Brady is pleased to share a preview of its forthcoming EMS Transition Series. The first offering is for the EMT level. Transition Series: Topics for the EMT by Joseph Mistovich and Daniel Limmer provides both an overview of new information contained within the National EMS Education Standards at the EMT level and a source of continuing education for practicing EMTs. Intended for a new generation of EMTs, the text integrates new “topics” that were not contained in the U.S. DOT 1994 EMT-Basic National Standard Curriculum and existing “topics” at a much greater depth and breadth than what was contained in the typical EMT-Basic education program. During 2011, EMS World Magazine will feature exclusive excerpts from this new textbook. Visit www.bradybooks.com for more information.
"No one ever died from a broken bone" is an inaccurate myth sometimes heard among circles of less-informed health care providers. It is true that orthopedic trauma is often classified as a lower priority than airway and breathing, and it is true that a broad spectrum of potential musculoskeletal injuries ranges from severe to minor; however, to universally consider orthopedic trauma to be insignificant or benign in nature is a very serious mistake.
Broken bones have killed. Furthermore, the immediate treatment of orthopedic injuries can play a major role not just in life or death but also in the overall impact of the injury on the patient. The assessment and proper prehospital treatment you provide play a direct role in the outcome of the injury.
According to the U.S. Centers for Disease Control and Prevention, traumatic injuries are the leading cause of death for people under the age of 44; each year, roughly 1 in 10 people will visit an emergency room to seek treatment for a traumatic injury. The tragic loss of life, loss of productivity, and the enormous cost of rehabilitation place a tremendous burden on the health care system.
On a personal level, orthopedic injuries are a major life-changing event for many of our patients. Aside from being potentially life-threatening injuries, musculoskeletal trauma may also threaten patients’ well-being, psychological health, and general independence.
Often, care of orthopedic trauma is mistakenly delegated to a lower priority. Although there certainly may be higher priorities of care in a trauma patient, appropriate treatment of a musculoskeletal injury may significantly affect the severity of the injury and, in general, improve the overall outcome of the patient.
The adult body contains 206 bones. These bones are connected to each other by ligaments and articulated with muscles and tendons. Together these bones and connective tissues form the musculoskeletal system. Before we consider what can go wrong, we should first consider the basic functions of the musculoskeletal system. Bone, muscle, and connective tissue work together to provide the body with five basic functions:
Giving the body shape
Protection of important structures
Creation of red blood cells
Storage of key minerals the body uses for metabolism.
When we consider orthopedic injuries, we need to think about how injuries affect these basic functions. In addition, when considering injuries, we should examine how the musculoskeletal system works in concert with other body systems. For example, most long bones are anatomically located next to very large blood vessels (arteries and veins) and nerves. Therefore, an injury to such a bone may, in fact, have an impact on the circulation of blood as well. With those factors in mind, let us now consider damage to the musculoskeletal system.
The most obvious injury to the musculoskeletal system is the fracture. In this case, bone is actually broken. A fracture can physically displace bones, as in an angulated fracture, or simply crack the bone, as in a greenstick fracture. Major concerns regarding fractures fall back to the musculoskeletal system function. Examples of this include loss of mobility (Did the fracture hinder movement associated with a particular bone, as it usually does?), loss of protection (Did the force that broke the bone also damage underlying organs?), and impact on associated systems (Did the fracture damage proximal blood vessels and or nerve tissue?).
In addition to fractures, connective tissue can be damaged in the form of strains and sprains. Generally, these injuries occur when movement of a joint exceeds the normal range of motion. Excessive motion can stretch and tear tendons and ligaments. Again, assessment of the injury must consider function. Sprains and strains are typically limited to disruption of movement and structure but can also have an impact on other systems, such as circulation and nervous function.
A joint can be dislocated when the junction of two or more bones is disrupted. These types of injuries can have a serious impact on structure and movement and can seriously impair blood flow and nervous function.
Life-Threatening Orthopedic Injuries
Most orthopedic injuries are not life threatening. However, certain injuries present an immediate lethal potential. For the most part, these injuries are the ones that directly affect the circulatory system. Fractures of the pelvis—a basin-shaped structure composed of large irregular bones that require tremendous force to fracture—are among the most dangerous orthopedic injuries. Because large blood vessels, such as the iliac arteries, pass through the pelvis, fractures (and the force required to fracture) can result in massive hemorrhage and blood loss.
In addition to adjacent blood vessels, large bones also have their own network of internal circulation that is vulnerable when the bone is fractured (see Figure 1).
Along with the pelvis, the femurs are very susceptible to severe bleeding associated with a fracture. A loss of up to 1.5 liters of blood can be associated with a single fractured femur. This blood loss can be serious in itself, but it would be even more dangerous when it contributes to blood loss from other injuries. If a force is great enough to break a large bone such as the femur, we must always be concerned with potential injuries to other parts of the body.
Always remember that the total blood loss may be made up of a variety of different sources of bleeding. We must consider (and treat) all the causes of blood loss. A fractured femur alone is serious; a fractured femur plus a lacerated liver is deadly.
Some injuries may not be immediately life threatening, yet they may still be considered critical. Although an orthopedic injury may not threaten the life of the patient, it might threaten the viability of a limb.
When fractures displace bones and when dislocations interrupt the joint space, circulation is frequently compromised. If a bone is displaced and impinges a major blood vessel, circulation in the distal parts of the limb may be compromised. In this case, tissues downstream from the site of the fracture will go without perfusion, critical nutrients and oxygen will not be delivered, and waste products will build up. Thus, tissue will rapidly become hypoxic and, without correction, will die.
Part of your assessment must include ensuring distal circulation. Injuries that threaten circulation must be rapidly resolved or the entire limb may be threatened.
Orthopedic Injury: A Life-Changing Event
Even simple, non-life-threatening orthopedic injuries may significantly alter the life of your patient. Consider a simple sprain. This joint injury is likely not to kill the patient, but if he lives alone on the second floor and needs to climb stairs each day to go to work, his lifestyle will be significantly changed. How will he buy groceries? How will he fill his prescriptions? Even this minor injury can have a major impact. Remember that your appropriate immediate treatments may help minimize the patient’s recovery time.
Furthermore, you should consider the emotional impact of such an injury. Although it may be a minor injury to you, this may be a life-changing disaster to the patient. Your empathy might be as important an element of treatment as any splint you carry.
Mechanism of Injury
Mechanism of injury will play a critical role in assessing an orthopedic injury. Many orthopedic injuries will be hidden behind intact skin. As a result, you will need to assess the forces at play in order to predict potential underlying injuries and their severity. Orthopedic injuries are typically the result of direct force, indirect force, or twisting force (see Figure 2).
Direct Force: In direct force injuries, force is transferred by a direct blow to the site of injury. An example of a direct force injury would be a fracture as a result of being hit by a baseball bat. Force is transferred directly from the bat onto the bone and tissue that it strikes.
Indirect Force: In indirect force injuries, force strikes one area and is transferred to an area away from the point of impact. For example, when a person falls from a height and lands on his feet, the force of impact may be transferred up his legs and result in pelvic fractures. The force never directly strikes the pelvis, but the transferred energy still results in a fracture.
Twisting Force: In twisting force, one end of a bone is held in place while the opposite end is turned. An example of this would be a runner stepping into a hole. His foot stays in place, while his leg is thrust forward. The mechanism can result in fractures to the bones of the leg.
Assess these forces when performing the scene size-up. Look not just at the nature of the forces but also at how severely they were applied. Consider factors such as the speed of a crash, height of a fall, and surface of impact.
Assessing Orthopedic Injuries
The primary assessment should always take priority. Although an orthopedic injury may be dramatic to look at, the more severe and life-threatening in-jury may be subtle. Always assess and treat airway, breathing, and circulation before committing to the care of orthopedic injuries.
Fractures may be easy to difficult to identify. In general, you should always err on the side of caution and treat a suspected fracture in the same manner as you would treat an obvious fracture. Fractures may be rapidly identified by deformity, such as displaced bones and unusual angulation.
You may also see bones protruding from the skin, as in an open fracture. Closed fractures (fractures where the overlying skin remains intact) may be more difficult to assess. In these cases, it may be useful to consider the “Six Ps of Assessment”:
1. Pain: Does the patient have pain in the injured area? Is the area sensitive to palpation (pain on palpation), or is the pain increased with movement?
2. Pallor: Is the injured area, or the area distal to the injury, pale, which would indicate compromised circulation?
3. Paresthesia: Does the patient complain of numbness/tingling or pins and needles in the affected extremity? These findings can indicate neurologic compromise.
4. Pulses: Are distal pulses present or lost?
5. Paralysis: Can the patient move the affected extremity?
6. Pressure: Does the patient complain of the sensation of pressure?
Another symptom of a potential fracture is guarding of the injury. In this case, the patient will position himself in such a way that the injured area is protected and immobilized. Consider also edema and crepitus as indicative signs of fracture.
The presence of any of these signs and symptoms would indicate the potential of a fracture. Without X-ray, it is very difficult to differentiate fractures from other soft tissue injuries, such as sprains and strains. Again, it is important to treat all injuries with signs and symptoms of a fracture as if they were, in fact, fractures.
Distal circulation, sensory, and motor (C/S/M) function must always be assessed. Deficits can indicate serious neurovascular compromise and may indicate a limb-threatening injury. Deficits in C/S/M function should be considered a true emergency.
A thorough assessment of an orthopedic injury must also consider the impact on other systems and/or organs. Remember that the force that broke the rib may also have injured the underlying lung. Beware the potential for spinal injury in forces great enough to fracture bones such as the pelvis and femur.
Emergency Medical Care
With most orthopedic injuries, other life-threatening problems need to be treated first. Use a thorough primary assessment to identify critical priorities before moving on to the treatment of orthopedic injuries. As stated previously, some orthopedic injuries in and of themselves may be life threatening. However, shock associated with blood loss from pelvic or femur fractures should be identified when assessing circulation in the primary survey and not based solely on a secondary assessment of an extremity.
After addressing immediate life threats, the basic principles of treating an orthopedic injury include immobilization, application of cold, and elevation. Remember that even in potentially critical orthopedic injuries, the basic application of these principles will generally provide the necessary immediate care that will help maximize outcomes.
A key principle of treating (and transporting) a patient with an orthopedic injury is immobilization. Immobilization prevents jagged bone ends from damaging adjacent soft tissue, nerves, and blood vessels. It helps maintain normal circulation and prevents occlusion of vessels through movement. Immobilization can help slow and stop bleeding associated with a fracture and, finally, immobilization de-creases pain. All these elements help improve both short-term and long-term outcomes of orthopedic injury and, as a result, should be important priorities of prehospital care.
In some cases, immediate treatment of airway and breathing may be your first priority. Remember that even in these cases, minimal immobilization may contribute to improved outcomes. Simply preventing movement is important. In short-term settings, this may mean using manual stabilization or fixation to a long board or another extremity. These simple steps should be considered even when larger priorities redirect your attention.
For example, with a patient with multisystem trauma, you might have an untrained person simply hold an obviously fractured femur in place while you complete your primary assessment. Although this would not be considered proper splinting, that quick manual immobilization might prevent jagged bone ends from damaging soft tissue as the leg moves. It might also help slow bleeding from the fractured area.
In a larger sense, immobilization refers to splinting or the application of a device to limit movement. Splinting can be accomplished with commercial or improvised devices. It is important to be creative when accomplishing the objectives of splinting. Immobilization of fractures and dislocations often requires nontraditional methods.
Key elements of splinting include the following:
Assess C/S/M functions in the distal extremity prior to application of the splint. This assessment not only provides a baseline but will also help you identify changes that might occur as a result of the splinting process.
Remove jewelry and cut away clothing before application of a splint. Edema associated with the injury can rapidly turn these items into constricting bands that limit circulation.
Apply a dressing to open wounds prior to splinting. Often the direct pressure of splinting can aid in bleeding control. Clean dressings will also minimize the threat of infection.
The goal of splinting is to immobilize the joint above and the joint below the injury site. In a joint injury, you should immobilize the bone above and the bone below the injured joint. These goals can be accomplished in a variety of ways. Padded board splints, traction splints, vacuum splints, and air splints can all be used to accomplish the objectives of splinting. Remember to be creative.
Special Splinting Circumstances
Pelvis Fractures: Always consider other internal injuries in association with a pelvic fracture. Typically, massive forces have been applied to cause such an injury. Spinal injuries are common in pelvis fractures; therefore, you should consider using a backboard to immobilize the patient. Various commercially available pelvic binders are available to splint these types of fractures (see Figure 3). Such devices are used to limit lateral movement of an unstable pelvis. You may also consider (when local protocol allows) using a pneumatic anti-shock garment (PASG) to immobilize the pelvis.
Femur Fractures: Recall that femur fractures alone can result in serious bleeding. Splinting not only treats the orthopedic injury but also potentially addresses a circulation problem. As a result, splinting such an injury might be a slightly higher priority than treating other isolated musculoskeletal trauma. When protocol allows, consider using a traction splint (see Figure 4) to immobilize the femur. Applying traction pulls displaced bone ends in line and also helps prevent muscle contraction that can lead to increased bleeding.
Splinting should always be assessed immediately after completion. Check distal C/S/M function. Improper splinting can often result in impaired C/S/M function. Remember also that improper splinting can lead to excessive movement and pressure-related injuries from inadequate padding.
Elevation and Cold
After the injury has been properly splinted, consider elevating it above the level of the heart. In theory, elevation helps decrease edema and minimizes pain. Elevate only if proper immobilization has been achieved first. Elevation without immobilization can actually aggravate an injury by causing excessive movement of displaced bone ends.
Application of cold packs and ice to an orthopedic injury is also thought to limit edema by causing peripheral vasoconstriction. As with elevation, the reduction in edema can help minimize pain. Never apply cold directly to bare skin, as this can cause cold-related injuries such as frostbite. Always wrap the ice or cold pack in a towel or similar cloth prior to application.
Orthopedic Injuries in Special Populations
Anatomical differences in pediatric and geriatric patients require special consideration. Pediatric patients often have less-calcified bones. As a result, their bones are more pliable and flexible. Because of this anatomical difference, true fractures are less common in younger patients than they are in adults. Although children certainly break bones, often more force is required. Furthermore, because children’s bones are flexible, often more internal damage can occur even though the protective bones remain intact. Beware of underlying injuries in children.
In geriatric patients, diseases such as osteoporosis may require an alternative approach to the assessment of mechanism of injury. Decreased bone density, a condition common in elderly patients, can often lead to fractures with minimal force applied. A mechanism of injury that would be unlikely to break the bone of a younger person may indeed result in fractures in a person with a disease such as osteoporosis. Have a higher index of suspicion when evaluating orthopedic injuries in geriatric patients.
Joseph J. Mistovich, MEd, NREMT-P, is chair of the Department of Health Professions and a professor at Youngstown State University in Youngstown, OH. He has more than 25 years of experience as an educator in emergency medical services. He is an author or coauthor of numerous EMS books and journal articles and is a frequent presenter at national and state EMS conferences.
Daniel Limmer, AS, EMT-P, has been involved in EMS for 31 years. He is active as a paramedic with Kennebunk Fire-Rescue in Kennebunk, ME. A passionate educator, Dan teaches basic, advanced and continuing education EMS courses throughout Maine.
Howard A. Werman, MD, FACEP, is professor of emergency medicine at The Ohio State University. He is a teacher of medical students in the College of Medicine and the residency training program in emergency medicine at The Ohio State University Medical Center.