity is severe - if you encounter resistance or extreme pain when applying traction to fracture *most dislocations should be splinted as found (do NOT try to reduce)

minor injuries

- minor sprains - fractures or digit dislocations

severe injuries

- multiple closed fractures - limb amputations - bilateral long bone fractures

critical injuries

- multiple open fractures of limbs - pelvic fractures with hemodynamic instability

moderate injuries

- open digit fractures - nondisplaced long bone or pelvic fractures - major sprains of a major joint

6 Ps of musculoskeletal assessment

- pain - paralysis - paresthesia - pulselessness - pallor - pressure

fractured knees

- splint limb with knee straight if adequate distal pulse and no deformity - splint limb in position of deformity if adequate distal pulse - if pulse absent, suspect vascular and nerve damage *never use a traction splint

care of elbow injuries

- two padded board splints on each side of the limb with soft roller bandages securing them - board should extend from the shoulder joint to wrist joint - don't manipulate limbs with no pulse

assessing tenderness in the pelvis:

1. place palms of your hands over the lateral aspect of each iliac crest and apply firm gentle pressure 2. with the patient lying supine, place a palm over the anterior aspect of each iliac crest and apply firm downward pressure 3. use palm to press firmly but gently on the pubic cartilage - check for hematuria or blood at urethral opening

secondary assessment

DCAP-BTLS - extremity deformity identification + stabilization - contusions/abrasions identification + neurovascular status of limb - puncture wounds, penetrating injuries ~ open fractures - identify and treat associated burns - palpate for tenderness - apply dressings to any lacerations - assess for swelling if no external injuries, ask pt to move each limb to assess for pain assess entire zone of injury for nonsignificant trauma (extends from joint above to joint below) assess circulation, motor function and sensations distal to injury - if pt fails any of these = urgent condition - recheck after splinting - recheck every 5-10 minutes

history taking

OPQRST can help if: - MOI unclear - pt condition stable - details of injury uncertain

A fracture is MOST accurately defined as a(n):

a break in the continuity of the bone

Which of the following scenarios is an example of a direct injury?

a passenger fractures her patella after it strikes the dashboard

displaced fracture

actual deformity of limb by shortening, rotating, or angulating it deformity often obvious

A construction worker's arm was severed just above the elbow when a steel girder fell on it. The stump is covered with a blood-soaked towel. The patient's skin is cool, clammy, and pale. The EMT should:

apply a tourniquet just below the shoulder

A 76-year-old male experienced sudden pain to his left thigh when he was standing in line at the grocery store. Your assessment reveals ecchymosis and deformity to the distal aspect of his left femur, just above the knee. Distal circulation and sensory and motor functions are intact. You should:

apply padded board splints to both sides of the leg

In moving joints, the ends of the bones are covered with:

articular cartilage

You have applied a zippered air splint to a patient's left arm. During transport, the patient complains of increased numbness and tingling in his left hand. You reassess distal circulation and note that it remains present. Your MOST appropriate action should be to:

assess the amount of air in the splint and let out air as necessary

sling

bandage or material that helps support the weight of an injured upper extremity, relieving downward pull of gravity knot of sling should be tied to one side of the neck must support ulna

swathe

bandage that passes completely around the chest, must be used to bind the arm to the chest wall leave pt's fingers exposed

Bone marrow produces:

blood cells

Which of the following structures is regulated by smooth muscle?

blood vessels

The musculoskeletal system refers to the:

bones and voluntary muscles of the body

musculoskeletal

bones and voluntary muscles of the body

proximal femur fractures

break goes through: - neck of femur - middle region - proximal shaft common in younger pts signs: - pt lying with leg externally rotated; injured leg shorter than other - pain referred to the knee - inability to walk/move leg

fracture

break in the continuity of the bone often as a result of external force compartment syndrome: potential complication due to elevated pressure within fascial compartment

knee ligament injuries

common in athletes, especially medial ligaments when foot is fixed to ground and lateral knee is struck by a heavy object signs: - pain in the joint - swelling - point tenderness - joint effusion (excess fluid) splint injuries from hip joint to the foot

types of fractures:

communicated - fracture in which bone is broken into more than two fragments epiphyseal - fracture that occurs in a growth section of a child's bone greenstick - incomplete fracture that passes only partway through the shaft of a bone (children) incomplete: - fracture that does not run completely through the bone (partial crack) oblique: - fracture at an angle across the bone due to sharp, angled blow pathologic: - fracture due to weakened or diseased bone (osteoporosis, infection) spiral: - fracture caused by a twisting or spinning force (abuse in young children) transverse: - straight across the bone (result of direct-blow injury)

When assessing a patient with a possible fracture of the leg, the EMT should:

compare it to the uninjured leg

A ____________ is a musculoskeletal injury in which there is partial or temporary separation of the bone ends as well as partial stretching or tearing of the supporting ligaments.

dislocation

A disruption of a joint in which the bone ends are no longer in contact is known as what?

dislocation

Which sign/symptom would give you a high index of suspicion that a patient may have compartment syndrome?

disproportionate pain

dislocation

disruption of a joint in which the bone ends are no longer in contact supporting ligaments are torn and allow bone ends to separate dislocations can either spontaneously reduce or be reduced (in a hospital) common dislocations: fingers, shoulder, elbow, hip, knee signs: - marked deformity - swelling - aggravated pain - tenderness on palpation - complete loss of normal joint motion - numbness or impaired circulation

open fracture

external wound caused by same blow that fractured bone OR broken bone ends lacerate skin

lower extremity

femur - head: ball-shaped part that fits into the hip - neck: common site for fractures, esp in older people tibia - larger leg bone responsible for weight-bearing - connects to patella - vulnerable to direct blows fibula - behind tibia - anchor for knee ligaments

splint

flexible or rigid device used to protect and maintain position of an injured extremity helps prevent: - further muscular or neurological damage - laceration of skin by broken bone ends - restriction of distal blood flow - excessive bleeding - increased pain - paralysis of extremities types: - rigid (remember to pad) - formable - traction key points: - assess neuromuscular function before/after splinting and cover wounds before - do not replace protruding bones - maintain manual stabilization while applying splint (very gentle to deformed fractures) - stabilize joints above and below fracture

joints

held together in a tough fibrous structure and support by ligaments in certain areas articular cartilage coats bones to allow joints to glide easily bathed in synovial fluid allow for circular (shoulder), hinge (knee, elbow), and minimum motion movement

shoulder dislocations

humeral head dislocates anteriorly and lies in front of the scapula most are "anterior dislocations" dislocated side often lower than the uninjured side splint the joint in whatever position is most comfortable posterior dislocations common in football players

closed fracture

if overlying skin not damaged

A 17-year-old football player collided with another player and has pain to his left clavicle. He is holding his arm against his chest and refuses to move it. Your assessment reveals obvious deformity to the midshaft clavicle. After assessing distal pulse, sensory, and motor functions, you should:

immobilize the injury with a wing and swathe

During your secondary assessment of a 19-year-old female with multiple trauma, you note bilateral humeral deformities and a deformity to the left midshaft femur. Her skin is diaphoretic and her pulse is rapid and weak. Your partner has appropriately managed her airway and is maintaining manual stabilization of her head. The MOST appropriate treatment for this patient includes:

immobilizing her to a backboard and rapidly transporting

Which MOI causes a fracture or dislocation at a distant point?

indirect force

amputation

injury in which an extremity is severed completely from the body

zone of injury

injury to soft tissues surrounding bones and joints, especially to adjacent nerves and blood vessels area surrounding obvious injury

smooth muscle

involuntary muscle; automatic work of the body walls of tubular structures and control their movement specialized smooth muscle = cardiac

Which of the following statements regarding striated muscle is correct?

it forms the major muscle mass of the body and usually crosses at least one joint

acromioclavicular (AC) joint

joint between outer end of clavicle and acromion process of scapula which is often dislocated often separated during sports when a player falls and lands on their shoulder "AC separation"

sciatic nerve

largest nerve in the lower extremity; controls activity of muscles in the posterior thigh and below the knee may be stretched/compressed in hip dislocation -> partial/complete paralysis of the nerve

When splinting a possible fracture of the foot, it is MOST important for the EMT to:

leave the toes exposed

Bones are connected to other bones by bands of tough fibrous tissues called:

ligaments

femoral shift fractures

may be open and bone fragments may press on nerves or vessels best stabilized with traction splint like Sager

pelvic binder

meant to provide temporary stabilization until definitive immobilization can be achieved applied by EMT (lightweight)

Which of the following statements regarding shoulder dislocations is correct?

most dislocations occur anteriorly

traction

most effective way to realign a fracture of the shaft of a long bone so that the limb can be splinted effectively types of splints: Hare traction splints, Sager splints, Reel splints, Kendrick splints contraindications: - injuries of the upper extremity - injuries close to the knee - injuries of the pelvis - partial amputations or avulsions - lower leg, foot, ankle injuries traction doesn't usually exceed 15 lbs grasp foot or hand at end and pull; do not release stabilization (will cause more damage if muscles contract) if pt resists traction, stop and splint limb

dislocation of the knee

most urgent injury: popliteal artery damage (due to laceration/compression by displaced tibia) posterior most common (results from extreme hyperextension); medial also occurs (due to direct blow to lateral leg) complications: - popliteal artery disruption - nerve injuries - joint instability

dislocation of the hip

mostly posterior; femoral head displaced posteriorly to lie in the muscles of the buttock signs: - "foot drop" - severe ip pain - lateral/posterior hip region tender on palpation - pts lying with hip joint flexed (knee joint drawn up toward chest)

forearm fractures

nightstick fracture: an isolated fracture of the shaft of the ulna Colles fractures ("silver fork"): fractures of the distal radius common in pts with osteoporosis

Of the following musculoskeletal injuries, which is considered to be the LEAST severe?

nondisplaced pelvic fracture

compartment syndrome

occurs with a fractured tibia in adults or forearm in children and can be overlooked, especially in patients with an altered LOC signs: - pain out of proportion to injury - pain on passive stretch of muscles within compartment - pallor - decreased sensation - decreased power (strength/movement of limb -> complete paralysis)

elbow injuries

often worsened by inappropriate emergency care - fracture of the distal humerus (common in children; deformities common; high intensity) - dislocation of the elbow (occur in athletes and sometimes young children; ulna and radius displaced posteriorly to humerus; joint usually locked with the forearm) - elbow joint sprain - fracture of the olecranon process of the ulna (associated with lacerations and abrasions; inability to extend the elbow) - fracture of the radial head (often associated with outstretched arms)

glenoid fossa

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

Which of the following fractures has the greatest potential for internal blood loss and shock?

pelvis

The MOST reliable indicator of an underlying fracture is:

point tenderness

What is the most reliable indicator of an underlying fracture?

point tenderness

When assessing distal circulation in a patient's lower extremities, which pulse should you palpate?

popliteal

A 30-year-old man complains of severe pain to his right tibia following an injury that occurred the day before. The patient's leg is pale and he is unable to move his foot. The EMT should suspect that:

pressure in the fascial compartment is elevated

The primary purpose for splinting a musculoskeletal injury is to:

prevent further injury

humerus fractures

proximal, midshaft, elbow proximal: often result from falls among older people midshaft: often result of violent injuries

Applying ice to and elevating an injured extremity are performed in order to:

reduce pain and swelling

pelvic fractures

risk factors: - high-velocity injury - discomfort in lower back and abdomen several liters of blood may drain into retroperitoneal space take immediate steps to treat shock even if there's minimal swelling open fractures uncommon, swelling/deformity hard to see reliable signs: - tenderness - instability on firm compression

complications from orthopedic injuries

risk factors: - strong MOI - complicated location - patient's overall health bleeding can be due to to injury of bone structures causing internal hemorrhaging OR external tissue loss due to force brush debris away before dressing wound EMTs must: - prevent further injury - reduce risk of wound infection - minimize pain - transport pts

The pectoral girdle consists of the:

scapulae and clavicles

In the musculoskeletal injury grading system, under which category would you place a laceration of a major nerve or blood vessel?

serious

nondisplaced fracture

simple crack of the bone that could be a sprain or simple contusion

Which of the following types of muscle is under direct voluntary control of the brain?

skeletal

skeleton

skull thoracic cage pectoral girdle - two scapulae - two clavicles upper extremity - humerus + radius/ulna (connected at elbow) hand - carpals (wrist bones) - metacarpals (hand bones) - phalanges pelvis - ischium - ilium - pubis lower extremity foot - tarsals (ankle bones) > calcaneus (heel bone): subject to injury from loading injuries - metatarsals (foot bones) - phalanges (toe bones)

Which of the following joints allows no motion?

skull sutures

Which of the following would you use to stabilize an AC separation?

sling and swathe

What type of muscle contracts and relaxes to control the movement of the contents within its structures?

smooth

A 31-year-old male fell and landed on his left elbow. Your assessment reveals that the elbow is grossly deformed, his forearm is cool and pale, and the distal pulse is barely palpable. His vital signs are stable and he denies any other injuries. Your transport time to the closest appropriate hospital is approximately 12 minutes. You should:

splint the elbow in the position found and transport

You are attending to a patient with a nondisplaced elbow fracture. She has a strong pulse and good capillary refill. How should you address this type of injury?

stabilize from the upper arm to the hand

strain (pulled muscle)

stretching or tearing of the muscle and/or tendon causing pain, swelling and bruising of soft tissues often no deformity and only minor swelling signs: - "snap" upon muscle tearing - increased sharp pain with passive movement - muscle weakness - point tenderness

Skeletal muscle is also referred to as __________ muscle.

striated

skeletal muscle

striated/voluntary muscle attached directly to bone by tendons (extensions of fascia)

Which of the following is a drawback of an air splint?

temperature changes affect air pressure in the splint

Skeletal muscle is attached to the bone by tough, ropelike fibrous structures called:

tendons

What is the primary goal of in-line traction?

to avoid further neurovascular compromise

reel splint

traction splint used by the US military designed to be used on a lower extremity

sprain

when a joint is twisted or stretched beyond its normal range of motion caused by injury to: ligaments, articular capsule, synovial membrane, tendons crossing the joint occur often in knee, shoulder, ankle do not usually involve deformity or joint incongruity signs: - pt unwilling to use limb (guarding) - swelling/ecchymosis - instability of joint from increased motion, especially at the knee

injuries to the clavicle

when do they occur: - children falling on a hand - crush injuries of the chest signs: - pain in shoulder - pain throughout arm in children - swelling and point tenderness over clavicle

injuries to the scapula

when do they occur: - forceful blows to back directly over scapula - thoracic cage injury complications: - airway difficulty - chest injuries

In which situations should you splint the limb in the position of deformity?

when you encounter resistance or extreme pain when applying traction, when the deformity is severe DOESN'T MATTER if extremity pulseless or if fracture open/closed