Chapter 37: Orthopaedic Trauma

How many bones are there in the human body?

206

What is osteomyelitis and how is it treated in the field?

A bacterial infection of the bone which can stem from an open wound, a decubitus ulcer, or naturally from a weakened immune system. It presents the same way any other infection would present: fever, chills, erythema over the site, swelling, and pain. EMS management is limited to identification, splinting, and transport. The patient will ultimately require antibiotics and possibly surgery.

What is septic arthritis?

A bacterial infection that involves the knee, hip, shoulder, ankle, elbow, or wrist. It's usually caused by a staph or strep infection and these patients may present with marked toxicity, fever, and an ALOC. Malaise, anorexia, and a lack of fever may complicate presentation in older individuals. These patients may or may not have a history of IV drug abuse.

What is a Colles fracture?

A complete fracture of the radius close the wrist resulting in an upward displacement of the radius with obvious deformity, called a "silver fork deformity." It's accompanied by pain and swelling around the deformity site.

What is a Boxer's fracture? How does this typically present?

A fracture of the neck of the 5th metacarpal (pinky finger). It commonly occurs after punching a hard object such as a wall. These patient typically have pain over the ulnar aspect of the hand and may have noticeable swelling.

What is an open pelvic fracture? What risk is associated with this?

A laceration of the skin in the pelvic region, vagina, or rectum. It does NOT need to involve an actual open fracture of the pelvis, although such a fracture would carry a very high rate of mortality. The biggest concern with these injuries is hemorrhage given the major vascular structures which run through the region.

Compare and contrast the presentation and common causes of the following fractures: overriding, distraction injury, impacted, avulsion, and depression

All of the following are types of displaced fractures: Overriding: Muscles pull the distal fracture fragment alongside the proximal one, leading them to overlap and resulting in shortening; occurs only when a fracture is fully displaced and there is no bone contact. Distraction injury: Occurs when a tensile force is rapidly applied to a bone, causing it not just to fracture but for the bone ends to be pulled apart; often seen with industrial equipment and machinery. Impacted: Occurs when a massive compressive force is applied to a bone, causing it to become wedged into another bone; more likely to happen in cancellous bone. Avulsion: Occurs when a powerful muscle contraction causes the insertion site of the muscle to be fractured off of the bone; caused by a sudden "jerking" of a body part. Depression: Occurs when blunt trauma to a flat bone (such as the skull) causes the bone to be pushed inward; caused by blunt trauma.

Compare and contrast the presentation and common causes of the following fractures: greenstick, buckle, plastic deformation, and fatigue.

All of the following are types of incomplete fractures: Greenstick: Typically occurs in the proximal metaphysis or diaphysis of the tibia or radius; when it occurs in the shaft, the cortex on the convex side is broken but the cortex on the concave side remains intact. These occur exclusively in children. Buckle: Also known as a torus fracture, these occur in the metaphysis of long bones in response to excessive compression loading on one side of the bone. The compressed cortex buckles and the opposite cortex is pulled away from the physis. This fracture is unique to children and is usually seen in the distal radius, commonly resulting from a fall on an outstretched hand. Plastic deformation: When a compression force is applied to a bone, numerous small fractures on the compressed side cause the bone to bend resulting in deformation. This most commonly occurs in children and young adults, and most commonly affects the radius, ulna, tibia, fibula, and clavicle. Fatigue: Occurs when the muscle develops faster than the bone and places exaggerated stress on the less-developed side. It may also be due to repetitive small injuries. It usually occurs in the legs or feet of people who engage in strenuous, repetitive activities, such as dancers, joggers, and military recruits.

What are fatigue fractures?

Also known as stress fractures, they're caused by repetitive submaximal loads causing microcracks in the bone, particularly in regions of poor vasculature.

What is a strain? How are these injuries typically characterized?

An injury to a muscle and/or tendon that results from a violent muscle contraction or from excessive swelling. Deformity is not typically present, although there might be some localized minor swelling. Some patients may report increased pain with passive movement of the injured extremity.

What population is at increased risk of an Achilles tendon rupture? How do these patients present? What signs and symptoms are usually present and what test can be done in the field somewhat diagnostically? How should it be managed in the field?

Athletes over the age of 30 who participate in start-and-stop sports (such as basketball and football) are at particular risk of this. The most immediate complications are pain from the heel to the calf and an inability for plantar flexion. Ecchymosis may develop along the posterior calf and there may be a palpable defect along the tendon. The Thompson test can be performed in the field and entails having the patient lie prone and squeezing the affected calf. If the foot plantarflexes while squeezing, it is at least partially intact; if not, no bueno. Management in the field involves RICES and pain control.

What is the difference between the axial skeleton and the appendicular skeleton?

Axial: Composed of the bones of the central part of the body - the vertebral column, skull, ribs, and sternum. Appendicular: Composed of the pelvic girdle, the pectoral girdle, and the bones of the upper and lower extremities.

What is the most common cause of pelvic fractures? What are the four main types of pelvic fractures?

Blunt trauma from MVAs, motorcycle crashes, and vehicles striking pedestrians. They may also be caused by crush injuries and falls from a height. Type I: (a) avulsion fractures, (b) fracture of pubis or ischium, (c) fracture of iliac ring, (d) fracture of sacrum, or (d) fracture of coccyx Type II: (a) single fracture of pelvic ring (including unilateral fractures of both pelvic rami), (b) subluxation of the pubic symphysis, or (c) a fracture near the sacroiliac joint Type III: Multiple breaks of the pelvic ring Type IV: Fractures involving the acetabulum

How do patients with tendinitis and bursitis present, respectively? How should these conditions be managed in the field?

Both present with point tenderness, swelling, erythema, and warmth. Both are treated with RICES and pain relievers. The patient will likely receive corticosteroid injections in the hospital.

What is carpal tunnel syndrome and cubital tunnel syndrome, respectively? How do these patients present? How should they be managed in the field?

Carpal tunnel is caused by compression of the medial nerve at the wrist where it passes through the carpal tunnel. This compression can be caused by inflammation and swelling of the tissue around the canal, by narrowing of the canal, or by pressure from outside the canal. Likewise, cubital tunnel is caused by compression of the ulnar nerve along the outer edge of the elbow. Patients with carpal tunnel present with numbness and tingling in the affected hand - particularly the middle finger, index finger, and thumb which are innervated by the median nerve. Patients with cubital tunnel present with burning, numbness, tingling, and possible partial loss of function in the little finger and in the medial aspect of the ring finger which are innervated by the ulnar nerve. Prehospital management involves recognition, splinting, and transport. Definitive care will involve rest, removal of the underlying cause (typically occupational or positional), and physical therapy. In the worst cases, surgical decompression of the canal can be performed.

Compare and contrast the presentation of comminuted and segmental fractures? What causes them?

Comminuted: More than two fracture fragments that occur in the same area of a bone. Segmental: More than two fractures fragments but the breaks occur in different parts of the bone. Both are caused by high-energy injuries. Comminuted fractures are more likely to be due to crush injuries.

What is a mallet finger? How does this typically present?

Commonly known as a "baseball fracture," it's an avulsion fracture of the extensor tendon that occurs when a finger is jammed into an object, such as a baseball. These patients will not be able to extend the distal phalanx of the finger and will keep it in a flexed position.

What is the difference between a complete and an incomplete fracture? What causes each?

Complete: Breaks through both cortices; typically due to high-energy injuries. Incomplete: Breaks through one cortex; typically due to low-energy injuries.

What is the difference between a displaced and a nondisplaced fracture? What causes each?

Displaced: Ends of the fracture move from their normal positions; caused by high-energy injuries. Nondisplaced: Bone remains aligned in its normal position despite the fracture; caused by low-energy injuries.

What does it mean for a fracture to be angulated?

Each end of the fracture is not aligned in a straight line and an angle has formed between them. Angulation may occur in the frontal plane, sagittal plane, or both.

How should injured joints be splinted? How should injured fractures be splinted?

For injured joints, the splint must extend the entire length of the bones above and below the joint. For fractures, the splint must immobilize the entire bone including both bone ends and the two adjacent joints.

When is a traction splint indicated?

For most isolated femur fractures in which the patient does not have another fracture below the knee on the same extremity.

What mechanism of injury is typically associated with tibia and fibula fractures? What complications can occur? What signs and symptoms are typically associated with them? How should they be managed in the field?

Fracture can result from direct trauma or from rotational or compressive forces. These injuries often present with significant deformity and soft-tissue injury. Complications may include compartment syndrome, neurovascular injury, infection, poor healing, and chronic pain. The leg should be splinted and pain medication should be administered as indicated. If angulated, you can attempt to realign the leg but be sure to document pre and post neuro statuses. Monitor for signs of compartment syndrome, elevate to the level of the heart, apply cold packs, and transport to a trauma center.

What mechanism of injury is typically associated with a forearm fracture? What signs and symptoms are typically associated with it? How should it be managed in the field?

Fractures of the forearm may involve the radius, ulna, or both. Injuries may result from a direct blow or from a fall onto an outstretched arm. The region will have associated pain, swelling, and ecchymosis. The entire forearm should be splinted and ice packs should be applied to reduce pain and swelling. Frequent neurovascular exams are warranted.

What mechanism of injury is typically associated with knee fractures? What signs and symptoms are typically associated with it? How should it be managed in the field?

Fractures of the knee may involve the distal femur, proximal tibia, and the patella itself, and often result from a direct blow to the knee, an axial load of the leg, and possibly powerful contractions of the quads. Significant knee pain, decreased range of motion, pain with movement and weight bearing, swelling, and possible deformity can all occur. If PMS is distally intact, the knee should be splinted in the position found. If there is no distal pulse, contact med control for consult on reducing the knee. Attempt to keep it in-line with the heart and apply ice packs for swelling and pain. Frequent neuro checks are a must.

What mechanism of injury is typically associated with a midshaft humeral fracture? What signs and symptoms are typically associated with it? How should it be managed in the field?

Fractures of the shaft of the humerus typically occur in younger people secondary to high-energy injuries such as MVAs. These injuries usually have significant deformity and examination typically reveals significant swelling, ecchymosis, gross instability, and crepitus. There is also significant risk of damage to the nerves and blood vessels which run through the arm. Of note, the radial nerve runs right along the humerus and the tell-tale sign of its compromise is wrist drop. If it's angulated, longitudinal traction may be applied unless it's too painful or neurovascular status worsens. Splint the arm from the axilla to the elbow, apply a sling and swathe, and apply ice packs to the site.

What mechanism of injury is typically associated with ankle fractures? What signs and symptoms are typically associated with them? How should they be managed in the field?

Fractures typically result from sudden, forceful movements of the foot which damage the malleoli and sometimes produce a dislocation. They can also be caused by an axial load being transmitted through the foot causing the talus to impact the distal tibia resulting in a fracture. In any case, signs and symptoms commonly involve pain, swelling, and deformity. The extremity should be splinted, elevated to the level of the heart, and a cold pack should be applied. If the foot is pulseless, contact medical control for orders to reduce the ankle.

What is compartment syndrome and how does it occur in the context of hemorrhage? How do these patients present and how should it be managed in the field?

Groups of muscles within a limb are surrounded by fascia - inelastic membrane which effectively create an enclosed space. Most typically secondary to a fracture or soft tissue injury, bleeding and swelling can occur within the fascia resulting in decreased blood flow through the muscles' blood vessels leading to ischemia and necrosis of the muscle. This condition can similarly be caused by bandages tied too tightly, crush injuries, snake bites, or any other condition which causes fluid to leak into the interstitial space. A seemingly disproportionate burning pain localized to the compartment is usually the first sign. Passive stretching usually worsens the pain and it is rarely alleviated by narcotics. The affected area may feel firm and appear pale, and neurologic symptoms can develop distally. A very late sign is distal pulselessness. The goal of treatment is to get the patient to a facility before pulselessness develops. The extremity should be elevated to the level of the heart but not above it. Cold packs can be applied to the site and the extremity can be splinted. Lastly, a bolus of isotonic crystalloids should be administered to help the kidneys flush the toxins resulting from the rhabdomyolysis.

What mechanism of injury is typically associated with a hip fracture? What signs and symptoms are typically associated with it? How should it be managed in the field?

Hip fractures involve fractures of the femoral head, femoral neck, intertrochanteric region, and/or proximal femoral shaft. These are typically seen in older patients with degenerative bones but can occur in anybody secondary to direct trauma. Patients will typically report pain in the affected hip and may report hearing a "snap." If the femur is displaced, it is almost always externally rotated and shortened. Regardless, tenderness, swelling, ecchymosis, and possible deformity are almost always present. Treatment is the same as for any other trauma: immobilization, vascular access, monitoring for shock, and transport to a trauma center. Simple falls in older patient can usually be managed without employing a traction splint. Care for these fractures almost always involves surgery.

What are the benefits of pneumatic splints? What are their limitations? How much should they be inflated?

In addition to splinting, air splints additionally (a) help slow bleeding and (b) minimize swelling by applying pressure over fracture sites which decreases small-vessel bleeding. They're useful for stabilizing fractures involving the lower leg or forearm, but are not useful for angulated fractures or for fractures involving a joint because they will forcefully attempt to straighten the fracture and joint. Likewise, they should not be used on open fractures. The splint should be inflated to the point where finger pressure makes a slight dent in the splint. Recall that to this end, air splints will not control arterial bleeding.

What is arthritis? Compare and contrast its three types.

Inflammation of a joint. i. Osteoarthritis: A disease of the joints that occurs as they naturally age and wear. This is characterized by pain and stiffness of the joints with the spine, hips, knees, and hips being most commonly affected. It's ultimately treated with low-impact physical therapy, pain control, anti-inflammatory meds, and on occasion joint replacement surgery. ii. Rheumatoid arthritis: A systemic inflammatory disease that affects the joints. Significant bone erosion can occur at the joints putting these patients at high risk of fracture and dislocation - especially for subluxation of the cervical spine following trauma or during intubation. Systemic involvement of the hands, feet, and wrists is most common, although it can occur in any joint. Primary treatment involves the use of NSAIDs. iii. Gout: Also known as crystal arthritis, this is caused by hyperuricemia (a build up of uric acid) which can crystalize within the synovial fluids of a joint. These patients will have red, hot, swollen joints, with a decreased range of motion. Be aware of their risk of kidney stones. Pre-hospital treatment involves stabilization, pain relief (NSAIDs and corticosteroids), and transport to an ED where the synovial fluids can be aspirated. Primary treatment then relies on the patient following dietary and lifestyle regimens to reduce uric acid build-up.

What is the general treatment of sprains and strains in the field?

It's the same as that of fractures: *R*est - Keep the patient quiet and comfortable *I*ce - Slows bleeding and reduces pain *C*ompression - Slows bleeding *E*levation - Decreases swelling *S*plinting - Decreases bleeding and reduces pain

What mechanism of injury is typically associated with a calcaneus fracture? What signs and symptoms are typically associated with it? How should it be managed in the field?

Jumping from a height and landing on your feet, or when a powerful axial load is applied directly to the heel. Foot pain, swelling, and ecchymosis are common, and you should be alert for possible injuries to the knee, pelvis and spine. Splint the foot with a pillow and apply an ice pack. Any patient with a calcaneus injury should be placed in spinal precautions given the high risk of associated spinal injury.

What mechanism of injury is typically associated with knee dislocations? How significant are these injuries? What signs and symptoms are typically associated with them? How should they be managed in the field?

Knee dislocations are true emergencies that typically occur due to high-energy trauma (such as MVAs) or powerful twisting forces (such as when an athlete attempts to avoid another player). The most common type is anterior dislocation occurring from hyperextension. Medial dislocations can occur secondary to lateral trauma. In all of these, the risk of damage to the popliteal artery is minimal, although ligaments can be stretched and torn. The most dangerous dislocation is a posterior dislocation that results from a direct blow, leading to a high risk of injury to the anterior cruciate ligament and the popliteal artery. Pain that feels as if the knee "gave out" is common, and there may or may not be deformity and decreased range of motion - be aware that knees can spontaneously reduce. In all cases, PMS should be assessed. If it is intact, splint the knee in the position found. If neurovascular status is compromised, contact medical control for guidance which will likely depend on on the transport time and how long its been dislocated. Elevation, ice, pain management, etc etc. Transport rapidly to a trauma center. Be aware that as bad as knee dislocations are, patella dislocations are relatively minor, and non-critical knee injuries include tears of the anterior cruciate ligament, medial collateral ligament, and meniscus.

If not angulated, how should the knees and elbows be splinted, respectively?

Knees: straight Elbows: at a right angle

What is crush syndrome? What is the major concern that arises secondary to crush injuries and how should these patients be managed in the field?

Like with compartment syndrome, when a body part is crushed the tissue distal to the injury can become ischemic and necrotic if circulation is impaired. "Rhabdomyolysis" is a term referring to the metabolic products that accumulate in the cut-off vasculature - namely: lactate, potassium, and myoglobin. This process typically takes 4 - 6 hours to develop, but immediately freeing the extremity can cause all of these toxins to flood the systemic vasculature. The lactate and potassium can cause metabolic acidosis, the potassium can cause cardiac dysrhythmias, and the myoglobin can lead to renal failure. The renal dysfunction can then lead to further hyperkalemia and hyperphosphatemia. Thus, treatment should involve consult with medical control. Prior to freeing the extremity, the patient should be placed on high-flow oxygen and should be administered a bolus of isotonic fluids to help the kidneys process the impending myoglobin. The patient should be placed on the cardiac monitor to monitor for signs of hyperkalemia. Administering albuterol during the extrication process may be helpful, as beta-2 agonism promotes an influx of potassium into cells. Once the patient is freed, calcium to stabilize the myocardium and sodium bicarb to treat the acidosis can be considered if signs of hyperkalemia persist. Rapidly transport the patient and manage injuries en route. Ultimately, the patient will likely receive hemodialysis in an intensive care unit.

Compare and contrast the presentation and common causes of the following fractures: linear, transverse, oblique, spiral, impacted, and pathologic.

Linear: Parallel to the long axis of the bone; commonly caused by low-energy stress injuries. Transverse: Straight across a bone at right angles to each cortex; caused by a direct, low-energy blow. Oblique: At a diagonal angle across a bone; caused by direct or twisting force. Spiral: Encircles the bone; caused by twisting injuries. Impacted: The end of one bone becomes wedged into another bone; caused by falls from significant height. Pathologic: Can present as either (1) a localized erosion of the cortical bone or (2) an abnormal overgrowth of bone; caused by primary or metastatic cancer.

What is the primary symptom of a fracture? What additional signs may indicate a fracture?

Localized pain to the site. Additional signs include: i. Deformity (a very reliable sign). ii. Shortening (occurs when the broken ends of a bone override one another). iii. Swelling and ecchymosis at the fracture site due to bleeding. iv. Guarding and loss of use. v. Tenderness to palpation. vi. Crepitus upon palpation (a grating sound caused by the bone-ends touching). vii. Exposed bone ends (in an open fracture).

What is the difference between a luxation and a subluxation? What causes them to occur? What is a dislocation and what causes it to occur?

Luxation: Commonly known as a dislocation, it's the total displacement of a bone from its joint. vs. Subluxation: The partial dislocation of a joint. Some movement may still be possible, but failure to recognize the subluxation can result in persistent joint instability and pain. They're caused by a body part moving beyond its normal range of motion.

What mechanism of injury is typically associated with hip dislocations? What signs and symptoms are typically associated with it? How should it be managed in the field?

More than 90% of hip dislocations involve posterior dislocation following a deceleration injury and an impact to the knee, in which instances the affected leg will be flexed, adducted, internally rotated, and shortened. Severe pain, an inability to move the leg, and soft-tissue swelling may be evident. Anterior hip dislocations are typically from a forceful spreading injury and result in the leg being flexed, abducted, externally rotated, and in severe pain. In any case, the hip should be immobilized with blankets and pillows. Be sure to do a full assessment due to the energy required to cause a hip dislocation. Manage pain and just be aware that the patient will likely need general anesthesia to allow for reduction in the hospital.

How do shoulder dislocations typically occur? How should they be managed in the field?

Most shoulders dislocate anteriorly and occur as the result of a fall. While reduction is theoretically pretty straightforward, the dislocation can potentially tear the rotary cuff, fracture the glenoid, and/or damage the brachial plexus, axillary artery, axillary vein, and axillary nerve. As such, sensation should be assessed over the deltoid muscle and PMS should be assessed distally. The extremity should be splinted in the position found so get creative with pillows and a sling/swathe. Consider pain medication as appropriate.

What are associated fractures?

Multiple fractures that occur together due to the way the causative forces are transmitted. For example, pain and swelling over the scaphoid bone of the wrist means the patient fell hard against an outstretched hand, meaning there may be other associated injuries along the axis from the hand to the shoulder.

What is myalgia? What is its most common cause? How is it treated?

Muscle pain that is symptomatic of some other cause. Most commonly, it's caused by repetitive strain injury or muscle overuse, although its causes range from viral infection to Lupus. Treatment typically relies on cessation of activities which worsens the pain and NSAIDs.

What is the difference between and open and closed fracture? Which is worse and why?

Open: A break in the overlying skin which allows the bone fracture to communicate with the outside environment. Closed: The skin over the fracture site remains intact. Open fractures are much worse because (1) much more energy is required to cause the injury, and (2) blood loss can be significantly greater if not confined to a closed space.

What are the 6 P's of the musculoskeletal assessment?

Pain Paralysis Paraesthesia (numbness of tingling) Pulselessness Pallor (pale or delayed cap refill in children) Pressure

What are the principle symptoms of a dislocation?

Pain or pressure over the site of the joint and a loss of motion of the joint.

In what way can peripheral nerve damage occur secondary to an orthopaedic trauma?

Peripheral nerves typically run deeply within the body and are shielded from day-to-day injury by the skeletal system. Broken and dislocated bones, however, can lacerate and/or place pressure on the nerves causing damage and pain.

How should fractures of the fingers and toes be managed in the field?

Place a gauze pad between the injured finger and one adjacent to it and "buddy splint" the two together.

How should fractures generally be managed in the field?

RICES: *R*est - Keep the patient quiet and comfortable *I*ce - Slows bleeding and reduces pain *C*ompression - Slows bleeding *E*levation - Decreases swelling *S*plinting - Decreases bleeding and reduces pain Control external bleeding and prevent infection in open fractures. Manage internal bleeding (shock considerations) and immobilize the limb. Consider fluid administration for blood loss and consider analgesics for pain.

How should patients with multiple fractures in a critical condition be managed on scene?

Rather than spending the time splinting each fracture individually, securing the patient to a longboard feasibly immobilizes the entire patient. The book additionally advocates for considering the use of a vacuum mattress and scoop stretcher. The same is true regarding the management of femur fractures in critical patients.

What is polyneuropathy? How do these patients typically present? How should they be managed in the field?

Simultaneous dysfunction of multiple peripheral nerves. The symptoms can present as motor, sensory, or both. Polyneuropathy can develop over days to weeks, and typically the patient will have a recent history of illness. Two prominent types of polyneuropathy are Guillian-Barre syndrome and poliomyelitis. Treatment in the field involves management of ABCDEs, pain management, and transport for diagnosis and definitive care.

How should sternoclavicular sprains and torn rotator cuffs be managed?

The biggest thing is ensuring that you're not dealing with neurologic deficits or a worse injury. Compare limb symmetry, determine range of motion, and assess distal PMS. Care is otherwise basically the same anyways: cold packs, elevation, stabilization, and transport.

What mechanism of injury is typically associated with an elbow fracture? What signs and symptoms are typically associated with it? How should it be managed in the field?

The elbow is a joint, and practically you're either fracturing the supracondylar humerus or the radial head, most commonly from a fall onto an outstretched arm or a direct blow. Supracondylar humeral fractures are common in children are leave the patient at particular risk for compression of the brachial artery and/or the radial and median nerves, thus leading to the possibility of compression syndrome. If this occurs and is not promptly treated, Volkmann ischemic contractures can occur in which the muscles which allow for movement of the fingers become contracted and nonfunctional. Patients with these injuries will usually present with pain in the area of the elbow and will have swelling and ecchymosis. Treatment includes splinting and repetitive PMS exams. Ice packs should only be applied if there are no signs of compartment syndrome. If PMS is compromised, contact medical control for direction on whether to attempt reduction.

What is the scaphoid? What complication can occur if it is fractured? How does a fractured scaphoid typically present?

The first wrist bone just distal to the radius. Due to the poor blood supply to this region, avascular necrosis (i.e. poor bone healing) can occur. These patients typically have pain and tenderness in the anatomic snuffbox.

How should injuries to the wrist and hand be managed?

The hand should be splinted in the position of function: that is, the wrist should be extended 30° with fingers slightly flexed. The hand should be secured to a rigid splint that extends proximally to the elbow and the hand should be kept slightly elevated to reduce swelling. If a finger is injured, it should be splinted to a foam-padded aluminum splint. In the case of penetrating trauma, bulky dressings should be applied to the site and the hand should be splinted to reduce bleeding.

What is devascularization?

The loss of blood flow to tissue distal to blood vessel damage.

What does the term "thromboembolic disease" include and why is it of particular concern following orthopaedic trauma? How should these patients be managed in the field?

The term includes deep vein thromboses (DVTs) and pulmonary emboli, and is a significant cause of death following musculoskeletal injuries - particularly those involving the pelvis and lower extremities. The reduced blood flow and immobilization increases one's risk of DVT, and a fractured long-bone can similarly create a fat embolism, both of which can travel to the lungs and get lodged in the pulmonary vasculature. Signs and symptoms of a pulmonary embolism include: a sudden onset of dyspnea, pleuritic chest pain (either side), tachypnea, tachycardia, low-grade fever, right-sided heart failure, shock, and possibly cardiac arrest. Treatment is limited to airway management and oxygenation, fluid administration, and rapid transport.

What type of elbow injuries are common and how urgently should they be treated? How do these patients typically present? How should these injuries be managed?

The vast majority of elbow injuries are posterior injuries that result from a fall onto an outstretched hand or from hyperextension of the elbow joint. An injury known as a "nursemaid's elbow" is common in children under 6, in which there is subluxation of the radial head from the child's arm being suddenly pulled. Regardless of the cause, there is usually significant swelling, ecchymosis, and pain around the elbow, and a palpable deformity may be noted around the olecranon process. The arm is generally held in a position of comfort and resistance will be met if you try to move it. Note that with a nursemaid's elbow, there may be very little swelling. In any case, the arm should be splinted in the position found with a sling and swathe so figure it out.

How do straddle fractures occur to the pelvis? What risk is associated with these injuries?

These occur when a person falls and sustains an impact in the region of the perineum producing bilateral fractures of the superior and inferior rami. This injury does not interfere with weight bearing but it has a high risk of associated complication with the GU system in the region.

How should dislocated wrists be managed in the field?

These patients will present similarly to patients with fractured wrists and this typically occurs via hyperextension of the wrist. Lucky for you, management is basically the same as for that of a fractured wrist: splint with a padded board in a position of function, sling and swathe the arm, apply ice, elevate the wrist to the level of the heart, and administer pain medication as indicated.

What mechanism of injury is typically associated with a shoulder fracture? What signs and symptoms are typically associated with it? How should it be managed in the field?

These typically follow a fall onto an outstretched hand, and are common in older patients - younger patients are more likely to just dislocate the shoulder. These involve fracture of the glenoid fossa of the scapula, the humeral head, and the humeral neck, and are rarely obviously deformed. There is, however, typically considerable swelling, ecchymosis, and pain. Injury to the brachial plexus is possible so be mindful of the possibility of distal neurologic changes. Pain is typically relieved by placing the arm in a sling and immobilizing it tightly to the chest with a swathe.

What mechanism of injury is typically associated with a femoral shaft fracture? What signs and symptoms are typically associated with it? How should it be managed in the field?

These typically occur following high-energy impacts and their presence should alert you to the possibility of other injuries. These patients will report severe pain and the fracture may be severely angulated or shortened. Edema in the thigh, bruising, crepitus, and muscle spasm are all likely upon exam. There is often significant blood loss and neurovascular damage is possible. Fat emboli can occur as well. Management involves stabilization with a traction splint, monitoring for signs of shock, establishing IV access, hemorrhage control, pain management, and rapid transport.

What mechanism of injury is typically associated with a scapular fracture? What signs and symptoms are typically associated with it? How should it be managed in the field?

These typically occur secondary to violent, direct trauma. Be sure to look for associated injuries - particularly intrathoracic injuries such as pneumothoraces, hemothoraces, and fractured ribs. Symptoms typically include pain that increases with abduction and swelling in the region of the scapula. The axillary artery and nerve and the brachial plexus can be injured, and pulmonary contusions and clavicular fractures often accompany the injury. Scapular fractures typically warrant full spinal immobilization given the significant energy required to fracture the large bone.

What mechanism of injury is typically associated with finger dislocations? What signs and symptoms are typically associated with it? How should they be managed in the field? If you reduce the finger, how should it be done?

They're caused by a "jamming" force or from an extension beyond their normal range of motion. There may be pain and deformity at the site and neurovascular structures may be compromised resulting in paraesthesia. The finger can be managed either by (a) splinting the entire hand in the position of function or (b) via buddy splinting. The finger should not be reduced unless directed to do so by medical control. If you're directed to do so, the method depends on the direction of dislocation: If dislocated to the dorsal side, the digit should be extended. If dislocated to the volar side, it should be flexed. Next, gentle longitudinal traction should be applied while pressure is applied at the joint so as to push it back into position. Then boom, you're basically an orthopaedist. But like, check PMS before and after because you're not really an orthopaedist.

How do lateral compression injuries occur to the pelvis? How life-threatening is this injury?

They're typically the result of of impact to one side of the body (such as being laterally struck in an MVA or falling onto one side of the body). The injured side becomes internally rotated around the sacrum. The pelvis typically remains stable, and since the volume inside the pelvis decreases rather than increases, bleeding is not usually life-threatening.

What mechanism of injury is typically associated with a clavicular fracture? What signs and symptoms are typically associated with it? How should it be managed in the field?

They're very common in children, particularly following a fall onto an outstretched hand or from direct lateral trauma to the shoulder (which is common in contact sports). These patients will generally have pain in the region of the shoulder, swelling, an unwillingness to raise their arm, and a tilting of the head toward the injured side. The most commonly injured segment is the middle-third of the bone and deformity may be visualizable and/or palpable. Pain is typically relieved by placing the arm in a sling and immobilizing it tightly to the chest with a swathe.

How do anterior-posterior compression injuries occur to the pelvis? How life-threatening is this injury?

This injury may occur following a head-on MVA or motorcycle crash, fall, or in a patient struck head-on by a vehicle. The impact forces the pelvis posteriorly, causing the pubic symphysis and supporting ligaments to tear apart. Thus, the pelvis spreads apart, hence its name as an "open-book pelvis," and the patient becomes highly susceptible to massive bleeding.

What possible complications make a posterior sternoclavicular joint dislocation concerning? What signs and symptoms should you be mindful of? How does this injury typically occur?

Typically the result of a direct blow to the clavicle (although also the possible result of strong pressure placed to the back of the shoulder), there's lots of critical structures underlying this area which are prone to fatal injury, including: the trachea, esophagus, jugular vein, subclavian vein and artery, carotid artery, and other vascular structures. As such, concerning signs and symptoms include: dyspnea, pain on swallowing, a sensation of choking, loss of consciousness, or unilateral pulse/neurologic deficits in an upper extremity.

How should an angulated joint be managed in the field?

Unlike an angulated fracture which can be realigned with gentle longitudinal traction, joints should not be realigned without medical control's approval. It's often incredibly painful and shouldn't be considered unless there is loss of distal PMS.

How does acromioclavicular joint separation typically occur? How should it be managed in the field?

Usually occurring from a direct blow to the superior aspect of the shoulder, as may happen during contact sports or from a fall, patients typically report pain and tenderness in the region of the AC joint and may have a noticeably protruding distal clavicle. A sling and swathe often provide considerable relief, and pain medication should be considered as appropriate.

How do indirect injuries occur with regard to trauma?

When a force is applied to the body, the energy may disperse along the skeleton until it hits a region too structurally weak to sustain the force. For example, when an individual's knee strikes the dashboard in an MVA, if the force is not great enough to shatter the patella directly, it can travel proximally along the femur until the femoral neck fractures.

How do vertical shear injuries occur to the pelvis? How life-threatening is this injury?

When a major force is applied to the pelvis from above or below, such as from a fall from a height, the patient is at risk of displacing one or both sides of the pelvis. Anteriorly, the rami can fracture and the pubic symphysis can be disrupted, and posteriorly, the ilium and/or sacrum can fracture and the sacroiliac joint can be disrupted. This fracture is unstable and is a high-risk for hemorrhage given the increase in pelvic volume.

What is a sprain? How are these injuries typically characterized?

When ligaments are stretched or torn, typically as the result of a sudden twisting of a joint beyond its normal range of motion. They're typically characterized by pain, swelling, and discoloration over the injured joint, and an unwillingness to use the limb. In contrast with fractures and dislocations, sprains do not usually involve deformity and joint mobility is usually limited by pain - not by joint incongruity.

What is diastasis?

When the ligaments that hold two bones in a fixed position are disrupted, resulting in the space between the two bones increasing.

How should an unstable pelvic fracture be stabilized?

Whether using a pelvic binder or sheets, the key is to laterally compress the greater trochanters (not the iliac wings) which forces the pelvis to internally rotate, thereby reducing the space into which bleeding can occur. Once immobilized, the patient should be rapidly transported to a trauma center. Isotonic fluids should be administered, although the patient may very well remain hypotensive during transport.

Is a dislocation considered to be an urgent injury? Why or why not?

Yes, because the dislocated bone can compress nerves and blood vessels resulting in neurovascular compromise.

When are heat packs useful in treating musculoskeletal injuries?

You want to avoid using hot packs during the first 48 - 72 hours following an injury as it may exacerbate swelling and pain. That being said, it can alleviate pain and increase blood flow once the acute period ends, and may provide relief to patients who calls for week-old injuries.