Prehospital Academy Lesson 36.1
Trauma: Orthopedic Injuries Overview
This lesson covers the assessment and management of orthopedic injuries, a common call type in prehospital emergency medicine. While often not life-threatening, musculoskeletal injuries can be limb-threatening and cause significant pain and long-term disability. Understanding the anatomy, identifying the type of injury, and applying appropriate splinting techniques are core skills for the EMT.
Anatomy of the Musculoskeletal System
The musculoskeletal system provides form, upright posture, and movement to the body. It also protects vital internal organs.
Bones: Hard tissue that forms the skeleton. There are 206 bones in the adult human body.
Joints: Places where bones meet. They can be immovable (skull sutures), slightly movable (spine), or freely movable (knees, elbows).
Cartilage: Flexible connective tissue found at joints, providing cushioning and reducing friction.
Muscles: Tissues that contract to produce movement.
Skeletal Muscle: Voluntary muscle attached to bones (e.g., biceps).
Smooth Muscle: Involuntary muscle found in walls of hollow organs (e.g., intestines, blood vessels).
Cardiac Muscle: Involuntary muscle found only in the heart.
Tendons: Connect muscle to bone.
Ligaments: Connect bone to bone, providing stability to joints.
Types of Orthopedic Injuries
Mechanisms of injury often include direct force, indirect force (energy transmitted along the bone), and twisting forces.
Fracture: A break in the continuity of a bone.
Open (Compound): Overlying skin is broken; high risk of infection.
Closed (Simple): Overlying skin remains intact.
Comminuted: Bone is broken into more than two fragments.
Greenstick: Incomplete fracture, common in children.
Dislocation: Disruption of a joint where ligaments are damaged and bone ends are no longer in contact. Often involves noticeable deformity.
Sprain: Injury to ligaments (stretching or tearing) surrounding a joint.
Strain: Injury to a muscle or tendon (stretching or tearing), often called a "muscle pull."
Assessment of Orthopedic Injuries
Assessment focuses on identifying life threats first, then the limb injury.
Primary Assessment: Rule out life-threatening bleeding or other trauma.
Inspection: Look for deformity (angulation, shortening, rotation), swelling, bruising (ecchymosis), and open wounds.
Palpation: Feel for point tenderness, crepitus (grating sensation), and instability.
Neurovascular Status (CSM/PMS): This is critical before and after splinting.
Circulation: Check distal pulses and capillary refill.
Sensation: Can the patient feel touch in the distal extremity?
Motor: Can the patient move their fingers or toes?
Compartment Syndrome
A limb-threatening condition where increased pressure within a confined space (compartment) restricts blood flow and damages muscle and nerve tissue.
Signs (The 5 Ps): Pain (out of proportion to injury), Pallor, Paresthesia (pins and needles), Pulselessness (late sign), Paralysis (late sign).
Management: Rapid transport is essential; this is a surgical emergency.
General Management and Splinting
The goal of prehospital care is to stabilize the injury, reduce pain, and prevent further damage.
Manual Stabilization: Support the injured limb immediately to prevent movement.
Expose the Area: Remove clothing to visualize the injury.
Check CSM/PMS: Verify neurovascular function before applying a splint.
Splinting: Immobilize the joint above and the joint below a long bone injury; immobilize the bone above and the bone below a joint injury.
Rigid Splints: Board splints, cardboard.
Formable Splints: SAM splints, vacuum splints, air splints.
Traction Splints: Specifically for isolated mid-shaft femur fractures.
Re-check CSM/PMS: Verify function after splinting. If pulses are lost, gently loosen or reposition.
Pain Management: RICE (Rest, Ice, Compression, Elevation) and pharmacological interventions if within scope.
Note on Realignment: Generally, splint in the position found. However, if a long bone is severely angulated and the limb is pulseless, you may attempt to gently realign it once to restore circulation (follow local protocols).
Critical Thinking Questions
You encounter a patient with a deformed lower leg and no distal pulse. What is your immediate course of action regarding the deformity?
Why is it crucial to check CSM/PMS before and after splinting?
Explain the concept of compartment syndrome. Why is "pain out of proportion to the injury" a key warning sign?
What are the specific indications and contraindications for using a traction splint?
Differentiate between a sprain and a strain in terms of the anatomical structures involved.