Orthorpedic care

1. Principles of Orthopaedic Care
Gordon H. Stock, MD
Orthopaedic Surgeon, Central Utah Clinic

3. 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

4. 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

5. 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

6. 75yo F Tripped Over a Chair

7. After Total Hip Replacement

8. 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)

10. Function of Bones
• Structure & Movement
• Bone marrow: produce RBC
• Protection

11. 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

12. Definitions
• Open (Compound)
• Closed (Simple)
• Complete
• Incomplete
• Displaced
• Non-displaced
• Greenstick
• Comminuted
• Segmental
• Butterfly
• Spiral
• Oblique
• Transverse
• Hairline
• Occult
• Epiphyseal
• Fatigue (Stress Fracture)
• Impacted

15. 47 yo M, 4-Wheeler Rollover

18. 13yo M Skateboarding

19. Post Reduction

20. Problems associated with Epiphyseal
(Growth Plate) Fractures

21. Tscherne Method for grading Closed
Fractures

22. Gustilo Classification for Open Fractures

23. Assessment of Skeletal System
• Airway
• Breathing
• Circulation
• Skeletal Assessment
– Observation
– Palpation
– Functional testing

24. 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

26. Assessment of the Skeletal System
• History
• Physical Exam
• X-ray
• CT scan
• MRI

27. Treatment
• Splint
• Casting
• Reduction/Realignment
– Where
– When
– Whom
• External Fixation
• Internal Fixation
• Amputation

28. Treatment

29. Treatment: Splints

30. Critical Orthopaedic Fractures
• Pelvic Fractures
– Massive blood loss potential (>2000ml)
– Treatment: Sheet wrap, SAM splint

31. 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

32. Critical Orthopaedic Fractures
• Hip Fractures
– Intracapsular Femoral Neck
• Subcapital
• Transcervical
• Basicervical
– Extracapsular
• Intertrochanteric
• Trochanteric
• Subtrochanteric
• Treatment
– Internal fixation
– Hip Replacement
• Total
• Partial
– Early Ambulation

33. 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

34. 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

35. 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

36. 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

37. 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

38. Orthopaedic Pharmacology
• NSAIDs
• Opiates
• Antibiotics
• Muscle relaxants
• Anticoagulants

39. 76 yo tripped at home, Temazepam

41. Questions

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

43. THANK YOU!