EMS World

AUG 2011

EMS World Magazine is the most authoritative source in the world for clinical and educational material designed to improve the delivery of prehospital emergency medical care.

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Page 61 of 71

ORTHOPEDIC TRAUMA ,QGLUHFW IRUFH 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. 'LUHFW IRUFH 6HYHUH WZLVWLQJ IRUFH Assessment Findings MECHANISM OF INJURY Mechanism of injury will play a critical Figure 2: Three basic mechanisms of orthopedic injury. 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, circula- tion in the distal parts of the limb may be compromised. In this case, tissues down- stream 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, 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 typi- cally 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 inju- 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 prescrip- tions? 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 58 AUGUST 2011 | EMSWORLD.com ries, force strikes one area and is trans- ferred 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 ortho- pedic injury may be dramatic to look at, the more severe and life-threatening injury may be subtle. Always assess and treat airway, breathing, and circulation before committing to the care of ortho- pedic 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 frac- ture 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 poten- tial 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

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