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Rad Lecttony 3 Extremities
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  2. 2. Outline presentation 2/7/2023  Objective  Introduction  Fracture, Flail Chest  Dislocation, Sprain And Strain.  Principles for bone and joint injuries.  Splint specific fractures.  Management for dislocation.  Management for sprain and strains 2
  3. 3. Objectives 2/7/2023 After studying this chapter, the student will be able to:  Define fracture, dislocation, sprain and strain.  Recognize f/a principles for bone and joint injuries.  Demonstrate how to splint specific fractures.  Demonstrate first aid management for dislocation.  Apply first aid management for sprain and strain. 3
  4. 4. Introduction  Musculoskeletal trauma involves injury to one or more of the following structures: Bone: A unit of the skeleton composed of the hardest variety of connective tissue.  Bones give shape and support to the body.  In addition to surrounding and protecting vital organs, they serve as points of attachment for the muscles of the limbs, making movement possible. 2/7/2023 4
  5. 5. Cont… Joint: The area where two or more bones articulate with one another.  Joints are usually classified in terms of the amount of motion permitted at the articulation.  Most joints of the extremities are synovial joints, which allow the greatest amount of motion. 2/7/2023 5
  6. 6. Cont… Ligament: A bundle of connective tissue forming part of the fibrous capsule surrounding a joint and attached to it.  Every joint of the extremities is reinforced by two or more ligaments Tendon: The fibrous structure connecting a voluntary muscle to bone, cartilage, or ligaments.  Tendons enable muscles to effect motion in the joint or body area to which they are attached 2/7/2023 6
  7. 7. Orthopedic injuries to these structures include the following:  Fracture -is a complete or incomplete break in the continuity of bones.  Fracture -is a complete or incomplete break in the continuity of bones.  Dislocation -is complete or Partial separation of the joint  Sprain- is a joint injury caused by excessive stretching of the supporting ligaments.  Strains- are caused by stretching or tearing of a muscle.  Subluxation -Partial disruption of a joint, in which some degree of contact between the articular surfaces remains 2/7/2023 7
  8. 8. Cont… 2/7/2023 Fracture-dislocation or fracture-subluxation  Disruption of a joint combined with fracture of at least one of the bones involved in the articulation. Diastasis:  A separation of the interosseous membrane connecting two syndesmotic joints as seen between the radius and ulna and tibia and fibula. 8
  9. 9. Mechanism of injury 2/7/2023 By. Kidane D ( Bsc in Emergency and Critical Care Nurse )  Motor vehicle accident  Industrial accident (machine)  Gunshot injury  Fall from a height, trivial  Fighting injury  Pathologic fractures  Stress fractures 9
  10. 10. Patient’s History 2/7/2023  The value of the history in cases of orthopedic trauma is often underestimated.  Knowing the precise mechanism of injury may be the key to diagnosing some fractures or dislocations.  For example, a history of shoulder injury combined with the complaint of dysphagia may be the only clue to the existence of posterior sternoclavicular dislocation. 10
  11. 11. Cont.. 2/7/2023  History taking should not necessarily be limited to orthopedic issues.  Depending on the situation, a general medical history should be obtained because it may have implications for further workup.  Relevant issues may include a history of cancer, heart disease or neurologic disease, taking anticoagulant medication. 11
  12. 12. Initial evaluation of orthopedic injuries 2/7/2023  Essential components of Initial evaluation of orthopedic injuries  General patient assessment  Examination of the injured limb  Evaluation of circulation, sensation, and movement 12
  13. 13. 2/7/2023 13
  14. 14. I. General patient assessment 2/7/2023  Associated life threatening injuries may be missed if evaluation of the patient is not systematic.  Limb injuries are not life threatening unless there is excessive bleeding from an open wound Note: Fx to pelvic = 3L bleeds , Fx to femoral =1-1.5 bleeds, Fx to tibia = 0.5-1 L bleeds.  Fx to each ribs bleeds 150ml, Fx to humerus =0.5-1L bleeds, 14
  15. 15. ll. Examination of the injured limb 2/7/2023 1. Inspect the injured limb and compare it with the opposite, uninjured limb. 2. Gently and carefully cut away any clothing covering the wound, if necessary. 3. When you examine the limb, you may find any one of the following: a. Open wound b. Deformity c. Swelling d. Bruising 15
  16. 16. Cont … 2/7/2023 4. Gently feel the injured limb for points of tenderness- is the best indicator of an underlying fracture, dislocation, or sprain. 5. To detect limb injury, start at the top of each limb and using both hands, squeeze the entire limb in a systematic, firm manner, moving down the limb and away from the body. 6. As you conduct the hands-on examination, ask the patient where it hurts most. 16
  17. 17. III. Evaluation of circulation, sensation, and movement. 2/7/2023 1. Once you suspect limb injury, you must evaluate the circulation and sensation in that limb. 2. Any injury may have associated blood vessel or nerve damage. 3. It is essential to check circulation and sensation after any movement of the limb. S/S  tingling or numbness in the extremity;  nerve damage or lack of circulation. 17
  18. 18. Cont …  After you have made a careful visual and hands-on examination, and if the patient shows no sign of injury, ask the patient to move the limb carefully.  If there is an injury, the patient will report pain and refuse to move the limb. 2/7/2023 18
  19. 19. Imaging 2/7/2023  The joints above and below a fracture should generally be imaged because injury at the proximal or distal joint may coexist with long bone fractures.  Injuries that may require special views or advanced imaging modalities in order to be visualized include acromioclavicular separation, fracture of the scaphoid, posterior shoulder dislocation, and sternoclavicular dislocation.  Plain radiographs are still the mainstay for fracture diagnosis 19
  20. 20. Fracture 2/7/2023 Types of Fracture 1. Closed fractures- closed (simple) fractures are those not associated with open wounds on the surface of the body. 2. Open fractures – open (compound) fractures are those associated directly with open wounds. 20
  21. 21. Signs and symptoms of fracture 2/7/2023  History of trauma  Pain, Swelling,  Inability to use the injured body part  Tenderness and bruising  Deformity, abnormal movement (sure signs of fracture).  Altered neurovascular status 21
  22. 22. Initial management /First aid measures 2/7/2023 Objectives of first aid  To prevent blood lose  To keep the broken bone joints from moving.  To give care for shock.  To relief pain  To transport the victim to hospital 22
  23. 23. Fracture of the scapula 2/7/2023  Fracture of the scapula (shoulder blade) is generally the direct result of the impact of a fall or an automobile collision.  Dislocations of the shoulder joint, sprains and contusions are common in this area.  First aid consists of applying a sling and bandaging the victim’s upper arm to his chest wall Consists of applying a sling to elevate and immobilize the arm and shoulder blade. 23
  24. 24. Fracture of the humerus (The bone of the upper arm) 2/7/2023 First aid for a closed humerus fracture Place a pad in the victim’s arm pit, apply a splint or improvised splint tied in place above and below the break area . Support the forearm with a sling that doesn’t produce upward pressure at the fracture site. Bind the victim’s upper arm to his chest wall 24
  25. 25. Cont… 2/7/2023 25
  26. 26. Fracture of fore arm and wrist 2/7/2023  The two bones of the fore arm (ulna and radius) may be fractured individually or together.  26
  27. 27. First aid measures 2/7/2023  Fractures in the mid portion of the fore arm and wrist are treated in the same way as fractures of the shaft of the humerus. 27
  28. 28. Flail Chest 28  Flail Chest  Direct injury to the chest resulting in an unstable segment of the chest wall that moves separately from remainder of thoracic cage  Typically results from two or more fractures on 2 or more ribs  Typically accompanied by a pulmonary contusion  Physical exam = paradoxical movement of chest segment  Treatment = improve abnormalities in gas exchange  Early intubation for patients with respiratory distress  Avoidance of overaggressive fluid resuscitation
  29. 29. CONT…  Segment of chest wall that don’t have bony continuity with the rest of thoracic cage .  Associated multiple rib fracture Clinical manifestation  Disrupts normal chest movement .  Paradoxical chest movement during breathing and pulmonary contusion are common.
  30. 30. CONT.  Palpation- creptus (rib/cartilage fracture) , uncoordinated respiratory motion  Diagnosis :- CXR- multiple rib fracture - ABG- respiratory failure with hypoxia  Management – Initial – adequate ventilation -administration of humidified air  -fluid resuscitation for hypotension(careful monitoring of fluid is mandatory-CVP)
  31. 31. Bulky Dressing for splint of Flail Chest  Use Trauma bandage and Triangular Bandages to splint ribs.  Can also place a bag of D5W on area and tape down
  32. 32. Fracture of the upper leg 2/7/2023  Fractures of the shaft of the femur usually result from falls or traffic injuries.  The victim is in severe pain and shock and markedly disabled.  The foot is characteristically turned outward and the limb shortened owing to overlapping of the bone ends due to muscular spasm. 32
  33. 33. 2/7/2023 33
  34. 34. First aid measures 2/7/2023  If the victim is to be transported only for short distance on a stretcher, place a blanket between the legs and bind them together.  To apply the board splint, assemble needed supplies.  If you use improvised board splints, they should be well padded and should reach from the victim’s armpit on the outer side and groin or the inner side to below his heel 34
  35. 35. Cont… 2/7/2023  The bandages will be tied on the following areas: just below the arm pit, at the abdomen, at the hip, above and below the fracture site, at the lower leg and ankle and foot with figure of eight bandage  Don’t try to cleanse open wound (if present).  If possible apply a traction splint for the fracture of the shaft of the femur. 35
  36. 36. Fracture of the kneecap (Patella 2/7/2023  The patella is in front of the knee Joint.  It is fractured usually by direct injuries sustained when control of the knee is lost, with the front thigh muscles pulling violently on the kneecap. 36
  37. 37. First aid measures 2/7/2023 Apply a pillow splint about the knee or padded splints from below the victim’s heel to his buttocks along the back of the leg, with the leg extended. Raise the leg slightly to prevent swelling. Send to hospital or a health center. 37
  38. 38. Fracture of the lower leg 2/7/2023  The bones of the lower leg are the tibia (shinbone), which supports the weight of the body and the fibula, which forms the outside wall of the ankle and is on the outer side of the leg. 38
  39. 39. Fracture of ankle and foot 2/7/2023  The ankle is made up of the lower ends of the tibia and fibula and the first bone of the foot (the talus). Fractures in this area occur most commonly in active sports, in falls, and in motor vehicle accident. 39
  40. 40. First aid measures 2/7/2023 Loosen or remove the victim’s shoes, and hose (socks) and keep him lying down with his leg elevated.  For an open wound apply large bulky dressings. 40
  41. 41. 2/7/2023 41
  42. 42. General Rx cont’d… 2/7/2023 All limb injuries are treated in the same way in the field. A..Fix ABC problems first; Administer anti pain B. Cover open wounds with dry, sterile dressings. C. Apply firm but gentle pressure to control bleeding, if necessary. D. Apply a cold pack to painful, swollen, or deformed extremities. E. Splint the injured limb and immobilize it. F. Immoblization prevents displacement of reduced Fx, reduce pain. 42
  43. 43. Splinting 2/7/2023  All limb injuries should be splinted before the patient is moved, unless the environment prevents effective splinting or threatens the pt’s life. Purpose:  prevents the movement of broken bone ends, a dislocated joint, or damaged soft tissues, thereby reducing pain.  Controls bleeding and decreases the risk of additional damage.  Prevents closed fractures from becoming open fractures during movement or transport. 43
  44. 44. General principles of splinting 2/7/2023 1. Note and record PMS distal to the point of injury, both before and after splinting. 2. Cover all open wounds with a dry, sterile dressing before applying the splint. 3. Do not move the patient before splinting, unless there is an immediate danger to the patient or the EMR. 4. Immobilize the joint above and the joint below the injury site 5. Splint the limb without moving it unnecessarily. 6. When in doubt, splint. 44
  45. 45. Materials used for splinting 1. Rigid splints  Are made from firm material ; are applied to the sides, front, or back of an injured extremity.  Common types of rigid splints include: Padded board splints, Molded plastic or aluminum splints .Padded wire ladder splints, Folded cardboard splints 2. Air splint  After it is applied, the splint is inflated.  comfortable for the patient and provides uniform pressure to a bleeding wound. 3. Iprovised 2/7/2023 45
  46. 46. Open or compound fracture 2/7/2023 - This is a fracture in which the fracture hematoma communicates with skin or mucous membrane. - Infection is the most feared complication. - may cause delayed healing, non union, sepsis or even death. - It is a surgical emergency. 46
  47. 47. Open or compound fracture….. 2/7/2023 Principles of management: 1. Early wound debridement & thorough irrigation with saline. 2. Broad Antibiotics & Tetanus prophylaxis 3. Rigid immobilization with access to the wound 4. Delayed wound closure! Never close a compound fracture immediately in an attempt to convert it to a closed one. You’ll cause a severe anaerobic infection! 47
  48. 48. Orthopedic consultation in the ED 2/7/2023  In many cases, such as fracture of the hip, the need for hospital admission and/or orthopedic consultation in the ED.  In some situations, however, differences of opinion may exist regarding whether the patient needs to be seen by an orthopedist in the ED.  Even patients with injuries that ultimately may require surgical repair, such as an unstable ankle fracture, sometimes may be immobilized and discharged with a referral for prompt orthopedic follow-up. 48
  49. 49. Complications of Fractures 2/7/2023 I- Soft tissue Injuries  Arteries, Nerves and Viscera may be injured II- Compartment syndrome  Is a dangerously increased pressure within the enclosed fascial compartments of extremities. 49
  50. 50. Complications of Fractures… 2/7/2023 III- Infection - Usually complicates open fractures - Chronic osteomyelitis may be resulted. - Cleaning and adequate debridement is the most critical factor in preventing infection. 50
  51. 51. Cont… 2/7/2023  The high compartmental pressure causes Ischemia and necrosis of soft tissues in the compartment.  Common to especially fore arm and leg.  Severe pain, especially with passive flexion of fingers is the earliest indicator.  4Ps - Paresthesia, Paralysis, Pallor or Pulselessness may develop later. 51
  52. 52. Dislocation 2/7/2023  A dislocation is a displacement of a bone end from the joint particularly at the shoulder, elbow, fingers or thumb usually as a result of a fall or a direct blow.  Unless proper care is given, a dislocation may occur repeatedly. 52
  53. 53. Signs and symptoms of dislocation 2/7/2023  Swelling.  Obvious deformity.  Pain upon movement.  Tenderness to touch.  Discoloration. 53
  54. 54. First aid measures 2/7/2023  First aid should be essentially the same as for closed fractures.  Splint and immobilize the affected joint in the position in which it was found.  Apply a sling if appropriate.  Elevate the affected part if a limb is involved.  Seek medical attention promptly.  Never attempt to reduce a dislocation. 54
  55. 55. Sprain 2/7/2023  A sprain is an injury to a joint, ligament or muscle and tendon in the region of a joint.  It occurs usually as result of forcing a limb beyond the normal range of movement. The ankles, fingers, wrists and knees are most often sprained. 55
  56. 56. Signs and symptoms of sprain 2/7/2023  Swelling  Tenderness  Pain upon motion  Discoloration  It might be difficult to differentiate a sprain from a closed fracture with out an X-ray. 56
  57. 57. First aid measures 2/7/2023  If the victim’s ankle or knee is affected, do not allow him to walk.  Loosen or remove the victim’s shoes, apply a pillow or blanket, splint and elevate the victim’s leg to prevent swelling .  Keep the injured part raised for at least 24 hours.  Apply cold wet pad or place a small bag of crushed ice on the affected area over a towel intermittently, to protect the victim’s skin.  If swelling and pain persist, seek medical attention. 57
  58. 58. Strain 2/7/2023  Strains are injuries to muscle resulting from over stretching.  Commonly strains occur on the back muscles, due to improper lifting technique.  To avoid back strain when a heavy object must be lifted, observe the following precaution.  Place the feet close to the object firmly and apart.  Lift slowly, pushing up with the strong thigh and leg muscles are bearing the weight.  58
  59. 59. First aid measures 2/7/2023  Bed rest, heat and use of a board under the mattress for firm support are recommended for person with a strained back  Cool the area by applying an ice pack or cold compress for the first 24 hours.  After 24 hours, apply heat, warm, wet and rest care.  Seek medical care; (severe back strains should be seen by a physician). 59
  60. 60. Prevention of accidents resulting in skeletal and muscular injuries 2/7/2023 The following discussion on prevention will limit it self to additional consideration regarding motor vehicle accidents:  Motor vehicle accident prevention  What follows is intended to provide a basis for discussion of the over all high way accident.  Driving skill, judgment and condition of driver  Vehicle condition  Environmental conditions and Pedestrian safety 60
  61. 61. Falling accidents 2/7/2023 Falls are the second leading cause of accidental death.  Ranking behind motor vehicle fatalities and a head of fire and burn fatalities.  The reader should further develop his/ her understanding regarding the following types of accidents by referring standard references.  Slipping and Tripping (Slight Walking) Hazards  Climbing and Reaching  Special Precautions  Joint and Muscle Tissue Injury Prevention 61
  62. 62. Summary 2/7/2023  Evaluation of orthopedic injuries is the cornerstone of the patients that used to identifying and treating orthopedic urgencies and emergencies.  Initial evaluation is crucial and critical to minimizing morbidity and mortality.  Immobilization is necessary for an orthopedic injury to heal properly. Injured bones, ligaments, tendons, and more will incur further damage if the affected areas aren't immobilized.  Keeping the area from moving also helps reduce pain. 62
  63. 63. References 2/7/2023 1.Tintinalli’s Emergency Medicine, A Comprehensive Study Guide Ninth Edition page number 1767. 2.Annual Update in Intensive Care and Emergency Medicine ISBN 9783030060664 ISBN 9783030060671 (eBook) https://doi.org/10.1007/9783030060671 3. Advanced Trauma Life Support ATLS Ninth Edition 63
  64. 64. 2/7/2023 64