9/14/14. Orthopedic Emergencies Approx 55 million musculo-skeletal injuries annually. 10 million fractures, 23 million sprains & dislocations

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Shana Curtis
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$10 million fractures, 23 million sprains & dislocations Half of all hospital admissions r/t trauma Majority w/ some type of fracture Elderly (>65) more likely to be admitted Single$ system or multi-system Blunt or penetrating Mechanisms of injury include MVC s Assaults Falls Sports & leisure activities Home activities ABC s Always primary concern Subjective:

system or multi-system Blunt or penetrating Mechanisms of injury include MVC s Assaults Falls Sports & leisure activities Home activities ABC s Always primary concern Subjective:

Motor Sensory Radial Median Extend wrist or thumb Oppose thumb to base of small finger Feeling on dorsum of thumb Feeling on tip of index finger Ulnar Abduct (fan) fingers Feeling

1 Kevin McFarlane BSN,RN,CEN,CPEN,EMT-I Orthopedic Emergencies Approx 55 million musculo-skeletal injuries annually. 10 million fractures, 23 million sprains & dislocations Half of all hospital admissions r/t trauma Majority w/ some type of fracture Elderly (>65) more likely to be admitted Single system or multi-system Blunt or penetrating Mechanisms of injury include MVC s Assaults Falls Sports & leisure activities Home activities ABC s Always primary concern Subjective: HPI PMH PQRST Associated symptoms / injuries Contributing factors Objective: Inspect & compare: Both extremities Skin & soft tissue Joints Swelling ROM Bones Nerves Vascular Nerve Motor Sensory Radial Median Extend wrist or thumb Oppose thumb to base of small finger Feeling on dorsum of thumb Feeling on tip of index finger Ulnar Abduct (fan) fingers Feeling on tip of small finger Tibial Superficial Peroneal Planar flex toes (curl down) Laterally evert foot Feeling on bottom of foot Feeling on lateral aspect of dorsum of foot Deep Peroneal Dorsiflex toes (curl toes up) Feeling in first toe web space 12 1

0 No pulse X Mark the spot 1 Weak & easily obliterated w/ pressure 2 Difficult to

& bounding consider doppler if unable to appreciate pulse 13 Pediatric Cartilaginous

un-witnessed! old fx! mechanism doesn t match injury!

shoes Vision changes Diminished reflexes Diagnostics X-ray CT MRI: soft tissue,

Interventions Positioning, splinting & immobilization control Non pharmacological &

2 0 No pulse X Mark the spot 1 Weak & easily obliterated w/ pressure 2 Difficult to palpate but easy to feel once located 3 Easily palpated & considered normal 4 Strong & bounding consider doppler if unable to appreciate pulse 13 Pediatric Cartilaginous & flexible Open epiphyseal plates susceptible to trauma Red flags:! spiral fx! un-witnessed! old fx! mechanism doesn t match injury! child not developmentally capable! The elderly can also be victims of abuse / neglect. Be vigilant in your assessments. Elderly Loss of bone & muscle mass Osteoporosis, arthritis Unsteady gait Ill fitting shoes Vision changes Diminished reflexes Diagnostics X-ray CT MRI: soft tissue, ligamentous, muscle tears etc US Angiogram: if suspected vascular compromise Interventions Positioning, splinting & immobilization control Non pharmacological & pharmacological Td & Antibiotics Contusion / Hematoma Closed injury. Disruption of blood vessels & bleeding into surrounding tissues Blunt trauma, exertion, stress SX:, discoloration & pain. 2

Sprain = stretch, separation, tear of supporting ligament Strain = separation or tear of musculotendinous unit from bone Sprain = Bone to Bone Strain = Muscle to bone Sprain = Bone to Bone Strain =

3 Sprain = stretch, separation, tear of supporting ligament Strain = separation or tear of musculotendinous unit from bone Sprain = Bone to Bone Strain = Muscle to bone Sprain = Bone to Bone Strain = Muscle to bone Sprain stretch or tear in a ligament Strain Injury to a muscle or a tendon Causes: sudden stretching, twisting, or excessive force to joint may report a popping sound Injury results in tearing of muscle or tendon. 1st degree minor tear, minor swelling, discomfort, absent or minimal ecchymosis 2nd degree Local pain, Point tenderness, more severe swelling, visible ecchymosis, unable to use limb more then briefly 3rd degree complete disruption of ligament or tendon, minimal to severe swelling, resultant separation of muscle from muscle, muscle from tendon or tendon from bone may be visible on xray May require x-ray Pain control RICE Rest Ice Compression (bandage) Elevation anti-inflammatories Discharge instructions include neurovascular symptoms, activity restrictions, and follow-up 3

Open Fracture Exposed bone Neurovascular compromise Femur Fractures Marked swelling Pulelessness Delayed cap refill Discoloration Cool to the touch

Suspect Compartment Syndrom Suspected osteomyelitis: Complications of delayed treatment can include loss of limb or limb function, septic shock, and death.

4 Open Fracture Exposed bone Neurovascular compromise Femur Fractures Marked swelling Pulelessness Delayed cap refill Discoloration Cool to the touch Possible septic joint: Severe pain. Complications of a septic joint include long-term damage to the joint. Suspect Compartment Syndrom Suspected osteomyelitis: Complications of delayed treatment can include loss of limb or limb function, septic shock, and death. Severe joint pain, rashes, or unexplained fevers Closed skin with boney deformity Intact pulses Color Sensation Motion slightly delayed cap refill Nonspecific chronic pain Back injuries Joint pain Extremity pain 4

Fractures Closed skin No boney deformity Good

$Sensation Temp Or cap refill A fracture is a$ $Simple fractures Bone broken Skin in tact Open$ the bone or other objects Will require

intervention Fractures Angulation/deformity

5 Fractures Closed skin No boney deformity Good rage of motion No alteration Color Pulse Sensation Temp Or cap refill A fracture is a disruption or break in the bone. Simple fractures Bone broken Skin in tact Open or compound fractures Puncture of the skin by the bone or other objects Will require antibiotic therapy Usually require surgical intervention Fractures Angulation/deformity Pain Regional/point tenderness Swelling Immobility Crepitus. highly unstable fracture 5

$Bending of the bone with incomplete fracture$ $Bone has been fractured into two or more$ $significant trauma An avulsion fracture occurs$ when an injury causes a ligament or tendon to

when an injury causes a ligament or tendon to

6 Most common in infants and young children Bending of the bone with incomplete fracture Bone has been fractured into two or more fragments. A result of significant trauma Bone has been fractured into two or more fragments. A result of significant trauma An avulsion fracture occurs when an injury causes a ligament or tendon to tear off (avulse) a small piece of a bone to which it's attached. Fracture in which one broken end is wedged into the other broken end 6

Articular surfaces NO longer in contact & loose

$possible fracture possible fracture An$ incomplete or partial dislocation of a joint.

consent Patent IV Oxygen, pulse oximetry

agents Emergency & rescue equipment Clavicle

Radius Ulna Hand: Boxer s & Snuffbox MOI Trauma

raise arm Head tilted down toward side of

7 Articular surfaces NO longer in contact & loose anatomical position Subluxation some articular surface contact remains Always assess for possible fracture Articular surfaces NO longer in contact & loose anatomical position Subluxation some articular surface contact remains Always assess for possible fracture An incomplete or partial dislocation of a joint. Some articular surfaces remain intact Informed consent Patent IV Oxygen, pulse oximetry Cardiac monitoring Medications & reversal agents Emergency & rescue equipment Clavicle Shoulder Humerus Elbow Radius Wrist & Distal Radius Ulna Hand: Boxer s & Snuffbox MOI Trauma Fall onto affected shoulder Sx Inability to raise arm Head tilted down toward side of injury but chin pointed away from injury 7

Anterior: Abduction & external rotation from FOOSH Sx: Can t adduct elbow

Abduction & internal rotation from seizure activity or blow to anterior

Sx: Arm held at the side & pt unable to externally rotate at wrist

Ecchymosis to shoulder, upper arm & possibly chest wall Elbow swelling

teens & athletes MOI Direct blow, fall FOOSH Deformity Immobility Radial

s arm or lifting them by the wrists Disuse Can flex, Can t supinate

8 Anterior: Abduction & external rotation from FOOSH Sx: Can t adduct elbow to chest or touch their opposite ear Posterior: (relatively rare) Abduction & internal rotation from seizure activity or blow to anterior shoulder. Sx: Arm held at the side & pt unable to externally rotate at wrist Proximal, midshaft & distal MOI FOOSH Direct trauma or twisting Ecchymosis to shoulder, upper arm & possibly chest wall Elbow swelling Limited ROM Possible sensory changes back of hand Common in children, teens & athletes MOI Direct blow, fall FOOSH Deformity Immobility Radial head dislocation Often seen in children under 5 Sudden jerk on the child s arm or lifting them by the wrists Disuse Can flex, Can t supinate FOOSH, exacerbated by supination & pronation Point tenderness Isolated fracture Usually the result of a sharp blow Defensive posture Consider assault / abuse Point tenderness 8

Smith s Hoe-type Landing on dorsum of hand Colle s Upside down dinner fork

box Fracture of the fifth metacarpal Usually the result of punching a hard

(chin, jaw, wall) If open, high degree of infection potential (fight bite)

Pelvis Tibia / Fibula Ankle Heel 67 Major trauma, falls, MVC Fractures of

Can loose up to 1500ml of blood in the thigh.

9 Smith s Hoe-type Landing on dorsum of hand Colle s Upside down dinner fork MOI FOOSH Common in young active adults Slow healing Point tenderness Snuff box Fracture of the fifth metacarpal Usually the result of punching a hard object. (chin, jaw, wall) If open, high degree of infection potential (fight bite) Point tenderness Possible disruption of skin Lower Extremity Femur Hip Pelvis Tibia / Fibula Ankle Heel 67 Major trauma, falls, MVC Fractures of the femoral neck are quite common in the elderly after a fall. Can loose up to 1500ml of blood in the thigh. Signs & symptoms: Inability to bear weight Internal or external rotation (depending on fracture site) Edema of thigh Deformity of thigh Evidence of hypovolemic shock Hare Traction Splint 9

$Posterior pelvic fractures more commonly$ 8%-10% mortality If open 40%-60% Signs &

$injury Often multiple fractures MAST$ compartments first, then abdominal

10 Hare Traction Splint Can be life threatening due to large blood loss and injury to GU system % will be arterial bleeds. Posterior pelvic fractures more commonly assoc w/ massive bleeding. 8%-10% mortality If open 40%-60% Signs & symptoms: Evidence of hypovolemic shock Abnormal rotation on affected side Intra-abdominal, GU or retroperitoneal injury Often multiple fractures MAST pants or PASG pants T-Pod Inflate leg compartments first, then abdominal compartments. (Deflation is done in the opposite manner) Each compartment is filled with 100 mmhg of pressure. Monitor blood pressure closely during deflation for sudden drops Contra-indications: Pregnancy Impaled objects Eviscerations Abdominal or chest bleeding Sam Sling 10

Falls, direct blows Rotation stress Deformity Point tenderness

$may be difficult to diagnose an ankle fracture over a sprain,$ dislocation, or a tendon injury.

Fitting 2-3 finger-space from top crutch to axilla Handgrips:

joints tightened Rubber tips intact Precautions Changes in

front, 6 inches to the side NWB PWB Going up stairs Up with the

11 Falls, direct blows Rotation stress Deformity Point tenderness Crepitus Inability to wt bear Rolling ankle, twisting, falls Sx; Point tenderness Deformity Discoloration Inability to wt bear It may be difficult to diagnose an ankle fracture over a sprain, dislocation, or a tendon injury. Falls, axial loading, MVC s Inability to wt bear Discoloration Fitting 2-3 finger-space from top crutch to axilla Handgrips: elbow should be bent degrees Before heading out Ensure joints tightened Rubber tips intact Precautions Changes in terrain Scatter rugs, small pets, toys 80 Tips 2 inches in in front, 6 inches to the side NWB PWB Going up stairs Up with the good Going down stairs Down with the bad Involves an open wound where the bone has punctured through the skin 11

$All OPEN fractures are considered contaminated.$ saline dressings. If patient s surgical intervention is delayed, flush the wound with 1 2 liters of normal saline and apply a dry sterile dressing.

saline dressings. If patient s surgical intervention is delayed, flush the wound with 1 2 liters of normal saline and apply a dry sterile dressing.

12 All OPEN fractures are considered contaminated. Serious risk of infection Osteomyelitis, poor tissue healing or sepsis can occur Treatment Initiate IV antibiotics early If patient is to go to surgery immediately, cover the wound with sterile saline dressings. If patient s surgical intervention is delayed, flush the wound with 1 2 liters of normal saline and apply a dry sterile dressing. Tetanus Loss of body part Complete or partial Alone or combined with other injuries. Decreased success associated with: Excessive contamination Prolonged time between injury & cooling (>6hr proximal arm/leg, > 12 hr distal arm/leg) Absolute contraindications to re-implantation: Life-threatening injuries Extensive damage (degloving, crush, mangled) Guillotine vs Avulsion Hemorrhage Fat Embolism Syndrome Acute Compartment Syndrome Rhabdomyolysis Other: Neurovascular injury Chronic pain syndromes Infection Mal-union or non-union Body area Humerus Elbow Forearm Pelvis Hip Femur Knee Tibia Ankle Volume loss ml ml ml ml ml ml ml ml ml Blood loss from fractures can be significant & lead to shock like states. 12

$Potentially life threatening complication of fractures Long bones and pelvis most common Disruption of blood flow & tissue oxygenation to brain, lungs, kidneys or other organs.$ 4-104 F) Petechiae over chest, axillae & conjuctiva in 50-60% of pts Decreased urinary output Diagnostics: CXR- initially appear normal but progresses to haziness & interstitial edema ABG s

4-104 F) Petechiae over chest, axillae & conjuctiva in 50-60% of pts Decreased urinary output Diagnostics: CXR- initially appear normal but progresses to haziness & interstitial edema ABG s

13 Potentially life threatening complication of fractures Long bones and pelvis most common Disruption of blood flow & tissue oxygenation to brain, lungs, kidneys or other organs. Signs & symptoms: Onset hr after fracture or surgery Tachypnea Tachycardia Rales, crackles, hemoptysis Hypoxemia with change in mental status Fever (38-40 C or F) Petechiae over chest, axillae & conjuctiva in 50-60% of pts Decreased urinary output Diagnostics: CXR- initially appear normal but progresses to haziness & interstitial edema ABG s hypoxemia, PaO2 <60mmHg & increase CO2 retention. Decreased pulse Ox Treatment: High flow O2, Mechanical ventilation w/ PEEP or continuous airway pressure to maintain PaO2 > 60 IVF to maintain UO & cardiac function Inotropics & pressors as needed Steroids Increased pressure in muscle fascicle. Results in impaired capillary blood flow & cellular ischemia. More frequently in lower extremities. 5 P s Pallor Pain Pulse Paresthesia Paralysis Pressures increase from an internal or an external force Bleeding Soft tissue swelling Casts Splints Crush injury Burns Cannulation of Artery Most common lower arm hand lower leg -foot Permanent nerve and muscle damage can occur within 4-8 hours 13

14 Remove the pressure Measure compartment pressure Normal pressure 8-10mmHg >30 mmhg can cause ischemia Elevate extremity to level of heart. Avoid ice Fasciotomy Avoid applying casts or dressings too early after trauma. Splints better. Ensure proper immobilization & alignment which helps prevent further injury, and edema & improves venous return. Ongoing CSM monitoring Most commonly associated w/ crush injuries. Skeletal muscle fibers breakdown: Myoglobin Creatine Kinase (CK) Other inflammatory mediators ARF occurs in approximately 15% of patients w/ rhabdomyolysis Signs & symptoms: Mostly nonspecific: Muscle pain, tenderness, swelling, bruising & weakness. Fever, malaise Confusion, delirium Cola colored urine May have decreased deep tendon reflexes. A doughy feeling in involved muscles. Treatment: IVF to maintain UO > 200cc/hr (adults) & prevent ARF NaHCO3 to alkalinize urine ABC s Vital signs 5 P s (pain, pallor, pulses, parathesia, paralysis) CSM (circulation, sensation, mobility) 14

Chapter 30 - Musculoskeletal_Trauma

Chapter 30 - Musculoskeletal_Trauma Introduction to Emergency Medical Care 1 OBJECTIVES 30.1 Define key terms introduced in this chapter. Slides 11 12, 19 20, 22 23, 37 30.2 Describe the anatomy of elements of the musculoskeletal system.