12/14/2015. Terminal Learning Objective. References. Orthopedic Principles PFN: SOMOOL05. Hours: 2.0

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1 Orthopedic Principles PFN: SOMOOL05 Hours: 2.0 Slide 1 Terminal Learning Objective Action: Communicate knowledge of Orthopedic Principles Condition: Given a lecture in a classroom environment Standard: Received a minimum score of 75% on the written exam IAW course standards Slide 2 References Pathophysiology for the Health Professions, 4 th edition, Gould BE & Dyer RM Field Guide to Wilderness Medicine, 2 nd edition, Mosby, 2003 Manual of Orthopedics, 5 th edition, Lippincott Williams & Wilkins, 2001 The Merck Manual, 17 th edition Slide 3 1

2 References The Sanford Guide to Antimicrobial Therapy, 42 nd edition Special Operations Forces Medical Handbook, 2008 edition Slide 4 Reason Orthopedic injuries are common daily occurrences in active training, recreational events, and deployments. SOF Medics must have a baseline ability to evaluate and properly manage a variety of orthopedic complaints. Slide 5 Agenda Recall the anatomy and physiology of the skeletal system Identify potential fractures based on history and mechanism of injury Identify a fracture by location of the fracture line and/or displacement Communicate the signs and symptoms, physical exam findings, diagnostic tests, and management of soft tissue injuries after a fracture Identify clinical features of a fracture Understand special examinations and associated fractures Identify special fracture types Slide 6 2

$Agenda Communicate the role and rules of radiographic images Communicate the proper disposition of and treatment of fractures$ $Identify the stages of a fracture healing Communicate the signs and symptoms, physical exam findings, diagnostic tests, and$

3 Agenda Communicate the role and rules of radiographic images Communicate the proper disposition of and treatment of fractures Understand when an orthopedic injury requires immediate referral/medevac Understand compartment syndrome and its treatment Identify the stages of a fracture healing Communicate the signs and symptoms, physical exam findings, diagnostic tests, and management of fracture complications Slide 7 Recall Anatomy and Physiology of the Skeletal System Slide 8 Name the Bones Slide 9 3

1 Epiphysis Red bone marrow Epiphyseal line Marrow cavity Yellow bone

4 How did you do? Slide 10 Wrist Slide 11 Copyright The McGraw-Hill Companies, Inc. Permission required for reproduction or display. BONE ANATOMY Articular cartilage Fig. 7.1 Epiphysis Red bone marrow Epiphyseal line Marrow cavity Yellow bone marrow Periosteum Nutrient foramen Diaphysis Site of endosteum Compact bone Spongy bone Epiphyseal line Articular cartilage Epiphysis Growth Plate a.k.a. Epiphyseal Plate (a) Living (b) Dried Slide 12 4

$Harris fractures Slide 13 Potential Fractures Based on History and Mechanism of Injury https://www.$ $v=mmxy zj3eohy\ *Play video at beginning of slide Slide 14 Mechanism of Injury (MOI) Direct trauma Bone$ breaks at the point of impact Indirect trauma Bone breaks at a distance from where the force is applied

breaks at the point of impact Indirect trauma Bone breaks at a distance from where the force is applied

5 Epiphysis The end of the bone, forming part of the adjacent joint Growth disturbance if injured Salter Harris fractures Slide 13 Potential Fractures Based on History and Mechanism of Injury zj3eohy\ *Play video at beginning of slide Slide 14 Mechanism of Injury (MOI) Direct trauma Bone breaks at the point of impact Indirect trauma Bone breaks at a distance from where the force is applied Forces Compression Tension Shear **In the clinical setting, with or without advanced imaging, the MOI is the greatest tool in determining the type and location of potential fractures. Slide 15 5

$H Slide 16 Examine for Associated Fractures Calcaneus Compression fractures of the spine Hip dislocations Knee injury Head injury$

6 F.O.O.S.H Slide 16 Examine for Associated Fractures Calcaneus Compression fractures of the spine Hip dislocations Knee injury Head injury Cervical spine lesions Distal tibia Proximal fibula Slide 17 Fracture by Location of the Fracture Line and/or Displacement Slide 18 6

$Definition of a Fracture Partial or complete disruption in the continuity of a bone Slide 19 Describing Fractures Anatomic location Direction of fracture line Stability Associated soft tissue injury$

7 Definition of a Fracture Partial or complete disruption in the continuity of a bone Slide 19 Describing Fractures Anatomic location Direction of fracture line Stability Associated soft tissue injury (esp. CMS) Slide 20 Location of the Fracture Line and/or Displacement Which bone Location on the shaft Proximal Distal Mid-shaft Intra-Articular (fracture extends into joint) Stability Stable Unstable Open or closed Example: Closed, stable, transverse fracture of the proximal 1/3 humerus. Slide 21 7

8 Proximal Humeral Fracture Slide 22 Distal Humeral Fracture Slide 23 Intra Articular Fracture Slide 24 8

Comminuted (multiple pieces) 4. Greenstick (Torus) 5.

Bergman/Corbis; (d): Custom Medical Stock Photo, Inc

9 Fracture Type 1 2 Type 1. Transverse (straight across) 2. Oblique (angled) 3. Comminuted (multiple pieces) 4. Greenstick (Torus) 5. Compression (Impacted) (a): Custom Medical Stock Photo, Inc.; (b): Howard Kingsnorth/Getty; (c) Lester v. Bergman/Corbis; (d): Custom Medical Stock Photo, Inc Slide 25 Stable vs. Unstable Transverse Oblique Comminuted Slide 26 Open or Closed Closed Fracture Open Fracture Slide 27 9

10 Signs and Symptoms, Physical Exam Findings, Diagnostic Tests, and Management of Soft Tissue Injuries After a Fracture Slide 28 Associated Soft Tissue Injury Complicated Uncomplicated Slide 29 Clinical Features of a Fracture Slide 30 10

$! "Cardinal Symptom" All fractures have pain of some degree Scale$

11 Clinical Evaluation Subjective Objective Assessment Plan Referral Slide 31 Clinical Features Classic Subjective Findings Pain Decreased function History MOI MOI MOI MOI Slide 32 PAIN!! "Cardinal Symptom" All fractures have pain of some degree Scale of 1 10/10 Slide 33 11

12 Loss of Function/ Guarding Slide 34 Objective Findings Deformity Crepitus Swelling Tenderness Exposed fragments False motion Slide 35 Deformity Slide 36 12

13 Crepitus Slide 37 Swelling Slide 38 Tenderness Slide 39 13

$R/O neurological complications R/O visceral lesions Check the joint above and the joint below the suspected fracture site Slide 42$

14 Exposed Fragments Slide 40 Specialty Examinations and Associated Fractures Slide 41 Special Examinations R/O vascular complication R/O neurological complications R/O visceral lesions Check the joint above and the joint below the suspected fracture site Slide 42 14

$Examine for Associated Fractures Calcaneus Compression fractures of the spine Hip dislocations Knee injury Head injury Cervical spine lesions Distal tibia Proximal fibula Slide 43$

15 Examine for Associated Fractures Calcaneus Compression fractures of the spine Hip dislocations Knee injury Head injury Cervical spine lesions Distal tibia Proximal fibula Slide 43 Special Fracture Types Slide 44 Pathological Fracture POTENTIAL CAUSES 1. Bone cysts (benign tumor) 2. Osteomyelitis 3. Cancer (consider testicular in young males) 4. Osteoporosis Slide 45 15

$reported pain in the second metatarsal does not show an obvious stress fracture. (Right) Three weeks later, an x-ray of same patient shows callus formation at the site of the stress fracture. (AAOS.$ $positioning or stretching Usually stable, but can become unstable if left untreated Slide 47 False Motion The unusual visual sensation of observing motion at a long bone fracture site where there is$

16 Stress Fractures Slow onset, mild swelling, and tenderness Little soft tissue damage Pain with weight bearing that does not resolve with stretching/exercise (Left) This x-ray of a patient who reported pain in the second metatarsal does not show an obvious stress fracture. (Right) Three weeks later, an x-ray of same patient shows callus formation at the site of the stress fracture. (AAOS.org) Slide 46 Clinical Findings of a Stress Fracture in the Foot History of strenuous activity; possible recent increase in activity (ruck marching) Pain on palpation Pain not relieved with positioning or stretching Usually stable, but can become unstable if left untreated Slide 47 False Motion The unusual visual sensation of observing motion at a long bone fracture site where there is no joint Slide 48 16

$in children With stress fractures and non displaced fractures in all ages, the injury may not be visible on radiograph until bone reabsorbs from the fracture ends in approximately 1 4 weeks Slide 51$

17 The Role and Rules of Radiographic Images Slide 49 Radiographic Examination Slide 50 Note A positive radiograph confirms the diagnosis, but a negative radiograph does not exclude epiphyseal injury in children With stress fractures and non displaced fractures in all ages, the injury may not be visible on radiograph until bone reabsorbs from the fracture ends in approximately 1 4 weeks Slide 51 17

$Rule of Two's Two views: Anteroposterior/lateral Two occasions: Repeat after reduction/retention Two joints: Above and below fracture Two$

18 Rule of Two's Two views: Anteroposterior/lateral Two occasions: Repeat after reduction/retention Two joints: Above and below fracture Two limbs: Especially in children Two times (stress fractures) Slide 52 Two Views Slide 53 Proper Disposition of and Treatment of Fractures Slide 54 18

$treating a fracture, control: Hemorrhage Asphyxia Shock Slide 55$ Emergency Plan M.A.R.C.H. S.O.A.P. P.R.I.C.E. Slide 56 Treatment

19 Before Fracture Management The saving of life comes first Before treating a fracture, control: Hemorrhage Asphyxia Shock Slide 55 Emergency Plan M.A.R.C.H. S.O.A.P. P.R.I.C.E. Slide 56 Treatment Correct shock Relieve pain Sterile dressing Prevent infection Slide 57 19

bleeding and edema Compression for support and controlling swelling Elevation for

20 P.R.I.C.E. Protect to avoid further damage Rest to help healing Ice (cold) for controlling pain, bleeding and edema Compression for support and controlling swelling Elevation for decreasing bleeding and edema Slide 58 4 R s in Fracture Treatment Recognition Reduction Retention of reduction Rehabilitation Slide 59 Step 1 Recognition Slide 60 20

21 Step 2 Reduction Slide 61 Anesthesia / Analgesia Muscle relaxation Unnecessary anxiety Relieve pain Slide 62 Step 3 Retention Slide 63 21

$joint below the fracture Slide 64$ Casting Same principle applies,

22 Splint The guiding principle in splinting and casting is to immobilize the joint above and joint below the fracture Slide 64 Casting Same principle applies, joint above/joint below CHECK PMS BEFORE AND AFTER Cast in position of function Use plenty of padding, increase comfort Beware of compartment syndrome Slide 65 Fracture Blisters Slide 66 22

23 External Fixation Slide 67 Internal Methods Plates Intramedullary Rods/nails K wires Slide 68 Step 4 Rehabilitation Slide 69 23

$Immediate Referral of Fractures Open fractures Suspected compartment syndrome Nerve, vascular, muscle damage Dislocation: not reduced$

24 Immediate Referral of Fractures Open fractures Suspected compartment syndrome Nerve, vascular, muscle damage Dislocation: not reduced after 2 attempts (consult with your surgeon) Spine, pelvis or skull fracture Slide 70 Open Fractures Slide 71 Compartment Syndrome Slide 72 24

Signs and Symptoms of Compartment Syndrome

25 Signs and Symptoms of Compartment Syndrome Pain out of proportion Pain with stretch Paresis (weakness) Paresthesias anesthesia Palor (paleness) Pulses intact Pressure (S.T.I.C. catheter) Slide 73 Compartments of the Leg Slide 74 Vessel Compression Slide 75 25

26 Compartment Syndrome Vicious cycle of: Pressure Vascular occlusion Hypoxia Necrosis Increased pressure Slide 76 Fasciotomy Slide 77 The Stages Of Fracture Healing Slide 78 26

27 Stages of Fracture Healing Slide 79 Bone Fracture Repair Slide 80 Bone Fracture Repair Slide 81 27

28 Hands and feet Average Healing Time Approximately 3 to 6 weeks Upper extremity long bones Approximately 4 to 8 weeks Lower extremity long bones Approximately 12 to 20 weeks Slide 82 The Signs And Symptoms, Physical Exam Findings, Diagnostic Tests, And Management Of Fracture Complications Slide 83 Variables in Fracture Healing Delayed Union Malunion Nonunion Osteomyolitis Avascular Necrosis Sudeck's Atrophy Fatty Embolus Slide 84 28

29 Slower healing than normal Delayed Union Slide 85 Malunion Healing with unacceptable deformity Slide 86 Malunion Slide 87 29

$Union or Delayed Union Infection Bone distraction Open fracture Movement$ $at fracture site Smoking, diabetes, poor nutrition Blood supply$

30 Nonunion Failure of the bone to heal Slide 88 Factors Contributing to Non Union or Delayed Union Infection Bone distraction Open fracture Movement at fracture site Smoking, diabetes, poor nutrition Blood supply interruption Slide 89 Osteomyelitis Associated more often with open fractures Slide 90 30

Osteomyelitis Those at greater risk include: People with diabetes,

hemodialysis Elderly IV drug users, alcoholism, kidney dialysis,

$secondary to fracture in femoral or humeral neck Slide 92 Fat$

31 Osteomyelitis Those at greater risk include: People with diabetes, a weakened immune system, sickle cell disease and receiving hemodialysis Elderly IV drug users, alcoholism, kidney dialysis, malnutrition and smoking Others that affect the immune response Slide 91 Avascular Necrosis Most common in humeral and femoral head secondary to fracture in femoral or humeral neck Slide 92 Fat Emboli Slide 93 31

$Fat Embolism Syndrome 24 48 hours post long bone fracture Triad Pulmonary distress Mental status change Petechial rash Positive End Expiratory Pressure (PEEP) Slide 94 Sudeck s Atrophy Reflex$

32 Fat Embolism Syndrome hours post long bone fracture Triad Pulmonary distress Mental status change Petechial rash Positive End Expiratory Pressure (PEEP) Slide 94 Sudeck s Atrophy Reflex Sympathetic Dystrophy (RSD) Broad spectrum of symptoms can be present: Burning sensation (initially) Edema, cold skin (months later) Atrophy, joint contraction (advanced) Also known as Complex Regional Pain Syndrome (CRPS) May be attributed to not providing early pain control Slide 95 Psychological Effects Disruption of life style, career goals and relationships Scars or deformities, limp, or uneven gait Consult for psychological support when indicated Slide 96 32

33 Questions? Slide 97 Terminal Learning Objective Action: Communicate knowledge of Orthopedic Principles Condition: Given a lecture in a classroom environment Standard: Received a minimum score of 75% on the written exam IAW course standards Slide 98 Agenda Recall the anatomy and physiology of the skeletal system Identify potential fractures based on history and mechanism of injury Identify a fracture by location of the fracture line and/or displacement Identify and describe associated soft tissue injuries Identify clinical features of a fracture Understand special examinations and associated fractures Identify special fracture types Slide 99 33

34 Agenda Communicate the role and rules of radiographic images Communicate the proper disposition of and treatment of fractures Understand when an orthopedic injury requires immediate referral/medevac Understand compartment syndrome and its treatment Identify the stages of a fracture healing Understand the signs, symptoms, and treatments of fracture complications Slide 100 Reason Orthopedic injuries are common daily occurrences in active training, recreational events, and deployments. SOF Medics must have a baseline ability to evaluate and properly manage a variety of orthopedic complaints. Slide 101 Break Slide

PEM GUIDE CHILDHOOD FRACTURES

PEM GUIDE CHILDHOOD FRACTURES INTRODUCTION Skeletal injuries account for 10-15% of all injuries in children; 20% of those are fractures, 3 out of 4 fractures affect the physis or growth plate. Always consider