Fracture Management

Refresher 2003Refresher 2003

Common Outdoor Common Outdoor Injury ManagementInjury Management

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Refresher 2003Refresher 2003

Common Outdoor Common Outdoor Injury ManagementInjury Management

ObjectivesObjectives Review mechanisms and patterns Review mechanisms and patterns

of traumatic injuryof traumatic injury Illustrate the types of injury that Illustrate the types of injury that

occur to the skeleton, soft tissue, occur to the skeleton, soft tissue, and skeletal support structuresand skeletal support structures

Explain the general principles of Explain the general principles of wound care and the emergency wound care and the emergency care for musculoskeletal injuriescare for musculoskeletal injuries

Mechanism of InjuryMechanism of Injury

Mechanism of InjuryMechanism of InjuryTypes of TraumaTypes of Trauma

Penetrating TraumaPenetrating Trauma Compression (Blunt) Compression (Blunt) TraumaTrauma

Bending TraumaBending Trauma

HyperflexionHyperflexion

HyperextensionHyperextension

Nail in Index FingerNail in Index Finger

Bending TraumaBending TraumaHyperflexionHyperflexionHyperextensionHyperextension

Severe Contusion of FootSevere Contusion of Foot

CervicalCervical(C5-C6) (C5-C6) Fracture Fracture

DislocatioDislocationn

Dorsal Dorsal DislocationDislocation

, Long , Long Finger Finger Middle Middle JointJoint

(PIP Joint)(PIP Joint)

Rotational TraumaRotational Trauma Distraction TraumaDistraction Trauma Crush TraumaCrush Trauma Deceleration TraumaDeceleration Trauma Acceleration TraumaAcceleration Trauma

Normal Normal Tibia Tibia Left Left

SpiralSpiral

FractureFracture

Tibia Tibia

RightRight

Dislocation of Right Dislocation of Right ShoulderShoulder

Train Crush Injury, LegTrain Crush Injury, Leg

Deceleration TraumaDeceleration Trauma

Car struck from behind Car struck from behind “accelerates” passengers, “accelerates” passengers,

producing an extension injury producing an extension injury to the neck!to the neck!

Acceleration Acceleration TraumaTrauma

Mechanism of InjuryMechanism of InjuryTypes of ForceTypes of Force

Direct ForceDirect Force Indirect ForceIndirect Force Twisting ForceTwisting Force High Energy ForceHigh Energy Force

DirectDirectMid-Shaft Fracture, Mid-Shaft Fracture,

FemurFemur

IndirectIndirectPosterior Dislocation, Posterior Dislocation,

ElbowElbow

TwistingTwistingSubtalar Dislocation, Subtalar Dislocation,

AnkleAnkle

High EnergyHigh EnergyFractured PelvisFractured Pelvis

Types of InjuryTypes of Injury

Types of InjuryTypes of InjuryFractureFracture

• Any break in the Any break in the continuity of a bonecontinuity of a bone

• May vary from a simple May vary from a simple crack to a completely crack to a completely

shattered boneshattered bone

Fracture ClassificationFracture Classification

Closed/OpenClosed/Open

Incomplete/CompleteIncomplete/Complete

Non-Displaced/DisplacedNon-Displaced/Displaced

Closed Fracture,Closed Fracture,

Base of ThumbBase of Thumb ClosedClosed

Dorsally Dorsally Angulated Angulated

Forearm FractureForearm Fracture

Open Fracture, TibiaOpen Fracture, Tibia

Open Fracture, ForearmOpen Fracture, Forearm

Open Fractures Are Open Fractures Are More Serious!More Serious!

Blood lossBlood loss

Potential contamination Potential contamination with risk of infectionwith risk of infection

Displaced/DisplacedDisplaced/Displaced

Incomplete Fracture, Incomplete Fracture, Distal RadiusDistal Radius

Complete Fracture, Complete Fracture, FemurFemur

Non-Displaced/DisplacedNon-Displaced/Displaced

Non-Displaced Fracture, Non-Displaced Fracture, Distal Tibia and FibulaDistal Tibia and Fibula

Displaced Forearm Displaced Forearm FracturesFractures

Other Types of FractureOther Types of FractureComminuted – fractured into Comminuted – fractured into more than two segmentsmore than two segments

Pathologic – fracture Pathologic – fracture through diseased bonethrough diseased bone

Epiphyseal – fracture passes Epiphyseal – fracture passes through the growth platethrough the growth plate

Comminuted Femur Comminuted Femur FractureFracture

Other Types of Fracture

Comminuted – fractured into more than two segments

Pathologic – fracture through diseased bone

Epiphyseal – fracture passes through the growth plate

PathologicPathologicLytic lesion (darker = Lytic lesion (darker =

tumor) in proximal phalanx tumor) in proximal phalanx of finger, with associated of finger, with associated

transverse fracturetransverse fracture

Other Types of Fracture

Comminuted – fractured into many pieces

Pathologic – fracture through diseased bone

Epiphyseal – fracture through the growth plate

Epiphyseal (growth-line) Epiphyseal (growth-line) Fracture, Fracture,

Distal Femur Distal Femur

Signs of a FractureSigns of a Fracture

TendernessTenderness Swelling and EcchymosisSwelling and Ecchymosis DeformityDeformity CrepitusCrepitus Exposed FragmentsExposed Fragments False MotionFalse Motion Inability to Use the LimbInability to Use the Limb

Seven Seven Signs of FractureSigns of Fracture TendernessTenderness Swelling and EcchymosisSwelling and Ecchymosis DeformityDeformity CrepitusCrepitus Exposed FragmentsExposed Fragments False MotionFalse Motion Inability to Use the LimbInability to Use the Limb

Fractured PatellaFractured Patella

AngulatedAngulated Fracture, Fracture, Radius and UlnaRadius and Ulna

Seven Seven Signs of FractureSigns of Fracture

CrepitusCrepitus

In a complete fracture, In a complete fracture, the the sounds of bone ends clicking sounds of bone ends clicking

or rubbing against each other;or rubbing against each other; denotes an unstable fracture!denotes an unstable fracture!

Seven Seven Signs of FractureSigns of Fracture

Open Ankle FractureOpen Ankle Fracture

False MotionFalse MotionThe unusual visual The unusual visual

sensation of observing sensation of observing motion at a long bone motion at a long bone fracture site wherefracture site where

““there is no joint!” there is no joint!”

Fracture, Right Clavicle Fracture, Right Clavicle Right Arm ProtectedRight Arm Protected

Seven Signs of Seven Signs of FractureFracture

The presence of The presence of

any oneany one

of the of the

seven fracture signs just listed seven fracture signs just listed

is sufficient to assess this injury!is sufficient to assess this injury!

Types of Injury Types of Injury DislocationDislocation

Disruption of a joint such Disruption of a joint such that the bone ends are no that the bone ends are no longer in normal contactlonger in normal contact

Must have torn ligaments Must have torn ligaments and joint capsuleand joint capsule

Signs of DislocationSigns of Dislocation

TendernessTenderness Deformity (usually Deformity (usually

marked)marked) Swelling and EcchymosisSwelling and Ecchymosis Loss of normal joint Loss of normal joint

motionmotion

Common DislocationsCommon Dislocations

ShoulderShoulder FingerFinger HipHip ElbowElbow

Anterior Dislocation, Right Anterior Dislocation, Right ShoulderShoulder

Dislocation, Middle Joint Dislocation, Middle Joint (PIP Joint), Ring Finger(PIP Joint), Ring Finger

Posterior Hip DislocationPosterior Hip Dislocation

Posterior Elbow DislocationPosterior Elbow Dislocation

Types of InjuryTypes of Injury Fracture-DislocationFracture-Dislocation

A combined injury with A combined injury with joint dislocation and an joint dislocation and an adjacent bone fractureadjacent bone fracture

Fracture–Dislocation, AnkleFracture–Dislocation, Ankle

Types of Injury Types of Injury SprainSprain

Partial or completePartial or completetemporarytemporary joint dislocationjoint dislocation

Ligaments are torn Ligaments are torn partially or completelypartially or completely

May produce as much May produce as much structural damage as a structural damage as a

dislocationdislocation

Sprain, Left AnkleSprain, Left Ankle

Types of InjuryTypes of InjuryStrainStrain

““Muscle Pull”Muscle Pull” Stretching or Stretching or

tearing of muscle, tearing of muscle, or muscle fascia or muscle fascia (covering)(covering)

Occurs frequently Occurs frequently in the lower back in the lower back secondary to poor secondary to poor posture and poor posture and poor abdominal muscle abdominal muscle controlcontrol

Assessing Assessing Musculoskeletal Musculoskeletal

InjuriesInjuries MOI on ApproachMOI on Approach ABC’sABC’s Injury History (“What Injury History (“What

happened?”)happened?”) Palpation of injury site --Palpation of injury site --

“ “Take one finger and Take one finger and show me where it hurts!” show me where it hurts!”

DCAP-BTLSDCAP-BTLS DDeformitieseformities CContusionsontusions AAbrasionsbrasions PPuncture Woundsuncture Wounds BBurnsurns TTendernessenderness LLacerationsacerations SSwellingwelling

Evaluation of Distal Evaluation of Distal Neurovascular FunctionNeurovascular Function

(CMS)(CMS)

Pulse (circulation)Pulse (circulation) Motor FunctionMotor Function SensationSensation

Radial Pulse Posterior Radial Pulse Posterior Tibial Tibial PulsePulse

(CMS)(CMS)

Extension Extension FlexionFlexion

Ankle Dorsiflexion Ankle Plantar Ankle Dorsiflexion Ankle Plantar FlexionFlexion

(CMS)(CMS)

Medial and Medial Foot Medial and Medial Foot Lateral FootLateral FootLateral HandLateral Hand

Principles of Principles of Musculoskeletal Injury Musculoskeletal Injury

ManagementManagement ABC’sABC’s Evaluate distal neurovascularEvaluate distal neurovascular

functionfunction Dress all woundsDress all wounds Splint all suspected injuriesSplint all suspected injuries Prepare patient for transportPrepare patient for transport

Injury ManagementInjury Management

All All

open woundsopen wounds

should be covered with a should be covered with a

dry sterile compression dry sterile compression dressingdressing

Injury ManagementInjury ManagementSplinting Immobilizes Splinting Immobilizes

the Injury and:the Injury and: Reduces PainReduces Pain Facilitates TransportFacilitates Transport Prevents further damage Prevents further damage

totoblood vessels, nerves andblood vessels, nerves andskin adjacent to the injuryskin adjacent to the injury

Decreases BleedingDecreases Bleeding

Principles of SplintingPrinciples of Splinting Check and record CMS Check and record CMS Dress all woundsDress all wounds Immobilize the joints above Immobilize the joints above

and below a suspected and below a suspected fracturefracture

With injuries at or near joints, With injuries at or near joints, immobilize the bones above immobilize the bones above and below the injuryand below the injury

Stabilize the injury site during Stabilize the injury site during splint application splint application

Principles of SplintingPrinciples of Splinting

Use gentle in-line manual traction Use gentle in-line manual traction to realign displaced long bone to realign displaced long bone fracturesfractures

Expect to encounter increased Expect to encounter increased pain and some resistance when pain and some resistance when attempting to realign a deformed attempting to realign a deformed limblimb

Immobilize all suspected spinal Immobilize all suspected spinal injuries injuries in a neutral in-line in a neutral in-line positionposition on a spineboard on a spineboard

Principles of SplintingPrinciples of Splinting

If the patient demonstrates If the patient demonstrates major signs of shock, align the major signs of shock, align the limb as close to its normal limb as close to its normal anatomic alignment as possible anatomic alignment as possible on a spineboard (immobilization on a spineboard (immobilization of total body), and provide of total body), and provide rapidrapid transport transport

Total Body Total Body ImmobilizationImmobilization

When in doubt:When in doubt:

SPLINT!SPLINT!

Rigid SplintsRigid Splints Quick Splint Cardboard Quick Splint Cardboard SplintSplint

Ladder Splint SAM Ladder Splint SAM SplintSplint

Soft SplintsSoft Splints Air Splint Vacuum Air Splint Vacuum SplintSplint

Sling and Swathe Blanket Sling and Swathe Blanket RollRoll

Traction SplintTraction Splint

When standard splints When standard splints are unavailable, are unavailable, improvisation improvisation

is better than doing is better than doing nothing!nothing!

UPPER UPPER EXTREMITYEXTREMITY

All fractures All fractures can be can be

immobilized immobilized by securing by securing

the extremity the extremity to the chest!to the chest!

LOWER EXTREMITYLOWER EXTREMITYAll fractures can be immobilized by All fractures can be immobilized by

securing the injured extremity to securing the injured extremity to the opposite lower extremity!the opposite lower extremity!

The EndThe End

Fracture Management

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