Orthopedic Trauma
Andrea L. Williams, PhD, RNEmergency Education & Trauma Program
SpecialistAssociate Clinical Professor
UWHC & UW-SON
Associated Conditions• Hemorrhage – Shock (~2L pelvis, 1L thigh
& 500 ml tibia)• Instability• Loss of tissue• Laceration with contamination• Interrupted blood supply – Ischemia• Nerve damage• Long-term Disability
Sprains• Partial tear of a ligament by twisting & stretching
of a joint beyond normal ROM– 1st Degree Sprain – No instability, few fibers torn.
Minimal hemorrhage & swelling– 2nd Degree Sprain – No instability, ligaments partally
torn, swelling and hemorrhage– 3rd Degree Sprain – Unstable, ligaments completely,
with significant swelling & hemorrhage.
Strains & Ruptures• Strain - Injury to a muscle or tendon from
overexertion (back, arms, calf)• Severe strains can cause bone avulsion
Joint Dislocations• Dislocation – Articulating surfaces of 2 bones
are displaced– Luxation – Complete dislocation– Subluxation – Incomplete dislocation– Rotator Cuff injuries – Usually deltoid– Common sites
• Shoulders, elbows, fingers, knees, & ankles
– Complications• Posterior popliteal injury
Principles of Splinting (p. 1238)
• Splint joints and fractures above & below injuries• Cover open fractures• Document pulses, sensation, motor function
before & after splinting• Stabilize the limb with gentle in-line traction to a
position of normal alignment• Immobilize dislocations in a position of comfort
with• Ice, cold compresses• Elevation – to or just below level of heart
Shoulder Injuries• Dislocations• Subluxations• Rotator cuff tendon
injuries• Sternoclavicular strain• Treatment
– Neurovascular status– Splint in position found
or– Sling & secure to body – Ice or cold compresses
Elbow Injuries• Falling on an outstretched arm or
flexed elbow• Pulled elbow – Nursemaids elbow
from a sudden lateral force• Athletic injury• Complications
– Volkmann’s contracture – Claw-like contraction of hand & arm deformity from ischemia
– Laceration of brachial artery– Ulnar nerve damage
• Treatment– Check neurovascular status – Splint in position found– Ice or cold compresses
Radial, Ulnar, Wrist Injuries• Check neurovascular
status• Splint in position found
(rigid or formable• Ice & elevation
Hand Injury• Boxer’s fracture 5th
metatarsal bone• Treatment
– Check neurovascular status
– Splint (rigid or semiformable) in position of function
– Ice & elevation
Finger Injuries• Assess neurovascular status• Splint in foam filled aluminum
splint, with tongue blades, or tape to adjacent finger
• Ice & elevation
Pelvic InjuriesSigns & Symptoms
• Pain• Hypovolemic shock• Shortening or abnormal
rotation of affected extremity
• Associated with injuries to the bladder, urethra, reproductive organs & sacral nerves
Pelvic InjuriesTreatment of Pelvic Fractures/Ring Injuries
• Open book – Vacuum mattress, Pelvic Binder, or sheet• Control hemorrhage – Direct pressure or close pelvic
ring• Fluid volume replacement – Normal Saline
(ED - PRBC, FFP, Platelets., Factor VII A &/or embolization)
External fixation/ORIF
Classification of Long Bone Injuries
• Fractures– Complete or incomplete– Open or closed– Epiphyseal – Cause bending or deformity– Comminuted – Several breaks in the bone– Greenstick - Break in periosteum w/i
bowing or buckling– Spiral – Twisted or circular break. ↑ child
abuse– Oblique – Diagonal, slanting break– Transverse – Right angle fracture– Pathological
Long Bone Fractures
Pathophysiology• Femur fractures result from major force• Long bone fractures from falls, MVC,
MCC• Femur neck fractures common in
elderly• Blood loss into a femur
– 1,000-1,500 ml
Long Bone FracturesSigns & Symptoms
• Pain• Ecchymosis & edema of the
site• Deformity at the site• Shortening of affected
extremity• Internal or external rotation• Hypovolemia or hypovolemic
shock
Long Bone Fractures
Assessment• Circulation – Hemorrhage or ischemia
– Neurovascular status– Pulses
• Deformity – Edema, hematoma, wounds• Compartment Syndrome
– 6 P’s – Pain, Pallor, Parasthesia, Pulses, Paralysis, Pressure
Long Bone FracturesTreatment
• Immobilize• Splint• Control pain• Realign – In ED• Skeletal traction – (In ED)
Usually temporary. Weights must hang free, meticulous skin care
• External fixators• ORIF
Splinting• Types of splints
– Rigid splint – body part fit to splint design
– Soft or formable splint – molded to shape or configuration of the body part
– Traction splint – (Femur fractures) – traction to stabilize and align
Open FracturesSigns & Symptoms
• Evidence of skin disruption over a fracture
• Protrusion of bone through an open wound
• Pain• Neurovascular compromise• Bleeding
Open FracturesTreatment
• Cover the wound• Splint• ED or OR Wound
cleansing & debridement• Realignment• Splint/Cast• External fixation• ORIF• Complications -
osteomyelitis, cellulitis
Techniques for Realignment• Finger realignment• Shouldar realignment• Hip realignment• Knee realignment• Ankle realignment
Jumper SyndromeJumper Syndrome• Vertical deceleration• Forces transmitted upwards from lower
extremities, pelvis, spine, chest• Lower extremity fractures & spinal cord
injuries• Retroperitoneal hemorrhage is the most
common cause of shock
AmputationsClassification
• Partial• Complete• Usually involves digits,
foot, lower leg, hand or forearm
• Life over limb considerations
AmputationsClassification
• Partial• Complete• Usually involves digits, foot, lower leg,
hand or forearm• Life over limb considerations• Re-implantation (Favorable in Peds &
with guillotine-type amputations)
AmputationsTreatment
• Reattachment• Amputation• Rehabilitation• Prosthesis Clinic
Assessment & Care• Keep body part
bagged not directly on ice
Compartment SyndromeCompartment SyndromeSigns & Symptoms
• Pain disproportionate to injury• Sensory deficit• Progressive muscle weakness• Tense swollen area• Elevated compartment
pressures• Loss of pulses
Compartment SyndromeTreatmentTreatment
• Elevation of limb Elevation of limb not abovenot above heart level heart level• Placement of an intracompartmental Placement of an intracompartmental
monitormonitor– <20 = normal<20 = normal– >20 = ischemia>20 = ischemia– > 30 = necrosis> 30 = necrosis
• Fasciotomies to release the pressureFasciotomies to release the pressure