Principles of Orthopaedic Care

Gordon H. Stock, MDOrthopaedic Surgeon, Central Utah Clinic

Objectives

• Describe differences in Orthopaedic injuries– Fractures, dislocations, subluxations

• Describe fractures using current medical definitions

• Understand physiology of Orthopaedic injuries

• Understand proper Orthopaedic assessment

• Understand proper treatment of Orthopaedic injuries

• Identify injuries most likely to cause hemodynamic instability

• Identify simple orthopaedic injuries from radiographic images

Objectives

• Understand the burden of Orthopaedic injuries on Society

• Briefly review fracture classifications & definitions

• Review Tscherne and Gustilo grading system for open injuries

• Review Salter-Harris Classification

• Review treatment modalities for Orthopaedic injuries

• Review critical injuries that can be seen during transport of orthopaedic injuries

EMS Considerations

• Isolated orthopaedic injuries are rarely fatal

• However, Multiple injuries & associated blood loss can be life threatening

• Knowledge of orthopaedic injures and proper care of these injuries will allow greater patient comfort and minimize long term disability

75yo F Tripped Over a Chair

After Total Hip Replacement

Burden to Society

• Orthopaedic Injuries• Pediatric• Elderly Falls

– Of those that fall 20-30% moderate to severe injuries• Hip fractures• Head trauma• Vertebrae, hip, wrist, ankle, pelvis, proximal humerus

– 3-5% of falls result in fracture– Total cost for falls >65 years of age

• 1994 $20.2 billion• 2020 $32.4 billion (estimated)

Function of Bones

• Structure & Movement

• Bone marrow: produce RBC

• Protection

Definitions

• Fracture– Any break in bone (complete or incomplete)

• Dislocation– Complete dissociation of a bone from it’s normal

position in a joint

– Associated with fracture and soft tissue injury

• Subluxation– Partial or incomplete dislocation

– Typically soft tissue injury

Definitions

• Open (Compound)

• Closed (Simple)

• Complete

• Incomplete

• Displaced

• Non-displaced

• Greenstick

• Comminuted

• Segmental

• Butterfly

• Spiral

• Oblique

• Transverse

• Hairline

• Occult

• Epiphyseal

• Fatigue (Stress Fracture)

• Impacted

47 yo M, 4-Wheeler Rollover

13yo M Skateboarding

Post Reduction

Problems associated with Epiphyseal (Growth Plate) Fractures

Tscherne Method for grading Closed Fractures

Gustilo Classification for Open Fractures

Assessment of Skeletal System

• Airway

• Breathing

• Circulation

• Skeletal Assessment

– Observation

– Palpation

– Functional testing

Assessment of Skeletal System

• Acute deformity– Fracture or dislocation until proven otherwise

– To reduce or Not to reduce?

• Laceration over deformity– Open fracture until proven otherwise

• Hemodynamic Instability– Intra-abdominal

– Intrathoracic

– Fractures

Assessment of the Skeletal System

• History

• Physical Exam

• X-ray

• CT scan

• MRI

Treatment

• Splint

• Casting

• Reduction/Realignment– Where

– When

– Whom

• External Fixation

• Internal Fixation

• Amputation

Treatment

Treatment: Splints

Critical Orthopaedic Fractures

• Pelvic Fractures

– Massive blood loss potential (>2000ml)

– Treatment: Sheet wrap, SAM splint

Critical Orthopaedic Fractures

• Femur Fractures

– Longest bone in body

– Not easily fractured

– Often associated with other injuries

– Blood loss potential (1500ml per femur)

– Treatment: Splinting

Critical Orthopaedic Fractures• Hip Fractures

– Intracapsular Femoral Neck• Subcapital• Transcervical• Basicervical

– Extracapsular• Intertrochanteric• Trochanteric• Subtrochanteric

• Treatment– Internal fixation– Hip Replacement

• Total• Partial

– Early Ambulation

Critical Orthopaedic Fractures

• Vertebral Fractures– Potentially Catastrophic

• Permanent disability

• Death

– Expensive Societal burden• Individual spinal injury can reach >$1 million lifetime

– Recognition is critical

• Cervical Spine

• Thoracic Spine

• Lumbar Spine

Critical Orthopaedic Fractures

• Humerus Fractures

– Blood loss (750ml per humerus)

– Splinting

– Treatment

• Rib Fractures

– Rib cage protects thoracic cavity

– Pulmonary compromise: pneumothorax

– 1st rib fracture: 30% risk of aortic injury

Critical Orthopaedic Fractures

• Femur Fractures

– Longest bone in body

– Not easily fractured

– Often associated with other injuries

– Blood loss potential (1500ml per femur)

– Treatment: Splinting

Critical Orthopaedic Injuries

• Amputation

– Eye catching

– Life over limb

– ABC’s

– Treatment• Stop further bleeding

• Rinse amputated part with saline

• Bandage moist gauze

• Place in plastic bag

• Place in container with ice

Critical Orthopaedic Injuries

• Pulseless extremity– Reduce/realign extremity

– Local protocols vary

– Discuss with ED physician

• Compartment Syndrome– 6 P’s

– Pain, pallor, paralysis, pulselessness, pressure, paresthesia

– Catastrophic if left untreated

– Treatment: facsiotomy

Orthopaedic Pharmacology

• NSAIDs

• Opiates

• Antibiotics

• Muscle relaxants

• Anticoagulants

76 yo tripped at home, Temazepam

Questions

References

• Principles of Orthopaedic Care. Chapter 19, Critical Care Paramedic. Brosius JR, Bledson BE

THANK YOU!